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The Nurses on Horseback and the People They Served is a three-part series covering the history of Frontier Nursing University. On the rugged hills of Eastern Kentucky, nurses earned trust by listening, learning from local families, and standing beside them in moments of illness, birth, and crisis. Over time, this collaboration improved health outcomes, reduced maternal and infant mortality, and strengthened the well-being of the community they served.

By Janet L. Engstrom, PhD, APRN, CNM, WHNP-BC, CNE, Anne Z. Cockerham, PhD, APRN, CNM, WHNP-BC, CNE, and Joanne M. Keefe, DNP, MPH, APRN, FNP-c, CNE

More Than Healthcare Providers: Nurses as Friends and Neighbors

The bond between the FNS nurses and the local people extended beyond professional care; it was a relationship rooted in mutual trust and shared survival. The nurses took care of the people in the community by providing essential health services, and the community took care of the nurses, the administrative staff, the animals, equipment, buildings, and properties. Local families assisted the nurses in numerous ways, guiding the nurses to a patient’s home during the night, offering shelter in bad weather, or helping a horse with a problem. Although the families had limited space and resources, they would invite the nurse to share their meal, feed their horse, make room for a nurse to stay overnight if needed, and sometimes giving the nurses handcrafted items.

One particularly challenging problem for both the nurses and families was floods, which could make travel difficult to impossible. One day a flood kept Gladys Peacock and Mary Bristow Willeford from seeing their patients. However, a man knocked on their door to tell them that his wife was in labor. Although his wife had sent him, he told the nurses that he didn’t think they should come because the trip was treacherous. But the FNS rule was that if the husband could get to the nurse, the nurse would get to the mother. And, the nurses wanted to go, they had been seeing the woman for prenatal care and wanted to assist her at birth. The weather prohibited travel by horse, so they set off on foot with the man carrying their saddlebags. Over the next three hours, they walked six miles across newly plowed fields that were knee deep in mud, traversed a rustic swinging bridge swaying above the tumultuous river, and climbed a steep mountainside using tree branches and roots to pull themselves up. When they arrived, they were wet, muddy, their sleeves were ripped, and their arms were scratched. But when they went into the cabin the mother smiled and told them she knew that they would come. The nurses quickly prepared for the birth, and minutes later, a daughter was born and named Mary Gladys after the nurses.

Community members also became an essential part of the FNS workforce, working alongside staff who came from elsewhere. The local people provided essential services such as cooking, cleaning, laundering, caring for the animals and buildings, maintaining equipment and properties, and every other task that needed to be done, enabling the nurses to do their work. Although the skills of the mountaineers were essential, it was also their knowledge of the land, the people, and the animals that kept the nurses safe and made the organization successful.

FNS nurses often developed friendships with community members. The nurses lived and worked centers in the community and were well known to their neighbors who not only received care from the nurses but also watched their comings and goings on their visits to families. As neighbors, the nurses might stop to chat with someone along their route about their health or the weather or who had a baby. FNS Nurse Della Int-Hout, known as Inty, frequently stopped by to visit an older neighbor who was unable to travel to the nursing center. The woman did not believe in germs because she could not see them and Inty had been unable to persuade her otherwise. One day the woman’s granddaughter came to the nursing center to ask for a pair of ‘old-age’ glasses for her grandmother. Inty put several pairs in a shopping bag and told the girl to tell her grandmother to try on each pair and then attempt to thread a needle so she would know which pair was best. When the girl returned with the leftover glasses she told Inty that her grandmother was very pleased with the glasses and had told the girl to tell Inty that she ‘can now see a germ’.

Leaving The Community with a Heavy Heart and Resettling Elsewhere

The FNS stayed in their original Eastern Kentucky community far longer than many other independent visiting nursing services remained in their communities. Although the FNS provided nursing services in the community for 86 years, changes in healthcare and market forces led to the closure of the nursing service in 2011. After the closure of the nursing service, Frontier Nursing University leaders worked to remain in the Eastern Kentucky community, but the challenges became insurmountable with providing enough student and faculty housing, proximity to airports and expressways, and the need for larger modern facilities to provide optimal student learning experiences. It was with a heavy heart that university leaders decided to leave its Eastern Kentucky neighbors, buildings, and properties to resettle in Versailles, Kentucky. Rightfully, the FNS deeded the original buildings and properties to the community that helped build and maintain them for almost a century.

