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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

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

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.

Explore your own feelings when participating in challenging conversations. Apply a reflective approach to practice to provide care that is sensitive and timely.

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?

Deirdre McGuigan is professionals facilitator in cancer care, Education Centre, University Hospitals Bristol NHS Foundation Trust, Bristol. Email: deirdre.mcguigan@uhbristol.nhs.uk

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.

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

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. NURSING STANDARD



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understanding and sensitivity. Maguire (1985) found that when bad news was delivered poorly the experience stayed in the patient’s and/or family member’s mind long after the initial shock of the news was dealt with. Effective communication is central to patient satisfaction and the provision of sensitive care. Nurses need to ensure that they are appropriately skilled to deliver information that patients could find difficult and/or distressing.

Asking patients to talk more as this can encourage them to ask difficult questions, such as how long they have left to live. Engaging in conversations that might be emotionally 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). Most nurses will have experienced, at some point in their career, a difficult conversation where they had to impart news that they knew would have a significant effect on a patient’s life. The anticipation of these conversations can be stressful and nurses need to be adequately prepared to deal with the emotional demands of such engagements.

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.

Self-awareness and reflective thinking Nurse-patient relationships
Communication in nurse-patient relationships is an integral part of nursing practice. Effective communication is important to provide accurate information and prevent misunderstandings and unrealistic expectations, particularly when giving patients bad news. Effective communication underpins the development of a therapeutic relationship between nurses and patients and their families. Miller (2002) described effective communication as a cyclical and interactive process between communicators, consisting of messages being sent, received and responded to, with feedback being given to the originator of the message. Communication failure can arise from a breakdown at any point in the cycle. There are many barriers to good communication including the fears of the nurse and the fears of the patient. Sheldon et al (2006) carried out a study looking at difficult conversations in nurse-patient interactions from the nurse’s perspective. They found that nurses’ personal experiences and emotional responses to clinical situations affected the way in which they communicated, often making such interactions more difficult for them. Maguire and Faulkner (1988) identified that nurses use distancing strategies 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 might perceive to be damaging to the patient, for example crying. 52 april 8 :: vol 23 no 31 :: 2009 To understand individuals’ needs and the uniqueness of each patient, nurses need to understand their own needs, personal qualities and weaknesses. Becoming more self-aware enables nurses to observe how they react to particular situations, what effect they can have on a situation and on others. It is through experience that an individual accumulates knowledge about how to communicate. Learning from experience through self-awareness and the ability to reflect allows nurses to improve their practice and the success of the care that is provided. Nurses should first care about themselves and recognise their own self-worth, taking into account their beliefs and values before being able to provide effective care for others. Senge (1990) described the need for organisations to integrate learning at work so that employees are given active encouragement to learn from problems, challenges and successes inherent in everyday activities. The skills involved in communicating bad news require teaching and practice to enable nurses to feel confident to deliver difficult information. Each individual can consider his or her unique learning styles and incorporate these into a learning approach or combination of approaches (Power 2008). This can be accomplished through the use of a combination of resources, such as online learning breaking bad news packages, reflective practice through case scenarios, and face-to-face sessions used to deliver instruction. Reflective practice is an important aspect of nursing diploma, undergraduate and masters degree curricula (Nursing and Midwifery Council NURSING STANDARD



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2002). Reflection is about more than simply being thoughtful. It involves learning from and analysing situations so that this experience can be applied to similar situations and future practice. In this instance, reflective practice seeks to respond to problems arising in difficult conversations so that it can allow nurses to continue to learn and develop through practice. Reflective thinkers are those who are open-minded, responsible and wholehearted in their approach to care (Dewey 1933). At a basic level, models of reflection exist to provide guidance to help nurses review events and turn them into learning experiences. There are many models that have been used to describe the reflective approach (Driscoll 1994, Johns and Graham 1996). For the purpose of this article, Gibbs’s (1988) reflective model has been chosen (Figure 1).

(McGill and Beaty 1995). More opportunities to learn collaboratively with other colleagues could be created through shared reflection among colleagues.

