BREAKING BAD NEWS

Clinical communication with patients, relatives and care givers can be a challenge to healthcare providers. However, the use of communication skills and a therapeutic relationship may help seriously unwell patients and their families achieve the best way possible to cope with the illness (Finset 2015).

The first thing to be done whenever a clinical interview takes place or very important medical information is going to be disclosed to patients and/or family is planning and preparing the interview. 

Breaking bad news is reported to be one of the most stressful communication tasks (Porensky et al. 2015), this is why preparation is so important, including where and how the information is going to be given and anticipating possible questions. Preparation includes preparing oneself, the patient/family and the environment (Barnett 2013). 

Allowing enough time is key to enable successful communication. As the Regional Guidelines state “that it is strongly recommended that the person (named or specialist nurse) accompanying the professional who delivers the news, remains with the patient or family member if appropriate and help provide continuing support” (Department of Health, Social Services and Public Safety 2003). 

Different strategies for managing difficult situations like the Ten-step approach, SPIKES (Box 1) and Seven-step approach have preparation as its first step (Lewis et al. 2010).

Use a “warning shot;” that is, say something to prepare such as, “I do not have good news.”

Regional Guidelines state “that warning a patient or family member that bad news is coming may help lessen the shock and may help to process the information they receive” (DHSSPS 2003). 

Social psychology research has suggested that this approach may be most effective in reducing shock and distress of news with potentially serious implications (Porensky et al 2015). 

The news should be given in small chunks with pauses in between allowing time for information to be processed and encourage questions (DHSSPS 2003). Although the medical team will always try to make decisions in the best interest of the patient, the involvement of the patient and the family is decisive as the evidence suggests that patients increasingly want additional information regarding diagnosis, prognosis and treatment (DHSSPS 2003). It is important to remember the use of simple words and short sentences to ensure that the information provided is as clear as possible.

Patients and family often express feelings without talking about them (Egan 2013), their reactions and non-verbal communication can give us an idea of what the patient and family think and feel. 

Planning and preparing includes establishing goals and objectives, select method of disclosure, select the content and arrange resources (Hargie 2010).  Patients and family who have a clear plan for the future are less likely to feel anxious and uncertain (DHSSPS 2003). Furthermore, communication has a direct impact on the degree to which patients cope (Hawthorn 2015).

A study has shown that individuals who hear the negatively-framed prognosis are significantly more distressed than individuals who hear the positively-framed prognosis (Porensky et al 2015).

Breaking bad news is often a continuing process, it is important not to offer unrealistic hope but it is equally important that patients and family can discuss, consider options and come to terms with limitations without feeling abandoned by the health professional team (DHSSPS 2003).

Every person is different and the degree of information desired can vary as well as their expectations and their coping mechanism.

Evidence suggests that tailoring the amount of information provided according to the level of information a patient desire is associated with lower anxiety and better problem-focused coping (Porensky et al. 2015).

Breaking bad news can be extremely stressful for the professionals involved, emotions such as anxiety, a burden of responsibility for the news and fear of a negative response can have an adverse effect on those receiving and those delivering the news (DHSSPS 2003). Preparing the interview and following steps is a useful way of gaining confidence. Being clear about care goals may also assist staff who may need formal support in order to deliver high quality of care (Lewis et al. 2010).

Sources:

-Egan, G. (2013) The Skilled Helper. 10th Pacific Grove, California Belmont Brooks Cole/Cengage Learning.

-Hargie, O. (2010) Skilled interpersonal communication: Research, theory and practice. Hove Routledge.

-Porensky, E.K. and Carpenter, B.D. (2015) Breaking bad news: Effects of forecasting diagnosis and framing prognosis. Patient Education and Counseling, 99, 68-76.

-Lewis, D. and Kitchen, C. (2010) The role of communication skills in end-of-life care. Journal of renal nursing, 22(2), 69-74.

-Hawthorn, M. (2015) The importance of communication in sustaining hope at the end of life. British Journal of Nursing, 24(13), 702-705.

-Barnett, M. (2013) Breaking Bad News – Pointers and Pitfalls. Scottish Universities Medical Journal, 2(2), 54-57.

-Leonard, M., Graham, S., and Bonacum, D. (2004) The human factor: the critical importance of effective teamwork and communication in providing safe care. Qual Saf Health Care, 13(1), 85-90.

-Department of Health, Social Services and Public Safety. (2003) Breaking bad news  Regional Guidelines. DHSSPS, Belfast.

