breaking bad news 3: encouraging the adoption of best practices

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Breaking Bad News 3: Encouraging the Adoption of BestPracticesElizabeth M. Campbell PhD & Rob W. Sanson-Fisher PhDPublished online: 25 Mar 2010.

To cite this article: Elizabeth M. Campbell PhD & Rob W. Sanson-Fisher PhD (1998) Breaking Bad News 3: Encouraging the Adoption ofBest Practices, Behavioral Medicine, 24:2, 73-80, DOI: 10.1080/08964289809596383

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Breaking Bad News 3: Encouraging the Adoption of Best Practices Elizabeth M. Campbell, PhD, and Rob W. Sanson-Fisher, PhD

Steps to encourage clinicians to adopt the best practices .for communicating bad news to patients are outlined. First, oficial, credible guidelines endorsed by key organizations or pwfessional bodies, giving a clear message about the components and importance of the best practices, must be produced. Second, the guidelines should be disseminated; publication in journals or mailing to clinicians is unlikely to be sufficient. Third, clinicians should be pmvided with feedback on whether their perjiormance meets established standards. This requires acceptable systems to collect valid and reliable perjiormance data. Fourth, clinicians need contingencies for providing best practice care, Fifth, barriers to improvement should be explored and strategies to address them, including interactional skills training, implemented. Continuous quality assurance, commitment, and evaluations will help clinicians use the best practices,for breaking bad news to patients.

Index Terms: breaking bad news, cancer; interpersonal skills, patients, practice guidelines

In this article, we outline steps to encourage clinicians to adopt the best practices for conveying bad news to medical patients. Altering the clinical behavior of healthcare providers is notoriously difficult, and the variables that influ- ence the extent to which particular clinical behaviors are adopted are incompletely understood.14 As the preceding articles have indicated, the area of breaking bad news has received little rigorous research attention, and empirically tested guidance on how to improve clinical performance in this area is not readily available.

Changing how medical bad news is given to patients involves overcoming many b a n i e r ~ . ~ At a structural level, the barriers include a prior lack of consistent information on best practices and a lack of education and training for clinicians. Bamers at the office level include time restrictions and forgetfulness. At the individual clinician level, barriers

Dr Campbell is Senior Project Oflicer, National Cancer Control Initiative, and Dr Sanson-Fisher is with the New South Wales Council Cancer Educiition Research Program (CERP) in Newcas- tle, Australia.

include old habits, low confidence in new approaches, low priorities for this aspect of patient care, a lack of feedback on current performance, and inadequate interactional skill^.^'

With so many diverse factors influencing clinicians’ practices, it is unlikely that any single strategy will ensure sys- temwide adoption of better practices. Diffusion of innovation theory’O suggests that the process of adopting a new clinical behavior is gradual, with timing of uptake among clinicians showing considerable variations. Some clinicians can be encouraged to adopt best practice care with relatively little effort. Others will be late adopters for whom encouraging change will be more difficult. Continued efforts that involve applying many strategies will be required.’

Step 1: Produce Best Practice Guidelines It has been argued that clinicians must be exposed to,

attend to, and comprehend the reasons for making changes” before they can adopt a new behavior. They are more likely to attend to and comprehend a message that is presented clearly and simply, argued persuasively, and perceived to be of immediate benefit. Clinical guidelines are

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BREAKING BAD NEWS 3: ADOPTING BEST PRACTICES

increasingly used to provide clinicians with information about best practice care.I Producing guidelines for best practice in breaking bad news is an important first step in encouraging change in this domain.

Certain characteristics increase the likelihood that clinical guidelines are credible and acceptable to clinicians.’ First, the guidelines should be based on the best available evidence. That quality evidence is found through a systematic review of randomized trials (Level 1 evidence).l.12 As Girgis and Sanson-Fisher indicated in the first article in this series, very few randomized trials on how to break bad news have been reported. Because of the dearth of Level 1 evidence, we can use the results of work with less rigorous study designs and refer to the perceptions of We particularly recommend using guideline documents that contain clear statements about the strength of the evidence on which they are based and the process used to derive them.l

Guidelines should have the endorsement of key professional groups (eg, guidelines for surgeons should have the endorsement of the appropriate surgical college). It is desirable that the guidelines document a strong rationale for the recommended actions in terms of likely outcomes, indicating why they are important for clinicians. In addition, the guidelines should be concrete and specific; should provide simple, clear directions; and should not be open to misinterpretation.’

