The strategies of bureaucratic caring implementation by nurse manager: A systematic review

Abstract

Objective

The systematic review was designed to get research related to the application of bureaucratic caring by the nurse manager.

Method

This systematic review used Medline, EBSCO, ProQuest, Science Direct, Scopus, Elsevier and CINAHL databases of quantitative and qualitative research reports (2006–2017) using PRISMA diagrams. Search results from 55 articles met the criteria are 13 articles.

Results

The results found 14 strategies of application in the four areas of bureaucratic caring (spiritual, ethical, organizational, and technological caring), but no research on the form of economic caring.

Conclusion

The unity and harmonization between humanistic caring and administrative aspects of the organization will create an organized health system. This system ranged from service units to organizational and managerial units as a unified whole in bureaucratic caring. Thus, bureaucracy caring can improve the competence of the nurse manager to enhance the quality of nursing care.

Introduction

Bureaucratic is an integrated system in organizations to maintain the quality of healthcare. The integrated systems of bureaucracy are closely related to economic, political, technological, legal, humanistic, spiritual, and ethical aspects of an organization. These include the hierarchy of administration, management processes, and the implementation of nursing care based on caring behavior.^1-4 However, sometimes, the complexity of bureaucratic decrease implementation of the caring practice. This negative impact makes bureaucratic and caring challenging to integrate.

Caring behavior in an organization is generated from staff's value, norms, and belief. The organizational culture forms this behavior so strictly depended on staff's roles and function in unit or departement.⁵ The primary purpose of managing this behavior is to increase the staff's satisfaction, retention, and productivity.² So, caring can connect dependently with organization bureaucracy in a qualified workforce. However, this is not in line with Habermas's theoretical concept which states that caring behavior in a health organization can decrease organizational benefits because the implementation of quality and sophisticated nursing care takes a long time.³

The combination of caring and bureaucratic had more positive impact nowadays than in the years bygone. Bureaucratic caring has successfully integrated two different parts into a robust strategy in nursing care. Implementation of bureaucratic caring with systematic planning can significantly increase clinical involvement and supports patient safety practices.⁵ However, bureaucratic caring can also weaken the nurse's professionalism.^2,3 Nurses right become neglected because there is strict regulation of health care services. This regulation in health administration is sometimes reducing the autonomy and creativity of nurses.^2,6

The nurse has the principal obligation in implementing quality nursing care. Competencies and performances of nurses become the necessary foundation for achieving this organization's goal. However, there are abundant reasons in a workforce that make nurses feel violated. These reasons will bring about nursing burnout, nursing fatigue, decreasing motivation, and performance will arise.⁷ Nurse manager had become the front line nurse in reducing the tension between nurses and the organization's regulation. These negative impact will influence all systems in an organization, such as economic, legal, political, education, and the most important is quality of care. At this point, the nurse manager becomes the front line nurse who becomes the glue between nurses and the organization.²

The nurse manager has the role and function of facilitating and developing the competence of the nurse practitioners, improving the motivation and retention of the nurse, as well as reducing the nurse's fatigue.⁸ This role and caring behavior of nurse manager toward her staff focus on strategies to improve the competency level, career path, and satisfaction level of nurse staff.¹ Also, the ability of nurse managers to access the bureaucratic and organizational hierarchy system aims to gain recognition and a better appreciation of the organizational system.⁹ However, the caring behavior of nurse managers who are overly concerned with their staff may prove dangerous to patient safety. The administrative workload of the manager's nurse can obscure the primary manager's role in focusing on the patient's nursing care.³ Based on this difference, we conducted a systematic review. The primary goal of this systematic review is to analyze and review the strategy of bureaucratic caring nurse manager toward the nurse practitioner.

Method

The systematic review (SR) method was used to analyze articles derived from international journals. The framework used in this search process was adopted from the concepts of bureaucratic caring Dr. Marilyn Anne Ray.¹ Article selection process generated from the systematic review method in an article on compassionate nurse.¹⁰

Search methods

The keywords used in the literature search process were bureaucratic caring, hospital, nurse manager, nurse practitioners, ethical caring, spiritual caring, economical caring and technological caring. The main databases used in this search were Medline, EBSCO, ProQuest, Science Direct, Scopus, and Elsevier.

The article search process used the bolemian Article code [Article], [OR], [NOT] to restrict incoming articles. This systematic review used a review protocol to guide the search process of articles related to bureaucratic caring. Limitations of the types of articles in this systematic review are articles which are not in the gray article, journals in English, and articles published in international indexed journals. There was no time limitation for article publishing because of the limited articles related to caring managers and bureaucratic caring. The design of the study was not limited to a particular design to extend and enrich the type of articles.

Selection

An initial search found 48,875 using caring and nurse manager. Articles that meet inclusion criteria and through a gradual screening process resulted in 55 studies. The search process begins with title screening, abstracts and the contents of the article based on five caring bureaucratic areas adapted from the concept of bureaucratic caring from Marilyn Anne Ray. We reviewed fifteen articles that meet the criteria. There are some strategies used in nurse manager bureaucratic caring (Fig. 1). This diagram gives five separate descriptions of strategies used in nurse manager bureaucratic caring.

