Communicating bad news in the practice of nursing: an integrative review

ABSTRACT Objective To analyze current scientific knowledge about communication of bad news by nurses. Methods This is an integrative literature review carried out by searching articles published in national and international journals indexed at SciELO, MEDLINE® (PubMed®), Scopus, Bireme and CINAHL, from 2010 to 2020, by crossing the controlled descriptors “communication”, “revelation of the truth”, and “nursing”, and the uncontrolled descriptor “bad news”. Results Ten articles with qualitative and cross-sectional design, as well as case reports were included. The analysis indicated the evidence available in the literature showed the nurses’ lack of ability to communicate bad news, although they are professionals who have close contact with patients and families and who establish a strong bond with them, and often face challenging situations for communicating bad news. Conclusion There is an evident need to invest in training of nurses on skills to communicate bad news and establish a nurse-patient bond when dialoguing with the family. There are few studies in the literature addressing this issue; therefore, it is recommended to perform research that can contribute to improvements in the clinical practice and developing protocols to promote such care.


❚ INTRODUCTION
The process of transmitting and receiving ideas or knowledge is called communication, and is considered the fundamental element of human relationships and one of the most complex practices developed by humans. Through it, the individual recognizes themselves and sees their meaning before society, enabling the creation of bonds that shape not only them but everyone around as well. (1,2) Communication is present in all human activities, whether through a look, a gesture, or a sentence. It is divided into two dimensions -verbal and non-verbal. The former occurs through words, which express an idea or thought, and the latter is characterized by gestures, features, tone of voice, and expression of emotions and feelings. (1)(2)(3) The goal of communication is that it happens efficiently; it is necessary that there be a good understanding between both parties, which does not always happen, since there are many factors that influence it, such as expectations, culture, level of education, and values. It does not matter if the message is only transmitted, and, for this reason, it is necessary that the other party understands it. (1)(2)(3)(4) In the field of health, communication is the key element of the interactions, whether among the teams or with the team-patient/family. Thus, it is ❚ OBJECTIVE To analyze current scientific knowledge about communication of bad news by nurses.
❚ METHODS This is an integrative review study, consisting of analysis, grouping, and synthesis of scientific evidence relevant to the desired subject, involving both theoretical and empirical literature, helping to form the study of a certain phenomenon, and generating knowledge to be used in quality clinical practice. (12) This review adopted the methodological steps proposed by Mendes et al., as follows: (13) identification of the research question that is relevant in the field of health and nursing for preparation of the integrative review; establishment of criteria for inclusion and exclusion of studies, sampling, or literature search; definition of pieces of information to be extracted from the selected studies/categorization of the studies; evaluation of the studies included in the integrative review; and interpretation of the results and presentation of the review and synthesis of knowledge.
The elements of the strategy PICO (14) (P for patient or problem, I for intervention, C for comparison, and O for outcomes) were used to formulate the following guiding question, "What is the nurse's knowledge about communicating bad news?".
The search in scientific literature was conducted in 2020, in national and international journals indexed at Scientific Electronic Library Online (SciELO), Medical Literature and Retrieval System Online (MEDLINE ® ) via PubMed ® , SciVerse Scopus (Scopus), Latin American and Caribbean Center on Health Sciences Information (Bireme), and Cumulative Index to Nursing and Allied Health Literature (CINAHL), via the Coordination for Improvement of Higher Education Personnel (CAPES -Coordenação de Aperfeiçoamento de Pessoal de Nível Superior) portal.
The descriptors used in the search are contained in the structured and multilingual vocabulary of the Medical Subject Headings (MeSH) and in the Health Sciences Descriptors (DeCS -Descritores em Ciências da Saúde). As an uncontrolled descriptor, the term "bad news" was included to broaden the results obtained. The search strategy in MEDLINE ® and Scopus included the combination of keywords: "truth disclosure" [All Fields] OR "communication" [All Fields] AND "nursing" [MeSH Terms]. For Bireme and SciELO, we used "truth disclosure" OR "revelación de la verdad" OR "revelação da verdade" [subject descriptor] OR "bad news" OR "má notícia" OR "malas noticias" [words] AND ("communication" OR "communicación" OR "comunicação") [subject descriptor] AND ("nursing" OR "enfermagem" OR "enfermeria") [subject descriptor]. Finally, for CINAHL: "truth disclosure" OR "disclosures, truth" OR "truth disclosures" OR "bad news" AND "communication" AND "nursing" were used. einstein (São Paulo). 2022;20:1-8 The following criteria were adopted for selection of articles: all categories, regardless of the type of study conducted, whether primary or secondary characteristics (quantitative, qualitative, literature review, descriptive study, cross-sectional study, reflection study, clinical case report, among others); articles with abstracts and full texts available electronically; those published in Portuguese, English, or Spanish, between 2010 and 2020, and articles that indicated the topic of interest of this review in the title, abstract, or body of the text. Articles that did not meet the proposed theme for the study and those different from the proposed languages were excluded.
All articles included in the sample were exported to the software EndNote Web Basic (Clarivate Analytics ® ), and duplicate articles were removed. At first, the titles and abstracts of the total sample were read by two independent reviewers, taking into account the inclusion and exclusion criteria. Subsequently, the articles were read in full, selecting only those that met the study criteria. Figure 1 shows the flowchart of the search and selection of studies, according to the model of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). (15) The instrument proposed by Ursi et al. (16) was used in this study for data extraction, with the purpose of collecting and organizing the following information: name of the authors, name of the journal, year of publication, country of the study, language, name of the article, type of the study, sample, results (nurse's abilities to communicate bad news, education, training, and previous experiences), method of data analysis, conclusion, recommendations, and quality assessment.
The evidence classification hierarchy proposed by Melnyk et al., (17) was used to describe the level of evidence of the studies: level I for systematic reviews or meta-analysis; level II for randomized controlled trial; level III for non-randomized clinical trials; level IV for cohort and case-control studies; level V for systematic review of descriptive and qualitative studies; level VI for descriptive or qualitative study, and level VII for opinion of authorities or expert committees.

