Background
Nursing knowledge is applied in the ways of nurses practice nursing. This is initiated on the ways that they know the patients as the focus of their professional care. The aesthetic way of knowing in nursing is one of the fundamental patterns of knowing (Carper, 1978). The other ways of knowing are empirical, personal, and ethical knowing. To appreciate these fundamental patterns of knowing in nursing, Carper (1978) emphasised ‘empathy’ as the essential component in understanding and practising the aesthetic way of knowing—the capacity of nurses to understand others as persons. Understanding the situation of the person being nursed is essential for nurses in order to foster their nursing care and facilitate quality health outcomes for patients.
The aesthetic way of knowing is also described as the art of nursing (Carper, 1978). The art of nursing does not only refer to the physical appearance of the result or effect of nursing care but also the involvement of the wholeness of nursing care. Aesthetic knowing in nursing can include an engaging dimension where nurses are required to engage at the moment and interpret the situation and needs of the patients (Bender & Elias, 2017). In doing so, nurses become involved in the nursing experience in terms of nurses’ ability to understand and perceive the situation of others.
Aesthetics in nursing practice has been examined in several studies (Dahal & Kongsuwan, 2021; Radmehr et al., 2015). Dahal and Kongsuwan (2021) described the meanings of aesthetics in nursing practice from the lived experiences of sixteen nurses in a cancer hospital in Nepal. This study found that aesthetics in nursing practice for patients with cancer included nurses’ actions of knowing persons as a whole, creating a pleasant healing environment, and creatively best-using resources for palliation. The goal of the practice was nurturing hope, and the outcome gained was rewarding the self. Another study in Iran by Radmehr et al. (2015) described nursing care aesthetics from the experiences of twelve patients and fourteen nurses. Their study revealed that nursing care aesthetics were described as what reflects holistic nursing with the emphasis on nursing skill and spirituality (Radmehr et al., 2015). In addition, aesthetics was used in nursing research in the form of aesthetic expressions through artworks in hermeneutic phenomenological study to understand the deep meanings of the lived experiences. For example, Galvez et al. (2021) examined the use of aesthetic expressions through a draw-and-write method in researching the lived experience among children with advanced cancer in the Philippines. Their study found that aesthetic expression was a well-suited method to understand the children’ life-worlds. Another study by Kongsuwan et al. (2021) investigated aesthetic expressions of caring in nursing among Japanese undergraduate nursing students. In their research, data were art-based graphic expressions, such as drawings and written reflections on the drawings to represent the meanings of caring in nursing from the nursing students’ understandings.
Nonetheless, studies regarding Indonesian nurses` understanding of aesthetics in nursing practice were limited. A literature search regarding aesthetics in nursing practice in Indonesia yielded only one review article (Ibrahim, 2017), which aimed to explore and discuss the cultural perspectives on aesthetics in nursing practice and education in the context of Indonesian nursing. The knowledge in the review article suggested that culturally appropriate care and individual approach should be provided to implement aesthetics in nursing practice in Indonesia (Ibrahim, 2017). However, no study was found to date which addresses how aesthetics in nursing was practised among nurses in Indonesia.
Examining aesthetics in nursing practice from the experiences of nurses is essential in order to contribute to nursing knowledge based on the illuminations of aesthetics in nursing practice. Furthermore, since aesthetic knowing is necessary for illuminating caring in nursing, understanding aesthetics in nursing practice as experienced by nurses is important to enhance the quality of nursing care.
The Theory of Aesthetic Nursing Practice (AesNURP) was developed by Kongsuwan (2020). This theory informed aesthetic nursing practice as a deliberate practice of nursing for persons during the caring encounters through co-creating processes between nurses and the nursed in which oneness is facilitated and realised. AesNURP theory consists of five assumptions as follows (Kongsuwan, 2020): 1) Persons are caring by virtue of their humanness (Boykin & Schoenhofer, 2001), 2) Ideal of wholeness is a perspective of oneness (Locsin, 2005), 3) Persons co-create aesthetic expressions in nursing, 4) Persons mutually interact with the environment, and 5) Aesthetics in nursing is within aesthetic nursing environment.
