Registered Nurses’ Experiences of Breaking Bad News: A Phenomenological Study

Jennifer Tylee RN, BA (Macquarie), MLitt (UNE), PhD (Newcastle)

Steven McKeown RN, DipAppSc (La Trobe), BEd, MEd (La Trobe)

Peter Tylee RN, BA (Deakin), MS(Psych) PhD (California Coast), GradDip InfoTech (InfoSys)Distinction (Charles Sturt), MASCH, MAPS

ABSTRACT

Nurses are frequently involved in situations where patients and their families are experiencing loss and nurses are often involved in giving bad news. Much has been written about the way that bad news is delivered, the skills that are needed and the impact of delivering the news on the recipients of the bad news. There are papers on the deliverer's strategies, their training and support and the 'dos and don'ts' of delivering bad news, but the actual experience of breaking bad news has at best received conjectural attention. It is acknowledged that the deliverer of the news has needs (associated with their feelings and coping) but there has been no exploration of the experience for the deliverer of the news. This project used a phenomenological approach to describe the meaning for nurses of breaking bad news.

A self identified purposeful sample of fifteen nurses working in oncology at the Peter MacCallum Cancer Institute were interviewed about their experiences of breaking bad news. The interviews were tape-recorded and transcriptions of the data analysed using the Colaizzi Method (Colaizzi 1978). The informants reviewed the analysis to ensure its validity.

The research findings suggest that the central feature of informants' experiences in breaking bad news was their relationship with the patient. This relationship facilitates nurses' caring role when breaking bad news. The caring may be at the physical, emotional and soul/spiritual levels. The nurses' and patients' characteristics and the circumstances which surround the situation of breaking  the bad news either hinder or enhance the nurses caring for the patient at a deep personal level. When the circumstances are favourable there is reciprocity in the caring role. When the caring is at a deep ‘soul’ level the nurse also receives ‘care’ and personal rewards. When the circumstances are less favourable the nurses experience a variety of negative and stressful emotions.

INTRODUCTION

It has long being acknowledged that breaking bad news is difficult, stressful and anxiety provoking and that the way the news is broken has an impact on the recipients of the news. It is clear that the training in this difficult area is inadequate and there are many examples in the literature of the ‘don’ts’ associated with delivering bad news. It is also clear that staff need support when they are involved in such stressful situations. The importance then of understanding the meaning of the experience of breaking bad news is clear. However, there is no literature on registered nurses’ experiences of delivering bad news, just the expectation that the deliverer of the news is a 'rational, controlled professional' who is flexible in their delivery pattern and sensitive to the recipients’ needs. This is probably not the reality of the experience for the deliver, but what the experience is actually like is unclear. This project aims to fill the gap by uncovering the registered nurses' experiences of giving bad news.

The lack of literature dealing with nurses' experiences of delivering bad news possibly stems from the general lack of acknowledgement that breaking bad news in a part of nursing. The tradition within nursing and within the health care system culture is that the medical profession delivers the bad news. It has been acknowledged though that it is frequently the nurse who is left to ‘pick up the pieces’ after a patient has been given bad news by the medical profession. At least part of the reason that nurses have not been seen as dealing with bad news is that bad news is often thought of as dealing with death, but bad news does come in various forms. Bad news implies "... drastic changes, either real or potential, in the quality of life or the ending of hope of an improvement again real or imagined for the future" (Nursing Times, Professional Development 1994, p.5). This understanding of the nature of bad news is the definition of the term for the purpose of the project. The range of the 'bad news delivery experiences' involving nurses may include the delivery of the news of death (as is seen in Glasser and Strauss's 1968 study) to more minor situations such as telling patients and their family that the hospital stay needs to be extended.

