xt7r4x54gm04 https://exploreuk.uky.edu/dips/xt7r4x54gm04/data/mets.xml The Frontier Nursing Service, Inc. 1972 bulletins English The Frontier Nursing Service, Inc. Contact the Special Collections Research Center for information regarding rights and use of this collection. Frontier Nursing Service Quarterly Bulletins Frontier Nursing Service Quarterly Bulletin, Vol. 47, No. 4, Winter 1972 text Frontier Nursing Service Quarterly Bulletin, Vol. 47, No. 4, Winter 1972 1972 2014 true xt7r4x54gm04 section xt7r4x54gm04 U
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RRUNTIER NURSING SERVICE QUARTERLY BULLETIN .~‘
Published at the end of each Quarter by the Frontier Nursing Service. Inc. I
Lexington, Ky. 2
Subscription Price $1.00 2. Year "
Editcr's Office: \Vem10vcr, Kentucky
VOLUME 47 SPRING, 1972 NUMBER 4 E
Second class postage paid at Lexington, Ky. 40507 I
Send Form 3579 to Frontier Nursing Service, Wendover, Ky. 41775 3
Copyright, 1972, Frontier Nursing Service, Inc. T
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E coNTENTs
i % ARTICLE AUTHOR PAGE
A Wet Spring 10
{ Annual Meeting 34
' Beyond the Mountains 36
[ Field Notes 39
f In Memoriam 30
s Old Courier News 19
A Old Staff News 25
E Someone Cared Esther Mack 23
g The Board of Governors of
L Frontier Nursing Service (illus.) 17
"The Cabin" at Wendover A Photograph Inside Back
- Cover
The Family Nurse and Primary
‘ i l Health Care in Rural Areas Gertrude Isaacs 3
The Sun Is Gone Down (verse) George McDonald 2
Urgent Needs 12
Q BRIEF BITS
Babes and Sucklings The Countryman 24
Bicycle Parts for Two The Countryman 35
College Qualifications! Modern Maturity 18
Just J okes—Chi1dren Contributed 11
(P Mark Twain on the Generation Gap: The Colonial Crier 9
Sign in gift shop: . . . Modern Maturity 29
{ Simple Subtraction The Countryman 43
The Hardest Thing . . . Modern Maturity 22
White Elephant 38

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The sun is gone down, ll
And The moon`s in lhe sl
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‘ QUARTERLY BULLETIN 3
THE FAMILY NURSE AND PRIMARY HEALTH
. CARE IN RURAL AREAS
pl GERTRUDE ISAACS, D.N.Sc.
EDITOR’S NOTE: Presented at Conference on Appalachia and Rural
‘ Health: Problems and Solutions, West Virginia University, School of
Medicine, Morgantown, West Virginia; June 7-8, 1971. This paper will
appear in the forthcoming book entitled RURAL AND APPALACHIAN
HEALTH, edited by Robert L. Nolan, M.D. and Jerone L. Schwartz,
Dr.P.H., to be published in late 1972 by Charles C. Thomas, Publisher,
Springiield, Illinois.
The Family Nurse as a provider of primary health care is
I a relatively new concept in this country. The nurse has, how-
ever, been used in this capacity by the Frontier Nursing Service
for 46 years. The FNS is a comprehensive primary health care
service and training center located in the Appalachian Region
of Southeastern Kentucky. It provides services in Leslie County
. and parts of Perry and Clay. The program is currently being
extended because of the continuing shortage of medical man-
power in rural areas and the growing demand for improved
health services. The Family Nurse who forms the nucleus of
_» the Service is a registered nurse with special preparation in the
Y health field.
. The FNS was developed to meet the crucial needs of rural
Y areas in 1925. The health manpower crisis is not new to the
rural areas. It is only the social cognition which is new. Indi-
viduals like Mary Breckinridge recognized it way back. Her aim
in the beginning was to develop a system whereby health serv-
ices could be made accessible to the people at a price they could
_ afford. The nurse-midwife was selected in the beginning to pro-
\ vide the primary health services. After 46 years experience, she
continues to be the basic professional for many reasons.
ei One, the nurse-midwife has many of the basic skills needed
»* to provide family services, and, given additional training in
diagnosis and management of common health problems, she can
readily extend her services to the total family. Two, the use of
the family nurse helps lessen manpower problems in rural areas.
There are 2-3 nurses to every physician in this country, and
nurses are geographically more equitably distributed than the
physician. This helps reduce the recruitment problem. Three,

