Development of the Emergent Theory of Aesthetic Nursing Practice (AesNURP)

Theory is necessary to science and science grounds legitimate and essential practice. This is true for Nursing as a discipline of knowledge and a practicing profession. Nevertheless, should all science or research within a scientific field be focused on theoretical development and testing? Currently, various nursing theories exist to describe and explain the phenomena of nursing. Often, the development of nursing theory is in response to advancing ontologies and epistemologies of nursing. The advent of technology is one of these advances challenging the professional practice of nursing. How will nursing practice be made visible and realistic in the face of traditional nursing care practice? Nursing practice processes, derived from theories of nursing, provide opportunities for demonstrating practice grounded in the science of nursing. The purpose of this article is to describe the development of the emergent theory of Aesthetic Nursing Practice, focus on illuminating caring for person through the process of encountering, co-creating caring relationships, and meaningful engaging between the nurse and nursed through caring encounters occurring in caring situations. Five assumptions and a model of practice are described. As a contemporary theory of Nursing, it describes caring for persons who remain wholes and enhance their well-being.


Introduction
Nursing theory is an integral component in the practice of professional nursing.
Its value in nursing practice depends largely on the ontology and epistemology of nursing that often dictates the classification and categorization of nursing theories. Ontological theories define and describe nursing as art, as science, How to cite this paper: Kongsuwan, W.
(2020) Development of the Emergent Theory of Aesthetic Nursing Practice (AesNURP).

The Theory Development Processes
Oftentimes, nursing concepts and nursing theories are understood as similar or the same term, so much so that developing theories become confusing and are sometimes ignored. Similarly, Thorne [13] has expressly delineated nursing science and nursing theory, in that the term nursing science has been frequently used to emphasize theorizing in nursing, rather than formalizing scientific investigations, and Thorne explained that, as such, this delineation often illustrates that nurses "participate in a skewed, partial, or watered-down version of the scientific enterprise (p. 1)" [13].
However, Walker and Avant [14] provided three strategies of theory development: theory synthesis, theory derivation and theory analysis. Theory synthesis is the construction of a theory from empirical evidence, while the three steps of theory synthesis are specifying focal concepts, reviewing the literature to identify the factors related to the focal concepts and relationships and then organizing concepts and statements into an integrated and efficient representation of the phenomena of interest.
Theory derivation is a strategy to develop theories from sets of concepts which are related to each other but have no structural way to present these relationships. In theory derivation, a parent theory is selected and use, while theory analysis is a strategy to determine the need for additional development or redefinition of the original theory [14]. To structure a theory, Walker and Avant [14] described the elements of theory building-concept, statement, and theory, and the approaches to theory building are synthesis, derivation and analysis. However, in theory development, a variety of processes of concept development are presented and the concept analysis is most familiar in concept development techniques such as by Chinn and Kramer [15] and Walker and Avant [14] built on Wilson's [16].
Other processes of concept development presented by Rodgers [17] were based on the evolutionary view that human beings are constantly changing with other related nursing phenomena. The process of "concept development is a W. Kongsuwan DOI: 10.4236/health.2020. 127056 767 Health cycle that continues through time and within a particular context (p. 81)" [17].
Nevertheless, Schwart-Barcott and Kim [18] developed a hybrid model of concept development that is composed of three phases, the theoretical phase, fieldwork phase, and final analytic phase. These processes include several distinct approaches or steps to clarify and explain a concept.
Another process of theory development defined Glaser and Straus's contribution in using grounded theory methodology as a qualitative research approach for developing middle-range theories [19]. Nonetheless, Meleis [20] reviewed and analyzed the literature of theory in nursing and noted four major strategies for theory development at all levels: 1) from theory to practice to theory; 2) from practice to theory; 3) from research to theory; and 4) from theory to research to theory. In addition, Meleis also informed integrative strategy in developing middle-range theory [20]. Hence, processes, approaches and strategies in theory development in nursing continuously change thereby remaining dynamic.
Guided by these descriptions of theory development and the ontological question of what is aesthetic nursing practice, and how to practice the aesthetic nursing? the theory of Aesthetic Nursing Practice is defined, described, and developed. The theory of Aesthetic Nursing Practice is structured within the philosophical perspective of the unitary-transformative paradigm, in which a person is viewed as unitary, evolving in a mutual and simultaneous process wherein change is creative and unpredictable, and the knowledge base is grounded in human science [21]. The theory of AesNURP is deductive, using some assumptions from grand theories, including Nursing as Caring [1], the Technological Competency as Caring in Nursing theory [2], and Florence Nightingale's legacy of caring [22]. The strategy of theory derivation [14] is used as some assumptions and concepts in these parent theories were adopted to build the practice processes of aesthetics in nursing. Related literature was searched by using keywords and their combinations such as nurse AND aesthetics, art AND aesthetics, aesthetics AND nursing practice. Concepts regarding art and aesthetics in nursing were results of reviews which were found relevant literature such as those by Boykin, Parker, and Schoenhofer [23], Carper [24], Chinn and Kramer [25], Gaydos [26], and Locsin [27].

