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learning zone CONTINUING PROFESSIONAL DEVELOPMENT Aims and intended learning outcomes This article aims to encourage nurses to use reflection to develop their knowledge and skills in communicating bad news and engaging in difficult conversations with patients. After reading this article you should be able to: Identify situations in clinical settings that can give rise to the need to communicate bad news to patients. Implement strategies that are useful when involved in difficult conversations with patients and relatives. Explore your own feelings when participating in challenging conversations. Apply a reflective approach to practice to provide care that is sensitive and timely. Defining bad news Kaye (1996) defined bad news as any news that alters a patient’s view of the future for the worse. Buckman (1992) suggested that the effect of bad news depends on the difference between the patient’s expectations and the reality of the situation. Circumstances that can give rise to difficult conversations in clinical settings include: Informing a patient that his or her operation has been cancelled. Informing a patient that his or her treatment will be delayed. Confirming a diagnosis that will affect a patient’s life expectancy and/or quality of life significantly. Discussing a placement of choice for long-term care provision. Communicating bad news to patients is a complex and difficult task requiring patience, april 8 :: vol 23 no 31 :: 2009 51 NURSING STANDARD NS487 McGuigan D (2009) Communicating bad news to patients: a reflective approach. Nursing Standard. 23, 31, 51-56. Date of acceptance: December 10 2008. Communicating bad news to patients: a reflective approach Summary Part of nurses’ unique and challenging role in healthcare settings is engaging in difficult conversations with patients. Effective communication is essential to establish a successful nurse-patient relationship, put the patient at ease and promote better interactions. A reflective approach to care can help nurses to learn from experience and use this knowledge to communicate bad news to patients in a sensitive and timely manner. Author Deirdre McGuigan is professionals facilitator in cancer care, Education Centre, University Hospitals Bristol NHS Foundation Trust, Bristol. Email: [email protected] Keywords Communication; Nurse-patient relationships; Reflective practice These keywords are based on the subject headings from the British Nursing Index. This article has been subject to double-blind review. For author and research article guidelines visit the Nursing Standard home page at nursingstandard.rcnpublishing.co.uk. For related articles visit our online archive and search using the keywords. Page 57 Communicating bad news multiple choice questionnaire Page 58 Read Michelle Buckle’s practice profile on haematuria Page 59 Guidelines on how to write a practice profile Time out 1 Reflect on a situation when you had to inform a patient of some bad news. Now try to answer the following questions: What was the bad news about? What skills did you use to communicate with the patient? What constitutes effective communication? p51-56w31 3/4/09 11:46 am Page 51

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Page 1: BREAKING BAD NEWS_REFLECTION

learning zoneCONTINUING PROFESSIONAL DEVELOPMENT

Aims and intended learning outcomes

This article aims to encourage nurses to usereflection to develop their knowledge and skills in communicating bad news and engaging indifficult conversations with patients. Afterreading this article you should be able to:

� Identify situations in clinical settings that cangive rise to the need to communicate bad newsto patients.

� Implement strategies that are useful wheninvolved in difficult conversations withpatients and relatives.

�Explore your own feelings when participatingin challenging conversations.

�Apply a reflective approach to practice toprovide care that is sensitive and timely.

Defining bad news

Kaye (1996) defined bad news as any news thatalters a patient’s view of the future for the worse.Buckman (1992) suggested that the effect of badnews depends on the difference between thepatient’s expectations and the reality of thesituation. Circumstances that can give rise todifficult conversations in clinical settings include:

� Informing a patient that his or her operationhas been cancelled.

� Informing a patient that his or her treatmentwill be delayed.

�Confirming a diagnosis that will affect apatient’s life expectancy and/or quality of lifesignificantly.

�Discussing a placement of choice for long-termcare provision.

Communicating bad news to patients is acomplex and difficult task requiring patience,

april 8 :: vol 23 no 31 :: 2009 51NURSING STANDARD

NS487 McGuigan D (2009) Communicating bad news to patients: a reflective approach. Nursing Standard. 23, 31, 51-56. Date of acceptance: December 10 2008.

