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ORIGINAL RESEARCH
Breaking bad news in inpatient clinical settings: role of the nurse
Clare Warnock, Angela Tod, Julie Foster & Cathy Soreny
Accepted for publication 5 March 2010
Correspondence to C. Warnock:
e-mail: clare.warnock@sth.nhs.uk
Clare Warnock BSc MSc RN
Practice Development Sister
Weston Park Hospital, Sheffield Teaching
Hospitals NHS Foundation Trust,
Sheffield, UK
Angela Tod MMedSci PhD RN
Principal Research Fellow
Centre for Health and Social Care Research,
Sheffield Hallam University, Sheffield, UK
Julie Foster BMedSci RN
Governance Coordinator
Gynaecology and Urology, Sheffield Teaching
Hospitals NHS Foundation Trust, Royal
Hallamshire Hospital, Sheffield, UK
Cathy Soreny BA RN
Opthalmic Assessment Nurse
Sheffield Teaching Hospitals NHS
Foundation Trust, Royal Hallamshire
Hospital, Sheffield, UK
WARNOCK C., TOD A., FOSTER J. & SORENY C. (2010)WARNOCK C., TOD A., FOSTER J. & SORENY C. (2010)
Breaking bad news in
inpatient clinical settings: role of the nurse. Journal of Advanced Nursing
doi: 10.1111/j.1365-2648.2010.05325.x
Abstract
Title. Breaking bad news in inpatient clinical settings: role of the nurse.
Aim. This paper is a report of an exploration of the role of the nurse in the process
of breaking bad news in the inpatient clinical setting and the provision of education
and support for nurses carrying out this role.
Background. The term ‘breaking bad news’ is mostly associated with the moment
when negative medical information is shared with a patient or relative. However, it
can also be seen as a process of interactions that take place before, during and after
bad news is broken. Little research has been conducted exploring the role of the
nurse in the process of breaking bad news in the inpatient clinical setting.
Methods. A questionnaire was developed using Likert scales and open text ques-
tions. Data collection took place in 2007. Fifty-nine inpatient areas took part in the
study; 335 questionnaires were distributed in total and 236 were completed
(response rate 70%).
Results. Nurses engaged in diverse breaking bad news activities at many points
in care pathways. Relationships with patients and relatives and uncontrolled and
unplanned events shaped the context in which they provided this care. Little formal
education or support for this work had been received.
Conclusion. Guidance for breaking bad news should encompass the whole process
of doing this and acknowledge the challenges nurses face in the inpatient clinical
area. Developments in education and support are required that reflect the challenges
that nurses encounter in the inpatient care setting.
Keywords: breaking bad news, clinical settings, inpatients, nurse
Introduction
In this paper we present the findings of a study exploring
the role of the nurse in the process of breaking bad news in
the inpatient clinical setting. In a healthcare context,
breaking bad news involves giving health-related informa-
tion that negatively alters an individual’s perception or
expectations of their present and/or future (Baile et al. 2000,
Randall & Wearn 2005). Much of the literature surround-
ing breaking bad news has focused on the moment when
bad news is broken by a doctor. Less attention had been
given to exploring breaking bad news as a process or to the
role of the nurse in breaking bad news in the inpatient
setting (Dewar 2000).
2010 The Authors. Journal compilation 2010 Blackwell Publishing Ltd 1
JAN JOURNAL OF ADVANCED NURSING
Background
Breaking bad news
A growing body of evidence has demonstrated that most
patients want to be informed about their illness, treatment
and prognosis, whether this information is good or bad
(Glass 2004, Hagerty et al. 2005, Cox et al. 2006). Giving
patients accurate information about their health can help
them make informed decisions about their treatment and take
responsibility for their care (Tuckett 2004), increase their
understanding of their situation and help them to make
appropriate plans for their future (Fallowfield & Jenkins
2004, Vivian 2006), prevent them from undertaking burden-
some treatment and facilitate end-of-life care planning
(Norton & Telerico 2000).
The term ‘breaking bad news’ is often used to describe the
moment when a patient and/or relative is given negative
medical information about diagnosis, treatment or prognosis
(Ptacek et al. 2001, Vandekieft 2001). In this framework, the
consultation itself is the focus of attention. The giver of bad
news is usually the doctor, the gatekeeper of information,
who takes on this role because they have responsibility for
medical treatment decisions (Morrissey 1997, Verhaeghe
et al. 2005).
However, breaking bad news can also be perceived as a
process, one that includes the interactions that take place
before, during and after the moment that bad news is broken
(Tobin & Begley 2008). Within this framework, preparing
patients or relatives for bad news, clarifying and explaining
the information they have been given and helping them as
they come to terms with the implications of their situation
become part of the process (Dewar 2000, Rossin et al. 2006).
The communication of bad news can also be seen as a multi-
disciplinary activity which requires the active involvement of
a wide range of healthcare professionals working as a team
(Fallowfield & Jenkins 2004, McSteen & Peden-McAlpine
2006).
Breaking bad news is a complex and highly skilled activity
that needs to be done well to prevent detrimental effects to a
patient, their family and their future relationships with
healthcare professionals (Baile et al. 2000, Rossin et al.
2006). If bad news is communicated badly ‘it can cause long
lasting distress, confusion and resentment’ (Fallowfield &
Jenkins 2004, p 317). The literature suggests that there are
differences across societies and cultures in relation to
disclosing bad news to patients. In western cultures there is
a predominant belief that patients should have full disclosure
of bad news if this is their wish, while this is not always the
case in other societies (Tuckett 2004, Hancock et al. 2007).
Cultural preferences and beliefs around who is told and the
information that should be given shape the context of
breaking bad news.
Nurse and doctor involvement in breaking bad news
Previous research in this area has focused on the role and
experiences of doctors at the moment of delivering bad news.
