BREAKING BAD NEWS: STRENGTHS, DIFFICULTIES AND STRATEGIES USED BY UNDERGRADUATE NURSING STUDENTS

COMMUNICACIÓN DE NOTICIAS DIFÍCILES: FACILIDADES, DIFICULTADES Y STRATEGIAS UTILIZADAS POR LOS ESTUDIANTES DE ENFERMERÍA EN SU FORMACIÓN

ABSTRACT

Objective:

identify strengths, difficulties, and strategies used by nursing students to communicate bad news within the Primary Health Care context during the undergraduate program.

Method:

exploratory-descriptive study addressing 12 students attending the 7^th to the 10^th semesters of the nursing undergraduate program of a federal university located in southern Brazil. Their perceptions focused on the Primary Health Care context. A non-probability sampling technique called snowball sampling was used. Data were collected in June 2019 in the university’s premises using Focal Groups and analyzed through Discourse Textual Analysis.

Results:

the strengths that the students identified at the time of communicating bad news included teamwork, bonds, self-knowledge, and knowing the patients. Regarding difficulties, the students mentioned a lack of formal preparation, dealing with their own feelings, patients’ responses, and not knowing how to deal with such responses. Regarding the strategies used to communicate bad news, the students mentioned empathy and sensitivity, clear communication, giving hope, scheduling more than one consultation, and finding an appropriate place to talk with patients.

Conclusion:

the students considered that teamwork, bonds, knowing patients, and self-knowledge are strengths that facilitate the communication of bad news within the Primary Health Care context. Difficulties included lack of preparation and not knowing how to deal with their own feelings. Various strategies were mentioned, such as empathy, sensitivity, and clear communication.

DESCRIPTORS:
Health communication; Primary health care; Ethics; Ethics nursing; Nursing

RESUMEN

Objetivo:

identificar las facilidades, dificultades y estrategias utilizadas por los estudiantes de enfermería en la comunicación de noticias difíciles, en la Atención Primaria a la Salud, durante el período de formación.

Método:

estudio exploratorio descriptivo con abordaje cualitativo. Participaron 12 estudiantes de enfermería, del 7° al 10° semestre, en una Universidad Federal en el sur de Brasil; las percepciones estuvieron enfocadas en la Atención Primaria a la Salud. La selección fue por muestreo no probabilístico do tipo bola de nieve. Los datos fueron recogidos en junio de 2019, en un local específico en la universidad, a partir de la metodología de Grupo Focal, y sometidos al Análisis Textual Discursivo.

Resultados:

como facilidades encontradas, en el momento de participar en la comunicación de noticias difíciles, los estudiantes citaron el trabajo en equipo, el vínculo, el autoconocimiento y el conocimiento del usuario; como dificultades fueron mencionadas la falta de preparación, el lidiar con las propias emociones, las reacciones de los usuarios y cómo lidiar con ellas; en lo que se refiere a las estrategias utilizadas para comunicar las noticias difíciles, fueron citadas: empatía, sensibilidad, clareza en la comunicación, mantener la esperanza, realizar más de un encuentro y espacio adecuado para comunicarse.

Conclusión:

se observó que el trabajo en equipo, el vínculo, el conocimiento del usuario y el autoconocimiento, citados por los estudiantes, son facilidades encontradas al comunicar noticias difíciles durante la Atención Primaria. Las dificultades están relacionadas a la ausencia de preparación para comunicar y al modo de lidiar con las emociones. Diversas estrategias fueron citadas, como empatía, sensibilidad y clareza en la comunicación.

DESCRIPTORES:
Comunicación en salud; Atención primaria de salud; Ética; Ética en enfermería; Enfermería

RESUMO

Objetivo:

identificar as facilidades, dificuldades e estratégias utilizadas pelos estudantes de enfermagem na comunicação de notícias difíceis na Atenção Primária à Saúde durante o período de formação.

Método:

estudo exploratório-descritivo com abordagem qualitativa. Participaram 12 estudantes de enfermagem, do 7° ao 10° semestre, de uma Universidade Federal do Sul do Brasil, cujas percepções tiveram foco na Atenção Primária à Saúde. A seleção foi por amostragem não probabilística do tipo bola-de-neve. Os dados foram coletados em junho de 2019, em local específico na universidade, a partir da metodologia de Grupo Focal, e submetidos à Análise Textual Discursiva.

Resultados:

como facilidades encontradas no momento de participar na comunicação de notícias difíceis, os estudantes citaram o trabalho em equipe, vínculo, autoconhecimento e o conhecimento do usuário; como dificuldades foram elencadas a falta de preparo, lidar com as próprias emoções e reações dos usuários e como lidar com elas; no que tange às estratégias utilizadas para comunicar as notícias difíceis, foram citadas a empatia e a sensibilidade, clareza na comunicação, manter a esperança, mais de um encontro e espaço adequado para comunicar.