Communicating bad news topatients:a reflective approach

SummaryPart of nurses’ unique and challenging role in healthcare settings is engaging in difficult conversations with patients. Effectivecommunication is essential to establish a successful nurse-patient relationship, put the patient at ease and promotebetter interactions. A reflective approach to care can help nurses to learn from experience and use this knowledge to communicatebad news to patients in a sensitive and timely manner.

AuthorDeirdre McGuigan is professionals facilitator in cancer care, EducationCentre, University Hospitals Bristol NHS Foundation Trust, Bristol.Email: [email protected]

KeywordsCommunication; Nurse-patient relationships; Reflective practice

These keywords are based on the subject headings from the BritishNursing Index. This article has been subject to double-blind review.For author and research article guidelines visit the Nursing Standardhome page at nursingstandard.rcnpublishing.co.uk. For relatedarticles visit our online archive and search using the keywords.

Page 57Communicating bad news multiple choice questionnaire

Page 58Read Michelle Buckle’spractice profile onhaematuria

Page 59Guidelines on how towrite a practice profile

Time out 1

Reflect on a situation when you had to inform a patient of some bad news. Now try to answer the following questions:� What was the bad news about?� What skills did you use to communicate

with the patient?� What constitutes effective communication?

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Page 2: BREAKING BAD NEWS_REFLECTION

� Asking patients to talk more as this canencourage them to ask difficult questions, such as how long they have left to live.

�Engaging in conversations that might beemotionally distressing to the professional.

The importance of effective communication skills when dealing with sensitive issues has been emphasised in the literature, particularly in relation to cancer and palliative care (Calman and Hine 1995, Department of Health 2000,2001, British Medical Association 2004). Mostnurses will have experienced, at some point intheir career, a difficult conversation where theyhad to impart news that they knew would have a significant effect on a patient’s life. Theanticipation of these conversations can bestressful and nurses need to be adequatelyprepared to deal with the emotional demands of such engagements.

Self-awareness and reflective thinking

To understand individuals’ needs and theuniqueness of each patient, nurses need tounderstand their own needs, personal qualitiesand weaknesses. Becoming more self-awareenables nurses to observe how they react toparticular situations, what effect they can have ona situation and on others. It is through experiencethat an individual accumulates knowledge abouthow to communicate. Learning from experiencethrough self-awareness and the ability to reflectallows nurses to improve their practice and thesuccess of the care that is provided. Nurses shouldfirst care about themselves and recognise theirown self-worth, taking into account their beliefsand values before being able to provide effectivecare for others.

Senge (1990) described the need fororganisations to integrate learning at work so that employees are given activeencouragement to learn from problems,challenges and successes inherent in everydayactivities. The skills involved in communicatingbad news require teaching and practice toenable nurses to feel confident to deliverdifficult information. Each individual canconsider his or her unique learning styles andincorporate these into a learning approach orcombination of approaches (Power 2008). Thiscan be accomplished through the use of a combination of resources, such as onlinelearning breaking bad news packages, reflectivepractice through case scenarios, andface-to-face sessions used to deliver instruction.

Reflective practice is an important aspect ofnursing diploma, undergraduate and mastersdegree curricula (Nursing and Midwifery Council

understanding and sensitivity. Maguire (1985)found that when bad news was delivered poorlythe experience stayed in the patient’s and/orfamily member’s mind long after the initialshock of the news was dealt with. Effectivecommunication is central to patient satisfactionand the provision of sensitive care. Nurses needto ensure that they are appropriately skilled todeliver information that patients could finddifficult and/or distressing.

Nurse-patient relationships

Communication in nurse-patient relationshipsis an integral part of nursing practice. Effective communication is important toprovide accurate information and preventmisunderstandings and unrealistic expectations,particularly when giving patients bad news.Effective communication underpins thedevelopment of a therapeutic relationshipbetween nurses and patients and their families.Miller (2002) described effective communicationas a cyclical and interactive process betweencommunicators, consisting of messages beingsent, received and responded to, with feedbackbeing given to the originator of the message.Communication failure can arise from abreakdown at any point in the cycle.

