A Phenomenological Study of Aesthetic Nursing Care as Experienced by Patients during Hospitalization ()
1. Introduction
Based on ontological theories, nursing is defined as an art, a science, or a practice involving significant contributions to the well-being of patients/persons [1]. As a profession, nursing is practiced in an aesthetic way, which has been described as one of the fundamental ways of knowing in nursing [2]. An aesthetic way of knowing implies nurses’ perception of what is important for the patients through the art and act of nursing [2]. This may include any expression while engaging in a caring relationship with patients. Nursing care is an art in which the “artists” implement their prior skill and knowledge in the act of caring for an individual [3].
Aesthetics in nursing has been studied, covering various aspects in the area of nursing education, research, and practice [4]-[7]. In the area of nursing education, aesthetic expressions were used to describe caring in nursing among Japanese nursing students [5]. In nursing research, aesthetic expressions through the Draw-and-Write method of data generation were used to study the lived worlds of children with advanced cancer [4]. Meanwhile, in nursing practice, aesthetic nursing care has been explored in the way nurses deliver nursing care [6] [8]. Dahal and Kongsuwan [7] described the meaning of the lived experiences of nurses providing aesthetic nursing care for patients with cancer in Nepal as creating a pleasant environment, knowing persons as a whole, creative use of palliative care resources, and rewarding self. Similarly, Betriana et al. [6] found that aesthetic nursing care was expressed by nurses in Indonesia through providing compassionate care, practicing good communication with patients and family, relieving the pain, and applying innovation in their nursing care. In addition, implementing aesthetic nursing care in practice showed valuable benefits both for nurses and patients, including increasing job satisfaction for nurses and improving relationships with patients and family [6], increasing patients’ positive feelings, and decreasing stress levels [9].
Aesthetic nursing care is often viewed interchangeably as compassionate care or holistic care. Nonetheless, those concepts are slightly different. Aesthetic nursing care is described as caring in nursing practice that is expressed as the engagement of the nurse and the one nursed through encountering, co-creating caring relationships, and meaningful engaging to maintain a person’s wholeness and enhance their well-being [1]. Compassionate care is a component of quality care involving empathy, sympathy, and respect, as well as concern and awareness of the situation that a person is suffering [10]. Meanwhile, the American Nurses Association defined holistic care as the integration of the body, mind, spirit, cultural, sexual, social, and environmental principles and modalities to promote health, increase well-being, and actualize human potential [11].
Implementing aesthetic nursing care requires knowledge that can be derived from both nurses’ and patients’ perspectives. However, there is a lack of research regarding how aesthetic nursing care is experienced by patients. Only a few studies were found to investigate aesthetic nursing care from patients’ perspectives, in which those studies collected the data through individual interviews in the same country [8] [12].
Patient participants considered nursing to be an art when they received compassionate nursing care that involved physical and psychological presence from the nurse [12]. Moreover, aesthetic nursing care was experienced by patients as spiritual and desirable caring behaviors that are combined with a sense of sympathy and unity between nurses and patients [8]. As desirable caring behaviors might be unique and different for people with different backgrounds and cultures, it is important to understand how aesthetic nursing care is experienced by patients from other contexts. For example, people in Indonesia may perceive caring behaviors differently from people in other parts of the world due to the influence of Eastern culture and religious aspects. However, oftentimes, aesthetic experiences are not reflected on or articulated well. As the experience of receiving aesthetic nursing care might not be well explained verbally, the use of aesthetic expression, for example, drawing, might help patients express and deliver the meaning of aesthetic nursing care that they experienced. Gadamer [13] argued that art is the representation of an experience; thus, an experience will become a new whole when it is expressed as an artwork. Other research from different backgrounds and settings with various data collection methods is needed to explore the aesthetic nursing care from patients’ perspectives; thus, findings of this study are expected to add to the body of knowledge of this field and inform current and future nursing practice. Therefore, this study aims to describe the meanings of aesthetic nursing care as experienced by patients.
2. Methods
2.1. Study Design
This is a qualitative study with hermeneutic phenomenology underpinning Gadamerian philosophy. Phenomenology is the study offering insights and original understanding of human experiences [14], while Gadamerian philosophy is a tradition of hermeneutic phenomenology, which regards a picture, or an image, as an artwork that has the power to give us the meaning of an experience through the understanding of that art [15]. This study aims to describe the meaning of aesthetic nursing care that was experienced by patients; therefore, phenomenology was chosen as the design of this study. Further, since aesthetic nursing care is a concept that might not be easy to describe verbally, drawing might help the participants to articulate their experiences. Thus, in this study, the participants were requested to reflect on their experience receiving aesthetic nursing care through drawing, and this was followed by individual interviews.
