3.1: Therapeutic Communication

Learning Objectives

By the end of this section, you will be able to:

• Describe the process of therapeutic communication in nursing
• Identify characteristics of effective therapeutic communication
• Recognize how to evaluate therapeutic communication

Effective patient communication generates an increase in positive outcomes. These positive outcomes may include but are not limited to improvements in a patient’s compliance with medical plans, self-regulation of diet and medications, and coping mechanisms. These outcomes improve the patient's functional status after treatment.

For example, chronic diseases are especially impacted by improved patient relationships and communication with healthcare providers, due to the complex nature of chronic diseases and the need for extensive treatment. High blood pressure, or hypertension, is a chronic illness that requires scheduled follow up visits. A patient who considers themself healthy, eats a balanced diet, and works out regularly might be very disheartened with this diagnosis. This patient will need to have a solid relationship with their nurse to navigate disease management, lifestyle adjustments, and possible mental health issues they might develop from feeling like “their body betrayed them.” Furthermore, this and every patient who receives a chronic diagnosis or life-altering health news depends on their nurse to serve as a healthcare guide. This role requires effective patient communication.

The specific techniques and strategies nurses use to establish a therapeutic relationship with patients and promote the patient’s well-being is referred to as therapeutic communication. Therapeutic communication techniques used by nurses have roots going back to Florence Nightingale, who insisted on the importance of building trusting relationships with patients and believed in the therapeutic healing that resulted from nurses’ presence with patients. Since then, several professional nursing associations have highlighted therapeutic communication as one of the most vital elements in nursing.

Therapeutic communication is a vital skill in nursing for multiple reasons. It can help establish a trusting patient-nurse relationship, prevent misunderstandings and errors, promote patient-centered care, improve patient satisfaction, and improve outcomes (Slade & Sergent, 2023). Nurses should understand and practice various therapeutic techniques as part of providing the best possible nursing care.

Process of Therapeutic Communication in Nursing

Establishing the therapeutic nurse-patient relationship is vital in nursing care. Nurses engage in compassionate, supportive, professional relationships with their patients as part of the art of nursing. This is especially true in psychiatric care, where the therapeutic relationship is considered the foundation of patient care and healing. The nurse-patient relationship establishes trust and rapport with a specific purpose; it facilitates therapeutic communication and engages the patient in decision-making regarding their plan of care.

Therapeutic nurse-patient relationships vary in depth, length, and focus. Brief therapeutic encounters might last only a few minutes and focus on the patient’s immediate needs, current feelings, or behaviors. For example, in the emergency department setting, a nurse may therapeutically communicate with a patient in crisis who recently experienced a situational trauma. During longer periods of time, such as inpatient care, nurses work with patients in setting short-term goals and outcomes that are documented in the nursing care plan and evaluated regularly. In long-term care settings, such as residential facilities, the therapeutic nurse-patient relationship may last several months, or even years, and include frequent interactions focusing on behavior modification. Whether the relationship is brief or longer-term, each therapeutic interaction is built on the same basic framework.

Clinical Safety and Procedures (QSEN): QSEN Competency: Patient Communication

See the competency checklist for Patient Communication. You can find the checklists on the Student resources tab of your book page on openstax.org.

Develop Communication Goals

Developing communication goals is a crucial first step in establishing a therapeutic relationship with a patient. Part of developing communication goals is assessing the patient's communication needs. This may involve reviewing the patient's medical history, identifying any communication barriers, and assessing the patient's emotional and cognitive status.

Based on the patient's needs, specific communication goals can be established. When developing these communication goals, think of the acronym SMART. SMART stands for specific, measurable, attainable, relevant, and timely (Figure 3.2). For example, a nurse may have as a general goal to spend more time with their patients. A SMART goal would be “I will spend an extra 15 minutes with Mrs. Cabrillo this morning and ask her three questions about her home environment in order to determine what kind of support system she has there.”

Figure 3.2: SMART goals offer a framework for developing patient goals that are specific, measurable, attainable, relevant, and timely. (CC BY 4.0; Rice University & OpenStax)

Create the Message

Once the nurse has identified goals, they can develop a plan to achieve them. The nurse must create a message to present to the patient in a way that benefits the therapeutic communication process and the patient. The message is the thought or content that someone wishes to convey. This involves selecting the appropriate communication techniques based on the patient’s language or other factors that may affect their ability to receive information, such as with a hearing, sensory, or vision impairment. Communication strategies may be based on the patient’s cognitive abilities, educational levels, cultural preferences, or other factors. It is the responsibility of the nurse to know as much as possible about these details in advance of the interaction with the patient.

