History, Organization and the Changing Culture of Care : An Historical Analysis of the Frontier Nursing Service

Mary Breckinridge established the Frontier Nursing Service (FNS) in a poor, rural, underdeveloped area of the Appalachian Mountains of Eastern Kentucky in 1925 and in so doing, marked the first effort to professionalize midwifery in the United States (US). Since its inception in 1925, the FNS has survived many challenges and still exists today. This historical analysis of the FNS' s 'early years' (1925-1960) yields valuable insights into not only on how such a remarkable feat was achieved but also on how these insights could benefit nurses today. The contemporary nursing profession is struggling with many of the same internal and external environmental forces that challenged those 'early nurses.' In keeping with the fragmentation approach to cultural analysis, the FNS' s culture is explored in this thesis and its formation as a community/people-focused organization at a time in history when the nation was moving toward a corporate/consumer-focused society is examined. The political implications for the FNS and its founder as the Service negotiated its place in both Appalachian and wider-society; the lack of clarity and disruptions that developed within the organization with regard to its move from a decentralized to centralized power structure and resultant relational transformation within its community; its work environment, nurse-physician relationships, educational environments, nurse recruitment and retention practices and public image are then examined. The oral history narratives ofFNS nurses and non-FNS nurses currently in practice as well as nurse and non-nurse FNS staff and community members have been employed in the study to build as complete a picture as possible of the FNS, the nurses who worked within it and the culture of nursing. The critical threads which emerged in relation to nursing's chronic recurrent recruitment problems include: retention, work environment and public image. These 'crisis issues' are woven throughout the wider socio-economic, political and health care agendas of US national culture. This cultural change has gradually intruded into Eastern Appalachia and is still reflected in the narratives of nurses in practice today as reported here. A more comprehensive, albeit complex, set of insights to nursing's ongoing crisis includes consideration that the profession has inherited a culture that has proven to be selfdefeating as it has perpetuated many of the corporate cultural traits that can be seen to be incongruent with its professional identity and goals. The continual crisis issues commonly cited as causes of 'nursing shortages' are not created solely by those barriers which exist external to the profession, such as a lack of political power, funding or even the institutionalization of health care. They are also being perpetuated by the profession's inability to deal with the barriers inside the existing culture. The question emerging from this analysis of the FNS and which needs to be posed to the profession as a whole is: "Has the embracing of institutional identity (namely, the business and medical models) within the nursing profession, its higher education and practice settings impeded the discipline's ability to impact more successfully for sustained, positive change within these environments?" In order for sustained positive change to occur nurses must be willing to unveil those barriers within the profession itself that deal with the very basic question of professional identity. This historical analysis supported by the oral history testimony offered within this thesis offers some insights into how this question might be further explored