In addition, AesNURP theory provides The Practice Processes of Aesthetics in Nursing (PraPan), involving the dynamic, continuous, and multiple phases of encountering, co-creating caring relationships, and meaningful engaging within the aesthetic environment (Kongsuwan, 2020). AesNURP theory was used in the explanation of the findings of this study. This study aimed to describe the meanings of aesthetics in nursing practice as experienced by nurses in Indonesia.
Methods
Study Design
This study followed a qualitative research design based on hermeneutic phenomenology (van Manen, 2014). Gadamer’s philosophy was used as a conceptual framework.
As a tradition of phenomenology, Gadamer believed that art provided human experiences with a new way to understand the world (van Manen, 2014). Once the experience is formed into an aesthetic expression, the truth of the lived meaning of human experience will become deeper. When the relationship of art with the human context is seen clearly, the aesthetics will provide humans with the experience of the truth. Thus, art is considered a source of lived experience (van Manen, 2014).
In this study, nurse participants were asked about their experiences of aesthetics in their practice. To help the nurses describe and express their understanding of aesthetics in nursing practice, they were requested to draw a picture as an aesthetic expression that reflected their experience, which was considered one of the data, followed by individual semi-structured interviews.
Participants and Setting
Thirteen nurses participated in this study. These participants were selected by a purposive sampling technique based on the following inclusion criteria: (1) being a registered nurse with experiences providing beautiful/ pleasurable/ compassionate/ appreciative/ inspirational/ satisfying nursing care in the clinical field for at least two years. Being a registered nurse for at least two years allow them to have adequate experience providing care for many patients with various conditions in different wards.
This study was conducted in a public hospital in West Sumatra Province, Indonesia. This hospital is a referral hospital in the province where patients from various regions with various diseases were referred. With these conditions, nurses in the hospital setting were exposed to different patients’ conditions, thus allowing them to deliver nursing care based on each nursing situation. Furthermore, data were collected from three wards (pediatric ward, respiratory ward, and cardiovascular ward) to allow researchers to obtain different experiences among nurses from other wards.
Data Collection
The researchers contacted and submitted a permission letter to the hospital to access the participants. After obtaining the permission, the researchers explained the information about the study and inclusion criteria for the participants to the head nurses. The head nurses assisted the researchers in announcing and endorsing the study to their staff. After their eligible staff agreed to be contacted, the researchers made contact with the nurse who was willing to participate in the study.
Data were collected from early March to April 2019. Data collection was held in nurses meeting rooms, consultation rooms, and vacant cabin wards, which were booked with permission from the concerned authority before the interview. The rooms for the interview had adequate lighting, comfortable seating arrangement, and quiet, which helped maintain the privacy and confidentiality of the sessions. Each interview lasted for approximately 30-60 minutes. Two authors (first and third authors) interviewed one interviewee together at the same time using an interview guide. Both researchers have experience in conducting qualitative studies and have experience as clinical practice instructors for approximately seven years.
The data collection procedures include the drawing and interviews phase, as described below.
Drawing. Researchers did not have a prior relationship with the participants. However, before the interview, the researchers established rapport with the nurse participants by beginning with informal conversations, such as “How was your day today? How do you feel?” Afterwards, the researchers asked the participants to illustrate their experiences providing aesthetics in nursing practice through drawings. The participants were provided with a sheet of A4 blank paper, a few colour pencils, a sharpener, and an eraser. They were given time to draw. Once they finished drawing, the researchers continued with the interview. However, if they requested more time to draw, they were allowed to submit their drawings on the agreed date and time based on their submission feasibility. The nurse participants were informed that they must draw by themselves and could not request somebody else to draw for them. The interview was conducted after they submitted the drawing at the agreed time.
