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106 UNIT II Nursing Philosophies

the social structure and spiritual and ethical caring 2. Caring is bureaucratic as well as spiritual/ethical,
patterns of meaning (Davidson, Ray, & Turkel, 2011; given the extent to which its meaning can be un-
Ray, 2010a). derstood in relation to the organizational structure
(Davidson, Ray, & Turkel, 2011; Ray, 1989, 2001,
2006; Ray & Turkel, 2010). In the theoretical model
Theoretical Assertions (see Figure 8-2). everything is infused with spiri-
Person, nursing, environment, and health are inte- tual-ethical caring by its integrative and relational
grated into the structure of the Theory of Bureaucratic connection to the structures of organizational life
Caring. The theory implies a dialectical relationship (e.g., political, educational). Spiritual-ethical caring
(thesis, antithesis, synthesis) among humans (person is both a part and a whole, just as each of the orga-
and nurse), the dimension of spiritual-ethical caring, nizational structures is both a part and a whole.
and the structural (nursing, environment) dimensions Every part secures its purpose and meaning from
of the bureaucracy or organizational culture (techno- the other parts. Understanding of spiritual-ethical
logical, economic, political, legal, and social). For Ray, caring in the bureaucratic organizational system, as
the dialectic of caring and bureaucracy is synthesized a holographic formation, facilitates improvement
into a theory of bureaucratic caring. Bureaucratic in patient outcomes and transformation of human
caring, the synthetic margin between the human and environmental well-being (M. Ray, personal com-
structural dimensions, is where nurses, patients, munication, April 13, 2008; Ray, 2010a).
and administrators integrate person, nursing, health, 3. Caring is the primordial construct and conscious-
and environment. ness of nursing. Spiritual-ethical caring and the
Theoretical assertions within the Theory of Bureau- organizational structures in Figure 8-2, when inte-
cratic Caring are as follows: grated, open, and interactive, are whole and oper-
1. The meaning of caring is highly differential, ate by conscious choice. Nurses’ choice making
depending on its structures (social-cultural, edu- occurs with the interest of humanity at heart, uti-
cational, political, economic, physical, technologi- lizing ethical principles as the compass in delibera-
cal, legal). The substantive theory of Differential tions. Ray (2001) states, “Spiritual-ethical caring
Caring discovered that caring in nursing is contex- for nursing does not question whether or not to
tual and is influenced by organizational structure care in complex systems, but intimates how sincere
or culture. Thus the meaning of caring is varied in deliberations and ultimately the facilitation of
the emergency department, intensive care unit, choices for the good of others can or should be
oncology unit, and other areas of the hospital and accomplished” (p. 429).
is influenced by the role and position that a person
holds. The meaning of caring emerged as differen-
tial because no one definition or meaning of caring Logical Form
was identified (Ray, 1984, 1989; Ray, 2010b). The The formal Theory of Bureaucratic Caring was in-
theoretical statement that describes the substan- duced primarily by comparative analysis and insight
tive theory of Differential Caring is formulated as: into the whole of the experience. Review of the litera-
ture on nursing, philosophy, social processes, and or-
“In a hospital, differential caring is a dynamic ganizations was combined with the substantive the-
social process that emerges as a result of the vari- ory, Differential Caring, that Ray discovered with
ous values, beliefs, and behaviors expressed about ethnography, phenomenology, and grounded theory
the meaning of caring. Differential Caring relates research. These ideas were analyzed and integrated
to competing [cooperating] educational, social, through a process that was inductive and logical—
humanistic, religious/spiritual, and ethical forces inductively building on the substantive theory and
as well as political, economic, legal, and techno- logically drawing upon the philosophical argument
logical forces within the organizational culture of Hegel’s dialectic (Moccia, 1986; Ray, 1989, 2006,
that are influenced by the social forces within the 2010b) and complexity science to synthesize caring
dominant American [world] culture” and bureaucracy to a new theoretical formulation
(Ray, 1989, p. 37). (Davidson, Ray, & Turkel, 2011; Ray, 2001).