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Although most physicians in medical settings have to deliver bad news, the skills of delivering bad news to patients have been given insufficient attention. Delivering bad news is a complex communication task that includes verbal and nonverbal skills, the ability to recognize and respond to patients’ emotions and the importance of considering the patient’s environment such as culture and social status. How bad news is delivered can have consequences that may affect patients, sometimes over the long term.
This project aimed to develop a Web-based formative self-assessment tool for physicians to practice delivering bad news to minimize the deleterious effects of poor way of breaking bad news about a disease, whatever the disease.
BReaking bAD NEws Tool (BRADNET) items were developed by reviewing existing protocols and recommendations for delivering bad news. We also examined instruments for assessing patient-physician communications and conducted semistructured interviews with patients and physicians. From this step, we selected specific themes and then pooled these themes before consensus was achieved on a good practices communication framework list. Items were then created from this list. To ensure that physicians found BRADNET acceptable, understandable, and relevant to their patients’ condition, the tool was refined by a working group of clinicians familiar with delivering bad news. The think-aloud approach was used to explore the impact of the items and messages and why and how these messages could change physicians’ relations with patients or how to deliver bad news. Finally, formative self-assessment sessions were constructed according to a double perspective of progression: a chronological progression of the disclosure of the bad news and the growing difficulty of items (difficulty concerning the expected level of self-reflection).
The good practices communication framework list comprised 70 specific issues related to breaking bad news pooled into 8 main domains: opening, preparing for the delivery of bad news, communication techniques, consultation content, attention, physician emotional management, shared decision making, and the relationship between the physician and the medical team. After constructing the items from this list, the items were extensively refined to make them more useful to the target audience, and one item was added. BRADNET contains 71 items, each including a question, response options, and a corresponding message, which were divided into 8 domains and assessed with 12 self-assessment sessions. The BRADNET Web-based platform was developed according to the cognitive load theory and the cognitive theory of multimedia learning.
The objective of this Web-based assessment tool was to create a “space” for reflection. It contained items leading to self-reflection and messages that introduced recommended communication behaviors. Our approach was innovative as it provided an inexpensive distance-learning self-assessment tool that was manageable and less time-consuming for physicians with often overwhelming schedules.
Bad news is defined as any information that adversely and seriously affects an individual's view of their future [
Recommendations for delivering bad news have mainly been developed to deliver a diagnosis of cancer [
Although these guidelines were mainly developed in the context of cancer, every chronic disease, irreversible condition, or striking event can have a major effect on a patient’s life. For example, the bad news may relate to neurological, musculoskeletal, cardiac, renal, or respiratory disease or a serious congenital condition in a child.
Furthermore, publishing recommendations are not sufficient to implement and change behavior, if needed. Healthcare providers also need to develop adaptive abilities to manage the complexity of clinical situations in which each patient is unique. Therefore, training on how to deliver bad news helps physicians (1) to analyze their practice and difficulties; (2) to grasp the specific elements of the situation, including the context and individual characteristics of the patient; (3) to perceive the factors that influence physician-patient interactions (verbal and nonverbal attitudes); (4) to facilitate the development of a repertoire of communication strategies for delivering bad news that the patient finds difficult to accept (both cognitively and emotionally); and (5) to decipher and understand the patient’s emotional, cognitive, and behavioral responses in order to respond appropriately. Such training sessions should be provided both as initial and in-service training to build on the practice and experience of the physician.
In France, training sessions on how to deliver bad news, either as initial training or lifelong training, are not widespread [
Over the past two decades, evidence from the literature indicates that formative self-assessment is an interesting way to improve learning (even “a
This strategy of learning also seems relevant for lifelong education because the learner can then directly integrate the self-assessment reflective process into their practice and thus proceed through an iterative process (but led by personal reflection).
