Uncertainty in Illness Theory (UIT)

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CHAPTER 6 Theory of Bureaucratic Caring

Marilyn A. Ray

In 1977, Leininger declared that “caring: [is] the essence and central focus of nursing” (p. 1). From an anthropological perspective, caring is one of the old- est and most universal expectations for human development and survival throughout human history. Caring is claimed by archeologists (besides the evo- lution of the brain) as paramount in human development (Ray, 1981b). Based on a philosophical analysis related to meaningfulness and understanding, I determined that, for nursing, caring and love are synonymous (Ray, 1981a, p. 32). Four decades ago, as a doctoral student researcher, my passion was the study of caring within hospitals as a way of knowing caring in nursing in prac- tice. I wanted to learn about the meaning of care and caring in the hospital culture, and embarked on a study focusing on the meaning and action of caring. My dissertation was a qualitative study that laid the foundation for the Theory of Bureaucratic Caring. This chapter about the Theory of Bureaucratic Caring includes: explication of the purpose of the theory; description of processes undertaken to generate the middle range theory; defi nition of the theoretical concepts; and identifi cation of uses of the theory in research and practice.

■ PURPOSE OF THE THEORY AND HOW IT WAS DEVELOPED

The middle range Theory of Bureaucratic Caring was discovered through description, analysis, and interpretation of the meaning of the phenomenon of caring in the complex institutional culture of the hospital. Interview data were analyzed from over 192 diverse healthcare professionals including nurses, phy- sicians, and allied health personnel as well as patients. Also included were fi eld notes or memos from participant observation of the nursing/social process in the hospital culture. This analysis prompted deep refl ective thinking about the meaning of the lived experience of caring and interpretation of patterns of culture or the organizational context from which the meaning was derived. The initial analysis led to the integration of data into a classifi cation system of institutional caring—psychological, practical, interactional, and philosophical (Ray, 1981b, 1984). Subsequently, substantive and formal grounded theories

Copyright Springer Publishing Company. All Rights Reserved. From: Middle Range Theory for Nursing, Fourth Edition DOI: 10.1891/9780826159922.0006

108 I I . M IDDLE RANGE THEOR IES READY FOR APPL ICAT ION

were discovered to articulate the fullness of the meaning of caring in the orga- nizational context. Qualitative data illuminated a paradox, juxtaposing the meaning of caring as humanistic, spiritual, and ethical with the bureaucratic system as political, economic, technological, legal, educational, and social– cultural. Through the use of Hegelian dialectical analysis of the thesis (car- ing) and antithesis (bureaucracy), a synthesis was articulated as the Theory of Bureaucratic Caring (Ray, 1981b, 1984, 2010a).

■ EVOLUTION OF THE THEORY OF BUREAUCRATIC CARING

Over three decades, with the research expertise of Dr. Marian Turkel and feder- ally funded grants using research approaches that drew on our growing under- standing of complexity sciences, testing of the Theory of Bureaucratic Caring was ongoing. We accomplished tool development using mixed methods to create valid and reliable professional and patient questionnaires, focusing on economic caring. Further data collection and analysis of the meaning of caring in organizational cultures in public, private, and military hospitals led to the determination that the Theory of Bureaucratic Caring demanded holographic expression with spiritual–ethical caring as the central essence. Many publications validated the theory as a middle range theory with strong potential for guid- ing practice and research (Coffman, 2014, 2018; Davidson, Ray, & Turkel, 2011; Gibson, 2008; Ray, 1987a, 1987b, 1989, 1997, 1998a, 1998b, 2010a, 2010b, 2010c, 2010d, 2010e, 2011, 2013a, 2013b, 2016; Ray & Turkel, 2010, 2012, 2014, 2015; Ray, Turkel, & Marino, 2002; Ray, Morris, & McFarland, 2013; Turkel, 2007; Turkel & Ray, 2000, 2001, 2004).

■ CONCEPTS OF THE THEORY

Bureaucratic Caring is spiritual–ethical caring emerging in bureaucracies. Bureaucracies are complex systems with political, legal, economic, technologi- cal, physical, educational and social–cultural dimensions. The central concept of the Theory of Bureaucratic Caring is spiritual–ethical caring. Spiritual–ethi- cal caring interconnects with the dimensional concepts gleaned and interpreted from data. Each of the concepts of the theory is briefl y defi ned.

Spiritual–Ethical Caring is defi ned as creativity, loyalty, faithfulness to spir- itual or religious traditions and is revealed in patterns of love, compassion, empathy, respect, and communication to facilitate moral choices for the good of self, persons, things, and the environment.

