Art of Nursing Competency Framework:
Integrating the Arts into Nursing Education and Practice.
Lynch 2026
“Nursing is both an art and a science. Nursing as an art form has three major components; medium, process, and product.” (Pepleu 1998:1). The science consists of the systematized knowledge, and the art can be a system of knowledge too, if the bio medical lens on health and healthcare is shifted and other ways of being healthy and seeing health are accepted. Barbara Carper (1978) outlined the ways of knowing in nursing that enable us to quantify the art and science. 50 years on these ways of knowing now need expanding to fit a 21st century fourth industrial revolution and build the radical imagination and human and non-human skills needed for a 21st century nursing profession.
Both nursing's art and its science are essential for excellence in nursing but are not quantified and so not taught in equal measure. Each time I see another nursing curriculum conversation or nursing policy I am reminded of streetlight effect and the cartoon showing someone looking for their keys under a lamppost, not because that is where they lost them, but because that is where the light is (Kuhn 1962).
For nursing we need to look beyond ‘the light’ and remind ourselves of those aspects invisible to others if we only look for utility.
Evidence and effort to advance to art of nursing is ongoing. (Leininger, 2012), (Alligood and Fawcett, 2017), Benner, 2000), (Weaver, 2021), (Lynch 2010, 2024,2025,2026). Such thinking reflects the past ways of knowing in nursing and looks to the post humanism world on 21st century nursing. (Dillard-Wright et al. 2024).
Lauren and Martin (2024) take this forward and propose using critical posthumanism and Braidotti’s (2019) affirmative ethics to challenge humanocentric nursing, and advocate for a shift toward a "becoming-world" that rejects neoliberal commodification.
They reimagine nursing as a proactive, relational, and political endeavour focused on socio-ecological justice rather than just human-centric care, one that integrates non-human actors into nursing too.
There is a presence making, delicately balanced movement between art and science portrayed by experienced nurses, something transcends as it uses the differences between these two forms. Perhaps if one imagines such work as relational, a sort of ‘dance with a patient’ rather than regulational, a qualification or competence to prove, the human relational aspect of nursing can be seen.
This relational aspect of nursing is one aspect of a way of knowing that keeps in the human in non-human health systems. It is what people mean what they say, in a good way, ‘I don’t know what that nurses did, she was just there’. Every nurse skilled in the art of nursing knows the effort and skills needed to be ‘just there’.
This relational aspect is part of artful intelligence™️, a 21st way of knowing that needs to be developed alongside artificial intelligence.
The Art of Nursing CIC competency framework therefore positions artful intelligence™ as a core capability for 21st century nursing: the capacity to integrate aesthetic, relational, ethical, narrative, and reflective ways of knowing into clinical judgement and system practice (Lynch, 2010, 2024).
This matters to nursing and to all involved in the design and delivery of health care and health systems because what can be seen and measured is what is counted and kept. If we as a professional do not consider the art of nursing as valuable it will not be valued and not be kept it.
In the technologised health systems, nursing is being seen as reduced to automated, virtual and or augmented with human’s care. In our neo liberal economies where health is seen both as something to create human capital, and as salutogenesis, (Antonovsky, 1979), (Eriksson and Lindström, 2010) nurses are placed between the utility of the work and the creating utility of humans, and the embodiment of nursing and creating emancipation of humans.
Social justice and feminist thinking in nursing, nursing being a gendered profession, creates another lens in which to view what it is to be a nurse and what nursing is (Aranda, 2019). Such thinking is important when viewing the gender bias towards men in positions of power in nursing, and so the dominant messaging in policy, publications and practice.
The complexity of competencies needed to be a fair, just, human in non-human systems is part of the radical imagination of nursing needed to flourish in complex systems of care and the thinking behind such competencies requires more than a utilitarian lens.
However, some competencies are more visible and valuable than others.
Competencies that can be seen to add health and human value in economic or biological terms are easier to quantify and so easier to see and ‘sell’ than those about human value, well becoming and human flourishing. In nursing the balance can be held by recognizing the multiple ways of knowing in nursing and adding to these to ensure nursing is fit for purpose for 21st century.
This is happening explicitly in the ‘utility’ of nurses and nursing and the use of artificial intelligence in nursing. Competencies linked to digital literacy and the automation and augmentation of nursing care bring aspects of professional skills development and health system design into a non-human or post human world.
