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    Rina Fitriani
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    Theory of Bureaucratic Caring

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    Continuing Education Dr. Marilyn Ray’s Theory of Bureaucratic Caring Marian C. Turkel, PhD, RN Albert Einstein Healthcare Network Goals: To provide an overview of Ray's theory of bureaucratic caring to members ofthe nursing profession. To pre- sent a framework for the administrative and clinical practice of nursing within organizational culture. Objective: Upon completion of this content the participant will: 1. Identify the major theoretical concepts of Ray’s theory of bureaucratic caring. 2. Describe how Ray’s theory can guide administrative nursing practice. 3, Describe how Ray’s theory can guide clinical nursing practice. 4. Understand how the grounded theory process resulted in substantive and formal theories. 5. Explain the interrelationship among the concepts in the holographic model. Abstract ‘Healthcare, healthcare systems, and the practice of nursing in complex organizations are constantly changing. Nurses are involved in a practice environment grounded in the spir- itual-ethical, political, economic, legal, technological, educational, physical, and social- cultural dimensions of caring. Given today’s healthcare environment, nurses need 10 ‘examine how the meaning of caring is related to and influenced by the organizational culture. The theory of bureaucratic caring provides direction and guidance for nurses to ‘understand the way caring is lived and expressed throughout the hospital organization, Intthis theory, the meaning of caring is first differentiated by hospital units and second, integrated into an organizational structure. Key Words: Theory of bureaucratic caring, ‘economics, differential caring, political caring, relational caring complexity Introduction ‘The issues that confront nurses today in- clude economic constraints in the managed care environment, the nursing shortage, complex patients, increased workloads, technological advancements, and a cultur- ally diverse patient population or co-worker ‘group. Nurses need in-depth knowledge of these issues to challenge and change organi zational culture while sustaining and sup- porting human caring. ‘The practice of musing takes place in or- {ganizations that are traditionally bureau cratic in nature. Political, economic, egal, and technical systems exist within the bu- reaucracy of a hospital. Hospitals have been affected by economic issues related to mar- ‘gins, costs, profits, mergers, acquisitions, and financial stability. Downsizing, loss of trust, commitment and loyalty to workers, ‘reduced benefits, and restructuring are the result (Ray, Turkel, & Marino, 2002). ‘Hospitals fell victim tothe corporatization of the human enterprise (Ray, 2006). The ‘conflict between healthcare as a business and caring as a human need isa crisis for nursing and hospitals (Page, 2004). [Ray's theory of bureaucratic caring illus- trates the practice significance of spiritual ‘and ethical caring in relation to the political, physical, and social-cultral dimensions of complex healthcare organizations. This the- cory guides understanding of how nursing can be practiced in contemporary hospital environments. Fora more philosophical or conceptual overview ofthe theory, related research and practice applications, readers are invite to review the theorists original work ay, 19818, 1981b, 1984, 1985, 19872, 1987b, 1989, 1991, 1994a, 1994, 1994e,1997a,1997b, 1998, 19986, 2001, ‘in press), as well as other sources (Coffman, 2006; Ray, Turk, & Marino, 2002; Take, 2001, 2006; Tukel & Ray, 2000, 2001, 2003). Introducing the Thearist Marilyn (Dee) Ray was bor in Hamilton, (Ontario, Canada and has been living in ‘Boca Raton, Florida since 1989. She eared ‘diploma from St. Joseph Hospital; a BSN, ‘MSN in Maternal-Child Nursing from the University of Colorado in Denver, Colorado, sn MA in Cukural Anthropology from ‘McMaster University in Hamilton, Canada, and a PRD from the University of Utah in ‘Transcultural Nursing. Dr. Ray has enjoyed a rich and varied ‘professional nursing career. Her clinical ex- petience included the areas of obstetric and ‘gynecology, emergency department, adult 2007, Vol. 11, No.4 ME Dr. Marilyn Ray's Theory of Bureaucratic Caring intensive care, pediatrics, neonatal intensive care, and fight nursing. She has held teach- ing positions a the University of California San Francisco, University of Sen Francisco, MeMaster University, University of ‘Colorado, and Florida Atlantic University. {In 1989, Dr. Ray was appointed as the (Christine E. Lynn Eminent Scholar at Florida