Validation of the esthetics of nursing care scale among Iranian nurses

Abstract

Background

The role of aesthetics in nursing care is increasingly recognized as a crucial component of high-quality practice. Professional development for nurses necessitates a thorough understanding of these aesthetic dimensions. While the Esthetics of Nursing Care Scale has previously demonstrated validity from patients’ perspectives, this study aimed to evaluate its psychometric properties from nurses’ perspectives. Therefore, we evaluated the nurse version of the Esthetics of Nursing Care Scale (ENCS) among a sample of Iranian nurses, with the goal of developing a reliable scale for assessing and enhancing aesthetic knowledge in nursing practice.

Methods

This cross-sectional methodological study measured the psychometric properties of the Esthetics of Nursing Care Scale through content validity (10 experts), face validity (10 nurses), a pilot study (50 nurses), construct validity [350 nurses for exploratory factor analysis (EFA) and 200 nurses for confirmatory factor analysis (CFA) and convergent validity], and reliability (internal consistency).

Results

The nurse version of the ENCS consists of 20 items divided into five subscales: compassionate commitment and competence (4 items), stress-free care (4 items), humanistic attention to patient (3 items), patient satisfaction and comfort (5 items), and admirable commitment and competence (4 items). These subscales explained 74.5% of the concept’s variance. The CFA sufficiently confirmed the structure extracted from EFA. Convergent validity was confirmed due to the strong correlation between the ENCS and the compassion competence scale (r = 0.537). Additionally, the scale had good reliability (Cronbach’s alpha coefficient = 0.956 and Omega coefficient = 0.957).

Conclusion

The nurse version of ENCS can be utilized in clinical settings to evaluate the esthetics and quality of nursing care from nurses’ perspectives. Further research within the nursing community is recommended to confirm these results.

Clinical trial number

Not applicable.

Background

Nursing care requires the integration of professional knowledge, technical competence, and emotional sensitivity. This complex practice consists of two essential components: instrumental care, which pertains to the measurable, physical, and technical aspects, and expressive care, which addresses patients’ emotional, social, and spiritual needs [1]. In recent years, the International Nursing Association has emphasized the importance of expressive care —characterized by empathy and compassion—as a key nursing skill. Elements such as valuing the patient, integrating nursing qualities into a cohesive whole, and creatively designing holistic care plans are part of the aesthetic nursing care [2, 3]. Aesthetic philosophy is interconnected with concepts such as truth, love, life, death, God, humanity, sin, and wrongdoing, each of which can be interpreted in diverse ways. Many scholars have explored aesthetics in various subjects, including humanity, objects, and nature [4]. While aesthetic has been associated with philosophy, psychology, and the arts, it is increasingly recognized as an essential aspect of nursing because of its emphasis on emotions and feelings [5]. Aesthetics plays a vital role in nursing, and is often described as the art of nursing. The esthetics of nursing care have gained significant interest among experts, who argue that science and art are complementary, with effective nursing practice relying on both [6]. Carper describes aesthetics as the appreciation of and empathy for patients’ experiences, the aggregation of nursing qualities into a meaningful whole, and the capacity to creatively design holistic care [7, 8].

Aesthetic-based nursing care involves acknowledging the spiritual aspects of care and the nurses’ dedication to alleviating patients’ suffering. It also includes educating on the emotional aspects of patient interaction and emphasizes the importance of nurses’ skills in delivering this type of care. Aesthetic care is necessary for addressing the emotional, spiritual, psychological, and physical needs of patients [9, 10]. The spiritual needs of hospitalized patients involve building trust, showing respect, providing genuine care, and honoring patients’ religious and spiritual beliefs— qualities that exemplify the nursing care aesthetics [11]. Performing basic nursing tasks with a focus on human dignity and well-being not only enhances patient outcomes but also embodies core values of an aesthetic approach [12].

The importance of aesthetic knowledge in nursing is widely recognized, leading some experts to advocate for its integration into the nursing curriculum. Despite its significance, there has been limited focus on these concepts in nursing education, research, and practice [1].

However, efforts through quantitative and qualitative research have sought to explore these ideas. For instance, Gramling (2004) questioned, “What is art?” and then asked, “When is nursing care perceived as art?” He argued that few studies examined the art of nursing care [13]. When nurses lack the essential skills to fulfill their roles, the distinction between the art and science of nursing becomes blurred [14].This presents a significant challenge in clinical education and management, emphasizing the need for a clear definition of aesthetic knowledge. Without such clarity and active application, the true value of aesthetic care may remain unrecognized. Merely defining aesthetic-based care is insufficient; it must be operationalized and measurable to achieve meaningful outcomes [15]. Watson’s theory highlights the importance of establishing specific frameworks to assess the aesthetic aspects of nursing care [16]. Oliveri et al. (2019) reported that utilizing aesthetic-based care can significantly reduce patient distress, enhance quality of life, and improve the mental well-being of nurses, ultimately elevating the overall level of care provided [17].

Bender and Elis state that the aesthetic pattern of knowing is critical for nursing practice, yet remains weakly defined and understood. This gap has arguably relegated aesthetic knowing to an” ineffable” form of creativity that resists transparency and understanding, posing a barrier to articulating its value in nursing and its role in achieving beneficial health outcomes. Recent developments in the philosophy of science suggest that aesthetic knowing can be considered a legitimate object of scientific inquiry, with empirical scholarship providing examples of scientific inquiry into manifestations of esthetic knowing [18]. Although the science and art of nursing practice are synergistic, the worldview of nursing as an art continues to evolve [19].

