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Holding on to the Star: Celebrating 100 Years of the Frontier Nursing Service is a three-part series covering the history of Frontier Nursing University. In this series, we explore the Frontier Nursing Service’s history from 1925 to 2025 through a chronological journey, highlighting the enduring themes that capture both the core mission that FNS stakeholders have consistently embraced, and the many ways that the service has changed.

Pressing Need for an Innovative Educational Shift

Throughout the 1970s, challenges intensified for the Frontier School of Midwifery and Family Nursing. Decreasing births, diminished overall population numbers in the area, faculty shortages, and financial constraints conspired to cause FNS leaders to consider closing the school. Midwifery students struggled to access enough births to meet graduation requirements, and a 1972 report from the American College of Nurse-Midwives’ site visit to Frontier confirmed the situation.

While effusive in its praise for the program’s ability to provide “comprehensive health services to the most isolated families in Appalachia,” the report documented that a weakness of the program was the insufficient number of intrapartum clinical experiences. To mitigate these problems, FNS leaders arranged for students to travel out of the area to gain the required clinical experience with births. But by 1980, the situation was becoming more dire. FSMFN Dean Lydia DeSantis was forced to notify prospective students that they would not be able to begin their graduate program as planned in the fall of 1980.

Many stakeholders actively resisted the idea of closure, in large part due to the unique nature of the education Frontier provided. The school’s dean expressed this sentiment in the Winter 1980 Quarterly Bulletin: “Our school has the only program in this country that prepares registered nurses as both family nurse practitioners and nurse-midwives. . . [our school’s] offerings. . . have been enormously successful and well-received, especially the Family Nurse-Midwifery Program. . . graduates of the school are in constant demand; 94% are presently employed in rural areas, and most are functioning in primary care settings. Rural primary care has always been a major objective of the FNS, and one of the most pressing health care needs in this Country.

In 1989, an innovative structural change in the school allowed the FNS to continue its commitment to graduate nursing education despite the changes in the service’s eastern Kentucky historical home area. Led by Kitty Ernst (a 1951 graduate of the Frontier Graduate School of Midwifery) and funded by the Pew Foundation, the Community-Based Nurse-Midwifery Education Program (CNEP) began as a pilot project. CNEP’s goal was to increase the number of practicing nurse-midwives working in underserved areas. The structure of CNEP would enable nurses to remain in their communities while obtaining graduate education as nurse-midwives by completing most of their didactic work at a distance, first by mail and phone and then online as technology evolved. Clinical experiences would be in students’ home communities.

Prospective students and FNS leaders embraced the concept. CNEP’s first class of seventeen students met to begin their program in April 1989 in Perkiomenville, Pennsylvania. This experience, modeled after the successful team-building program, Outward Bound, was called Midwifery Bound. In a June 1990 alumni newsletter, Kitty Ernst reported that 1,200 nurses had expressed interest in the program that year and that a second class of forty students had been admitted. Also in 1990, the FSMFN officially recognized that the CNEP model of education matched its own goals and mission. The President of the School and the Board of Governors voted to officially adopt CNEP as its nurse-midwifery education program in 1991.

In addition to being a practical solution to the challenges of residential education based in Hyden KY, CNEP allowed for a different type of emphasis on rural health. The flexible, innovative, decentralized approach allowed students to remain in their communities throughout their education and, importantly, after graduation. Maintaining an explicit focus on rural health despite this change in education program structure meant that the re-envisioned school could prioritize the education of rural-dwelling students who would go on to practice in rural areas. Leaders reported that, as of Fall 1991, just two years after CNEP’s inception, 181 students had been enrolled in CNEP and 59% of students lived in rural or semi-rural communities.

In the decade after the distance learning model began, the school continued to grow, beginning with nurse-midwives and then adding family nurse practitioners. Although the FNP track had been placed on hold years earlier, the commitment to education FNPs never waned. In 1999, the FNP track was relaunched as a distance learning program. By Spring 2000, 1,363 students had graduated from the nurse-midwifery educational program and 173 students were currently enrolled and working toward their dreams.

Frontier in the 21st Century

The themes that capture the accomplishments and goals of Frontier stakeholders at the dawn of the 21st century echoed those seen since the organization’s inception in 1925: flexibility and adaptiveness as the organization maintained a focus on rural health, and commitments to graduate education and primary care of families. As FNS leaders, staff, and community members marked the 75th anniversary of the Frontier Nursing Service in 2000, productivity and patient safety outcomes prompted celebration and pride: in 75 years, FNS staff had cared for 414,121 registered patients, attended 24,794 maternity patients for delivery, and recorded 11 maternity deaths.

