Abstract
Dr. Marilyn A. Ray, nurse scholar and retired United States Air Force (USAF) veteran and former flight nurse, began her nursing scholarship in Canada. She was influenced by the experiences and interprofessional scholarly ideas that she encountered along her career trajectory. Her early love of the air and space led her to the United States Air Force Nurse Corps, where she served as a flight nurse during the Vietnam war era, followed by leadership positions in nursing education, administration, practice, and research. Dr. Ray’s contributions to nursing knowledge includes two nursing theories and a caring inquiry methodology. Dr. Ray is helping to create a new caring science certificate program at Florida Atlantic University, Christine E. Lynn College of Nursing. In this column, Dr. Ray shares the story of her scholarly influences and how they helped her care for her husband and gain insight into her contributions to nursing knowledge development.
For this issue’s scholarly dialogue column, I was able to spend some time with nurse scholar Dr. Marilyn A. Ray, a dual citizen of Canada and the United States. Often, she is referred to by her nickname, Dee, given to her by her family as a baby. Dr. Ray is professor emeritus and adjunct professor at Florida Atlantic University’s (FAU) Christine E. Lynn College of Nursing and a retired Colonel and veteran of the U.S. Air Force (USAF) Nurse Corps. She was a mentee of the late Dr. Madeline Leininger (1981, 1991) and the first person to graduate from the University of Utah’s transcultural nursing (TCN) PhD program. Dr. Ray has a master of science in maternal/child nursing and a master of arts in anthropology. She has received a cadre of honorary degrees and fellowships, one of which is an honorary doctor of laws degree from McMaster University in Hamilton, Ontario, Canada, as well as being named a fellow of the American Academy of Nursing, the Society for Applied Anthropology, and the Transcultural Nursing Society Scholars. She is an honorary distinguished fellow of the European Society for Person-Centered Healthcare and a distinguished fellow of the National Academies of Practice, as well as an honorary scholar, Global Academy of Holistic Nursing. She is certified in transcultural nursing as well as formerly in nursing administration, both at the advanced levels. Dr. Ray serves on the advisory council of the Nightingale Initiative on Global Health and was the Christine E. Lynn Eminent Scholar at FAU for five years. She is the creator of the theory of bureaucratic nursing (1981, 1984, 1989, 2010, 2021a, 2023), which became the cornerstone for the development of the USAF interprofessional practice model and contributed to the first Tri-Service joint practice model for the United States’ Defense Health Agency.
Dr. Ray, thank you for agreeing to meet with me. Please tell us a bit more about yourself and your nursing knowledge influences.
Thank you and Dr. Parse for asking me to be a part of your Nursing Science Quarterly (NSQ) column. I was born in Hamilton, Ontario, Canada, one of six children, and initially after high school I was educated at St Joseph Hospital School of Nursing. It was a diploma program [They no longer have any diploma programs in Canada. Baccalaureate (BSN) programs are now entry level for nursing in Canada]. It was a wonderful school of nursing because the focus was on wholistic nursing-body, mind, and spirit. As we know today that is still the foundation of nursing. I was pleased throughout my whole career to have that initial foundation of knowledge. After graduation, three of my colleagues and I went to Los Angeles and worked at the University of California Los Angeles (UCLA) Medical Center. It was thriving and on the edge of innovations in healthcare; it had all these advances in nursing and medicine, especially critical care, kidney dialysis, and other high-tech approaches to caring. At the same time, I thought that the hospital had this very real central focus on caring for patients. I loved it. I wanted to get additional education, and working at UCLA, I saw the need to go back for my BSN. So, I moved to Colorado and started my BSN at the University of Colorado in Colorado Springs while working at the famous Penrose Hospital. They had developed a critical care unit and I helped to develop a cardiac care unit that I enjoyed working in while studying for my BSN.
