San Diego's sunshine still a magnet for travel nurses

"There's no old buildings. There's no trash anywhere. And the weather..."

In California, San Diego nursing jobs pay the lowest - from $24 to $30 an hour.
  • In California, San Diego nursing jobs pay the lowest - from $24 to $30 an hour.
  • Image by Martha Rich

When Mariette Parsons, RN, tells her patients she's a traveler, she says they often look puzzled. "They're, like, 'You work for a travel agency or something?'" Parsons explains that travel nurses fill assignments all over the United States. A native of Arlington, Virginia, Parsons came to San Diego at the beginning of February 2004. When I talked to her seven months later, she was contemplating a move to Denver. If the general public hasn't yet become familiar with the idea of itinerant health-care professionals, Parsons says most nurses have. She says young nurses ask her what they have to do to follow her example. Parsons, who's only 27 herself, advises them to acquire a few years of nursing experience before they take to the road. "Being a new grad is really where you learn the most. Depending on the hospital, you usually spend about two months in an orientation program with another nurse, where you're with her on a daily basis. You take what you have in your head and apply it to people. Learning something from a book and applying it to a mannequin is all fine and well, but it's not the same." Once a nurse starts to travel, "People assume you know what you're doing," Parsons says. They see travelers "as people who know how to jump from A to B to C to D -- to pick it up and go."

A slender young woman with delicate features and creamy skin, Parsons wore her fine, copper-colored hair pulled into a bun at the back of her head. She told me she was "so, so young" when she began to think of herself as potential nurse material; she has a vague memory of taking a test in elementary school that suggested she was suited to work in a helping profession. "I thought about sociology, and then I realized I felt a little too shy to talk to people too much." But nursing intrigued her, and by the end of high school, she knew she wanted to study it in college.One of her great-great-great-grandfathers had been a doctor, but the men on her mother's side of the family were mostly lawyers. "My dad is in sales, and my mom is an office manager of a company back in Virginia." Both supported their daughter's aspirations. Becoming a physician never appealed to her, Parsons said. At first the educational requirements seemed onerous; then later, while working as a nursing assistant in college, "I noticed that nurses get a lot more time bedside. You're there all day, basically." Doctors "have to see so many people they don't get to spend as much time with the patients as they might want to. But in nursing, you really get that. I appreciate how much time I can spend learning about my patients and their bodies. I need that time to be able to assess changes."

She began attending York College, a small private college in Pennsylvania with a well-respected nursing program, in the fall of 1996. It was around then, she says, that she first became aware of the national nursing shortage. Teachers would exclaim over what a wonderful time it was for the students to be venturing into the job market. "You knew you'd get a job," Parsons recalled, though she and her peers also fretted about the negative implications of the shortfall. "You weren't sure if you'd be working your butt off because there weren't enough nurses. That's something I think about down the road, because I think the nursing shortage is getting worse, not better. And you don't want to be put in a position where there are six travelers and one regular staff person. Then nobody really knows what they're doing."

She graduated with a bachelor's degree in nursing at the end of 2000 and, as predicted, had no trouble finding work, joining the coronary-care staff of the Arlington hospital where she'd worked as an assistant. "I knew I wanted to work with more critically ill patients. And I prefer the ratio of two to one or three to one [common in intensive-care units]. You're not running around as much. Also, it's very interesting trying to determine what the problems are and trying to help fix them, working with the doctors."

After a few years in Arlington, Parsons says, a couple of factors persuaded her to contact a travel-nursing agency. She wanted to live in other parts of the country, and being a travel nurse would make that almost effortless. The agency would find her a job, pay for her moving expenses, cover her health-care insurance, and provide her with a furnished apartment. Moreover, the standard travel-nursing assignment is 13 weeks. Parsons figured she could stand anything that long. If she didn't like a job, she could always move on.

She didn't want the agency to place her just anywhere. "I was afraid I'd end up in some weird small town that I never wanted to go to. I actually had New York City in mind, because I have a lot of friends there." She also thought about Denver, as well as San Diego. "I did like San Francisco as well, but I was, like, 'Well, if I'm going to California, I might as well spoil myself and go where it's warm all the time.' "

Parsons says San Diego quickly rose to the top of her list. Although farthest from Virginia, "It's still a nice, relaxed place," she judged. "The only reason you feel like you're in a city sometimes is if a trolley rolls by you and you're standing next to a tall building. I'm used to Washington, D.C., and New York City, so San Diego feels a lot different to me. There's no old buildings. There's no trash anywhere. And the weather drew me here a lot."

The job that suited her best turned out to be in the medical and surgical intensive-care unit at Sharp's Chula Vista facility (no position was available in a more specialized cardiac-care unit, such as the one she had been working in). "But I was willing to try something new," Parsons said. "Half the point of my moving was so I could try new things. This forced me to do that sooner than I wanted, but it was fine."

Although most travel nurses are interviewed over the phone, Parsons was interviewed at the Chula Vista hospital while on a reconnaissance trip to San Diego. While she was there, the hospital offered her a six-month contract rather than the more typical three-month one, and Parsons says she felt confident enough about the hospital to commit to it. Sharp would be paying her directly, an uncommon arrangement. (Most hospitals pay the travel-nursing agencies, which in turn act as paymasters.) Parsons also took a nonstandard approach in arranging her housing. A friend of hers had lived downtown in the Archstone Harborview apartment complex at G Street and Pacific Highway, and Parsons liked the building so much she negotiated with Access Nurses, her travel-nursing agency, to receive a monthly stipend to cover the rent on a studio there. "I really wanted something downtown, just to have the experience," Parsons explained. "The good thing about travel nursing is you can pick and choose a lot of what you want. You get spoiled, I think."

