Introduction

Chapter 1: History of Nursing

Chapter 2: Alternative Careers

Chapter 3: Entrepreneurship

Chapter 4: Making the Change

References

Apendicies

Course Exam

CHAPTER TWO: ALTERNATIVE CAREERS

The face of health care is changing.  In order to make a positive career move it is necessary to heed the trends and to channel your particular interests and talents in a direction compatible with the future of the entire industry.  In general, the concept of decreasing costs while providing a high quality of care has become a symbol of the new way of health care into the next century.  Hospitals are beginning to operate much more like corporations than our nursing predecessors might ever have dreamed.  Competition has become intense between the various health care providers, who depend on the expertise of marketing departments to keep beds filled and revenue up.  In the past decade, we have witnessed hospital mergers, budget cut-backs and massive lay-offs of nursing staff.  This alone has created a huge shift in the concentration of nurses from acute care facilities into the many other disseminated branches of our health care system.

With the advent of Medicare’s diagnosis related guidelines (DRG’s) we began to see stricter criteria for hospitalization of patients as well as dramatically decreased lengths of stay.  One can imagine a scale, whereupon the patient’s entire course of illness is weighed.  While acute care hospitalization is greatly reduced, the patient’s dependence upon other extended services, such as home care, long term care and rehabilitation has dramatically increased.

Without regulation, health care costs were allowed to soar, while at the same time experts began to question whether patients were actually receiving appropriate and timely treatment, or were they becoming victims of a system out of control.  Cost containment and quality of care are now buzz words in the industry, and have brought about such entities as Health Maintenance Organizations (HMO’s), Preferred Provider Organizations (PPO’s), Managed Care, Utilization Review and Quality Assurance.

All of these trends have opened up a plethora of opportunities for nurses throughout the health care industry.  Nurses have many more choices now than ever before, and can take their education, experience, talents and skills into a wide variety of fascinating career options.  Whether the nurse is business-minded or still enjoys the rewards of the bedside, the right career opportunity can be found to meet every need and goal.

Through there is an expansive list of careers nurses might pursue, this course is particularly focused on what is available outside of acute care hospitals and those that are stable and viable options for our economic times.  Certain specialties, such as school nursing, though rewarding and interesting, are being gradually phased out from many school districts and is therefore not discussed in this course.  It also serves to introduce nurses to career options which can be fairly easily entered, without advanced degrees or elaborate training.  Though experience might be desired by an employer, individuals who are bright, professional, confident and assertive can often break into a new area successfully.  With a look towards the future, the following career alternatives present a variety of experiences for nurses to chose from and pursue.

MANAGED CARE

Managed care came about as a remedy to the spiraling costs of health care.  Without guidelines and management, health care costs were allowed to rise out of control over the past several decades.  Figure 2-1 indicates that national health costs increased by more than four fold in a twelve year time span.  The aim of managed care companies is to decrease these costs while insuring high quality of care to patients.  Managed care works with insurance companies in a hand-in-glove type of relationship.  Each patient’s case is monitored by a case manager for appropriate and timely treatment.   The treatment is constantly evaluated for effectiveness so that if the patient is not showing improvement in an expected period of time, an alternative method can be suggested.  This exerts some control on a provider, who without such restrictions might suggest batteries of tests and courses of treatment without justification or evidence of improvement.  Managed care protects insurance company dollars as well as being an advocate for patients, protecting them from exploitation by providers of health care, and insuring that they are receiving necessary and beneficial treatment.

Managed care is an efficient approach to administering health care services.  It aims to integrate clinical and financial aspects of patient care and to identify variables that prevent the patient and physician from reaching an achievable outcome within a reasonable period of time (Larter 1992).  The aim of managed care is to collaborate with other health care professionals in a team approach, to insure the best quality of care, to avoid fragmentation in the patient’s care and to shift away from a protective turf mentality in which all parties act independently according to their own priorities and goals (Larter 2992).

There are several aspects to managed care.  The first is assessment of the patient’s problem.  Next are the planning, procurement, delivery and coordination of services.  And finally, monitoring to assure that the multiple service needs of the client are met.

Managed care can exist as a function or department within the general makeup of an insurance company, or it can exist as a separate business altogether, forming contracts with various insurance companies to provide their managed care services.  For example, Blue Shield of California now has a managed care approach to dispensation of benefits, and hires case managers as employees of their own organization.  However, US Behavioral Health (USBH) is an example of a company which works with insurance companies to provide managed care of mental health services.  In like manner, Kemper National Services, Inc. works with insurance companies to manage medical and workers compensation cases.

Kathi Walsh of USBH explains that the concept of managed care for mental health is less than ten years old; for medical care it has been around only slightly longer.  Managed care for mental health was developed, Walsh explains, after the elimination of the “certificated need requirement” under President Reagan.  This resulted in for-profit hospitals billing in a completely unregulated manner, causing health care costs to sky-rocket.  Chemical dependency treatment had become popular, with “individuals entering in-patient treatment in droves”.  The cost to insurance companies became overwhelming and unmanageable.  Particularly in a for-profit situation, a patient could easily be exploited, and thus managed care was borne to see that this did not happen.

Walsh explains that USBH establishes contracts with providers who can demonstrate that they offer high quality care.  They manage the patient’s benefits in a cost efficient way by being able to provide quality services at a discount through these contracted providers.  They try to use the patient’s benefit in a more creative way.  For example, they will attempt outpatient treatment and/or medication before considering a costly in-patient treatment program, unless it is a psychiatric emergency which would require immediate hospitalization.

USBH also establishes contracts with employers to manage the mental health benefit portion of employees’ health insurance.  If the company has an Employee Assistance Program (EAP), USBH works in conjunction with the EAP to provide appropriate care to the employee.

Nurses can find many opportunities in managed care, where their clinical expertise is highly valued.  At USBH, the first step for a patient is to be evaluated by an intake coordinator.  This person assesses the patient’s need over the phone and then makes an appropriate referral; generally this is to an outpatient therapist.  This is often a good entry for nurses interested in managed care.  From this point on the case is handled by a care manager.  The care manager receives the evaluation from the provider to which the patient was referred.  Together they design a treatment plan that uses the benefit well.  Walsh explains that care managers are sometimes able to manipulate the benefit to better meet the clients need.  For example, if the patient has depleted his/her out-patient benefit, yet has $25,000 available in his/her in-patient benefit, and it would be more beneficial to treat the patient outside the hospital, the care manager may be able to draw funds from the in-patient benefit to cover out-patient treatment.  Walsh states that this is an extremely powerful position to be in and that it is very gratifying to help patients better access their insurance coverage.

She describes the care manager as “traffic controller”.  Care managers interface with patients, providers, employers and sometimes with entire families.  They “provide continuity of care …. make sure the patient is actually getting appropriate treatment”.

At USBH, RN’s are hired as care managers with a minimum of an Associate degree and they must be licensed.  Because this company deals specifically with mental health, a background in psychiatric nursing and/or chemical dependency treatment is necessary.  It is often helpful to have had experience other than clinical, such as business, administrative, supervisory or admissions.  Care managers must have good, clear communication skills and be assertive, particularly when working with difficult physicians.  Walsh states that she looks for maturity, solidness and the ability to take control while in the interview.  She states that this person must “be ready to advance beyond direct patient care”, and that she wants “someone who is interested in managed care because it’s exciting and interesting, because they want to move up and they’re stimulated by the newness of it.  I don’t want someone who’s trying to get away from shift work, get away from a stressful environment; someone who’s just burned out.  Managed care is much more stressful than the hospital”.
Walsh states that she likes to hire nurses as care managers, “because they’re not afraid to get their hands dirty, they’re very organized, can juggle a lot of things happening at once, they’re not as linear as certain other disciplines and they have good assessment skills”.  She emphasized the need to be assertive and professional and stated that if nurses are “accustomed to doctors telling them what to do they shouldn’t be in managed care”.