The elements of clinical guidelines for breaking bad news outlined in the previous article were developed through a consensus process in Australia, where an expert multidisci- plinary panel rated items deemed important in the literature. These elements have been included in official Australian guidelines for the management of early breast cancer.13

To produce best practice guidelines for communicating poor prognoses in other countries or regions, local commit- tees should review both the evidence and the proposed guidelines from the Australian model. This would encourage “ownership” of the guidelines by local policy makers and help ensure their relevance and suitability for particular clinical groups. F’roduction should be coordinated to ensure that different organizations do not produce conflicting guidelines.

Step 2: Disseminate the Guidelines The most commonly used mechanisms informing pro-

viders about guidelines are publication in journals or distribution through the mail. Educational meetings or conferences have also been ~ s e d . ~ . ’ ~ These simple and relatively low-cost, passive strategies may increase awareness, but they seem unlikely to be sufficient to achieve behavior changes among most clinicians.2.’,’s.‘6

In published reviews of clinical guidelines involving two studies (59 in one case, 87 in the other), the authors con-

cluded that guidelines improve clinical practice and patient outcomes. The size of effects, however, varied enormous- l ~ . ~ . ’ ’ Although they did not specifically examine the impact of different methods of disseminating the guidelines, Grimshaw and Russell4 suggested that guidelines distrib- uted through specific educational interventions or continuing education program, with patient-specific reminders or feedback, may have a higher probability of being effective than those published in journals or disseminated through targeted mailing^.^ The authors of the Effective Health Care Bulletin review suggested the importance of strategies that are integrated into existing healthcare delivery systems.”

In a review of the effectiveness of printed educational materials in changing the behavior of healthcare professionals, Freemantle et all5 concluded that these materials have, at best, a small impact of uncertain clinical significance. Because of the small number of studies, these authors were unable to draw reliable conclusions about the value of such additional strategies as conferences, feedback, or outreach visits.

Freemantle et all5 could identify only 1 I rigorous studies on the impact of printed education materials, used alone or with other strategies. Rigorous evaluations included randomized controlled trials, interrupted time-series analyses, and controlled “before and after” studies. This revealed the dearth of rigorous research on the cost effectiveness of the most common strategies used to encourage behavior change among healthcare providers. Further research is needed to clarify the most effective mechanisms for disseminating guidelines:

The reviews cited above are derived from studies that have addressed a range of clinical behaviors. However, they suggest that additional rigorous steps are required to establish better ways of giving bad news in clinical practice generally.

Step 3: Provide Performance-Based Feedback to Clinicians

A further step is to determine whether clinicians’ performance in delivering bad news falls above or below a desirable standard. Providing clinicians with written feedback on how their current performances rate against established standards can be effective in encouraging improved clinical performance, particularly if the feedback has the following

First, the feedback should relate to performance standards that have credibility to the clinician^.'^-^^ Establishing a minimum level of competence or a performance goal provides clinicians with a target. Performance goals can be listed in official guideline documents or set by treatment units and individual clinicians. The latter approach allows clini-

characteristics2. 10.14.I8-2 1 .

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CAMPBELL & SANSON-FISHER

cians to nominate levels that they view as appropriate for their particular situation. For example, the minimal level of competence may be that at least 1 1 of the 13 steps listed in the guidelines occur in 90% of the consultations in which bad news is conveyed.

The feedback to clinicians should be specific, personal- ized, and immediate.’~’~”’~’4 Global summaries of information collected from a number of treatment centers are likely to be less effective than more specific feedback. Clinicians should be given information about (a) their individual performance, (b) their performance with particular patients, (c) the performance of their treatment unit as a whole, and (d) their treatment compared with data from other units. The feedback reports could also provide assessments of each of the elements contained in the guidelines, in addition to over- all levels of competence.

