I asked Burlock to explain for readers what the title "nurse practitioner" means. What does a person with this title do for a living?

"That depends," says Burlock. "Although all nurse practitioners are advanced nurses trained to be more independent in their assessment and treatment of patients, where you live can make a big difference in what you do."

She travels the far northern regions and northern Alberta, Canada, working at what Canadians call "nursing stations." These are clinics -- much like a doctor's office -- but they also have an emergency room, a chest and limb x-ray, blood analysis equipment for hemoglobin and white blood count, a formulary (pharma- cy), and a two-bed hospital ward. Patients needing short-term observation or treatment (but not sick enough to warrant flying them out to a hospital) can stay overnight in this mini-hospital.

"Generally," she says, "where I work, nurse practitioners are the only on-site health officer. We obtain medical histories, perform physical examinations and general health assessments. From these, we diagnose health deficits and form a treatment plan." These deficits often are common infections like a urinary tract infection, ear infection, infected puncture wounds. Or the common communicable diseases like strep throat and pneumonia. But, nurse practitioners also see and manage chronic conditions like asthma, high blood pressure, heart disease, and lung disease.

"There's the usual emergency room stuff, too." says Burlock, "the suturing of lacerations [stitching cuts and wounds] and removing imbedded foreign objects like fish hooks and glass."

 "In my situation," says Burlock, "I am often very isolated; and when elaborate testing is required, we have to fly the patient out to a larger facility. Consequently, we must rely more on our physical diagnosis and consultation-seeking skills than city practitioners who have ready access to sophisticated diagnostic equipment and tests. Based on the diagnosis, the nurse practitioner may prescribe medications and other treatments (such as physical therapy). Nurse practitioners help prevent disease and promote health with screening, family planning services, prenatal monitoring and care of the pregnant woman. The nursing station often sets aside morning hours for clinic and afternoon hours for health and wellness promotion.

Listening to Diane Burlock's story, I wondered: What about babies? If doctors and hospitals are so far away, do nurse practitioners deliver all the babies, too?

"We don't routinely deliver babies," says Burlock. She adds with a chuckle: "Though we do deliver a surprise package on occasion."

"What's supposed to happen and usually does happen," she says, is that the nurse practitioner assesses the risk involved in the pregnancy and schedules a "fly out" to the nearest hospital two weeks to several weeks ahead. The exact timing depends on the risk assessment and the expected due date.

"In reality," Burlock snickers, "Women we've never seen before sometimes drag themselves into the nurse's station when they're already in labor. And even the best-monitored pregnancy can deliver early. So our routine, our protocol, is to schedule a fly out. But, we are capable and prepared to handle the occasional unanticipated delivery."

Whether or not they deliver the baby, rural nurse practitioners follow-up with well baby check-ups, childhood immunizations, growth monitoring, and general well-child check-ups. Later still, they monitor the adults that sprout from these children. They include considerable counseling and family health education as part of their health services.

Nurse practitioners also manage their patients' care by steering patients to related services and resources. When medical problems are beyond the scope of mid-level practice -- even with outside consultation -- the nurse practitioner refers patients to appro- priate physicians and other specialists.

They also arrange for patients requiring intensive care and long-term care to be transferred to appropriate tertiary facilities (like hospitals and skilled nursing homes).

The nurse practitioner movement began about 25 years ago as an advanced rural nursing specialty to provide primary health care services to under-served rural areas unable to attract primary care physicians. As nurse practitioners became more accepted, their practices began to spread to inner city clinics, also shunned by physicians.

Nurse practitioners originally evolved as a service to the patients no one wanted. In more recent times, the revolt against the growing price tag on health care has led government agencies and insurance programs to seek ways of transforming health care from a system dependent an acute care (high-tech hospitals and emergency rooms) to one more focused on primary care settings (offices, clinics, HMOs). The challenge is how to get medical care to more people and do it on a shrinking budget. As mid-level practitioners with mid-level salaries, willing to work where they are most needed, nurse practitioners have answered this need.

Today, nurse practitioners work in a variety of settings, both urban and rural, often as members of a health care team -- in public health departments, rapid care clinics, group practice offices, corporate occupational health clinics, hospitals, nursing homes -- not as bedside nurses, but as mid-level primary care practitioners. Some set up their own private practices. Others join nurse practitioner group practices. Their call for more independence from doctors, once automatically dismissed, is now being fostered through advanced training in clinical assess- ment and treatment skills and more liberal state licensing laws for nurse practitioners. Licensing laws in many states still say that nurse practitioners must be "supervised" by a physician. Passage of these supervision laws were partly motivated by the sincere concern of lawmakers for protection of the public; but also by the suspicion that physicians would have revolted against the nurse practitioner movement without such a provision. Rural nurse practitioners today are rendering the services once provided physician general practitioners (the "country doctor") before they were obliterated in the post-World War II rush to specialization, behemoth urban medical centers, and the abandon- ment of rural practice.

As Diane Burlock points out, "In remote areas, like the ones I visit -- villages out in the Western Arctic with populations of 180, 300, 1800 -- it's a nurse practitioner or it's nobody. In these situations, `supervision' has a different meaning."

