Breaking significant news: The experience of clinical nurse

specialists in cancer and palliative care

European Journal of Oncology Nursing

Nina Mishelmovich 1, Anne Arber 2, Anki Odelius 2

1. Macmillan palliative Clinical Nurse Specialist, Kingston Hospital foundation

Trust, Surrey, KT2 7QB, UK

2. Faculty of Health and Medical Sciences, University of Surrey, Guildford GU2

7XH, UK

1. INTRODUCTION

The nurse’s role in the delivery of significant news is all but unknown as, until

recently, the delivery of bad news was considered to be the role of medical staff

(Dunniece and Slevin, 2000). Some authors suggest that nurses may be well placed

to deliver significant news as they are often the people patients feel most comfortable

with (Higgins 2002; Faulkner 1998). The nurse’s role in breaking significant news

(BSN) has been identified in the past as supportive to that of the medical staff

concerned with monitoring the patient’s awareness of his/her condition prior to

disclosure of the cancer diagnosis and communicating this to the doctor (Morton,

1996); understanding the psychological needs of the patient following a diagnosis of

cancer and offering support (Claxton, 1993). Others such as May (1993) describe

nurses as, ‘practical mangers’ of the events which follow disclosure, and also

interpreters of medical information for patients and their families. Thus nurses have

many roles to play in delivering significant news and it is important to understand

what roles clinical nurse specialists play in BSN to patients.

The breaking of significant and bad news is challenging particularly in the acute

oncology setting when news of the failure of curative treatment was communicated

and was found to be the one of the most difficult topics for oncologists to discuss

(Baile et al., 2002). Other research reports the use of ambiguous language being

used when delivering bad news about a poor prognosis in contrast to discussions

about potentially curative treatments (Fallowfield et al., 2002). Personal experiences

of medical and nursing staff can also complicate the picture and factors such as a

recent bereavement or personal fears about one’s own mortality can cause additional

difficulties for staff and requires good staff support (Lloyd et al., 2009; Gordon and

Daugherty, 2003).

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Many researchers have found that patients wish to discuss the progress of their

illness although they also wanted to be given hope (Brown et al., 2011; Spiegel et

al., 2009). The communication needs of patients are not static and change

throughout the illness trajectory (Schofield et al., 2001). Furthermore choosing

the wrong timing for BSN, or disclosing more than the patient can cope with for

their stage of illness, may devastate the patient (Watson and Lucas, 2010). Many

patients prefer specialists to check whether they want to be given information

regarding their illness and the extent of the information they wish to receive

(Hagerty et al., 2005).

Although guidelines for delivering significant news exist some practitioners were

found to be more open to incorporating BSN guidelines with practice (Walker et al.,

1996). Others argue that guidelines compromise clinical independence and may

constrain and complicate the process of BSN leading to inflexibility (Watson and

Lucas, 2010). Nevertheless, healthcare professionals benefit from resources giving

them an idea of what other people found helpful in order to develop their own

personal style of BSN (Buckman and Kason, 1992). The most commonly cited

guideline for breaking bad and significant news is the SPIKES protocol; however the

efficacy of SPIKES is not empirically supported and its relevance to care across

cultures remains under researched (Baile et al., 2000; Buckman, 2005; Ptacek and

Ptacek, 2001; Vandkieft, 2001). There was criticism that guidelines are inexplicit

regarding emotional and supportive content, focussing on breaking significant news,

rather than receiving significant news (Arber and Gallagher, 2003; Duke and Bailey,

2008). Most studies of health care professionals and BSN have focused on medical

staff (Hancock et al., 2007). However it is not clear how well prepared specialist

nurses feel or their comfort with delivering significant news (De Valck and Van de

Woestijne, 1996). The aim of this research is to understand the lived experiences of

CNSs in cancer and palliative care in relation to BSN.

2. METHODOLOGY

The study used a qualitative approach informed by a hermeneutic phenomenological

perspective facilitating access to the meaning of the experience from the participants’

points of view. Phenomenology is based in philosophy (Patton, 1990) and is the

study of lived experience (Van Manen, 1984 p 37). It pertains to how people

understand the world in context, the central point being consciousness (Willig, 2001).