Figure 1.

Systematic review path using PRISMA-E.

Source adapted from PRISMA flowchart diagram.

Quality assessment

To assess each article published in this review, we used a quality assessment tool adapted from several systematic review article.^10,11 A quality tool used in this article using four areas of research, which are design, sample, measurement, and statistical analysis.

Results

Articles selected in the SR process had to go through a review process using the concepts of bureaucratic caring. We sorted selected articles according to the five central parts of the bureaucratic caring, namely spiritual, organizational, ethical, economic, and technological caring (Table 1).

Table 1.

The strategies of bureaucratic caring implementation by nurse manager.

Caring	Strategy	Research	Quantity
Spiritual	Manager:1. Activity to relieve burnoutNurse practitioner:2. A harmonious atmosphere3. Stimulation and inspiration environment to development	Jiun-shen, Chen, and Wang (2012)	1
Organizational/Bureaucracy	4. Work scheduling5. Work adjustment antecedent to turnover6. Organizational climate7. Healthy work environment	Stordeur and D’Hoore (2006)	1
	8. Manager's ability to access evidence-based activities	Stewart, Hanson, and Usher (2006)	1
	9. Structural empowerment	1. Dirik and Intepeler (2017)2. Armellino and Griffin (2010)	2
Ethical	10. Affective commitment	1. Huyghebaert, Gillet, Becker, Kerhardy, and Fouquereau (2017)2. Kodama, Fukahori, Sato, and Nishida (2016)3. Lalleman, Smid, Lagerwey, and Shortridge-Baggett (2016)	3
	11. Leader as a support system	Paliadelis and Cruickshank (2007)	1
	12. Rule application	4. Lu and Lin (2014)5. Lemmergaard and Lauridsen (2008)	2
Economic	No		0
Technological	13. Virtual team pathway14. Communication using updated technology	1. Cordery, Soo, Kirkman, Rosen, and Cordery (2009)2. Wassenaa, Pearce, Hoch, and Wegge (2010)	2

Spiritual caring

The research that emphasizes spiritual caring was done by Shen (2012), which divides bureaucratic caring into two point of views include manager and nurses. Nurse manager plays a role in planning the structured activities of nurse practitioners to reduce the nurse's fatigue. Whereas, from the nurse manager, they expect nurse manager to create a conducive atmosphere, stimulating and inspirational activities to develop the competence of nursing nurses.¹² The synergistic of these two strategies are desirable for nurses in implementing quality nursing care.¹²

Ethical caring

Caring ethic has three main strategies that are effective in the implementation of affective commitment, manager as a support system and implementation of regulations in nursing services as the legal ethics. Affective commitment is the strategy that most influence the application of bureaucratic caring.^13-15 Nurse manager with transformational styles are shown to significantly affect affective commitment with OR = 2.23, 95% CI: [131–3.80].^14,16-18 Job satisfaction of nurse practitioners also proves to increase in line with the increase of effective manager with, P < 0.00117. One of the positive impacts of job satisfaction is that nurses will improve nurse retention and create a conducive working environment.

Organizational caring

A nurse-friendly organizational system will increase the nurse's job satisfaction score.⁹ The level of job satisfaction and nurse commitment is higher in the attractive hospital, followed by a decrease in fatigue level and the desire to move to another hospital (P < 0.001).⁹ The nurse relationship of the manager (average ¼ 3.08 vs. 2.84, P < 0.001) has values equivalent to the general management structure (average ¼ 3.44 vs. 2.93, P < 0.001) indicating that communication between the two parts has a hierarchical structure more simply at attractive hospitals.

The nurse's structural strengthening process by the manager nurse has been shown to significantly increase nurse awareness during nursing care (P < 0.001).^19-21 The willingness of the nurse to report a complaint during the provision of care is closely related to the nurse skills of the manager in the process of nurse interpersonal strengthening through factual data (P < 0.05).^19,21,22

Technological caring

Technological caring can provide several benefits to improve the effectiveness and efficiency of nursing care processes.²³ Application of caring strategy using technology that is a communication path using virtual communication. The nurse manager must be able to be a source of information to the 24-h nurse. Using information technology will be easy.

Discussion

Bureaucratic caring becomes more optimal when the implementation is integrated with organizational hierarchy.¹ Implementation of an effective bureaucratic caring can improve the quality of nursing care regarding management support for the improvement of competence and respect for nursing quality.

Caring spiritually and ethically primarily focuses on the internal development of skills which thus increases the satisfaction rate of the nurse implementer. Work environment, a healthy working atmosphere also has a positive impact on nurse competence development. Roles and functions of managers become the main center in the process of maintaining the performance of nurses work by organizational goals.