-Finset, A. (2015) The elephant in the room: How can we improve the quality of clinical communication during the last phases in patients’ lives? .  Patient Education and Counseling, 99, 1.

-http://www.ama-assn.org/ethic/epec/download/module_2.pdf

 http://www.jpalliativecare.com/article.aspissn=09731075;year=2010;volume=16;issue=2;spage=61;epage=65;aulast=Narayanan

SKILLED INTERPERSONAL COMMUNICATION

The importance for health care professionals of having a "good bedside manner" has long been realized. In 400 BC, Hippocrates noted how the patient "may recover his health simply through his contentment with the goodness of the physician". In recent years, this belief in the power of communication to contribute to the healing process has been borne out by research.

Rider and Keefer (2006) and Tallman et al. (2007) have shown that high levels of practitioner interpersonal skill are positively correlated with increases in the quality of care and effective health outcomes, while ineffective skills are associated with decreased patient satisfaction, increased medication errors and malpractice claims. These findings are corroborated in the field of nursing, where effective interpersonal communication has been shown to be related to improved health outcomes, such as greater patient satisfaction and quality of life (Klakovich and dela Cruz, 2006).

The nature of interpersonal skills

Hargie (2006a: 13) defined interpersonal skill as "a process in which the individual implements a set of goal-directed, inter-related, situationally appropriate social behaviours, which are learned and controlled", it emphasises seven separate components of skill:

1. Skilled performance is part of a transactional process which involves: formulating appropriate goals, devising and implementing related action plans, monitoring the effects of behaviour, being aware of and interpreting the responses of others, taking into account the context in which interaction occurs and adjusting, adapting or abandoning goals and responses in the light of outcomes.

2. Skilled behaviours are goal directed: goals both motivate and navigate the interpersonal process (Berger, 2002; Oettingen et al., 2004).

3. Skilled behaviours are interrelated and synchronised.

4. Skills should be appropriate to the situation.

5. Skills are defined in terms of identifiable units of behaviour: verbal and nonverbal.

6. Skilled behaviours are learned.

7. Skills are under the cognitive control of the individual: learning when to employ behaviours is just as crucial as learning what these behaviours are and how to use them.

Zimmerman (2000) identified four key stages in the learning of skills:

-Observation
-Emulation
-Self-control
-Self-regulation: the person learns to use the skill appropriately across different personal and contextual conditions.

Communication and interpersonal communication

Communication is a transactional process, inevitable, purposeful, multidimensional and irreversible.

Conceptual model of skilled interpersonal communication 

This model builds upon skill models developed, inter alia, by Dickson et al. (1997), Bull (2006) and Hargie (2006c), based upon early theorising by Argyle (1983). It identifies six elements of skilled interpersonal interaction:

1. Person-situation context: personal characteristics, knowledge, motives, attitudes, personality, emotion, age, gender, situational factors and culture.

2. Goals: 

-Task and relational goals

-Instrumental and consummatory goals

-Implicit and explicit goals

Goals are hierarchically structured and have a temporal dimension (short or long term). They differ in their level of concreteness and compatibility, goals may be similar, complementary or opposed.

3. Mediating processes: these processes mediate between the goal being pursued, our perceptions of events and what we decide to do about them.

-cognitive processes: Nelson-Jones (1996) recommended a seven-stage framework for rational decision making: confront, generate options and gather information, assess the predicted consequences of options, commit to the decision, plan how to implement the decision, implement the decision and assess consequences of implementation.

-affective processes: skilled communication must always be adaptively and reflexively responsive to the emotional needs of the other.

4. Response: plans and strategies decided upon are implemented at this stage, there is no guarantee that their translation into action will be flawless or successful, When people fail to achieve an interactional goal but persist, they tend to adjust low-level elements of the plan (e.g. volume or speed of speech) rather than more abstract higher order elements (e.g. general strategy)(Knowlton and Berger, 2007).

5. Feedback: enables us to assess the effects or our communications, convergence towards mutual understanding and shared meaning is proportional to the degree which feedback (verbal or nonverbal) is put to effective use.

6. Perception: not all information potentially available via feedback is perceived, and not all information received is perceived accurately. Perception is an active and highly selective process (Eysenck, 1998). Skilled communicators have the ability to make accurate perceptions of self and how one is being perceived by others.

Sources:
-http://www.redtierabbit.com/what-are-interpersonal-skills/
-Hargie O. 2010 Skilled interpersonal communication: Research, theory and practice. Hove Routledge.