MARILYN ANNE RAY, RN, PhD, CTN-A

BACKGROUND:
❖ MARILYN ANNE (DEE) RAY WAS BORN IN HAMILTON, ONTARIO, CANADA, AND GREW
UP IN A FAMILY OF SIX CHILDREN.
❖ 1958, MARILYN RAY GRADUATED FROM ST. JOSEPH HOSPITAL SCHOOL OF NURSING,
HAMILTON, AND LEFT FOR LOS ANGELES, CALIFORNIA. SHE WORKED AT THE UNIVERSITY
OF CALIFORNIA, LOS ANGELES MEDICAL CENTER ON A NUMBER OF UNITS, INCLUDING
OBSTETRICS AND GYNECOLOGY, EMERGENCY DEPARTMENT, AND CARDIAC AND
CRITICAL CARE WITH ADULTS AND CHILDREN.
❖ IN 1965, RAY RETURNED TO SCHOOL FOR HER BSN AND MSN IN MATERNAL-CHILD
NURSING AT THE UNIVERSITY OF COLORADO, SCHOOL OF NURSING. THIS IS WHERE SHE
MET DR. MADELEINE LEININGER, WHO WAS THE FIRST NURSE ANTHROPOLOGIST AND THE
DIRECTOR OF THE FEDERAL NURSE SCIENTIST PROGRAM.
 BACKGROUND:

❖ 1973-1977 Ray completed a master of arts in cultural anthroplogy at

Mcmaster university & studied human relationship, decision making &
conflict and the hospital as an organizational culture.
❖ In 1981 Ray’s doctoral dissertation was related to the study of caring in
the complex hospital organizational culture, from the research the
THEORY OF BUREAUCRATIC CARING emerged.
❖ She has been a certified transcultural nurse since 1988 & is a member of
the international transcultural nursing society
❖ 1984, Ray was awarded the Leininger transcultural nursing award given
for excellence in transcultural nursing.
❖ Renowned Nursing Educator and Researcher of caring in complex
health care systems and Transcultural Nursing
❖ She is an advanced transcultural nurse committed to the development
and progress of transcultural caring in nursing worldwide.
 ACHIEVEMENTS:
 Colonel (1984-1999) – United States Air Force
Reserve
 Researcher at USAF School of Aerospace
Medicine, Brooks Air Force Base, Texas
 Federal Nursing Services Essay Award
 MENTORS
 Dr. Madeleine Leininger- anthropology and
health.
 Dr. Jean Watson - advanced the theory and
practice of human caring in nursing
 Dr. Max van Manen- phenomenology and
hermeneutic human science research methods
THEORY OF BUREAUCRATIC CARING

