Nurs Admin Q

Vol. 41, No. 4, pp. 310–320

Copyright c 2017 Wolters Kluwer Health, Inc. All rights reserved.

Applying Bureaucratic Caring

Theory and the Chronic Care
Model to Improve Staff and
Patient Self-Efficacy
Marcia A. Potter, NC, DNP, FNP-BC;
Candy Wilson, NC, PhD, APRN, WHNP-BC

Patient activation and engagement can be powerful enablers for health outcomes that are just
as important as staff engagement and satisfaction. The authors applied the Bureaucratic Caring
Theory and the Chronic Care Model to a process improvement project designed to link activation,
engagement, satisfaction, and health outcomes. Twenty-two adults with diabetes and 7 staff mem-
bers caring for them participated in a 12-week process improvement project that incorporated a
time-based element of longitudinal care with skill-based competencies to provide collaborative,
team-based care to patients with type 2 diabetes. Patients completed satisfaction surveys at the end
of their clinical encounters. Staff members completed satisfaction surveys pre- and postimplemen-
tation. The authors analyzed hemoglobin A1C levels pre- and postimplementation. As engagement
and activation increased for both staff and patients, hemoglobin A1C levels decreased. The clinical
implication is that the use of Bureaucratic Caring Theory may foster caring while broad application
of the Chronic Care Model may improve self-efficacy, create healthier populations, and reduce
health care costs. Key words: activation, Bureaucratic Caring Theory, Chronic Care Model,
engagement

I N 2000, the Military Health System (MHS)

began a transformational process aimed
at improving quality of health care for its
approximately 10 million beneficiaries. As
Author Affiliation: Malcolm Grow Medical Clinics
& Surgery Center, Joint Base Andrews, Maryland.
The authors especially acknowledge their gratitude to
Dr Marilyn Ray for her generous mentoring, guidance,
and support.
The opinions expressed are those of the authors and
do not reflect those of the US government or the US
Air Force. The authors have no financial relationship
with any sources cited. No funding was received for this
work from the National Institutes of Health (NIH), Well-
come Trust, Howard Hughes Medical Institute (HHMI),
or other source.
The authors declare no conflict of interest.
Correspondence: Marcia A. Potter, NC, DNP, FNP-BC,
US Air Force, Malcolm Grow Medical Clinics & Surgery
Center, 1050 W. Perimeter Rd, Joint Base Andrews, MD
20762 (marciapotter705@gmail.com).
DOI: 10.1097/NAQ.0000000000000256
family members and retirees, nearly 70% of
these beneficiaries are not active duty military.
Their health conditions reflect the general
health conditions of the US society at large.1
Roughly 20% of these beneficiaries have type
2 diabetes mellitus (T2DM), requiring a signif-
icant outlay of cost, resources, and manpower
to assist patients to achieve high-quality health
outcomes.1 These outcomes are measured by
the Healthcare Effectiveness Data Information
Set (HEDIS) metrics, established by the Na-
tional Quality Council.2 In most cases, clinical
teams have historically been unable to attain
and/or sustain patient outcomes within the
desirable range for HEDIS scores. In 2011, the
MHS adapted the Triple Aim (better health
care, better health, and best value) and added
military readiness as a fourth aim as a means
to more fully measure performance on these
quality indicators.3,4 (This is not to be con-
fused with the Quadruple Aim known in

310

Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.