The Social–Cultural dimension is defi ned as values, beliefs, and attitudes regarding ethnicity, patterns of identity, or diverse social structures, such as family and communities that impact social structures, political, economic, legal, and technological factors in complex national or international systems.

6 . THEORY OF BUREAUCRAT IC CAR ING  109

The Physical dimension is defi ned as factors related to the physical, mental, and emotional states of being, health/illness, healing, and dying (or peaceful death) of patients or persons in organizational healthcare contexts.

The Educational dimension is defi ned as both formal and informal teach- ing–learning communicating caring processes and programs to improve the health, healing, and well-being of persons, families, communities, and organizations.

The Political dimension is defi ned as the energy patterns and communica- tive action associated with power, control, and authoritative behaviors, usually of leaders, administrators, and staff. Political relates to hierarchical systems, roles and their differentiation or stratifi cation, unions, and governmental infl u- ences that facilitate competition and cooperation in complex organizations.

The Economic dimension is defi ned as the exchange of goods, money, ser- vices, insurance systems, and healthcare laws, including an understanding of caring as interpersonal resources to appreciate and manage budgets and to maintain the fi nancial viability and fi scal management of an organization that interfaces with the larger community or social structure.

The Technological dimension is defi ned as nonhuman resources, such as machines and diagnostic instruments, pharmacologic agents, computers, elec- tronic health records (EHRs), smartphones, social media in the virtual world, and robots, and the ethical caring knowledge and skill needed to support per- sons, families, communities, organizations, and cultures.

The Legal dimension is defi ned as factors related to responsibility and accountability for rules, regulations, standards of practice, procedures, informed consent, rights to privacy, professional behaviors, insurance systems or laws, and issues that endeavor to facilitate social justice and stability in com- plex systems.

■ RELATIONSHIP AMONG THE CONCEPTS: THE MODEL

The model of the Theory of Bureaucratic Caring (Figure 6.1) is represented by a circle that shows the interrelationship among the central and surround- ing concepts. The theory model is intended to be holographic in the sense that the part and the whole are interconnected, “…everything is a whole in one context and a part in another—each part being in the whole and the whole being in the part” (Ray & Turkel, 2015, pp. 464–465). Spiritual–ethical caring is central to the model and relates to and with dimensional concepts (economic, political, legal, technological, educational, physical, social–cul- tural) at the periphery of the circle. Data revealed that the meaning of caring was not only spiritual and ethical but also was expressed by participants in the research and interpreted by the researcher as contextual—the interrela- tionship of caring with structural phenomena of complex organizations, the bureaucracy. “Caring [spiritual–ethical caring] is a relational pattern; it is the

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fl ow of nurses’ and others own experiences in the structural context of the organization [the bureaucracy]” (Ray & Turkel, 2015, p. 464). The arrows in the model extend outward from each of the dimensional concepts to show that Bureaucratic Caring connects beyond the organization, to the environ- ment or the social world or culture at large.

Bureaucracies are cultures; they are cocreated through the interactions of people within them, each with their specifi c cultural orientations, goals, norms, patterns of behaviors, rituals, professional practices, and languages. Spiritual– ethical caring thus is in relationship with the dimensional concepts descrip- tive of the organization—economic, political, technological, legal, physical, educational, and social–cultural (Ray & Turkel, 2015). As a living system, the bureaucratic organization manifests in different ways depending on the pro- cesses that are valued. Bureaucratic organizations thus are “complex, dynamic, relational, integral, informational, computational and emergent, and open to sets of possibilities” (Ray & Turkel, 2015. p. 465). Decisions are made in net- works of relationships that represent a simultaneous patterning of interacting parts. The Theory of Bureaucratic Caring (Coffman, 2014, 2018; Davidson, Ray, & Turkel, 2011; Ray & Turkel, 2015) emerges to refl ect the reality of what it means to care for persons in an organization in the contemporary Western and developing world.

Educational

Political

Economic

Technological

Legal Spiritual- ethical caring

Social- cultural

Physical

FIGURE 6.1 Holographic theory of bureaucratic caring. Source: With permission from Parker, M., & Smith, M. (2015). Nursing theories and nursing practice (4th ed.). Philadelphia, PA: F. A. Davis.

