This chapter explores the history of Roman Catholic religious women in nursing in the United States by focusing on Catholic sisters, or nuns, who are part of the official Catholic Church structure. They profess public vows of poverty, chastity, and obedience; commit themselves to live communally; and follow constitutions, or rules, of their particular religious order.1 A focus on these women allows us to rethink religious roles in nursing by seeing sisters’ power within religious institutions, such as Catholic hospitals. They exerted a significant influence on professional nursing in public and private facilities, in times of epidemics and wars, in cities, in mining and railroad centers, and on the frontier. This history is divided into three chronological periods: Catholic nursing and caretaking up to 1800, Catholic hospitals and nursing in the United States in the 19th and 20th centuries, and transitions in church and society after 1950.
History is important to nurses, especially today when issues of health care policy and practice are becoming prominent in the public arena. History provides a critical place to explore “the contingent relationships among the social, political, and economic forces that shaped nursing practice and modern health policy.”2 Although many understand the history of nursing as only that of powerlessness, of women who cannot gain control over their profession, there are alternative histories that show otherwise. Religion plays an important part in these alternative histories. One way to conceptualize power is through the experiences of Catholic nursing sisters, often invisible in the history of nursing, who did not see themselves as powerless3 and whose religious identities created a special space for them to nurse.
The Catholic Church owns the nation’s largest group of not-for-profit health care systems and facilities; thus, it is a major stakeholder in the health care field. As of 2009, more than 85 million patients were assisted in 636 Catholic hospitals. Furthermore, more than 4,500,000 full-time employees work in Catholic hospitals, many of whom are nurses.4 Only 14.6% of nurses employed in Catholic hospitals are Catholics.5 In the United States, then, Catholic health care institutions are significant conduits for religious ideas about health and healing to both Catholics and non-Catholics. It is important to note that it was sister-nurses who were the leaders, developers, nurses, supervisors, and administrators of these Catholic hospitals. An examination of their work can create new knowledge about nursing’s origins and its actual power and work in hospitals and policy.
In the 19th and 20th centuries, Catholic sister-nurses, more than most women of the day, wielded significant power and authority as hospital owners and administrators. They shared power in their hospitals with physicians, with whom nuns often battled over who should control access to care. In Catholic hospitals, sister-nurses created a space in the United States where a specific, socially beneficial type of care could be provided and purchased.6 These sisters, while clearly mission-driven, were nevertheless skillful business managers who learned to fully understand and work within the often perilous hospital marketplace.
Catholic sisters also had an influence on Florence Nightingale. Even though Nightingale had a significant effect on modern nursing, in the 1850s she worked with both Protestant and Catholic sister-nurses in England, Germany, and France. Her experience as a nurse was relatively slight before the Crimean War, and Nightingale’s work with nuns during that war significantly influenced her conception of nursing as a religious duty and as a disciplined and organized practice under a female hierarchy.7
Catholic hospitals began as individual, stand-alone institutions, and the majority of the ones in the United States were established and managed by sisters. An exception to female-based institutions was the Alexian Brothers from Aachen, Germany, who also were founded to care for the sick and dying. These women and men established their hospitals in the United States with religious missions to care for both Catholics and non-Catholics. In the last 50 years, however, all hospitals have experienced massive transformations as modern medicine made new demands and the number of Catholic women and men in religious orders plummeted.
A nursing tradition developed during the beginning years of Christianity when church members cared for the sick, helped widows and children, and offered hospitality to strangers. Charity continued with the growth of monastic orders in the 5th and 6th centuries and extended into the 1500s as monasteries added hospital wards to their buildings. Caring meant giving comfort and spiritual sustenance, and it provided the rationale for nursing the sick to become part of the work of Catholic men and women’s religious orders. Yet, just because nursing was done, it did not mean that women became nuns specifically to nurse. Indeed, many factors influenced women to join religious orders. Until the 17th century, nursing was irrelevant to their primary goal of spiritual perfection. Thus, whatever nursing they did, it was not a ministry but a means to obtain grace from God.8,9
The Alexian Brothers organized in Germany and the Low Countries in the early 14th century to bury the dead during the Black Death, or bubonic plague. By the 17th century, they had expanded their care to a variety of social outsiders, such as criminals and the mentally ill. Although many religious orders of men nursed in the medieval period, in the 17th century St. Vincent de Paul and St. Louise de Marillac made women more prevalent in nursing when they established the Daughters of Charity in France in 1633.10 This was an active community of unmarried women and widows who lived together and dedicated themselves specifically to charitable works, including serving the sick poor.11 Unlike the cloistered women’s communities that participated primarily in contemplative prayer, the Daughters of Charity cared for the sick by living among the people that society had abandoned. They joined humility, obedience, and simplicity to good works, and they practiced nursing as an imitation of Christ’s charitable qualities.
