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Catholic Educators And Institutions Must Make Explicit the Values on Which Their Practices Are Based

Dr. Lane is professor, Maternal Child Health, Loyola University of Chicago.

Summary

Although Catholic nursing education in the United States has traditionally instilled Gospel values in students, pressures from a secular culture are making it increasingly difficult to sustain this heritage. As the twenty-first century approaches, Catholic educators and healthcare administrators need to ask themselves whether Christian values still serve as the explicit basis of nursing service and education at their institutions. They must also ask what distinguishes graduates of Catholic nursing programs from those of other programs.

The percentage of schools that are Catholic has remained roughly the same during the past 30 years, but in many cases these schools no longer instill Christian values. Although most programs offer courses in ethics, philosophy, and religion, few provide the value-laden experiences of the past. In fact, many instructors avoid addressing questions of values or ethics because they believe doing so would be a form of indoctrination. Catholic nursing education, like Catholic higher education in general, is becoming increasingly secular.

To return Christian values to nursing practice and education, leaders need first to instill a sense of self-worth in nursing staff by letting them know they are valued and their efforts are appreciated. Leaders also need to emphasize the good their institutions do for their communities and make explicit the values on which their practices are based.

The care of the sick, a Gospel imperative, has been a hallmark of Christianity throughout the ages. The growth of the Catholic healthcare ministry in America is the result of efforts by religious and laypersons to actualize this imperative. For more than a century Catholic hospitals and institutions of higher education have been educating nurses to facilitate this ministry.

However, as we approach the twenty-first century, educators and healthcare administrators need to ask themselves three questions:

• Have Christian attitudes and values explicitly served as the basis for the organization of nursing service in Catholic healthcare institutions over the past 30 years?
• Do graduates of Catholic nursing programs demonstrate a specifically Christian philosophy of nursing that distinguishes them from graduates of other programs?
• If Catholic nursing programs continue to disappear or be affected by secular forces, how will we maintain our Catholic heritage of caring for the sick with dignity, compassion, and competence?

The Rise of Nursing Education
Until the nineteenth century, nursing education was conducted through apprenticeships. Following the Reformation, in English-speaking countries, the care of the sick fell into disrepute as a result of the departure of the women religious who traditionally served in this role and the use of prisoners to care for the sick. On the Continent, however, women religious continued to provide care. The nursing care provided to English soldiers during the Crimean War (1854-56) under the direction of Florence Nightingale established the importance of nursing and led to the development of formal nursing education programs. In 1873 three such programs using the Nightingale model were established in the United States. Hospitals at that time numbered 178. By 1909 the number of hospitals had increased to more than 4,000 and schools of nursing to 1,129.¹

Catholic institutions began educating nurses in 1886, starting with programs for the sisters who operated the hospitals. The first laypersons were admitted in 1889. By the turn of the century, about 14 percent of the U.S. nursing programs were under Catholic auspices.²

Formal university-controlled nursing programs did not evolve until the late 1920s, beginning at Saint Louis University. However, hospital "training" programs continued to be the dominant form of nursing education until the development of community college programs and the advent of federal support for nursing education encouraged state schools to add a nursing curriculum.

As the Second Vatican Council began in 1963, 22 percent of the 885 hospital schools accredited by the National League for Nursing were under Catholic auspices, as were 20 percent of the 136 college programs.³ Community colleges were just beginning to develop. Today, 38 of the 136 diploma (28 percent), 103 of the 584 baccalaureate (18 percent), and 14 of the 565 (2 percent) community college programs are Catholic. Seventeen of the 156 masters and 5 of the 53 doctoral programs are in Catholic universities.⁴

Fewer Catholic Programs
Several factors suggest that the number of Catholic schools of nursing will decline in the coming decades. At present Catholic hospital and collegiate nursing programs still represent about the same percentage of programs as they did 30 years ago. However, expansion of nursing programs today occurs for the most part in state-supported community colleges. The United States has fewer than 230 Catholic colleges and universities. About half of these have fewer than 500 full-time students and thus cannot bear the expense of operating a nursing program. The number of Catholic graduate programs—which prepare future nursing leaders, administrators, clinical specialists, and educators—is also limited.