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 the conversation was challenging and how it made you feel. Ask your colleague to share his or her views on how you approached the situation, what went well, what did not, and how the situation could have been approached differently.

Ten-stage approach to communicating bad news
There are many strategies and tools developed to support nurses when communicating bad news. The ten-stage strategy has been developed from work carried out by Buckman (1992), Kaye (1996), Faulkner (1998) and Abel et al (2001) in a model to support and assist nurses engaging in difficult conversations with patients (Box 1). Preparation Nurses need to be sure about the information that they have to give to patients. The most relevant facts need to be obtained from all resources available, such as hospital notes, nursing documentation and other members of the multidisciplinary team. This enables nurses to give accurate information and ensures that they are able to answer any questions that patients might ask. Nurses should try to plan, in collaboration with colleagues, protected FIGURE 1 Gibbs’s (1988) reflective model

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. Gibbs’s (1988) reflective model can be used in clinical settings to establish an accurate account of events. The model promotes six key stages: description, feelings, evaluation, analysis of the situation, conclusion and the formation of an action plan to improve future practice. Working through these stages allows nurses to reflect on a particular incident and have a better understanding of what to expect if a similar situation should arise again. Although the importance of reflection is acknowledged, it has been argued that reflection in isolation cannot ensure learning, because it does not challenge or support shared reflection (Atkinson and Claxton 2000). Group processes, or group dynamics, can generate rich insight and understanding of complex professional issues through the challenge and support offered to participants in the process NURSING STANDARD

Stage 6 Action plan If it arose again, what would you do?

Stage 1 Description What happened?

Stage 2 Feelings What were you thinking and feeling?

Stage 5 Conclusion What else could have been done?

Stage 4 Analysis What sense can you make of the situation?

Stage 3 Evaluation What was good and bad about the experience?

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time to talk to patients so that important conversations are not interrupted. It is vital to ask the patient if he or she wishes to have a relative or friend present when communicating bad news. Start the discussion by getting the patient’s agreement for the conversation to take place. The patient should be made aware that you are about to have a serious and important conversation with him or her. Establish what the patient knows It is important to establish what patients already know about their illness or situation. This should be expressed in their words and nurses should avoid using jargon or technical terms. Questions could include: ‘What have you been told about your illness or situation so far?’ or ‘What do you understand about your illness or situation?’ This will help nurses to determine whether patients have unrealistic expectations or gaps in their understanding. Some patients could already suspect what they are about to be told. It is important to identify the discrepancy between the patient’s expectations and the reality of the situation as this can affect how they process and deal with the information (Buckman 1992). Establish what the patient wants to know It can be helpful to ask the patient’s permission before continuing to explain the situation further. Some patients might not want to have a discussion at this time. If possible, nurses should acknowledge this request and arrange to talk at a more appropriate time, for example when the individual is better prepared or a relative or BOX 1 Ten-stage strategy to help nurses communicate bad news
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 in being 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 what will happen next.
(Adapted from Maguire 1985, Buckman 1992, Kaye 1996, Faulkner 1998, Abel et al 2001)

friend is present. Some patients might also prefer such information to be given to someone else on their behalf. Give a warning sign The warning sign can be a phrase. If using supportive words it is important that nurses use words with which they are comfortable. An example could be: ‘I am sorry it is not good news …’ or ‘I am afraid that things are more serious than we had hoped.’ This could be followed by a pause to enable the patient to prepare themselves. The intent should be to provide accurate information – the intricacies of the actual words used are not always the most important element of good communication. Nurses should try to remain professional, honest and compassionate. The focus of the receiver will be to experience the nurse’s compassionate approach to his or her unique situation and this can be shown through good eye contact and supportive body language. Leininger and McFarland (1995) confirmed that patients seek caring behaviours that reflect respect for human beings, including the need to be listened to. Following the use of a warning sign, active listening, being supportive and the use of silence or pauses to enable individuals to gather their thoughts can be helpful. Communicate bad news sensitively The conversation should continue at a slow pace, and the nurse should use a gentle tone and supportive body language. Communicating bad news is a complex task that requires expert verbal and non-verbal skills. Verbally, cognitive and affective messages are sent through words, voice inflection and rate of speech. Non-verbal messages are conveyed through eye movement, facial expressions, and body language (Smith 1996). The nurse’s ability to show concern and actively listen to the patient’s fears and anxieties are crucial when breaking bad news. Acknowledge distress and support the expression of feelings It is important to allow and acknowledge the expression of feelings no matter how patients express their distress (Maguire et al 1996). Nurses should try to ensure privacy, where possible, and should be sensitive to the needs of other patients who might be nearby. No one can predict how an individual will react to bad news. It is important, therefore, that nurses ensure they are prepared and skilled to manage different responses. These may include silence, physical withdrawal, tearfulness, anger, agitation, volatile behaviour and violence. Identify and prioritise concerns When the patient is ready the nurse should continue by offering advice and reassurance and recapping on what has been said and what is understood. Patients should be encouraged to be open about any concerns or feelings that they might have. NURSING STANDARD