Interview. The researchers used the drawings and the semi-structured interview guide to describe their experience providing aesthetics in nursing practice. Researchers further asked questions based on the symbols found in the drawings and the colours they used in the drawings. Some of the questions of the semi-structured interview guide are presented in Table 1.
| No. | Questions |
|---|---|
| 1. | Would you please draw the reflection of beautiful/pleasurable/compassionate/appreciative/ satisfying/inspirational nursing care for your patient? |
| 2. | Can you please describe the meaning of the picture you have drawn to me? |
| 3. | Can you please tell me your experience of providing beautiful/pleasurable/compassionate/appreciative/satisfying/inspirational nursing care to your patient? |
| 4. | What made you think it is beautiful/pleasurable/appreciative/satisfying/inspirational nursing care? |
| 5. | What made you do practice nursing care this way? |
| 6. | How did you feel after that? |
| 7. | What were the reactions of the patients/family members and other health professionals? |
Probing questions were used when clarification was needed. No repeat interview was performed. Interviews were recorded by using two recorders. During data collection, researchers logged field notes to record significant events, including the date and place of the interview, the environmental conditions during the interview, the participants’ expressions, and the researchers’ reflections. The transcripts were not returned to participants for correction; however, the probing questions were used between questions when clarification was needed.
Data Analysis
Data were analysed based on van Manen’s approach (van Manen, 2014). Each interview was transcribed and reread line by line several times, together with examining the relevant drawings and reading field notes. This was done to get a comprehensive understanding of the data. The significant excerpts were highlighted and coded. Then, analysing the drawing, the researchers examined each drawing as a whole for any pattern, the colour used, and participants’ excerpts about their drawing. Data were first coded in Bahasa Indonesia by the first and third authors, then were grouped into the same sub-themes and thematic categories. The essential excerpts, sub-themes and thematic categories were translated into English by the first and third authors and audited by the second author. Essential themes were grouped based on existential themes of van Manen’s life worlds, which were lived other, lived body, lived space, lived times, and lived things (van Manen, 2014). The emerging sub-themes and themes were discussed and agreed upon by the team.
Trustworthiness
The trustworthiness of this study was established through triangulation, member checking, and detailed transcription (Gunawan, 2015). Triangulation involved multiple data sources, including interviews, drawings, and field notes. Member checking was done at the end of each interview in which the researchers read the summary of the interview, and that was confirmed by the participants. The thick description of the study included explanations of the contexts and data collection procedures. An audit trail was confirmed to demonstrate the descriptions and meanings of aesthetics in nursing practice. All documents of this study and data analysis were kept and demonstrated among researchers to confirm the findings.
Ethical Considerations
This study was approved by The Social and Behavioral Sciences Institutional Review Board of Prince of Songkla University, Thailand (#2019 NL-QL 003). Before data collection, the researchers obtained permission to collect data from the Department of Education and Research of the hospital setting. This study did not pose any direct risk to the participants, both physically and psychologically. The information was given to participants before data were collected. If they agreed to participate, the participants were asked to sign an informed consent form. They were assured that their participation was voluntary. The participants were allowed to withdraw anytime without any penalty. Their information was collected under strict confidentiality. Their names were replaced by numbers in reporting this study. All the data were kept in the researchers’ personal computer, secured with a password that only the researchers knew.
Results
From fifteen nurses who were contacted initially, thirteen participants participated in this study, while two nurses dropped because they did not provide a drawing. All thirteen participants were women, whose ages range from 28 to 51 years (average = 39.8 years). Twelve of them were married, and one was single. Seven graduated from vocational schools, while six received a baccalaureate nursing degree. Their length of working experience ranges from 4 to 32 years (average = 17.13).
The findings revealed five major thematic categories reflecting the five-life worlds (van Manen, 2014) derived from the data. Those thematic categories are 1) Lived other: engaging in caring for persons; 2) Lived body: full of compassion; 3) Lived space: a sympathetic place of care; 4) Lived time: a joyful time of care; and 5) Lived things: distracting the inconvenience in care.
Lived other: Engaging in caring for persons
Engaging in caring for persons referred to the nurses’ engagement with the patients and their families. This theme was constructed from two sub-themes: the art of communication in nursing care and appreciation of caring.