In today’s healthcare environment, heavy workloads and the increasing integration of technology into nursing practice have, unfortunately, contributed to a gradual diminishment of the art of nursing because nurses have less time to engage in it [20]. Donahue (2011) emphasized that the lost art of nursing is experiencing a revival, accompanied by new claims and demands. Now is the time to explore the evidence supporting the aesthetic and artistic aspects of nursing, which are rooted in knowledge, dedication, and spirituality [21]. However, research has highlighted the significance of education in aesthetic-based nursing care. For instance, Mohammadi and Radmehr (2020) examined the relationship between aesthetic-based care and self-compassion of nurses, finding that increased feelings of isolation among nurses corresponded with a decline in the quality of aesthetic care [22]. Radmehr et al. (2015) explored clients’ perceptions of the art of nursing through unstructured interviews with 12 patients. Participants reported that aesthetic-based nursing care encompasses both spiritual and visible aspects, fostering a sense of unity and empathy between nurses and clients, and helping to alleviate the challenges of illness by creating feelings of satisfaction and comfort [23]. Oliveri et al. (2019) demonstrated that aesthetic-based care can effectively reduce distress and enhance the quality of life for cancer patients [17].

Additionally, Shahmohammadi et al. (2024) reported that education in aesthetic-based care positively influences nurses’ perceptions of end-of-life care for cancer patients, suggesting that designing aesthetic-based care training programs can enhance nurses’ perception of end-of-life care [12]. Our literature review revealed no specific measurement tool for assessing aesthetic-based care from the perspective of nurses. While Radmehr et al. (2017) developed and validated the Esthetics of Nursing Care Scale (ENCS) from the perspective of patients, no comparable scale exists for nurses [24]. To address this gap, this study aimed to validate the ENCS from the perspective of nurses. Additionally, our research team searched databases such as Magiran, SID, Irandoc, as well as international databases like Medline, PubMed, ProQuest, and Science Direct, and found no precise measuring tool that aligns with Iranian culture and meets the needs of Iranian patients. Consequently, this study aimed to evaluate the psychometric properties, reliability, and validity of the Esthetics of Nursing Care Scale from the perspective of nurses.

Materials and methods

Study design and setting

This cross-sectional methodological study aimed to examine the validity and reliability of the ENCS. The research setting was four teaching hospitals affiliated with Kerman University of Medical Sciences in southeastern Iran.

Participants, sample size, and sampling

The statistical population included all nurses working in above hospitals in Kerman between April 1st and July 30th, 2024. The total number of nurses was approximately 6,500. Convenience sampling was used. Inclusion criteria included having a minimum of one year of work experience with permanent, contractual, committed to service, or corporate contract employment statuses. Exclusion criterion was incomplete questionnaires (more than 10%).

The number of participants for each stage of the study was as follows: (1) Qualitative face validity: 10 nurses, (2) Quantitative face validity: 10 nurses, (3) Qualitative content validity: 10 experts, (4) Quantitative content validity: 10 experts, (5) Pilot study (for internal consistency assessment before exploratory factor analysis): 50 nurses, (6) Exploratory factor analysis: 350 nurses, and (7) CFA and convergent validity: 200 nurses. Additionally, 37 questionnaires were excluded due to failure to meet inclusion criteria, misleading information, and missing values.

Measures

This study used a demographic information form, the Esthetics of Nursing Care Scale (ENCS), and the Compassion Competence Scale.

The demographic information form included information such as age, gender, marital status, education level, years of work experience, position, and shift type.

The Esthetics of Nursing Care Scale (ENCS) was developed by Radmehr et al. (2017) to assess the quality of aesthetic behaviors in nursing care based on patients lived experiences. The initial items were generated from insights gathered through in-depth interviews with patients and nurses in hospitals, as well as a thorough review of relevant studies and tools that measure various aspects of nursing care quality [23, 24]. The ENCS includes 37 items with four subscales: Admirable and compassionate commitment and competence (16 items): This subscale measures caring, kindness, and competency in dealing with difficulties or perceived inadequacies to alleviate suffering, which are crucial for mental health, Patient satisfaction and comfort (8 items), Humanistic attention to the patient (8 items), Stress-free care (3 items with negative loadings; scores are reversed). The intra-class correlation coefficient and Pearson correlation of the ENCS with the Caring Behaviors Inventory were 0.84 and 0.84, respectively (p > 0.001). The Cronbach’s alpha coefficient was 0.96, and the intra-class correlation coefficient was 0.93. Responses are scored on a 6-point Likert scale from never (0) to always (5). The total score ranges from 0 to 185, with higher scores indicating higher quality of care [24].

