Nurses' experiences in giving bad news to patients with spinal cord injuries.

The techniques that the nurses used were to "put themselves in the patient or families' shoes" and decide what they would want to know in these circumstances. To defuse their own emotions, they worked as a team with others and debriefed among themselves. They also attempted to give patients good news whenever possible:

Discussion

Even though delivering or reinforcing bad news is not perceived to be their role, the realities of clinical practice indicate that nurses are involved. This study described some of the dilemmas that nurses face during this process and the strategies they use to maintain patients' well-being and meet their own needs.

The lifestyle adjustments that patients with spinal cord injuries must make are significant. The nurses in this study reported that when patients are given information relating to such profound changes, the information does not readily sink in. Patients may not understand the implications, or actively seek clarification of those implications, until they feel ready to do so. Patients also maintain beliefs that the outcome, for them, will be positive despite information to the contrary. If the information does not sink in, it can be due to differing perceptions of disclosure, differing understandings about the outcome of an injury or illness, or a lack of readiness to hear the information. This is similar to studies of patients with cancer. (14,15,27) These findings have many implications for nurses because they must continually answer the patients' questions and manage the patients' emotional responses. The nurses must assess how to deliver information that will assist the patient with the many difficult adjustments that accompany spinal cord injury.

Nurses are placed in a difficult position of meeting the patients' and their families' needs for information. Morrissey indicated that when patients do not understand technical information, nurses become the translators of bad news between patients with cancer and physicians. (14) The nurses in this study reported that, when working with patients with spinal cord injuries, their role may exceed that of translator, and they may become the bearers of bad news. It is impossible to avoid this role because the nature of their daily interactions means being in proximity when patients or families wish to have their questions addressed. The nurses stated that giving bad news is at times inescapable; they must respond to questions or jeopardize their own integrity and credibility with patients and their families. Many nurses found this role difficult because of underlying concerns about patients' reactions, fears about misinforming the patients, and beliefs that maintaining hope was an important method of providing support. To assist them in answering patients' questions, nurses in this study developed various approaches that they believed benefited both the patients and themselves. One such approach was to use their standard line, which enabled them to be prepared to answer questions truthfully without destroying the patient's hope.

This study has determined that much of the literature on successfully delivering bad news recommends situations that are not always feasible for nurses. These include finding a quiet location with few distractions, providing privacy, having a supportive significant other present, and allowing time to elicit the patients' feelings and reactions. (3,20,27) Nurses work in situations in which delivering bad news is ongoing, has multiple components, and occurs at times when it is impossible to be prepared for the unexpected questions and reactions. After giving such information, the nurse must continue to work in close contact with the patient. Opportunities to retreat or debrief may be restricted.

Time is needed for patients to make lifestyle adjustments, and emotional responses to their injuries may fluctuate. An important aspect of bearing bad news was the nurses' skills in reinforcing the reality of the patients' circumstances and maintaining their hope so that the patients would work toward developing independence.

The initial disclosure of the information still remains the prerogative of the physician, and the nurses in this study saw initial disclosure in this way. Nevertheless, nurses could not avoid being involved. Delivering bad news becomes a part of nursing work that is not acknowledged except in an ad hoc manner. Failure to acknowledge this role and the skills required accentuates that many aspects of nursing work are vital but invisible. Lawler has found that many aspects of nursing work are invisible and this lack of visibility devalues nursing care. (8)

Nurses have limited time to engage in meaningful dialogue that will help release or explore patients' feelings. Unless the nurse feels comfortable in soliciting such reactions, many of the patients' concerns may not be addressed. The nurses indicated that they needed more skills to perform this sensitive role successfully. An important issue relates to the realistic nature of the nurses' fears about upsetting patients. If many individuals do, as the findings indicate, undergo a time of believing that they will walk again, it appears that giving them information may have only a minimal influence on this belief. Future studies of both patients and nurses would address this issue.

Limitations

Data collection in this study was difficult because the pressure of the nurses' work situation limited the time for the focus group discussions. The ward may not have been the most appropriate location for in-depth discussions that are helpful in focus groups, and the focus groups were very small. It was not possible to correlate length of nurses' experiences to development of skills in giving bad news. Further research that elicits the patients' perspectives on how they were given bad news by nurses and other healthcare professionals would broaden our understanding of this issue.

Summary

Nurses are involved in the complex and difficult responsibility of giving patients bad news. An important step in making this process easier is to acknowledge that nurses do indeed bear bad news by giving nursing care or by addressing patients' and their families' concerns. Coming to terms with the multiple losses associated with spinal cord injury is a difficult and long-term process. Patients and their families need support with this process, which should be tailored to their individual requirements. Nurses also need support and open discussion of this sensitive issue.

Communication policies to support nurses when giving sensitive information to patients, together with opportunities to develop skills and strategies to assist in this process, would be helpful to nurses who face these challenges. Such approaches will facilitate the provision of patient care as well as the professional development of nurses.

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