The value of including peer comparisons in feedback reports to clinicians has also been demonstrated. Such feedback establishes standards that peers will strive to equal or exceed.* Feedback provided promptly after performance is monitored will be more relevant to clinicians than that given after some time has elapsed.

The process of quality assurance-working to ensure that the clinician is providing adequate care and that problem areas are improved-has long been a tradition in clinical or technical aspects of medicine.2?~23 This process has seldom been used to provide quality control for interpersonal aspects of care, such as clinician-patient communication. Operating a quality assurance system in the realm of breaking bad news requires the capacity to collect credible data on clinical performance and provide feedback in an acceptable and efficient manner. Because neither specific measurement instruments nor feedback mechanisms currently exist, other quality assurance systems will have to serve as models for developing performance guidelines.

Measuring pegormance levels

The instruments developed to measure clinicians’ performance in breaking bad news should have the following characteristic^^^^^':

First, they should be valid and reliable so that the information derived has credibility and comparability. An instrument is valid i f it measures the concept it is intended to measure. For breaking bad news, this implies assessment of all the elements in the guidelines.

Mechanisms for assessing validity depend on the measures used. For example, the validity of using a patient’s report to assess whether elements of best practice were undertaken in a consultation could be assessed by comparing the patient’s report with a videotape of the consultation. A measurement

instrument is reliable if it produces results that are free from random error and provides consistent results, unless a real change has occurred. Thus, scores on a patient questionnaire should not be influenced by such factors as the time or day when the questionnaire was completed.

Second, the measures should be sensitive to change. This makes it possible to detect improvements or deteriorations in performance.

Third, the measurement instruments must be acceptable to patients and clinicians. This increases the likelihood of compliance and implies that the measures can be easily understood, quick to complete, easy to incorporate into rou- tine practice, easy to score and collate, and implemented at a manageable cost.

Finally, it is desirable that the measures can be used in a variety of clinical settings. Standardized measures that can be used across treatment centers make it possible to com- pare experiences.

From whom and by what methods can performance datu be obtained?

Data on performance levels can be collected from patients, next of kin, and clinicians, as well as by direct observation of consultations or by using audio or video recordings.

Data can be collected from patients’ responses to questionnaires or interviews. The interviewer can ask patients whether they have received each of the elements of best practice for breaking bad news. Their perspective would be particularly valuable in assessing whether a clinician com- plied with each of the guideline variables (Did the patients find explanations simple? Were they encouraged to express their feelings‘? Did the clinician responded with empathy?). However, because patients’ self-reports can be associated with either underreporting or overreporting,26 research to establish the validity and reliability of such information is needed.

Data can also be collected through clinicians’ use of questionnaires or audit systems, with clinicians asked to complete retrospective questionnaires or postconsultation checklists indicating whether the elements in the breaking bad news guidelines were undertaken. Again, given that clinician reports can overestimate or underestimate levels of healthcare provided, the reliability and validity of the measures should be expl~red .~*~’ Respondents’ desire to portray themselves in the best possible light is a potential bias. Using audit techniques to measure performance calls for hav- ing an unbiased outsider get information from the medical record about how the bad news was communicated to the patient and what information was provided. Medical records

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are currently unlikely to contain detailed information on communication techniques. If an audit is implemented, the process for recording information should be altered to include more specific information on how the bad news was delivered. Even so, medical records may not be adequate.28 The reliability of the coding system will also need to be examined.

Assessing clinical performance by direct observation can involve rating videotaped, audiotaped, or directly observed consultations. If reliable rating scales can be developed, this approach can provide a good indication of whether best practice care had been provided. Direct observation, however, can be threatening to clinicians and can pose logistic difficulties, particularly if the recorded material is intended for repeated use. Clinician reaction when under observation may not necessarily represent usual care.

