T • E • N

Mary Breckinridge: Angel on Horseback

Denise M. Tate

U.S. postage stamp issued in 1998 honoring Mary Breckinridge.

Mary Breckinridge (1881–1965) is an iconic figure in the history of Kentucky and a woman who exemplified true leadership through her life’s work. Praised as an “angel on horseback,” she devoted over 40 years to building and sustaining the Frontier Nursing Service, an organization created to provide professional health care to one of the poorest and most rural regions in the Appalachian Mountains of Kentucky. From Mary’s life experiences, one can glean the leadership qualities in her that make her stand out as a successful leader who has earned her rightful place among famous nurses in history.

Like other female activists of her era, Mary focused her drive and energy on addressing the concerns of motherhood and childrearing and believed that women were happiest in their traditional roles of wives and mothers. Deprived of these socially prescribed roles of her class by the deaths of her children and her first husband, she dedicated her life to the improvement of maternal–child health care (Goan, 2008). In this new role, she challenged prevailing social traditions and developed the skills and knowledge necessary to follow her dreams. The events of this turbulent period transformed Mary Breckinridge and placed her on a path that led to her life’s work in eastern Kentucky.

This chapter highlights Kouzes and Posner’s (2012) five exemplary leadership practices as a basis for a review of Breckinridge’s contribution and service to public health, her dedication to the improvement of maternal and child health outcomes, and her impact on nursing history. It focuses on how Breckinridge overcame several barriers while working and living in the Progressive Era—a time in American history lasting from the 1890s through the 1920s—during which America experienced rapid urbanization and industrialization and issues of gender, class, and educational inequality became a greater societal concern. We examine how Mary labored in order to (a) model the way, (b) inspire a shared vision, (c) challenge the process, (d) enable others to act, and (e) encourage the heart while achieving her impressive success in the establishment of rural health care for the impoverished residents of a remote backwater region of Appalachian Kentucky.

NURSING LEADERSHIP

According to Kouzes and Posner (2012), leaders challenge the process as they search for opportunities and constantly challenge the status quo. They take risks and learn from their errors. They inspire a shared vision when they passionately believe that they can make a difference. They envision a future and through appeal and influence, they solicit the help of others to share in their vision. Leaders enable others to act by promoting collaboration as well as strengthening people by empowering them. They create energetic teams through shared respect, building of trust, and support. True leaders model the way via leading by example. They behave in ways that are in alignment with shared values and produce small wins that promote consistent progress and build commitment. Leaders encourage the heart by connecting performance and rewards and by celebrating and recognizing individual and/or team accomplishments.

Mary Breckinridge was an extraordinary nurse leader of her time. She epitomizes Kouzes and Posner’s (2012) five practices of exemplary leadership as she articulated a vision of a better future, was passionate about working to make that vision a reality, was successful enlisting the help of others in the effort, was willing to take risks, accepted constructive feedback and suggestions, displayed great determination and drive, and was unwilling to accept the status quo.

The leadership principle, of enabling others to act (Kouzes & Posner, 2012), is clearly defined as a trait of leaders who promote collaboration and create strong, effective teams. They actively seek to involve others and make each team member feel skillful and empowered. Mary Breckinridge demonstrated this principle of leadership during the creation of her vision to bring home care to families and midwifery into the rural mountains of Kentucky, a region that had the highest infant and maternal mortality rates in the United States. To accomplish her dream of providing health care to this underserved population, Mary influenced foreign nurses to come to America, thus demonstrating her leadership ability to mobilize others to help accomplish her goals and got them not only to follow but also to be transformed in achieving Mary’s shared aspirations.

Leaders challenge the process as they search for opportunities and innovate ways to improve the current situation (Kouzes & Posner, 2012). Along the way, Mary inspired a shared vision by engaging the help of many people to raise funds for her innovative plans. Mary’s success was largely the result of her effectively speaking with others about how much better their communities would be in the future and creating a common vision by appealing to the local people to get involved. They, in turn, provided her with ideas and suggestions about how to improve living conditions and health care services in their region. Mary was known for her commitment and untraditional ways of improving health for women and children who had many barriers to accessible, affordable health care. She made her vision a reality and helped in modeling the way for many others. Like many good leaders, Mary was seen as one who took risks and made decisions.

This was a remarkable woman who turned her personal tragedies into a lifelong journey to help others. Mary’s exemplary leadership practices had an important impact on nursing in her time that extends to nursing today.