This reflects their central role as providers of information
about prognosis, diagnosis and treatment. Barriers encoun-
tered by doctors when breaking bad news include concerns
about not upsetting the patient, fears of not being able to
cope with their own or the patient’s emotional responses,
lack of privacy, time and/or information, poor training,
language and cultural barriers and discrepancies between
relatives’ and patients’ wishes as to whether information is
withheld or shared (Fallowfield & Jenkins 2004, Schildmann
et al. 2005, Hancock et al. 2007).
In addition, a number of guidelines for best practice
have been developed (see for example, Baile et al. 2000,
Vandekieft 2001). Many of these offer step-by-step guidance
for each stage of the process of breaking bad news. These
guidelines tend to be based on an interaction where there is
an opportunity to prepare for the consultation and give
information in a relatively ordered manner in a controlled
environment.
Some suggest that the focus on the moment of breaking
bad news by the doctor may be too narrow, both in terms of
understanding the patient’s experience of receiving this news
(Randall & Wearn 2005, Tobin & Begley 2008) and the
involvement of a wider range of healthcare professionals
(Dewar 2000). The supportive activities that nurses have
been found to engage in around bad news include assessing
needs for information, identifying and clarifying misunder-
standings, initiating discussion, obtaining and explaining
complex medical information and helping patients and
relatives cope with their emotional reactions (Morrissey
1997, Norton & Telerico 2000, McSteen & Peden-McAlpine
2006, Stayt 2007). The activities described in these studies
suggest that patients’ needs for information and support go
beyond the moment of breaking bad news, and nurses are
involved in delivering this care.
In a study exploring the nurse’s role in breaking bad news
in a spinal injuries unit, Dewar (2000) revealed that patients
often relied on the nurse to clarify and explain the informa-
tion they had been given by the doctor. This could be because
the patient had not understood the terminology used or the
implications of the information they had been given, or
because they did not want to ask questions until they felt
ready to do so. In explaining this information, nurses became
C. Warnock et al.
22010 The Authors. Journal compilation 2010 Blackwell Publishing Ltd
actively involved in the process of breaking bad news. They
were also involved in the bad news process as they helped
patients understand the implications of their illnesses. For
example, helping a patient transfer into a wheelchair could
prompt the patient to ask the nurse if they were going to be
able to walk again. In responding to the patient’s question,
the nurse engaged in breaking bad news (Dewar 2000).
Dewar (2000) identified particular challenges associated
with the way in which nurses were involved in the bad news
process. These included being presented with unexpected
questions, not having time to prepare, having to continue to
work in close contact with the patient with no time to debrief
or retreat, and time constraints due to competing workload
demands within the nursing shift. An overarching challenge
was that their involvement in breaking bad news tended to
occur ad hoc and at opportunistic moments.
Nurses may play a particular role in relation to breaking
bad news in the inpatient clinical setting. They are often close
at hand when the reality of a situation becomes apparent, and
the patient and relatives feel the need to ask questions
(Norton & Telerico 2000). They may have a personal
understanding of the patient and their family which has been
built up over time. As a consequence, they may be able to
identify when there is a need to initiate discussions with
patients and relatives about current or future care, and when
interventions to give information and support might be
needed (Morrissey 1997, Norton & Telerico 2000, Georges
& Grypdonck 2002). The role of the nurse in the process of
breaking bad news has not been fully acknowledged or
researched. As a consequence, little is known about the
support, education and training required by nurses to carry
out this activity.
The study
Aim
The aim of the study was to explore the role of the nurse in
the process of breaking bad news in the inpatient clinical
setting and the provision of education and support for nurses
carrying out this role.
Design
A descriptive survey design was adopted using a question-
naire to generate quantitative and qualitative data to explore
three topics: (1) the role of the nurse in relation to breaking
bad news, (2) nurses’ experiences of being involved in the bad
news process and (3) the type and range of education received
by nurses in breaking bad news.
Participants
Fifty-nine inpatient areas took part in the study; 335
questionnaires were distributed in total, 236 were returned
completed (response rate of 70%). These included 212 out of
295 questionnaires from the wards, 14 out of 30 from
Evidence-based Council (EBC) members and 10 from the
pilot study. The speciality areas of participants are detailed in
Table 1.
Of the participants, 142 (60%) were staff nurses, 64 (27%)
were ward sisters/charge nurses and 10 (4%) were nurse
specialists. The others were four clinical educators, three
midwives and one matron.
Table 1 Number of questionnaires sent to and received from each specialty
Medical wards
Number
sent
Number
returned Surgical wards
Number
sent
Number
returned
Acute medicine 80 48 General surgery 20 17
Oncology 25 22 Cardiothoracic 10 9
Haematology 10 4 Orthopaedics 10 7
Neuromedicine 5 3 Vascular surgery 10 7
Burns unit 5 4 Gynaecology 15 12
Stroke rehabilitation 5 3 Urology 10 8
Palliative care 5 5 Other
Spinal injuries 15 10 Intensive/high dependency care 20 15
Cardiology 15 13 Obstetrics 5 4
Coronary care 10 10 Neonatology 10 6
Emergency admissions 5 1 Location not recorded – 5
Renal 10 7 Evidence-based Council 30 14
Genitourinary medicine 5 2
Total 195 132 Total 140 104
JAN: ORIGINAL RESEARCH Breaking bad news in inpatient clinical settings
2010 The Authors. Journal compilation 2010 Blackwell Publishing Ltd 3
A total of 226 participants responded to the question
asking how many years they had been qualified as a nurse.
Their responses were as follows: 3 (1%) had been qualified
less than 1 year, 22 (10%) 1–2 years, 30 (13%) 3–5 years, 32
(14%) 6–9 years, 60 (27%) 10–19 years, 59 (26%) 20–
29 years and 20 (9%) over 30 years.
Questionnaire
The content of the questionnaire was based on items
identified following a systematic literature review and
consultation with nurse specialists in palliative care and the
study hospitals’ EBC. The EBC is a group of nurses and
allied health professionals who collaborate to develop and
implement evidence-based practice within the hospitals
where the study took place (Palfreyman et al. 2003, Tod
et al. 2007).