❚ RESULTS
By combining the controlled descriptors and the uncontrolled descriptor "bad news", a total of 1,054 articles were found, 69 in MEDLINE ® , 177 in the Virtual Health Library/Bireme, eight in SciELO, 448 in Scopus, and 352 in CINAHL. Most of the articles were neither related to nor specifically reported on the subject of communication of bad news in relation to nurses and their role. Thus, only ten met the study criteria; they are presented on table 1. (8,11,18,(19)(20)(21)(22)(23)(24)(25) The analysis of the studies included in this review allowed us to identify three main points addressed in the articles. The first is about the little or no communication skills developed during nurses' training, a situation described in all articles analyzed. The second point discussed is about how the disclosure of bad news appears during nurses' practice, from primary to tertiary care. (8,11,19,21,25) Finally, another aspect identified is the creation of the link between patient/ family/nurse for an effective communication of bad news, (22,23) as well as for strengthening the trust between them in difficult moments. (8,(18)(19)(20)(21)(22)(23)(24)(25) Regarding the communication skills of students and nursing professionals in general, the studies showed that, during undergraduate course or technical training, there are no subjects or courses addressing this issue, and, consequently, this produces a deficit in the development of professional skills. (20,21) The results of studies (21,23,25) point out that nurses, among the other health disciplines, are the professionals who have the largest workload of direct care delivery to patients and their families. This means that, regardless of the environment, whether in the inpatients´unit, intensive care unit, outpatient clinic, or primary healthcare unit, nurses are present at the moment of conveying bad news, as the agent of disclosure or a member of the interdisciplinary team. (21,23)   The study provides a list of several difficulties presented by nurses of the service, at the time or in the process of breaking bad news. "Traditional issues, such as information on diagnosis and treatment, were described, but additional topics were identified, such as the impact of illness and end-of-life care." A description was made of the issues most present as difficulties at the time of disclosure; these were: organization, the situation in which the disclosure is made, reactions and issues related to the patient and their families; and finally, personal issues, such as lack of skills or confidence Structural analysis of the obtained data, with independent and collaborative phases, which identified some preliminary thematic indexes.
Then, the similarities and differences were evaluated forming the final thematic index The study provides "an understanding of the scope of challenges faced by staff", when they are involved in the process of breaking bad news. Nurses are participants in the process of communicating bad news, which is not a one-time process, but one that occurs throughout the course of care. They act as educators, facilitators, and supporters of the patient and their family members during the communication. Therefore, the process must be done within ethical principles and the patient's preferences. Their skills must be developed for best practice VII * Levels of evidence I to VII. (17) einstein (São Paulo). 2022;20:1-8 Regarding the nurse-patient bond, the results of studies (8,22,23) showed the existence of the bond facilitates communication of bad news and strengthens ties. (8,20,21) ❚ DISCUSSION Evidence proves communication of bad news by nurses is a subject still poorly explored. (10,11) According to the findings of this study, it is possible to verify there is a discrepancy in the background of nurses regarding this theme, whether in undergraduate teaching or in the different work organizations that do not promote professional training. Studies show that there is a growing concern with quality communication, but investments are insufficient. (22,26) The literature points out that there are few