Deliver the Message

Delivering the message is a key aspect of therapeutic communication. It involves conveying information in a clear, supportive, and respectful manner, using appropriate verbal and nonverbal communication skills. The verbal communication involves the use of words to deliver a message. On the other hand, nonverbal communication refers to conveying a message without the use of words (Figure 3.3). Nonverbal communication can involve such qualities as facial expression, body language, tone of voice, and personal space.

Figure 3.3: Pain can be communicated through body language. (credit: “Image” by Jessica Branstetter/Flickr, CC BY 2.0)

To deliver the message effectively, nurses should use a clear tone and plain language, be mindful of the patient’s body language, use the patient’s preferred language so they understand, actively listen to the patient, and demonstrate patience and respect throughout the conversation. Additional considerations may be needed to reiterate and reinforce key points. Nurses should use visuals (as applicable), demonstrate empathy, encourage active two-way communication, and adapt the communication style to be culturally appropriate. When verbal communication signals match nonverbal communication signals, it can help increase the level of trust and comfort between the patient and nurse. As the nurse conducts a conversation, it is important for them to continually practice and evaluate the communication techniques being used.

Listen to the Response

Therapeutic communication is not a one-way process; delivering the message is only part of the task. The nurse must also listen to the patient, seeking feedback in the form of both verbal and nonverbal communication. This may involve asking directly for feedback from the patient or observing their nonverbal responses to different techniques used during the conversation.

Seek Clarification of the Response

The nurse should clarify any indirect, unclear, or ambiguous responses with the patient when possible. For example, a nurse may ask a patient if they eat a special diet when they are performing the admission assessment, and the patient responds “no,” but their tone sounds angry and they suddenly become quiet. A question such as “I noticed that your arms are crossed and you have stopped talking; are you upset?” can help clarify nonverbal communication from the patient. Based on the feedback received, adjust the plan as needed to better meet the patient's communication needs and achieve the established goals.

Characteristics of Effective Therapeutic Communication

Effective therapeutic communication is crucial to delivering high-quality healthcare. It is a skilled approach to caring for patients that requires training and education. There are numerous strategies that can be classified as either therapeutic or nontherapeutic approaches to communication.

Therapeutic communication requires respect, trust, empathy, and a nonjudgmental culturally aware approach from the nurse. Other key characteristics of therapeutic communication include active listening, clarity and simplicity, openness and honesty, encouragement, a supportive environment, a patient-centered approach, positive reinforcement, and appropriate use of silence. Nurses who incorporate these elements in their communication style can enhance patient outcomes and provide better quality care.

Patient Conversations: A Therapeutic Conversation with a Nervous Patient

Scenario: The nurse enters the patient’s room to complete their morning assessment and notices nonverbal communication from the patient.

Nurse: Good morning, Ali. How are you feeling today?

Patient: Not so good, my pain is still bothering me.

Nurse: I’m sorry to hear that. Can you tell me more about your pain?

Patient: It’s a sharp pain in my lower back, and it gets worse when I try to move. It’s about a 7 out of 10.

Nurse: I see. Have you been taking your pain medication that the doctor ordered?

Patient: No, I don’t like the way it makes me feel.

Nurse: I understand. Can you tell me what it is that you don’t like?

Patient: They make me feel dizzy and sleepy.

Nurse: Hm. Well let’s see if we can try some other strategies to help manage your pain. Have you tried any relaxation techniques, like deep breathing or meditation?

Patient: No, I haven’t.

Nurse: Well, those techniques can be really helpful for managing pain. I can show you some exercises that might work for you. And we can also talk to your doctor about adjusting your medication if necessary.

Patient: Okay, that sounds good.

Nurse: Great. Let’s start with some breathing exercises. I’ll guide you through them, and you can let me know how it feels.

Patient: Okay, thank you.

Build Trust Through Honesty

A trusting nurse-patient relationship can lead to increased adherence to the treatment plan and improved outcomes. Also, a patient who trusts their interviewer is more likely to communicate personal and private information regarding themselves and their lifestyle. The nurse can build a trusting relationship through admitting mistakes/errors, honoring patient’s autonomy and choices, finding unknown answers and following up to close the loop, providing realistic expectations, building rapport, demonstrating consistent behavior, and encouraging open communication.