FAMILY AND EARLY LIFE

Mary Carson Breckinridge was born into a prominent southern family in Memphis, Tennessee, on February 17, 1881. She was the daughter of Clifton Breckinridge, a U.S. Congressman from Arkansas, and the granddaughter of U.S. Vice President John C. Breckinridge, who served under President James Buchanan. Her mother, Katherine Carson Breckinridge, was the daughter of Mississippi aristocrats. Mary had three siblings, a brother Carson born in 1878, a sister Lees born in 1884, and a younger brother Clif, born in 1895.

Growing up, Mary traveled extensively, living in various places and learning the cultural ways and lifestyles of others. As a young child, she lived on family estates in Mississippi, Kentucky, and upstate New York. As a teenager, she lived in Washington, DC; Russia; and Western Europe. Although she was an indifferent student, Mary enjoyed learning and school, and had a happy nomadic childhood (Breckinridge, 1952/1981).

In 1894, Mary and her family moved to St. Petersburg, Russia, when President Grover Cleveland appointed her father to serve as the U.S. ambassador to that country. Mary’s first encounter with childbirth occurred when her younger brother was born in 1895. She was only 14 years old at the time, and although Madam Kouchnova (a Russian midwife) who attended to her mother and delivered her brother had made a great impression and taught her the value of a trained midwife, she, at that time, had no interest in nursing or midwifery. The Russian method of childbirth involved the birth of the baby delivered by the midwife while the physicians stood by in a corner in their white coats in case of an emergency (Breckinridge, 1952/1981). Because trained midwives did not exist in the United States during this time, it was undoubtedly Mary’s first exposure to her future profession.

During their time in Russia, the Breckinridge family attended the coronation of Czar Nicholas II in Moscow; however, Mary was more impressed by her visit to a Moscow foundling asylum, which was founded by Catherine the Great, with her mother than the coronation ceremonies. She learned that the foundling asylum took in about 25 to 30 babies a day and kept about 3,000 babies at the asylum. These babies were either picked up from the streets or brought to the asylum by their mothers who would nurse them before dropping them off at the door. All of the babies were breastfed by wet nurses, two to a wet nurse (Breckinridge, 1952/1981). It was said that all of the “normal” babies were given away at 1 month of age to the local peasants who were paid for taking them in until they reached the age of 10, when their services would pay for their keep. It was then Mary realized for the first time that all children were not as lucky as she and her siblings (Ruffing-Rahal, 1991).

Mary was very lonely in Russia as she missed her American girlfriends and felt it largely in the evenings when her sister Lees and their two governesses would go to bed. She suffered physically and emotionally and demonstrated perhaps her first battle with depression. The family’s physician recognized that she was unwell and limited her food intake believing that fasting could improve any condition. Over the course of 2 years of this treatment, Mary became weak and felt that she had no one with whom she could share her worries; she took up journaling and would sit for hours in her room and cover the pages of her diary with entries about her boredom and loneliness. She claimed that her journaling was the foundation for her autobiography and also helped her in learning to write and spell as no one taught her English grammar. Mary turned to books as an outlet, and admitted that she had no aptitude for arithmetic and did not care to learn it. She did realize, however, that she had a real talent for intellectual pursuits and resented her parents for failing to take her education seriously. Her older brother attended the best schools in Washington, DC, before transferring to a European boarding school. Meanwhile at home, Mary and her sister Lees were both educated by French and German governesses who spoke little English. Mary’s mother had been educated in this manner and wanted the same for her daughters. The idea that her daughters may have to financially support themselves one day never entered her mind. It was assumed that both girls would marry appropriate gentlemen who would provide for them (Breckinridge, 1952/1981).

When she turned 15, Mary was overjoyed when she learned she would attend the Rosemont Dezaley boarding school in Switzerland. During her 2 years of study there, she experienced a profound intellectual awakening. The faculty scheduled frequent day trips that allowed the students to take in the culture of nearby towns and the surrounding countryside, where the girls were paired up and allowed to explore the streams and caves. Mary later claimed that during her time at Rosemont she developed a strong affinity to the mountains and their people. She excelled academically at school but, true to Victorian thinking, her parents expressed concern that she was working too hard and cautioned that she should consider her health. During this period in history, a woman’s pursuit of higher learning did not come without conflict. Critics warned that higher education would physically and emotionally damage delicate females, causing neuralgia, uterine disease, hysteria, and other nervous system instabilities. When her father’s assignment as ambassador ended, the family returned home to America, where Mary finished her last 2 years of high school at Miss Low’s finishing school in Stamford, Connecticut (Breckinridge, 1952/1981).