Theories and Concepts Which Influence the Theory of Aesthetic Nursing Practice
The foundational concepts of the theory of Aesthetic Nursing Practice are grounded in the unitary-transformative paradigm [21]. Its development is informed by theoretical and conceptual influences such as those from Florence Nightingale's [22], setting the ontology of aesthetic nursing practice as emphasizing persons as interacting with the environment, the latter synthesized and referred to as an aesthetic environment. Carper's [24] fundamental patterns of knowing in nursing influenced theory development by evolving the practice processes of aesthetic nursing in order to know the persons, the aesthetic The influence of aesthetic knowledge as described by Chinn and Kramer [25] [28] has impacted the focus of practice as based on specific knowledge-those derived from aesthetic knowing in nursing. One notion that has critically influenced the process of nurs-ing in AesNURP is co-creating the aesthetic process as explained by Gaydos [26], aesthetic knowing as described by Boykin, Parker, and Schoenhofer [23], and aesthetic expressions as explained by Locsin [27].
In the theory of Nursing as Caring as model for transforming practice [

Significance of the Theory of Aesthetic Nursing Practice
As nursing is a discipline of knowledge and a practicing profession, and its Practice is uniquely informed as a theory-based practice in which the revelation of the person as being whole is known through a practice process in which persons' representativeness is the information derived from knowing the person as being whole thereby facilitating ways through which human health and wellbeing is known. Aesthetic nursing practice will prevent nursing practice becoming a routine, thus encouraging expert and satisfying nursing practice to improve

Focus of the Theory
The focus of the theory is caring for persons, in which caring nursing practice is ex-pressed as the engagement of the nurse and nursed through the caring encounter occurring in caring situations. As a middle-range theory, AesNURP is appreciated as affirming the practice process of engaging nurses and persons cared for in co-creating processes in which oneness is facilitated and realized.

Assumptions of the Theory
Five assumptions structure the AesNURP theory which serves as the substantive foci built on the conceptualizations of nursing, and framed on a unique practice process of engagement. The following assumptions are described and explained: Persons are caring by virtue of their humanness [1].
This unique perspective is a major assumption of the Theory of Nursing as Caring [1]. "Persons are caring and caring is a process" offers the realization of knowing and expressing self as a caring person and respecting the others as caring persons in the practice processes of aesthetics in nursing.
Ideal of wholeness is a perspective of oneness [30].
This concept is an assumption of the Theory of Technological Competency as Caring in Nursing [2] [30] which is derived from a basic concept-"persons are whole or complete in the moment (p. 1)" in the Theory of Nursing as Caring [1]. A person is viewed as a whole and a unity. Persons cannot be predicted and are dynamic, and changing all the time due to their having thoughts, imagination and being creative [2] [30]. This view of a person offers the practice processes of aesthetic nursing as continuous in order to appreciate persons' thoughts, dreams and aspirations in relation to time, persons, and the environment which is changing and dynamic.
Persons co-create aesthetic expressions in nursing.
Being a person means participating in creating truthfulness. In human science, it suggests that in being human, the truth is in the human experience consisting of thoughts and feelings [31]. Persons are co-creators and this means they are participants in creating the experience [29]. This view helps the nurses to respect and opens possibilities and opportunities to themselves and those being nursed to share experiences, co-create experiences, and mutually express meaningful experiences in caring to appreciate wholeness and enhance the wellness of the individual.

Persons mutually interact with the environment.
This view is derived from Florence Nightingale's assumption that was identified and explained by Victoria Fondriest and Joan Osbourne (cited in Dunphy) [22]. This concept provides the notion that in the practice processes of aesthetics in nursing, persons and environment are related.
Aesthetics in nursing is within aesthetic nursing environment. Gaydos [32] described nursing as aesthetics in a way of making special, in-  [34] and aesthetics in nursing focus attentions on the practice processes between the nurse and the person being nursed who co-creators of a caring situation within the aesthetic environment. In the practice processes, the persons' wholeness is appreciated and enhanced as illuminations of their well-being.

The Process of Aesthetic Nursing Practice
The processes of Aesthetic Nursing Practice are uniquely described as a model of nursing practice (PraPan-creating poetry in the Thai language). It is explained in Figure 1. This process of nursing responds to the question, "how will a nurse practice nursing grounded in the theory of Aesthetic Nursing Practice?" There are three processes herein described concerns how nursing is practiced. Utilized as a guide for facilitating expert nursing, these are encountering, co-creating caring relationship, and meaningful engaging.

