Mrs. Smith was a 7old widow who lived alone with no significant social support.

Mrs. Smith was a 7old widow who lived alone with no significant social support..

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Mrs. Smith was a 7old widow who lived alone with no significant social support. 3-year- 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 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.
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
What is the difference between grand theory and middle-range theory?
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 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.
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 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
Person/Cultural Being
Environment/Culture of Organization
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.
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 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 is a complex spiritual, ethical, ecological and cultural phenomenon. This conceptualization embodies knowledge & conscience about the beauty of life forms & 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 & 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

Mrs. Smith was a 7old widow who lived alone with no significant social support.


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