Educated through private tutors and world travel, Mary still yearned for more knowledge and viewed “serious study as a delightful thing” (Breckinridge, 1952/1981, p. 30). Her conservative family did not approve of higher education as suitable for women and encouraged their daughter to follow the more traditional path of the times—to marry and have a family (Ruffing-Rahal, 1991). After Mary suggesting several times that it would be nice to do something with a purpose, Mary’s mother finally permitted her to attend a summer session at the University of Tennessee.

The social role of a woman during this time was at home—first in her father’s house until she married and then residing in her husband’s home. Mary knew that this life did not come without costs:

Societal pressures of the times demanded that women conform to these expectations, and those who deviated from this path faced disapproval from society and rebuke from family. For example, Mary’s cousin, Sophonisba Breckinridge, trained as an attorney and social worker, but many family members regarded her departure from the norm as an unacceptable breach of societal expectations. Breckinridge’s mother opposed higher education for her daughter. She focused on Sophonisba Breckinridge’s education as an example of foolishness and the waste of education for young, single women (Breckinridge, 1952/1981).

After the summer spent at the University of Tennessee, Mary complied with her family’s wishes; she relinquished her dream of furthering her education and made her choice to marry. In 1904, she married a lawyer, Henry Ruffner Morrison, whom she considered her soul mate. She described marriage as “an everlasting kind of thing and not entered into it lightly” (Breckinridge, 1952/1981, p. 48). They settled down in Hot Springs, Arkansas, and were eager to start a family. When no pregnancies occurred, Mary consulted with a New York doctor to find the cause of their infertility. Sadly, however, her husband developed appendicitis and died shortly after their first wedding anniversary (Goan, 2008). She rarely spoke of this marriage but wrote of it in her autobiography, “Of my own brief marriage I shall not write except to say it gave me all, and more than all, I had wanted in a friendship” (Breckinridge, 1952/1981, p. 49).

Morrison’s death left her a widow at the young age of 24. She did not return to her family’s home for fear of becoming an “object of their endless solicitude” (Breckinridge, 1952/1981, p. 51). Mary knew she wanted to provide care to others, not to receive it. Instead, she opted to travel to Banner Elk in the mountains of North Carolina. Here she spent a few months at Elizabeth McCrae Institute, a girls’ settlement school. This was her first charitable work experience and introduction to Appalachia and its people. While there, Mary witnessed a child dying of typhoid fever and realized she could not offer assistance to the child or the child’s mother. For the first time, Mary thought of training to become a nurse (Breckinridge, 1952/1981).

LATER LIFE

Devastated by her husband’s death, Mary turned to nursing. In February 1907, after a little more than a year as a widow and with the help of a family friend, Dr. William Polk, she applied to and was accepted into St. Luke’s Hospital Nursing School in New York City. It was one of the first schools to offer nurses’ training and turned away hundreds of applicants each year. Her decision to study nursing allowed Mary to further her education in a socially accepted profession that welcomed women. Nursing was a career that allowed women to further their education in addition to the ability to display their nurturing and feminine characteristics. Nursing education was called “training” during this time period as in reality it was work—both physically and intellectually challenging as it required long hours of study in the classroom and 12-hour shifts, 6 days a week on the wards. Nursing students found themselves walking miles through hospital hallways and constantly lifting, pushing, and pulling patients and medical equipment. In return for their hard labor, the nursing students received free tuition, uniforms, textbooks, and room and board (Kessler-Harris, 2003).

Mary flourished in this environment and praised the education she received. During her 3 years at St. Luke’s, she did well in her studies and graduated with a nursing degree in 1910. She passed her nursing examinations and received her nursing license shortly thereafter.

During her clinical rotations as a student, Mary experienced maternity nursing among the poor of the city of New York. There she encountered a sick child who profoundly impacted her eventual career path. She provided nursing care to a baby girl who had been abandoned at the hospital by her mother because the girl suffered from spina bifida, a birth defect that is caused by incomplete development of the spinal cord in the fetus. In the early decades of the 20th century, spina bifida was commonly fatal and few treatments were available. Mary developed an attachment to the baby and arranged to adopt her. She took the infant home and named her Margaret, thinking that the hospital approved the adoption. Upon her return to work, she was suspended from the hospital as they thought she had stolen the baby. Eventually it was sorted out, but from this incident, Mary acquired a distaste for bureaucratic maneuvering. Margaret died a few days later, and Mary paid the funeral costs, recognizing that all she could do now for the infant was save her from the further indignity of being buried in a pauper’s grave. She completed her nursing education while dealing with the grief of her “little friend” (Breckinridge, 1952/1981, p. 57). After graduation, Mary returned to Arkansas to nurse her mother through a brief illness and attend to household affairs (Ruffing-Rahal, 1991).

