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CONTINUING PROFESSIONAL DEVELOPMENT
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Communicating bad Read Michelle Buckle’s Guidelines on how to
news multiple choice practice profile on write a practice profile
questionnaire haematuria
Communicating bad news to
patients:a reflective approach
NS487 McGuigan D (2009) Communicating bad news to patients: a reflective approach.
Nursing Standard. 23, 31, 51-56. Date of acceptance: December 10 2008.
Summary
Part of nurses’ unique and challenging role in healthcare settings
is engaging in difficult conversations with patients. Effective
communication is essential to establish a successful
nurse-patient relationship, put the patient at ease and promote
better interactions. A reflective approach to care can help nurses
to learn from experience and use this knowledge to communicate
bad news to patients in a sensitive and timely manner.
Author
Deirdre McGuigan is professionals facilitator in cancer care, Education
Centre, University Hospitals Bristol NHS Foundation Trust, Bristol.
Email: deirdre.mcguigan@uhbristol.nhs.uk
Keywords
Communication; Nurse-patient relationships;
Reflective practice
These keywords are based on the subject headings from the British
Nursing Index. This article has been subject to double-blind review.
For author and research article guidelines visit the Nursing Standard
home page at nursingstandard.rcnpublishing.co.uk. For related
articles visit our online archive and search using the keywords.
Aims and intended learning outcomes
This article aims to encourage nurses to use
reflection to develop their knowledge and skills
in communicating bad news and engaging in
difficult conversations with patients. After
reading this article you should be able to:
 Identify situations in clinical settings that can
give rise to the need to communicate bad news
to patients.
 Implement strategies that are useful when
involved in difficult conversations with
patients and relatives.
NURSING STANDARD
 Explore your own feelings when participating
in challenging conversations.
 Apply a reflective approach to practice to
provide care that is sensitive and timely.
Time out 1
Reflect on a situation when you
had to inform a patient of some
bad news. Now try to answer the
following questions:
 What was the bad news about?
 What skills did you use to communicate
with the patient?
 What constitutes effective communication?
Defining bad news
Kaye (1996) defined bad news as any news that
alters a patient’s view of the future for the worse.
Buckman (1992) suggested that the effect of bad
news depends on the difference between the
patient’s expectations and the reality of the
situation. Circumstances that can give rise to
difficult conversations in clinical settings include:
 Informing a patient that his or her operation
has been cancelled.
 Informing a patient that his or her treatment
will be delayed.
 Confirming a diagnosis that will affect a
patient’s life expectancy and/or quality of life
significantly.
 Discussing a placement of choice for long-term
care provision.
Communicating bad news to patients is a
complex and difficult task requiring patience,
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understanding and sensitivity. Maguire (1985)
found that when bad news was delivered poorly
the experience stayed in the patient’s and/or
family member’s mind long after the initial
shock of the news was dealt with. Effective
communication is central to patient satisfaction
and the provision of sensitive care. Nurses need
to ensure that they are appropriately skilled to
deliver information that patients could find
difficult and/or distressing.
Time out 2
Make a list of what you think are
the main barriers to effective
communication. Compare your
conclusions with the information
that follows.
Nurse-patient relationships
Communication in nurse-patient relationships
is an integral part of nursing practice.
Effective communication is important to
provide accurate information and prevent
misunderstandings and unrealistic expectations,
particularly when giving patients bad news.
Effective communication underpins the
development of a therapeutic relationship
between nurses and patients and their families.
Miller (2002) described effective communication
as a cyclical and interactive process between
communicators, consisting of messages being
sent, received and responded to, with feedback
being given to the originator of the message.
Communication failure can arise from a
breakdown at any point in the cycle.
There are many barriers to good
communication including the fears of the nurse
and the fears of the patient. Sheldon et al (2006)
carried out a study looking at difficult
conversations in nurse-patient interactions from
the nurse’s perspective. They found that nurses’
personal experiences and emotional responses to
clinical situations affected the way in which they
communicated, often making such interactions
more difficult for them. Maguire and Faulkner
(1988) identified that nurses use distancing
strategies when having difficult conversations
with patients so that they avoid:
 Eliciting patient emotions that the nurse
might be unable to manage.
 Provoking emotions that the nurse might
perceive to be damaging to the patient,
for example crying.
52 april 8 :: vol 23 no 31 :: 2009
 Asking patients to talk more as this can
encourage them to ask difficult questions,
such as how long they have left to live.