A two-stage pilot was carried out to determine ease of
completion, wording of questions and relevance to clinical
practice. The initial stage of the pilot involved distribution of
the questionnaire to members of the EBC. Their comments
led to changes to the structure and content of the question-
naire.
The revised questionnaire was piloted again among nursing
staff in two wards – oncology and gynaecology. Five nurses in
each ward completed the questionnaire and made comments.
Minor amendments were suggested and implemented. These
ten questionnaires were included in the final sample as only
minimal changes were made to the questionnaire at this
point.
The questionnaire comprised five sections. Each section
had Likert scales and, where explanation or detail was
required, open-ended questions asked for descriptions of
participants’ experiences. The sections were:
•The role of the nurse in breaking bad news. Participants
were asked to report how often they carried out seven
breaking bad news activities. An open ended question
asked them to list the types of bad news they were involved
in breaking as part of their work.
•Barriers to breaking bad news experienced by nurses.
Participants were asked to indicate how often they
encountered nine barriers. A free text question asked them
to describe one example of a difficult experience when they
had been involved in breaking bad news.
•Nurses’ experiences of being involved in the process of
breaking bad news. These statements explored confidence
in their own skills, systems of support available and pos-
sible consequences for themselves and their relationships
with patients. Participants were asked to rate the degree to
which they agreed with each statement.
•Previous training received in relation to breaking bad news
and preferred approaches to education.
•Information about their role and the length of time they
had been qualified as a nurse.
Data collection
Data collection was carried out over a 3-month period during
2007 in the inpatient clinical areas within a large NHS
Teaching Hospitals Trust in the North of England. Five
questionnaires were sent to the ward managers in 59
inpatient areas. They were asked to distribute them to nurses
within their ward from a range of grades and experience.
Thirty questionnaires were also sent to members of the EBC.
Participants were asked to return their completed anony-
mized questionnaires in sealed envelopes directly to the
clinical effectiveness department.
Ethical considerations
The study was reviewed by the clinical effectiveness unit of
the hospitals where the study was carried out and was
categorized as service evaluation. Full ethics committee
approval was therefore deemed not necessary and the study
was conducted in line with the organization’s ethical proce-
dures (Mawson et al. 2007).
Data analysis
Data from the structured questionnaires were analysed
using descriptive statistics. Statements that asked partici-
pants to identify how often they were involved in or
experienced a particular questionnaire item were given a
frequency rating by combining the responses rated as ‘all
the time’, ‘often’ or ‘sometimes’. Questions about level
of agreement with a statement were given a frequency
rating by combining responses rated as ‘strongly agree’ or
‘agree’.
Responses to the open-ended questions were coded accord-
ing to their content, and then those with similar coding were
grouped to form themes. Relationships between the themes
were explored to develop categories that described the data.
The number of responses relating to each theme and category
was identified.
Data analysis of the open-ended questions was carried out
independently by the project lead (CW) and an academic
partner (AT). Codes, themes and categories were compared.
Analysis and interpretation of the responses was discussed by
both researchers and the final categories were refined and
agreed.
C. Warnock et al.
42010 The Authors. Journal compilation 2010 Blackwell Publishing Ltd
Results
Role of the nurse in breaking bad news
Table 2 shows the frequency of breaking bad news activities
in which participants had been involved during the previous
3 months. The most frequent were giving patients and
relatives support and opportunities to talk after they had
received bad news. The least frequent activity was actually
breaking bad news to a patient/relative.
Barriers to breaking bad news experienced by nurses
The most frequently reported barriers were not having the
time to break bad news, the patient not wanting to know, and
the nurse not feeling prepared as the issue was raised
unexpectedly (Table 3). Seventy-three (30Æ9%) had experi-
enced verbal or physical abuse from a patient/relative. Only
18 participants (7Æ9%) reported that they were not encour-
aged to be involved in breaking bad news in their clinical
area.
A total of 129 participants described examples of difficult
experiences they had encountered when being involved in the
bad news process (Table 4). Five categories of difficult
experience were identified:
•How the bad news was broken
•Information held by patients and relatives
•Unexpected death
•Reactions to bad news
•Significant events
The number of times each category was present in a
description is identified in Table 4. These numbers are greater
than 129 as some participants’ descriptions contained com-
ponents related to more than one category.