In 1912, Mary married a second time, to Richard Ryan Thompson, a Kentucky native who, at the time, was president of Crescent College Conservatory in Eureka Springs, Arkansas. Different from her first marriage, Mary chose to pursue her own goals instead of helping to further her husband’s career. Mary taught French and hygiene at the same college where her husband worked. She involved herself in the local community and helped create a nursing practice act for the state of Arkansas (Miller, 1988). She soon became pregnant with their first child and delivered a son they named Clifton Breckinridge “Breckie” Thompson, born in January 1914.

Mary devoted the next several years to caring for her son and working to advance the cause of child welfare. She used the latest scientific methods on childrearing and tracked her son’s growth and development claiming that “the lives of few young children have been recorded in such detail” (Breckinridge, 1952/1981, p. 60). Breckie’s growth and development was unremarkable and Mary had great hopes for her son. She imagined his future when she wrote that she believed he would be “in his manhood a leader of men, and would strike at the roots of poverty, vice and ignorance and rescue childhood” (Breckinridge, 1952/1981, p. 6). Mary again conceded to a social system that dictated she project her own ambitions onto her male child instead of pursuing them for herself.

In 1915, Mary became pregnant with their second child. This pregnancy was not easy, however, and she had to reduce the amount of time she devoted to her community work and focus on her pregnancy. In July of 1916, after a long premature labor, Mary delivered her daughter, Polly, who lived for only 6 hours (Breckinridge, 1952/1981).

If that was not enough grief, 2 years later, their beloved son, age 4, suddenly became ill and was hospitalized for a suspected intestinal obstruction. Breckie underwent surgery with his mother in attendance in the operating room. Mary was dismayed to learn that an infection had spread to his abdomen. He remained in the hospital for a week and eventually died from appendicitis. Mary was devastated and knew that, from that moment on, her life had changed forever.

Following these tragic events, which she claimed broke her marriage, Mary did the unthinkable and filed for divorce from her husband. She asked the court to take back her maiden name as she believed the Breckinridge name was more identified because of her powerful political family. Although she was entitled to use “Miss” Mary chose to use “Mrs.” Breckinridge as she felt it provided her an acceptable place in society as a married woman instead of a single or divorced woman. She reasoned that her generation frowned on discussing a broken marriage and viewed it as a distasteful, embarrassing episode (Breckinridge, 1952/1981). She renounced marriage and the joys of motherhood and vowed never to love anyone or have anyone love her again (Pletsch, 1981).

CHALLENGING THE PROCESS

A leader challenges the process by taking the initiative to seek out and accept opportunities to change the status quo through experimentation and by taking risks (Kouzes & Posner, 2012). Examples that characterize this exemplary leadership practice include searching out opportunities to grow and innovate and to improve. Mary found herself in this situation when she needed a change to help her overcome the deaths of her children and her divorce. She was sad and lonely, but she did not feel sorry for herself. The loss of her children gave her the motivation and drive to help other children to live happy and healthy lives. She returned to nursing, and in 1918, after World War I, she joined the American Committee for Devastated France (CARD), where she organized a visiting nurse service in France. CARD provided nutritious meals for French children to help relieve the famine following the war. She rose quickly in the organization and was eventually responsible for a large district that contained 72 rural villages. She developed a community health nursing program for this area that provided health care, nutrition for children, and coordinated relief efforts. Because of a shortage of nurses, Mary used her prior experience in education and designed a professional nurses’ training program in Paris (Campbell, 1984). She was recognized for her efforts and received the Médaille de la Reconnaissance française (Bullough, 1988).

This work set the stage for her future life’s work of caring for the poor, especially children in Kentucky, and it was during her time in France that Mary again encountered midwives. Trained British midwives had volunteered for CARD and provided maternal and child health care in the homes of the local residents. She was unfamiliar with this type of nursing as America had “granny midwives” who were not professionally educated. As a result of this encounter she envisioned two goals: The first was to improve the health of rural American children and the second that nurses who are trained in the nurse–midwife model could meet the health care needs of the underserved population of the Appalachian Mountains (Breckinridge, 1981).

She wrote to her mother,

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