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.