civilian health care that addresses clinician
burnout.5
The perpetual dilemma for health care
teams is that HEDIS metrics reflect patient be-
havior as much as health care system behav-
ior. Therefore, the question remains regarding
how to best partner with patients to improve
their own health outcomes. An integral mem-
ber of the health care team, the patient has
the responsibility to carry out health advice.
Work by Hibbard et al6 established domains
of activation and engagement as part of the
larger concept of self-efficacy or the ability to
learn new competencies to achieve a goal.7
These important concepts became the foun-
dation for understanding how to create pro-
cesses that involve all health care team mem-
bers, including patients, to improve health
outcomes. At the same time, the health of the
health system itself requires attention. Creat-
ing new processes must be coupled with a
wise use of resources. In the case of the MHS,
resource management (stewardship) is espe-
cially important because the MHS is funded
by the American public. The unique needs of
all stakeholders impact the overall health sys-
tem, so the authors sought a unifying theory to
inform practice. They determined that the ap-
plication of Bureaucratic Caring Theory (BCT)
laid an appropriate foundation for address-
ing issues while understanding all stakehold-
ers’ involvement in the health of the health
system.
BUREAUCRATIC CARING THEORY
Bureaucratic Caring Theory, developed
by nursing scholar Dr Marilyn Ray, illumi-
nates the relationship of all stakeholders
within a bureaucratic (complex organization)
system.8-12 Both health care and military sys-
tems are inherently bureaucratic in nature.
Each has a specific mission or aim for the
use of its resources and energies. The fun-
damental mission of health care systems is to
deliver health care services. What binds each
of the stakeholders within the system is the
concept of caring. This is also valid in the
MHS.
Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Applying Bureaucratic Caring Theory 311
Within a bureaucracy, diverse groups
of people essentially cocreate the culture
through social interactions. As stated by
Davidson et al, “the inter-play of com-
munication and ethical choice making
within relationships forms a community
and sets the moral tone of the work-life
environment.”13(p98) There are 8 interre-
lated dimensions described in the BCT,
each reflecting a domain of caring. These
domains—educational, spiritual-ethical, legal,
physical, technological, economic, political,
and social-cultural—interact to create an
organizational culture within the focus of
caring. Caring within a complex organization
“is an expression of beliefs and behaviors
relating to the competing technological,
ethico-religious, political, legal, economic,
educational, humanistic, and social factors of
the organization and dominant culture.”13(p99)
Fundamental to BCT is the Hegelian dialectic,
which defines caring as thesis; dimensions of
bureaucracy as antithesis; and bureaucratic
caring as synthesis, essentially the reconcilia-
tion of 2 diametrically opposed or paradoxical
concepts, imbuing meaning and purpose
within the organizational culture.9,11 Further
work by Davidson and colleagues13 acknowl-
edged and clarified the organization as a
complex adaptive system. This understanding
of the interrelatedness of each of the stake-
holders and the organizational environment
forms the basis for application of a particular
model of MHS process improvement.
THE CHRONIC CARE MODEL
The Chronic Care Model (CCM) developed
by Wagner et al14 is a model of a care pro-
cess designed to optimize each health care
team member’s abilities, expertise, and will-
ingness to achieve high-quality health out-
comes. These outcomes, defined by the In-
stitute of Medicine,15 are safe, necessary,
cost-effective, timely, desired, and patient-
centered. The CCM embodies 6 elements, al-
though research has supported the applica-
tion of only the pertinent elements to each
health system application.16 Focused on the
312 NURSING ADMINISTRATION QUARTERLY/OCTOBER–DECEMBER 2017
community, the health system, the patient,
and the clinical staff, its goal is to create
improved health outcomes through planned,
productive visits. This is achieved by creating
engaged patients and informed staff.14,16 The
CCM is well established in both literature and
practice for its application to the management
of patients with T2DM.17
Each community has particular resources
available for both the health system and the
patients. These resources vary between and
within communities and must be considered
when designing health system responses and
priorities.14 For example, communities en-
gaged in health promotion efforts may allo-
cate resources for walkability, access to health
services, or access to locally grown produce.
The health system encompasses delivery
system design, decision support, and clini-
cal information systems.14 The interplay be-
tween the community resources and the
health system fosters or enables a patient’s
self-management support. For example, edu-
cational offerings for patients with diabetes
or heart disease to help them improve self-
management skills, template management,
and schedule availability foster an environ-
ment of caring outreach from the health sys-
tem to the patient.
A productive interaction has 4 elements,
defined as coordinated; timely and effi-
cient; evidence-based and safe; and patient-
centered.14 This interaction takes place be-
tween patient and clinical team members.
The patient element must be engaged and in-
formed; the staff element must be prepared
and proactive. At the clinical microsystem
level, these elements come together to cre-
ate improved health outcomes. The challenge
at this level is to create the conditions con-
ducive to this outcome.
METHODS
One of the central tenets of the CCM is
the planned, proactive visit, in which the
health care team members have the informa-
tion needed at the time of the visit. Of course,
this requires forethought about what informa-
Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
tion is needed, followed by seeking this infor-
mation proactively. Subprocesses for creating
the planned, proactive visit form the elements
of the CCM.14 For this process improvement
project, the following elements of the CCM
were used: employ all staff members to the
top of their skill sets; allot time specifically to
address chronic health states separately from
acute issues; and incorporate shared decision-
making among all health care team members.
It is important to recognize that each clinical
team member (including the patient) brings
a different perspective to health care, that is,
the caring process itself. The CCM elements
employed reflect the following domains of
caring: spiritual-ethical, physical, technolog-
ical, and economic.9,11
Each health care team member also brings
a unique set of skills to the health interaction
as well as an agenda for its outcome, reflect-
ing the spiritual-ethical, social-cultural, eco-
nomic, political, and educational domains of
caring.9,11 For example, a clinician may want
the patient to have a glycosylated hemoglobin
(HbA1C ) level of 6% to 7%. The patient may de-
sire to continue eating foods culturally impor-
tant to him or her. The nurse may want the
patient to be able to make judgments about
their glucose testing, and the health care ad-
ministrator may want the HEDIS metrics to
be in the recommended range. It becomes
apparent that multiple agendas create com-
plexity within this common health care inter-
action, reflecting the potential to create ei-
ther increasing order or disorder.12,13 When
multiplied by the sheer number of patients
with T2DM seen in clinics every day within
the MHS, the process rapidly becomes over-
whelming. To more effectively address both
the complexity and the health outcomes, the
CCM uses multiple elements to create process
from structure. Research14,16 supports the use
of only the elements pertinent to each health
system. That is, not all elements will be rele-
vant to each system or may not be possible to
initially incorporate.
Employing all team members to the top
of their skill sets is founded on the concept
of mutuality, which is a respect for each

