They represent the most difficult job I ever had.
I often joke that my doctorate was sponsored by cheese puffs. I had the support of my family, friends, colleagues, and DNP committee but, ultimately, I was alone. I spent countless cheese-puff-fueled nights, clicking away at my keyboard. Each time I submitted a draft to my committee chair, my prayers carried the file to her inbox. When she requested revisions, it was my resolve—and occasional tears—that rose to meet the challenge.
A Doctor of Nursing Practice is called a terminal degree. Something about “terminal” sounds quite final. As I approached the end of my program, I reflected on the beginning of my nursing career. I was working hard to earn the right to type DNP after my name, but my mind kept returning to the first three letters I had earned—CNA. I have replaced those three letters over the years, first with BSN, then MSN, and now, finally, with DNP.
My DNP mentor warned me that pursuing a doctorate would take more grit than I could imagine. She was correct. I have been amazed by how much more there is to nursing than I previously thought. It was inspiring to mentally connect nursing theory to practice and learn my place in it all. Despite everything I have discovered during my doctorate program, I learned the more important lessons as a certified nursing assistant: I learned how to care for people with dignity, integrity, presence, and compassion.
I became a certified nursing assistant while completing the prerequisite courses for my nursing program. I wanted to be a registered nurse, and I could not wait to begin caring for patients. I remember the CNA instructor cautioning me about becoming a nursing assistant if my goal was nursing. She thought I would become disillusioned with healthcare if I worked at the nursing home. I ignored her advice and came into my role as a nursing assistant with gleeful naiveté.
I had never been exposed to the neglect, elder abuse, loneliness, advanced disease, disability, and accidents that often bring people to long-term care. I had never witnessed anyone actively dying. It was overwhelming, but I worked shoulder to shoulder with more experienced nursing assistants. Those assistants were not concerned about the circumstances that had brought the patients to the facility. They saw the people who were in the beds and chairs, not the labels of their medical conditions.
Nursing assistants taught me the importance of clients smelling good, being clean, and wearing matching clothes. Not one of those caregivers could cite the nursing theories that explain how these activities of daily living contribute to human dignity. They instinctively knew that a clean-shaved man feels better about himself, and that a woman accustomed to never leaving her house without her “face on” needs her lipstick applied before breakfast. They never lectured a geriatric client bent over with multiple sclerosis to give up smoking. They wheeled her outside for her afternoon smoke and chatted with her while she took her few independent puffs. A person may lose a limb, bladder control, or memory but never needs to lose his or her dignity.
Talking to my patients while performing care tasks is a habit I began as a nursing assistant. I always explain what I am doing as I go. I cared for a man who had advanced Alzheimer’s disease. Nonverbal, he had severe contractures of his arms and legs, was completely incontinent, and received nutrition through tube feedings. It appeared that he had withdrawn deep into his mind. Despite that illusion, I spoke to him as if he was fully present as I cleaned him, turned him every two hours, smoothed his sheets below and around him, and adjusted his pillows.
One evening, as I leaned over him to place a pillow between his gnarled knees, his hand closed around my wrist, and he pushed out the words “Thank you.” I paused in shock. I automatically blurted out, “You’re welcome.” I don’t know if his verbalized gratitude was an automatic response to my stream of chatter. It may have been a reply, programmed in his brain from a lifetime of use, that randomly surfaced at an appropriate time. It did not matter. That moment cemented the idea of always doing the right thing more strongly into my being than any university ethics lecture I would attend.
I routinely cared for a pleasant, elderly woman who needed only minimal attention. Every couple of hours, I would stop by her room, checking her water pitcher and chatting briefly. She was ambulatory and continent, unlike most of the residents in that section. One evening, something was different. I didn’t know what. I talked to the nurse about it, and she dismissed my concern. The next day, I learned the woman had fallen and broken her hip. She died later that week. That was the first time I cried about a patient.
I learned two lessons from that experience. From that point on, I trusted my intuition, even in the absence of obvious clinical findings. I may not always be correct or have the answer, but questions are important. I also learned not to tolerate being dismissed and not to dismiss the concerns of others. Those who spend the most time with a patient notice subtle changes that may indicate a change in patient status. Family members, friends, and caregivers are sensitive to changes in their loved ones that others may not notice. Listening to concerns and addressing them are important elements of being truly present with a patient.
I came into nursing, in part, because of the compassion I felt toward others and the desire I had to help them. Compassion comes easily when the stakes are low. Reading a news story about a lost child or a family home destroyed by fire inspires compassion, which may even lead to action. Putting compassion into daily practice, no matter the circumstance or personal struggles you may be experiencing, does not come as easily. My stint as a nursing assistant provided me with opportunities to practice compassion. Rather than feel annoyed when the 90-year-old woman called out “Johnny” for the hundredth time that night, I learned to feel compassion by reminding myself that she had outlived her son and, more than anything in the world, wanted him to answer her call. Instead of being offended by rude comments or insults, I learned compassion for those who no longer had the capacity to remember the day of the week or even their own spouse. I learned to choose compassion in all sorts of situations where feeling disgust, anger, or shame would have been easier.
My work as a certified nursing assistant was the most difficult job I have ever experienced. I came home exhausted and smelling awful every night. My back and legs hurt from lifting, pushing, pulling, and crouching. I never felt I could do enough to ease the pain and loneliness of the nursing home residents I served. As my CNA instructor had predicted, it would have been easy to become disillusioned with healthcare. I am thankful I was too naïve to take her advice. I have traded in my CNA for a DNP, but I would not trade my nursing assistant experiences for an entire alphabet behind my name.
Carrie Sue Halsey, DNP, CNS-AD, RNC-OB, ACNS-BC, a clinical nurse specialist and advocate of natural birth and breastfeeding, resides in Boise, Idaho, USA. As a mother and nurse, her experiences of pregnancy, labor, and birth have made her passionate about perinatal empowerment. To learn more, click here. She discusses nursing topics and issues on the nursing podcast Stat Sisters.