Art of Nursing Competency Framework (Lynch 2026).
Art of Nursing Competency Framework: Integrating the Arts into Nursing Education and Practice
‘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 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 humans 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 poliy, 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 utalitiarn 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.
The 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 the Future too.
“ How are we to keep the human in non human systems if we do not value it and make it visible? The arts can help, they always have”. Lynch 2026
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 of meaning
Measurable Indicators: Accuracy and depth of narrative interpretation
Assessment Methods: Narrative writing assignments; storytelling workshops, patient / service user feedback in revalidation
Domain: Ethical Sensibility
Competency: Recognises moral dimensions of care encounters
Observable Behaviours: Identifies ethical tensions in scenarios
Measurable Indicators: Ability to articulate values and dilemmas
Assessment Methods: Case-based discussion; reflective essays, forum theatre
Domain: Creative Expression
Competency: Uses arts-based methods to provide nursing care, manage own health and reflect on practice
Observable Behaviours: Engages in creative health work, social prescribing, and arts related activities such as drawing, writing, or performance to explore care
Measurable Indicators: Participation in placement activity, teaching activity and personal insight generation
Assessment Methods: Portfolio of learning, placement hosts and service user feedback, creative outputs
Interpretation: At this first level, professional competence is beginning and so is expected to be developmental (knows about) and exploratory (curious about the issues, and few concrete responses).
The arts in the art of nursing are part of the way we learn to be human, and so act here in nursing as pedagogic scaffolds, enabling the students to access forms of knowing not easily reached through didactic teaching alone (Lynch 2010). For nursing theory and teaching guidance refer to Carpers ways of knowing in nursing (1978) and Miller’s pyramid.
Level 2: Proficient (Registered Nurse / Early Career)
Domain: Aesthetic Judgement
Competency: Integrates sensory and contextual cues into clinical reasoning
Observable behaviours: Adjusts care based on subtle patient cues
Measurbale Indicators: Quality of clinical decisions incorporating patient context
Assessment Methods: Case reviews; supervisor assessment, content of revalidation portfolio.
Domain: Relational Coordination
Competency: Builds trust and psychological safety in teams
Observable Behaviours: Facilitates inclusive communication and adapts own communication style and content to context
Measurable Indicators: Team climate measures; reduced conflict incidents, perhaps reduced complaints or a safe complaints system in place.
Assessment Methods: Positive feedback from colleagues in 360 feedback and team’s observation in revalidation and appraisal processes.
Domain: Narrative competence intrgration (building to narrative capability)
Competency: Uses patient stories to inform care planning
Observable Behaviours: Co-creates care plans reflecting patient identity, preferences and context of thier life (holisitc care)
Measurable Indicators: Patient satisfaction scores; agreement and adherence to care plan content.
Assessment Methods: Person centredness seens and noted through reflection and through care plan audits).
Domain: Ethical Action
Competency: Acts on ethical insight in complex situations and manages ethical dilemmas personally and professionally.
Observable Behaviours: Advocates for patient dignity and equity of access to care, processes during care and outcomes of care.
Measurable Indicators: Documentation of advocacy actions, reflections and decision making processes in line with NMC code.
Assessment Methods: Reflective case analysis as part of appraisal.
Creative Health Facilitation
Competency: Uses arts-based approaches in care delivery and or self care.
Observable Behaviours: Introduces creative activities for own learning and health and in nursing work appropriately
Measurable Indicators: Patient engagement metrics; wellbeing indicators
Assessment Methods: Practice-based project evaluation, self care activities and wellbeing scores
Interpretation: This is the professional progression towards capability. Art of Nursing competence of artful intelligence™ shifts from reflection on this as a concept to application of this as nursing knowledge. The nurse demonstrates how artful intelligence™ shapes their real-time decisions, improving patient care and experience, team functioning as well as her own wellbeing.
Level 3: Advanced
(Specialist / Advanced Practice Nurse)
Domain: Aesthetic Leadership
Competency: Models and teaches aesthetic knowing in practice
Observable Behaviours: Coaches others in noticing and responding to patient experience and possibly using the arts to help.
Measurable Indicators: Staff feedback; observed teaching impact and use of the arts in health
Assessment Methods. Teaching observation; mentorship evaluation, arts in health course content and placement opportunities for creative health, availability of restorative supervision.
Domain: Creating Relational Infrastructure
Competency: Designs environments that support relational care
Observable Behaviour:Implements practices enhancing psychological safety
Measurable Indicators: Nursing staff retention; wellbeing metrics, engagement in supervision.
Assessment Methods: Workforce data analysis; ethnographic observation
Domain: Narrative Systems Thinking
Competency: Uses narrative data to influence service design
Observable Behaviour: Integrates patient stories into quality improvement
Measurable Indicators: Evidence of service change informed by narrative, service user involvement.
Assessment Methods: Quality improvement reports; case studies, service user and patent leadership and parternship.
Competency: Ethical Stewardship
Competency: Leads ethical decision-making processes with evidence based rational.
Observable Behaviour: Facilitates ethical deliberation in teams in non judgemental way and is able to articulate own baises.
Measurable Indicators: Reduced moral distress; increased wellbeing and increased activation scores (linked to social return on investment scores.
Assessment Methods: Reflective leadership logs, application of gender, equity and social inclusion assessments (GESI) in design and delivery of healthcare and health care education.