member’s skills, knowledge, education, and
expertise.14 This also reflects the spiritual-
ethical, educational, legal, political, and tech-
nological domains of caring. In this project,
the focus centered on the clinician, nurse,
medical technicians, and patients assigned to
a primary care team within a military treat-
ment facility family health clinic. Protocols
were developed to ensure that all members
were familiar with their roles and responsibil-
ities (Table 1). Protocols formed the structure
of the information needed, but process was
still required to carry it out. Each member also
had a process plan for implementation. For ex-
ample, the RN was responsible for reviewing
the disease registry. This meant looking for
patients with T2DM assigned to the team and
who had not been seen in clinic in the past
6 months, or whose HbA1C was not completed
in the past 6 months. The RN then contacted
the patient and implemented the protocol ap-
propriate for nursing measures (Table 1). In
each case, the nurse created a medical record
entry for the clinician review. This fundamen-
tally acknowledged and engaged the role of
the RN—to assist the patient in the navigation
of his or her health condition.
Medical technicians within the military
treatment facility are highly educated and
skilled members of the health care team. Per
Air Force Surgeon General guidance, Air Force
medical technicians are educated as emer-
gency medical technicians, while civilians em-
ployed in this capacity are licensed practi-
cal nurses.18 Their role is to assist patients
through the navigation of their health care and
to help manage workflow within the clinic.
For the medical technicians, a protocol sim-
ilar to the RN protocol was created. How-
ever, they were responsible for looking at the
patients already on the clinician schedule in
the upcoming 4 weeks. For any patient with
T2DM, the technician reviewed the record
for the individual protocol such as laboratory
tests, medication refills, supplies, and so forth.
If any elements were not completed, the tech-
nician entered orders under a standing order
set and contacted the patient to remind him
or her to complete these elements at least 2
Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Applying Bureaucratic Caring Theory 313
weeks prior to the visit (Table 1). In each case,
the technician electronically opened the ap-
pointment and documented the interaction.
For clinicians, review of the medical
records prior to the patient’s visit was a cru-
cial step in maximizing the time allotted to
provide care. Because the RN and/or techni-
cian had already created an information foun-
dation, the clinician had available critical data
to help guide care decisions and recommen-
dations. Reviewing the record with the pa-
tient helps clarify any unclear data, paving
the way for shared decision-making. Shared
decision-making is a process founded on mu-
tually respecting the special expertise of the
clinician and the unique health experience of
the patient.19 This acknowledges and engages
the role of the clinician, which is to bring
health care expertise and advice to assist pa-
tients to make decisions about care of their
health conditions.
The patient’s role in this process was to
complete recommended testing, provide in-
formation helpful to the clinical team, and
follow through on individual health care re-
sponsibilities, including contacting the clini-
cal team if changes became necessary. This
acknowledged the special role of the patient
to partner with the health care team to im-
prove understanding of how each person ex-
periences his or her health condition.
OUTCOME MEASURES
Self-efficacy
The goal was to foster self-efficacy for
all health care team members. Self-efficacy
has been defined as both activation and
engagement.6,20 Clearly, most work has been
accomplished with the idea of the patient as
activated and engaged. This process improve-
ment project took these concepts a step fur-
ther by applying them to staff as well.
Patient activation and engagement
Patient activation is defined as the belief
that it is important for persons to care for
themselves.6 Engagement is defined as the
 314