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Phenomenology encompasses numerous philosophical strands (Taylor, 1995) but

one of the key individuals associated with this framework is Martin Heidegger

(Moran, 2000) who is associated with hermeneutic phenomenology (Walters, 1994).

Heidegger was concerned with the notion of being in the world where people and the

world they live in should be regarded as coexisting and therefore also understood

together as a ‘person in context’ (Larkin et al., 2006). The focus of the present study

was on the exploration of specialist nurses in cancer and palliative care experiences

of breaking significant news to patients with advanced cancer. The study used a

hermeneutic phenomenological perspective, which provided a framework to generate

an understanding of these nurses’ experiences. The research question was ‘what is it

like for specialist nurses to break significant news to patients with advanced cancer?’

Ethical review was undertaken through one collaborating NHS trust and the

University of Surrey Ethics Committee. The setting where the study took place is an

acute National Health Service Trust in the UK. The research site is a medium sized

hospital with 520 beds serving a population of 350,000 people on the edge of a large

city in the South East of England. The hospital has a cancer unit and employs 18

clinical nurse specialists in cancer and palliative care. Sampling for the study was

purposeful and encompassed CNSs (n=10) from palliative and cancer specialities

(including lung, breast, gynaecology, upper and lower gastrointestinal cancer

nursing). The CNSs had all received training in advanced communication skills, were

all female and most had many years of clinical experience. The number of years of

clinical experience ranged from three to twenty years with nearly all having at least

nine years of clinical experience (Table 1).Ten out of a possible 18 CNSs came

forward to be interviewed for the study. The inclusion criteria were CNSs currently

employed and working in one acute hospital trust having worked in the role of CNS

(band 7-8) for at least six months. Six cancer and four palliative nurse specialists

came forward and were recruited to the study.

Data were collected through individual, semi-structured interviews lasting

approximately one hour, which were audio-recorded and conducted by the first

author. A topic guide was prepared to guide the interview (See table 2 for the topic

guide). The opening question for the interview was ‘could you tell me about a time

where you were involved in giving significant news to the patient?’ The interviews

were transcribed verbatim by the first author and anonymised so that confidentiality

was maintained. Data were kept in accordance with the Data protection Act (1998)

and only shared between the three authors. Transcripts were read and re-read by the

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first author and a coding scheme was developed (Burns and Grove, 2001; Moule and

Hek, 2011), which was discussed with the other authors and agreed.

Table I

Characteristics of participants.

Participant ID Role titleYears of

experienceTraining Gender

1 CNS in Palliative Care 10 Advanced communication skills course Female

2 CNS in Palliative Care 14 Advanced communication skills course Female

3 CNS in Lung Cancer and Palliative Care 13 Advanced communication skills course Female

4 CNS in Palliative Care 10 Advanced communication skills course Female

5 CNS in Colorectal Cancer 10 Advanced communication skills course Female

6 CNS in Lung Cancer and Palliative Care 15 Advanced communication skills course Female

7 CNS in Gynaecological Cancer 20 Advanced communication skills course Female

8 CNS in Breast Cancer 3 Advanced communication skills course Female

9 CNS in Breast Cancer 17 Advanced communication skills course Female

10 CNS in Upper GI Cancer 9 Advanced communication skills course Female

Table 2Topic guide.

1. Could you tell me about a time you were involved in giving significant news to the patient?

Probe: who else was involved in the conversation?

2. Can you tell more about your experience? Probe: what happened? What did you say? How

did you feel about it?

3. Can you tell me more about your role in delivering news? Probe: can you give me an example?

4. How do you prepare for the significant news conversation with the patient? Probe: setting up

the room, reading patient notes, talking to other members of the team.

5. What helps you deliver significant news? Probe courses attended, personal reading, significant

news guidelines.

6. Can you tell me of any difficulties you have in discussing significant news of terminal diagnosis

with the patient? Probe: how does this conversation affect you? Is there anything that makes it

easier? What so you think might help you to overcome those difficulties?

