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

Contributor: Marilyn (Dee) Ray
September 15, 2018

Practice/Theory Exemplar (Ray’s Theory of Bureaucratic Caring)

Ray’s Theory of Bureaucratic Caring/Application Person-Centered Caring Partnership PC2P Model. Used by permission

Location – Worldwide through the US Air Force Nurse Corps (USAF NC)
Description of the settings

The USAF Medical Service responds to the needs of over 200,000 airmen/women and delivers healthcare to 2.6 million patients through a system of 239 clinics at 76 AF installations worldwide.

Key nurses involved in implementation

Dorothy A. Hogg, Lieutenant General, Surgeon General of the United States Air Force, Medical Service/Nurse Corps, Office of the Surgeon General, The Pentagon, Washington, DC

Robert J. Marks, Brigadier General, USAF, AMC Command Surgeon and AF Chief Nurse

Deedra L. Zabokrtsky, Colonel, USAF, NC , DNP, NEA, BC, Director AF Nurse Corps, Division Chief, Medical Officer Force Development, Office of the Surgeon General

Marcia A. Potter, Colonel, USAF, NC, DNP, FNP-BC, Master Clinician, FNP Consultant, 779 MDG, Joint Base Andrews, MD

Date of Implementation
Theoretical Framework

Bureaucratic Caring Theory is a synthesis emerging from the dialectic between the thesis of caring as humanistic (i.e., spiritual-ethical, social-cultural, educational , physical domains) and the antithesis of caring as bureaucratic (i.e., economic, political, legal and technological domains).

Substantive theory of BCT is Differential Caring: dominant caring characteristics vary in terms of professional roles, areas of practice or units.

Domains guiding practice:

  • Caring: Focus on the relationship between charity and right action, between love as compassion in response to suffering and need, justice (fairness) in terms of what ought to be done.
  • Spiritual-Ethical Caring: Focus on values, holism- body, mind, spirit interconnectedness and moral choice—
    the meaning of caring as love, compassion, respect, trust, moral obligation or right action for the good of others/cultures/society.
  • Social-Cultural: Focus on meaning of caring within social interactions and support for others: communication, seeking understanding of diverse groups, ethnicities, families, organizations, national and global societal cultures.
  • Legal: Focus on the meaning of caring regarding responsibility and accountability, rules, regulations, policies, standards of practice, rights to privacy, malpractice, defensive medicine and nursing.
  • Political: Focus on meaning of caring within power and governance structures and authority within individuals, healthcare organizations, and societal organizations.
  • Economic: Focus on the meaning of caring related to goods, money, services, budget, scarce human and material resources to maintain economic viability of persons, units, and complex organizations.
  • Technological: Focus on meaning of caring using nonhuman resources, use of machines, computers, internet, texts, social media, robots, diagnostic tests, pharmacologic agents to maintain physical and emotional well-being of patients, staff, and organizations.
  • Educational: Focus on the meaning of caring within formal and informal educational programs including multiple media to convey information, all forms of teaching and sharing information and learning, including Inter-professional education and research.
  • Physical: focus on physical state of being, including biological and mental patterns and how body, mind and spirit are interconnected and influence each other.

Colonel Marcia Potter, DNP, FNP, USAF, NC under the leadership of Lieutenant General Dorothy Hogg, Surgeon General of the United States Air Force and Colonel Deedra Zabokrtsky, Director of Project is participating in and addressing the Trusted Care initiative to help build and sustain a High Reliability Organization in the development of a Person-Centered Caring Partnership Inter-Professional Practice Model for the Nurse Corps and Medical Service (global military health system.).

The practice model places ‘people at the center and caring at the core” using the USAF Colonel (Retired) Marilyn A. Ray’s Theory of Bureaucratic Caring (BCT) as its cornerstone or framework. As a master clinical and educator in the USAF primary care and family practice arenas, Colonel Potter has developed strategic goals and educational innovations to bring theory-guided person-centered caring practice to AF nursing and other healthcare disciplines globally.

