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CHAPTER 8 Marilyn Anne Ray 113

(Turkel & Ray, 2000, 2001; Davidson, Ray, & Turkel,
2011; Ray, Turkel, & Cohn, 2011). Study data show end-of-life period as comfortable as possible.
that relational caring between administrators, nurses, Upon consultation with the Vice President for
and patients are the strongest predictor of relational Nursing, the Nurse Manager and the unit staff
self-organization aimed at well-being. Relational self- nurses decided against moving Mrs. Smith to the
organization is a shared, creative response that in- Palliative Care Unit, although considered more
volves growth and transformation (Ray, Turkel, & economical, because of the need to protect and
Marino, 2002). Transformative processes that can lead nurture her as she was already experiencing signs
to relational self-organization include respecting, and symptoms of the dying process. Nurses were
communicating, maintaining visibility, and engaging prompted by an article they read on human caring
in participative decision making in the workplace. as the “language of nursing practice” (Turkel, Ray,
Finally, Ray’s work emphasizes the need for reflexive & Kornblatt, 2012) in their weekly caring practice
ethics for clinical practice, to enhance understanding meetings.
of how deep values and moral interactions shape ethi- The Nurse Manager reorganized patient assign-
cal decisions (Ray, 1998, 2010a). ments. She felt that the newly assigned Clinical
Nurse Leader who was working between both the
Medical and Surgical Units could provide direct
Summary nurse caring and coordination at the point of care
The Theory of Bureaucratic Caring challenges partici- (Sherman, 2010). Over the next few hours, the
pants in nursing to think beyond their usual frame of Clinical Nurse Leader as well as a staff member
reference and envision the world holistically, while who had volunteered her assistance provided per-
considering the universe as a hologram. Appreciation sonal care for Mrs. Smith. The Clinical Nurse
of the interrelatedness of persons, environments, and Leader asked the Nurse Manager to see if there
events is key to understanding this theory. The theory was a possibility that Mrs. Smith had any close
provides a unique view of how health care organiza- friends who could “be there” for her in her final
tions and nursing phenomena interrelate as wholes moments. One friend was discovered and came to
and parts in the system. Unique constructs within say goodbye to Mrs. Smith. With help from her
Ray’s theory include technological and economic car- team, the Clinical Nurse Leader turned, bathed,
ing. Theory development by Ray’s colleagues and and suctioned Mrs. Smith. She spoke quietly,
other scholars continues. Ray challenges nurses to prayed, and sang hymns softly in Mrs. Smith’s
envision the spiritual and ethical dimensions of car- room, creating a peaceful environment that ex-
ing and complex organizational health care systems pressed compassion and a deep sense of caring for
so the Theory of Bureaucratic Caring may inform her. The Nurse Manager and nursing unit staff
nurse creativity and transform the work world. were calmed and their “hearts awakened” by the
personal caring that the Clinical Nurse Leader and
the volunteer nurse provided. Mrs. Smith died
with caring persons at her bedside, and all mem-
CASE STUDY
bers of the unit staff felt comforted that she had
Mrs. Smith was a 73-year-old widow who lived not died alone.
alone with no significant social support. She had Davidson, Ray, & Turkel (2011) note that car-
been suffering from emphysema for several years ing is complex, and caring science includes the art
and had had frequent hospitalizations for respira- of practice, “an aesthetic which illuminates the
tory problems. On the last hospital admission, her beauty of the dynamic nurse-patient relationship,
pneumonia quickly progressed to organ failure. that makes possible authentic spiritual-ethical
Death appeared to be imminent, as she went in choices for transformation—healing, health, well-
and out of consciousness, alone in her hospital being, and a peaceful death” (p. xxiv). As the
room. The Medical-Surgical nursing staff and the Clinical Nurse Leader and the nursing staff in this
Nurse Manager focused on making Mrs. Smith’s situation engaged in caring practice that focused
Continued