Conclusão:

visualiza-se que o trabalho em equipe, vínculo, conhecimento do usuário e o autoconhecimento, citado pelos estudantes são facilidades encontradas ao comunicar notícias difíceis na Atenção Primária. As dificuldades estão relacionadas à ausência de preparo para comunicar e o modo de lidar com suas emoções. Diversas estratégias foram citadas, como empatia, sensibilidade e clareza na comunicação.

DESCRITORES:
Comunicação em saúde; Atenção primária à saúde; Ética; Ética em enfermagem; Enfermagem

INTRODUCTION

Bad news refers to information that drastically and negatively changes a patient’s life. It is generally associated with situations that threaten a patient’s life, his/her personal, familial, or social well-being, besides causing potential physical and psychological consequences1. Most of the time, the recipients of these messages think about severe illnesses or family loss. However, its definition depends on the individuals’ personal experiences2. Therefore, a patient’s life expectations, values, experiences, and social situation influence the meaning assigned to each message communicated by a health worker or future health worker. Thus, a wide variety of information can be considered bad news2.

Breaking bad news is one of the most challenging tasks faced in the health field, and it can be even more daunting among students, considering the potential emotional consequences on patients and their support network,3 as well as on the professionals responsible for this task. The way bad news is communicated directly influences the relationship between health providers and patients, how patients deal with this particular information, their level of hope, their personal and familial relationships, and whether they will strive to improve quality of life and adhere to the treatment4.

Knowing how to communicate bad news is a complex and challenging skill, though essential for health workers to learn and practice5. It can be developed and improved and needs to be incorporated into the complex context of Primary Health Care. Many communication strategies can improve the care provided to patients, such as verbal and non-verbal communication. However, communication needs to be qualified as it provides information that helps patients and families understand the message and prepare for future decision-making5.

The training of health workers in Brazil presents weaknesses in terms of the communication of bad news. To fill in this gap, this topic needs to be incorporated by higher education institutions to prepare future health workers to deal with situations that concern death and the communication of bad news6. Failure to address this topic during the undergraduate program may become a barrier when these professionals see themselves in the future with the complicated duty to communicate bad news7.

Primary Health Care comprises the delivery of care to individuals or the community, including health promotion, preventive measures, treatment, rehabilitation, and health maintenance, and is an important setting for nurses’ practice8^-9. A large portion of care actions are provided within the context of Primary Health Care, which is the entrance door to the Brazilian health care system. Hence, there are numerous situations in which patients’ health conditions and diagnoses are communicated daily when patients require guidance or are referred to a facility with a medium or high technology level.

The situations demanding the communication of bad news within the Primary Health Care are closely linked to nursing procedures such as rapid tests (e.g., HIV, Syphilis, and Hepatitis), pregnancy tests; nursing consultations, the follow-up of chronic patients, and other situations that may be a potential problem for the messenger and recipient of the message.

The relevance, contribution, and impact of this study are linked to the discussion in the academic milieu regarding the communication of bad news within the Primary Health Care context. It is a topic seldom addressed in the scientific literature, while most undergraduate programs in the health field fail to include knowledge that can contribute to future workers’ practice regarding the communication of bad news.

For this reason, the following question is asked: How nursing students experience the communication of bad news in the context of Primary Health Care? Health workers and future health workers are expected to enhance communication skills to provide quality care. Based on the previous discussion, this study’s problem refers to the lack of knowledge regarding strengths, difficulties, and strategies used by nursing students when communicating bad news within the Primary Health Care context. This study’s objective was to identify the strengths, difficulties, and strategies adopted by nursing students when communicating bad news in the context of Primary Health Care during the undergraduate program.

METHOD

This qualitative, exploratory, and descriptive study addressed 12 undergraduate students attending the 7^th to the 10^th semester of the nursing program provided by a federal university located in southern Brazil. Students attending supervised training courses in the Primary Health Care network were selected. The interest in this topic emerged because Primary Health Care is the gateway to the Brazilian health system, and there is a frequent need to communicate bad news that concerns the patients’ health conditions and diagnoses.

The participants were recruited according to the non-probability snowball sampling technique10. Thus, the authors’ first participant suggested the next participant until a total of 12 students was recruited. The first participant was chosen because of his interest in Primary Health Care, prior experience with supervised courses, and extension projects within Primary Health Care. Six students were attending the 7^th semester; two were in the 8^th semester; one in the 9^th semester; and three were attending the 10^th semester.

The Focal Group technique, which enables the participants to discuss a given topic extensively and directly, was used11. All the 12 students attended three meetings in June 2019. The meetings took place in a previously reserved classroom on the federal university’ premises. The weekly meetings lasted 1h and 30mins each and were coordinated by a moderator and monitored by one observer. A semi-structured script was used to guide the focal groups, with questions addressing different situations, as shown below.

An introduction to the topic was provided in the first meeting, and the movie “Empathy - Cleveland Clinic”^* was presented. The movie addresses how to put oneself in someone else’s situation and practice empathy. It depicts different situations experienced by people in life, including their fears and doubts, eliciting viewers to reflect upon the question: “if you could stand in someone else’s shoes, hear what they hear, see what they see, and feel how they feel, would you treat them differently?” The movie was presented to observe the participants’ level of understanding, knowledge, and attitudes toward the subject. With only the expression “Bad News” written, paper sheets were delivered immediately after the movie. The participants were supposed to record on the paper all their feelings regarding the subject and movie. Finally, to promote interaction, conversation, and discussion within the group, the students were asked to verbalize their feelings.

