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CONTINUING PROFESSIONAL DEVELOPMENTCPD

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Breaking bad news: issues relating to nursing practiceNS751 Warnock C (2014) Breaking bad news: issues relating to nursing practice. Nursing Standard. 28, 45, 51-58. Date of submission: February 28 2014; date of acceptance: April 28 2014.

AbstractThe breaking of bad news was traditionally regarded to be the time when a doctor and nurse sat down with a patient and family members to provide information about, for example, a life-limiting diagnosis or a poor prognosis. However, breaking bad news is now generally accepted as a process, not a one-off event, and is considered to refer to any bad, sad or difficult information that alters patients’ perceptions of their present and future. Nurses have an important role in the process of providing information and helping patients prepare for, receive, understand and cope with the bad news they have been given. This article aims to help nurses understand the process of breaking bad news and discuss the challenges and difficulties that nurses can face when they are involved with patients who have been given bad news. It also provides guidance with regard to preparing for breaking bad news, giving difficult information, responding to possible reactions, and supporting patients and their relatives after they have received bad news.

AuthorClare WarnockPractice development sister, Weston Park Hospital, Specialist Cancer Services, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield.Correspondence to: clare.warnock@sth.nhs.uk

KeywordsBreaking bad news, communication, nursing: care, nursing: role

ReviewAll articles are subject to external double-blind peer review and checked for plagiarism using automated software.

OnlineGuidelines on writing for publication are available atwww.nursing-standard.co.uk. For related articles visit the archive and search using the keywords above.

Aims and intended learning outcomesThe aim of this article is to increase readers’ understanding of the role of the nurse in the process of breaking bad news and the factors that influence nursing care. After reading this article and completing the time out activities you should be able to: Understand that breaking bad news is a process, not just a single event, and that bad news refers to any information that may have a negative effect on patients’ present and future. Describe the range of ways in which nurses can be involved in the process of breaking bad news. Discuss the benefits of providing patients with honest and accurate information, and state when providing such information may not be appropriate. Identify the challenges and difficulties that can be faced by nurses when involved in the process of breaking bad news. Evaluate the guidelines and advice that surround breaking bad news.

IntroductionTraditionally, breaking bad news has been perceived as the moment when a doctor provides significant information about diagnosis, prognosis or treatment to patients and their families. Within this framework, the role of the nurse is to be present during the consultation to assist both parties, acting as a witness to what has been said and providing support to the recipient of the news once the consultation is over. More recently, this portrayal of breaking bad news has

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been challenged by suggestions that it is too simplistic and may not reflect accurately the experience of those receiving or providing the information (Eggly et al 2006). In particular, questions have been raised about the way in which this depiction focuses on the moment that bad news is given within a planned consultation and the narrow scope of topics that it classifies as bad news (Dewar 2000, Tobin and Begley 2008). The depiction also affords little consideration to the contributions of nurses and other members of the healthcare team who engage in an increasingly diverse range of breaking bad news activities, including providing information in one-to-one consultations (Warnock et al 2010).

Developing a description of breaking bad news that is closer to the experiences of patients, relatives and healthcare professionals is an important first step in exploring the role of the nurse and the care that contributes to meeting patients’ needs.

What is bad news?A frequently cited definition of bad news in health care is that it is any bad, sad or significant information that alters negatively people’s expectations or perceptions of their present or future (Fallowfield and Jenkins 2004). This definition moves beyond the narrow perspective of diagnosis, prognosis and treatment, which restricts the scope of bad news to key moments in the medical pathway. It suggests that a wide range of information can be classified as bad news, including subjects that often lie within the remit of the wider multidisciplinary team. Evidence of this broader view is seen in literature that describes the types of information provided by nurses and allied health professionals that can be classified as bad news, examples of which are provided in Box 1. The case scenario in Box 2 describes one person’s experiences of receiving bad news over the course of her cancer journey.

It demonstrates the potentially wide range of subjects that can be interpreted by patients as bad news (Box 1 and Box 2).