LITERATURE REVIEW

The fact that nurses are frequently involved in breaking bad news is highlighted in the literature. Many papers deal with the way that news is delivered, in particular the skills needed in delivering bad news (Clark & La Beff 1982, Guttenberg 1983, Thayre 1993, Faulkner, Maguire & Regnard 1994, Nursing Times Professional Development 1994) and the 'how to' and 'how not to' of the delivery situation (Davidhizer & Monhaut 1985, Speck 1991, Parathian & Taylor 1993, Hon 1994). These papers frequently deal with the situation from the recipient's perspective and whether the way the news is delivered will "...facilitate acceptance and understanding while minimising the risk of provoking denial, ambivalence, unrealistic expectations, overwhelming distress or collusion" (Faulkner, et al. 1994, p.144). Clark & LaBeff (1982), Guttenberg (1983), Thayre (1993) and the Nursing Times Professional Development (1994) provide guidelines and skill development for nurses involved in breaking bad news and Faulkner et al. (1994) presents a flow chart of the bad news breaking process. These papers, and in particular the flow chart presented by Faulkner et al. (1994), see bad news breaking as a rational process consisting of a collected set of strategies. The news breaker is not seen as being a part of the process, a part of the experience with a flow of thoughts, feelings and ideas. However the deliverer's involvement in the interaction, that is, their experience also needs to be understood as the deliverer’s experiences directly impact on the way the news is delivered.

While there is literature that explores the recipient’s experiences of bad news the deliverer’s experiences of the process have not been systematically examined. There is some conjecture as to the nature of the deliverer’s experiences and Thayre (1993. p.5) states that there are "personal costs to staff" and the need to confront one's own feelings of sadness and loss. Similarly, the Nursing Times Professional Development Supplement (1994) suggests that nurses worry about the silences that occur and that if they cry they will be seen as unprofessional. The nurses have a sense of "muddling through" (p.5). Further, Parathian and Taylor (1993, p.801) consider that nurses may not feel equipped to give the sympathy and support which patients need. These instances of conjecture indicate the importance that the experiences have for those involved and that it is therefore important to understand this side of the equation in order to fully understand the whole process. Indeed it is possible that improving the understanding of the deliverer’s experiences will enable an improvement of the training, the skill development and the levels of appropriate support available to the deliverer, thus improving an important part of nursing care. It is important that the carer is also cared for so that the stresses that a nurse may experience as a part of their caring for others is acknowledged and that some means for assisting carers are established.

METHODOLOGY

The study was based on the phenomenological approach to research which has as its primary aim describing the "total structure of the lived experience, including the meaning that these experiences have for the individuals who participate in them" (Omery 1982, p. 50). The informant’s perception of their experience is what is investigated and the researchers set aside their own values, views and knowledge about the experience (Streubert and Carpenter 1995).

SUBJECTS

The registered nurses working in a cancer hospital were addressed at ward meetings and invited to participate in the project. Twelve experienced registered nurses who self identified as having broken bad news were interviewed.

DATA COLLECTION AND ANALYSIS

The interviews were conducted by one of the three researchers involved in the project. This occurred at a time and place that was mutually acceptable to both the informant and the researcher. The initial question asked was: "What is it like for you to break bad news?" The only other questions asked were for the purpose of exploration and clarification of points raised by the informants. All interviews were tape recorded and then transcribed. The transcriptions were compared to the tape recordings to ensure accuracy and the transcriptions were then analysed using the Colaizzi Method (Colaizzi, 1978).

The procedural steps in Colaizzi's Method of analysis are as follows:

1. Read the entire informant description to gain a sense of the whole contents.
2. Identify the units in the experience, that is, phrases and sentences that directly pertain to the experience.
3. Identify the meaning of each significant statement.
4. Organise the clusters of themes from the groupings of identified meanings.
5. Compare the theme clusters to the original descriptions to validate the cluster and to examine discrepancies.
6. Develop an unequivocal statement of the essential structure of the experience, that is, the exhaustive description.
7. Have the original informants review the exhaustive description for validation of the original experience.

FINDINGS

What constitutes breaking bad news?