There are many barriers to goodcommunication including the fears of the nurseand the fears of the patient. Sheldon et al (2006)carried out a study looking at difficultconversations in nurse-patient interactions fromthe nurse’s perspective. They found that nurses’personal experiences and emotional responses toclinical situations affected the way in which theycommunicated, often making such interactionsmore difficult for them. Maguire and Faulkner(1988) identified that nurses use distancingstrategies when having difficult conversations with patients so that they avoid:

�Eliciting patient emotions that the nurse might be unable to manage.

�Provoking emotions that the nurse mightperceive to be damaging to the patient, for example crying.

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52 april 8 :: vol 23 no 31 :: 2009 NURSING STANDARD

Time out 2

Make a list of what you think are the main barriers to effective communication. Compare your conclusions with the information that follows.

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2002). Reflection is about more than simplybeing thoughtful. It involves learning from andanalysing situations so that this experience can be applied to similar situations and futurepractice. In this instance, reflective practice seeksto respond to problems arising in difficultconversations so that it can allow nurses tocontinue to learn and develop through practice.

Reflective thinkers are those who are open-minded, responsible and wholehearted intheir approach to care (Dewey 1933). At a basiclevel, models of reflection exist to provideguidance to help nurses review events and turnthem into learning experiences. There are manymodels that have been used to describe thereflective approach (Driscoll 1994, Johns andGraham 1996). For the purpose of this article,Gibbs’s (1988) reflective model has been chosen(Figure 1).

Gibbs’s (1988) reflective model can be used inclinical settings to establish an accurate account of events. The model promotes six key stages:description, feelings, evaluation, analysis of thesituation, conclusion and the formation of anaction plan to improve future practice. Workingthrough these stages allows nurses to reflect on a particular incident and have a betterunderstanding of what to expect if a similarsituation should arise again.

Although the importance of reflection isacknowledged, it has been argued thatreflection in isolation cannot ensure learning,because it does not challenge or support sharedreflection (Atkinson and Claxton 2000). Groupprocesses, or group dynamics, can generate rich insight and understanding of complexprofessional issues through the challenge andsupport offered to participants in the process

(McGill and Beaty 1995). More opportunitiesto learn collaboratively with other colleaguescould be created through shared reflectionamong colleagues.

Ten-stage approach to communicating bad news

There are many strategies and tools developed to support nurses when communicating badnews. The ten-stage strategy has been developedfrom work carried out by Buckman (1992), Kaye(1996), Faulkner (1998) and Abel et al (2001)in a model to support and assist nurses engagingin difficult conversations with patients (Box 1). Preparation Nurses need to be sure about theinformation that they have to give to patients.The most relevant facts need to be obtained fromall resources available, such as hospital notes,nursing documentation and other members ofthe multidisciplinary team. This enables nursesto give accurate information and ensures thatthey are able to answer any questions thatpatients might ask. Nurses should try to plan, in collaboration with colleagues, protected

april 8 :: vol 23 no 31 :: 2009 53NURSING STANDARD

Time out 3

Imagine that you have to tell a patient who has recently been diagnosed with prostate cancer that the cancer is advanced and has metastasised to other vital organs. How would you approach this difficult conversation?

Time out 4

Refer back to the scenario in Time out 3. Now use Gibbs’s (1988) reflective model to analyse how you dealt with the situation. Consider what you could improve and how you would deal with a similar incident in the future.

Time out 5

Ask a colleague to support your reflective practice. Identify a difficult conversation that you had with a patient. Describe to your colleague why theconversation was challenging and how it made you feel. Ask your colleague to share his or her views on how youapproached the situation, what went well, what did not, andhow the situation could have been approached differently.

FIGURE 1

Gibbs’s (1988) reflective model

Stage 1Description

What happened? Stage 2Feelings

What were youthinking and

feeling?

Stage 3 Evaluation

What was good and bad about the

experience?Stage 4 Analysis

What sense can you make of the

situation?

Stage 5 Conclusion

What else couldhave been done?

Stage 6 Action planIf it arose

again, what would you do?