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3. FINDINGS

3.1 Four themes emerged from the data namely

The importance of relationships, perspective taking, ways to break significant news,

feeling prepared and putting yourself forward.

3.2 Importance of relationships

Participants identified great importance in forming a relationship with patients. They

spoke about how this relationship enabled them to conduct difficult conversations.

Participant 6 reports her encounter with a patient, whose prognosis was poor, and

how the bond that developed with the patient was significant and deep:

‘It’s sad, but on the other hand you often get really...meaningful relationships with people but you may not have met before... in this short space of time this, this atmosphere of complete trust can, is often created. So you can have extremely deep sort of either discussions or a deep just non verbal communication with someone um, which I find, it’s a privilege.’(6:349-358)

Participant 6 describes the deep and meaningful relationship she has with the

patient, which is both verbal and non-verbal. She describes how the relationship

creates the climate of trust that enables her to communicate with the patient on a

deep level over a short space of time.

Participant 7 also identifies the importance of trust and non-verbal communication

using touch to break the news that the illness was ‘moving on’:

‘...I touched her arm and I just stopped and, in mid flow, because she was talking very quickly about a lot of things and I, I just touched her arm and I said (name of the patient), I think that things are moving on. And she hesitated and she, she gave me a look sort of thing and I held my breath a second, thinking that you know, she’s going to become hysterical or she’s going to be, you know she’s going to be very difficult and she looked at me and she said, OK, you know. And I think she accepted that purely because we’ve had several days of building up that trust, you know...’(7:328-335)

Participant 7 like participant 6 identifies the importance of non-verbal communication

such as touch when breaking significant news about the illness. Participant 7 felt

able to break the news of the advancing illness because she had built a relationship

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of trust with the patient and this is described as helping the patient to accept the

significant news. In this data extract the reciprocal relationship is evident with the

nurse describing how the patient ‘gave me a look’ and ‘I held my breath a second’.

Participant 7 is preparing herself for the patient’s reaction to the news, which was

one of acceptance. The trust that developed between the nurse and the patient was

the supportive relationship that enabled the news to be communicated and accepted

in the context of a mutually supportive relationship developed over several days.

The relationship was identified as so important in the process of delivering significant

news and in contrast one of the most difficult things for the CNS was delivering bad

news when you don’t know the patient:

‘...if you don’t know people well really...when you first go in to see them and then you sometimes have to deliver that bad news, that’s the most difficult thing I think.’(1:97-100)

Participant 1 finds BSN very challenging and difficult to deliver outside of an

ongoing relationship with the patient. Another factor that was difficult was where the

CNS had information before the patient:

‘...I find it difficult, the fact that we know the information before them and I know that we do because we discuss them at MDT.’(5:11-12)

Participant 5 feels uncomfortable holding information discussed at the

multidisciplinary meeting about the patient and having that information before the

patient. This is a strain on the relationship from her point of view and seems to add

to the imbalance of power that the CNS would like to avoid. The CNS seems to

prefer the context of open awareness between herself and the patient.

3.3 Perspective taking

Participants in this study often made a link between themselves and the patient. This

link or self-identification with patients and situations was important in how the nurses

were able to take different perspectives on what was happening between them and

the patient. Perspective taking involves nurses’ ability to perceive other people’s

feelings (Duke and Bailey, 2008). Lobchuk, (2006) cited two views in perspective

taking. “Imagine-patient” perspective taking involves the ability to sense others

people’s feelings and relates to empathy, whereas “imagine-self” is about imagining

one’s own feelings in similar circumstances and often relates to sympathy.

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Participant 2 describes an ‘imagine-patient’ strategy seeking to understand the

situation from the patient’s point of view:

‘I try to see it from their point and see the information they have...’(2:337-338)

Participant 2 tries to see things from the patient’s perspective and one of the ways

she does this is to find out their understanding of the situation. Participants also

adopted the “imagining self” perspective, attempting to put themselves into the

“patient’s shoes”:

‘...I know all the time when I’m having those conversations I’m thinking in my head about if that was me...and I think all the time about how I would feel in that position.’(3:222-224)

Participant 3 is trying to gain a deeper experience of the patients life-changing news

by thinking about herself in that position. Participant 3 is trying to imagine how she

would feel in the situation of ‘those conversations’. Perhaps this is her way of getting

close to the patient situation. This CNS is trying to take the approach, “treat the

patient as you would want to be treated”. Through imaginative and reflective

processes, participants describe how they draw alongside their patients and practice

empathy as well as sympathy and seek to extend their understanding of the patient’s

needs and feelings at a very challenging time.

