In 1964, when I was a fifth grader, my mother began working as a nursing assistant in a Children's Convalescent Hospital on the evening shift. The term convalescent was a socially acceptable term in an era when society vehemently avoided any discussion of death, the title implying that the "hospital" was a peaceful place where children "convalesced" until they recovered their happy and healthy lives.

In reality, beyond the long driveway and thick trees sheltering the hospital from the community, the facility was the home of seriously ill, grossly impaired children with diagnosis such as spina bifida, hydrocephalis, cystic fibrosis, or severe brain injury. Most children were either wards of the state from very-low-income families or children sheltered away by families with financial resources yet living in a culture where having a less than perfect child was simply not accepted.

As a preadolescent filled with all the usual life crisis (hoped for boyfriends, bickering with girlfriends, needing a note to excuse me from the next day's dreaded PE class), I would often walk to the Children's Convalescent Hospital to seek urgent advice from my mother. Self-absorbed by my own preadolescent concerns, I observed only peripherally my mother's work as a nursing assistant. On occasion, I would divert from my own concerns to observe in total oblivion her amazing, compassionate, impeccable attention to the needs of these children, most plagued by extreme physical disabilities. Her tender care of the hydrocephalic infant, suctioning of the preschooler with cystic fibrosis, or intimate care of the body of a quadriplegic adolescent with severe brain injury were mysterious to me. I didn't "get it." I was in awe of her care but had no idea why anyone would chose to do this work. I did observe that the evening-shift RN had little interaction with the children and seemed to give medications and write in charts. It was my mother who cared for these children. I did know that she was equally compassionate, loving, and kind as my mother and I knew that her immaculate mothering was perhaps borne of her old childhood as she was raised in an orphanage deprived of loving care.

My mother continued her job as a nursing assistant for 10 years until she simply could no longer bear the chronic loss of these children. Remember this was years before hospice in America, before Elizabeth Kubler- Ross spoke of death and dying, and decades before the idea of pediatric palliative care was known. She worked the next several years as a janitor on the evening shift for a school until she became disabled from severe osteoarthritis-the same year I first considered nursing as a major in college. I still didn't "get it"; there was no divine calling for me to the nursing profession, but rather my desire for gainful employment and steady income.

It was only the subsequent years as a nursing student and then new graduate-and ultimately my transition to hospice-that I got it. I understood what it meant to be a nurse, mostly through observing the care provided by nursing assistants. I learned that a bed bath well done is the ultimate act of honoring human dignity. I watched nursing assistants lift exhausted and emaciated bodies on commodes. I raced about the oncology unit frantic with my nursing tasks and only occasionally paused to witness a nursing assistant spoon-feed a demented elder. I watched as the nursing assistants responded to episodes of diarrhea, gave enemas, removed impactions, and with sacred attention cleansed bodies following death. I learned how to be a nurse because I saw the care delivered by nursing assistants.

In 1997, exactly 20 years after I became a nurse, my mother was diagnosed with lung cancer. I knew that the most important thing I could do was to ensure her admission to hospice so that she could receive the care she deserved and my father, and her husband of 55 years, could be supported as her primary caregiver. I was able to "be the daughter" only because I trusted hospice to be her nurse.

Seven months after her lung cancer diagnosis, my mother began the final days of her life. Because of hospice, my mother's end of life was met with impeccable care, the kind of care that a mother-and a woman who cared for a decade for seriously ill children-deserved. On the morning of her death, I awoke and knew her death was hours away. Hospice called to ask if we needed a nursing visit, and without hesitation, I declined. I asked them to please send the nursing assistant.

The nursing assistant arrived, and while death was clearly imminent, we decided to bathe my mother's body, beleaguered by fevers, perspiration, and recent diarrhea. In silence, the nursing assistant guided me as we bathed and shampooed, lotioned and positioned, calmed and comforted. And as we finished the bath by changing the drenched sheets beneath her, I held my mother as she was turned into my arms as the nursing assistant placed the clean sheets beneath her, and at that moment, she took her final breath and died in my arms. Fourteen years later, as I reflect on that day, I know that I was blessed by the greatest gift a daughter could receive.

The nursing assistant stayed long enough to notify hospice and ensure we were okay, and then she left. Another thing I have recognized about nursing assistants is that they know when to be present and when to be absent.

As members of HPNA, we are fortunate to be a part of an organization that recognizes, certifies, and honors nursing assistants. The cover of this issue honors a nursing assistant, and the content of this issue-patient depression, dyspnea management, care in nursing homes, communication with family caregivers, home care-comprises areas that would be seriously neglected without the care provided by nursing assistants.

This issue of JHPN arrives in the month of my mother's birthday. I hope that these words can honor my mother and cause each of us to honor the sacred care provided by our colleagues, nursing assistants.

Betty Ferrell, PhD, MA, FAAN, FPCN, CHPN

Editor-in-Chief

[email protected]