Authors – Marilyn (Dee) Ray, RN, PhD, CTN-A, FAAN – Theory of Bureaucratic Caring; Marian Turkel, PhD, RN, NEA-BC, FAAN – co-author, Transtheoretical Evolution development

Note on page content: two sections are included on this page after the author biographical information: “Cited Sources” and an original essay by Dr. Ray titled “The Meaning of Bureaucracy and the Theory of Bureaucratic Caring.”

Exemplars –

• United States Air Force Professional Caring Practice Using Ray’s Theory of Bureaucratic Caring

Year First Published – 1981

The following files are also available for download:

Ray, Marilyn – Bureaucratic Caring Theory GRAPHICS 1981-2015

BUREAUCRATIC CARING THEORY IN FRENCH BY NACE WESSELBEL, LAUSANNE, SWITZERLAND, JANUARY 2012 Posted by permission.

RAY’S THEORY OF BUREACRATIC CARING MODEL – SPANISH TRANLSATION Translated by  Ender Vilaria, former IT Specialist at FAU CELCON, currently with  Computing Development LLC, 3243 NW 32nd Terrace, Lauderdale Lakes, FL 33309.

Article on the BCT translated into Japanese in the Japanese journal, Health Care. Posted by permission of the authors.  Citations for Japanese translations:

Honda, J., Ray, M. A., & Hohashi, N. (2013). Ray’s “Theory of
Bureaucratic Caring” and nursing organization management. Health Care,
55(12), 819-825. [In Japanese]

Hohashi, N., & Honda, J. (2015). Marilyn A. Ray: Theory of Bureaucratic
Caring. In M. Tsutsui (Ed.), Achievement and theory evaluation for nursing
theorists (pp. 377-389). Tokyo: Igaku-shoin. ISBN: 978-4-260-02085-5 [In
Japanese]

Major Concepts

Bureaucratic Caring: is spiritual-ethical caring—complex, dynamic patterns of meaning of caring emerging in and related to the context or institution. Qualitative research data from ethnographic, phenomenological, and grounded theory data generation and analysis, discovery and Hegalian dialectical inquiry from the thesis of caring as spiritual-ethical-humanistic (physical) and the antithesis of the caring expressed within the context of the institution (bureaucracy) as political, legal, economic, technological, educational and social-cultural was synthesized as the Theory of Bureaucratic Caring.

Spiritual-Ethical Caring: Central concepts that interconnect all complex phenomena in organizations within this Theory of Bureaucratic Caring through creativity, loyalty, devotion, and faithfulness to humanistic, spiritual or religious traditions revealed in patterns of interconnectedness—co-presence, love, compassion, empathy, attention, respect, and caring communication to facilitate moral choices for the good of self, persons, things, and the environment (including organizations, institutions).

Social-Cultural: 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 local, national, and international systems.

Physical: Dynamic forces 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.

Educational: Formal and informal teaching-learning pattern of meaning, communicating the dynamics of caring, processes, and programs to improve the health, healing, and well-being of persons, families, communities, and organizations.

Economic: Exchange of goods, money and services, including and understanding of caring as an inter-personal value-added resource, insurance systems, healthcare laws to appreciate and manage budgets, and to maintain the financial viability and fiscal management of an organization that interfaces with the larger community and social structure of society.

Political: Patterns of energy and communicative action associated with authority, power, control usually of leaders, administrators, and clinical staff (nurses, physicians, allied health personnel). Political relates to hierarchical systems, roles and their differentiation or stratification, unions, and governmental influences that facilitate or challenge competition and cooperation in complex organizations.

Technological: Non-human resources, such as machines and diagnostic instruments, pharmacologic agents, computers, electronic health records (EHRs), smartphones and social media in the virtual world, robots, and the ethical technological caring knowledge and skill needed to support persons, including culture groups, families, communities, and organizations.

Legal: Factors related to responsibility and accountability for rules, regulations, licensing, policies, standards of practice, procedures, informed consent, rights to privacy, professional behaviors, insurance systems, laws and issues that endeavor to facilitate social justice, fairness, and stability in complex systems.

Typology

I classify my theory as a complex holographic theory (Coffman, 2018; RAY, 2018; Ray & Turkel, 2014, in press).

Other scholars have classified the BCT as a middle-range theory (Smith, in press, Smith & Parker, 2014; Ray, in Smith, MJ & Liehr, 2018).

The Theory of Bureaucratic Caring (BCT) has been classified within a variety of perspectives. From my own philosophical (metaphysical) analysis of caring (Ray, 1981b), caring is a universal (spiritual, ethical–love and co-presence as the essential nature of nursing) so, from my perspective the BCT first is a universal theory of nursing; second, the BCT is classified as a grounded theory, generating from research in the social context of a hospital focusing on the meaning of caring in practice, with the discovery of substantive theory (differential caring) grounded in meanings of role differentiation and work unit experiences in the complex organization of the hospital; and then synthesized as formal theory – the Theory of Bureaucratic Caring (theory advanced from the Hegalian dialectal argument of the thesis of caring as spiritual –ethical-humanistic caring in relation to contextual data of the social-culture of complex healthcare organizations and historical data of the meaning of bureaucracy.

Brief Description

The theory of Bureaucratic Caring originated as a grounded theory from a qualitative study of the meaning of caring with 192 respondents using ethnography, phenomenology, and grounded theory methods in a complex organizational culture and was published first as a dissertation (Ray, 1981) and appeared in the literature in 1984, 1989 and in subsequent publications from that time (Coffman, 2007, 2010, 2014, 2018; Ray, 2001, 2005, 2010a, b, 2017, 2018; Ray & Turkel, 2005, 2010, 2012, 2014, 2015, in press). In the qualitative research within the hospital institutional context, the research revealed that nurses and other professionals struggled with the paradox of serving the bureaucracy (system) and serving human beings, especially patients through human caring experience (feeling), knowledge and action.

