Introduction

Medical facilities are places where patients and medical professionals interact frequently and exchange information regarding the treatment process and patients’ clinical conditions, and other issues [1]. Breaking bad news (BBN) to patients and their families by medical staff is one of these critical conversations. Medical professionals have the responsibility to deliver bad news to patients [2], which can be defined as any circumstance that leads to a sense of hopelessness or restricted decision-making for the patient’s future life, as well as threatening their mental and physical health [3]. Improper breaking of bad news to a patient can have detrimental consequences. It may lead to stress, anxiety, and misunderstandings about the patient’s diagnosis, treatment, and prognosis, and ultimately results in undesirable outcomes [4].

In contrast, a previous study indicated that proper and considerate BBN could reduce patients’ unrealistic expectations, denial, disappointment, confusion, and anxiety [5]. BBN is a complex process that requires the participation of all healthcare providers [6, 7]. Moreover, recognizing patients’ attitudes and beliefs about BBN methods can enhance the success rate of bad news deliverers, which can result in better adaptation of patients to current conditions and increase their life expectancy. Therefore, it is critical to take patients’ preferences into account when developing BBN [8]. Saqib et al., conducted a study in Pakistan and found that the content of the message, delivery location, and the knowledge of the person delivering the news were critical parameters for patients [9]. Besides, Aghamohammadi et al., reported that the socioeconomic and demographic conditions of individuals should be taken into account during BBN in Iran [3]. In research by Woldemariam et al., in Ethiopia, most patients preferred to receive information about their illness personally or with their families present. However, most family caregivers and a significant portion of the general public believed that bad news should be delivered primarily to the patient’s family [10].

The emergency department is often the first point of contact for patients and their companions with various complaints and clinical conditions, and they may not have received an initial prognosis. In the emergency room, it might be challenging to deliver bad news successfully since there isn’t enough time to build up a good rapport with patients, and therefore, patients and their companions might not be emotionally prepared to receive the news [11]. As a result, the emergency department is more vulnerable to adverse outcomes related to BBN [12]. Determining the present state of affairs and contrasting it with the ideal state based on patients’ preferences are essential for ensuring efficient BBN in the emergency department. This study aimed to compare emergency department employee performance and patients’ preferences in BBN.

Materials and Methods

This descriptive-analytical study was conducted in 2022. The study population included patients admitted to the emergency departments of Kowsar and Tohid Hospitals in Sanandaj, Iran. The sample size was calculated to be a minimum of 135 individuals based on the design of a previous cross-sectional study design, and by considering an alpha level of 0.05, a beta level of 0.1, and r=0.276 [13], the sample size was estimated to be at least 135 individuals.

Based on the number of beds in each department, the sampling procedure was conducted using the quota sampling method in the emergency departments of the two aforementioned hospitals. The inclusion criteria were willing to participate in the study, being over the age of 18, having full consciousness, having stable hemodynamic status, being admitted to the emergency department for at least three hours, and having experienced receiving bad news about their health during the current visit. Exclusion criteria included deteriorating patient conditions and failure to complete the questionnaires.

A demographic questionnaire, a researcher-made questionnaire titled “Assessment of the Performance of Emergency Department Personnel in BBN from the Perspective of Patients,” and a standard questionnaire assessing patients’ attitudes towards the delivery of bad news in the emergency department were used to collect the data. The demographic questionnaire dealt with age, sex, education level, marital status, place of residence, employment status, time of receiving bad news, the person who delivered the news, history of the current disease, and previous history of receiving bad news in the emergency department. The researcher-made questionnaire consisted of 19 binary items (yes or no) and was designed based on a review of previous studies [9, 13-15]. The non-compliance score (score of zero) and compliance score (score of one), which could be simply translated into a percentage, were used for scoring and reporting the findings of the questionnaire. To determine the content validity of the questionnaire, it was delivered to ten professors of Nursing and Midwifery, at Kurdistan University of Medical Sciences, and their feedback was incorporated. The Content Validity Index (CVI) and Content Validity Ratio (CVR) were calculated, and satisfactory values (0.79 and 0.81, respectively) were obtained. To investigate the face validity of the questionnaire, 30 participants were asked to assess the clarity and level of understanding of the items. Then, the questionnaire was revised accordingly. Cronbach’s alpha coefficient was used to evaluate the reliability of the questionnaire, which was verified in a sample of 30 participants (α=0.80).

