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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, and 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 because 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, 2012). Over the next few hours, the clinical nurse leader and a staff member who had volunteered her assistance provided personal care for Mrs. Smith. The clinical nurse leader asked the nurse manager whether 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 expressed 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, and 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-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, and the nursing staff in partnership with the vice president for nursing. The actions of the nursing administration, clinical nurse leader, and staff 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. What caring behaviors prompted the nurse manager to assign the clinical nurse leader to engage in direct caring for Mrs. Smith? Describe the clinical nurse leader role established by the American Association of Colleges of Nursing in 2004.
2. What issues (ethical, spiritual, legal, social-cultural, economic, and physical) from the structure of the theory of bureaucratic caring influenced this situation? Discuss end-of-life issues in relation to the theory.
3. How did the nurse manager balance these issues? What considerations went into her decision making? 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 clinical nurse leader fit into the theory of bureaucratic caring for implementation of a caring practice?
4. What interrelationships are evident between persons in this environment—that is, how were the vice president for nursing, nurse manager, clinical nurse leader, staff, and patient connected in this situation? Compare and contrast the traditional nursing process with Turkel, Ray, and Kornblatt’s (2012) language of caring practice within the theory of bureaucratic caring
5. What is the difference between grand theory and middle-range theory? Grand theory is broader and provides an overall framework for structuring ideas.

In description, Grand Theories are broad and complex in scope. They present a conceptual framework for identifying the key principles and concepts of the nursing practice. Even though they are known to provide intuitions useful for practice, they cannot be used for empirical testing.

• General Systems Theory – Imogene King
• Modeling and Role Modeling Theory – Erickson, Tomlin, and Swain
• Transcultural Nursing (formerly Culture-Care) – Madeleine Leininger
• Conservation Model – Myra Estrine Levine
• Health as Expanding Consciousness – Margaret Newman
• Nursing Process Theory – Ida Jean Orlanda
• Theory of Human Becoming – Rosemarie Rizzo Parse
• Humanistic Nursing – Josephine Paterson and Loretta Zderad
• Interpersonal Relations Model – Hildegard E Peplau
• Science of Unitary Human Beings – Martha E Rogers
• Roy Adaptation Model – Sister Callista Roy
• Philosophy and Theory of Transpersonal Caring – Jean Watson
• Emancipated Decision Making in Health Care – Wittman-Price
• Self-Care Theory – Dorothea Orem

On the other hand, middle-range theories are focused on a particular phenomenon or concept. They are limited in scope and deals with tangible and reasonably operative concepts. Their propositions and concepts are more specific to the nursing practice and they can be used for empirical testing.

• General Systems Theory – Imogene King
• Modeling and Role Modeling Theory – Erickson, Tomlin, and Swain
• Transcultural Nursing (formerly Culture-Care) – Madeleine Leininger
• Conservation Model – Myra Estrine Levine
• Health as Expanding Consciousness – Margaret Newman
• Process Theory – Ida Jean Orlanda
• Theory of Human Becoming – Rosemarie Rizzo Parse
• Humanistic Nursing – Josephine Paterson and Loretta Zderad
• Interpersonal Relations Model – Hildegard E Peplau
• Science of Unitary Human Beings – Martha E Rogers
• Roy Adaptation Model – Sister Callista Roy
• Philosophy and Theory of Transpersonal Caring – Jean Watson
• Emancipated Decision Making in Health Care – Wittman-Price
• Self-Care Theory – Dorothea Orem

Middle-range theory addresses more narrowly defined phenomena and can be used to suggest an intervention.

• The Framework of Systemic Organization – Marie-Louise Friedemann
• Theory of Group Power within Organizations – Christina Sieloff
• Theory of Comfort – Katharine Kolcaba
• Theory of Maternal Role Attainment- Ramona Thieme Mercer
• Nurse as Wounded Healer – Marion Conti O’hare
• Synergy Model – AACN
• Behavioral Systems Model – Dorothy Johnson
• Quality of Nursing care Theory – June H Larrabee
• Theory of Unpleasant Symptoms – Elizabeth R Lenz and Linda C Pugh
• Advancing Technology, Caring, and Nursing – Rozzano C Locsin
• Health Belief Model – Blanche Mikhail
• Theory of Uncertainty in Illness – Merle Mishel

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