However, nursing has a human side too. Alongside artificial intelligence we require another way of knowing. I frame this as artful intelligence™️.
With the two in tandem nursing can create the competencies needed and the infrastructure for safe, humane, and equitable care and building these together will keep the human in non-human systems.
One way of seeing how such competencies can contribute to each other and to health is to move away from thinking on individual competencies and towards thinking about collective competencies (Lingard 2016), (which need human relational elements) and knotted competencies (which need human elements).
This Art of Nursing CIC competency framework provides the information needed to address the current gap, keeping the human in non-human systems, and uses the arts to do so.
By articulating these competencies along a continuum of professional development, observable behaviours, and assessment strategies aligned to educational levels this framework builds on nursing theory and educational practice.
My work draws on nursing theory (Carper, 1978; Pepleu, 1988, Chinn & Kramer, 2018), relational practice literature (McCormack & McCance, 2017), competency development in health and the arts (Lynch 2010), and creative health evidence (National Centre for Creative Health [NCCN], 2023), Lynch (2026), the framework reframes nursing capability as both scientific and artful, cultural practice.
It aligns with Art of Nursing CIC’s pedagogic model, where arts-based methods (visual art, narrative, movement, theatre) function as mechanisms to make visible the often tacit dimensions of care.
It nods to the heritage of nursing as an art.
“Nursing is an art; and if it is to be made an art, it requires as exclusive a devotion, as hard a preparation, as any painter’s or sculptor’s work; for what is the having to do with dead canvas or cold marble, compared with having to do with the living body - the temple of God’s spirit? It is one of the Fine Arts; I had almost said the finest of the Fine Arts.”
Florence Nightingale
And a nod to the future.
“We need to make visible the human elements of nursing, the elements that cannot be automated or augmented by artificial intelligence. Such aspects are the artful intelligence™ of nursing, and as such need to be human, and need to be valued. They can be quantified and a competency framework is one way to start.” Lynch 2026
Art of Nursing Competency Framework
Level 1: Foundational (Pre-registration / Early Training)
Domain: Aesthetic Awareness
Competency: Recognises sensory and emotional dimensions of care
Observable Behaviours: Describes patient experience beyond clinical data; notices environment and affect
Measurable Indicators:Reflective depth in written work; ability to identify emotional cues
Assessment Methods: Reflective journals; facilitated art response (drawing, poetry)
Domain: Relational Presence
Competency: Demonstrates attentive, compassionate engagement
Observable Behaviours: Maintains eye contact, active listening, appropriate silence
Measurable Indicators: Patient-reported experience measures (PREMs); simulated OSCE feedback
Assessment Methods: Observed structured clinical examination (OSCE); peer feedback
Domain: Narrative Competence
Competency: Listens to and interprets patient stories
Observable Behaviours: Reframes clinical histories as narratives that hold meaning for the patient / service user and the nurse.
Measurable Indicators: Accuracy and depth of narrative interpretation, awareness of bias and tone, cadence and culture.
Assessment Methods: Narrative writing assignments; forum theatre,
Domain: Ethical Sensibility
Competency: Recognises moral dimensions of care encounters
Observable Behaviours: Identifies ethical tensions in scenarios and the causes of these.
Measurable Indicators: Ability to articulate values and dilemmas and the biases and structural violence that cause inequity.
Assessment Methods: Case-based discussion; reflective essays, peer group discussions and presentations.
Domain: Creative Expression
Competency: Uses arts-based methods to reflect on nursing practice and own skills and wellbeing.
Observable Behaviours: Engages in the use of the arts of all kinds, for example drawing, writing, or performance to explore nursing care and healthcare, and provide care.
Measurable Indicators: Participation in the work, meeting learning outcomes and personal insight generation.
Assessment Methods: Portfolio of creative outputs.
Knows About the Art of Nursing.
At this first level, competence is beginning and as with Miller’s triangle the first step is knowing that this is something that exists. The art of nursing competencies here are starting with curiosity and so are developmental and exploratory. The arts act as pedagogic scaffolds, enabling students to access forms of knowing not easily reached through didactic teaching alone (Lynch 2010).
Level 2: Proficient (Registered Nurse / Early Career)
This is moving onto being able to apply one’s learning.