A questionnaire which was developed by Labaf et al., [14] was used to evaluate patients’ attitudes towards BBN in the emergency department. This questionnaire had 19 items and was scored using a five-point Likert scale (strongly agree=4 to strongly disagree=0). The mean of each item (ranging from 0 to 4) and the mean of all items (ranging from 0 to 76) were reported as the results of this questionnaire. A higher score indicated a greater willingness to comply with the conditions stated in each item. This questionnaire had a content validity of 0.75 and a Cronbach’s alpha coefficient of 0.79 [14].

Upon entering the research environment, the participants were informed about the goals of the research, and written informed consent was obtained from them. The researcher then presented a list of bad news scenarios related to the clinical context, which was prepared based on a review of the literature [5, 14, 15] and expert opinions. The study included patients who had only received bad news during the same visit. The patients completed the list of bad news scenarios themselves. For illiterate patients, the questions were read aloud by the patient’s companion or the researcher, and the patient’s response was recorded on the questionnaire. Patients who met the other inclusion criteria and also had a history of receiving bad news completed additional questionnaires.

Statistical Analysis

Data were analyzed using SPSS 16.0 (SPSS, Chicago, IL). The quantitative variables were expressed as mean±SD, while the qualitative variables were reported as frequency and percentage. The normality of the data was examined using a one-sample Kolmogorov-Smirnov test, which demonstrated a lack of normal distribution. Spearman correlation was used to evaluate the relationship between the variables. Wilcoxon signed-rank test was used to compare the performance and attitude scores. P values less than 0.05 were considered statistically significant.

Results

Out of 139 patients who participated in the study, one patient declined to participate, and three individuals returned incomplete questionnaires. As a result, 135 questionnaires were eligible for investigation. The patients were mostly over 30 years old. Besides, 44.4% of the participants were female and 55.6% were male. The majority of the patients (69.6%) received bad news from nurses, and 70.4% had never previously experienced receiving bad news in medical centers (Table 1).

The results of the study showed that the overall performance of emergency department personnel in observing the conditions mentioned in the questionnaire during BBN was only 6.08±4.22. Moreover, only four of the 19 questions revealed that the personnel observed the mentioned circumstances in BBN. These questions included the presence of relatives or friends when delivering bad news to the patient, delivering the bad news by someone who was directly involved in the patient’s treatment, presenting the bad news frankly and without borders, and introducing the patient to the news and delivering it in their local language. Respecting privacy, preparing the person psychologically before BBN, and using religious terms during BBN had the lowest scores. Each of these behaviors was noticed by just 0.06 of the personnel. The highest score was related to delivering BBN in the local language, which was observed in 0.84±0.371 of the personnel (Table 2).

The patients’ overall attitude score toward receiving bad news was 59.66±7.66 out of 76, indicating a high willingness to receive bad news based on the conditions mentioned in the questionnaire. As indicated in Table 3, only item 10 (desire to receive bad news from a companion) with a score of 1.20±1.348, and item 14 (talking about the consequences of the delivered bad news) with a score of 1.87±1.390 obtained a score below the mean (2 out of 4).

There was a significant difference between the total score of personnel’s performance and patients’ general attitude in the emergency department (p=0.001). Items 1, 3, 6, 9, 10, and 17 were negatively correlated and indicated a significant and strong difference (Table 4).

Discussion

The present study found that nurses were primarily responsible for BBN in the emergency department, while physicians had less involvement. This finding was in line with research by Karim et al., which indicated that most nurses were involved in BBN activities along with their other responsibilities, and even broke bad news to patients independently [6]. Similarly, Warnock et al., reported that 47.7% of nurses spent most of their time helping patients and their families cope with bad news over time [16]. However, Shakrinia [17] and Labaf et al., [18] found that BBN was one of the main responsibilities of emergency department physicians.