The discovery of the Theory of Bureaucratic Caring resulted in both a substantive theory and a formal theory. The substantive theory emerged as Differential Caring, and the Formal Theory of Bureaucratic Caring which was discerned from a synthesis of Differential Caring and the argument using the Hegalian dialectic of thesis, antithesis, synthesis. Differential Caring showed that caring in the complex organization of the hospital was complex and differentiated itself in terms of meaning by its meaning in context (different units) and roles. In other words, there were dominant caring characteristics related to different areas of practice or units in the hospital wherein professionals worked and patients resided. The substantive theory, Differential Caring showed that the different units promoted different caring models/modalities based on their unit and organizational goals, values and different care needs, such as critical care units, cardiac and step-down units, oncology unit, medical-surgical nursing care units, pediatric nursing care unit, emergency, operating and recovery rooms, as well as different departments, such as the budget and finance, admissions, materials’ management, and supportive units, such as physical therapy, occupational therapy departments, and so forth. A Classification System of caring was identified (Ray, 1984; 1989).

The formal Theory of Bureaucratic Caring symbolized a dynamic structure of caring that was synthesized (using Hegel’s philosophy of thesis, antithesis, synthesis) from a dialectic between the thesis (notion of caring as humanistic, social, educational, ethical and religious/spiritual (elements of humanism and caring), and the antithesis (opposite) of caring as economic, political, legal, and technological (elements of bureaucracy) into a new synthesis–the Theory of Bureaucratic Caring (Coffman, 2018; Ray, 1989, 2018; Ray & Turkel, 2015; Wu & Ray, 2017). The research revealed that the economic, political, legal and technological dimensions were dominant caring characteristics in relation to the humanistic, social and ethical/spiritual dimensions (there was an interplay between and among the dimensions highlighting the organizational system.

After additional research, especially highlighting the economics of caring in civilian and military hospitals, later descriptive models emerged showing the dominance of first, ethical caring, then spiritual-ethical caring in conjunction with the system dimensions. The latest description is now referred to as holographic–the whole is in the part and the part is in the whole, thus, everything is an unbroken whole as Bohm (2002) stated. Overall, the theory revealed that the meaning of nursing and caring are not only transpersonal but also, contextual, in other words, influenced by the social structure of complex organizations (the value system of a bureaucracy and humanistic caring). Interactions and symbolic meaning systems are formed and reproduced from the construction of/or dominant values held within nursing and indeed, other professions, including patients, and the organization. This research responds to the position that “we are the organization”, we are the language and action/s of the organization; the organization is a living organization (Morgan, 2006).

Nurses thus need to see “caring” in a new way; a change of heart, that does not repel or keep at bay the organization but incorporate the bureaucratic elements and thus, continue to co-create the meaning of a complex system, such as a hospital or health care system, and indeed a family system if in community health, as a living organization (Nirenberg, 1993). By understanding and incorporating the Theory of Bureaucratic Caring, nurses and others bring caring into being–what makes a human community and organizations possible and what is edifying to our spiritual well-being and intellectual lives (Ray, 2005, 2017, 2018).

(citations are listed in the “Cited Sources” section below)

Primary Sources

1981 PhD Dissertation, A study of caring within an institutional culture, University of Utah, Salt Lake City, UT. (Dissertation Abstracts International 42/06 (University Microfilms No. 81-27,787)

1984 1st Phase of Theory Evolution from PhD Dissertation:
Ray, M. (1984). The development of a classification system of institutional caring. In M. Leininger (Editor and Author). Care: The essence of nursing and health. Thorofare, NJ: Slack Incorporated.

1989 Theory of Bureaucratic Caring (Substantive and Formal Theories)
Ray, M. (1989). The theory of bureaucratic caring for nursing practice in the organizational culture. In B. Brown (Ed.). Nursing administration quarterly, 13(2), 31-42.

2010: Book:
Ray, M. (2010). A study of caring within an institutional culture: The discovery of the Theory of Bureaucratic Caring. Saarbrüken, Germany: Lambert Academic Publishing.

Authors

Marilyn (Dee) Ray (1938 – )

Dr. Ray is Professor Emeritus at Florida Atlantic University, Christine E. Lynn

College of Nursing, Boca Raton, Florida, USA. She holds a diploma in nursing from St. Joseph Hospital, School of Nursing, Hamilton, Canada; Bachelor and Master of Science degrees in Nursing from the University of Colorado, Denver, Colorado; Master of Arts in Anthropology from McMaster University, Canada; Doctor of Philosophy in Nursing with a specialty in Transcultural Nursing from the University of Utah, Salt Lake City, Utah. Ray has held faculty positions at the University of San Francisco, University of California San Francisco, McMaster University, the University of Colorado, and the Christine E. Lynn Eminent Scholar, and Professorial positions at Florida Atlantic University and the University of Colorado, and Visiting Scholar, Virginia Commonwealth University. She is certified as an advanced Transcultural Nurse (CTN-A) and a transcultural nursing scholar.  Her focus is caring science/human science/complexity sciences publishing widely with 5 books, many articles and chapters, and presenting nationally and internationally, and advancing Caring Science Inquiry methodology, and her Theories of Bureaucratic Caring and Transcultural Caring Dynamics in Nursing and Healthcare in healthcare inter-disciplinary environments. Her Theory of Bureaucratic Caring was featured as a model of caring with the academic leadership group of the American Association of Colleges of Nursing, and has been adopted as the structural framework/cornerstone for the interdisciplinary collaborative practice Person-Centered Caring Practice Model in the United States Air Force, Medical Service. Her Transcultural Caring in Nursing and Healthcare featuring her theory has been adopted by the publishing company, F. A. Davis Company as the central transcultural caring book for undergraduate and graduate nursing education.

