It is a fairly common occurrence for nurses to find themselves in the position of having to impart information to patients, families, or friends that is difficult to take on board. In situations where the information relates to a potentially life-changing or life-limiting diagnosis, this is often referred to as ‘breaking bad news’.
It is important to remember though that what constitutes bad news will be shaped by the social context and the individuals concerned. The most obvious of these are circumstances of death or dying, including progression of terminal illness or suicide, but can also include moments of diagnosis or coming to terms with disability or loss of function. Dealing with parents of sick children can be particularly emotion-laden work.
In everyday nursing practice, what constitutes bad news is also shaped by context and circumstance. For example, where an inpatient is expecting to be discharged home and has to be told they are unable to because some blood results have not been returned from the clinical laboratory, or where a person has been prepared for surgery which is then cancelled at short notice.
The terminology of breaking bad news is itself quite loaded, and not ideal, but it is the language used in most formal guidance.
• The extent to which news is ‘bad’ will ultimately be in the impact for the recipient of the news, so nurses need to be vigilant at all times when information exchange deals with significant matters likely to cause upset.
• It is equally important that nurses deal with patients and families with equanimity and humanity, communicate honestly and compassionately, attend empathically to their concerns and needs for further information or elaboration, and respect the fact that people will respond differently.
• It will not always be absolutely clear that people are ready, or even wish, to hear bad news, so nurses need to ascertain their preparedness to receive difficult information before beginning the process.
Models for breaking bad news do exist, expressed as sequential stages, for example the SPIKES strategy based on the work of Robert Buckman: Setting up the interview; assessing the patient’s Perspective; obtaining the patient’s Invitation; giving the patient Knowledge and information; managing the patient’s Emotions with empathic responses; and strategy and Summary.
Originally, interventions like this were developed for physicians where the nursing role was to bear witness and offer support to the patient. Latterly, with the development of specialized roles, particularly in the community, nurses play a much more significant part in the process of delivering bad news. This has been explored and developed in the context of nursing practice under the following headings.
This is about setting the scene in environmental and emotional terms. For example:
• Making sure there is a ‘safe’ space to guarantee privacy and minimal interruption.
• Deciding who needs to be present.
• Making sure individuals involved understand the interaction is about a specific issue, rather than a routine meeting (sometimes referred to as ‘firing a warning shot’).
• Being well informed and taking time to consider how the encounter will be organized.
This is about ensuring the message is delivered with clarity, in a way that can be understood.
• Ambiguous language and euphemisms, which can be interpreted in different ways, should be avoided, for example using the word ‘cancer’ rather than ‘growth’, or ‘died’ rather than ‘no longer with us’.
• Give the information in manageable ‘chunks’, allowing time for the person to think about what has been said and to ask questions.
• Constantly check for understanding and reassure those involved that you or a colleague will be available, should further concerns arise.
Responding to reactions
This is about anticipating some type of emotive response from the person receiving the news. If this happens:
• Allow the person to ventilate their feelings.
• Validate the response by acknowledging their distress or anger.
• Do not close down the interaction, and allow for questioning and further discussion.
Planning the next step
Breaking bad news is normally a process, rather than a single event. As part of the healthcare team, nurses will need to develop a plan for future working together and ideally, the patient, relatives, and carers should be involved in this. If appropriate, written information should be provided.
This stage is focused on the emotional labour of breaking bad news and the effect it has on nursing staff. Within nursing or healthcare teams, there are often mechanisms in place to address the impact of stressful experiences.
It is a responsibility of senior managers to provide both time and opportunity for reflection and professional guidance—particularly for students or more junior members of staff.
In everyday nursing practice, it may not always be necessary for nurses to debrief after breaking bad news.
Bad news in everyday healthcare situations is not necessarily going to be of the magnitude of life-changing information, but nonetheless it is important that nurses address this in a sensitive and compassionate manner.
Whilst the SPIKE framework is useful for structuring a ‘bad news’ interaction, from a person-centred approach, it needs to be acknowledged that the terminology is clumsy and limiting.
An empathic understanding of the potential impact particular information may have on a person is important, particularly in relation to issues that may seem of little consequence to nurses or the healthcare organization. Nurses should never assume, or predict, the emotional impact of a piece of news without talking to those who are personally involved.
For example, a single old person who has come into hospital for minor elective surgery may have spent a great deal of time organizing security for their home, care of their pet, transport to and from the hospital, and support once they return home. So the cancellation of surgery at short notice could be devastating to them.
The principles of preparation, giving information, responding to reactions, and planning the next step are all important in breaking bad news in everyday situations, and in some situations debriefing may also be useful.
In everyday ‘bad news’ situations, the way nurses give information, respond to emotional reactions, and plan the next steps will be central to maintaining a dignified and respectful interaction.
Useful sources of further information
• Buckman R (2005). Breaking bad news: the S-P-I-K-E-S strategy. Community Oncology, 2(2), 138–42Find this resource:
• National Institute for Health and Care Excellence. www.nice.org.uk
• Warnock C (2014). Breaking bad news: issues relating to nursing practice. Nurs Stand, 28(45), 51–8Find this resource: