1. Background
Breaking Bad News (BBN) refers to conveying any sad information that negatively and significantly affects a patient's view of the present and future (1). Breaking bad news is a difficult task for the medical team, and as much as it is hard and unbearable for patients to hear, it is stressful and dreadful for the involved health care providers to announce (2). Breaking bad news is very important because it has been shown that most patients prefer to be informed of their illness and survival (3). They want accurate and honest answers about treatment options, diagnosis, and prognosis to make the right decision. Indeed, in modern medical ethics, it is patients' right to know the reliable and necessary information about their disease. It should also be noted that while Western societies strongly advocate for patient's autonomy and the right to be informed of their medical status, regardless of the severity and prognosis, Eastern societies consider the vital role of the family's perspective in the patient management and decision-making, which could create a complex ethical conflict (4). Some research indicates that providing information as awful news always does not result in depression, anxiety, and hopelessness, but it might even help the patient and relatives to handle the conditions (5) if the news is delivered appropriately (6). It is traditionally the stressful duty of physicians; however, studies have shown that it is not a single event, but multidisciplinary teamwork and nurses are frequently involved in this process and are faced with so many challenges and difficulties (7).
Warnock et al. demonstrated that nurses' diverse role in BBN is divided into three critical items: Preparing the proper conditions, giving information, and supporting the patient (8). However, the nursing students' curriculum, like other educational programs of medical universities, traditionally focuses on clinical and manual skills and learning specialized academic topics rather than the importance of communication skills (9). The nurses' work setting influences the way they involve in the process of BBN. In many situations, like intensive care units or emergency wards, nurses might be the first to face the task. They are involved before, during, and after the bad news is created and can help patients prepare for receiving bad news and cope with the distressing conditions (10, 11). Studies have shown that being actively involved in this process improves patient-nurse relationships (12-14).
The vital role of nurses who spend long, daily time with the patients is to have the chance to detect the cues that indicate whether or not patients want to know more about their conditions. Given the critical role of nurses, it seems that enough attention has not been paid to the issue.
2. Objectives
This study investigated the way of BBN by nurses employed in academic hospitals affiliated with Guilan University of Medical Sciences (GUMS).
3. Methods
This descriptive cross-sectional study was conducted at academic hospitals affiliated with GUMS in 2020. The study protocol was approved by the Research Ethics Committee of the University and was registered (Ref. IR.GUMS.REC.1399.170). The study population was the nurses working in the academic hospitals affiliated with GUMS.
First, the study objectives were explained to the nurses employed in academic hospitals, and their informed consent was obtained by the responsible medical student who collaborated with the study. The bad news was limited to the incidence and prognosis of incurable diseases and death. The responsible medical student filled out the questionnaires through face-to-face interviews with nurses. The questionnaire contained 16 items, divided into two parts of environmental and psychical support. Baseline demographic characteristics were also recorded. The first 10 questions were about psychological support, providing information regarding how the nurse delivered terrible news to the patients and families and supporting them psychologically. These questions included assessing the patient's request to know about his/her illness, providing statistics on the survival rate, squeezing the patient's hand or arm during BBN, pointing to the importance of the issue before entering the details, providing information about the patient's possible life expectancy, paying attention to the patient's fears and interests, providing timely news, encouraging the patient to express feelings when hearing bad news, and giving the patient confidence and hope.
The following six questions evaluated nurses' performance in providing psychical support to the patients and their families. These questions included respecting the privacy of the environment, choosing the right time, observing the close distance with the patient, introducing the patient to support groups, ensuring companionship, and not using the mobile phone during the process of BBN. Each question had five options, including always, often, sometimes, seldom, and never. Each item scored from 10, indicating "never," to 50, "Always." The questionnaire was taken from a similar study conducted by Ghafari Nezhad et al., whose reliability and validity were confirmed by 10 faculty members (15). Finally, the scores of the questionnaires were calculated.
To calculate the sample size, we performed a pilot study. The P was the ratio of those aware of the principles of informing the patient.
P = 0.10, q = 0.90, α = 0.05, d = 0.03
The collected data were entered into SPSS version 21 software for statistical analysis. Proportion and Pearson correlation tests were used to determine and describe the variables. A P value of less than 0.05 was considered significant.