Table 1. Proactive Visit Protocol

Health Care
Team
Member Assess Plan Implement Evaluate Timing

RN How is the patient tolerating Laboratory test orders Order any needed Patient’s Review T2DM
medications Testing supply refills supplies or bridge understanding of Registry every
Glucose testing/readings/ Bridge medication medications plan month
trends, exercise type/ refills Enter consult Patient’s acceptance
frequency/duration Upcoming requests of plan
Dietary measures appointment with Reinforce lifestyle Patient’s
Barriers and successes for clinician measures follow-through
self-management: social, Consults needed with
physical, spiritual, Primary prevention recommended
psychological needs interventions
Document in
electronic health
record
Aerospace Has patient picked up supplies Ensure patient enrolls Conduct screening Patient’s 2 wk prior to visit
Medical and medications from in secure examination at visit understanding of
Technician pharmacy? messaging encounter the need to
Has patient completed Contact patient to complete previsit
requested laboratory work? remind him or her labs, etc
NURSING ADMINISTRATION QUARTERLY/OCTOBER–DECEMBER 2017

Has patient completed primary of any incomplete Document in

prevention services? actions electronic health
Has patient activated consult record
request and scheduled
specialty appointment?
(continues)

Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
 Table 1. Proactive Visit Protocol (Continued)

Health Care
Team
Member Assess Plan Implement Evaluate Timing

Clinician Review all laboratory data, Identify mutually Tailor plan of care to Patient’s At the clinical visit
nursing information, and important health patient’s needs understanding of
screening data with patient goals based on nursing plan of care
Conduct necessary physical Identify resources for evaluation, Patient’s acceptance
examination meeting health clinician evaluation of plan of care
Patient’s follow-through with goals and and judgment, Clarify any questions
plan of care (from prior visit) overcoming patient-identified Document in
barriers goals electronic health
record
Patient Provide information for the Identify important Work with clinician Understanding and Previsit labs, supplies,
health care team about how goals for own to establish acceptance of plan medications
own health is experienced: health mutually agreeable of care completed at least
lifestyle measures, barriers Identify needed plan, ie, shared 10 d prior to the
and successes with resources decision-making visit; remainder
self-management; glucose Follow through on done at the clinical
testing, trends, readings agreed upon plan visit
Communicate with
health care team if
plan cannot be met

Abbreviations: T2DM, type 2 diabetes mellitus.

Applying Bureaucratic Caring Theory

Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
315
316 NURSING ADMINISTRATION QUARTERLY/OCTOBER–DECEMBER 2017

Table 2. Patient Satisfaction Survey

Dear patient/family: Please complete this short survey and drop in the patient advocate box in the
main lobby. Your responses help us improve your care experience! Thank you.

