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 .

1. 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

2. 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.
Critical thinking activities

3. Based on this case study, consider the following questions.
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