Kandeyce Jenkins, the recruiter at USBH, states that nurses hired as care managers need to be comfortable with the extensive amount of telephone work and the fact that there is no personal contact with patients.  “This would not be for the nurse who thrives on primary nursing and contact with patients.”  She suggests that having some experience with insurance, especially to understand terminology, is helpful, and that having an affinity with the business aspect of health care is necessary.

Jenkins states this is a very good area for nurses right now.  It is a “good way to expand their knowledge base into the way the entire system works…can apply clinical knowledge in a corporate environment”.  Walsh feels managed care provides an opportunity for nurses to feel empowered, to feel they have an impact on the types of services patients receive and on the outcome of treatment, rather than feeling victimized by a “system that isn’t always realistic in regards to the benefits provided”.  Walsh states that she has “a much bigger influence then she ever had giving direct patient care”.

Walsh states this is a very stressful work environment, with a heavy workload and pressure to save money.  She states that clinical integrity must always be monitored in order to make sure that managed care is not restricting patients from receiving needed treatment because of money.

This is a very secure career direction for nurses in the current economy and in view of the direction of health care.  Jenkins states, “It is the way of the future” and “the needs are never-ending”.  She has hired approximately 80 nurses in the past two years.  Walsh encourages nurses who have an affinity for this kind of work, stating “there is enough new managed care companies starting up that a nurse could get in at the ground level and have a lot of opportunities”.

Kathy Barker of Kemper National Services, Inc. also feels this is an excellent time for nurses to enter case management.  She explains that within the next few years certain states will begin to require that rehabilitation cases managers be certified.  This would mean they would need two years of work experience before they could sit for the exam.  However, right now the field is wide open.  Barker also referred to managed care as “the wave of the future”.

She looks for nurses who “are self-starters, self motivators, having high energy level, are assertive, good problem solvers, like to function autonomously and understand the business end of health care”.  She has found that nurses with a background in occupational health do well with Kemper, since they largely deal with workers compensation cases.

Medical case managers with Kemper have more face to face interaction with the patient and the medical community than care managers with USBH.  In providing medical rehabilitative services to workers compensation claimants, the nurse evaluates each case, defining the patient’s needs and problems, renders an opinion regarding the case’s cost, problem areas and outcome, gives recommendations to the insurance carrier and interprets medical records.  These case managers work independently out of their own homes and are in the field about 50% of the time, meeting with the patient and the various providers of care to facilitate the employee’s timely return to work.  The goal, again, is cost containment.  Barker also emphasized the need for nurses to be assertive and good communicators in dealing with providers to obtain the appropriate treatment for the patient in a timely manner.

Starting salaries in managed care range from the mid $30,000’s to the low $40,000 range.  However, there are opportunities for advancement into supervisory positions.  The work is generally Monday through Friday with daytime hours.  Barker would like to see more interest from nurses towards managed care.  She feels that many nurses do not fully understand what managed care is all about, and feels this is a good time to enter the field because so many companies are willing to train nurses.

Acknowledgements:
Kathy Barker, Human Resources, Kemper National Services, Inc., (800) 877-3514
Kathi Walsh, RN, Director of Training and Continuing Education, US Behavioral Health
Kandeyce Jenkins, Recruiter, US Behavioral Health, (800) 888-2998

HEALTH INSURANCE COMPANIES

Nurses may find a variety of different positions within insurance companies where clinical expertise is valuable in assuring appropriate use of benefit funds.  Whether a Health Maintenance Organization (HMO), Preferred Provider Organization (PPO) or a traditional indemnity plan company, nurses may be hired in similar types of positions.

Donna Pheiff, the recruiter for Blue Shield of California, gives a general idea of the types of positions available to nurses at her company.  Job titles include:  Pre-admission Review, Discharge Planning, Case Management, Hospital Review, Quality Assurance, Utilization Review and Peer Review.  The work varies according to the position.  Nurses in discharge planning and case management work heavily with hospitals, physicians and outpatient services.  Those who work in hospital review go out to hospital sites and interact with the discharge planning department, admissions and anyone else involved with the case.  Some of the other positions deal primarily with paperwork and interact with the medical community over the telephone.

As mentioned in Managed Care, Pheiff feels it is important for nurses looking into a career with an insurance company to be comfortable making the shift from direct patient care to the business side of health care.  She likes to see nurses with a background in Quality Assurance or Utilization Review, but has brought nurses on board without this and the company has trained them.  She states, “It is becoming more and more important to have some experience with computers”.  A BSN is the minimum educational requirement, along with a state license.  The number of years experience can vary.  She generally looks for a med-surg, ICU or CCU background.  Sometimes it is necessary to find a nurse with a particular specialty such as OB/GYN, prenatal or psychiatry.
Though the starting salary is lower than that for clinical nursing, around $40,000 in the San Francisco Bay Area, nurses can advance into management positions and eventually earn close to what they would in a hospital.  These are positions which operate Monday through Friday, during the day, with no weekend or holiday work.  Pheiff feels this type of work, compared with clinical nursing, is “less pressured not having to deal with minute to minute life or death type situations”.  She also states that this is a secure area for career opportunities.  She explains that Blue Shield has not experienced lay-offs and because the company offers an extensive training program to nurses, “they are not inclined to lay-off”.

Acknowledgements:
Donna Pfeiff, Recruiter, Blue Shield of California

EMPLOYEE ASSISTANCE PROGRAM (EAP)

The function and scope of an Employee Assistance Program (EAO) may vary from company to company.  Essentially, they were designed as a preventative strategy which focuses on the corporation as a system.  According to Dr. Jay Talkoff, Clinical Director of EAP for Wells Fargo Bank, “EAP’s seek to recognize individual employees in the early stages of their difficulties and refer them to appropriate points of assistance”.  The concept is one of cost containment through the implementation of prevention strategies.  In early intervention the aim is to decrease costs by referring patients to outpatient mental health or chemical dependency treatment, rather than wait until the problem becomes so severe as to necessitate a costly hospitalization.

Talkoff states, “If you can do early intervention then you are decreasing absenteeism, thefts, work place accidents and workers compensation costs, law suits, bad business decisions and increasing productivity, employee welfare, communication, work environment morals.”

A company with an EAP would make available to their employees counselors to assess substance abuse and various emotional problems.  EAP counselors are generally not available for ongoing counseling, but rather limit sessions to just enough to make an assessment of the problem and refer the employee to appropriate treatment.  EAP’s often work with managed care companies to provide a network of providers at a discounted contract rate.  This ultimately saves the company money by controlling insurance costs.

Wells Fargo Bank hires qualified nurses as EAP counselors.  They must have a BSN with a strong psychiatric and chemical dependency background.  They must have excellent assessment and consultation skills.  EAP counselors at Wells Fargo provide from one to four sessions for the purpose of assessment and referral.  They also might provide stress management workshops to managers and other personnel, AIDS education and crisis debriefing after hold-ups.  Talkoff explains there are no advancement opportunities at Wells Fargo EAP for nurses; however, this might be different at the large technical companies.

Talkoff feels this is a good way for nurses to employ their psychiatric experience and knowledge to a corporate environment.  He states that “The company can be very supportive of individual’s ideas for growth and change” and “there is often more respect and recognition” in this environment where “there is a tendency to defer to the nurse”.  There is much more independence, making this an attractive career choice for nurses who are comfortable operating with a lot of autonomy.

This can be a difficult environment for nurses because of the corporate politics.  Also, the work is difficult, the demands are never-ending and it is not just an eight hour work day.  Counselors carry a beeper and are on call evenings and weekends.

Salaries can range from the mid $30,000’s to the mid $50,000’s.  It is a more secure position than a staff nurse position in a hospital right now, however, the security will vary with the company.  EAP’s are non-revenue producing departments in a company and therefore might be considered a place to cut back.