4 FRONTIER NURSING smnvicm _
in one year a nurse can be prepared to provide primary health ,
care. Therefore, care can be provided at a lesser cost and made l
more accessible to the people. Four, by using the nurse in this ‘
capacity, the physician is freed to use his skill to better advan- 3
tage, and overall health care can be markedly improved.
Five, traditionally the nurse has been trained to be more ·
involved in helping the family cope with the day-to-day problems
of health and illness—primarily a nurturant role. The physician,
on the other hand, has been much more involved in the intrica-
cies of diagnosis and treatment of disease—a curative role. Both
are of vital importance in health services. In underdevoloped
areas, however, the nurturant role is of particular importance
because people in these areas are less well prepared to deal with
the problems of health and illness. The physician tends to get
bored with these problems, while nurses continue to accept this
aspect of care as a challenge. The nurse for these reasons is
particularly well suited for this role. I
Both the role of the nurse and the system in which she A
operates is unique. The system is designed to reach out to the
people; and as stated earlier, the nurse rather than the physician
forms the nucleus of the service. Instead of a big central station
with all the latest modern equipment and specialty services,
where patients may have to travel long distances to receive
health care, the Frontier Nursing Service has a series of very
moderately equipped nursing outposts in the communities where 1
the people live. These outposts are strategically situated. No
family living in a nursing district is further than one hour’s Q
travel time from a primary health center. Each outpost, in turn,
has ready access to the hospital and health center where a resi- »
dent physician is available at all times. He may, if necessary, ..
refer the patient to specialty services outside the area. For
example, a patient may be referred to, or consultation sought M
from, one of the nearby regional hospitals or the University of ..
Kentucky Medical Center, depending on his need. This network v_
makes it possible to provide the best of medical care available
in the state to the most isolated patient in the area. It also I
helps keep primary health care more personalized.
The Frontier Nursing Service has a total of approximately
53,000 outpatient contacts a year. The majority of the patient

` QUARTERLY BULLETIN s
,· contacts, approximately 30,000, occur at the nursing outposts.
Each outpost is staffed by one or two nurses, and a single nurse
A serves an average population group of 200-250 families or 900-
‘ 1000 individuals. Experience has taught us that this is the
maximum load that a nurse can carry adequately, in terrain
· that is as rugged as Leslie County. Half of the visits are made
in the home and half in the nursing clinic at the outpost. Medi-
cal consultation and/or referrals are sought on approximately
a quarter of the patients seen.
The nurse at the outpost is prepared to diagnose and man-
age common health problems in the family, to provide prenatal,
postpartal, and well child care, including family planning, and,
if necessary, do a home delivery. She combines treatment with
‘ prevention and health maintenance skills, and, when indicated,
refers the patient to the physician or other members of the
. health team. She has available to her Medical Directives which
have been developed by the physicians with nursing collabora-
tion. They have the joint approval of both nursing and medicine,
and they provide guidelines regarding the action that a nurse
may undertake in the management of specific conditions, includ-
ing emergencies. They also specify the points at which she must
consult with or refer to the physician.
The physician visits each outpost at least once a month to
review and assist the nurse with problem cases, and to see those
· patients who need medical care but find it difficult to come to
_ the hospital. A Utilization Review Committee, consisting of one
I physician, two nurses, and a social service worker, visits each
1 center every three months to review records and promote sound
' health care. A Held nursing supervisor and a coordinating nurse
“ help to keep the outposts’ services coordinated with each other
H and with the hospital.
"'· The hospital has an ambulatory care center, where a total
’ of 23,000 patients are seen annually. It is operated on the same
l general principles as the nursing outposts, except that a phy-
i - sician is immediately available; and it has more supportive and
` diagnostic facilities and services. Patients are screened by the
nurse who does a preliminary diagnostic work-up to determine
if the condition is one that she can manage with the use of the
Medical Directives, or if medical consultation and/or referral is