Sisters framed their hospital roles after Vincent de Paul’s model as they expanded to other countries. In 1728, the Ursuline sisters opened the first Catholic hospital in the North American continent in New Orleans, but the settlement was not part of the United States at that time. In 1809, Elizabeth Ann Seton founded the first American congregation, the Sisters of Charity of St. Joseph in Emmitsburg, Maryland. The sister-nurses linked charity and market activities as they expanded in the United States in the 19th century. In 1823, university officials at the Baltimore Infirmary asked them to staff their facility, where the nuns charged a small fee for admission. In 1828, Mullanphy Hospital, the first Catholic hospital in the United States, was founded, and the local bishop invited the Sisters of Charity to staff it. Between 1828 and 1860, this congregation established 18 hospitals in 10 states and the District of Columbia. These 18 hospitals constituted more than half of the Catholic hospitals founded before 1860. They cared for medical and surgical cases, patients with mental disorders, and those affected by epidemics.12 In 1850, the Emmitsburg community joined with the international Daughters of Charity based in Paris, thus beginning the first American community of the Daughters of Charity of St. Vincent de Paul.13
It was in the 1840s and 1850s that the unprecedented immigration enlarged the possibilities for nursing by religious orders of women. Between 1820 and 1840, over 260,000 Irish came to the United States, fueled by the Great Famine that struck Ireland between 1846 and 1851. Germans were another Catholic immigrant group that settled in the United States before 1860, and larger increases in immigration occurred after 1890 when southern and eastern Europeans emigrated.14 A primary reason for establishing Catholic hospitals was that Catholics could not enter non-Catholic facilities without being proselytized by Protestants. Urbanization and industrialization also contributed to hospital establishments as labor unrest and a breakdown of traditional sources of moral authority occurred. Church leaders sensed that significant Catholic populations existed with inadequate spiritual institutions. To tap this growing group, the Catholic Church created separate hospitals, orphanages, and schools, and staffed them with sisters who could preserve the Catholic identity.15
The epidemic-stricken cities of the mid-19th century needed hospitals immediately, and the Sisters of Charity of Nazareth was another congregation that responded quickly. After the cholera epidemic of 1832, they began caring for the sick in Louisville, Kentucky, under the direction of Mother Catherine Spalding. In 1842, they started a hospital in Nashville, Tennessee. The cholera and yellow fever epidemics between 1830 and 1840 brought other sisters into health care. For example, the Sisters of Charity of Our Lady of Mercy worked in a hospital in Charleston, South Carolina.16,17 Racial discrimination limited African Americans’ institutional development, but two communities of African American women cared for the sick during epidemics: the Oblate Sisters of Providence, founded in Baltimore in 1828, and the Sisters of the Holy Family, founded in New Orleans in 1842. During the 1832 cholera epidemic, the Oblate Sisters nursed over 200 patients in the Baltimore Almshouse; and in New Orleans in the 1850s, the Sisters of the Holy Family cared for victims of cholera and yellow fever.18
The daily arrival of immigrants, the church’s fear of Protestant proselytizing, and the social problems brought on by urban growth all provided the impetus for nuns to establish hospitals in the United States. Although Protestant growth occurred particularly in the southern regions of the country, Catholic enclaves of European immigrants predominated in eastern cities such as New York, Boston, and Philadelphia, and midwestern cities such as St. Paul, St. Louis, and Chicago. The Catholic Church was in the minority in Texas and Utah, but these areas attracted many immigrant miners and railroad workers from Catholic countries who were potential American Catholics.19,20 Thus, sisters went there, as well.
From 1840 to 1870, nuns from 34 different congregations either established or took charge of more than 70 acute hospitals in the United States.21 Many sisters came from Europe, including the French Congregation of the Sisters of St. Joseph, who arrived in the United States in 1836. From 1849 to 1859, they staffed St. Joseph’s Hospital in Philadelphia, largely to care for Irish immigrants. They also opened a hospital in Wheeling, Virginia (now West Virginia) in 1853 and St. Joseph’s Hospital in St. Paul, Minnesota, in 1854.22
Irish women were particularly active in nursing. A prominent community that augmented nursing in the United States after 1840 was the Sisters of Mercy, founded by Catherine McAuley in Dublin in 1831. They arrived in the United States in 1843 with a history of caring for the sick poor in homes and in hospitals. They established a hospital in Pittsburgh in 1847 and in Chicago in 1852.23 The Sisters of Mercy also went to Vicksburg, Mississippi, where they nursed victims of war and epidemics.24
Catholic women’s congregations followed the immigrant into new industrial, railroad, and mining centers in the Trans-Mississippi West. For example, led by Mother Joseph Pariseau, the Sisters of Providence came from Montreal in 1856 to open a hospital in Vancouver, Washington, and eventually they established many hospitals in the Northwest. Another group of Irish Sisters of Mercy (now of Burlingame) under the direction of Mother Baptist Russell arrived in San Francisco in 1854. Mother Baptist, an immigrant from Ireland, and her sisters took charge of the county hospital during a cholera epidemic, but the county did not pay them for their care of 140 patients. Mother Baptist told the county supervisors to assume responsibility for payment or she would open her own hospital. She did so in 1857 when she established St. Mary’s Hospital.25,26
Sisters’ images as nurses improved during wars, such as when they nursed both Union and Confederate soldiers during the Civil War. The Sisters of the Holy Cross were not nurses until they volunteered their services during this period. Sister Paula Casey had left her family in Ireland and entered the Congregation of the Sisters of the Holy Cross at the age of 19. She had only been in the convent 3 years before she was sent to work as a nurse at St. Johns’ Hospital in Cairo, Illinois, in 1861. The initial task of the nurses was to clean the hospitals because no sanitary regulations were observed. Upon her arrival at St. Johns’, Sister Paula recalled the filth of the hospital and the amputated arms and legs that piled up. She and another young sister were distressed, but their superior provided guidance. Sister Paula wrote, “Mother looked at us both in a kind, pitying look, and said now stop, you are here and must put your heart and Soul to the work. Pin up your habits, we will get three brooms, three buckets of water and we will first begin by washing the walls and then the floors.”27 Nursing care included giving supportive care through nutritional diets, providing hygienic care, administering nonspecific medications, and carrying out doctors’ orders for dressing wounds. In addition to working in U.S. Army hospitals, the Sisters of the Holy Cross staffed the first U.S. Navy hospital ship, the USS Red Rover, thus becoming the first Navy nurses. As a result of good nursing care, the public’s perceptions of nuns and the Catholic Church itself improved dramatically after the Civil War.28
Because of religious persecution in Germany under Bismarck, additional German women’s communities sought refuge in the United States and opened hospitals across the Midwest. In 1869, the Poor Handmaids of Jesus Christ established hospitals in Fort Wayne and Mishawaka, Indiana, and in Chicago, Illinois.29 The Sisters of the Third Order of St. Francis expanded their work in Illinois, which included the founding of St. John’s Hospital in Springfield in 1875. That same year, the Poor Sisters of St. Francis Seraph of the Perpetual Adoration opened St. Elizabeth’s Hospital in Lafayette, Indiana, one of 20 health care institutions they established across the Midwest in the late 19th and early 20th centuries. Many of these hospitals were founded to strengthen group cohesion for German immigrants, particularly in the areas of language and devotional life.30