Atlantic University, College of ‘Nursing, followed by a professorial role. Dr. Ray retired from the university in 2004 and is currently Professor Emerita, ‘She retired as a Colone! in 1999 after 30 years of service withthe U.S. Air Force Reserve Nurse Corps. During her years of service, Dr. Ray was the recipient of numer- ‘ous awards and medals. Most notably, in 2000, she received the Federal Nursing Services Research Award in recognition of her research on economics and the nurse- patient relationship that received approxi- ‘mately $1 million in funding from the ‘TeService Military Nursing Research Program. Dr. Ray is one of the founders ofthe ‘National Caring Research Conference (1978), later renamed the International Association for Human Caring (IAHC). In honor of her late husband, James (im) L. Droesbeke, Dr. Ray established the Droesbeke Caring Award through the TAHC. Bach year, an international nursing student is awarded $1,000 toward expenses for attendance atthe annual LAHC confer- cence. The award reflects her commitment to and transcultural caring. She has published ‘numerous articles and book chapters and her theory has been studied and used as a framework for research by nurses in various ‘practice settings. The following is an over- view and summary ofthe theory of bureau- cratic caring. Introducing the Theory ‘The theory of bureaucratic caring origi- nated as a grounded theory from a qualita- tive study of caring within the context of the healthcare organizational culture (Ray, 1981a). “The purpose of Ray's dissertation study was to generate a theory of the dy- ‘namie stracure of caring in a complex orge- nization” (Coffman, 2006,p. 122). The research study involved the use of grounded theory to generate substantive and formal theories, phenomenology to elicit the mean ing ofthe experience, and ethnography to reveal the patterns within the organizational culture, ‘Dr. Ray spent almost 8 months inthe field studying caring in all areas of a se- lected hospital. Areas of sudy included clinical nursing units, materials manage- ‘ment, outition support, administration, and ‘nursing administration. The sample size in volved more than 200 participants. The principal question asked of participants ‘was, “What s the meaning of caring to ‘youT” A process of dialogue and explo- ‘ation of caring evolved from in-depth in- terviews, participant observation, care siving. and field note documentation (Ray, 1989). - ‘The research revealed that nurses and other healthcare professionals struggled withthe paradox of serving the corporate needs ofthe bureaucracy while serving the caring needs of human beings, especially patients. These findings resulted in both substantive and formal theories (Coffman, 2006; Ray, 1981, 1984, 1989, 2001, 2006), Differential caring emerged asthe substan- tive theory and showed that caring within the organization was complex and compli- cated. Caring was differentiated in terms of ‘meaning and context related to areas of practice or nursing units The theory of bu- reaucratc caring was identified as the for- smal theory. (Caring varies by areas of practice orhos- pital units. For example, nurses inthe inten- sive care unit (CU) have a dominant value of technological caring in terms of nursing care activites related to monitors, ventla- ‘tors, procedures, or medication titration. [Nurses working on an oncology unit value ‘humanistic or spiritual caring in terms of ‘amily-focused care, compassion, and com- fort measures. Staff nurses valued caring in HENS international Journal for Human Caring terms of the relationship to patient care, ‘while administrators valued caring in terms ofthe relationship tothe system, such as se- cing the economic well-being ofthe hos- pital. Differential caring theory showed that diferent units espoused different meanings of caring based on their specific onganiza- tional goals and values. Major concepts in the theory of bureaucratic caring are sum- marized in Table 1. The formal theory of bureaucratic caring symbolized the dynamic structure of caring ‘within the complex organization (see Figure 1). The formal theory is a dialectic be- ‘ween the thesis of caring as humanistic, 90- cial, educational, ethical, and religious/ spiritual (dimensions of humanism and spir- ‘tualty) and the antithesis of caring as eco- ‘nomic, political, legal, and technological (Gimensions of bureaucracy) (Coffman, 2006; Ray, 19812, 1989, 2001, 2006). ‘The research revealed thatthe economic ‘and politcal dimensions were dominant, followed by the technological and legal di- ‘mensions i relation tothe edueation/so- cial, ethical, and spiritual dimensions (Coffman, 2006; Ray, 2001, 2006). Accord- {ng to te theory narsing