BY: KATHLEEN D. SANFORD, D.B.A., RN, CENP, FACHE
As the nurse executive for a Catholic health care system, I visit hospitals and long-term care facilities all over the country. I always enjoy the murals, pictures and written histories of the founding sisters displayed on their walls. My colleagues are obviously proud of their past and of their founders. They're also a bit wistful. Those who have a few nuns working with them invariably make a comment about how fortunate they still are, obviously dreading the day when that won't be true. Those who are no longer blessed with on-site women religious can tell me when the last one retired or went to heaven.
In our hospitals, we remember the sisters with respect and affection. In our corporate headquarters, there is talk about the importance of ensuring that we lay leaders continue the nursing sisters' mission. I believe that this is the time for nurses in Catholic health care institutions to begin a serious dialogue about what it means to practice nursing in a faith-based organization and what our roles should be in perpetuating the legacy of the American women religious.
REMEMBERING THE LEGACY
Nursing is poised for change. We are acutely aware of rising costs in our delivery systems; problems with quality and safety for those we serve; inequities in care between races, genders and socioeconomic groups. We're immersed in what will be a continuous technological and scientific revolution. We prognosticate that care will migrate out of hospitals to outpatient and home settings.
Some of these changes excite us; others alarm us. We struggle with the need to achieve a balance between what should change about our current systems and what must be preserved. Nurses in Catholic health care organizations have an additional legacy to protect: that of the sister-nurses who founded our present-day health care systems. The legacy of these women religious is especially dear to nurses, because we are blessed with a common heritage. As M. Patricia Donahue stated in her comprehensive book, Nursing, the Finest Art, "The history of nursing first became continuous with the beginning of Christianity … Christ's teaching of love and brotherhood transformed not only society at large but also the development of Nursing."1
Since the early beginnings of the church, one major way the religious have chosen to serve has been as nurses. Donahue described how St. Jerome (A.D. 345-420) wrote admiringly of the Roman matrons who served as nurses and preceded formal establishment of Catholic orders.
The evolution of professional nursing as both art and science is inextricably intertwined with the history of women and men religious. In the 16th century alone, more than 100 female orders, as well as new male orders, were founded for the specific purpose of nursing.
One of the earliest known nursing theories is credited to Mother Catherine McAuley, founder of the Sisters of Mercy. Her 19th-century "careful nursing" system, as described by Therese Connell Meehan, includes 10 key concepts for professional nursing that still resonate with nurses today:
- Disinterested love (unbiased by the nurse's personal interest or advantage)
- Contagious calmness (calm, quiet dependability)
- Creation of a restorative environment (as free as possible from influences adverse to healing)
- Perfect skill in fostering safety and comfort (attention to detail, technical skill)
- Nursing interventions (specific healing procedures developed by nurses)
- Health education (formal and informal education for individuals, families and communities)
- Participatory-authoritative management (professional nurses have authority and are responsible for nursing practice though they may have assistants to whom they delegate)
- Trustworthy collaboration (mutual trust and respect between professions in the interest of patient care)
- Power derived from service (the source of power is excellence and competence)
- Nurses care for themselves (spiritually, physically, emotionally and socially)2
WHAT'S LOVE GOT TO DO WITH IT?
The lack of understanding of who nurses are or what they do is a challenge for the profession and the health care system. We have peers who fear that nursing will never be recognized as a profession if nurses continue to be seen primarily as caregivers. These peers would like to see us emphasize the science and intellectual side of nursing. They criticize an ad campaign which challenges young people to become nurses because they "dare to care." The fear is that this slogan implies that caring (or love) is all that is needed to be a nurse, for few outside of the profession understand the complexity of our work — and nurses, like women religious, have historically been undervalued.
Too many in our society hold the misperception that love and kindness are the opposites of professionalism and intelligence. They are probably unaware that among nursing's forebears, the Roman matrons like Fabiola, a protégée of St. Jerome who personally cared for the poor and sick, were the most learned women of their time, educated in Hebrew, Greek and Latin.
