aesthetic, meaning, nursing, patient care



  1. Herholdt-Lomholdt, Sine Maria
  2. Uhrenfeldt, Lisbeth


Review question/objective: This systematic review seeks to identify, appraise and synthesize available qualitative studies describing nurses' experiences of the essence and meaning of the phenomenon "aesthetics" in patient care.


The specific purpose of the review is to examine the qualitative literature to describe nurses' experiences of the phenomenon "aesthetics" within patient care in healthcare settings.


More specifically, from the nurses' perspectives, the aims are:


* To describe the essence of aesthetics within patient care.


* To describe the meaning of aesthetics within patient care.


* To describe what an aesthetic sensitivity requires.



Article Content


Since the late 19th century, nursing research throughout the western world has had an enormous growth. In this period, the term "evidence-based practice" (EBP) first appeared,1 with the aim of defining best practice through empirical research and evidence.2,3 The assumption behind EBP is that it is possible to guide the decisions of nurses in patient care on the basis of empirical research and general evident knowledge expressed through clinical guidelines.2


According to Benner,4 the extent to which clinical and research-led guidelines are incorporated in clinical reasoning and decision making depends on the nurse's level of experience. Where the beginner is primarily concerned about "completing all the ordered treatments and procedures", 4(p.28) the proficient and expert nurse attends clinical situations with an "increased perceptual acuity and responsiveness to a particular situation".4(p.104) Benner4,5 points to the fact that experienced nurses act on a basis broader than EBP alone, by knowing when it is time to break the rules. Jacobs-Kramer6,7 and Chinn,7 who built their understanding on Barbara Carper's scholarly work,8 also describe knowledge and decision making in patient care as being dependent on different kinds of knowledge. What is of interest in their study is that empirical knowledge is only one of the four different kinds of knowledge, which nurses draw on while developing and offering care. The other three are ethical, personal and aesthetic knowledge. Following the research of Chinn and Kramer, nursing is fundamentally, in all kind of settings, about integrating these different kinds of knowledge into patient care. Benner5 showed that clinical wisdom - and what we earlier described as a "responsiveness" to particular situations - among expert nurses entails a deep understanding of unique care situations and implies a tacit and intuitive kind of knowledge. Benner5(p.67) described this responsiveness as "clinical wisdom" involving, among others, clinical forethought entailing an ability to do clinical judgment on behalf of an "immediate understanding of the clinical situation". Benner pointed to the fact that such dimension in nursing grows through experience, and thereby the possibility to intuitively recognize critical conditions. In a Scandinavian context, Martinsen9 merely described sensitive and intuitive knowledge as something fundamental for mankind no matter how experienced you are and as something that needs to be addressed by a special kind of sensitivity and openness, named the heart's eye.10 This points to an important difference between the way Benner and Martinsen understood the actions and background of the wise nurse and what responsiveness was all about. When Benner described responsiveness to particular situations and thereby clinical wisdom, she linked it to an ability to recognize and act in complex situations based on the nurse's traits, experience and common sense. This sense was, in a Danish context, described by the concept of ethical discernment.10 Benner's wise nurse can be described as a kind of cultural master who intuitively knows what to do based on recognition and experiences of similar situations. Benner's5 inspiration was, in this sense, and among others, the Dreyfus brother's model of skill acquisition. At the same time, Benner pointed to the wise and also artistic nurse, as a nurse who is thinking in action, and differed this kind of "thinking" from the concept of reflection seen in the work of Schon. Thinking is, according to Benner,5 situated in particular and ongoing situations and differs from reflection by the way reflection implies a stepping back, being outside the situation. Although acknowledging the importance of experience in nursing and agreeing on the situatedness of thinking and the importance of having a sense of the good, Martinsen extended the understanding of wisdom, responsiveness and thinking to be more - and sometimes even something different - than being a cultural master or being able to recognize situations. From a phenomenological point of view, Martinsen pointed to a special kind of seeing or listening to nurses from within care situations, phenomenon's calling upon nurses, telling the nurses what would be good and meaningful to do in particular care situations. Responsiveness, in Martinsen's terms, is merely linked to nurses' sensitive receiving of impressions within unique situations and, on based on these impressions, the nurses develop ways to express themselves. Martinsen described this as a kind of listening to a call from practice. Martinsen further pointed to this call as something implying a possibility for nurses to break the thoughts and practices we culturally take for granted, understanding and doing something in different ways while intuitively knowing what to do in unique situations. This kind of knowledge does not only - and not always - rely on experience, but on a special kind of phenomenological openness and presence in practice, an openness and presence that both expert and novice nurses can have.11 Following this approach, nursing is also about a special kind of sensing of the moment and the patient and a special kind of 'in-seeing', meaning seeing into the unique moment, as van Manen said.12 Martinsen and Eriksson13 described this by using the term "ontological evidence" as a kind of evidence differing from the merely used medical and empirical evidence, by stating that "ontological evidence implies that the true reality may emerge and become visible in all its beauty and goodness".12(p.625) Martinsen's inspiration was in this sense - and among others - the Danish philosopher Loegstrup's work on "sovereign life-expressions".11 Such types of special moments of "in-seeing" or deeply understanding what a situation calls for will be described and explored as aesthetic moments in nursing.


