mission of caring” and “managed care emphasizes
the efficiency of nursing tasks over caring” (Miller,
1995, p. 30). These nurses felt that the practice
of caring was being seriously threatened by the
economic pressure associated with health-care
changes.
Ray (1997) interviewed six nurse administrators
to study the art of caring in nursing administration.
The theme—economic-political-ethical valuing
and its three attributes of exchanging commodity
values, negotiating the politics, and valuing the
ethic of caring—showed that the caring expressions
of nurse administrators are bound to the econom-
ics and politics of the organization (Ray, 1997).
Narrative examples of the attribute, exchanging
commodity values, were “making caring tangible”
and “patient care is a commodity (economic good
or value).” Narrative examples of the attribute ne-
gotiating the politics were “the nurse administrator
is a system coordinator, nurses are the system and
know what impinges on them,” and “nurses are po-
litical beings (powerful in the organization).”
Narrative examples of the attribute, valuing the
ethics of caring, were “the nurse administrator
needs to be caring and shouldn’t be like other ad-
ministrators,” and “value of nursing is to care holis-
tically.” Findings from this research study validate
the interwoven relationship among caring, eco-
nomics, and politics within organizational culture.
A recent nursing study demonstrated that high-
quality care is located in the reciprocal actions of
the interpersonal nurse-patient relationship
(Hoggard-Green, 1995). Turkel (1993) used an
ethnographic approach to study nurse-patient in-
teractions in the critical care environment. The
subsequent theme generated among all categories
of interaction was the nurse-patient relationship. In
a qualitative study, Price (1993) examined the
meaning of quality nursing care from the perspec-
tive of parents of hospitalized children. A key cate-
gory that emerged from the data was a positive
relationship between quality of care and parents’
perspectives. In the wake of workplace restructur-
ing as a result of health-care reform and managed
care, nurses are finding themselves in a period of
transition, moving from traditional in-patient hos-
pital practice to community-based practice. In a re-
search study conducted by Turkel, Tappen, and Hall
(1999), the development of a positive nurse-patient
relationship was shown to be seen as a reward for
nurses undergoing change in practice roles.
The foregoing studies identified the critical na-
ture of the nurse-patient relationship. However,
these studies did not merge economic concepts into
nursing research or theory. As the nursing practice
environment has continued to change, new re-
search is needed to explore how nurses can con-
tinue to provide humanistic care with limited
economic resources.CHALLENGE TO RESEARCHERS
The challenge to articulate the economic value of
the nurse-patient relationship as a commodity, just
as goods, money, and services are viewed in tradi-
tional economics, is imperative. Foa (1971), an ex-
change theorist, designed an economic theory that
could bridge the gap between economic and
noneconomic resources. In this model, noneco-
nomic resources (love, status, and information)
were correlated with economic resources (money,
goods, and services). According to Ray (1987,
p. 40), “[T]he inclusion of these resources is neces-
sary and will require a major effort on the part of
nurses and patients to see that they become an in-
tegral part of the health-care economic analysis.”
In order to appraise the nurse-patient relation-
ship as an economic interpersonal resource, it is
necessary to conduct qualitative and quantitative
research studies to describe this unique relation-
ship as an economic exchange process and eco-
nomic resource. The philosophical framework of
the economic dimension of bureaucratic caring has
served in part as the basis for this type of needed
nursing research. Turkel (1997) interviewed nurses,
patients, and administrators from the for-profit
sector to examine the process involved in the devel-
opment of the nurse-patient relationship as an
economic resource. This research was conducted
as managed care penetration was having an enor-
mous impact on the current health-care delivery
system.
Turkel found that diminishing health-care re-
sources was the basic social problem encountered
by nurses, patients, and administrators. The basicThe basic social process of the nurse-
patient relationship as an economic re-
source was struggling to find a balance,
which referred to sustaining the caring
ideal in a new reality controlled by costs.CHAPTER 23 Applications of Marilyn Ray’s Theory of Bureaucratic Caring 373