The art of communication in nursing care. Aesthetics in nursing was implemented through practising good communication. Participants noted that beautiful care was expressed by keeping up good communication with patients and family, applying therapeutic communication, delivering understandable explanations about the treatment and nursing care, active listening, overcoming conflict, asking about topics that interest the patients, greeting the patients and asking how they feel before performing a treatment. The way of practising good communication, or “the art of communication”, was a kind of art in nursing care.
“I communicate with them (patient and family) therapeutically, I explained to them the patient’s condition, which treatment, etc. … I understand that nurses should communicate well.” (Participant 1)
“To make them (patients) comfortable, I asked how their children and families are doing, how many children they have, where their children are now, and so on. You know, sometimes the patients feel happy when we ask about their family. I did it while doing a nursing intervention, like when I inserted IV fluid, I made a conversation about the topic they like.” (Participant 3)
Appreciation of caring. Aesthetically nursing practice resulted in appreciation from patients and families for the nurses who cared for them. The participants noted that the patients expressed their recognition of them as respect, happiness, and trust, which enhanced their relationship with patients and families and their cooperative participation in care.
“.. patient was happy. So, that’s it, if the patient is happy with our care, he/she follows our instruction, I feel the relationship with patient and family becomes better.” (Participant 2)
“They are happy. When they trust us, it seems like they just want to be cared for by us. The patient trusts us.” (Participant 2)
The aesthetics in nursing practice in terms of engaging in caring was depicted by the following drawing of a nurse communicating with the patient (Figure 1). Participant 2, who drew the picture, explained that this picture showed a conversational situation between two nurses (on the right) and a patient (on the left). When the patient or family heard unclear information, they would ask the nurse. In the story recounted by Participant 2, a patient’s family asked nurse A to clarify some information. However, the family did not understand nurse A’s explanation. Afterwards, the family asked nurse B (Participant 2) the same question. Nurse B explained her answer to the family. The explanation was understandable, and the patient’s family was satisfied with the response of nurse B.
Lived body: Full of compassion
The practice of aesthetics in nursing was described as providing care that was full of compassion. Participants described compassionate care as caring with a sincere heart. This theme was derived from two sub-themes: beauty in caring with a sincere heart and satisfaction after providing care.
Beauty in care with a sincere heart. Aesthetics in nursing practice was expressed in terms of providing beautiful things in their care, which came from a sincere heart that cared for patients, such as the feeling of happiness when caring for patients; or feeling comfort, peace, calmness, neatness, and beauty.
“… to do IV insertion neatly, beautifully…. when I did it neatly and beautifully, there was such a satisfaction for me that I felt, and I think it was also felt by the patient and family. You know, IV insertion should be done neatly, correctly, and not in a hurry.” (Participant 2)
“.. pink (the colour the participant selected in the drawing) is identical with a lady with full of compassion … I think the nurse is identical with female instinct, compassion, like mother’s care to patients. That’s why I chose pink (in the drawing).” (Participant 1)
Satisfaction after providing care. Because of providing care with a sincere heart, participants described satisfying feelings after giving care. They felt satisfied with their job caring for patients and after receiving gratitude from patients.
“I feel satisfied with my job. I also feel satisfied with my relationship with my patients and their family.” (Participant 2)
Providing care full of compassion was illustrated by the picture of peaceful scenery (Figure 2). Participant 4, who drew the picture, explained that beautiful nursing care was like the peaceful scenery with a peaceful and warm feeling. It was similar to the nurse’s experience after fulfilling a patient’s need by providing beautiful care.
Lived space: Sympathetic place of care
Within aesthetics in nursing care, the experienced space was a sympathetic place, giving comfort to both nurses and patients. Patients preferred to be cared for in certain units because of the beauty of the care received. On the other hand, the nurses also got the patients’ acception.
Preferred place to receive care. Because of aesthetics in nursing care provided by nurses, some patients preferred to stay at the same unit where they were hospitalised firstly.
“That patient wanted to hospitalise in our unit; he said he liked the way that nurses in our unit cared for him.” (Participant 7)
Welcoming nurses to the room. Nurses felt acceptance from patients and families as they entered the patients’ room.
