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National Survey of Psychologists’ Training and Practice in Breaking Bad News: A Mixed Methods Study of the MUM Effect
Abstract
Research on breaking bad news has involved undergraduates, medical students, and physicians. However, to date, no studies have examined how, or whether, psychologists are trained to break bad news, as well as their current practice of breaking bad news. This mixed methods study explored the training and practice of 329 licensed psychologists/APA members in breaking bad news, using the MUM effect as a theoretical backdrop. Results suggest (1) psychologists are, as hypothesized, significantly more reluctant to break bad news than good news, (2) anxiety accounts for 30.6% of the variance in their reluctance, and (3) three-out-of-four psychologists break bad news "to some extent" or more, most typically related to a patient's psychological health, major Axis I diagnosis, or learning disability. Results also suggest most psychologists are not trained to break bad news, with only 2.7% being familiar with existing recommendations and guidelines; and anxiety, concerns for self/other, context, and norms play an important role in the bad news breaking process. Implications for theory, research, and practice are discussed and a training model is proposed.
... Our framework further predicts that clinicians' anxiety influences their use of blended news delivery. Research on the MUM effect (Mum about Undesirable Messages; Rosen & Tesser, 1970) demonstrates that people generally exhibit reluctance to relay negative information to others, an effect exacerbated and largely accounted for by anxiety (Merker, Hanson, & Poston, 2010). Although many news delivery guidelines focus on reducing patients' discomfort and anxiety, clinicians' own anxiety is underemphasised. ...
... Protection motives vary from situation to situation, and they are determined in part by the degree of anxiety and empathy experienced by clinicians. Anxiety tends to exacerbate the MUM effect, making bad news delivery more uncomfortable for clinicians (Merker et al., 2010). This distress and discomfort can then translate into self-protection motives as clinicians attempt to manage their overwhelming anxiety and discomfort over delivering bad news. ...
Clinicians often inject good news into bad news delivery, and they do so for a variety of reasons. We present a framework that draws from research in the fields of health and social psychology to shed light on situations in which clinicians add superfluous good news into bad news conversations in an effort to ease the conversation or mitigate patients' distress, a broad strategy we refer to as blended news delivery. Our framework includes predictors of clinicians' use of blended news delivery, characteristics of blended news, and outcomes of this strategy for both patients and clinicians. This framework addresses a common aspect of health communication and can direct future research on ideal strategies for and likely consequences of blended news delivery and communication more broadly.
... While not all evaluations that include assessment (e.g., forensic evaluations) are followed with a formal feedback session, this should be explained to a client in advance (APA, 2013). It is unacceptable not to provide feedback because of anxiety about presenting "bad news" to clients (Merker et al., 2010) or not wanting to provide feedback about invalid test performance (Carone et al., 2010). ...
... As stated above, the subject of delivering bad news has been researched mainly with respect to physicians. Similarly, though less extensively, studies examine this aspect with respect to other professionals such as nurses (Abbaszadeh and Ehsani 2014), occupational therapists (Sexton 2013) and school psychologists (Merker et al. 2010). SLTAs are also responsible for delivering news which may be perceived by the receiver as negative in a variety of settings and clinical circumstances. ...
Background
As part of their professional responsibilities, speech–language therapists and audiologists are required to deliver bad news.
Aims
The aim of this qualitative study is to describe and characterize the subjective experience of speech–language therapists and audiologists when delivering bad news to clients or their family members.
Methods & Procedures
A group of 156 speech–language therapists and audiologists replied in writing to an open question asking them to describe a clinical encounter in which they delivered bad news. The texts that were generated in response to this question served as a data base. Qualitative content analysis was used to analyse data and generate themes.
Outcomes & Results
Thematic analysis of participants’ texts revealed the challenges inherent to the delivery of bad news. Four main themes emerged from text analysis: difficulty in phrasing the news; the deliverer's emotional experience; the receiver's reaction; and being alone or in companion with another healthcare provider during the delivery of the bad news.