Overall, BBN to patients is a collaborative process that involves all members of the treatment team, including physicians, nurses, social workers, and even the patient’s family [6]. Therefore, it is critical to avoid placing the burden of BBN merely on a specific group of medical staff in hospital departments that are overcrowded and under a lot of stress such as the emergency department. Instead, interprofessional collaboration should be encouraged to ensure that BBN is carried out properly while minimizing the psychological pressures on patients and any potential negative reactions.

The findings of our study indicated that the performance of emergency department personnel in BBN differed significantly from the optimal performance based on the patients’ attitudes. Despite high attitude scores towards receiving bad news, as measured by a standard attitude questionnaire, the performance scores showed that these conditions were not well observed. This was consistent with previous research by Seifart et al., [13] and Goncalves et al., [19], who found significant differences between patients’ preferences and how BBN was delivered.

BBN, particularly when related to health status, might have inherently stressful and negative consequences for individuals. These negative consequences might be exacerbated if the bad news was delivered improperly. Therefore, to minimize its negative impact, the staff must approach this responsibility sensitively and adhere to scientific protocols and evidence-based methods.

Furthermore, our study demonstrated that across all items, the patients’ attitudes and emergency department staff performance were significantly different. Additionally, a considerable number of questions had a negative correlation with patients’ desired manner of receiving bad news. These findings underscore the importance of training emergency department personnel in effective communication skills and ensuring that they are equipped with the necessary tools to deliver bad news in a compassionate and empathetic manner that minimizes negative consequences while respecting the patient’s preferences.

In the present study, the performance of emergency department personnel in maintaining patient privacy during BBN in a private environment received a low score. This indicated that most personnel did not respect the patient’s privacy while delivering bad news. The majority of patients, however, desired privacy protection while receiving bad news, which caused a significant difference between the current performance of emergency department personnel and the patients’ attitudes. Similarly, Warnock et al., found that 48.7% of nurses did not respect patients’ privacy during BBN [16]. In another study by Loge et al., it was found that 52% of patients received bad news at the physician’s office, 19% in hospital hallways, and 19% did so over the phone [20]. Furthermore, Managheb et al., reported that 63.2% of patients emphasized the need to receive bad news in private, however, 77.6% and 64.6% of patients received bad news in hallways and emergency departments, respectively [21]. The importance of breaking bad news in a private setting was also highlighted by Schofield et al., [22]. In the same line, Warnock et al., reported that a barrier to communicating bad news with patients was a lack of respect for their privacy [16].

With so many patients and their companions present in the emergency room compared to other medical departments, there is a higher chance that patient privacy will be violated during BBN. Patient privacy must be given more consideration during BBN, since improper delivery can lead to stress, anxiety, and misunderstanding about diagnosis, treatment, and prognosis, and this can negatively affect treatment processes and even lead to mistrust in treatment staff [23, 24].

The data of the present study indicated that the emergency department personnel’s ability to make eye contact with patients during BBN had a significant impact on patient attitudes. In addition, Abazari et al., discovered that making eye contact with patients during BBN assisted them in accepting bad news [25]. Previous studies highlighted the importance of making eye contact as a non-verbal tool for effective communication with patients while breaking bad news [26-28]. Making eye contact can reflect the importance of the topic as well as respect for the recipient of the news, potentially minimizing negative reactions and tension between the bad news deliverer and the patient.

Only 13% of emergency department personnel were found to physically interact with patients and expressed empathy, which had a significant impact on patient attitudes during BBN. Similar research by Karim et al., revealed that only 24.7% of nurses provided emotional support to patients after delivering bad news [6]. According to Warnock et al.,55.5% of nurses totally and 36% partially expressed empathy and provided support to patients, while breaking bad news [16]. Although religious and cultural beliefs in Iran may limit the expression of empathy towards patients of the opposite sex, particularly through physical contact [29-31], it is still possible to express empathy both verbally and non-verbally. Therefore, the poor performance of emergency department personnel in this regard is not entirely justifiable. Failure to express sympathy appropriately and in accordance with standards may result in adverse outcomes, such as patient resentment, anger, and stress [6, 32].