“When I entered their room, they welcomed me with a smile, then they called me by my name. They even asked about my shift schedule and when I would be on my next duty. I felt like they waited for me to care for them.” (Participant 4)
Lived time: A joyful time of care
The joyful time of care was regarded as the pleasant time nurses spent during and after caring for patients. This theme was derived from two sub-themes: a long time in remembrance and an immediate response to patients.
A long time in remembrance. Practising aesthetically in nursing care resulted in patients remembering nurses for a long time even after being discharged from the hospital.
“The patients who already discharged still remembered me when they met me outside, even hugged me (of the hospital).” (Participant 3)
“My impression was the patient who I took care has been discharged, they still remembered me, and they even called my name when we accidentally met outside the hospital.” (Participant 4)
Immediate response to patients. Aesthetics in nursing care is described as the immediate response to patients when nurses are doing procedures.
“I knew how it felt like to be in patient’s position. When we were in pain, we needed immediate help, I directly helped the patients without delay or making them wait whenever.” (Participant 4)
Joyful time was illustrated in the below image of a smiling nurse (a woman). Participant 7 stated that she expressed beauty in caring as she cared for patients with a smile and happiness in her heart (Figure 3).
Lived things: Distracting the inconvenience in care
Aesthetics in nursing practice is also understood by participants as minimising discomfort during their care and applying innovation in care.
Applying innovation in care. Aesthetics in nursing practice can be expressed by applying innovation in care to enhance patients’ outcomes and speed their recovery.
“Another example was when I offered wound care using honey. So here, the patient did not know about applying honey to the wound.” (Participant 2)
Minimising discomfort during care. According to participants, pain relief was required when delivering care to patients.
“I guided patients to relax and feel comfortable before inserting the IV fluid; I tried distracting them from their pain.” (Participant 13)
Additionally, according to participant 10, beautiful nursing care could be expressed by providing adequate equipment to patients, making them comfortable, relieving their pain, and preventing infection. The summary of life-worlds and each thematic category were presented in Figure 4.
Discussion
Aesthetics in nursing practice was understood and expressed by nurse participants through various aspects of their care. These included engaging in caring, being compassionate, providing a warm and caring space, allowing time for patients, and distracting them from the inconvenience of care.
From those findings, the most prominent theme was full of compassion. Being full of compassion was described as caring that came from a sincere heart, which resulted in nurses receiving appreciation for their care. Such care was represented by the beauty, calmness, and neatness of nursing care. The beauty or sublimity of nursing depends on the feelings involved in the act of caring (Siles-Gonzalez & Solano-Ruiz, 2016). Beauty was perceived as something pleasant, such as the feeling of someone who was looking at a flower or tree (Kant, 2003). In this study, participants drew pictures of beautiful scenery with trees, water, and ships that expressed beautiful nursing care.
The theme of “lived other” was experienced as engaging in caring. It meant nurses applied the art of communication in their care so that they could get appreciation from the patients. Nurses need the capability of delivering information to patients in various situations for patients and their families to understand the issue easily. Thus, the art of communication was essential in nursing practice. Good communication between nurses and patients was principal to achieve the successful outcome in nursing care (Kourkouta & Papathanasiou, 2014).
Furthermore, the art of communication in nursing was synthesised in different ways, such as treating patients with dignity and respect and calling them by how they preferred (Palos, 2014). Similar to a previous study (Palos, 2014), nurse participants shared their experience by talking to patients about topics they were interested in.
The theme “lived space” was experienced as a sympathetic place of care where nurses intentionally presented for the patients. Hence, patients wanted to receive care in the same unit, as well as they wanted to welcome nurses into the room. Oldland et al. (2020) reported that empathy and care, patient and family’s comfort, and clean and tidy environment were factors enhancing the quality of healthcare.
Furthermore, beautiful moments in nursing care were identified through simple content of fulfilment of care and inspiring feelings because nurses were involved in the process of satisfying patients’ needs (Siles-Gonzalez & Solano-Ruiz, 2016). In this study, lived time was experienced as a joyful time when patients remembered nurses even after their discharge. This joyful time was created as nurses fulfilled their patients’ needs immediately. Similar to a previous study about patients’ expectations regarding nurses and nursing care, an immediate response to the patient need was one of the critical expectations of patients (Najafi Kalyani et al., 2014).