The Compassion Competence Scale, developed by Lee and Seomun (2016), is a self-report tool for measuring the level of compassion competence from the perspective of nurses. This scale consists of 17 items with three subscales: communication (8 items, e.g., “I know how communicating with patients encourages them.”), sensitivity (5 items, e.g., “I am fully aware of changes in patients’ emotional states.”), and insight (4 items, e.g., “Because of my diverse clinical experiences, I have a positive view of patients.”). Scores for each item range from 1 (strongly disagree) to 5 (strongly agree). The total score is calculated as the average of all item responses. Concurrent validity was established through correlations with the Emotional Competence Scale and the Compassionate Love Scale, ranging from 0.29 to 0.68. Additionally, reliability analysis indicated a Cronbach’s alpha coefficient of 0.91 for the entire scale, with subscale values of 0.88 for the communication, 0.77 for sensitivity, and 0.73 for insight. Test-retest reliability was 0.80 [25]. In Iran, Niroomandan and Ahi validated (2020) this scale culturally. They reported favorable content validity and content validity index values. Exploratory factor analysis confirmed a three-factor structure accounting for 60.53% of the total variance. The test-retest reliability coefficients for the three factors were 0.74, 0.69, and 0.80, with Cronbach’s alpha values of 0.810, 0.76, and 0.90, and composite reliability scores of 0.84, 0.78, and 0.93, respectively. The examination of internal consistency showed correlations between the overall score of the Compassion Competence Scale and the subscales, yielding scores of 0.76, 0.77, and 0.81, respectively. Furthermore, a significant negative correlation was found between compassionate competence, burnout, and secondary traumatic stress, while a significant positive correlation was observed with compassion satisfaction [26].

Procedure, data collection, and data analysis

Face validity

Two qualitative and quantitative methods were used to determine face validity. In order to determine the qualitative face validity, 10 nurses were interviewed face-to-face and the level of difficulty, relevancy, and ambiguity of items were investigated. For quantitative face validity, the Item Impact Method was used to reduce and remove inappropriate items and determine the importance of each item. Items with the impact score of 1.5 or more remained for further analysis [27].

Content validity

To ensure content validity, we engaged 10 experts in both qualitative and quantitative assessments. The experts provided feedback on content coverage, grammar, appropriate statements, and item placement. We used the Waltz & Bausell content validity index to calculate the content validity index (CVI). The item-content validity index (I-CVI) was determined by the number of experts rating an item as relevant (3 or 4) divided by the total number of experts [28]. To calculate Scale-CVI (S-CVI), the mean content validity index of all items was used. The I-CVI of 0.8 and the S-CVI of ≥ 0.9 were acceptable [29].

Validation of items in a pilot sample

The initial scale was tested on a pilot sample of 50 nurses using a convenience sampling method. Item analysis included examining the percentage of responses to each item, identifying missing values, calculating central tendency and dispersion indices, assessing variability skewness and kurtosis indices, and checking for the floor and ceiling effects [30]. Items with more than 15% missing values were deleted, revised, or replaced [31]. Individual respondents with more than 20% missing values were excluded [32]. Skewness values outside the range of ± 2 were considered significant [33], and the total score of skewness should fall between − 1 and 1 [34]. Skewness values outside the range of ± 4 indicated kurtosis [35], with an acceptable range of ± 8 for individual item kurtosis [36]. If more than 80% of the samples selected the highest or the lowest option on the Likert scale, the ceiling or floor effect was taken into account, and the corresponding item was removed. The floor and ceiling effects were calculated for the entire instrument and individual items. If more than 80% of the samples received the maximum or minimum scores, the level of floor and ceiling effects was unacceptable [37]. Additionally, the initial reliability of the tool was measured by calculating the internal consistency using Cronbach’s alpha. Item analysis was conducted, including Inter Item Correlation and Item Total Correlation. The change in alpha was examined when each item was removed. Items with Corrected Item Total Correlation below 0.3 were removed [38].

Construct validity

The instrument was tested on a large sample representing the community in order to calculate the construct validity and reliability. This study selected 550 nurses using the convenience sampling to complete the scale. In the current study, structural validity and convergent validity were used to measure construct validity.

Structural validity

To ensure structural validity, both exploratory and confirmatory factor analyses were carried out. The exploratory factor analysis involved factor extraction through principal component analysis (PCA), principal axis factoring, and maximum likelihood methods. Item rotation was done using Varimax and Promax rotation methods [38–42]. The number of factors was determined based on eigenvalues < 1, scree plots, and items loading ≥ 0.4 on each factor [39, 42, 43]. The optimal extraction method was found to be principal axis factoring (PAF) with Promax rotation.

CFA was conducted to assess the derived structure using indices such as χ2/df, GFI, AGFI, CFI, IFI, NFI, and RMSEA. An acceptable model fit was indicated by a χ2/df ratio below 3.0 and an RMSEA value below 0.08 [44, 45]. Additionally, GFI, AGFI, CFI, IFI, and NFI values were considered acceptable if they were ≥ 0.9 [46, 47]. Convergent validity was assessed by calculating Composite Reliability (CR) and Average Variance Extracted (AVE), with the thresholds of ≥ 0.7 and ≥ 0.5 respectively, and CR > AVE [48]. Discriminant validity was examined through the calculation of Maximum Shared Variance (MSV) and Average Shared Variance (ASV) were calculated, which should be < AVE to confirm distinct factors. In addition, Heterotrait-Monotrait Ratio (HTMT) was calculated. HTMT should be < 0.85–0.90 to confirm distinct factors [49].

Convergent validity

Convergent validity is the extent to which a measure correlates with other measures or tasks that assess the same construct [50]. This study used the Compassion Competence Scale, and 200 nurses completed both scales. Convergent validity was confirmed by a Spearman correlation coefficient greater than 0.4 [51].