Another way to create a safe and trusting space for patients is by being transparent. Having transparency means being open and honest with the patient about their health conditions, treatment options, and potential outcomes. It also involves educating the patient on these issues and options in plain language that is readily understandable by the patient, including using a translator if necessary.

Keeping promises is another way to build trust through honesty with patients. For example, if the nurse tells the patient they will return in one hour with their pain medication, they should try their best to keep their promise to their patient in order to foster a pattern of trust.

Active Listening

Listening is obviously an important part of communication. There are three main types of listening: competitive, passive, and active. During competitive listening we are focused on sharing our own point of view instead of listening to someone else. During passive listening we are not interested in listening to the other person and we assume we understand what the person is communicating, without verifying the other person’s message. During active listening, we are communicating verbally and nonverbally that we are interested in what the other person is saying while also actively verifying with the speaker that we understand. For example, an active listening technique is to restate what the person said and then verify our understanding is correct. This feedback process is the main difference between passive listening and active listening.

Active listening involves fully focusing on and understanding the message being conveyed by the speaker. It requires paying close attention to both verbal and nonverbal cues, such as tone of voice, body language, and facial expressions, and responding appropriately to the speaker’s message. Active listening involves withholding judgment and providing feedback, without interruption to the speaker, that shows the speaker that they have been heard and understood. This technique is important in building and maintaining effective communication and relationships, as it helps to create an environment where individuals feel heard, valued, and understood.

Nonverbal communication is an important component of active listening. SOLER is a mnemonic for establishing good nonverbal communication with patients. SOLER stands for the following:

• S: Sitting and squarely facing the patient
• O: Using open posture (such as avoiding crossing arms)
• L: Leaning toward the patient to indicate interest in listening
• E: Maintaining good eye contact
• R: Maintaining a relaxed posture

Link to Learning

This brief video shows examples of active listening as well as strategies for demonstrating the skill.

Respect the Patient’s Values and Beliefs

According to the American Nurses Association (ANA) Code of Ethics (2015), nurses must practice with cultural humility and inclusiveness (ANA, 2015). Cultural humility is a lifelong process where one examines their own cultural beliefs and practices as well as adopts a humble and respectful attitude while learning about individuals of other cultures. Culture is constantly changing and evolving, so true cultural competence requires a lifetime of learning and adapting to these changes. It is important for the nurse to accept their own cultural beliefs, as well as their patient’s when building a trusting relationship.

There are both intrapersonal and interpersonal components to cultural humility (Hughes et al., 2020). The intrapersonal component consists of a personal awareness of one’s own limited knowledge of the patient’s culture. The interpersonal component involves a respect for the patient’s culture and openness to their beliefs and experiences. By focusing on developing partnerships with patients, the nurse can create a space that encourages learning and appreciation for other cultures. It is a patient-centered way of providing culturally sensitive care.

Cultural Awareness

An individual’s cultural background influences their beliefs, feelings, and attitudes toward health care. Their culture determines how they view health and illness, which in turn shapes how they view healthcare providers and how receptive they are to their treatment plans. Culture also determines who receives care and the quality of their care. Certain cultures experience higher rates of disease due to genetics or health disparities caused by socioeconomic factors. Various cultures have their own traditional healing practices and beliefs, and many people still use these practices, either alongside or in place of Western medicine. Nurses face patients from different cultures with their own beliefs and practices. Cultural awareness is the recognition of the characteristics of one’s own culture and other people’s, and of the differences between cultures. It is important that nurses be respectful of these individual differences in order to counteract any biases so that patients can receive the best possible care.

To ensure patients feel respected and heard, healthcare professionals should actively listen to their patients, respect cultural practices, ask open-ended questions, and use nonjudgmental language. They should also be aware of their own biases and avoid imposing their beliefs or values on patients.