In exchange, hospitals expect the traveler to function at full efficiency after only one or two orientation shifts. "There are so many ways of doing things in nursing," Parsons says. "A lot of it's a matter of finding where things are. Or different pharmacies can work in different ways as far as what kind of meds do they bring to you and what you're supposed to get yourself on the unit. They're stored in different places." Emergency-code names aren't always standard, she says, and "you also have to familiarize yourself with the paperwork. Everybody has different kinds. Less is definitely better."

Parsons says her colleagues at the Chula Vista intensive-care unit made her feel she'd chosen well in coming to work there. "My manager is wonderful -- very warm." Although hospitals "don't necessarily need to put a lot of emotional effort into their travelers, I have to say they do at the hospital I'm at. They're very warm and accepting. They know that travelers keep them from being short [handed] all the time. So they're very happy that you're there." Parsons also found the Chula Vista job to be less stressful than her old post in Virginia, a difference she attributed to better nursing support and a stricter adherence to having one nurse take care of no more than two patients. (The California legislature mandated that ratio for intensive-care units on January 1, 2004.) "At my old job, they didn't use travel-nursing agencies as much. If you were down two nurses and you couldn't find anybody, you were just down two nurses."

As a consequence, Parsons says she watched some of her colleagues in Virginia develop poor attitudes over time. "Not poor in the sense that they provided bad care. But they were really stressed out, and they couldn't handle as much. Nursing is so physically and mentally stressing that the combination can really burn you out pretty easily. You're on your feet a lot. Not so much in this particular job, which I really like. I'm able to actually sit, as opposed to the last job, where I honestly wouldn't sit except for maybe the 15 minutes when I ate lunch or did stuff on the computer."

Parsons had been working a 7:00 p.m. to 7:30 a.m. shift three times a week, a common work schedule. I asked what she did on a typical night. That always began, she said, with an exchange of information with the day nurse. "So the real shift actually starts about 7:30 [p.m.]. You want to get your patients assessed within the first half hour. You're saying hi, looking them over, listening to their heart and lungs." This was crucial, Parsons added, "Because unfortunately these patients can change within minutes, depending on how sick they are." In order to recognize such a change, "You need to know what their baseline is."

A wide spectrum of individuals find their way into the intensive-care unit, she added. Patients might include pregnant women with complications or those who'd delivered but had developed problems while birthing. Ailing hearts and life-threatening cancers and mysterious abdominal masses all could require intensive care. "We also get a lot of folks who cross over the border for medical care," a fact that often led to linguistic frustration, according to Parsons. The only language she had studied in school was German. "We get a lot of communication done with hand gestures," she said. One saving grace was that "the Hispanic community definitely provides for having a lot of family support. There's always, like, 10 or 15 people coming in and out. And that's very good because you usually have somebody there to help you translate."

After the initial patient assessments, "What happens after that really depends," Parsons said. "Unfortunately, you can walk into a room to assess your first patient, and they start crashing, and you can't even get to your next patient. There's those kinds of nights. Then you also have the kind of nights where both patients are really needy, and you're running back and forth a lot. Medication time is around 9:00 or 10:00, and retrieving the medications from the pharmacy can take a lot of time. In addition, you have to recheck all the orders to make sure you're getting the right kind of medication.

"Fortunately, with nights, it's a lot more relaxed -- which is one of the reasons I don't mind doing nights," Parsons said. Although intensive-care-unit patients are more apt to be awake than other patients, "There are definitely some times when you're sitting and just charting or doing other paperwork. And you can take a good break."

Outside the hospital, Parsons had also been happy. People here were much more relaxed than on the East Coast, she believed. "I mean relaxed in the way they go about doing things. Relaxed in their driving. I feel like I'm the only one speeding down the highway at 85 miles per hour with a cell phone." Compared to the hustle and bustle of Washington, D.C., or Arlington, San Diego seemed hardly a city at all. "They're building the high buildings, but the trolley system is kind of laughable, as far as I'm concerned. And nothing's open late. You have the Gaslamp that has the restaurants and other things, but there's no late-night deli. When the 7-Eleven opened up down on Kettner, I almost lost it. I was, like, 'Yes!' " Parsons hastened to add that she had enjoyed her downtown-living experience, but after extending her six-month contract with the hospital for an additional three months, she was thinking about moving to Pacific Beach.

Parsons confessed that when she moved to San Diego she had felt scared about leaving her family and friends. " 'Cause I'm not a good phone person. I'm not a letter writer or anything like that." But working the three 12-hour shifts often left her with blocks of five or six days off, she said, and she had used some of those to visit her boyfriend and other loved ones back East. Her boyfriend had visited her a few times too, before coming out to live with her at the end of the summer. Despite the travel, Parsons had managed to save "a good amount," she disclosed. "What I do is I use the money I get from paychecks from Sharp to live off," paying her rent out of that money. "And I save what Access gives me for the rent." She was living in a much more expensive apartment than she had had in Virginia. "There my roommate and I had a place for $1000, so my share was $500." The San Diego studio, in contrast, cost $1400 a month. "But I'm getting paid more here as well, plus I make a night differential." Whereas she had been making $23 an hour when she left Virginia, her wage rate in Chula Vista was $29 an hour.