Sisters and brothers from Germany also opened health care institutions in areas with especially large numbers of German immigrants. Between 1866 and 1894, the first community of nursing brothers in the United States, the Alexian Brothers, opened hospitals in Chicago; St. Louis; Elizabeth, New Jersey; and Oshkosh, Wisconsin. Established in 1866 in a German neighborhood in Chicago, the Alexian Brothers Hospital drew patients mostly of German origin, along with men from dozens of other ethnic groups.31 As the Chicago Tribune noted in August 1880, the institution wore the “stamp of decided German character”; patients could eat German food and obtain German Nauheim baths.32 Admission demographics changed over time, however, as more U.S.-born patients were admitted, second-generation German Americans moved to the suburbs, and U.S.-born men joined the congregation.33
From 1870 to 1920, 189 different Catholic religious congregations established 275 Catholic acute care hospitals.34 The Daughters of Charity continued their hospital expansion, opening St. Vincent’s Hospital in Indianapolis in 1881 and many others across the United States. The Sisters of the Sorrowful Mother came from Rome in 1889 and opened 10 hospitals in the Midwest and Southwest. Beginning in 1891, Mother Frances Cabrini and the Missionary Sisters of the Sacred Heart established hospitals in New York, Chicago, and Seattle to care for Italian Americans. Also in 1891, Katherine Drexel, an heiress from Philadelphia and convert to Catholicism, founded the Sisters of the Blessed Sacrament for Indians and Colored People, and this community staffed nine different hospitals.35–37
Sisters also nursed in 1898 during The Spanish–American War, and eventually 282 nuns either volunteered their services or were asked to serve by the government and military officials. At Camp Hamilton in Lexington, Kentucky, 12 Sisters of the Holy Cross worked with both secular and religious sisters. Holy Cross Sister Lydia Clifford, a Civil War nurse who had experience in several hospitals, was “Chief Nurse” to: 50 Daughters of Charity from Emmitsburg, Maryland; 11 Sisters of St. Joseph of Carondelet; and 50 lay nurses.38 The Sisters of St. Joseph of Carondelet went on to different camps in Georgia and Cuba. Most of the nursing care in the camps involved comfort measures and help with feeding and bathing for men suffering with typhoid fever. In her letters to her superior, Sister Lydia described long hours of hard work and the sisters’ on-the-job training. In asking for more sister-nurses, she wrote, “There is so much walking . . . Sr. DeSales could give [the new sister nurses] some lessons on taking pulse, temperature, and respiration—for a day or two, and practice here will soon make them proficient.”39
Significantly, sister-nurses’ religious congregations offered some of the earliest health insurance policies. In 1875, for example, the Sisters of the Holy Cross established a scheme whereby miners in Salt Lake City, Utah, could receive care whenever they needed it if they donated $1.00 from their salaries.40 During the 1890s, the Sisters of St. Joseph in Minneapolis generated funds to care for the needy during an economic depression. They issued “Sisters’ Tickets” to those who would donate $100. These tickets allowed the donor to send a needy person to the hospital, where the ill person could have care free of charge.41
Years before the first nurse training schools were established in America in the 1870s, Catholic sisters were receiving nursing instruction in an apprentice-like system. Most women’s religious communities had a period of training either during or after the novitiate, when young sisters trained for their future work. Teaching included not only nursing skills but also instructions on prayer, the Catholic Mass, and other religious practices. Congregations’ constitutions articulated how the sick were to be treated, what daily schedule nurses should follow, how they should relate to physicians, how they were to prepare food and medicines, and most important, by what means the nuns should prepare a person for death.42
One of the earliest Catholic texts for sister-nurses is a handwritten one in two parts for the Daughters of Charity. The first section was written in French by a priest that included rules for religious nurses in France. Composed in 1796 during the French Revolution, it was particularly important for the Daughters of Charity, because priests could not exercise their clerical functions and the Daughters carried out much of the religious instruction of the sick during their work as nurses. This first section was recycled in 1841 when Mother Xavier Clark, superior of Elizabeth Seton’s Daughters of Charity in the United States from 1839 to 1845, wrote a second section, in English, entitled Instructions on the Care of the Sick.43 She wrote her Instructions to sister-nurses so they could carry the text in their pockets as a supplement to directions of doctors and experienced sister-nurses. For example, she instructed the sisters how to pray with a patient while not ignoring physical problems. Indeed, they were to care for them first because “the union between the soul and the body is so close that when the latter is suffering a great deal, the other, attentive to its wants, cannot think of anything else.” She insisted, “But remember one thing—never begin to speak of religion before you have afforded them all the little relief and comforts you can to the poor body. By these you will find your way to the soul.”44
In their evangelical work, sisters’ rules and constitutions also provided guidelines. The 1888 Manual of Decrees of the Sisters of St. Joseph stated that they were to attend to a patient’s bodily wants while being “very solicitous for the welfare of his soul.” They were to avoid actively seeking Protestant converts, though, and to respect their religious convictions.45 Yet, sisters’ very work was a powerful form of evangelization. They proselytized by the virtue of their deeds and accomplished conversions in this way. Upon going to Utah in 1875, Sister Augusta Anderson remarked that the best way to do any good with the Mormons was “to have little to say, and give them good example.”46
Sioban Nelson contextually situates sister-nurses in North America before the Civil War, in contrast to those in France, as being subject to Protestant hostility and part of a financially poor Catholic Church. Thus, they had to construct a new kind of nursing that focused on accountability, innovation, skill, and flexibility.47 Mother Xavier’s text reflects these concerns. She reminded sister-nurses that they would be in charge. The experienced sisters should “know everything,” so that they could guide the less experienced sisters and also teach the men who were caring for male patients. Although the sister’s model emphasized self-abnegation, respect, and devotion, the nurse also was to seek knowledge and ask questions. Sister-nurses were to be concerned with practical nursing care as well. They were to speak softly and to work gently, quietly, and unhurriedly. Nurses were to keep medicines covered to prevent evaporation, avoid mixing them, know the correct doses, and use clean utensils and clean water in all the preparations.48
Soon after the training school movement started, sisters of the various nursing congregations began providing official hospital training for their own nurses and eventually for non-Catholic nurses.49 Few Catholic schools of nursing were in existence before the Spanish–American War; however, although the Sisters of Mercy’s Mercy Training School for Nurses opened in Chicago in 1889. The war catalyzed the formation of other Catholic nursing programs, such that, between 1903 and 1913, following the trend of secular schools of nursing, Catholic sisters opened 203 training schools.50 Nursing leaders’ crusade to separate the trained from the untrained nurse was especially influential on nuns. Nursing was evolving from a service to a trained practice, and scientific and technological advances were developing. Hence, a good nurse came to be measured not only by her character but also by her technical competencies, knowledge of disease prevention, discipline, and organization.51 Nuns responded to these challenges and updated their nursing practice by establishing their own nursing schools.
