However, their actions and the action of other ad-
ministrators must then reflect these values to en-
sure that the caring philosophy of the hospital
remains in the forefront of organizational profit-
making or economics. The issue of time constraints
and inadequate staffing has been identified as prob-
lematic. Nurses and patients view lack of time as a
hindrance to forming a caring nurse-patient rela-
tionship. This points out the need for administra-
tors to restructure the organization so that the
maximum of nursing time is focused on direct
nurse-patient interactions. Hospital administrators
desire high levels of quality care and see financial
benefits from return business when patients are sat-
isfied with nursing care. To maintain this standard,
administrators must maintain adequate staffing ra-
tios in order to allow time for nurses to be with
their patients.
In the research conducted by Turkel and Ray
(2000, 2001, 2003), administrator participants con-
firmed the above but also discussed the concomi-
tant need for maintaining care and quality. The
challenge facing administrators in a managed care
environment is the simultaneous management of
costs, care, and quality. Ray (1989) asserted that this
can be accomplished if administrators consider
both the tangible and intangible benefits of services
provided within the organization.
Administrators need to recognize caring as a
value-added interaction. From this point of view,
the benefits of the interaction outweigh the expense
of the registered nurse. Caring can be viewed as an
“opportunity cost” or the cost of doing it right. This
concept is applicable to contemporary health-care
organizations. If people don’t come back to a
hospital (because of poor care), “you’ve lost an
opportunity.”
NURSING PRACTICE
The economic and political dimensions of bureau-
cratic caring can be used to guide practice. Now is
the time for professional nurses to become proac-
tive and use theory-based practice to shape their
future instead of having the future dictated by oth-
ers outside the discipline. Staff nurses can hold
close their core value that caring is the essence of
nursing and can still retain a focus on meeting the
bottom line.
Empirical studies have firmly established a
link between caring and positive patient outcomes.
Positive patient outcomes are needed for organ-
izational survival in this competitive era of
health care. Given this, professional nursing practice
must embrace and illuminate the caring philosophy.
Staff nurses describe the essence of nursing as
the caring relationship between nurse and patient
(Trossman, 1998). However, nurses are practicing
in an environment where the economics and costs
of health care permeate discussions and clinical de-
cisions. The focus on costs is not a transient re-
sponse to shrinking reimbursement; instead, it has
become the catalyst for change within corporate
health-care organizations.
Nurses are continuing to struggle with eco-
nomic changes. With a system goal of decreasing
length of stay and increasing staffing ratios, nurses
need to establish trust and initiate a relationship
during their first encounter with a patient. As this
relationship is being established, nurses need to
focus on being, knowing, and doing all at once
(Turkel, 1997) and being there from a patient per-
spective. For the nurses, this means completing a
task while simultaneously engaging with a patient.
This holistic approach to practice means viewing
the patient as a person in all his or her complexity
and then identifying the needs for professional
nursing as they arise.
Changes that incorporated the human caring di-
mension and the critical nature that human rela-
tionships play in hospital organizations were
identified by Ray over two decades ago. Ray (1987)
described the problems associated with economic
changes in health care and the negative impact eco-
nomics would have on nurse caring.
Current research (Turkel & Ray, 2000, 2001,
2003) on the economics of the nurse-patient rela-
tionship showed that the preservation of this rela-
tionship and humanistic caring was continuing to
grow despite the heavy emphasis by administrators
and insurance companies on cost control. The re-
searchers recommend that administrators recog-
nize and respect the contributions nursing could
make in developing hospital organizations as polit-
ically moral, caring organizations.FUTURE CHALLENGES
The political dimension of bureaucratic caring is
reflective of the organizational climate in many of
the current health-care environments. Relation-
ships grounded in trust, respect, and mutual caringCHAPTER 23 Applications of Marilyn Ray’s Theory of Bureaucratic Caring 375