Teaching and Learning in Nursing 12 (2017) 295–297
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History of Nursing Education Evolution Mildred Montag Melissa Harker, MSN, RN, BC ⁎ Nursing Education Hackensack Meridian Health, 1350 Campus Parkway, Neptune, NJ 07753, USA
a r t i c l e Keywords: Nursing education Evolution Mildred Montag Associate Degree
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a b s t r a c t Mildred Montag, doctor of philosophy, is renowned for her influence on nursing education. Her evolutionary steps to address a nursing shortage moved nursing students into a decisive curriculum model and out of hospital-based programs. Her doctoral dissertation proposed that creating a 2-year program to prepare technical nurses would address the nursing shortage occurring at that time. The goal was to provide a workforce to assist the professional nurse who she envisioned as having a baccalaureate degree. The implications of Dr. Montag's work for our current generation of nurses still centers around the dilemma she notes in 1963. How will nurses and health care centers provide “top of license” performance, and who will provide direct care to our patients? This article strives to find an answer in the work of Mildred Montag's doctoral dissertation “The Education of Nursing Technicians.” © 2017 Organization for Associate Degree Nursing. Published by Elsevier Inc. All rights reserved.
The Rationale
Early Years
Introduction
Mildred Montag was born on August 10, 1908 in Struble, Iowa. She was orphaned at an early age and raised by her uncle and aunt on a family farm. She graduated from Hamline University in St. Paul Minnesota in 1930 as a history major. She decided to become a nurse and attended the University of Minnesota in Minneapolis. Mildred graduated in 1933 with a bachelor of science degree in nursing. World War II created an immediate need for increased numbers of nurses as the United States entered the war. The military was in need of trained nurses, and it is at this point that Dr. Montag makes nursing education history (Klainberg, 2010).
Mildred Montag, doctor of philosophy, was director and founder of the Adelphi College School of Nursing from 1942 to 1948. She is renowned for her influence on nursing education in the United States and throughout the world. Dr. Montag's work sought to alleviate a serious shortage of nurses by decreasing the length of their education to 2 years. She innovated a new educational base for nursing instruction by putting the program into community and junior colleges (Klainberg, 2010). Before the design and expansion of associate degree programs, more than 85% of graduating nurses' curriculum was designed by physicians and hospitals. This evolutionary step in nursing education moved nursing students into a decisive curriculum model designed to help them meet professional learning objectives (Orsolini-Hain & Waters, 2009). This revolutionary model of change in nursing education can serve as a model for future change as we face complex, ever changing, and multifaceted health care systems.
Education Evolution the Successful Nurse of the Future ⁎ Corresponding author. Tel.: +1 732 776 4201, +1 732 730 9041; fax: +1 732 814 6757. E-mail address:
[email protected].
Professional Development In 1942, Dr. Montag was asked by Adelphi College to determine if local hospitals would cooperate in creating a school of nursing at Adelphi. This school would be created under a grant from the United States Public Health Service. By January of 1943, Dr. Montag was named the director of the Adelphi College School of Nursing, which was the first nursing program on Long Island. Under the Nurse Training Act of 1943, also known as the Bolton Act, 25 students were admitted. Dr. Montag's leadership resulted in an increasingly steady enrollment. The student population grew at such a rate that Adelphi built Alumnae and Harvey Halls. These were two federally funded residence halls for women in 1944. Their completion was marked with a ceremony attended by First Lady Eleanor Roosevelt.
http://dx.doi.org/10.1016/j.teln.2017.05.006 1557-3087/© 2017 Organization for Associate Degree Nursing. Published by Elsevier Inc. All rights reserved.