Bureaucratic caring integrates knowledge of

human caring within complex technological,
economic, legal, and political systems in hospital
organizations.
 ORIGIN OF THE THEORY
She worked at the University of California, Los
Angeles Medical Center on a number of units,
including obstetrics and gynecology, emergency
department, and cardiac and critical care with adults
and children. In Southern California, she enjoyed
meeting new friends from different cultures and cared
for children from vulnerable populations. While
working with people of diverse cultures, particularly
African Americans and Latinos, Ray began to see how
important cultures were in the development of
people’s views about nursing and the world.
 ORIGIN OF THE THEORY
 Health care organizations are hierarchical and show management
system methods that show some degree of command, authority,
and control for effective functioning. Hospital tends to be
bureaucratic; that is, they are not only places for the care of the
sick, but they also are integrated technical-politico-economic and
legal organizations
 How are political, economic, legal and technological caring
decisions made?
 How is spiritual caring fostered?
 How can ethical caring be the grounds on which moral decisions
are made?
 DEVELOPMENT OF THE THEORY
The Theory of Bureaucratic Caring was generated in a hospital
organization from a qualitative research study using three research
approaches 30 years ago (Ray,1981).
1. Ethnography – The description of the hospital as a culture,
2. Phenomenology – The meaning of caring in the life world
3. Grounded Theory Method – the discovery of conceptual categories
and subcategories and theories of the structure and process of caring
in the complex organization.
 DEVELOPMENT OF THE THEORY
Substantive Theory called Differential Caring was
generated from the diversity and dominant
meanings of caring expressed by participants in
different units in the hospital. The formal theory
was developed from interpretation of the initial
qualitative data and data related to complex
systems, such as bureaucracy.
 CONCEPT OF THE THEORY
CARING is defined as a complex, transcultural, relational process
grounded in an ethical, spiritual context. Caring is the relationship
between charity and right action, between love as compassion in
response to suffering and need and justice or fairness in terms of what
ought to be done. Caring occurs within a culture or society, including
personal culture, hospital organizational culture, and societal and
global culture (M. Ray, personal communication, March 27, 2002).
“Caring in Nursing is contextual and is influenced by organizational
structure”
 CONCEPT OF THE THEORY
SPIRITUAL-ETHICAL CARING
-Spiritual-ethical caring for nursing focuses on how facilitation of choices
for the good of others can or should be accomplished (Ray, 1989, 1997a)
EDUCATIONAL
-Formal and informal educational programs, use of audiovisual media to
convey information, and other forms of teaching and sharing information
are examples of educational factors re-lated to the meaning of caring
(Ray, 1981a, 1989).
PHYSICAL
-Physical factors are related to the physical state of being, including
biological and mental patterns. Because the mind and body are
interrelated, each pattern influences the other (Ray, 2001, 2006).
 CONCEPT OF THE THEORY
SOCIAL-CULTURAL
Examples of social and cultural factors are ethnicity and family structures; intimacy with
friends and family; communication; social interaction and support; understanding
interrela-tionships, involvement, and intimacy; and structures of cultural groups,
community, and so-ciety (Ray, 1981a, 1989, 2001, 2006).
LEGAL
Legal factors related to the meaning of caring include responsibility and accountability;
rules and principles to guide behaviors, such as policies and procedures; informed
consent; rights to privacy; malpractice and liability issues; client, family, and professional
rights; and the practice of defensive medicine and nursing (Ray, 1981a, 1989).
TECHNOLOGICAL
Technological factors include nonhuman resources, such as the use of machinery to
maintain the physiological well-being of the patient, diagnostic tests, pharmaceutical
agents, and the knowledge and skill needed to utilize these resources (Ray, 1987, 1989).
Also included with technology are computer-assisted practice and documentation (M.
Ray, personal communica-tion, June 16, 2004)
ECONOMIC
Factors related to the meaning of caring include money, budget,
insurance systems, limita-tions, and guidelines imposed by managed care
organizations, and, in general, allocation of scarce human and material
resources to maintain the economic viability of the organization (Ray,
1981a, 1989). Caring as an interpersonal resource should be considered, as
well as goods, money, and services (Turkel & Ray, 2000, 2001, 2003).
POLITICAL
Political factors and the power structure within healthcare administration
influence how nursing is viewed in healthcare and include patterns of
communication and decision making in the organization; role and gender
stratification among nurses, physicians, and administra-tors; union activities,
including negotiation and confrontation; government and insurance
company influences; uses of power, prestige, and privilege; and, in
general, competition for scarce human and material resources (Ray,
1989).
 ASSUMPTIONS
NURSING
Nursing strives toward excellence in the activities of
caring through the dynamics of complex cultural contexts
of relationships, organizations, and communities
PERSON
A person is a spiritual and cultural being, and they
engage co-creatively in human organizational and
transcultural relationships to find meaning and value
HEALTH
Health is not simply the consequence of a physical state of being.
People construct their reality of health in terms of biology, mental
patterns, characteristics of their image of the body, mind, and soul,
ethnicity and family structures, structures of society and community
(political, economic, legal, and technological), and experiences of
caring that give meaning to lives in complex ways.
ENVIRONMENT
Functional forms identified in the social structure or bureaucracy
(i.e., political, legal, technological, and economic) play a role in
facilitating understanding of the meaning of caring, cooperation, and
conflict in human cultural groups and complex organizational
environments.
 LOGICAL ADEQUACY OF THE
THEORY
SIMPLICITY
Ray’s theory simplifies the dynamics of complex
bureaucratic organizations. From numerous descriptions of
the inductive grounded theory study, Ray derived the
integrative concept of spiritual-ethical caring and the
seven interrelated concepts of physical, social-cultural,
legal, technological, economic, political, and educational
structures. Given the complexity of bureaucratic
organizations, the number of concepts is minimal.
 LOGICAL ADEQUACY OF THE
THEORY
USEFULLNESS
The formal Theory of Bureaucratic Caring symbolized a dynamic
structure of caring. This structure emerges from the dialectic between
the thesis of caring as humanistic (social, education, ethical, and
religious-spiritual structures) and the antithesis of caring as bureaucratic
(economic, political, legal, and technological structures). The dialectic
of caring in relation to various structures illustrates that everything is
interconnected with caring, and the organizational system is a
macrocosm of the whole of culture.
 GENERALITY

