A Literature Review of Nurses Challenges and Barriers in Assisting Patients and Families Facing Breaking Bad News
How to cite this article: Wahyuni S, Gautama MSN, Simamora T. A literature review of nurses challenges and barriers in assisting patients and families facing breaking bad news. Indian J Palliat Care 2023;29:243-9.
Breaking bad news (BBN) is a challenging task for healthcare professionals, including nurses. The manner in which bad news is delivered can have a significant impact on patients and their families, either positive or negative. Understanding the roles, methods, obstacles, and challenges that nurses face in the process of delivering bad news is crucial for improving the quality of the delivery process.
Material and Methods:
This narrative review synthesises related studies. The search was conducted through PubMed, Scopus, ScienceDirect and Sage, with no restriction on publication year. The main keywords were ‘nurse’s challenge’, ‘nurse’s barrier’, ‘bad news’, ‘breaking bad news’, and ‘communicating bad news.’ A total of 12 articles were selected from 1075 articles.
Nurses play a key role in BBN before, during and after the process. Their activities include preparing patients to receive bad news, supporting patients and families when doctors deliver bad news and clarifying information obtained by patients and families regarding the prognosis of their illness. Nurses should possess skills such as building interpersonal relationships, therapeutic communication and providing emotional care for patients and their families. The main challenges and barriers for nurses in implementing BBN are due to a lack of skills and unpreparedness for patient and family reactions. After BBN, the most reported roles of nurses were supporting patients and families and helping them understand the information received from doctors. It is essential for nurses to have the necessary skills and preparedness to effectively deliver bad news to patients and their families.
Nurses play a crucial role in delivering bad news to patients and their families. They should be equipped with the necessary skills to effectively communicate with patients and their families during this difficult time. Further training for nurses in therapeutic communication, emotional care for patients and their families, and building interpersonal relationships could help to improve the quality of the delivery process.
Breaking bad news
Breaking bad news (BBN) is defined as news that changes a patient’s view of themselves or their future and is considered bad by the patient Delivering bad news to patients and families is one of the most difficult and challenging jobs experienced by healthcare workers. The delivery of bad news is often seen as an event or moment when patients and their families receive negative medical information about diagnosis, treatment, or prognosis. However, the delivery of bad news can also be seen as a process, namely the interactions carried out by health workers with patients and families before, during and after bad news is delivered. In palliative care, BBN about conditions such as cancer diagnosis, survival and disease progression is crucial. The trust relationship between the health professional and the patient is essential for effective communication. Palliative care aims to improve the patient’s quality of life and involves the patient’s family. BBN is a complex yet important communication skill that empowers and informs the patient, allowing them to plan ahead. Effective communication of bad news can help patients and their families better understand their situation and make informed decisions about their care.
Depending on how bad news is conveyed to patients or their families, it can have either a negative or positive impact.[3,9,10] As a result, physicians’ and nurses’ knowledge and abilities in delivering bad news continue to evolve.[10-13]
In general, the delivery of bad news is considered the responsibility of a doctor, even though nurses are involved in it. There have been many studies that explain the role of doctors in delivering bad news, but there are still few studies that explain the role of nurses in delivering bad news to patients and their families. Therefore, this study described the roles, methods, barriers, and challenges felt by nurses in delivering bad news to patients and their families.
MATERIAL AND METHODS
A narrative literature review followed the PRISMA scoping review framework. The search strategy used the participant/population, concept, and context approach. Electronic databases were searched through PubMed, Scopus, ScienceDirect and Sage, with no year limit for article publication. All articles were searched with the same keywords, namely ‘challenge’, ‘barrier’, ‘bad news’, ‘breaking bad news’, and ‘communicating bad news’.
The inclusion criteria were:
Articles in English that involves nurse as one of the subjects of research
The exclusion criteria were:
Opinions and systematic reviews.
The articles selected were those that could answer the research question related to the role or intervention of nurses in assisting patients and families while BBN. The criteria compliant studies were extracted and presented as a qualitative synthesis. Author, year, title, country, study design, total sample size and results were extracted. In addition, the findings highlighted the roles, barriers and challenges of nurses in the process of BBN.
The search results were exported using Endnote version 20 software, which was also used to automatically remove duplicates. Three authors screened the articles, while SW retrieved the full-text articles. The methodological quality of each article was not assessed as this study is not a systematic review.
The database search yielded a total of 1076 articles, of which 23 were duplicates. After screening the titles and abstracts of 1052 articles, 24 articles were selected for full-text screening. Full-text articles were excluded because they focused only on doctors, and did not focus on nurses, review studies or editorial studies. Of the 24 articles selected for full-text screening, only 12 fulfilled the inclusion criteria and were included in the review [Figure 1].