For Information:
National Employee Assistance Professionals Association (EAPA)
4601 North Fairfax Drive
Arlington, VA   22203 (703) 522-6272
Contact National EAPA for local chapter.

Acknowledgements:
Jay Talkoff, Ph.D., Clinical Director for EAP, Wells Fargo Bank

QUALITY ASSURANCE AND UTILIZATION REVIEW

Quality Assurance (QA) and Utilization Review (UR) are excellent areas for the nurse who has an interest in the business side of health care and finds satisfaction in containing costs and evaluating care given by providers on the multidisciplinary team.  The ever increasing criteria set forth by third party payor sources have created a vast need for regulation in the delivery of health care services.
Lonnie Friedman, RN of Quality Review Associates defines UR as “the analysis of medical records and medical activities to evaluate the need for care to be give, the level of the care, quality of the care and the timeliness of the care”.  QA is “related to UR.  It is the more analytical and focused part of the total process.  It evaluates the quality of care given as compared to pre-set standards that were set up by the providers of care”.

A QA/UR nurse is a fact-finder and problem solver.  This nurse must understand the guidelines of Medicare, Medicaid and other payors and apply these guidelines to the patient’s needs and the care being given.   This nurse also assists clinical staff to contain care within the guidelines of the payor (insurance company).  This is a necessary process in order for facilities and health care organizations to maintain Medicare licensure and contracts with other payors.

The QA/UR nurse is an analytical individual who must bring meaning to a vaguely defined problem.  This is “expressed in the ability to analyze and detect problems, formulate and sharpen them, isolate the factors involved and ultimately state each problem in terms in which it can be understood and resolved.  The analyst must be able to perceive and select the relevant information, judge its significance, detect patterns in the data and organize the information to support conclusions concerning the nature of the problem, including its probable technical, social or organizational causes.  The end result of this stage of the problem solving process is a diagnosis of the problem in all its key elements, sufficiently detailed to enable an appropriate response” (O’Reilly 1989).  The analyst then becomes involved with clinical staff in finding an approach to resolving the problem and facilitates the process of change or improvement while collaborating with other team members in doing so.

The QA/UR nurse must be analytical, good with numbers, confrontive and be a good communicator while establishing good rapport with the medical staff.  This nurse must be able to work in an autonomous fashion and be highly knowledgeable about disease processes in order to support his or her decisions with facts and criteria.

QA/UR nurses work in hospitals, insurance companies, HMO’s, PPO’s, IPA’s, managed care companies, corporations and any other health care organization or business which has a QA/UR department or program.  QA/UR nurses usually answer to administration and finance departments, rather than nursing departments.  The work involves dealing with statistics, denials and appeals.

Salaries are initially lower than in the clinical area.  Starting salaries are around $35,000 to $42,000.  However, advancement opportunities do exist and some QA/UR nurses in management can earn up to $70,000 annually.

In order to break into this field Friedman suggests, “Educate yourself in the field as much as you can, start networking, see if you have colleagues or associates who can help you get into the field.”  There are “no entry level nationally recognized certification programs for UR/QA in the country”.
However, there are certain employers who will hire a nurse without experience and these are generally non-hospital employers, such as insurance companies, HMO’s or other managed care organizations.

Through Quality Review Associates (QRA), a Utilization Review Nurses Registry, Friedman offers home study courses which are developed to prepare people to enter the field or to enhance their present skills.  These courses do not “qualify” anyone, but simply serve to aid in preparation.  QRA also provides temporary QA/UR work assignments to a variety of clients (hospital and non-hospital), does permanent recruitment for these employers and performs consulting services.
Friedman feels this is a “good, solid career direction for someone if they are really interested in it”.  She doesn’t like to encourage nurses in this direction if they are simply looking for an escape from clinical nursing.  It is so far removed from personal contact with patients, the strokes that often give nurses satisfaction in their jobs, Friedman feels that unless a nurse has a sincere interest in this field it may prove to be a very unsatisfying experience.  The excitement in this career is in ability to have an impact on the operations and management of health care delivery.  Friedman states that in QA/UR one “must see that you’re helping people in the bigger picture by keeping up the quality of care; helping people but not in as direct a way as before”.

For information:
National Association of Health Care Quality
5700 Old Orchard Road, First Floor
Skokie, IL  60077
(708)966-9392
Publishes bimonthly Journal for Health Care Quality; annual convention; educational opportunities.  Contact for information about individual state associations of health care quality.

Acknowledgments:
Lonnie Friedman, RN, Ph.D., owner of Quality Review Associates a Utilization Review Nurses Registry
(800)562-2160 or (310)473-7971

OCCUPATIONAL HEALTH

The concept of occupational health nursing (OHN) began in 1881 with services provided by a nurse to coal miners in Drifton, Pennsylvania.  The trend was further launched in 1911 with the enactment of workers’ compensation laws, which encouraged accident prevention and immediate attention to injuries sustained on the job.  Since then several other organizations have been developed, among them Educational Resource Centers (ERCs) to provide specialized education in OHN.
Occupational health nursing is described in the standards of the American Association of Occupational Health Nurses (AAOHN) as follows:

  • Occupational health nursing applies nursing principles in promoting the health of worker’s and maintaining a safe and healthful environment in occupational settings.
  • The knowledge is a synthesis of principles from several disciplines in the health sciences including, but not limited to, nursing, medicine, safety, industrial hygiene, toxicology, administration and public health epidemiology.
  • Occupational health nursing activities focus on health promotion and protection and maintenance and restoration of health.  The occupational health nurse is primarily concerned with the preventive approach to health care, which includes early disease detection, health teaching and counseling.
  • Whether the nurse is a sole provider or supervises other professional nurses and paraprofessionals, standards of care are applicable to nursing practice in all types of occupational health settings.  Standards focus on nursing practice rather than on the health care provider.
  • As a professional, the occupational health nurse is accountable for the nursing care provided to the employee first and to the employer second.  Standards of nursing practice provide a means for determining quality of care, as well as accountability of the practitioner.  (Kelly 1991)

In most cases, OHNs work independently with a physician available on a contractual basis to provide medical care as needed.  However, there are situations where the OHN is part of a multidisciplinary team in a large department with several examination and treatment rooms, diagnostic equipment and a laboratory.

In an occupational health setting the nurse does far more than administer first aid to injured workers.  Often the nurse in involved with the physical and psychosocial aspects of not only the employee, but the family as well.  Focus has turned more and more to health problems that are not caused by the job, but that may be affecting job performance, such as drug and alcohol problems, emotional problems, stress and family relations.  The nurse may be involved in developing an employee assistance program, thereby assessing these needs and making appropriate referrals for treatment.  Prevention is an important part of this position, thus the nurse may be involved in some teaching.  Also, assessing and promoting worksite safety is accomplished by working with management and the safety engineer to comply with Occupational Safety and Health Administration (OSHA) standards.  The nurse must understand the guidelines that govern employee health and will likely be involved in developing policies which affect workers’ health and safety.

Salaries and benefits will vary according to the size of the business and geographic location.  In general through, salaries are lower than other areas of nursing.  To qualify for a position in occupational health a nurse must receive a certificate from the American Board for occupational Health Nurses.

For Information:
American Association of Industrial Nurses
P.O. Box 478
Dallas, TX   75221
American Association of Occupational Health Nurses (AAOHN)
50 Lenox Pointe
Atlanta, GA   30324
(404)363-8263
Offers placement service and maintains library of 1200 volumes on occupational health and general nursing.