 Engaging in conversations that might be
emotionally distressing to the professional.
The importance of effective communication
skills when dealing with sensitive issues has
been emphasised in the literature, particularly
in relation to cancer and palliative care (Calman
and Hine 1995, Department of Health 2000,
2001, British Medical Association 2004). Most
nurses will have experienced, at some point in
their career, a difficult conversation where they
had to impart news that they knew would have
a significant effect on a patient’s life. The
anticipation of these conversations can be
stressful and nurses need to be adequately
prepared to deal with the emotional demands
of such engagements.
Self-awareness and reflective thinking
To understand individuals’ needs and the
uniqueness of each patient, nurses need to
understand their own needs, personal qualities
and weaknesses. Becoming more self-aware
enables nurses to observe how they react to
particular situations, what effect they can have on
a situation and on others. It is through experience
that an individual accumulates knowledge about
how to communicate. Learning from experience
through self-awareness and the ability to reflect
allows nurses to improve their practice and the
success of the care that is provided. Nurses should
first care about themselves and recognise their
own self-worth, taking into account their beliefs
and values before being able to provide effective
care for others.
Senge (1990) described the need for
organisations to integrate learning at work
so that employees are given active
encouragement to learn from problems,
challenges and successes inherent in everyday
activities. The skills involved in communicating
bad news require teaching and practice to
enable nurses to feel confident to deliver
difficult information. Each individual can
consider his or her unique learning styles and
incorporate these into a learning approach or
combination of approaches (Power 2008). This
can be accomplished through the use of
a combination of resources, such as online
learning breaking bad news packages, reflective
practice through case scenarios, and
face-to-face sessions used to deliver instruction.
Reflective practice is an important aspect of
nursing diploma, undergraduate and masters
degree curricula (Nursing and Midwifery Council
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2002). Reflection is about more than simply
being thoughtful. It involves learning from and
analysing situations so that this experience can
be applied to similar situations and future
practice. In this instance, reflective practice seeks
to respond to problems arising in difficult
conversations so that it can allow nurses to
continue to learn and develop through practice.
Reflective thinkers are those who are
open-minded, responsible and wholehearted in
their approach to care (Dewey 1933). At a basic
level, models of reflection exist to provide
guidance to help nurses review events and turn
them into learning experiences. There are many
models that have been used to describe the
reflective approach (Driscoll 1994, Johns and
Graham 1996). For the purpose of this article,
Gibbs’s (1988) reflective model has been chosen
(Figure 1).
Time out 3
Imagine that you have to tell a
patient who has recently been
diagnosed with prostate cancer
that the cancer is advanced and
has metastasised to other vital organs.
How would you approach this difficult
conversation?
Time out 4
Refer back to the scenario in
Time out 3. Now use Gibbs’s
(1988) reflective model to analyse
how you dealt with the situation.
Consider what you could improve
and how you would deal with a similar
incident in the future.
(McGill and Beaty 1995). More opportunities
to learn collaboratively with other colleagues
could be created through shared reflection
among colleagues.
Time out 5
Ask a colleague to support your reflective practice.
Identify a difficult conversation that you had with
a patient. Describe to your colleague why the
conversation was challenging and how it made you feel.
Ask your colleague to share his or her views on how you
approached the situation, what went well, what did not, and
how the situation could have been approached differently.
Ten-stage approach to communicating
bad news
There are many strategies and tools developed
to support nurses when communicating bad
news. The ten-stage strategy has been developed
from work carried out by Buckman (1992), Kaye
(1996), Faulkner (1998) and Abel et al (2001)
in a model to support and assist nurses engaging
in difficult conversations with patients (Box 1).
Preparation Nurses need to be sure about the
information that they have to give to patients.