[Table 1] shows details about the study characteristics.
|S. No.||Author/[year]||Country||Study design||Sample||Findings|
et al. 
|Iran||Quasi-experimental||60 nurses||Nurse’s role
•Explain bad news a simple and understandable manner
•Lack of nurse knowledge
•Lack of communication skills
•Worry about the patient’s emotional reactions and management
et al. 
|Iran||Qualitative study||19 nurses||Nurse’s role
•Make basic preparations for delivering bad news
•Minimising the negative things associated with the
•Help patients and families in treatment
|3.||Arbabi et al. ||Iran||Cross-sectional||50 nurses||Nurse method
•Nurses prefer to tell bad news to patients when the patient is alone or with a partner
•Lack of communication skills
•Worry in managing the patient’s emotional reactions
et al. 
|Amerika serikat||Cross- sectional||250 nurses||Nurse’s role
•Provide support after delivery of bad news
•Give the patient/relatives the opportunity to talk about the bad news
•Help patients/relatives understand the implications of bad news
•Present when the doctor delivers bad news
•Discuss bad news when patients/relatives ask questions
•Prepare patient/relatives for bad news
•There is no preparation in delivering bad news
•Don’t have enough information
•The family’s request to keep the patient's condition confidential
•Lack of privacy
•Verbal or physical violence from patients/relatives
•Nurses receive less support in conveying bad news in certain areas
|5.||Griffiths et al. ||UK||Qualitative study||40 nurses||Challenge
•Poor patient response
•Limited preparation of nurses
|6.||Matthews et al. ||Selandia Baru||Qualitative study||Five patients, four caregivers, two surgeons and two nurses||Nurse’s role
•Recognise the patient’s emotional needs
•Convey information correctly
•Build interpersonal relationships
•Reaction of the patient or family when receiving bad news (closure)
|7.||Mishelmovich et al. ||UK||Qualitative study||10 oncology nurses||Nurse’s role
•Establish a trusting and meaningful relationship with the patient, finding out what the patient wants
•Lack of skills
•Lack of confidence
Nurse time constraints
•Deal with the patient's response
•Help patients to stay excited and not give up
|8.||Rayan et al. ||Yordania||Cross-sectional||210 nurses||Nurse’s role
•Deliver bad news precisely
•Provide emotional support
•Lack of training to improve nurses’ skills and knowledge in BBN.
|9.||Warnock et al. ||UK||Qualitative study||145 nurses||Nurse’s role
•Provides information about diagnosis and treatment.
•Accompanying patients in treatment
•Preparing the patient for the BBN process
•Anticipating the patient’s reaction after receiving the information
•Help families understand information
|10.||Banerjee et al. ||USA||Qualitative study||146 nurses||Nurse barriers
•Difficulty in showing empathy to patients
•The burden of delivering bad news
•Lack of skills in communicating
•Negative patient and family reactions
|11.||Warnock et al. ||UK||Qualitative study||236 nurses||Nurse’s role
•Provide support and opportunities for patients and families to talk about bad news
•Helping patients and relatives accept the implications of bad news
•Discuss bad news when the patient or relative
•Prepare patients and relatives for bad news
•Deliver bad news directly
•Unpreparedness of patients and nurses
|12.||Reinke et al. ||USA||Qualitative study||55 patients, 36 family members, 31 doctors and 22 nurses||Nurse’s role
•Support patient expectations
•Help meet information needs
The role of nurses in BBN can be divided into three parts, namely:
The role of the nurse before BBN is to prepare the patient, family, and environment before BBN.[14-16] Therefore, the nurse must be able to establish a trusting and meaningful relationship with the patient and find out the patient’s wishes.[17,18] In addition, the nurse also has a role in anticipating the patient’s and family’s reactions to the bad news that will be delivered.
During the BBN
The role of the nurse during the BBN is to be present during the breaking of bad news.[15,16,19] During the BBN process, the nurse must recognise and pay attention to the special emotional needs of patients and caregivers.[17,20] Studies report that nurses also break bad news directly to patients and families.[15,21]
After the BBN
The most reported role of nurses is to help the family understand the bad information received from the doctor with simpler language until the patient or family can accept or manage the bad news.[15,16,19-21] Nurses also play a role in helping patients and families to plan for logical treatment and make treatment decisions.[14,22] Nurses continuously provide emotional support[15-20] and help patients to have a quality life.[19,23]
One study was identified that discusses nurses’ methods of delivering bad news. According to this study, nurses prefer to deliver bad news privately to patients or their partners.