Mechanisms for data collection

The most common methods for collecting data from patients or clinicians are manual pen-and-paper or computer-recorded accounts. Paper surveys completed by patients are customary,29 but clinician-completed paper surveys, checklists, or self-audits have also been used.30 Manual scoring and collation of results is required when paper instruments are used unless mark-sense or machine-read- able forms are used.

Previous studies suggest that touch-screen computers can. be successful for collecting sensitive information from patients, even from people with little prior computer expe- r i e n ~ e . ~ ~ . ~ ' Newel1 et a13' used a touch-screen computer to assess levels of physical side effects, anxiety, depression, and perceived needs among 229 cancer patients, 60% of whom had no previous computer experience. Patients found this method very acceptable; 96% were happy for the oncol- ogist to see the results, and 89% said they would be happy to complete such a survey each time they visited the hospi- tal. In a survey of general practice patients, 91% preferred a computer survey to the same survey in paper form or rated both surveys equally.29 Clinicians also are likely to accept computerized self-audit systems. Computerized patient or clinician surveys related to breaking bad news preclude missing items, allow data to be readily collated, and are worthy of further exploration.

Developing a manual or computerized system for collecting performance data on breaking bad news and providing feedback to clinicians is likely to require considerable effort. Creation of a widely applicable, cost-effective system should occur in a planned and systematic fashion that assures reliability, validity, and acceptability and avoids duplication of effort.

How frequently should pe$ormance data be collected and reported to clinicians?

Regular performance feedback is more likely than spo- radic feedback to enhance clinical per f~rmance .~ . '~-~ ' , '~ Repeated feedback allows clinicians to monitor their performance continually and to judge whether they have improved.

The frequency with which data on breaking bad news is collected and reported back to clinicians is influenced by several practical considerations. Low-cost, quick, acceptable systems can have more frequent application. For example, a system that uses a touch-screen computer to collect information from patients could be in continual operation. A system that requires clinicians to complete checklists on each patient may be feasible only for several weeks and once or twice a year or could be continuous throughout the year, applied to only a small number of randomly selected patients each week.

The frequency of collecting performance data will also depend on how treatment units wish to use the information. Some may use the data in a continuing quality-improvement cycle in which clinicians are provided evaluations on a variety of aspects of care at 3-month intervals. Other units may use the data as part of an accreditation process that occurs less frequently (eg, every 3 years).

Step 4: Provide Performance-Based Contingencies Providing clinicians with contingencies (rewards) on the

basis of best practice care is an important mechanism for encouraging behavior change.'* Intangible contingencies can take the form of positive messages on feedback forms or verbal reinforcement from senior clinicians. Tangible contingencies can also be provided. Treatment units (or all clinicians within a unit) can be required to achieve a minimal level of competence for breaking bad news as part of an institutional quality-assurance program.

Junior clinicians _can be required to demonstrate such competence to obtain qualifications. Using contingencies such as these will reinforce the importance treatment institutions and professional colleges place on interactional skills.33 Financial contingencies can also be considered. Although contingencies are likely to be helpful in encouraging best practice care, their contribution to achieving the desired outcomes in the context of breaking bad news has never been studied.

Step 5: Explore and Modify Barriers To Improvement If individual clinicians or entire treatment units continue

to perform at less than specified levels of competence, it will be important to understand why this is so and to implement structural changes to help clinicians improve their perfor-


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mance. ’’-*I The barriers that are most important for clinicians in the context of breaking bad news, and the clinicians’ perceptions about how to address them, can be explored in a numbers of ways. These range from informal discussions to more formal processes of needs assessment, depending on how widespread the suboptimal performance is.

Surveys among entire professional groups may be an appropriate way to assess each group’s need for training and other support in this area. Time constraints and a lack of pri- vacy for sensitive conversation can be corrected administra- tively, and clinicians’ personal insecurity or inadequate information can be remedied by further training.

Provide interactional skills training

One reason for suboptimal performance is that clinicians may not possess prerequisite interactional skills. The skills needed for effective doctor-patient interactions in areas such as breaking bad news are not necessarily acquired through clinical practice.” Researchers have shown that many professionals feel incompetent in their interactions with patients.’.’ Girgis et al found that most surgeons reported that they felt “not at all competent” at breaking bad news about patients’ diagnosis or prognosis or at encouraging patients to express their anxieties about their condition, despite their belief that these skills are important for good surgeons.’

