Making Visible What Matters: Professional Culture, Nursing Narrative, and Global Health

Nursing is indispensable to global health systems. It constitutes the largest health workforce globally and is central to universal health coverage and health promotion (ICN, 2025). Yet the way nursing is described in policy is often narrow missing what some call the art of nursing. Nursing appears as workforce capacity, service delivery, productivity, and resilience. These are important descriptors. They are not sufficient ones, they are not what brings people to nursing, makes people stay in nursing, and are not the aspect that people remember when they remember a nurse.

There is a therefore a gap between how nursing is measured and how it is lived. The measurable aspects, staffing ratios, cost-effectiveness, mortality reduction, productivity through digital care, virtual wards are visible in strategy documents and current Trust and Neighbourhood Health cases. The less visible aspects, dignity building, relational labour, moral judgement, organisational memory, creativity and managing complexity, rarely shape system design. Their absence is most apparent when they are missing: when care becomes efficient but impersonal; think of all the inquiries into failed care, throughput increases but trust diminishes, think of all the referrals to the NMC, when we stop seeing people and only see patients, see the rise is corridor care.

Abimbola (2026), in the article evidence of things not seen, opens with Hebrews 11:1: “Now faith is the substance of things hoped for, the evidence of things not seen” .

Whilst a religious phrase it is an example of a universal human dilemma and so a current methodological problem in how nursing is seen, heard and harmed. Not everything that matters is immediately visible. Structural inequities, epistemic injustice, and professional dignity are real forces in global health systems, and in nursing, yet they do not readily appear in dashboards or in debates about what the future of health, and of nursing will be.

The challenge for 21st century nursing is therefore cultural as much as it is technical. What counts? Who counts? What forms of knowledge are recognised as legitimate?

This paper argues that developing a professional culture for nursing that will contribute to global health and 21st century nursing practice requires balancing nursing’s utilitarian and emancipatory dimensions, grounding that balance in all of Carper’s (1978) ways of knowing, and making visible the relational and structural dimensions of nursing practice and global health through the arts.

Holding the tension between utility of nursing and emancipation of nursing.

Haddara and Lingard (2013) describe utilitarian and emancipatory discourses within interprofessional collaboration. The utilitarian discourse privileges measurable outcomes, efficiency, and demonstrable impact. The emancipatory discourse focuses on power, hierarchy, and structural inequity.

Nursing operates within both, yet one is seen more than the other. The utilitarian dimension is clear in policy documents and for those looking at nursing through a ‘jobs done’ lens. Investment in nursing numbers improves patient outcomes, reduces complications, and strengthens system efficiency. In resource-constrained contexts, nursing capacity is central to universal health coverage. On a global level we will are, and will be too short of nurse to provide the health systems needed to improve health. In this sense, nursing contributes to human capital formation and economic stability and the problem of too few nurses to do what needs to be done suggests a new approach is needed. To ignore this utilitarian view of nurses would be irresponsible, to think this is all nursing is, is not just true.

Nursing is also emancipatory. It is historically embedded in struggles against gendered subordination and professional marginalisation. It witnesses, daily, how poverty, precarious housing, debt, racism, and environmental degradation shape illness trajectories, and creates ways for people to continue to live in health and with hope.

Abimbola (2026) reminds us that public health repeatedly declares the structural determination of health, yet often defaults to downstream action. It is a concern if NHS nursing strategy is only focused on such downstream action and not on the real reasons why health is unjust and nursing is undervalued and unfair. Nursing cannot be reduced to efficiency interventions within inequitable systems.

The problem is when nurse utility is the sole narrative, when nursing is described exclusively in terms of outputs, its ethical and political dimensions so unseen, unless you are in need of a nurse, or are a nurse. A professional culture that seeks to evolve and have legitimacy in the 21st century needs to hold effectiveness and equity, utility and emancipation together.

Carper’s epistemic spine.

Carper’s (1978) four patterns of knowing, empirical, ethical, personal, and aesthetic, have informed nursing for 50 years yet seem forgotten in policy development. Her work provides a coherent framework for the integration needed to form a nursing profession fit for the future.

Empirical knowing values research evidence and measurable outcomes.
Ethical knowing addresses questions of social justice and professional responsibility.
Personal knowing situates care within a trusted person centred relationship and professional reflexivity.
Aesthetic enables nurses to make sense of what cannot be seen, create safe trusted spaces and use the human aspects of nursing care to create meaning, see patterns, and practice the embodiment of care.

Global health discourse, and current UK nursing policy papers frequently privilege empirical knowing. Funding streams require measurable return. Health systems reward what can be counted. Beyond the tangible impact on waiting lists and mortality there is another measure system evolving. Even the social return of investment measures in healthcare are calculating how interventions in health will improve people’s fitness to work. This is understandable in contexts of limited resources and with a bio medical model influencing what matters.

However, Abimbola (2026) argues that knowledge must also be contextual and transformational. From his perspective this is within global health, but the same thinking informs how one may think of nursing. Local sensemaking and lived experience are not secondary forms of knowledge, they are not less.

Carper anticipated this epistemic breadth on her work, but in 20206 policy it seem empirical knowing is the only one that counts. Ethical, personal, and aesthetic knowing are foundational to safe and humane practice. They are what make nurses human.

When only empirical knowing is seen and heard and so valued, relational labour becomes invisible. And so unvalued. And so unnecessary. When ethical knowing is sidelined, moral dilemma appear and moral injury occurs. When aesthetic knowing is dismissed, meaning making of what health means to one’s life, the human element, becomes unnecessary for health. We become merely meat.

Developing global health and a professional culture for nursing and requires explicit recognition of all four patterns in education, evaluation, and leadership, and of the structural violence, the systems we as people have designed, and accepted to get exactly the inequality in health and in nursing we currently have.

The upstream question and some poetry.

The global distribution of health resources remains profoundly unequal and these disparities are linked to economic and political arrangements that extend beyond clinical care, (Abimbola, 2026). Nursing is part of this inequity as a gendered and unequally distributed and unvalued workforce. The issues faced by people with less means, and the nurses who are part of their lives are not new. The arts can help show them.