Aesthetics can be described through a philosophical aesthetics approach developed by the Danish philosopher, Dorte Jorgensen. According to Jorgensen, who again refers to Baumgarten, philosophical aesthetics can be described as an important supplement to the prevailing paradigm of knowledge by introducing different kinds of awareness and ways of knowing.14,15 According to the research of Jorgensen, knowledge and truth can be gained in both logical and aesthetical ways. Philosophical aesthetics concentrates on the aesthetic experience as a way to gain insight and wisdom that differs from a logical thinking approach. Aesthetics is in this sense is understood as a sensitive admission to the world, an experience of a sudden opening of the world that needs interpretation and offers new insight.14,15 An aesthetic experience then is ambiguous. Jorgensen described aesthetics as a metaphysical experience of something speaking to us, telling us about the truth and what is good, and she pointed to such experiences as truly existential. When Jorgensen14 described aesthetics as a metaphysical experience, she took her leave from the platonic experience of beauty entailing traces of divinity,16 bringing the one who experienced it closer to being. Beauty then can be understood as a kind of revelation of a surplus of meaning embedded in the world. In this sense, Jorgensen had a very close relation to - and also draws on - Gadamer's hermeneutic understanding of aesthetics and his critique of the kind of aesthetic awareness that only focused on subjective experiences while overlooking the metaphysical insistence of truth revealed within aesthetic experiences.17 According to Jorgensen,18 contemporary aesthetics seems to forget these experiences of transcendence or, in other words, experiences of meaning or truth embedded in beauty. Therefore, Jorgensen17 suggested an understanding of philosophical aesthetics as a special kind of realization and interpretation of truth, given to us through aesthetic experiences. Referring to Baumgarten, she pointed to the complete aesthetic experience as beautiful, and to beauty as an illustration or a suggestion of truth and goodness.18,19 She wrote the following about philosophical aesthetics:.


It shows that we can deal seriously with the world of our experiences in all its variety without giving up the philosophical quest of truth, and the feeling of cohesion and meaningfulness as to which it conveys an insight ([horizontal ellipsis]). This is the feeling that turns the epitome of aesthetic experience, i.e the experience of beauty, into the experience that something is of value, in itself.18(p33)


Following this approach, beauty as a "feeling of life", as Kant according to Jorgensen puts it, plays an essential part of aesthetic experiences.18(p.14)


As shown earlier, several nursing researchers have tried to grasp the importance of aesthetics, and some of them also truth recognitions comparable with the truth recognition that Jorgensen wrote about. Although interesting and important, none of the above-mentioned studies explicitly dealt with the nurses' perspectives and experiences of being in aesthetics or, according to Jorgensen, beautiful moments, neither did they deal with the nurses' perspectives on the meaning of aesthetics while caring for the patient. Many of the narratives in Benner's5 research actually could be understood as aesthetic experiences, but the nurses' comprehension of the meaning and essence of these experiences as aesthetic experiences was not explored.


Although aesthetics has been described in contemporary nursing research,20-23 a synthesis of nurses' experiences of being in aesthetic and/or beautiful moments, the essence and meaning of aesthetics when providing patient care and the kind of sensitivity it requires, are still missing. As aesthetics is an important part of nursing, such review and synthesis are of importance for the continuing development of patient care.


This review attempts to summarize the meaning and essence of aesthetics and thereby also beautiful moments and the kind of sensitivity it requires, as seen from the nurses' perspectives.


Such a review has not been undertaken as demonstrated by a search of the Joanna Briggs Institute (JBI) Database of Systematic Reviews and Implementation Reports, the Cochrane Database of Systematic Reviews, PROSPERO or Google Scholar.


Inclusion criteria

Types of participants

Given the research of Martinsen, aesthetic and beautiful moments are not only a matter of experience, but could also find their way into nursing practices of a novice. Therefore, this study will include all kinds of registered nurses who have experienced the phenomena "aesthetics" within patient care, no matter how experienced they are.


Phenomena of interest

This review will consider studies focusing on the phenomena: nurses' experiences of aesthetics and/or beautiful moments in patient care, within all sorts of healthcare settings.


Types of studies

This review will consider studies focusing on qualitative data including - but not limited to - phenomenology, hermeneutic, grounded theory, ethnography, philosophic studies and action research.


Search strategy

The search strategy aims to find both published and unpublished studies. There will be no restrictions of time or language. Assessment for inclusion of publication in languages other than Nordic, German and English will be based on the English abstract and - if considered appropriate and feasible - an English translation will be sought.


A three-step search strategy will be utilized in this review. An initial limited search of PUBMED and CINAHL will be undertaken followed by analysis of the text words contained in the title and abstract, and the index terms used to describe the article. A second search using all identified keywords and index terms will then be undertaken across all included databases. Third, the reference list of all identified reports and articles will be searched for additional studies.


The databases to be searched will include:


CINAHL Complete; PubMed; Academic Search Premier.


The search for unpublished studies will include:


ProQuest is searched for relevant dissertations and thesis'; Mednar; Google Scholar.


Relevant web pages to be searched such as:


Jean Watsons Caring-Science Institute & International Caritas Consortium:


Initial keywords will be:


Aesthetic* or esthetic* or beauty or beautiful AND Nurs* or patient-care AND experience* or mean* or essence*.


Assessment of methodological quality

Articles selected for retrieval will be assessed by two independent reviewers for methodological validity before inclusion in the review using standardized critical appraisal instruments from the JBI-QARI (Appendix I Critical Appraisal Checklist for Interpretive and Critical Research). Any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer.


Data extraction

Data will be extracted from articles included in the review using the standardized data extraction tool from JBI-QARI (Appendix II Data Extraction form for Interpretive and Critical Research). The data extracted will include specific details about the phenomena of interest, populations, study methods and outcomes of significance to the review question and specific objectives.


Data synthesis

Wherever possible, the qualitative data will be pooled using JBI-QARI. This involves an aggregation of findings that are pooled into categories on the basis of similarities in meanings. If possible, these categories will be subjected to a meta-synthesis to present a comprehensive set of findings related to aesthetics in patient care, with the aim of informing practice with a basis of evidence.


Appendix I: Appraisal instruments

QARI appraisal instrument

Appendix II: Data extraction instruments

QARI data extraction instrument



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