Many of the collegiate and hospital schools will likely close in the near future, as will some Catholic healthcare institutions. Other factors adversely affecting Catholic nursing education are the increasing number of students attending community colleges, the high costs of nursing programs, the growing gap between private and public tuition, and a lack of philanthropic support. Within 20 years, I believe, only the largest Catholic universities—and only those with a strong institutional commitment—will be financially able to support undergraduate nursing programs. Fewer yet will be able to support graduate programs.

Furthermore, as Catholics integrate more fully into an increasingly secular culture, students and families will choose schools based on prestige, financial support, and tuition costs. Gospel values, Christian milieu, and religious sponsorship are no longer influencing choice as they did before Vatican II.

Decline of Values-Based Education
In the past, Gospel values were the basis of both education and service in Catholic institutions—though these values were probably more implicit than explicit. I was "trained" by the Daughters of Charity. We were immersed in an overtly Catholic environment, where attitudes and values were both demonstrated and caught.

Thirty-eight years later several things remain with me: the sisters' devotion to the poor, the importance of the sacramental system and the morning ritual of Holy Communion, the competency and commitment of the faculty, and the expected participation of physicians in the care of the sisters' poor patients. In working long hours and taking on major responsibilities, students developed self-esteem, competency, and maturity. I do not believe the word "Christian" or "Gospel" was ever mentioned, but we imbibed the essence. As suggested by the motto, "Caritas Christi Urget Nos" (the love of Christ drives us), we sensed we had a special calling, a vocation. This sense permeated everything from morning prayer and uniform inspection, to night duty and daily mass.

One significant weakness of that type of training was that students did not learn how to translate the "calling" into action in their future roles nor how to share with others the Gospel values that directed their practice. In fact, they may not have even defined the values for themselves, since emphasis was placed on obedience and docility.

Catholic nursing education has changed in the past 30 years. Although most programs offer courses in ethics, philosophy, and religion, few provide opportunities for the value-laden experiences of the past. Students are taught Gospel values as theoretical constructs, but unless the teacher can show how these values relate to real-life situations, students will be unable to translate them into active practice. Nursing students used to have a distinctive identity, but today they are more like other collegians. Many factors besides curriculum influence their character. Some of these are personal, others cultural, societal, familial, economic, and political.

Second, Catholic agencies usually do not discuss religious background with applicants for either nursing staff or faculty positions, focusing instead on education, experience, competence, scholarly publication, and research achievement. Although most schools would give preference to a Catholic who meets all other requirements, religious orientation is no longer the sine qua non it was in the past. In addition, many faculty resist addressing values or ethical considerations because they believe doing so would be a form of indoctrination. Or even more troubling, they hold values and ethical beliefs contrary to those of the magisterium and believe academic freedom gives them license to espouse them.

What students do hear about Gospel values from nursing service is usually restricted to the orientation program. Rarely do staff nurses or clinical mentors discuss the motivation that underlies their practice with students and other staff. Although students can discern differences in practice between professionals, they may attribute them simply to different levels of expertise.

Furthermore, many students and graduates do not possess a sense of vocation. The word "vocation" is seldom used to describe nursing any longer because of its presumed negative connotation of subserviance.

Students and new graduates are affected by the stresses within the profession. These include the absence of a clear articulation of what constitutes professional nursing practice in the organization, multiple paths for entry into the same profession, lack of recognition of the social significance of the profession within the community and among other health and business professionals, and sometimes lack of pride and contentment on the part of the nurse herself. These stresses often militate against commitment to nursing as an important lay vocation in the world today.

Although the profession's commitment to holistic care dictates that every nursing curriculum have a module on the spiritual care of the patient, few students have the opportunity to observe nurses providing such care. Many nurses believe spiritual care is the sole responsibility of the pastoral staff, and some pastoral workers may agree. Gone are the days when "sister would stay with the dying," when nurses baptized babies, and when they felt a duty to ensure that patients received the sacraments when they needed them.

Lastly, Catholic higher education itself is becoming increasingly secular. Despite the best efforts of campus ministry and faculty, the values of secularism and individualism permeate the culture and hence the students' views.

Restoring Gospel Values
Nursing schools can do more. The young student is a fragile person who is sorting out beliefs and values that will carry through to maturity. Thus it is very important that the school, the clinical practice sites, and employing Catholic agencies demonstrate that Gospel values are integral to the way they deliver healthcare. If this is reinforced, values can become an inner light that will illumine a lifetime of service as a professional nurse.

Our own university nursing program uses about 60 agencies. We choose them for ethnic and religious diversity, as well as competency of care, but our primary criterion is that the agencies care for the poor with dignity and compassion.