The study was designed to allow the informants to define ‘breaking bad news’ and therefore what constituted bad news. All the informants provided their understanding of bad news. Responses typical of the informants are as follows:

• having radiotherapy treatment cancelled, having chemotherapy treatments come late or not turn up at all, getting results back that are poor or their ‘chemo’ is not going well or they are not responding to treatment;
• your IV’s tissue, you can’t start radiotherapy because the machine is broken down, your results aren’t through, the CT scanner is broken and you can’t get one for another week ... you are going to have to stay here for two more weeks because you have a clot in your leg;
• advising relatives that I feel that their relative in hospital is deteriorating or recommending that the relatives should stay in the hospital overnight;
• when a patient may be eager to go back to their normal home situation and I suggest that may be they are not at that stage at the moment; and
• it might be with the patient's blood count that you (the patient) have to stay in a single room longer or have antibiotics longer...perhaps a death or a worsening of the condition.

It can be seen from these that breaking bad news is a frequent feature of nursing care and involves far more than the common idea of breaking the news that some one had died or is deteriorating, although this may be an aspect of the bad news breaking. The actual telling of the bad news was only one aspect of the breaking bad news process and in many of the interviews it was seen as a part of an ongoing process of communication in the nurse patient relationship. It is the nurse’s experiences of these wide ranging situations that are under study here.

Analysis of the Experiences

A Summary of the findings

Table 1

Theme

Nurse's Caring Role

The nurse's role of caring was seen as an important part of why a nurse may be involved in breaking bad news. The informants considered breaking bad news to be one of the functions of nursing care and as such it was a vehicle for the provision of nursing care. The care could have been at a number of levels including the physical/practical, the emotional and the soul or spiritual level. The informants did not see the process of breaking bad news as ending with telling the news but as a part of the continuation of the totality of nursing care.

Practical/physical caring

All the informants saw the physical practical level as a feature of breaking the bad news, that is, the ‘how to’ of the situation. There was an emphasis on the provision of facts that were honest and being able to provide information that answered all of the patient’s questions. This ‘how to’ also included the following:

• the preparation of the nurses themselves in terms of finding out the facts;
• the preparation of the patient, for example, taking the patient into a quite private area; and
• the aftermath of telling the news with answering questions, being available to talk and the provision of care, such as a cup of tea.

The informants saw a close connection between the physical/practical aspects and the provision of emotional care.

• what you do first is to look at the facts;
• If you are going to say to someone your chemotherapy is not going to be ready you have to be able to say when its going to be ready... if you say the machine is broken they will want to know when it is going to be fixed...you need to know your facts before you go in;
• You take them to a quiet area and say I’m terribly sorry but so and so has died or if it is over the phone that their condition is much worse and I think you should come into the hospital; and
• ...then I do something practical for them like get them a cup of tea.

Emotional Caring

The informants considered emotional caring as being a part of the aftermath of a patient's receipt of bad news, although how the news was delivered was also seen as having an impact on the patient’s emotions. Several of the informants were critical of the way that medical practitioners broke bad news. The patient was just left following delivery of the bad news and there was no real opportunity for the patient’s emotions to be treated. These informants made it a part of their nursing to provide emotional care by going back to the patients after the doctor’s ward rounds had been completed. The nurses then provided an opportunity for the patients to talk and to ask questions and they provided the patient with support and comfort.

• we are very much about caring for people and I will go back and make sure they're ok and that they understood. I will be there for them to help them to cope with the news that they have been given;
• I am there to help them to understand and to support them really after they have been told;
• You go back in and they might be in tears and want to talk about it to someone... you might just be able to comfort them or support them through... sometimes to just get it off their chest or to have a good cry;
• I do it (break bad news) as warmly as I can. I try to show that we are thinking of them and that we care about them; and
• I act as a comforter.

Soul touch caring

Three informants indicated that soul touch caring was a part of their nursing role. Other informants were aware of these aspects but either did not see it as a specific part of nursing or did not consider that they had the skills and understanding necessary to carry out soul caring. These informants did arrange for pastoral care workers to visit patients who had received bad news. The informants who believed that nursing care included caring for the patient’s soul or spiritual aspects considered that this form of caring was embedded in a deep nurse patient relationship. (The nurse patient relationship is examined as a separate theme).

• sometimes you are able to take the breaking the bad news time to care for someone deeply in a soul touching way;
• You can get into a sort of deeper consciousness with the person and you are able to really help them in some way; and
• there are some people who you are able to deeply touch as you care for them after the telling of the news.