I moved to Denver, Colorado, because the Colorado Springs site did not have the full range of nursing courses I needed. I did clinical nursing at Swedish and University Hospitals and the Gates Rubber Company Clinic part time. While completing my BSN, I became a U.S. citizen and joined the USAF Nurse Corps! Even as a little girl I was very interested in the air and space. Several of us in Denver were also members of the 187th air evacuation squadron of the Air National Guard in Cheyenne, Wyoming, because they had an active flight nurse operation. We did flight nursing in the domestic arena in Eastern Canada and the United States and in the Caribbean (Cuba, Puerto Rico, Panama), transporting people who were ill (not wounded Vietnam military personnel). During that time, I went to flight school at Brooks Air Force Base in Texas and became a qualified flight nurse within the USAF. I had a long military career from 1967 to when I retired in 1999—32 years of service to the USAF and the reserve force. Along with my Air Force career, I went on to graduate school for my master’s in nursing (MSN) and met the late Dr. Madeleine Leininger, who was the director of the nurse scientist program at University of Colorado. I was extremely impressed with this notion of nursing as a human science, as well as this notion (although she had not coined the phrase yet) of transcultural nursing and nurses caring for persons of diverse cultures and ethnic groups. It was exciting to me. After finishing my MSN, I decided to return to California, this time to the north, to San Francisco. I was working in clinical practice and had also joined the 65th Air Evacuation Squadron, Travis AFB, to continue my flight nurse activities. I met a lot of flight nurses in the unit, and one was a professor at the University of California San Francisco (UCSF). She was impressed with my background in culture, nursing, and caring and encouraged me to apply to work at UCSF. I considered myself a clinical nurse as opposed to an educator, especially since I had the clinical specialist degree with my masters. She called me about three times a week for about a month or so, so I thought, “I have to pursue this.”
I went to see the nurse educator at UCSF, and she said they wanted me to teach in the senior nursing program (which was a 5-year program at the time). She told me “Students are going to have a revolt if they do not have a clinician educator.” As my first entry into nursing education and to be at UCSF was quite an experience. Professor and Dean Helen Nahm and many other high-level educators were on the faculty at the time, including Glaser and Strauss (1967), the sociologists who designed the grounded theory method, and their nursing protégé, Jean Quint. For a period while I was in the Bay area, I also held a faculty position at the University of San Francisco.
At the same time, as a member of the 65th Air Evacuation Squadron, which had a flight nursing mission for the Pacific arena, including the war zone in Vietnam and flight operations in Japan, I was able to participate in aeromedical evacuation flights from Japan to the United States caring for wounded military personnel both as a flight nurse and as a medical crew director. That was a wonderful experience. We used to carry 150 patients on the aircraft. Bringing home that many young people at one time in different missions (I was not that much older than they were) was a truly deep experience for me—to participate with these young soldiers who had been sent to Vietnam because of the draft (and as you know at that time there was a lot of protest about the war). The sad thing was bringing home the wounded to a country that would not accept them. And they were wounded military soldiers, young people who had almost given their lives for this country. That experience penetrated me deeply as a young flight nurse.
Again, being at a high-level in schools of nursing, I felt I needed to go on for my PhD. I was trying to figure out where to go since Dr. Leininger had become the Dean of Nursing at the University of Washington, Seattle. Simultaneously, I was attracted to all the nursing scholars at the University of Arizona, as many were also anthropologists and I wanted to be an anthropologist as well. Then my dad had gotten ill, and my sister had a son whom she needed help with, so I decided to go back to Hamilton, Ontario. I joined the faculty at McMaster University as the educational coordinator for the nurse practitioner (NP) program—the first one in Canada. At that time, it had not been incorporated into a master’s program yet; it was more like a certificate program. The great thing was that as faculty we were exposed to interprofessional experience early on. We got to interface with medicine, social work, nutrition, women’s health, and anthropology . . . which was exciting for me! And at that time, the “father” of evidence-based medicine, Dr. David Sackett, was on the medical school faculty. Imagine working with him! People think of him as more of a quantitative and population health researcher, but he also had a great belief in human centeredness and culture. He believed in person centeredness for the development of population health and culture. That is why we had an anthropologist aboard our team. Dr. Sackett was very encouraging; he encouraged me (because I loved anthropology and culture) to go over to the anthropology department and see if they would accept me into their program. Then he sponsored a seminar for health scientists, and he asked me to give a talk on culture. I ended up applying to the anthropology department and when they asked me who I had studied with and I said Leininger, believe it or not they knew of her! They asked me to submit papers I had written for her. Even though my papers had her written comments all over them, I wanted to study anthropology, and I had studied nursing and anthropology with her at the University of Colorado, so I submitted them.