4. Results
A total of 384 out of 410 nurses filled out the questionnaires, and a response rate of 93.65% was obtained. As shown, 346 (90.1) responders were women, and 38 (9.9%) were men. The mean age was 30.23 ± 6.17 (22 - 54) years and the mean years of experience were 6.44 ± 5.3 (1 - 29). Also, 289 (75.3%) had passed educational courses in a nursing school. The frequency of nursing responses to the 18 items of the questionnaire are presented in Tables 1 and 2.
Table 1.Frequency of Answers to Environmental Support Questions a
| Questions | Always | Often | Sometimes | Seldom | Never |
|---|---|---|---|---|---|
| 1-I attract family support. | 145 (37.8) | 186 (48.4) | 50 (13) | 3 (8) | 0 (0) |
| 2-I appraise the patients' information requirements. | 148 (38.5) | 181 (47.1) | 49 (12.8) | 4 (1) | 2 (0.5) |
| 3-I give them an exact survival time. | 68 (17.7) | 164 (42.7) | 98 (25.5) | 36 (9.4) | 18 (4.7) |
| 4-I hold their arm for warm empathy. | 54 (14.1) | 130 (33.9) | 111 (28.9) | 67 (17.4) | 22 (5.7) |
| 5-I highlight the importance of the issue before telling the details. | 115 (29.9) | 193 (50.3) | 68 (17.7) | 7 (1.8) | 1 (0.3) |
| 6-I also carry them hope. | 133 (34.6) | 149 (38.8) | 82 (21.4) | 19 (4.9) | 1 (0.3) |
| 7-I exactly tell them how long they will live. | 19 (4.9) | 48 (12.5) | 64 (16.7) | 108 (28.1) | 145 (37.8) |
| 8-I care about their concerns and interests. | 111 (28.9) | 159 (41.4) | 88 (22.9) | 24 (6.2) | 2 (0.5) |
| 9-I deliver bad news as soon as they are aware of their illness. | 39 (10.2) | 102 (26.6) | 134 (34.9) | 65 (16.9) | 44 (11.5) |
| 10-I encourage them to express their feeling. | 95 (24.7) | 152 (39.6) | 95 (24.7) | 32 (8.3) | 10 (2.6) |
aValues are expressed as No. (%).
Table 2.Frequency of Answers to Psychical Supports a
| Questions | Always | Often | Sometimes | Seldom | Never |
|---|---|---|---|---|---|
| 1-I choose a private location. | 192 (50) | 128 (33.3) | 50 (13) | 11 (2.9) | 3 (0.8) |
| 2-I choose a time that relatives feel comfortable. | 182 (47.4) | 141 (36.7) | 47 (12.2) | 13 (3.4) | 1 (0.3) |
| 3-I sit beside them, not at the station. | 118 (30.7) | 138 (35.9) | 79 (20.6) | 33 (8.6) | 16 (4.2) |
| 4-I introduce them to patient support groups. | 93 (24.2) | 144 (37.5) | 87 (22.7) | 51 (13.3) | 9 (2.3) |
| 5-I make sure that a relative is available. | 163 (42.4) | 164 (42.7) | 46 (12) | 11 (2.9) | 0 (0) |
| 6-I turn off my mobile while doing this job. | 89 (23.2) | 79 (20.6) | 84 (21.9) | 73 (19) | 59 (15.4) |
aValues are expressed as No. (%).
The findings showed a positive correlation between psychical and environmental support and the age of nurses (P = 0.007, P = 0.003) and their years of experience (P = 0.013, P = 0.004) (Tables 3 and 4).
Table 3.Correlation Between Environmental and Psychical Support Scores and the Age and Work Experiences of Nurses
| Age (y) | Work Experience (y) | |
|---|---|---|
| Psychical Support Score | ||
| Pearson correlation | 0.138 | 0.127 |
| P-value | 0.007 | 0.013 |
| Type of correlation | Positive correlation | Positive correlation |
| Environmental Support Score | ||
| Pearson correlation | 0.149 | 0.146 |
| P-value | 0.003 | 0.004 |
| Type of correlation | Positive correlation | Positive correlation |
Table 4.Frequency Distribution of Breaking Bad News Status Concerning Psychical and Environmental Support Among Studied Nurses a
| Status | Psychical Support Score | Environmental Support Score | Psychical Support | Environmental Support |
|---|---|---|---|---|
| Weak | 10 - 23 | 6 - 13 | 2 (0.5) | 4 (1) |
| Moderate | 24 - 36 | 14 - 22 | 203 (52.9) | 148 (38.5) |
| Good | 37 - 50 | 23 - 30 | 179 (46.6) | 232 (60.4) |
a Values are expressed as No. (%).