Question Definitely Somewhat No

1. In your most recent encounter, did your provider team

explain things in a way you could understand?
2. In your most recent encounter, did your provider team
listen carefully to you?

belief that they can do so, even in adverse
circumstances.6 Adverse circumstances can
include disruptions in usual daily activities,
family demands, and workload.
Staff activation and engagement
Staff activation is defined as the clinical
team member’s belief that his or her work is
important to patient health outcomes.6 Staff
engagement is defined as the belief in an indi-
vidual’s ability to perform work at his or her
skill level, even in adverse circumstances.6
These adverse circumstances include man-
power issues, workload, and leadership
support.
Instruments
Activation and engagement for both
staff and patients were measured using
the Confidence/Conviction Ruler, a 2-item
questionnaire widely used as a surrogate for
activation and engagement.16,21 Confidence
was operationalized as engagement; con-
viction was operationalized as activation.21
This questionnaire was chosen for its cost-
effectiveness, reliability and validity, as well
as its ease of administering.
Staff and patients also completed a satisfac-
tion survey with opportunities to numerically
rate their experience on a scale of 1 to 5, with
higher scores suggesting higher satisfaction
and a free-text area to give feedback (Tables 2
and 3).
Data analysis
Descriptive data analyses were used to il-
luminate mean differences pre- and postinter-
vention in CCR, satisfaction scores, and HbA1C
levels. Content analysis was used to describe
responses from staff and patient satisfaction
surveys.
Patient outcomes
The patient sample consisted of 22 pa-
tients with T2DM. The aggregate HbA1C prior
to the interventions was higher (M = 8.25,
SD = 2.01) than postinterventions (M =
7.03, SD = 1.20). The aggregate patient

Table 3. Staff Satisfaction Survey

Please complete this short survey and deposit it in the envelope in the Raptor’s break room. Your
responses will help us improve care processes. Thank you!

Question Definitely Somewhat No

1. In the past week, did your patients treat you with courtesy
and respect?
2. Are your patients upholding their responsibility to partner
with you in their care?

Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.