How the bad news was broken
Forty-five responses related to the ‘How the bad news was
broken’ category, and two main themes were identified:
Table 2 Frequency of involvement in each breaking bad news activity in the past 3 months
Aspect of breaking bad news
All of the
time/often,
n(%)
Sometimes,
n(%)
Rarely/never,
n(%)
Number of
responses
Providing support to a patient/relative
following the breaking of bad news
131 (55Æ5) 85 (36) 20 (8Æ5) 236
Providing the patient/relative with opportunities
to talk about the bad news given to them
132 (55Æ9) 77 (32Æ6) 27 (11Æ5) 236
Helping patients/relatives come to terms
with the implications of bad news over time
112 (47Æ7) 89 (37Æ9) 34 (14Æ4) 235
Being present when a doctor informs the
patient/relative of bad news
92 (39Æ1) 102 (43Æ4) 41 (17Æ5) 235
Discussing bad news when the patient/relative
asks questions on an ad hoc basis
85 (36Æ5) 102 (43Æ8) 46 (19Æ7) 233
Preparing patients/relatives for bad news 84 (35Æ5) 96 (40Æ7) 56 (23Æ8) 236
Actually breaking bad news to a patient/relative 53 (22Æ5) 88 (37Æ3) 95 (40Æ2) 236
Table 3 Frequency of encountering specific barriers to breaking bad news
Barriers to breaking bad news
All of the
time/often,
n(%)
Sometimes,
n(%)
Rarely/never,
n(%)
Number of
responses
Not having time to do it properly 43 (18Æ2) 105 (44Æ5) 88 (37Æ3) 236
The patient not wanting to know 12 (5Æ1) 130 (55Æ5) 92 (39Æ4) 234
Not feeling prepared as the issue was raised unexpectedly 19 (8) 124 (52Æ8) 92 (39Æ2) 235
Barriers to communication (e.g. language, dysphasia) 18 (7Æ7) 115 (49Æ1) 101 (43Æ2) 234
Not having enough information 25 (10Æ6) 108 (45Æ8) 103 (43Æ6) 236
Relatives requesting that a patient is not told bad news 23 (9Æ8) 106 (45Æ3) 105 (44Æ9) 234
Lack of privacy 51 (21Æ6) 70 (29Æ7) 115 (48Æ7) 236
Verbal or physical abuse from the patient/relative 15 (6Æ4) 57 (24Æ5) 161 (69Æ1) 233
Nurses are not encouraged to be involved in breaking
bad news in my area
4(1Æ8) 14 (6Æ1) 210 (92Æ1) 228
JAN: ORIGINAL RESEARCH Breaking bad news in inpatient clinical settings
2010 The Authors. Journal compilation 2010 Blackwell Publishing Ltd 5
Table 4 Categories of difficult breaking bad news experiences
Categories and themes (number of times
each item was present in descriptions) Examples
How the bad news is broken (45)
Barriers to communication
1) Practical barriers (19)
Lack of privacy
Over the phone
Unable to contact family
Lack of time to explain
Cognitive impairment
Another patient walked into the room while I was breaking bad news
A patients lack of insight and denial of changed abilities meant she could not understand the
reasons why she could no longer drive
Sometimes a baby’s condition deteriorates quickly and there is not enough time to explain
things in privacy
Trying to give information over the phone of a patient who had died when the relatives did
not seem to understand the seriousness of the situation
2) Language/cultural barriers (8)
Interpreter required
Cultural differences
No English spoken by relatives, interpreter present but very difficult to explain the medical
complications that had occurred. The family found the experience very stressful
3) Nursing knowledge deficit (8)
Lack of knowledge about the patient/family
Lack of knowledge of events
Concerns about own clinical knowledge
I had to talk to the relatives of a young man who had been on dialysis and had died earlier
that day. I was on a late shift and this had occurred during the morning. I was not present at
the time of death. I found it difficult to answer the family’s questions. It was distressing for
all concerned
A patient arrived onto the ward and died within 15 minutes. I did not know any of the
patent’s relatives and I had to break the bad news to them on their arrival
The decision to take a very ill patient off a ventilator: I found this difficult and hard to
support the family as I had limited knowledge in this area
Who is present (10)
Family not present
The nurse is not present
Own doctor not present
A lady was told she was unable to have a coronary artery bypass graft due to poor health. She
was advised to have a relative present but insisted to be told before the relatives arrived. The
relatives were annoyed and abusive to staff that she was told without their presence
A patient was told bad news by the doctor with no nurse present. I eventually found the
patient crying. I wasn’t very helpful as I did not have enough information to help
It was difficult caring for a dying patient from a different specialty. Relatives needed
information from medical staff who were busy elsewhere
Unexpected death (26)
Dying without relatives present
Providing information in difficult circumstances
Family unprepared
A patient had died just as the relatives arrived on the ward. I tried to take them to the quiet
room but they insisted on asking about their loved one on the corridor
Telling a relative their mother had died unexpectedly. Relatives had telephoned earlier and
been told their mum’s condition was stable and she was felling better. Consequently the
relative was totally unprepared and shocked when she arrived and had to be told her mum
had died
A young patient was brought into hospital and suddenly deteriorated. I had to inform the
relatives to come quickly and within a couple of hours the patient died unexpectedly. The
relatives were not expecting their loved one to die
Information held by patients and relatives (28)
1) Issues around disclosure (21)
Patient not told at relatives request
Patient told despite family request
Patient doesn’t want to know
Relatives not being honest
We had a young girl whose treatment had stopped working and she was commenced on a
palliative care regime. However, her parents wanted her to continue to think she was going
to be cured. It was difficult to explain anything as you always had to watch everything you
said to her
The two daughters and their children were told by the consultant that their father only had a
short time to live. The family did not want the father to know. Staff found this situation
stressful
When a patients wife did not want him to know about his poor prognosis. The doctors went
and told him without the wife or a nurse present. This had a huge impact on the family, they
were distraught and it took a lot of time to win their confidence back
A woman not wanting to hear that a mass in her abdomen could be malignant
A relative asked how long the patient had left. The doctor tactfully replied less than a year.
The patient was furious as he did not want to know. When the relatives left the patient
blamed the staff for ruining what was left of their life by telling them how long they had to
live.
A female patient was keen to go home she was aware she was dying. Her partner was
agreeing with her while in the room but as soon as he was away from her he was expressing
concerns that he wouldn’t be able to manage and didn’t want the responsibility of looking
