The Integrative Nursing framework has a broad reach, particularly when applied to the transitions that occur when patients are shifting from hospital to home, hospital to long term care, hospital to hospice, or hospital to transitional care. Not uncommonly, it's this transition from being cared for to caring for yourself that's missed in many healthcare encounters, especially when being discharged from an acute care setting to home. For most hospitalized patients, the hospital environment has little semblance to what they will be experiencing at home. Whether it is someone who is recovering from surgery to receive treatment for cancer, or giving birth, each individual and family needs to learn to manage change within the context of their own environments, resources, relationships, and self-advocacy. Without attention to individual needs, information provided at discharge isn't likely to be well received or understood. All parts of a person's life must be considered, access to resources including finances, transportation, social support, cultural practices, education, cognitive abilities, health status, mobility, and many more. Each population setting offers opportunities to develop a meaningful partnership for setting goals that promote health and wellbeing. A smooth transition from an acute care setting to home requires understanding and consideration of, what are they going home to? What do their caregivers need to know? Access to resources, sources of support, home environment-- all of these need to be explored. Motivational interviewing is a powerful tool you can use to elicit information that will help patients set meaningful goals. It is a patient-centered counseling style based on the principles of the humanistic psychology of Carl Rogers. Rogers argued that for a person to grow, we need an environment that provides us with genuine openness that enables self-disclosure. Acceptance that includes being seen with unconditional positive regard and empathy, where we feel like we're being listened to and understood. Motivational interviewing means to encourage the patient's autonomy and decision making, where the clinician acts as a guide, clarifying the patient's strengths and aspirations. Listening to their concerns, boosting their confidence in their ability to change, and eventually, collaborating with them on a concrete plan for change. Motivational interviewing requires four key communication skills that support and strengthen the process of eliciting change talk, also known as OARS-- Open-ended questions, Affirmation, Reflection and Summarizing. Open-ended questions give patients the opportunity to tell their story, and allow you to gather subjective data. Try to avoid asking closed questions, where the patient can say yes or no, and leading questions. Good open-ended questions often start with who, what, where, when or how? Here are some examples from Julie's previous assessments. "When exactly did the back pain start?" "What's hard about being away from your family?" Affirmation builds the rapport, demonstrates empathy, and captures patient's strengths and abilities. This can develop self-efficacy, and help clients believe in the possibility of change. Affirmations need to be genuine to be effective. Some affirmations Julie has shared with Syd include, "That sounds really hard. It makes sense that you'd be worried about this. I'm impressed with your resilience." Reflection occurs when you share your perceptions of what you are hearing and seeing with a patient. You can reflect with words, behavior, and feelings, or emotions. Julie has reflected throughout the encounters with Syd by saying things like, "Clearly your family brings you a lot of joy. You seem to be keeping things in perspective." Summarizing can give the conversation a beginning, middle and ending, provides an opportunity to check your understanding of what the patient has shared, and helps frame patient goals. A summary might flow through a few elements: "Let's go over what we've talked about so far. You've mentioned x, y, and z. Which is the most important? Did I miss anything?" You'll see Julie uses OARS in the next scenario to help set goals for a successful transition to home care.