The second meeting started with two movies,” “50/50: El Diagnóstico”^** and “Comunicando notícias difíceis^*** which address the interaction between a physician and patient in which a difficult diagnosis is communicated. The physician explains all the disease’s aspects without checking what the patient wants and does not want to know and without letting the patient process information or clarify doubts. This movie was presented to promote a discussion, and the participants were asked to think and reflect upon the professional’s behavior and the main challenges nurses experience when communicating bad news within Primary Health Care.

A synthesis of the second meeting was presented in the last meeting to recall the topics discussed. Then, the group was asked to discuss and present ways to communicate bad news. The objective was to propose strategies that facilitate effective communication beginning in the undergraduate program.

The content addressed in the Focal Group was transcribed and submitted to Discourse Textual Analysis, which is based on four components: unitization, categorization, apprehension of new emergent content, and self-organized process12. The first component, unitization, was conducted by exhaustive reading the content from the focal group and establishing units of meaning linked to the topic: breaking bad news within Primary Health Care.

The second component consisted of grouping similar units of meaning. Later, these units were named and organized into categories. This stage follows an inductive and intuitive process; that is, the categories emerged after reading the text, comparing and organizing them into similar meanings, resulting in in-depth knowledge regarding the topic.

The new emergent was the third component of the discursive textual analysis. Common meanings regarding what was collected during the study were described and interpreted, facilitating understanding. These three components led to the fourth component, called self-organized process. In this stage, a new understanding emerged after the disorder experienced during the process.

The study was initiated after the Institutional Review Board approved the study while all ethical guidelines concerning research addressing human subjects were complied with. The participants consented and signed free and informed consent forms, after which the focal group was initiated. Confidentiality was ensured by coding the participants’ identities; that is, the students were identified by letter “E” followed by the number that corresponded to their first reports, i.e., “E1, E2,...” until the last participant, “E12,” was identified. Naturally, participants could speak more than once; however, their identifications remained.

RESULTS

Three categories emerged from data analysis: strengths the students identified regarding the communication of bad news within Primary Health Care; difficulties students identified regarding the communication of bad news within Primary Health Care; and strategies listed by the students regarding the communication of bad news within Primary Health Care. Figure 1 presents a summary of the results.

Figure 1 -
Strengths, difficulties, and strategies in the communication of bad news within Primary health care.

Strengths the students identified regarding the communication of bad news within Primary Health Care

This category presents the factors, which, according to the nursing students, facilitate the communication of bad news within Primary Health Care. These factors include teamwork, the establishment of bonds, self-knowledge, and knowing patients. Note that the students consider that teamwork and having the support of a multi-professional team facilitate the communication of bad news because the relationship that is established and the specific knowledge from each profession promote a bond of trust, while support provided by the team stands out, together with providing greater support to patients in order to provide quality care:

But when you think within a team, things get more comfortable. Because you may say something and don’t realize the person has a question, but then someone else realizes it and intervene, clarifying doubts - this sort of concern (E6).

[...] Teamwork makes you self-assured, so you can work it out, deliver bad news, confirm bad news, and then give support (E7).

According to the students, bonds also facilitate the communication of bad news because greater proximity is established with patients. Hence, communication is more effective between workers and patients, and attentive listening and dialogue prevail. In turn, it facilitates treatment adherence and the actions implemented by primary health care units, relieving the tension that usually accompanies the communication of bad news.

Most workers in the network can establish bonds with patients. I think that having a bond facilitates the disclosure of bad news (E2).

[...] Nurses more frequently establish bonds with the community. Bonds make patients more comfortable to seek you when facing difficult times (E6).

Self-knowledge was mentioned as a factor that facilitates communication because the students believe it is essential to establish boundaries, not exceeding one’s communication skills, thus avoiding poor communication with patients. This issue is essential in the context of Primary Health Care, considering that poor communication or miscommunication may impose barriers and hinder the relationship between patient/worker/PHC unit, leading patients and families to have doubts and experience anxiety.

[...] I need to know myself, I may not want to touch anyone, but I’ll have to play my part, and that’s what matters. The person will leave the service well informed and with treatment (E1).

[...] It makes me think of self-knowledge because we need to know ourselves too; there are different kinds of people. Some people will touch, while some professionals won’t, but will be able to give support, to assist. So I guess that more critical than having classes or courses addressing how to communicate bad news is to know yourself, know your limits, and see the point you can get as a professional and as a human being (E7).

The students reported that knowing patients facilitate the workers’ job when communicating bad news - having close contact with patients enables workers to adapt communication to each patient according to their expectations, level of understanding, and interest, promoting improved understanding.

We have to know a little bit about the patient’s life, what he does to make a living, his daily experiences to understand and make him understand […] (E6).

Actually, we have to know our patients, so we know how to behave (E10).