The most relevant facts need to be obtained from
all resources available, such as hospital notes,
nursing documentation and other members of
the multidisciplinary team. This enables nurses
to give accurate information and ensures that
they are able to answer any questions that
patients might ask. Nurses should try to
plan, in collaboration with colleagues, protected
FIGURE 1
Gibbs’s (1988) reflective model

Gibbs’s (1988) reflective model can be used in

clinical settings to establish an accurate account Stage 1
Description
of events. The model promotes six key stages:
Stage 6 What happened? Stage 2
description, feelings, evaluation, analysis of the
situation, conclusion and the formation of an Action plan Feelings
If it arose What were you
action plan to improve future practice. Working
again, what thinking and
through these stages allows nurses to reflect
would you do? feeling?
on a particular incident and have a better
understanding of what to expect if a similar
situation should arise again. Stage 3
Although the importance of reflection is Stage 5
Evaluation
acknowledged, it has been argued that Conclusion
What was good
What else could
reflection in isolation cannot ensure learning, and bad about the
have been done? Stage 4
because it does not challenge or support shared Analysis
experience?
reflection (Atkinson and Claxton 2000). Group What sense can
processes, or group dynamics, can generate you make of the
rich insight and understanding of complex situation?
professional issues through the challenge and
support offered to participants in the process

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time to talk to patients so that important
conversations are not interrupted.
It is vital to ask the patient if he or she wishes to
have a relative or friend present when
communicating bad news. Start the discussion
by getting the patient’s agreement for the
conversation to take place. The patient should be
made aware that you are about to have a serious
and important conversation with him or her.
Establish what the patient knows It is important
to establish what patients already know about their
illness or situation. This should be expressed in their
words and nurses should avoid using jargon or
technical terms. Questions could include: ‘What
have you been told about your illness or situation so
far?’ or ‘What do you understand about your illness
or situation?’ This will help nurses to determine
whether patients have unrealistic expectations or
gaps in their understanding. Some patients could
already suspect what they are about to be told.
It is important to identify the discrepancy between
the patient’s expectations and the reality of the
situation as this can affect how they process and
deal with the information (Buckman 1992).
Establish what the patient wants to know It can
be helpful to ask the patient’s permission before
continuing to explain the situation further. Some
patients might not want to have a discussion at
this time. If possible, nurses should acknowledge
this request and arrange to talk at a more
appropriate time, for example when the
individual is better prepared or a relative or
BOX 1
Ten-stage strategy to help nurses
communicate bad news
1. Preparation.
2. Establish what the patient knows.
3. Establish what the patient wants to know.
4. Give a warning sign either verbally or non-verbally.
5. Communicate bad news sensitively.
6. Acknowledge distress and support the patient in
being open about his or her feelings.
7. Identify and prioritise concerns.
8. Check the patient’s present information needs.
9. Identify the patient’s support networks.
10. Make apparent what support is available and what
will happen next.
(Adapted from Maguire 1985, Buckman 1992, Kaye 1996,
Faulkner 1998, Abel et al 2001)
54 april 8 :: vol 23 no 31 :: 2009
friend is present. Some patients might also
prefer such information to be given to someone
else on their behalf.
Give a warning sign The warning sign can be a
phrase. If using supportive words it is important
that nurses use words with which they are
comfortable. An example could be: ‘I am sorry it
is not good news …’ or ‘I am afraid that things
are more serious than we had hoped.’ This could
be followed by a pause to enable the patient to
prepare themselves. The intent should be to
provide accurate information – the intricacies of
the actual words used are not always the most
important element of good communication.
Nurses should try to remain professional, honest
and compassionate. The focus of the receiver
will be to experience the nurse’s compassionate
approach to his or her unique situation and this
can be shown through good eye contact and
supportive body language. Leininger and
McFarland (1995) confirmed that patients seek
caring behaviours that reflect respect for human
beings, including the need to be listened to.
Following the use of a warning sign, active
listening, being supportive and the use of silence
or pauses to enable individuals to gather their
thoughts can be helpful.
Communicate bad news sensitively The
conversation should continue at a slow pace,
and the nurse should use a gentle tone and
supportive body language. Communicating bad
news is a complex task that requires expert verbal
and non-verbal skills. Verbally, cognitive and
affective messages are sent through words, voice
inflection and rate of speech. Non-verbal messages
are conveyed through eye movement, facial
expressions, and body language (Smith 1996).
The nurse’s ability to show concern and actively
listen to the patient’s fears and anxieties are crucial
when breaking bad news.
Acknowledge distress and support the
expression of feelings It is important to allow
and acknowledge the expression of feelings
no matter how patients express their distress
(Maguire et al 1996). Nurses should try to
ensure privacy, where possible, and should be
sensitive to the needs of other patients who
might be nearby. No one can predict how an
individual will react to bad news. It is important,
therefore, that nurses ensure they are prepared
and skilled to manage different responses.
These may include silence, physical
withdrawal, tearfulness, anger, agitation,
volatile behaviour and violence.