Cultural Context: Providing Culturally Sensitive Care

One way the nurse can show cultural sensitivity is by safely incorporating elements of the patients’ culture into their care. The nurse will speak with the patient and try to identify a cultural norm that can be safely integrated into the patients’ prescribed plan of care. An example of this could be in allowing the patients’ newborn baby to be wrapped in a special blanket that does not have animals on it. Another example might be the nurse showing respect of the Judaism practice of waiting until the eighth day of life for circumcision to take place. This allows the patient to feel safe that their baby’s soul will not be stolen by the animals. While this practice might seem confusing to the nurse, a culturally sensitive nurse will see this as an opportunity to safely incorporate the patients’ belief into their care.

Show Compassion

In addition to the therapeutic techniques listed in Table 3.1, nurses should genuinely communicate with empathy. Communicating honestly, genuinely, and authentically is powerful. It opens the door to creating true connections with others. Communicating with empathy has also been described as communicating with emotion. Research has demonstrated that when healthcare teams communicate with empathy, there is improved patient healing, reduced symptoms of depression, and decreased medical errors.

Table 3.1: Therapeutic Communication Techniques

Techniques	Description
Using Silence	At times, it’s useful to not speak at all. Deliberate silence can give both nurses and patients an opportunity to think through and process what comes next in the conversation. It may give patients the time and space they need to broach a new topic.
Accepting	Sometimes it is important to acknowledge a patient’s message and affirm that they’ve been heard. Acceptance isn’t necessarily the same thing as agreement; it can be enough to simply make eye contact and say, “Yes, I hear what you are saying.” Patients who feel their nurses are listening to them and taking them seriously are more likely to be receptive to care.
Giving Recognition	Recognition acknowledges a patient’s behavior and highlights it. For example, saying something such as “I noticed you took all of your medications today” draws attention to the action and encourages it.
Offering Self	Hospital stays can be lonely and stressful at times. When nurses are present with their patients, it shows patients they value them and are willing to give them time and attention. Offering to simply sit with patients for a few minutes is a powerful way to create a caring connection.
Giving Broad Openings/ Open-Ended Questions	Therapeutic communication is often most effective when patients direct the flow of conversation and decide what to talk about. To that end, giving patients a broad opening such as “What’s on your mind today?” or “What would you like to talk about?” can be a good way to allow patients an opportunity to discuss what’s on their mind.
Seeking Clarification	Similar to active listening, asking patients for clarification when they say something confusing or ambiguous is important. Saying something such as “I’m not sure I understand. Can you explain it to me?” helps nurses ensure they understand what’s actually being said and can help patients process their ideas more thoroughly.
Placing the Event in Time or Sequence	Asking questions about when certain events occurred in relation to other events can help patients (and nurses) get a clearer sense of the whole picture. It forces patients to think about the sequence of events and may prompt them to remember something they otherwise wouldn’t.
Making Observations	Observations about the appearance, demeanor, or behavior of patients can help draw attention to areas that may indicate a problem. Observing that they look tired may prompt patients to explain why they haven’t been getting much sleep lately, or making an observation that they haven’t been eating much may lead to the discovery of a new symptom.
Encouraging Descriptions of Perception	For patients experiencing sensory issues or hallucinations, it can be helpful to ask about these perceptions in an encouraging, nonjudgmental way. Phrases such as “What do you hear now?” or “What does that look like to you?” give patients a prompt to explain what they’re perceiving without casting their perceptions in a negative light.
Encouraging Comparisons	Patients often draw upon previous experiences to deal with current problems. By encouraging them to make comparisons to situations they have coped with before, nurses can help patients discover solutions to their problems.
Summarizing	It is often useful to summarize what patients have said. This practice demonstrates to patients that the nurse was listening and allows the nurse to verify information. Ending a summary with a phrase such as “Does that sound correct?” gives patients explicit permission to make corrections if they’re necessary. Reflecting patients often ask nurses for advice about what they should do about particular problems. Nurses can ask patients what they think they should do, which encourages patients to be accountable for their own actions and helps them come up with solutions themselves.
Focusing	Sometimes during a conversation, patients mention something particularly important. When this happens, nurses can focus on the important statement, prompting patients to discuss it further. Patients don’t always have an objective perspective on what is relevant to their case, but as impartial observers, nurses can more easily pick out the topics on which to focus.
Confronting	Nurses should only apply this technique after they have established trust. In some situations, it can be vital to the care of patients to disagree with them, present them with reality, or challenge their assumptions. Confrontation, when used correctly, can help patients break destructive routines or understand the state of their current situation.
Voicing Doubt	Voicing doubt can be a gentler way to call attention to incorrect or delusional ideas and perceptions of patients. By expressing doubt, nurses can force patients to examine their assumptions.
Offering Hope and Humor	Because hospitals can be stressful places for patients, sharing hope that patients can persevere through their current situation and lightening the mood with humor can help nurses establish rapport quickly. This technique can keep patients in a more positive state of mind. However, it is important to tailor humor to the patient’s sense of humor.