Ray is a retired Colonel in the United States Air Force Reserve, Nurse Corps (USAFR NC) serving for 32 years. She is a veteran (alongside her late husband, James L. Droesbeke), contributing as a member of the Veterans Action League at FAU for research into veteran access to adequate healthcare. She also participates with the Military Officers Association of America. During her military career, Ray served as a flight nurse during the Vietnam conflict, followed by clinical nursing, USAF command positions in nursing education and administration in Denver, CO, Washington, DC and San Antonio, TX. She was a researcher and consultant in military hospitals, and aerospace nursing research, education and practice at the School of Aerospace Medicine. She attended the NASA Marshall Space Center for introduction into astronaut duties for the eventual development of nursing in space. She and her colleague, Dr. Marian Turkel were funded for almost 1 million dollars to study organizational caring with a focus on economic caring within military and civilian health care facilities by the TriService Nursing Research Program (Uniformed Services University of the Health Sciences), developed the Theory of Relational Caring Complexity, and received the national research award from the Military Surgeons Association of the United States. Presently, Ray is an advisor to the Surgeon General of the United States Air Force, Lieutenant General Dorothy Hogg with the assistance of Master Clinician, Colonel Marcia Potter, DNP, FNP, in the development of and education in the Person-Centered Caring Model using her Theory of Bureaucratic Caring for nursing and inter-professional practice.

Ray has received numerous awards, such as: Transcultural Nursing Scholar Award, the University of Utah Distinguished Alumni Award, University of Colorado College of Nursing Alumni Lifetime Achievement Award, Lifetime Achievement status from Marquis Who’s Who Biographers, Honorary Nurse Practitioner of Ontario,  Fellow of the Society for Applied Anthropology, Fellow of the American Academy of Nursing, the Distinguished Fellowship in the European Society for Person-Centered Healthcare and  the National Academies of Practice. Ray also is an active member of the South Florida Haiti Project where she participates as a transcultural nursing advocate to ensure culturally responsive mental health research and practice in Haiti. Her Archives of Caring are housed in the Museum at Florida Atlantic University, Christine E. Lynn College of Nursing, Boca Raton, Florida.

Marian Turkel, co-author, Transtheoretical Evolution development

Dr. Turkel is Affiliate Associate Professor at Florida Atlantic University Christine E. Lynn College of Nursing, Boca Raton, Florida, USA and a Watson Caring Science Post-Doctoral Scholar. She holds a Master of Science in Nursing from Florida Atlantic University and a PhD in Nursing from the University of Miami, Miami, Florida. She is board certified as a Nurse Executive Advanced (NEA-BC), Past President of the International Association for Human Caring, a fellow in the American Academy of Nursing and served as Chair of the Nursing Theory Guide Practice Expert Panel from 2016-2017.

Dr. Ray was hired as the Eminent Scholar within the College of Nursing in 1990. As students we knew that it was an important tile but we did not know if we were allowed to talk with her. I was fortunate that she was my professor and we immediately bonded over our passion for studying caring and economics within complex healthcare systems. Dr. Ray and I wrote our first grant Nurse-Patient Relationship Patterns: An Economic Resource over Thanksgiving holiday 1994. We could not use the “C” word in the title but Ray’s Theory of Bureaucratic Caring served as the nursing theoretical framework.  Over the course of our nursing research career with Dr. Ray as PI and myself as CO-PI we have received almost one million in federal funding to study organizational caring (caring and economics) within military and civilian health care systems.

In 2007, I joined the faculty of the Watson Caring Science Institute (WCSI) teaching in the Caritas Coach Education Program, mentoring nurses studying caring science and assisting Dr. Watson with planning of national/ international conferences. I was Director of Professional Practice/ Magnet and Research at Einstein Hospital in Philadelphia, we were one of the first hospitals designated in 2010 as a WCSI Affiliate hospital for the intentional and authentic integration of Watson’s Theory of Human Caring into practice.

I authored a textbook on strategies for obtaining Magnet Program Recognition©®, Magnet status: Assessing, pursuing, and achieving nursing excellence, co-authored Nursing Caring and Complexity Science for Human Environment Well Being  (AJN Book of the Year Award 2011) with Dr. Marilyn  Ray and the late Alice Davidson. I co-authored with Dr. Marlaine Smith and Dr. Zane Robinson Wolf Caring in Nursing Classics: An Essential Resource (2012) and served as one of the Associate Editors for a Handbook for Caring Science: Expanding the Paradigm (2018).  I have published articles in nursing peer-reviewed journals, contributed chapters in nursing textbooks and presented at national and international conferences.

Video Interview (used by permission)

Original Essay by Marilyn (Dee) Ray –

THE MEANING OF BUREAUCRACY AND THE THEORY OF BUREAUCRATIC CARING

Bureaucracy has multiple meanings, often associated with diverse metaphors, such as, organizations, political systems, cultures, machines, psychic prisons, brains, and organisms (Morgan, 2006). Bureaucracies are represented generally as complex systems with divisions of labor, and political, legal, economic and technological dimensions. As such, they are social-structural entities of society with socio-cultural characteristics. Often they are viewed negatively, however, as anthropologists, Britan and Cohen (1980) stated, “T[t]he study of bureaucracies is, in effect, the study of the most salient [most important] and powerful organizations of the contemporary world. How bureaucracies react to their own problems and/or ours determine how we live–indeed whether we live at all. Like it or not, humankind is being driven into a bureaucratized world whose forms and functions, whose authority and power, must be understood if they are ever to be even partially controlled” (p. 27). Researchers and planners must establish which aspects of bureaucratic growth benefit a particular organization or population as a whole. Leaders/researchers have identified an understanding of central components of bureaucracy which are considered dynamic, creative or emergent based upon choices made in networks of relationships and thus become essential [such as caring, compassion, resilience, courage] (Bar Yam, 2004; Britan & Cohen, 1980; Davidson, Foa, 1971; Leavitt, 2005; Mises, 2017; Ray, 1989, 2010; Ray & Turkel, 2015). Weber (Boone & Bowen, 1980 ), the foremost sociologist and economist, and considered one of the great thinkers of the meaning of bureaucracy illuminated its meaning (see below). The term is used by sociologists, anthropologist, and organizational theorists or professionals to identify a group of workers (for example, in government service or in complex organizations) who are considered the bureaucracy or bureaucrats. Bureaucracy generally outlines a set of principles that impact both the private and public sectors of a nation. Weber (Boone & Bowen, 1980) identified six major principles. They are as follows:

1. A formal hierarchical structure where at each level in an organization, controls are in place for the purposes of central planning and often centralized decision-making.