The application of quality caring is still considered to be costing hospital operations. The economics caring has a prospective middle ground in addressing this issue. The economic caring of nurse managers’ center on the existence of an innovative culture of effective and efficient nursing action in cost.⁵ The culture of innovation based on research results become one alternative strategy in lowering hospital operational cost without degrading the quality of nursing care. Nurse practitioner's caring behaviors have economic value to healthcare organizations through effects on patient satisfaction, physiology, self-disclosure, and self-esteem, and subsequent use of medications, laboratory tests, and procedures.⁵

Caring for healthcare professionals can affect the finances of healthcare organizations through five consequences of caring behavior. The first, patient satisfaction generates revenue. Next, three other consequences are physiological, self-disclosure, and self-esteem, resulting in cost avoidance for the organization. The last, fifth, consequence is legal, a cost saving resulting from the other four consequences.²⁴

Each of the five consequences is a result of a set caring behavior. Patient satisfaction is a result of communicating and respect. Patient's physiological changes caused by a stressful situation will reduce by inform, aid, and comfort. Communicating and empathizing with healthcare professionals will create trust between patient and they can be enhanced through self-disclosure. Acts of caring, especially respect, aiding and communicating will enhance a patient's self-esteem. Legal actions against health care professionals seem related to the amount of time spent with patients and the quality of communication, including empathy.²⁴

Nurse manager with the ability to access hospital resources has the power to encourage the use of technology as part of the technological application of caring. Power based on caring technology is more applied than conventional communication methods. Caring technology had primarily linked to nursing manager's behaviors with nurse teams. The positive impact of technology caring is the possibility of a nurse manager to gain the latest knowledge of nursing science. Nurse manager has for long used technological caring to develop nurse awareness and online communication. So, nursing teams have updated nursing science to effective and efficient nursing care regularly.

Organizational characteristics are also critical factors for the retention of qualified nurses.⁹ The development of an attractive organizational concept becomes an essential factor to create a conducive working environment. The conducive working environment has a significant contribution to the development of nursing competency. The organizational structure that has a horizontal or straightforward bureaucratic pathway shortens the communication between the nurse manager and the executing nurses. Therefore, leadership competencies of nurse manager are responsible for realizing and passing on ethically caring cultures. Thus, morally caring can create prerequisites for the staff's growth and development.²⁵

Nurse leaders are the bearers of culture and responsible for managing the core of caring to create caring cultures that serve life and health and alleviate human suffering.²⁵ Their ethical attitudes, use of language, thought patterns, norms, and values of caring and caring tradition create cultural prerequisites that are passed along to the staff. Through their management, nurse leader together with the team nurture and form a fundamental value base that consists of respect, among others, justice, the excellent meeting of patients and staff and evidence-based care.

In bureaucratic caring; nurse manager has a vital role in maintaining the motivation and performance of nurses work. The role of nurse managers in bureaucratic caring is mentoring, supervising the quality of the performance of virgin work and creating an innovative working environment. Several studies have found some strategies as a solution to the application of bureaucratic caring in a hospital organization. We categorize two groups of caring from four of the five caring bureaucratic areas of caring. The first group dwells on humanistic caring and is ethical and spiritual. The second group determined with administrative caring which contain organizational and technological caring.

The spiritual and ethical caring has a form of rewarding strategies, maintaining systems and developing efficient technologies in the implementation of nursing care. Organizational, economic and technological caring emphasizes the role of nursing managers in creating a healthy, innovative organizational climate. These role of nurse manager are in line with the organization's primary objective. The development of nursing competence in the organization's management system is the aim of the organization's primary object.

Integration of bureaucratic caring in a hierarchical organization structure is aimed to teach the organization's goal. The primary purpose of the organization's vision is achieving quality nursing care and qualified nursing staff. Another interesting strategy is the existence of togetherness activities in the form of nursing gatherings, nursing care based on the results of research and structural strengthening of external and personal.^8,26 It should be noted that the application of bureaucratic caring that prioritizes the nurse will negatively affect the nursing service. This overconcern of nurse manager toward nurse practitioner will decline the nurse manager's awareness of patient safety.

The magnitude of the positive impact of bureaucratic caring implies the need for further research on the application of bureaucratic caring in the hospital's organizational and managerial system. We seem to identify the research related to bureaucratic caring because of the absence of proper terminology on the scope of bureaucratic caring. Also, the management of caring in the hierarchical system is still not fully stated clearly in nursing science.

In conclusion, this review found 14 strategies can be used by the nurse manager to implement of bureaucratic caring (in four areas: spiritual, ethical, organizational, and technological caring), but no research on the form of economic caring. This finding leads us to conduct further research studies using these strategies as an intervention to create and enhance the caring culture in healthcare services.

Conflict of interests

The authors declare no conflict of interest.

Acknowledgments

This work is supported by Hibah PITTA 2017 funded by DRPM Universitas Indonesia No. 382/UN2.R3.1/HKP.05.00/2017.