discipline (Newman, 1986, 1992; Newman, Sime, &
Corcoran-Perry, 1991). Many caring theories corre-
spond to one or all of these paradigms (Morse et al.,
1990). The Theory of Bureaucratic Caring has its
roots in all these paradigms by its synthesis of car-
ing and the organizational context (see Figure
23–1).
BUREAUCRATIC CARING THEORY:
EMERGENT GROUNDED THEORY
The Theory of Bureaucratic Caring originated
as a grounded theory from a qualitative study of
caring in the organizational culture and appeared
first as the author’s dissertation in 1981 and as arti-
cles in 1984 and 1989. In the qualitative study of
caring in the institutional context, the research
revealed that nurses and other professionals strug-
gled with the paradox of serving the bureaucracy
and serving human beings, especially clients,
through caring. The discovery of bureaucratic car-
ing resulted in both substantive and formal theories
(Ray, 1981, 1984, 1989). The substantive theory
emerged as differential caring and showed that
caring in the complex organization of the hospital
was complicated and differentiated itself in terms
of meaning by its context—dominant caring di-
mensions related to areas of practice or units
wherein professionals worked and clients resided.
Differential Caring Theory showed that different
units espoused different caring models based on
their organizational goals and values. The formal
Theory of Bureaucratic Caring symbolized a dy-
namic structure of caring, which was synthesized
from a dialectic between the thesis of caring as hu-
manistic, social, educational, ethical, and reli-
gious/spiritual (elements of humanism and
spirituality), and the antithesis of caring as eco-
nomic, political, legal, and technological (dimen-
sions of bureaucracy) (Ray, 1981, 1989).
Although the model demonstrates that the di-
mensions are equal, the research revealed that the
economic, political, technical, and legal dimensions
were dominant in relation to the social and ethi-
cal/spiritual dimensions. The theory reveals that
nursing and caring are experiential and contextual
and are influenced by the social structure or the
culture (normative system) that is given in the or-
ganization. Interactions and symbolic systems of
meaning are formed and reproduced from the
constructions or dominant values held within
the organization. In some respect, “we are the or-
ganization,” which is analogous to Wittgenstein’s
(1969) adage, “we are our language.”
The theory has been embraced by educators, re-
searchers, nursing administrators, and clinicians
who, after witnessing changes in health-care policy
in the past decade, have begun to appreciate how
the context—micro- and macrocultures—influ-
ences nursing. Moving away from centering on pa-
tient care to the economic justification of nursing
and health-care systems has prompted profession-
als to desire a fuller understanding of how to pre-
serve humanistic caring within the business or
corporate culture (Miller, 1989; Nyberg, 1989,
1991, 1998). The theory also has been used in part
as a foundation for additional research studies of
the nurse-patient relationship (Ray, 1987; Turkel,
1997; Turkel & Ray, 2000, 2001).Practice Theory Reviewed:
Evolution of Theory
DevelopmentFacing the challenge of the crisis in health care and
nursing, disillusionment of registered nurses about
the disregard for their caring services, and the con-
cern of the nursing profession and the public about
the effects of the shortage of nurses (Page, 2004),364 SECTION IV Nursing Theory: Illustrating Processes of Development
CARINGEthical Spiritual/ReligiousEducational/
Social EconomicPoliticalLegalTechnological/
PhysiologicalFIGURE 23–1 The grounded Theory of Bureaucratic Caring.