Encountering
Encountering is the primary process delineating two questions-who are the persons being cared for, and "what" are these persons? Encountering occurs when persons (both the nurse and nursed) demonstrate knowing each other as caring person [1]. These persons are embodying (mind-body-spirit) wholeness as distinctive persons [28]. In nursing practice, persons reflect both the nurse and the persons who are being cared for, or clients known as patients and family members. Knowing self and others as caring persons encompasses multiple patterns of knowing described succinctly by Carper [24] as empirics that is explained as the science of nursing; ethics as the moral component on matters of obligations in nursing; personal knowing as the ways of self-relating with others, and aesthetics as the art of nursing. One timely way of knowing in nursing, technological knowing derived from Locsin's theoretical descriptions [35].
Therefore, knowledge about persons is derived from multiple ways of knowing, What are the realities of the person in the data gained from the use of technologies?

Co-Creating Caring Relationship
Co-creating caring relationship is the fundamental way of designing simultaneous nursing practice through aesthetic processes. The nurse and the person being nursed co-create caring practices. Aesthetic processes are embodied and synchronous interactive motions between the nurse and person being nursed, in which relating imaging (or expression of) and valuing is communicating nursing through aesthetic knowing. Synchronous interactive movements between the nurse and person being nursed contain processes of mutual knowing, interpreting, and understanding/appreciating within aesthetic environment.
Aesthetic knowing has been described and explained by some nursing scholars. Carper [24] declared that the aesthetic pattern of knowing in nursing involves the perception and empathy of nurses on abstracted care priorities or behaviors of patients which help the nurse by interpreting them in relationship with situations around him/her treated as a whole being instead in several parts.
Aesthetic knowing helps to develop future creative actions to design appropriate nursing care practices which can be effective, and satisfying [24]. According to Boykin, Parker and Schoenhofer [23], aesthetic knowing is creating experience in the nursing situation, expression of the experience, and appreciation of it through the encounter. These expressions (representation) and appreciation are uniquely related to the experience itself, which cannot be predicted by others.
Boykin, Parker and Schoenhofer [23] stated that aesthetic knowing encompasses the other patterns of knowing into the nursing situation, the shared lived experience in which the caring between the nurse and nursed enhances personsood.
Similarly, Gaydos [26] developed a co-creative aesthetic process which included engagement, mutuality, movement and new form, in which Gaydos demonstrated that the co-creative aesthetic process was an expression of aesthetic knowing. Chinn [36], Chinn and Kramer [25] viewed the aesthetic pattern of knowing as a process to develop knowledge that can be integrated into nursing. This process of aesthetic knowing included dimensions of critical questions, creative processes, formal expressions of aesthetic knowing (criticism and works of art), integrated expressions in practice (transformative art/act) and authentication processes (appreciation and inspiration) [25]. In co-creating caring practice, aesthetic knowing is viewed as creating and sharing the experience between the nurse and the clients to appreciate the experience and create possibilities in designing nursing practice.

Meaningful Engaging
Meaningful engaging is the process of interactive relating between caring persons wherein all nursing occurs. Mutual participation in the caring between the nurse and client relationship, and expressing caring through aesthetic processes within an aesthetic environment. Caring between is where nursing situation occurs, that shared, lived experience in which the caring between enhances personhood. This concept is derived from the theory of Nursing as Caring [1] and defined as the nurse and the nursed presence and the giving of time and space to nurture personhood. In meaningful engaging, the nurse-client relationship is co-created towards personhood. All nursing occurs in nursing situations through mutual participation and expression of caring within the aesthetic environment. Nursing is construed as appreciating the wholeness of persons towards enhancing their well-being. The person's hopes, dreams, and aspirations are supported, affirmed and celebrated. and Schoenhofer [23] thought that aesthetic expression is a reflection and communication of experience of aesthetic knowing which can be performed by both nurse and other being nursed. The aesthetic expression will become a new experience to the others. This is related to Archibald [37] who claimed that the aesthetic expression of nursing is an expression of creative art from aesthetic experience.
Phenix [39] categorized the aesthetic realms into four types: 1) music; 2) visual art such as painting, drawing, graphic arts, sculpture, and architecture; 3) the art of movement or dance and play; and 4) the art of literature such as poems, novels and stories. Locsin [27] [27]. Furthermore, Locsin [38] added that visualizations of the experience in order to communicate the meaning of the experience can be illuminated through the quilt, paintings, outcome space, and dance to mention a few. Articulating experiences through words and phrases can be expressed through poetry, prose, stories, and quilts (p. 3).   Table 1.

Aesthetics in Nursing Environment
Florence Nightingale [22] who is regarded as the founder of modern nursing  Objective domain is the physical or material space surrounding the persons that can be perceived through senses. Senses are seeing, tasting, smelling, hearing and touching.