The challenges felt by nurses in BBN are the unpreparedness of nurses to face reactions from patients or families and how to build and maintain a supporting relationship with patients so that they do not despair.[16,23] Nurses also reported a lack of time in the BBN process due to busy work.
about the patient’s emotional reactions and how to manage them.[16,17,21,24,25] In addition, nurses also had barriers in building trusting relationships with patients due to lack of time, lack of knowledge about the patient’s illness, and lack of experience.[15,16,18,21,25] Nurses also did not always feel prepared when asked by patients or patients’ families.[20,22]
The role of nurses
BBN is one of the most challenging duties healthcare providers face. The role of nurses in BBN can be divided into three parts: Before, during and after BBN. Before BBN, the nurse’s role is to prepare the patient, family and environment, establish a trusting relationship with the patient and anticipate reactions to the bad news. During BBN, the nurse’s role is to be present and pay attention to the emotional needs of patients and caregivers. After BBN, the nurse’s role is to help the family understand the bad news, plan treatment, provide emotional support and help patients to have a quality life. However, nurses may face difficulties during the BBN process due to unclear roles in the BBN process. According to the literature, the doctor is responsible for delivering bad news and nurses have a role in assisting the doctor.[4,15] Literature identifies numerous duties for nurses during the BBN process, including providing information and assisting patients.[27,28]
Barriers in delivering BBN
Ineffective communication skills pose the greatest barrier for nurses in imparting bad news. Weak communication can lead to high levels of stress.[14,29] Carers may carry the added burden of feeling because they conceal information from patients to protect them from further distress.[30,31] Many factors influence the delivery of bad news such as complex communication and managing negative patient reactions, tailoring delivery to meet individual patient preferences and cultural needs,[33,34] managing their own emotional reactions and working within the time and resource demands of their workplace.
Nurses tend to deliver bad news about the transition to death in community settings, especially in other countries such as European, Scandinavian and North American nations.[36-39] Hence, the nurse is often the first point of contact when the patient is transitioning to death. The nurse’s method is to deliver bad news when the patient is alone or with a partner.[25,41] The provision of effective BBN can also be prepared since patients receive early palliative care, not only improving their quality of life but also preparing them to face the worst conditions. However, it is important to note that this is the finding of a single study and further research is needed to draw more definitive conclusions.
Challenges faced by nurses while delivering BBN
Nurses face several challenges while delivering BBN. These include unclear roles in the BBN process, ineffective communication skills, managing negative patient reactions, tailoring delivery to meet individual patient preferences and cultural needs, managing their own emotional reactions and working within the time and resource demands of their workplace. The difficulties experienced by nurses and healthcare staff when engaging in the process of BBN are influenced by multiple, complex and interrelated factors. Being involved in difficult situations and events associated with BBN has negative consequences for patients, relatives and healthcare staff. Nurses also can experience a high rate of burnout and compassion fatigue from BBN, which may have distressing effects on professional performance and general health.
Nurses play an important role in accompanying patients and their families when doctors deliver bad news and in clarifying information about the prognosis of their disease. The nurse’s duties in assisting patients and their families in dealing with bad news are divided into three parts, namely before BBN, during BBN and after BBN.
To effectively carry out these tasks, nurses must possess skills in fostering interpersonal relationships, engaging in therapeutic communication and managing the emotional state of patients and their families. However, these tasks can present challenges and obstacles for nurses. To overcome these challenges and empower nurses to break bad news, several strategies can be implemented. These include providing training and education in communication skills, offering support and resources such as ecounseling services or peer support groups and choosing an appropriate time to deliver BBN. By implementing these strategies, nurses can be empowered to effectively break bad news to patients and their families.
Strength and limitation
This study aims to investigate the role of nurses in the process of BBN, as well as the challenges and barriers they perceive. While previous research has suggested that only doctors can deliver bad news, numerous studies have demonstrated that nurses play a unique role in this process. This research can provide clarity on the role of nurses in delivering bad news and can be expanded to explore how their perspectives and roles vary across different health services. However, this study has several limitations. It is restricted to the use of English, which may have resulted in the exclusion of relevant articles. In addition, the positive outcomes cited were examined qualitatively.
Nurses play a crucial role in BBN to patients and their families. This role can be divided into three parts: Before, during and after BBN. Nurses prefer to deliver bad news privately with patients or their partners. However, they face several challenges while delivering BBN, including unpreparedness to face reactions from patients or families and lack of time due to busy work schedules. The most commonly reported barriers by nurses were lack of communication skills, concerns about managing patient’s emotional reactions and difficulties in building relationships with patients due to lack of time, knowledge and experience.
Declaration of patient consent
Patient’s consent not required as there are no patients in this study.
Conflicts of interest
There are no conflicts of interest.
Financial support and sponsorship
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