There are leaders and leaders imply followers. “Leaders plus followers means hierarchy-not the old rigid hierarchy to be sure [in the contemporary era], but hierarchy nonetheless” (Leavitt, 2005, p. 141). At the same time in hierarchies, decision-making occurs at different levels related to professional and non-professional roles but they are always obligated to uphold the rules and regulations of the central authority.

In a hospital organization, there is a President or Chief Executive Officer of Director in Charge with executive staff, such as, as Chief Operating Office, Chief Financial Officer, Vice Presidents or Directors of Nursing, Medicine, Ancillary Personnel, Materials’ Management, Human Resources, Volunteers and so forth. In nursing there are registered nursing administrators or directors, such as, vice-presidents, nurse executives, nurse managers, charge nurses, clinical nurse leaders, clinical nurse specialists, nurse practitioners, staff nurses, practical nurses, certified technical nurses, or registered nursing assistants, technicians, and orderlies. Other supportive personnel, include but are not limited to, Respiratory Therapists, Occupational Health Professionals, Patient Representatives, Social Workers, and Physical Therapists. Hospitals have different names for different roles but professionals are usually classified according their role in care of the patient or in relation to the administration. Care or caring values or virtues are or become dominant based upon different roles (Ray, 1981, 1984, 2010a; Ray & Turkel, 2015, in press).

Complex hospital organizations or systems, such as, general hospitals, the military health care or the Veterans’ Administration system, or any large scale health care system are now influenced by health care law, such as, in the United States (although altered), the Patient Protection and Affordable Care Act (PPACA).

Complex Organizational dynamics are not always a direct outcome of the formal organization or the hierarchical structure but a result of complex issues related to, for example in hospitals or other health care organizations, constantly shifting economics, physician authority and perceived control, social and relational caring patterns, cultural and transcultural understanding, and other factors outside the organization’s control, such as, in hospitals or other health care systems, the patient’s right to make his or her own decisions related to health, healing and well-being, pharmacological interventions and changes, and the changes in health care related to government health care or interventions, and health insurance issues.

Despite the movement over recent decades toward The end of bureaucracy and the rise of the intelligent organization (E. & G. Pinchot, 1994), decentralization, or the development of flat” structures or systems, hierarchies are here to stay and we, as professionals, must learn to manage these complex systems more humanely, effectively and efficiently with caring, human and cultural rights, and (such as, through boundary-crossing leadership, patient centered and relational caring, the understanding of Ray’s Theory of Bureaucratic Caring, leading and caring for people on the front-lines of care, shared governance, and co-creation of community with communitarian ethics and transcultural caring) (Allen, 2013; Davidson, Ray & Turkel, 2011; Eggenberger, 2011; Leavitt, 2005; Ray, 1981, 1984, 1989, 2010a, b, c; 2011; Ray & Turkel, 2013; 2014, 2015; Sherman, 2014).

2. Management by rules which have been made by not only rules within an organization, but also, rules from external organizations (such as, in nursing, the American Nurses Association Code of Ethics with Interpretive Statements, 2015), National Institutes of Health, National Academy of Medicine directives, Quality and Safety Education for Nurses, other regulatory organizations, insurance companies, and internal regulations, rules and policies.

3. Organization by functional specialty, such as Boards of Directors, President, Chief Executive, Chief Financial Officer, clinicians, staff, and so forth. In nursing, professionals are organized by professional clinical skills, types of work, competencies, roles, unit organizations and particularly registration such as, in nursing, licensed registered nurses, nurse practitioners, clinical nurse specialists according to diverse certifications, such as critical care, oncology, holistic nursing, transcultural nursing and so forth, and other allied health professional functions.

4. For-Profit or not-for-profit or public organizations which, in for profit organizations serves the stockholders and stakeholders, such as the board of directors, or whatever agency is empowered as a regulatory board. In not-for-profit systems, it can be the government, the military health care system e.g. TriCare, the Veterans’ Administration, religious organizations or voluntary organizations.

5. Equal treatment of employees means that there is a quest to treat all employees equally in their performance of their professional roles and, in essence, not be influenced by individual differences. In health care situations, patients’ rights must be protected, e.g. HIPAA federal privacy rules and regulations under the Health Insurance Portability and Accountability Act (HIPAA)(www.hhs.gov.; HIPAA Public Law 104-191, 110, stat. 1936, August 21, 1996). And in the contemporary situation, individual differences based upon need is usually taken into consideration (such as, attention to cultural or religious diversity). Under equal treatment for all, the potential of impersonalization of individuals exists based on certain issues or problems arising in complex systems. In situations where there is substance abuse or legal issues, rules and professional regulations are initiated and laws are in effect. In contemporary hospitals, there is a Human Resources Department that has been created to both support or oppose employees if rules are not followed.

6. Employment based on professional or technical qualifications gives the rights to an arbitrator of the acquisition of legal counsel if there is a dispute.

