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Year : 2013  |  Volume : 12  |  Issue : 4  |  Page : 205-211  

Breaking bad news in clinical setting - health professionals' experience and perceived competence in southwestern Nigeria: A cross sectional study

1 Neurology Unit, Department of Medicine; Department of Medicine, Ladoke Akintola University of Technology Teaching Hospital, Ogbomoso, Oyo-State, Nigeria
2 Department of Psychiatry, Ladoke Akintola University of Technology, Ogbomoso, Oyo-State, Nigeria
3 Department of Medicine, Ladoke Akintola University of Technology Teaching Hospital, Ogbomoso, Oyo-State, Nigeria
4 Department of Surgery, Urology Unit, Obafemi Awolowo College of Health Sciences, Olabisi Onabanjo University/Olabisi Onabanjo University Teaching Hospital, Sagamu, Ogun State, Nigeria

Date of Web Publication4-Dec-2013

Correspondence Address:
Philip Babatunde Adebayo
Department of Medicine, Neurology Unit, Ladoke Akintola University of Technology, Ogbomoso, Oyo-State
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1596-3519.122687

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Background: Communication skills are vital in clinical settings because the manner in which bad news is delivered could be a huge determinant of responses to such news; as well as compliance with beneficial treatment option. Information on training, institutional guidelines and protocols for breaking bad news (BBN) is scarce in Nigeria. We assessed the training, experience and perceived competence of BBN among medical personnel in southwestern Nigeria.
Materials and Methods: The study was a cross-sectional descriptive study conducted out among doctors and nurses in two healthcare institutions in southwestern Nigeria using an anonymous questionnaire (adapted from the survey by Horwitz et al.), which focused on the respondents training, awareness of protocols in BBN; and perceived competence (using a Five-Point Likert Scale) in five clinical scenarios. We equally asked the respondents about an instance of BBN they have recently witnessed.
Results: A total of 113 of 130 selected (response rate 86.9%) respondents were studied. Eight (7.1%) of the respondents knew of the guidelines on BBN in the hospital in which they work. Twenty-three (20.3%) respondents claimed knowledge of a protocol. The median perceived competence rating was 4 out of 5 in all the clinical scenarios. Twenty-five (22.1%) respondents have had a formal training in BBN and they generally had significant higher perceived competence rating (P = 0.003-0.021). There is poor support from fellow workers during instances of BBN.
Conclusion: It appears that the large proportion of the respondents in this study were unconsciously incompetent in BBN in view of the low level of training and little or no knowledge of well known protocols for BBN even though self-rated competence is high. Continuous medical education in communication skills among health personnel in Nigeria is advocated.

   Abstract in Spenish 

Communication compétences sont essentielles en milieu clinique parce que la manière dont les mauvaises nouvelles est livré pourrait être un énorme déterminant des réponses à ces nouvelles ; ainsi que de la conformité avec l'option thérapeutique bénéfique. Information sur la formation, institutionnelle des lignes directrices et des protocoles pour briser les mauvaises nouvelles (BBN) est rare au Nigeria. Nous avons évalué la formation, expérience et compétence perçue de BBN parmi le personnel médical dans le sud-ouest du Nigeria.
Matériaux et méthodes: l'étude était une étude descriptive transversale menée sur auprès des médecins et des infirmières dans deux établissements de soins de santé dans le sud-ouest du Nigeria, à l'aide d'un questionnaire anonyme (adapté de l'enquête par Horwitz et al.), qui porté aux intimées, formation, sensibilisation des protocoles BBN ; et perçu de compétence (à l'aide d'une échelle de Likert de cinq points) dans les cinq scénarios cliniques. Nous avons également demandé les intimés sur une instance de BBN, ils ont récemment été témoins.
Résultats: Un total de 113 de 130 sélectionné (taux de réponse de 86,9 %) de répondants ont été étudiés. Huit (7,1 %) des personnes interrogées connaissaient des directives sur les BBN dans l'hôpital dans lequel ils travaillent. Vingt-trois (20,3 %) répondants réclamé connaissance d'un protocole. La médiane perçue cote de compétence était de 4 sur 5 dans tous les scénarios cliniques. Vingt-cinq (22,1 %) répondants ont eu une formation formelle en BBN et ils ont généralement significatif plus élevé perçu compétence moyenne (P = 0,003 -0,021). Il y a mauvais soutien de collègues de travail au cours des instances de BBN.
Conclusion: Il semble que la forte proportion des répondants de cette étude ont été inconsciemment incompétent dans BBN étant donné le faible niveau de formation et peu ou aucune connaissance des protocoles connus pour BBN quoique n'auto-évaluation de compétence est élevé. Formation médicale continue des compétences de communication parmi le personnel de santé au Nigeria est préconisée.
Mots clés: Bad health travailleurs, Nigeria, expérience, confiance, nouvelles