Participant 3 spoke about her clinical and personal experience of having a family

member with cancer and how it affected her approach to patients and gave her more

insight into the situation. She learned that, instead of concentrating solely on giving

information, it is important to tune in to patients’ personality and temperament:

‘...you know, my father had cancer and I nursed him. And I saw how health professionals interacted with him and I saw how often they had no clue whatsoever through his personality or how he’d want to interact with someone.’(3:423-426)

Participant 3 felt that health care professionals really didn’t understand her father’s

personality and needs especially when she observed the shortcomings of the care

offered to him and how she thought he would want to be interacted with.

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Similarly, participant 1 had better insight into the feelings of patients’ family members

having been through her father’s death. Her personal experience prompted her to be

more sensitive and emphatic towards family members and to be more aware of how

life-changing such an experience was for her:

‘I remember coming out of the hospital...and looking around and seeing everybody just carrying on normally. And I always remember thinking “do these people not understand that my dad’s dying?” This was completely a life changing event...’(1:417-423)

Participant 1 claimed that younger patients with young families would not be ready to

die and associated patients’ acceptance with how difficult or bad a death could be. In

this regard, age itself could mediate nurses’ response to the emotional needs of the

patient as well as their own feelings:

‘But when I think of the people who I would term as dying badly, it’s young people who often have had children you know and so it’s people who would never be ready to die.’(1:491-493)

Participants identified a correlation between their own age and the age of the patient

and there was a clear identification with the patient’s situation. Participant 8 reported

how similarity in age could accentuate her own anxieties and feelings towards

patient’s suffering made it harder to rationalise and accept:

‘...she was you know having her first baby. She’d just got married...just starting this new chapter in her life and then to be told that she’s, you know, she’s got maybe a few years to live is just awful...she’s not that much you know similar age probably to me...I suspect that’s harder to rationalise I suppose in your brain...’(8:256-262)

Participants in the study discussed differences between younger and older patients

and their influence on BSN. They commented that communication with younger

patients could be more challenging, due to the fact that a younger person leads a

more active lifestyle and experiences greater loss by dying and, therefore, are not

ready to accept significant news of advanced cancer. In comparison those that are

older perhaps having had a longer life are more satisfied with what they have

achieved and were thought to adjust more readily to the diagnosis of a terminal

illness. The interconnection and parallel between the CNS and the patient’s stage of

life could bring an emotional imbalance to the nurse’s experience, which was harder

to resolve and rationalise.

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3.4 Ways to break significant news

Participants describe working in partnership with the patient to understand what it is

that patients want from them by listening carefully to the patient’s needs:

‘...if you do listen, you do try to understand, then very often you can work as a partnership and that’s when best care takes place, because you can, you can work at their pace. You can make plans for how they would like things to be and that empowers them, you know, rather than taking the power away and telling them what’s going to happen.’(7:310-314)

The above participant describes the skill of listening to the patient and forming a

picture of what is best care for the patient such as not rushing them and working

alongside the patient at their pace. To participant 7 knowing how the patient would

like their care to be she describes as empowering and enables her to develop a plan

of what the patient would like to happen rather than telling them what to do.