Parsons told me that Sharp had offered her a permanent position. Although it tempted her, she said she wasn't ready to abandon her dream of living in Colorado, maybe even in New Zealand. She imagined she might travel another five years.

The drawbacks of being a travel nurse were minor, she reflected. Professional educational opportunities were more limited. "If an in-service class is filled with the full-time staff, you might not get in. Which is understandable. You're not going to do them any good knowing about [some new skill] if you're leaving." Parsons had also found her nursing supervisors reluctant to allow her to handle more specialized procedures without proof of her competency. "I'll say, for example, that I've worked with balloon pumps, and they're, like, 'Oh, well. But you need to go to our class -- which is not available until October.' Which doesn't help me at all." As a result, Parsons felt her learning might have hit a plateau.

Another disadvantage was that travelers were more vulnerable to displacement when times got slow. "A few weeks ago, they had only 5 patients in the intensive-care unit, instead of the normal 18." So the hospital "floated" Parsons, having her work in units where patients were being monitored for potential heart problems. There each night nurse took care of between 4 and 6 patients. "When you're not used to taking care of that many people, it's really stressful to do so, 'cause you have to organize your time differently. It's a totally different way of doing nursing."

Parsons caught herself. "As far as I'm concerned, we're really spoiled, when it comes down to it. I feel very, very lucky to be able to do this -- nursing in general, but also the traveling. I really can't complain on any level. I mean, I whine when I get floated, but that's pretty much it. And I whine for only, like, two seconds."

When Parsons decided to become a travel nurse, she turned to the Internet. "I found there were so many companies," she said. "Google brought up page after page." She signed up with Access Nurses because it seemed small, and Parsons thought she might get more personal attention.

Headquartered in Sorrento Mesa, Access in fact is a midsized operation, with about 70 employees, according to Alan Braynin, the president and chief executive officer. Braynin founded the company in 2001, seven years after graduating from UCSD. In the interim, he helped supply information-technology workers to companies in the Bay Area. Braynin also ran a San Francisco dot-com for a while and came to think he should marry his online experience with the growing need for travel nurses. "You have thousands of nurses in your database." They need housing all over the country. "If you're able to retrieve information more efficiently, it's a significant competitive advantage. It's all information, really," Braynin said.

Money, he says, provides a powerful incentive for nurses to travel. "A nurse in Tennessee, an RN, might be making $17 an hour. They can come out to California and make more than $30 and live in housing rent-free. They get benefits. They get health insurance, a 401(k) plan." In California, San Diego nursing jobs pay the lowest, according to Braynin. "For one thing, there are a few hospital systems that are dominant in this marketplace. So they can kind of control the [wage rates]. But the other thing is it's a more desirable location. Actually, [pay rates in] Hawaii and San Diego are lower than many places. It's sunshine dollars." Braynin estimated that San Diego salaries ranged from $24 to $30 an hour. "Thirty would be very high in San Diego. It would be low in San Francisco."

I asked Braynin where the travel nurses come from, and he replied, "We take a lot of nurses from Southern states and put them into California, because Southern states like Alabama and Mississippi don't have as acute a [nursing-shortage] problem. I think Minnesota actually may have a surplus, for some weird reason. But right now, the shortage is a worldwide problem. The U.S. recruits nurses from the Philippines and India and Canada and the UK and Australia and Ireland. Australia also has a shortage now, so it recruits nurses from the Philippines and India and other countries. There's this musical-chairs game being played, where you have nurses being moved around overseas as well as domestically. It is an acute national problem, and it's getting worse."

The same assessment comes from Susan Nowakowski. She's the president and chief operating officer of AMN Healthcare, the largest travel-nurse provider in the United States. Recent mayoral candidate Steve Francis founded the company in 1985 in Las Vegas, but two years later he moved it to San Diego County, with the current headquarters located in Carmel Valley. When Nowakowski joined the company in 1990, she says it had about 20 employees and 200 travelers. Today it boasts 900 corporate employees (including about 600 locally), who place and serve about 6100 nurses at any given time. "We went public in 2001," Nowakowski says. Now AMN Healthcare is the eighth-largest public company in San Diego.

Nowakowski says travel-nursing began in the late '70s in response to the seasonal needs of hospitals in Florida and Arizona. "Those areas have a big influx of the elderly for four or five months out of the year. Their hospital censuses grow, and they need more staff -- but only for four or five months." When people realized that nurses could be induced to follow the snowbirds, an industry was born.

Other factors have helped it to flourish. Nowakowski says, "In order to be competitive, hospitals are constantly opening new units with the latest technology. But with every opening of a new unit comes a need for more nurses, and you end up with specialty-specific shortages. Or sometimes there's just an increased utilization in a particular specialty. The operating room, for example, is very tied to the economy. When the economy is doing well and people are more employed, they're going in for more surgeries, and there's a need for more O.R. nurses."

Another factor is that 95 percent of nurses are female, according to Nowakowski, and many staff nurses take family medical leaves to have babies or care for ailing parents. "A traveler fits in perfectly for a two- or three-month stint." Even if there were no nursing shortage, the company president says, travel nursing would be a viable industry.