Conclusions & Implications
Speech–language therapists and audiologists experience difficulties similar to those experienced by other healthcare professionals when delivering bad news. Nevertheless, speech–language therapists and audiologists seem to perceive the delivery of bad news situation in a broader sense than the conventional definition given to this term in the medical arena.
What this paper adds
What is already known on the subject
• The task of delivering bad news is stressful to healthcare professionals. Most of the literature on the topic pertains to physicians. Little is known regarding the delivery of bad news in speech–language therapy and audiology.
What this paper adds to existing knowledge
• This study highlights the challenges that speech–language therapists and audiologists encounter when delivering bad news. Furthermore, it illuminates the implicit perceptions of these professionals regarding what is considered ‘bad news’.
What are the potential or actual clinical implications of this work?
• The emotional challenges associated with the delivery of bad news underscore the importance of support and training regarding the delivery of bad news. It is especially important to prepare for a client's difficult questions, and to prefer a collaborative approach to the delivery of bad news.
... Toisaalta psykologisiin tutkimuksiin liittyy sen tyyppistä uskomustietoa,jonka tunnistaminen ja korjaaminen voivat olla toteutuvan vuorovaikutuksen kannalta merkityksellisiä (Kuuskorpi, 2012). Asiakkaalle annettavaan palautteeseen sisältyy usein sekä käsitteellisesti että emotionaalisesti vaativia osia, kuten teknisen ja vaikeaksi koetun testikielen "kääntämistä" ymmärrettävään muotoon sekä huonojen tai muulla tavoin yllättävien uutisten kertomista ja vastaanottoa (Ward, 2008;Merker, Hanson & Poston, 2010). Psykologit pitävät erityisen haasteellisena kielteisen (Merker ym., 2010) tai muutoin asiak-kaan uskomuksia haastavan ja yllättävän (Ward, 2008) palautteen kertomista asiakkaalle. ...
A client orientation in making follow-up plans in psychological assessment feedbacks
The aim of this study was to examine a client orientation in making follow-up plans in psychological assessment feedback sessions. Specifically, we studied what types of interaction occur in these situations with particular interest in to what extent the interaction is client-oriented.
The research material comprised six recorded feedback sessions and related rating forms for clients and psychologists. Qualitative discursive methods were applied to the transcriptions of recordings. The study is part of a project titled Interaction in Psychological Assessment Feedback Sessions, which aims to collect basic information on these encounters.
The results showed that a client-orientation is constructed collaboratively in psychological assessment feedback sessions. The following interaction categories emerged from the discussion of clients’ follow-up plans: sharing information, negotiation, unilateral interaction, motivation and persuasion. In the categories of negotiation, motivation and sharing information, the psychologists used a rich variety of interactional means and the clients participated in interaction more actively than in unilateral interaction. Rapid transitions between categories were observed. This occurred through invitations by psychologists as well as client initiative. Despite such invitations, the clients did not always participate. Clients’ interaction ratings indicated that their own active participation was not related to their experiences of the feedback utility. The psychologists’ means of interaction were more important.
While these results have potential for increasing the benefit to clients of psychological assessment feedback, they need to be supplemented by further research with a larger interaction dataset.
... Learning how to tell families about a child's autism spectrum disorder takes time and practice. Many clinicians report a lack of formal training in providing feedback to families (Baile et al., 2000;Merker, Hanson, & Poston, 2010). A good first step is to observe experienced clinicians and receive consultation from them. ...
Background: During training, clinicians learn how best to review evaluation results, deliver an Autism Spectrum Disorder (ASD) diagnosis, and discuss recommendations with families. This part of the evaluation visit is often referred to as the “feedback session”. To date, materials in existence for teaching effective feedback practices have been in written format only. We hoped to enhance the learning experience by creating a video on this topic.
Objectives: To develop a training video and accompanying materials that outline and review best practices for delivering feedback to families after an evaluation for an ASD. We intended these materials to be used in LEND programs at other UCEDDs for teaching fellows about how to deliver effective feedback after an evaluation.