Relatively brief training can be effective in teaching interactional skill^.^'.^^ A review of more than 200 studies on the effect of interactional skills training showed that such training had a positive impact on clinicians’ skill in communicating with patients.35 Training is appropriate at several levels-as part of undergraduate or postgraduate training, and, where needed, as a component of continuing ed~cation.)~

Teaching interactional skills to undergraduates is important for establishing a skills base and encouraging an appre- ciation of interactional competence. Published studies have indicated that training for a range of behaviors, including counseling for HIV and smoking cessation, has resulted in improved interactional Maguire et a13x reported that the positive effects of training in interactional skills at the undergraduate level can be preserved. Five years after their initial training, the doctors who had received interactional skills training as medical students demonstrated better interactional skills during history taking than doctors who had not had such training.

Other research findings, however, have suggested that interactional skills may deteriorate over time and may not generalize across clinical s i t ~ a t i o n s . ~ ~ ~ ’ ’ ~ ~ A lack of reinforcement of the learned skills in the clinical environment may contribute to such deterioration. Teaching interactional skills in postgraduate training programs can assist in main-

taining interactional skills and reinforcing their impor- t a n ~ e . ~ ~ Such training is important for many professional groups, including general practitioners and medical special- ists (surgeons, neurologists, and therapeutic radiologists). Nurses also need this training so that they can follow up sensitively with patients after physician consultations that generate psychological shock.

Because many practicing clinicians may not have learned interactional skills during their training, the training can be required outside of formal postgraduate programs. Treat- ment institutions or professional organizations can provide interactional skills training as a component of continuing education or quality assurance programs. Elements that should be considered for inclusion in interactional skills training programs are listed below.33*3x~4145

Clearly define the target behavior

Provide concrete and specific definitions so students or clinicians have a clear understanding of exactly what the desired behavior entails.

Provide a strong rationale for behavior change

A strong rationale can help students and clinicians understand the importance of the desired behavior.41 In the case of breaking bad news, it is important to emphasize the impact the clinician’s behavior can have on the patient during this key period in his or her illness.

Use credible models

The training should provide effective models of the desired behavior. These can be provided through videos of real or simulated consultations. The interactional skills must be taught and modeled by medical professionals from a range of disciplines, rather than only those from behavioral science, psychiatry, or psychology. This will reinforce the relevance of interactional skills for all clinical discipline^.^'

Offer opportunities to practice the skills and receive individualized feedback

Giving students and clinicians a chance to practice the skills they are learning with real or simulated patients and to receive feedback on their performance can result in significant improvements in interactional ~ompe tence .~~ A video or audiotape of a real or simulated consultation pre- sents an opportunity for students or clinicians to practice their skills, review their own performance, and have their performance evaluated by peers and clinical teacher^.^^,^^

One trial showed that immediate feedback from peers was more effective than video feedback in enhancing clinicians’ interactional skills for smoking cessation, suggesting

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the potency of immediate peer-based feedba~k. '~ A rating scale that lists the behaviors enumerated in the best practice guidelines can be used to review performance and ensure that feedback is specific and comprehensive.

Make formal assessments

Assessment of performance is central to effective learn- Formal evaluations can provide undergraduate and

postgraduate students with feedback on their competence and indicate that the faculty or college believes that such skills are as important as other clinical skills.

Assessment and grading may be powerful motivators for students who are trying to acquire the necessary level of interactional skills. Assessment can also be incorporated into a continuing education program. Clinicians can gain accreditation points for updating their clinical qualifications through assessed courses in interactional skills. As a mechanism for assessment, rating scales can be used to score interactional performance in simulated or real consultations. Several examples of training in interactional skills have incorporated these elements.