The goal of our research project was to build a Web-based formative self-assessment tool for physicians to practice delivering bad news: the BReaking bAD NEws Tool (BRADNET). BRADNET was envisioned as a way to create a space for self-reflection and for self-practice analysis to minimize the deleterious effects of a poor way of breaking bad news about a disease, whatever the disease.
Development of and evidence-based health interventions are increasingly based on intervention mapping (IM), a protocol that consists of an iterative process integrating theoretical aspects, expert input and several data from the target population [
We reviewed the existing protocols and recommendations for delivering bad news and instruments to assess patient-physician communication.
Interview guides (one targeting patients and the second physicians) were the product of brainstorming with 3 health psychologists (LM, CR, ES) and 3 physicians (1 pediatrician, RV and 2 rheumatologists, FG and ACR) who were experienced in delivering bad news. Individual interviews were conducted by 6 trained psychologist interviewers, with 25 patients (11 with rheumatoid arthritis, 11 with heart failure, and 3 with cancer) and 22 physicians (10 nephrologists, 4 cardiologists, 4 oncologists, 3 neurologists, and 1 rheumatologist).
BRADNET development.
We used a referral sampling strategy in which clinicians from the research team recruited other physicians in private practice or hospitals. The sampling strategy was based on the maximum variation strategy to achieve maximum diversity on relevant aspects of breaking bad news [
Data analysis proceeded in an iterative manner using the grounded theory methods approach [
Specific issues related to breaking bad news were retrieved from existing protocols. We also used recommendations for delivering bad news and instruments that assess patient-physician communication, and specific issues related to breaking bad news were retrieved from physician and patient interviews. Issues were then selected, and close issues were merged by 4 independent groups composed of 3 health psychologists (LM, CR, ES), 2 sociologists, 2 epidemiologists, and 3 clinicians (FG, ACR, RV). Finally, the 4 lists were pooled and restructured to achieve a consensus on a common list (good practices communication framework list) of dimensions to serve as a basis for item development. The dimensions were also grouped into domains.
Items were then created from the good practices communication framework list (
Each item targeted a specific aspect of bad news delivery (such as the physician’s reaction to a patient’s anger). For each item, the question required the users to actively recall their past experience and beliefs and how they coped with that situation. The answering modalities ask respondents to position themselves according to various behaviors or attitudes of their practice (multiple responses were possible and no answer modality was considered a
Because BRADNET did not assess knowledge, the message was not personalized. Instead, it aimed to develop the understanding and awareness of cognitive-behavioral processes and the abilities and motivation necessary to improve skills related to breaking bad news. Even if the message was the same for everybody, how users received and processed the messages was different and could have different impacts. This may increase physician awareness of the importance of select behavioral or communication issues, validate some practices and thoughts, or introduce a reflection on the benefits of change. There was no score because BRADNET did not assess the level of knowledge or desirability. Questions were not intended for self-testing, but rather for reflection.
To ensure that physicians found BRADNET acceptable, understandable, and relevant to their patients’ condition, the tool was refined by a working group of the “Patient Therapeutic Education in Rheumatology Section” consisting of 8 clinicians familiar with delivering bad news, as well as experts in therapeutic education, and the chair of a patient association. Items and messages were reworded and completed to improve acceptability and content during 3 sessions of 2-3 hours each and during reviews and email exchanges. Items were also refined by 4 health psychologists (LM, CR, LR, and ES).
“Think aloud” is a method for modeling cognitive processes. Different studies involving the think-aloud method agree that “this is a very direct method to gain insight into the knowledge and methods of problem solving in humans” [
As part of the BRADNET development, the think-aloud approach was used to explore the impact of the items and messages and why and how these messages could change physicians’ relations with patients or how to deliver bad news. The objective was to determine whether the items could be useful to physicians, including initiating participant reflection on the meaning of the item, in terms of their own practices. The interviews were conducted with 2 physicians (neonatology and palliative care). Each physician spoke aloud during 3 sessions of 2 hours each.
Format of a BRADNET item.