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M. Harker / Teaching and Learning in Nursing 12 (2017) 295–297
Eleanor delivered the address “The Challenge of Nursing for Young Women Today” (Adelphi University, 2010). The Program Dissertation In 1948, Dr. Montag decided to complete her doctoral studies at Columbia University Teachers College and left Adelphi College. It was Dr. Montag's doctoral dissertation that changed the way we educate nurses in the United States. It was in “her doctoral dissertation that she proposed creating a two-year program to prepare technical nurses to assist the professional nurse whom she envisioned as having a baccalaureate degree” (Klainberg, 2010, p. 35). The rationale for Dr. Montag's work was the premise that nursing should be an “occupation with a professional and a technical component” (Montag, 1963, p. 101). For the professional nurse to make the provisions to patient care that was expected of her, she would need to be sustained by many nursing technicians according to Montag. The differences in their educations would be the basis of their professional practice: the nursing technician educated in a 2-year college and a nursing professional educated in a 4-year college (Montag, 1963). The program proposed by Montag for these technical nurses had key elements that made it different from traditional programs of that time. The curriculum included general, supporting, and specialized nursing courses. The nursing courses comprised about half of the curriculum, which was much different from the diploma school model. The content of the program was grouped in broader areas of study that were specialized and sequenced. The clinical experiences were provided in many different facilities because Dr. Montag realized that no one hospital or health care agency would be sufficient to provide all that was needed. These learning experiences were developed as laboratory experiences. One credit was given for 1 hr of class and one credit for 3 hr of laboratory. In a four-credit course, 2 hr would be spent in class activity, and 6 hr (two 3-hr periods) in laboratory experience each week for a semester. The teaching and development of curriculum was done by college faculty. The nursing faculty was employed by the college rather than a hospital. The students were required to meet the admission requirements of the college, and the graduation requirements as well upon completion of the program. The college tuition and fees were the same as for all the other students attending the college. The students would graduate with an associate degree and be eligible to sit for the state licensing examination from the state in which the college was located (Montag, 1963). The Implications Ideas in Action The implications of Dr. Montag's work for our current generation of nurses still centers around the dilemma she notes in 1963. “The question of who shall give nursing care to patients must be answered in the patients' best interests” (Montag, 1963, p. 103). The current discussion in health care centers on “top of license” performance and the delegation of many of the direct care tasks to ancillary unlicensed staff. Dr. Montag in her 1963 article in The American Journal of Nursing states, “The allocation of all, or practically all, direct care of patients to unqualified or poorly qualified persons is only a further invitation to poor quality nursing care” (Montag, 1963, p. 103). Dr. Montag sought to alleviate a critical shortage of nurses by decreasing the length of the education process to 2 years. Is there a greater message in her work as we face our current shortage of qualified nurses in an environment of the 2010 Affordable Care Act?
Application Today The Affordable Care Act represents the broadest health care overhaul since the 1965 creation of the Medicare and Medicaid programs. The goal of transforming the health care system to provide safe, quality, patient-centered, accessible, and affordable care will require a comprehensive rethinking of the roles of many health care professionals and nurses' chief among them (Institute of Medicine, 2010, p. 1). Knowing the history will not foretell the future but will widen experience and allow a greater number of experiences to draw from to answer the questions related to the role of the associate degree nurse's place in practice today and tomorrow (Matthias, 2010). There is a call for radical transformation in how nurses are educated and prepared for clinical nursing practice. Nursing programs are where students experience how to care for patients. They fully expect to learn and grow in a profession that they believe they will love for many years. Their transition into real practice is anything but ideal. The primary goal of our practice as educators needs to focus on closing the practice–education gap (Benner, Sutphen, Leonard, & Day, 2010). Dr. Montag's model was based on creating technical nurses who were proficient at delivering care. Educators need to follow Dr. Montag's lead and shift their classrooms away from abstract theory and create learning environments that integrate knowledge into an actual practice context. Time spent helping the student learn about what is important and unimportant about a clinical situation would improve their holistic approach and supporting their ability to integrate practical reasoning into their care decisions. Creating a learning environment that integrates both clinical and classroom would support a multifaceted, assimilated use of knowledge and skills that nursing practice demands (Benner et al., 2010). Dr. Montag knew the importance of this element as she created both the college classroom experience and diverse clinical experiences in various health care settings. If nursing is to evolve to meet the demands of maintaining wellness for whole populations of patients, we need to see the value for our students in creating more intentional use of transformational experiences. For nursing students to form habits and dispositions for use of their knowledge and skills, educators must understand that “students are formed by all they do, all they