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Maguire et al (1996) suggested that nurses reconsider and revisit this approach by asking individuals to express their unique concerns following their immediate distress. It is impossible to assume that anyone can know or guess the individual concerns of patients without asking them first (Box 2). Check the patient’s information needs Having clarified the patient’s unique, personal concerns it is a good idea to revisit his or her understanding of the information given and provide further details or clarify information as required. Identify the patient’s support networks It is important to identify what support the patient has at home, for example family, friends and/or colleagues. If there are gaps in this network nurses should provide information on support groups or voluntary organisations that the individual can contact. If patients are unable to do this, family members may wish to contact these organisations on their behalf. Nurses can also assist in this process if appropriate and if the patient agrees. Make apparent what help is available and what will happen next Nurses should ensure that patients are given the correct information and kept informed about what will happen next. Patients need to know who is available and what specialist support exists. When communicating bad news it can be difficult for the patient to take all the information on board at once. Further discussions with the same professional, or others, can help to address any information needs and concerns. Communicating bad news well means that, where possible, preparation has been carried out, the information is given in a way that is sensitive to the individual’s needs and the individual’s response is acknowledged and supported.

BOX 2 Case study
A 78-year-old man living alone was experiencing dizzy spells. He had had a recent fall, which caused superficial cuts and bruises. A decision was made to admit the patient to the local hospital for further investigation. The nurse informed the patient of the recommendations made by his GP and he reluctantly agreed to be admitted to hospital. However, he became agitated when it was suggested that he could be admitted that same day. The nurse explained what would happen and tried to answer all the patient’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 being admitted to hospital. He quietly responded that he did not mind going into hospital but did not know who was going to look after his cat while he was away as his neighbour was on holiday abroad. The nurse was able to establish the patient’s priorities and concerns and by doing so could actively seek 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.

The effects on nurses of communicating bad news
Communicating bad news can be stressful, emotionally distressing and draining. There should be networks in place to support nurses. These could include peer-support groups and debriefing exercises following such incidents. Training and case scenarios can help nurses to be better prepared to deal with such complex interactions. The use of role play in small groups can increase self-awareness and confidence in handling the emotions of nurses and patients when they are involved in difficult conversations (Maguire and Faulkner 1988). Communication skills training can also play an important role in providing nurses with the skills necessary to communicate bad news to patients effectively (Chant et al 2002).

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 include communicating 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? NURSING STANDARD

Nurses often have to give information to patients that could alter their expectations about their present situation or future circumstances. Communicating bad news is complex and information should be delivered in a timely and sensitive manner that acknowledges the uniqueness of a patient’s situation and concerns. april 8 :: vol 23 no 31 :: 2009 55



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Experienced nurses can share best practice through reflection and mentorship of less experienced colleagues. Nurses need to seek opportunities to enhance their communication skills and nurture the nurse-patient relationship. Self-awareness is crucial. It enables nurses to understand their own needs and self-worth and, in turn, to understand better patients’ and relatives’ needs, and so provide appropriate care and support NS

Acknowledgement The author wishes to acknowledge the contribution of the Communication Skills Group, which created and delivers the Breaking Bad News Interactive Workshops at University Hospitals Bristol NHS Foundation Trust

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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