Acquisition of knowledge increases when learning sessions are separated [
BRADNET was developed according to the cognitive load theory [
We envisioned BRADNET as a tool comprising static illustrations and printed text. Indeed, as compared with dynamic animation and narration learning formats, static illustrations and printed text have the advantage of reducing extraneous processing (cognitive processing that confounds training objectives), helping to manage intrinsic processing (cognitive processing of the key material) because students can control the pace of presentation and promoting learning retention. A static format allows people to control the pace and order of presentation and to engage in deeper processing such as making connections between words and pictures. It also encourages them to focus on the most relevant information. Finally, it allows for engaging people in active processing through activities such as generating explanations or answering questions during learning. A static format is also more appropriate than a dynamic one because BRADNET is a formative self-assessment tool, with items that lead to self-reflection. Static media can lead to better learning than dynamic media (such as animation and narration) [
The presentation of words and pictures, rather than words alone, causes learners to use both visual and verbal channels.
Coherence principle: exclusion of words or images that are not relevant
Spatial contiguity principle: corresponding words and pictures are presented near to, rather than far from, each other on the screen to help build connections
Temporal contiguity principle: learners must have corresponding words and images in working memory at the same time in order to make connections between them
Signaling principle: cues highlighting the organization of the essential material designed to call attention to the important material
Segmenting principle: message is segmented into meaningful units rather than a continuous unit
Spaced education principle: educational encounters that are spaced (space distribution) result in more efficient learning and improved learning retention compared with mass distribution of the educational encounters (bolus education) [
Pretraining principle: people learn better when they know the names and characteristics of the main concepts
Progressive difficulty: intrinsic cognitive load depends on the expertise of the learner in the domain (knowledge available in long-term memory), so to reduce it, the difficulties related to breaking bad news points to issues that are improved as the sessions progress (as the learner becomes more of an expert). Moreover, in our training design, we further enhanced the level of difficulty by proposing two last items (session 12) without any response options (for full space for reflection) to extend acquired skills [
Personalization principle: the words are presented in a conversational style, changed into first and second person with some conversational sentences
Embodiment principle: onscreen agents display human-like gestures, movements, eye contact, and facial expressions
Control of the pace and order of presentation principle
The essential ideas of each training session will be reiterated at the end of the session and at the beginning of the next session to increase learning retention
Stressing the same content repeatedly over time results in more efficient learning and improved learning retention
The protocol SPIKES and recommendations from the World Health Organization and the Haute Autorité de Santé in France were some examples examined as recommendations on delivering bad news [
Semistructured interviews were designed to allow patients and physicians to describe their own experiences with breaking bad news, while addressing their understanding and emotions in these situations and how they manage interpersonal relationships. The main topics of the open-ended interview guides are presented in
Factual description of delivering bad news about disease
Cognition (eg,
Emotion, behavior around the delivery of bad news
Interpersonal relationships (eg,
Feelings and potential for improvement
Factual description of delivering bad news about disease
Cognition (eg,
Emotion, behavior around the delivery of bad news
Interpersonal relationships (eg,
For patient interviews, 3 categories were retrieved from the thematic analysis (
The time of delivering bad news: reaction to the diagnosis (awareness of the disease, uncertainties surrounding the disease, psychological reactions), illness representation, and evolution of interpersonal relationships (with work colleagues, the healthcare team, family, and relatives)
Care pathway and medical care: period after the breaking of bad news, with medical care after the diagnosis (description, questions and doubts of the patient, psychological reactions, interpersonal relation)
Life with the disease (how care is delivered, physical and psychological impacts of the disease, adjustment to the illness)
For physician interviews, 8 categories were retrieved from the thematic analysis (
Elements that might be taken into account for breaking the bad news
Difficulties experienced by the physician at the time of delivering bad news
Physician’s training in delivering bad news
Information provided by the physician about medical treatments and overall disease management
Specific characteristics of the disease
Physician-patient relationship
Physician’s perception of their role
Physician’s emotional experience