Keywords: Bad news, confidence, experience, health workers, Nigeria

How to cite this article:
Adebayo PB, Abayomi O, Johnson PO, Oloyede T, Oyelekan AA. Breaking bad news in clinical setting - health professionals' experience and perceived competence in southwestern Nigeria: A cross sectional study. Ann Afr Med 2013;12:205-11

How to cite this URL:
Adebayo PB, Abayomi O, Johnson PO, Oloyede T, Oyelekan AA. Breaking bad news in clinical setting - health professionals' experience and perceived competence in southwestern Nigeria: A cross sectional study. Ann Afr Med [serial online] 2013 [cited 2022 Dec 7];12:205-11. Available from:

   Introduction Top

Bad news in clinical setting has been defined as "any news that drastically and negatively alters the patient's view of his or her future." [1] This news can range from telling a patient he or she has a terminal illness, telling parents that their child will not develop like other children or telling someone that their loved one is dead or that a client has human immunodeficiency virus (HIV)

infection. [2] Communication skills are vital in this respect as the manner in which the messenger conveys the news could be a huge determinant of the responses to such news, which may include shock, numbness, denial, anger, intense sadness or

guilt. [3],[4] These emotional responses may adversely affect treatment outcome since patients' comprehension of information could be defective during this period of intense emotionality, thus jeopardizing the prospect for shared decision and compliance with treatment. [5],[6] Therefore, when bad news is broken inadequately, the patient's comprehension of information may be thwarted further, [7],[8] they may be dissatisfied or frustrated with medical care, [9],[10] as well as develop poor psychological adjustment to the news. [11],[12]

In addition, physicians who find it difficult to give bad news may subject patients to harsh treatments beyond the point where treatment may be expected to be helpful. [13] The task of breaking bad news (BBN) however, can be improved by understanding the process involved and approaching it as a stepwise procedure, applying well-established principles of communication and counseling. [14]

One of the such protocols is the "Set the stage, Perception, Inform, Knowledge, Empathy, and Summarize" (SPIKES) model developed by Buckman [14] which can be used in various clinical settings. The acronym "SPIKES" is a useful recall of a scripted methodology in bad news delivery; [15] and the first step recommends that in setting up the stage for the interview, the doctors should: arrange for some privacy, involve significant others, sit down, make connection with the patient and manage time constraints and interruptions. Other well known structured method of disclosing bad news include the ABCDE (A - Advance preparation; B - Build a therapeutic environment/relationship; C - Communicate well; D - Deal with patient and family reactions; E - Encourage and validate emotions) five steps model developed by Rabow and Mcphee. [16] and BREAKS (B - obtain Background; R - establish Rapport; E - Explore patient's knowledge; A - Announce a warning; K - Kindling; S - Summarize) protocol developed by Narayanan et al. [17]