and caring are e periential and contextual and are influenced by the social structure or culture within the ‘organization. Interactions and meanings are formed from the dominant values held ‘within the organization. In 1989, Dr. Ray reconceptualized the theory based upon research and reflection Figure 1B illustrates the concept of differ- ential caring within a bureaucratic caring structure. Major assumptions (nursing, per son, health, environment) of the theory are presented in Table 2. ‘Moving Forward ‘Upon completion of her dissertation ‘work, Dr. Ray continued to evolve her the- cory by conducting research on specific di- ‘mensions of the theory. Subsequent re search focused on caring in the high tec:- nology area of critical care nursing pract (19872). Ray noted, “Critical care nurs Dr. Marilyn Ray's Theory of Bureaucratic Caring Table 1 Major Concepts ‘Concept Caring Spiritual-ethical Educational Physical Legal Technological Political nea ‘Caring is defined as a complex, transcultural, relational process, grounded in an ethical, spiritual context. As such, caring is the relationship between charity and right action, between love as compassion in response to suffering and need, and justice or faimess in terms of what ought to be done. Caring occurs within a culture ‘or society, including personal culture, hospital organizational culture, or society and global culture. Spiritual-ethical caring relates to holism and integration of body, mind, and spirit. Spirituality involves ‘creativity and choice and is revealed in attachment, love, and community. The ethical imperatives of caring ‘that join with the spiritual relate to our moral obligations to others. This means never treating people simply ‘as a means to an end or an end in itself but rather as beings who have the capacity to make choices. Spiritual- cthical caring for nursing focuses on how the facilitation of choices forthe good of others can or should be ‘accomplished. Formal and informal educational programs, use of audiovisual media to convey information, and other forms of teaching and sharing information are educational factors related to the meaning of caring. Physical factors related tothe physical state of being, including biological and mental patterns. Because the ‘mind and body are interrelated, each pattern influences the other. Social and cultural factors are ethnicity and family structures; intimacy with friends and family; communi ‘cation; social interaction and support; understanding interelationships, involvement, and intimacy; and structures of cultural groups, community, and society. Legal factors related to the meaning of caring include responsibilty and accountability; rules and principles to guide behaviors, such as polices and procedures; informed consent; rights to privacy; malpractice and liability issues; client, family, and professional rights; and the practice of defensive medicine and nursing. ‘Technological factors include non-human resources, such asthe use of machinery to maintain the physio- logical well-being of the patient, diagnostic tests, pharmaceutical agents, and the knowledge and skill needed to utilize these resources. Also included with technology are computer-assisted practice and documentation. Factors related to the meaning of caring include money, budget, insurance systems, limitations, and guide- lines imposed by managed care organizations and, in general, allocation of scarce human and material resources to maintain the economic viability of the organization. Caring as an interpersonal resource should be considered as well as goods, money, and services. Political factors and the power structure within healthcare administration influence how nursing is viewed in hhealtheare and include patterns of communication and decision making in the organization; role and gendez| stratification among nurses, physicians, and administrators; union activities, including negotiation and ‘confrontation; government and insurance company influences; uses of power, prestige, and privileges are, in ‘general, competition for scarce human and material resources. “Theory of Burecucratc Caring, Cana, 200, pp. 121-22 ‘tensely human, moral, and technocratic” (9-172). The Dimensions of Critical Care ‘Nursing journal presented Ray with re- searcher ofthe year award fr this sentinel work. Ray (19876) challenged nurses and nurs- ing to discover the meaning ofthe moral foundation of human caring and economics. The economic and political dimensions of the theory of bureaucratic caring served as the basis for the ongoing research con- cted by Ray and Turkel. In a grounded theory smdy conducted by Ray and Turkel (2000), qualitative interviews were con- ducted in not-for-profit