1. Gerber, Lois MPH, BSN, RN

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KS, A NURSING STUDENT at an inner-city health department, returned from her initial home visit angry and upset. "Mrs. C's house is filthy and disgusting," she said. "You can't expect me to go back there."

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"The family's not ready for discharge," I said. "There's more teaching to do."


KS went on. "Mrs. C needs to lose weight. The kitchen table is covered with dirty dishes, there's black soot on the windowsills, and the bathroom sink has a ring around the inside."


"Anything positive?" I asked.


"Her three kids are adorable," she said.


I told her to sit down so we could talk.


Impaired vision

As we sat down, my memory flashed back to my early days as a community health nurse and my distaste when I encountered a family with a dirty house. I remembered one woman, Mrs. E, the primary caregiver for her wheelchair-bound husband who was recovering from a stroke. He slept in a hospital bed in the living room. Dog hair from their two beagles covered the furniture. Mrs. E's recliner, placed next to her husband's hospital bed, had coffee stains all over it. Dirty dishes filled the sink.


On my first two visits, I focused on Mr. E. Mrs. E seldom initiated conversation and answered my questions in a perfunctory manner. Her aloofness didn't encourage me to ask her about her or her needs.


At a team meeting, I described my interaction with Mrs. E and my dismay at her dirty house to my colleagues. ML, a seasoned community health nurse, said, "Community health brings out our personal prejudices and stereotypes. You were probably brought up in a neat and organized home, right? When our minds are caught up defending our belief systems, we can withdraw emotionally and not see our patients clearly.


"Before you make a personal judgment about someone because of his or her living situation, look within yourself first. Think back to how, when, and what you learned from those around you. As children, we pick up negative stereotypes easily and quickly-ideas about religion, politics, sexual orientation, even housekeeping. Deeply ingrained personal values that stereotype our patients can interfere with care without our awareness. We can't develop an effective care plan until we can see the problems from the patient's perspective."


Seeing things clearly

ML's comments changed my focus. She was right that my organized family home and my parents' belief that a dirty house equaled laziness and disrespect had compromised my care to Mr. and Mrs. E. I'd subconsciously judged Mrs. E as sloppy and uncaring without knowing her as a person.


On my next home visit, Mrs. E and I sat down to talk. "You look tired today," I said.


She shrugged. "No more than usual. We're doing least we were. Things were great after the other nurse left, but I guess the 11 months of taking care of my husband have taken its toll."


I realized then that Mrs. E wasn't lazy. I saw a woman who was tired, anxious, and depressed. Once I took off the smoke-tinged glasses that were preventing me from seeing Mrs. E as a person, I could see the problem clearly. Now, maybe I could help KS take off hers.


Time to talk

KS and I sat down for a chat. "There are many reasons that people may have a dirty house-depression, difficulty moving around, or poor eyesight," I said. "Some people aren't interested in housekeeping. They like to do different things with their time."


"There are 24 hours in a day," KS said. "People need to use them wisely."


"Let me tell you about a similar situation," I said. KS listened attentively as I recounted my experience with Mr. and Mrs. E. "Can you see any parallels between Mrs. E and your patient?" I asked.


"Even though she has a husband who helps her," KS said, "Mrs. C is probably anxious and depressed, too. I see your point. On my next visit, I'll try to do what you did, talk to Mrs. C one-on-one."


I smiled at KS. "See?" I said. "You're not seeing through smoke-tinged glasses anymore."