In the native Yoruba African society however, cultural as well as religious beliefs and values do modify the way bad news are broken and received. Traditionally, in this setting, instructions and guidance on life issues (including health-related issues) are often transmitted through oral traditions and folklores. The elders - custodians of oral traditions and folklores - and the medicine man (traditional healer), who sometimes doubles as the religious leader, are highly respected. When they speak, their words are taken as those of an oracle and therefore, simply believed and adhered to. [18],[19] Sometimes, emotionally charged issues are relayed through these personalities; so, it is not infrequent for medical personnel to communicate bad news to patients through these individuals. The other culturally based disclosure model involves relaying the bad news to the eldest male in the family; who is believed to be matured enough to handle the situation and is expected to communicate to other members of the family with a lot of discretion. This model is not limited to the native African setting; for example, in eastern societies such as China, Taiwan, Hong Kong and Japan, the family is considered more significant than the individual. Thus, in such societies, it is customary to disclose bad news to family members, who then decide whether to disclose it to the patient as well. [20],[21] This culturally based communal mindset is reflected in the outcome of a survey of neurosurgical patients in Nigeria; in which majority (88.1%) of the respondents preferred that the hard news of the diagnosis or prognosis of their neurosurgical conditions be broken in the presence of other relatives or family members. [22]

In an attempt to bridge the gap that exists in ethical practice in Nigeria and some west African states, the west African college of physician recently has made compulsory, the attendance of a two days course on medical ethics and communication for candidates attempting to sit for part one membership examination of the college. [23] In addition to the above training program, the society for palliative care, Nigeria also includes a module on BBN in their update courses. [24] Nevertheless; information on institutional and regional trainings on BBN is still scarce in Nigeria in spite of the scale of the literatures on the subject of BBN.

It is in the light of the foregoing, that we wanted to know the levels and the content of trainings in BBN that have been received by nurses and doctors in active clinical practice in south-western Nigeria. We equally wanted to evaluate their most-recent experience of BBN as well as their self-reported competence in performing this task.

   Materials and Methods Top

This was a cross-sectional descriptive study carried out at two major government-owned facilities in southwestern Nigeria between January and February, 2012. These healthcare facilities provide tertiary and secondary healthcare services to Inhabitants of Oyo and Ogun-States respectively. The study involved doctors and nurses in these institutions who volunteered to participate in the survey. One hundred and thirty subjects of about 400 clinical duty staffs of both institutions were selected using a convenient sampling method. The number of subjects from each clinical cadre was determined by proportionate allocation based on the staff strength of each cadre during the study period. All the selected subjects volunteered to participate in the study. However, only 113 participants returned the completed questionnaire.

Data were collected using an anonymous self-administered questionnaire which was developed after a review of literatures on the subject. The initial draft of the instrument was pilot-tested among 20 health workers in another hospital followed by refinement of ambiguous items before the preparation of the final structured semi-closed questionnaire. The items on guideline and training as well as the respondent's recent experiences of BBN were adapted from those used by Horwitz and Ellis. [25] The questionnaire asked for the participant's year of qualification, and if they had received trainings in BBN. We also asked if they were aware of any protocol for BBN and what protocol they knew. Furthermore, we asked participants to rate how competent they felt in dealing with five clinical scenarios on a Five-Point Likert Scale. These clinical scenarios (Appendix 1) were purposively selected based on our empirical local experiences in these facilities. The clinical scenarios included breaking the news of demise in two different situations; to an aggressive relative and to a non-aggressive relative. The other clinical scenarios included one about disclosing the diagnosis of cancer, disclosing the diagnosis of sickle cell disease and lastly, giving the prognosis of a complete cord transection. Furthermore, we asked about the participant's own experience of breaking the news of HIV infection to a patient, including whether some guidelines had been followed in his or her most-recent experience of observing a colleague break a bad news; and whether the interview went well based on the way in which the news was delivered and the patient's response. Informed consent and institutional health research committee approval were obtained for the study. Data were analyzed using SPSS v16.0.1 for Windows (SPSS Inc., Chicago, IL, USA).

Chi-squared tests were used to compare proportions. The self-perceived ratings were described by median and mode response with interquartile ranges (IQR). Between-group differences in responses were analyzed using the Kruskall Wallis test. The level of statistical significance was set at <0.05.