Brecht’s poem A Worker’s Speech to a Doctor crystallises the upstream question and this is the world nurses’ live alongside too. One part of the poem sums up poverty and stucural violence within health.

The pain in our shoulder comes

You say, from the damp; and this is also the reason

For the stain on the wall of our flat.

So, tell us;

Where does the damp come from?

Bertolt Brecht

The bio medical clinician identifies symptom and the cause. The worker asks about the conditions that produce the damp. Housing, wages, labour markets, political economy.

This poem exposes the limits of interventions that address symptoms without addressing context. If we only address nursing’s pain we will not address the issues causing the pain.

Brecht’s poem demonstrates how the arts can illuminate health determinants that lie beyond immediate clinical focus, and when applied to nursing, why nursing numbers are not enough to understand the issues.

Getting back to health. Nurses encounter the ‘damp’ daily, it is more than damp. The campy for people cared for is insecure employment, overcrowded housing, environmental stress, cumulative disadvantage.

The damp in nursing is, lack of regard, lack of professional value, lack of autonomy, increased moral injury, gender inequality, racism, and then recruitment challenges and retention challenges.

Professional culture must legitimise the capacity to ask upstream questions as to why there are issues alongside designing services and education to deliver competent care. Without this duel orientation, nursing risks being seen as a task based profession and confined to symptom management within inequitable

Relational Labour, health, interdependence and One Health.

The upstream question leads directly to relational health. Health is not solely an individual attribute; it is produced within networks of relationship, between people, professions, communities, and ecosystems.

Carper’s personal and aesthetic knowing enables one to see this relational dimension. Ethical knowing extends responsibility beyond the individual to the social conditions that generate illness. Empirical knowing can measures outcomes within this relational field, the social return on investment, but this is not built into nursing knowledge as yet.

‘One Health’ approaches reinforce this wider than ‘my health’ perspective. Human health is connected to environmental sustainability and animal health. Climate instability, antimicrobial resistance, and zoonotic disease reveal the limits of purely clinical responses and nursing is noticing it is nursing the planet too.

The question “Where does the damp come from?” becomes ecological as well as social. It requires collaboration across disciplines and sectors, the public health aspect of nursing that cannot be seen if nurses are task based and medically managed. Nursing’s professional culture must therefore be seen beyond task delivery and as relational stewardship within people, communities and the planet too.

Evidence of Things not seen. Nursing and the Exhibition.

Returning to Hebrews 11:1, cited by Abimbola (2026): “Now faith is the substance of things hoped for, the evidence of things not seen”. Professional culture is built as much through what is unseen and unvalued as through what is seen and valued measured.

The arts are part of evidence making and sense making in society; the arts are what make us human. The arts make the relational and human dimensions of health visible in ways that conventional metrics cannot.

And so there is an exhibition to show the emancipatory aspect of nursing.

The three-day exhibition at the Clore Learning Centre, Kensington Palace, is designed as a nursing narrative to suooort professional culture and a new narrative on nursing.

HIVStory demonstrates relational care and professional autonomy through testimony of nurses
SHIFT the play stages the sharing of power between nurses and patients as a dance, a lived encounter.
Embers of Care portrays migration and professional identity through portraits.
Capes of Home, Health and Hope carries intergenerational narrative and seven-generation thinking in one artifact.
Mrs Drake’s Lace makes personhood visible beyond cognitive decline with dementia.
Can You See Me Now? a menopause sculpture and The Pause, a story that translates evaluation findings on menopause into a story.
Queens and Vaccines connects historical public health leadership of women of colour or from royal households to current trust of vaccines.
Heads of Nursing presents collective identity from student nurses.
Art of Care explores different kinds of love and ways of knowing using artifacts from caring during the middle 1900’s.
The Face of Nursing, an 8ft by 4ft montage of hand-drawn portraits, situates each person attending within a collective professional narrative.

Each work makes visible a dimension of nurses and nursing care that policy texts rarely do. Together, they show how relational care, dignity, and belonging are core components of health systems and professional culture. They tell a new nursing narrative through the arts

Conclusion

Developing a professional culture for nursing requires three shifts: balancing utility and emancipation thinking, using all of Carper’s ways of knowing and using the arts to help address inequity and improve health as well as advance nursing for 21st century care.

It must count what can be counted and insist that what cannot easily be measured still matters.

Professional culture is shaped by what is rewarded, published, funded, and exhibited. It is also shaped by evidence unseen. If relational and ethical dimensions are excluded from the design these disappear.

Brecht’s work asked where the damp comes from. Nursing, as profession and as cultural force, must continue to ask this and sort it out, and the damp is more than damp. It cannot be painted over and be fine. Nurses help with health and relationships and trust and avoid the ‘damp’ happening, nurses build health systems that have humans at the core, nurses skills in doing this can be shown through the arts, they cannot be seen on a rag rating score.

References

Abimbola, S. (2026). The evidence of things not seen. Health Promotion International, 41(1), daag016.

Carper, B. (1978). Fundamental patterns of knowing in nursing. Advances in Nursing Science, 1(1), 13–23.

Haddara, W., & Lingard, L. (2013). Are we all on the same page? A discourse analysis of interprofessional collaboration. Academic Medicine, 88(10), 1509–1515.

King James Bible. (2017). Cambridge University Press. (Original work published 1769)

ICN (2025) New Definition of Nursing.

MacGregor W, Horn M, Raphael D. Beyond Empathy to System Change: Four Poems on Health by Bertolt Brecht. J Med Humanit. 2024 Mar;45(1):53-77. doi: 10.1007/s10912-023-09801-5. Epub 2023 Jun 21. PMID: 37341851.

Will Artificial Intelligence be the Anaesthetic of Nursing? Reflections using Menopause as a Case of Nursing Care.