The definition by Fallowfield and Jenkins (2004) also emphasises that the classification of information as ‘bad news’ depends on how the news is perceived by the person receiving it. Different people may interpret similar information in different ways, such as being good, bad or neutral (Eggly et al 2006). How information is interpreted will therefore be influenced by subjective factors such as the patient’s expectations, values, life experiences and social situation. It can also be affected by the events leading up to and surrounding the moment that the information is given (VandeKieft 2001, Fallowfield and Jenkins 2004). Clearly, certain news, such as a diagnosis of terminal illness, is likely to be perceived as bad by most people. However, it may not always be possible to determine in advance how information will be received (Eggley et al 2006). For example, informing patients that they are to have an operation could be perceived positively by one person, as it is confirmation of a plan for life-saving or symptom-improving treatment. However, a person who has an overwhelming fear of hospitals or anaesthesia may view the news negatively. Another person could find the news upsetting because the date scheduled for surgery clashes with a valued, planned event such as a family wedding.

The recognition that information is appraised subjectively as good, bad or neutral has implications for those providing the information. In particular, it limits healthcare professionals’ ability to predict when they might be engaging in the provision of bad news and their opportunities to plan and prepare for the encounter (Eggly et al 2006). An example of such a situation is seen in the case scenario (Box 2) where Julie lists learning about restricted hospital visiting hours as significant bad news because it limits the amount of time her daughter can spend with her. However, for most staff, visiting times are generally perceived as routine information.

The traditional picture of breaking bad news can also be challenged because the provision of negative information could be seen as part of an ongoing process and not restricted to pre-planned, single consultations. For example, Dewar (2000) explored the role of the nurse in breaking bad news in a spinal injury unit. She found that patients were provided with the initial information about their diagnosis, treatment and potential outcomes early in

BOX 1 Examples of types of information that can be classi�ed as bad news

Informing relatives of a patient’s deterioration or death. Advising patients that they need to move into a residential care home. Explaining the details of arduous treatments such as renal dialysis or chemotherapy. Providing daily updates to family members when a patient’s condition is not improving. Discussing the meaning and implications of transitions in care, such as moving from curative care to palliative care and end of life care.

(Verhaeghe et al 2005, Warnock et al 2010, Shannon et al 2011)

Join our First Friday Twitter discussion about issues raised in this article.Friday August 1 from 12.30-1.30 using #NursingJC

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diagnosis, prognosis and treatment options, outcomes and consequences (Hagerty et al 2005, Clayton et al 2008). Variations have been identified in the depth and level of knowledge that individuals desire, particularly in relation to general qualitative information (such as intention of treatment, for example, curative or palliative) as opposed to detailed quantitative facts (such as statistics and time frames) (Innes and Payne 2009).

However, the majority prefer honest, accurate and reliable information and want to receive it as close as possible to the time that the facts are known (Campbell et al 2010, Cleary et al 2010).

The literature also identifies potential positive outcomes as a result of disclosing information. These include building a sense

1 Write down some examples of ways in which you might be involved in breaking bad news in your own professional practice. Then compare your list with the examples listed in Box 3.

