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Two nurses. Two paths. One conclusion. Karen Haase-Herrick, MN, RN, and Melinda Beswick, MSN, RN, sit at the top of their respective organizations: Haase-Herrick as executive director of the Northwest Organization of Nurse Executives in Seattle, and Beswick as chief executive officer of Anaheim (Calif.) Memorial Medical Center.

Haase-Herrick hails from the Army and meets the nursing and leadership demands of a 23-year military career on her way to graduate school and the executive office. Beswick describes her rise and on-the-job training as an administrator as "totally serendipitous," being in the right place at the right time with the right skills and ambition.

Each has concluded, however, that success at this level is locked in their years as practice nurses. So while the executive role demands that they be women of vision, Haase-Herrick and Beswick often find themselves peering through the keyhole, so to speak, at their pasts.

"At one point, I was very clear in my mind that I was going to stay in a clinical avenue to advance my leadership," Haase-Herrick said. "I always prided myself on being a very good clinical nurse." As an administrator, "You have to find a way to keep yourself connected to the clinical essence that hospitals are about," she said.

Three times a year, Beswick and her chief operating officer at Anaheim Memorial set aside a day to spend with a hospital unit or department, she said. "Not that we can do things, but we observe, talk. Maybe you do give some water or push a stretcher. The most enlightening thing we can do in this day and age is to remember why we're here, who's doing the work, what kind of work they're doing and what the patient's perception of that work is."

The rest of the time--good days run from 7 a.m. to 7 p.m., Beswick said--is the business side of health care, for which RNs generally are not trained in their practice-based education.

For Melinda Stephenson, MBA, RN, chief nursing officer at Clear Lake Regional Medical Center in Webster, Texas, a baccalaureate degree provided the foundation for setting nursing practice standards.

But financial acumen and staff management, the requisites for her role as chief operating officer of the 434-bed hospital, had to come from elsewhere.

Stephenson found it in what most consider traditional executive training: a master's degree in business administration from the University of Houston, Clear Lake.

"I think the biggest hurdle is stepping out of the role of being a nurse and looking at the entire clinical side," Stephenson said. The ability to do that, though, makes her the "No.1 patient advocate," overseeing all clinical departments--labs, physical therapy, cardiopulmonary--not just nursing.

"The good thing is there's one person that looks at coordinating all of those departments so that in the end the best happens for the patient," Stephenson said. "We fall back on doing what's best for the patient. If you make your decisions that way, for the most part, things will fall into place financially and operationally."

Beswick learned that in the real world, what some people call "the school of hard knocks," rather than at a university.

It was as vice president for patient services at California Hospital Medical Center in downtown Los Angeles for five years that she learned the art of serving two masters: costs and care. Those years as de facto chief operating officer at the inner-city hospital provided what she calls her on-the-job master's degree in business administration.

The hospital, thanks to a staff that was "blessedly behind it," managed the goal of efficient, quality care while "pursuing our role as an essential resource in an underserved community," Beswick said. Under her watch, "we accumulated a cash position that the hospital had never enjoyed."

After she was chosen CEO at Anaheim Memorial, Beswick was told that the board of directors had not been inclined to place an RN at the helm, she said. She suspects, though, that the financial picture at California Hospital worked in her favor, as well as her reputation for a strong rapport with the staff. "Physicians really appreciate someone who understands what they're trying to do and how they're trying to do it,'' she said.

Beswick strives for a "collaborative environment" in which she not only is a patient advocate but also the voice of nursing, she said.

"The hardest thing--and having been a nurse I think I can say this freely--is that nurses know what needs to be done, but they don't know how to communicate it. The language of communication is very different than the emotions that nurses have and are so good at using to take care of patients.

"But you can't use those emotions to communicate to the business aspect, so they're not heard.

"The most difficult thing for me is watching health care turn away from being a service and turning into more of a business or commodity," Beswick said. "It's a real schizophrenic kind of environment for me because I still believe health care is a right and not a privilege."

For years after moving into management, Beswick said, "I would find myself walking back into labor and delivery just to see what was going on. That's where I would sort of gravitate to.

"To this day, I still miss the bedside," she said. "On the other hand, I only remember the good parts, so that makes it easier to miss it."

Haase-Herrick, who has a master's degree in nursing administration from the University of Washington's department of business, said that the primary downside of being a nurse executive "is that it moves you away from the bedside." Another is that "by virtue of how we as humans react in this world, it automatically puts you in the 'they' camp in the 'we-they' situation. I don't particularly like to think of myself as a 'they,' even though I am."

Haase-Herrick's career has taken her from the ICU to staff development in the Army and, after retiring from the military in 1988, to executive director of the Northwest Organization of Nurse Executives, in which she administers programs, identifies nursing trends and watches the regulatory, policy-making and legislative arenas for its members.

"For all those things I thought 'If only they could be done a little better' when I was a staff nurse, I'm now there to create those environments," she said.

"That's a big positive. It's enriched my appreciation for what the profession of nursing is about."

Most surprising, Haase-Herrick said, is the number of executives who have shared with her how little time they have for what she says is her best advice to them: "Once every two weeks get out there to reconnect with what health care is about: the patients.

"My fond memories of nursing, my storytelling around nursing, don't involve paperwork that I might do, they involve patient contact," Haase-Herrick said.

"I think for every rough day that you have, if you can walk down the corridor of a hospital or the hallways of a clinic or out into the field to see the end of a public health visit, and see the look in the person's eye who has received care because you're one of the leaders … those brief five- or 10-minute interludes make all those rough days worthwhile."