after her
C. Warnock et al.
62010 The Authors. Journal compilation 2010 Blackwell Publishing Ltd
Table 4 (Continued)
Categories and themes (number of times
each item was present in descriptions) Examples
2) Patient/relatives’ understanding of the situation (7)
Poorly informed
Not understanding the implications of the information
I was asked to see a patient to give them pre-dialysis information. When I
saw them they had no idea that there was anything wrong with their
kidneys. The doctor had neglected to tell them
A young man diagnosed with a malignant brain tumour was discussed
with his relatives. His prognosis was not given clearly and they were not
clear about his condition and were under the influence that he would be
cured
A patient having an angiogram was found to have no blood supply to the
lower leg so needed an amputation. At the time the patient did not fully
understand. I never saw him again and was left wondering what had
happened to him
Reactions to bad news (19)
Verbal abuse
Anger
Hysterical
Threatening
Physical aggression
Needing a lot of time and attention
Denial
I was with a lady in sister’s office with the surgical registrar. We had to
explain that her husband’s operation was open/close as he had
widespread malignancy. She became hysterical and then fainted, banging
her head against the furniture. It was quite traumatic, I worried for weeks
Patient had been informed by the consultant she needed open heart
surgery. After consultant left she became very upset and angry and had
lots of questions which I found difficult to answer
A middle aged man came into A&E, had a cardiac arrest and died. One
relative arrived later. When she was told she became aggressive and tried
to slap me across the face
I had to inform a family they were unable to take their mum out for day
one. They became very abrupt and started to intimidate other members of
staff. They were asked to leave the ward
A relative was unable to accept that no further treatment for his mother
would be of benefit, became very angry and loud. He took up a great deal
of our time because we had to explain the reason why this decision was
made
Denial from a patient’s partner to accept that the prognosis was extremely
poor and the patient was not going to recover. The partner was unable at
the time to accept this despite days of preparation
Significant events (25)
Emotionally significant events
Challenging deaths
Demands on role or responsibility
How to console a young mother in the terminal stages of disease and
especially how to break the news to her children and how they would
cope without her
A patient who was dying, but whose death was prolonged. I had contacted
the family and asked them to sit with the patient. I had thought that the
patient would pass away imminently however, a week later I was still
telling the relatives the same news, this was a distressing time for the
family
Not being able to see a patient for over a day whose babies had died. I
found her at the window crying with her babies in her arms. She had not
seen a member of staff all day. I still think of her
When a patient was dying the relatives wanted us to give more drugs to
expedite the death. The relatives wanted the death to happen quickly
because it was too painful for them to watch
A patient in a terminally ill condition had two daughters who did not
communicate and hated each other caused a terrible atmosphere around
the patients bed side
I looked after a patient who had died. The deceased came from a large
family who all came at different times to say their goodbyes. I had to
escort each relative separately to see the body (5 times)
On one shift I spent the whole day breaking bad news to relatives. I found
this stressful and upsetting I cried later in the company of colleagues
I had to attend a difficult death of an infant Muslim…The infant Muslim
was to be buried before sunset on the day of death…I found myself
accompanying the parents to the cemetery as a social worker was
unavailable
JAN: ORIGINAL RESEARCH Breaking bad news in inpatient clinical settings
2010 The Authors. Journal compilation 2010 Blackwell Publishing Ltd 7
barriers to communication and who is present when bad
news is broken. Three types of barrier to communication
were identified: practical/physical, language/culture and a
deficit in nursing knowledge. Practical/physical barriers in-
cluded lack of privacy, lack of time to explain, giving bad
news over the phone and difficulty contacting the family.
Challenges to privacy and time could come from the ward
environment (e.g. a shared bay, lack of staff) or from events
(e.g. an emergency with many staff present or a rapidly
changing situation).
Problems were also encountered when the nurse felt that
there was a deficit in their own knowledge. Sources of
knowledge deficit included not knowing the relative/patient
prior to breaking bad news, having limited knowledge of
the events surrounding the need to break bad news and
concerns about their own level of clinical knowledge in
relation to a specific aspect of care. Problems could also
occur when a key person was not present when the
bad news was broken. This could be a relative, a doctor
from the patient’s own medical team or the nurse (see
Table 4).
Information held by patients and relatives
Twenty-eight descriptions related to the ‘Information held by
patients and relatives’ category, which contained two key
themes: issues around disclosure and the patient’s and rela-
tives’ understanding of the situation. The most frequently
described difficulty in relation to disclosure was the family
requesting that the patient was not given information about
their diagnosis or prognosis. Negative outcomes were iden-
tified from the descriptions: impaired nurse/patient commu-
nication, nurses feeling dissatisfied with the care they had
given and tension between the relatives and the healthcare
team, particularly if the patient was informed despite the
relatives’ requests.
Difficulties were described when patients or relatives were
not aware of fundamental information relating to the
patient’s condition or treatment. This was due to them either
not having been given the information, or to misunderstand-
ing or misinterpreting the information they had been given.
Sometimes this created a difficult context for breaking bad
news as it meant that the news being given was contrary to
their expectations.
Unexpected death
Twenty-six descriptions related to difficulties encountered in
relation to breaking bad news following an unexpected
death. These included patients dying without a relative
present, and practical concerns such as having to break the
bad news on the phone.
Reactions to bad news
Negative reactions from patients or relatives featured in 19
descriptions and offer insight into the complexity and
strength of emotions involved in situations where bad news is
broken. These included verbal abuse, anger, physical
aggression, intimidation, hysteria and complete denial. Cat-
alysts for these responses included being given negative
information about prognosis or treatment, unexpected death
and attempting discharge against medical advice.
Significant events
Twenty-five descriptions related to events that appeared to be
emotionally or professionally significant for the nurse. In
some cases they pushed the boundaries of the nurse’s skills or
ability to cope. Significant events included deaths that were
particularly challenging or emotional for the relatives and/or
nurse, events that were burdensome for the patient, family
disagreements about treatment decisions and exceptional
demands being made of the nurse. Examples are given in
Table 4.
Some participants’ descriptions contained elements that
suggested that breaking bad news could have an enduring
effect which stayed with them long after the event. This was
exemplified in phrases such as ‘I worried for weeks’, ‘I still
think of her’ and ‘I never saw him again and was left
wondering what had happened to him’. These phrases were
present across the categories, suggesting that involvement in
breaking bad news could had a significant and lasting impact
on participants.
Sources of difficulty
Each of the descriptions was evaluated to identify a main
source of difficulty, and six key sources emerged. The event
itself (for example, an unexpected death or emergency) was
the key source of difficulty in 45 descriptions, while relatives
actions featured in 42. Nineteen arose from organizational
issues such as inadequate staffing or services, 11 centred on
difficulties with the patient, 8 on issues relating to medical
staff and 5 on the participants’ self-expressed lack of
knowledge or expertise.
Nurses’ experiences of being involved in the process of
breaking bad news
A mixed response was given by participants in relation to the
items concerning nurses’ experiences of being involved in the
process of breaking bad news (Table 5). Many participants
thought that there were positive consequences of being
involved; for example some felt that it helped patients/
relatives prepare for the future and had strengthened their
C. Warnock et al.
82010 The Authors. Journal compilation 2010 Blackwell Publishing Ltd
relationships with patients/relatives. For 71Æ5%, being
involved in breaking bad news had encouraged them to
reflect positively on their own priorities and what was
important in life.