In total, 70 dimensions or specific issues related to breaking bad news were selected and structured. The good practices communication framework list consisted of 8 main domains, each domain consisting of dimensions constituting items to be developed in BRADNET (the number in brackets refers to the number of dimensions for each domain):
Opening (3): general questioning about the experience of breaking bad news, such as the kind of bad news delivered by the physician
Preparing for the consultation wherein bad news will be delivered (3): physicians are asked to consider how they prepare for a consultation in which they have to deliver bad news (eg, ensuring an enabling environment, asking patients to be accompanied by relatives)
Communication techniques (22): devoted to attitudes and behavior that can improve the quality of the physician-patient relationship (eg, introduce oneself, take time, respect silence, and ask open-ended questions)
Consultation content (19): the physician is asked to question the kind of the information that should be sought (eg, the patient's concerns) and transmitted (depending on the patient's beliefs or health skills) and how the patient can be supported (eg, by mentioning the future and life with the disease)
Attention (5): the patient’s verbal and nonverbal attitudes, emotional difficulties, and cognitive limitations, to which the physician should pay attention
Physician emotional management (3): physicians are asked to question their emotions during a consultation wherein bad news is delivered, their behaviors and attitudes that betray their emotions, and how they cope with these emotions
Shared decision making (12): how physicians can develop a relationship with the patient, during which the patient has a role of care partner with whom decisions are made
Relationship between the physician and the medical team (3): questions of transmitting information regarding the patient or care of the patient to other healthcare professionals
With the good practices communication framework list thus defined, the final intervention could be developed.
Experts constructed 70 items based on the good practices communication framework list. Questions were built to foster reflection on how each physician delivered bad news in the past to anchor messages introducing recommended communication behaviors related to the physician’s practice. The answering modalities of an item were a particular communication behavior in a specific situation (see items from domains 2, 4, 6, 7, 8 in
As a result of the first refinement phase, besides extensive rewording, adaptation of the content and message adjustments, an additional dimension “the severity of the diagnosis also depends on the patient and their needs” was added to the domain “Consultation content.” The item generated highlights that the severity of the diagnosis depends on individual perceptions and that the impact of delivering bad news on individual perceptions should not be underestimated, even if it may seem unimportant. Finally, the Web-based self-assessment tool to practice delivering bad news, BRADNET, was composed of 71 items (ES, LR, ACR).
The analysis of the verbal material resulting from the think-aloud approach allowed for classifying the elements of the verbatim into 8 points:
Reflections on the content of the items: physicians verbally indicated their degree of support with each of the items: complete support, confirming what is said in the questions, propositions or messages; partial support; or disagree with all or some of the items.
Items analysis: physicians show hesitations, misunderstandings, want to correct text, criticize the item, or simply make remarks.
Analysis of their own practice: physicians question their own practice and how to improve it in terms of the questions posed by the tool.
Reactions to the items: brings together all the psychological defensive processes observable in the discourse of physicians when they are confronted with the content of the formative self-assessment tool: processes of resistance, distancing, reassurance, conflicts or opposition, identification, humor, doubt, and associations.
Factual description of the practice: factual aspects of the practice of medicine mentioned by the participants. These are comments without reflection and conceptualization; the participants listed what they do without associating it with any meaning or representations.
Associated thoughts: thoughts not directly related to the tool but derived from its analysis.
Global assessment and suggestions for improvement.
Prospects for future use: based on their own experience and perspectives from the initial training, participants reflect on proposing a relevant implementation of the tool.
Following this step, the items were again extensively refined to make them more useful to the target audience (ES, LM, MP).
Examples of BRADNET items are shown in
In total, 12 formative self-assessment sessions were constructed (8 sessions with 6 items, 2 sessions with 7 items, 1 session with 5 items, and 1 session with 4 items). Five sessions included items from 4 main domains, 4 sessions from 4 main domains, and 3 sessions from 5 main domains. Session durations were estimated at 10 to 15 minutes
The interface will consist of a modal window of connection, allowing either the inscription on the website and the creation of a user account or a login to access the contents of the website. These identification data will be used to track the user's progress throughout the sessions and the items included in each session.
