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104 UNIT II Nursing Philosophies

and economic structures occupied a larger dimen- nurse-patient relationship. Qualitatively different sys-
sion to illustrate their increasing influence on the tems, such as political, economic, social-cultural, and
nature of institutional caring (Ray, 1981a). Subse- physiological, when viewed as open and interactive,
quent research conducted in intensive care and in- are whole and operate through the choice making
termediate care units (Ray, 1989) emphasized the of nurses (Davidson & Ray, 1991; Ray, 1994a). Spiri-
differential nature of caring, as seen through its tual-ethical caring suggests how choice making for
competing structures of political, legal, economic, the good of others can be accomplished in nursing
technological-physiological, spiritual-religious, eth- practice.
ical, and educational-social elements (see Figure 8-1, B). Ray’s research reveals that in complex organiza-
In her 1987 article on technological caring, Ray noted tions, nursing as caring is practiced and lived out at
that “critical care nursing is intensely human, moral, the margin between the humanistic-spiritual dimen-
and technocratic” (p. 172). Ray encouraged other sion and the systemic dimension. These findings are
researchers to study this area to enhance nursing’s consistent with worldviews from the science of com-
understanding of the advantages and limitations of plexity, which propose that antithetical phenomena
technology in critical care. The Dimensions of Critical coexist (Briggs & Peat, 1999; Ray, 1998). Thus, tech-
Care Nursing journal recognized Ray as Researcher of nological and humanistic systems exist together.
the Year for her groundbreaking work. Complexity theory explains the resolution of the
With continued reflection and analysis, com- paradox between differing systems (thesis and antith-
bined with research on the economics of the nurse- esis) represented in the synthesis or the Theory of
patient relationship, Ray began to illuminate the Bureaucratic Caring.
ethical-spiritual realm of nursing (Figure 8-2) (Ray, In summary, the Theory of Bureaucratic Caring
2001). Spiritual-ethical caring became a dominant emerged using a grounded theory methodology,
modality because of discoveries that focused on the blended with phenomenology and ethnography.

Ethico-
religious-
humanistic Ethical Spiritual/
religious
Economic
Educational
Educational/ Economic
social
Caring Caring

Political Technological/
Technological physiological
Political
Legal
Legal

A B
FIGURE 8-1 A, The Original Grounded Theory of Bureaucratic Caring. B, Subsequent Grounded Theory
Revealing Differential Caring. (A from Ray, M. A. [1981a]. A study of caring within an institutional culture.
Dissertation Abstracts International, 42[06]. [University Microfilm No. 8127787.]. B from Parker, M. E. [2006].
Nursing theories and nursing practice [3rd ed.]. Philadelphia: F. A. Davis. Graphics redrawn from originals by
J. Castle and B. Jensen, Nevada State College, Henderson, NV.)