Although the experiences of the original FNS nurses and staff in its original location can never be replicated, the experiences of the nurses and their community live on in the stories of the Frontier Nursing Service. Those stories provide inspiration and guidance to current students and faculty on how to enter a community, build relationships and trust, and create a nursing practice that meets the unique needs of the community. Although modern students no longer face the rugged and remote environment that the early nurses confronted, current students face different challenges and new frontiers in healthcare. The stories of the past also inform the university on how to resettle in its new community and build relationships with its new neighbors. Finally, the stories of the FNS constitute a remarkable part of American nursing history and should be told as an example of the very best that nursing has to offer and what can be accomplished when nurses work closely and respectfully with the community they serve.

Read the Nurses on Horseback and the People They Served: A Community of Caring and Collaboration series on our blog.

The Nurses on Horseback and the People They Served is a three-part series covering the history of Frontier Nursing University. On the rugged hills of Eastern Kentucky, nurses earned trust by listening, learning from local families, and standing beside them in moments of illness, birth, and crisis. Over time, this collaboration improved health outcomes, reduced maternal and infant mortality, and strengthened the well-being of the community they served.

By Janet L. Engstrom, PhD, APRN, CNM, WHNP-BC, CNE, Anne Z. Cockerham, PhD, APRN, CNM, WHNP-BC, CNE, and Joanne M. Keefe, DNP, MPH, APRN, FNP-c, CNE

Trusting the Nurses to Provide New Types of Care and Treatments

A major challenge for the FNS nurses was building enough trust with the community so that they would accept unfamiliar treatments such as vaccines. At the time, typhoid and diphtheria outbreaks were common and both were important causes of illness and death in children and adults. When there was an outbreak of typhoid fever in one community, two nurses were sent to the area to vaccinate as many people as possible. Although the community members had already gathered when the nurses arrived, no one stepped forward to receive the injection. Finally, one brave man understood the dilemma and stepped forward to be vaccinated and then brought his children to the nurses to be vaccinated. Everyone else followed. The next day the nurses administered 140 vaccines and by the end of the week, the entire community was vaccinated.

While many people welcomed the nurses’ care for illnesses and injuries, some were reluctant to use the FNS nurse-midwives to attend their birth. Families often had pre-existing relationships with the local midwives and continued to have them attend their births. However, the local midwives did not provide prenatal, postnatal, or infant care, so the FNS nurses provided these important services regardless of who would attend the birth. During the first year of the service, the nurses attended only 30 births, and it would take several years to before they attended most of the births in the area.

Another important way of building trust in the community was to demonstrate respect for the local people’s tradition and wishes, which sometimes conflicted with the standard nursing procedures. When one nurse was attending a woman during labor, a chicken kept jumping on the woman’s bed. When the nurse tried to ‘shoo’ the chicken off the bed, the mother asked the nurse to let the chicken stay because the chicken gave them an egg every day. Eggs were an important part of the mountaineer’s diet, so the chicken stayed and laid her egg, and then the mother gave birth to a healthy baby.

Opening Their Lives to the Nurses and Guests

Many families supported the work of the FNS by allowing people from outside their community access to their lives for the purposes of documentation, marketing, and fundraising. Since much of the money needed to run the FNS came from donations from outside of the mountains, the stories of the nurses’ work and the people they served had to be told and shown to the outside world. Thus, families were asked to allow people from the outside to visit their homes, eat dinner with the family, and even sleep in their home. The families allowed their stories and pictures to appear in magazines, books and films. The sharing of their personal lives as well as their space with visitors was a great gift as many families sacrificed their privacy, their limited food sources, and precious space in their small homes.

Another demonstration of trust was when Nurse Mary Bristow. Willeford collected research data for her dissertation. Willeford surveyed families in the FNS service area asking personal questions about all sources of income and every type of health-related expense. Such questions could only be asked and answered because Willeford had worked and lived among the families and was a trusted nurse and community member.

The Nurses on Horseback and the People They Served is a three-part series covering the history of Frontier Nursing University. On the rugged hills of Eastern Kentucky, nurses earned trust by listening, learning from local families, and standing beside them in moments of illness, birth, and crisis. Over time, this collaboration improved health outcomes, reduced maternal and infant mortality, and strengthened the well-being of the community they served.