   Results Top

One hundred and thirteen respondents (response rate 86.9%) comprising of 67 males (59.2%) and 46 (40.7%) females (P = 0.078) were studied. The median year of qualification was 2005 (IQR 1977-2012). Eighty-eight (77.8%) respondents were middle -level officers (residents, medical and nursing officers), while senior clinical staff members (consultants and chief nursing/medical officers), and junior officers (house-officers and staff nurses) were 16 (14.2%) and 9 (8.0%) respectively.

While majority have not had any formal training in BBN, 25 (22.1%) respondents have had a formal training at some point in their career. Most of these respondents (n = 21) were middle-level officers. Only 8 (7.1%) respondents knew of any guideline for BBN in the hospitals in which they worked while the others either denied the existence of any guideline (58, 51.3%) or don't know (47, 41.6%). [Table 1] shows respondents training and awareness about guidelines in BBN.
Table 1: Frequency table showing respondents awareness about guideline and protocols

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There was a high perceived competence rating among the respondents in BBN; with a median rating of 4 out of 5 in all the scenarios. There was no significant gender difference in BBN in all the scenarios (P = 0.120-0.844). The number of years of experience correlated positively with perceived competence in the scenario of breaking the news of demise to an aggressive relative. Otherwise, there was no correlation between the year of experience and perceived competence in BBN in the other clinical scenarios. Those who have had formal training in BBN generally had significantly higher competence rating (P = 0.003-0.021) than those who have not had formal training except in the scenario of disclosing the diagnosis of sickle cell disease in which no difference existed between them (P = 0.469). There was no difference in rating between nursing and medical personnel in all the clinical scenarios (P = 0.09-0.54).

Sixty-three (55.7%) respondents have been personally involved in disclosing the diagnosis of HIV to a patient and only 20 (31.7%) have received any support from a colleague when making this disclosure. Fifty-three respondents (46.9%) have witnessed an instance of BBN recently. [Table 2] summarizes their experience.
Table 2: Experience of the respondents who witnessed an instance of breaking bad news

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   Discussion Top

Communication skill between physician and patients is a core clinical skill that health workers should be proficient in. When the clinician is well trained in this art, his self-efficacy grows; he tends to readily uptake new communication strategies and skills; and transfer of these strategies and skills into the clinical practice. [26] Bylund et al. [27],[28] examined various programs aimed at developing communications skills for practitioners delivering bad news in a clinical setting and found positive effects of workshop skills training demonstrated by objective reviewers grading physician-patient interaction. [27],[28] Trainee seeking to acquire skills usually go through the four phases of learning which includes: Stage [1], the stage of unconscious incompetence-the individual at this stage does not understand or know how to do something and does not necessarily recognize the deficit.In stage [2], the stage of conscious incompetence-although the individual does not understand or know how to do something, he or she does recognize the deficit, as well as the value of a new skill in addressing the deficit. Stage [3]: The stage of conscious competence-the individual understands or know how to do something, however, he needs a lot of concentration in demonstrating this skill, and stage [4]: The stage of unconscious competence-the individual has had so much practice with a skill that it has become "second nature" and can be performed easily. [29]

We found in this study, that the level of training and awareness about a guideline in BBN is generally low [Table 1] and inadequate among this group of doctors and nurses even though most of them rated their perceived level of competence in dealing with the clinical scenarios highly. We also noted that the practice of BBN was largely variable based on the experience of those who had witnessed a scenario lately [Table 2]. Only few provided a private place for the interview, and they were seldom accompanied by nursing staff. It appears that a large proportion of our respondents were unconsciously incompetent in view of the relative lack of training and poor knowledge about protocols; while it could be argued that few of them, particularly those who claimed knowledge of some protocols, were consciously incompetent (aware that there is a protocol but don't know the details). When asked to name the protocol,they were aware of, the responses of those who claimed knowledge of a protocol [Table 1] were either very superficial or revealed the fact that they perceived that the cultural model they adopt in their practice, was a protocol of reference. The responses could also be a reflection of a possible knowledge or skill decay; since the scripted method of BBN is not in regular use in this population.