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■ USE OF THE THEORY IN NURSING RESEARCH

The following presentation illuminates the diverse ways in which the Theory of Bureaucratic Caring was tested or used to guide research. Classifi cation systems, conceptual models, or further middle range theories emerged from this theory-guided research. For example, a classifi cation system, called an Institutional Caring Classifi cation System, was developed by Ray (1984). A conceptual model of Technological Caring, called Experiential and Principle- Based Ethics in Critical Care, was intuited from a phenomenological study of patients and nurses in the intensive care unit (Ray, 1987b). Clarifi cation of the ethical principles of benefi cence, justice, and autonomy emerged from this study. A theory of Refl ective Ethics emerged from a study in a critical care step- down unit (Ray, 1998a). Technological Caring was reinforced in the research of Wu and colleagues on the use of virtual technologies in a study of patients with cardiac disease comorbid with diabetes (Wu & Ray, 2016). From knowledge on economic caring reported by Ray (1981b, 1989), Turkel (1997) discovered Struggling to Find a Balance: A Grounded Theory of the Nurse-Patient Relationship Within an Economic Context. Ray and Turkel conducted research from 1995 to 2004 using Grounded Theory, phenomenological methods, and other mixed methods for the study of caring and the economics of caring in diverse public, private, and military hospitals (Davidson, Ray, & Turkel, 2011; Ray & Turkel, 2009; 2012; Turkel & Ray, 2000, 2001). Political caring was identifi ed in a study of reservists in the U.S. Air Force (USAF) regarding the expansion of the mili- tary TriCare health system (Ray & Turkel, 2001; Turkel & Ray, 2003). All of the research of Ray and Turkel led to further grounded theories: the Theory of Relational Complexity, the Theory of Relational Caring Complexity; and a Theory of Workplace Redevelopment (Ray, Turkel, & Marino, 2002). The eco- nomic caring research of Ray and Turkel was enhanced by theoretical testing and tool development to understand more fully the meaning and the statistical signifi cance of the economics and politics of caring.

Many researchers were interested in theory-guided research and practice using the Theory of Bureaucratic Caring. In 1997, Valentine applied the the- ory in her study of economics and caring. Prestia (2016a) followed through with an application of Ray’s ideas (1997) emerging from a phenomenological study of caring in nursing administration; Prestia studied caring strategies for living leadership presence in nursing administration. Nyberg (1990) applied the Theory of Bureaucratic Caring to facilitate understanding, research and development of nursing economics with nurse administrators and in the orga- nizational culture. Eggenberger (2011) used the theory to guide a qualitative research related to charge nurses on the front line of practice. Conroy (2013) applied the Theory of Bureaucratic Caring in a study of the effect of the orga- nizational culture on implementation of evidence-based practice and how the staff assigns a value to improvements in nursing practice. The Theory of Bureaucratic Caring was incorporated by Prestia (2016b) into her dissertation

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research, a phenomenological study of chief nursing offi cers in the contin- ued practice of nursing leadership. In the USAF Medical Service, a research study was conducted by Potter (2015) using the Theory for Nurse-Directed Primary Care of patients with type 2 diabetes resulting in quality improve- ments in clinical health and healing and sizable economic outcomes. In the Veterans Administration, Lusk (2015) conducted a mixed method study using the Theory of Bureaucratic Caring to compare the knowledge, skills, and atti- tudes of newly hired nursing staff before and after the implementation of a quality and safety competency-based nursing orientation program.

Overall, the Theory of Bureaucratic Caring has provided substantive guid- ance for researchers wishing to focus on systems of care and those who are employed in those systems. It is a middle range theory that shifts attention to macrosystem perspectives, linking institutional culture, while considering the interplay of macrosystems with microsystems, like caring. The theory provides a structure for researchers to study the meaning of caring in institutional nurs- ing and healthcare practice.

■ USE OF THE THEORY IN NURSING PRACTICE AND EDUCATION

Nursing practice addresses the needs of patients, nurses, and administrators as well as an understanding of the context within which nursing practice occurs. The challenge in nursing practice is the integration of knowledge gleaned from nursing education and experience, which should align with the philoso- phy, vision, and values that nursing has adopted. The Magnet Recognition Program® has been established to achieve nursing excellence by incorporat- ing theory-guided or conceptual professional practice models to transform nursing and healthcare (Turkel, 2004). Theory-guided practice encompasses the why of nursing through ways in which practitioners of nursing have inte- grated their knowledge and understanding of what makes things work—the pedagogy, philosophy of caring, health, and social–cultural sciences to inform the art of nursing. The philosopher Hans-Georg Gadamer remarked that we, as human beings are always theorizing—we are meaning-making people who are always seeking to understand—trying to make sense out of relationships and things of this world (van Manen, 2014). The art of practice, thus “. . . serves to foster and strengthen the embodied ontology [way of being], epis- temology [ways of knowing], and axiology [ways of valuing what is valuable or ethical] of thoughtful and tactful action” (van Manen, 2014, p. 15). The fol- lowing highlights ways in which the Theory of Bureaucratic Caring is being used to guide nursing education as well as nursing, healthcare, and organi- zational practice.