BOX 2 Case scenario: a patient’s perspective on bad news

Julie Jones is a 58-year-old woman with colorectal cancer. She has recently developed widespread liver metastases and was told earlier in the day at an outpatient appointment that the cancer is no longer responding to her current treatment. The consultant and nurse specialist have outlined the different treatment options available and Julie has a return appointment the following week to talk through her decision. Later that evening, Julie is thinking back to all the times when she has heard bad news since she developed cancer. To get things clear in her head she notes them down on a piece of paper, as follows: 1) Going to see the GP when I had symptoms and being told I would get an urgent appointment in two weeks to see the specialist. I knew then it was potentially serious and it could be cancer. 2) Being told by the hospital doctor that the tests showed it was cancer and I needed surgery. 3) When the nurse specialist explained to me what the surgery would involve, especially finding out about the stoma. 4) Attending the preoperative assessment clinic and hearing about the details of the operation and hospital stay, especially the anaesthetic and the risk of developing blood clots. 5) Being admitted to the ward and finding out that visiting hours were restricted so my daughter could be with me for only a few hours a day. 6) Being marked for the stoma site – this really brought home what I was having done. 7) Seeing my stoma for the first time and being taught how to keep it clean and put on the bags. 8) Finding out I would need to have chemotherapy at the cancer centre. 9) Having the treatment explained to me by the doctor and then the nurse at the cancer centre – the months and months of treatment, the scary side effects, all of the things I had to look out for and remember to do. 10) Being informed that I had neutropenic sepsis and had to stay in hospital for intravenous antibiotics. 11) Hearing that I needed to go for more scans when I told the doctor about the new pain in my side. 12) My nurse specialist explaining to me why the scans were being done and what they might show. 13) Learning that I had liver metastases and that the chemotherapy I am on at the moment is not working. 14) Listening to the different treatment options earlier on today – how on earth am I going to decide what to do?

their admission to the unit. However, bad news situations also arose over the course of the patients’ stay as they began to realise the implications of the original news that they had been given. When patients raised questions and concerns about their situation, the staff member who provided explanation and information was then engaged in breaking bad news. Dewar’s (2000) findings widen the concept of breaking bad news from a single consultation to a process that occurs over time as events unfold or patients and relatives raise questions and concerns. This perspective is supported by studies that have explored patients’ experiences of receiving bad news where they describe the initial consultation as the start of a process or journey, rather than an isolated event (Randall and Wearn 2005, Tobin and Begley 2008). It can also be seen in the case scenario where Julie describes her exposure to diverse bad news events as she moves through the stages of her illness (Box 2).

From this wider perspective, the process of breaking bad news can be considered to involve activities that take place before, during and after the initial provision of information (Warnock et al 2010). These activities include: Before the bad news is given – anticipating and identifying that information is needed and preparing the patient or relative so they know they are going to receive significant information (Stayt 2007, Gauthier 2008). After the information has been provided – clarifying the understanding, supporting decision making and helping patients and relatives adapt to the consequences of bad news (Stayt 2007, Gauthier 2008).

Complete time out activity 1

The ways in which individual nurses are involved in breaking bad news will be influenced by many factors, including their role and work setting. For example, a nurse in an outpatient department may have more involvement with doctor-patient consultations compared with a nurse in a community setting. In any case, nurses often have a pivotal role in shaping patients’ experiences of receiving and coping with bad news. This can be seen in the examples of the range of activities that nurses carry out across the process of breaking bad news, summarised in Box 3.

Why is breaking bad news important?Research has shown consistently that most patients want to be informed about their

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of trust and openness between patients and the healthcare team and increasing patients’ confidence in relation to asking questions (Hancock et al 2007, Erichsen et al 2010). By being fully informed, patients and relatives are provided with the knowledge they need to make informed decisions and plans based on a realistic insight into their situation (Hancock et al 2007, Erichsen et al 2010). Nurses have reported that being involved in the process of breaking bad news strengthens their relationships with patients and relatives and therefore benefits the nurse-patient relationship (Warnock et al 2010). Complete time out activity 2

The importance of information disclosure is most clearly identified in examples from the

literature of the negative impact on patients, relatives and healthcare professionals when patients have not been provided with bad, sad or difficult news. A summary of key points from the literature is provided in Box 4.

There are situations when it may not be appropriate to disclose information fully. Some patients prefer not to receive some or all of the facts, because not knowing the truth is their way of coping with their illness (Tuckett 2004, Reynolds 2013). Cultural differences have been identified with regard to preferences and behaviours around information relating to particular diagnoses, such as cancer, and prognosis and end of life decisions (Georgaki et al 2002, Glass and Cluxton 2004). Even though information disclosure is now the norm in Western societies, in some cultures it can be common practice for the family to be given the information while the patient is shielded from the full facts (Lapine et al 2001). Such cultural expectations can shape and influence, but not determine, a patient’s wishes (Hancock et al 2007). Therefore, it is important to ascertain individual patients’ preferences about the information they want to receive and allow these preferences to guide the content, timing and delivery of information (VandeKieft 2001, Shannon et al 2011).