Reliability

Internal consistency (Cronbach alpha and McDonald omega coefficient) was used to determine the reliability. In this study, the internal consistency of the scale was measured in two steps: first with 50 samples before factor analysis, and then with 350 samples after factor analysis. A Cronbach’s alpha and McDonald’s Omega coefficients above 0.9 were considered excellent, 0.7–0.9 as good, 0.5–0.7 as moderate, and below 0.5 as unacceptable [52, 53]. SPSS v.26 and AMOS v.26 were used for data analysis.

Results

Face validity

Ten nurses were interviewed face-to-face, and all participants found the items appropriate without any need for changes. The item impact was calculated, revealing that only one item (Item 26) had a score below 1.5. No items were removed at this stage, and the 37-item scale was prepared for the next phase (Table 1).

Table 1.

Face and content validity indexes and item analysis based on a pilot study on 50 nurses

Items	Item impact score (n = 10)	Content validity index (n = 10)	Pilot study (n = 50)
			Corrected item-total correlation	Cronbach’s alpha in case of item deletion	Floor/ceiling effect (%)	Skewness	Kurtosis
1. The nurse takes into account the patient’s religious beliefs when caring for them.	3.78	1.0	0.107	0.972	38/4	-1.087	0.150
2. In addition to physical care, the nurse also pays attention to the patient’s mental state.	3.87	0.9	0.724	0.968	48/0	-1.039	0.346
3. The nurse helps the patient voluntarily.	3.28	0.9	0.557	0.968	36/0	-0.602	-0.499
4. The nurse respects the patient’s cultural customs and traditions.	3.2	1.0	0.648	0.968	40/0	-0.806	0.178
5. The nurse’s behavior towards others shows that human health is valuable to them.	4.6	0.9	0.480	0.968	60/0	-1.025	-0.116
6. The nurse shows their feelings and emotions in speech and behavior towards the patient.	3.78	1.0	0.657	0.968	56/0	-1.276	0.824
7. The nurse kindly cares for the patient.	3.78	1.0	0.681	0.968	52/0	-1.102	0.535
8. If the nurse encounters a problem during care (such as injections, bandages, etc.), they humbly seek help from their colleagues.	4.4	1.0	0.525	0.968	46/0	-0.522	-0.590
9. The nurse’s behavior during care does not cause further suffering or distress to the patient.	1.5	1.0	0.391	0.970	44/2	-1.281	0.766
10. The nurse has the ability to communicate with all patients with different mental conditions (older adults, depressed patients, even nervous patients).	3.78	1.0	0.690	0.968	30/0	-0.497	-0.728
11. The nurse’s behavior makes the hospital environment tolerable for the patient.	3.28	1.0	0.584	0.968	30/2	-1.171	1.408
12. The nurse’s communication with the patient brings joy and a smile to the patient.	2.87	1.0	0.683	0.968	38/2	-0.995	0.442
13. Listening and talking to the patient reduces their pain and suffering.	3.96	0.9	0.681	0.968	34/2	-1.019	1.058
14. The nurse keeps despair and hopelessness away from the patient.	4.1	1.0	0.754	0.967	28/2	-1.044	1.831
15. The nurse helps the patient feel better about themselves and their illness.	3.2	1.0	0.707	0.968	30/2	-0.748	-0.141
16. The nurse’s behavior during care accelerates the patient’s recovery.	4.4	1.0	0.746	0.967	26/6	-0.408	-0.373
17. The nurse tries to provide comfort to the patient in any situation.	3.78	1.0	0.807	0.967	32/0	-0.483	-0.739
18. The nurse’s behavior makes the patient think less about their discomforts.	2.66	1.0	0.768	0.967	26/0	-0.631	0.061
19. The nurse calmly and skillfully tries to make the patient feel lower pain in painful procedures (such as injections).	4.5	1.0	0.812	0.967	32/0	-0.499	-0.511
20. The nurse is the best guide for the patient when needed.	3.96	1.0	0.805	0.967	30/0	-0.422	-0.591
21. The nurse prioritizes meeting the essential needs of patients over other issues.	3.12	1.0	0.678	0.968	38/0	-0.339	-1.111
22. The nurse cares for the patient as if they are one of their close family members.	3.04	1.0	0.706	0.968	38/0	-0.598	-0.751
23. The patient can easily communicate their needs and desires to the nurse.	2.87	1.0	0.704	0.968	34/0	-0.250	-1.043
24. The nurse performs their caregiving duties compassionately.	4.5	1.0	0.774	0.967	52/0	-1.114	0.402
25. The nurse regularly checks on patients and is easily accessible to them.	3.69	1.0	0.669	0.968	40/0	-0.713	-0.335
26. The nurse does not show a negative or aggressive reaction towards patients’ aggression.	0.54	1.0	0.623	0.968	34/0	-0.777	-0.349
27. The nurse can be a good source of patience for patients when needed.	1.9	1.0	0.770	0.967	36/0	-0.482	-0.744
28. The nurse tries to address and follow up on patients’ problems as much as possible.	3.78	1.0	0.784	0.967	30/0	-0.827	0.551
29. The nurse’s interest in caring for and following up on patients has a significant impact on patient recovery.	3.78	0.9	0.770	0.967	38/2	-0.934	1.326
30. The nurse tries to provide the best care based on the patients’ physical and mental conditions.	4.5	1.0	0.734	0.968	42/0	-0.678	-0.241
31. The nurse is willing to sacrifice their own comfort for the patients.	2.22	0.9	0.690	0.968	36/2	-0.598	-0.272
32. The nurse’s patience and tolerance exceed expectations.	2.22	0.8	0.701	0.968	50/0	-0.993	0.180
33. The nurse provides care for the patient well considering the conditions and available resources.	4.1	1.0	0.733	0.968	48/0	-0.480	-1.354
34. The nurse aesthetically takes care of the patient/client.	3.51	0.9	0.794	0.967	42/2	-1.177	1.058
35. The patient enjoys the way the nurse takes care of them.	3.2	1.0	0.832	0.967	24/0	-0.546	-0.064
36. The nurse’s help to the patient is admirable and cannot be described in words.	4.14	0.9	0.728	0.967	54/0	-1.118	0.413
37. Reminding the patient/client of the nurse’s care is pleasant.	1.92	0.9	0.761	0.967	42/0	-0.803	-0.314

