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• To understand how the use of a structured framework can assist you when are breaking bad news
• To appreciate the importance of providing a suitable physical environment when engaging in challenging conversations
• To learn how to respond to emotional reactions by patients and family members when breaking bad news
Rationale and key points
Breaking bad news is a fundamental yet challenging aspect of the role of healthcare professionals, including nurses. This article provides a step-by-step framework that nurses can use when delivering bad news and having challenging conversations with patients and/or families.
• Preparation is important to ensure that challenging conversations are carried out in a suitable physical environment and with family members and/or friends present as appropriate.
• Using a framework can aid nurses when undertaking challenging conversations, ensuring that all necessary aspects of the process are incorporated.
• Nurses need to manage the expectations of patients and family members and respond appropriately to their emotional reactions.
‘How to’ articles can help to update your practice and ensure it remains evidence based. Apply this article to your practice. Reflect on and write a short account of:
• How this article may help you to deliver bad news using a step-by-step framework in your practice.
• How you can use the information in this article to communicate effectively and address emotional distress when breaking bad news.
Emergency Nurse. doi: 10.7748/en.2023.e2174Peer review
This article has been subject to external double-blind peer review and checked for plagiarism using automated software
Mitchell A (2023) How to break bad news. Emergency Nurse. doi: 10.7748/en.2023.e2174Disclaimer
Please note that information provided by Emergency Nurse is not sufficient to make the reader competent to perform the task. All clinical skills should be formally assessed according to policy and procedures. It is the nurse’s responsibility to ensure their practice remains up to date and reflects the latest evidence
Published online: 20 June 2023
Bad news is often defined as information received by an individual that negatively and seriously affects their view of the present and the future (Baile et al 2000). Examples of bad news that might be delivered in the context of emergency care include discussing the outcome of a traffic accident with family or carers, explaining the result of a brain scan to a patient following an out-of-hospital collapse, or communicating the outcome of a diagnosis or treatment.
Breaking bad news is an important part of the role of healthcare professionals, and many nurses will be involved in such challenging conversations throughout their careers. Nurses have an important role in providing information and helping patients to prepare for and receive bad news. They also have a responsibility to provide education and support to patients and their families during this process through evidence-based practice (Nursing and Midwifery Council (NMC) 2018).
Breaking bad news can be challenging. Tesser et al (1971) theorised about the MUM (minimising unpleasant messages) effect, whereby individuals may experience feelings of anxiety, reluctance and a sense of responsibility associated with delivering bad news. Additionally, individuals imparting bad news often experience feelings of self-concern, concern for others and concern with norms (Tesser et al 1971, Dibble and Levine 2010).
The protocol for breaking bad news cannot be prescriptive, since every situation is different; however, it is important to use frameworks and protocols to structure these conversations so that the nurse can support and guide the patient and/or family members while imparting all the relevant information. The purpose of this article is to outline important steps for nurses to take when breaking bad news.
• Before meeting with the patient and/or their family members, prepare in advance what you are going to say. It may be beneficial to rehearse mentally or with a colleague and reflect on the plan and the approach you will take when delivering the bad news. Practise how you might respond to the emotional reactions of the patient and/or family members (Baile et al 2000).
• It is important to ensure that the physical environment is appropriate, since this can affect those receiving bad news and alter the dynamic of the conversation, particularly if it is held in a busy ward area or clinic (Mitchell 2022). Ensure that the room is private or if this is not possible draw the curtains around the patient’s bed. Make sure that all colleagues and members of the team are aware that the conversation is taking place and that there should be no interruptions.
• Ask the patient if they would like anyone else to be present during the discussion, such as a family member or close friend. It may be appropriate to wait until a family member or friend arrives. If a family member or friend is unavailable, ask the patient if they would like to have the conversation at another time. Conversely, it might be appropriate to ask the patient if they would prefer to be alone; if so, you may need to ask their family members and/or friends to leave at this point.
• Ensure that the patient and family members are comfortable, and that water and tissues are available.
• Arrange chairs at a 45 degree angle to ensure that there are no physical barriers that could hinder the conversation (Mitchell 2022) and that everyone involved in the discussion can maintain appropriate eye contact. Sit in a position where you are able to observe all non-verbal communication.
• Ensure that all phones are on silent, and that a colleague is covering any calls for you.
The procedure for delivering bad news outlined in this article is based on the SPIKES protocol (Baile et al 2000), which comprises six steps:
• S – Setting up the interview.
• P – assessing the person’s Perception.
• I – obtaining the person’s Invitation.
• K – providing Knowledge and information to the person.
• E – addressing the person’s Emotions with Empathetic responses.
• S – Strategy and Summary.
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.
Breaking bad news is a fundamental yet challenging aspect of the role of healthcare professionals, including nurses. Preparation is important to ensure that challenging conversations are carried out in a suitable physical environment and with family members and/or friends present as appropriate. It is important for nurses to ensure that the information shared with patients is understood and they feel reassured that support is available.
Using a tool such as the SPIKES protocol can provide a framework to aid nurses when undertaking challenging conversations, ensuring that all necessary aspects of the process are incorporated. The SPIKES protocol has four main objectives for breaking bad news (Baile et al 2000):
• Gathering information from the patient.
• Transmitting the medical information.
• Providing support to the patient.
• Eliciting the patient’s collaboration in developing a strategy or treatment plan for the future.
Nurses need to manage the expectations of patients and family members and respond appropriately to emotional reactions, and it is important to avoid any miscommunication in these highly charged emotive situations. Therefore, it is crucial that nurses delivering bad news use appropriate verbal and non-verbal communication skills to support the flow of communication between patients, family members and healthcare professionals, as well as strategies to manage their own emotions and patient distress. Rogers (1957) suggested that effective communication requires three core conditions:
• Congruence – genuineness and honesty when communicating with others.
• Unconditional positive regard – caring, acceptance and demonstrating respect.
• Empathy – conveying an understanding and appreciation of what an individual is feeling.
According to Rogers (1957), failure to develop fully open relationships with patients may result in them disengaging and withdrawing from healthcare services. This can lead to a breakdown in communication, a barrier developing between the patient and healthcare professionals, and a lack of trust. Evidence has suggested that barriers to a trusting relationship between patient and nurse can include lack of respect, which in turn can affect patient collaboration, connection and reciprocity (Leslie and Lonneman 2016).
Alongside the core conditions for communication, it is essential for nurses to use non-verbal communication skills to ensure challenging conversations go smoothly (Mitchell 2022). These include adopting an open and engaging posture, maintaining appropriate eye contact, not making any sudden physical movements, active listening, and displaying open and relaxed body language (Hannigan et al 2020). Throughout the process, asking open-ended questions in response to non-verbal cues may elicit further disclosure and discussion (Chauhan and Long 2000). For example, if a patient is not making eye contact or showing any changes in body posture after receiving bad news, the nurse might ask, ‘How do you feel after hearing that?’
Empathic communication is essential in terms of how people respond psychologically to bad news (Mitchell 2022). Empathy can be conveyed by accurately and sensitively communicating an understanding of how the patient feels. Touch can be an effective communication tool that can convey compassion, empathy and reassurance. It has been described as a language in itself that can signify a level of understanding which cannot be articulated in words (Chauhan and Long 2000, Mitchell 2022). However, while touch can reduce anxiety and increase self-confidence and sense of worth (Maksum et al 2019), it is important to ensure it is used appropriately.
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