In 1915, the Catholic Hospital Association (later the Catholic Health Association [CHA]) was formed in response to technological advances and the hospital standardization movement that was changing health care delivery in the United States. At that time, more than 30 women’s religious congregations sponsored 220 schools of nursing. By 1925, there were 581 Catholic acute and specialty hospitals in the United States, mainly under the care and administration of nuns; and most had their own nurse training programs.52 Lectures typically included anatomy and physiology, medical and surgical problems, infection and contagion, orthopedics, bacteriology, surgical cases, sterilization and preparation of dressings, gynecology, obstetrics, and pediatrics. Sisters used textbooks, which secular training schools adopted.53 Nurses worked 12-hour shifts, usually 6 days a week, and while physicians gave most of the early lectures, sisters provided the clinical instruction on hospital units. Yet there was little time to teach ethical and religious instruction. It was not until the 1920s that many Catholic schools of nursing introduced history and ethics courses.54 In the mid-20th century, nursing education began to move from 3-year hospital-based diploma programs to 4-year baccalaureate schools in U.S. colleges and universities, and Catholic schools followed this path. Sisters eventually relocated their programs from hospital-owned to private and public baccalaureate schools.55
Nuns also worked to raise the standards of nursing education. In the 1930s, Sister John Gabriel Ryan, a Sister of Providence in Seattle, Washington, lobbied the state legislature against exploitation of nursing students. One judge said, “She took a man’s name in religion, and I said of her that she was the ablest man in Olympia.”56 Her masculine name helped her transcend the usual female stereotype, and this minimized gender limitations. This was particularly helpful in the male-dominated realm of education policy.
As sisters adapted to changes in modern medicine and nursing, their training schools legitimized their nursing practice and increased their influence with student nurses and physicians. Nuns opened their schools to both sisters and lay women. As they updated their scientific training, sisters also could impress upon their students that nursing was a ministry to suffering humanity and in this way influenced secular nursing education.57,58
Writings by 19th-and early 20th-century theologians as well as sisters reveal a range of interpretations of illness and suffering that affected nursing practice. According to Catholic beliefs, both religious and non-religious explanations prevailed when one became ill. Disease could be a deviation from normal health, caused and potentially correctable by natural means, or it could be caused by supernatural means, with healing by religious measures. Often, natural causes were subsumed under ultimate supernatural causes that only divine intervention could ameliorate.59,60 Sisters of the 19th and 20th centuries adhered to all of these beliefs.
The 1888 Manual of Decrees of the Sisters of St. Joseph of Carondelet recorded a statement on sickness as a guide for sister-nurses. Indicating God’s hand in illness, it stated: “God’s fatherly providence frequently visits negligent Christians with sickness, in order to lead them back to the fold from which they unfortunately strayed.”61 It followed that Catholic sisters viewed illness not only in biological terms but also within a spiritual framework. Yet sisters’ care differed from priests, who provided patients with messages that they should endure suffering as a means of strengthening faith. Rather, nuns placed greater emphasis on alleviating pain and suffering.62,63
In addition, records make it clear that sisters were concerned about making their patients well. In 1847, Sister Matilda Coskery, a Daughter of Charity, taught nursing to young sisters in the United States. Her notes, assembled in A Manual for the Care of the Sick, included a long section of care for patients with mental conditions such as alcoholism. She provided information on how to minister to physical and spiritual needs, how to interview a relative or friend of the patient, and the questions to ask when taking a history of the patient’s past conditions.64
The Manual of Decrees for the Sisters of St. Joseph of Carondelet prescribed practical nursing tips: “She tries to be exact in carrying out the directions with regard to the remedies ordered, either by the physician or by Superiors, and does not, except by the doctor’s advice, give any but ordinary remedies.”65 Prescriptions also focused on caring and compassion as necessary attitudes for sister-nurses. The Incarnate Word Sisters were to “serve [patients] with a tireless zeal,” and entertain for the sick, not only a compassion, kindness and devotedness, but likewise a great respect.66 The Sisters of the Holy Cross were to be mild, vigilant, patient yet firm, and compassionate for the suffering of others.67
By the latter decades of the 19th century, in addition to taking temperatures, pulses, and respirations, sister-nurses prepared and applied dressings and used hot and cold body packs for fever cases. They administered medications such as laudanum (opium in its liquid form), ointments, and poultices for pain relief; bathed patients; changed their linen; and prepared and administered food for special diets. They kept the sick room clean and well ventilated, protected the patient against contagious diseases, and prepared the dead for burial. They also observed patients for signs and symptoms of disease and its complications, recorded them in some form of clinical record, and reported them to the physician.68 During one particularly hectic week in 1889, the Sisters of Charity of the Incarnate Word at St. Joseph’s Infirmary in Fort Worth, Texas, admitted 19 patients, discharged 6, transferred 1 to another room, and cared for 24 others, prompting the annalist to remark, “Our heels are praying very hard all day.”69
The experiences of the Sisters of St. Francis of Our Lady of Lourdes in Rochester, Minnesota, provide a case study of nursing in the late 19th and early 20th centuries. They cared for persons after a tornado struck that city in 1883. Afterward, Mother Mary Alfred Moes proposed to build and staff a hospital in that city if Dr. William Worrall Mayo and his sons would agree to provide the medical care. This collaboration resulted in the development of St. Mary’s Hospital and what is now known as the Mayo Clinic. The first sister-nurses were trained by Edith Graham, the only trained nurse in Rochester and an employee of the Mayo physicians. No other formal training was available for the sisters, and nursing was extremely challenging. Their duties included preparing and serving meals, bathing patients and keeping them comfortable, dressing wounds, and giving medications. They used thermometers and gave enemas. Nurses particularly had to rely on their powers of observation, and they learned how to distinguish between pallor from anemia and pallor from internal bleeding. St. Mary’s Hospital and the Mayo Clinic excelled not only because of the skill of the Mayo brothers as surgeons but also because of the excellent nursing care by the sisters. Patients found that the hospital was a place where people could go to be healed. Within five years of St. Marys’ opening, the sisters treated more than 500 patients annually.70 Sisters carried the major responsibility for nursing and other departments as they headed different floors, X-ray departments, kitchens, and the like.