Difficulties the students identified regarding the communication of bad news within Primary Health Care

According to the nursing students, the aspects hindering the communication of bad news include lack of preparation, the health workers’ feelings, and the patients’ responses and not knowing how to deal with them. The students consider that not being prepared to deal with bad news is closely related to the fact that this topic is not addressed during the undergraduate program. It is an issue faced in both contexts. Breaking bad news is a difficult situation that is not adequately addressed during the undergraduate program. It seems to be even more challenging in Primary Health Care, a context in which bad news is often disregarded or seldom acknowledged, hindering professionals’ work even more.

We are not trained to communicate bad news (E1).

For me, the greatest difficulty is lack of preparedness; it’s the fear of dealing with the subject, not knowing how patients will respond. I guess that all this results from a lack of preparedness (E4).

You know, we have little, very little contact; we have no contact with this topic. There is no way we will know how to give bad news or what we can use; it depends on what we infer, like, the little we know, what they tell us, and we figure out what we can do (E11).

The need to deal with one’s own feelings was also considered a difficulty that hinders the communication of bad news. When future workers need to give bad news, they experience a mix of feelings and might be emotionally affected. In this sense, they need to work on this aspect, deal with their feelings first, and avoid getting carried away by emotion to use adequate communication, keep composed, be sensitive and objective, and provide support.

I try to keep my feelings aside and express my feelings only later. This is how it’s been so far, but I don’t know how it will be in my practice (E1).

Most people have no idea that you’re dealing with bad news; you have to deal with the bad news first [...] (E4).

I guess we never, actually nobody is ever prepared because it is something that you deal with feelings. People also don’t know how to deal with their own feelings, and dealing with the feelings of someone else’s, who is going through pain, is complicated (E6).

Another difficulty frequently mentioned by the students is related to the patients’ responses and how to deal with them. According to the participants, responses are unpredictable, and students may not feel prepared to intervene, which may become difficult when communicating bad news, whether in a hospital setting or within the Primary Health care context.

[...] Reactions vary; there’s no way we are absolutely sure about how people will respond. He may cry when receiving a piece of sad news, get angry, irritated, or simply become apathetic, showing no reaction. You have to know how to deal with it. I’ve seen many different responses, so each person has a different response when receiving bad news (E6).

It is a dilemma you know, you can’t tell how your patient will react, even if you‘re sensitive, if you see things from that perspective because you’ve been through it yourself, you don’t know how the patient will react, whether he’ll get angry, whether he’ll experience all the mourning stages, it’s very complicated (E9).

Perhaps the person will have a given response, and we’ll be like, “God, what do I do now?” I won’t know how to react. Because I don’t know how to deal with all that, so I guess it is difficult (E10).

Strategies listed by nursing students regarding the communication of bad news within the Primary Health Care context

This category includes strategies the nursing students adopt when communicating bad news to facilitate communication, namely: empathy and sensitivity, clear communication, giving hope, scheduling more than one consultation, and finding an appropriate environment to make this communication. Sensitivity and empathy were mentioned as strategies to communicate bad news, assuming that when we stand in someone’s place, we expand our ability to establish and keep affective bonds, which is essential for the communication process. Communication that is based on empathy and sensitivity can minimize potential negative effects bad news may entice.

I guess that the main feeling that we, as professionals must have, is empathy, putting ourselves in someone else’s place (E6).

[...] I guess that we keep thinking about how we can speak in a way that won’t sound rude or cold. I suppose that sometimes people giving bad news lack sensitivity. Being sensitive and empathic is essential. It is about a person, a human being, who has feelings as well. So, what I am going to say will affect this person somehow (E10).

Clarity was mentioned as a fundamental aspect of the communication of bad news, considering that not all patients have the same level of understanding. Hence, communication has to be adequate to each patient to promote understanding of what is being said. This (individual) adaptation of communication can be based on a detailed explanation, written explanation, drawing and simple language to facilitate understanding.

[...] I guess that is a matter of “reading the patient” and adapt it to that specific situation (E1).

I’ll try an approach he understands; one I can help him to understand (E5).

I guess that in addition to talking about the pathology, giving information about the pathology, you have to use clear language so he can understand what it is, all the process he’ll go through, what will happen from the time of the consultation, from that moment on, from the moment I deliver the news [...] (E6).

Another strategy was to give hope, letting the patient know what can be done, encourage the patient and keep him/her motivated to deal with the new condition, even in the face of bad news. Giving hope can be, for instance, combining news, that is, providing good news after bad news. Hence, it is possible to highlight positive aspects even when facing a difficult situation.

[...] I guess we should always give some hope, encourage people to comply with the treatment, so they’ll try to understand what is happening. I think it is important to not discourage them (E2).

Talking positive things as well, not focusing only on what is negative. I guess it is essential to give some hope to patients (E4).

[...] Always listing positive aspects, telling about good things that can happen, acknowledging what is bad, but highlighting the fact that there is treatment. Presenting solutions for the problems that may arise (E6).