Participant 5 cited principles of BSN, including giving a warning shot, leaving hope,

choosing an appropriate time and trying not to disclose all in one go and especially

not lying to the patient. According to participant 5 unexpected, significant news

delivered without hope, could lead to severe distress:

‘...we all know the right ways of doing things, warning shots, and giving information but, and not lying to people, but I think sometimes not completely destroying all hope for them.’(5:71-73)

Participant 6 identified several qualities and skills that contribute to BSN such as:

being compassionate, talking in “simple language”, being human and having a plan:

‘I like to think I do it with compassion and I do it sort of slowly but I speak very clearly about it. ... I’m not sort of wrapping it up in all sorts of words, ... so I think people are able to sort of maybe take it on board as, as much as they possibly can because it’s sort of I put it in a simple language.’(6:49-55)

Participant 6 describes being compassionate but also being clear when she delivers

the significant news so it is not complicated by too many words and it is presented

simply. Most of all she does it slowly so she is not rushed and it gives the

opportunity for the patient to understand and adjust to what is being said. This

strategy is one that in her views helps the patient take on board what she is saying.

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Similarly, participant 9 described other qualities that help build relationships, e.g.

being non-judgmental, sensitive, kind and allowing the patient to express his/her

emotions:

‘But you have to allow them to be emotional so you can’t be seen to be judgemental…it’s a very fine balance of keeping professional and keeping kind and understanding.’(9:98-100)

Participant 9 describes a fine balancing act between being professional and the more

human side and remaining kind and understanding and allowing the expression of

emotions.

Other participants identify significant aspects of their role in BSN as being present

alongside the medical staff when significant and bad news is broken (participant 10),

others describe picking up the pieces after bad news is broken (participant 2 and 4)

and explaining and summarising what the doctor has said and the treatment plan

(participant 10) and helping with the emotional adjustment to significant news

(participant 2 and 7).

3.5 Feeling prepared and putting yourself forward

Participants felt that previous clinical experience gave them better comprehension of

new situations, using past experiences to guide BSN. Some participants made

comparisons between their early and current practice, highlighting the importance of

learning through experience:

‘...when I first started doing this job, I found it really, really hard...As I’ve gone through the years, I’ve started...you have a bit more of a wider experience about people’s reactions and how they react to bad news and you, I suppose I’ve learned to deal with it...it’s just experience.’ (8:326-332)

One of the significant factors identified above is the challenge of how people react to

bad news and the unpredictability of reactions. All participants acknowledged that

many years of practice enabled them to feel confident in BSN. The more the CNSs

have to deal with BSN, the more they feel confident and at ease with the process.

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Furthermore, participants made reference to competence that is mastered and when

confidence develops, CNSs put themselves forward and become more involved in

BSN:

‘...you’re more competent at it and therefore obviously you put yourself forward to be involved more than you would have done in the early years.’(3:587-589)

The CNS’s acknowledge the difficulties they face in delivering significant news;

however after many years of experience they feel competent in how to deliver news

and feel able to put themselves forward to be involved in the process as identified by

participant 3.

Through clinical experience, nurses acquire knowledge of how to deal with BSN and

treat it “as it comes”, averting a recipe-type approach. They also learn to accept that

things might go wrong and might not be straightforward:

‘I don’t use recipes you know...I’m prepared to deal with whatever happens basically. So I think it helps me...’(6:405-409)

Moreover, with experience participants gain knowledge and assurance that they can

improve patient care, even though the news they give is sad. Keeping their own

expectations low helps nurses overcome difficulties they face in the process:

‘...I believe that I can be of support and that I can improve their situation. But I also protect myself by keeping my expectations small and small steps make big progress.’(2:178-180)

Again this is the balancing act of not making big expectations but keeping them small

and through the small steps described there is the possibility of improving the

situation and offering support.

Participant 4 promoted change in her practice through evaluation of past experiences

when managing difficult questions:

‘...I can still see her face. She said to me um, do you think I’m dying. And it was such a frank question...I said to her yes I think you are and she promptly dies that night and I can remember thinking to myself, oh gosh was I too brutal? You know...So I reflected on that and now, when someone asks me, “do you think I’m dying?”...I wouldn’t give that answer generally.’(4:58-64)

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Although participant 4 was honest with the patient she reflected on her response to

the question ‘do you think I’m dying?’ as possibly too brutal. On reflection she would

choose another way of answering this direct question, a more gentle approach.

