The Theory of Bureaucratic Caring for Nursing Practice in the Organizational Culture MARILYN A. RAY Understanding and changing the emerging corporate culture of the health care system to benefit humankind is the most critical issue facing the nursing educators, administrators, and practitioners. The transformation of American and other Western health care systems to corporate enterprises emphasizing competitive management and economic gain seriously challenges nursing’s humanistic philosophies and theories and administrative and clinical practices. The recent refocusing of nursing as a human science and the art and science of human caring1–3 places nursing in a vulnerable position. When pitted against the new goal of corporate advancement in health care delivery, nursing faces a loss of self-identity and an increased risk of alienation and confusion in this competitive arena. The need for the executive team to possess knowledge of organizations as businesses4 while continuing to support the human side of nursing practice gives direction to new forms of theory development. Relying solely on an administrative framework designed by organizational theorists or concentrating only on nurse–patient relational theories regarding direct care jeopardizes the development of a new structure to guide practice in contemporary health care organizations. A new synthesis of blending traditional management views and the nursing perspective is necessary.5 The purpose of the qualitative research study on which this chapter was based was to generate a theory of the dynamic structure of caring in a complex organization. The study was conducted in the cultural system of a hospital. Two theories emerged and were discovered from a content analysis of interview responses and participant observation data concerning the meaning of caring to nurse and nonnurse administrators, clinical nurses, physicians, patients, and allied health personnel. The study was intended to advance administrative and health care professionals’ understanding of the hospital as a cultural system and to clarify the meaning of caring to those who work in hospitals. The goal was to initiate new administrative caring interventions for the continual growth and development of nursing practice and organizations. To this end, a brief review of the context—research, culture, bureaucratic, and caring—through which the meaning was understood and from which the theoretical knowledge was generated will be discussed. A presentation of the data analysis, results, theory development, and implications for nursing will follow. CONTEXT OF THE STUDY Research Context Interpreting the meaning of phenomena within a context is the central aim of qualitative research. “Meaning in one form or another permeates the experience of most human beings in all societies,” claimed Spradley.6 As Mishler pointed out, “Meaning is always within context and context incorporates meaning. Both are produced by human actors through their actions.”7 Thus, ethnographic and grounded theory approaches8–10 using the techniques of interview and observation were selected to study the meaning of caring. The cultural and bureaucratic context of the hospital facilitated the discovery of both a substantive theory (knowledge grounded in data) and a formal theory (conceptual knowledge integration) of caring in the organization. Organizations as Cultures The concept of culture has a long history in the discipline of anthropology and has been advanced in nursing by Leininger.11 Only since Japanese competition made culture a real issue in North America have corporations adopted the culture concept as a metaphor for understanding how organizations work.12–15 Culture has been defined in terms of social context or in terms of cognition.16,17 The most contemporary definition of culture is shared meaning systems. Geertz explained that culture is “an historically transmitted pattern of meanings embodied in symbols, a system of inherited conceptions expressed in symbolic forms by means of which men [women] communicate, perpetuate, and develop their knowledge about attitudes toward life.”18 How ideas, values, and symbols relate to or transform attitudes, feelings, and behavior is the central issue in understanding culture and organizations as cultures. As del Bueno and Vincent wrote, “Cultural norms and values are reflected in [hospital] policies and practices related to dress, personal appearance, social decorum, physical environment, communication, and status symbols” (p. 16).19 A framework for understanding the organizational culture can be grouped under the following properties: collective, organized, multiplex, and variable.20 Each property helps the researcher to grasp the distinctive locus of order in culture. For example, the collective nature of culture holds that every human community functions with a group consensus about the meanings of the symbols used in the communications that constitute social life. The organized nature of culture holds that customs studied are connected and comprehensible only as parts of a large organization of beliefs, norms, values, or social action from which the meaning is derived. The multiplexity of culture relates to the integration of explicit rules and beliefs and implicit or self-evident responses or what is taken for granted. Finally, variability in culture suggests that wide variations exist in culture; however, the history of cultural diversity does not preclude the search for broad principles of order as a framework for understanding. Cultures are always in transition, and organizational cultures reflect changes in the values of the dominant culture. Organizations as Bureaucracies Bureaucracy plays a significant role in the meanings and symbols of organizations. Despite strong views in favor of the decentralization of decision making in formal organizations, including hospitals, much of the social life in the workplace continues to be managed and