Summary

A woman sits in a clinic room, or perhaps at her desk, wondering aloud: “I think I am starting menopause and I am lost what to do.” In that moment, the response matters. It can soothe or confuse, empower or diminish. This paper explores how artificial intelligence (AI), now entering health conversations, might respond. Using Carper’s four ways of knowing as a lens, I asked ChatGPT to generate four replies to that single statement. Each reply reflects a different way of knowing: empirical, ethical, personal, and aesthetic. The shift exercise reveals both the promise and the problems of AI in capturing the art and science of nursing. AI offers facts at speed, frames options, mimics empathy, and gestures toward metaphor. Yet what is missing, presence, accountability, attunement, may become just as visible to the human involved. Drawing on Patrica Benner’s (1984) theories and practice of being in nursing, I reflect on whether AI will automate or augment nursing practice, or will it take sympathetic presence and human connection out completely? Will AI be the anaesthetic of nursing?

This essay is an off shot of thinking from my work evaluating innovatove approaches to menopause services and care. I ponder how artificial intelligence (AI) can both support and disrupt communication in menopause care through the lenses of nursing theory and a bit of personal experience. I wanted to see what AI would do if I programmed it to respond with some of my findings as to what women value in their (our) menopause care.

Using Carper’s four ways of knowing (Carper, 1978) as a framework, I asked ChatGPT to generate responses to the statement “I think I am starting menopause and I am lost what to do.” My analysis highlights the pros and cons of four types of AI generated responses, I ponder the accuracy of content, the type of communication, and the relational qualities of care. I reflect on this reflected in relation to Benner’s (1984) definition of Being a Nurse, which situates nursing as more than technical skill, emphasising presence, ethical practice, and relational artistry. I discuss the potential of AI to automate or augment nursing, noting where it may add value and extend access to information and where it cannot provide relational, ethical, and aesthetic knowing. I conclude by asking: if you were in this situation and asking this question to an AI bot, which response would you prefer?

Introduction

I am writing this paper because I am evaluating innovation in menopause care. For many experiencing menopause, this life stage can feel disorienting: full of bodily changes, emotional turbulence, and uncertainty about what is “normal” and what warrants medical attention. At the same time, menopause is gaining attention in public discourse, with calls for better recognition and more compassionate care.

I am noticing the emergence of AI as a tool in health care (NHS 2025), and see this is menopasue care too (Ang and Hillard (2025). Increasingly, people are turning to chatbots, search engines, and digital assistants for advice about symptoms, treatments, and self care. Health professionals too are being encouraged to use AI to summarise guidelines, generate patient education material, or even simulate clinical conversations.

I am curious about the similarities and differences between human and non-human responses to personal and cultural and social health issues like menopause. Issues arise both in the content of the information (Is it accurate? Up to date? Biased?) and in the type of communication (Is it empathetic? Relational? Respectful of an individual’s autonomy, values and cultural norms?).

Nursing communication is complex: it is more than what is said. It involves tone, presence, silence, gesture, intuition, and the weaving together of knowledge, ethics, relationship, and artistry (Carper, 1978). Nursing care in complex too, and the challenges in showing the complexity, ensuring equity, power and gender balance in nursing leadership, and creating a system in which nursing is heard (Stillwell and Newman 2022) are influenced by how nurses are seen, now nursing is understood and who decides what nursing is, what it is not, and what is needed in 21st century care.

Method

My method was straightforward: I asked ChatGPT to respond to the same patient statement. “I think I am starting menopause and I am lost what to do”. Using Carper’s four ways of knowing as a prompt to respond to this sentence. This programming of artificial intelligence produced four distinct AI generated responses, each reflecting a different way of knowing. I considered these responses to see how they reflect the art and science of nursing, and our professional styles of communication and I wonder which one I would prefer. I set you the same question: If you were in this situation (this already takes some interpretation), which response would you prefer?

Here they are. Four AI Responses

AI Empirical Response

“Based on your age and the symptoms you’ve mentioned, it is likely you are in the perimenopausal phase. Studies show that menopause typically begins between ages 45–55, with symptoms including hot flashes, mood changes, sleep disruption, and irregular cycles.

There are several evidence based treatment options available, such as hormone therapy, non hormonal medication, and lifestyle adjustments. I can provide a summary of current clinical guidelines tailored to your profile. (I had not told it my profile.)

AI Ethical Response

It’s important that you are aware of your choices and that your autonomy is respected. Some people prefer not to use medications and instead explore natural or lifestyle,based approaches. Others may find hormone replacement therapy to be the right choice for them.

Each option has risks and benefits, and no one approach is universally right. I am here to outline options without bias so you can make the decision that best aligns with your values.

AI Personal Response

It sounds like you’re feeling lost and perhaps overwhelmed by these changes. Many people share this uncertainty when they enter menopause. Would you like to tell me more about which symptoms affect your daily life the most; sleep, mood, energy, or physical changes? That way, I can focus on the areas that matter most to you and provide resources tailored to those concerns.

AI Aesthetic Response

Every person’s journey through menopause is unique. Some describe it as crossing a threshold into a new stage of life, one that brings challenges but also renewal. If you’d like, I can share stories, journaling prompts, or mindfulness resources that help reframe this transition as an opportunity for self,discovery and growth. You can choose the narrative that feels most authentic for you.

My Thinking

Each AI response reveals both pros and cons. The empirical response is efficient and informative, yet lacks the warmth of relational framing. It also went for a personal profile that was not given, an is wrong. The ethical response demonstrates respect for autonomy, but does so with generic phrasing, lacking the accountability of a practitioner. The personal response uses empathetic language but cannot convey true presence. The aesthetic response attempts metaphor and meaning, but risks cliché. I think being on a journey is a nice way to say it but is not really what it feels like.

Together, these highlight Benner’s (1984) point that nursing is not only about technical competence but also about being present, responsive, and attuned to unique individuals.

Discussion

The broader question for me is whether AI will be used to automate nursing, replacing human presence with digital scripts, or to augment nursing, extending access to information and freeing time for deeper human engagement. Automation risks reducing nursing to a set of protocols, stripping away ethical discernment and aesthetic artistry. Augmentation, by contrast, offers promise: AI can improve access for all who can use it to reliable information, standardise prompts, and enable people to be prepared with some of the knowledge needed for richer conversations (be that right or erong for their situation). The limits therefore become clear when testing this approach out for menopause nursing care.

AI cannot empathise, help shoulder moral responsibility of somoeone’s life, cannot dwell in silence, and cannot interpret the meanings of life transitions, that journey, in the deeply situated way a nurse can.