Content validity

Ten experts, including three with master’s and seven with Ph.D degrees in nursing, reviewed the scale. Minor changes were made to most of the items based on the experts’ feedback. The same ten experts determined the Content Validity Index (CVI). The CVI for all items was found to be higher than 0.8, with the CVI for the entire scale being 0.946. Therefore, no items were removed during this phase (Table 1).

Item analysis (pilot test)

After establishing the face and content validities, 50 nurses completed the scale. The mean age of the pilot sample was 34.28 ± 8.98 years, with ages ranging from 23 to 53 years. Participants had 6.83 years of work experience, with a minimum of one year and a maximum of 18 years. Most of the participants were married (70.0%), held a bachelor’s degree (92.0%), worked as nurses (84.0%), and were on rotating shifts (76.0%).

At this stage, items exhibiting floor or ceiling effects above 80%, a Corrected Item-Total Correlation below 0.3, skewness of ± 2, or kurtosis of ± 2 or more were identified. Only one item (Item 1) had a Corrected Item-Total Correlation of less than 0.3; all other items were within acceptable ranges. Consequently, Item 1 was removed for the next phase of analysis (Table 1). The Cronbach’s alpha at this phase was 0.972.

Construct validity

The current study used structural validity and convergent validity to measure construct validity.

Structural validity

A total of 350 nurses working in hospitals affiliated with Kerman University of Medical Sciences participated in this phase of the study and completed the scale. No questionnaires were removed due to missing data. The mean age of participants was 36.14 years, with an average work experience of 11.97 years. The majority of the sample consisted of female, married nurses with undergraduate degrees (Table 2). At this phase, none of the items exhibited ceiling or floor effects above 80%, nor did they show skewness or kurtosis rates of ≥ + 2 or ≤ -2. Consequently, an EFA was conducted on the 36-item scale.

Table 2.

Demographic characteristics of the nurses participating in the research

	Exploratory factor analysis (n = 350)	Confirmatory factor analysis (n = 200)
Quantitative Variables	Mean ± Standard deviation	Mean ± Standard deviation
Age (years)	36.14 ± 8.89	36.75 ± 8.87
Work experience (years)	11.97 ± 8.08	12.63 ± 8.53
Qualitative Variables	Frequency (%)	Frequency (%)
Sex
Male	75 (21.4)	45 (22.5)
Female	275 (78.6)	155 (77.5)
Marital Status
Single	110 (31.4)	50 (25.0)
Married	221 (63.2)	143 (71.5)
Divorced	14 (4.0)	6 (3.0)
Widowed	5 (1.4)	1 (0.5)
Education
B.Sc.	304 (86.9)	175 (87.5)
M.Sc. and above	46 (13.1)	25 (12.5)
Employment status
Permanent	208 (59.4)	118 (59.0)
Contractual	39 (11.1)	19 (9.5)
Corporate contract	45 (12.9)	22 (11.0)
Committed to service	58 (16.6)	41 (20.5)
Position
Head Nurse	44 (12.6)	17 (8.5)
Staff nurse	18 (5.1)	17 (8.5)
Nurse	288 (82.3)	166 (83.0)
Shifts
Fixed	81 (23.1)	24 (12.0)
Rotating	269 (76.9)	176 (88.0)

Subsequently, 200 additional nurses participated to perform a CFA. Again, no questionnaires were removed due to missing data. The mean age of this group was 36.75 years, with an average work experience of 12.63 years. Like the previous sample, the majority of the participants were female, married, and held undergraduate degrees (Table 2).

Exploratory factor analysis

There was no missing data. Following EFA using various extraction and rotation methods, the results with PAF and Promax Rotation were identified as the most interpretable and provided optimal item placement. Bartlett’s test of sphericity was statistically significant (χ² = 8567.486, df = 406, p < 0.001), and the Kaiser-Meyer-Olkin (KMO) coefficient was 0.956, indicating the adequacy of the correlation matrix for factor analysis.

Five distinct factors were identified for this scale, accounting for 73.332% of the total variance. The factors consisted of 9, 5, 5, 6, and 4 items, respectively (Table 3). Following the exploratory factor analysis, seven items were removed, reducing in a total number of 29 items. Items #8, 9, 10, and 21 did not load onto any factor. Item #26 had low communality (initial = 0.426 and extraction = 0.346), while items #7 and 33 showed cross loading.

Table 3.