In relation to skills and confidence, 166 (70Æ6%) partici-
pants thought that they were able to initiate discussions with
patients about bad news, and only 12 (5Æ5%) avoided being
involved in this process as they found it difficult. A total of
146 (61Æ8%) thought that they had good strategies for coping
with their own emotional reactions when involved in
breaking bad news, and 59 (25Æ1%) found it difficult to deal
with patients’/relatives’ reactions to bad news. Fewer partic-
ipants (55Æ4%) expressed confidence in their skills in relation
to the process of breaking bad news. Supporting patients
from different cultural backgrounds was identified as a
particular concern as only 41Æ7% felt confident in doing this.
Previous training received in relation to breaking bad news
The majority of participants had received little or no formal
education on breaking bad news, with only 27 (11%) having
received more than one day’s training (Table 6). A total of
166 stated they had learnt through informal methods such as
experience gained over time, while 141 had learnt by
observing the practice of others. Over half of the participants
thought that observing the practice of others and learning by
experience were the types of education that would be most
useful in preparing them to break bad news, while 110
thought that formal taught programmes specific to breaking
Table 5 Nurses’ feelings and experiences in relation to the process of breaking bad news (BBN)
Feelings and experiences in relation to the process
of breaking bad news
Strongly
agree/agree,
n(%)
Neither agree
nor disagree,
n(%)
Disagree/strongly
disagree, n(%)
Number of
responses
Being involved in the process of BBN
can be rewarding as it can help the
patient/relative prepare for the future
193 (81Æ8) 34 (14Æ4) 9 (3Æ8) 236
Being involved in the process of BBN has strengthened
my relationship with a patient/relative
183 (77Æ5) 45 (19Æ1) 8 (3Æ4) 236
Being involved in the process of BBN has encouraged
me to reflect positively on my own priorities and
what is important in life
168 (71Æ5) 48 (20Æ4) 19 (8Æ1) 235
Being involved in the process of BBN has
allowed me to share in important life
changing moments with patients/relatives
164 (69Æ5) 58 (24Æ6) 14 (5Æ9) 236
I feel able to initiate discussions with
patient/relatives relating to bad news
166 (70Æ6) 38 (16Æ2) 31 (13Æ2) 235
I have good strategies for coping with my emotional
reactions when involved in the process of BBN
146 (61Æ8) 66 (28) 24 (10Æ2) 236
I feel confident in my skills in relation to the
process of breaking bad news
130 (55Æ4) 60 (25Æ5) 45 (19Æ1) 235
The area I work in has a good system of
support for nurses involved in the process of BBN
117 (49Æ5) 66 (28) 53 (22Æ5) 236
I feel able to support patients and relatives from
different cultural backgrounds in relation to the
process of breaking bad news
98 (41Æ7) 70 (29Æ8) 67 (28Æ5) 235
I find it difficult to deal with patient’s/relative’s
emotional reactions to bad news
59 (25Æ1) 54 (23) 122 (51Æ9) 235
Being involved in the process of BBN has had a
negative effect on my relationship with a patient/relative
13 (5Æ5) 54 (23) 168 (71Æ7) 235
I try to avoid being involved in BBN as I find it difficult 13 (5Æ5) 33 (14) 190 (80Æ5) 236
Table 6 Formal education received on breaking bad news
Amount of education
Number
(percentage)
of responses
None 126 (53)
1–2 hours 28 (12)
Half day 28 (12)
Full day 25 (11)
2–5 days 12 (5)
6–10 days 3 (1)
More than 10 days 12 (5)
Not recorded 2 (1)
JAN: ORIGINAL RESEARCH Breaking bad news in inpatient clinical settings
2010 The Authors. Journal compilation 2010 Blackwell Publishing Ltd 9
bad news would be helpful. The least preferred method was a
self-learning package.
Seventy-five per cent of respondents said that support was
available in their area for staff involved in the process of
breaking bad news, while 49Æ5% agreed with the statement
that good support systems were available in their area,
suggesting that half thought that that the support they
received was not of a good standard. Most support was
informal, although a small number of areas used more formal
approaches such as clinical supervision and debriefing.
Discussion
Study limitations
One of the limitations of the study is that it was carried out in
one group of hospitals within a small geographical area.
While a range of specialties are represented in the sample, the
findings may be indicative of the local culture. It is also
important to note that the study was carried out in England,
and in the UK there is a predominant belief that patients
should be informed about their illnesses and prognoses
(Hancock et al. 2007). This is not the case in all countries
and cultures, and so these findings must be taken as
representing a particular approach and attitude to breaking
bad news (Tuckett 2004). However, the study does give a
snapshot of the situation in the area where it was carried out,
and is a point of comparison for studies carried out
elsewhere. One of the areas of least confidence expressed by
participants was in supporting patients and relatives from
different cultural backgrounds. The reasons for this were not
explored, and this merits exploration in future research.
A second limitation relates to the sampling method. The
distribution of the survey by ward managers might have
induced some staff selection bias. However, the involvement
of 59 areas and varied specialties may have ensured the
inclusion of a range of nursing staff.
The challenges of breaking bad news
It was noted earlier that breaking bad news has often been
perceived as the moment that negative medical information
about diagnosis, prognosis or treatment was given to a
patient or relative, usually by a doctor. This study offers some
important insights into the ways in which nurses are involved
in breaking bad news in the inpatient clinical setting and how
this differs from this traditional perspective. It demonstrates
the size and complexity of the challenge faced by nurses when
involved in breaking bad news; an experience that is shared
by nurses working across a wide range of clinical areas.
The findings provide new evidence to support the proposal
that, for nurses, it is more appropriate to see breaking bad
news as a process. They engage with it at many points in a
patient’s care pathway, which extends beyond the moment
that bad news is given. These factors shape the role of the
nurse and give it unique characteristics and challenges,
including diversity of role, the influence of the nurse–patient
relationship and an inability to control events and circum-
stances around breaking bad news. These characteristics are
closely interrelated, but the importance of the findings in each
of these areas is considered below.