organizations that use protocols to help professionals at the time of announcing bad news. (10) The SPIKES tool (27) is a medical protocol that contemplates six steps for the action in a didactic way, and has been used by nurses around the world to train their communication skills. (10) Two of the studies included in this review cite the benefits of using the SPIKES protocol, as well as the advantages of other protocols in clinical practice. (19,24) Evidence shows the SPIKES protocol is a widely disseminated toll used in hospitals around the world, with free access and easy retrieval by health professionals. (27)(28)(29) It may be an ally for those who are beginning to learn the disclosure of bad news or feel insecure to perform this action, since the tool directs the conversation between professional-patient/family, (29) and builds nurses' communication skills. (10) Since nurses have the largest workload and more contact with patients and family members, they are key players in the disclosure of bad news, and should establish an important bond at this moment. (30,31) Results of previous studies showed the creation of the nurse/patient bond is essential for a relationship of trust between them. (29,31) Therefore, even if it is not the nurses who communicate the bad news, their presence is fundamental to establish the necessary confidence to the patient and family, besides being the professionals who provide continuity of care to these subjects, and follows all consequences of the announced news. (29,31) Among the studies selected, some of them demonstrated the nurses remain close to the patients and their family even after disclosure, clarifying terms, helping to understand the extent of the news, comforting the patient and family, and offering support. (8,11,25) Therefore, it is important to highlight that this communication must occur as a team, because even if it is the physician or the nurse who conveys bad news, there is a repercussion that reaches all other professionals who deal with the patient. (30) In communicating bad news in delivering comprehensive care, nurses are fundamental professionals who favor the establishment of a relationship of trust between the parties. This highlights the need to promote the development of communication skills of such professionals to ensure quality care.
This study had as limitations a reduced number of studies available on the subject, low levels of evidence in all studies found (with descriptive and qualitative designs and opinions of authorities or expert committees), exclusion of articles with no texts available on the CAPES portal, and exclusion of those published in languages other than Portuguese, English, and Spanish. The search did not find review studies that allowed comparisons with the findings of this research, demonstrating the need to explore the content in search of evidence that can promote the communication of bad news in clinical practice. Thus, this study provides a consolidation of information already published in the literature over the last 10 years.

❚ CONCLUSION
Nurses are frontline professionals in disclosure of bad news, but the deficiencies in their education and training are clear, culminating in inability to perform such a practice. Therefore, it is urgent to implement efforts for the training of communication skills in educational and work organizations. Moreover, the production of knowledge on this subject is also scarce, and it is recommended that new studies be carried out to add to and expand the discussion on the disclosure of bad news by nurses and, consequently, to enhance the quality of care for patients and their families.

❚ ACKNOWLEDGMENTS
To the Nursing School, Universidade Estadual de Campinas (Unicamp) and to the Library of Faculdade de Ciências Médicas da Unicamp.

❚ AUTHORS´ CONTRIBUTION
The authors Beatriz Lopes Agnese, Ana Carolina Queiroz Godoy Daniel and Rafaela Batista dos Santos Pedrosa carried out data analysis and interpretation, writing of the article, critical review of the intelectual content, and final approval of the version to be published.