perceive and interpret, and all models of practice” (Benner et al., 2010, p. 88). Educators need to shift their focus to that of the student experience. The students' experience and their ability to reflect on the transformational impact these experiences have on their practice would enrich the student's identity and sense of self as a nurse (Benner et al., 2010). Dr. Montag believed that the increased number and complexity of nursing functions necessitated segregation of those functions (Matthias, 2010). She understood that formation is a method to prepare nurses for particular tasks and allows them to be capable of functioning in a particular role. She envisioned that the intentional use of formation would equip students with the skills to act in the role of nurse in any health care setting. “The dynamic landscape of healthcare requires that nurses move away from a focus solely on completing patient care tasks to a more comprehensive or holistic perspective of managing patient-centered care” (Strong, Kane, Petras, Johnson-Joy, & Weingarten, 2014, p. 196). Conclusion To transform our health care system, we need to transform how we educate our largest health care provider—the nurse. We need to ensure that nurses can practice to the full extent of their education and improve their opportunities to critically think effectively. Create opportunities for nurses to assume leadership positions and to serve as full partners in the health care redesign and improvement efforts. We need to improve data collection for workforce planning and
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policy making. Mildred Montag's associate degree level of entry into the profession is still highly valued and sought after by students. “An analysis by Aiken and colleagues (2009), nurses whose initial degree is the ADN are just as likely as BSN-prepared nurses to seek another degree approximately eighty percent of the time” (Institute of Medicine, 2010, p. 17). The associate's degree program can still prepare students well for the practice of nursing, and with its shorter duration and more manageable cost, it is the most viable option for many people to begin their careers as nurses. However, several factors are putting the bachelor of science degree into the spotlight. A 2006 study published in the Journal of Nursing Education publicized that nurses who had completed either a Bachelor of Science in Nursing program or an Registered Nurse to Bachelor of Science in Nursing program had been offered more educational development of autonomous clinical judgment skills. These skills will be needed in an ever-increasingly multifaceted work environment (Shin, Jung, Shin, & Kim, 2006). We are seeing patients who require a higher level of nursing care than ever before. There is a growing focus on evidence-based nursing practice, and nursing performance can improve by taking advantage of a formal educational preparation in interpreting research and assimilating findings into safe practice. Dr. Mildred Montag was one of the most prominent nursing education leaders of the 20th century. She restructured nursing more in her lifetime than any other personality before or yet to come. She has stood at the center of one of the most contentious struggles in nursing and not one of her own making. Mildred Montag, Professor Emerita of Teachers College died on January 21, 2004, at the Westhampton Care Center at the age of 95 years. Montag lived with her friend Ruth Harley for 64 years before her passing. Her words from her book Community College Education for Nursing still ring true to this day, although they were written over 56 years ago.
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It is to be hoped that nursing educators and nursing service administrators can accept the challenge offered. It is not enough to prepare nurses as they were prepared 25 or 50 years ago, and nurses are not being unrealistically prepared in the new programs. To simply prepare nurses to meet today's exigencies would be shortsighted (Ellis & Hartley, 2012). Nursing service will have to let, even require, nurses to do the kind of nursing now required by patients if their total needs are to be met (Montag & Gotkin, 1959, p. 365). References Adelphi University (2010). History Adelphi university college of nursing and public health. We are building on 70 years of success. Retrieved March 6, 2015, from Adelphi University http://http://nursing.adelphi.edu/about/who-we-are/history/. Benner, P., Sutphen, M., Leonard, V., & Day, L. (2010). Educating nurses. Stanford, CA: Jossey-Bass. Ellis, J. R., & Hartley, C. L. (2012). Nursing in today's world. Philadelphia, PA: Lippincott Williams & Wilkins. Institute of Medicine (2010). The future of nursing focus on education (Institute of Medicine of the National Academies no. 0–309–15824-9). Retrieved from http:// www.nap.edu/catalog/12956.html. Klainberg, M. (2010). An historical overview of nursing. Burlington, MA: Jones and Bartlett LLC. Matthias, A. D. (2010). The intersection of the history of associate degree nursing and "BSN in 10": Three visible paths. Teaching and Learning in Nursing, 5, 39–43. Montag, M. L. (1963). Technical education in nursing? The American Journal of Nursing, 63(5), 100–103 Retrieved from http://www.jstor.org/stable/3452697. Montag, M. L., & Gotkin, L. G. (1959). Community college education for nursing. New York: McGraw Hill Book Company, Inc. Orsolini-Hain, L., & Waters, V. (2009). Education evolution: A historical perspective of associate degree nursing. Journal of Nursing Education, 48(5), 266–271. http://dx. doi.org/10.9999/0148434-20090416-05. Shin, K., Jung, D. Y., Shin, S., & Kim, M. S. (2006). Critical thinking dispositions and skills of senior nursing students in associate, baccalaureate, and RN-BSN programs. Journal of Nursing Education, 45(6), 233–237. Strong, M., Kane, I., Petras, D., Johnson-Joy, C., & Weingarten, J. (2014). Direct care registered nurses' and nursing leaders' review of the clinical competencies needed for the successful nurse of the future. Journal for Nurses in Professional Development, 30(4), 196–203.
