Physicians and nurses were instrumental in the ideology, design, and implementation of many atrocities of the Holocaust (Reis et al., 2019). Nurses and midwives actively participated in Nazi racial hygiene policies, identifying and killing tens of thousands of their patients, including disabled children and infants and patients with mental and physical illnesses or intellectual disabilities. These killings were camouflaged as “euthanasia” or “mercy killing” of German citizens and others (Copeland, 2021) and preceded the Final Solution and mass murder of Jews and others deemed “lives unworthy of living” at extermination death camps (Copeland, 2021). Some nurses were involved in unethical, cruel experiments on human subjects (Benedict & Georges, 2006).
BACKGROUND
Confronting and learning about the legacy of the role of medicine and nursing in the Holocaust is a “medical imperative” within health professions education, informing our understanding of the Nuremberg Code as the ethical foundation for medical research (Horton, 2020) and serving as a powerful platform to support ethical, lifelong professional identity formation (PIF; Reis et al., 2019). The Lancet Commission on Medicine and the Holocaust (Roelcke et al., 2021) aims to support health professions education on this topic.
Nursing PIF, defined as “sense of oneself, and in relationship with others, that is influenced by characteristics, norms, and values of the nursing discipline, resulting in an individual thinking, acting, and feeling like a nurse” (Godfrey & Young, 2020, p. 364), has four pillars: values/ethics, knowledge (including critical reflection), leadership, and professional comportment (Brewington & Godfrey, 2020). Within this, the legacy of the role of nurses in the Holocaust provides a context for critical reflection on sociopolitical, economic, and professional pressures impacting contemporary nursing (Copeland, 2021) as well as implicit bias, overt racism, and prejudice. Such nursing education curriculum inclusion supports the American Association of Colleges of Nursing Essentials curriculum standards of “demonstrate the professional identity of nursing” and “integrate diversity, equity, and inclusion as core to one’s professional identity” (https://bit.ly/39kYsej). The purpose of this evaluation was to assess the effectiveness of an innovative educational intervention highlighting the role of medicine and nursing in the Holocaust within nursing students’ emerging PIF.
METHOD AND DESIGN
“The Legacy of the Role of Medicine and Nursing in the Holocaust for Resilient Professional Identity Formation” was an invited seminar presentation and colloquium (by author H.S.W.) within an undergraduate community health nursing ethics curriculum. Attendance for this scheduled class was encouraged, and suggested readings were provided. Prior to this presentation, students participated in a curriculum module on community health nursing ethical principles/ethical decision-making (Kruse, 2021). The module consisted of a one-hour seminar followed by a colloquium on the role of medicine and nursing in the Holocaust (45 minutes). The seminar provided students (N = 68) with historical knowledge including perpetrator, resistance, and personal narratives (daughter of a Holocaust survivor). Seminar topics included Holocaust origins, racial hygiene, neglect of a moral code, role of empathy and equal worth of individuals, and implications of Holocaust-related ethical issues for contemporary nursing (e.g., potential abuse of power, empathy, hierarchy/obedience, dual loyalties, and COVID-19-related moral complexities/PIF challenges).
The colloquium goal was to guide reflection on the difficult reality of the active role of health professionals in the Holocaust (Wald et al., 2022) within the context of students’ own PIF. The colloquium was presented twice to support small-group reflective dialogue: 38 students attended immediately after the seminar, and a smaller group of 22 attended after the first group. This interactive colloquium used humanities for emotional processing and reflecting on seminar content and personal and contemporary relevance; this included art interpretation and interactive, guided reflective writing (RW). Thoughts and feelings evoked by various paintings, some abstract and some Holocaust-related, were discussed, followed by a guided RW exercise about the content and students’ identity formation, with invitation to share within the small group.
Prior to the program, students completed a seven-item anonymous survey related to the seminar/colloquium objectives. Students completed the same survey following the seminar/colloquium, with additional items on RW and art. These items also related to the objectives, supporting survey face and content validity. Quantitative questions were scored on a 5-point Likert scale (1 = not knowledgeable at all, 5 = extremely knowledgeable), and reliability coefficients were calculated. Cronbach’s alphas were .774 (pre) and .950 (post). The postprogram survey included two qualitative items on takeaways and additional thoughts/comments. The Oakland University Institutional Review Board determined that the program evaluation was not human subject research.
RESULTS
Seventy-three students completed the seven-item presurvey; 68 students attended the seminar component. Presurvey results indicated that the majority of participants were “not knowledgeable at all” or only “slightly knowledgeable” in relation to program objectives. Mean scores ranged from 1.3 to 2.2.
Of the 60 students who attended both program components, seminar and colloquium, 38 (63.3 percent) completed the optional postprogram evaluation survey. SPSS software was used to analyze these results, and a paired-samples t-test was conducted to evaluate program effect, with significance set at p ≤ .05. All seven items produced significant results. Presurvey and postsurvey scores were also compared, indicating statistically significant increases (p < .001) in total scale scores (pre, M = 11.39, SD = 3.00; post, M = 24.5, SD = 4.58).
The magnitude of the effect of this program was tested by conducting a Cohen’s d test for each survey item and total pre- and postsurvey scores. Five items on historical knowledge and contemporary relevance had an extremely strong effect size; two items on the use of art and RW had a very strong effect. The statistical magnitude of the overall program (derived from total pre- and postsurvey scores) had an extremely strong effect (Sawilowsky, 2009).