The students believed that a good strategy is to disclose bad news in more than one consultation or allow the patient to meet more than once. The communication of bad news may contain information that causes doubts and anxiety, so that information should be broken into parts, as not all content can be assimilated in a single meeting. Additionally, patients need continuous support and care, facilitated when there is more than one consultation.

I guess having more than one consultation is ideal and seeking out the patient if he misses a consultation (E3).

Because I won’t see him only in that single time. You can’t clarify all doubts in a single consultation. Other consultations are needed, regardless of whether they will consult with me, the worker he saw the first time. Even if I don’t see him a second time, he’ll be assisted and get support from other professionals (E6).

Another strategy adopted by the students is to seek an appropriate environment to communicate bad news. This place should be pleasant, welcoming, and keep patients’ privacy, so they can express their feelings without feeling constrained, free of noise or interruptions, seeking to make patients comfortable, so that the professional can communicate effectively and without interferences.

I guess that the first consultation has to be in a calm environment, a referral office (E1).

No noise because it may be distracting. I guess we should avoid exposing the patient (E9).

First thing, respect the patient’s privacy (E12).

DISCUSSION

From the nursing students’ perspective, teamwork facilitates the communication of bad news. Teams composed of different specialties and complementary knowledge seem to provide quality care to those receiving bad news13. Teamwork enables a broader and collective view, facilitating the division of tasks and the need to collaborate to achieve common objectives14.

Therefore, it appears that workers are not alone when communicating bad news, considering that they can get the support of the remaining members of the team, exchange experiences, and work15 as a team to meet patients’ needs. However, for teamwork to occur, workers need to recognize the relevance of working as a team, considering that each one plays an essential role in the care provided to the population16.

Communication in the nursing work environment emerges as a basic and essential tool to provide care and to establish bonds between workers and patients17. Bonds are a therapeutic mechanism, an essential element for the functioning of Primary Health Care, as it mediates the communication between patients and workers and builds closer relationships18. Bonds also promote co-responsibility and continuity of care, aiding patients to adhere to the workers procedures. Bonds are essential when communicating bad news, considering it enables workers to implement humanized actions such as attentive listening, supporting, and dialoguing to establish a relationship of trust and ensuring integral care is provided to patients.

The students mentioned self-knowledge also facilitates the communication of bad news. Self-knowledge is related to workers recognizing their limitations and knowing the point to which they can advance in the communication process. In this sense, self-knowledge enables individuals to understand their own responses and emotions and improve their confidence and relate better with others. This element is essential during the communication process because it allows workers to identify the best time to disclose bad news, avoiding miscommunication and problems in the relationship with patients.

Knowing patients was another element considered a facilitating factor. According to the students, it enables workers to communicate with patients while considering their needs, life history, beliefs, and culture. This finding corroborates with the Oikonomidou,19 who states that the most efficient way to communicate bad news is through an individualized approach intended to meet patients’ needs.

According to nursing students, one of the factors weakening the communication of bad news is the lack of formal preparation during the undergraduate program. This finding is in line with a study20 that identified that various communication problems might be related to a failure of undergraduate programs in providing specific knowledge for future workers to be technically more competent when conducting a conversation with patients.

The curriculum of some undergraduate nursing programs does not include the subject “bad news”. This lack of formal preparation affects the students attending mandatory supervised training in Primary Health Care more intensively because, in this context, bad news is seldom acknowledged. Therefore, the current context regarding the communication of bad news still has a long way within teaching institutions to ensure that this topic’s importance is acknowledged1.

The difficulties reported by the students addressed here concerning this communication within Primary Health Care are related to the fact that bad news is seldom addressed at this level of care. That is, when these situations do occur, they are not considered bad news. This weakness in the communication process causes problems to occur. Hence, the students addressed here believe that knowing this topic is vital to dealing with these situations. Given the strengths identified in this study, it is possible to change the current context surrounding the communication of bad news within Primary Health Care.

What makes the communication of bad news a complex task is that it triggers feelings in both workers and patients. Patients experience sorrow and despair while workers have to cope with their own feelings. Therefore, patients and families are not alone when there is the communication of bad news21.

Health workers are the first to receive the bad news and need to process it promptly to pass it on to the patients and their families22. In this sense, workers’ feelings are not usually taken into account while technical quality is a priority. However, the impact of bad news can directly interfere with the care provided to patients,23 mainly because it involves a range of different feelings.

Another difficulty frequently mentioned by the students is related to the patients’ responses and how they are supposed to deal with these. The students argue that responses vary and are unpredictable. This finding corroborates with a study24 reporting that one of the problems workers experience is not knowing how patients will react to bad news. Each patient responds differently, demanding skills workers do not use frequently, nor are prepared to develop, making the task complex and reinforcing the need to broaden the discussion in undergraduate programs.

Even though they received little guidance during the undergraduate program, the participants mentioned some strategies they adopt when communicating bad news, seeking to implement appropriate and humanized communication, which is the case of sensitivity and empathy. Adopting an empathic behavior when delivering bad news is perhaps the best way to communicate with patients. Empathy is the ability to provide support and comfort in a time of vulnerability, anxiety, and anguish, all feelings patients usually experience when receiving bad news25. When practicing empathy, workers approximate themselves to patients and make themselves open to provide emotional support to patients and families. Empathy is believed to positively influence the relationship between workers and patients.