In 1913 at Mercy Hospital in Chicago, the Sisters of Mercy had various specialties in addition to nursing, including operating room care, X-ray technology, and pharmacy. Three sisters were anesthetists. A sister-nurse was in charge of the obstetrical department, and each floor was supervised by a nursing sister.71
After 1900, religious congregations’ successes in the United States improved their financial standings. Hospitals installed electricity and other conveniences, while at the same time, chapels were built that included beautiful religious icons. Sisters marketed their health care institutions as including “sacred” space within the “medical” space of the hospital. Hospital art and architecture were important to Catholics, and they accepted paintings, sculptures, and other religious icons that distinguished them from the Protestant tradition, which emphasized preaching. To Catholics, artworks were signs that mediated religious meanings. Because Catholic sisters viewed illness in both biological terms and within a spiritual framework, they supplemented their nursing care with prayer cards, rosary beads, and other religious symbols designed to provide comfort and healing. They also accompanied patients to Mass in hospital chapels.72
Catholic sisters also held devotions to the saints with their Catholic patients to remind them of their faith. In the 19th to the mid-20th century, devotions were an important aspect of Catholic spirituality. As McDannell asserts: “Catholics learned and accepted the reality of a supernatural community because they were taught how to interact with it through their devotional practices.”73 Devotions were a form of popular religion that bridged the Church’s intellectual teachings and expressed one’s personal piety. Sisters helped patients with exercises such as the rosary, a private prayer consisting of stating 150 “Hail Mary’s” and devotions to the Sacred Heart of Jesus, which focused on His divine love for mankind and encouraged humility. Devotions to the saints and the Virgin Mary were especially popular,74 making the hospital’s Catholicism unmistakable. At the same time, by caring, serving, and treating the poor, the sick, and the dying, sisters were involved in important religious experiences. Indeed, nursing the sick and dying placed religious sisters in situations that linked the worldly and the divine. They could participate in important and dramatic religious experiences such as baptism and helping a Catholic to confess their sins before dying; this conferred on them a special mission. In their hospitals, sister-nurses could do spiritually important work for their patients.75–77
Prayers for the sick and dying had a long history in the Catholic Church, and references were particularly prominent in nuns’ writings. Rather than representing a single action, however, prayer was integrated into sister-nurses’ work. Their prayers served as invitations to religious encounters.78 To Catholics, prayer and the sacraments could bring grace and favors from Jesus and Mary, including healing the sick. Lay Catholics often asked sisters to pray for them, believing that nuns’ prayers were more powerful than their own. For example, in 1897 a patient at Santa Rosa Infirmary in San Antonio requested that his remaining salary go to the Incarnate Word Sisters so that they would pray for him after he died. A few months later, family members transferred a woman’s remains from one cemetery to another that was in closer proximity to Santa Rosa so the Incarnate Word Sisters could pray for her when they visited the site.79 In addition to healing the sick, one of the corporal works of mercy, according to Catholic tradition, was to bury the dead.80 The Incarnate Word Sisters kept a “dead house” behind Santa Rosa Infirmary, which held bodies of the deceased until relatives arrived. Sisters frequently held wakes in their hospital parlors, and families often asked nuns to attend to burial services.81
Catholic sisters participated in all of these activities in their traditional dress. They maintained their authority in the Catholic community partly through their vow of chastity, which marked a boundary between them and members of the laity. They underscored their asexual identities not only by their vow of chastity but also through their religious clothing that covered their physical bodies.82 Sisters’ religious clothing was a physical representation of religion. In the early 20th century, however, they adapted their clothing to meet newer scientific standards by wearing washable white habits instead of the traditional black ones, considered by some medical authorities to harbor germs.83
As late as 1945, Catholic nursing texts continued to call for compassion for the suffering patient and prayers for deathbed conversions.84 In her book, The Nurse: Handmaid of the Divine Physician, Sister Mary Berenice Beck, RN, PhD in nursing education, wrote about the Catholic nurse’s obligations for the spiritual care of patients. She included lessons for the care of dying Catholic patients and specific prayers to use. She also had a chapter on care of the non-Catholic patient. Catholic nurses, either lay or sisters, were to emphasize common beliefs and practices and to encourage patients to seek ministrations from their own churches. Although the nurse could use indirect methods such as prayers and the exercise of good example, she may more directly leave reading materials conveniently at hand for the patient to pick up and read. Yet, she should never engage in heated arguments or belittle others’ religions.85
By examining sisters’ writings, including those of both Mother Xavier Clark and Sister Mary Berenice Beck, one can see continuity of instruction in the religious meaning of sickness and dying and a religious understanding of nursing. Indeed, care was an essential component of Catholic sisters’ nursing, and it included tending the sick physically, psychologically, and spiritually. In the late 19th to the mid-20th century, everything about the design and ambiance of the Catholic hospital reflected that it was both a medical facility and a sacred place.86
Much changed for American Catholics after World War II as their affluence and education rose. In the 1950s, the Sister Formation Conference led to better education for sisters, including nurses, and prepared them for their professional roles. By 1966, for example, 65% of the nation’s 175,000 sisters had college degrees, and many of them were nurses working and administering hospitals.87
Paralleling educational changes were transformations within the Catholic Church. Between 1962 and 1965, the Second Vatican Council (Vatican II) met, which, begun by Pope John XXIII, attempted to bring the church up-to-date. Aggiornamento, or change and adaptation to meet the needs of the times, was a key term used during the Council. The Council document most often linked with aggiornamento is Gaudium et Spes (“Joy and Hope,” or the Pastoral Constitution on the Church in the Modern World), which for the first time saw all people, including laymen and women, as having distinctive missions in the church rather than being mere “helpers of the hierarchy.” As a result, more leadership roles in Catholic institutions became open to the laity.88 After Vatican II, religious congregations of women renewed their commitment to the poor and oppressed.
