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"I don't think U.S. nurses work for us for the money. They do it for the experience," he said. "They like the challenge, the travel, the chance to work in an extended role. Crews are from 60 different countries, so you meet people from around the world."

The application process is more rigorous than at a hospital, Williams said, including case studies and tests.

"Nurses often work fairly independently. They might be working at night on their own, so they need triage and assessment capability," she said.

Cruise ships that carry 2,500 to 2,700 passengers and 900 to 1,000 crew members are typically staffed with two physicians and three nurses. Larger ships have four nurses; smaller ships may have one physician and two nurses. During shipboard health center hours, a physician and a nurse will be in the center.

"Holland America employs three nurses and one doctor, and nurses take 24-hour call," Van Boheemen said. "The morning they get off call is the most down time they have, and they can usually go ashore if in port."

Cruise lines work out of various ports, where employees are based. Carnival, for example, works out of 10 U.S. cities.

If a nurse wants to work out of a particular city or in a certain area, the line will work with them, Williams said. But assignments depend on vacancies as well. Holland America's 12 ships travel the world.

In the summer, there are generally six ships in Alaska, Van Boheemen said, and several in Europe and the Caribbean. In the winter, most ships will be in the Caribbean, with one in Hawaii or Mexico, one in South America and another going around the world.

Customized care

In addition to critical care experience, the ability to work independently and have good assessment skills, cruise nurses need good interpersonal skills. "The job is very public relations oriented," Lilly said.
"You must be able to work with all different cultures, languages and different medical viewpoints. The ability to think on the run and problem solving are also crucial."

Holder worked in a bone marrow transplant unit at Johns Hopkins Hospital in Baltimore and said the ICU experience made her comfortable on the cruise ship. "You may be the only one there if the doctor isn't on board.
You don't have social work support and other things you depend on in a hospital."

Holder planned to work for a couple weeks, but has been with Carnival for three years. "Once you're out here for a while, it is a real transition to go back to land life. You work long, hard hours while you're out here, but then you have two months vacation and can travel a lot."

Cruise ship nurses are officers, which means they have private cabins and privileges like eating in an officer's dining room, Holder said. Carnival nurses typically work for six months, followed by six to eight weeks off, and receive four cruises per year.

Katie Pratt, RN, ADN, a lead nurse for Holland America, has always enjoyed traveling. "My part-time job at home is with a traveling nurses group. Cruise nursing gives me the opportunity to travel and function as a critical care/emergency nurse at the same time. It's been fascinating seeing different medical facilities around the world and how they differ from what we are used to."

Pratt also became certified for and enjoys scuba diving in her time off.

Shipmate Lilly enjoys learning about different cultures while in port. "Katie and I are both into wines," she said, "and try to sample the grape at all the different ports."

Global family

Nurses find plenty of culture on board ship, too. "My favorite thing is working with nurses from all over the world," Holder said. "We are working with a group of nurses from 55 nationalities, with all different kinds of skill bases, from different countries where practices may vary. I learn a great deal of cultural medicine." She also has made good friends from all over the world.

Van Boheemen said that is common. "You make family at sea, and meet wonderful people from all over the world. Since you are on board for months at a time, you make friends that last a lifetime. And no matter where you travel, you'll always have a place to stay."

Cruise lines offer nurses opportunities for continuing education, and special training is often provided. Equipment is generally up to date. "Cruise lines are working to improve the quality of medical care on board," Williams said. "We run a weeklong intensive course on cruise ship medicine annually. We have lots of new equipment. There are over 600 items on board, from aspirin to sophisticated equipment, even an ultrasound on one of our ships. Over the past few years, we've seen an increase in the number of guests who call before a cruise about specific health issues. Guests are more educated and demanding. We have a fairly advanced medical team on board and regularly treat trauma and things you see in an emergency room."

Recent highly publicized incidents like outbreaks of Norwalk virus on board ships have not affected recruiting, Williams said. "Most of our nurses are ICU or ER nurses, so that is no big deal."

Cruise ship nursing is different from emergency nursing in one important way, Van Boheemen said; on cruise ships, nurses get thanks and respect.

There are minor drawbacks. Holder's least favorite task is billing. Lilly's least favorite thing is wearing hose and heels in uniform 24 hours a day.

But wearing a bathing suit on days off helps make up for that.

Contact Melissa Gaskill at gaskill@dbcity.com