In summary, the characteristics of bureaucracies are as follows:

• a. a division of labor,
• b: a hierarchy of offices, (leaders who enact or manage political, legal, economic, technological components of complex systems including social-cultural healthcare contexts or other environments)
• c: a set of rules that govern performances,
• d: a separation of the personal from the official,
• e: a selection of personnel on the basis of technical or professional qualifications,
• f: equal treatment of all employees or standards of fairness,
• g: employment viewed as a career/profession by participants, and
• h: protection of dismissal by permanent status or tenure or through legal action (see in Ray, 1989, 2001, 2010a, b, 2018; Ray & Turkel, 2012, 2013, 2014, 2015, in press; Coffman, 2014, 2018).Bureaucracy, while condemned by some as associated with “red tape” and inflexibility continues to provide the most reasonable way in which to view complex systems/organizations/governments and facilitate reasonably their preservation or change. Organizations are recognizing creativity and imagination as well as how stress impacts systems and incorporate research or in some organizations, the institution of Heart Math®, or Caritas Processes (body, mind and spirit), or the Theory of Bureaucratic Caring (Davidson, Ray & Turkel, 2011; Ray & Turkel, 2014, 2015, in press; Watson, 2008) to deal with complex issues or problems that need to be solved to improve the quality of care and caring.

Cited Sources

Significant References in Conjunction with this Presentation of the Theory of Bureaucratic Caring

Bar-Yam, Y. (2004). Making things work: Solving complex problems in a complex world. Boston: NECSI, Knowledge Press.
Boone, L. & Bowen, D. (Eds.)(1980). The great writings in management and organizational behavior. Tulsa, OK: PennWell Publishing Company.
Bohm, D. (2002). Wholeness and the implicate order. London: Routledge.
Britan, G. & Cohen, R. (1980). Hierarchy & society: Anthropological perspectives on bureaucracy. Philadelphia: Institute for the Study of Human Issues.
Coffman, S. (2018). Marilyn Anne Ray’s theory of bureaucratic caring. In M. Alligood (Ed.), Nursing theorists and their work (9th ed.)(pp. 80-97). St. Louis: Elsevier.
Davidson, A. & Ray, M. & Turkel, M. (Eds.) (2011). Nursing, caring and complexity science: For human-environment well-being. New York: Springer Publishing Company. (2011 American Journal of Nursing Book of Year Award for Professional Development and Issues)
Foa, U. (1971). Interpersonal and economic resources. Science 17(29), 345-351.
Leavitt, H. (2005). Top down: Why hierarchies are here to stay and how to manage them more effectively. Boston: Harvard Business School Press.
Mises, L. (2017). Bureaucracy. Victoria, BC: The Dead Authors’ Society (first published in 1944).
Morgan, G. (2006). Images of organization (2nd ed.). Thousand Oaks: Sage Publications.
Nirenberg, J. (1993). The living organization. San Diego: Pfeiffer Publishing Company.
Pinchot, G. & E. (1994). The end of bureaucracy & the rise of the intelligent organization. San Francisco: Berrett-Koehler Publishers.
Ray, M. & Turkel, M. (in press). Marilyn Anne Ray’s theory of bureaucratic caring. In M. Smith (Ed.). Nursing theories and nursing practice (5th ed.). Philadelphia: F. A. Davis Company.
Ray, M. (2018). Theory of bureaucratic caring. In MJ Smith and P Liehr (Eds.). Middle range theory for nursing (4th ed.)(pp. 107-117). New York: Springer Publishing Company.
Ray, M. (2017). Theory of bureaucratic caring. The nurse theorists portraits of excellence with Dr. Martha Alligood (Video #3). Ohio: FITNE.
Ray, M. (2016). Transcultural caring dynamics in nursing and health care (2nd ed.). Philadelphia: F. A. Davis Company.
Ray, M. & Turkel, M. (2014). Caring as emancipatory nursing praxis: The theory of relational caring complexity. Advances in Nursing Science, 37(2), 132-146.
Ray, M. & Turkel, M. (2015). Marilyn Anne Ray’s theory of bureaucratic caring. In M. Smith & M. Parker (Eds.), Nursing theories and nursing practice (4th ed)(pp. 461-482). Philadelphia: F. A. Davis Company.
Ray, M. (2010a). A study of caring within an institutional culture: The discovery of the Theory of Bureaucratic Caring. Saarbrüken, Germany: Lambert Academic Publishing.
Ray, M. (2010b). Transcultural caring dynamics in nursing and health care. Philadelphia: F. A. Davis Company.
Ray, M. & Turkel, M. (2005). Economic and patient outcomes of the nurse-patient relationship. Final Research Report. TriService Nursing Research Program, The Uniformed Services University of the Health Sciences, Bethesda, MD.
Ray, M. (1997b). The ethical theory of existential authenticity: The lived experience of the art of caring in nursing administration. Canadian Journal of Nursing Research, 29(1), 111-126.
Ray, M. (1989). The theory of bureaucratic caring for nursing practice in the organizational culture. Nursing Administration Quarterly, 13(2), 31-42.
Ray, M. (1981). A philosophical analysis of caring within nursing. In M. Leininger (Ed. and Author), Caring: An essential human need (pp. 25-36). Thorofare, NJ: Charles B. Slack, Inc.
Watson, J. (2008). The philosophy and science of caring (2nd rev. ed.). Boulder, CO: University Press of Colorado.
Weber, M. (1987). Legitimate authority and bureaucracy. In L. Boone & D. Bowen (Eds.). The great writings in management and organizational behavior. (pp. 5-21). Tulsa, OK: PenWell Publishing Company.
Wu, C J. & Ray, M. (2016). Technological caring for complexities of patients with cardiac disease comorbid with diabetes. International Journal for Human Caring, 20(2), 83-87.