and military sectors of the healthcare delivery system. The pur- [pose of this research was to continue the study of the nurse-patient relationship as an ‘economic interpersonal resource. Findings from this study identified thatthe nurse-pe- tient relationship was both outcome and process. Categories, which emerged during data analysis, included relationships, caring, and costs. "The formal theory of relational caring ‘complexity iustrated thatthe caring rela- ‘tionship among the nurse, patient, and ad- ‘ministrator is complex and cocreative, is ‘both process and outcome, and is a function of a set of economic variables and a set of ‘urse-patient relational caring variables. ‘Foonomic variables are depicted as time, technical, and organizational resources. ‘Nurse-patient relational caring variables are ‘caring, relationships, and education (Turkel & Ray, 2000). 2007, Vol. 11, No. 4 Dr. Marilyn Ray's Theory of Bureaucratic Caring igre 1A. The orignal grounded hoor of bureaucratic caring. Note: From Ray, MA. (1881) A study of caring win n inttuionl culture. Decor easton, Dissertation Absbacs Intemational, 4206), (UMI No. 8127787) pe Figure 18, Subsequent grounded theory reveaingdifretil caring, "Note: From Parker, ME. (2008). Nursing theories and nursing practice, Philadelphia: FA. Davis. $EQE International Journal for Human Caring Table 2 ‘Major Assumptions Dr. Marilyn Ray's Theory of Bureaucratic Caring ‘Assumption Health Environment Definition “Nursing is holistic, relational, spiritual, and ethical caring that seeks the good of self and others within complex community, organizational, and bureaucratic cultures. The foundation of spirtual-a ofthe bed and inereased the oxygen scation. A schedule was worked out ildren could stay in the room Soir presence had a calming effect on ‘The next day Joseph began experi- so'bg more difficulty breathing, The physi tis time to place him ane 98" Joseph weakly replied, "No Diane, Joseph’s nurse, reminded the cian of the papers thet Joseph had fier reviewing the document, the an booted the request. A decision ~ade to transfer Joseph out of the ICU Wate oom. Joseph's children and ‘dren stayed with him. They sang, znd took turns holding Joseph's ibbing his back, Joseph died in his following day wit his family at + What dimensions from the theory of ceaucratic caring did the RNs apply in this mursing situation? + How did the RNs express curing in Dr. Marilyn Ray’s Theory of Bureaucratic Caring ‘this nursing situation? ‘+ How was spiritual-thical caring con ‘nected to the other dimensions ofthe theory? ‘Nursing Situation: Advanced Practice Nurse Marie isa 48-year-old Hispani woman living in a Chicago suburb working 3 days a ‘week in a grocery store nearer home and assisting in the child-care responsiilies of ployer offers no health insurance and her current earings are just over the eligibility limit for Medicaid. Consequent, Mare re- ceives no preventive or screening serves and does not se a primary care provider on a routine basis. Over the past 6 months she has been seen and treated in two different emergency room, once fora respiratory fection andthe second time for feeling ex husted Recently, she felt lump on her right breast righted and confused shout where ogo for care, she asked a co-worker for guidance. Marie learned about a mobile van operated by the loca college of musing where advanced practice nrses (APNS) provide healthcare serening without charge. In order receive ths free servic, Maric ha to lose day's wages end depend on public transportation to goto the pat of tte city wheré'the van was located. Since herrent was due soon, Marie could not af ford to foe a day's pay, so she put of going for her screening for 3 weeks. This also ave her the time to save some extra money fore taxi fare, otherwise she would have to take to buses and sil walk over a mile since the cline was not readily accesible by bus or ti Finally, Mie was able to seek medical attention. The APN recommended thet she hhave & mammogram ad veered he to public health clinic, Unfortunately, the fist available appointment was 4 weeks amay, Again, inorder to go to the clinic, Marie would either need to take a day off work ‘without pay, make arrangements for som ‘one lo waich her grandedildren, or bring the grandchildren with her tothe clinic. She ‘could not afford to take a day off, so the ‘best option was forthe children to go with ‘her forthe day. The APN arranged for some ‘snacks and toys forthe children while they ‘waited for their grandmother. Once the ‘mammogram was performed and read, “Marie's worst fear was confirmed. The Jump appeared to be cancerous and she ‘would need to see.a breast surgeon as soon as possible. Immediately, her