1. Sit comfortably in your chair to show that you are not in a rush. If there are any issues or time constraints, make sure everyone is aware of these at the beginning of the conversation so that a plan can be made to address them. This may include arranging a date for a follow-up conversation at the outset.

2. It is important to establish a connection with the patient and/or family members. You can do this by reassuringly touching the arm or hand of the patient or family member if this is appropriate (Mitchell 2022). If touching is deemed inappropriate, adopt an open posture and maintain eye contact where suitable to establish a connection with the patient.

3. Ask the patient specific questions to gather information and gain an understanding about their disease status, education level, level of emotional awareness, cultural background and support networks (Narayanan et al 2010). This will be helpful when planning care.

4. Develop a rapport with the patient and/or family members using unconditional positive regard and an empathetic tone of voice. Keep to a structure for the conversation, since this may help to ensure it remains focused.

1. Start by asking open-ended questions to determine the perception and level of understanding of the situation of the patient and/or family members. Examples of such questions include, ‘What has been explained to you about the diagnosis?’, ‘What is your understanding of your medical condition?’ and ‘Do you know why you had the CT scan?’ This kind of questioning can increase the readiness of the patient and/or family members to receive new information. If they are aware of the seriousness of the situation, it may be possible to confirm what they know rather than having to break bad news (Narayanan et al 2010).

2. Explore what the patient thinks about their condition, and their own health beliefs and sense of reality concerning their condition or prognosis (Mitchell 2022). Challenge any misunderstandings the patient and/or family members may have and assess whether there are any signs of denial, unrealistic expectations or wishful thinking about their illness or injury. Patients may exhibit these behaviours in conversations with the nurse by omitting essential or unfavourable information about their condition. Avoid giving premature reassurance or false hope.

3. Discuss the sequence of events that led up to the point of the discussion. Ask the patient about any current and previous symptoms they have experienced.

4. Use indicator phrases to introduce the notion that unpleasant news is coming, thereby lessening the shock of diagnosis or outcome of treatment. Examples of indicator phrases include, ‘Symptoms like those you have described can sometimes be a result of a serious underlying condition,’ ‘As you know we have taken blood tests, and the results are not what we were hoping’ and ‘I am sorry, but the news is not good.’ This should be followed by a pause before delivering the bad news to provide time for the patient to process it and prepare themselves (Velez et al 2022).

1. Determine how much information the patient and/or family members can process at one time (Collini et al 2021). Use simple, easy-to-understand sentences and if possible provide only up to three pieces of information at one time (Narayanan et al 2010). Many people express a desire to hear all the information about a diagnosis, prognosis and proposed treatment; however, for others this is too much information to take in. Rejecting information is part of a psychological coping mechanism that the patient may use increasingly as their symptoms progress or their condition deteriorates (Joekes 2019).

2. Ask the patient if they would like to receive all the relevant information during the discussion or just a summary. Tailor the delivery of such information to the individual patient by providing the ‘right amount’ at the ‘right pace’ (Mitchell 2022), for example by asking, ‘Would you like me to tell you your test results now?’ Check that the patient and/or family members have received and understood the information by asking them to tell you what they have heard.

3. If the patient does not want to receive information at this time, offer to answer any questions and explain how they can contact you or the service for a discussion in the future.

1. Deliver information in small pieces to ensure that it is not too overwhelming. Make sure that the conversation aligns with the patient’s current level of understanding of their condition (Mitchell 2022).

2. Assess the patient’s health literacy during the conversation by paying attention to the language they use to describe their condition and symptoms. Avoid using medical jargon or technical language, for example instead of ‘metastasised’ use ‘spread’. It is important to find a balance between imparting clear, concise information and using excessive bluntness that could leave the patient feeling angry and isolated.

3. When delivering bad news relating to trauma and accidents it is important to avoid giving unnecessarily gruesome information such as detailed descriptions of their injuries. For patients who have survived such events, focus on the bigger picture, for example their recovery.

4. Allow the patient and/or family members time to process the information. This could mean allowing for long silences and waiting for the patient to continue the conversation. Avoid filling uncomfortable silences with unnecessary talk and avoid making definitive statements such as, ‘There is nothing more we can do.’

1. Observe and identify any signs of emotion in the patient or family member, which could be displayed as a change in mood, change in body language or withdrawal from the conversation (Baile et al 2000). Respond appropriately by asking the patient how they are feeling or what they are thinking, and support them to express these feelings. If the patient has become quiet, use prompt questions, for example, ‘Can you describe how you are feeling right now?’

2. Acknowledge any display of emotion by the patient and give them permission to express their emotions where appropriate, for example by saying, ‘It is okay to cry.’ Use sentences such as, ‘I am so sorry that this has happened’ to let the patient know that you have heard and understood their emotional response.

3. Avoid interrupting the patient and/or family members when they are speaking. Repeat or paraphrase some of what they have said to demonstrate understanding and engagement. This could be framed as a question to seek clarity or as an acknowledgement (Mitchell 2022); for example, ‘You mentioned that you feel confused,’ ‘You have identified some concerns about your treatment plan’ or ‘You have said you are worried about the future.’

1. Reassure the patient and/or family members that they will have time to make decisions and be involved in treatment planning. This is an essential part of the patient’s care and can assist with reducing stress and anxiety about the future. Check if the patient is ready to discuss a proposed treatment plan, and listen and respond appropriately to their preferences and concerns (NMC 2018). Plan the next meeting and set a date.

2. Check the patient and/or family members’ understanding of the information they have been given. It may be appropriate to ask the patient to repeat what they have heard, because often people may not hear what is said after bad news is delivered.

3. Give the patient and/or family members time to ask any questions.

4. Provide the patient and/or family members with written material and information about relevant services that the patient may need to contact or be involved with during their treatment.

5. Reassure the patient that they will receive continued support from the healthcare team.