6 imowrxma Nunsmc smavxcm
indicated. Approximately half of the general clinic patients are `.
seen by the physician. In the midwifery clinics, which include
prenatal, postpartal, and family planning services, approxi-
mately 12% of the patients are seen by the physician in a given ”<
week. All midwifery patients have a routine medical work-up _
early in pregnancy and are seen by the physician again during ‘
the iinal month of pregnancy. This system permits the physician
to devote more of his time to the care of those conditions which
require his skill. He also becomes more involved in teaching,
consultation, administrative details, and community activities.
A total of 1,900 patients were admitted to the hospital
during the last fiscal year, for an average of 3.1 patient days. .
The hospital has a total of 26 beds and 12 bassinettes. Seven
beds are reserved for midwifery and five for pediatrics. The
hospital averages about 275-300 deliveries a year. Approxi- ·_
mately 95% of the deliveries are managed by the nurse-mid- ,
wives. The nurse-midwife is qualified to assume complete re- I
sponsibility for the care and management of uncomplicated
maternity patients. Obstetrical consultation is sought when
complications arise. The nurse-midwives may admit and dis-
charge patients according to hospital by-laws and regulations. °
The family nurse may also admit patients for nursing observa-
tion and care up to twelve hours according to Medical Directives.
This lessens the demands made upon the physician markedly. _
Major illnesses like major surgery are referred to one of the j
regional hospitals or to the University Medical Center. In these f
situations, the hospital or out-patient department serves as a
primary contact agent. Mental health care is considered an
integral part of the total services offered. Psychiatric patients
are admitted along with the general medical patients and re- "
ferred to the local community mental health center or to the Q
. state institution as indicated. Many of them return home after ‘l
3-5 days of hospitalization, and state institutionalization is thus
avoided. Follow-up care may be provided by one of the nurses l
from the Community Mental Health Center or by one of the i
district nurses. A regional psychiatrist is available to the
county one day every two weeks. When care of the mentally ill i
was discussed and put up for vote at a local committee meeting, _
the members stated that mental health services had never been

QUARTERLY BULLETIN 7
X separated from general care and this should not be changed.
Much of the success of the Frontier Nursing Service is
j attributed to its life-long pattern of local citizen participation.
4* Before Mrs. Mary Breckinridge started the Service, she did an
. extensive survey of the area, visiting the people in the homes
to learn first hand what the major problems were and what the
people wanted. No outpost was built without local participation,
and to this day, each outpost maintains an active local com-
. mittee which participates in local planning and is consulted re-
garding any major changes in the total services offered. They
are also actively involved in fund raising. Of the 154 people
, employed by the FNS, 112 are local citizens. This includes pri-
marily hospital and clinic aides, clerical workers, and mainten-
ance and housekeeping personnel.
f Indigenous health worker programs such as are used in
, many of the OEO projects remain to be deveolepd. In the past,
_ the nurse taught a member of the family to take care of the sick
in the home, and the grapevine system was very effective in
p home health teaching. Family ties are cohesive and it is a rare
occasion when a suitable member cannot be found either in the
A immediate or the extended family to assume this responsibility.
- The pattern is, however, changing. Individuals are beginning to
expect pay for taking care of a family member, and waning
birth rates and an increase in outside jobs lessen the choices
l that are available, and therefore, new patterns will need to be
* established.
5 Currently there is considerable controversy regarding the
I type of worker that would be best suited for the system that
` has been developed by the FNS. To introduce a family health
worker into the system to assist the family nurse at this time
would seem premature. Until the areas of responsibility for pri-
—». marylhealth care provided by the family nurse have been more
clearly defined and legal sanction established, it would only add
é to the confusion.
{ Nursing aides offer valuable services in both inpatient and
1 outpatient areas at the hospital, but attempted use of their
3 services has not been as successful in the districts. The develop-
, ment of clerical assistants, who have been taught some of the
i technical procedures, has been more successful. Several high