controlled by the rational-legal principles of bureaucracy outlined by the sociologist Weber.21,22 The rational-legal principles include equal treatment of all employees; reliance on expertise, skills, and experience relative to the position; introduction of specific standards of work and output; record keeping; and rules and regulations binding on employees as well as managers. In addition, in formal organizations, power flows from official authority that is vested in hierarchical roles and principles, and the allocation and exchange of resources.23 Perrow remarked that criticisms of bureaucracy as inflexible, inefficient, uncreative, unresponsive, and stifling are echoes of radical left or right groups. He pointed out that less often seen in organizational literature are the charges related to bureaucracy’s superiority as a social tool over other forms of organization.24 As bureaucratization gained greater prominence in modern social development and actually advanced as a theory of social development, Weber predicted that the future would belong to the bureaucracy, not to the working class.25 Current sociological writings in the West have borne out Weber’s predictions, pointing to the bureaucratization of enterprise that can be seen, for example, in current mergers of many industrial firms, in health care organizations evolving into large-scale systems, and in society as a whole emerging as an interdependent economic multipolarity. Thus, the concept of bureaucratization is a worldwide phenomenon. Britan and Cohen stated the following: “Like it or not, humankind is being driven to a bureaucratized world whose forms and functions, whose authority and power must be understood if they are ever to be even partially controlled” (p. 27).26 Caring as a Conceptual Context Caring as nurturant behavior has been afforded little scholarly attention until quite recently, although it has been essential throughout history for the preservation of human race. Not until the human enterprise was sufficiently challenged by rapidly growing technologies did the concept of caring and interhuman knowledge reach any level of prominence. In the past decade, popularized notions of caring have evolved in the marketplace and its word usage has increased markedly, especially in advertising on radio and television and in print. Major shifts in worldviews from positivism to postcritical philosophy and human science have contributed to the growing interest in academia in human interactive knowledge.27 In professional nursing from Nightingale to the present, the concept of caring has been dominant, but largely taken for granted in research activities. Many nurse scholars now recognize caring as the central focus of study in the development of nursing epistemology, but “some of the critical knowledge and methodological questions have yet to be explored by nurses.”28 Caring was the central focus of this study within the organizational culture. Although some caring theories had been developed by nurse scholars ranging from theories and philosophies of altruistic humanism to support, oblatory love, and transcultural nursing phenomena,29,30 all preconceived theoretical constructs of caring were held in abeyance, as data were generated to allow the substantive theory to emerge from the empirical data. A literature review of relevant information was conducted after the emergence of the substantive theory to support the discovery of the formal theory. RESEARCH APPROACH Ethnographic and grounded theory qualitative research was conducted in an acute care, urban hospital to address the following areas: descriptions of the meaning of caring in a hospital culture, identification of categories of caring within an organization, identification of dominant caring behaviors manifested within each clinical unit, and formulation of organizational caring theory. The principal question asked to participants was, “What is the meaning of caring to you?,” and interviews evolved from a process of dialogue and exploration of caring. DATA GENERATION More than 200 respondents participated in the study and represented all employee groups working in the hospital. The study was divided into two phases, administrative and clinical, using purposive and convenience samples, respectively. Data generation lasted a total of 7 months—4 months for the administrative phase and 3 months for the clinical phase. The process of data generation involved the following activities by the researcher: active involvement in the everyday activities of the hospital; documentation by field notes of experiences in administrative and clinical units; in-depth interviewing about the meaning of caring using an audiotape recorder with nurse and nonnurse administrators, nurse clinicians, physicians, patients, and allied health care personnel; participant observation of administrative and clinical caring interactions; and caregiving by the researcher to interact more closely with patients. Validity and reliability of the data were established through qualitative research principles of content, face, and concurrent validity, repeated observations, and constant comparative analysis.31,32 DATA ANALYSIS AND RESULTS The analytical process of the content was adapted from Spradley33 and Glaser and Strauss34 and involved the following: immersing the self in the transcribed and recorded data to compare, contrast, and describe the experiences of caring phenomena; looking for categories of caring by identifying and grouping like themes of the data; developing a classification system of caring categories (previously published35); defining categories from the data descriptions; developing and defining clinical caring categories; watching for the emergence of a substantive theory (intensive theory) grounded in the data; analyzing the substantive theory; reviewing the relevant literature; initiating deep introspection of all relevant data to facilitate insight into the meaning of