LONG TERM CARE

While positions in acute care settings are on the demise, they are proliferating in long term care facilities (also called nursing homes or skilled nursing facilities).  Modern technology and medicine have prolonged life, causing the percentage of elderly in our country to increase dramatically over the past several decades.  Figure 2-2 indicates a significant increase in the elderly population since 1950, with a dramatic projection for the future.  In the past, many of the aged were cared for at home by a younger female family member.  Today, many more young women must work outside the home.  Also, families are much more mobile than they used to be.  Members of a family may find themselves scattered all over the map.  It is not at all unusual for aging parents to be thousands of miles away from an adult child.  Thus, more elderly need the services of long term care facilities.
Changes in federal law now require these facilities to staff more registered and licensed nurses.  The law also requires that nurse’s aides complete formal training, be registered with the state and take continuing education courses annually.  An ombudsman program protects the rights of nursing home residents and investigates any charges of misconduct (Morgan 1993).  Thus, the conditions of long term care facilities for patients, as well as staff, have improved.

Long term care facilities can be either privately owned or be part of large national chains.  They may vary in population from twenty to two hundred patients.  Generally, the RN supervises a particular unit or if the facility is small, the entire house.  Nurse’s aides or licensed practical nurses will work under the RN, providing direct patient care at the bedside.  The RN is usually responsible for all medications and treatments, as well as charting.
This type of work is less pressured than the acute care environment.  Residents are usually sent out of the facility if they require more skilled care than their usual routine.  For example, IV therapy is generally not given in a long term care hospital.

Figure 2-2 Number of Elderly by Age Groups in the United States
1950-2050

From US Bureau of the Census, Current Population Reports, Series P-25, No 764, US GPO, Washington, DC, 1977.

This is a wonderful career option for those who truly value the aged and enjoy working with them.  It provides opportunities to develop friendships over a long period of time, often several years, with patients and their families.  An acceptance of death as a natural outcome is important.  This would be a difficult area for a nurse who is results oriented and relies on the curing of a disease process for gratification.  The gratification here comes from providing a comfortable, pleasant and safe environment for patients who can no longer participate in the life they have known.  Working with the elderly requires a lot of patience, gentleness and understanding.

Nurses in long term care will find themselves working with a predominantly non-professional and unlicensed staff.  While to some this might feel professionally isolating, others see it as an opportunity for teaching, team leading and supervising.  In general, salaries are lower than acute care hospitals.  However, this has improved in recent years due to the huge demand for RNs in this work environment.  This is also an area which is fairly accommodating to nurses re-entering the field after a prolonged absence.

Conditions in long term care hospitals will vary dramatically.  In selecting a facility to work in, several things should be considered during the interview process.  Evaluate the cleanliness of the environment.  When you walk in the door is there a strong odor of urine?  Are staff members unkempt or professional looking?  How do the residents appear – dressed and groomed or disheveled?  If residents are up in a day room is there ample staff on hand to supervise?  Take a look in some of the rooms.  Again, how do they smell and are they neat and orderly, perhaps with personal touches, or with piles of laundry on the floor?  Notice how staff talks to and treat the residents.  Are there any special activities, such as exercise, arts and crafts and musical events?  What is the attitude of the nursing supervisor towards quality of life?  Does she value innovative ideas and creative involvement with the residents?  You will want to choose a facility whose values and professionalism match your own, and where opportunities for professional growth and learning are available.

Retirement homes are also proliferating to meet the needs of our rapidly growing elderly population.  These are residential centers developed for the mature adult who would like a structured and protective environment, but does not require skilled nursing.  These individuals may be declining in health and find the responsibilities of operating their own household too taxing.  Retirement homes often provide social life with onsite activities and excursions to shopping or the theater, a central dining room where meals are served, maid service and the safety of having a staff available in case of emergency.  Many retirement homes have a RN on the premises for these emergencies.

REHABILITATION NURSING

Rehab nursing has been developing over the past several years into an expansive and extremely viable career option for the 1990’s.  Medical and technological advancements have increased the survival rate of trauma victims, which increases the number of patients requiring rehabilitative services.  While insurance companies have reduced the number of days for acute care hospitalization, many have simultaneously increased reimbursement towards the longer and overall less costly services of rehab, whether provided in a long term care facility or in the home.  A survey showed that “every dollar spent on rehabilitation saves at least $10 on medical costs (Hammers 1993)”.  Since rehab services are usually DRG-exempt, the reimbursement is generally better than for other health care services.

The number of facilities that provide rehab services has doubled in the past decade.  Nationwide there are currently 169 rehab centers, 770 inpatient units and 102 long-term care hospitals (Hammers 1993).  In 1984 there were 49 rehab centers and 308 inpatient units.  There is no data on the number of long-term care hospitals in 1984 (Hammers 1993).

Because of improved medical technology, more patients than ever are surviving trauma and life-threatening illnesses and require rehabilitation to continue an optimum level of life.  “The survival rate of head injury patients has increased from 50 percent to 90 percent (Hammers 1993)” in the last decade alone.  Other types of patients who often require rehab are stroke victim, patients with respiratory or cardiac problems, amputees and cancer survivors.

The goals of rehabilitation are to help patients achieve their highest potential, adapt to their disabilities or illnesses and work toward independence (Hammers 1993).  Rehab can take place in specialized units within acute care hospitals, nursing homes as well as patients’ homes and work settings.

Programs have been developed which enlist the efforts of an interdisciplinary team of nurses and other professionals to create treatment plans for patients at their home, school or job sites.  The practicality of this is obvious.  To work with patients in their own environment can only save time and cost by better preparing them for the world in which they musts learn to function.  It has been found that this type of rehab costs approximately one-third less than conventional inpatient rehabilitation (Hammers 1993).

Rehab nurses need to be excellent educators, communicators, assessors and team players.  Registered nurses will generally be in charge of a unit and supervising unlicensed personnel.  The nurse is part of a team composed of allied health professionals, such as physical therapists, occupational therapists and speech therapists.  While these therapists help the patient to relearn skills of daily living, it is the nurse’s responsibility to support and reinforce these skills and to supervise the unlicensed staff in follow-through.   This type of work requires a great deal of patience, a positive attitude and the ability to be encouraging and supportive to patients who will progress quite slowly.  It is a rewarding career for nurses who like to see very concrete evidence of their efforts.  As in long term care, rehabilitation nurses tend to become quite involved with patients and their families and receive a lot of appreciation and strokes from these individuals.  In addition to working in inpatient and outpatient care settings, rehab nurses can work as expert witnesses for attorneys and serve as case managers for insurance companies.

The salaries of management-level rehabilitation nurses have increased by 17 percent since 1990, 11 percent for rehab staff nurses and 12 percent for rehab nurses working for insurance companies (Hammers 1993).  This is good evidence of the need for nurses in this area, as well as an indication of its enduring into the future.

Since most nursing schools do not include rehabilitation in their curricula, nurses receive training and education on the job.  Training programs for new graduates and inexperienced nurses is offered in many rehab settings.  The Association of Rehabilitation Nurses (ARN) has resources available for interested nurses.  They offer courses, a textbook and other publications, videos, audiocassettes and independent studies.  They also conduct seminars and workshops at various locations.  The ARN also offers a certified rehabilitation registered nurse (CRRN) credential.  A nurse who has worked two of the past five years in rehab is eligible to take this exam.

There are only six universities in the United States which offer a master’s degree in rehabilitation nursing.  These include the University of Alabama at Birmingham, Rush University in Chicago, Thomas-Jefferson University in Philadelphia, the State University of new York at Buffalo, Columbia University in New York and the University of Texas in Arlington (Hammers 1993).

For information:
American Congress of Rehabilitation Medicine
5700 Old Orchard Road, First Floor
Skokie, IL   60077-1057
(708)966-0095
Represents all disciplines and specialties within medical rehabilitation.

Association of Rehabilitation Nurses
5700 Old Orchard Road, First Floor
Skokie, IL   60077-1057
(708)966-3433
National organization of RN’s working in the various settings of rehabilitation nursing.  Provides continuing education, publications, certification program, seminars, workshops and an annual conference.