s FRONTIER NURSING smzvxcm
school students who have worked in these capacities have gone ·
on for further education, some in nursing and some in secretarial .
work. Few of those, however, return to the area after they com-
plete their training. The use of the indigenous workers is a pos- W
sibility that needs further exploration. Consideration has been
given to the training of a home aide, rather than a health
worker. The difference is subtle but highly significant.
Professional personnel are recruited primarily from the
areas beyond the mountains. Most of them have a very special .
interest in the type of care provided by the FNS, and they come
from all parts of the country. Many have had past experience
in underdeveloped areas, and they bring with them a wealth of ;
knowledge and experience. The FNS currently employs one
physician who has her boards in family practice and vast ex-
perience in group practice; one physician who has his Doctorate
in Public Health and has trained medical assistants in Ethiopia;
one physician with a Masters in Public Health training has been
actively involved in family planning at the international level,
and has had considerable experience in program planning and d
development in rural areas. The nurses come from an equally
varied background. All help to add new dimension to both the
service and the training program. I
The training program in family nursing which is offered Q
at the FNS is an extension of the nurse-midwifery training pro-
gram which was developed in 1939. A total of 360 nurse-mid-
wives have graduated from this program. It is a program that I
has evolved out of need and experience and is service-learning
oriented. It is designed to give students exposure to, as well as I
front line experience with, the day-to-day problems of health I
care in rural areas. It also provides opportunities for testing I
what they are taught. The aim is to add breadth, depth, and
, relevance to their learning. Too many students in this day and IE
age receive their training in a sterile classroom atmosphere, far V
removed from the problems which they need to understand first
hand if they are to handle them effectively.
The program is divided into three trimesters. During the
iirst trimester, they are taught dignosis and management of I
common health problems, family health assessment, counselling,
and utilization of community resources. During the second tri- I
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, QUARTERLY BULLETIN 9
_ mester, they have basic midwifery, prenatal, part postpartum
and child care, and family planning. During the third trimester,
they have the option of taking advanced midwifery, which
ig focuses on intrapartal care, obstetrical and gynecological prob-
lems and management of the newborn; or they may select out-
post nursing which focuses on community health, district man-
agement, and family dynamics and therapy. The physical, psy-
chological, social and cultural aspects of health and illness are
given heavy emphasis throughout the program. Much of this is
through tutorial instruction. Each trimester is 15 weeks in
I length, and students have approximately 10 hours of classroom
instruction and 30 hours of clinical practice a week.
I The program is exciting, and interests in this type of train-
ing are spreading rapidly. The FNS has a contract with Van-
derbilt University School of Nursing for the development of a
masters program in Family Nursing; and it is exploring Univer-
sity affiliation for baccalaureate credit for the certificate pro-
gram which has been outlined above. The future looks bright
for continued program development, but much work remains to
I be done if the family nurse is to play a significant role in im-
proving the delivery of health services in rural Appalachia.
I
I MARK TWAIN ON TIHH GENERATION GAP:
"When I was 14, I thought the old man was a pretty dumb
s sort of person. When I got to be 21, I was real surprised at how
I, much he had learned in the last seven years."
I —The Colonial Crier, J uly—Aug., 1971
I Colonial Hospital Supply Company
I Chicago, Illinois
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10 1¤·RoN·r1ER NURSING smnvicm
A WET SPRING '
On the cover of this Bulletin you will see a photograph of _
four of our young people struggling to break up a pile of debris {
that had accumulated on the bank of the Middle Fork River in
front of Wendover during an early spring "tide." The kind of
torrential rainstorms which we had on several occasions this
spring washes quantities of logs, tree branches and just plain
trash from the edges of the creeks and the river bank itself.
The swift-flowing, rising river picks up the debris and deposits
it, thickly matted together, in among the trees that are normally
above water level. There it remains after the water recedes, an
unsightly mass that is almost impossible to move without a
bulldozer. Holly Cheever, Betsy Robertson, Doug Carroll and
Chris Klosson decided to try to move this particular jam while ·
the river was still rising. They did not feel they had made much
of an impact but they must have loosened the pile because it
swirled away as the water went down.
We have had one of the mildest winters we can remember
with little ice, little snow, and only two or three brief periods
of zero temperatures. We had rain instead. Spring came—and
we had more rain. Now the "blossom" and the early spring
flowers are almost gone, the leaves on the trees are fully out,
the weather is warm——and it is still raining. In one way or
another, we seem to have been coping continuously this year
with the effects of too much water.
Construction on the new hospital in Hyden has been con- ,
siderably delayed. There is one consolation: we are sure that
all of the wet-weather springs on the hospital site will be dis- ~
covered and taken care of before the foundation is finished! {
Wendover, built on a mountainside which tends to become rather ;
liquid in the spring, has suffered a fair amount of damage.
Cracks have had to be repaired in the stone cistern that holds
our water supply, water pipes and drainage pipes have broken
or have pulled apart, and the stone retaining wall along the
roadway between the Garden House and the Big House has been
pushed out by the sliding hillside and will have to be rebuilt.
A rather alarming crack in the ground was discovered on the
west side of the Big House but we believe we have taken care