ADDITIONAL CHAPTERS AND ARTICLES (Primary and Secondary Sources)

Ray, M. & Turkel, C. (in press). Relational caring questionnaires. In K. Sitzman & J. Watson (Eds.), Assessing and measuring caring in nursing and health sciences. (3rd. ed.). New York: Springer Publishing Company.
Ray, M. (2018). Theory of bureaucratic caring. In MJ Smith and P Liehr (Eds.). Middle range theory for nursing (4th ed.)(pp. 107-117). New York: Springer Publishing Company.
Ray, M. (2015). Rootedness in holistic nursing: The ontologic mystery and structure of caring. Beginnings, 35(2), 12-14.
Ray, M. & Turkel, M. (in press). The theory of bureaucratic caring. In M. Smith (Ed.). Nursing theory and nursing practice (5th ed.). Philadelphia: PA. FA Davis Company.
Ray, M. & Turkel, M. (2015). The theory of bureaucratic caring. In M. Smith & M. Parker (Eds.), Nursing theory and nursing practice (4th ed.)(pp. 461-482). Philadelphia: FA Davis Company.
Ray, M. & Turkel. M. (2014) Caring as emancipatory nursing praxis: The theory of Relational Caring Complexity. Advances in Nursing Science, 37(2), 137-146.
Ray, M., Morris, E. & McFarland, M. (2013). Leininger’s Ethnonursing Method. In C. Beck (Ed.), The Routledge international handbook of qualitative research. New York: Routledge.
Ray, M. (2013). The theory of bureaucratic caring. In M. Smith, M. Turkel & Z. Wolf (Eds.), Caring classics in nursing. (pp. 309-320). New York: Springer Publishing Company.
Ray, M. (2013). Caring inquiry: The esthetic process in the way of compassion. In M. Smith, M. Turkel & Z Wolf (Eds.), Caring in nursing classics: An essential resource (pp. 339-345). New York: Springer Publishing Company.
Ray, M. (2012). Transcultural nursing scholars’ corner. Journal of Transcultural Nursing, 23(4), 412.
Ray, M. & Turkel, M. (2012). A transtheoretical evolution of caring science within complex systems. International Journal for Human Caring., 16(2), 28-49. (Includes Patient and Professional questionnaires)
Turkel, M., Ray, M. & Kornblatt, L. (2012). Instead of reconceptualizing the nursing process, let’s rename it. Nursing Science Quarterly, 25(2), 194-198.
Ray, M. & Turkel, M. (2011). Prologue. In A. Davidson, M. Ray & M. Turkel (Eds.), Nursing, caring, and complexity science: For human-environment well-being (pp. xxiii-xxxvii). New York: Springer Publishing Company.
Ray, M., Turkel, M. & Cohn, J. (2011). Relational caring complexity: The study of caring and complexity in healthcare hospital organizations. In Davidson, A. & Ray, M. & Turkel, M. (Eds.) (2011). Nursing, caring, and complexity science: For human-environment well-being (pp. 95-117). New York: Springer Publishing Company.
Ray, M. (2011). Complex caring dynamics: A unifying model of nursing inquiry. In Davidson, A. & Ray, M. & Turkel, M. (Eds.) (2011). Nursing, caring, and complexity science: For human-environment well-being (pp. 31-52). New York: Springer Publishing Company.
Campling, A., Ray, M., & Lopez-Devine, J. (2011). Implementing change in nursing informatics practice. In A. Davidson, M. Ray & M. Turkel (Eds.), Nursing, caring, and complexity science: For human-environment well-being (pp. 329-329). New York: Springer Publishing Company.
Ray, M. & Turkel, M. (2011). Complexity science. In H. Feldman (Ed.), Nursing leadership: A concise encyclopedia (2nd ed.). New York: Springer Publishing Company.
Ray, M. (2010). Creating caring organizations and cultures through communitarian ethics. World Universities Forum Journal, 3(5), 41-52.
Ray, M. (2010). Transcultural caring dynamics in nursing and health care: A framework for transcultural caring analysis: In M. Douglas & D. Pacquaio (Eds.). Core curriculum for transcultural nursing and health care. Thousand Oaks, CA: Sage.
Ray, M. (2010). Grounded theory method for the study of transcultural nursing. In M. Douglas & D. Pacquaio (Eds.). Core curriculum for transcultural nursing and health care. Thousand Oaks, CA: Sage.
Ray, M. (2010). Phenomenological-hermeneutical research method for the study of transcultural nursing. In M. Douglas & D. Pacquaio (Eds.), Core curriculum for transcultural nursing and health care. Thousand Oaks, CA: Sage.
Ray, M. (2010). Critical theory for transcultural nursing research. In M. Douglas & D. Pacquaio (Eds.). Core curriculum for transcultural nursing and health care. Thousand Oaks, CA: Sage.
Ray, M. & Turkel, M. (2010). The theory of bureaucratic caring. In M. Smith & M. Parker (Eds.), Nursing theory and nursing practice (3rd ed.). Philadelphia: F.A.Davis Company.
Ray, M. & Turkel, C. (2009a). Relational caring questionnaires. In J. Watson (Ed.), Assessing and measuring caring in nursing and health sciences (pp. 209-218). New York: Springer Publishing Company.
[Professional and Patient Questionnaires are posted on the Watson Caring Science Institute of the Springer Publishing Company website; also, in Article: A transtheoretical evolution of caring science within complex systems. International Journal for Human Caring, 2012,]
Ray, M. & Turkel, M. (2009b). Caring for not so picture perfect patients”: Ethical caring in the moral community of nursing. In R. Locsin & M. Purnell (Eds.), A contemporary nursing process: The (un)bearable weight of knowing in nursing (pp. 225-249). New York: Springer Publishing Company.
Ray, M. (2008). Caring scholar response to: “Achieving compassionate excellence: A cooperative accelerated BSN program. International Journal for Human Caring, 12(2), 39-41.
Ray, M. (2007). Technological caring as a dynamic of complexity in nursing practice. In A. Barnard & R. Locsin (Eds.). Perspectives on technology and nursing practice. United Kingdom: Palgrave MacMillan.
Ray, M. (2006). The theory of bureaucratic caring. In M. Parker (Ed.), Nursing theories and nursing practice (pp. 360-368). Philadelphia, Pa: F. A. Davis Company.
Ray, M., Turkel, M. & Marino, F. (2002). The transformative process for nursing in workforce redevelopment. Nursing Administration Quarterly, 26(2), 1- 14.
Turkel, M. & Ray, M. (2004). Creating a caring practice environment through self-renewal. Nursing Administration Quarterly, 28(4), 249-254).
Turkel, M. & Ray, M. (2003). A process model for policy analysis within the context of political caring. International Journal for Human Caring, 7(3), 17-25.
Ray, M. (2001). The theory of bureaucratic caring. In M. Parker (Ed.), Nursing theories and nursing practice. Philadelphia, Pa: F. A. Davis Company.
Turkel, M. & Ray, M. (2001). Relational complexity: From grounded theory to
instrument development and theoretical testing. Nursing Science Quarterly, 14(4), 281-287.
Turkel, M. & Ray, M. (2000). Relational complexity: A theory of the nurse-patient relationship within an economic context. Nursing Science Quarterly, 13(4), 307-313.
Ray, M. (1999), Critical theory as a framework to enhance nursing science. In E. Polifroni & M. Welch (Eds.). Philosophy of science in nursing (pp. 382-386). Philadelphia: Lippincott.
Ray, M. (1998a). Complexity and nursing science. Nursing Science Quarterly, 11, 91-93.
Ray, M. (1998b). A phenomenologic study of the interface of caring and technology: A new reflective ethics in intermediate care. Holistic Nursing Practice, 12(4), 71- 79).
Ray, M. (1997). The ethical theory of existential authenticity: The lived experience of the art of caring in nursing administration. Canadian Journal of Nursing Research, 29(1), 111-126.
Ray, M. (1991). Critical theory as a framework to enhance nursing science. Nursing Science Quarterly, 5(3), 98-101.
Ray, M. (1989). A theory of bureaucratic caring for nursing practice in the organizational culture: Nursing Administration Quarterly, 13(2), 31-42. (Also translated and published in the Japanese Journal of Nursing Research.)
Ray, M. (1987a). Technological caring: A new model in critical care. Dimensions in Critical Care, 6(3), 166-173. (Winner of the Annual Research Award, 1987).
Ray, M. (1987b). Health care economics and human caring: Why the moral conflict must be resolved. Family and Community Health 10(1), 35-43.
Ray, M. (1984). The development of a nursing classification system of caring. In M. Leininger (Ed.), Care, the essence of nursing and health (pp. 93-112). Thorofare, NJ: Charles B. Slack.
Ray, M. (1981). A study of caring within the institutional culture. Doctor of Philosophy Dissertation, University of Utah, Salt Lake City.

