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APA style
300 words
10% maximum plagiarism
Mrs. Smith was a 73-year-old widow who lived alone with no
significant social support. She had been suffering from
emphysema for several years and had had frequent
hospitalizations for respiratory problems. On the last hospital
admission, her pneumonia quickly progressed to organ failure.
Death appeared to be imminent, and she went in and out of
consciousness, alone in her hospital room. The medical-surgical
nursing staff and the nurse manager focused on making Mrs.
Smith’s end-of-life period as comfortable as possible. Upon
consultation with the vice president for nursing, the nurse
manager and the unit staff nurses decided against moving Mrs.
Smith to the palliative care unit, although considered more
economical, because of the need to protect and nurture her
because she was already experiencing signs and symptoms of
the dying process. Nurses were prompted by an article they read
on human caring as the “language of nursing practice” (Turkel,
Ray, & Kornblatt, 2012) in their weekly caring practice
meetings.
The nurse manager reorganized patient assignments. She felt
that the newly assigned clinical nurse leader who was working
between both the medical and surgical units could provide
direct nurse caring and coordination at the point of care
(Sherman, 2012). Over the next few hours, the clinical nurse
leader and a staff member who had volunteered her assistance
provided personal care for Mrs. Smith. The clinical nurse leader
asked the nurse manager whether there was a possibility that
Mrs. Smith had any close friends who could “be there” for her
in her final moments. One friend was discovered and came to

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say goodbye to Mrs. Smith. With help from her team, the
clinical nurse leader turned, bathed, and suctioned Mrs. Smith.
She spoke quietly, prayed, and sang hymns softly in Mrs.
Smith’s room, creating a peaceful environment that expressed
compassion and a deep sense of caring for her. The nurse
manager and nursing unit staff were calmed and their “hearts
awakened” by the personal caring that the clinical nurse leader
and the volunteer nurse provided. Mrs. Smith died with caring
persons at her bedside, and all members of the unit staff felt
comforted that she had not died alone.
Davidson, Ray, and Turkel (2011) note that caring is complex,
and caring science includes the art of practice, “an aesthetic
which illuminates the beauty of the dynamic nurse-patient
relationship, that makes possible authentic spiritual-ethical
choices for transformation—healing, health, well-being, and a
peaceful death” (p. xxiv). As the clinical nurse leader and the
nursing staff in this situation engaged in caring practice that
focused on the well-being of the patient, they simultaneously
created a caring-healing environment that contributed to the
well-being of the whole—the emotional atmosphere of the unit,
the ability of the clinical nurse leader and staff nurses to
practice caringly and competently, and the quality of care the
staff were able to provide to other patients. The bureaucratic
nature of the hospital included leadership and management
systems that conferred power, authority, and control to the
nurse manager, the clinical nurse leader, and the nursing staff in
partnership with the vice president for nursing. The actions of
the nursing administration, clinical nurse leader, and staff
reflected values and beliefs, attitudes, and behaviors about the
nursing care they would provide, how they would use
technology, and how they would deal with human relationships.
The ethical and spiritual choice making of the whole staff and
the way they communicated their values both reflected and
created a caring community in the workplace culture of the
hospital unit.

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Critical thinking activities
Based on this case study, consider the following questions.
1. What caring behaviors prompted the nurse manager to assign
the clinical nurse leader to engage in direct caring for Mrs.
Smith? Describe the clinical nurse leader role established by the
American Association of Colleges of Nursing in 2004.
2. What issues (ethical, spiritual, legal, social-cultural,
economic, and physical) from the structure of the theory of
bureaucratic caring influenced this situation? Discuss end-of-
life issues in relation to the theory.
3. How did the nurse manager balance these issues? What
considerations went into her decision making? Discuss the role
and the value of the clinical nurse leader on nursing units. What
is the difference between the nurse manager and the clinical
nurse leader in terms of caring practice in complex hospital care
settings? How does a clinical nurse leader fit into the theory of
bureaucratic caring for implementation of a caring practice?
4. What interrelationships are evident between persons in this
environment—that is, how were the vice president for nursing,
nurse manager, clinical nurse leader, staff, and patient
connected in this situation? Compare and contrast the
traditional nursing process with Turkel, Ray, and Kornblatt’s
(2012) language of caring practice within the theory of
bureaucratic caring
Lecture
What is the difference between grand theory and middle-range
theory?

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Grand theory is broader and provides an overall framework for
structuring ideas. In description, Grand Theories are broad and
complex in scope. They present a conceptual framework for
identifying the key principles and concepts of the nursing
practice. Even though they are known to provide intuitions
useful for practice, they cannot be used for empirical testing.
On the other hand, middle-range theories are focused on a
particular phenomenon or concept. They are limited in scope
and deals with tangible and reasonably operative concepts.
Their propositions and concepts are more specific to the nursing
practice and they can be used for empirical testing.
Middle-range theory addresses more narrowly defined
phenomena and can be used to suggest an intervention.
Ray’s Theory of Bureaucratic Caring
Marilyn Anne Ray
Improved patient safety, infection control, reduction in
medication errors, and overall quality of care in complex
bureaucratic health care systems cannot occur without
knowledge and understanding of complex organizations, such as
the political and economic systems, and spiritual-ethical caring,
compassion and right action for all patients and professionals.”
The theory was generated from qualitative research involving
health professionals and patients in the hospital setting,
The theory implies that there is a dialectical relationship
(thesis, antithesis, synthesis) between the human (person &
nurse) dimension of spiritual-ethical caring and the structural
(nursing, environment) dimensions of the bureaucracy or
organizational culture (technological, economic, political, legal