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friend is present. Some patients might also prefer such information to be given to someoneelse on their behalf.Give a warning sign The warning sign can be aphrase. If using supportive words it is importantthat nurses use words with which they arecomfortable. An example could be: ‘I am sorry itis not good news …’ or ‘I am afraid that thingsare more serious than we had hoped.’ This couldbe followed by a pause to enable the patient toprepare themselves. The intent should be toprovide accurate information – the intricacies ofthe actual words used are not always the mostimportant element of good communication.Nurses should try to remain professional, honestand compassionate. The focus of the receiverwill be to experience the nurse’s compassionateapproach to his or her unique situation and thiscan be shown through good eye contact andsupportive body language. Leininger andMcFarland (1995) confirmed that patients seekcaring behaviours that reflect respect for humanbeings, including the need to be listened to.Following the use of a warning sign, activelistening, being supportive and the use of silenceor pauses to enable individuals to gather theirthoughts can be helpful.Communicate bad news sensitively Theconversation should continue at a slow pace, and the nurse should use a gentle tone andsupportive body language. Communicating badnews is a complex task that requires expert verbaland non-verbal skills. Verbally, cognitive andaffective messages are sent through words, voiceinflection and rate of speech. Non-verbal messagesare conveyed through eye movement, facialexpressions, and body language (Smith 1996). The nurse’s ability to show concern and activelylisten to the patient’s fears and anxieties are crucial when breaking bad news.Acknowledge distress and support theexpression of feelings It is important to allowand acknowledge the expression of feelings no matter how patients express their distress(Maguire et al 1996). Nurses should try toensure privacy, where possible, and should besensitive to the needs of other patients whomight be nearby. No one can predict how anindividual will react to bad news. It is important,therefore, that nurses ensure they are preparedand skilled to manage different responses. These may include silence, physical withdrawal, tearfulness, anger, agitation,volatile behaviour and violence.Identify and prioritise concerns When thepatient is ready the nurse should continue byoffering advice and reassurance and recapping on what has been said and what is understood.Patients should be encouraged to be open aboutany concerns or feelings that they might have.

time to talk to patients so that importantconversations are not interrupted. It is vital to ask the patient if he or she wishes tohave a relative or friend present whencommunicating bad news. Start the discussion by getting the patient’s agreement for theconversation to take place. The patient should bemade aware that you are about to have a seriousand important conversation with him or her.Establish what the patient knows It is important to establish what patients already know about theirillness or situation. This should be expressed in theirwords and nurses should avoid using jargon ortechnical terms. Questions could include: ‘Whathave you been told about your illness or situation sofar?’ or ‘What do you understand about your illnessor situation?’ This will help nurses to determinewhether patients have unrealistic expectations orgaps in their understanding. Some patients couldalready suspect what they are about to be told. It is important to identify the discrepancy betweenthe patient’s expectations and the reality of thesituation as this can affect how they process anddeal with the information (Buckman 1992).Establish what the patient wants to know It canbe helpful to ask the patient’s permission beforecontinuing to explain the situation further. Somepatients might not want to have a discussion atthis time. If possible, nurses should acknowledgethis request and arrange to talk at a moreappropriate time, for example when theindividual is better prepared or a relative or

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54 april 8 :: vol 23 no 31 :: 2009 NURSING STANDARD

1. Preparation.

2. Establish what the patient knows.

3. Establish what the patient wants to know.

4. Give a warning sign either verbally or non-verbally.

5. Communicate bad news sensitively.

6. Acknowledge distress and support the patient inbeing open about his or her feelings.

7. Identify and prioritise concerns.

8. Check the patient’s present information needs.

9. Identify the patient’s support networks.

10. Make apparent what support is available and whatwill happen next.

(Adapted from Maguire 1985, Buckman 1992, Kaye 1996,Faulkner 1998, Abel et al 2001)

