CULTURE AND THE PROVISION OF CARE: FRONTIER NURSING SERVICE 1925-1940 by Barbara Ann Criss A dissertation submitted to the faculty of The University of Utah in partial fulfillment of the requirements for the degree of Doctor of Philosophy Department of Nursing The University of Utah August 1988 THE UNIVERSITY OF UTAH GRADUATE SCHOOL SUPERVISORY COlVIlVIITrrEE APPROVAL of a dissertation submitted by Barbara Ann criss This dissertation has beel! read by each melllber of the following supervisory committee alld by majority vote has been found to be satisfactory. Chair: Patr �cia C. Albers Ronald G. Coleman 19t 7 IfI THE Ur\!VERSITY OF l'TAH GRADUATE SCHOOL FINAL READING APPROVAL To the Graduate Council of The Universitv of Utah: Barbara Ann Criss I have read the dissertation of in its final form and have found that (1) its format, citations, and bibliographic style are consistent and acceptable; (2) its illustrative materials including figures, tables, and charts are in place; and (3) the final manuscript is satisfactorr to the Supervis­ ory Committee and is ready for submission to the Graduate School. J / rl·I · f� Chairpenon. Supervisory Committee Approved for the Major Department Linda K. Amos Chairman I Dean Approved for the Graduate Council B. Gale Dick Dean or The Graduate School Copyright © Barbara Ann Criss 1988 All Rights Reserved ABSTRACT The purpose of this ethnohistorical research was to study the first fifteen years of the Frontier Nursing Service in Hyden, Kentucky, the years 1925 to 1940. This time span was chosen for several reasons. First, the founding of the Kentucky Committee for Mothers and Babies (the name was changed to Frontier Nursing Service in 1928) occurred in 1925. Second, by 1940, the agency had met the challenges posed by three major events: the devastation of ,the economy caused by the depression and drought of the thirties, the return of the British nurse-midwives to their homeland and the closure of nurse-midwifery educational programs to foreign nurses upon that nation's entrance into the Second World War, and finally, the opening of the Graduate School of Midwifery at Frontier Nursing Service. This study began with several basic questions. What caused the founder of the Frontier Nursing Service, Mary Breckinridge, to initiate a health care agency? For what reasons did nurse-midwives go to work at Frontier Nursing Service? What were the early work experiences encountered at Frontier Nursing Service? What were the responses of public agencies to the establishment of a philanthropic work to deliver health care? Perhaps, most significantly, what was the status of health care at the time, and specifically, what role did establishment of a philanthropic nursing service play in the broader issue of health care delivery? This research examined these aspects and integrated these findings with the data available from other studies and sources and synthesized this material into an ethnohistorical framework. The findings may be used to analyze, plan for or implement health care delivery systems. The study demonstrated the significance of economic, social and political factors upon the health care delivery system and had as its goal contributing nursing knowledge in the specific area of health care delivery. v TABLE OF CONTENTS ABSTRACT. • iv LIST OF TABLES . viii ACKNOWLEDGEMENTS • ix Chapter I. INTRODUCTION • 1 Selected Nurse-Midwifery History. • 4 Opposition to Nurse-Midwifery. · 9 The American Social Context: The 1920s .27 II. MARY BRECKINRIDGE: The EARLY YEARS • 35 The Work in France. • • • 48 The Service: A Window to the Future • · 59 III. FRONTIER NURSING SERVICE: THE FOUNDING. 63 The Financinq of the Work of the Service. • 66 Public Fundinq. 69 IV. THE WORK OF THE SERVICE • • 87 The Daily Work • • • . • • 87 Manaqinq Complicated Patients • 94 Concern for the Staff. • 97 The Emphasis on Education. .103 The Locale of the Work • 105 Staff Motivation for cominq • • .108 The Uniform . • . • • • 110 The Time of the Nurse-Midwife 112 Emphasis on statistics 114 Early Fundinq • • • • • • • • 117 The Use of Nurse-Midwives in Kentucky. 120 The Nationality of the Staff • 128 The First One Thousand Deliveries • 129 V. ECONOMIC CONTEXT • 136 The Depression and Drouqht of the Thirties. .145 Salary Deferments • • 156 A Health Care Demonstration . 165 VI. THE FNS STAFF AND THEIR RELATIONSHIP TO NURSING ROLES TODAY. 168 VII. LESSONS FOR TODAY - RESEARCH FOR TOMORROW. 187 The PhilosophY of the Service and of Nursing. 