FNS leaders recognized the importance of seeking regional and programmatic accreditation and becoming a master’s degree-granting institution to keep the FSMFN competitive with other programs. Work began in earnest in 2000 with long hours of diligent efforts by leaders, faculty, staff, and others. By 2004, FSMFN was accredited by the Southern Association of Colleges and Schools Commission on Colleges (SACSCOC) to offer a Master of Science in Nursing, the first hooding of MSN graduates had occurred, and the American College of Nurse-Midwives Division on Accreditation (ACNM DOA) had granted accreditation for the nurse-midwifery program.

After earning accreditation and authority to grant a master’s degree for nurse-midwives and family nurse practitioners, several new educational options for Frontier students followed in quick succession. In 2005, students could choose to earn a Master of Science in Nursing as a women’s health nurse practitioner. In 2007, the Associate Degree in Nursing to Master of Science in Nursing (ADN to MSN) Bridge program launched, allowing students whose nursing degree was an ADN, rather than a Bachelor of Science in Nursing (BSN) to bridge into the midwifery or nurse practitioner program by taking one additional year of courses. In 2008, the first Doctor of Nursing Practice (DNP) students enrolled. Although the school was successful and growing, the Frontier Nursing Service experienced a difficult period between 2008 and 2011. National trends, such as the economic downturn that began in 2008, and private and federal reimbursement challenges for health care contributed to the financial unsustainability of FNS health care entities. In the fall of 2010, 70 employees lost their jobs, and the maternity unit at Mary Breckinridge Hospital closed its doors. In 2011, Appalachian Regional Healthcare, Inc. (ARH) bought Mary Breckinridge Hospital, the home health agency, and FNS clinics. An August 10, 2011, press release described the sale: “as has been the case throughout the country, a number of standalone hospitals are merging with larger healthcare systems in order to continue to be viable and sustainable.” With this sale, the Frontier Nursing Service transitioned to a single focus of educating nurse-midwives and nurse practitioners.

After the separation between the health care entities and the school, changes in the school continued. A major shift happened in 2011 when the Board of Directors approved a name change to Frontier Nursing University (FNU) to better reflect the institution’s scope and status. Since the name change, FNU has continued to expand in alignment with the university’s mission and the major focus dating back to the inception of the Frontier Nursing Service. By 2012, FNU admitted approximately 600 students annually.

In 2017, FNU added a new specialty track, allowing aspiring psychiatric-mental health nurse practitioners (PMHNP) to join the FNU community. FNU leaders and faculty selected the PMHNP from an array of advanced practice specialty options due to the institution’s commitment to providing mental health care, a service that individuals in rural areas often have difficulty accessing.

As the university’s offerings expanded, FNU leaders decided to move its campus from Hyden to Versailles, Kentucky. Although this was a difficult decision due to its historical roots in Leslie County, FNU’s growth necessitated more campus space, access to technology, and centralized administrative and on-campus activities. FNU purchased the 217-acre property in 2017, and construction and renovations proceeded during the next few years. The COVID-19 pandemic caused delays in opening the new campus but by May 2022, all Frontier Bound and Clinical Bound student sessions took place in person on the Versailles campus.

The world looks dramatically different than it did a century ago when the Frontier Nursing Service came into being. Frontier has undergone changes that would make many aspects unrecognizable to early FNS leaders and staff. But as we reflect on the goals and accomplishments of Frontier stakeholders between 1925 and 2025, we can appreciate that today’s leaders, faculty, staff, students, couriers, alumni, donors, and friends continue, in Mary Breckinridge’s words, to “adhere to the principles that gave it being.” Now solely focused, as Frontier Nursing University, on graduate education of nurse-midwives and nurse practitioners, the organization retains its commitment to primary care of the family with a robust family nurse practitioner program, primary care education for all specialty tracks, and a focus on mental health care. Frontier Nursing University continues to address the great needs present in health care shortage areas, particularly in underserved and rural areas. In 2024, 51% of students resided in Health Professional Shortage Areas, 65% in Mental Health Provider Shortage Areas, and 18% in designated rural areas. A crucial factor in the ability of the organization to persevere through changes and obstacles it has faced in the last 100 years is the ability to be flexible and adaptive. We hope Mary Breckinridge would be proud of how the organization has adapted and grown.