 "A doctor might hold a clinic once or twice a month," she says, "to see complicated patients, to look over your records, and discuss cases with you just to see how you're handling things. With our long -- often severe -- winter climate, sometimes `supervision' amounts to consultation by phone or fax."

Burlock says a nurse practitioner in Canada gets "a base wage of about $54,000 Canadian, but there is extra pay for being on-call, for call-backs, for being in charge of a nursing station, which can bring the pay up to $75,000 to $85,000 Canadian per year."

There are perks as well. Burlock says she is given a paid trip "out" at least once a year, a 50% rent subsidy, and additional hardship pay for working in such isolated areas. It's harder to pin down nurse practitioner salaries in the United States. It depends who you listen to. The following figures were produced by the State of Washington and the U.S. Department of Health and Human Services. A nurse practitioner may start out anywhere from $30,000 to $40,000 per year. That works out to $14 to $20 per hour, depending on the salary and the exact number of hours per week worked. In the Pacific Northwest (where managed care is common) the average salary for nurse practitioners is $49,500 - $54,250 per year. The national average is $45,000 per year. Keep in mind: the average figure is diluted by a lot of entry-level salaries. Large salary increases come with each year of experience. Increases tend to level off at $60,000-$70,000 per year. In certain specialties, though, advanced practice nurses can earn in excess of $100,000 per year.

This sounds like a lot of money; but imagine that you are health care administrator with a primary care position open. A new doctor -- with a dozen 25-year school loans at 8-to-10% compounded (tax non-deductible) interest and a work life shortened by 11-15 years of post-secondary education and training -- needs a six-figure income just to keep afloat. You can hire a nurse specialist to do the routine stuff (75%-80% of the doctor's cases) for $50,000- $75,000 a year. Those few nurse specialists who command $100,000 or more a year render the mid-level services of a physician specialist expecting to make $200,000 or more a year. Who would you hire?

And that is exactly what is happening. In both rural and urban settings, third-party payers are starting to balk at paying a doctor's fee for something that a less-costly mid-level practi- tioner can do. In HMOs, rural and inner city clinics, and other group practice settings, practices are being expanded by hiring nurse practitioners before hiring more physicians. As a result, mid-level practitioners are getting good salaries and greater respect.

Career guidance experts are predicting persisting demand for nurse practitioners and other clinical specialty nurses; and this demand will allow them to continue getting $50,000 to $100,000 a year, depending on their specialty.

"As the only on-site health officer, educator, counselor, referral agent, and public health officer," says Burlock, "your position is respected. The position is demanding and people know that. If you fulfill your duties to the best of your ability and act as a positive role model within the community, then you, as an individual, will be respected as well." In talking with Diane Burlock and reading the notes she sent me, I get the impression that many rural patients and community leaders treat nurse practitioners with the kind of respect once accorded to the general practice country doctor.

Burlock says that the minimum requirement for nurse practitioner in Alberta or the Northwest Territories, Canada, is the R.N. license, the Bachelor of Nursing degree and two or three years of rural nursing experience. New university graduates can take a fast-track intensive nurse practitioner course provided by the government and receive a subsidy IF they pledge to serve two years employment in the region which sponsors them through the course.

In the United States, the procedure for becoming a nurse practitioner is longer and usually requires more years of schooling. A nurse usually earns a B.S.N. (Bachelor of Science in Nursing) or B.N. (Bachelor of Nursing) and takes the Registered Nurse licens- ing examination. After three or more years of experience, s/he goes to graduate school for an M.S.N (Master of Science in Nursing) or an M.N. (Master of Nursing) in a nurse practitioner specialty. This is the general idea. Specifics varies somewhat. Some people, for example, take their R.N. licensing exams before completing their Bachelor of Nursing degree. And requirements vary from one state to another.

Nurse practitioners may specialize in neonatal (premature birth) practice, pediatric and adolescent health, OB/GYN and women's health, geriatrics, family practice, psychiatric/mental health practice, and occupational health. Some advanced practice nurses may have different titles -- such as Nurse-Midwife (labor and delivery) or Nurse Anesthetist (anesthesiology) -- rather than nurse practitioner.

There are basically three routes to becoming a registered nurse today. Two-year colleges and vocational-technical schools offer associate degree in nursing which leads to "technical nursing" careers. Four year colleges usually offer the B.S.N. (Bachelor of Science in Nursing) or B.N. (Bachelor of Nursing) degree which leads to "professional careers" in nursing.

Basically, technical nurse training focuses on direct patient care, whereas profes- sional nurse training focus more on the decision-making aspect of patient care and on managerial responsibility. Professional nurses tend to make more money and to have more opportunities for advancement into management or clinical specialty fields.

Another route to technical nursing careers is the hospital-based diploma program. I saved this one until last because there are advantages and disadvantages to this route. Hospital diploma programs exist because, during the nineteenth century, women were barred from most universities in the United States. Hospitals trained their own nurses by apprenticeship. Rural areas are more desperate for nurses than metropolitan areas and hospitals sometimes find it is easier to "grow their own" in a nurse training program than to recruit from the nearest university. Tuition is a lot more reasonable in hospital programs, too. Sometimes can even get your training free in exchange for a promise to work in the area a certain period of time after graduation. The hospital-trained nurse gets a lot more direct patient contact and more practical, hands-on training than college programs can offer.