Bureaucratic Caring Theory of Marilyn Anne Ray Written by Other Authors (2006-2012)

Coffman, S. (2018). Marilyn Anne Ray’s Theory of bureaucratic caring. In M. Alligood (Ed.), Nursing theorists and their work (9th ed.)(pp. 80-97) St. Louis: Mosby/Elsevier.
Coffman, S. (2014). Marilyn Anne Ray’s Theory of bureaucratic caring. In M. Alligood (Ed.), Nursing theorists and their work (8th ed.)(pp. 98-119). St. Louis: Mosby/Elsevier.
Coffman, S. (2010). Marilyn Anne Ray’s Theory of bureaucratic caring. In M. Marriner Tomey & M. Alligood (Eds.), Nursing theorists and their work (7th ed.)(pp. 113-136). St. Louis: Mosby/Elsevier.
Coffman, S. (2006). Marilyn Anne Ray’s Theory of bureaucratic caring. In A. Marriner Tomey and M. Alligood (Eds.), Nursing theorist and their work (6th ed.)(pp. 116-139). St. Louis: Mosby/Elsevier.
Gibson, S. (2008). Legal caring: Preventing retraumatization of abused children through the caring nursing interview using Roach’s six Cs. International Association for Human Caring, 12(4), 32-37.
Turkel, M. (2007). Dr. Marilyn Ray’s theory of bureaucratic caring. International Journal for Human Caring, 11(4), 57-74.
Turkel, M. (2006). Applicability of bureaucratic caring theory to contemporary nursing practice: The political and economic dimensions. In M. Parker (Ed.), Nursing theories and nursing practice (pp. 433-444). Philadelphia, PA: F. A. Davis Company.

Examples of Dissertations/Articles Using the Theory of Bureaucratic Caring:

Abiri, Olga, (2017). Examining the relationship between Labor and Delivery nurses’ perceptions about unit safety, physician-nurse communication and care delivery structures. PhD Dissertation, Florida Atlantic University, The Christine E. Lynn College of Nursing, Boca Raton, Florida.
Allen, S. (2013). An Ethnonursing Study of the Cultural Meanings and Practices of Clinical Nurse Council Leaders in Shared Governance, University of Cincinnati College of Nursing, Cincinnati, Ohio.
Chadwell, K. (2018). Caring from the inside in an era of precision health. Forthcoming presentation to ELSI Congress for Ethical, Legal, Social Implications of Precision Health, Washington, DC.
Eggenberger, T. (2011). Holding the frontline: The experience of being a charge nurses in an acute care setting. PhD Dissertation, The Christine E. Lynn College of Nursing, Florida Atlantic University Boca Raton, Florida.
Johnson, P. (2015). Ray’s theory of bureaucratic caring: A conceptual framework for APRN primary care providers and the homebound population, International Association for Human Caring, 19(2), 41-44.
Prestia, A. (2015). Chief nursing officer sustainment in the continued practice of nursing leadership: A phenomenological inquiry. PhD Dissertation, Florida Atlantic University, Boca Raton, Florida.
Prestia, A. (2016). Existential authenticity: Caring strategies for living leadership presence. International Association for Human Caring, 20(1), 8-11.