Domain: Aesthetic Judgement
Competency: Integrates sensory and contextual cues into clinical reasoning
Observable Behaviours: Adjusts care based on subtle patient cues and creates presence.
Measurable Indicators: Quality of clinical decisions incorporating patient preserences, the context of care and the consent and co operation of the patient / service user.
Assessment Methods: Case reviews; supervisor assessment, patient feedback.
Domain: Relational Coordination
Competency: Builds trust and psychological safety in teams
Observable Behaviours: Facilitates inclusive communication and adapts to accomodate needs and manner of communication.
Measurable Indicators: Team climate measures; reduced conflict incidents and potentially complaints.
Assessment Methods: 360-degree feedback; team observation
Domain: Narrative Integration
Domain: Uses patient stories to inform care planning
Competency: Co-creates care plans reflecting patient identity, preferences and context. Person centred holisitic approach.
Measurable Indicators: Patient satisfaction scores; co creation of, agreement with and adherence to care plans
Assessment Methods: Care plan audits; patient interviews
Domain: Ethical Action
Competency: Acts on ethical insight in complex situations and understands the dilemmas.
Observable Behaviours: Advocates for patient dignity and equity and health as a human right
Measurable Indicators: Documentation of advocacy actions and social justice activity.
Assessment Methods: Reflective case analysis; revalidation conversations.
Domain: Creative Facilitation
Competency: Uses arts-based approaches in care delivery
Observable Behaviours: Introduces social prescribing, creative health and creative activities (e.g., drawing, music) appropriately
Measurable Indicators: Patient engagement metrics; wellbeing indicators and activation scores.
Assessment Methods: Practice-based project evaluation, colleague feedbac
Knows how to practice the art of nursing, and can practice it.
Competence develops as there is a shift from knowing about and reflection to knowing how and the application of knowledge. The nurse demonstrates how artful intelligence™ shapes their real-time decisions, thereby improving patient experience and team functioning as well as their own wellbeing.
Level 3: Advanced (Specialist / Advanced Practice Nurse)
Domain: Aesthetic Leadership
Competency: Models and teaches aesthetic knowing in practice and articulates the art of nursing competencies.
Observable Behaviours: Coaches others in noticing and responding to patient experience and using the arts in nursing.
Measurable Indicators: Staff feedback; observed teaching impact. patient or service user feedback.
Assessment Methods: Teaching observation; mentorship, evaluation, leadership assessments and restorative supervision.
Domain: Relational System thinking and infrastructure building
Competency: Designs environments that support relational care.
Observable Behaviours: Implements practices enhancing psychological safety.
Measurable Indicators: Staff retention; wellbeing metricsm cultures of care.
Assessment Methods: Workforce data analysis; ethnographic observation.
Domain: Uses Narrative as Evidence in Systems Thinking
Competency: Uses narrative data to influence service design
Observable Behaviours: Integrates patient stories into quality improvement and policy development.
Measurable Indicators: Evidence of service change informed by narratives and service users are part of the team.
Assessment Methods: Quality improvement reports; case studies, peer working and partnerships with service users.
Domain: Ethical Stewardship
Competency: Leads ethical decision-making processes
Observable Behaviours: Facilitates ethical deliberation in teams
Measurable Indicators: Reduced moral distress; increased wellbeing and increased activation scores ( in line with social return on investment scores).
Assessment Methods: Revalidation reflections; significant event incident reviews with others, reflective leadership logs
Domain: Creative Innovation
Competency: Develops arts-based interventions for care improvement, professional development and personal wellbeing and florishing.
Observable Behaviours: Designs and evaluates creative health and social prescribing programmes using evidence based tools.
Measurable Indicators: Improvements in outcomes (anxiety reduction, retention in work, social return on investment)
Assessment Methods: Programme evaluation; realist evaluation methods, calculation of social return on investment using Social Value Green Book.
Practices the art of nursing.
At this level, artful intelligence™ becomes part of the way of working. The nurse shapes environments and practices, embedding relational and creative dimensions into care delivery alongside the advancement of artificial intelligence.
Level 4: Expert / Transformational (Consultant / System Leader)
Domain: Aesthetic System Design
Competency: Embeds arts and humanities into health system strategy
Observable Behaviours: Integrates creative health into policy and commissioning within Integrated Care Boards, and Neighbourhood Health modeMeasurable Indicators. Inclusion of arts in system-level plans; funding allocation within neighbourhood health plans with or without nurse involvement.