However, even though patients may initially indicate that they do not want to be told about their diagnosis and prognosis, nurses must remain alert for cues that the patients have changed their minds and want more information about their condition (Hallenbeck and Arnold 2007, Reynolds 2013).Complete time out activity 3

Why is breaking bad news di�cult?Having established the benefits associated with providing patients and relatives with honest and realistic information, it is useful to consider why this is not always achieved. There may be a reluctance or concern on the part of information providers to enter into discussion of a subject that is emotionally difficult for all those involved and which may elicit a strong emotional response (Fallowfield and Jenkins 2004, Taylor 2007, Campbell et al 2010).

The reactions of patients and relatives to bad news are not predictable. They can include anger, tears, hysteria, denial, verbal abuse, threatening behaviour, bargaining and silence (Taylor 2007, Campbell et al 2010). Fears of invoking such reactions are an understandable reason why some health professionals have concerns about

BOX 3 Activities carried out by nurses in the process of breaking bad news

Assessing the needs for further information of patients and relatives and recognising their cues and prompts. Working with the patient and family to achieve consensus when there are issues about who should be informed. Identifying and prioritising the patient’s preferences for information. Where the need for information is identified or requested, liaising with the appropriate members of the healthcare team to initiate discussions. Coaching and supporting patients and relatives who find it difficult to ask questions or talk to doctors. Being present in consultations where patients and relatives are given bad news. Helping patients ask questions during consultations when they appear to be confused or reluctant to ask questions. Supporting others who are providing the information to find alternative words or explanations if the patient appears not to understand or needs clarification. Communicating to the rest of the healthcare team what has been said in the consultation. Eliciting patients’ and relatives’ feelings about the information they received. Listening to and acknowledging the emotional reactions of patients and relatives to bad news. Explaining and discussing the information provided and its implications. Answering questions as they arise, identifying and clarifying misunderstandings and explaining complex medical terminology. Providing information about the next steps in the care pathway, including the expected course of the illness, its treatment and its consequences for the patient and family. Helping the patient and relatives explore their goals and options so they can make decisions about care (weighing the burden of treatment against its aim and intention). Providing information and opportunities for discussion as patients and relatives address complex issues – for example, what is meant by DNAR (do not attempt resuscitation), informed consent and advance care directives. Supporting patients and relatives when they realise the implications of their situation or the information they have been given. Helping the family reach a consensus when there is disagreement between them about the plan of care. Acting as an intermediary between patients, relatives and healthcare team.

(Dewar 2000, Norton and Talerico 2000, McSteen and Peden-McAlpine 2006, Vivian 2006, Stayt 2007, Gauthier 2008, Warnock et al 2010, Shannon et al 2011)

2 Have you experienced a situation when a patient was not fully informed about his or her illness, treatment or its outcomes? What effect did this have on the patient, family and the healthcare team?

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engaging in the process of breaking bad news (Fallowfield and Jenkins 2004, Taylor 2007, Campbell et al 2010). In addition, managing the reactions and continuing the consultation require sensitive skills and expertise, as well as time, which is a resource that is not always readily available in busy healthcare settings (Fallowfield and Jenkins 2004).

Knowing that the information being provided is not what patients want to hear can be difficult for nurses, particularly if they have had the opportunity to build relationships with patients and their families over time (Stayt 2007). Nurses can also feel guilt or a sense of failure that they have not managed to ‘fix things’ for patients, even when they know they are placing an unrealistic expectation on their own role or ability to influence outcomes (Stayt 2007). Other concerns for providers of bad news include managing their own negative feelings during the discussion, not knowing what to say, anticipating when it is the right time to broach subjects and being unsure about whether they will be able to answer questions adequately (Hancock et al 2007, Gauthier 2008). When staff are unable to overcome their concerns, they can feel uncomfortable discussing difficult information and may be unwilling to engage with patients and relatives (Norton and Talerico 2000).