Diversity of roles
The data illustrate that nurses were engaged with breaking
bad news in diverse ways. Their involvement occurred at all
points in the inpatient pathway from diagnosis, through
treatment and rehabilitation to death. A single event might be
involved, for example informing a relative whom the nurse
had not met before of the death of a patient. The process
could also continue over a longer period of time and involve
multiple interactions with the patient or relatives. Each of
these created different challenges for the nurse. The diverse
ways in which nurses engaged with breaking bad news
illustrates the complexity of their role. It also highlights the
wide range of knowledge and expertise needed to be able to
deliver this care.
Relationships
Ongoing relationships with patients and relatives are a un-
ique dimension of the role of the nurse in breaking bad news
in the inpatient care setting. Many nurses thought that that
being involved in this process had strengthened their rela-
tionships with patients and relatives, but their responses also
suggested that it could create difficulties, particularly when
divergent views were held by the nurse, patient and/or rela-
tive over the disclosure of bad news or the patient’s plan of
care. In the inpatient care setting, these factors can have an
ongoing detrimental influence on interactions between nur-
ses, patients and relatives, the appropriateness of the patient’s
treatment plan and nurses’ satisfaction with the quality of
care they have given (Kramer et al. 2006, Vivian 2006). Lo-
pez (2007) notes that nurses do not receive the training re-
quired to manage the complex interactions they encounter
when working with family systems. This is an important issue
to consider when delivering education and training for nurses
involved in breaking bad news in the inpatient care setting.
Lack of control
Lack of control over events or interactions was a thread
which ran through many participants’ descriptions. It was
C. Warnock et al.
10 2010 The Authors. Journal compilation 2010 Blackwell Publishing Ltd
evident in the unexpected event or emergency situation which
created a difficult context for breaking bad news. It was also
present in interactions when the patient or relative did not
behave in a controlled manner (for example, an aggressive or
abusive response to bad news) or behaved in a way that
prevented the nurse from giving information or care as they
would wish. Nurses were also unable to control the timing of
their involvement in breaking bad news, and felt unprepared
as issues around bad news could be raised unexpectedly. Due
to the unpredictable nature of healthcare, nurses encounter
situations which they cannot always control. Our findings
suggest that this presents clear challenges to their role in the
process of breaking bad news.
Guidelines developed to support healthcare professionals
when breaking bad news usually focus on the moment when
bad news is given. They emphasize the need for a calm and
organized approach aided by preparing for the event, being
knowledgeable about the patient’s situation, creating an
environment which ensures privacy and ensuring that the
consultation is structured, with a clear beginning, middle and
end (for example Buckman 1992, Kaye 1996, Baile et al.
2000). These guidelines offer a clear framework for practice
at the moment when bad news is provided. Crucially, this
study highlights the potential limitations of these guidelines
for nurses working in inpatient areas, as they do not
acknowledge the ongoing nature of the process of breaking
bad news, the diversity of nurses’ roles, the impact of the
nurse–patient relationship and the lack of control over events
in this complex care environment.
Breaking bad news is a highly skilled activity, and those
involved need to feel confident in their ability to carry it out
effectively (Fallowfield & Jenkins 2004). The data suggest
that many nurses had doubts about their confidence in their
skills, and encountered situations which they found difficult
to manage, for example supporting patients from different
cultural backgrounds. Few had received formal education or
training in breaking bad news, with most gaining their skills
by watching others and learning from experience. The
findings suggest that learning ‘on the job’ alone is not
meeting the educational needs of many nurses.
Conclusion
The role of the nurse in breaking bad news risks being
overlooked if their contribution is not identified, recognized
and valued. In order to give effective care in relation to
breaking bad news, nurses require support and education
which reflects the reality of their experiences. This study has
shed further light on the context in which nurses are involved
in breaking bad news. Future guidance and education
provision should encompass this context and acknowledge
the complex challenges nurses face when involved in breaking
bad news in the inpatient clinical area.
Our findings also suggest areas for future research. We
acknowledge that this was a single site study, and it would
be useful to test the generalizability of the findings in other
UK healthcare settings as well as in healthcare systems in
other countries. Our questionnaire could be adapted and
used elsewhere as a foundation for further research. Due to
the sampling approach used, we did not explore the influence
of factors such as years of experience in nursing or current
role on the findings. This could also be explored in future
studies.
What is already known about this topic
•The term ‘breaking bad news’ is often used to describe
the moment when a patient and/or relative is given
negative medical information about diagnosis,
treatment or prognosis.
•Breaking bad news can also be seen as a process that
includes interactions that take place before, during and
after the moment that bad news is broken.
•The role of the nurse in the process of breaking bad
news in the inpatient clinical setting has not been fully
acknowledged or researched.
What this paper adds
•Nurses in the inpatient care setting engage in breaking
bad news as a process involving a diverse range of
activities.
•Their unique role is underpinned by relationships with
patients and relatives and the unpredictable nature of
the inpatient setting.
•Nurses may not receive adequate education and support
to enable them to develop confidence and skills in their
roles in breaking bad news.
Implications for practice and/or policy
•Guidance for breaking bad news should encompass the
whole process of doing this and acknowledge the
challenges nurses face in the inpatient clinical area.
•Nursing education should meet the needs of nurses
working in complex care settings who have to break
bad news.
•Further research into the nurse’s role is required to build
a more complete picture of their contribution to
breaking bad news.
JAN: ORIGINAL RESEARCH Breaking bad news in inpatient clinical settings
2010 The Authors. Journal compilation 2010 Blackwell Publishing Ltd 11
Acknowledgements
We would like to thank Janet Turner, Service Evaluation
Manager, Clinical Effectiveness Unit, Sheffield Teaching
Hospitals NHS Foundation Trust, for her advice and assis-
tance particularly with data collection. Grateful thanks to the
Evidence Based Council, Sheffield Teaching Hospitals NHS
Foundation Trust, for their encouragement and support.