5. Discussion
The present study found that almost all nurses believed in respecting the patient's privacy and finding the right time for the patient and his/her companions to feel comfortable. Also, they always tried to ensure the presence of a relative during BBN. Also, most of them admitted that they always cared about patients' concerns and tried to give them hope. They also assessed the patients' willingness to know about their disease before giving details. It emphasizes their acceptable ethical performance.
However, holding patients' arms and telling the patients the exact survival time was not appreciated, pointing to the area's cultural characteristics. Turning off the cell phone when BBN was not met by most participants, should be corrected and advised due to the negative impacts on patients and relatives.
Notably, 75.3% of participants had passed educational courses to be prepared for BBN. It was significantly higher than the previous studies because, in the last few years, based on recent post-graduated nurses' statements, a new chapter titled communication skill was added to the curriculum of nursing students. Thus, this percentage involves both postgraduate courses and the mentioned items. However, no significant difference was observed regarding environmental and supportive scores between nurses who had participated in teaching programs and others.
In similar research on physicians working in academic hospitals, 86.4% of them were not educated on the issue of BBN, but still for 13.6% of them, participation in educational courses had no significant effect on the individuals' point of view regarding the way of BBN (16). It uncovers that the current curriculum is not effective enough and has to be revised. If the mentioned educational classes were well planned, those who had participated in these courses could achieve higher scores. In Abdalazim Dafallah et al. study, only 56.3% of Sudanese doctors received education and training, and the majority ( > 90%) agreed that training courses for BBN were essential (17). In Yazdanparast et al. study, they asked nurses to participate in an integrated workshop on communication skills. They filled out the SPIKES questionnaire before and after the educational intervention, and the difference was statistically significant (18). Another study conducted by Dawson et al. practiced some scenarios on standardized patients' experiences in BBN that enhanced health care staff's communication skills (19). Role-play simulation was another way to improve nursing students' ability to BBN, build their confidence in that ability, and assist them in engaging in the process of self and peer reflection, as studied by Laranjeira and Querido. Also, it developed a greater capacity for treating others with respecting and understanding of requirements in palliative care nursing (20). Moreover, similar to Biazar et al. (16), we found that age and years of experience were positively correlated with higher scores. Overall, these results show that therapeutic teams, including physicians and nurses, should act better based on their experience, not according to educational programs, a thought-provoking finding that needs special attention. As nurses with less experience, who are more likely to have taken communication skill courses in their studies, scored lower, experience is more effective than training.
Not in line with this study, Alshami et al. enrolled physicians and nurses from 40 different countries and reported that one-third of the participants received training courses, and they were more likely to BBN to patients and families (5). Biazar et al. found that only 19.1% of faculty members and residents of GUMS had the belief that it is the patients' right to know about their exact survival time. In this study, this belief was even less probable, and only 17.7% of the nurses had the perspective of being honest about this topic (16).
Studies revealed that the physical space where profound messages are delivered is significant. A department setting with no privacy or lack of sufficient time on a busy day causes lasting negative effects on patients' perspectives (21). Jeraine and Wakefield in a literature review, reported that the nurses' confidence, knowledge, and attitude towards BBN were not adequate in the clinical setting. Moreover, they found the stimulating effects and the need for good education programs to improve such a skill (22).
Most individuals chose the proper conditions for this purpose. Although based on the answers of our participants, their beliefs and attitudes towards the issue seem acceptable in some items, according to these results, we cannot judge the way the nurses may act when facing actual conditions. This is because they only stated their preferred answers and ideas.
5.1. Limitations
This study was restricted to academic hospitals, and the performance of nurses employed in private sectors was not explored. Moreover, in this study, nurses' beliefs were questioned while people do not precisely act in actual conditions as they believe.
5.2. Conclusions
It was revealed that nurses had acceptable performance in some items, such as respecting the patient's privacy. However, corrective interventions are recommended for other items, such as turning off the cellphone while giving bad news. Furthermore, this study strongly indicated that the current educational programs were not practical and effective because passing these courses had no significant impact on the nurses' answers. In general, practical planning should be done according to the weaknesses and strengths of nursing performance. In order to tackle the gap, in addition to improving the quality of post-graduate courses, as a fundamental step, adding an item titled professionalism or communication skills is strongly encouraged. Novel educational models such as simulators could improve the conditions if available.