Nurse Patient Relationship

The nurse patient relationship was considered by informants to be very important in knowing how to break the bad news and also in knowing how to provide care that the patient needed. It was because the informants knew the patient or had a desire to establish a strong relationship with the patient that determined how informants approached breaking bad news.

Centrality of the relationship

It was the relationship or the desire to establish a relationship with a patient that was a major guide for the informants. The nurse patient relationship formed an important part of the informants nursing care.

• it’s going to depend on the patient and its going to depend on the person telling them;
• it all depends on the relationship with the patient; and
• we are very close to them (the patients) and with their families so it is easier to communicate all sorts of things with them.

Knowledge of the patient

Knowledge of the patient was seen as important in determining how the news would be broken and what sort of after care the patient was going to need.

• you have to know the patient you have to know how they are going to react, whether they are an anxious person, whether they are the sort of person you can use a bit of humour with;
• knowing the patient, how you think they are going to react and having some plan, having some idea what is going to happen down the track...giving them something they can work with; and
• You get the ones that are very anxious and you know they are going to react badly... then its a matter of making sure that their support people are there or having enough time to spend with them after you have given them the news... you have to know that person well enough.

Reciprocity in caring

When the surrounding circumstances, that is, the time available, the patient’s personal aspects and the nurse's personal aspects, and so forth, are favourable then the caring the nurse provides to the patient at the soul touch level is reciprocated by the patient to the nurse. Both the nurse and the patient receive in the process of providing attention to the patient’s deep personal needs. The nurse receives care and rewards in the process of providing care and support.

• I felt really good about the experience ... the personal contact was real and deep... it affected both of us at a deep level;
• It was something I had to do and it turned out to be a nice experience and I have never forgotten that; and
• It might sound strange but I love the fact of being faced with mortality...these patients help my personal life ...it can be very rewarding.

Nurse's personal aspects

These aspects have an impact on how deeply the nurse is able to care for their patients and how at ease they will be with the process of breaking bad news.

The nurse's practice at breaking bad news

The more the nurse has to deal with breaking bad news the more likely it is they will feel at ease in the situation.

• its probably practice when I first came here six years ago I would have probably said that telling bad news was pretty awful and one of the worst things that I had to do but I don’t consider it that any more;
• it is easier once you have become a bit more practiced at it;
• I think one becomes quite skilled at it; and
• with practice I think you tend to become fairly good at it.

Positive and negative emotions

Breaking bad news either contained positive or negative emotions for the informants depending upon the personal aspects of the informant and the circumstances surrounding the breaking bad news situation. The positive emotions were associated with the deep caring and the reciprocity of caring (as covered earlier). Negative emotions were the most frequently mentioned by the informants. These emotions were associated with the lack of preparation the informants felt or their personal inadequacy in dealing with the difficulties of the circumstances or the difficulties with particular patients.

Positive emotions:

• I felt really good about the experience; and
• it was very rewarding.

Negative Emotions:

• it’s always painful and never easy;
• it is an area that I tend to avoid;
• I am uncomfortable;
• I don’t really feel comfortable with bad news and I would rather someone else told them;
• I feel inadequate and as though I don’t have enough information;
• I don’t like to make people feel unhappy it is awful to have to do that;
• I felt helpless and I just had to do it... you just try and cope because it is your role to nurse them...but it gets you down a bit;
• I become sort of tongue tied...and that I have gone home with a burden on my shoulders that day if I have had to perform a task like that...you learn not to take everyone’s individual circumstances to heart; and
• It is sometimes difficult to have all that emotional stuff from not just one person but probably from several different instances on your mind.

Patient’s Personal Aspects

A patient’s personal characteristics affect the way that nurses are able to care for them in general circumstances. The patient’s personal characteristics will also therefore affect the way that nurses are able to care for them when they receive bad news. If the patient is considered difficult or if the family interferes with the nurse establishing an honest and direct relationship with the patient then these factors affect the interactions between the patient and the nurse when the patient receives bad news.