Rotated factor matrix of the esthetics of nursing care scale (n = 350)

Items	Factor load					Communalities
	Factor 1	Factor 2	Factor 3	Factor 4	Factor 5	Initial	Extraction
2. In addition to physical care, the nurse also pays attention to the patient’s mental state.			0.728			0.664	0.699
3. The nurse helps the patient voluntarily.			0.794			0.614	0.649
4. The nurse respects the patient’s cultural customs and traditions.			0.892			0.620	0.658
5. The nurse’s behavior towards others shows that human health is valuable to them.			0.725			0.657	0.678
6. The nurse shows their human feelings and emotions in speech and behavior towards the patient.			0.539			0.625	0.631
11. The nurse’s behavior makes the hospital environment tolerable for the patient.		0.799				0.642	0.650
12. The nurse’s communication with the patient brings joy and a smile to the patient.		0.765				0.673	0.660
13. Listening and talking to the patient reduces the patient’s pain and suffering.		0.821				0.623	0.612
14. The nurse keeps despair and hopelessness away from the patient.		0.749				0.803	0.795
15. The nurse helps the patient feel better about themselves and their illness.		0.699				0.794	0.790
16. The nurse’s behavior during care accelerates the patient’s recovery.				0.955		0.729	0.756
17. The nurse tries to provide comfort to the patient in any situation.				0.817		0.776	0.781
18. The nurse’s behavior makes the patient think less about their discomforts.				0.807		0.739	0.756
19. The nurse calmly and skillfully tries to make the patient feel lower pain in painful procedures (such as injections).				0.592		0.688	0.653
20. The nurse is the best guide for the patient when needed.				0.440		0.600	0.526
22. The nurse cares for the patient as if they are one of their close family members.				0.558		0.728	0.715
23. The patient can easily communicate their needs and desires to the nurse.	0.575					0.636	0.516
24. The nurse performs their caregiving duties compassionately.	0.814					0.730	0.695
25. The nurse regularly checks on patients and is easily accessible to them.	0.528					0.655	0.596
27. The nurse can be a good source of patience for patients when needed.	0.744					0.729	0.702
28. The nurse tries to address and follow up on patients’ problems as much as possible.	0.910					0.726	0.704
29. The nurse’s interest in caring for and following up on patients has a significant impact on patient recovery.	0.608					0.709	0.656
30. The nurse tries to provide the best care based on the patients’ physical and mental conditions.	0.845					0.747	0.759
31. The nurse is willing to sacrifice their own comfort for the patients.	0.862					0.717	0.693
32. The nurse’s patience and tolerance exceed expectations.	0.759					0.608	0.551
34. The nurse aesthetically takes care of the patient/client.					0.616	0.715	0.701
35. The patient enjoys the way the nurse takes care of them.					0.662	0.683	0.683
36. The nurse’s help to the patient is admirable and cannot be described in words.					0.782	0.666	0.703
37. Reminding the patient/client of the nurse’s care is pleasant.					0.844	0.699	0.753
Eigenvalue	15.373	2.107	1.373	2.281	1.132
Explained variance	53.010	7.265	4.735	4.416	3.905
Cumulative variance	73.332

Item 1 was removed in the pilot phase and items 7, 8, 9, 10, 21, 26, and 33 were removed in the EFA phase

Comfirmatory factor analysis and convergent and discriminant validity

After identifying a five-factor solution through EFA, CFA was conducted to further test the derived factor model. First-order CFA models and goodness-of-fit indices were used to assess how well the data aligned with the hypothesized models. All factor loadings were significant (p < 0.001). Following the application of several modification indices, and removing nine problematic items with very high standardized residual covariances (i.e., Items #3, 4, 12, 20, 24, 25, 29, 30, and 32), the χ2-associated p-value was still below the significance level of 0.05 (χ² = 315.7, df = 153, p < 0.001). While the PCMIN/DF ratio (χ²/df = 2.063), RMSEA = 0.073, CFI = 0.928, IFI = 0.929 were within the acceptable range, other fit indices were not satisfactory: GFI = 0.861, AGFI = 0.809, and NFI = 0.872. Therefore, as the four indices are acceptable, and the three are borderline, the CFA model can confirm the structure identified in the exploratory factor analysis. Therefore, the final scale consists of 20 items with five factors: the first factor with 4 items (#items 23, 27, 28, and 31), the second factor with 4 items (#items 11, 13, 14, and 15), the third factor with three items (#items 2, 5, and 6), the fourth factor with 5 items (#items 16, 17, 18, 19, and 22), and the fifth factor with 4 items (#items 34, 35, 36, 37) (Fig. 1).

Fig. 1.

The confirmatory factor analysis of the ENCS

Furturmore, we checked the convergent and discriminant validity of the factors in CFA model. All AVE values were ≥ 0.50, and CR values were ≥ 70, confirming convergent validity. Both ASV and MSV values were lower than AVE (Table 4). In addition, the HTMT Ratio was calculated for all factors, with only the F2◊ F4 ratio reaching 0.891; all other ratios ragned from 0.335 (F1◊F2) to 0.799 (F3◊ F4). These results support, the disciminant validity of the model.

Table 4.