Changes in health care also occurred as all American hospitals had to face rising hospital costs; consequently, hospitals had to balance their responsibilities to the public with economic realities. Medicare and Medicaid expanded coverage for the elderly and poor, investor-owned hospitals entered the hospital marketplace, and not-for-profit hospital systems grew. For the sisters, in particular, social justice issues began taking priority as they worked to expand care for minorities and the uninsured. Thus, in the 1960s, they took social causes of disease, such as unemployment, racism, and poverty, into account as significant factors in disease causation.89 This was a distinct change.
Social justice has been a fundamental part of Catholic social teaching, beginning in 1891 when Pope Leo XIII issued his encyclical, Rerum Novarum, which offered a program of reform for labor based on the concept of social justice. In 1963, Pope John XXIII addressed the world in his encyclical, Pacem in Terris (Peace on Earth), which included the right to health care as part of his list of individual human rights. It was at this time that sisters came to believe that charity alone was only part of their mission. Many became active in the civil rights movement.90 Events in the 1960s provide examples of how Catholic sister-nurses, in particular the Sisters of St. Joseph from Rochester, New York, and the Daughters of Charity in Chicago, expanded their work for racial justice.91
The Sisters of St. Joseph participated in the southern civil rights movement that culminated on March 7, 1965, or “Bloody Sunday,” when Selma authorities attacked 600 marchers who were crossing the Edmund Pettus Bridge in route from Selma to Montgomery as a protest against voting restrictions. The Sisters of St. Joseph cared for the injured marchers in their Good Samaritan Hospital throughout the afternoon, and the workers tended more than 100 people.92,93 On March 10, a group of priests and nuns from the Midwest chartered a plane and arrived in Selma to stand in solidarity with the marchers. Two of the sisters were nurses: Sister Ann Benedict from St. Joseph’s Hospital in Kansas City, the first African American to enter the Sisters of St. Joseph of Carondelet; and Sister Mary Antona Ebo, one of the first African American members of the Franciscan Sisters of Mary. When the protest march began on March 10, the sister-nurses walked in the front lines.94
Three months after “Bloody Sunday,” some of the Daughters of Charity of St. Vincent de Paul became involved in racial protests in Chicago. Since 1947, they had operated a settlement house, Marillac House, in an African American section of the city. The Daughters were especially aware of the poverty and racial discrepancies that handicapped their neighbors, having lived in the same neighborhood with them. Sister Jane Breiden-back, for example, was a nurse and was also known as “the Alley Sister” because she organized neighborhood cleanups to make playgrounds safe for children.95
On June 12, 1965, Sister Jane heard about a civil rights gathering that would be held that afternoon to protest public school segregation. She decided to participate in the march because she wanted to represent the people in her neighborhood who were unable to attend, “and because I myself believe that the Negro children are not given equally good educational advantages in this city . . . And I believe there is a need for religious to support their cause.”96 The march soon turned acrimonious when a policeman told them that unless they got back on the sidewalk, they would be arrested. At the instruction of the leaders of the march, Sister Jane knelt and promptly was arrested. She and the others went to police headquarters and were fined $200. She considered the demonstration and the fine to be a small price to pay for the privilege of representing the needs of the poor.97
It was also in the post-Vatican II period that the Vatican had greater influence in medical ethics documents for Catholic hospitals in the United States. The Ethical and Religious Directives for Catholic Health Care Services affirm certain ethical standards of behavior based on the church’s teaching on the dignity of the human person; as such, they provide direction on moral issues. In 1920, the Archdiocese of Detroit published the first written set of medical ethical norms for Catholic hospitals, which most Catholic facilities followed. In the 1950s, Catholic theologians took a leading role in bioethical discussions, such as those concerning abortion and reproductive issues that were becoming matters of public policy.
In the last decades of the 20th century, ethical issues continued to develop over the growth of biotechnology. For-profit hospitals also were expanding, and many Catholic hospitals began to merge or partner with non-Catholic facilities. As these hybrid organizations emerged, tensions developed that challenged Catholic identity. To counter these threats, bishops and the Vatican became more influential in hospital decisions.98 In 1971, the bishops came out with a new version of Ethical and Religious Directives, which more clearly banned tubal ligations, artificial insemination, and artificial birth control. In 1975, the Vatican barred sterilizations that might be performed when necessary to avoid diseases arising from pregnancy.99 In 1994 and 2001, the National Conference of Catholic Bishops again revised the Ethical and Religious Directives, this time to be more specific about partnerships between Catholic and non-Catholic hospitals, especially in banning reproductive services such as sterilization and in vitro fertilization. Today, supporting the Catholic Church’s teachings on abortion and reproductive services has become a distinct mark of Catholic hospitals’ identity. Nurses who work in these facilities were (and still are) expected to keep these Ethical and Religious Directives.
At the beginning of the 1970s, as the Vatican reasserted the Catholic Church’s traditional male supremacy, sisters’ decreasing numbers in congregations were also occurring, as many sisters left and fewer entered religious communities. Other roles in the church opened up to women who did not require taking vows. Thus, nuns’ influence in the overall hospital market declined as the laity, usually men, took over administrative positions. In some parts of the country, however, individual sisters maintained power over their institutions, whereas in others they lost control over hospital operations but gained influence as members of boards of directors and officers in the CHA.100 Many sisters have now moved into new areas of care. Just as they formerly nursed patients during cholera epidemics, they now work with patients with HIV/AIDS and care for the elderly, people whose needs are not being met by other groups.