Medical Rehabilitation Education Foundation
1910 Association Drive, Suite 200
Reston, VA   22901
(703)648-9350
(800)368-3513
Provides information to consumers, employers, insurers, governmental policy-makers and the health care community.

HOME CARE

Home care is an excellent way for nurses to continue to reap the rewards of primary care nursing in a more relaxed and autonomous environment.  Other terminology used for home care would be home health, visiting nurses and hospice.  All one need do is look in the classified section of any newspaper or nursing publication to see that home health is alive and well in the current economy.  Again, as hospital stays decrease, the need for skilled nursing care in the home is increased.  Procedures that were once done exclusively in the hospital, such as intravenous therapy, are now being performed in the home under the supervision of nurses.

A study done of the six counties of the San Francisco Bay Area indicates that home health will experience the fastest employment growth of any sector of health care.  Figure 2-3 indicates that employment needs in home health will double between 1987 and 1995.  Health care delivered in the home has proven to be a cost-effective form of care, which may lead to legislative changes providing improved funding of home health care, as well as increased reimbursement through private insurance plans.

Figure 2-3 Growth Rate of Health Jobs by Industry Ranked Fasterst to Slowest

Six-County Bay Area 1987 - 1995

In a home health agency the RN is a case manager who has a case load of patients to see as often as required.  A patient requiring dressing changes for a pressure ulcer might initially be seen one or two times per day.  As a family member or other caregiver at home is trained to do this, the RN might decrease these visits to once a week to check on progress and insure against infection.  A patient requiring nothing more than a catheter change would generally be seen only once a month, unless there were a complication.  An unlicensed home health aid may spend several hours a day with the patient for unskilled care, such as bathing, dressing and feeding.  The case manager is responsible for supervising the unlicensed personnel in these activities.  Home health nurses generally dress in their own casual professional attire, rather than a uniform.  Sometimes a lab coat is worn.  Most home health nurses carry a beeper so they can be reached out in the field.  The normal workday may find the nurse checking into the agency first thing in the morning, or at the end of the day, with the bulk of his or her time spent out in the field seeing patients.   It is usually a Monday through Friday daytime schedule, with an alternating person on call for the weekend.  Nurses may work full or part-time.

Home health nurses have a lot of autonomy and are responsible for juggling their own case loads.  They must continually assess the patient’s needs and make recommendations to the physician regarding appropriate treatments, therapies and medications.  When a patient is in the home environment, there are many needs which need to be addressed.  Psycho-social and family issues will become apparent, as well as possible problems with a home structure.  Home health nurses have the opportunity to greatly influence and facilitate all areas of a patient’s care.

A nurse entering home health would need to have a strong med-surg background and good assessment skills.  This nurse must truly enjoy the personal contact of being in a patient’s home and interacting with families of various ethnic backgrounds.   This type of nursing often calls for visits into neighborhoods where safety must be considered.

There are about 25 home health agencies which are large national chains.  However, there are many thousands more which are independently owned and operated (Morgan 1993).  The highest salaries can be found in for-profit agencies, as opposed to government or nonprofit agencies (Morgan 1993).  There may be advancement opportunities into supervisory positions, nursing education and possible even marketing, depending on the size and structure of the agency.

Nurses who love home care feel they are connecting with the roots of what nursing is all about.  It provides the satisfaction of developing long term relationships with patients and their families, becoming an exceedingly important person in their lives, and the satisfaction of making a direct impact on the care of the patient.  If you want to continue giving primary care but with more autonomy and personal contact than in acute care, this is a good avenue to chose.

SALES

Medical equipment and pharmaceutical companies, particularly those with high tech products, often like to hire nurses as sales representatives.  The nurse as a sales rep is the liaison between the manufacturer and the end user of the product, which could be the patient, nurse or doctor.  Organizational and communications skills developed as an RN are of great value in the business world.  In sales, the nurse is promoting and maintaining health in a business arena.

Such items as specialty beds, cardiac catheters or operating room equipment, require some scientific knowledge and an understanding of the disease process for which they are intended.  Many companies prefer to hire RNs because of the ability of the nurse to comfortably call on health care professionals and the credibility that the nurse lends to the product.  The nurse has often used the product and can therefore stand behind it with experience.

The sales rep may be calling on individual doctor’s offices, home health agencies, hospital purchasing departments or even hospital administrators.  The “sale” may range from taking an order of office supplies for a doctor’s office, to negotiating a contract with a hospital for durable medical equipment worth thousands of dollars.

Nurses are particularly valuable to a company with high tech equipment.  When such products are introduced to a hospital, the rep is often required to in-service the staff on its use.  The sales rep who is also a nurse might already have used the product clinically, have had a good experience with it and is therefore enthusiastic in its presentation.  This rep also has a good understanding of what the product is for, how it can assist the nursing staff and the types of problems nurses experience in giving care.  He or she speaks the language of the clientele, which is beneficial in establishing trust and rapport.

Most sales reps work out of their homes, which offers the luxury of a flexible schedule, but also means they, must be self-motivators.  Time is divided between the home office and being out in the field meeting with prospective customers.  Many cold calls over the telephone are usually made before a face to face meeting is secured.  Some representatives, such as pharmaceutical reps, will attempt to meet with the physician by making a cold call in person during business hours.  As you can imagine, there is a lot of rejection involved and the successful sales rep must be able to take this in stride, keep a positive attitude and not take it personally.  This is usually more difficult in the beginning of one’s sales career.  After some time in the field, reps build up a solid client base of customers who respect and appreciate their services.

This type of job requires a high energy level, confidence, assertiveness and the ability to establish rapport and trust with people quickly.  The person must be a self-starter and enjoy working independently.  For nurses who thrive on the camaraderie of a peer group, this could be a difficult transition.  A nurse going from a hospital salary to sales must be prepared for an initial drop in salary before commission starts to build up.  It can take from six months to a year for the commission to get to the point of equaling a hospital nurse’s salary, but then the earning potential is unlimited.  Successful salespeople can earn an income of up to six figures.  It takes time to build this kind of business and you must be financially prepared for this temporary setback in salary.  A company car is usually offered, as well as an expense account for phone, gas, office supplies and entertainment of clients.

There are thousands of pharmaceutical and medical supplies companies.  You may go to a library with a good research section to obtain a listing.  There are many companies willing to hire nurses without previous sales experience.  A professional appearance and assertive presentation during the interview is often what the company is looking for.  Most have training programs with the continuing support and guidance of a manager.  For nurses who enjoy business and working autonomously, and would like to feel that they can directly influence their earning potential, this is an exciting career path.  It can be particularly exciting to be on the cutting edge of new products and technologies appearing on the market and knowing you have the ability to make an impact on health care and patient outcomes through the promotion of such products.

For networking:
National Nurses in Business Association (NNBA)
1000 Burnett Avenue, Suite 450
Concord, CA   94520
(510)356-2642
Offers opportunities to meet and network with other nurses in the business arena, bi-monthly newsletter, discounts on products and services, conferences and seminars.

MARKETING

Marketing is an exciting area for nurses who love to be out meeting and networking with the health care community.  In the past few decades health care has been taking on the face of corporate America.  Competition is fierce, and providers at all levels have found it necessary to advertise themselves to the public as never before.  Patients have many choices now, and consumers have become quite discriminating.  With the advent of HMOs, PPOs, Managed Care and EAPs, providers have had to establish themselves as unique and superior to the competition in order to contract for services.  Who would ever have ever thought hospitals, long term care facilities or treatment programs of any sort would be in competition for business?  Many years ago we would never have seen the advertisements on television for hospitals health plans that we see today.

This trend has opened up many opportunities in the area of marketing.  Nurses have an advantage here in that they know the business from the inside out and have developed professional relationships with the medical community.