Methods: LEND faculty at University of Colorado School of Medicine collaborated to develop the feedback training materials. We discussed and outlined a list of the steps and activities integral to providing effective feedback to families whose child is receiving an ASD diagnosis and developed a checklist to assess the quality of a feedback session. We then scripted and filmed a video that incorporates the advice and real-life experiences of clinical psychologists and parents. An instructor’s manual was also developed as a written guide to the best practices presented in the video.
Results: The result is a training video of an hour and 20 minutes in length. The video is divided into 4 separate chapters for ease of downloading and viewing. 1: The Importance of Feedback; 2: Preparing for the Feedback Session; 3: Providing the Diagnosis; 4: Recommendations and Next Steps. The instructor’s manual, which discusses each segment of the feedback session, includes specific instructions and strategies for making the session a productive and positive experience for the family. The manual ends with an extensive bibliography on this subject. The quality checklist presents an efficient way of reviewing the most important components and clinician qualities demonstrated during an effective feedback session. The checklist is meant to be used by trainees and their mentors to rate feedback sessions and enhance student’s learning of best practices.
Conclusions: We have developed a video and manual for teaching clinicians how to deliver effective feedback to a family receiving an ASD diagnosis.
Acknowledgements: The Feedback Training Video/Manual was supported by a grant from the Autism Treatment Network, a program of Autism Speaks, and was funded in part by cooperative agreement UA3 MC 11054 through the Health Resources and Services Administration (HRSA).
... In psychology, it is an ethical obligation (American Psychological Association, 2010) that serves as an opportunity to explain the results of evaluation, discuss treatment and rehabilitation, assist in understanding the effects of the condition on every day functioning and decision-making, and provide individual and family support (American Psychological Association, 2012; Gass & Brown, 1992;. Despite the potential impact of this information on patients and their families, many psychologists are not formally trained in feedback or do not consistently provide feedback (Butcher, 1992;Curry & Hanson, 2010;Merker, Hanson, & Poston, 2010;. Furthermore, research examining the benefits of feedback and the utility of different feedback methods is limited (Gass & Brown, 1992;Pope, 1992). ...
Feedback methods have been studied in medical and psychotherapy settings, but limited research is available in neuropsychology.
The purpose of this study was to examine whether supplementing oral feedback with written information would lead to greater
retention of information and improved adherence to recommendations. Seventy-two veterans were enrolled in the study and randomized
to receive oral feedback only or oral feedback with written information. The participants were then interviewed immediately
after feedback and 1 month later by phone. Univariate analyses revealed that the written group freely recalled more recommendations
at the phone interview; however, there were no differences in recall of diagnostic information or the number of recommendations
attempted. Findings indicate that receiving supplemental written information improves recall of recommendations and that patients
prefer to receive written information in addition to oral feedback. Recommendations to improve the retention of feedback information
are discussed.
Messengers are reluctant to reveal bad news, and this reluctance can hamper effective communication. With this investigation, we explore linkages among the topic of the news, messengers’ reasons for sharing, messenger concerns about sharing, the locus of the news, and whether these variables associate systematically with messenger reluctance to share the news. Retrospective self-reports (n = 330) revealed that bad news occurred in reliable topic categories, which in turn related to reasons for sharing, how extreme the news was perceived to be, and the concerns messengers had before sharing the bad news. Messengers reported more reluctance to share the news when they were also the locus of the news than when they were not, and they felt reluctance was greater when the topic was seen as more extreme. Theoretical implications and limitations are discussed.
Medical Communication in Clinical Contexts is an edited collection designed to show and tell how patient-centered medical communication can be performed in clinical contexts. Medical Communication in Clinical Contexts contains three primary themes: An integrated view of health communication in applied clinical contexts. An appreciation of medical communication as a multidisciplinary, yet specialized, field of study. Medical communication as simultaneously social scientific, humanistic, and professional in orientation. Medical Communication in Clinical Contexts is divided into four sections aimed at demonstrating the three primary themes. The first and second sections primarily are concerned with using theories and methods to examine acts of communication to understand when medical communication has been patient-centered and when it has needed improvement. The third and fourth sections focus on theoretically and methodologically informed communication interventions that seek to promote patient-centered medical communication. Medical Communication in Clinical Contexts demonstrates the power of communication to create or interfere with the creation of a patient-centered medical communication environment. The research interventions and applied projects can serve as models for health communication practitioners, medical communication scholars, and clinical practitioners to improve their understanding of theories, methods, and models for promoting patient-centered medical communication.