Catholic hospitals’ public identities as institutions that originated largely through religious movements and values dimmed over time. Yet religion still has an important role in the American health care system and nursing. Today, pastoral care is emphasized with participation by laity, sisters, brothers, Protestant ministers, and Catholic priests.101 Although sisters are not as readily visible in their hospitals, they mentor pastoral care ministers who are charged with the role of carrying out the hospital’s original missions. Furthermore, some Catholic hospitals still have sister-nurses as administrators who understand that it is people themselves that ultimately matter most—not dollars and cents, but individuals’ needs.102
Finally, the health care crisis beginning in the 1990s saw greater participation of Catholic sister-nurses as leaders of the CHA. Most significant is their support for universal health care insurance. In July of 2009, the CHA published a statement calling upon legislators to enact health care reform that would provide access to care for all Americans. Yet abortion was the key negotiating issue that held up passage of any bill, pitting bishops, who feared the bill would support abortion, against sisters, who did not. Rather, they saw the legislation as supporting health care for the poor and marginalized. The historic legislation (HR 3590, the Patient Protection and Affordable Care Act) passed on March 21, 2010, and sisters’ support was definitely influential, although some bishops and conservative laity have criticized the sisters in public and private. Abortion issues reveal the conflicts within the church over how much to pit opposition to abortion and other procedures against concerns for social justice.103
In closing, Catholic hospitals have historically recognized the importance of nursing. In the early 20th century, sisters’ nursing roles gave them influence and prestige with physicians and their patients. Although they could not administer the sacraments, they still could influence nursing education for both Catholics and non-Catholics while also functioning as spiritual agents of care.104 The sisters’ historical construction of nursing in the 19th century and the obstacles they faced later, such as the Vatican’s greater attempt to control hospitals through the Ethical and Religious Directives, indicate a distinct approach to Catholic nursing.
Today, as they move away from the bedside into administrative and corporate roles, sister-nurses use skills they learned as nurses.105 Most important, as Catholic sister-nurses worked with non-Catholics in public arenas such as hospitals and military facilities, admitted laywomen into their nurse training programs, hired more lay people for their hospitals, and worked toward accepted standards of education, they also stamped their own understanding of nursing onto society.
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2. D’Antonio, Patricia, Cynthia Connolly, Barbra M. Wall, et al. “Histories of Nursing: The Power and the Possibilities.” Nursing Outlook 58.4 (2010): 208.
3. Ibid., 207–213.
4. Nicholson, Sumitra, ed. Official Catholic Directory 2009. New York: National Register Publishing, 2009.
5. American Hospital Association. American Hospital Association Annual Survey 2009. Chicago: American Hospital Association, 2009.
6. Wall, Barbra M. Unlikely Entrepreneurs: Catholic Sisters and the Hospital Marketplace, 1865–1925. Columbus, OH: Ohio State University Press, 2005.
7. Wall, Barbra M. “Textual Analysis as a Method for Historians of Nursing.” Nursing History Review 14 (2006): 227–242.
8. Wittberg, Patricia. The Rise and Fall of Catholic Religious Orders: A Social Movement Perspective. Albany, NY: SUNY Press, 1994.
9. Wall, 2005, op. cit.
10. Rapley, Elizabeth. The Devotes: Women & Church in Seventeenth-Century France. Montreal: McGill-Queen’s University Press, 1990.
11. Nelson, Sioban. Say Little, do much: Nursing, Nuns, and Hospitals in the Nineteenth Century. Philadelphia: University of Pennsylvania Press, 2001.
12. Farren, Suzy. A Call to Care: The Women Who Built Catholic Healthcare in America. St. Louis: The Catholic Health Association of the United States, 1996.
13. Hannefin, Daniel. Daughters of the Church: A Popular History of the Daughters of Charity in the United States, 1809–1987. Brooklyn, NY: New City Press, 1989.
14. Dolan, Jay. The American Catholic Experience: A History from Colonial Times to the Present. Notre Dame and London: University of Notre Dame Press, 1992.
15. Wall, 2005, op. cit.
16. Stepsis, Ursula, and Doris Liptak, eds. Pioneer Healers: The History of Women Religious in American Health Care. New York: Crossroad, 1989.
17. Kauffman, C. Ministry and Meaning: A Religious History of Catholic Health Care in the United States. New York: Crossroad, 1995.
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23. Clough, Joy. “Chicago’s Sisters of Mercy.” Chicago History 32.1. (Summer 2003): 42–55.
24. Oakes, Mary. Angels of Mercy: An Eyewitness Account of the Civil War and Yellow Fever by a Sister of Mercy. Baltimore: Cathedral Foundation Press, 1998.
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26. Kauffman, op. cit.
27. Casey, M. P. Letter to Mother M. Augusta Anderson. Bertram Hall, Saint Mary’s, Notre Dame, IN: Archives, Congregation of the Sisters of the Holy Cross, 1894.
28. Wall, Barbra. “Grace Under Pressure: The Nursing Sisters of the Holy Cross, 1861–1865.” Nursing History Review 1 (1993): 71–87.
29. Specht, A. “The Power of Ethnicity in a Community of Women Religious: The Poor Handmaids of Jesus Christ in the United States, 1868–1930.” U. S. Catholic Historian 19 (Winter 2001): 53–64.
30. Ibid.
31. Alexian Brothers’ Hospital. 74th Annual Report. Elk Grove Village, IL: Alexian Brothers of America, 1939.
32. Chicago Tribune. August 25, 1880.
33. Alexian Brothers Archives. Hospital Statistics. Alexian Brothers Archives, Arlington Heights, IL: 1942.
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36. Kauffman, op. cit.
37. Wall, 2005, op. cit.
38. Wall, Barbra. “Courage to Care: The Sisters of the Holy Cross in the Spanish-American War.” Nursing History Review 3 (1995): 55–77.
39. Clifford, Mary Lydia. Letter to Mother M. Annunciata McSheffery. Bertram Hall, Saint Mary’s, Notre Dame, IN: Archives, Congregation of the Sisters of the Holy Cross, 1898, September 21.
40. Wall, 2005, op. cit.
41. Sampson, A. T. Care with Prayer: A History of St. Mary’s Hospital and Rehabilitation Center. Minneapolis: St. Mary’s Hospital and Rehabilitation Center, 1987.
42. Wall, Barbra. “Science and Ritual: The Hospital as Medical and Sacred Space, 1865–1920.” Nursing History Review 11 (2003): 51–68.
