Duke Nursing Project Optimizes Delivery of Bad News

Cancer patients and their families can be devastated when bad news is conveyed piecemeal without full healthcare team knowledge, participation, and support. This communication breakdown also tends to have a negative impact on the healthcare team itself, causing moral distress. It’s critical for physicians and nurses to participate together in delivery of bad news (DBN), in a coordinated message at a preset time, with the family present and no interruptions.

At the 37th annual Oncology Nursing Society Congress, a team of nurses from Duke University, Durham, North Carolina, described a practice-changing study that developed from the need to put nurses and physicians in their unit ‘on the same page’ regarding DBN. The goal was to improve physician-nurse communication in this area and formally incorporate DBN as an action item in daily patient care.

Before the intervention, while 95% of unit nurses surveyed said they wanted to participate in DBN, 75% had no prior involvement with DBN and 88% said they often learned after the fact from patients and families that the bad news had already been conveyed by other healthcare team members (eg, physicians). Clearly, an intervention was needed to integrate nurses into the healthcare team’s culture of care regarding DBN.

Deborah Allen, MSN, RN, CNS, FNP-BC, AOCNP, inpatient oncology, Duke University Health System, discussed the study during a poster session at ONS Congress (meeting abstract 1341444). Her coauthors on the study are Pamela N. Bowman, BSN, RN, OCN, and Kim Slusser, MSN, RN, CHPN, from the inpatient oncology department, and Camille Lambe, PhD, RN, AOCNP, from the Duke University School of Nursing. The study was funded by the Duke Translational Nursing Institute.

The Duke team used Lewin’s planned change theory processes to develop a collaborative practice model (CPM) for DBN. The multistep process of planned change theory proposes opportunities to shift practice in a desired direction while acknowledging possible barriers. Ms. Allen and her coauthors described the planned change theory as “unfreezing” behaviors that need to change, “moving” behavior and communication toward the more positive practice model, and then “refreezing” the improved modes of interaction.

As part of the “unfreezing” process, unit nurses were surveyed to assess their perceptions of what constitutes bad news and barriers preventing nurses from participating in DBN. The unit in the study has 65 members: 45 nurses (average experience, 2 years), 12 attending and 9 fellow physicians, 3 physician assistants, and 5 multidisciplinary staff (chaplain, social worker, discharge planners, advanced practice nurse). A total of 61 members completed the survey.

Most team members in the unit agreed on common types of “bad news,” with 80% or more characterizing it as being diagnosed with cancer, experiencing a recurrence, having no further treatment options or being resistant to treatment, and needing a referral to hospice/end-of-life care. About 60% or more identified bad news as the need to communicate information about DNR status, complications or difficult side effects during treatment, and specific events affecting a patient’s care. Barriers to nurse participation in DBN, as perceived by nurses (n = 38), were mainly “not knowing all the answers” and “not being asked to participate,” with time constraints and inexperience cited as secondary concerns. Among physicians surveyed (n = 18), 50% or more believed nurses were too busy for DBN and/or did not want to be involved; other potential barriers to nurse involvement perceived by the physicians included difficulty in identifying “who is caring for the patient” and “not enough time to look for the nurse.”

A multidisciplinary task force then met and developed the following CPM (as an algorithm) for DBN: Any identified bad news is discussed by physicians in their late-morning rounds. The attending physician conveys any DBN issues for a particular patient to the charge nurse, who relays them to the care nurse. Physician and care nurse coordinate a meeting with the family for DBN, contacting other team members (social worker, chaplain, advanced practice nurse) to join them as needed. The multidisciplinary team meets prior to DBN to briefly summarize specific discussion goals, and after the DBN with the patient and family, to identify next steps. These actions were supported by development of a documentation sheet to be used by healthcare team members.

The healthcare team was also surveyed prior to the “moving” portion of the intervention, so their DBN education and support needs could be identified and addressed.

As part of moving towards the desired new communication and documentation behaviors for DBN, group and individual educational sessions were provided over a 3-month period, with case studies provided so DBN skills could be reviewed as a team, following the CPM for DBN.

The next phase of the “moving” process, which reinforced skill-building in DBN, was called “Picking Up the Pieces.” It involved four didactic sessions and small-group discussions offered over a 2-month period, plus four additional sessions offered for new staff or team members who missed earlier sessions. The educational sessions reviewed the collaborative practice model for DBN as well as two communication models that can be effective tools for DBN: “SPIKES” and “NURSE.” (Very good summaries of SPIKES and NURSE, as well as strategies to optimize difficult conversations with patients, are presented in a 2008 article in ASCO’s Journal of Oncology Practice.)

SPIKES, a model for physician-patient communication developed at MD Anderson Cancer Center, follows a six-step protocol:

S = Plan the setting of the interview (with patient privacy/comfort; family involvement, if the patient desires it; and no interruptions).
P = Assess the patient’s perception of the medical situation, by asking open-ended questions.
I = Invite the patient to tell you how much information s/he wants regarding diagnosis/prognosis.
K = Give the patient knowledge using small amounts of information in a manner that is easy to process (eg, using plain English and avoiding medical jargon).
E = Provide empathetic responses that address and acknowledge the patient’s emotional response to information/bad news.
S = Provide a clear care strategy for treatment/palliative care options, to lessen patient anxiety.

NURSE, developed by James Tulsky, MD, director of the center for palliative care at Duke University, and colleagues, can be used by any healthcare member. It teaches how to express empathy using continuer statements that allow patients to both feel heard and continue expressing emotions.

N = Name the patient’s emotion. (This provides support and lets the patient know it’s okay to discuss feelings.)
U = Understand the emotion being expressed.
R = Respect what the patient is communicating and feeling.
S = Show support.
E = Explore what emotions s/he is experiencing.

In the DBN project reported by Ms. Allen, a medical actor played the role of a patient with progressive symptoms receiving bad news, while the healthcare team engaged in role-playing and analysis/group discussion of positive (eg, attentive listening, ask-tell-ask) and negative DBN strategies.

Physician and nursing/allied healthcare staff completed pre- and post-intervention Likert-like surveys, in which participants used a 1-to-5 (“never” to “always”) scale to rank statements about skills, support, and communication related to DBN. Post-implementation surveys were completed by 75% of healthcare team members. The results showed significant improvements in early notification and involvement of nurses regarding DBN; colleague support of nurses for care coverage, enabling nurses to participate in DBN; better communication between healthcare team members regarding DBN; and successful incorporation of DBN as a formal action item in daily practice.

In discussing the “refreezing” phase of this DBN improvement project, Ms. Allen and her colleagues noted nurse inclusion in DBN can be further enhanced by holding team members accountable for incorporating the CPM into daily practice; identifying missed opportunities; and continuing the “Picking Up the Pieces” training program for new hires, twice a year.