We also found a positive correlation between the year of experience and the scenario of breaking the news of demise to an aggressive relative [Figure 1]. This is similar to the findings of Ibrahim et al. [30] in which the number of years of experience influenced the perceived competence in communication skills among their cohort of surgical residents; although, in our study, it appears that those who have had 3-7 years of experience felt less competent in this scenario than those with 1-3 years of experience. We do not have a ready explanation for the pattern, but we would like to posit that in reality, the excitement and perceived competence in performing a task tends to wane as the enormity and demands of such a task become obvious. Although, in the actual sense, the number of years of experience may not even predict a better performance, especially since there was no appropriate measure of feedback.
Figure 1: Error bar showing the relationship of the year of experience on the perceived competence of the clinicians in breaking the news of demise to an aggressive relative

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Respondents who have witnessed a bad news scenario (53, 46.9%) represented less than half of the respondents in this study and only 19, 35.8% reported the presence of a member of the nursing team during a disclosure. This could be a pointer to the fact that medical personnel who break the bad news in this population are more likely to do it unaccompanied . This practice is not in tandem with the principle of "involvement of significant others" as recommended by the SPIKES [14] and other protocols. [16],[17] The relatively low proportion (31.7%) of those who have received support from other colleagues while making disclosure of HIV infection also lends support to the assumption that clinicians were more likely to perform this task unaccompanied, unassisted, and un-assessed. This practice creates more room for haphazard news delivery, creates little or no motivation for improvement of skill while reducing the opportunity for observational learning.

This study is not without its limitations. The possibility of a recall bias exists among those who witnessed a colleague break a bad news since this aspect of the survey was retrospectively evaluated. This is in addition to the fact that the observers were largely untrained peers. A prospective evaluation in which the witness gives a "score" in relation to the level of competence of BBN and adherence to protocol would have been more appropriate. A larger, prospective, well designed study using a multiple source, objectively structured, feedback method of assessment will be able to address this concern.

In conclusion, this study showed a low level of training in BBN among this population of health professionals even though self- rated competence is high. There is poor knowledge and usage of guidelines and protocols. The level of support from a colleague when breaking a bad news is equally low. It appears that a large proportion of this population of health professional were unconsciously incompetent in BBN. There is a need for further medical education and training in communication skills among medical/nursing students and postgraduate trainees in Nigeria, both as a fulfillment of a medical curriculum and on a continuous medical education basis so that they are well equipped to discharge this inevitable clinical duty. There is also the need to provide feedback method for assessing the competence on the performance of this task in the routine clinical practice. Whether the cultural model of BBN impacts on patients' satisfaction, improves adaptation, and enhances their quality of life is also a subject of further research.

   Appendix 1 Top

Section 2: scenarios

The following are some clinical scenarios that you might face. Please indicate how competent you feel in dealing with the following scenario on a scale of 1-5 (1 = not at all competent, 5 = fully competent). Please circle the most appropriate number.

2.1 A 36-year-old man with paraplegia due to complete spinal cord transection is being managed by your team. How competent do you feel about telling him that he will never walk again?

Not at all competent 1 2 3 4 5 fully competent

2.2 A child was just diagnosed with sickle cell anaemia. How competent do you feel about telling the parents?

Not at all competent 1 2 3 4 5 fully competent

2.3 An aggressive relative has just demanded you to tell him about your patient who just died (whom he saw the previous day). How competent do you feel about telling him?

Not at all competent 1 2 3 4 5 fully competent

2.4 A 30-year-old housewife has just being diagnosed of ovarian cancer. How competent do you feel about telling her the diagnosis?

Not at all competent 1 2 3 4 5 fully competent

2.5 A 20-year-old female graduate with loving and committed relatives just died on your ward. How competent do you feel in disclosing the news of her demise to her relatives?

Not at all competent 1 2 3 4 5 fully competent

   References Top

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  [Figure 1]

  [Table 1], [Table 2]

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