More from “Holding on to the Star: Celebrating 100 Years of the Frontier Nursing Service”

Part 1: The First Decade of the Frontier Nursing Service

Part 2: The War Years, Major Changes for the FNS Community at Midcentury, and Family Nurse Practitioner Education

Holding on to the Star: Celebrating 100 Years of the Frontier Nursing Service is a three-part series covering the history of Frontier Nursing University. In this series, we explore the Frontier Nursing Service’s history from 1925 to 2025 through a chronological journey, highlighting the enduring themes that capture both the core mission that FNS stakeholders have consistently embraced, and the many ways that the service has changed. Read part 1 – The First Decade of the Frontier Nursing Service – here.

The War Years

The cataclysmic events of the Second World War in the late 1930s and 1940s caused chaos and devastation for millions of people, including those in the Frontier Nursing Service. FNS leaders addressed challenges during this period by maximizing flexibility, keeping the FNS mission at the forefront, and maintaining a firm commitment to the FNS model of nursing care.

Great Britain’s entrance into the war in 1939 created a dire midwifery staffing shortage for the Frontier Nursing Service. British nurse-midwives comprised nearly the entire FNS staff and with their homeland at war, most departed Kentucky to return to England. FNS assistant director Dorothy Buck described the emotional and practical devastation for the service: “Waiting … in the far-off Kentucky mountains. England, our England! We must go home!…Eighteen of the [service’s] twenty-two nurse-midwives, from Great Britain. . .nurse after nurse left us with regret and with the promise to return when the war is over.”

The FNS lacked a mechanism to replenish its ranks, so opening its own school became a necessity. Quickly navigating obstacles such as shortages of faculty, space, and funds, FNS leaders opened the Frontier Graduate School of Midwifery on November 1, 1939, just two months after England entered the war. The school grew slowly but steadily during the war years, having begun with two students in the first class. The program expanded in 1940, increasing the number of students to three. FNS leaders came to count on their graduates to staff the service. With two classes per year, this gave the school the potential to have six new midwives per year to staff the service, a small but realistically sustainable number for the tiny new school.

Studying midwifery on the rural frontier attracted students looking for adventure but required flexibility and adaptiveness for students and instructors. Student recollections from the initial decades of the school’s existence are chock full of dramatic stories illustrating the environment in which they worked and learned in eastern Kentucky. Given the steep and snow-covered mountain trails, flood-swollen creeks, and rutted roads, many areas were only navigable on horseback. One early graduate recalled pushing away her anxiety as she negotiated the treacherous paths on a dark and icy night. The horses were shod with ice nails and, on the way to a birth, the supervisor’s horse ahead of her gave off sparks. This sight helped the student feel reassured that, although she couldn’t see her supervisor’s horse ahead of her, it was there. The sure-footed horses also helped the nurses navigate the miles of trails, sometimes swimming across the swiftly flowing rivers that lay between the nurses and the patients’ homes.

Major Changes for the FNS Community at Midcentury

Significant societal shifts during the 1950s and 1960s dramatically affected the experiences of Frontier nurses and graduate students and changed the lives of the individuals and families the FNS served. These shifts required FNS leaders, staff, and students to redouble their efforts to remain flexible and adaptive as they continued to serve the community.

Physician unavailability continued to plague the FNS, and nurses sometimes provided care without a service Medical Director or any other physician whom the nurses could summon in an emergency. To handle problems, nurses often relied solely on written standardized protocols, termed Medical Routines, and consulted with the physician afterward, long after the situation had been resolved. The lengthy 1958 search for a medical director demonstrated that the challenges were not solely due to physicians’ choices about where to live: the norms of physician training practices by midcentury evolved to be misaligned with medical practice in rural areas. FNS leaders conveyed to readers of the Autumn 1958 Quarterly Bulletin that “No doctor can be responsible for a rural hospital and vast field of work who has not had residencies in either surgery or obstetrics-gynecology. [The] trend toward early specialization…is so marked today that doctors who have had as much as two years residency in either surgery or obstetrics-gynecology want to carry on with the specialty and go to the cities…”

Another major societal shift that affected the daily lives of FNS nurses and community members was the transition from home to hospital births. Nationwide, this trend had been increasing throughout the twentieth century. FNS leaders and nurses had resisted the national trends and continued to encourage home birth in specific circumstances. However, around midcentury, the number of FNS home births dropped dramatically. Diminishing home births changed the nurses’ and students’ routines by spending more time at the hospital and less time in patients’ homes. As time went by, students cherished the increasingly rare opportunity to attend a home birth: a 1966 graduate recalled that she was one of only two students in her class who was able to attend a home birth.