Breaking bad news in oncology is a difficult task for physicians, generating anxiety. The theory of emotion regulation suggests that physicians are using emotion regulation strategies to influence their emotions when breaking bad news to patients. The literature has led us to question the impact of the emotion regulation strategies of physicians facing giving bad news in oncology, on their patient's psychological adjustment. To address this topic, four studies were carried out. The first one enables us to analyse physicians' anxiety and two emotions regulation strategies (expressive suppression and cognitive reappraisal) at three different stages of the announcement : just before, just after and a week later. In the second study, the results of qualitative analysis from semi-structured interviews with physicians allow us to expand the range of emotions (negative and positive) and physicians' emotion regulation strategies when announcing a bad news. In the third study, the interpretative phenomenological analysis of the physicians' interviews enables us to understand two key elements of the subjective experience of physicians facing the announcement : the importance that physicians give to the announcement and their role, and the relationship established with their patients. Tha last study focusses on the analysis of the link between anxiety, emotion regulation strategies and the physicians' interpersonal skills when breaking bad news in oncology, and the patient's psychological adjustment fifteen days after the announcement. The results of these four studies allow to provide new lines of approach regarding the training in breaking bad news currently available for physicians.
Objective:
Truth telling or transmitting bad news is a problem that all doctors must frequently face. The purpose of this cross-sectional study was to investigate if medical students' opinions of truth telling differed from their observations of attending physicians' actual clinical practice.
Methods:
The subjects were 275 medical clerks/interns at a medical center in northern Taiwan. Data were collected on medical students' opinions of truth telling, their observations of physicians' clinical practice, students' level of satisfaction with truth telling practiced by attending physicians, and cancer patients' distress level when they were told the truth.
Results:
Students' truth-telling awareness was significantly higher than the clinical truth-telling practice of attending physicians (p<0.001), and the means for these parameters had a moderate difference, especially in three aspects: method, emotional support, and providing additional information (p<0.001). Regardless of this difference, students were satisfied with the truth telling of attending physicians (mean ± SD=7.33 ± 1.74). However, our data also show that when cancer patients were informed of bad news, they all experienced medium to above average distress (5.93 ± 2.19).
Conclusions:
To develop the ability to tell the truth well, one must receive regular training in communication skills, including experienced attending physicians. This study found a significant difference between medical students' opinions on truth telling and attending physicians' actual clinical practice. More research is needed to objectively assess physicians' truth telling in clinical practice and to study the factors affecting the method of truth telling used by attending physicians in clinical practice.
In this empirical, mixed methods study, we explored test feedback training, supervision, and practice among psychologists, focusing specifically on how feedback is provided to clients and whether feedback skills are taught in graduate programs. Based on a 48.5% return rate, this national survey of clinical, counseling, and school psychologists' suggests psychologists provide test feedback to clients but inconsistently. Most respondents, 91.7%, indicated they give verbal feedback at least some of the time, whereas 35% do so every time. However, 2.8% indicated they never give feedback. A negative correlation exists for clinical psychologists between years since graduation and providing verbal feedback. Of particular interest, approximately one third of respondents indicated predoctoral coursework, practica, and internship were of little-to-no help in preparing them to provide feedback. Also, feedback training in predoctoral coursework, practica, and internship was not correlated to actually providing feedback. There was, however, a significant correlation between postdoctoral training and providing feedback. Consistent with existing ethical exceptions, the most frequent reason for not providing feedback was using assessments in forensic settings. Individuals who indicated their training was not helpful cited "trial and error" and self-instruction as ways in which they learned feedback skills. We discuss implications and suggestions for feedback training, research, and practice.
To assess the quality of preregistration house officer training in eight English regions.
Postal questionnaire.
Thames, East Anglian, Mersey, Northern, and Wessex regions.
1670 preregistration house officers.