Add the nursing shortage into the equation, and the result has been a red-hot market for travelers. Nowakowski says the number of nursing-school graduates in the U.S. declined every year from 1998 to 2002. Although the supply of new nurses now appears to have leveled off again, the company president says there's no end in sight to the rising demand, since that's being driven by the aging of the U.S. population. From about two million nurses in the year 2000, the demand is expected to grow to about three million by 2020.

Of course, more young women (and men) could enter nursing schools to meet that rising demand. "And nurse wages have risen a fair amount over the last few years in order to try to attract and retain more people," Nowakowski says. She says the average nurse in the United States now earns about $50,000 a year. But at that level, the supply of nurses has been static, rather than growing. "How much do you think you'd have to raise that $50,000 to send a message to the world: 'Nursing is where it's at. Come here and you're going to make a great living'?" she asks. "Do you raise it to $53,000? That's probably not going to make a big impact. Maybe if you raised it to $60,000 or $70,000." But since 25 cents out of every dollar spent in a hospital goes toward nurse wages, raising nurse salaries that much across the board could mean a 30 percent increase in hospitals' expenses. "And they already are having a difficult time making ends meet," Nowakowski notes. "So that's not something they're jumping on the bandwagon to do."

On the other hand, hospitals have embraced the use of travelers, she says. AMN Healthcare currently works with more than 3000 facilities, which Nowakowski says constitutes about 40 percent of the nation's acute-care hospitals. And "every year we sign up more." Competition among the agencies to both recruit and retain travelers is fierce. "The thought within the industry is that people tend to travel for two to three years. But we have people who've been doing it for ten years." Others try one contract only to realize they're not cut out for the peripatetic life.

Lisa Khan at first thought she might be one of the latter. Khan left her home on a dirt road in a two-stoplight town in the Deep South to help deliver babies in San Francisco. "That was culture shock!" The crowds and traffic and homeless people dumbfounded her. "I wanted to gawk at everything, but I didn't want to look like I was gawking. I was thrown by it. It took me a while to adjust."

But adjust she did. Khan, who's 43, is a short woman with long blond hair, a wide face, and a voice full of Southern honey. Five years after her departure from Luverne, Alabama, she gave the impression she'd be unruffled if she found herself having to deliver a set of twins by herself. In the back of a taxi. In the middle of a snowstorm. In Greenland.

We met at La Mirage, a warren of apartment buildings coated with brown-, gold-, and tan-toned stucco that overlooks the north side of Mission Valley, just east of Interstate 15. Winding cement pathways connect the various units and pass by numerous boulders and generous plantings of hibiscus, oleander, and palms. At the time we spoke, Khan was living in one of the two-bedroom units with her husband and 20-year-old daughter.

Khan recalled having to learn the bones of the body when she was in high school and thinking, "This is the most useless thing! It is never going to be something I'm going to need to know." She'd never been hospitalized until she had her first child a year or so after graduating from high school. But she had complications from that delivery, and she says the nurses' skill and self-assurance impressed her during her week-long postpartum stay. "They seemed to know exactly what to do." She began to wonder if she might join their sisterhood.

"My mother worked for the state Department of Human Resources. And my father was self-employed. But I think they felt like if I went into nursing, I would always have a job." Khan's first inclination, she says, was to become a licensed practical nurse (the equivalent of a licensed vocational nurse in California). "Back then it only took a year, and they had these programs that basically paid for everything, with loans and grants and stuff like that."

While enrolled in the licensed practical nurse program, however, Khan says she and some friends had second thoughts about the more limited degree. "There's skilled things that RNs can do that LPNs can't do." They can administer intravenous drugs, for example, or work in intensive-care units. "RNs are more trained for critical thinking and to make decisions. So if you're the kind of person who enjoys doing everything you have the potential to do, it's better to go ahead and be an RN." Khan says one friend found an accelerated program in Selma that enabled her to get her RN in just one additional year. "I've always been so thankful that I did it that way -- got it behind me."

Khan was 21 when she obtained her license, and within short order, she found herself pregnant again. Having a second child didn't derail her career. "In the hospital [where] I worked at the time, you worked seven days on and seven days off. But I had a grandmother who took care of my kids the days I was at work, so I didn't have to worry about daycare or anything like that. I just paid her."

The hospital, the only one in the little town, required nurses to work 12-hour shifts on seven-day stretches. "But with a small community hospital like that, you don't have the hustle and bustle that you have in big hospitals," according to Khan. "We did do routine surgeries, like gall bladders and appendectomies, and we did labor and delivery. But very low risk. There were days when it was very busy. But there was also a lot of downtime." The nurses set up a barbecue under a gazebo in a little courtyard, and on sleepy weekends they'd grill for themselves and the doctors.

On two occasions, Khan says she left the little hospital in search of a more traditional work schedule. Both times she became a community health nurse. "I kept thinking Monday through Friday would be better, but in the end it never worked out. And every day the hospital was calling me on the phone, saying, 'Please come back.' "

She learned about travel nursing in the early 1990s. "Two of the nurses at the hospital became travel nurses. They were single, and they went together. They took a job somewhere in Texas. One of them couldn't handle it. She came back halfway through. She just missed home too much. The other one finished out her assignment but then came back," also convinced she wasn't cut out for life on the road. "So that's how I first heard about it, but I didn't know any details."

