Two Mnemonics for Nurse Coaching Improve Change Talk: RULE and WAIT

Lane Therrell FNP, MSN, RN, NP · Jul 12, 2023

If you want to have healthy conversations about change with your patients, or anyone else, all you need to do is to follow the RULE and WAIT. I learned about RULE and WAIT from the book, Nurse Coaching: Integrative Approaches for Health and Wellbeing, which is the nurse coaching textbook endorsed by the International Nurse Coach Association.

According to the book, RULE and WAIT have their roots in the practice of Motivational Interviewing (MI), which is an effective form of coaching whenever a change needs to be made and there is ambivalence about it. MI originated in the substance abuse and addiction management arena as a method of supporting behavior change, and there is a substantial body of research to support its efficacy.

First, follow the RULE. (Think of it as "the RULE of change.")

R = Resist the righting reflex, or, the urge to be right

The urge to fix your patient is known as "the righting reflex." You fall prey to the righting reflex whenever you start to believe you know what's best your patient, and tell him the steps to take to reach it. By giving in to the righting reflex, you are actually preventing the patient from achieving a positive outcome because the patient has no ownership in the goal. When you successfully resist the righting reflex, you open the door for the patient to be accountable and make lasting changes.

Resisting the righting reflex can be incredibly difficult for well-trained, time-crunched nurses. I find it helpful to remind myself that taking the shortcut of telling the patient what to do will short-circuit the patient's ability to integrate a lasting change into his life. When I put that together with my intention to help the patient make a change, it becomes easier to let go of my urge to be right.

U = Understand the patient's motivations

The patient's internal drive to take action toward a specific goal is his motivation. Part of the job of the nurse coach is to help the patient identify and articulate that inner drive.

Truly understanding the patient's point of view requires being mindful, and staying present in the moment with the patient. Let him tell his story in his own words, then respond with specific statements and questions that allow you to clarify the patient's meaning. Examples of clarification statements include: "Tell me more about that..." "Here's what I'm hearing you say..." "Do I have it right that..." and "Did I understand you correctly when you said..."

L = Listen with empathy

Listening with empathy allows us to connect with the patient in an authentic way that establishes trust. Yet, it's not always an easy thing to do. Walking in the other person's shoes does not mean merging identities with the other, nor does it require completely walling off your emotions.

Engage in the conversation by recognizing the patient's experience as valid, and respond in ways that show you genuinely care. Making eye contact and mirroring the patient's posture demonstrate nonverbally that you are listening with empathy. Making affirmative statements, such as, "That must have been traumatic for you," or, "I can only imagine how painful that must have been" will reassure the patient. These statements also help define your own personal boundaries so you don't confuse empathy with sympathy and end up suffering along with your patient.

E = Empower the patient

All too often our nursing interventions are done to the patient rather than with the patient. Set the stage for empowerment by asking the patient's permission for simple, seemingly mundane, things during the encounter - such as, "What would you like to be called?" "May I sit here?" "Would you like me to hold your hand?" or "May I ask you a couple of different questions now?" The requests will vary according to what is appropriate in your situation, but by granting you permission in the moment, even for something that is seemingly insignificant, the patient gets to take control, which instills a sense of confidence.

You can further empower a patient by reflecting his demonstrated strengths back to him in a way that reinforces positive actions he is already taking. When you make observations like, "It sounds like you showed admirable restraint when ...," or, "I really appreciate that you brought your medication containers with you today," you acknowledge the patient's strengths. This type of acknowledgement reinforces the self-belief that they can successfully take action toward any goal. An empowered patient will be more likely to adhere to the plan of care, in part, because he helped develop it.

Following the RULE helps you step outside the expert role and extend autonomy to the patient. When you are willing to see the patient as the expert and use the encounter as a means for helping the patient uncover his own inner motivations and desires, you pave the way for change. And of course, once you've followed the RULE...

Then, WAIT before you speak.

WAIT = Why Am I Talking?

This is a powerful question you can ask yourself every time you communicate with another person. You can use it in the beginning, middle, or end, of any patient encounter.

WAIT prior to, or at the beginning of, any encounter, as a way of focusing your intention for the interaction. Be clear about your intention: Some encounters are instructional or educational, others support change. Think not only about what you are going to say to the patient, but why you will be saying it.

WAIT during an encounter, by noticing how much you are talking compared with how much the patient is talking. If you notice that you're saying all the words and the patient has not had any input for a while, stop and give the patient a chance to share his perspective. It may be helpful to pause and take a breath. Invite the patient to take a breath with you by saying something like, "I'm going to pause here for a moment, and I'd like to invite you to take a breath with me." Then, actually do it.

WAIT at the end of an encounter in order to respect the patient's autonomy, and to allow for his input before. You might choose to ask a purposeful open-ended question such as, "What have I missed?" or "What else would you like me to know?"

RULE and WAIT work together to help you improve your communication with patients about change. Remember to follow the RULE of change and WAIT before you speak. Try them with the next patient you see. Happy communicating!