mind became flooded with questions: Where will go for treatment? Who will pay for my care? T have no sick time; when can I go back to ‘work? Who will watch my grandchildren? and What if Ireally ave cancer? “The nurse and the social worker at the clinic tried to answer some ofthese ques- tions. Marie had difficulty understanding and communicating in English and neither the APN nor the social worker was fluent in Spanish. They spoke slowly, used pictures, held Marie's hand and looked at her while speaking. The APN made numerous phone calls until she found a physician who would see Marie in 3 weeks. The bad news, though, was that his office was not accessi- ble by public transportation. Again, she ‘would need to take a day off work and bud- get the unamicipated taxi fare. No problem, she thought, if don buy anything but rice ‘and beans atthe grocery store for a while, will be okay. Sensing the patent's appre hension, the APN told Marie about the free teansportation available from the Am ‘Cancer Society and made arrangements for her to have a car ride the day of her appoint. ‘ment. The APN called a local day care and srranged forthe grandchildren wo spend day a the center, the day ofthe sppoint- ment ‘When Marie saw the surgeon almost 3 months after discovering the lump, she was (old that she wouid definitely need a biopsy ‘and in ll probebility.a mastectorny. She idly asked if they could save her breast ‘and just take out tae jump. All she heard was the harsh “NO.” The gond news was that che would need to wait only 1 month for an open surgical siot at tne community Br, Marilyn Ray's Theory of Bureaucratic Caring hospital. ‘During this time, Marie’s employer told her he might not be able to hold a job for her since she would be off work for awhile Her daughter could take 2 days off work 10 ‘watch the children while Marie was inthe hospital but she would not be paid for the ‘ume off. Four months after discovering her lump. Marie had a mastectomy, and the i= agnosis was Stage If cancer with metastasis to the Lymph nodes. She would need to take ‘Tamoxifen for the next 6 months, The APN contacted the American Cancer Society for financial assistance with the medication After a careful review of hee immigration satus. arrangements were made for Marie toapply for Medicaid to cover the costs as- sociated with her illness. The APN ex- plained to the family that by working only 2 days per week, Marie would be eligible for “Medicaid, public transportation assistance, and food stamps. Questions: + What dimensions from the theory of bureaucratic caring did the APN’ apply in this nursing situation? ‘+ How were the various dimensions of the theory connected in this nursing situation? ‘+ How are the various dimensions con nected to the larger issue ofa lack of universal coverage for healthcare in the United States? + How would this nursing situation evolve in countries that have univer sal access and coverage for health + How did the APN express caring, while interacting with Marie and her family? + Why do you think the physician did ‘not spend time to communicate with Marie? References Coffman, S. (2006). Theory of bureaucratic cing. In A.M. Tomey & MR. Alligood ‘(Eds.), Nursing theories and their work (Gtned) (pp. 116-138). St. Louis. MO: Mosby Harmon, W (1998), Global mind change (2nd ed), San Francisco,CA: Berret- Kochler Publishers, oe. Page, A. (Ed), (2004). Keeping patients safe: Transforming the work environment of nurses, (osttute of Medicine Report, ‘Washington, DC: The National ‘Academics Press. Peat, R. (2003). From certainty to uncer taimy: The story of science and ideas in the twentieth century. Washington, DC: Joseph Henry Press. Ray, M, (2006). The theory of bureaucratic caring. le M. Parker (Ed), Nursing theo- ries and nursing practice (pp. 360-368). Philadelphia: FA. Davis Ray, M. (2001). The theory of bureaucratic caring. In M. Parker (Ed.), Nursing theo- ries and nursing practice (pp. 421-44). Philadelphia: FA. Davis. Ray, M, (19986). Complexity and nursing science, Nursing Science Quarterly, 11, 91-93. Ray, M. (19980). A phenomenologic study ofthe interface of caring and technology: ‘A new reflective ethics in intermediate ‘care. Holistic Nursing Practice, 12(4), 1-9. Ray, M. (19974). Consciousness and the ‘moral ideal: A transcultural analysis of ‘Watson's theary of traspersonal caring. ‘Advanced Practice Nursing Quarierly, 30,2531 Ray, M. (19978). The ethical theory of exis- tential authenticity: The lived experience of the art of caring in nursing administra- tion, Canadian Journal of Nursing Research, 2{1), 111-126. Ray, M, (1994). Complex caring dynam- ics: A unifying model of nursing inquiry. Theoretic and applied chaos in nursing, 