Because of my experience of studying with Dr. Leininger, they accepted me into their master’s program. It ended up being a fabulous education. I left my full-time educator position and took a part-time job in neonatal intensive care at the health sciences center, so I was back working in the clinical setting and attending school full-time. I got to study with, Dr. Richard Slobodin, the student of the first anthropologist, Dr. Franz Boas in Canada. Dr. Slobodin developed the anthropology program at McMaster, and he was committed to advancing all the arenas of physical, social-cultural, linguistics, and archaeological anthropology. He was my philosophy and theory professor and a marvelous educator. I also focused on political anthropology. At that time, I was extremely interested in the issues that were going on in nursing, nursing education, and practice. I wanted to do my thesis research in nursing practice. I always knew there was more than just the relationship between the nurse and the patient—there was this context, the institutional context, which was incredibly significant from the standpoint of the practice of nursing. I asked them if I could use the institutional hospital healthcare organizational culture as the culture for my thesis. They were impressed, as most students selected an indigenous group to study. [I had done literary research with the Ojibwa (or Chippewa), but I did not visit the reservation]. They agreed to my request, and I researched how healthcare organizational decisions were made. I had to meet with the 25-member hospital board [all male physicians except for the female chief nursing officer] to get permission to conduct my study in the hospital. Many could not understand why I wanted to study their organizational system. I stood strong, though, and answered their questions.
As it turned out the physician who was the chairperson of the board was in the Canadian military. (Even though I was back in Canada, I was doing my military service in Niagara Falls, New York, about 50 miles from Hamilton, Ontario.) He was impressed with me being an officer in the US military and with the idea of a studying a complex healthcare organization (although we did not call them that at the time). And of course, the military in all cultures is one of the most complex systems. In the end they approved my project, and that was the beginning of my organizational research development.
The anthropology department wanted me to get my medical anthropology PhD degree and come back and oversee the program, but guess who called me? Dr. Leininger! She was developing a TCN PhD program at the University of Utah College of Nursing and asked if I would like to be one of the first students. Of course, they still had to evaluate my credentials and education, but I told my family, “I am going back to the U.S. I have this opportunity to get my PhD, so I am going.” My father said, “Oh my goodness, another degree?” I explained that the PhD degree was the pinnacle for nurse education. So, I ended up in Salt Lake City, Utah.
Dr. Joyceen Boyle and I were the first PhD students in the transcultural program. (I finished first though, so technically I was the first graduate.) Again, I wanted to study context and use the institutional organizational culture as my basis of culture. Fortunately, my dissertation committee and many of my teachers were anthropologists. (Plus, I had already studied at a small village in the state of Jalisco, Mexico, in 1972 for 3 months.) So rather than going to a foreign country, they gave me permission to again use the healthcare institution/organization as my culture to study.
As I started thinking how I would study organizational culture and human caring, I met this wonderful gentleman, Jim Droesbeke, and within 8 months we were married and I was living in Denver (I did not take his last name, as Jim was afraid that being in the military it would cause some confusion). So, I conducted my research in the Denver area, going back and forth to Salt Lake City to meet with my dissertation committee. I developed my theory of bureaucratic caring (BCT) from my dissertation research. Even though the concept of caring was advancing in nursing and identified as the essence of nursing by Leininger (1981) and Watson (1979), the idea of the nurse-patient (N-P) relationship was not new, but the idea of bringing in the organizational context was challenging as it was always considered problematic due to that we-they phenomenon. Nursing was not as receptive to this theory as I had hoped, and even using the word bureaucratic was challenging. My committee thought I should use the word corporate, or something a little less edgy. But I had read Max Weber’s (1864-1920) (1987) work, considered the “father” of universal bureaucracy, and thought, no, this is what I want to study and analyze—the interplay between bureaucracy and caring because it impacted the N-P (or the MD-patient) relationship and other factors that went on in nursing care. I generated within my research similar structural characteristics in the healthcare organization that had been identified in bureaucratic systems by Weber. I analyzed complex issues that I organized as political, economic, legal, technical, humanistic-spiritual-religious, physical, educational, and social-cultural and the way research participants understood them as caring within the workplace.