the research experience, to allow for the emergence of a formal theory or extensive, integrated theory; and engaging in another review of selected literature. The formal theory was a synthesis of caring understood as a humanistic phenomenon and influenced by competing structures and processes within the organizational culture and the society as a whole. The following subsection is a presentation of the process of the discovery of substantive and formal theories. Discovery of Substantive Theory Prior to the discovery of the formal theory called Bureaucratic Caring, a substantive theory called Differential Caring was discovered. The data demonstrated that caring in a hospital was grounded in a mutiplicity of meanings ranging from humanistic definitions, such as empathy, love, and concern, to political–legal definitions, such as decision making, liability, and malpractice, to ethical-religious definitions, such as trust, respect, acts of “brotherly” love, and ideals of “doing unto others,” and to economic definitions, such as budget management and the economic well-being of the institution. The meaning of caring in the organization emerged as differential because no clear definition or meaning of caring was identified. The meaning of caring was markedly influenced by the role and position a person held and the place within which a person worked in the organization. Caring was defined first in humanistic terms, followed by terms related to role, and finally by terms related to one’s position and place within the organization. A significant interrelationship existed between the individual personalities and the culture of the hospital. In administration and on the clinical units, the context itself to a large extent influenced how caring was defined and practiced. Primary or dominant caring descriptors could be identified. In administration, caring was defined and played out more in relation to the competition for human and material resources to sustain the economic viability of the organization itself. Nonnurse administrators saw themselves as caring by describing empathetic dimensions, but recognized their role as maintaining the organization economically and politically so that direct care to patients could be provided. Nurse administrators generally referred to caring as a humanistic concept, and expressed the need to support both the nurse and the patient directly as well as the organization through sound political and economic decisions. Often, nurse executives were in conflict between organizational goals and patient care needs. From the perspective of the clinical units, the meaning of caring varied. On the oncology unit, caring was described and observed as intimate and spiritual, whereas in the intensive care unit, caring was identified as technical. In the emergency department, caring was described and observed as technical, political, and legal, regulated by Medicare and Medicaid, and practiced as defensive medicine and nursing to reduce professionals’ fears of malpractice suits. On the medical–surgical units, caring was described and observed more specifically as a team effort, where caring activities were divided by roles and where competition for scarce resources affected patient care; on the surgery (operating room) unit, caring was described and observed as patient advocacy, teamwork, and technical competency. Patients primarily expressed the need for human care and had to devise strategies to get what they needed or succumb to what they claimed were injustices to their humanity. Physicians’ descriptions of caring were generally within the technical sphere, but they recognized the need to convey human care to patients. Allied health personnel emphasized the meaning of caring as support both for the organization and for staff and patients. Development of Categories of Caring From an analysis of the descriptions of caring values, beliefs, and behaviors, the investigator classified the data under the following structural caring categories within the organizational culture of the hospital. Political is used to describe the following factors related to the meaning of caring: role and gender stratification in the functioning of the hospital among physicians, administrators, and nurses; team nursing (or the division of labor); decision making; patterns of communication; union activities; processes of negotiation; confrontation; external government and insurance company influences; uses of power, prestige, and privilege; and in general, competition for scarce (human and material) resources to maintain and sustain the organization. Economic is used to describe the following factors related to the meaning of caring: money, budget, and insurance systems; and in general, allocation of scarce (human and material) resources in maintaining the economic viability of the organization. Legal is used to describe the following factors related to the meaning of caring: accountability, responsibility, rules and principles to guide behaviors, informed consent, client and professional rights, rights to privacy, problems of malpractice, and liability leading to the practices of defensive medicine and nursing. Technological/physiological is used to describe the following factors related to the meaning of caring: use of machinery in relation to maintaining the physiological well-being of the patient, nonhuman resources, and knowledge and skill needed to operate machinery to support the patient. Educational is used to describe the following factors related to the meaning of caring: information, teaching, and informal and formal educational programs and use of audiovisual media to convey information. Social is used to describe the following factors related to the meaning of caring: communication; social interaction and support; understanding interrelationships, involvement, and intimacy; knowing clients, families, and colleagues; humanistic potential for growth and development by acts of