Another strategy adopted by the students is to communicate bad news clearly to facilitate understanding of patients. Considering that comprehension varies from person to person, it is extremely relevant that news is clearly and directly communicated, using simple language and avoiding the use of technical terms so that patients acquire a better understanding of what is said26.

When dealing with complex situations, such as delivering bad news, health workers are supposed to support patients and families, letting them know they will not be alone to fight the battle and give hope to patients and families²⁷. Workers who communicate news in a hopeful and optimistic way are seen as more sensitive than those who provide the same information without giving hope or combining bad news with good news²⁸. Delivering a combination of news means providing bad news while at the same time providing good news, that is, the bad news is accompanied by a solution or a plan of treatment, for instance28. When good news accompanies bad news, the workers are acting empathically toward patients. Empathy behavior enables good communication/relationships and increases the satisfaction of workers and patients28.

The entire content of bad news should not be delivered in a single consultation, and nurses should be aware of this fact to help patients and families process information and clarify doubts,² as well as provide emotional support. When communicating bad news, it is essential to have a broadened perspective, considering the care delivery process; that is, this approach should not be used only when the news is communicated29.

A private room should be used when communicating bad news to ensure patients’ privacy and that there will be no interruptions or interferences30. This piece of information corroborates this study’s findings. Additionally, according to the students, having a private room, free of noise and interferences, enables efficient communication while patients can express their feelings without constraints.

This study’s limitations include the fact that it was conducted with a single group of students; thus, it may not reflect all opinions regarding the topic. Additionally, there is a lack of scientific studies addressing the communication of bad news within Primary Health Care. This study suggests that discussions and reflection regarding this topic need to be further explored in the future.

CONCLUSION

The strengths identified by the students at the time of communicating bad news include teamwork, the establishment of bonds, self-knowledge, and knowing patients. Difficulties include lack of formal preparation, dealing with one’s own emotions, and patients’ responses. The strategies used to communicate bad news included empathy, sensitivity, clear communication, giving hope, scheduling more than one consultation, and finding an adequate room for communications.

Note that Primary Health Care’s weaknesses concerning the communication of bad news are related to the fact that bad news is seldom acknowledged in this context. However, the strategies that the students listed throughout the study have the potential to transform daily practice. Additionally, health workers and future workers need to deepen discussions and reflect upon the topic during undergraduate nursing programs and health settings, which is an excellent strategy to (re)think about one’s professional practice.