43. Clark, Mother X. Instructions on the Care of the Sick. St. Louis, MO: Marillac Provincial House, Daughters of Charity of St. Vincent de Paul, 1841.
44. Ibid.
45. Sisters of St. Joseph of Carondelet. Manual of Decrees, Customs and Observances, for the use of the Congregation of the Religious of St. Joseph of Carondelet. St. Louis, MO: Ev. E. Carreras, Steam Printer and Binder. Archives of the Congregation of the Sisters of St. Joseph of Carondelet, 1888: 114.
46. Sisters of the Holy Cross. Sister Augusta Anderson Letter to Father Sorin. Saint Mary’s, Notre Dame, IN: Congregation of the Sisters of the Holy Cross, 1875, July 13.
47. Nelson, Sioban. Say Little, Do Much: Nursing, Nuns, and Hospitals in the Nineteenth Century. Philadelphia: University of Pennsylvania Press, 2001.
48. Clark.
49. Wall, 1995, op. cit.
50. Kauffman, op. cit.
51. Reverby, Susan. Ordered to Care: The Dilemma of American Nursing, 1850–1945. Cambridge: Cambridge University Press, 1987.
52. O’Grady, John. Catholic Charities in the United States. New York: Arno Press, 1971.
53. Wall, Barbra. “Definite Lines of Influence: Catholic Sisters and Nurse Training Schools. Nursing Research 50.5 (2001): 314–321.
54. Kauffman, op. cit.
55. Wall, Barbra. American Catholic Hospitals: A Century of Changing Markets and Missions. Piscataway, NJ: Rutgers University Press, 2011.
56. Geraghty, James. Letter to Sister John [of the Cross], 7 Jul. 1939. (1257) RPP, Box 2, Biography, Miscellaneous Correspondence, Sisters of Providence Archives, Seattle, WA.
57. Richardson, Jean. “Sisterhood is Powerful: Sister-Nurses Confront the Modernization of Nursing.” Florence Nightingale and her Era: A Collection of New Scholarship. Ed. Vern Bullough et al. New York and London: Garland Publishing, Inc., 1990. 261–273.
58. Wall, 2001, op. cit.
59. Amundsen, Darrel. Medicine, Society, and Faith in the Ancient and Medieval Worlds. Baltimore: Johns Hopkins University Press, 1996.
60. Ferngren, Gary. Medicine and Health Care in Early Christianity. Baltimore: Johns Hopkins University Press, 2009.
61. Manual of Decrees, op. cit.
62. Wall, 2001, op. cit.
63. Wall, Barbra. “Textual Analysis as a Method for Historians of Nursing.” Nursing History Review 14 (2006): 227–242.
64. Kauffman, op. cit.
65. Manual of Decrees, op. cit.
66. Sisters of Charity of the Incarnate Word. Directory of the Sisters of Charity of the Incarnate Word. Archives of the Motherhouse, Sisters of Charity of the Incarnate Word, 1906. 207.
67. Sisters of the Holy Cross. Rules of the Congregation of the Sisters of the Holy Cross. Bertram Hall, Saint Mary’s, Notre Dame, IN: Archives, Congregation of the Sisters of the Holy Cross, 1895. 142.
68. Hinssen, L. The Nursing Sister: A Manual for Candidates and Novices of Hospital Communities. Springfield, IL: H. W. Rokker Co., 1899.
69. Sisters of Charity of the Incarnate Word. Remark Book, St. Joseph’s Infirmary., San Antonio, TX: Archives of the Motherhouse, Sisters of Charity of the Incarnate Word, 1889.
70. Whelan, Ellen. The Sisters’ Story; Saint Mary’s Hospital – Mayo Clinic 1889–1939. Rochester, NY: Mayo Foundation for Medical Education and Research, 2002.
71. Sisters of Mercy. “Training School Methods and Organization Under Religious Orders.” American Journal of Nursing 13.1 (1913): 260–263.
72. Wall, 2005, op. cit.
73. McDannell, Colleen. Material Christianity: Religion and Popular Culture in America. New Haven: Yale University Press, 1995. 142.
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79. Sisters of Charity of the Incarnate Word. Remark Book, Santa Rosa Infirmary. San Antonio, TX: Archives of the Motherhouse, Sisters of Charity of the Incarnate Word, 1896. Web. Jan. 6 and Oct. 27.
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81. Remark Book Santa Rosa Infirmary. 24 Oct. 1896; 6 Jan. and 27 Oct. 1897.
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85. Sister Mary B. Beck. The Nurse: Handmaid of the Divine Physician. Philadelphia: Lippincott, 1945.
86. Wall, 2005, op. cit.
87. Kennelly, Karen. The Religious Formation Conference, 1954–2004. Silver Spring, MD: Religious Formation Conference, 2009.
88. Sullivan, Maureen. The Road to Vatican II: Key Changes in Theology. New York: Paulist Press, 2007, 120.
89. Wall, 2011, op. cit.
90. Ibid.
91. Wall, Barbra. “Catholic Sister Nurses in Selma, Alabama, 1940–1972,” Advances in Nursing Science 32.1 (2009): 91–102.
92. Wall, 2011, op. cit.
93. Ibid.
94. Stepsis and Liptak, op. cit.
95. Chicago Sun Times. 20 March 1966.
96. Jane B. Personal Statement Regarding June 12, 1965 Demonstration. Marillac House Papers, Box 2, June 1965 folder. Chicago, IL: Chicago History Museum, June 13, 1965.
97. Wall, 2011, op. cit.
98. Pellegrino, Edmund. “Catholic Health Care Ministry and Contemporary Culture: The Growing Divide.” Urged on by Christ: Catholic Health Care in Tension with Contemporary Culture. Ed. E. J. Furton. Philadelphia: National Catholic Bioethics Center, 2007, 13–30.
99. Wall, 2011, op. cit.
100. Kauffman, op. cit.
101. Wall, 2011, op. cit.
102. Wall, 2011, op. cit.
103. Wall, 2005, op. cit.
104. Wall, 2011, op. cit.
105. Wall, 2011, op. cit.