2.2. Participants
A purposive sampling technique was used in this study. Data were collected until saturation was reached, in which no more new information arose, and the study provided maximum information about the phenomenon [16]. In this study, saturation was achieved from twelve participants who met the inclusion criteria, which were 1) having experiences in being hospitalized for at least three days, 2) having been hospitalized within six months before they were interviewed, and 3) being willing to share their experience in receiving aesthetic nursing care through drawing and interview.
2.3. Ethical Consideration
Ethical approval was obtained from the Social and Behavioral Sciences Institutional Review Board, Prince of Songkla University, Thailand (Number: 2019 NL-QL 003). This study is a part of a larger study entitled “Aesthetics in Nursing Practice as Experienced by Nurses and Patients in Three ASEAN Countries: Thailand, Indonesia, and the Philippines.” Before data collection, participants were provided information regarding the study, and after they agreed to participate, they were asked for informed consent. Their information was kept confidential. They were informed that they were free to withdraw from the research at any time until data collection was finished without any penalty.
2.4. Data Collection
Data were collected in the hospital wards where patients were admitted in a public hospital in West Sumatera province, Indonesia, as well as in patients’ homes and by phone calls with patients from the area of West Sumatera Province, Indonesia. The decision regarding the place and manner of conducting the interview was based on the participants’ choice and preferences at the time of the initial communication with the participants.
After obtaining ethical approval, researchers asked for permission to approach participants by sending a letter to the hospital. After having obtained a positive response to the letter asking for permission, researchers contacted the head nurses of several wards and explained about the study. Then, the researchers approached the patients who were interested in participating in the study. Researchers also approached other participants by obtaining the contact details of the prospective participants from the hospital medical records department and researchers’ network regarding those who had been hospitalized recently. Those participants were contacted by phone and were informed about the study. If they were interested and willing to participate, the researchers made an appointment to explain the study to them, either to meet in person in the ward to which they had been admitted, to meet in their homes or to conduct interviews by phone based on their preferences. Data was collected by drawing followed by individual interviews.
At the time agreed upon for data collection, the researchers explained the study to the participants, including the aim, the procedures, how the data would be collected, and the risks and benefits of this study. The participants whose data was collected by meeting in person were invited to sign an informed consent form as evidence of their consent. For those who were contacted by phone, their consent was obtained verbally, and the researcher marked it in the research notes.
After the participants gave their consent, they were requested to draw a picture that reflected their experience in receiving impressive or beautiful care during their hospitalization. They were given as much time as they wished and were asked to submit the drawing to the researcher within the agreed time. All drawings were submitted to the researchers within one week after the contact.
On the agreed day after the drawings were submitted, an interview was conducted either by phone call or face-to-face, at the participants’ convenience. The interview started with researchers asking participants questions not related to the study to build rapport with the participants, such as how they were doing that day, how they were feeling, etc. Some participants’ families were present during the interview. Afterwards, the interview was continued by asking the participants about their drawings and their experiences receiving impressive or beautiful care during hospitalization. Probing questions were used in case further confirmation was needed. At the end of the interview, a summary was read for participants to confirm. No repeat interview was carried out. Each interview lasted around thirty minutes to one hour and was recorded using an audio recorder. An interview guideline was used to interview participants (see Table 1), and the researcher took field notes during the interview to record any significant events or reflections from the researchers. The research team consisted of three female researchers with two PhD holders and one master’s degree holder, who are experienced in conducting qualitative studies in the area of aesthetic nursing care. All of them are female nursing lecturers. Interviews were conducted by authors 1 and 3 and were validated by author 2.
Table 1. Interview guideline.
No. |
Questions |
1. |
Could you please explain the picture that you have drawn? What does the meaning of this picture reflect regarding your experience? |
2. |
Could you please tell me about your experience receiving impressive or beautiful care from nurses when you were hospitalized? |
3. |
Why did you regard that experience as beautiful or impressive care? |
4. |
How did you feel about receiving such nursing care? |
2.5. Data Analysis
Data were analyzed following six steps of van Manen’s phenomenological approach [17], which are 1) turning to the nature of the lived experience, 2) investigating experience as lived, 3) reflecting the essential themes that characterize the phenomenon, 4) describing the phenomenon through the art of writing and rewriting, 5) maintaining a strong and oriented relation to the phenomenon, and 6) balancing the research context by considering parts and a whole.