Aesthetic knowing, also called the art of nursing, focuses on holistic, subjective, and creative aspects of care, emphasising empathy, intuition, and the ability to meet unique patient (person) needs. Here the danger from AI is perhaps most worrying for me. Will AI become the anaesthetic of nursing, (removing that aesthetic care, dulling human relational connection, removing human creativity, flattening the subtle art and nuances of nursing, what some call ‘just being there’ into predictable phrases? Or is there hope. I am always the optimist and taking an asset based approach here. Can AI be designed to enhance artistry, amplifying rather than erasing the human aspects of care? Or should it?

Conclusion

When a person voices uncertainty about menopause, the exchange that follows is never just about symptoms. It is about our identity, dignity, trust, and meaning, the meaning of this in the context of a full life, and in the context of the culture women live in where this is not seen as a journey, it is an end! This ‘end’ world (maybe not the whole world) view is being turned around in many ways. The evaluation of menopause circles (Lynch 2023), the work of Eleanor Mills on Queenagers (noon.org.uk) and the work with women in the arts (Morden 2024) all bring new ways of knowing to what it is to be in the menopause and what support is sought. Carper’s framework makes visible the richness of nursing communication, allowing all ways of knowing to be noticed. Patrica Benner (1984) reminds us that nursing is about being present, not just doing tasks. This is what has kept me in nursing, and kept me studying nurses. I believe that AI may support, but it cannot replace, the art and science of nursing. Its use must be carefully considered: will it automate or augment? Will it anesthetise or enhance nursing care?

I go beyond the clinical gaze (as Foucault (1973) would say), beyond the clinic where we started this discussion ro the wider issues of women’s health, power and the future. I have so many questions that are also being asked across nursing, beyond those of women’s health issues and into issues of social justice and gender equity. This is a wider consideration that frames where menopause sits in our life, in health systems and in society. Does menopause matter? Does it matter that the leaders within nursing are disproportionally male considering the demographics of the profession? Does this change the ways of knowing used in considering the future of nursing, or are the ways of knowing not linked to gender roles or socialisation into behaviours? Does it matter that those writing about AI and the menopause referenced here are male? If it does not matter then have we done all that is needed considere to consider the equity impact? If it does then what are the issues and actions for all involved? Does AI in and for nursing need to be more nuanced if it is to provide both the art and science in nursing, or is the current pathway okay?

More questions than answers here. I engage with the arts to help ask more questions, answer some of these questions, and expand aesthetic ways of knowing in nursing just a little more.

Come and join the webinar on Thursday 13th November, hear from Rebecca Morden from Scary Little Girls about their show Queenagers, from myself about Paula Rego, and others too. No slides, no hormone conversations, a fireside chat to expand your ways of knowing.

See resources page here for the links to webinars past and future.

References

Ang, S. B., & Hillard, T. (2025). Preparing for the future: artificial intelligence in menopausal health care. Climacteric, 28(2), 95–97. https://doi.org/10.1080/13697137.2025.2469476
Carper, B. (1978). Fundamental patterns of knowing in nursing. Advances in Nursing Science, 1(1), 13–23.

Benner, P. (1984). From novice to expert: Excellence and power in clinical nursing practice. Addison,Wesley.

Foucault, M. (1973) The Birth of the Clinic: Archaeology of Medical Perception. London. Routledge.

Lynch, M. (2022) Menopause Circles with NHS Nurses. Evaluation Report. ELC Design.

Morden, R. (-) Scary Little Girls Theatre Company. http://scarylittlegirls.co.uk/

NHS (2025) Fit for the Future. NHS. https://www.england.nhs.uk/long-term-plan/

Noon (-) Queenager Directory. http://noon.org.uk/

Ravi, P. (-) Group Clinic Case Study. Orpington PCN. ELC Programme Person Centred Care. https://www.elcworks.co.uk/wp-content/uploads/2025/02/Orpington-Menopause-CS-V2-040225-1.pdf

Stillwell, B and Newman, C. (2022) Nursing Learning to be Powerful Leaders: What will it take? Creative Nursing. 28 (1) pp23-28

Please reference Lynch, M. (2025) Will Artificial Intelligence be the Anaesthetic of Nursing? Reflections using Menopause as a Case of Nursing Care. Essay. ArtofNursing.co.uk if you use any of my words here. I wish to shine a light of the issues, and expand thinking, so lets do this as humans.

Nurses as a 21st-Century Profession:

How to be Human

Dr Marion Lynch

Introduction

A nurse sits at the bedside of a patient living last days with myeloma. On one side of her chair, the monitor scrolls an endless stream of numbers, oxygen saturation, heart rate. Algorithms decide what to show and what the numbers say. On the other side, she notices the patient’s hand tremble slightly when he reaches for his water. She leans forward, catching his eyes, steadying the glass, and in that gesture communicates presence, reassurance, and artful nursing care.

This scene captures the paradox of nursing in the 21st century, and my memories of being a newly qualified general nurse on a haematology ward in Oxford the 1980s. Back then, the machines were background noise, sometimes soothing, sometimes shouting for attention, but the focus was on the person in front of me. Today in 2025 it is maybe different, maybe the same. This balance of human and non human interaction is however more than I initially trained for. This need led to my thinkinig on how to human in a non human system (Lynch 2025), and this Art of Nursing movement.

Nurses now work in health systems saturated with technology, globalised by policy, and shaped by relentless pressures toward efficiency. Yet the heart of our work remains profoundly human: being present, noticing absences, and responding with empathy. I am wondering what does it mean to be a nurse when there is demand for both patient data and patient dignity?

Charles Kenny (2021) reminds us that things are getting better, the arc of global progress is real: life expectancy has risen, child mortality has plummeted, literacy has expanded. The progress towards the Sustainable Development Goals, although not fast enough, is forward. None of this progress could have occurred without us nurses, who have historically been both implementers of public health advances and the people we see and speak up the uneven distribution of health, wealth and privilege. At the same time as this unequal rise in health and opportunity across the world, the fourth industrial revolution is bringing the world artificial intelligence. For nursing this has resulted in contemporary developments in artificial intelligence and digital health technologies that in turn demand new configurations of nursing practice (Ronquillo et al., 2021).