Participant 9 noted that, with experience, she developed a high level of self-

awareness. She made a reference to reflection and learning from difficult

conversations or disturbing experiences, more than from positive ones:

‘I think I have become quite good at recognising when I’m uncomfortable...learn more from the ones that don’t go well, than the ones that do go well.’(9:301-304)

Like participant 4, participant 9 reflects on her communication practices and

recognises that it is possible to learn from the more complex and challenging

situations; especially those that do not go well by further reflection and learning.

Participant 4 has a high level of insight into her own feelings and is aware of when

she is feeling uncomfortable in a situation.

Participant 3 after years of experience has come to an acceptance of her own

mortality as a coping or self-defence mechanism, which in turn, made the process of

delivering news easier:

‘I have kind of accepted that death is part of life...and whether some of that is a self-defence mechanism or whether it is just that, you know, having done it for so many years, and I’ve kind of accepted my own mortality...’(3:441-446)

Participant 3 with 13 years experience as a CNS describes coming to terms with her

own mortality and this gives her the confidence to manage her own emotions and to

support those who are dying through her own personal self-awareness and personal

acceptance of dying.

4. DISCUSSION

Throughout the study CNSs referred to the emotional burden of BSN and its impact

on them especially early on in their role as a CNS, leaving them sometimes with

feelings of sadness and creating emotional exhaustion. CNSs talked about the

challenge of BSN to young patients and made a comparison with older patients. They

felt that age had a role to play making the disclosure of significant news to younger

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patients much harder to bear. They describe how it felt easier for them to discuss

end-of-life issues with older patients who had had a long past life, whereas BSN to

younger patients was described as emotionally difficult. This was because they felt

that those that are younger had more difficulty accepting news of terminal illness.

Furthermore those younger patients were also closer in age to the CNS themselves

and this seemed to break down the barrier between ‘them and us’. They describe

finding it difficult to balance their emotions and keep their emotional distance from

patients that are younger and of a similar age to themselves. This finding requires

more exploration as age could be an important factor influencing nurses’ responses

to the emotional needs of patients and indicates further need for good support

mechanisms from early on in the CNS career.

CNSs identified the emotional and psychosocial support they provided to patients

when significant news was broken. They mentioned verbal and non-verbal

communication, e.g. touch and active listening. Participants’ accounts revealed that

emotion work forms a considerable part of the CNSs’ role. The term emotion work

refers to the quality of face-to-face interaction between healthcare professionals and

patients, addressing patient’s emotions and providing emotional support (Zapf, 2002;

Sorensen, 2009). Hochschild (1983) first defined emotional labour in a study of flight

attendants. The concept comprises responses to common circumstances and

involves regulation and management of feelings through action and reaction.

Although this concept has been critically analysed in the literature, it has also been

recognised and increasingly explored in nursing (James, 1989; Smith, 2012).

Emotional labour is regarded as synonymous with empathy (McQueen, 2004).

Professional connections between patients and nurses create an intense exchange

of feelings and involve “deep acting”. “Deep acting” refers to consciously applying

effort to regulate the nurse's own feelings (Hochschild, 1983). However, in the

absence of personal exchange and connection nurses mostly focus on the exterior,

visible aspect of interaction, in the literature termed, “surface acting” for example

being nice (Larson and Yao, 2005). Deep engagement with patients at a level where

empathy is possible may be instinctive for some, yet might be emotionally draining or

laborious for others (Hochschild, 1983). It is evident from this study that some nurses

use emotional labour to give care and employ empathy in order to gain better

understanding of what it is like to be given devastating news. Some participants run

the risk of identifying too closely with the patient’s situation, consequently applying

“deep acting”, which can cause emotional imbalance. This is described as causing

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the CNSs to confront their own mortality and that of their families (Sorensen and

Iedema, 2009).

Nurses’ attitudes towards death and dying can influence their professional behaviour,

and provision of care (Gama et al., 2012). Alternatively, when viewing the situation

from the patient’s perspective, nurses may suppress their emotions in order to enable

them to address patients’ needs and remain professional. Li (2004) adds that nurses

and patients are involved in a collaborative, reciprocal relationship represented by

“symbiotic niceness”. That is, by addressing patients’ emotional needs, nurses

project warmth and niceness during communication and this is reciprocated by

patients. Li argues that niceness is not about “surface acting”, putting on a smile and

saying nice words, but is about the meaning and implication of interactions, which

could be viewed as a mechanism for managing the nurse-patient relationship.