Findings of convergent and discriminant validity

	Total score		AVE	CR	MSV	ASV
	R	P-value
Factor 1	0.650	< 0.001	0.666	0.824	0.433	0.313
Factor 2	0.856	< 0.001	0.798	0.857	0.819	0.535
Factor 3	0.701	< 0.001	0.741	0.755	0.659	0.430
Factor 4	0.839	< 0.001	0.666	0.828	0.819	0.606
Factor 5	0.764	< 0.001	0.724	0.818	0.568	0.438

R: Spearman’s rank correlation coefficient; AVE: average variance extracted; CR: composite reliability; MSV: Maximum Shared Variance; ASV: Average Shared Variance

Convergent validity

To ensure convergent validity, 200 nurses who completed the scale in the construct validity section also completed the Compassion Competence Scale. According to this study, the Spearman correlation coefficient between the Compassion Competence Scale and the Esthetics of Nursing Care Scale ranged from 0.337 to 0.537; thus, the convergent validity was confirmed (Table 5).

Table 5.

Correlation between the esthetics of nursing care scale and the compassion competence scale (N = 200)

Esthetics of nursing care scale	Nurses’ compassion competence scale
	r	P value
Factor 1	0.427	< 0.001
Factor 2 Factor 3	0.477	< 0.001
	0.396	< 0.001
Factor 4	0.434	< 0.001
Factor 5	0.337	< 0.001
Total	0.537	< 0.001

Reliability

The reliability of the 20-item scale was assessed using Cronbach’s alpha and McDonald’s omega coefficients in a sample of 350 participants. The Cronbach’s alpha was 0.956 for the overall scale and above 0.90 for all subscales. The McDonald’s omega coefficient was 0.957 for the entire scale and above 0.90 for all subscales (Table 6).

Table 6.

The cronbach’s alpha and mcdonald’s Omega coefficients of the esthetics of nursing care scale

Subscales	Cronbach’s alpha correlation coefficient	McDonald’s omega correlation coefficient
Factor 1	0.872	0.875
Factor 2	0.901	0.901
Factor 3	0.843	0.843
Factor 4	0.920	0.922
Factor 5	0.898	0.899
Total Scale	0.956	0.957

Practicability

Totally 37 quessionares were excluded; therefore, the valid response rate was 98.56%. The average response time to completing the scale was 10 min (Min = 2 min and Max = 12 min).

Final version of the scale and scoring

The 20-item nurse version of ENCS has five subscales: compassionate commitment and competence (4 items), stress-free care (4 items), humanistic attention to patient (3 items), patient satisfaction and comfort (5 items), and admirable commitment and competence (4 items). The response range of the scale includes never = 0, rarely = 1, sometimes = 2, often = 3, most of the times = 4, and always = 5. There are no inverse items in the scale. The minimum score of the scale is zero and the maximum score is 100.

Discussion

This study presented a comprehensive psychometric evaluation of the nurse version of ENCS, which encompasses five key subscales: compassionate commitment and competence, patient satisfaction and comfort, stress-free care, humanistic attention to patient, and admirable commitment and competence. The psychometric evaluation utilized various methods, including content validity, face validity, and construct validity through exploratory and confirmatory factor analyses, as well as Cronbach’s alpha and McDonald’s omega to assess reliability, highlighting the scale’s robustness. Furthermore, the scale’s correlation with the Compassion Competence Scale confirms its convergent validity. Mohammadi and Radmehr (2020) studied the correlation between self-compassion and the quality of aesthetic-based care among nurses, suggesting that nurses with higher self-compassion tend to provide more aesthetical care. This finding highlights the importance of incorporating psychological factors into the design of aesthetic assessment tools [54]. While Kyde prefers qualitative approaches for identifying nursing care factors, Watson also advocates for the inclusion of quantitative methods. She believes that many quantitative studies face methodological issues or have insufficient sample sizes [55].

A well-designed quantitative study with an adequate sample size allows for the application of analytical techniques like factor analysis, which can uncover hidden structures or multivariate factors. Watson (2009) argues that nursing care research should clearly focus on empirical criteria [56].

Khalil Al-Soufi et al. (2024) highlighted the necessity of a valid and standardized tool for assessing the aesthetic-based nursing care for both patients and their families. They measured the psychometric properties of the ENCS in Iraq and found that the scale demonstrated adequate validity and reliability after removing one item. This scale can be utilized by researchers to measure the aesthetic quality of nursing care [57].

The results of current study closely align with that of other qualitative research focused on key concepts and practical aesthetics in nursing care. These findings are consistent with nursing theories. For example, a study in Japan analyzed semi-structured interviews with nurses and found that they prioritized aesthetic aspects such as creating a calm and pleasant environment, paying attention to details in care, and respecting patients’ values and preferences. The researchers emphasized that incorporating aesthetic approaches into nursing practice can enhance patients’ experiences and satisfaction, serving as an effective strategy for improving the overall quality of care [58].

Kongsuwan et al. (2024) identified six key thematic categories reflecting aesthetics in nursing care from children’s perspectives during hospitalization. These categories included enjoyment, kindness, impressive care, appreciation of safeness, intention to know children, and connecting others [59]. Similarly, a study examining nurses’ perspectives on aesthetics in nursing practice in Indonesia identified four thematic categories: compassionate care, the art of communication, pain relief, and innovation in care. This highlights that aesthetic in nursing goes beyond visual appearance and involves creating a caring environment through thoughtful communication, effective pain management, and innovative approaches to patient care [60].

