Theoretical Foundation of Nursing

CASE STUDY # 2 (Ray’s theory)

Mrs. Smith was a 73-year-old widow who lived alone with no significant social support. She had been suffering from emphysema for several years and had had frequent hospitalizations for respiratory problems. On the last hospital admission, her pneumonia quickly progressed to organ failure. Death appeared to be imminent, as she went in and out of consciousness, alone in her hospital room. The Medical-Surgical nursing staff and the Nurse Manager focused on making Mrs. Smith’s end-of-life period as comfortable as possible. Upon consultation with the Vice President for Nursing, the Nurse Manager and the unit staff nurses decided against moving Mrs. Smith to the Palliative Care Unit, although considered more economical, because of the need to protect and nurture her as she was already experiencing signs and symptoms of the dying process. Nurses were prompted by an article they read on human caring as the “language of nursing practice” (Turkel, Ray, & Kornblatt, 2012) in their weekly caring practice meetings. The Nurse Manager reorganized patient assignments. She felt that the newly assigned Clinical Nurse Leader who was working between both the Medical and Surgical Units could provide direct nurse caring and coordination at the point of care (Sherman, 2010). Over the next few hours, the Clinical Nurse Leader as well as a staff member who had volunteered her assistance provided personal care for Mrs. Smith. The Clinical Nurse Leader asked the Nurse Manager to see if there was a possibility that Mrs. Smith had any close friends who could “be there” for her in her final moments. One friend was discovered and came to say goodbye to Mrs. Smith. With help from her team, the Clinical Nurse Leader turned, bathed, and suctioned Mrs. Smith. She spoke quietly, prayed, and sang hymns softly in Mrs. Smith’s room, creating a peaceful environment that ex[1]pressed compassion and a deep sense of caring for her. The Nurse Manager and nursing unit staff were calmed and their “hearts awakened” by the personal caring that the Clinical Nurse Leader and the volunteer nurse provided. Mrs. Smith died with caring persons at her bedside, and all members of the unit staff felt comforted that she had not died alone. Davidson, Ray, & Turkel (2011) note that caring is complex, and caring science includes the art of practice, “an aesthetic which illuminates the beauty of the dynamic nurse-patient relationship, that makes possible authentic spiritual-ethical choices for transformation—healing, health, well[1]being, and a peaceful death” (p. xxiv). As the Clinical Nurse Leader and the nursing staff in this situation engaged in caring practice that focused on the well-being of the patient, they simultaneously created a caring-healing environment that contributed to the well-being of the whole—the emotional atmosphere of the unit, the ability of the Clinical Nurse Leader and staff nurses to practice caringly and competently, and the quality of care the staff were able to provide to other patients. The bureaucratic nature of the hospital included leadership and management systems that conferred power, authority, and control to the Nurse Manager, the Clinical Nurse Leader, as well as nursing staff in partnership with the Vice President for Nursing. Nursing administration, Clinical Nurse Leaders, and staff’s actions reflected values and beliefs, attitudes, and behaviors about the nursing care they would provide, how they would use technology, and how they would deal with human relationships. The ethical and spiritual choice making of the whole staff and the way they communicated their values both reflected and created a caring community in the workplace culture of the hospital unit.

  1. Discuss the role and the value of the Clinical Nurse Leader on nursing units. What is the difference between the Nurse Manager and the Clinical Nurse Leader in terms of caring practice in complex hospital care settings? How does a CNL fit into the Theory of Bureaucratic Caring for implementation of a caring practice?
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