Nurse Joe works in a community health clinic where he regularly cares for Mr. Anand who
has type 2 diabetes and hypertension.
During the past several visits, Nurse Joe has encouraged Mr. Anand to stop smoking by
teaching him the risks of smoking and also providing him with educational material on
ways to quit.
During the clinic visit today Mr. Anand says, “I really want to quit smoking but it just
feels impossible.”
Nurse Joe recently learned about motivational interviewing and decided to use this technique
today with Mr. Anand.
Definition of Motivational Interviewing Motivational interviewing is a client-centered
strategy that can be used to encourage clients to change a behavior that can be harmful to
their health.
It’s based on intrinsic motivation which is when a person engages in a behavior because
it is personally rewarding to them.
So, by using motivational interviewing, Nurse Joe can help Mr. Anand to identify personal
goals that are meaningful for him to achieve so he feels more motivated to make a behavioral
change.
Motivational interviewing can be very effective when working with clients who need assistance
making lifestyle changes, especially those clients who may feel ambivalent about making
a change.
Ambivalence is when your client feels uncertain or unmotivated to take the steps needed to
produce behavioral change.
Nurse Joe recognizes Mr. Anand is showing signs of ambivalence when Mr. Anand goes on
to say, “I know I should quit smoking, but I really enjoy it.”
Motivational interviewing can take some practice but there are three acronyms you can use to
guide you, including, RULE, PACE, and OARS.
Let’s start with RULE which can help you remember the four guiding principles of motivational
interviewing: Resist, Understand, Listening, and Empower Empathy.
When using motivational interviewing with your client, the “R” in RULE stands for
resist.
This means it’s best to resist using the righting reflex, which is where you impose
your solution about what they should do.
Motivational interviewing is most successful when change is made at a pace that is comfortable
for your client.
Next, the “U” in RULE stands for Understand, meaning, you should try to understand your
client’s own intrinsic motivations.
With this in mind, Nurse Joe asks Mr. Anand to describe the reasons that he wants to quit
smoking.
Mr. Anand replies that he wants to quit because his first grandchild was just born and he
wants to be around to see the child grow up.
The “L” in RULE stands for Listening with empathy.
Empathy is when you understand someone else’s point of view.
Nurse Joe is listening with empathy when he encourages Mr. Anand to express his frustration
in past attempts to quit smoking, and acknowledges that the addictive components found in cigarettes
make it extremely difficult to quit.
Lastly, “E” stands for Empowering your client which means you let your client know
that they are in charge of their decisions and have the ability to change their behavior.
So, to empower Mr. Anand, Nurse Joe offers education on techniques to help quit smoking
that Mr. Anand can use to take control of his own decision-making.
The next acronym is PACE which can help you get into the right mindset and be successful
when using motivational interviewing.
PACE stands for Partnership, Acceptance, Compassion, and Evocative discussion.
First, Partnership describes the relationship built between you and your client.
In motivational interviewing, you shed your authoritative role in order to become a collaborator
in your client’s care.
Nurse Joe has built a partnership with Mr. Adnand over past clinic visits.
They now work collaboratively to develop a plan to stop smoking based upon Mr. Anand’s
goals.
The “A” is for Acceptance which means being non-judgmental of your client because
of the choices they have made.
Instead, you should have Compassion, for your client, which is the “C” in PACE.
Compassion is understanding the circumstances, difficulties, and obstacles that your client
has faced.
Nurse Joe shows acceptance and compassion for Mr. Anand by acknowledging that quitting
smoking is very difficult and avoiding any blaming language when speaking to him about
quitting.
Finally, the “E” in PACE is for Evocative discussion.
Evocative discussion means engaging your client in conversation with emotional depth.
To be successful in motivational interviewing, you need to guide your client to understand
their own internal motivation for pursuing the change.
To do this, Nurse Joe asks Mr. Anand to talk about how the arrival of this new grandchild
is a strong motivator for him to quit smoking.
Techniques for Motivational Interviewing The last acronym is OARS which can help you
remember the core skills and techniques of motivational interviewing.
OARS stands for Open-ended questions, Affirming, Reflective listening, and Summarizing.
Now first, the “O” in OARS is for Open-ended questions.
When you ask an open-ended question, it allows your client to provide a narrative response
and convey what is important to them.
An example of an open-ended question that Nurse Joe asks is, “How were you first introduced
to cigarettes?”
Mr. Anand’s response might include a story about the first time he smoked, the age at
which he first smoked, and the fluctuations in the amount he has smoked over the years.
That is a lot of information!
On the other hand, the opposite of an open-ended question is a close-ended question where you
ask a direct question with predefined responses.
An example of a close-ended question that Nurse Joe could ask is, “Were you young
when you started smoking?”
Mr. Anand would likely respond with a simple “yes” or “no” which provides Nurse
Joe with very little information.
Next is “A” in OARS for Affirmation.
This means that when you talk with your client, you offer support for their efforts and journey
in the process of making a behavioral change.
Nurse Joe uses affirmation by commending Mr. Anand’s past smoking cessation efforts and
his internal motivation to stop.
The “R” in OARS is for Reflective listening.
This means that you repeat back what your client has told you.
This is a helpful tool for clarifying what your client has said and also lets your client
know that you have heard them and understand what they are saying.
Nurse Joe uses reflective listening by saying, “Mr. Anand, I’m hearing you say that you
are ready to quit smoking because you want to be able to watch your grandchild grow up,
but you feel as though it will not be possible for you to quit for good.”
Last, is the “S” in OARS, which stands for Summarizing.
Summarizing occurs at the end of the motivational interviewing session and allows you and your
client to work together to summarize important highlights from the visit.
Nurse Joe summarizes the visit by stating, “We have spoken about your desire to quit
smoking and the motivation behind that desire.
We also talked about what has worked for you in the past when making a behavioral change
and discussed several options for smoking cessation.
I will call you next week after you have had time to think about the different options
and we can finalize your smoking cessation plan then.”
It is not possible to evaluate the success of motivational interviewing instantly because
change occurs over time.
However, a positive sign is when your client begins to include “change talk” into their
conversation.
Change talk is when your client talks about their behavioral
change regularly.
So, three months later at Mr. Anand’s next clinic visit, he tells Nurse Joe that his
cigarette cravings are much more manageable and that his family have been praising him
for his hard work.
He also states that he has significantly reduced the number of packs of cigarettes he smokes
in one week from 7 to 2.
Mr. Anand acknowledges that he still has work to do but is proud of the progress he has
made.
Alright, as a quick recap…
Motivational interviewing is a client-centered strategy that is effective in producing changes
in client behavior.
This strategy uses your client’s intrinsic motivation, which is when a person engages
in a behavior because it is personally rewarding to them, so they feel more motivated to make
a change.
You can use the three acronyms RULE, PACE, and OARS to help guide your interview.
RULE is for the guiding principles of motivational interviewing and stands for Resist, Understand,
Listen with empathy, and Empower.
PACE describes your mindset during the interview to best engage your client.
It stands for, Partnership, Acceptance, Compassion, and Evocative discussion.
Finally, OARS helps you remember the core techniques of motivational interviewing.
It stands for Open-ended questions, Affirmation, Reflective listening, and Summarizing.
You will know that motivational interviewing has been effective when your client begins
to meet their goals and includes “change talk” in conversation.