Breaking significant news: The experience of clinical nurse specialists in cancer and palliative care
Introduction
The nurse's role in the delivery of significant news is all but unknown as, until recently, the delivery of bad news was considered to be the role of medical staff (Dunniece and Slevin, 2000). Some authors suggest that nurses may be well placed to deliver significant news as they are often the people patients feel most comfortable with (Higgins, 2002, Faulkner, 1998). The nurse's role in breaking significant news (BSN) has been identified in the past as supportive to that of the medical staff concerned with monitoring the patient's awareness of his/her condition prior to disclosure of the cancer diagnosis and communicating this to the doctor (Morton, 1996); understanding the psychological needs of the patient following a diagnosis of cancer and offering support (Claxton, 1993). Others such as May (1993) describe nurses as, ‘practical mangers’ of the events which follow disclosure, and also interpreters of medical information for patients and their families. Thus nurses have many roles to play in delivering significant news and it is important to understand what roles clinical nurse specialists play in BSN to patients.
The breaking of significant and bad news is challenging particularly in the acute oncology setting when news of the failure of curative treatment was communicated and was found to be the one of the most difficult topics for oncologists to discuss (Baile et al., 2002). Other research reports the use of ambiguous language being used when delivering bad news about a poor prognosis in contrast to discussions about potentially curative treatments (Fallowfield et al., 2002). Personal experiences of medical and nursing staff can also complicate the picture and factors such as a recent bereavement or personal fears about one's own mortality can cause additional difficulties for staff and requires good staff support (Lloyd et al., 2009, Gordon and Daugherty, 2003).
Many researchers have found that patients wish to discuss the progress of their illness although they also wanted to be given hope (Brown et al., 2011, Spiegel et al., 2009). The communication needs of patients are not static and change throughout the illness trajectory (Schofield et al., 2001). Furthermore choosing the wrong timing for BSN, or disclosing more than the patient can cope with for their stage of illness, may devastate the patient (Watson and Lucas, 2010). Many patients prefer specialists to check whether they want to be given information regarding their illness and the extent of the information they wish to receive (Hagerty et al., 2005).
Although guidelines for delivering significant news exist some practitioners were found to be more open to incorporating BSN guidelines with practice (Walker et al., 1996). Others argue that guidelines compromise clinical independence and may constrain and complicate the process of BSN leading to inflexibility (Watson and Lucas, 2010). Nevertheless, healthcare professionals benefit from resources giving them an idea of what other people found helpful in order to develop their own personal style of BSN (Buckman and Kason, 1992). The most commonly cited guideline for breaking bad and significant news is the SPIKES protocol; however the efficacy of SPIKES is not empirically supported and its relevance to care across cultures remains under researched (Baile et al., 2000, Buckman, 2005, Ptacek and Ptacek, 2001, VandeKieft, 2001). There was criticism that guidelines are inexplicit regarding emotional and supportive content, focussing on breaking significant news, rather than receiving significant news (Arber and Gallagher, 2003, Duke and Bailey, 2008). Most studies of health care professionals and BSN have focused on medical staff (Hancock et al., 2007). However it is not clear how well prepared specialist nurses feel or their comfort with delivering significant news (De Valck and Van de Woestijne, 1996). The aim of this research is to understand the lived experiences of CNSs in cancer and palliative care nurses in relation to BSN.
Section snippets
Methodology
The study used a qualitative approach informed by a hermeneutic phenomenological perspective facilitating access to the meaning of the experience from the participants' points of view. Phenomenology is based in philosophy (Patton, 1990) and is the study of lived experience (Van Manen, 1984). It pertains to how people understand the world in context, the central point being consciousness (Willig, 2001). Phenomenology encompasses numerous philosophical strands (Taylor, 1995) but one of the key
Four themes emerged from the data namely
The importance of relationships, perspective taking, ways to break significant news, feeling prepared and putting yourself forward.
Importance of relationships
Participants identified great importance in forming a relationship with patients. They spoke about how this relationship enabled them to conduct difficult conversations. Participant 6 reports her encounter with a patient, whose prognosis was poor, and how the bond that developed with the patient was significant and deep:
‘It's sad, but on the other hand you often get
Discussion
Throughout the study CNSs referred to the emotional burden of BSN and its impact on them especially early on in their role as a CNS, leaving them sometimes with feelings of sadness and creating emotional exhaustion. CNSs talked about the challenge of BSN to young patients and made a comparison with older patients. They felt that age had a role to play making the disclosure of significant news to younger patients much harder to bear. They describe how it felt easier for them to discuss
Conclusion
The findings of this study indicate that specialist nurses in oncology and palliative care have a significant role in disclosing significant news. CNSs report using guidelines developed to support BSN in a flexible way. Supporting the delivery of significant news is confidence developed over many years of practice and the development of a trusting relationship with the patient. There are some situations that are difficult and challenging for CNSs and where they need further support. Challenging
Conflicts of interest
“No conflict of interest has been declared by the authors”.
Acknowledgements
The authors would like to thank the research participants for their valuable time in contributing to this study.
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