Roads less traveled
A tour of some of the
uncommon career paths in nursing

By Diane Sussman
July 24, 2000

In 20-plus years of nursing, Donna Doetsch, RN, has been a traveling nurse, a home care nurse, a dialysis nurse, a burn unit nurse, an intensive care nurse and a wound care specialist. But when the Grosse Pointe, Mich., resident began feeling "burned out," she decided to revisit home care. Now, Doetsch is happily employed as co-director of an assisted living program, where she does everything from counseling families to picking out paint colors.

"I’m kind of a jack-of-all-trades, and I love it," she said. "No day is the same."

After nine years in med/surg and nine more teaching health sciences, Katherine Ricossa, MS, RN, spends her days "networking, coordinating" and taking her nurse Barbies to schools to talk about health professions.

The Santa Clara, Calif., resident is special projects manager for the state-run Regional Health Occupations Resource Center, which helps communities meet their needs for health care workers by developing occupational programs at local community colleges. "All that experience I gained in nursing I’m applying in a whole new way," she said. "And it’s fun because you’re not limited to anything except what’s in your own head."

Both Ricossa and Doetsch reflect what is now the norm in the United States: careers that unfold in two or three stages. Only in their case, they didn’t have to leave nursing to find a satisfying sequel.

What nurses have
What nurses bring to the job market often is underestimated and inadequately understood. "It sounds simplistic, but it’s actually really powerful – the nursing process," said Karen Johnson Brennan, Ed.D., RN, professor and interim director at the School of Nursing at San Francisco State University.

"By nursing process, I mean the ability to gather data, analyze data, make clinical inferences and take actions, and evaluate those actions," she continued. "Some people are only good at one aspect – they see only the evaluation part. But nurses see the whole picture."

Hospitals will always be the largest employers of nurses, but nurses increasingly are being wooed by other sectors such as pharmaceutical companies, insurance companies, corporations and law firms. While some areas are good, others are white-hot.

"There are definite cycles and trends," said Laura Mahlmeister, Ph.D., RN, president of Mahlmeister & Associates legal consulting firm in San Francisco. "Ten years ago it was nursing informatics and case management. Then it was my specialty, legal nurse consulting. Now it’s geriatrics, correctional, school nursing, community nursing . . ."

Here is a brief look at some of the newest and most needed specialties.

What’s new
The Internet. Last October, Atherton, Calif., diabetes educators Michelle Perrot, RN, and Penelope Mayes, RN, went out on a cyberspace limb and introduced DiabetesWell, a comprehensive Web site for diabetics. Now, the little start-up is hiring, Mayes said. Disease management is just one opportunity for nurses on the Web. Other e-health jobs include writing clinical content, developing and teaching courses – watch for "streaming video" – telemedicine, and consulting for software companies that are developing future medical applications.

Complementary healing. According to a survey published in the New England Journal of Medicine, nearly a third of Americans reported using at least one alternative therapy to treat a medical problem within the last year. This turn toward alternative therapies prompted the University of California, San Francisco to offer a program in Integrated Complementary Healing for nurse practitioners. The curricular subjects – imagery, energy healing, relaxation therapy, herbs and dietary supplements – all fall within the scope of licensed nursing in the state, program coordinators said. So far, the program is the only one in the country, but if Americans continue to mix alternative and mainstream, others could be on their way.

What’s hot
Medical legal nurse consulting. Given the complexity – and ubiquity – of medical litigation, lawyers are increasingly turning to nurses to help them with cases in product liability, medical malpractice and workers compensation claims. "This was a big specialty years ago and it’s still big," Mahlmeister said. "And I just don’t see that changing." Candidates should be skilled at conducting research, explaining complex medical ideas to laypeople (including lawyers), writing clearly and finding expert witnesses.

Traveling nurse. Mountains, beaches, deserts, corn fields – any experienced nurse willing to go from one to the other is a hot commodity these days as hospitals turn to traveling nurses to meet their staffing needs. Experts estimate that on any given day, there are about 10,000 traveling nurses working in the country. Agencies pay travel expenses and take care of the nurses’ housing and utilities. Some agencies offer health insurance, retirement plans and completion bonuses.