confidence preintervention score (M = 7.73,
SD = 1.08) was elevated following the inter-
vention (M = 8.68, SD = 0.57). Furthermore,
the patients’ aggregate conviction (M = 8.45,
SD = 0.86) to manage their illness was ele-
vated following the intervention (M = 9.14,
SD = 0.47). All of these changes were clin-
ically significant. Patients reported that they
were satisfied with their care via hospital-
generated satisfaction forms. A content anal-
ysis of the 11 comments provided was sepa-
rated into accolades for the staff (n = 10); plan
of care (n = 2); and appreciation for the en-
couragement to manage the disease (n = 2).
The following are 2 examples of the patients’
experiences:
• Mrs Baker (pseudonym) was identified
early in the project launch. She had been
resistant to starting medication for her di-
abetes because she felt that she should be
able to manage her health on her own.
The RN contacted her and discovered
that she had been struggling for the past
year with complex family issues that of-
ten left her placing her own health needs
at the bottom of the priority list. Her ini-
tial HbA1C was 11%. While she had good
knowledge of proper nutrition and ex-
ercise recommendations, she lacked the
support to be able to take care of herself.
During the nurse practitioner (NP) visit,
she opted to begin daily glucose-lowering
medication, as she began to incorporate
behavior change into her daily routine.
While her family situation did not resolve,
she was able to identify other resources
she could use to assist her with manag-
ing these issues. She had been a member
of her church-based support system for
many years, providing care and service
to others. Now she reached out to them
for assistance. At her 12-week follow-up
visit, her HbA1C was 6.3%. She reported
feeling well and healthy and capable of
meeting her own health needs. She was
still learning to see herself as equally de-
serving of care from others but was hope-
ful for her ability to be healthier. She ex-
pressed deep satisfaction with her health
care team partnership, telling one of the
Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Applying Bureaucratic Caring Theory 317
authors that she felt respected for her
needs and abilities.
• Mr Turner (pseudonym) scheduled his
office visit with a clinician NP as his new
health care provider. The medical tech-
nician noted his prior history of T2DM
and contacted him to initiate nursing
outreach. At his clinic visit, he and the
NP reviewed all of his laboratory data,
medications, health needs, barriers, and
successes with self-care. Shared decision-
making imbued the process of crafting a
plan of care together that met his health
needs, personal goals, and capabilities. At
the end of the visit, he told the clinician
that he had been happy with his health
care until he met his new NP, but now he
knows what he should have expected all
along.
Staff outcomes
The staff sample consisted of 7 hospital per-
sonnel. The confidence/conviction ruler re-
sults demonstrated a preimplementation con-
fidence (M = 7.67) that increased following
the project implementation (M = 9.67). How-
ever, the conviction did not change signifi-
cantly between the preimplementation (M =
9.33) and following the implementation (M =
10). Comments by staff demonstrated an ac-
ceptance of the project. Examples were, “no
one seems to care about anything except how
many patients are seen” and “there is no sup-
port”. Staff participants seemed to be look-
ing for validation from external sources such
as their leaders. After the project implemen-
tation, the staff participants felt validated in
their practice due to the positive patient care
resulting from the quality planned care. A staff
participant stated,
[The clinic runs] smoother, more focused on the
patients’ needs, and we know what those needs
are before the patient gets here. For the first time
in the many years I have been coming here, I feel
like a real nurse. I know what I do is so much more
effective because I am giving nursing care to my
patients.
When staff professionals were asked for
practical and actionable advice, there was a
318 NURSING ADMINISTRATION QUARTERLY/OCTOBER–DECEMBER 2017
shift in their responses from the preimple-
mentation to the postimplementation project
phases. Before the implementation, 4 of the 7
staff participants looked to external sources
for solutions. They gave advice to hospital
leaders such as reducing the patient quota to
be seen in 1 week; listening to staff; and stop-
ping focus on numbers. Following the imple-
mentation, 3 of the staff participants stated
that the project should be expanded, and
the role of the nurse should be boosted in
the clinic. This essentially underscored team-
based problem solving. Two other comments
focused on external solutions, namely, hiring
more providers, and increasing provider time
with patients.
The richness of these patients’ experiences
along with those of their health care team il-
luminates the relational bonds created when
theories and evidence meet practice in a car-
ing environment. Intentionally linking mean-
ing and purpose to achieve desired outcomes
in true partnership with our patients fosters
activation and engagement, creating better
health care, better health, and undeniable
value.
DISCUSSION
This project, “Bureaucratic Caring Theory
and the Chronic Care Model to Improve Self
Efficacy in a Military Clinic,” has broad impli-
cations for addressing significant issues with
patient and staff satisfaction as well as health
outcomes in chronic illness. The essence of
health care is the relational bond of caring.
As Ray has stated, “the choice to care is the
magnetic appeal that will keep the universe of
nursing, medicine, and health care emerging,
unfolding, and enfolding together into a new
vision of relational self-organization.”8(p105)
An interesting observation from the study
is that, despite the structural deficits in
staffing, this project was successful in lever-
aging improved satisfaction and health out-
comes across multiple domains of caring.
The authors postulate that this underscores
the idea that a strong process can mitigate
some structural deficiencies. The process,
Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
which is essentially the lived experience of
all of the stakeholders, is a primary driver
to achieve high-quality care. A highly effec-
tive process can overcome some challeng-
ing barriers, such as low staffing. However,
no structure can completely overcome poor
process. Simply increasing staff or appoint-
ments will not create high-quality health out-
comes. The Theory of Bureaucratic Caring
emphasizes caring as relational bonds which
can be intentionally focused to cocreate de-
sired outcomes. Change must be intentional
and focused on the desired outcomes. This
project required no additional expenditure
in terms of direct or indirect financial sup-
port; no additional staff resources; no increase
in information technology system elements;
and no additional burden of time or training
for the staff. This project innovatively lever-
aged the power of nursing to create better
health care, better health, best value, and
readiness.
An unintended side effect was that the
continuity of care metric for this team
plummeted to 49%, meaning that of the
patients booked on the schedule every day,
only 49% of them were enrolled to this team.
A review of the other clinician’s schedules
showed that their continuity of care hovered
around 65% to 75%. What did this mean?
From a review of schedules, it was clear that
patients were using excessive appointments
to address their health care needs. When
providers did not have time allotted to
address chronic issues, patients simply had
to make more appointments. Because of the
delivery system design, patients and providers
were being forced into increased, episodic
interactions that undermined the Quadruple
Aim, patient-centered medical home, and
the caring process. Structuring templates in
this new approach resulted in more access
for patients enrolled to others, undermining
the continuity of care that is so important to
patient-centered medical home and the caring
domains. It became apparent that simply hav-
ing more appointments available supported
neither patient-centered medical home nor
the Quadruple Aim. Calculating the impact