About five years ago Khan tried to find out more. At that point, she had divorced her first husband and married a banker who had grown up in London, England. "The small town I lived in didn't have the job opportunities that he needed." Khan says she was flipping through a nursing journal one day when her eyes lit upon an ad from a travel-nursing agency. "I'm a sucker for advertisement," she laments. "Advertisement sells me." Her husband was also intrigued by the prospect of seeing more of the United States, so Kahn called one of the recruiters. Although she'd worked almost every nursing job at her little hospital, she says she gave some thought to how she ought to market her skills. "I talked to one of the doctors back home about it, and he told me he thought I'd be better in the ER. But the only ER nursing I had ever done was small-town." Big messy trauma cases were a rarity. "I could just envision it in these big cities -- like ER on TV! I didn't want to go somewhere where I would feel incompetent. So I decided to go with labor and delivery. Because labor and delivery is just labor and delivery. That baby's only going to come out in one of two ways."

She loved the ease of the relocation. "I'd never done any big moving. Even when I was married, I lived just right down the road from where I grew up." She says she and her husband and daughter (then 15) drove from Alabama to California, arrived in San Francisco on a Friday afternoon, and slept that night in the apartment that Khan's company had prearranged for them. "They took care of utilities and everything. I didn't have to put anything in my name. It was a very nice apartment complex."

She worked at the Kaiser Permanente facility on Geary Street, and Kahn says it took her at least six weeks to get over the culture shock. By the end of her original three-month contract, she felt confident enough to stay another three months. At the end of that period, her mother became ill, "and I wanted to get back on the eastern side of the United States. So I was making plans for a contract in Ohio, which shows you I know nothing about geography, because that was nowhere near Luverne. You can make it in a day's drive, but it's a hard day's drive." As things turned out, her mother died before Khan's California contract ended. She and her husband and daughter nonetheless moved to Ohio for 13 weeks, where she enjoyed her stint at Ohio State University Hospital, a huge teaching facility. But her husband's professional opportunities were limited in Ohio, "so we decided to go to Washington, D.C. We lived in Alexandria, Virginia. We were there for about two years," Khan recalls. "I worked at different hospitals, and he got a job at the credit union in the Pentagon."

She never warmed to her first Washington assignment, a Catholic hospital that seemed gloomy to her. She spent a more satisfying year at a private medical center, then got a contract working at a large inner-city institution. There, "A lot of the patients were drug addicts. It was sad. A lot were high-risk. And while we were there, two hospitals closed. The last one was a large delivering hospital, and it flooded the other hospitals in labor and delivery. We would have people lined up in the hallways, sitting in chairs, waiting for monitors, laboring. It was overwhelming at times, especially toward the end."

Khan says the last three or four months of her Washington tenure almost extinguished her enthusiasm for nursing. Her older child, a son, had married by then, and his wife was expecting a baby, so Khan and her husband and daughter returned to Alabama. They still had their home there, a significant tax advantage (since living expenses on the road aren't considered income if you have a permanent residence). "But every year or two, you have to go back home and reestablish your residency," Khan explains. As she waited for her grandson's birth, she returned to Luverne's community hospital. "There I kind of dibble-dabbled in labor and delivery. You don't always have someone in." During the slow periods, she worked with medical and surgical patients again, a welcome change, she says. "I didn't realize that by specializing like I'd done for the past three years, I had kind of lost touch with medicine."

Khan says she and her husband stayed in Luverne for three months after her grandson's birth. Then, to her surprise, "I kind of got itchy to be back on the road again. And my husband said, 'Well, let's go back to California.' " No contract was available in San Diego, their preferred destination, "So we went to Palm Springs -- in the summertime! I had no clue what that meant. But I do now. Enjoyed it very much, but it was hot." After five months, Khan took an assignment in the mountains, in Santa Maria, which she remembers as "a very lovely place. It was nice and cool. There was fall in the air." Then a position at Sharp Mary Birch Hospital for Women opened. "I was there for seven months. They're delivering an average of 700 babies a month. But as long as you have the nurses to handle it, it's not hideous." On the contrary, she thinks Mary Birch is "an excellent hospital. Very well organized. You may have seen them on Discovery Health a couple of times."

Around this time, Khan's husband began to think about starting a medical-billing business. As he went back to school to study that subject, Khan decided to check out another hospital here, and at the beginning of July, she took a job at Kaiser, five minutes away from her apartment, tending to women recovering from high-risk pregnancies and gynecological surgery. "It's an excellent hospital, also," she told me toward the end of her contract there. "It's a teaching hospital. But I don't like being out of labor and delivery for prolonged periods of time, because labor and deliver can be very intensive and very critical. It's a specialized field, and if I'm out of it for a prolonged period of time, I have to stop and think about what to do next." By September 2004, another labor-and-delivery post for a traveler had opened up at Mary Birch, and Khan was planning to return. "The nurses are wonderful there," she said. "Very supportive."