Another reason for being reluctant to break bad news is a fear of causing harm by destroying hope (Glass and Cluxton 2004). This is particularly the case when the bad news relates to life-limiting prognoses and end of life care (Gauthier 2008), and in discussions about long-term conditions and the consequences of illness, such as permanent disability or chronic or difficult-to-manage symptoms (Dewar 2000, Cleary et al 2010). Research into patients’ experiences of receiving bad news reveals that maintaining hope is highly valued and essential to coping (Hagerty et al 2005, Clayton et al 2008). Therefore, it may seem that this reluctance has some foundation.

However, the same research also reveals that providing honest information does not preclude most patients from being able to maintain a sense of hope (Hagerty et al 2005, Clayton et al 2008). On the contrary, evidence suggests that honest information can support patients in their efforts to maintain hope, as it reduces fear of the unknown and enables patients to match their hopes with the reality of their experience (Tuckett 2004).

The way in which hope is perceived and maintained needs to be understood. Campbell et al (2010) explored the requirement to balance realism and hope in discussions about poor

prognosis as follows: ‘When we worry about destroying hope we are generally referring to a very specific hope of getting better or living longer. But hope is a complex, multidimensional and above all flexible construct... One can shift from hoping for a cure... to hoping to go home from the hospital. Such a shift in the things one hopes for requires a reframing of goals to meet the realities at hand... [a reality] that none of us would wish for.’

Campbell et al (2010) recognised that, while the news can drastically alter patients’ perceptions of their present and future, it does not necessarily lead to a loss of hope, as new hopes and goals can be adopted in the light of changing circumstances. Elsewhere in the literature there is evidence of other ways in which patients maintain hope by reframing goals. For example, hopes described by patients with a life-limiting illness have been found to include: Living longer than expected. Good symptom management.

BOX 4 Potential consequences of not disclosing bad, sad or di�cult information

Impact on treatment and decision making Patients receiving burdensome, inappropriate or unnecessary treatment. Reduction in patient satisfaction with treatment outcomes. False optimism and being unable to equate what is happening with the information received. Misunderstanding and confusion over the intention and aim of treatment. Denying patients the opportunity to participate in decision making about their treatments and future plans. Unnecessary anxiety in worrying about the unknown.

Impact on end of life care Depriving the patient and their family and friends of essential time together before the patient’s condition deteriorates. Preventing the discussion of end of life preferences. Denying patients the opportunity to put their affairs in order.

Impact on relationships between the patient and the healthcare team Patients feeling unable to trust and have faith in the healthcare team. Poor communication between patients and the healthcare team, leading to patients and staff members feeling distant from each other. Inability to achieve a shared understanding of the aims and intentions of treatment – compromising informed consent.

Impact on relationships if relatives are informed and the patient is not Patients and relatives feeling isolated and unable to communicate with each other. Unnecessary strain on family relationships. Families carrying the burden of deception.

Impact on the healthcare team Job stress and burnout. Poor job and role satisfaction. Disagreement and fractured relationships if not all staff members agree with the level of information provided.

(Norton and Talerico 2000, Fallowfield and Jenkins 2004, Glass and Cluxton 2004, Tuckett 2004, McSteen and Peden-McAlpine 2006, Vivian 2006, Hancock et al 2007, Campbell et al 2010, Cleary et al 2010, Erichsen et al 2010, Reynolds 2013)

3 Think back to a difficult experience you have encountered when involved in the process of breaking bad news. What factors made it difficult?

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Getting the most out of the time that is left. Living long enough for specific events or in order to achieve certain goals. Mending damaged relationships. Spending special time with family and friends (Hagerty et al 2005, Clayton et al 2008, Warnock and Tod 2014).