They may know that Florence Nightingale (who learned nursing from nuns) was celebrated in Victorian England as "the lady with the lamp," the Crimean War's ministering angel who made rounds with a light to see and touch the sick and wounded patients in her care. They may not know that Nightingale also was a brilliant administrator, social reformer, statistician and author of a standard nomenclature for diseases.
They may not realize that in modern times, a growing number of nurses have master's degrees and doctorates, evidence of nursing as an intellectual endeavor with interventions separate but complementary to those of other medical colleagues. These interventions heal, ease distress, comfort and keep patients safe. They also represent major best practices as hospitals strive to increase the quality of their patient care.
Intellect and love are not mutually exclusive. To emphasize the science and de-emphasize the love in nursing would be harmful to our patients, our communities, ourselves and the sisters' legacy. The world is still in need of caring.
HOW TO LIVE THE LEGACY OF LOVE
As nurses in faith-based systems, we must continue to openly discuss which actions demonstrate love and where we could improve in our loving service. To be loving means to treat others with kindness, cultivate justice, combat prejudice and act as an advocate for others. Love requires bravery, including the valor to speak the truth and to foster change. It includes being accountable for ensuring that we are practicing with competency and fiscal responsibility. It also means caring for ourselves. Love is a large part of the sisters' legacy, intertwined with courage and faith.
But the continuation of the sisters' work of love won't occur just because we say it will. As nurse leaders, we have to preserve their legacy, even as we continue to lead change. We can start by ensuring that the sisters' history is known and understood by every new Catholic health nurse from his or her first day of orientation to our systems.
It might seem that this isn't something needing our attention. When I visit Catholic hospitals, nurses can tell me the stories of their founding congregations. Many of the current staff have had the benefit of actually working with nursing sisters. However, most future nursing staff members are unlikely to enjoy this privilege. Besides, the ability to recite historical events is not the same as understanding how they can provide insight and guidance for our own nursing practice. We need nursing managers and frontline staff leaders who will help new nurses — as well as tenured team members — to see each patient encounter and each work experience through the lens of faith-based nursing.
Catholic nursing leaders must work with their nursing educators to incorporate the use of brief patient-care stories with facilitated discussions on how individual nurses and patient-care teams can address the issues surrounding these cases in keeping with the loving charisms of their founders.
Here are two examples:
- One of your patients is HIV-positive due to use of illegal intravenous drugs. Another is HIV- positive due to a blood transfusion. How should your nursing care of these two patients differ?
- You've just been assigned care of a young married woman who was admitted to your unit because of complications resulting from her voluntary termination of pregnancy in a community clinic. As a nurse in a Catholic hospital, how should you interact with her?
The discussion could be led by a nurse educator or a member of the hospital mission team. It would be an even richer conversation if it could be led by a nursing sister. But the important points will center on acknowledgment that all people have biases and emotions about human actions that don't just disappear with the donning of a habit or nursing uniform. Both our Christian belief in a forgiving God and our nursing heritage dictate that we care for all of our patients with equal compassion. At times, we may not love the actions that brought them to us for nursing, but in keeping with the sisters' legacy, we must treat all patients with love.
Here are a couple of very different, challenging scenarios. They involve situations almost every nurse will experience, but few know how to bring up for discussion.
- You are standing at the nurses' station when you overhear a conversation between an experienced nurse and a new colleague. The veteran is castigating the younger nurse for a medication error. "How could you be so stupid?" she says. "How did you ever get through nursing school?" After several belittling comments, she walks away, leaving the novice in tears. What should you do?
- You are the charge nurse on a busy medical unit. There never seems to be enough staff, so you rarely take a break during your 12-hour shift. That enables the rest of your team members to get lunch. For meals you grab a cola and chips from the vending machine, because you can eat these while charting. You know you should take better care of yourself, but you feel you are doing the right and loving thing. After all, you are ensuring that your patients and staff are being cared for. Is this living the sisters' legacy?
Open discussion of these scenarios will be more difficult than conversations about loving patient care. We understand what we need to give our patients. We are less competent at caring for our colleagues and ourselves.