10),23-32. Ray, M. (19944), Communal moral experi- ‘ences asthe starting point for esearch in health care ethics. Nursing Outlook, 41, 101-109, Ray, M, (1994), Transcultural nursing ethics: A framework and model for tran- scultural ethical analysis. Journal of Holistic Nursing, 12(3),251-264. HEHE international Journal for Human Caring thetic process inthe way of compass InD. Gaut & M. Leininger (Eds Caring: The compassionate healer (p National League y oF bureau Ray, M. (1988). The the caring for nursing practice in ational oulrure. Mursing Administra Quarterly, 130),31-42. Ray, M. (19872). Technological caring: A mode! in riteal care, Dimensions: Critical Care, 63), YT. ‘Ray, M. (19876). Health care ecozomics and human caring: Why the moral co: ‘it must be resolved. Fanny and Conanuity Heats, 10(1), 35-43, Ray, M.(1985).A philosophical method to study nursing phenomena. In M. Leininger (Ed), Qualitative research methods in nursing (pp. 81-92), New York: Grune & Stratton. Ray, M. (1984), The development of a nxrs- ing classification system of caring. In Mi Leininger (Ed), Care, the essence of ‘mursing and health (pp. 93-112). ‘Thorofare, NI: Charles B. Slack. Ray,M. (1981a).A study of caring within ‘the institutional culture. Unpublished doctoral dissertation, University of Utah, ‘Salt Lake City. Ray, M. (19816). A philosophical analysis cof caring within nursing. In M. Leininger (EA), Caring: An essential human need (p. 25-36). Thorofare, NJ: Charles B. Slack. Ray, M.,& Turkel, M. (2003). Economic ‘and patient outcomes ofthe nurse-patien: relationship. Unpublished research data rmturkel@mindspring.com Ray, M., & Tarkel,M. (2000). Economic and patient outcomes ofthe nurse-patient relationship. Grant funded by Department of Defense, Ti-Service Narsing Research Council. Ray, M., & Turkel, M. (1996). Econometric ‘analysis ofthe nurse-patient relationship 1411. Grant funded by Department of Defense, Tr-Service Nursing Research Council. Ray, M., & Turkel, M. (1995). Nurse- ‘patient relationship patterns: An eco- ‘nomic resource. Grant funded by Department of Defense, Tr-Service ‘Nursing Research Council. Ray, M., Tukel, M.,& Marino, F, (2002) The transformative process for nursing in workforce redevelopment. Nursing Administration Quarterly, 26(2), 1-14. Turkel, M. (2006). Applicability of bureau cratic caring theory to contemporary sursing practice: The political and eco- nomic dimensions. In M. Parker (Ed.), Nursing theories and nursing practice (9p. 369-379), Philadelphia: FA. Davis. Tarkel, M. (2001). Applicability of bureau- cratic caring theory o contemporary nursing practice. The political and eco- nomic dimensions. In M, Parker (Ea. [Nursing theories and nursing practice (pp. 433-444), Philadelphia: FA. Davis. ‘Turkel, M. (1997). Struggling to find a bal- ance: A grounded theory study of the ‘nurse-patient relationship within an eco- omic context. Dissertation Abstracts International, 58(08). (UMI No. 9805938) Teel, M,,& Ray,M. (2004). Creating a 2 _scizg practice environment through self Ss. Nursing Administration Qmerserly, 28(4), 249-254, ake. M..& Ray, M. (2003). A process ‘mmmce: “<= policy analysis within the con- sex x eiscl caring. International Beers ier Human Caring, 73), 17-25. ‘M. & Ray. M, (2001). Relational © smmeex:zy: From grounded theory to in- “emit development and theoretical sem Susing Science Quarterly, 144), 2. Dr. Marilyn Ray's Theory of Bureaucratic Caring ‘Tutkel, M., & Ray, M. (2000). Relational ‘complexity: A theory ofthe nurse-patient relationship within an economic context. ‘Nursing Science Quarterly, 13(8),307- 313. Wilber, K. (Ed). (1982). The holographic ‘paradigm and other paradoxes. Boulder, CO: Shambhala. saolesz2. and friend. ‘Author Note ‘Wacuc C. Turkel, Director of Professional Nursing Practice, Albert Einstein Healthcare Network, Philadelphia, PA, is responsible for the smezecc of caring theory, research, evidence-based practice and the Forces of Magnetism across the network. She has a special interest in ‘me s52rship among caring, economics, and patient outcomes in healthcare organizations. Marian considers Marilyn “Dee” Ray a mentor, radence concerning this article should be addressed to Marian C. Turkel, Albert Einstein Healthcare Network, 5501 Old York Road, _2~ + Nursing Administration, Philadelphia, PA 19141 USA. Electronic mail may be sent via the Internet to Turkelm@einstein.edu 2007, Vol. 11, No.4 Maa Continuing Education Unit Test Please circle the correct answer for each question below. 1. Ray's doctoral dissertation was the framework forthe theory of bureaucratic caring. In what setting did this research take place? | j \ & z EF i g

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