Campbell et a136 trained senior medical students to coun- sel patients who requested an HIV test, providing students with both positive and negative test results. The program included a written manual and a lecture that provided a rationale as well as a specific list of behaviors to be per- formed. Students practiced skills by making a video with a simulated patient. They participated in small group sessions at which their videotaped performance was reviewed by peers and a clinical facilitator who used a rating scale that defined minimal levels of competence. The randomized trial showed that 3 months after the training, students who participated in the program demonstrated significantly greater improvement in counseling skills than an untrained control group.

A similar model is used with several postgraduate training programs in Australia. For example, the Australian Col- lege of Obstetrics and Gynecology has interactional skills as one of the assessable modules that trainees must complete. The trainees are sent a package containing a rationale outlining the importance of interactional skills and listing specific guidelines, rating scales, and patient scenarios for four clinical situations, one of which focuses on breaking bad news. The trainees practice their skills by making an audiotape for each of the scenarios, and the audiotape is sent out for assessment and feedback.

Address other barriers

Another explanation for clinicians' suboptimal performance is that they may have the interactional skills to break

bad news compassionately but other factors make i t difficult to apply those skills. Tools that remind the clinicians to employ best practice can help address barriers, such as for- getting. Reminders, especially office systems incorporating computer reminders, can be effective in altering the clinicians' b e h a v i ~ r . ~ ' , ~ ~ A desk pad or prompts on computerized patient records can remind clinicians to cover all of the steps recommended in the guidelines each time they must convey troubling news. Facilitators help establish such a system.47

Patient information resources, such as printed handouts, can provide information for patients who want details about treatment options for a particular disease. Clinicians can also use these resources during the consultation to give information and provide reinforcement and further details for patients after they leave the consultation. The development of such strategies for dealing with bad news and evaluation of their acceptability and cost effectiveness in encouraging adoption of best practice care would be beneficial.

The physical environment or the organization of clinical services can also present barriers to adopting best practice care for sensitive communication. Breaking bad news to a patient requires a private environment and, often, a consultation of considerable length. Systems that schedule appointments at 5-minute intervals and ward rounds with multiple onlookers clearly present an environment that is less than optimal for giving or receiving bad news. Altering conditions, such as how patient rounds are arranged or appointments scheduled, may make it easier to provide the best practice care. These changes call for attention at an organizational and policy level.

Step 6: Encourage Maintenance of Best Practice Once established, best practices for breaking bad news

should be maintained. Perhaps the most important of the steps described earlier is the inclusion of performance assessment and feedback in an institutional system with continuous quality assurance. It is beneficial to ensure that systems for providing positive and negative contingencies are ongoing and that continued attention is devoted to iden- tifying and addressing barriers as they appear.

In any area of healthcare, the elements recommended for best practice care can change as new evidence becomes available. Maintenance of best practice care in the area of troubling communications should include provisions for reviewing and updating guidelines regularly.

A Continuing Commitment Encouraging clinicians to alter the way they break bad

news to their patients is an important area for changes in


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professional behavior. To achieve widespread improvement and consistency of practice in this area is challenging and requires a firm commitment in time and resources. Given the difficulty in altering clinical behavior, it is not reason- able to expect that widespread adoption of best practice will be achieved by simply producing best practice guidelines.

Developmental research and evaluation in the areas we have described will add substantively to empirical data about how clinical practice for breaking bad news can be improved. However, the current absence of research specifically devoted to breaking bad news does not imply that all action must wait until the results of further research are complete.

Credible guidelines can certainly be established. Other strategies, including those for dissemination of guidelines, can be implemented, preferably in the context of evaluation trials. Developing reliable, valid, and acceptable measurement instruments to evaluate how to share bad news repre- sents a significant priority. These must be developed before quality assurance systems based on performance assessment and feedback are implemented more widely, and they will also be required for outcome assessment in evaluation trials.

NOTE This article was prepared on behalf of the New South Wales

Cancer Council Cancer Education Research Program team. The views expressed are those of the authors and not necessarily those of the Cancer Council.

For further information, please address correspondence to the Secretary, NSW Cancer Council Cancer Education Research Pro- gram, Locked Bag 10, Wallsend, NSW, Australia, 2287.

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breaking bad news 3: encouraging the adoption of best practices

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