After graduating from the University of Utah, I was committed to do a year as a researcher in Toronto for the College of Nursing, or what Canadians call the Board of Nursing because I had received a grant to study for my PhD from the Ontario government. That was an important year. I learned more about the context, the culture, and multicultural and diverse groups in the Toronto area. My work for the college included visiting the areas where nursing was practiced in the different districts, both rural and urban. I also taught qualitative research in one of the hospitals.
After that year, I went back to Denver, and Dr. Jean Watson was the Dean at the University of Colorado School of Nursing (now a college of nursing). She knew me from the small caring conferences Dr. Leininger had had at the University of Utah when I was a doctoral student. She knew I had a background in caring and culture and was knowledgeable in and loved the different qualitative research methodologies (for example, phenomenology, hermeneutics, ethnography, and grounded theory), so she assigned me to teach right into the doctoral program. And because of my background, I collaborated closely with her. She also wanted me to be the division head for the Family and Community with nursing administration program, which I did, but it was not easy! I loved clinical caring and research in organizations and transcultural nursing. If faculty and clinicians truly understood the complexity of nursing administration within clinical or caring practice. . . .
I had difficulty getting my theory published at first. By the time it was published in Nursing Administration Quarterly (Ray, 1989) I had engaged in other research and published on technological caring and economic caring. In retrospect, it was a staging of those published articles before people really understood the significance of my theory. It was just where we were with nursing back then.
In the late 1980s, Dean Dr. Anne Boykin from FAU asked Dr. Watson if she could recommend a faculty person who might want to help develop a caring program at FAU. And lo and behold, Dr. Watson recommended me! (At first, I wondered if I had messed up.) I loved the University of Colorado and Dr. Watson as a dean. She was so unique and there were not too many in nursing that thought caring was a theoretical concept at that time. Dr. Boykin invited me to Florida and called frequently to convince me to make the move. Of course, my husband, who was born on the west side of the Rockies, did not want to leave the Rocky Mountain area entirely, so we decided I would take a position in Florida during the school year and come back to our little ranch during the summer. It was the really the best of both worlds: a warm climate during the winter and the mountains in the summer. I worked it out so I could also teach qualitative methods and TCN in the summer at the University of Colorado. I did that for years.
I have been at FAU ever since, now over 34 years. I served as eminent scholar for 5 years and received Sigma and federal research grants. I was fortunate to get federal grants for research on economic caring and organizational caring from the TriService Nursing Research Program of the U.S. military (I had moved up the ranks to colonel by then.) Dr. Marian Turkel was my co-principal investigator and we studied caring within various complex organizations using private, public, not-for-profit, for-profit, and military hospitals as our contexts. Our initial economic caring research was published in Nursing Science Quarterly in 2000 and 2001 (Turkel & Ray).
I served as faculty under two deans, Dr. Anne Boykin followed by Dr. Marlaine Smith. Dr. Smith is a Rogerian scholar and paradigmatic expert in nursing and now she is developing a caring paradigm. I helped to develop the dynamic complexity paradigm, first with the late Dr. Alice Davidson and then with Dr. Marian Turkel. I also developed and advanced another theory, the transcultural caring dynamics in nursing and healthcare theory (2010, 2016). It was conceived of as a conceptual model first when Dr. Leininger was still alive. Of course, she asked me, “Why didn’t you advance theory?”
Dr. Ray, what would you say are your main contributions to nursing knowledge?