The main disadvantage to graduating from a hospital diploma program is that hospital-trained nurses tend to get pegged as hospital nurses. It may be harder to branch out into other fields with a hospital diploma than with a college degree in nursing. With hospitals downsizing, this could be a severe drawback. Still, don't despair if you are a hospital-trained nurse. It isn't hopeless. Read on.

The shortage of certain specialty nurses is stretching some rules and traditions. More colleges are offering "outreach" programs that allow diploma-trained nurses to demonstrate their knowledge for college credit. They then apply those credits toward their B.S.N. and complete their degrees at-a-distance by satellite television by computer, and independent study.

That's what Diane Burlock did. She earned an R.N. through a hospital diploma program, then worked as a rural nurse for 12 years. When Burlock entered the Northwest Territories, she took a post-R.N. completion degree: the at-a-distance Bachelor of Nursing from Athabasca University and became eligible to enter practice as a nurse practitioner.

Burlock is now making excellent progress toward a Master of Science (M.S.) degree through California College for Health Sciences. "If it were not for C.C.H.S. and its at-a-distance M.S. degree program," says Burlock, "I probably couldn't manage a Master's at all." I asked Burlock what she saw as the benefits of studying at-a-distance as opposed to earning a degree by going to classes. "I can study when I have time," says Burlock, "and go at my pace, not according to some preset schedule. I can keep my job. The best part is: the California College of Health Sciences program allows me to schedule classes that are related to my current work assignments. They mesh. It's so much easier to learn new ideas when you can see the application in your daily work!" I asked her about the drawbacks to this approach.

"For myself," Burlock says, "self-motivation can be difficult unless I work out a plan of action with definite steps. Many find that working on their own slows their progress, but I found that taking two courses at a time (rather than one) gave me the variety I needed to keep up the pace. I could not have gotten this far without the cooperation of my family. Many times, they have been a source of encouragement."

Diane Burlock is already a full-fledged nurse practitioner. She doesn't really need a Master of Science (M.S.) degree from California College for Health Sciences. So, I wondered, why is she working so hard to get it?

"There are many reasons," says Burlock. "Self-improvement, you know, to broaden my knowledge. But, also, because nurse practitioners -- especially out away from it where I go -- do a lot more than emergency and regular clinical care. I'm family life educator, health educator, counselor. (Luckily, nursing stations have recently started providing a professional social worker.) Anyway, you need many skills. The course content at C.H.H.S. directly supports my career and makes me a better nurse practitioner."

"Plus," she adds, "the Master's degree gives me more opportunities. I can apply to the administrative relief positions. When I go to a one-nurse station, I can be left as Nurse-in-Charge. This means more responsibility; also a pay bonus. Luckily, I've found the content of my C.H.H.S. Master's-level courses directly helpful in these situations."

Except for her hospital-based R.N. credential, Diane Burlock has completed all of her education at-a-distance while living in a rural area, even while she has worked in remote and isolated outreach stations. How remote is remote, you ask? Consider this: "For six months of the year," says Burlock, "my principal means of transportation to work is snowshoe and snowmobile."

The primary care and specialty nursing shortage is worse in rural areas than in the city. Employers tend to be far less persnickety about your credentials coming from a big name school or what study format you used to get them. If you've got the skills, you've got the job. As it should be. There once were many one-year non-degree certification programs in United States -- for more experienced nurse -- similar to the intensive program offered in Canada. There are only a few left today.

In a bid for greater status, prestige, and independence, the nurse practitioner profession in the United States has pushed to increase higher educational requirements. Non-degree certification programs are fading and may disappear. Check with your state licensing agency to see if they provide alternate career pathways to experienced nurses.

In the end, you may get only as far as the B.S.N. by distance learning. You may have leave town for your nurse practitioner Master's degree. But, as a rural nurse practitioner, the chances are extremely good that you'll be able to come back. But, as this goes to press, there are three distance learning Master's degree programs that require only brief summer residencies on campus. Which means: men or women wanting to stay in the backwoods but desiring a good-paying, exciting, evolving -- and, yes, admirable -- career ought to look into becoming a nurse practitioner.

National League for Nursing
Ten Columbus Circle
New York NY 10019
1-800-669-1656
Internet: nlninform@nln.org

NLN is the official accrediting agency for nursing programs in the United States, so they know if approved programs are near you. NLN also publishes many books on nursing, including an excellent introduction called Your Career in Nursing.Your library probably has it in the reference section.

Shortly after this article was written, Diane Burlock wrote me a note saying she finished her Master of Science degree. Her husband, Doug, scrawled at the bottom of the note: "And in record time too (according to CHHS)." Just a tad proud of her, hey, Doug? Good for you, Diane. Congratulations!

If you have a good story -- like Susan Lerner &Tracy Smith or Diane's -- that illustrate the value of distance learning, please contact us. He is also principal of DegreeFinders.comSMCounseling Service, matching people with distance degree programs based on results of an extensive questionairre.