Still, she doubted that she and her husband would remain in San Diego for much longer. "I have a son and a daughter-in-law and a grandchild back there in Alabama," she reminded me. Also, the cost of living in San Diego could seem overwhelming. "When we first came back out, I decided there must be no cows or chickens here because eggs and milk were so expensive! Unfortunately, I have to buy my groceries. My company doesn't do that for me." While the top pay Khan had earned in Alabama was $24 an hour versus $26 to $34 an hour in San Diego, "The cost of living [in the South] is nothing! I could have a mansion for $100,000 there. With lots of land." Moreover, neighborliness in California seemed in short supply. "Like, for example, when we were in Santa Maria, my car broke down on the way to a doctor's visit. It was at a busy intersection, and I was able to get it off to the side of the road. I just needed a little jump to get to the service station across the road. But nobody would stop." She called AAA, which solved her problem, but she couldn't help comparing that experience to what had happened to her husband on the couple's last trip back to Alabama. "He was alone on this stretch of deserted highway, and something happened to his car. And within ten minutes, three people had stopped to see what he needed. So there's a difference, and it has to do with the region you're living in."

On the other hand, traveling had taught her about different cultures, she pointed out. "Being from the South, you know there's certain prejudices with certain people. There's no different cultures back there. It's just a slow, sleepy town that's still living in the past. Which is nice. It's like Mayberry. It's a great place to raise kids. But when I started traveling, I met all these different races, especially in labor and delivery." Traveling had exposed her to much more racial and ethnic diversity, which she enjoyed. Khan told me she felt sad that people in Alabama were missing out on this "because they want to cling to the past."

Travel nursing had also taught her about the diversity in American medicine. "I've learned there's different ways to achieve the same end," she said. She also believed that traveling had forced her to become more efficient. "I wouldn't want anyone to regret that they'd hired me. And I'd hate for travel nurses to have a bad name. So I try to excel in the things that I do."

I wondered if travel nurses ever serve as a conduit for transmitting good ideas between hospitals, but Khan said she hesitated to tell one group how others did things. "People don't like to hear that," she observed. "I myself don't like it. And you don't want anyone to think you're talking down about their facility." Over the years, she'd learned to hold her tongue for several weeks after arriving in a new place. "I just watch and listen. That way you know who to approach or who not to approach if you have an idea or a suggestion. You learn the lay of the land."

She said she'd had the most luck at passing along suggestions to the community hospital in Luverne. One of the doctors there had asked her outright how people did things elsewhere. "And he changed a few things. Like, they were giving moms a type of medicine that was old, and it wasn't really necessary. They quit giving it, because nobody else does." She added, "Even though I may never, ever go back to that little hospital again, I'm always on the lookout for things that I think will help them out. Like I told them about an inexpensive disposable vacuum for helping to deliver babies, and I think they actually started using it."

At the community hospital, Khan had served on a number of committees over the years. One of the drawbacks of being a traveler, she thought, was that she couldn't get involved with hospital infrastructure. "I miss being involved with the inside policies and procedures of how things are going. Helping make decisions."

She'd like to do more of that if and when she stops traveling, she says. "I wouldn't want to be totally management, but I like being on the fringes of it." If she settled into a permanent hospital position, she could also see being drawn into something other than labor and delivery. "The kind of nursing I enjoy is the fast-paced hustle-bustle. The blood, the guts, and the gore. That's why I love the ER."

Toward the end of our conversation, Khan and I got to talking about the nursing shortage. "It's a stressful job," she reflected, "and there's a lot of responsibility. Not just everybody's cut out to be a nurse." Her daughter, who was studying cosmetology, "would run away from it in a minute. She's very squeamish. And she can't stand the thought of inflicting pain on anyone. She doesn't want to see anything that's the least bit messy." Khan's son, on the other hand, had confided to her that the field appealed to him. Khan says she told him, 'You just waited too long to entertain that thought, because now you're married with a child.' " But he would make a good nurse, she believed. "He likes things that are exciting. He's very calm and can think things through. He's just the kind of person who has a good, stable inner self, so he'd be able to handle multitasks well."

Men may make up only 5 percent of nurses, but some do travel. I spoke at length with two. Brian Becker told me nursing had called to him "because I knew of the opportunities that were in it." As a nurse, he might work in a hospital or sell drugs or medical equipment. He might work as an expert witness. "With that one degree I have a lot of options."

Becker, 35, acknowledged that it took him a while to recognize this. A native of Philadelphia, he'd thought about a medical career while in high school. But instead he studied hospitality management in college, and after graduating in 1991, he managed several restaurants over the course of five years. Although he liked the work at first, he grew discouraged by the long hours and salary limitations. He also by then had become aware of the nursing shortage and knew that as a nurse he would never lack for job opportunities. Still, he says he agonized for about a year before deciding to change careers. "It was pretty hard to go back to school at a nontraditional age in a nontraditional gender role."

He took out loans and waited tables during the three years it took him to get a bachelor of science degree in nursing from Kennesaw State University in Georgia. Since then, Becker told me, he'd never regretted the career switch. While working at his first nursing job -- caring for patients recovering from heart and lung surgeries at a large Atlanta hospital -- he heard about travel nursing. "It sounded like a pretty good deal.... I had always wanted to move around the country and see different parts of it, even when I was doing hospitality management." Becker signed up with an agency, and his first assignment brought him to Mercy Hospital's cardiothoracic step-down unit.

In the three and a half years since then, he'd worked in Oakland, Denver, Chicago, San Diego (for a second stay at Mercy), San Jose, Philadelphia, and Laguna Hills. In the future, "The Virgin Islands is on my list," he told me. "Savannah, Georgia, is another one that I would like to do a lot. Sometimes for the winter, I like to do a ski area, and sometimes I like to stay warm." Visions of Maine had been coming to him, he said. Reno/Lake Tahoe sounded appealing.