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and social).
The Model is holographic, illuminating the holistic nature of
caring & synthesis of the humanistic systems and technologic,
economic, political, legal systems.
Major Concepts
Caring:
a complex, transcultural, relational process, grounded in an
ethical, spiritual context. Caring is the relationship between
charity and right action, between love as compassion in
response to human suffering and need, and justice or fairness in
terms of what ought to be done. Caring occurs within a culture
or society, including personal culture, hospital organizational
culture, or society and global culture (Ray, 1989; Ray in
Coffman, 2006; 2010, 2013).
Spiritual-Ethical Caring:
Spirituality involves creativity and choice revealed in
attachment, faith, hope, love, and community. The ethical
imperatives of caring that join with the spiritual & relate to our
moral obligation to others. Spiritual- ethical caring for nursing
focuses on how the facilitation of choices for the good of others
(caring, healing, well-being that should be accomplished or can
be
Educational:
Formal and informal educational programs, use of audiovisual
media to convey information, and other forms of teaching and
sharing information are examples of educational factors related
to the meaning of caring.

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Physical:
Physical factors relate to the physical state of being including
biological and mental patterns. Because the mind and body are
interrelated, each pattern influences the other.
Socio-cultural:
Social-Cultural factors are ethnicity and family structures;
intimacy with friends and family; communication; social
interaction and support; understanding interrelationships,
involvement, and structures of cultural groups, community and
society.
Legal:
Legal factors relating to the meaning of caring include
responsibility and accountability; rules and principles to guide
behaviors, such as policies and procedures; informed consents;
right to privacy; malpractice and liability issues; client, family,
and professional rights; and the practice of defensive medicine
and nursing.
Technological:
Technological factors include nonhuman resources, such as the
use of machinery to maintain the physiological well-being of
the patient, diagnostic tests, pharmaceutical agents, and the
knowledge and skill needed to utilize these resources. Also
included with technology are computer assisted practice and
electronic documentation and social media.
Economic:
Economic factors relating to the meaning of caring include
money, budget, insurance systems, limitations and guidelines

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imposed by managed care organizations and in general,
allocation of scare resources including to maintain the economic
viability of the organization. Caring as an
interpersonal resource (love, communication, professional
knowledge)
should be considered, as well as goods, money and services.
Political:
Political factors and the governance & power structure within
health care administration influence how nursing is viewed in
health care and include patterns of communication and decisions
in the organization; role and gender stratification among nurses,
physicians, and administrators, union activities, including
negotiation and confrontation; government and insurance
company influences; uses of power, prestige, and privilege; and
in general, competition for scarce human and material
resources.
Major Assumptions
Nursing/Caring
Person/Cultural Being
Health
Environment/Culture of Organization
Nursing

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Nursing is holistic, transcultural & relational, spiritual, and
ethical caring that seeks the good of self and others in complex
community, organizational, and bureaucratic cultures.
Dwelling with the nature of nursing reveals that the foundation
of spiritual caring is love. Love calls forth a responsible ethical
life that enables the expression of concrete actions of caring in
the lives of nurses and for health & healing.
Person
A person is a spiritual and cultural being. Persons are created
by God, the Mystery of Being, a higher power and engages co-
creatively in human organizational and transcultural
relationships to find meaning and value.
Health
Health is a pattern of meaning for individuals, families and
communities. Beliefs and caring practices about health & illness
are central features of culture. The social organization of health
and illness determines how persons are recognized as sick or
well, how health or illness is presented to health care
professionals and the way health is interpreted by the
individual.
Environment
Environment is a complex spiritual, ethical, ecological and
cultural phenomenon. This conceptualization embodies
knowledge & conscience about the beauty of life forms &

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symbolic systems or patterns of meaning.
Nursing practice in environments embodies the elements of the
social structure and spiritual and ethical caring patterns of
meaning.
Theoretical Assertions
Caring is the essential construct and consciousness of nursing.
The meaning of caring is love and is highly differential
depending on its context--structures (social-cultural,
educational, political, economic. physical, technological and
legal) as expressed in complex organizations.
Caring is viewed as love
and
bureaucratic, given the extent to which its meaning can be
understood in relation to science & the complex organizational
structure.
Application to Practice/Education/Research
Practice: Ray’s research has shown that nurses, patients and
administrators value caring science, & the caring intentionality
that is co-created in the nurse-patient or administrator
relationship.
By creating spiritual-ethical caring relationships, clinical nurses

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& administrators can transform the workplace into moral
communities within the culture of humanistic, social, economic,
political and legal values.
Education: The theory is useful to nursing education because of
its broad focus on caring & complexity science /s in nursing and
the conceptualization of the health care system—used as an
organizing framework for curricula.
Universities and hospitals have incorporated Ray’s Model of
Bureaucratic Caring in the framework for the baccalaureate
nursing programs, and clinical environments to guide nursing
evolution, practice, research, and administration.
Research: Through Ray’s extensive experience with research,
she has developed a phenomenological-hermeneutical approach
(caring inquiry) that continues to guide her research and has
been adopted by many researchers for the humanistic approach,
using a lens of caring & caring science to study the human
experience in health situations.
Presenting
Caring Inquiry Method
August, 2013 at 32nd International Human Science Research
Conference, Aalborg, Denmark