At first use, a welcome message will introduce the purpose and flow of the formative self-assessment program. During subsequent uses, this welcome message will recall where the user is in the program, focus on key elements of the previous session, and offer the ability to resume the course of the program where the user left off.
Each session will offer 4-6 items consisting of a question, predefined response modes or free input fields, and a message offering information or reinforcements on the attitudes and behaviors that may be appropriate to the situations encountered by the user in his or her practice. The sequence will be implemented as follows: the question appears first, then after 5 seconds, the response proposals or the free text field that was initially blurred appears on the screen under the question. Once the user has provided a response, a “continue” button appears and allows the user to display the message related to the question asked. This message is accompanied by a button to go to the next item but remains inoperative for 15 seconds (grayed out), allowing the user to take the time to read the message before proceeding to the next step.
At the end of a session, the user is thanked and is encouraged to return to the website in a few days to partake of the next session. The user will be offered the possibility to print the session in a pdf format.
During the use of the application, the following information is collected: the dates and times of connection, the time spent on each page or before the click to move to a next step in the program (eg, time spent displaying the message of an item), the overall time during each login session, and answers given.
The Web application was initially configured using a content management system (CMS) specifically developed for the purposes of the study and the collection of information mentioned above. CMS must allow for 1) setting up the greeting messages, the number and contents of the sessions, the expected durations between the sessions, the time of presentation of the messages, the possibility of sending a reminder by email the day before or the same day of a session, etc, and 2) accessing the data of use of the tool. All collected data will be managed by a website administrator with strict confidentiality rules.
Consistency of BRADNET features with theoretical learning principles is described in
Description of the BRADNET features and theoretical learning principles.
Theoretical learning principles | BRADNET features | ||
Multimedia principle | Presentation of words and pictures | ||
Coherence principle [ |
Expressing questions and messages in a neutral and simple language | ||
Signaling principle (reduction of extraneous cognitive load) | Highlighting key ideas of the items messages Provide take-home messages at the end of each session |
||
Spatial contiguity principal | Combining written text and pictures or illustrations in the items messages (eg, a physician looking at the computer screen) when appropriate | ||
Pretraining principle | Presentation of the formative self-assessment tool at the beginning of the training: description of the 8 domains addressed, number of sessions and items by sessions and approximate time needed to complete one session | ||
Segmenting principle Spaced education principle (Allow for starting to apply changes progressively during the self-assessment and to become aware of the content of the message, implement it, and ponder the messages) |
Learning sessions organization: segmentation in 12 spaced sessions | ||
Limited capacity assumption | Short sessions | ||
Progressive difficulty | Learning sessions organization: progression of difficulty |
||
Personalization principle | Use of the first and second person conversational style | ||
Adaptation of the tool to health care professionals and daily practice | Refinement and reformulation of items and messages by healthcare professionals | ||
Control of the pace principle |
Presentation of the session item by item (one screen for the questions and answering modalities and one screen for the message and key words) with a “continue” button at the bottom right side of the screen. | ||
Reinforcement of long-term memory | Recall of the key messages at the beginning of the next session | ||
Development of understanding, abilities, motivation, and self-regulation [ |
Formative self-assessment Reflection on one’s practice Open questions Messages provide no judgment on practice or behavior Refractory period between the screens (whatever the judgment of rate of learning [ |
||
Support of the physician during implementation | Session printed in a pdf format |
The formative self-assessment tool, BReaking bAD NEws Tool (BRADNET), for physicians to practice breaking bad news to patients, contains 71 items, each including a question, response options, and a corresponding message. Questions are as important as messages. These 71 items were divided into 8 domains practiced with 12 formative self-assessment sessions.
