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CHAPTER 8 Marilyn Anne Ray 103

MAJOR CONCEPTS & DEFINITIONS—cont’d

Social-Cultural technology are computer-assisted practice and
Examples of social and cultural factors are ethnicity documentation (Campling, Ray, & Lopez-Devine,
and family structures; intimacy with friends and 2011; Swinderman, 2011).
family; communication; social interaction and sup-
port; understanding interrelationships, involve- Economic
ment, and intimacy; and structures of cultural Factors related to the meaning of caring include
groups, community, and society (Ray, 1981a, 1989, money, budget, insurance systems, limitations, and
2001, 2006, 2010a). guidelines imposed by managed care organizations,
and, in general, allocation of scarce human and ma-
Legal terial resources to maintain the economic viability
Legal factors related to the meaning of caring in- of the organization (Ray, 1981a, 1989). Caring as an
clude responsibility and accountability; rules and interpersonal resource should be considered, as well
principles to guide behaviors, such as policies and as goods, money, and services (Turkel & Ray, 2000,
procedures; informed consent; rights to privacy; 2001, 2003; Ray, Turkel & Cohn, 2011.
malpractice and liability issues; client, family, and
professional rights; and the practice of defensive Political
medicine and nursing (Gibson, 2008; Ray, 1981a, Political factors and the power structure within health
1989, 2010a, 2010b). care administration influence how nursing is viewed
in health care and include patterns of communication
Technological and decision making in the organization; role and
Technological factors include nonhuman resources, gender stratification among nurses, physicians, and
such as the use of machinery to maintain the physi- administrators; union activities, including negotiation
ological well-being of the patient, diagnostic tests, and confrontation; government and insurance com-
pharmaceutical agents, and the knowledge and skill pany influences; uses of power, prestige, and privilege;
needed to utilize these resources (Davidson, Ray & and, in general, competition for scarce human and
Turkel, 2011; Ray, 1987, 1989). Also included with material resources (Ray, 1989, 2010a, 2010b).

including nursing administration. More than 200 focused, comforting, compassionate). Staff nurses val-
respondents participated in the purposive and con- ued caring in relation to patients, and administrators
venience sample. The principal question asked was valued caring in relation to the system, such as the
“What is the meaning of caring to you?” Through economic well-being of the hospital.
dialogue, caring evolved from in-depth interviews, The formal Theory of Bureaucratic Caring symbol-
participant observation, caregiving observation, and ized a dynamic structure of caring. This structure
documentation (Ray, 1989). emerged from the dialectic between the thesis of car-
Ray’s discovery of bureaucratic caring began as a ing as humanistic (i.e., social, education, ethical, and
substantive theory and evolved to a formal theory. The religious-spiritual structures) and the antithesis of
substantive theory emerged as Differential Caring, caring as bureaucratic (i.e., economic, political, legal,
that the meaning of caring differentiates itself by its and technological structures). The dialectic of caring
context. Dominant caring dimensions vary in terms of illustrates that everything is interconnected and that
areas of practice or hospital units. For example, an in- the organization is a macrocosm of the culture.
tensive care unit has a dominant value of technological The evolution of Ray’s theory is illustrated in
caring (e.g., monitors, ventilators, treatments, and Figure 8-1, with diagrams of the bureaucratic caring
pharmacotherapeutics), and an oncology unit has a structure published in 1981 and 1989. In the origi-
value of a more intimate, spiritual caring (e.g., family nal grounded theory (see Figure 8-1, A). political