Maintaining his friendships and ties with family had proved to be "no problem," he asserted. "With cell phones and e-mail, it's pretty much a piece of cake. Although my longstanding friends have been more jealous than anything. I have so many friends that work in the business field, and when I first started doing this, they were always saying, 'Why didn't I go to nursing school?' "

Becker thought his capacity to be flexible aided him. "A lot of nurses tend to only want to work days or nights. But I'll work all kinds of shifts. I love my job, but it's only three days a week. I can go in and do anything for three days, to have my four days off to do whatever really makes me happy." For that reason, he avoided working overtime. "I always have it in my mind that I'm going to work overtime, but I have too much fun when I'm not at work."

Becker told me people often ask him how he went from restaurant management to nursing. But so much of both jobs is the same, he thought. "It's all public relations, management, and people skills. In nursing, you're constantly building bridges to manage the care between the doctors and patients and families. More often than not, you're dealing with more than one doctor. And the weirdest thing is it seems like doctors don't like to talk to each other about what's going on. So you're an intermediary.... It's like you have doctors on one side and patients and family on another, and the nurse is the valley. It all rolls down on both sides of you, and you have to build the bridge between the two."

Thirty-two-year-old Edward McNamara often remarks that he has 30 to 40 years of nursing ahead of him. He sounds enthralled by that prospect. When I asked if he might not tire of the work at some point, he shot back, "Never! Oh, I'll be a nurse until the day I die. I don't know why God made me a McNamara. I don't know a lot of things. But I do know that God put me on this earth to be a nurse. It's my one true calling."

A baby-faced man with short dark brown hair and expressive brown eyes, McNamara was the only male in his graduating class in Louisiana, where he studied to get his LPN degree. There, some of the nursing instructors made it clear they viewed men as intruders. "I'm not going to lie to you," McNamara told me. "They don't like men. I had one instructor who said, 'The doctors are men. The administration's men. Nursing is the one area that's female-dominated and female-controlled.' And they wanted to keep it like that."

McNamara had worried about the academic demands of nursing school and indeed found the course work to be "18 months of hell." But as a working LPN, he chafed at having "all these RNs over me. I was, like, 'I'm doing what they're doing. I'm just as smart as they are.' " So, like Khan, he found a college with a program that enabled him to become a registered nurse with one more year of arduous study. At that college, in Chicago, he says 10 out of his 62 classmates were male. McNamara then worked for a few years in New Orleans before signing up with a travel-nursing agency. Having shuttled throughout his childhood between his father's home in New Orleans and his mother's in Dixon, Illinois, he figured traipsing around the country would feel natural. But as he settled into his first travel-nursing post at the Brotman Medical Center in Culver City, he found himself flailing.

"It's a very difficult transition," he says. "I had to literally pull myself out of my apartment and say, 'You're going to get on the freeway today. You're going to find out where the Starbucks is or a Chili's.' Because I love Chili's restaurants. But I didn't know where anything was." At times he would call friends in Chicago and wail, "I hate it here! I hate the traffic! And the people are mean! Midwest people are friendly. They're conservative; good people, for the most part. But in L.A., people are just all about film, comedians, singers, actors, producers, directors."

I asked whether McNamara detected more obnoxious behavior among his patients than he'd seen in the Midwest or New Orleans, but he said no. "To me, people are people. They're either generous, genuine, honest. Or they're manipulative, drug-seeking, scared." Only at coffeehouses and grocery stores had he witnessed repulsive behavior, he said. "I was in the grocery store in L.A., and this guy walked up to me and said, 'I'm a producer.' And I looked at him and said, 'Okay.' " The man repeated his assertion. "It was like he wanted me to get his autograph," the nurse recalls. "And I'm, like, 'What a weirdo!' But that's L.A."

In Culver City, he worked with patients recovering from heart surgery, but he yearned to get back to exclusive duty in the emergency room, his specialty. "What I like best about the ER is that patients come in, and you fix them. You see results. And they go home." The pace is always intense. "You never know what you're walking into. There's no specific routine. You just go with the flow." He says he disliked the Brotman center for other reasons. "The nurses I worked with didn't know what they were doing. We had a guy come in, and I said, 'He has AIDS.' And they were, like, 'No, he doesn't.' And I'm, like, 'Look at his respiratory rate. Look at his color.' " McNamara says his judgment turned out to be correct. Moreover, "We were always short-staffed, so I was always overworked." After ten weeks, he moved to the Verdugo Hills Hospital's emergency room in Glendale, where he says he saw a lot of drug overdoses. "Oh, my gosh! We would have one every other night. Upper-income bored housewives."

While at the second hospital, McNamara lived in an apartment in the Hollywood Hills for which his travel-nursing agency paid $3500 per month. But he didn't like it as much as the place he'd had in Culver City, which was located "in a very middle-class, normal type of neighborhood. It wasn't that expensive," he said, "but it had a very comfortable, homey-type feel to it. It had a fireplace." In contrast, the Hollywood apartment "was right across from Warner Brothers studio, and it had all these little snotty, snobby people. And you know what? I said, 'I'm a registered nurse. I have blood on me. I have poop on me. I don't need to be living in some high-class place.' "

When he moved to San Diego in July of last year, he settled into the Archstone complex across Villa La Jolla Drive from La Jolla Village Square, also "a very ritzy area," in his judgment. But he found La Jolla beautiful and unpretentious. Everything about San Diego, in fact, appeared to please McNamara. "People are very, very friendly. Flip-flops, T-shirts, and shorts. My first week here, I called my recruiter at Access Nurses, and I said, 'Somebody walked past me and said hello.' She kind of laughed and said, 'Edward, you're not in L.A. anymore.' I said, 'I know! I love it! I love San Diego.' The difference from L.A. is night and day."