Nontherapeutic Communication

Communication patterns or techniques that have negative effects on the development of a therapeutic relationship are referred to as nontherapeutic communication. It can also have negative effects on the patient’s well-being. Nontherapeutic communication can include behaviors such as interrupting the patient, giving personal opinions or advice without being asked, using judgmental or dismissive language, being insensitive to cultural or individual differences, or failing to provide adequate emotional support. These communication patterns may lead to misunderstandings, increased anxiety, decreased trust, and diminished patient satisfaction. Nurses must be aware of these types of potential barriers to communication. There are several nontherapeutic responses to avoid. Table 3.2 lists responses that often block the patient’s communication of their feelings or ideas.

Table 3.2: Nontherapeutic Responses

Response	Why It Is Nontherapeutic
Asking Personal Questions	Asking personal questions that are not relevant to the situation is not professional or appropriate. Don’t ask questions just to satisfy your curiosity. For example, asking, “Why have you and Mary never married?” is not appropriate. A more therapeutic question would be, “How would you describe your relationship with Mary?”
Giving Personal Opinions	Giving personal opinions takes away the decision-making from the patient. Effective problem-solving must be accomplished by the patient, not the nurse. For example, stating, “If I were you, I’d put your father in a nursing home” is not therapeutic. Instead, it is more therapeutic to say, “Let’s talk about what options are available to your father.”
Changing the Subject	Changing the subject when someone is trying to communicate with you demonstrates a lack of empathy and blocks further communication. It seems to say that you don’t care about what the person is sharing. For example, stating, “Let’s not talk about your insurance problems; it’s time for your walk now” is not therapeutic. A more therapeutic response would be, “After your walk, let’s talk some more about what’s going on with your insurance company.”
Stating Generalizations and Stereotypes	Generalizations and stereotypes can threaten nurse-patient relationships. For example, it is not therapeutic to state the stereotype, “Older adults are often confused.” It is better to focus on the patient’s concern and ask, “Tell me more about your concerns about your father’s confusion.”
Providing False Reassurances	When a patient is seriously ill or distressed, the nurse may be tempted to offer hope with statements such as, “You’ll be fine” or “Don’t worry; everything will be all right.” These comments tend to discourage further expressions of feelings by the patient. Here is a more therapeutic response: “It must be difficult not to know what the surgeon will find. What can I do to help?”
Showing Sympathy	Sympathy focuses on the nurse’s feelings rather than the patient’s. A statement like, “I’m so sorry about your amputation; I can’t imagine losing a leg.” shows pity rather than trying to help the patient cope with the situation. A more therapeutic response would be, “The loss of your leg is a major change; how do you think this will affect your life?”
Asking “Why” Questions	A nurse may be tempted to ask the patient to explain “why” they believe, feel, or act in a certain way. However, patients and family members may interpret “why” questions as accusations and become defensive. It is best to phrase a question by avoiding the word “why.” For example, instead of asking, “Why are you so upset?” it is better to rephrase the statement as, “You seem upset. What’s on your mind?”
Approving or Disapproving	Nurses should not impose their own attitudes, values, beliefs, and moral standards on others while in the professional nursing role. Judgmental messages contain terms such as “should,” “shouldn’t,” “ought to,” “good,” “bad,” “right,” or “wrong.” Agreeing or disagreeing sends the subtle message that nurses have the right to make value judgments about the patient’s decisions. Approving implies that the behavior being praised is the only acceptable one, and disapproving implies that the patient must meet the nurse’s expectations or standards. Instead, the nurse should help the patient explore their own beliefs and decisions. For example, it is nontherapeutic to state, “You shouldn’t consider elective surgery; there are too many risks involved.” A more therapeutic response would be, “So you are considering elective surgery. Tell me more about it.” This gives the patient a chance to express their ideas or feelings without fear of being judged.