By Janet L. Engstrom, PhD, APRN, CNM, WHNP-BC, CNE, Anne Z. Cockerham, PhD, APRN, CNM, WHNP-BC, CNE, and Joanne M. Keefe, DNP, MPH, APRN, FNP-c, CNE

The centennial of the founding of the Frontier Nursing Service (FNS) offers the opportunity to reflect on the work of the nursing service and celebrate what was accomplished by the nurses and the community they served. Despite living and working in one of the most rugged, remote, and impoverished areas of the United States, their collaborative efforts significantly reduced maternal and infant mortality to lower than state and national rates. Their work also significantly improved child health and well-being, and the overall health of the community. Exploring how the nurses and their community accomplished these remarkable outcomes offers valuable lessons for health care providers today. This article reviews how the FNS built relationships and trust with the community and how together they created an effective and successful healthcare organization and university. 

Building Relationships and Trust with the Community

When the FNS decided to settle in Leslie County, the organization had to carefully build relationships and trust within the community. The process began by surveying the area to determine the existing health needs and resources. Mary Breckinridge spent the summer of 1923 riding through the most remote areas of the mountains, meeting families, talking to people about their health needs, and speaking with the local midwives who served the local families. Two years later, another survey was conducted to obtain a current census of the county and determine baseline birth and death rates. Two nurses were part of the survey team, and although their job was to complete the census, the head of the survey team noted that “it was perfectly wonderful how they managed to give advice, bandage sores, bathe wounds . . . while traveling rapidly from one house to another gathering statistics.”

This early demonstration of the nurses’ willingness to provide care regardless of the circumstances laid the foundations of trust in the community. Indeed, community members offered land, lumber, and labor to bring more nurses into the area.

Another important step in connecting with the community was the creation of the Kentucky Committee for Mothers and Babies to establish a plan for reducing maternal and infant mortality and improving public health. Once the plan was formalized, the next step was to develop the first local committee in Hyden, where the nurses would begin their work. The local committees were responsible for the nursing center in their area and played an important role in the operation of the center. This decentralized approach allowed community members to tailor the work to meet the specific needs of their area.

After the committees were established, the FNS rented a building in Hyden to use as a clinic. The nurses planned to begin gradually, focusing first on converting the building into a clinic. However, many people came to the clinic and requested home visits for illnesses, injuries, and pregnancies. By the end of their first month, the two nurses had completed 561 visits for 233 patients and attended four births. Once the Hyden nursing center was established, the FNS needed to build district nursing centers to meet the needs of people in the more remote parts of the county. The building of these district nursing centers required extensive collaboration between the FNS and the community. Each community had to commit to building and supporting the nursing center, donating the land, materials, and labor for the center’s construction.

The first district nursing center was built at Beech Fork in 1926. Two nurses, Gladys Peacock and Mary Bristow Willeford, were assigned to oversee the construction of the nursing center. The nurses protested the assignment, stating that they knew nothing about construction, but Mary Breckinridge told them that they would learn. When they arrived at the construction site on the first day, the man in charge asked them what they wanted to do about the sills—the wooden beams that serve as the foundation of a building. Neither nurse knew what sills were, but Willeford respectfully asked the man what he would recommend doing about the sills. He explained how the sills should be positioned on the land, the type of lumber that should be used, and where the lumber could be located.

For every decision thereafter, the nurses responded with the same respectful question: “And what would you suggest, Mr. Hoskins?” The builder must have known that the nurses had no knowledge of construction, yet he walked them through the process, teaching them about construction and preparing them to build four more nursing centers.

The “learning” that Breckinridge had promised the nurses was achieved through their respectful acknowledgment of community members’ expertise and their willingness to accept guidance.

Beyond the work of building the nursing centers and volunteering to serve on local committees, community residents were often called upon to help the nurses transport sick or seriously injured patients to the hospital. Such transport often required carrying a person down or over a mountain using a makeshift stretcher, or placing someone in a boat and rowing to the hospital. Because the nurses always stayed with the patient, local people took care of the nurse’s horse and moved it from one location to another so the nurse could continue her work or return home once the patient was stabilized.