Lack of support isn't new to our profession. Early in my career I read an article about nurses' poor treatment of one another. Thirty years later, I reviewed a new study about the same problems. Older nurses speak disparagingly of younger colleagues; day shift accuses night shift of leaving work undone; the emergency department staff complain the inpatient unit nurses are too slow to admit patients; critical care professionals disparage the skills of the mental-health or long-term-care nurses. Outright bullying occurs from nurse managers to staff nurses, and between staff nurses.
Research explains this sad reality as a result of nursing's history as an oppressed discipline. Nurses have historically suffered from occupational stress and gender subjugation. Individuals exhibit low self-esteem as a result of widespread undervaluing of our work. As with other oppressed groups, we sometimes deal with our own pain by lashing out at peers, accepting such abuse as the norm for the profession. We speak of "eating our young," but we don't talk about how this harms us and our patients.
Nurses in Catholic health care institutions can be the professionals who break this pattern by looking to the history of our sisters. Women religious have also been under-appreciated for their contributions, subjected to gender discrimination and placed in unbelievably stressful conditions. Yet, their stories contain example after example of mutual support. They appreciated different types of work nuns were called to perform, "each according to her gifts." The charisms of the congregations provide guideposts for us on how we can extend the love of Christ to each other; their stories have endowed us with exemplars to follow.
To extend their legacy, we must change our culture to one in which nurses help each other learn and grow from mistakes rather than exchange blame for imperfections. Our faith-based norm must be to care for other caregivers and to refuse to stand by when any team member is abused.
Another norm we need to develop is admiration for nurses who care for themselves. Mother Catherine McAuley counseled that nurses could not continue to give to others unless they were spiritually, physically, emotionally and socially healthy themselves. Psychologists tell us that a person who does not love herself cannot truly love others. It is not self-loving to play the martyr, continually giving to others at a cost to personal health and well-being. Nurses who do not make time for exercise, good nutrition, personal growth, family, friends and spiritual connections are at risk of professional burn-out. We need the courage to admit we need, then to carry out change that will optimize our healing environments by strengthening a culture of self-care, another legacy from our sisters.
HOW TO LIVE THE LEGACY OF COURAGE
Throughout their history, women religious have acted to serve others. The Roman matrons went into the streets to give hands-on care to the poor and sick; nuns risked their own lives to personally care for victims of plagues; American sisters traveled into an unknown wilderness to found hospitals. We can look to their courage to emulate with our own challenges. Scenarios to help nurses understand courage include stories like these:
- You watch as a surgeon known for being a bit on the arrogant side changes a dressing for one of his patients. He then moves on to examine another patient without washing his hands. What should you do?
- Your nursing manager has just shared a new way of performing a nursing procedure that she says is evidence-based. It involves use of new technology that is unfamiliar to you. You are an expert at the way you currently perform the procedure. Should you adopt the new technique?
People don't have to work in health care to know the answer to the first question. They are aware that people die from hospital-acquired infections and that hand washing is the No. 1 way to prevent those infections. So they would be as shocked as I was a few months ago when I heard about one hospital's new program in which they had educated the nursing staff to intervene immediately whenever they saw a colleague who did not wash his or her hands — unless that colleague was a physician. If the doctor didn't wash, he or she was "reported" to the medical staff leaders, who would, at some later date, discuss this breach in procedure with the individual. I was told this was because the nurses were afraid to ask a medical staff member to wash his hands. In other words, patients were put at risk so that nurses would not have to endure a possibly uncomfortable encounter. I think our foundresses would be appalled.
In the second example, courage may seem unrelated to the adoption of a new procedure — but it is. Health care professionals, including nurses, sometimes resist changing practices because we do not want to be, or appear to be, incompetent. It takes courage for professionals to change, because until we master a new technology or procedure, we are not as competent as we were when doing things the old way. Whether change is small, as in a hospital nursing procedure, or large, as it will be with new care models, our self-worth is challenged when what we do well is no longer the best practice.