Here he was earning the same wage he'd made in New Orleans (about $28 an hour), and the staff he was working with, at the University Community Medical Center, ranked among the best he had known anywhere. "It's the old Villa View Hospital," at the intersection of University Avenue and 54th Street in East San Diego, McNamara explained. The neighborhood looked so rough it almost scared him away at first, he recalled. "I thought, 'Oh my God. What did I get myself into?' But when I went in, the nurses were all smiling. One nurse gave me a tour of the entire facility, and all the staff members welcomed me with open arms." Nurses can be "very territorial," McNamara interjected. "One ICU I worked in, the nurses all had assigned seats, and I sat down in the wrong seat, and I got chewed out by this older nurse. From there on, I said, 'Oh my God! Before I walk into any new unit, I'll never sit in another chair again without finding out whose it is.' That's how badly she scared me." But the University Community Medical Center staff wasn't like that at all, he attested. "Where I am right now is heaven. The nurses never call in sick. Never! They're extremely good to one another. There's no animosity. It's a team."

"You can have the most psychotic, manipulating, demanding patients in the world and still have a great night" if the staff works well together, McNamara offered. Many of the medical center's emergency-room visitors did, in fact, appear to him to be "very psychotic. We see a lot of outbursts." Many were also "really, really, really, really, really ill," he added. "Because of the neighborhood, the knowledge base isn't like you or I have, where we were taken to the doctor when we were young and had physicals and exams and this and that. These people go years without going to a doctor. We had a 22-year-old come in with a blood sugar of, like, 800!" A normal range is 80 to 120, McNamara pointed out. When blood sugar gets that high, it can thicken and even stop the blood flow. "He could have died!"

Other people "come in for every little thing. Abdominal pains that they've had for three months. They finally decided to come in at three in the morning. And you're thinking, 'You've had this for three months, and now you want to come in? At three in the morning? Why couldn't you wait five more hours until your doctor's office opened at 8:00 a.m.? What's going on here?' "

Sometimes Medi-Cal recipients abuse the system, in McNamara's opinion. "One guy came in in Los Angeles, and he wanted a drug test for a job. And every person that presents, you have to see. You never, ever, ever, ever turn anybody away. There are very strict laws." So the ER staff performed the drug test for the man, "But I asked the physician later, I said, 'This is like a clinic!' And he said, 'Edward, they have Medi-Cal. If they come here, they don't pay anything. They go to a doctor's clinic, and they pay 10 or 15 bucks.' " That irritates him, McNamara admitted. "We'll have four beds full, with two people in triage, and three people outside waiting to come in. And they're wasting our time."

Although McNamara had worked in a number of emergency rooms before coming to San Diego, none were Level I trauma centers -- places capable of dealing with victims of gunshots, stabbings, car accidents, and other messy disasters. The emergency room at the University Community Medical Center was a Level III facility. "For example, if somebody's got a gunshot wound, they'll ship them directly to Mercy, instead of taking them to where I am."

On the other hand, people in East San Diego sometimes walked in off the street with serious conditions, so McNamara was pleased to note, "I have now had access to all sorts of different cases that I never saw at my little upscale New Orleans hospital or the ERs in Los Angeles. I now have had a gunshot wound. It was in the guy's left chest wall. That's where the heart is." The nurse recalls that he covered the wound with a dressing to stop the bleeding, then "got two 18-gauge needles in his veins. I had two liters of normal saline in each arm. The doctor was in there with me the whole time, and the other RN was outside, calling the police.... We had a chest X-ray done and found that the bullet had fragmented. It went in and split, and it was in the lungs. The man was very ashy gray and sweaty. I was screaming at him to stay with me. And after we shipped him out, all of us just hugged." McNamara says the doctor he worked with that night later wrote him a letter of recommendation. "So I can put this on my résumé now." He'd also handled a knife stabbing, he boasted.

After nine months of working as a travel nurse, McNamara still thought like a staff nurse, he confessed. "Somebody will throw something away, and I'll say, 'Don't do that! It's not cost-efficient!' Or, 'You're using too many paper towels.' " But he was planning to travel for a few more years.

When I checked in with him one year after we first talked, he had covered a lot of ground, both physically and psychologically. In January he had left San Diego to move on to a Level I trauma center in San Francisco; then in June he'd transferred to the University of Maryland's hospital in Baltimore, where the emergency-room services were reputed to be the best in the country. "It's just like the TV show ER!" he told me.

He would continue working there through either December of this year or sometime next spring, but then he planned to move to the Chicago area, where most of his family lived, and find a position as a staff nurse. "I've kind of gotten this out of my system," he reflected. "For the past six months I've felt like my life has been on hold." He wanted to sink some roots, create a real home for himself. "I've had my fun." He added that if he ever did decide to take another travel-nursing assignment, "I'd probably go back to San Diego. It was paradise."

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