The path to the chief executive officer's suite is far from smooth for many nurses, women in particular. Many of them spent years, if not decades, juggling the responsibilities of frontline health care jobs and raising families before establishing a clear career path to the top.

As senior vice president and area manager for Kaiser Permanente Northern California Region, Sandra Small, MSN, RN, is the CEO of two Kaiser hospitals in Vallejo and Walnut Creek. However, it took 26 years for her to reach that position. During the first part of her career, she worked as a nurse at hospitals in Santa Cruz, two public health departments, raised two daughters and obtained her master's degree.

When Small and her husband moved to Stockton, Calif., in 1977, she took a job at the San Joaquin County Health Department as a family planning nurse practitioner. A large farming town 90 miles east of San Francisco, Stockton has long had an edgy reputation, and Small was assigned to one of its rougher neighborhoods. She made rounds in East Stockton in a county-owned Ford Pinto, visiting rundown neighborhoods that seemed to be filled with large, barking dogs. "The [residents] would see the Pinto, the dogs would bark and everyone knew there was a county worker coming," Small recalled. In 1978, she took a hospital job at a Kaiser facility in Sacramento, Calif., running the ob/gyn department. She's been with the organization ever since.

Catherine Fickes, MHA, RN, who's been both permanent and acting CEO of several hospitals in the Los Angeles area, spent 14 years working at the Hemet Valley Hospital District, a facility in a small desert town about 100 miles southeast of Los Angeles. Fickes had followed her physician husband to the position in Hemet. During that time, she raised a family and began a longtime avocation of performing relief work in Nicaragua while working up to the position of nursing director in charge of special services. Although Fickes likes the work, it had its share of frustrations. "There always had to be somebody representing nursing to the administration," she said. "You needed to keep advancing patient rights and keep that focus."

Moreover, even though Fickes was overseeing many aspects of hospital operations, as a nursing director she found herself all but cut out of the budget process as late as the mid-1980s. Discrimination was among the causes, Fickes believes. "The senior administrators were men who came through college courses in management, and there weren't a lot of nurses in senior management. Mostly, the budget was worked out by somebody else, and we had to accept it as it was presented," she said.

At about the same time, Fickes began to focus on making the transition to health care management. She earned a bachelor's degree in business from the University of Phoenix in 1986, and an MHA from the University of La Verne a year later. Nearly 20 years into her career, she took a job as an assistant administrator at a hospital in Los Angeles.

Catherine Kutzler, MHA, RN, CEO of St. Joseph's Hospital in Philadelphia, went through an accelerated nursing program in the early 1970s while raising an infant, then worked at a variety of staff nurse and nurse manager jobs at Philadelphia-area hospitals for more than two decades. Although her husband, a lawyer, was supportive in family matters, there were just as many days when she was worried about finding baby sitters as she was caring for patients.

Kutzler didn't think she would become a CEO until 1996, when St. Joseph's then-CEO left and she was promoted from vice president of patient care into a newly created position, vice president of operations/associate administrator. "I knew then there would come a day," she said. "I knew then I would be a CEO." That day came just a year later.