I suggest that nurses must claim their place as leaders in shaping the future of health care by harmonising what I have have named as artful intelligence™️. This includes the irreplaceable human capacities of empathy, presence, judgment, creativity, and hope (Loaiza & Rigobon, 2020), and the art of nursing so needed in times of crisis but so invisible in policy documents, and misunderstood in politician speeches about vocation, care and and other gendered tropes linked to less pay, less voice, and less power. The artful intelligence approach in nursing may be the balancing weight accompanying the computational power of artificial intelligence. If we hold both in equal measure, maybe nurses can ensure that technological progress amplifies rather than erases the relational and ethical dimensions of care.

My thinking unfolds in six parts: (1) nursing within the frame of global progress, (2) the dual identity of nursing as both science and art, (3) the interplay of artificial and artful intelligence™️, (4) ethics and equity in digital health, (5) professional identity and agency, and (6) future directions for a harmonised profession.

Nursing in a Century of Global Progress

When Charles Kenny (2021) opens Your World, Better with the tragic life and early deaths of Louis XIV’s children, and the paintings that show this family as a unit of care, he makes a startling point: even the wealthiest families of the 17th century endured losses that modern medicine has largely prevented. In other more positive royal accounts (to be continued in the Highness of Health Series I am writing), there are stories of Queens taking it upon themselves to innoculate their children against Smallpox in a time where mistrust of such actions prevented lives being saved. (A moment here perhaps for nursers to relfect on current vaccine hesitency. Today, in 2025, far fewer parents bury their children. Infant and maternal mortality have declined dramatically, life expectancy has nearly doubled in many world regions, and vaccines have turned once deadly illnesses into rare events. However, misinformation and removal of global health finding is putting this progress at risk, and so needing nurses to notice the impact of these individual and collective omissions in public health progress, and act as one.

The gains, Kenny argues, are not accidents of history but the product of collective action of people. evidence that progress is possible, uneven, but they are real and that uniting people for a common good brings good. A note of caution that such collective calls for public good are not universal drivers and the differing approaches to nursing evolution in neo liberal and collective societies means a global phosophical lenses is needed as well as a practical workforce one.

Nursing has been an agent in this public health transformation. The eradication of smallpox (with the Queen’s help), the control of measles ( which is currently not so good), and the dramatic reduction in deaths from pneumonia and diarrheoa depended not only on scientific discovery but also on nurses’ relentless efforts to deliver vaccines, teach sanitation practices, and sustain patients through recovery (World Health Organization [WHO], 2019). In hospitals and communities, we nurses have made this happen: the hands and voices through which public health becomes personal health and people trust their nurse to help them get well or be well in whatever context they are.

Kenny (2021) reminds us that all all is fair, and progress is never universal. Millions still live without reliable access to clean water, adequate food, or affordable health care. The WHO / Unicef report (2025) states that only 50% of healthcare facilities in the poorest countires have basic WASH, waste and reliable electricity services. My own global health work made this so clear to me when, on an evaluation visit to rural health posts in Zambia, the requested powerpoint presentation was impossible as there was no power.

Nurses stand at these dual front lines of progress and lack of progress, working in rural clinics without broadband access, improvising treatments when supplies run out, and advocating for patients left behind by uneven global systems. Nursing, in this sense, has always embodied the paradox of progress: it is both a marker of how far we have come and a reminder of how far we have yet to go.

The 21st century now adds new layers to our global story. Migration, climate change, and pandemics reveal how interconnected health truly is. The COVID-19 crisis demonstrated both the fragility of health systems and the indispensable role of nurses as the largest group of health professionals worldwide (International Council of Nurses [ICN], 2025). In Kenny’s terms, “billions of people have been part of solutions” (2021, p. 9), and we nurses are counted among those billions, not only as caregivers but also as the innovators, educators, and advocates for equity. As nurses we are the agitators at the edge of policy changes but rarely get the limelight for the work we do and the difference we make.

The story of global progress therefore shows nurses as successful in some ways, but so silenced in others, and so sets the stage for reimagining nursing as a 21st-century profession. If the last century was about scaling sanitation, vaccines, and maternal care, this century requires scaling the non human in health and nursing, artificial intelligence, digital health, digital competencies, ethical governance, and the human side. artful intelligence™️. Hanlon (2011) called the move from the fourth wave of public health, i.e. telling people what to do about their health (run more, eat less, do not smoke) to the fifth wave of public health as a shift to addressing the wider culture that enables health, this includes the arts and also how the world views what it is to be healthy. In this wave culture will take more of a role in helping us be healthy, and define what that is too.

As health systems in some of the world start to move away from telling people how to behave to be healthy and instead start shaping society so people can be healthy (perhaps the neighbourhood approaches bering advocated in the UK as part of the NHS Fit for the Future Plan (NHS, 2025), there is a accompanyinh shift away from bio medical approaches. This may shift thinking on personal responsibility and blame to social determinants of health, neighbourhood approaches and collective cultural community approaches to health making. Or it may be about getting people healthly enough to get into work and earn money rather than cost money. Nurses are never passive bystanders, we are part of this future and we are therefore at the balancing point between building on our agency or being pushed into ambivalance because of how we are seen, not heard and unvalued. I choose action over ambivalace which is why I act and develop this work. We as a collective of wise innovative nueses are ensuring that the benefits of progress are distributed fairly and that its human meaning is never lost. This is possible as long as we are here to do this, there in places of power (or here on the website) to share this, and that what we do is seen as effective. Wer need to show, tell and provwhy the art of nursing matters.

The Dual Identity of Nursing; Science and Art

Consider the image of a nurse adjusting an infusion pump while simultaneously noting the hesitation in a patient’s voice. One action is technical, measurable, and easily documented in an electronic health record; the other is relational, subtle, and invisible to most systems. This juxtaposition illustrates what Barbara Carper (1978) named the patterns of knowing in nursing: empirical, ethical, personal, and aesthetic. Together, these ways of knowing remind us that nursing has always been more than technical proficiency, a task, or a semi professional which is how it was still being framed in 1995.