For the first step, our phenomenon of interest was clarified as the aesthetic nursing care experienced by patients. In the second step, the experiences were investigated by inviting the participants to reflect on their experiences through drawing and share their stories through individual interviews. Then, in the third step, the researchers reflected on the essential themes derived from the collected data. All interviews were recorded and transcribed verbatim in the Indonesian language (Bahasa). The transcriptions were reread several times, and the picture is attached along with the transcriptions. The significant excerpts of each participant were highlighted. After this initial analysis, those excerpts were grouped with other participants’ excerpts that contained similar categories, along with the supported drawing. This initial analysis was performed by authors 1 and 3 and was validated by author 2. Researchers also checked the field notes taken during the data collection process for any reflections related to the supporting data. For the fourth, fifth, and sixth steps, researchers described the phenomenon by interpreting the data following van Manen’s approach [18], in which the themes were categorized into five life worlds: lived body, lived relation, lived thing, lived time, and lived space.
2.6. Trustworthiness
Trustworthiness of this study was established through triangulation, detailed transcription, and member checking [19]. Triangulation was done by collecting data from various sources, including drawings, participants’ interviews, and researchers’ reflection notes. Detailed transcription and repeated reviews of the transcript were performed during data analysis. Member checking was conducted by reading the summary at the end of the interviews, which was confirmed by the participants.
3. Results
Twelve patients participated in this study. Two of them were men, and ten were women. Their ages ranged from 23 to 55 years old. They were admitted to the hospital for three to 14 days, with the diagnoses of admission comprising dengue fever, delivery (postpartum), fever and shortness of breath, breast tumor, cardiovascular disease, diabetes mellitus, and melanoma surgery. To keep the confidentiality of the participants’ identities, P (participant) and numbers were used to report their excerpts.
The aesthetic nursing care that was experienced and understood by participants is presented in five themes following five life worlds based on van Manen [18], which are: (1) lived body: caring with being fully present, (2) lived relation: the empathic hospitable communication, (3) lived space: the comforting care space, (4) lived thing: the nuances of caring, and (5) lived time: the special caring moment.
3.1. Theme 1: Caring with Being Fully Present
Caring with being fully present describes the participants’ experiences of receiving aesthetic nursing care where nurses are truly present for the patients. This theme reflects the nurses’ action of immediately responding to patients’ needs, being fully present for patients, and providing compassionate care through touch.
“I was very impressed with their caring attention, and they truly accompanied me. Their care and their true presence.” (P2)
“The nurse responded to my pain. Yes, it is a simple act, but I felt comfortable with the way the nurse communicated. When a nurse did an intervention, it showed that what they did came from their heart, through their touch, with graciousness.” (P9)
3.2. Theme 2: The Empathic Hospitable Communication
Aesthetic nursing care is experienced by participants in the form of empathic, hospitable communication, in which the actions refer to providing an understandable explanation regarding any action performed on patients, asking for permission for any intervention provided for patients, and communicating with patients.
Participant 3 stated, “Before the nurse took my blood sample, the nurse communicated with me; she said, ‘Today we will take your blood for a laboratory test so that we know your thrombocyte level. Please be relaxed,” that is how the nurse talked to me while observing my condition, and also asked if I felt limp, if I had red spots on my skin, and if I had a headache or not.”
3.3. Theme 3: The Comforting Caring Space
Van Manen explained lived space as felt space, in which the space persons find themselves in affects the way persons feel [18]. In this study, when participants were asked about their experience receiving aesthetic nursing care, they reported that aesthetic nursing care is experienced as the comforting place provided by nurses. The patient felt the space (the hospital ward/unit) was a comforting space despite the painful situation and illness that they went through during hospitalization. Furthermore, patients reported that nurses’ attitude and behavior during caring for them changed the environment from the painful and sorrowful space to a comfortable space.
Participant 5 stated, “It’s like I placed myself in their hands (explaining the picture of holding hands (Figure 1)). They really cared for me, telling me to be patient when I felt pain. They said, “Take a deep breath, take a drink, let us do this for you, let us clean you, let us give you the intravenous fluid.” You know, it’s like I placed myself in their hands.”