Domain: Creative Innovation
Competency: Develops arts-based interventions for health promotion and healthcare improvement
Observable Behaviour: Designs and evaluates creative health services and creative health learning programmes
Measurable Indicators: Measurable improvements in personal outcomes (anxiety reduction), system outcomes (retention on work), and societal outcomes (ability and opportunity to work and contribute to society)
Assessment Methods: Education programme evaluation; use of realist evaluation methods, use of arts informed evaluation methods, system level measures of social return on investment.
Interpretation: At this competence to capability level, art of nursing and within it the idea of artful intelligence™ becomes part of the wider system for education and for health service delivery and design. The nurse shapes environments and practices, embedding relational and creative dimensions into care delivery, matching dialogical literacy alongside digital literacy and the advancement of artificial intelligence.
Level 4:
Expert / Transformational (Consultant / System Leader)
Domain: Aesthetic System Design
Competency: Embeds arts and humanities into nursing education, research, practice and leadership to inform and so improve health system policy, strategy and plans
Observable Behaviours: Integrates creative health into policy and commissioning of nursing services, nursing education, and own practice
Measurable Indicators: Inclusion of creative health and social prescribing activity (with nurse involvement) in system-level plans; funding allocation for Integrated Care Boards and Neighbourhood Health plans.
Assessment Methods: Health policy analysis; strategic review of evidence and activity within nursing, curriculum content, and toolkits, inclusion of art of nursing elements, and use of ther arts in nursing care and self care in nursing revalidation.
Domain: Relational Policy Leadership
Competency: Advocates for relational care as part of infrastructure of nursing, including as part of professional identity, professional culture and a new narratvie of nursing.
Observable Behaviours: Influences workforce policy, research, planning and nursing care models
Measurable Indicators: Workforce satisfaction; reduced burnout, intention to stay in post, equity of opportunity and pride in work. as a nurse.
Assessment Methods: National surveys into art and science of nursing in 21st century; NHS Fit for Future impact evaluation, and any inclusion of these aspects of art of nursing and the arts within 15 year nursing plan (NHS)
Domain: Narrative Influence
Competency: Shapes public and professional narratives of nursing, potentially by using the arts.
Observable Behaviours: Produces evidence, publications, exhibitions, webinars and media outputs
Measurable Indicators: Support from nursing organisations and arts in health organisations to help with reach and recogntion. Social value impact metrics; proferssional engagement and discourse change. Number of artifacts created to show art of nursing.
Assessment Methods. Numbers registered with the Special Interest Group for Nurses and Creative Health. Engagement with Creative health and Nurses Summit. Evaluation of the impact of the exhibition Nurses: Being Seen. Being Heard. Being. Media analysis, invitations to speak with otehr nursing groups, and publication for research, leadership, education and practice (via SIG).
Domain: Ethical Transformation
Competency: Advances equity and gender-transformative practice (social justice in nursing and removal of structural violence.
Observable Behaviours: Embeds dignity and inclusion in systems using impact assessments and the arts to establish evidence and identify experiences.
Measurable Indicators: Equity indicators; reduction in disparities (CORE 250, nursing school progress and equity in career opportunies.
Assessment Methods: Equity audits; GESI analysis, Political conversations that address the needed shift in leadership within nursing to be represenatative of the demogrpahics of the profession.
Domain: Creative Health Integration
Competency: Leads large scale arts and health and nursing partnerships
Observable Behaviours: Establishes sustainable creative health ecosystems within Universities, nursing organisations, neighbourhoods, and nursing networks.
Measurable Indicators: Availability of creative health placements, creative health modules, creative health post graduate programmes for nurses, and nurses leading social enterprises offering creative health activities. Social return on investment (SROI); system outcomes
Assessment Measures: Mapping of activity (via SIG), review of activity and evidence (mapping), realist evaluation on how art of nursing networks and resources are improving nursing and nursing care, economic evaluation; longitudinal studies (Cia NCCH and SIG)
Impact.
This is the cultural and system level change that will enable this art of nursing work to have a transformative aspect. The challenge to nursing is to make visible the elements that are not transactional, make visible the aspects that cannot be automated or augmented by artificial intelligence. Such aspects therefore need to be seen as a competence, or capability, or more than that a collective relational aspect of ‘being’ a nurse.
This moves nursing competencies from a transactional model to one fit for 21st century human and non human complex, equitable care. 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). This new form of ‘human nurse capital’ contributes to the economic aspect of nursing human capital model (Yakusheva, 2024), by ensuring that the utility of nursing human capital (what we add to the economy), is matched with the emancipation of what we do.
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 the work on creative health, social prescribing and social return on investment, alongside the moral imagination of nursing and the development of all ways of knowing in nursing. Such work requires modes of data gathering that go beyond the metrics mentioned in NHS reports at the moment. This art of nursing work therefore includes:
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 arts pedagogy and nursing (Lynch 2010, 2026).
Curriculum Integration
To operationalise this framework, curricula should include:
Structured arts-based modules (e.g., drawing for observation (slow looking), narrative medicine, theatre for empathy and social justice and presence building skills)
Longitudinal reflective portfolios evidencing development of artful intelligence™
Practice-based learning integrating creative methods into clinical placements
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).
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 respon 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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