I would say it was my two theories and the caring inquiry methodology that I developed (Ray, 1991, 2019). That methodology was dormant at first but now people are using it. I am clarifying that inquiry process. Mine is based on the philosophic foundation of caring and the spirituality of consciousness and conscience. I hope to expand on Dr. Edith Stein’s (1917) idea of empathy within the phenomenological context and the Ricoeurian and Teilhardian philosophy, and caring science. [To put that in context, Dr. Stein was a compatriot of Dr. Edmund Husserl (1931, 1970a, 1970b), the father of phenomenology.]
Of course, no person does anything alone. I am beholden and grateful to those who have helped me over the years, including the mentorship of Drs. Madeline Leininger, Jean Watson, and Rosemarie Rizzo Parse. After Dr. Martha Rogers died, there was a small group of unitary scientists at New York University who wanted to expand her paradigm. They invited me as a TCN scholar to join the group, and with the support of Drs. Rosemarie Rizzo Parse and Margaret Newman, I did join, and I met and dialogued with the Rogerian scholar group for 3 years.
I am also interested in complexity science. One of my students, Dr. Todd Swinderman, wanted to use the BCT, information technology, and computer science development as a foundation for his research. He wanted to study in Italy with the late Dr. F. David Peat (2002), one of the fathers of complexity science and chaos theory, along with Dr. John Briggs (Briggs & Peat, 1999) and Dr. David Bohm (1980), an early quantum physicist. Todd needed a sponsor to take this course in Italy, and I said yes. So here we were at the Pari Center for New Learning in Tuscany, Italy, the first nurses to attend the course at the center. When we arrived in Pari, Dr. Peat asked us why nurses would want to learn complexity science. I expressed why, sharing the views of Drs. Martha Rogers and Alice Davidson, and of course Miss Nightingale (He was from the United Kingdom and Canada so knew about Nightingale).
In the first class, Dr. Peat wrote on the white board the word relationship and a stick image of a human on either side of it. Right away I thought, “That is our profession!” He went around the room asking us all to comment on this and aesthetics and when it came to my turn, I spoke about Miss Nightingale calling nursing the finest of the fine arts and having the human-to-human caring connection. As I explained my answer, they all looked at me and were in awe. Here Dr. Peat was presenting nursing, the stick people in the image, and the interconnection and Buber’s (1958) notion of the in-between, the relationship. Here were renowned physicists of the world sharing also about David Bohm’s (1980) vision of the implicate and explicate orders, the whole idea of explicit order being the actual empirical expression and implicate order being the mystery, the soul so to speak. Again, I thought, “Wow they are talking about us, about our nursing profession.”
At the center, there were several people in the class who had nursing needs. Who did they call . . . me! Dr. Peat had a party at a vineyard at the end of the course and sat me beside the Italian host (which in Italy was a big deal). After dinner, Dr. Peat asked me, “What do you think happened here with our education, our whole dialogue together this week?” I answered, “People were affected deeply by their experiences and though maybe they had that empirical knowledge, scientific knowledge, they may not have necessarily been open to the human dimension which you were bringing to light in these classes.”
When Todd and I left to fly back home, who walked us to the bus stop? Dr. Peat, the quantum theorist. He was impressed with what we said about nursing and this human connection. He has written about these connections. I am still part of the Pari Center. I said to Todd, “We have to go back to the center someday, I think we changed it.” Dr. Peat has since passed away and his wife, Maureen Doolan, wanted me to write an article on the 20th anniversary of the Pari Center in their journal, Pari Perspectives (Ray, 2021b). Since it was the year of the nurse, I asked if I could write about nursing. Ms. Doolan agreed, and she was able to get beautiful photographs from the Florence Nightingale exhibit in England. Of all the articles in that edition of the journal, mine was the most artistic, communicative, ethically caring and dotted with the story and photos of Florence Nightingale.
You know how reticent we often are in nursing and leaders say we should be on boards of directors, in government, and become policy advocates? I believe that is so, but I feel from my own experience with scientists and politicians that we must do it in a way that is not too aggressive, or proclaiming we are the best. My experience has been that when you share in a respectful way, you see how others respect us and our discipline. I felt that way as an officer in the military too. When I think about all the nursing knowledge that has been generated over all these years, of caring for people, of facilitating the health and well-being of people. . . .