Expectations and Perceptions

• it depends on the patient's perceptions of what bad news is;
• a lot has to do with what they (the patients) think the news means for them and what is going to happen for them; and
• are they expecting to go home or to be ok with the treatment... then you have to come in and possibly have to say that this isn’t going to happen.

Cultural and Family Factors

• families say don’t tell them they have cancer… and then all the people are totally pretending...you're playing games, you're not honest...you can’t establish a proper relationship...its very hard on the nursing staff;
• there are patients that we don’t tell everything to because of cultural or family relationships ...you have to consider that... if the patient is angry they can turn you (the nursing staff) off going near them; and
• some patients put on a brave face, well you just carry on the best you can and try to help them.

Surrounding Circumstances

The circumstances surrounding breaking bad news were seen by the informants as being those areas that, though not directly related to breaking bad news, did effect the situation and therefore the outcome of the nursing care that was delivered. Some of the circumstances included the medical and nursing roles that were a part of the social and cultural expectations of the ward. Another important circumstance was the amount of time that nurses had available for delivering patient care. The physical aspects of the patient’s nursing needs were catered to first and only if there was sufficient time available was attention given to the patient’s emotional needs. Another important circumstance was the ability to work as a part of a team. The team meant that there were others available who could assist in caring for the ‘whole’ patient including their soul/spiritual aspects.

Nurses’ and Doctors’ Roles

• some of the news we don’t have to tell patients very often because the medical staff do it but you often have to reinforce that because they haven’t heard it the first time round;
• they (the patients) will ask you the same questions so its like telling them the first time; and
• a patient asked me had their cancer spread ... now it really wasn’t up to me to say yes or no, but this patient had been in for investigations to see if his cancer had spread and yes it had...so what to do...in that situation I was trying to establish rapport with the patient and at the same time you know the doctor hadn’t been around to say its spread at this stage...I took the bull by the horns. I knew the patient, I’d known him for a long time and I said I think it has, I think it is in your liver but you will need to confirm that with the doctor...I mean I knew damn well, I had read the reports ...I guess I shouldn’t have said but it certainly helped my rapport with the patient and the patient really appreciated my saying it.

Time Pressures

• sometimes it is impossible to spend the time with the patient when they really need to talk or to find things out... you just have to do the best that you can in the circumstances;
• time often interferes with what you want to do; and
• Sometimes the patient doesn’t get the attention they need because we are so busy there just isn’t the time to see to them properly.

Team work

• the pastoral workers are really good at helping the patients when they are having a bad time;
• We try to work together with the rest of the team so that the patient gets what they need; and
• we work well with the support team and there are often times when the pastoral care worker is called in to talk to a patients after they have received bad news.

Structural Definition

The central feature in the nurse’s experience in breaking bad news is the nurse’s relationship with the patient. This relationship facilitates nursing's caring role when breaking bad news. The caring may be at the physical, emotional and soul/spiritual levels. The nurse’s and patient’s characteristics and the circumstances which surround the breaking bad news situation either hinder or enhance the nurse's caring for the patient at a deep personal level. When the circumstances are favourable there was reciprocity in the caring role. When the caring is at a deep ‘soul’ level the nurse also receives ‘care’ and personal rewards. When the circumstances are less favourable the nurses experience a variety of negative emotions.

DISCUSSION

It is generally considered that nurses are responsible for caring for patients after medical staff have broken bad news and that the nurses are not generally involved in delivering the news. As can be seen from the study nurses do break bad news to patient and their relatives and at times this can be considered entry into the medical practitioners’ realm. This is seen in the situations where a nurse informs relatives that a patient has died or a patient is informed about their pathology results. The nurses in the study were willing to break the bounds of traditional nursing expectations because of the value that they placed on the nurse patient relationship. This meant that they were willing to tell patients their pathology report results rather than making the patients wait until the doctor was available to tell the patients. This was especially the case if the doctor was likely to be some time before being able to talk to the patients. The closeness of the relationship that was developed with patients meant also that the nurses were willing to care for the whole patient.