Black (2018) examined three main themes related to the ethics and aesthetics of care: the embodied linguistic constitution of care, the performance of care, and exlusion from care. He underscored the importance of embodied communication in constitution of ethical care and argued that these processes reveal common ethical-aesthetic processes that are shared across various social and cultural contexts [61].

The scale developed in this study, compared to other care-related questionnaires, focuses on aesthetics in nursing care, which leads to a more operational and transparent definition of this aspect for healthcare providers in clinical practice. For example, the Quality Patient Care Scale (QUALPAC) emphasizes technical aspects of care and pays less attention to emotional and aesthetic aspects [17]. Similarly, the Caring Nurse-Patient Interaction Scale, based on Watson’s theory of human caring, includes ten subscales measuring the impact of care on patients but does not address aesthetic or operational aspects of care [62, 63]. Kong et al. (2023) examined aesthetic attitude based on Kant’s aesthetics of caring relationships in nursing and found that nurses who are trained in and apply aesthetic attitude can serve as ethical agents, promoting human dignity in caring relationships. The authors suggested that incorporating Kant’s aesthetic principles into nursing practice can enhance patient care experiences and the overall quality of healthcare [64].

Aesthetics in nursing care is crucial for nurse-patient interactions, impacting the quality of care, reducing patient stress, and enhancing the therapeutic experience. This concept, combining art and science, highlights the importance of nurses’ technical skills, emotional and empathetic aspects, and understanding of patients’ needs. Recent research indicates that nurses who prioritize aesthetics in their practice develop stronger patient relationships and improve healthcare quality [3].

A major challenge in the aesthetic nursing care is the absence of standardized definitions and reliable measurement tools. Research has revealed varying interpretations of the concept, making evaluation challenging due to the lack of clear theoretical frameworks (MohammadiFesharaki & Radmehr, 2020). Cultural differences further complicate matters, as some cultures value a close nurse-patient relationship, while others prioritize maintaining professional distance. To address these challenges, definitions and assessment criteria must be tailored to accommodate these cultural differences [22].

Limitations

One of the main limitations of this study is the use of self-report measures, which may lead to social desirability bias. Nurses might have unintentionally provided responses that reflect ideal or socially acceptable behaviors rather than their actual clinical practices. Although we took several steps to minimize this bias—such as ensuring anonymity, maintaining confidentiality, and presenting the study’s purpose in a non-evaluative manner—the possibility of such bias cannot be entirely eliminated. Therefore, future studies should consider using mixed-method approaches, such as direct observation or peer assessments, to validate self-reported data and enhance the reliability of the finding. Finally, while most of indices in the CFA were acceptable, some were not within the acceptable range; therefore, the construct validity of the scale should be examined in future studies with a larger sample size.

Conclusion

The concept of aesthetic in nursing care is crucial for enhancing the patient experience and improving the quality of care services. The nurse version of ENCS, validated in this research, covers various aspects of aesthetic in nursing care and is suitable for clinical and educational settings. To enhance the credibility of this scale, further studies are suggested to validate its factor structure and explore its correlation with other established assessment tools. Moreover, offering training programs that leverage nurses’ practical expertise can empower them to improve their aesthetic abilities, ultimately enhancing the overall patient experience. The scale comprises 20 items with five subscales of compassionate commitment and competence, stress-free care, patient satisfaction and comfort, humanistic attention to patient, and admirable commitment and competence. The findings suggested that the nurse version of ENCS is a reliable and valid tool for identifying and measuring aesthetic-based care in healthcare settings, especially among nurses.

Abbreviations

ENCS

Esthetics of Nursing Care Scale

EFA

Exploratory factor Analysis

CFA

Confirmatory Factor Analysis

CVI

Content Validity Index

I-CVI

Item-Content Validity Index

PCA

Principal Component Analysis

KMO

Kaiser-Meyer-Olkin

GFI

Goodness-of-Fit Index

AGFI

Adjusted Goodness-of-Fit Index

CFI

Comparative Fit Index

IFI

Incremental Fit Index

NFI

Normed Fit Index

RMSEA

Root Mean Square Error of Approximation

CR

Composite Reliability

AVE

Average Variance Extracted

MSV

Maximum Shared Variance

ASV

Average Shared Variance

HTMT

Heterotrait-Monotrait Ratio

Author contributions

MR, MD, JF, and SKS contributed to conceiving and designing the research. Data was collected by MB. Data analysis and interpretation were made by MR, SKS, and MD, who also participated in data interpretation. MB conducted the intervention. SKS, MD, SFE, and AT participated in drafting the manuscript. MR, MD, JF, and SKS revised the manuscript critically for important intellectual content and final approval of the manuscript. All authors read and approved the final manuscript.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Data availability

The data are available upon request to the corresponding author after signing appropriate documents in line with ethical application and the decision of the Ethics Committee.

Declarations

Ethics approval and consent to participate

The Ethics Committee of Kerman University of Medical Sciences approved the study (IR.KMU.REC.1403.135). At the request of the ethics committee, the study was conducted in accordance with the Declaration of Helsinki and Ethics Publication on Committee (COPE). Each participant signed an informed consent during the research process and was informed of the study objectives, the way of cooperation, the method of data collection and recording, the role of the researcher and the participants, and their voluntary participation and privacy. All interviews’ time and places were arranged according to the participants’ preference. All methods were carried out in accordance with relevant guidelines and regulations.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.