194 Appendices A: METHODOLOGY. • 205 B: DOCUMENTS. .219 REFERENCES. .261 vii LIST OF TABLES Table 1. Breckinridge Adaptation of Nightingale Model of Nursing Education and Nursing Practice. • 171 ACKNOWLEGMENTS To my committee I have a sense of personal indebtedness that can only be fulfilled by the contribution of this piece of work to the body of nursing research. Each member has made unique contributions to my research and to the more difficult task of interpreting the data revealed by that research. I have particular comments to make about the importance to me of the contribution of each member and how they challenged my intellectual endeavors in individual ways. Dr. Peter Morley had that most difficult task of creating and supporting an environment that cultivated the unique universe of this study. Of equal importance to me were his insightful comments that positioned all events, both those occurring in the educational setting and those related to the research, in perspective and that helped me keep not only my focus but also my sense of humor. No study would have been worth the loss of that component of my world view. Dr. Ronald G. Coleman contributed from the earliest days of his involvement in this study by continually asking me to be self-reflexive. Whether his sagacious words were suggesting ways to proceed with the actual process of research or helping me examine difficult areas of interpretation, they were valued. At one point, when I was bitterly disappointed by a research finding that answered one of the initial questions, I wanted to quit. Dr. Coleman gently suggested that I might need to acknowledge my own prejudices; th~t I not let them influence my interpretation of this finding and that I utilize this knowledge in the examination of the data of the study. It was a painful time. The advice served me thenceforth and I trust will not be forgotten in the future. Dr. Pat Albers listened from the first moment I mused about conducting research of this Nursing Service. She shared my good news of being permitted access to the Service and archival data. She listened as attentively when my considerations were unclear as when they were well-organized. That seems to me a highly undervalued contribution to a student's growth--the notion of being able to try all ideas, the well-considered along with the insubstantial, in dialogue with one's professor. It served my thinking well to be able to verbally explore ideas. This seems so rarely permitted within academic settings. Dr. Alber's pragmatic knowledge of the type of archival material with that I would be dealing provided anticipatory guidance that made it possible to effectively use the time in the Appalachian Archives. Dr. Theresa Overfield's sense of humor and x perspective and unswerving faith in the contribution of this research to nursing was a steadfast influence. I'll not forget her particular expenditure of time, her ability to communicate confidence in a nurse's ability to conduct research in a tangential area, nor her confidence in the calibre of that effort. Her commitment to rigorous research, her confidence in the product of that research and her support of nurses undertaking such research are extraordinary. Dr. Jan Thompson has had that most difficult, yet most essential task, that of the offsite consultant. The contribution of the offsite member seems critical in the relatively new universe of nursing research. The quality of this work was certainly favorably influenced by telephone conversations with her and by her written comments on the material. Dr. Thompson has such personal dedication to rigor and integrity in any approach to an examination of matters of nursing's philosophic and historical roots that this judgment is conveyed to those blessed enough to have her as a mentor. To see commitment to intellectual rigor conveyed in such an integrated construct provides a role model for lifelong commitment. There is a personal debt owed by me in the writing of this dissertation to the following former and present Frontier Nursing Service nurse-midwives. They are Molly xi Lee, Dr. Gertrude Issacs, Joan Fenton, and Ruth Blevins. They participated in the formulations that evolved into the chapters dealing with the roles of the Frontier Nursing Service staff nurse-midwives. They bear no responsibility for any weaknesses but deserve all the credit if this is a worthy interpretation of the place of the Frontier Nursing Service nurse-midwife in the expanded role of nursing. The most unpleasant feature of writing has been the decision to delete hundreds of pages because the material did not directly relate to the years selected for this study, the years of 1925 to 1940. The majority of oral interview data I collected was withheld for that reason. It is hoped a future researcher will write a scholarly biography of the life of this spectacular woman who founded the Frontier Nursing Service, Mary Breckinridge, for her accomplishments merit no less recognition than that accorded her grandfather John C. Breckinridge. Most importantly, I give thanks to my family and friends who made the many contributions with which the completion of this work became a reality. My family have encouraged in many ways. Thanks are due friends Essie White Face, Linda Pavel, Cherryi Povey, Chris Jones, Bob Jones and Shirley Tapio.