Responses to the two qualitative survey questions were analyzed, exploring emergent themes. Twenty-six of the 38 students replied with 33 responses to the question on takeaways; 14 students responded to the “additional comments” query with positive feedback (e.g., “very informative and appreciated”). Four identified themes are discussed below with exemplar quotes from different students: 1) increased awareness and knowledge of the role of nursing in the Holocaust, 2) nurse as patient advocate/judicious obedience, 3) importance of adherence to ethics and values, and 4) use of art and reflective writing for processing experience.
Knowledge of the Role of Nursing in the Holocaust
The theme of increased knowledge emerged in most responses, including some describing heightened awareness or “eye-opening” experience (n = 19) with emotional experience. Ten responses included contemporary relevance. Some examples of this theme and inclusion of contemporary relevance include the following: 1) “I have learned another side to the Holocaust that I did not even know existed. This being the brutal acts the medical professionals were doing to the innocent people who were just seeking medical help.” 2) “Nurses thought that killing patients was the right thing to do, they took orders blindly without wondering or thinking for themselves.” 3) “The people who were supposed to be heroes and help others who were sick [nurses and doctors] contributed to the deaths during the Holocaust. Nursing is a very trusted profession in today’s world. The people during the Holocaust trusted the nurses when they sent them to ‘take a shower.’” 4) “I had no idea how nurses played such a significant role in the Holocaust, and it was very reassuring to learn that there was still some good people [nurses and doctors] that stood up for human decency and stood up for what was right.” 5) “We need to learn about history, so history doesn’t continue to repeat itself. #TheMoreWeKnow.” 6) “I work with the elderly…to think of groups/populations that were sought to be ‘eliminated’ simply due to the thought that they were ‘weak’ and ‘invaluable’ is both scary and sad.” 7) “These issues still arise today of hate, crime, and injustice.”
Nurse as Patient Advocate/Judicious Obedience
Six responses for this theme highlighted the importance of nurses serving as patient advocates and of exercising critical thinking for “judicious obedience” within nursing care. 1) “Voice your concerns —don’t be afraid to go against the grain if you think something is wrong.” 2) “I believe this lecture show[ed] immense importance to why a nurse should not just simply follow the doctors’ orders. A nurse should always make sure it is the right decision for her patient instead of just assuming what the doctor says is correct.” 3) “Re-acknowledgment that we as nurses should have empathy towards our patients and not just blindly follow doctors’ orders”.
Adherence to Ethics and Values
Seven responses were classified within the importance of adherence to ethics and values theme. 1) “Not standing up for your moral and ethical beliefs can have dire consequences.” 2) “If you feel something is wrong or unethical voice your opinion. It is better to do what you feel is right than fall victim to things such as group thought, which I believe may also have contributed to health professions in the Holocaust.” 3) “[I learned]…how important it is to operate under your own moral compass. Do not operate under the assumption that you should do as you are told…. Question authority and do not make choices that misalign with your moral objective. Understand your own biases.”
Art and Reflective Writing for Processing Experience
Six students provided insights regarding how art and RW can help process experience. 1) “Reflective writing can help develop thoughts and feelings.” 2) “I also found the reflection at the end to be very interesting. It was eye-opening to look at the different pieces of artwork and see how everyone interpreted them differently. I think that reflection time played an imperative role in understanding our individual feelings about the information given today.”
DISCUSSION AND IMPLICATIONS FOR NURSING
The impact of this educational intervention for shared critical reflection on the legacy of medicine and nursing in the Holocaust and its contemporary implications for ethical conduct and responsibility was positive. The undergraduate students demonstrated perception of key elements supporting PIF. Along with greater awareness and knowledge of this history and its contemporary relevance, students became aware of the centrality of the nurse as patient advocate and the importance of judicious obedience, ethics, and values in the nursing profession. The nature of nurses’ active and intentional participation in the murder of tens of thousands of their vulnerable patients (mentally and physically disabled) during the Nazi era (Copeland, 2021) is distinctive as an extreme example of the failures of nursing and medicine and offers a powerful platform for ethical PIF reflection.
Limitations include results from one institution and optional program attendance and evaluation, which may have impacted the return rate. Within this, emergent themes did align with PIF “pillars” of values/ethics, knowledge (including critical reflection), leadership, and professional comportment (Brewington & Godfrey, 2020), supporting this educational innovation. The value of educational experiences supporting PIF has been well documented, including improving students’ perceptions of nursing professionalism, sense of belonging to the profession, and confidence in nursing as a career (Kruse et al., 2020). Rebalancing the art and science of nursing through incorporation of the medical or “health” humanities, including such critical history, can enhance reflective capacity and have a positive impact on the cognitive and affective aspects of learning (Wald et al., 2019) to support PIF and nurses’ role as humanitarian (Kelsey, 2018).
CONCLUSION
PIF with adherence to ethical principles and diversity, equity, and inclusion goals to impact safe, quality nursing care is a key aim of nursing education. Critical reflection on the legacy of the role of medicine and nursing in the Holocaust for contemporary issues in nursing education and practice is a powerful platform for scaffolding PIF and ethical conduct and can be effectively incorporated into nursing curricula with a humanities approach.
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