Thanks also to Irene Mabbot, Practice Development Coor-
dinator, Education and Development Unit, Sheffield Teaching
Hospitals NHS Foundation Trust and Peter Almark, Princi-
pal Research Fellow, Centre for Health and Social Care
Research, Sheffield Hallam University, for their helpful
comments on the content and structure of this paper.
Funding
This research received no specific grant from any funding
agency in the public, commercial, or not-for-profit sectors.
Conflict of interest
No conflict of interest has been declared by the authors.
Author contributions
CW, AT, JF and CS were responsible for the study conception
and design. CW, JF and CS performed the data collection.
CW and AT performed the data analysis. CW and AT were
responsible for the drafting of the manuscript. CW, AT, JF
and CS made critical revisions to the paper for important
intellectual content.
References
Baile W., Buckman R., Lenzi R., Glober G., Beale E. & Kudelka A.
(2000) SPIKES – a six-step protocol for delivering bad news:
application to the patient with cancer. The Oncologist 5, 302–311.
Buckman R. (1992) How to Break Bad News. Macmillan publica-
tions, London.
Cox A., Jenkins V., Catt S., Langridge C. & Fallowfield L. (2006)
Information needs and experiences: an audit of UK cancer patients.
European Journal of Oncology Nursing 10, 263–272.
Dewar A. (2000) Nurse’s experiences in giving bad news to patients
with spinal cord injuries. Journal of Neuroscience Nursing 32,
324–330.
Fallowfield L. & Jenkins V. (2004) Communicating sad, bad and
difficult news in medicine. The Lancet 363, 312–318.
Georges J. & Grypdonck M. (2002) Moral problems experienced by
nurses when caring for terminally ill people: a literature review.
Nursing Ethics 9, 155–178.
Glass E. (2004) Truth telling. Ethical issues in clinical practice.
Journal of Hospice and Palliative Nursing 6, 232–242.
Hagerty R., Butow P., Ellis P., Lobb E., Pendlebury S., Leighl N.,
Macleod C. & Tattersall M. (2005) Communicating with realism
and hope: incurable cancer patients views on the disclosure of
prognosis. Journal of Clinical Oncology 23, 1278–1288.
Hancock K., Clayton J., Parker S., Wal der S., Butow P., Carrick S.,
Currow D., Ghersi D., Glare P., Hagert R. & Tattersall M. (2007)
Truth-telling in discussing prognosis in advanced self-limiting ill-
nesses: a systematic review. Palliative Medicine 21, 507–517.
Kaye P. (1996) Breaking Bad News: A Ten Step Approach. EPL
Publications, Northampton.
Kramer B., Boelk A. & Auer C. (2006) Family conflict at the end of
life: lessons learned in a model program for vulnerable older adults.
Journal of Palliative Medicine 9, 791–801.
Lopez R. (2007) Suffering and dying nursing home residents. Nurses
perceptions of the role of family members. Journal of Hospice and
Palliative Nursing 9, 141–149.
Mawson S., Gerrish K., Schofield J., Debbage S. & Somers A. (2007)
A pragmatic governance framework for differentiating between
research, audit and service review activities. Clinician in Manage-
ment 15, 29–35.
McSteen K. & Peden-McAlpine C. (2006) The role of the nurse as
advocate in ethically difficult care situations with dying patients.
Journal of Hospice and Palliative Nursing 8, 259–269.
Morrissey M. (1997) Extending the theory of awareness contexts by
examining the ethical issues faced by nurses in terminal care.
Nursing Ethics 4, 370–379.
Norton S. & Telerico K. (2000) Facilitating end of life decision
making: strategies for communicating and assessing. Journal of
Gerontological Nursing 26, 6–13.
Palfreyman S., Tod A. & Doyle J. (2003) An integrated approach to
evidence based practice. In Foundation of Nursing Studies
Dissemination Series (Shaw T. & Saunders K. eds), London, 9,
1–4.
Ptacek J., Ptacek J. & Ellison N. (2001) ‘‘I’m sorry to tell you’’
Physicians reports of breaking bad news. Journal of Behavioural
Medicine 24, 205–217.
Randall T. & Wearn A. (2005) Receiving bad news: patients with
haematological cancer reflect on their experiences. Palliative
Medicine 19, 594–601.
Rossin M., Levy O., Schwartz T. & Silner D. (2006) Caregivers’ role
on breaking bad news. Cancer Nursing 29, 302–308.
Schildmann J., Cushing A., Doyal L. & Vollmann J. (2005) Breaking
bad news: experiences, views and difficulties of pre-registration
house offices. Palliative Medicine 19, 93–98.
Stayt L. (2007) Nurses’ experiences of caring for families with rela-
tives in intensive care units. Journal of Advanced Nursing 57, 623–
630.
Tobin G. & Begley C. (2008) Receiving bad news. A phenomeno-
logical exploration of the lived experience of receiving a cancer
diagnosis. Cancer Nursing 31(5), E31–E39.
Tod A., Bond B., Mabbott I. & Palfreyman S. (2007) Exploring the
contribution of the clinical librarian to facilitating evidence based
nursing. Journal of Clinical Nursing 16, 621–629.
Tuckett A. (2004) Truth telling in clinical practice and the arguments
for and against: a review of the literature. Nursing Ethics 11, 500–
513.
Vandekieft G. (2001) Breaking bad news. American Family Physician
64, 1975–1978.
C. Warnock et al.
12 2010 The Authors. Journal compilation 2010 Blackwell Publishing Ltd
Verhaeghe S., Defloor T., Van Zurren F., Duijnstee M. & Grypdonck
M. (2005) The needs and experiences of family members of adult
patients in an intensive care unit: a review of the literature. Journal
of Clinical Nursing 14, 501–509.
Vivian R. (2006) Truth telling in palliative care nursing: the dilem-
mas of collusion. International Journal of Palliative Nursing 12,
341–348.
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