What’s needed
Correctional health care. The United States is the global leader in incarceration, with some 1.8 million people behind bars. Furthermore, this population has a constitutional right to health care because of a 1976 Supreme Court ruling. The large number of prisoners has changed correctional health care from a fringe concern 20 years ago to a $3.6 billion a year business. Some experts project it will grow by $6.5 billion a year by mid-decade.

Geriatrics. "There’s a need for nurses in all areas of geriatrics," Mahlmeister said. "Boy, I’ll tell you, if you want to work in geriatrics, the work is there."

Home care. The number of nurses working in home care grew 38 percent between 1988 and 1992, according to the Department of Health and Human Services, Division of Nursing, making it one of the fastest-growing segments of health care. Home care nurses serve every segment of the community, from urban apartment dwellers to large assisted living communities such as the one Doetsch now runs. "For nurses who like managing and being part of a whole community, it’s great. Or for nurses who like the idea of running their own business," she said. "All they have to do to get a sense of the opportunity that’s out there is to look at the want ads."

What’s back
Some specialties have been in remission but are rebounding.

School nurse. "All those preterm babies, the little mini-babies, are growing up and going to school," leading to a resurgence in the hiring of school nurses, Mahlmeister said. "They are finding it’s not enough to train aides and nurses to give medications and care."

Community nursing/community outreach nursing. This can range from working for a corporation to working for a health club, from teaching sex education to conducting mobile health screenings in the neighborhood. "Communities are looking at their own health needs, creating opportunities for nurses," Mahlmeister said. Another trend is the rise of the community nursing center, which provides care to residents at less cost than most outpatient centers. As with any community work, nurses need to be up to date on a wide range of health and wellness issues, including prenatal care, nutrition and childhood health.

What else
Quality assurance/utilization review/case management. This is a field that has grown considerably, borne by managed care and Medicare. The work is analytical, not hands-on, with most of the nurse’s time spent reviewing files, doing research, evaluating care, making recommendations about treatment and contacting providers to clarify care goals. HMOs, PPOs, insurance companies and consulting firms are the usual employers.

Sales. It’s no small thing to know the mechanism of a drug or a defibrillator, which is why so many medical equipment and pharmaceutical companies like adding nurses to their sales teams. The work offers flexibility and commissions, but nurses considering sales should expect to make frequent road trips to call on hospital purchasing departments, nurse managers and health agencies.

Corporate wellness manager. Corporate wellness programs have moved away from monthly wellness newsletters to bona fide programs that help employees lose weight, control hypertension, monitor cholesterol, exercise and reduce stress. "This is a big area for nurses, the whole area of employee wellness," Mahlmeister said.

Consulting. It’s not as easy as hanging out a shingle, but nurses with strong clinical, problem-solving and administrative abilities do find work consulting for hospitals, day care centers, complementary healing centers and companies without a full-time, in-house nurse. Success depends on the nurse’s organization and expertise, as well as a willingness to pass out those business cards at every opportunity.

Teaching. Once scarce, jobs in academia are expected to open up soon as experienced nursing faculty ages and retires. "We’re all going to be getting a lot older," Brennan said, "and that means schools will be hiring." Most positions require at least an MSN plus clinical experience, but some LVN and CNA programs hire nurses with bachelor’s degrees.

Writer/editor. Nice work if you can get it. And some can. While full-time editing positions are hard to come by without years of journalism experience, many nursing journals and publications rely on freelancers to fill in the gaps. Expertise is always valuable, but being a generalist with a clear writing style is a good start. Ask for writer’s guidelines and familiarize yourself thoroughly with the publication before sending a query letter.

Entrepreneur. Some universities, San Francisco State among them, offer outreach programs for budding nurse entrepreneurs who want to plunge into the world of owning their own businesses. "These are people who want to run their own birthing center or work with computers or have their own business," Brennan said. Those far from an intact program can contact their local Small Business Development Association, a branch of the U.S. Small Business Administration, which helps newcomers navigate the world of licenses, loans and marketing plans.

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