Increasingly widespread use of contraception represented another change during the 1960s that affected the lives of FNS patients and students. Reflecting the nationwide birth control movement, FNS leaders established an official family planning program in 1961 with access to oral contraceptive pills and intrauterine contraception. In a short time, the average size of families in the FNS territory decreased markedly and Leslie County’s birthrate decreased by almost 50% between 1959 and 1968. FNS publicity materials of the time reported, “The Medical Director and the nurse-midwives conduct a family planning program which is well accepted by the community and shows excellent results. The pill and IUDs are used successfully, resulting in a lowered birth rate in a county which, up until very recently, had one of the highest birth rates in the country. The parents of today are happily learning to space their children.” The decreased birth rate resulted in an unintended consequence for the FNS: fewer births for FNS nurses to attend and more difficulty for midwifery students in obtaining the requisite number of births to complete their course of study. This shift would lead to a major upheaval in the Frontier graduate school in upcoming years.

Family Nurse Practitioner Education

In the mid-1960s, nursing education and practice changes elsewhere in the nation would result in major effects on the FNS graduate school. In Colorado, Loretta Ford and Dr. Henry Silver founded a novel education program to prepare nurses to provide advanced nursing care of children as pediatric nurse practitioners. FNS nurses immediately recognized Ford and Silver’s model of care because FNS nurses had been providing this type of advanced nursing care for four decades. In addition to maternity care, FNS staff and students had been caring for all members of families through acute and chronic illnesses, injuries, and preventive care needs. Skilled in applying the Medical Routines, FNS nurses knew when care fell within their training and when consultation with or referral to a physician was indicated.

Thus, when FNS leaders learned of the pediatric nurse practitioner education program, they immediately considered adding a nurse practitioner education program at Frontier. A family nurse practitioner program was aligned perfectly with the FNS mission to improve the health of rural-dwelling individuals and families. After a management consultant firm studied the issue in 1969, the firm recommended that the FNS graduate school expand its offering to include comprehensive family nursing.

Planning and implementation proceeded quickly. Helen Browne described the aim of the family nursing programs: “to develop the team approach with the physician and the nurse working closely together so that the families would have well-coordinated continuity of care.” They intended to “bridge the gap that exists between the traditional role of medicine and nursing.” Indeed, as Browne noted, there was “a defined need for a new breed of family nurse practitioners – a sophisticated, knowledgeable, clinically and theoretically oriented group of professionals.” FNS faculty welcomed the first four students into the FNP program on June 15, 1970.

With the addition of the FNP program, the FNS ushered in a new era of growth and service to the community, rural health care, and the nursing profession. As the first FNP students began their studies, the name of the school changed from the Frontier Graduate School of Midwifery to the Frontier School of Midwifery and Family Nursing (FSMFN) to reflect its broadening educational role. As the school catalog noted, the FNP would be “a blending of nursing with selected medical and public health functions.” The traditional nursing role would be expanded to include “basic diagnostic, treatment and preventive skills . . . so that FNPs would be able to provide assistance to families, whether they be living in Appalachia, inner cities or developing countries. . .” The new program fit with the school’s original mission. During the 1970s, the FNP program grew rapidly, and applicants sometimes waited more than a year to be accepted because of the sheer number of nurses interested in a combined midwifery/FNP program or one of the two tracks.

Next: Pressing Need for an Innovative Educational Shift and Frontier in the 21st Century

“We have come a long way since our work began…We hitched our wagon to a star then, and when we traded wagons for trucks, we held on to the star. The heart of our work has lain in its start with things as they were and its acceptance of the laws of growth. In planning for future growth, the Frontier Nursing Service still adheres to the principles that gave it being.”

Mary Breckinridge wrote the words above in her autobiography, Wide Neighborhoods, describing the evolution of the Frontier Nursing Service. A key factor in the service’s success had been pragmatism and a willingness to change when circumstances dictated, all while holding on to the star of the service’s core mission. Although Wide Neighborhoods was published only a few decades after the founding of the Frontier Nursing Service, the sentiment holds true today as we celebrate the service’s 100th anniversary.

In this article, we explore the Frontier Nursing Service’s history from 1925 to 2025 through a chronological journey, highlighting the enduring themes that capture both the core mission that FNS stakeholders have consistently embraced, and the many ways that the service has changed. Indeed, whether we examine FNS leaders’ and staff members’ goals and accomplishments in the early years or recent years, we see throughlines of a focus on rural health, a dedication to primary care of the family, a commitment to graduate education of nurse-midwives and nurse practitioners, and flexibility and adaptiveness in navigating obstacles.