Assessment Method. Policy analysis; strategic review, curriculum content.
Domain: Relational Policy Leadership
Competency: Advocates for relational care asprofessional capability, service standards and system infrastructure.
Observable Behaviours: Influences workforce and care models.
Measurable Indicators: Workforce satisfaction; reduced burnout, increased pride and joy in nursing work.
Assessment Methods: National surveys for mapping of education, inclusion in standards; policy impact evaluation, art of nursing within 15 year nursing plan (DHSE, 2026).
Domain: Narrative Influence
Competency: Shapes public and professional narratives of nursing
Observable Behaviours: Produces research, resources, publications, exhibitions, or media outputs
Measurable Indicators: Reach and impact metrics from Special Interest Group; webinars, and creative health and nursing summit.
Assessment Methods: Media analysis, mapping iof evidence and activity, publication for research, leadership, education and practice (via SIG)
Domain: Ethical Transformation
Competency: Advances aocial justive in nursing care and equity and gender-transformative practice in nursing
Observable Behaviours: Embeds dignity and inclusion in systems and within own practice.
Measurable Indicators: Equity indicators; reduction in disparities
Assessment Methods: Equity audits; GESI analysis on policy and service design.
Domain: Creative Health Integration
Competency: Leads large scale arts and health partnerships and or arts in nursing and health education.
Observable Behaviours: Establishes sustainable creative health ecosystems, including networks and communities of practice.
Measurable Indicators: Social return on investment (SROI); system engagement and outcomes via cultural web mapping.
Assessment Methods: Economic evaluation; longitudinal studies (via NCCH and SIG), health policy and nursing professional practice changes
Embodies the art of nursing and leads system change for the art of nursing.
This is the transformative aspect that moves nursing competencies from a transactional model to one fit for 21st century human and non-human complex equitable care. This is a shift to capability and expert work. The nurse operates at the level of culture, policy, and public narrative, repositioning nursing as a form of humane capital within complex systems (Lynch, 2026).
Assessment Philosophy and Measurement Strategy
Traditional competency frameworks privilege what is easily counted, the nursing tasks, procedures, outputs that are evidence in the NHS Fit for Future document (DHSC 2025), and NMC frameworks. This framework deliberately extends measurement into the qualitative and relational, combining and includes work on creative health, social prescribing and the moral imagination in nursing:
· Quantitative indicators: PREMs, staff surveys, retention rates, SROI
· Qualitative methods: narrative analysis, ethnography, reflective accounts
· Arts-based evaluation: visual elicitation, performance feedback, co-produced artefacts
Such plural methods align with realist and complexity-informed evaluation, recognising that outcomes emerge through context-mechanism interactions (Pawson & Tilley, 1997), and with the research into art in health, arts pedagogy and nursing (Lynch 2010, 2026).
Curriculum Integration
To operationalise this framework, curricula could include:
1. Structured arts-based modules (e.g., drawing for observation (slow looking), narrative medicine, theatre for empathy), such as those in Exeter and Plymouth, Wolverhampton. John Moores, and UCL.
2. Longitudinal reflective portfolios evidencing development of artful intelligence™ aligned to standards being reviewed by NMC
3. Practice-based learning integrating creative methods into clinical placements such as those in Chester.
4. Assessment redesign, valuing narrative, relational, and aesthetic competencies alongside technical skill
This approach aligns with calls to “re-humanise healthcare” through integration of arts and humanities (NCCN, 2023). This works adds to the nursing human capital value model (Yakusheva, 2024), building on this utilitarian and economic lens, and add the emancipation aspect of nursing work, creating the human nurse capital aspect to the way we view nursing being human.
Conclusion
The Art of Nursing CIC competency framework reframes what counts as nursing expertise. It asserts that the capacity to be human, to see, feel, interpret, and respond is to practise with aesthetic, relational, and ethical intelligence is part of 21st century nursing. It is the dialogical alongside the digital competency needed to ‘be there’ and ‘be’ a nurse . By making these competencies explicit, teachable, and assessable, the framework offers a route to embed humanity and bring human within increasingly non-human systems. In doing so, it shifts nursing education from the transactional, the transmission of skills to the cultivation of artful practitioners capable of sustaining care that is not only effective, but meaningful in systems that are complex, non-human and not fair.
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