The scientific dimension of nursing is undeniable. Evidence based protocols, pharmacological knowledge, and infection-control practices sustain safe and effective care, degree educated nurses save more lives. All the evidence is there to support the economic agruement for desgree qualified nurses and high quality nursing. We as nurses are trained in systematic assessment, diagnosis, and intervention, a knowledge base that is testable, replicable, and essential for accountability, and we measure what can be counted, and potentially miss what matters but cannt be counted. I recall always being told, if it is not written down it did not happen. I do not think I have ever written down the sympathetic presence shown when the person in front of me is broken with grief, or the matching of my calm 4x4 breathing for a person too scared to take another breath on their own. Our ways of counting only count some of what we do. what can currently be counted is the part of nursing that aligns most easily with the technological age, where algorithms and predictive analytics can support clinical reasoning (Ronquillo et al., 2021).

But there is also the art. Jean Watson (2008) describes nursing as the philosophy and science of caring, where presence, empathy, and compassion are as vital as medications or procedures. The artistry of nursing lies in sensing what is unspoken: the pause before a patient answers, the absence of laughter in a child’s play, that 1000 yard state that any nurse who has worked in a trauma informed way can see in a child’s eyes, the grief folded into silence hidden behind a forced smile. These are acts of noticing that cannot be reduced to metrics, yet they often make the difference between good nursing care and poor nursing care, they make the difference to the tone we take, the words we use, the time between the silences that say so much. People do not feel cared for if they do not feel connected to. Nurses know that healing is the recovery of the body, the restoration of dignity and the return to one’s life. Tghis aspect of human may be possible through an AI bot, as it has been possible through a screen, I am both glass of water on my desk half full and half empty on this.

As nurses we inhabit the dual roles of scientist and artist, technician and companion, evidence gatherer and storyteller. The Art of Nursing webinar content and stories, and the poems in the resource section of this website are testiment to that, Our authority rests precisely in our ability to hold both and to translate the rigor of data (and sometimes the metaphorical rigormortis of more paperwork into compassionate action.

The challenge of the 21st century is that technology risks amplifying one side at the expense of the other. Artificial intelligence can process data faster and more accurately than any human, but it cannot offer that sympathetic presence, remember when someone said that they did not know what the nurse did, ‘she was just there’. Digital health tools can chart symptoms, but they cannot sit quietly holding that suffering. Without attention to the aesthetic and ethical dimensions, nursing risks being reduced to “what can be measured” (Krick et al., 2020), and what can be recorded as ‘there’. The relational aspect between two people, maybe described as not here or there, and so not so easily measured using the metrics that currently matter. Does it matter?

I beliece so an that the dual identity of nursing must be protected and amplified if the human in the non human healthcare is to survive. As we turn toward artificial intelligence, the question becomes: how do we preserve and elevate artful intelligence™️ alongside the scientific?

Artificial + Artful Intelligence™️ in Nursing

Artificial intelligence (AI) has entered nursing in the same way as it has entered other areas of life. Like the new electricity. Policy frameworks such as the NHS Fit for the Future Plan (NHS, 2025) predict automated documentation, predictive risk scores, and therapeutic chatbots as solutions to workforce shortages and efficiency pressures (Buchanan et al., 2021). In theory, these tools we liberate us nurses from routine tasks and allow more time for human connection and the automation or augmentation of work may free up nurses to do the human elements so needed. Maybe that ‘being there’ aspect of relational presence. However, the introduction of AI does not simply add new capacity to care; it reconfigures what counts as knowledge, what is valued as labour, and who gets to decide what is right or true.

The promise of such time saving processes is seductive in an economic way, and as we know money talks and this is where the power is. The issue of the power in the future of nursing thinking is scary. As AI can detect sepsis hours earlier than clinicians, predict patient deterioration from subtle biometric shifts, and generate care recommendations based on population-level data (Koo et al., 2024) will it replace some of what we do, and be welcomed as the time saving solution it is, and at what cost?

Most AI systems have been designed without nurse input, leading to tools misaligned with practice realities and inattentive to relational care (Zhou et al., 2021). When algorithms structure decision-making, the invisible work of presence, empathy, and advocacy risks being removed, irrelivant to the role of a nurse. If care becomes what machines can contribute and calculate, then what remains of the art of nursing, the hearing a silence, sensing a shift, making moments safe by what Bell Madden’s poem in the resources section shows as ‘sorted’. It’s okay Jennie is here may bring the same trust and relief if Jennie is not Jennie and human in all senses of the word.

Here, the concept of artful intelligence™️ becomes critical. This builds on what Loaiza and Rigobon (2020) identify as the five domains that cannot be replicated by machines: empathy, presence, judgment, creativity, and hope. These are core to nursing’s professional identity. AI may simulate empathy, offering warm phrases in response to patient queries, but it cannot feel with patients. It cannot sense the tremor in a hand, the fatigue in a parent’s eyes, or the moral weight of a decision that the end of life symptom management medication package now needs to be opended. Or can this be via an algorithm and resolved by a bot? And if so, how would this be decided and discussed?

Zohny et al. (2025) have demonstrated how large language models can mimic four physician–patient communication styles: paternalistic, informative, interpretive, and deliberative. For nursing, the lesson is double edged. On one hand, AI can help patients articulate preferences and practice dialogues, potentially empowering them before clinical encounters. On the other hand, the persuasive power of AI risks manipulation, reinforcing biases rather than fostering autonomy. Nurses, long attuned to relational ethics, are uniquely positioned to mediate these tensions, to ensure that communication remains value sensitive and person centred. If the AI bot is programmed for paternalistic there will be one way of speking about dealth, if it is programmed for interpretative there will be another. I wonder whether last words and last rites are so reduced.

A vignette makes this tangible. A nurse in an oncology ward uses an AI tool to flag elevated infection risk in a patient receiving chemotherapy. The algorithm predicts with striking accuracy, but it is the nurse who contextualises the alert, explaining gently to the family why neutropenia matters and offering reassurance that vigilance does not mean there should be fear, we as nurses are aware of everything that is going on around the person. As Gaye Poole in the webinar on Novel Nurses so wonderfully said, we as nurses are nosy. Maybe AI can be viewed as nosy too, over and above the noisy monitors defining what is happening. The machine informs; the nurse interprets, translates, and sustains that relationship.