O’Brien (2008) incorporated the core principles of the Theory of Bureaucratic Caring in her project to orient new public health nursing consultants in a major

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state public health nursing system (Personal communication, 2008). In a cor- rectional facility for adolescents in Georgia, McCray-Stewart used the theory to improve the care of young detainees and reduce recidivism (Personal com- munication, 2008). In 2012, Iowa Health (three hospitals), in Des Moines, Iowa, adopted the Theory of Bureaucratic Caring to guide interprofessional practice (Iowa Health) and as the theoretical foundation for Magnet recognition status to become a center of excellence.

Elevating a successful innovation of an interprofessional practice model is focused on a commitment by leaders to all stakeholders. Leaders must be cog- nizant of how a system can continue to form or enhance relationships with its members in current and projected environments. A signifi cant goal of achieving the status of a Magnet facility employs both the spread or horizontal diffusion of an idea, such as a nursing theory or model of caring, and scale or centralized action to implement a single system of excellence for nursing and other dis- ciplinary practices across a whole organization (Bar-Yam, 2004; Martin, 2017; Turkel, 2004). Collaboration of this magnitude for policy development takes knowledge of theory, and a theory-guided effort to determine its impact on a complex organization and multidisciplinary practice. The collaboration takes a deep understanding of relationships and caring communication, especially in a complex bureaucratic culture and with people who may continue to embrace an individualized professional culture or belief system. The process of devel- oping a model using the middle range Theory of Bureaucratic Caring in the Iowa Health System took a commitment by nurse leaders and others to make things work (Bar-Yam, 2004). Inspiring a collection of diverse healthcare pro- viders from varying disciplines to undertake whole system change focused on unifi ed healthcare is a challenge but the Iowa Health System embraced the challenge.

Within nursing education, the Nevada State College under the leadership of Dr. Sherrilyn Coffman (2014) from 2007 to 2014, applied, in part, the Theory of Bureaucratic Caring for the development of a curriculum model for the Bachelor of Science in Nursing program. In the nursing administration pro- gram at the Capital University in Ohio, Burkett (2016) used the theory to guide administrative course development. Johnson (2015) developed a conceptual framework applying the Theory of Bureaucratic Caring for advanced practice nurses as primary care providers using a new approach—making house calls with the homebound population to meet their healthcare needs. The Theory of Bureaucratic Caring is currently being used in nursing education at the National University in Bogota, Colombia, and the University of Santiago in Santiago, Chile.

The Theory of Bureaucratic Caring is being applied in primary nursing practice by the USAF Nurse Corps to improve the care of patients with type 2 diabetes (Potter, 2015). Creation of an Interdisciplinary Professional Person- Centered Practice Model in the USAF is in process.

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■ CONCLUSION

The Theory of Bureaucratic Caring originated from qualitative research focused on caring in a complex organizational culture. It was published fi rst as a dissertation (Ray, 1981b) and appeared in the literature in 1989 and in subsequent publications noted throughout this chapter (Coffman, 2014, 2018; Ray, 2001, 2010a, 2010e; Ray & Turkel, 2010, 2012, 2014, 2015). The theory sym- bolizes a dynamic structure of caring that was synthesized from the dialectic of caring as humanistic, social, educational, ethical, and religious/spiritual (elements of humanism and caring), and the antithesis of caring as economic, political, legal, and technological (elements of bureaucracy) into a new syn- thesis—the Theory of Bureaucratic Caring (Ray, 1989, 2010a, 2010b, 2010c, 2010d, 2010e). The interplay between and among the dimensions highlighting spiritual–ethical caring and the bureaucratic system as holographic or emer- gent showed that the whole is in the part and the part is in the whole; every- thing is an unbroken whole (Bohm, 2002; Coffman, 2014). Humanistic caring and the elements of the bureaucracy are value-added. Interactions and sym- bolic meaning systems are formed and reproduced from the construction of dominant values held within nursing and indeed, other professions, includ- ing patients, and the organization. A hospital, community health, or a health- care system is a living organization. By understanding and incorporating the Theory of Bureaucratic Caring, nurses bring caring into being that makes a human community and an organization edifying to our spiritual well-being and intellectual lives.

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