Identify and prioritise concerns When the
patient is ready the nurse should continue by
offering advice and reassurance and recapping
on what has been said and what is understood.
Patients should be encouraged to be open about
any concerns or feelings that they might have.
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Maguire et al (1996) suggested that nurses
reconsider and revisit this approach by asking
individuals to express their unique concerns
following their immediate distress. It is
impossible to assume that anyone can know
or guess the individual concerns of patients
without asking them first (Box 2).
Check the patient’s information needs Having
clarified the patient’s unique, personal concerns it
is a good idea to revisit his or her understanding
of the information given and provide further
details or clarify information as required.
Identify the patient’s support networks It is
important to identify what support the patient
has at home, for example family, friends and/or
colleagues. If there are gaps in this network
nurses should provide information on support
groups or voluntary organisations that the
individual can contact. If patients are unable
to do this, family members may wish to contact
these organisations on their behalf. Nurses can
also assist in this process if appropriate and if the
patient agrees.
Make apparent what help is available and
what will happen next Nurses should ensure
that patients are given the correct information
and kept informed about what will happen
next. Patients need to know who is available
and what specialist support exists. When
communicating bad news it can be difficult for
the patient to take all the information on board
at once. Further discussions with the same
professional, or others, can help to address any
information needs and concerns. Communicating
bad news well means that, where possible,
preparation has been carried out, the
information is given in a way that is sensitive to
the individual’s needs and the individual’s
response is acknowledged and supported.
Time out 6
Using the ten-stage strategy and
the knowledge that you have
gained from reading this article,
devise your own plan of action
to approach incidents that include
communicating bad news to patients
effectively.
Time out 7
Communicating bad news to
patients can be stressful and
emotionally demanding. How do
you care for yourself to minimise
the emotional impact of such interactions?
Who do you speak to and what support
networks, if any, do you access?
NURSING STANDARD
BOX 2
Case study
A 78-year-old man living alone was experiencing
dizzy spells. He had had a recent fall, which caused
superficial cuts and bruises. A decision was made
to admit the patient to the local hospital for further
investigation.
The nurse informed the patient of the
recommendations made by his GP and he reluctantly
agreed to be admitted to hospital. However, he
became agitated when it was suggested that he
could be admitted that same day. The nurse explained
what would happen and tried to answer all the
patient’s queries. When the nurse returned later
she found the patient in tears.
The nurse asked the patient what was wrong and
to explain to her what his concerns were about being
admitted to hospital. He quietly responded that he
did not mind going into hospital but did not know
who was going to look after his cat while he was
away as his neighbour was on holiday abroad.
The nurse was able to establish the patient’s
priorities and concerns and by doing so could actively
seek a solution to the problem. In this case, a
member of the patient’s family was contacted to
care for the cat while the patient was admitted to
hospital. The patient was then more relaxed and in
a more positive emotional state when receiving care.
The effects on nurses of communicating
bad news
Communicating bad news can be stressful,
emotionally distressing and draining. There
should be networks in place to support nurses.
These could include peer-support groups and
debriefing exercises following such incidents.
Training and case scenarios can help nurses to be
better prepared to deal with such complex
interactions. The use of role play in small groups
can increase self-awareness and confidence in
handling the emotions of nurses and patients
when they are involved in difficult conversations
(Maguire and Faulkner 1988). Communication
skills training can also play an important role in
providing nurses with the skills necessary to
communicate bad news to patients effectively
(Chant et al 2002).
Conclusion
Nurses often have to give information
to patients that could alter their expectations
about their present situation or future
circumstances. Communicating bad news is
complex and information should be delivered
in a timely and sensitive manner that
acknowledges the uniqueness of a patient’s
situation and concerns.
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Acknowledgement
learning zone reflective practice The author wishes to acknowledge the contribution
of the Communication Skills Group, which created
and delivers the Breaking Bad News Interactive
Experienced nurses can share best practice Workshops at University Hospitals Bristol NHS
through reflection and mentorship of less Foundation Trust
experienced colleagues. Nurses need to seek
opportunities to enhance their communication
skills and nurture the nurse-patient relationship. Time out 8
Self-awareness is crucial. It enables nurses to Now that you have completed
understand their own needs and self-worth and, the article you might like to write
in turn, to understand better patients’ and a practice profile. Guidelines to
relatives’ needs, and so provide appropriate help you are on page 60.
care and support NS

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