Ray’s theory addresses questions such as, What is the nature of

caring in nursing? And, What is the nature of nursing practice as
caring? Philosophies are broad and propose general ideas about how
the profession of nursing fulfills “its moral obligation to society
 TESTABILITY
 The methods used were grounded theory, phenomenology and ethnography to
elicit the meaning of caring to study participants.
 This process results in the evolution of substantive theory (caring data generated
from experience) and formal theory (integrated synthesis of caring and
bureaucratic structures).
 Ray spent longer than 7 months in the field studying caring in all areas of a
hospital, from nursing practice to materials management to administration,
including nursing administration. More than 200 respondents participated in the
purposive and convenience sample. The principal question asked was “What is
the meaning of caring to you?” Through dialogue, caring evolved from in-depth
interviews, participant observation, caregiving observation, and documentation
in field notes (Ray, 1989).
 Ray’s discovery of bureaucratic caring began as a substantive theory and
evolved to a formal theory. The substantive theory emerged as Differential
Caring, revealing that the meaning of caring differentiates itself by its context.
Ray’s research reveals that in complex organizations, nursing as caring
is practiced and lived out at the margin between the humanistic-
spiritual dimension and the systemic dimension. These findings are
consistent with worldviews from the science of complexity, which
propose that phenomena that are antithetical actually coexist (Briggs
& Peat, 1999; Ray, 1998). Thus, technological and humanistic systems
exist together. Complexity theory explains why there is a resolution of
the paradox between differing systems (thesis and antithesis)
represented in the synthesis or the Theory of Bureaucratic Caring.
 IMPLICATION 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. Some
theories maybe more effective for a given setting than
another. The Theory of Bureaucratic Caring as synthesis of
the two primary components of nursing in organizations –
Caring and Bureaucratic components that make up the
functioning of complex organizational system.
 STRENGTHS AND WEAKNESSES
One of the major strengths in Ray’s Theory of Bureaucratic Nursing
is that its assumptions can be highly applicable in the modern nursing
profession. With the fast advances in technology and healthcare,
Nursing today has been more elaborate such as having so many fields
in nursing, Nurses have also assumed administrative positions such as
supervisors and directors/ chief nurse.
However, one limitation is that the theory is focused on Nursing in
the hospital, the organization mentioned in the theory pertains to a
hospital administration. Hence, this theory is less flexible and may not
be applicable to other fields of nursing like public health.
 REACTION
The practice of Nursing is Dynamic, it is continually emerge in
change, development and evolution with the goal of ensuring beyond
satisfactory health care services to the patient, in order to achieve this,
Nurses must be well equipped by knowledge, experience ,attitude and
a nature of conscience with regards to decision making, this theory
emphasize the importance and the effect of decision making
considering the political, legal, technological aspect that will be
integrated to spiritual-ethical caring of the patients, it also helps the
young nurses or middle manager nurses that the meaning of caring
differentiate itself from its context, it can also illuminates the ideas of
middle manager nurses that patient care(bedside care) and the
managerial care can go hand in hand and it is a part of a whole or a
whole with a part. However, the theory is so vague and general.