Nurse’s report that, with experience, they became more self-aware and learn how to

distinguish between their own problems and patient problems and come to terms with

accepting their own mortality through strategies such as ‘imagine patient’ referred to

earlier.

CNSs report how important it was to having a good relationship with the patient and

this took time but enabled a relationship of trust, which facilitated communication to

proceed in an honest and open manner. The developing relationship enabled CNS to

meet the needs of the patient and to support the patient. CNSs explain how patients

were grateful when their questions were answered truthfully. For many patients

uncertainty increases suffering, whereas better understanding of their situation may

allow patients some degree of control.

CNSs report in-depth knowledge of the principles of BSN outlined in the SPIKES and

other protocols and guidelines; including: giving a warning shot, choosing an

appropriate timing and not disclosing news all in one go (Buckman, 2005; Girgis et

al.,1998). Nurses explained that they tread cautiously when BSN, unpicking what has

been said to patients and ensuring they do not overwhelm the patient with

information. They clarify the patient’s knowledge first and then build on it. One

participant described that, whenever possible, she conducts conversations slowly,

using clear and simple language, which helps patients to understand what is

happening to them. Glaser and Strauss (1965), in their seminal work, were the first

to identify awareness concepts in terminal illness. They concluded that the majority of

health professionals preferred not to tell patients about impending death at the time

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of their study. Their research has been criticised for not responding to the emotional

needs of patients. Field (1984) explored nurses’ opinion on awareness concepts and

found that nurses favoured open communication when working with patients.

Similarly, in the present study, nurses preferred open disclosure and regarded

informed patients as easier to work with and less stressful, which in turn enabled

nurses to facilitate patient acceptance of significant and bad news.

The findings suggest that in the process of BSN nurses treat the patient as a whole

rather than focusing solely on giving information. Throughout the interviews CNSs

acknowledged patients’ personal experiences of illness, showed interest in patients’

values, preferences and expressed needs, shared information and provided

psychosocial support. Participants in this study report working towards the patient’s

emotional adjustment to significant news and facilitating acceptance of the news.

The skills described by the CNSs are in accordance with principles of patient-

centred communication (Van Mossel et al 2011). It has been found that patient

centeredness increases satisfaction, reduces anxiety amongst patients, and

facilitates more accurate recall of information and better emotion management

(O’Keefe et al., 2001). The recent focus of patient centeredness has been on the

ability of healthcare providers to explore patients’ preferences and needs, while

providing them with information that helps them to make decisions (Bensing, 2000).

Heaven et al (2003) argue that in order to achieve patient-centred communication,

two key elements should be followed: “facilitation of disclosure” and “positive

responsiveness to disclosure”. The current findings revealed that, from the nurse’s

perspective, knowing the patient, having a therapeutic relationship and partnership

with the patient are vital aspects of patient-centred care. Knowledge of the patient

was seen as important in ascertaining how significant news should be broken and

what sort of support the patient might need. Participants believed that knowing the

patient helped them with BSN, interpreting patients’ concerns and addressing needs

through care plans. Forming relationships is a key attribute of specialist nursing,

central to those working in cancer and palliative care (Canning et al (2007).

5. Conclusion

The findings of this study indicate that specialist nurses in oncology and palliative

care have a significant role in disclosing significant news. CNSs report using

guidelines developed to support BSN in a flexible way. Supporting the delivery of

significant news is confidence developed over many years of practice and the

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development of a trusting relationship with the patient. There are some situations

that are difficult and challenging for CNSs and where they need further support.

Challenging situations reported by the CNSs concern recent personal experience of

loss and bereavement. Other situations described as challenging concern not having

time to develop a relationship with the patient and younger patients especially those

with young children. These situations heighten sensitivity and emotions within the

CNS and require further support so that emotional balancing is achieved.

Conflict of interestNone declared

AcknowledgementsThe authors would like to thank the research participants for their valuable time in

contributing to this study.

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