REFERENCES

• 1. Silva AE, Sousa PA, Ribeiro RF. Communication of bad news: perception of physicians working in oncology. Rev Enferm Cent-Oeste Min [Internet]. 2018 [cited 2019 Sept 22];(8):e2482. https://dx.doi.org/10.19175/recom.v7i0.2482
  » https://dx.doi.org/10.19175/recom.v7i0.2482
• 2. Warnock C. Breaking bad news: issues relating to nursing practice. Nurs Stand [Internet]. 2014 [cited 2019 Sept 22];28(45):51-8. Available from: https://doi.org/10.7748/ns.28.45.51.e8935
  » https://doi.org/10.7748/ns.28.45.51.e8935
• 3. Calsavara VJ, Scorsolini-Comin FS, Corsi CAC. The communication of bad news in health: approximations with the person-centered approach. Rev Abordagem Gestál [Internet]. 2019 [cited 2019 Sept 22];25(1):92-102. Available from: https://doi.org/10.18065/RAG.2019v25.9
  » https://doi.org/10.18065/RAG.2019v25.9
• 4. Sombra Neto LP, Silva VLL, Lima CDC, Moura HTM, Gonçalves ALM, Pires APB, et al. habilidade de comunicação da má notícia: o estudante de medicina está preparado? Rev Bras Educ Méd [Internet] 2017 [cited 2019 Sept 22];41(2):260-8. Available from: https://doi.org/10.1590/1981-52712015v41n2RB20160063
  » https://doi.org/10.1590/1981-52712015v41n2RB20160063
• 5. Hollyday SL, Buonocore D. Breaking bad news and discussing goals of care in the Intensive Care Unit. Adv Crit Care Nur [Internet]. 2015 [cited 2019 Sept 22];26(2):131-41. Available from: https://doi.org/10.4037/NCI.0000000000000082
  » https://doi.org/10.4037/NCI.0000000000000082
• 6. Bastos RA, Fonseca ACG, Pereira AKS, Silva LCS. Formação dos profissionais de Saúde na comunicação de más notícias em cuidados paliativos oncológicos. Rev Bras Cancerol [Internet]. 2016 [cited 2019 Sept 22];62(3):263-66. Available from: https://doi.org/10.32635/2176-9745.RBC.2016v62n3.342
  » https://doi.org/10.32635/2176-9745.RBC.2016v62n3.342
• 7. Silva LPS, Santos I, Castro SZM. Giving bad news in the context of cancer care: integrative literature review. Rev Enferm UERJ [Internet] 2016 [cited 2019 Sept 22];24(3):e19940. Available from: https://doi.org/10.12957/reuerj.2016.19940
  » https://doi.org/10.12957/reuerj.2016.19940
• 8. Lavras C. Atenção Primária à Saúde e a Organização de Redes Regionais de Atenção à Saúde no Brasil. Saúde Soc [Internet] 2011 [cited 2019 Sept 22];20(4):867-74. Available from: https://doi.org/10.1590/S0104-12902011000400005
  » https://doi.org/10.1590/S0104-12902011000400005
• 9. Ministério da Saúde (BR). Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Política Nacional de Atenção Básica. Portaria Nº 2.436, de 21 de setembro de 2017. [Internet] 2017 [cited 2020 Apr 19]. Available from: http://www.saude.df.gov.br/wp-conteudo/uploads/2018/04/Portaria-nº-2436-2017-Ministério-da-Saúde-Aprova-a-Política-Nacional-de-Atenção-Básica..pdf
  » http://www.saude.df.gov.br/wp-conteudo/uploads/2018/04/Portaria-nº-2436-2017-Ministério-da-Saúde-Aprova-a-Política-Nacional-de-Atenção-Básica..pdf
• 10. Vinuto JA. A amostragem em bola de neve na pesquisa qualitativa: um debate em aberto. Temáticas Rev Ciênc Sociais (Unicamp) [Internet]. 2014 [cited 2019 Aug 8];22(44):203-20. Available from: https://econtents.bc.unicamp.br/inpec/index.php/tematicas/article/view/10977
  » https://econtents.bc.unicamp.br/inpec/index.php/tematicas/article/view/10977
• 11. Busanello J, Lunardi Filho WD, Kerber NPC, Santos SSC, Lunardi VL, Pohlmann FC. Grupo focal como técnica de coleta de dados. Cogitare Enfermagem [Internet] 2013 [cited 2019 Sept 22];18(2):358-64. Available from: https://doi.org/10.5380/ce.v18i2.32586
  » https://doi.org/10.5380/ce.v18i2.32586
• 12. Moraes R, Galiazzi MC. Análise textual discursiva. 2th ed. Ijuí, RS(BR): Editora Unijuí; 2013.
• 13. Bianchini D, Peuker AC, Bittencourt FR, Kern de Castro E. Comunicação em oncologia: uma análise qualitativa sob o enfoque psicanalítico. Psicol Estud [Internet]. 2016 [cited 2019 Oct 01];21(2):349-58. Available from: https://doi.org/10.4025/psicolestud.v21i2.29707
  » https://doi.org/10.4025/psicolestud.v21i2.29707
• 14. Duarte MLC, Boeck JN. O trabalho em equipe na enfermagem e os limites e possibilidades da estratégia saúde da família. Trab Educ Saúde [Internet]. 2015 [cited 2019 Oct 01];13(3):709-20. Available from: https://doi.org/10.1590/1981-7746-sip00054
  » https://doi.org/10.1590/1981-7746-sip00054
• 15. Monteiro DT, Quintana AM. A comunicação de Más Notícias na UTI: Perspectiva dos Médicos. Psicologia: Psicol Teor Pesq [Internet]. 2016 [cited 2019 Oct 01];32(4):e324221. Available from: https://doi.org/10.1590/0102.3772e324221
  » https://doi.org/10.1590/0102.3772e324221
• 16. Fernandes HN, Thofehrn MB, Porto AR, Amestoy SC, Jacondino MB, Soares MR. Relacionamento interpessoal no trabalho da equipe multiprofissional de uma unidade de saúde da família. Rev Pesq Cuid Fund [Internet]. 2015 [cited 2019 Oct 01]:7(1):1915-26. Available from: https://doi.org/10.9789/2175-5361.2015.v7i1.1915-1926
  » https://doi.org/10.9789/2175-5361.2015.v7i1.1915-1926
