Nurse-midwife Sister Angela Murdaugh, MSN, RN, left a comfortable job in Washington, D.C., to build and run a birth center for families in the desperately poor community of the Rio Grande Valley in Texas.

Chris Riccitelli, RN, PHN, a school nurse in Southern California, went to the home of a terrified high school girl to tell the girl's father that his daughter needed surgery as a result of a sexually transmitted disease.

Daryl Young, MS, FNP, RN, director of a university student health center in Anchorage, Alaska, promised the parents of a patient who needed a tonsillectomy that he would visit their child in the hospital for them because by the time they could fly to Alaska, the operation would be over.

Kyle Burnis, RN, CCRN, a critical care nurse in Mesa, Ariz., realized why she became a nurse when she cared for patients as a volunteer in a West African hospital.

These nurses, all of whom were among the finalists or winners in NURSEWEEK's Nursing Excellence Awards program, are examples of nurses who go above and beyond their commitment to their profession and their communities. To find out what makes an exceptional nurse, we asked them to explain why and how they remain devoted to nursing in the face of obstacles that many nurses confront: low pay, poor benefits, constraints on time, constant paperwork.

We received some interesting answers. These nurses do not see themselves as heroes. They call themselves "problem solvers" or "instruments in the healing process." They consider themselves lucky to do the work they do. They refer to their profession as "a calling." They would not unequivocally recommend nursing to a young person choosing a profession.

They don't get a lot of sleep.

They have certain characteristics in common, including some they don't always mention. They are creative. They dare to take risks. They have vision. They value the challenges and rewards of autonomy. They see themselves as champions of those who cannot negotiate the health care system-the poor, the young, the isolated. They want to give back to their communities.

And all believe in doing their jobs as well as they can, despite the obstacles. Because that's the only way they can face themselves when they go home.

More than their words, their deeds answer the question: Why be a nurse?

In the genes
At nursing school graduation ceremonies, Sister Murdaugh tells students: "If you do not feel called to this … do me a favor and don't practice."

Sister Murdaugh refers to her own calling to be a nurse-midwife and a member of a holy order as "a double vocation." She said she knew she wanted to work with mothers and babies the minute she set foot on the maternity floor as a nursing student.

"My mother was an OB nurse, so I guess I came by it in my genes," she said.

For nearly the last 20 years, Sister Murdaugh has chosen to answer her calling by serving as director of the Holy Family Birth Center in Weslaco, Texas. The birth center's bright-yellow buildings are made of pressed wood and cement blocks, like most of the dwellings in the dusty valley on the Mexican border.

She and her staff live at the center. They are available night and day to parents and children who need them.

They offer prenatal care, well-baby visits, natural labor and delivery and other health services to mostly Spanish-speaking families who often have nowhere else to go. In return, many families work at the center, doing laundry, yard work and cooking. Their children play on the grounds. At midday, they sit down to a nutritious meal, sometimes the only one they'll have.

Sister Murdaugh used to work in Washington, D.C., as president of the American College of Nurse-Midwives. But before going to Washington, she worked at a clinic in the Rio Grande Valley in Texas. She wanted to return and build her own birth center from the ground up. After much grant writing, coalition building, handshaking and calling in favors, she got her wish.

Sister Murdaugh and the nurses who work with her don't think much about pay or benefits, she said. When you serve poor people, you don't expect much in the way of monetary compensation, she said. But she never has a shortage of workers.

The nurses determine their own hours and make their own decisions about patient care. "That kind of autonomy is important to nurse-midwives," she said. But the main source of job satisfaction is "that you feel the people you work with are on the same wavelength as you are." She also derives great satisfaction when a woman who has had a baby at the birth center obtains insurance and the opportunity to go to a hospital, but comes back to the birth center instead. Or when a little boy lifts a doll to his chest and pretends he's breast-feeding a baby.

Nurses who are unhappy in their work should think about changing jobs or trying something new so they can do what they are called to do, Sister Murdaugh said.

"What draws me to nursing is that it makes me happy. It just plain makes me happy," she said. When she isn't nursing, she's fishing or playing cards with her neighbors. If she had to live her life again, she said, she wouldn't change a thing. "On my tombstone," she said, "I want them to write: Here lies Sister Angela. She had pizazz."

After five years of hospital nursing, Chris Riccitelli realized her job wasn't giving her the satisfaction she wanted. She hated the schedule and felt she wasn't spending enough time with her family. Her husband was a teacher, and she decided to try school nursing. She has never looked back.

"It's kind of like being a big fish in a little pond, vs. being a little fish in the big pond," she said, comparing her job with the Vista (Calif.) Unified School District to her hospital job. "I'm the health expert in my department and that's allowed me to soar."

Making a difference
Riccitelli has worked with every age group. She started with high school, developing substance abuse and pregnancy prevention programs. She moved to middle school and now works with special education students in elementary and preschool.