The kind of nursing care patients receive directly affects their perception of the institution. As it prepares for the future, Catholic nursing education must place more emphasis on the nurse as "servant leader" in both the theological and political sense. In caring for patients, nurses also influence other care givers.

Students need to learn the skills of assertiveness within the context of "gentle love." They must be taught the effectiveness of affirmation in changing behavior and the importance of leadership in developing vocations for laypersons committed to changing the world. Introducing students to the social encyclicals on labor and appropriate Vatican II documents can be one step toward achieving this goal.

I am not suggesting that only Catholic educational institutions can instill Gospel values as the motivating force of nurses' lives, but I do think that a critical mass of persons so prepared is essential to maintain the desired environment. Hospitals and other institutions, organizations, and agencies can devise educational programs—without indoctrination—to instill in nursing staff the philosophy of care, competence, and compassion that should characterize a Catholic agency.

A maxim that should guide administrators is, Where there is no love, put love, and you will find love. For too many executives, nurses and other workers are simply part of a functional social system called the hospital. Administrators and managers at every level must ensure that staff believe they are essential to the operation and their efforts are appreciated.

Nurses must also be aware of the good their institution does for its community. Care of the poor is often less direct today than it was 30 years ago. Now hospitals spend millions to support pure charity cases, more millions in bad debt subsidies, and many millions in unreimbursed care for Medicaid and Medicare patients. Healthcare workers, who tend to be idealists, often do not see these expenses as real charity. Frequently administrators do not let them in on the secret.

The time at which a nurse applies for employment is a critical opportunity for communicating Gospel values. At the initial interview, the applicant can be introduced to the organization's mission statement and asked how he or she would implement it in a work situation. The applicant can also be asked how the employer should implement it in regard to the employee. Finally, the annual employee evaluation should include items focusing on how the mission statement is actualized in nursing practice.

One Catholic hospital has biannual paid days of reflection in which all staff can reflect on their work in the light of Christian values. Another institution has appointed a chaplain solely to minister to its nurses. This priest makes daily rounds to the nursing units and offers the nurses personal and spiritual counseling.

Another way to attune nurses more directly with the Gospel values that drive the organization is to appoint a group of them as the ministers of communion to the patients on their unit. Many students are Eucharistic ministers in college, but their work hours prevent them from continuing this holy calling after graduation. The role of Eucharistic minister would promote the holism essential to good nursing practice.

I would also encourage Catholic hospital systems to work together in forming parish ministry programs. Involvement in such a ministry would make hospital nurses more sensitive to the difficulties patients encounter when they return to their homes. It would also reinforce the idea that health and illness are much broader concepts than those of disease and cure and that it is the human spirit that makes people well.

We Must Act Now
Over the past 120 years nursing education and nursing students have changed. As we approach the twenty-first century, change will be more rapid and healthcare workers will find it increasingly difficult to develop the Gospel values critical to the continuance of Catholic healthcare.

As we look to the future, it behooves us to remember that the word "health" comes from the old English word meaning "holy." Unless we act now to maintain and foster Gospel values in all our staff, our Christian heritage in the care of the sick will gradually be lost to the forces about us.

NOTES

1. Richard Shryock, The History of Nursing, W. B. Saunders, Philadelphia, 1959, pp. 300-301.
2. Shryock.
3. National League for Nursing, "Diploma and Associate Degree Programs Accredited by the National League for Nursing, 1962," Nursing Outlook, vol. 10, no. 2, 1962, pp. 122-126; "Baccalaureate and Higher Degree Programs Accredited by the National League for Nursing, 1961," Nursing Outlook, vol. 10, no. 2, 1962, p. 126.
4. National League for Nursing, "Accredited Diploma Programs," Nursing and Health Care, vol. 13, no. 8, 1992, pp. 443-444; "Accredited Associate Degree Programs," Nursing and Health Care, vol. 13, no. 4, 1992, pp. 214-219; "Accredited Baccalaureate and Higher Degree Programs," Nursing and Health Care, vol. 13, no. 6, 1992, pp. 326-332.

For Pat McGarry, being a good nurse means seeing the best in people during the worst of times. As an emergency room nurse at Marian Health Center, Sioux City, IA, she has practiced that philosophy for 46 years, without ever missing a day of work.

