Application of Bureaucratic- Caring Theory to Nursing Practice

The application of this theory is based on a hospital setting wherein these stories are
personally experiences of the nurses shared with the author while she is still
working implementing a caring model for professional nursing practice.
Marilyn A. Ray, RN, PhD, CTN-A, Professor Emeritus, Florida Atlantic University
Renowned nursing educator and researcher of caring in complex health care systems
and transcultural nursing.
- Dr. Ray is an advanced transcultural nurse committed to the development and progress of
transcultural caring in nursing worldwide.
- She is well known for her theory of bureaucratic caring, which integrates knowledge of
human caring within complex technological, economic, legal, and political systems in hospital
organizations.
- Previous awards include the Christine E. Lynn Eminent Scholar Chair in Nursing, Florida
Atlantic University; Yingling Visiting Scholar, Virginia Commonwealth University; Visiting
Lecturer, University of Alberta, Canada, Clinical Sciences Division. Ray attended seminars at the
Kennedy Institute of Ethics, Georgetown University.
- She also studied with Dr. F. David Peat in Pari, Italy, the distinguished physicist in the
sciences of complexity. Other fellowships include the Ministry of Health of Ontario and
visiting scholar positions in universities in Australia. She has held faculty positions at the
University of Colorado, College of Nursing; the Union Institute, Cincinnati; McMaster
University, Hamilton, Canada; the University of California, School of Nursing; and the
University of San Francisco,School of Nursing.
- From 1967 to 1999, Dr. Ray served as an officer in the United States Air Force, beginning
first with the Wyoming Air National Guard followed by the United States Air Force Reserve. She
held the rank of Colonel from 1984 to her retirement in 1999. During her military career, Ray
held many diverse positionsflight nurse, educator, researcher, and administrator in many
USAF Commands across the United States. She attended the Marshall Space Center to support
the potentialrole of nursing in space. During the last 8 years of her career she was a researcher at
the USAF School of Aerospace Medicine, Brooks Air Force Base, Texas.
- Ray recently completed a book titled Transcultural Caring Dynamics in Nursing and Health
Care. She edited one book with Dr. Jean Watson and has numerous chapters and peer-reviewed
articles in many journals. Her work is translated into different languages.
- She has over 20 funded research grants totaling almost one million dollars, and
presents nationally and internationally, the most recent at the World Universities Forum in
Davos, and universities in Lausanne, Switzerland. Ray recently visited the WHO, and the
International Council of Nurses in Geneva, Switzerland, sharing knowledge and her experience
of transcultural nursing, theory and research, and a vision for the future of nursing within
the complex global environment.
INTRODUCTION
Health care organizations are hierarchical and show management system methods that show
some degree of command, authority, and control for effective functioning. Hospitals tend to be
bureaucratic; that is, they are not only places for the care of the sick, but they also are integrated
technical-politico-economic and legal organizations. Revolutionized health care environments
have raised questions associated to patient care. How are political, economic, legal, and
technological caring decisions made? How is spiritual caring fostered? How can ethical caring be
the grounds on which moral decisions are made? What new policies must be designed to enhance
the human perspective in corporate policy, and how will these principles and policies guide
actions? The introduction of the Theory of Bureaucratic Caring on the corporate background will
necessitate a system shift from a narrow to a broad focus where management and caring views
can exist side by side and realistically represent the transformation of health care organizations to
benefit humankind As the twenty-rst century is developing, nursing in multifaceted
organizations has to advance as well. Bureaucratic caring theory encourages us to envision how
a new model may assist us in comprehending how nursing can be practiced in contemporary
health-care setting by illustrating the importance of spiritual and ethical caring in relation to
organizational cultures. , such as political, economic, legal and technological aspects of hospital
organization.

MAJOR CONCEPTS OF THE THEORY

Concept Definition
Caring Is defined as a complex, transcultural, relational process, grounded in an
ethical, spiritual context. Caring is inevitable within a culture or society, such
as, personal culture, hospital organizational culture, and society culture.
Spiritual- This pertains a holistic integration of the body, mind and spirit. Spiritual-
ethical caring ethical caring for nursing focuses on the facilitation of alternatives for the good
of others can or should be attained.
Education Education both formal and informal programs make use of audiovisual media
to disseminate information, and also other forms of teaching and relaying
information are factors related to defining care.
Physical This factor is related to the physical state of being, which includes, biological
and psychological patterns. The reason is that, both the human mind and body
are interrelated, showing a pattern that influences the other.
Socio-cultural Social and cultural aspects are factors related to ethnicity and structures of the
family; intimacy with friends and family; communication; interaction and
support with a social group, community and society.
Legal Definition of caring in terms of legal factors are responsibility and
accountability; rules and principles as guidance of ones behavior, such as
policies and procedures; informed consent; rights to privacy; malpractice and
liability issues; client, family, and professional rights; and the practice of
defensive medicine and nursing.
 Technological Factors relating to technology such as non-human resources, like the use of
machines to sustain physiological well-being of the patient, diagnostic
investigations, pharmaceutical agents, and also the knowledge and skills
required to operate the resources.
Economic Related factors of the definition of caring include money, budget, insurance
systems, limitations, and guidelines imposed by managed care. Caring as an
interpersonal resource should be considered like goods, money, and services.
political How nursing is viewed within a healthcare administration is influenced by
political and the power structure. This included the communication patterns,
decision making within the organization, role gender stratification among
nurses, physicians, and administrators; union activities including negotiation
and confrontation; government and insurance company influences; uses of
power, prestige, and privileged are, in general, competition for scares human
and material resources.