Dr. Parse (2021) says we have this mutual rhythmic co-creative process with others. In my experience with these scientists, and even my late brother, an economist, lawyer, and politician in Canada, I feel that once we open to these people of other disciplines and they are attentive to us, like in Pari, Italy, they will be impressed. What I really saw at the Pari Center, which focused on science, art, and the sacred, was that what they were looking for is what we already have as nurses. That is why we cannot be so reticent to share our beliefs, our values, and our historical and professional knowledge and the way we have established our philosophic foundation, our caring, our research, and where we are going from here.
My interest in complexity science led me to become a member early on of the Center for Complex Systems and Brain Sciences at FAU. Drs. Alice Davidson, Marian Turkel, and I (Davidson et al., 2011) published the book Nursing, Caring and Complexity Science: For Human Environment Well-Being. (Earlier Dr. Davidson was a student of mine who wanted to do a dissertation on complexity science in nursing. I told her that I was not qualified but I would be her chair if she got a physicist on the committee. She got two.) While we were planning the chapters for the book, Alice was diagnosed with melanoma and passed away before the book was fully developed and published. Dr. Turkel and I then brought the book to fruition. We wanted Alice to be first author, and Springer (our publishing company) did not initially approve, but we spoke up and finally convinced them saying we would not have complexity science in nursing or the book without Dr. Alice Davidson. When we won the American Journal of Nursing Book of the Year Award in 2011, I was fortunate to be able to present the award to her children at her memorial service.
I have been interested in all my theories and showing the interface of complex systems with all the identified phenomena in the BCT of caring, one being technological caring. Dr. Rozzano Locsin, Professor Emeritus at FAU, further advanced this perspective with his own model of technological competency as caring (Locsin, 2005). He went on to study technology and caring with robots and nursing at Tokushima University in Japan. There remains the ethical question: Can robots have consciousness? Can they be caring? (Tanioka et al., 2017). The famous Dr. Kai-Fu Lee (2018) from China, and head of Google China, believed that robots could have consciousness. But when he was diagnosed with cancer, he was cared for by nurses. He changed his mind about robots having consciousness. It was then that he saw the criticality of the need for the service professions and people who care. He stated that they are the people who maintain one’s humanity. Again, that is why I feel so strongly about our contributions not only to nursing but also to science, engineering, and even economics. You know, economics is a human science. As my late brother once shared, the focus of economics is a human and moral endeavor because all economic decisions deals with the health and welfare of people. It is like our discipline, which focuses on the total human-environment relationship and that criticality. Until we humans understand that and the deep meaning of the human-human relationship, we will be a bit off track.
I am concerned that philosophy, history, and the more artistic disciplines are not being taught any longer in BA or BS programs. Subsequently, we are not learning the evolutionary knowledge that the more artistic disciplines present in Western and Eastern cultures. In the 2021 American Association of Colleges of Nursing Essentials, they say we must be more skill oriented, which feels like we are going back in time rather than going forward. However, the 2021 American Nurses Association Definition of Nursing says, in the first sentence, “Nursing integrates the art and science of caring and focuses on the protection, promotion, and optimization of the health and human functioning; prevention of illness and injury; facilitation of healing; and alleviation of suffering through compassionate presence” (p. 1). I believe that definition had to do with the contributions of Dr. Marlaine Smith.
This theme of the Nursing Science Quarterly is about paradox and pattern. Do you have anything thing you want to share about those topics?
