Theory of Bureaucratic Caring

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