"It's a pure labor of love for me," McGarry says. "I think you can make a difference in people's lives by treating them well, doing upbeat things." As a student she learned from the Sisters of Mercy the importance of preserving the dignity of the patient. And although much has changed since she began her career, she says the Mercy value of patient-centered care has remained a constant at Marian over the years.

Two aunts who were Sisters of Mercy were McGarry's first exposure to the Mercy values and tradition. "When I was a child, they would come every year and visit my folks on the farm," she says. "My personal contact with them started my loyalty to the Sisters of Mercy." One of her aunts, Mother Carmelita Manning, arranged for the construction of Sioux City's first emergency outpatient department in 1940. The other, Sr. Benigna Manning, was at one time director of Mercy's school of nursing.

McGarry got her initiation into emergency room service while in nursing school. The students lived at the school, which was near the hospital. When an emergency occurred, they would come to the hospital and help out. The sisters' response during times of crisis made the Mercy values vivid for her, McGarry recalls. "Those who were not working with patients would help out with family members. Everyone pitched in."

"One of the things that impressed me as a student is how the sisters would stay up all night with the dying and their families," she says. "The director of the nursing school taught the students to view everyone, families as well as patients, as special and to treat each person they came into contact with as an individual."

Exposure to the Mercy tradition also taught McGarry to take pride in her work. "When I first began nursing, there was a sister in charge of each floor. Each of them was proud of her unit. This rubs off on you."

McGarry learned from the sisters how to support and reassure people during times of great stress. And her years as an emergency room nurse have sharpened her sensitivity to the special needs of patients and their families. "Sometimes they are frightened, and their families are frightened," she says. "At those times, it's more important than ever to be a good listener so that you can find out what they need."

An explosion at a local meat packing plant in 1949 was the first major emergency McGarry dealt with after she became a nurse. The tragedy mobilized the community, McGarry recalls. Sioux City did not have ambulances at the time, and the emergency room did not have two-way radios. So the nurses and physicians at the hospital did not at first understand the extent of the tragedy. Local undertakers, police officers, and fire fighters brought in the victims. In all, 15 people died and 90 were injured in the incident.

The recent death of Jonas Salk, who discovered the polio vaccine, reminded McGarry of the polio epidemic of the early 1950s. "New nurses don't know what things were like then," McGarry notes. Sioux City was hit particularly hard. McGarry still has a newspaper with a headline stating the polio outbreak in the community was the worst in the nation in 1952. The hospital admitted 923 cases that year, and 53 people died. During the summer months, 10 or more patients would come in each day. "The epidemic struck everyone—small children, men and women—no one was safe," she said.

Most victims were admitted through the emergency room, and many required immediate treatment. "A lot of times it started with a headache. People didn't realize what it was for a while. By the time they made it to the hospital, many of them had a hard time breathing and swallowing, and we had to perform a tracheostomy before we could send them to the floor."

The demands on care givers were so intense that nurses worked double shifts and gave up days off. For help with breathing, patients frequently had to be placed in iron lungs, where they would remain for as long as six weeks after admission. At one point, the hospital had close to 30 iron lungs in operation, McGarry recalls. The floor that housed the machines had to be rewired to carry the added electrical load.

Volunteers from local churches used to come to feed people in the iron lungs, and care givers had to reach through portholes to attend to them. After they were taken out of the devices, patients would often remain at the hospital for another six months. "People were in the hospital so long that we really got to know a lot of them," McGarry says. "We would visit some of the patients after hours." Many of the victims were permanently disabled. She still sees some of them.

The role of the emergency room nurse today is essentially the same as when she began her career, McGarry says. Nurses still assess patients' needs, provide treatment, and help families through crises. Time has brought some changes, she acknowledges. Drug-related emergencies, for example, have been much more common in the last two decades. "But no matter what people come in for," she says, "our job is to care for them and preserve their dignity."

Through the years, the Mercy heritage has always uplifted McGarry. "I'll continue to work as long as I am able," she says. McGarry admits to missing the presence of the sisters—only one serves at Marian now—but she says that the nursing staff carries on the Mercy tradition. "Their high ideal—the dignity of the patient—has always been utmost. We work together so well, and the experience has always been upbeat. I look forward to going to work today as much as I did the day I began."

—Phil Rheinecker

Copyright © 1993 by the Catholic Health Association of the United States
For reprint permission, contact Betty Crosby or call (314) 253-3477.