The First Decade of the Frontier Nursing Service

From its start in 1925, the Frontier Nursing Service prioritized rural health care. Mary Breckinridge had sought a remote service area for her health care project, largely due to the enormous unmet needs of rural-dwelling people. Reformers had focused on improving the health of city dwellers, particularly urban children, during the Progressive Era years of 1890-1920, but as Breckinridge pointed out, “remotely rural children had been neglected.”

Although FNS leaders and staff were deeply committed to caring for rural people, the remote nature of the service area created challenges. Frontier nurses faced extreme difficulties, including obstacles to reaching and caring for their patients given the treacherous mountainous terrain, unpredictable weather, a nearly nonexistent road network, access to clean water, and adequate lighting. The FNS’s rural setting also limited access to physicians to care for patients with complicated medical needs. Few doctors chose to live and work in such a remote area. Scott Breckinridge, Mary Breckinridge’s cousin and prominent physician, provided several reasons in a 1931 letter to the editor of the Lexington newspaper: “The raising of the standards of medical education and the increasing need of laboratory and hospital facilities for the satisfactory practice of medicine creates difficulties persuading qualified practitioners to locate in isolated communities where those facilities are lacking and where the returns for the services rendered are, at best, most meager.”

A rural focus conferred important advantages as well as challenges for the FNS. Remoteness contributed to an image of the service that enhanced fundraising and staff recruiting. A romanticized version of the FNS’s rural environment allowed potential donors and staff members to return vicariously to an idyllic, bygone era. In fact, Breckinridge referred to her trips between remote eastern Kentucky and the large cities when she attended meetings of the volunteer committees as “commuting between centuries.” The rugged, rural eastern Kentucky setting also appealed to some nurses who longed to be a famed “nurse on horseback” in a rustic and natural mountain setting. To recruit adventure-minded nurses, Breckinridge penned colorful articles intended for young, public health-focused nurses in the American Journal of Nursing and women’s magazines. Prospective nurses also consumed dramatic tales of nursing care in the Kentucky mountains in publications such as journalist Ernest Poole’s widely read 1932 book Nurses on Horseback.

From the earliest years, FNS leaders and staff maximized flexibility and developed strategies to cope with the rural setting and other challenges. Gaining insight from rural health providers in other areas of the world, such as the Highlands and Islands Medical and Nursing Service in Scotland, FNS leaders designed a specific geographic distribution of staff and facilities. Breckinridge explained, “The principle of organization in a remotely rural field of work is one of decentralization. In such a country time and not mileage is the factor involved in daily travel and in all emergencies. It is not a question of the patient’s distance from his nurse but of how long it takes her to reach him.” By delineating districts with the nurse at the center and considering natural arteries of travel, nurses could generally reach any patient in the district by horseback in less than an hour.

FNS leaders developed the Courier Service as a creative and adaptive strategy to address another challenge, nearly constant budgetary shortfalls. Couriers played an important part in keeping the FNS solvent and running smoothly. Many couriers were college-aged daughters and nieces of FNS donors and committee members and stayed on-site for 6-8 weeks, volunteering their time to care for horses, ferry messages and supplies, escort visitors around the FNS territory, assist nurses, and much more. The couriers’ work benefited the FNS by providing thousands of hours of unpaid work each year. Additionally, former couriers became lifelong advocates for Frontier, an even more far-reaching benefit of the courier program. Seeing the service’s work up close allowed the couriers to return home as effective ambassadors for the Frontier Nursing Service and to tell their friends and family members of the work being done in Kentucky. Couriers took the FNS message out of the mountains and strengthened long-lasting ties between donors and the FNS.

Although Breckinridge founded the Frontier Nursing Service for the initial purpose of caring for mothers and babies, the pressing need to care for the entire family became apparent immediately. Primary care and public health initiatives quickly rose to the same level of importance as maternal-child care. Before the FNS established itself in the area, community members had little access to modern systems of acute or preventive care. FNS nurses quickly set up comprehensive public health programs focused on sanitation, vaccination, health education, and care for many types of illnesses and injuries. The health care needs were great as individuals and families suffered from the effects of numerous infectious diseases such as typhoid fever, dysentery, measles, scarlet fever, whooping cough, tuberculosis, pneumonia, and hookworm. Families, especially children, suffered from malnutrition and vitamin deficiencies because their diet was generally limited to what they could grow, raise, or hunt. Other serious health concerns included injuries from logging and mining accidents, snakebites, gunshot wounds, and more.

Part 2: The War Years, Major Changes for the FNS Community at Midcentury and Family Nurse Practitioner Education

Part 3: Pressing Need for an Innovative Educational Shift and Frontier in the 21st Century