compassion and concern; and love and empathy. Spiritual/religious is used to describe the following factors related to the meaning of caring: acts of faith and being spiritual, prayer, and acts of “brotherly” love, including “doing for the least of my brethren.” Ethical is used to describe the following factors related to the meaning of caring: “right” acting by religious, legal, and/or moral behavioral standards by respect and trust of and dedication to persons. A total of 65 administrators participated in this study—28 non-nurses and 37 nurses. Table 21.1 represents the dominant caring descriptors and structural categories of caring of administrators in the hospital. Table 21.2 represents the dominant caring descriptors and structural categories of caring within the clinical units of the hospital. Caring data from the in-depth interviews of administrators and nurse clinicians and from participant observation on all hospital clinical units demonstrated that the meaning of caring was distinct, yet integrally related to the culture of the organization. Thus, caring as synonymous with the organizational culture could be viewed as an organized and collective structure and represented a dynamic interplay of structural categories that were both humanistic and bureaucratic. Theoretical sampling refined, elaborated, and exhausted conceptual categories so that an actual integration of descriptors and categories occurred forming the substantive theory itself. As a result, a major hypothesis emerged wherein the core theory was identified. Thus, the substantive theory (knowledge generated that was intensively grounded in the data) was called Differential Caring and the theoretical statement was formulated as shown in the table. In a hospital, differential caring is a dynamic social process that emerges as a result of the various values, beliefs, and behaviors expressed about the meaning of caring. Differential caring relates to competing educational, social, humanistic, religious/spiritual, and ethical forces as well as political, economic, legal, and technological forces within the organizational culture that are influenced by the social forces within the dominant American culture. From the discovery of the substantive (intensive) theory, the extensive or formal Theory of Bureaucratic Caring was discovered. Discovery of the Formal Theory of Bureaucratic Caring Social and organizational research, nursing research, substantive theory discovered in the study, and specific philosophical knowledge were the forces for generating higher level formal theory. In integrating formal theory, the design involves a progressive building up from facts (cumulative knowledge) through substantive theory to formal grounded theory,36 and is induced primarily by comparative analysis and insight into the whole of the experience. Bureaucratic Caring thus emerged as the formal or extensive theory represented in Figure 21.1. The discovery of the formal Theory of Bureaucratic Caring from the substantive Theory of Differential Caring within an organizational culture and the additional review of the literature on organizations as bureaucracies was a complex process. This process that led to the development and ultimate synthesis of the theory was inductive and logical. It was inductive in building on the data from the substantive theory and the literature and logical in using the philosophical argument of Hegel’s dialectic37,38 to synthesize bureaucracy and caring to a new structural form called bureaucratic caring. TABLE 21.1 Differential Caring in an Organizational Culture: Caring Categories of Administrators Table 21.2 Differential Caring in an Organizational Culture: Caring Categories on Clinical Units DISCUSSION The formal Theory of Bureaucratic Caring was a result of a dialectical synthesis between the thesis of caring as humanistic, social, educational, ethical, and religious/spiritual and the antithesis of caring as economic, political, legal, and technological (elements of bureaucracy). To clarify the processes involved in a dialectical theory, Moccia outlined the laws of the dialectic based on the philosophies of Hegel and Marx. FIGURE 21.1 A bureaucratic caring structure. The laws of the dialectic demonstrated that the understanding of caring as a whole is merely its essential nature in contemporary organizational culture, reaching its completeness through the process of its own becoming.39 These laws are the transformation of quantity into quality (qualitative difference), the connecting of polar opposites into a codetermining relationship (interidentification), the negation of the negation (thesis, antithesis, and synthesis), and the spiral form of development (transformation and change)40 used to reinforce the argument in the generation of a formal Theory of Bureaucratic Caring. For nursing, the dialectic between the traditional thesis of caring as humanistic and the modern antithesis of caring as bureaucratic interidentified as a synthesis of bureaucratic caring is a superior form of caring in the contemporary world. The logical connectedness of caring to the cosmopolitan social order demonstrates that the Theory of Bureaucratic Caring is unifying rather than alienating. It is a construct put together by analyzing the diverse changes in the nature of caring in the contemporary hospital culture. When integrated or synthesized, the concept of caring becomes coherent. Bureaucratic caring is a natural historical process for nursing. Sovie41 wrote that nursing is experiencing the trends of a maturing profession. She identified the following concepts related to professional maturation outlined by Schein: convergence, differentiation, and bureaucratization. When these maturational concepts are applied to this study of caring in the organizational culture, significant analogies can be made. First, caring is the convergent focus of professional nursing42,43; second, in this research, caring is highly differential