• 17. Rocha L, Melo C, Costa R, Anders JC. The Communication of bad news by nurses in the context of obstetric care. REME (Online) [Internet]. 2016 [cited 2019 Oct 01];20:e981. Available from: https://doi.org/10.5935/1415-2762.20160051
  » https://doi.org/10.5935/1415-2762.20160051
• 18. Santos RCA, Miranda FAN. Importância do vínculo entre profissional-usuário na estratégia de saúde da família. Rev Enferm UFSM [Internet]. 2016 [cited 2019 Oct 01];6(3):350-9. Available from: https://doi.org/10.5902/2179769217313
  » https://doi.org/10.5902/2179769217313
• 19. Oikonomidou D, Anagnostopoulos F, Dimitrakaki C, Ploumpidis D, Stylianidis S, Tountas Y. Doctors’ perceptions and practices of breaking bad news: a qualitative study from Greece. Health Commun [Internet]. 2016 [cited 2019 Sept 19];32(6):657-66. Available from: https://doi.org/10.1080/10410236.2016.1167991
  » https://doi.org/10.1080/10410236.2016.1167991
• 20. Oliveira-Cardoso EA, Garcia JT, Santos LL, Santos MA. Comunicando más notícias em um hospital geral: a perspectiva do paciente. Rev SPAGESP [Internet]. 2018 [cited 2019 Sept 19];19(1):90-102. Available from: http://pepsic.bvsalud.org/pdf/rspagesp/v19n1/v19n1a08.pdf
  » http://pepsic.bvsalud.org/pdf/rspagesp/v19n1/v19n1a08.pdf
• 21. Camargo NC, Lima MG, Brietzke E, Mucci S, Góis AFT. Teaching how to deliver bad news: a systematic review. Rev Bioética (Online) [Internet]. 2019 [cited 2019 Oct 01];27(2):326-40. Available from: https://doi.org/10.1590/1983-80422019272317
  » https://doi.org/10.1590/1983-80422019272317
• 22. Instituto Nacional de Câncer (BR). Comunicação de notícias difíceis - compartilhando desafios na atenção à saúde. Rio de Janeiro, RJ(BR): INCA; 2010. Available from: http://bvsms.saude.gov.br/bvs/publicacoes/comunicacao_noticias_dificeis.pdf
  » http://bvsms.saude.gov.br/bvs/publicacoes/comunicacao_noticias_dificeis.pdf
• 23. Koch CL, Rosa AB, Bedin SC. Bad news: meanings attributed in neonatal/pediatric care practices. Rev Bioética (Online) [Internet]. 2017 [cited 2019 Oct 01];25(3):577-84. Available from: https://doi.org/10.1590/1983-80422017253214
  » https://doi.org/10.1590/1983-80422017253214
• 24. Mishelmovich N, Arber A, Odelius A. Breaking significant news: The experience of clinical nurse specialists in cancer and palliative care. Eur J Oncol Nurs [Internet]. 2016 [cited 2019 Oct 01];21:153-59. Available from: https://doi.org/10.1016/j.ejon.2015.09.006
  » https://doi.org/10.1016/j.ejon.2015.09.006
• 25. Bramhall E. Effective communication skills in nursing practice. Nurs Stand [Internet]. 2014 [cited 2019 Oct 01];29(14):53-9. Available from: https://pubmed.ncbi.nlm.nih.gov/25467362/
  » https://pubmed.ncbi.nlm.nih.gov/25467362/
• 26. Silva MJP. Comunicação tem remédio: a comunicação nas relações interpessoais em saúde. São Paulo, SP(BR): Loyola; 2010.
• 27. Prado RT, Leite JL, Silva ÍR, Silva LJ. Comunicação no gerenciamento do cuidado de enfermagem diante do processo de morte e morrer. Texto Contexto Enferm [Internet]. 2019 [citado 2020 Mar 06];28:e20170336. Available from: https://doi.org/10.1590/1980-265X-TCE-2017-0336
  » https://doi.org/10.1590/1980-265X-TCE-2017-0336
• 28. Legg AM, Sweeny K. Blended news delivery in healthcare: a framework for injecting good news into bad news conversations. Health Psychol Rev [Internet]. 2015 [cited 2019 Oct 01];9(4):452-68. Available from: https://doi.org/10.1080/17437199.2015.1051567
  » https://doi.org/10.1080/17437199.2015.1051567
• 29. Dean S, Willis S. The use of protocol in breaking bad news: evidence and ethos. Int J Palliat Nurs [Internet]. 2016 [cited 2019 Oct 01];22(6):265-71. Available from: https://doi.org/10.12968/ijpn.2016.22.6.26 5
  » https://doi.org/10.12968/ijpn.2016.22.6.26
• 30. Pereira ATG, Fortes IFL, Mendes JMG. Comunicação de más notícias: Revisão Sistemática da Literatura. Rev Enferm UFPE on line [Internet]. 2013 [cited 2019 Oct 01];7(1):227-35. Available from: http://portaldeboaspraticas.iff.fiocruz.br/wp-content/uploads/2019/01/10226-20406-1-pb.pdf
  » http://portaldeboaspraticas.iff.fiocruz.br/wp-content/uploads/2019/01/10226-20406-1-pb.pdf

NOTES

• ORIGIN OF THE ARTICLE

  Extracted from the thesis - Communication of bad news within the Primary Health Care Context, presented to the Graduate Nursing Program at the Universidade Federal de Rio Grande, in 2019.

• APPROVAL OF ETHICS COMMITTEE IN RESEARCH

  Approved by the Ethics Committee in Research with Human Beings of CEPAS- Universidade Federal de Rio Grande, Opinion Report No.118/2019, Certification of Presentation for Ethical Appreciation 12570919.0.0000.5324.
• *
  https://www.youtube.com/watch?v=BOIn9JbhCA4
• **
  https://www.youtube.com/watch?v=21RHG4hr25g
• ***
  https://www.youtube.com/watch?v=HkcfWA2Dllg

Publication Dates

• Publication in this collection
  14 July 2021
• Date of issue
  2021

History

• Received
  19 Mar 2020
• Accepted
  18 June 2020