Marketing is the process of bringing one’s product or service to the awareness of the public or the selected market.  In this case we are talking in general terms about health care.  Within health care there are several different types of services and providers; those providing direct care, those providing payment of care, those managing the payment of care and more.  Marketing generally involves many different activities to accomplish the desired goal, which is to attract attention to the business and thereby increase revenue.  The marketing executive may be required to call on individuals or groups to explain the service or product, to be involved with press releases and advertising campaigns and to attend professional functions in order to network with influential people.

All the different types of insurance companies and managed care companies rely on marketing personnel to sell their packages to employers for coverage of employee health benefits.  Quality of care at a reasonable cost to the employer is very important.  These third party payor companies must develop special services and rates in order to invite contracts.  The efforts of the marketing staff will bring the company’s services to the attention of the public.  Someone in this type of job would be active with the media, advertising and networking in the professional community.  The image of the marketing staff is important because they are seen as representing the company to the public eye.

The larger home health agencies hire marketing personnel to call on individuals involved with the discharge of patients from hospitals, such as discharge planners, social workers, unit directors or charge nurses and utilization review.  Often the person involved in doing the marketing will also become quite involved with the clinical team on particular cases to evaluate the patient’s needs for home care and to insure a smooth transition upon discharge.  They will set up any therapy and equipment the patient will require at home, as well as determining the level of care needed, whether a home health aide is required to assist with bedside care, or if a limited number of visits is appropriate, perhaps to train a family member in giving care.  Nurses who become involved at this level are often called home health liaison nurses.  They are employed by the home health agency, but spend much of their time in a particular hospital.  The position combines marketing with clinical expertise.  A marketing executive for a home health agency might also call on individual physicians, particularly those specializing in a geriatric population, rehabilitation or oncology, as well as speaking to groups of seniors.  Skilled nursing facilities and rehabilitation hospitals also employ marketing/liaison nurses to draw in business.  Small, for-profit hospitals, such as those offering mental health services, greatly benefit from having a marketing department.  If it is not an emergency admission, this is an area where the patient or referring therapist can exercise some choice, particularly in the areas of eating disorder or chemical dependency treatment.  The marketing executive in this case would need to call on the mental health professionals in a given geographic area to discuss the program, and then follow up with those individuals on a regular basis.  He or she would also want to attend professional functions in order to network and become a well-known and trusted colleague.  Organizing promotional activities, such as speakers or workshops at the hospital site, is a good way to attract attention from the professional and lay communities.

A marketing executive can expect a salary in the upper 30’s to mid 40’s to start.  This is dependent upon the size and profitability of the organization.  Also, some companies may offer an incentive package, which would involve a commission or bonus structure.  Automobile or mileage allowance is generally offered since so much time is spent out in the field, as well as an expense account for entertaining clients.

As with sales, anyone seeking a career in marketing must not be afraid to approach unknown colleagues, must be assertive and at the same time sensitive with highly developed communication skills.  This person must be able to keep a positive attitude despite constant rejection or disinterest.  Because of the autonomy it is important to be self-motivated and focused on goals.  There is often quite a bit of pressure to meet quotas or to produce a certain amount of referrals or revenue.  As a marketing executive you must be able to meet corporate or administrative expectations, realizing that you have the influence and power to drive the business forward towards success.  This is generally not a typical 40-hour work week with a regular daytime schedule, due to the numerous social obligations or speaking opportunities that may arise.  This is a high profile and exciting position for the person who likes this kind of challenge.

The larger corporations will generally seek individuals with some sales or marketing experience.  However, this is an area where nurses without such a background can find opportunities to break in.  This is particularly true in home health agencies or the small for-profit mental health facilities.  Nurses with no experience who can present themselves professionally and with confidence, demonstrate the charisma needed for this type of high profile position and a good understanding of the business of health care, stand a good chance of breaking in.  An outgoing and dauntless personality along with a professional appearance has a lot to do with successful marketing.  Other helpful attributes might be some public speaking experience and evidence of influential contacts in the field, or of a good professional reputation.

For networking:
National Nurses in Business Association (NNBA)
1000 Burnett Avenue, Suite 450
Concord, CA  94520
(510)356-2642
Offers opportunities to meet and network with other nurses in the business arena, bi-monthly newsletter, discounts on products and services, conferences and seminars.

For information:
Academy for Health Services Marketing (AHSM)
c/o American Marketing Association
250 S. Wacker Drive, Suite 200
Chicago, IL   60606
(312)648-0536
Offers placement service and continuing education.

American Society for Health Care Marketing and Public Relations (ASHCMPR)
American Hospital Association
840 N. Lake Shore Drive
Chicago, IL   60611
(800) 621-6712
Offers several professional publications and membership directory.

MEDICAL-LEGAL NURSE CONSULTANT

As evidence of this growing field, the Association of Legal Nurse Consultants (AALNC), founded in 1989 by 35 RNs from five states, in 1992 reported a membership of 700 nurse’s nationwide (Madison 1992).  This is a fascinating area for nurses with a penchant for the courtroom.  A nurse’s expertise is a valuable asset to attorneys dealing with medical cases.

The legal nurse consultant (LNC) collaborates and strategizes with attorneys to better represent a case, and to save the attorney time by applying medical expertise to gathering pertinent information for the case.  It is the LNC’s role to prepare attorneys so well that they are as knowledgeable and comfortable with the medical issues of their cases as they are with the liability issues.  Nurse consultants work with lawyers in cases involving litigation, personal injury, products liability, medical malpractice, toxic torts, workman’s compensation, criminal and other applicable cases (Madison 1992).  Legal nurse consultants are different from paralegals, who also assist lawyers in legal matters, but usually do not have expertise in the area of medicine.

Following is a detailed outline of the duties of a legal nurse consultant.  Certain activities pertain to working with an attorney in a plaintiff capacity or a defense capacity and some apply to both.

Plaintiff:

  • Meets with referring attorney(s) and/or client(s) for interview purposes in malpractice, personal injury, toxic torts and products liability cases.
  • Presents cases to attorney for decision regarding participation.
  • Prepares letters for approval by attorney on cases which are declined or prepares attorney with relevant facts to decline case.
  • Assists attorney in preparing the Complaint in malpractice, personal injury, toxic torts and products liability cases.

Defense:

  • Meets with defendant attorney(s), physician(s) and/or clients(s) for interview purposes in malpractice, personal injury, and toxic torts and products liability cases.
  • Reviews complaint and assists attorney in determining plaintiff’s case strategy
  • Reviews Complaint and assists attorney in responding to Complaint.

Plaintiff and Defense:

  • Assists attorney in determination of potential liability.
  • Determines, obtains and reviews all medical records and billing statements necessary for complete case review.
  • Prepares memorandum and chronology regarding case medical facts, or deviations from standard of care exercised by defendants or potential defendants.
  • Performs medical library research regarding case subject areas and standards of care and summarizes medical literature.
  • Educates attorney regarding medical facts and issues relevant to case.
  • Identifies appropriate experts in case subject areas and contracts and secures their services.
  • Locates demonstrative evidence (i.e. medical charts and models) for deposition/trial use.
  • Assists attorney in preparing and answering Interrogatory responses and Requests to Produce Documents involving medically related questions.
  • Assists attorney in preparing arbitration briefs involving medically related items.
  • Prepares attorney for depositions and/or trials and advises attorney of appropriate strategies with medical witnesses.
  • Attends depositions/trials and advises attorney of appropriate strategies with medical witnesses.
  • Reviews and summarizes depositions during discovery.
  • Selects medical textbooks for purchase for attorney(s) medical library.

Legal nurse consultants earn from $60 to $150 per hour working in the following capacities:

  • full-time or part-time as an employee with a law firm;
  • full-time or part-time as an independent contractor to a law firm;
  • full-time or part-time in the clinical setting and consulting with a law firm and/or testifying as an expert witness on a part-time basis;
  • full-time or part-time as an employee with an insurance company or hospital in risk management.