to providers revealed that the clinician leader
was able to provide patient-centered care and
help patients achieve better health, while
requiring 50% fewer appointments for the
patient group. These “saved” appointments
could then be used to help the provider
teams improve readiness by allowing them to
interact with their supported population in
that population’s workplace. In addition, for
the NP, the ability to spend time with each
patient based on his or her individual need
was an attractive benefit.
Research also indicates that there is an
economic impact to use of the CCM as well
as the BCT.16,22 This impact represents a pro-
jected annual cost savings of $650 to $980 per
patient per year in direct patient care costs.16
Based on HEDIS and economic data within
the military treatment facility, this is a pro-
jected annual savings somewhere between
$2.5 million and $3.5 million just for patients
with T2DM.1 Within the MHS, projected sav-
ings is nearly $2 billion. Moreover, application
of the BCT and the CCM could potentially
stem clinician loss due to dissatisfaction, thus
saving an additional $2 million in turnover
costs annually for the Air Force Medical
Service. (Turnover costs are estimated on the
REFERENCES
1. Defense Health Agency. Quality, patient safety and
access information for MHS patients. https://health
.mil/Military-Health-Topics/Access-Cost-Quality-and-
Safety/Patient-Portal-for-MHS-Quality-Patient-Safety-
and-Access-Information. Published 2016. Accessed
November 15, 2016.
2. National Committee of Quality Assurance. HEDIS &
quality measurement. http://www.ncqa.org/hedis-
quality-measurement/performance-measurement.
Published 2014. Accessed November 2014.
3. Berwick D, Nolan T, Whittington J. The triple aim:
care, health, and cost. Health Aff. 2008;27:759-769.
4. Office of the Air Force Surgeon General. AFMS Strat-
egy KX. https://kx2.afms.mil/kj/kx8/AFMSStrategy
Mgmt/Pages/home.aspx. Published 2017. Accessed
May 24, 2017.
5. Bodenheimer T, Sinsky C. From triple aim to quadru-
ple aim: care of the patient requires care of the
provider. Ann Fam Med. 2014;12(6):573-576.
Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Applying Bureaucratic Caring Theory 319
basis of family health physicians who exit the
Air Force each year and the costs to replace
them.) These numbers are staggering but rep-
resent only known quantifiable cost savings.
In addition, healthier patients more robustly
contribute to society, their communities, and
families. Health liberates energy so that an
individual can focus on living a high-quality,
meaningful life. Nursing and caring become
economic fulcrums for leveraging the health
of the health care system.23 This is the hidden
value of nursing and one that needs to be
illuminated and celebrated.
This project showcased the power of nurs-
ing in the primary care setting, and the po-
tential to create high-quality, effective, mean-
ingful health care to improve health. The
health of the health care system is highly in-
fluenced by nursing. The nursing profession
carries on its shoulders the ability and obli-
gation to leverage the shift in organizational
culture from fragmented, productivity-based
health care to relationship-based caring. The
integration of the BCT, CCM, and Chaos The-
ory offers a powerful framework for creating
healing, health, and relational caring across all
domains and for all stakeholders of the health
care system.