Rays theory focuses on caring in organizations (e.g. hospital) as cultures. The theory suggests
that caring in nursing is contextual and is influenced by the organizational structure.
She emphasized the interconnectedness of nursing care and health care organizations. The theory
emphasizes the holistic nature of an organization rather than simple cause-effect relationships of
individual actions. Spiritual-ethical caring by nurses, the ultimate goal of which is the promotion
of well-being through caring, has a positive effect on health care organizations and can become
an economic resource.
- Example: ICU had a dominant value of technological caring (i.e., monitors, ventilators,
treatments), Oncology unit had a value of a more intimate, spiritual caring (i.e., family focused,
comforting, compassionate). Furthermore, the meaning of caring was further influenced by the
role and position a person held. Staff nurses valued caring in terms of its relatedness to client,
while administrator valued caring as system related.
- Spiritual ethical caring influences each of the aspects of the bureaucratic system (political,
legal, economic,, educational, physiologic, social-cultural, and technological)
PROPOSITION/IDEA
Caring in nursing is contextual and is influenced by organizationalstructure. Spiritual-ethical
caring for nursing does not question whether or not to care in complex systems, but intimates
how sincere deliberations and ultimately the facilitation of choices for the good of others can or
should be accomplished
Strengths and Weaknesses
One of the major strengths in Ray's Theory of Bureaucratic Nursing is that its assumptions can
be highly applicable in the modern nursing profession. With the fast advances in technology and
healthcare, Nursing today has been more elaborate. There have been several fields such as
oncology nursing, infection control nursing, gerontologic nursing and many more. Nurses have
also assumed administrative positions such as nurse supervisors and chief nurse. These different
fields if nursing may affect the nurse's interaction and view on patient care. Ray's theory suggests
that caring in nursing is contextual and is influenced by the organizational structure. For
instance, a staff nurse who is primary involved in direct nursing care may have a different caring
approach to a patient as compared to his chief nurse who is more concerned in the nursing
system in the hospital.
Also, the Bureaucratic Theory has never lost the heart of the profession. Ray states that care for a
patient may be affected by political, legal, economic, educational, physiologic, socio-cultural and
technological factors. But these factors are influenced by spiritual-ethical caring. In this theory,
the nurses, especially those in the administrative position serve two masters. First is the patient,
second is the organization the nurse is working for. As part of the administrator, the nurse is
responsible to make decisions that will be beneficial for the organization (this is the politics,
legal and economics factors). But, as a nurse, whose primary role in patient-care, she is also in
the position to make decisions to ensure that quality of care is given to the patient.
However, one limitation is that the theory is focused on nursing in the hospital. the organization
mentioned in the theory pertains to a hospital administration. Hence, this theory is less flexible
and may not be applicable to other fields of nursing like public health.

Nursing Situation: Registered Nurse

It started when Joseph, 84 year- old white male, was admitted. He was found by a neighbor
laying in the kitchen floor. Upon admission the RN assess the patient and found out that his left
arm and his left leg are weak. When the RN ask him, he was reluctant answering the questions.
He was asked by this RN " What is most important to you about this time? Joseph explained that
it is the second death anniversary of his wife and he wanted to go to the cementery to pray with
her.
The RN recognized that this was not possible.She and her colleaugues, the other health care
nursing assistants came up with the idea to help Joseph meet his spiritual needs. Some of them
went to pick up the chaplain, one nursing assistant went to buy flowers from the gift shop. When
the chaplain arrived, they went to the room and offered a prayer and a song. Karen,his nurse,
offered to accompany him to the cementery to place flowers in his wife's grave.
The following day, he was asked by Karen, "What do you remember about your wife?". He
replied, "That her wife is a caring perosn and it was difficult for him to see her suffer at the bed.
You see, we never sign any papers, and the doctors put a lot of tubes in her at the end.I don't
want to live or be like that."
Karen uphold Joseph's personal struggle and he asked him if he would want to have an advance
directive. She explained to him that this will allow him to put his wishes in writing and from a
legal perspective the nurse and physicians must honor and respect his wishes. Later in the
afternoon, the paper was finished.
During the night shift, Joseph experience an increased blood pressure and difficulty of breathing.
He was transferred to the Intensive CAre Unit and placed on a intravenous medication for blood
pressure controlled. When he was stabilized already, he was asked by his nurse"What can I do
for you?". He replied that he wants to see his children and he instruct the RN to look over the
paper. He said, " I don't want any tubes in me if I will breath".
At the middle of the night, he experienced more difficulty of breathing. The physician decided
that it is time to hook him in the inspirator. Joseph weakly replied, " No tubes". Nurse Dianne,
who is on duty that night inform the physician regarding the paper that the patient signed. After
reviewing the documents, the doctor honored the request. The children decided to transfer Joseph
from Intensive Care Unit to a Private room. They sang and they took turns holding Joseph's
hand. He died the following day in his bed, accompanied by his family.
References:

Mosby's Medical Dictionary, 8th edition. 2009, Elsevier.

Parker, Marilyn E. Nursing Theories and Nursing Practice. Second Edition. Boca Raton, Florida.
F.A. DAVIS COMPANY
PHILADELPHIA K.Scott (June 12, 2007). Nurse Practitioner: Patient Care or Administator
http://www.bod.com/index.php?id=3435&objk_id=4031074.
http://media.axon.es/pdf/92311.pdf
RNPedia.com (n.d). Fundamentals of Nursing: Caring
http://marilynray.com/wp-content/uploads/2012/10/Theory-of-Bureaucratic-Caring.pdf