A nurse interested in this career change must possess good communication skills and writing abilities.  Obtaining some education in law is helpful, but not a pre-requisite, however, a basic understanding of civil litigation is important.  Legal training, such as law school or paralegal training is not necessary to become a legal nurse consultant.  A nursing background alone qualifies you as the expert on nursing standards of care.  A nurse’s opinion on these standards is respected by attorneys.  It is important as a legal nurse consultant to know how to prepare and present yourself appropriately.  There are many workshops and seminars offered to prepare nurses to enter the field of legal nurse consulting.

For information:
American Association of Legal Nurse Consultants (AALNC)
500 North Michigan Ave., Suite 1400
Chicago, IL   60611-3796
(312)670-0550

Carondelete Management Institute
7760 E. Speedway Blvd.
Tucson, AZ   85710
(800)726-3888
Offers Medical-Legal Consulting Workshop for CEU’s.

BIOTECHNOLOGY

The technology of medicine is a fascinating area of work for nurses.  New discoveries are happening all the time which will affect mortality rates as well as the quality of life we experience. Biotechnology is a growing area whose expansion will only continue into the future.

Nurses may find opportunities in various capacities, depending on the product and the company structure.  They may assist in the area of research, compiling and verifying data and assisting with trials of the product.  Some companies like to send nurses out to demonstrate a new product to physicians or other health care members who will be using the product, to insure its proper use.

At the Collagen Corporation, nurses are hired as Medical Device Experience Specialists.  The company produces injectable collagen for the augmentation of wrinkles and acne treatment.  Leslie Holderby of Human Resources described what this position would entail.  Nurses receive phone calls from individuals who have experienced an adverse reaction to the product.  This might be a doctor or a patient.  The nurse would be required to document the problem according to FDA guidelines, investigate and then follow through with the physician or patient.  The nurse is not giving advice, but providing some direction.  This nurse would also respond to inquiries regarding the indications, contraindications and ramifications of product use, classifying and documenting inquiries and maintaining a computer database and patient files in strict adherence to FDA guidelines.

In this type of position it is important to understand terminology, have some computer knowledge and be detail-oriented.  It is a stressful position because the nurse often has to deal with an unhappy consumer.  Interpersonal skills must be very good, with the ability to be diplomatic and tactful.  A BSN is the minimum requirement.  The starting salary is approximately $45,000 with the ability to advance up a career ladder.

Holderby feels this is an exciting area for nurses to be in.  She states that biotech is a growing area which provides an exciting learning opportunity for nurses in a corporate environment.

The public library can be helpful in producing a list of biotechnology companies.  A phone call to their human resources department can provide information on the types of positions they have for nurses.

Acknowledgments:
Leslie Holderby, Human Resources, Collagen Corporation

MEDICAL WRITER

There is a great demand for medical, health and scientific information, particularly with the acceleration of medical breakthroughs today.  Americans have become increasingly more aware of, and interested in health and fitness, and want to better understand medicine, science and technology.  Medical coverage in the mass media (newspaper, radio and television) has expanded dramatically and there is even a cable television network devoted entirely to health subjects.   With each new drug or piece of medical equipment produced, medical writing is required.  Growth in pharmaceuticals has been dramatic over the past several years, providing many opportunities for medical writers (Swanson 1989).

Medical writing is used in many different areas of the health care industry.  Following are some examples of the opportunities available:

  • Personal health column of local newspaper
  • Package inserts which accompany pharmaceuticals
  • Highly technical educational materials for medical students
  • Medical and health news for television and radio
  • Public relations copy, such as information brochures, in-house newsletters, press releases, magazine articles and exhibits for hospitals, clinics, medical schools and medical societies
  • Highly technical instructional manuals for the operation of new diagnostic and treatment equipment
  • Developing computer software
  • Writing advertising copy for pharmaceutical and medical equipment companies
  • Scripts for public service announcements and health education films
  • Writing scripts and producing educational videos for patients and/or health care personnel
  • Continuing education courses for registered nurses
  • Ghost writing for health care professionals
  • Professional journals
  • Publishing a book on an area of expertise (anything from how to care for an elderly loved one at home to understanding and maximizing your insurance benefits)

Most medical writers are not health care professionals.  Generally their background is in English or journalism, with perhaps some education in the sciences.  A nurse, who sincerely enjoys writing and can demonstrate the ability to communicate medical information through the written word, has a chance of acquiring work as a medical writer.  Medical writers often must take extremely complicated and technical information and translate it into very plain language that the average human being can understand, such as nurses do every day with their patients.  Or, they must provide a sophisticated and accurate account of findings to a highly professional audience.  When producing advertising copy, the writer must have an understanding of the psychology of sales.

There are full time jobs to be found, as well as part time and freelance work.  A freelance writer must constantly be seeking work opportunities, but the rewards can be great in the areas of flexibility in time and topic interest.  Medical writers can work for newspapers, magazines, the medical press, textbook publishers, pharmaceutical and medical equipment companies, laboratories, hospitals, clinics, schools and associations for health care professionals, government, radio, television and advertising agencies (Swanson 1989).

In order to acquire work as a medical writer, one must build a portfolio of published work.  To get some experience and build this portfolio nurses can break in with their local newspaper, a regional nursing publication, their hospital’s newsletter or anything else that might help to get started.  This type of writing generally pays very little, from a few dollars to perhaps $100, but it will be the beginning of a writing career.   There are many local special interest publications, such as those for parenting and child care, which would be very happy to have articles submitted by registered nurses.

The American Medical Writers Association (AMWA) is a national organization for medical communicators.  AMWA offers writing and editing workshops and seminars and publishes a job market sheet listing job opportunities.  AMWA also offers a program called the Core Curriculum which teaches the writer improved skills in the area of biomedical communications.  Upon completion of this course a certificate is awarded.  AMWA reports that writers with this certificate tend to command higher fees and are more in demand (Swanson 1989).

In general, however, most medical writers learn by doing (Swanson 1989), by simply stepping out, getting experience and building a foundation for a career.   It would be important to be proficient with a computer or word processor.  Swanson describes some of the most important qualities a medical writer should possess:

  • A genuine love for writing and the temperament to wrestle with a concept until it is in language that accurately, clearly and appropriately communicates what needs to be said.
  • A genuine and abiding curiosity about medical and scientific topics.
  • Essential journalistic abilities – talent for interviewing, a knack for researching and digging for facts, the ability to relate well to others and the ability to produce under deadline.

For information:
American Medical Writers Association (AMWA)
9650 Rockville Pike
Bethesda, MD   20814

The Society for Technical Communication
815 Fifteenth Street, N.W., Suite 506
Washington, DC   20005

Health Sciences Communications Association (HESCA)
6105 Lindell Blvd.
St. Louis, MO   63112
(314)725-4722
Sponsors workshops, competitions and an annual convention; publishes a newsletter with employment listings.

INTERNATIONAL NURSING

Working as a nurse in a foreign country can be an exciting way to travel, to bring sophisticated knowledge and expertise in health care to an underdeveloped area, and also to learn much about other cultures and health care systems.  The opportunities can range from the gratification of missionary work in a third world country to experiencing the glamour of living in the City of Lights while working at the American Hospital in Paris.  In most cases, proficiency in a specialty area of nursing, as well as knowledge of the language of the destination is required.  Following is a listing of potential opportunities.

Saudi Arabia
Kama Enterprise, Inc. is a recruiter specifically for health care positions in Saudi Arabia.  The parent company is one of the largest health care management companies in Saudi.  American nurses would work in internationally staffed hospitals that serve the needs of Saudi nationals.  They recruit for all specialty areas.

The salary varies according to the specialty, but is somewhat comparable to salaries in the United States.  The advantage, however, is that the salary is completely tax-free.  There is also free housing and utilities, thirty paid vacation days per year, as well as nine paid holidays.  The commitment is from three months to two years.