depending on its structures (ethical, religious/spiritual, social, educational, political, economical, legal, and technological/physiological); and third, caring is bureaucratic given the extent to which its meaning can be understood in relation to the rational–legal social structure of the hospital and the extent to which the concept of bureaucratization is a vital part of the whole social structure of humankind.44,45 Understanding the full meaning and interpretation of caring in the organization as bureaucratic caring can give clearer direction to the formulation of more purposeful caring goals within the health care organizations. IMPLICATIONS FOR NURSING PRACTICE The mandate for the application and implementation of nursing theory to guide nursing administration and clinical practice has been given to nurse executives.46,47 Stevens asserted that some theories may be more effective for a given setting than another. The Theory of Bureaucratic Caring is the most effective for administrative and clinical practices because it is grounded in the everyday world of organizational experience. The Theory of Bureaucratic Caring as a synthesis of the two primary components of nursing in organizations—caring and bureaucratic components that make up the functioning of complex organizational systems—sets the stage for new organizational development. Organizational development is an effort to democratize and humanize work; it emphasizes both executive team and staff participation.48 People create organizational cultures and either facilitate their transformation or contribute to their disintegration. To deal with the challenges of the new corporate culture, it is helpful to view organizational development from the human side using the Theory of Bureaucratic Caring generated from the values, beliefs, and behaviors of persons within the organization. This approach can be used to develop mechanisms for creative problem solving. Thus, from this perspective, the executive team can recognize the vital nature of the bureaucratization of caring as a new structure that needs different principles for directing innovations in caring and organizational development policy. Changes in the health care environment have raised many questions related to patient care. How are political, economical,49 legal, and technological50 caring decisions made? How is spiritual caring fostered? How can ethical caring be the grounds on which moral decisions are made? What new policies must be designed to enhance the human perspective in corporate policy, and how will these principles and policies guide actions? The impact of the Theory of Bureaucratic Caring on the corporate enterprise will necessitate a system shift from a narrow to a broad focus where management and caring views can exist side by side and realistically represent the transformation of health care organizations to benefit humankind. REFERENCES 1. Leininger, M. M. (Ed.). (1981). Caring: An essential human need. Thorofare, NJ: Charles B. Slack. 2. Leininger, M. M. (Ed.). (1984). Care: The essence of nursing and health. Thorofare, NJ: Charles B. Slack. 3. Watson, J. (1979). Nursing: The philosophy and science of caring. Boston, MA: Little, Brown. 4. Miller, K. L. (1987). The human care perspective in nursing administration. Journal of Nursing Administration, 17, 10–12. 5. Jennings, B. M., & Meleis, A. I. (1988). Nursing theory and administrative practice: Agenda for the 1990s. Advances in Nursing Science, 10(3), 56–69. 6. Spradley, J. P. (1979). The ethnographic interview (p. 95). New York, NY: Holt, Rinehart & Winston. 7. 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Leininger (Ed.), Care: The essence of nursing and health. Thorofare, NJ: Charles B. Slack. 36. Glaser, B. (1978). Theoretical sensitivity. Mill Valley, CA: The Sociology Press. 37. Moccia, P. (1985, November 1–2). The dialectics of theory development. Paper presented at the conference, “Qualitative Research: Viable, Valuable and Visible,” The University of Akron, Akron, OH. 38. Moccia, P. (Ed.). (1986). New approaches to theory development. New York, NY: National League for Nursing, Pub. No. 15-1992. 39. Moccia, ed. New appraoches to theory development. 40. Moccia. “The dialectics of theory development.” 41. Sovie, M. (1978). Nursing: A future to shape. In N. L. Chaska (Ed.), The nursing profession: Views through the mist. New York, NY: McGraw-Hill. 42. Leininger. Caring: An essential human need. 43. Leininger. Care: The essence of nursing and health. 44. Britan and Cohen. Hierarchy and society: Anthropological perspectives on bureaucracy. 45. Bell. The coming of post-industrial society. 46. Chaska, N. L. (1983). Theories of nursing and organizations: Generating integrated models for administrative practice. In N. L. Chaska (Ed.), The nursing profession: A time to speak. New York, NY: McGraw-Hill. 47. Stevens, B. (1983). Applying nursing theory in nursing administration. In N. L. Chaska (Ed.), The nursing profession: A time to speak. New York, NY: McGraw-Hill. 48. Fisher, D. (1980). A review of organizational development. Journal of Nursing Administration, 10, 31–36. 49. Ray, M. A. (1987). Health care economics and human caring in nursing: Why the moral conflict must be resolved. Family and Community Health, 10(1), 35–43. 50. Ray, M. A. (1987). Technological caring: A new model in critical care. Dimensions of Critical Care Nursing, 6, 166–173. QUESTIONS FOR REFLECTION Master’s 1. What were the data sources identified by Ray (1989) in her study on bureaucratic caring for nursing practice in the organizational culture? Describe and list them. 2. How were the categories of caring developed? List them. 3. What were Ray’s (1989) tacit and explicit assumptions as she approached the study of caring in organizational cultures?
Smith RN PhD AHN-BC FAAN, Marlaine C.. Caring in Nursing Classics: An Essential Resource (Kindle Locations 8755-9090). Springer Publishing Company. Kindle Edition.