6. Hibbard JH, Mahoney ER, Stock R, Tusler M. Self-
management and healthcare utilization. Health Serv
Res. 2007;42(4):1443-1467.
7. Bandura A. Self efficacy theory: toward a unifying the-
ory of behavior change. Psychol Rev. 1997;84(2):191-
215.
8. Ray MA, Turkel MC, Cohn J. Relational caring com-
plexity: the study of caring and complexity in
healthcare organizations. In: Davidson AW. Nurs-
ing, Caring, and Complexity Science: For Human-
Environment Well-Being. New York, NY: Springer
Publishing Company; 2011:104-105.
9. Ray MA. The theory of bureaucratic caring for nursing
practice in the organizational culture. Nurs Adm Q.
1989;13(2):31-42.
10. Ray MA. Complexity and nursing science. Nurs Sci
Q. 1998;11:91-93.
11. Ray MA. A Study of Caring Within an Institu-
tional Culture: The Discovery of the Theory of
320 NURSING ADMINISTRATION QUARTERLY/OCTOBER–DECEMBER 2017
Bureaucratic Caring. Saarbrucken, Germany: Lam-
bert Academic Publishing; 2010.
12. Ray M, Turkel M. Marilyn Ann Ray’s Theory of
Bureaucratic Caring. In: Smith M, Parker M, eds.
Nursing Theories and Nursing Practice. 4th ed.
Philadelphia, PA: F A Davis Company; 2015.
13. Davidson AW, Ray MA, Turkel MC. Nursing, Caring,
and Complexity Science: For Human-Environment
Well-Being. New York, NY: Springer Publishing;
2011.
14. Wagner EH, Austin BT, Davis C, Hindmarsh M, Schae-
fer J, Bonomi A. Improving chronic illness care:
translating evidence into action. Health Aff. 2001;
20(6):64-78.
15. Institute of Medicine of the National Academies.
Crossing the quality chasm: a new health system
for the 21st century. http://iom.edu/Reports/2001/
Crossing-the-Quality-Chasm-A-New-Health-System-
for-the-21st-Century.aspx. Published 2001. Accessed
June 3, 2014.
16. The Institute for Healthcare Improvement. Improv-
ing chronic care: delivery system design. http://
www.ihi.org/resources/Pages/Changes/Use
PlannedInteractionstoSupportEvidenceBasedCare
.aspx. Published 2014. Accessed November 2, 2014.
17. Stellefson M, Dipnarine K, Stopka C. The chronic
care model and diabetes management in US primary
care settings: a systematic review. Prev Chronic Dis.
2013;10:E26.
Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
18. Nelson EC, Batalden PB, Godfrey MM, Lazar JS. Value
by Design: Developing Clinical Microsystems to
Achieve Organizational Excellence. San Francisco,
CA: Jossey-Bass; 2011.
19. Office of the Air Force Surgeon General. AFI 46-
101, Nursing services and operations. http://static
.e-publishing.af.mil/production/1/af_sg/publication/
afi46-101/afi46-101.pdf. Published 2015. Accessed
May 24, 2017.
20. Edwards A, Elwyn G. Shared Decision-Making in
Health Care: Achieving Evidence-Based Patient
Choice. 2nd ed. Oxford, United Kingdom: Oxford
University Press; 2009.
21. Stepleman L, Ritter M, Hibbard J, Johns L, Wright D,
Hughes M. Validation of the patient activation mea-
sure in a multiple sclerosis clinic sample and impli-
cations for care. Disabil Rehabil. 2010;32(19):1558-
1567.
22. MacLean CD, Littenberg B, Gagnon M, Reardon
M, Turner PD, Jordan C. The Vermont diabetes
information system (VDIS): study design and sub-
ject recruitment for a cluster randomized trial of
a decision support system in a regional sample of
primary care practices. Clin Trials. 2004;1(6):532-
544.
23. Turkel MC. Relational complexity: a theory of
the nurse-patient relationship within an eco-
nomic context. Nurs Sci Q. 2000;13(4):307-
313.