Another patient stated, “I remembered when I was about to undergo surgery. I was really scared of things related to medicine… Yes, I was scared, but in the operating room, the nurses told me funny stories, so I was not scared.” (P8)
The comforting care space is illuminated in Figure 1. Participant 5, who drew the picture, stated that when the researcher asked her to draw a picture that reflected her experience receiving beautiful nursing care, she said that the scene that came to her mind was a nurse holding her hand when she was delivering her baby. The nurse held the participant’s right hand with both nurses’ hands and said, “Please be patient,” and even though the participant felt severe labor pain at that moment, she also felt a sense of comfort at the same time. Furthermore, she explained that the light pink color in the roses around the hands represents love and caring, while the dark pink of the roses’ line represents gratefulness and empathy. The green leaves represent freshness, calm, and comfort. Participant 5 summarized the meaning of the overall picture as caring that brings comfort as the meaning of aesthetic nursing care based on her experience.
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Figure 1. A picture of handling hands that illuminates the condition where patient placed herself in the hands of a nurse, drawn by participant 5.
3.4. Theme 4: The Nuances of Caring
The nuances of caring mean any attributes of things that remind patients of the nursing care that they received during their hospitalization, and those things are regarded as the representatives of aesthetic nursing care that they received. In their drawing, they drew things such as an IV pole, bandages, etc., and when they were asked why they drew those things, they said those things reminded them of the care they received in the hospital. Participants stated that those things were representative of the aesthetic nursing care that they received from nurses.
A participant hospitalized with dengue fever said, “Every morning, the nurse came to my room, gave the medication, checked and changed the infusion fluid, checked my laboratory results, asked how I was, checked my body temperature, checked everything, and asked my family if I had vomited, had dizziness, or had nausea.” (P1)
3.5. Theme 5: Appreciating the Special Caring Moment
Lived time is understood as the time a person experiences it, in the way a person experiences the world on a temporary level [18]. In this study, time during receiving aesthetic nursing care is experienced by patients as a caring moment that is appreciated by nurses.
A participant stated, “So, after my baby was born and cleaned, the nurse asked me for my phone, then took the picture and video of my baby and me. For me, it was a precious moment, especially at that time; no family accompanied me, and I didn’t even have a thought to take a picture of my newborn baby, but the nurse did… How can I say? Her empathy was high.” (P2)
4. Discussion
This study described the meanings of aesthetic nursing care as experienced by Indonesian patients. Findings show that participants experienced and understood aesthetic nursing care in many forms, including nursing actions, gestures, and nuances during their encounter with nurses. Aesthetic nursing care is a combination of scientific knowledge and creative imagination of all knowledge in nursing [8]. In this study, aesthetic nursing care involves the wholeness of nursing and nurses themselves, including the small gestures that are meaningful and valuable for patients.
Caring with being fully present is the most prominent theme in this study, as nurses’ being present by the patient’s side is frequently quoted by participants as the impressive care that they received. It describes the condition where nurses are being fully present for patients, not only in terms of physical presence but also psychological presence. This result is in accordance with a previous study [8], which found that patients perceived aesthetic nursing care as a sense of closeness of nurses’ presence and companionship with patients.
According to the Theory of Aesthetic Nursing Practice (AesNURP) [1] [20], the nurses’ presence by the patient’s side is related to the aesthetic environment where nurses and persons being nursed interact within the subjective and objective domains. The subjective domain is the psychological space constructed by a person’s connection with another person [1] [20], which is shown by the genuine presence of nurses that can be felt by the participants in this study. Meanwhile, the objective domain refers to physical or material space surrounding the person that is perceived through the senses [1] [20], which is shown in this study by the nurses’ touch to the patients and was perceived by participants as an aesthetic act.
The theme of empathic, hospitable communication shows the patients’ experience of receiving good communication from the nurses. Participants perceived care as aesthetic nursing care when nurses provided understandable and clear explanations regarding any intervention performed on them, when nurses asked for permission before delivering nursing care to them, and when nurses practiced good communication with them. Healthcare is regarded as responsive care when patients experience empathy and are welcomed when interacting with healthcare professionals, while stressful and insecure care occurs when healthcare fails to inform patients about the plans for care [21]. An empathic relationship can be achieved through actual conversations between nurses and patients, and it could contribute to improving patients’ clinical outcomes [22]. Verbal communication, combined with non-verbal communication and the performed technique of a nurse’s care, manages to constitute an artwork in which beauty in care and a sense of good are perceived [3].
