Analysis

Breaking bad news: what you need to know

Informing patients and their families of bad news is never easy, but it is part of life in emergency departments

Informing patients and their families of bad news is never easy, but it is part of life in emergency departments

  • Nurses often take the lead in breaking bad news when working in emergency departments
  • Alison Franklin, a senior trainer with the Maguire Communication Training Skills Unit, gives guidance on structuring difficult conversations
  • Advice on overcoming communication challenges presented by PPE and social distancing during the COVID-19 pandemic
Picture: iStock

When Angela Harris started out in emergency nursing, she says it was was rare for nurses to take the lead in breaking bad news. This has now changed for the better, she says.

Twenty five years ago it was always the consultant who would give

Informing patients and their families of bad news is never easy, but it is part of life in emergency departments

  • Nurses often take the lead in breaking bad news when working in emergency departments
  • Alison Franklin, a senior trainer with the Maguire Communication Training Skills Unit, gives guidance on structuring difficult conversations
  • Advice on overcoming communication challenges presented by PPE and social distancing during the COVID-19 pandemic
Picture shows a serious conversation between a nurse and a man.  Informing patients and their families of bad news is never easy, but it is part of life in emergency departments
Picture: iStock

When Angela Harris started out in emergency nursing, she says it was was rare for nurses to take the lead in breaking bad news. This has now changed for the better, she says.

‘Twenty five years ago it was always the consultant who would give the bad news,’ says Ms Harris, who is now nurse director for acute and emergency care with Sheffield Teaching Hospitals NHS Foundation Trust.

‘Back then, it was quite hierarchical, and that has changed. It depends on circumstances – you have to read the situation to decide who is the best person at this point of time to give that information to the family member. It’s about being intuitive to people’s needs at what is a very difficult time.’

‘Often they’re dealing with people who are in a highly anxious or angry or adrenaline-fuelled state, with no preparation at aIl’

Alison Franklin, senior trainer

Breaking bad news is never easy, but it is part of life in emergency departments (EDs). Although bad news can involve anything from informing a patient or relative of a life-changing illness or situation, in the ED it frequently involves telling someone their loved one has died, or will die soon.

Difficult for families and patients to process information

 Alison Franklin, a senior trainer with the Maguire Communication Training Skills Unit
Alison Franklin

‘The nature of emergency nursing is that often the news is unexpected,’ says Alison Franklin, a senior trainer with the Maguire Communication Training Skills Unit, which is based at the Christie NHS Foundation Trust in Manchester.

‘Someone has gone out to work that morning or got up as usual, and then there’s been some sort of catastrophe. So often they’re dealing with people who are in a highly anxious or angry or adrenaline-fuelled state, with no preparation at all. When we speak to our colleagues who work in EDs, they will say that’s one of the hardest things.’

This makes it difficult for families and patients to process information, she says.

‘But also, because of the nature of the department, often the staff are in a highly charged state too, especially if they’ve just been desperately trying to save someone’s life. But empathy and compassion go a long way.’

Taking people through what’s happened and using lots of ‘warning shots’ is important, she says.

Advice on breaking bad news in the emergency department

Quiet place iconFind as quiet a space as possible to break bad news

Make sure you’ve got the right information to hand

Repeat information iconGive the person time to understand what you’ve said, then repeat it

Communicate honestly and factually – avoid phrases like ‘passed away’ or ‘they’ve gone to a better place’

Breaking bad news is hard – be kind to yourself and support your colleagues

‘If you were breaking bad news in a cancer setting, for example, you would start by finding out what that person knows, but you might be in a situation where someone is coming in to the ED and they don’t know why. So you have to start from the point of saying that, “Unfortunately your father was involved in a road traffic accident this morning,” then pause. It’s about taking people with you and allowing them to digest each chunk of information as you go.

Warning shots only work if you pause after them

‘Often people will ask how serious was the accident, so you could respond that you’re afraid it was very serious, then pause. What you’re doing is allowing them to manage each chunk as they get it. Then you might go on to say something like: “Unfortunately your father had some very serious injuries and despite our best efforts, we were unable to save him, and he has died.”

‘It’s about taking them on the journey of what’s happened to their loved one through to the fact that their loved one has died, or is very seriously injured, or is at risk of dying, and doing that in small chunks. The warning shots only work if you pause after them.’

If people can realise what has happened just slightly ahead of you telling them, this can help them process it, says Ms Franklin.

‘Ideally it should be that the nurse goes in and breaks the news and the doctor supports with any technical questions’

David Smith, RCN Emergency Care Association chair

‘If you just come in and say “he’s died” it overwhelms the system. If they can come to the conclusion that that’s what’s coming ahead of you, it just helps them manage it. It’s not about torturing people or dragging it out – it’s just about gently taking them with you.’

Nurses should take more ownership and responsibility for breaking bad news

RCN Emergency Care Association chair David Smith believes nurses should be taking more ownership and responsibility for bad news – and that they are often best placed to do it.

RCN Emergency Care Association chair David Smith
David Smith

‘We can be as sympathetic and empathetic, if not more so, than doctors. We can manage the situation. Often what would happen is that they would break the bad news and then leave the nurse to deal with the aftermath, but there is a shift in attitude now, that nurses can do it.

‘Ideally it would be nurse-led, but the issue would be that if there were particular questions, the nurse may not necessarily have the medical knowledge to be able to answer all of the questions.

‘For example, if the patient’s got a progressive cancer diagnosis, potentially terminal, the nurse may not have the knowledge that the doctor would have.