In this sense, the future of nursing is not about nurses resisting AI but about embedding artful intelligence™️ into its deployment and keeping the human elements of nursing where non human cannot help . Nurses must therefore be the co-designers of any AI care, ensuring that technology augments rather than undermines the relational, ethical, and imaginative heart of practice. This is a challenge as nurses and AI engineers speak different languages. Clare Su-Yeon Park’s poem In the Twilight zone; between AI and nursing ( in the resources section) highlights the issues we face. The task ahead for us nurses is not therefore to choose between artful and artificial intelligence, but to harmonise them into a profession that remains both scientifically rigorous and profoundly human, and ethical.

Ethics, Equity, and the Unfinished Conversation

The integration of AI into nursing is not occurring in a vacuum. Algorithms are built on data sets that carry the biases of the societies that produced them. As Peirce, Smith, and Kolotylo (2020) caution, electronic health records and machine learning outputs are not morally neutral; they embed histories of injustice, including racial disparities in diagnosis and treatment. I attempted to create some images of nurse leaders using AI for a presentation. I gave up as with each specific request I got a more and more unrepresentive image that become less and less like the leaders I know looking image. If we as nurses uncritically adopt such tools, we risk amplifying inequities rather than reducing them. Social justice is part of being a nurse, it is not as evident as direct nursing care, but it is there, here and there.

Kenny (2021) reminds us that progress is real but is uneven. While child mortality has fallen globally, five million children under five still die each year from preventable causes. Universal health coverage remains elusive for millions. The efforts to address this have been hampered by global politics and cuts to health care where the funds are needed most. The digital divide adds a new layer: hospitals in urban centres may boast AI-driven decision support, the huge AI investment promised by Trump and Starmer in September 2025 is useless while rural clinics lack broadband to upload vital signs. In this landscape, technology may widen rather than bridge gaps but the relational aspect of nursing, the trust built wihtin that community will prevail.

Nurses, grounded in the ethics of care, are well positioned to surface these inequities. If we are heard and if what we say matters. Consider my experience in Zambia. The clinic lacks reliable internet, rendering AI decision-support tools unusable. Instead, the nurse needs to draw on experiential judgment, community knowledge, and trust built with families to guide care.

The ethical challenge, then, is not only whether AI works but also for whom, under what conditions, and at what cost. Transparency, accountability, and distributive justice must be part of nursing’s engagement with digital health. If AI systems cannot explain their reasoning, or if they are deployed only in wealthy settings, they risk betraying the very ethos of nursing: to advocate for those most vulnerable.

In this unfinished nursing of the future conversation, artful intelligence™️ is not something aligned to old tropes of caring and nice quiet kind nurses, it is the human compass to where we need to be. Empathy, judgment, and presence guide nurses in asking hard questions about fairness and access. As Kenny (2021) insists, progress requires intentional effort and nurses need to now be intentionally artfully intelligent as well as harness artifical intelligence. For nursing, this effort means ensuring that such technological innovation does not take away our focus on equity, and that the humanity of care remains visible even in an algorithm led non human system.

Professional Identity and Agency

For much of our history, nursing has been cast in the shadow of medicine, essential but subordinate, technical but undervalued. Particularly worrying is the gender inequity in leadership posts in nursing, and the continued gendered concept to nursing. Whilst these words of Davies are from 1995, they resonate with much of the current power battles influecning the future of nursing.

“..there is a sense in which nursing is not a an adjunct to a gendered concept of profession, Nursing is an activity, in other words, that enables medicine to present itself as masculine/rational and to gain power and privilege of doing so. It has clearly had the first bite of the cherry in defining its work and… We get closer to the matter of recognizing that (nursing) is trying to put a conceptual framework around just those aspects of the work of health and healing that are ‘left over’ after medicine has imposed as essentially masculine vision.” (Davies 1995; p61).

I find that there are still many who see nursing as such, mostrly those who have not needed nursing and not been in nursing. In the 21st century, this framing is dangerous to patients and unhelpful to our profession. Nurses are still the largest group of health professionals worldwide, often the first and last point of contact for patients, and increasingly recognised as leaders in interprofessional teams (ICN, 2025). Yet as digital health expands, there is a risk that professional identity could be pushed backwards and narrowed to what algorithms can measure and delegate, and what other health professions deem that they need from nurses. If that happenes nurses will be deskilled in their cognitive processes, mis skilled due to biased algorithms, and unskilled because we will never feel have learnt what we need to do if it is something AI can do.

To mitigate this risk we need to expand our professional agency and resist such narrowing. We and other health professionals need to tell the “hidden stories” of our work, more than the stories of work left undone. We need to tell of the improvisations, negotiations, and moral labour that do not fit easily into metrics set for measuring quality and the tasks set out for nursing in NHS Fit for the Future (NHS, 2025). For nurses, these stories are the quiet advocacy for a patient waiting too long for care, the careful calibration of a gentle smile and humour to ease a child’s fear, the courage to challenge a physician’s decision when it conflicts with observed patient values, and loud activism for gender equity, patient safety and professional respect. These acts are invisible to AI and constitute our profession’s ethical backbone. They are not invisible if we look at nursing in other ways than ‘adjunct to medicine’, there are other wider way of viewing nurses’ ways of knowing.

Carper (1978) reminds us that professional identity is not only about competence but also about self-awareness. Nurses continually navigate tensions between autonomy and hierarchy, between algorithmic recommendations and lived patient realities and consider weighing up both sides all of the time. To claim agency in this forthcoming context where AI is everywhere means weighing up both sides again, and refusing to be reduced to data entry clerks for machines or passive recipients of an algorithmic authority. It means positioning nursing knowledge, empirical, ethical, aesthetic, and personal, within all developments of care. Whilst I imagine an image of an ethical bathbone, I am also now seeing large nursing elbows coming into view.