For information contact Valerie Bagnas at (800) 433-7791, or write Kama Enterprise, Inc., 4380 Southwest Macadam Avenue, Suite 490, Portland, OR  97201.

International Business
This would include occupational health nursing for companies with branches in other countries.  In particular, the oil companies in Mid-eastern countries have had quite a large demand in the past.  For information, contact the individual companies with overseas interests as well as trade journals for that particular industry.

World Health Organization (WHO)
The major concern of WHO and its regional office, the Pan American Health Organization (PAHO) is in primary care, but education may also be a possibility.  The WHO headquarters is in Geneva.  PAHO can be contacted at 525 Twenty-third St. N.W., Washington, D.C.  20037.

Peace Corps
There are sixty Peace Corps countries in which both volunteer and staff nurses serve.  The staff nurses work in preventive and curative programs developed to care for the volunteer workers.  Contact the Peace Corps, P-301, Washington, D.C.  20526

Project Hope
The purpose of Project HOPE is to bring the skills and techniques of American health care to the people of other countries in their own environment and adapted specifically to their needs and way of life.  HOPE has projects in the United States as well as its international interests.  Contact Project HOPE, Millwood, Virginia  22646.

Missionary Work
This type of work requires a lot of stamina for the long hours and difficult work in vary underdeveloped areas.  The pay is generally very low.  Nurses in this type of work would also be expected to provide religious teaching to the population served.  Information can be obtained through individual churches.  These churches to not always require that the nurse be of that particular religious denomination.

THE MILITARY

Nursing in the armed forces can provide excellent opportunities for nurses wishing to continue a career in an acute care environment.  The military offers education benefits, training in a specialized area of nursing, excellent salary and benefits package, retirement, thirty days paid vacation per year and the ability to serve in various locations around the world.  Registered nurses are commissioned officers and can increase in rank as they advance in their careers.

Nurses *in the armed forces are given many opportunities that civilian nurses do not have.  They are given management responsibilities early on, which correspond to the nurse’s rank as a commissioned officer.  The military encourages advanced education by providing tuition assistance and opportunities for specialized training.  According to military nurse recruiters, this is an area which has not been effected by current economics.  Their recruitment needs are continuous.

Nurses have a choice of where they would like to serve.  The first part of training is generally not at this location, but involves several weeks at a training base to learn about the military way of life.  Accommodations are not provided for families during this time.  However, once stationed, nurses, whether single or with families, are offered on-base housing or an allowance for off-base housing.  During wartime or other national emergency nurses may be relocated as needed.

Nurses may join the reserve corps in any branch of the armed forces without joining the regular service.  Reserve nurses are usually required to put in one weekend a month and two consecutive weeks a year of paid training at a local medical unit.  These nurses will be called upon for service in time of war or other national emergency.

Reserve nurses have many of the same benefits of those serving in the regular military service.  These would include opportunities for promotion, continuing education, fringe benefits such as low-cost insurance, retirement pay (after 20 years) and veterans benefits, PX shopping and opportunities for personal travel.

Qualifications to serve in any of the branches of the armed forces are essentially the same.  The nurse must be a U.S. citizen, a graduate from an accredited nursing program and licensed.  Each branch has its own age limitations.

The Army Nurse Corps
A newly graduated nurse will be commissioned as a second lieutenant.   Applicants with experience or advanced degrees may enter at a higher rank.  Army nurse Corps officers may advance to the rank of Brigadier General.

Opportunities for nurses in the Army include giving direct patient care in any clinical specialty as staff nurses, head nurses or nursing consultants; directors or instructors for military courses in various hospitals and the Academy of Health Sciences or be responsible for nursing education and staff development within a department of nursing; involved in administration in various clinical services or at Army headquarters; function as nursing methods analysts, nurse researchers, nurse counselors, consultants to the surgeon general or advisors to military nurses of allied nations (Kelly 1991).

For information contact the local Army recruiting station and ask for the Army Nurse Crops recruiter, or write to Army Opportunities, Army Nurse Crops, P.O. Box 7700, Clifton, NJ  07015-4865.

Navy Nurse Corps
Newly appointed Navy nurses are given ranks of ensign to lieutenant, according to education and professional background.  Nurses may advance to the rank of Rear Admiral.

Navy nurses have opportunities to provide primary care to patients; teach patients, corpsmen and other health care team members; assume administrative positions; and serve as executive/commanding officers of medical facilities.  Assignments can be to hospitals, clinics, ships, headquarters, Officer Indoctrination School, Hospital Corps schools and other duty stations around the world (Kelly 1991).

For information contact the local Navy recruiting station or by writing the Nursing Program, Navy Recruiting Command, Naval Department, Washington, D.C.

The Air Force Nurse Corps
Initial assignment of rank for Air Force Nurses is at second lieutenant, or higher depending on education and experience and nurses may advance to a grade of Brigadier General.

Opportunities in Air Force Nursing include delivery of primary nursing care in a variety of specialties and settings, such as administration, mental health, operating room, anesthesia, clinical nursing, education, research, flight nursing, nurse practitioner and midwifery (Kelly 1991).

Flight nursing is a position unique to the Air Force.  These nurses participate in aeromedical evacuation in peacetime and during conflicts.  Flight nurses must complete a program at the School of Aerospace Medicine at Brooks Air Force Base, Texas, before receiving an assignment.

For information contact a local Air Force recruiter or write to HQ USAF Recruiting Service/RSHN, Randolph Air Force Base, TX 78150.  For information on Air Force Reserve Programs write HQ Air Force Reserve/SG, Robins Air Force Base, GA  31098 or HQ ARPC/SG, Denver, CO  80208.  For information on Air National Guard programs write National Guard Bureau/SG, Room 2E69, The Pentagon, Washington, D.C.  20310.

OTHER GOVERNMENT POSITIONS

U.S. Public Health Service (PHS)

The U.S. Public Health Service is a federal agency whose responsibility is to promote and assure the highest level of health for every individual and family in the country.  It also promotes world health by collaborating with governments and organizations on an international level.  The PHS is a vital force in advancing research in the health sciences, in developing public health programs and in providing therapeutic and preventive services.  Nurses may find opportunities at the Clinical Center Research Hospital in Bethesda, Maryland, public health and clinical nursing in the Indian health Service and consultation in such fields as community health, environmental health, hospital services, clinical specialties, nursing education and nursing research.

Nurses may enter the PHS either by appointment to the Commissioned Corps, a uniformed service composed of professionals in medical and health-related fields or through the Federal Civil Service.  Benefits and privileges of the Commissioned Corps are similar to those of officers of the armed forces.

The Indian Health Service offers a unique nursing experiencing serving a population of more than one million Native Americans and Alaska natives in approximately 200 hospitals and treatment centers across the country.

The Clinical Center at the National Institutes of Health (NIH) is a world center for biomedical research (Kelly 1991).  This vast organization includes the National Eye Institute, National Cancer Institute, National Institute of Aging, National Institute of Neurological and Communicative Disorders and Stroke, National Heart, Lung and Blood Institute, National Institute of Arthritis, Musculoskeletal and Skin Diseases, National Institute of Allergy and Infectious Diseases, National Institute of Dental Research and National Institute of Child health and Human Development, National Cancer Institute, National Institute of Environmental Health Sciences, National Institute of Diabetes and Digestive and kidney Diseases and the National Center for Nursing Research (Kelly 1991).

The NIH Clinical Center employs staff nurses to participate in planning for the total care of patients undergoing medical research, and are encouraged to be innovative in developing new skills and determining their role (Kelly 1991).
For information contact the Federal Job Information Center in your area listed in the telephone directory under “U.S. Government”.

Next: CHAPTER THREE: ENTREPRENEURSHIP