My BCT is a theory generated from paradox. That is how it emerged from the meanings of caring, and its opposite, the principles of the bureaucracy, to a new form, a new structure. I used the philosopher Hegel (Stace, 1955; Weiss, 1974) in my analysis. Hegel’s philosophy is that much of everything in the context of the universe or thinking has to do with paradox. He was prolific, a metaphysician, a rationalist, a critical philosopher, a phenomenologist, a philosopher of spirit, and one who wrote on the science of logic and the dialectic. He explicated his philosophy of the dialectic as thesis, antithesis, synthesis, which describes a change of forms through their own internal contradictions into a higher form that unites the two opposites. Thus, that is what I did with my theory. I used the thesis of caring in relation to the antithesis of bureaucracy (the complete opposite, the paradox) and I negated each to become a new form, a synthesis of the opposites, the BCT. What is the meaning of synthesis? To reiterate, it is the interpretation of the paradox that brings the opposites to a synthesis or a new form. So first using Hegel’s upward process of philosophic analysis where two independent phenomena are the foundation of the paradox, then you cancel or negate each individual form (Hegel calls it the negation of the negation), and you reinterpret the results as a synthesis. As stated, my synthesis was the BCT using the Hegelian analytic philosophic framework to bring it to that conclusion.
The turning point for me in studying bureaucracy and caring was when I met with the chief financial officer (CFO). The focus of my research was studying caring in the organizational culture. Generally, study participants would say that caring means empathy, or compassion, or relationship. But when the CFO said that caring meant maintaining the economic viability of this organization, followed by the statement, “If I do not do that, there is no hospital, no place for patients, and no place for you to do nursing,” I thought, “That’s it!” I started to expand my own consciousness to this new meaning. Then when I interviewed the other upper-level executives, many expressed caring as governing the system. I realized that is the politics of a bureaucratic organization. You have a governing structure for the organization; even the nurse manager (who is in charge and has to make sure the unit is run safely and efficiently) has to talk with the chief nursing officer and the upper-level administrators. That is the politics of having to work together to care.
I began to see all these diversities within roles. When I interviewed people in critical care, I saw the whole interplay between caring and technology. Nursing, caring, and technology were totally integrated to maintain the life of the patient. (Nowadays technology has expanded to maintain the technological function of the organization.) That is how I began to further understand not only that humanistic caring was critical but, also, how the context played a significant role in the meaning of caring. I went to Max Weber’s (1864-1920) (1987) work in my analysis. I saw how he identified all those phenomena that had emerged in my theory—hierarchy, merit, human resources (mind, body, spirit), role differentiation, efficiency, politics (governance), economics (exchange of goods, money, and services), legal (standards of practice), technical (nonhuman resources)—in his definition of bureaucracy and how I had integrated the structure of the meanings of caring with these various principles. I thought, that is the philosophical and empirical foundation of my theory.
Grounded theory, as you know, has two types of theories: substantive theory and formal theory. Substantive theory is the expression of the meaning, which in my study was caring. So participants were expressing these various meanings within the administrative or clinical units in which they worked and within the distinct roles that they had. Then I began to see what dominant caring characteristic was expressed specifically within these units and in administration. These were the substantive components of my theory; my substantive theory was called differential caring. I eventually would name the structural concepts. In my analysis, if someone used the word budget, I would call it an economic concept; life support system became a technical concept, and so forth. Then I created a structural model of these concepts, which became the formal theory. Thus, my BCT emerged from the substantive or the meaning of the caring expressions. The formal theory emerged by using the Hegelian analytic framework (thesis, antithesis, synthesis) to bring together the paradox and form, the result or synthesis, bureaucratic caring. Again, the turning point for me was when that CFO helped me understand that finance was not nursing’s enemy. He helped me understand that the finance people cared and wanted to preserve the organization for patients and nurses to be able to care. I realized that we must work together and that people in diverse roles have different dominant expressions of the meaning of caring in their respective roles.
Dr. Ray, what are you most proud of over the course of your career?
Around 1995, my dear husband was diagnosed with lung cancer. Here, he served as a marine in Vietnam, never smoked a day in his life, and got a diagnosis of lung cancer. He lived a long time with metastatic disease (he died in 2001), and he always said I was the one who helped him to live that long. Really our faith, his oncology medical and nursing team, and I worked the cancer caring process for and with him. I also would like to point out that my friend Dr. Francelyn Reeder helped Jim and me so much with her love, caring, and therapeutic touch. The University of Colorado Oncology Department was a great lung cancer research center, and using our nursing clinical care knowledge in conjunction with science, the biological and pharmacologic sciences, and working together as a team, we strove to help Jim be as healthy as he could with this diagnosis.