Kenny’s (2021) broader argument about progress resonates here: societies evolve when professions step into leadership, aligning their expertise with the arc of human betterment and explore boundaries and scope of their practice. Nurses can do the same for the evolution of nursing. This evolutionary stage is that of boundary maintainence and inter-professional negotiation and will require ongoing negotiation within the healthcare system and against emerging roles such as digital health and AI. Key traits in this phase of any professional evolution are the expansion of scope of practice and resistance to role dilution or deskilling. So we as the nursing profession are not alone here, it is how all professions evolve.

One tangible aspect of this evolution is the need to be active in engineering AI. As Clare Su-Yeon Park has shown in her poem, the mismatch of language is shown by the responses; thw work on nursing and AI is “too philosophical” from the AI engineers, and seen as “too technical” from the nurses. As nursing has reached this professional evolution stage we need to now embed ourselves in AI design, governance, and evaluation so that we can ensure that nursing knowledge shapes rather than merely adapts to digital futures. By advocating for patient-centred outcomes and the need for artful intelligence™️ as much as efficiency metrics, we can hold systems accountable to values as well as numbers and build a shared language.

In this light, no professional identity is or has ever been static, and nursing identity needs to now evolve. Nurses in the 21st century must claim our dual role as designers of health systems that include AI, and the providers of and guardians of relational care. Our agency lies in harmonising technological innovation with artful intelligence™️, ensuring that progress serves not only efficiency and the utalitarian view of what we do, but also equity and human dignity and emancipatory view too.

Future Directions: Harmonising Artful and Artificial

What, then, does the future of nursing look like in a century shaped by both exponential technology growth and widening inequities? It looks bright and bleak to me. I always see both sides. I am a mental health nurse after all!. To make the bright outshine the bleak I believe we need three things.

First, education must prepare nurses as digitally literate, ethically reflective and able to embody the human aspects of nursing that humans need. However, not on its own. Scoping reviews warn that AI in nursing education often emphasises technical skill at the expense of relational practice (Buchanan et al., 2021). Nursing curricula should therefore integrate training in digital tools with sustained engagement in humanities and arts-based methods, preserving empathy and creativity alongside computation. This is called diological literacy and needs to be named and supported alongside digital literacy. This is where the art of nursing movement and the concept of artful intelligence TM can help.

Second, governance structures need to include nurses at every stage of AI design and deployment. Excluding them, as the current trends suggest, results in tools misaligned with practice realities and inattentive to patient-centred outcomes (Zhou et al., 2021). Nurses’ proximity to patients makes us indispensable in evaluating whether technologies enhance or erode care. We need to avoid wasting time and money and expertise, and the waste in the system will be seen when work arounds appear to allow patients and nurses to get around the AI. We have all seen these work arounds with technology when it has not been tested with the nurses who are supposed to use it, and benefit from it first.

Third, metrics of progress must shift. Efficiency cannot be the only outcome. As Kenny (2021) reminds us, global improvement is measured not only in wealth or survival but in dignity, opportunity, and shared wellbeing. For nursing, this means developing indicators that capture relational outcomes, trust, comfort, presence, alongside clinical effectiveness, efficiency and all the economic models of quality that can be counted. This is the challenge for the social return on investment meaasures and accounting for nurses’ worth. Whether this is more than ‘staff wellbeing’ and more than ‘more nurses’ remains to be seen

Return to the opening vignette but 40 years ago. This was me as a nurse at a bedside, one hand steadying a glass of water, the other monitoring a monitor, not an AI-generated one, just one with numbers I needed to read out of the corner of my eye. This was a side room when the machine was there as a prop and prompt as this was the final part of this man’s life. Let’s call him Mr Smith. Becasue that was his name. I still remember him because he was the first person to die with me when I was also in charge of the ward and had other pressing priorities too. This memory of being torn between being there and being somewhere else distills for me the essence of 21st-century nursing. We need to have the capacity to hold responsibility, technology and humanity in unison whatever century we are in, whatever monitor is there. I know, because later his wife told me, that it made a difference to both of them that I was there. Not the monitor, the human.

I am suggesting that nursing’s future depends on harmonising artificial and artful intelligence™️. Global progress, as Kenny (2021) reminds us, has transformed health outcomes, but inequities across the world remain, and may well be getting worse. Nurses, as agents of this progress, must ensure that digital tools do not deepen the current structural violence and social divides. Carper’s (1978) patterns of knowing and Watson’s (2008) philosophy of caring remind us that nursing is irreducibly both science and art. AI promises efficiency, but it cannot replace empathy, presence, or hope. I hope. Our professional identity, long marked by invisibility, must now be reasserted in design rooms, policy debates, and ethical governance. Those elbows I mentioned. Education, leadership, and advocacy will be key to embedding relational outcomes alongside clinical ones.

If the 20th century belonged to antibiotics, vaccines, and sanitation, (Hanlon 2011), the 21st will belong to data, algorithms, and digital platforms, and culture, and maybe the new profession of nursing. I hope so, but as I was always reminded in senior health management meetings, hope os not a plan.

We as nurses will not be replaced, completely, but we do need to be redefined. Nurses will be and do what we have always been and done: bridge art and science, human and non human care, and maybe have the artful intelligence counted and be counted as more than just being there. How will this happen?

Artful intelligence™️ now it is named, (and trade marked as I have often found my thinking and work when given freely has been taken and made not free) needs to be considered as a professional resource. In an era when machines can calculate risks and suggest treatments, it is the uniquely human capacities of empathy, judgment, and hope (not as a plan but as a position in life) that distinguish nursing and will enable nurses to flourish. These are essential for navigating ethical ambiguity, service complexity and sustaining patient trust so needed and wanted.

Kenny’s optimism offers a closing reminder that progress is not inevitable but possible if enough people contribute. “Billions of people have been part of solutions” (2021, p. 9). This speaks to me of collective action and positive assett based approaches to being healthy. Among those billions, nurses have always been and must continue to be central in communities. We are millions. At the last count I think it was 10 million. The 21st-century nurse needs to perhaps advocate for both artificial and artful intelligence™️. This Art of Nursing movement works is one way of helping us to do so.

References

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