Complete time out activity 4

Much of the literature on breaking bad news highlights that the way in which the news is given is fundamental in supporting patients to maintain hope and cope with the news immediately and in the long term (Randall and Wearn 2005, Innes and Payne 2009). Providing information in a way that helps patients assimilate and cope with what they are told requires skill, knowledge and expertise (Fallowfield and Jenkins 2004). Guidelines and good practice advice have been developed to support staff when involved in the process of breaking bad news.

Guidelines and advice for breaking bad newsA significant amount of guidance and advice on breaking bad news can be found in the literature. Some is specific to particular circumstances and patient groups, such as Taylor’s (2007) clear and concise advice for communicating bad news over the telephone and Tuffrey-Wijne’s (2013) model for breaking bad news to people with intellectual disabilities. Examples of open questions and acknowledging statements that can be used throughout discussions are listed in Box 5. However, the majority of the guidance available is generic and focuses on the moment that bad

BOX 5 wOpen questions and acknowledging statements

Examples of open questions Can you tell me what you understood about what the doctor said to you? What are your greatest fears or concerns now? Do you have any questions about what you have been told? Can you tell me what it is that is making you most angry/sad/anxious? Can you tell me more about how you are feeling? Tell me more about what you are thinking? When you think about the future or your illness, what worries you most? Is there any other information that you feel you need at the moment?

Acknowledging statements This must be difficult for you. I realise it is distressing for you to hear this news. I appreciate it is difficult for you to take this in. It seems like this news has stunned you. I imagine this must be a shock for you.

(Taylor 2007, Gauthier 2008, Campbell et al 2010, Shannon et al 2011)

news is given in a pre-planned consultation. All guidelines on breaking bad news are structured differently but most have similar content and themes. Box 6 summarises the guidance and advice found in the literature. Box 5 contains examples of open questions and acknowledging statements that are referred to in Box 6.Complete time out activity 5

One of the primary nursing roles is providing information and support in response to questions asked by patients and relatives about the news they have been given or the implications of their situation. These moments are usually unplanned, unpredictable and can occur at awkward times (Dewar 2000). Therefore, the ability to prepare for a conversation can be compromised if questions and concerns are raised unexpectedly in the middle of a busy shift, clinic or schedule. Warnock et al (2010) asked nurses in inpatient areas to describe the difficulties they had encountered when involved in the process of breaking bad news. Many of the problems described by the participants related to events when it was not possible to achieve a controlled provision of information – for example, not knowing what the patient had already been told by the doctor, unexpected events such as a sudden death or deterioration and providing bad news over the telephone. The authors concluded that guidance focusing on a planned consultation is not always easily applied to the diverse situations faced by nurses when they engage in the process of breaking bad news.

Although the guidance outlined in Box 6 excludes a number of the activities associated with the process of breaking bad news, it is potentially useful for many clinical practice situations. However, additional negotiation and planning may be required in unplanned events. If nurses feel they do not have the knowledge, expertise or time to respond to concerns raised by patients and relatives, it is essential that they acknowledge the importance of the concerns and inform patients and relatives that they plan to address them, albeit not at that moment.

There is clearly a need for further guidance that more closely matches the reality of clinical settings and the range of ways in which sad, bad or difficult news is provided to patients and relatives in complex care environments.

ConclusionTraditionally, breaking bad news has been perceived as the moment when patients and

4 Discuss with a colleague the proposal that patients who have been fully informed about poor prognosis can still maintain hope. Reflect on this in the light of your experiences in practice. 5 Study the guidance

for breaking bad news in Box 6. Are there items that you have not used before? Consider whether they could be beneficial in your own area of clinical practice.

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their relatives are provided with significant information in relation to diagnosis, prognosis and treatment. More recently, this perspective has been widened with the recognition that information which alters people’s perceptions of their present or future can relate to a wide range of topics and

circumstances and involves the participation of the multidisciplinary team. Within this framework, nurses play a diverse range of roles that include providing information and helping patients prepare for, receive, understand and cope with the bad news they have been given.