A Web-based tool has the potential to reach a large number of physicians at low cost and thus ensure maximal dissemination. Indeed, a Web-based communication skills training that can be followed at any time is more accessible than classroom training. It can also reach physicians with weak motivation to follow intensive face-to-face training. Web-based teaching has been successfully developed for a variety of medical training domains. The advantages include accommodating different learning styles, a self-paced mode, and the use of computer-adapted technology. This approach allows for multiplying different educational supports and is consistent with recent teaching approaches [
Research on clinical communication training demonstrating efficacy and sustained effects is sparse [
BRADNET was built to take into account physicians’ time constraints and to optimize communication skills learning. It contains several principles to lessen physicians’ cognitive load while attending the training sessions (segmenting principle, coherence principle, dual channel assumption, temporal contiguity principle, signaling principle, spaced education principle). Learning sessions are short, spaced, and organized to increase difficulty and reflection over the training to allow learners to construct schemas when they connect new information to the things they already know and further decrease cognitive load. Segmentation of content into spaced sessions is important to deal with time constraints, to enable the learner to become aware of the content of the message and implement it, and to return to the messages.
The originality of our project lies in the development of a generic tool suitable for different chronic diseases. So, far, guidelines about delivering bad news have been developed mainly to deliver a diagnosis of cancer, but every chronic disease, irreversible condition, or striking event can have a major effect on a patient’s life. How bad news is communicated can have consequences that may affect patients, sometimes definitively. It likely affects the patient–health care provider relationship, therapeutic alliance, adhesion to care, and patients’ subsequent adjustment to the disease [
The content of BRADNET was developed by iterative processes that integrated theoretical aspects, interviews, and expert input. By collecting broad and deep information from various sources and by using a refinement step, we tried to increase the accuracy and validity of the BRADNET content [
Theoretical framework.
In the PPM model, PRECEDE means Predisposing, Reinforcing, and Enabling Constructs in Educational/environmental Diagnosis and Evaluation and PROCEED means Policy Regulatory, and Organizational Constructs in Educational and Environmental Development. In this planning model, all aspects of a person’s environment are considered potential intervention targets, as are the person’s skills and behavior. The plan starts from the end goal of producing objectives and intermediate objectives, to developing a plan to achieve the objectives defined and then implement and evaluate the intervention [
A potential limitation of this study was the absence of specialists in the science of education involved the development of BRADNET. However, FG, LM, ACR, RV, and ES are academic professionals and are thus experienced in teaching, and ACR also teaches in a graduate diploma in therapeutic education or self-management programs. Moreover, formative self-assessment adopts principles of psychologic interviews: benevolence, understanding, and bringing knowledge without imposing it. Creating a space for reflection by giving the opportunity to initiate change is one approach to behavioral change.
In conclusion, most courses for training on the disclosure of a bad news use either classical classroom training sessions on communication skills training courses [
The BRADNET intervention, a simple Web-based intervention, is expected to meet physicians’ needs when breaking bad news. In France, only a few physicians have been trained and there is a need for training and personal self-reflection related to the delivery of bad news. BRADNET could be used to complete a previous training or be considered as a basic training. Improving the delivery of bad news could improve patients’ adaptation to diseases and therapeutic alliances and decrease their anxiety and depression.
Supplementary table: Breaking Bad News Reading Grid for patient.
Supplementary table: Breaking bad news Reading Grid for physicians.
Supplementary table: Examples of 8 items, one for each of the 8 main domains of BRADNET.
content management system
intervention mapping
PRECEDE-PROCEED model
Setting-up, Perception, Invitation, Knowledge, Emotion, Strategy
BReaking bAD NEws Tool
Funding has been provided by La région Lorraine, LR postdoctoral fellowship. The authors thank the clinician rheumatologists and experts in therapeutic education Catherine Beauvais, Serge Perrot, Violaine Foltz, Didier Poivret
None declared.