The process required a commitment to a paradigm change to humanize healthcare and strengthen and foster collaboration using principles of trusted care, zero preventable harm, caring communication, and formation of partnerships with USAF Nurse Corps and other health care disciplines. Examples of Colonel Marcia Potter’s leadership and innovations using the Theory of Bureaucratic Caring (BCT) are the following:

  1. Development of Spiritual Caring within USAF Chaplaincy Program.
  2. Applying the BCT and Chronic Care Models to improve staff and patient self-efficacy for patients with diabetes to improve clinical and economic outcomes for over 2 million dollars.
  3. Communication within the National Capitol Regional-Enhanced Market in partnership with the Academic Health System.
  4. Mentoring Emergency Room personnel to create process improvement projects using the BCT-guided practice.
  5. Mentoring Acupuncture and Integrative Medicine clinical nursing staff to create patient discharge instruction.
  6. Using simulation technology and communication strategies to improve caring conveyed verbally and non-verbally.
  7. Creating Evidence-Based/Informed Practice Councils within military treatment facilities (MTFs).
  8. Creating an educational program with modules, “Taking Your Theorist to Lunch: Conversations with Dr. Marilyn Ray” to teach nurses the fundamentals of the BCT with real-world examples.
  9. Developing a film documentary series, “People at the Center, Caring at the Core” using social media, You-Tube, and Facebook to disseminate information about the Inter-Professional Caring Practice Model using the BCT as a framework.
  10. Developing summative and formative evaluative research of inter-professional patient-centered caring programs using the BCT.

Potter, M & Wilson, C. ( 2017). Applying Bureaucratic Caring Theory and chronic care model to improve staff and patient self-efficacy. Nursing Administration Quarterly, 41(4), 310-320.

Approach to Evaluation

Select Activities Regarding Professional and Interprofessional Practice — PC2P Model (Col (Ret.) Ray, and Col. Potter)

  • Development of Strategic Goals and Educational Innovation for Implementation within TNF. Projections for Continuous Evaluation and Research.
    • National Academies of Practice and Inter-professional Education Collaboration: Presentation: BCT( Ray) and Application in USAF, MS (Potter), 2017.
    • Society for Applied Anthropology- Council on Nursing and Anthropology- Presentation: BCT (Ray) and Application in USAF, NC (Potter), 2017.
  • Select Activities Regarding Professional and Interprofessional Practice — PC2P Model (Colonel Potter.
    • Spiritual Care in Primary Care, 2017 (and on-going).
    • Expanded Primary Care Model using BCT to create person-centered caring in select Primary Care Clinics, 2017 (and ongoing).
    • Creation of Evidence-based Practice Council at Joint Base Andrews: Quality Improvement and Patient Safety: Application of BCT and Trusted Care Principles, 2017 (and ongoing).
    • Video Documentary Series and Creation of Simulation : Application of BCT and PC2P in relational interactions, problem identification, and solutions, 2017 (and ongoing).
Relevant Sources

Coffman, S. (2018). Theory of bureaucratic caring. In M. Alligood (Ed). Nursing theorists and their work (9th ed.). St. Louis: Elsevier.

Davidson, A. & Ray, M. (1991). Studying the human-environment relationship using the science of complexity. Advances in Nursing Science, 14(2), 73-87.

Davidson, A, Ray, M. & Turkel, M. (2011). Nursing, caring and complexity science: For human-environment well-being. New York: Springer.

Hogg, D. et al. (2018). Person-Centered Caring, United States Air Force Medical Service (2017). Person-Centered Caring Partnership (PC2P) Model. [Professional Practice Model], USAF, SG, Washington, DC.

Potter, M. & Wilson, C. (2017). Applying Bureaucratic Caring Theory and Chronic Care Model to improve staff and patient self-efficacy. Nursing Administration Quarterly, 41(4), 310- 320.

Potter, M. (2015). Using theory-guided practice to improve diabetes health outcomes in primary care. Doctor of Nursing Practice Project. Chicago, Ill: Chamberlain University.

Ray, M. (1981). A study of caring within an institutional culture. Dissertation Abstracts International, 42(06), (University Microfilms No. 8127787).

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

Ray, M. (2016). Transcultural caring dynamics in nursing and health care (2nd ed.). Philadelphia: F. A. Davis Company. (1st edition, published, 2010).

Ray, M. (2017). Ray’s Theory of Bureaucratic Caring in M. Alligood (Ed.), Nurse theorists: Portraits of excellence, Volume III. Video, Ohio: FITNE Corporation (fitne.net).

Ray, M. (2018). Theory of bureaucratic caring. In M. Smith & P. Liehr, Middle range theory for nursing (4th ed.). New York: Springer Publishing.

Ray, M. & Turkel, M. (2012). A transtheoretical evolution of caring science within complex systems. International Journal for Human Caring, 16(2), 28-49.

Ray, M. & Turkel, M. (2014). Caring as emancipatory praxis: The theory of relational caring complexity. Advances in Nursing Science, 37(2), 132-146.

Ray, M. & Turkel, M. (2014). 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.