Additional Information

Provided by Marilyn “Dee” Ray, February, 2020

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1. Application of the Theory of Bureaucratic Caring (BCT) within the United States Air Force Nurse Corps, and the National Capitol Region of the United States

Within the United States Air Force, Colonel Marcia Potter, DNP, FNP-BC,
Chief Primary Care Nurse has initiated and applied the Theory of
Bureaucratic Caring (BCT), not only, first, to facilitate with the
executive team, the creation of the USAF Professional Person-Centered
Caring Partnership Model (PC2P), but also, to apply the BCT to primary
care. The BCT is used as a guide to frame evidence-based clinical practice
and business operations in Primary Care within the National Capitol Region
of the Defense Health Agency, impacting the care delivery of 450,000
Military Health System enrollees.

The PC2P Professional Person-Centered Caring Partnership Model also has
formed the basis of the Triservice (Air Force, Army and Navy) professional
nursing practice model developed within the Uniformed Services University
of the Health Sciences to assist military healthcare. Colonel Potter’s
efforts have impacted professional nursing practice for 10 million Military
Health System beneficiaries worldwide.

2. Specific Outcomes of the Application of the BCT to the Military Health System Worldwide
3. Person-Centered Partnership Models that enhances chronic care model
4. Person-centered Caring Communication Initiative
5. Spiritual care Embedment Project
6. Multidisciplinary evidence-based Practice Council
7. Patient Discharge Instructions Using Acupuncture
8. Take Your Theorist (Dr. Marilyn A. Ray) to Lunch Education Series
9. Creation of Simulation Projects
10. Tri-Service Nurse Corps (Army, Navy, US Air Force) Professional Practice
    Model
11. Reshaping Military Health System for Human Caring
12. Outreach to Community Stakeholders for Health and Wellness Promotion
13. Application of BCT to Nursing Curricula with Senior Leaders and Nursing
    Faculty of the Uniformed Services University of the Health Sciences
14. Creating alliances for Multi-Dimensional Caring in Human Sciences and
    Business Operations
15. Enhanced Patient Safety, Use of and Medication Adherence, Understanding
    of Chronic Health States
16. Positioning of New Advanced Practice Nurses to Use BCT in Daily
    Clinical Practice and Leadership Roles

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Specific Application of Categories (Concepts, Domains) within the Theory of Bureaucratic Caring by Human Beings to the COVID 19 Pandemic (By Colonel Marcia Potter, USAF, NC, DNP, Chief Primary Care Nurse, Adjunct Professor Uniformed Services University of the Health Sciences)

1. Technology:

Use of phone, text, other social media, teleconferencing/distance learning
platforms for engagement while maintaining social distance.

The impact and professional ablilty of nurses, physicians, respiratory
therapists, EMTs, cleaning personnel, and others (all frontline workers)
for understanding the COVID 19 illness, the use of ventilators, and
medications to facilitate life.

2.* Education*:

Provision of evidence-based and creative knowledge/advice to patients,
staff, and general public after learning more about the symptoms, course
and distribution of virus, mitigation, containment, treatment, and
predictions of pandemic on local, national, and global perspective levels.
Application of new care approaches to COVID 19 patients, such as
respiratory care and placing patients in prone position for lung capacity
and relief. Appreciation of all education undertaken by teachers remotely.

3. Social-cultural:

Understanding the “new” culture of COVID 19 where traditional practices,
rituals, symbols have to be performed in new ways.

Redefinition of the meaning of local and global culture, community, faith,
and family. Reunderstanding of the culture of aging and illness.

Understanding cultural genetics and its impact on health and well being,
especially diverse cultural groups.

4. Political:

Resources, authority, policy, power, and “power of caring”, and personal
influence impacting engagement in human-human relationships and bonding.

Sensitivity to needs of all for the creation of new policy for all,
especially, the most vulnerable. Assistance of all branches of the military
to the civilian sector for application of technical help and provision of
human resources for care of the sick.

5. Economic:

Financial resources being poured into caring for people on a massive,
inprecedented scale in manufacturing of life-saving technologies,
scientific and medication developments, and preservation of the economic
well being of people and organizations.

Shifting of manufacturing and design to immediate financial support to
individuals , families, communties, and businesses, illuminating the
economic power of caring that is leveraged daily to improve health, lives,
rescue and the sustaining communities. Shift of some primary care resources
to tertiary care during COVID 19.

6. Legal:

Attention to assuring the highest quality of standards for care yet
relaxing some, in order to ensure that resouces can be applied as broadly
as possible.

New latitude given to conducting telehealth, transfer of state licensure
requirements for professionals to serve in other states; use of volunteers
to work in health care; enabling of governments to leverage power for the
good of all.

Physical:

In time of social distancing for the sake of life, nurses and other health
care professionals, and other essential personnel are placing themselves at
risk to care for the needs of the sick and to keep people well. This
ultimate sacrifice cannot be overlooked or underestimated.

Spiritual-Ethical:

At the center of every decision (related to the categories (concepts,
domains)) in the BCT, the very essence of humanity, the desire to do good,
to place another person’s welfare before one’s own In the deepest, most
fundamental essence of being, is finding our connection to the
Spiritual-the Holy. This connection compels us to rise above our fears, and
self-centeredness to bring this holiness into life and action to instill,
often through prayer, faith, courage, hope, love, and light to self and
others. Creating new ways of caring for the dying in isolation from family
and friends. Sharing in the joys of returning patients to health; and
professionals sharing in the sorrows of dying and death.