The exploration of nurses’ experiences in breaking bad news has highlighted the importance that nurses place on the nurse patient relationship and their role as carers. The informants considered that the ideal circumstance for delivering bad news was when there was a strong relationship established with the patient. If the nurse knew the patient well, was informed with the facts surrounding the news and had the time to plan the interaction and provide the needed care, then the experience was likely to be positive. When the ideal was possible the nurse, as well as caring for the patient, also received care from the patient. However the circumstances for breaking bad news are not always ideal. There are factors that inhibit the nurse patient relationships from developing and therefore also the depth of the caring that the nurse is able to deliver to an individual patient. When the circumstance that surrounded delivering bad news was unfavourable then the emotions that the nurses experienced were negative and stressful. The informants considered that the number of negative situations greatly outnumbered the positive situations.

All the informants acknowledged the soul/spiritual aspects of the patients. This aspect of caring has traditionally been a part of nursing. However with rise of biomedical science the more wholistic aspects appeared to have diminished. Caring for the spirit or the soul is not usually a part of nursing education courses (Tylee 1992). Indeed some of the informants did not consider that they had the skills and the knowledge to assist at the soul/spiritual levels and handed that aspect of the patient over to others. However, for others the relationship with the patient enabled then to give caring at that level. These informants, at the time of giving the care, did not consider their skills or knowledge or that they were caring at the soul/spiritual level. At the time of the caring they were ‘simply’ caring for someone with whom they had established a deep nurse patient relationship. The relationship then facilitated a transcendence of skill, knowledge and roles.

CONCLUSIONS

Nursing deals with situations that are associated with loss and therefore breaking bad news is a part of nursing. When the circumstances surrounding the news breaking situations are favourable the experience for the nurse can be positive. However the circumstances are only occasionally favourable and when they are unfavourable the nurse is likely to experience negative emotions. Further research to examine more fully the variables involved in breaking bad news and in particular the place of the nurse patient relationship in facilitating a positive experience for both the patient and the nurse is warranted.

REFERENCES

Clark, R.E. & La Beft, E.E. (1982). Death telling: Managing the delivery of bad news. Journal of Health and Social Behaviour, 123, pp. 366-380.

Colaizzi, P.F. (1978). Psychological research as the phenomenologist views it. In Vails, R.,& King, M. (Ed). Existential phenomenological alternative for psychology. Oxford University Press: New York.

Davidhizar, R.M. & Monhaut, M. (1985). Guidelines for giving bad news by phone. Nursing 85 (April), p. 58-59.

Faulkner, A., Maguire, P. & Regnard, C. (1994). Breaking bad news: A flow diagram. Palliative Medicine 8, p. 145-151.

Glasser, B.G. &. Strauss, A.L. (1968). Time for Dying. Aldine: Chicago.

Guttenberg, R. (1983). Softening the blow: How to break bad news to a patient's family. Nursing Life, July – August, pp. 17-21.

Hon, J. (1994). Bad news, I'm afraid. Nursing Standard, 8 (32), pp.52-53.

Nursing Times Professional Development. (1994). Breaking bad news: Knowledge for practice. Nursing Times, 90 (10), pp. 1-8.

Omery, A. (1983). Phenomenology: A method for nursing research. Advances in Nursing Science, No.5, pp.49-63.

Parathian, A.R., & Taylor, F. (1993). Can we insulate trainee nurses from exposure to bad practice? A study of role play in communicating bad news to patients. Journal of Advanced Nursing, No.18, pp.801-807.

Spiezelberg, H.(1976).The phenomenological movement. Nijhoff: The Hague.

Streubert, W.J., & Carpenter, D.R. (1995). Qualitative research in nursing: Advancing the humanistic imperative. Lippincott: Philadelphia.

Thayre, K. (1993). Never going to be easy: Giving bad News. RCN UPDATE. Nursing Standard, 8 (12), pp.3-13.

Tylee, J. (1992). Nursing education in the tertiary sector in New South Wales, 1986-1989: An analysis of ideological orientations of curriculum, with particular reference to one institution. Unpublished Doctoral Thesis, The University of Newcastle.

 Publications | Search | Contact