Evaluating the Effectiveness of Therapeutic Communication

As discussed previously, therapeutic communication is defined as the specific techniques and strategies nurses use to establish a therapeutic relationship with patients and promote the patient’s well-being. Therefore, the general goal of every therapeutic interaction between a nurse and patient is the mutual exchange of information that leads to a new understanding on the part of the patient. After every therapeutic communication, the nurse must evaluate the interaction for its effectiveness in order to determine if more education or assistance is needed. Sometimes, specific phrases are encouraged for use at the end of the conversation. “Is there anything else I can do for you? I have the time.” is one such phrase that is encouraged. It allows the patient to ask for any additional assistance while showing that the nurse is present and available. The hope is that patients feel heard and attended to by their healthcare providers.

Reflect on Response

Nonverbal cues such as the patient’s general mood can be an indicator of how they are feeling about an interaction. If the patient’s body language indicates that they might be angry, scared, or upset, ask them about it. Using therapeutic techniques, talk to the patient and try to find out why they are feeling negatively about the interaction.

If the goal of the conversation has been met, seek feedback directly from the patient. Ask if the conversation was helpful for them. Specific questions to ask patients might include:

• What concerns do you have about your plan of care?
• What questions do you have about your medications?
• Did I answer your question(s) clearly or is there additional information you would like?

Listen closely for feedback from patients. Feedback provides an opportunity to improve patient understanding, improve the patient-care experience, and provide high-quality care.

Compare Response to Desired Communication Goals

The best way to determine patient understanding of the conversation is to use the teach-back method. In order to judge their level of understanding, have the patient re-state to you, in their own words, your original message. Then, compare the patient’s understanding of the therapeutic communication with the original communication goals. Remember that a SMART goal should be set prior to a therapeutic communication in order to provide specific details to guide the interaction (Table 3.3). This goal will not always be met, even if the nurse and patient get along and communicate well. The important thing is to determine if the goal was met, and if not, what prevented it.

Table 3.3: SMART Goals SMART goals should be set prior to therapeutic communication in order to provide specific details to guide the nurse-patient interaction.

SMART Goal	Action/Response	Met/Not Met
The patient will notify the nurse promptly for pain intensity level that is greater than their comfort-function goal throughout shift.	The patient called for pain management for a pain level of 4/10 during the shift.	Met
The patient’s blood pressure and heart rate will return to baseline levels by the end of the shift.	During last round of shift, patients’ vital signs included: Heart Rate 104 B/P 114/74	Met
The patient will identify and perform preferred actions to ensure adequate sleep by discharge.	The patient verbalized techniques for healthy sleep promotion, including decreasing stimulation by turning TV off and using soft ambient lights.	Not Met- Patient identified actions to promote quality sleep but did not perform these actions. At midnight the patient had overhead room lights on, the TV was loud, and four friends were at the bedside.
The patient will demonstrate appropriate use of adaptive equipment (e.g., a walker) for safe ambulation by the end of the shift.	Patient demonstrated use of walker to ambulate to bedside chair and again when returning to bed.	Met

Clinical Safety and Procedures (QSEN): QSEN Competency: Using the Teach-Back Method

See the competency checklist for Using the Teach-Back Method. You can find the checklists on the Student resources tab of your book page on openstax.org.

Link to Learning

This Use the Teach-Back Method sheet describes how nurses can incorporate plain language, teach-back, and coaching to promote consistent use of teach-back when educating patients.

Revise Message if Communication Ineffective

If the therapeutic communication proves ineffective, the first step is to attempt to determine why. It could be due to nontherapeutic communication techniques from the nurse or an emotional response from the patient. Explore and address any communication barriers, as well as any patient concerns. If necessary, revise and redeliver the goal message.

An example of a nurse encountering a therapeutic barrier is when the nurse asks the patient about their pain control. “Are you in pain? What about when you’re walking around? The medication should help you with that.” The nurse asks these questions while typing on the computer and looking at the screen. The patient responds, “No it’s fine. I’ll be all right.” The nurse should realize that they have met a communication barrier. They asked several questions without waiting for a response; they also suggested a response for the patient, and they did not make eye contact with the patient. In order to fix this, the nurse can close the computer screen and sit at the patient’s bedside; make eye contact; ask one question at a time; and wait for the patient’s response before continuing. This scenario shows that sometimes it is necessary for the nurse to rephrase their questions or messages and deliver them in a different way to elicit a more detailed patient response.