The theme of a comforting caring space reflected the nursing situations in which patients experienced a sense of comfort and caring despite the suffering and painful situation that the patients were undergoing. For example, participant 5 drew a picture of a holding hand (Figure 1) as the representation of the comfort situation when a nurse held her hand during her painful moment of delivery. Receiving comfort care and providing comfort care seem to be a common expression of aesthetic nursing care from both patients’ and nurses’ perspectives. In previous studies, patients found beauty in nursing care through a sense of security and comfort provided by nurses [8], while nurses expressed the aesthetic nursing care for their patients by giving comfort and minimizing discomfort during the nursing encounter [6].
Furthermore, in this study, the themes of lived things and lived time are connected on a particular level. Lived things reveal the theme of the nuances of caring, which refers to the attributes of caring (lived things) that remind patients of the caring moments (lived time) they had with nurses. Those attributes, be it infusion fluid, bandages, or a stethoscope, became the representations of aesthetic nursing care that they received. The caring moment illuminates the moments when patients received nursing care, which they perceived as aesthetic.
Figure 2. Model of practice process of aesthetic nursing practice from nurses’ actions perceived by patient participants.
Findings in this study reflect three processes of aesthetic nursing practice according to AesNURP theory [1] [20], which are encountering, co-creating caring relationships, and meaningful engaging. (Figure 2) Encountering describes the process where the nurse and the persons being nursed (patient and family) know each other as caring persons through multiple patterns of knowing and embodying the whole person [1] [20]. In this study, encountering is practiced by nurses being embodied in order to know the person being cared for through being truly present for patients and family, checking the laboratory results, intravenous fluid, etc., and being ready for patients. The second process, co-creating caring relationships, is the process where the nurse and the one nursed co-create the simultaneous caring practice [1] [20]. Some nurses’ actions perceived by participants that illustrate this process include empathic, hospitable communication; providing understandable explanations to patients and family before performing a nursing intervention; demonstrating a good way of communicating; asking permission from the patient and family before doing any intervention; and advising the patient to be cooperative during any nursing intervention.
Figure Legend: This model shows two big boxes containing 1) practice process of aesthetic nursing practice based on Kongsuwan [1] on the left side and 2) perceived actions of aesthetic nursing care experienced by participants in this study on the right side. Dotted lines show the elaboration relationship between the first and second boxes. For example, encountering [1] is reflected in this study as the action of being truly present for the patient and family.
The last process, meaningful engaging, is defined as the process of engaging in an interacting relationship between caring persons wherein all nursing occurs [1] [20]. In this study, meaningful engaging is shown by nurses through understanding and honoring patients’ precious moments, immediately responding to patients’ complaints and pain, showing compassionate care, creating a comfortable environment, and providing comfort and a caring touch, for example, by holding a patient’s hand when the patient felt labor pain. Findings of this study integrated into the practice process of aesthetic nursing practice [1] [20] are proposed as a model of the practice process of aesthetic nursing practice from nurses’ actions perceived by patient participants. This model is expected to provide an easier understanding of representative aesthetic actions that can be clinically implemented in nursing practice.
This study described the meaning of aesthetic nursing care experienced by Indonesian patients who are mostly from the same region in Indonesia and have the same culture. Thus, generalizing these findings to other contexts and settings should be considered.
5. Conclusion
This study described the meanings of aesthetic nursing care as experienced by Indonesian patients within five themes: caring with being fully present, the empathic hospitable communication, the comforting caring space, the nuances of caring, and the special caring moment. Findings show that aesthetic nursing care is experienced and noted by patients in the wholeness of nursing care through the various forms and nurses’ actions that patients observed during their encounter with nurses. These findings can be used to inform nurses in clinical settings and nursing students practicing in the hospital regarding aesthetic acts of nursing care that might be clinically relevant when they are applied to patients. In addition, the findings can be used to develop a tool to measure aesthetic nursing care.
Acknowledgements
The authors acknowledge the Faculty of Nursing Grant, Prince of Songkla University, Thailand, for supporting this study. The authors also extend the gratitude to participants for their participation in this study.