QUARTERLY BULLETIN 11
· of this by putting in new stone drainage ditches to reroute the
flow of water coming off the hillside behind the house.
The saddest thing we have to report is that we are afraid
`* the damage to the old Log Cabin, the first building in the FNS,
is irreparable. The Cabin was built in two parts—at different
times and on different levels. As the mountain has moved over
the years, so has the Cabin shifted, with the four rooms seem-
ingly going in four different directions. We have done every-
thing we could to stabilize the building after each wet season
but this year it has slipped much further and we can see many
new cracks in the fundation and in the chimneys. We feel that
the building is sufficiently damaged that it would be unsafe to
try to heat it through another winter and it will be torn down
this year. As many of you know, the Cabin has three bedrooms
. and a bath and also the little Wendover Chapel. It is our hope
. that we will be able to find enough good logs in the old building
to be able to build a small Chapel on the site.
A one-room Chapel, built on one level without the weight
· of the stone chimneys, will be stable and safe. We have not
listed the Chapel project as one of our "urgent needs" because
we have never before undertaken this sort of renovation and
we cannot begin to estimate the cost. Much of the work which
will have to be done to tear down the Cabin and rebuild the
Chapel can be done by our own workmen as they have time but,
even so, there will be some expense involved. If any of the old
staff or old couriers or old friends who have enjoyed the Cabin
would like to contribute to this project, we would be most
grateful. '
€
1 JUST JOKES — CHILDREN
Teresa’s mother served spareribs for dinner one night. She
put an end piece which had no bone in Teresa’s plate. To such
injustice this little seven-year-old protested: "Mommie, you
know when I want ribs I want ’em with the sticks."
-—Contributed

iz r·RoN·r1ER mmsrnc. smavxcm
URGENT NEEDS A
For more years than many of us can remember, the prepa- 1
ration of the Urgent Needs column has been in the capable hands
of Agnes Lewis who has spent days and weeks in the meticulous
compilation of the figures. Even after Agnes retired, she re-
turned to Wendover each spring to do this portion of the Bul-
letin-—until this year when she deserted us to visit family and _
friends in England and France. So, her substitutes (and it has
taken several!) have had to see what they could do in her
absence.
This year we have decided to concentrate primarily on the
most necessary replacement items at our various stations, on
equipment essential to the expansion of our educational and
service programs, and on the work necessary to repair the
damage done at Wendover by too much rain.
We realize that this column may not be quite as detailed as
usual, with not quite as wide a selection of items or projects,
but we do assure you that our needs are many and many of
them urgent!
HYDEN HOSPITAL
1. Vinyl Floor Covering: First floor hallway-—materials
and labor ......................................................................... $ 110.00
2. Heavy-duty Food Mixer: ................................................ 143.20 *
3. Electric Meat Slicer: ................................................. 1 ..... 57.75
4, Electrocardiograph Machine: .................................. - ....___ 965,30 _
5, Glot Timer: For Prothrombin Tests ........___.____..____________ 550,00 Y
6. Emergency Power System: Required by Law
Diesel Generator (Army Surplus) ......................_.,.________ 250,00
Wiring ................................................................................. 1,000.00
7. Loading Chair: For transporting patients up steep
stairways ........................................................................ 125.00
8. Plaster Vac Attachment: "Vacuum c1eaner" for cast-
removal equipment ........................................................ 160,00