BOX 6 Guidance and advice for breaking bad news

Preparation Identify who needs to be present – if disclosure is planned the patient should be invited to have a friend or family member present to provide support, hear what is said and be able to share the burden of telling others the news. Find a setting that is private, where interruptions will be minimised; ensure chairs are available so everyone can be seated. Ensure those being given the information know beforehand that they are going to receive significant news by alerting them to the seriousness of what they will be told. Ensure there is time available for explanation, questions and emotional reactions so that the patient does not feel rushed. Familiarise yourself with the relevant information — if you do not have the opportunity to do this because the situation is unplanned then listen, find the information and take it back within an agreed time frame. Think beforehand how you will deliver the news and also the words and phrases that you are comfortable to use (be aware of words and phrases you should avoid and any jargon and euphemisms). Use open questions to find out what the patient knows and is expecting to hear; determine preferences for what and how much the patient wants to know (see Box 5 for examples of open questions). Do not make assumptions about what the patient or relatives know or what they want to know; seek their clarification.

Giving the information Provide the information accurately and clearly, getting a balance between being honest while at the same time being encouraging, supportive and hopeful. Do not use jargon or medical terms without a thorough explanation. If patients do not understand they may feel confused or stupid and reluctant to ask questions. Use words and phrases that have a clear meaning to prevent misunderstanding or multiple interpretations. Do not use euphemisms such as ‘growth’ instead of ‘cancer’, ‘they didn’t make it’ instead of ‘they have died’, and ‘they are better’ when they have improved a little but there is no significant change. Break the information into chunks, giving one piece of information and then moving on once you are sure the recipient has understood. Continually assess preferences for additional information; confirm this with the patient and follow the patient’s lead. Repeat key information; be aware that those receiving the news may not take in further information once the bad news has been given.

Respond to reactions and answer questions Expect an emotional reaction. Allow time and opportunity for expressing emotions — as Gauthier (2008) suggested, ‘listen more and talk less’. Acknowledge the emotions being expressed and name them to give them legitimacy — for example, ‘I can see you are sad/angry/overwhelmed by this news’. Provide frequent opportunities for questions.

Plan the next step Agree a plan about what will happen next so patients and relatives have a sense of control and know what to expect. Offer hope and encouragement about the options that are available. Inform the patient and relatives that you will be available to discuss and listen to concerns in the future (if you will continue to be involved in their care) and/or provide information about support services that are available and the contact details of those involved in the next stage of their care. Provide written information where this is available and appropriate.

Debrief: develop and use support systems Managers should be aware that breaking bad news is time consuming and demanding and can have an impact on workload and the emotional wellbeing of staff. Formal and informal opportunities to reflect and provide support should be made available. Senior staff should take responsibility for ensuring sources of support are developed and used. Individual practitioners should pay attention to looking after themselves and find effective ways of coping with the stressful consequences that can follow involvement in breaking bad news.

(Kaye 1996, Dewar 2000, Norton and Talerico 2000, Baile et al 2001, Buckman 2001, VandeKieft 2001, Fallowfield and Jenkins 2004, Randall and

Wearn 2005, Eggly et al 2006, Taylor 2007, Gauthier 2008, Campbell et al 2010, Shannon et al 2011, Tuffrey-Wijne 2013)

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Being involved in the process of breaking bad news is a complex activity that requires knowledge, expertise and skill. It is important that it is done well, as the consequences for patients and relatives are long-lasting and can influence their experience and satisfaction with treatment as well as relationships with the healthcare team. If done well, the process can also have a beneficial effect on the ability of patients and those close to them to cope with the consequences of the illness.

Guidance that can support those involved in breaking bad news exists, but its tendency to focus on the planned consultation means that there are limitations relating to its usefulness in other contexts and settings in which the information is provided. Nurses’ important contribution to the process of breaking bad news should be recognised and supported by guidance and education to help the development of skills that reflect the role nurses play NSComplete time out activity 6

6 Now that you have completed the article, you might like to write a practice profile. Guidelines to help you are on page 62.

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