"I've really had diversity and that's what's kept me excited and interested," she said. School nursing allows her to plan and develop events such as health fairs and workshops. Before she became a school nurse, she could never have imagined herself addressing a crowd. Now she does it without thinking. She loves setting up nutrition, asthma and dental programs.

"I think that's where I belong, as a community health nurse," she said.

She also has many students who haven't forgotten her, including a special education student, now 30 years old, who still writes, calls and sends her pictures. And there's the high school student who had been treated at a clinic for a virus that causes venereal warts and was told she needed permission from her parents to have surgery to remove them. "She was scared to death to tell her dad," Riccitelli said. So Riccitelli offered to tell him herself.

She knocked on the door that evening and was greeted by a large, imposing man. After she told him, he crumpled into a chair, but eventually accepted the news. Six or seven years later, Riccitelli met up with the student, who was working as a model. "She said that she would never forget what I had done," Riccitelli said.

"I would never get out of nursing. [I love] the fact that you're autonomous, you have this opportunity to make a difference in someone's life and you can work on prevention." To anyone considering a career as a nurse, she says, "You have to look at what your goal in life is. Is your goal to make as much money as possible or is it to make a difference? Nurses can make a difference and to me that's the ultimate reward."

Alaskan outreach
There are a lot of things Daryl Young would like to change about his job. The low pay. The paperwork he forces himself to do every afternoon when he'd rather see patients. The cramped space in his facility. A health care system that denies care to many of his patients who don't have health insurance or money.

But Young, who created the Student Health Center at the University of Alaska in Anchorage 10 years ago, continues to come in every weekday at 6:30 a.m. and works for nine or 10 hours without a break. His staff hates it when he answers phones because he can't turn anyone away, no matter how busy the clinic is. He finds time to organize education and outreach campaigns and community efforts such as helping the state health department give immunizations during epidemics.

Much of Young's work displays a playful creativity. To reach depressed students, he set up a "Lucy Booth," based on the Peanuts character who offered psychiatric counseling for 5 cents. Five years ago, he organized a drive-through flu shot clinic that allowed people to drive up, stick their arms out the window and get a shot. The annual clinic has been featured on the news and is now a popular community event.

Young can't remember why he became a nurse. "I honestly don't know what the motivation was for it all. It's part of who I was," he said. "It's a process, a process of growing up and maturing."

He wakes at 4:30 a.m. to run and exercise. His exercise time is sacred. It helps him face the days when his job is especially difficult, when he must tell a patient he or she is HIV-positive. Or when he sees patients like the one who needed the tonsillectomy, who have no money and no health insurance. "I've gone as far as I can with them, what more can I do?" Young said.

Still, he doesn't give up. He spent 20 minutes reassuring the parents of the tonsillectomy patient. The least he could do, he said, was to visit their child in the hospital in their stead. Being a nurse means stepping out of yourself, he said, to do what's right for someone else.

"I believe that when you do something, you do it well and you do it with pride," he said. "I think people are drawn to nursing and you need to go where your heart is. Whatever it is, it's drawing you and you'd better do it right."

Around the world
The beauty of nursing, said Kyle Burnis, is that it has no limits. Nursing has taken Burnis to Africa and the Middle East. It has taken her to an American Indian reservation to teach, to an animal shelter to find foster homes for dogs, to health fairs to take blood pressures and to charity events to work as an auctioneer.

Burnis is a full-time critical care nurse at Lutheran Heart Hospital and also works as a helicopter nurse, but her greatest nursing adventures and satisfaction have come from the work she isn't paid for.

For a long time, Burnis wondered why she had become a nurse. She didn't have the need to hold hands or give backrubs, the way some nurses did, she said. Then she accompanied a physician to Africa to do open-heart surgeries in a hospital there. "I knew at that moment, this is why I became a nurse," she said. "To volunteer. To share my skills."

In Africa, she watched nurses cut saline bottles in two to make water cups for their patients. They used IV tubing as straws for people who couldn't sit up. She practiced bedside nursing in a way that she could not at her job, where time is short, patients are many and hospital policy dictates what nurses can and can't do.

"I'm not really able to spread my wings," she said, "and when I volunteer, I can."

Nurses who want to give something back should start by taking 10 minutes out of the day to think about why they entered the profession, she said. Then they should think about where their interests lie.

If they like the outdoors, they might consider working for an outfitter. If they like teaching, they could tutor or participate in a health care community outreach program. If they feel disturbed by seeing a homeless person on the street, they can work at a clinic for the homeless.

She recommends starting out small-volunteering for a group such as the American Heart Association. She herself got started when a friend talked her into working one Saturday at a health fair, taking blood pressures. She has never stopped. Now, she is helping to establish a clinic for the homeless, gathering supplies for a trip to Africa, gathering information to set up an open-heart surgery program on the Ivory Coast, working at a local animal shelter and helping direct local supplies and money to the Red Cross to help victims of the terrorist attacks in New York and Washington, D.C.

"As a nurse, the sky is the limit," she said. "There is not one thing a nurse cannot become involved in. All you have to do is have a dream and you can make your nursing profession into your dream."