BOX 1

Ten-stage strategy to help nurses communicate bad news

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Maguire et al (1996) suggested that nursesreconsider and revisit this approach by askingindividuals to express their unique concernsfollowing their immediate distress. It isimpossible to assume that anyone can know or guess the individual concerns of patientswithout asking them first (Box 2).Check the patient’s information needs Havingclarified the patient’s unique, personal concerns it is a good idea to revisit his or her understandingof the information given and provide furtherdetails or clarify information as required.Identify the patient’s support networks It isimportant to identify what support the patienthas at home, for example family, friends and/orcolleagues. If there are gaps in this networknurses should provide information on supportgroups or voluntary organisations that theindividual can contact. If patients are unable to do this, family members may wish to contactthese organisations on their behalf. Nurses canalso assist in this process if appropriate and if thepatient agrees.Make apparent what help is available andwhat will happen next Nurses should ensurethat patients are given the correct informationand kept informed about what will happennext. Patients need to know who is availableand what specialist support exists. Whencommunicating bad news it can be difficult forthe patient to take all the information on boardat once. Further discussions with the sameprofessional, or others, can help to address anyinformation needs and concerns. Communicatingbad news well means that, where possible,preparation has been carried out, theinformation is given in a way that is sensitive tothe individual’s needs and the individual’sresponse is acknowledged and supported.

The effects on nurses of communicatingbad news

Communicating bad news can be stressful,emotionally distressing and draining. Thereshould be networks in place to support nurses.These could include peer-support groups anddebriefing exercises following such incidents.Training and case scenarios can help nurses to bebetter prepared to deal with such complexinteractions. The use of role play in small groupscan increase self-awareness and confidence inhandling the emotions of nurses and patientswhen they are involved in difficult conversations(Maguire and Faulkner 1988). Communicationskills training can also play an important role inproviding nurses with the skills necessary tocommunicate bad news to patients effectively(Chant et al 2002).

Conclusion

Nurses often have to give information to patients that could alter their expectationsabout their present situation or futurecircumstances. Communicating bad news iscomplex and information should be delivered in a timely and sensitive manner thatacknowledges the uniqueness of a patient’ssituation and concerns.

april 8 :: vol 23 no 31 :: 2009 55NURSING STANDARD

BOX 2

Case study

A 78-year-old man living alone was experiencingdizzy spells. He had had a recent fall, which causedsuperficial cuts and bruises. A decision was made to admit the patient to the local hospital for furtherinvestigation.

The nurse informed the patient of the recommendations made by his GP and he reluctantlyagreed to be admitted to hospital. However, hebecame agitated when it was suggested that hecould be admitted that same day. The nurse explainedwhat would happen and tried to answer all thepatient’s queries. When the nurse returned later she found the patient in tears.

The nurse asked the patient what was wrong and to explain to her what his concerns were about beingadmitted to hospital. He quietly responded that hedid not mind going into hospital but did not knowwho was going to look after his cat while he wasaway as his neighbour was on holiday abroad.

The nurse was able to establish the patient’s priorities and concerns and by doing so could activelyseek a solution to the problem. In this case, a member of the patient’s family was contacted to care for the cat while the patient was admitted to hospital. The patient was then more relaxed and in a more positive emotional state when receiving care.

Time out 6

Using the ten-stage strategy and the knowledge that you have gained from reading this article, devise your own plan of action to approach incidents that includecommunicating bad news to patients effectively.

Time out 7

Communicating bad news to patients can be stressful and emotionally demanding. How do you care for yourself to minimise the emotional impact of such interactions? Who do you speak to and what support networks, if any, do you access?

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AcknowledgementThe author wishes to acknowledge the contributionof the Communication Skills Group, which createdand delivers the Breaking Bad News InteractiveWorkshops at University Hospitals Bristol NHSFoundation Trust

Experienced nurses can share best practicethrough reflection and mentorship of lessexperienced colleagues. Nurses need to seekopportunities to enhance their communicationskills and nurture the nurse-patient relationship.Self-awareness is crucial. It enables nurses tounderstand their own needs and self-worth and,in turn, to understand better patients’ andrelatives’ needs, and so provide appropriatecare and support NS

learning zone reflective practice

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Buckman R (1992) How to Break BadNews: A Guide for Health CareProfessionals. The Johns HopkinsUniversity Press, Baltimore MD.

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Chant S, Jenkinson T, Randle J, Russell G(2002) Communication skills: some problems in nursing education and practice.Journal of Clinical Nursing. 11, 1, 12-21.

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References

56 april 8 :: vol 23 no 31 :: 2009 NURSING STANDARD

Time out 8

Now that you have completed the article you might like to write a practice profile. Guidelines to help you are on page 60.

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