In the present study, only 8.9% of the personnel designated a specific time to break bad news. Although the score assigned to this issue indicated a lower priority of this performance, it revealed the importance of specifying the time of breaking bad news to a considerable extent (2.67 out of 4). In this regard, Warnock et al., reported that only 18.2% of the patients experienced receiving bad news during a specific time. They also stated that one of the most important barriers to nurses properly delivering bad news was a lack of appropriate time due to a heavy workload [2]. Setting a time for BBN appears to be impractical in the emergency department due to time restrictions, the desire of family and patients to find out the patient’s diagnostic and treatment status sooner, and the necessity for prompt transfer of the patient to the ward, discharge, or dispatch.

In the present research, only 22.2% of the personnel asked the patients about their prior information about the disease during delivering bad news, while the patients’ attitude score (3.71 out of 4), which indicated their willingness to receive information about their disease before receiving the bad news about their health. In this regard, Azu and Jane reported that 46% of the personnel exhibited this behavior, and 59% of their patients requested disease information before hearing the bad news [33]. This issue has received more attention in patients with higher education levels, thus they preferred to receive relevant and comprehensive information [34, 35]. Providing training and information tailored to each patient’s knowledge is necessary to achieve a better understanding on behalf of the patient. Therefore, a preliminary investigation of the level of information about the subject of the news before breaking the news to patients can make them more satisfied with the process of BBN. The findings of this study showed that only 31% of the personnel broke the bad news to the patients gradually, while the majority of the patients preferred to receive the bad news gradually (3.62 out of 4). The findings of a previous study indicated that 44% of patients acknowledged that delivering bad news to them took less than five minutes, which was obviously insufficient to meet their needs [20]. These results can be largely justified due to the time constraints in the emergency department, however, caution should be taken to try to avoid announcing bad news suddenly and without preparing the patient psychologically. As lack of preparing the patient can increase the risk of reactions such as severe stress and emotional shock in the patient, as well as the possibility of confrontation and tension between the patient and the person delivering the bad news [5].

The present study showed that the majority of patients were opposed to initially informing their friends and relatives of terrible news. In contrast to our findings, 87% of patients in a study by Monagheb et al., [21], 78% of patients in a study done in Japan [36], and 61% of patients in a study conducted in Portugal [19] tended to break the bad news to the family members first or in the presence of their family or companion.

One limitation of the present study was that it was conducted just in two hospitals. Therefore, a larger study will be required to confirm or reject the findings of the present research. Furthermore, this study did not investigate the patients’ attitudes who had not previously received bad news. Hence, it is recommended that future research be conducted by involving these patients to yield more complete information and enhance the generalizability of the findings.

Based on the patients’ attitudes, the findings of this study suggested that emergency department personnel’s performance in BBN was not optimal. The patients expected better performance from the personnel regarding privacy observation, eye contact with patients, and assessing prior information about bad news while breaking it to patients or their companions. It is essential to provide proper BBN training to medical professionals, particularly physicians, and nurses. This can be accomplished through providing academic training and holding in-service workshops.

Declaration

Ethics Approval and Consent to Participate: This article was part of a master’s thesis approved by the School of Nursing and Midwifery and Vice-Chancellaor of Research and Technology of Kurdistan University of Medical Sciences (IR.MUK.REC.1400.241). The patients were informed about the study objectives, and written informed consent was obtained from them. They were also assured about the confidentiality of the information they provided.

Consent for publication: All the authors gave their consent for the publication.

Conflict of Interest: The authors declare no potential conflicts of interest concerning the research, authorship, and publication of this article.

Funding: This work was financially supported by the Vice-chancellor for Research and Technology affiliated with Kurdistan University of Medical Sciences, Iran.

Authors’ Contributions: Study design: Salam Vatandost, Sina Valiee, and Naser Kamyari. Data collection: Mohammad Gholami. Data analysis: Naser Kamyari and Salam Vatandost. Study supervision: Salam Vatandost. Manuscript writing: Sina Valiee, Mohammad Gholami, and Salam Vatandost. Critical revisions for important intellectual content: Sina Valiee, Mohammad Gholami, Naser Kamyari, and Salam Vatandost.

Acknowledgment: We would like to express our gratitude to the members of the Vice-Chancellaor of Research and Technology of Kurdistan University of Medical Sciences and all the study participants who helped us with this research.