‘Ideally it should be that the nurse goes in and breaks the news and the doctor supports with any technical questions, but I don’t think we’ve got that shift in paradigm yet. But where I am we try to make it nurse-led if we can.’

Mr Smith left his role as senior charge nurse and practice development lead in the ED at London’s Whipps Cross Hospital in September to move to University Hospitals Plymouth NHS Trust in a matron’s post. He believes education and training in breaking bad news are essential for nurses working in emergency care.

Never offer false hope and be as honest as you possibly can

‘In my experience, training in this is sporadic. I’m passionate about palliative care. In my last role I brought in palliative care specialist nurses to have a chat with the nurses and give them training on breaking bad news.

‘One thing I will always remember is never to say: “I know how you feel.” That’s the absolute no-no. You can empathise, but don’t try to say: “I know how you feel” or: “I can put myself in your shoes” – this is their grieving, and you cannot take that from them. What you can say is that you’re sorry for someone’s loss and ask if there’s anything we can do.

‘We never offer false hope – we always have to be as honest as we possibly can be. Offering false hope can bring problems down the line because people will hold on to that. Give them reality from the beginning, don’t lie, and don’t sugar-coat anything.’

Nurses use better terminology and have a rapport with the family

Dartford and Gravesham NHS Trust paediatric ED sister Tina Fairhead wanted to help her staff prepare for the sudden death of a child, so she organised study days that include learning about breaking bad news.

‘Breaking bad news has become more nurse-led, whereas before we’d have to go in to support the doctors to provide that support to the parents or relatives.

‘In the past 15 or so years when witnessed resuscitation has come into it, EDs have a nurse there who is dedicated to being with the parents or relative on the children’s or the adult side. That means the nurse has more rapport with the family to say those words.

‘Nurses use better terminology. We’re not scared to say the word “dead”. I’ve sat in a few times when doctors have used the terminology “gone to sleep” or “we couldn’t save them” whereas I personally – and I’ve seen colleagues do the same – would go in and say: “I’m very sorry but…” – and use the person’s name – “has died”.

Her practice has developed partly through experience, but also because she has been on bereavement training, which advised using direct words.

It’s not about using a script, she says. ‘I do go in thinking I’m going to say this and this – but you always take your cues from the family. You’re almost assessing the family to see what words or terminology you would use with them.’

Communication challenges during the COVID-19 pandemic

COVID-19, face masks, social distancing and visiting restrictions have brought additional communication challenges.

Yet basic concepts such as empathy and compassion remain crucial when breaking bad news, says Alison Franklin, a senior trainer with the Maguire Communication Training Skills Unit, which is based at the Christie NHS Foundation Trust in Manchester.

‘It’s about being creative. It’s important to empathise verbally. If you can’t hug someone, if you can’t show clearly on your face how compassionate you’re feeling, you can say it. You can say: “I’m just so, so sorry,” which is sympathy, but you can also say: “I can see how utterly shocked and devastated you are.” That verbal naming of the emotion is a powerful skill.’

Hospitals are also being creative with technology. RCN Emergency Care Association chair David Smith says during the first wave of the pandemic his department used donated iPads to connect patients with their loved ones, but also to talk to families unable to come to the ED.

Even if someone was in the last hours of life, he says, families gained comfort from knowing that a nurse was with their loved one, and that attention was being paid to their needs.

His department made extensive use of an infographic drawn up by palliative care consultants Antonia Field-Smith and Louise Robinson, which was designed to help staff communicate compassionately with the relatives of seriously ill patients when visiting wasn’t allowed or was not possible. ‘We pinned it up everywhere and it was a real help.’


In Sheffield, Ms Harris – who was part of the team that won the Emergency Nurse award at the 2019 RCNi Nurse Awards for improving end of life care – says it’s also vital to ensure that nurses are supported.

‘You can read about it in a book, but you really need to see what happens – that’s when you learn that you’ve got to have empathy and compassion’

Angela Harris, nurse director for acute and emergency care

‘What I wouldn’t have is a brand new staff nurse going in and giving bad news. That’s not fair on them, and it’s also not fair on the family because they will have lots of questions and that individual may not be the right person to answer these questions. Sometimes it might be me and a consultant anaesthetist who goes in, sometimes it might be one of the sisters – there’s no hard and fast rule. It’s about reading the situation and doing what’s best in each case.’

Don’t be afraid to stop and think about how best to communicate something

She advocates providing ‘bite-sized’ education sessions for staff, and communications and breaking bad news are among the most popular topics.

‘Also, all of my nurses are in teams, and each team has a band 6 and band 7, and when nurses start in the department they have a buddy and a mentor to work alongside them. I’ve had a junior nurse in with me, and so have the senior sisters, when they are breaking bad news because they need to learn the tone. You can read about it in a book, but you really need to see what happens – that’s where you learn that you’ve got to have empathy and compassion.’

Communication is underestimated across all of healthcare, she says, and nurses should not be afraid to stop and think about how best to communicate something – whether it’s telling a patient about a possibly life-changing diagnosis, or informing a relative that their loved one has died.

‘Be clear and concise,’ says Ms Harris. ‘If you’re wishy-washy people won’t interpret it properly. There have been times when I’ve been upset when I’ve been with a relative – they’ve cried and I’ve cried, and that’s okay. But it’s about reading the situation and understanding what’s going on. We need to nurture our staff and give them experience – make sure that they see difficult situations and give them that support.’


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Maguire Communication Skills Training Unit

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