QUARTERLY BULLETIN is
. 9. Air Conditioners: For Midwifery Clinic Trailer ............ 439.00
For Operating Room .,....._................ 242.59
For Attic Supply Room. ................... 279.95
1 For Medical Records Room which
has no outside ventilation. This
will also help cool patient waiting
room ....... . ......................................... 458.00
i MARGARET VOORI-HES HAGGIN QUARTERS
FOR NURSES
1. Vinyl Floor Covering: Hallway, downstairs ................ $ 222.66
2. Carpet: Living and dining rooms ...............................o.... 438.00
3. Folding Tables-2: Dining room .................................... 80.00
4. Dining Chairs—12: ........................................................... 240.00
5. Screens: For all windows——materials and labor .......... 500.00
MARDI COTTAGE
1. Deep Freezer: .................................................................... $ 300.00
2. Vinyl Floor Covering: and repairs to utility room floor
—-material and labor .................................................... 100.00
BOLTON HOUSE
Gift of Frances P. Bolton
‘ 1. Electric Kitchen Stove: .................................................... $ 261.00
JOY HOUSE
Gift of Helen Newberry Joy
1. Carpet: For living room, dining room, den and hall-
. way to cover badly worn iloors .................................. $1,038.00
2, Vinyl Floor Covering: For utility room ._..__..__._._._....__._ 60.00
SCOTT HOUSE
1. Deep Freezer: ........................... . ......................................... $ 300.00
2. Rewire Basement: (Part of the basement is used as
an oiiice by the Field Supervisor) materials and
labor ................................................................................ 120.00

14 momxmn mmsme smwxcn
3. Kitchen Cabi11et: materials and labor ............................ 75.00 y
4. Replace Guttering and Repair Porch: materials and
labor ................._................,............................................. 150.00 l
THE DUPLEX {
3 When additional property was purchased for the Mary
Breckinridge Hospital, the Duplex was one of two buildings on
the site which were suitable to move and use for staff accom-
modations. One apartment is occupied by the Director of Nurs-
ing Service and his family and staff nurses share the second
apartment.
1. Electric Refrigerator: ......................................_.._......,... $ 300.00
2. Electric Water Heater: installed .._...._......_.........,......... 131.30
3. Furnit1u·e: Needed for bedrooms and small `
living room ......,...................._............,...._................,..... 712.20
4. Parking Area: Between Scott House and The Duplex
—materials and labor (including the use of a bull-
dozer) ....................................................................._........ 201.38
. BEECH FORK NURSING CENTER
Jessie Preston Draper Memorial
1. New Roof: Badly needed-—materials and labor esti-
mated .................................._.. . .__.._..,......_..__.....__........_..... $ 800.00
BRUTUS NURSING CENTER
Belle Barrett Hughitt Memorial
1. Vinyl Floor Covering: For clinic and waiting room..$ 125.00 g
2. Vinyl Floor Covering: For bathroom ............................ 50.00
1
FLAT CREEK NURSING CENTER j
Caroline Butler Atwood Memorial i
NONE 1
RED BIRD NURSING CENTER
Clara Ford
1. Sofa: For living room ..........................................__..,.______ $ 150.00

QUARTERLY BULLETIN 15
. WOLF CREEK NURSING CENTER
Margaret Durbin Harper Memorial
I? 1. Slip Covers: For living room couch and chair ............ $ 75.00
! 2. Rockers—2: To replace chairs which carmot be re-
paired .............................................................................. 145.00
4 3. Draperies: For living ro0m—materials and labor ...... 100.00
4. Washing Machine: .......................................................... 200.00
WENDOVER
1. Water Damage Repairs:
Retaining Wall between Garden House and Big House
—rebu.ilt. We are fortunate in having cut stone
‘ which was retrieved from the site of the new hos»
pital to use for repairing this wall but labor is esti—_
` mated @ .......................................................................... $ 600.00
Lower Cistern and Drainage Ditches—repaired.
Labor ................................................................................... 200.00
2. Power Mower: To save labor costs in keeping weeds
cut on the grounds ........................................................ $ 65.00
3. Refrigerator: Big House Kitchen. To replace the
one which was purchased when electricity was in-
stalled in 1948 .............................................................. 1,299.60
4. Mimeograph Machine: The office staff at Wendover
keeps. the FNS supplied with over 200 different
i mimeograph forms, in addition to mimeographing
1 the brochure of the Frontier School of Midwifery
and Family Nursing and much of the educational
Q material used by the School. The old machine is
’ beginning to spend more time in the repair shop
than at home! ................................................................ 600.00
5. Calculator: For use in the Executive Secretary’s
Office ................................................................................ 625.00
6. Jeep: Army Surplus—F'or use by the Field Super-
visor ....................................... . ......................................... 300.00

16 1=·RoN·1·1m>. Nuasmc smzvrcm
EXPANSION OF SERVICES .
During the past year the Frontier Nursi