Nurses’ understanding of aesthetics in care reflected the process of aesthetic nursing practice described by Kongsuwan (2020) in her theory of Aesthetic Nursing Practice (AesNURP). AesNURP informed aesthetic nursing practice as a deliberate practice of nursing for persons during the caring encounters. Within AesNURP, the process of nursing consisted of encountering, co-creating caring relationships, and meaningful engaging.
Encountering allowed nurses to know the clients being cared for, especially on the question of “what” these persons were (Kongsuwan, 2020). In this study, encountering was reflected in “engaging in caring” and “full of compassion” themes. To know clients, nurses provide them with compassionate care and sustained good communication. Co-creating a caring relationship was defined as the relationship between the nurse and person being nursed to co-create caring practices (Kongsuwan, 2020). In this study, co-creating a caring relationship was seen through the theme of “distracting from the inconvenience in care.” Nurse participants understood that patients suffered from the feeling of pain and discomfort. Therefore, they tried minimising the pain by applying innovative techniques to comfort the patients. Meaningful engaging was described as the interaction between nurses and clients in their relationship (Kongsuwan, 2020). In this study, the themes of “sympathetic place of care” and “joyful time” represented meaningful engaging. Their interaction was reflected in the nurses’ immediate responses to their patient’s needs, as well as the patients’ immediate expressions of acceptance for their nurses. As a result, patients remembered nurses even after they were discharged and chose to readmit to the same ward in the same hospital.
In addition, the way that nurse participants described the meaning of aesthetics in nursing practice depended on their understanding of what was aesthetics in their care and how they implemented it based on the context and cultural appropriateness. In this study, aesthetics in nursing practice was not only understood as physical beauty or neatness inherent in a nursing act, but also through the wholeness of their nursing care, involving physical presence and way of communication. For example, for Indonesian nurses, asking about patients’ families while inserting an IV fluid was perceived as an aesthetic act in their care, making the patient feel caring. Therefore, the Indonesian tended to ask and talk about family and personal life as an expression of caring for others.
This study applied qualitative design by combining interviews with drawing to understand the meaning of aesthetics in nursing practised by nurses in Indonesia. Allowing nurse participants to express in an aesthetic form, particularly drawing, made a bigger chance for participants to convey their experience and for researchers to explore the phenomenon.
Implications of this study
Aesthetics in nursing is practised by Indonesian nurses in various ways, not limited to the beauty or tidiness of a nursing action but reflected in the whole nursing process. The findings of this study were expected to inform other nurses in Indonesia and other countries as well on how to implement aesthetics in their practice. In addition, the findings also were expected to inform nurse educators to include and emphasise aesthetics in nursing in the curriculum so that nursing students can learn.
Limitation
In this study, all participants were female nurses, so both genders had no representation. Before approaching the participants, we explained the eligible criteria and study procedures to the head nurses and contacted those who agreed to participate in our study. However, only female nurses agreed to be contacted to participate in our research. Therefore, future research to examine aesthetics in nursing practice from the perspective of male nurses was suggested.
Recommendations for future research
Aesthetic expressions such as drawing provided opportunities for the participants to express their experiences beyond words. For future work, allowing patients to describe their experience receiving nursing care through aesthetic expressions is recommended. In addition, future studies involving male nurses regarding how they implemented aesthetics in nursing practice are also recommended.
Conclusion
This study described the meanings of aesthetics in nursing practice as experienced by nurses in Indonesia. Findings revealed that aesthetics in nursing practice by nurses in Indonesia could be described as engaging in caring for persons with a heart full of sincere compassion through distracting the patients from any unpleasant sensation and allowing them to experience joyful time inside a sympathetic place of care. Furthermore, these findings could be used to inform nurses of various ways in applying aesthetics in practice to enhance both the nurses’ and patients’ satisfaction from providing and receiving care.