Their orders' histories tell us many nuns moved into communities thinking they were going to start schools, but they ended up nursing instead because that was the greater need. I have no doubt their initial nursing abilities were less refined than their teaching skills, but they learned to be competent. Remembering them, we can face the future with faith that we, too, will evolve our professional competencies to meet new needs of our communities. Faith is another part of the sisters' legacy.
HOW TO LIVE THE LEGACY OF FAITH
In keeping with Catholic tradition, we share reflections at the beginning of our meetings. These stories and prayers remind us of our spiritual heritage. They bring calm to our gatherings. They remind us of whom and why we serve. They grant us the gift of contemplation in a hectic world where we otherwise might forget to take that time.
If lay nurses are going to carry on the work of our sister-nurses, we need to pause for a longer reflection. We need to remind ourselves that none of their accomplishments would have occurred without deep faith.
Catholic Health Initiatives (CHI) nursing leaders have begun the conversations crucial to ensuring the sisters' legacy continues. At our 2009 annual chief nurse executive conference, we came together to talk about our future, and we started that discussion with a presentation about our past. Our keynote speaker was Sr. Mary Margaret Mooney, president of the Sisters of the Presentation of the Blessed Virgin Mary in Fargo, N. D. and professor emerita at North Dakota State University. She gave us a Catholic health care history lesson which included her personal history as a nurse.
Throughout the two-day meeting, attendees continually referenced the information she shared with us and noted how her words brought clarity and insight to our planning. One of the goals was to share and examine various nursing theories we could use as a foundation for professional nursing in our organizations. We wanted to be sure that theories selected agreed with and supported our faith-based beliefs.
It was during the theory discussion that most of us first learned about Mother Catherine McAuley's "careful nursing" model. Not even all of the nursing leaders at hospitals originally founded by the Sisters of Mercy were aware of this rich, insightful framework for nursing that is as meaningful today as it was 200 years ago. We were thrilled to be given this gift, and sobered to realize it could have been lost to us, if we had not come together to talk.
At CHI, we think now is the time for lay nurses to have conversations with sister-nurses about the future of Catholic nursing. We can't assume common understanding of what it means to carry on the mission of the founding congregations. We believe we need to consider and verbalize how alternative care models best support the continuation of faith-based nursing care.
CHI nursing leaders invite our colleagues in every Catholic organization to join us in this dialogue about Catholic health care's past and future. By examining and discussing the sisters' charisms, we can help ensure that those historical exhibits on display in so many of our buildings are more than relics from the past. They will continue to remind us of all we can learn from the love, courage and faith they represent. As we plan for the future, we can look to the example of the sisters who believed and then, without fanfare, did "great things with great love." Catholic nursing cannot, must not lose this heritage.
KATHLEEN D. SANFORD is senior vice president and chief nursing officer, Catholic Health Initiatives, Denver.
NOTES
- M. Patricia Donahue, Nursing, the Finest Art: An Illustrated History, (St. Louis: Mosby-Year Book, Inc., 1966).
- Therese Connell Meehan, "Careful Nursing: A Model for Contemporary Nursing Practice," Journal of Advanced Nursing 44, no. 1 (October 2003): 99-107.
TRAVELING EXHIBIT
The Sisters of Mercy were among a number of congregations who brought their faith-based nursing to America. By 1872, there already were 75 Catholic hospitals in the United States, mostly founded by women religious. Currently, the Women & Spirit: Catholic Sisters in America exhibition is making a three-year tour around the country, educating the public about the work of nuns, including those who brought health care to our communities and frontiers.
Visitors will learn they owe much to these courageous women who faced incredible hardships as well as prejudice because of their vocation. Nurses owe them more — our educational evolution and our development as a profession. Remembering their history and mission is the first step in planning our future as nurses in Catholic health care.
To learn more about the traveling exhibit, including its schedule, visit www.womenandspirit.org.
Copyright © 2010 by the Catholic Health Association of the United States
For reprint permission, contact Betty Crosby or call (314) 253-3477.