But back to your question, though, what I was most proud of about Jim’s care was that my husband never got pneumonia. I did respiratory therapy with him, helping him with his breathing and chest physical therapy. He was only hospitalized initially for surgery, then only once in those five and a half years and it was for a procedure on his pleura. He told me, “You kept me as healthy as possible.” It was a real example of the type of care nurses can provide to keep persons healthy despite their medical diagnosis, by addressing loving human caring and incorporating their own professional knowledge.
Another area I am very proud of is the institution of the BCT, which was integrated into the USAF caring inquiry methodology. Lieutenant General Dorothy Hogg, now-retired Air Force Surgeon General, wanted a structural framework for the development of the professional nursing practice program in the USAF, so upon the advice of one of her executive nurses, Colonel (Ret.) Marcia Potter, who had used the theory in her doctorate of nursing practice project, they chose the BCT. They even made a coin for me with the professional image—the words of caring in the center with the national monument in the background with Nightingale’s lamp and the BCT concepts around the periphery. A coin is considered “top notch” in the military. Dr. Colonel Marcia Potter (2021) then presented my theory to the Defense Health Agency to include the other military services, even space! I am delighted that my theory has been found to be relevant and can guide professional nursing and healthcare practice. When I think of the number of people who have been influenced by my theory, it is astounding. A few months ago, Dr. Jacqueline Fawcett stated that the implementation of a theory in practice is what every nurse theorist dreams of!
Dr. Ray, what are you currently working on?
Currently I am working on FAU’s Caring Science Certificate program (Teaching and Learning Grounded in Caring Science) supported by the Anne Boykin Institute for the Advancement of Caring. The Anne Boykin Institute is trying to enhance the evolution of caring in nursing globally. I am also advancing my theory through articles, book chapters, and presentations. Once the certificate program is set up, I want to work on facilitating caring within long-term care (LTC) and skilled nursing facilities. I want to help nurse leaders, and nursing assistants who are primarily doing the care in those types of facilities, understand the responsibility of their role as caring persons within an understanding of the aging process and dementia care. I currently live in a retirement community that has three levels of care: independent living, LTC, and skilled nursing. There is a wonderful executive director here who is supportive of my ideas and is committed to improving gerontological nursing care.
This summer I will be attending the 2023 International Council of Nurses (ICN) conference. I am excited that it will be in Canada. I look forward to sharing with other nurses in the global community and learning how the ICN organization is viewing nursing in the world now. I appreciate what we have accomplished in the discipline with our own professional knowledge and how we can continue to encourage nurses to work in the global environment.
Is there anything else you want to tell our readers?
First, I would like to thank you and Dr. Rosemarie Parse very much for your kindness and support, and you for interviewing me and writing my story for NSQ. After an almost 7-decade long career in our beloved profession, I am grateful to so many people, including my late parents and husband, Jim, and my many friends and colleagues for sharing their faith, hope, and love. I have experienced immense joy, happiness, grief, loss, change, and most of all beauty during my lengthy career. Preserving nursing’s caring and its unique relationship of humanbecoming within the context of complex systems is a number one priority for me. This honors nurses and all people with openness and compassion and presents scientists with new knowledge to meet the challenges within not just a small sphere of scholars but within all cultures, ethnic groups, and nation states, including our immigrant communities. We have global responsibilities as nurses, even into the new frontier of space. There are a lot of things where nursing can make a tremendous contribution to, including cosmology. (As nurses, we must love and expand our view of the cosmos, just like many physicists and theologians.) Dr. Jean Watson (2021) is doing just that, and I believe my contributions to the Pari Center are another example. Nurses need to know that we can communicate with continued vision and forethought. The public needs us to continue our commitment to them by following from my perspective, the fingerprint of God’s love. We should not be too cautious or lack the confidence to speak up and share. Confidence, as the caring philosopher Roach (2002) declared, is a central key in nursing. Again, I am very privileged and grateful to share my story of nursing and my love of our discipline and profession with you.
Dr. Ray, thank you for your time, your knowledge, and sharing your story with our readers.
