Four years into her career as an Army nurse, Michelle Renaud, Ph.D., a critical care RN, left her commission and hired on at a hospital in Columbia, S.C., to explore civilian nursing. A year later, she was back in the Army, relieved to return to a world where her word carried more weight and health care seemed to make a lot more sense.

"I was frustrated by the lack of collegiality and respect between doctors and nurses," the neonatal nurse said.

"I had no ability to ask questions or to make a decision of my own in relation to the care of an infant. Things I was used to doing on my own, I wasn’t allowed to do. I had to call the physician for everything."

Renaud is just one of many former military nurses who have found that the same job can be vastly different in the armed forces and the civilian sector.

Uncle Sam extracts a toll on military nurses, including long hours, physical-fitness exams and the uncertainty of not knowing if next year you’ll be stationed in Kansas or Hawaii.

But the uniformed life, nurses say, offers handsome compensation, postings around the world and a degree of freedom and equality that might surprise their civilian counterparts.

Renaud, who retired from the Army as a full colonel, remembers many occasions when she outranked the physicians with whom she worked.

That, along with the sense of camaraderie common to the Army, tended to negate the unequal footing between physicians and nurses more typical of civilian hospitals. With that equality came the freedom to do what needed to be done for the patient.

"I appreciate the ability to think for myself in the military," said Renaud, who now works as an assistant professor of nursing at Pacific Lutheran University in Tacoma, Wash. "There wasn’t an issue of who’s ordering who or that sort of thing. It’s more [a question of ] who has the most experience."

The Navy has 3,097 active-duty nurses, Navy spokeswoman Jan Davis said. The Air Force has 3,890, according to Lt. Col. Vanessa Wise, MSN, RN, an Air Force recruiting chief, while the Army has 3,400, according to Col. Carol Reineck, Ph.D., RN, chief nurse of the Army medical command. The armed services have little difficulty filling these officer-level positions, finding ready replacements among enlisted medical personnel and recently graduated nursing students.

Nurses also have risen through the ranks in the armed services to the top of their fields. Maj. Gen. Nancy Adams, commander of Tripler Army Medical Center in Honolulu, is a nurse, as is Rear Adm. Kathleen Martin, commander of the National Naval Medical Center in Bethesda, Md.

It’s a far different story for the armed services’ civilian nurses, who can make up 50 percent of the nursing staff at major military hospitals.

"We’re seeing the same aging of the civilian nurses as in the civilian sector," said Reineck, who added that most civilian Army nurses are in their mid-40s.

"We’re facing a lot of [civilian] retirements in the next few years, and we’re concerned about that."

The Army, Reineck said, is working to relax some hiring standards in order to bring in more nurses.

While the starting salary for a nurse usually is better in the civilian sector, the military compensation package begins to outstrip civilian pay by the third year of service, nurses said.

Some benefits are hidden: The nurses receive a housing allowance and a food allowance in addition to their salaries, and part of their income is exempt from taxes. All nurses interviewed for this story said their pay decreased when they left active service.

Tim Bushey, MSN, RN, a nurse who left the Army three years ago, estimates that his new job as a clinical researcher at the Medical Center of Central Georgia pays as much as his previous job, but the reduction in other benefits equals $10,000 to $12,000 less. It’s only his pension that keeps him and his family afloat, Bushey said.

What does it mean when the nurse outranks the physician, or the patient outranks the nurse? Less than civilians might think. Nurses reflected that their health care colleagues seemed less attached to the pecking order than other branches of the military, or even their civilian counterparts.

"I think in the military there’s more of a team and a partnership," said Patti Page, MSN, RN, an Army nurse who went on to work as a civilian nurse and community college instructor in North Florida.

"You’re on more of an equal status. I don’t think that you see that in all civilian hospitals."

But rank can come in handy in a pinch. "In the military when you have a rank you can go through channels to resolve problems and there are ways to get that done. In the civilian sector, it’s less clear."

Still, some find the lack of structure and discipline in the civilian setting a little unsettling.

"I’m very rigid. I’m ‘yes’ or ‘no,’ " said Sgt. Martin Yamzon, RN, an independent-duty medic for the Air Force who moonlights on weekends as an emergency room nurse at Sutter Davis Hospital in Davis, Calif. At Sutter Davis, Yamzon noted, "You can’t tell your patients, ‘Suck it up.’ "

Is work more exciting in the military than in a normal hospital? "That’s a roger," Yamzon said.

Military nurses work with a wide variety of people in many kinds of medical facilities.

In a 15- to 20-year career, it’s not uncommon to have six or more major postings, including ones abroad. Many nurses spend a stint in Germany or Korea. For Yamzon, who accompanied U.S. troops to Haiti and Korea, these postings were among the most exciting times of his life.

"You’re a walking hospital," said Yamzon, who treated Bangladeshis, Pakistanis and Jordanians who were part of the multinational force in Croatia. "You make all these decisions. As a [civilian] nurse, there are certain protocols you have to adhere to and it’s frustrating."

While military nurses must be self-reliant, they also often have more manpower to get the job done than in the civilian sector.

"I’m familiar with just about every piece of equipment, every drug, every medical situation," said Susan Lewsen, who was an Army nurse for 12 years, worked as a private nurse in home health and now runs Utah’s state nursing registry. "That’s why I felt so confident in home health. You’re thrown out in the field with minimal equipment and you just have to make do."

Back in the hospital, however, she missed the lack of help from orderlies. "In the civilian world, you’re pushing pills, you’re doing everything, and there’s just no support."

But in the civilian sector, at least you know where you’ll be in a few years—an attractive enticement for people like Bushey, who ended a 15-year military career when his oldest son reached high school. He knew that after that, he didn’t want to move again.

Now, he works standard eight-hour days as a researcher and doesn’t miss the 60- to 70-hour weeks he put in as he performed his regular nursing duties, served on compulsory committees and boards and prepped for his physical-fitness exams, which included a 2-mile run and a certain number of push-ups and sit-ups every six months.

According to the Navy, the top reasons listed by nurses in their exit interviews were the permanent change-of-station moves every two to three years and the difficulty of maintaining a career for a nonactive-duty spouse.

All former military nurses said their service gave them a sense of flexibility and open-mindedness that they believe they would have been unable to acquire otherwise.

"When I hear [civilian] young people complain because of schedules or their patient load or whatever, it gives me a perspective that those problems aren’t particular to one system, and there are proactive ways of dealing with them that aren’t complaining,"Page said.

"When I was in the military, I learned a variety of ways of doing things. There’s more than one way of accomplishing a goal."