Nursing Practice
The theory of AesNURP views nursing as aesthetics and praxis, within the commitment of caring practice for person who are participants in their care, rather than simply objects of care [29]. As a middle-range theory, its emphasis is on exercising nursing care grounded in explicit theories of nursing for the purpose of knowing persons who are always wholes and remain complete, regardless of missing composite parts. Its assumptions and concepts elucidates flexibility and non-specificity of nursing care, with caring encounters [42] as the essential occasion of dictating the caring situation.

Nursing Research
Nursing is caring in the human health experience [21], and as such can be studied from the unitary-transformative perspective in which mutuality is an integral determinant. Understanding synchrony and mutuality of nurse-person In addition, in order to predict and prescribe actions and interventions derived from the findings of the study assumptions and concepts of the theory can be used in other ways. In predicting cause and effect relationships, quantitative studies using methodological research such as instrument or tool development can be harnessed from this theory.

Nursing Education
The theory of AesNURP has several implications for nursing education. Recommendations include designing and implementing programs of nursing studies in undergraduate, graduate and continuing studies. The assumptions and practice processes of this theory are useful in the practice of nursing education.
Nursing institutions can implement this theory to design courses which allow the faculty/lecturers and students to be co-creators in designing and interactive in teaching and learning activities. This theory can be used effectively as substantial nursing knowledge in the nursing courses such as nursing concepts, nursing theories, and nursing knowledge development.

Conclusions and Recommendations
The Following practice exemplar can be guided the use of this theory in nursing practice.
Practice exemplar through the theory of AesNURP I am a nurse who was assigned to care for Mr. A, a patient with leukemia in a hematological ward. One day, I came to meet him in his patient care room. In meeting Mr. A, I began to know him, that he was in pain and afraid to eat because of his oral ulcers which were side effects of chemotherapy treatment. I used a thermometer to check his temperature and determined whether or not he had infection. Mr. A told me that he would like to have ice-cream very much but eating ice cream, although soothing to his mouth, might cause oral ulcer infection since his immune system was low. I valued myself to do the best care for him in relieving his pain and in his desire to have ice-cream. I knew how to make a simple sterile ice-cream from sterile water, syrup and milk, I prepared this ice treat in the freezer. Syrup and milk would provide energy and some nutrient sources, and the cold treat will sooth his mouth. The coldness of the ice would make him feel better, by providing relief of his pain from oral ulcers. I affirmed that we could make it together. I and Mr. A made sterile iced treats in many beautiful patterns and colors. I decorated some with flower designs and on the table, natural flowers to make the environment pleasing. I invited other patients and nurses too to join. I witnessed that Mr. A's eyes lit up and he smiled. He ate the ice-cream with happiness. He said thank you very much to me as I made his dream come true. He also took some pictures of the ice-cream and shared this with his family. I also shared and reflected this experience of satisfaction in my caring for Mr. A to other nurses in the next shift. Analysis: Encountering: The nurse has known about Mr. A based on Carper's ways of knowing, that Mr. A did not have infection because his temperature was normal (empirics). Mr. A felt pain and was afraid to eat. Mr. A valued doing his best to protect him from infection as well as the nurse valued maintaining practices that were beneficial and to do no harm (ethics). The nurse knew how to make the simple sterile ice-cream (personal knowing) and the artful addition of colors and flowers (aesthetic knowing). With technological knowing, the nurse was able to affirm that Mr. A did not have any fever and can participate in a caring encounter with the nurse and other patients. Co-creating caring relationship: The nurse and Mr. A mutually knew each other. The nurse could understand the meaning of Mr. A's health experience by interpreting and appreciating the situation that Mr. A had strongly desired to have ice-cream but because of his fear of pain due to oral ulcers, he was reluctant to engage in any eating activity, except eating ice cream. Knowledgeable information communicated by the nurse about the sterile ice-cream and its advantages made Mr. A value himself as a co-creator in mutually designing his care to make the sterile ice-cream. Meaningful engaging: The nurse and Mr. A mutually participated in expressing caring by making the sterile ice-cream using their imagination and creativity-aesthetically expressing these through a variety of color patterned ice-cream. Mr. A was impressed and participated well in the created pleasure and happiness of sharing.
All these practice processes of aesthetics in nursing occurred within the aesthetic environment in which the nurse and Mr. A (the nursed) co-created a mutual process through the experience shared in the caring situation. Subjective domain of the aesthetic environment was the feeling of perceptions that the nurse and Mr. A had such shared happiness, while the objective domain of aesthetic environment was the visual expression achieved through the decoration with beautiful flowers on the table. Aesthetic expressions in this caring situation were visualized through the caring encounter with Mr. A sharing his value and desires to live a meaningful life.