Education, hours of work, workload, conditions of work, and attitudes to job and medicine as a career.
Response rate was 69% (1146 replies). Most house officers had attended induction courses (1036/1129 (92%)); 74% (757/1024) found them satisfactory. The proportions who had never received adequate guidance on how to break bad news and how to control pain were 59% (670/1135) and 56% (634/1136) respectively. There was much variation between regions. Overall, 65% (736/1138) reported confidence in performing cardiopulmonary resuscitation. Most respondents (95% (1089/1142)) worked an on call rota, 3% (36) a partial shift, and 0.6% (seven) a full shift; 19% (202) were on duty for average weekly hours that exceeded the targets for 1 April 1993. House officers had a median of 20 patients under their care and clerked a median of 10 emergency cases, six routine cases, and two day cases a week. Over half (690/1128 (61%)) could not obtain hot food after 8 pm, 20% (223/1095) did not always have clean sheets available in their on call room, and 45% (462/1036) did not consider the protection of staff against violence to be adequate at their hospital. The most important problems with the preregistration year were inappropriate or non-medical tasks (ranked first by 360 respondents), hours of work (359), and pay for out of hours work (167). Overall 57% (646/1125) would encourage a friend to apply for their post, but only 24% (266/1112) would encourage a friend to take up medicine and 44% (494/1112) would discourage the idea.
House officers' training is deficient in important respects, with inappropriate tasks and heavy clinical workloads impeding the provision of proper education.
To determine if pediatric residents and emergency department (ED) fellows could improve their ability to counsel and inform standardized patients (SPs) about bad news.
A crossover, self-controlled design in which trainees were their own control individuals, and SPs provided feedback after the first interview. The setting was the consultation room in the ED of a large children's hospital. The outcome measures included examining the counseling and informing skills of study participants.
Trainees improved their informing skills after being provided feedback in the broad areas of communication and follow-up and in the total number of content areas asked. Their counseling skills improved in two areas: 1) promoting more trust and 2) making parents feel less dependent. Those trainees who scored higher on counseling skills discussed more total and critical content issues with SPs in the study. Trainee feedback revealed a very high rating of the educational process, and the trainees also felt much more confident about their skills after the first and second sessions.
Using SPs to teach residents and ED fellows to give bad news is an effective educational process that provides trainees with interactions that simulate real-life experience
In 1991, Archer, Maruish, Imhof, and Piotrowski presented survey findings based on the responses of a national sample of psychologists who performed psychological assessment with adolescent clients. The current survey was designed to update their results by examining the test use practices reported by 346 psychologists who work with adolescents in a variety of clinical and academic settings. These respondents represented an adjusted survey return rate of 36% and predominantly consisted of doctoral prepared psychologists (95%) in private practice settings (51%). The survey respondents had a mean of 13.6 years of post-degree clinical experience, and spent an average of 45% of their clinical time working with adolescents. Survey results reveal a substantial similarity in test usage between the 1991 survey and the current investigation. For example, the Wechsler Intelligence Scales, Rorschach, Thematic Apperception Test (TAT), and Minnesota Multiphasic Personality Inventory (MMPI) remain among the widely used tests with adolescents. However, several changes were also noted including a reduction in the use of the Bender-Gestalt and increases in the use of parent and teacher rating instruments. The current findings are used to estimate the relative popularity of an extensive list of test instruments, compare current findings to 1991 survey results, and to examine several issues related to general effects of managed care procedures and policies on test usage with adolescents.
Objective:
To design a structured curriculum concerning issues of communication with patients and families for use during training of pediatric residents.Background:
The stimulus for this initiative arose from residents' perceived need for such a program and the realization that a structured approach to communication techniques did not currently exist in our residency and, in fact, in many undergraduate and graduate medical education curricula.Methods:
Our program was designed to address complex and difficult areas in physician-patient interaction, including how to deliver "bad news," deal with hostile parents, and speak to children about serious illness; the psychosocial aspects of death and dying were also covered in the program. Various teaching techniques were used. We attempted to assess residents' response and alteration in behavior consequent to the program.Results:
The program was successfully incorporated into the training of our residents and was carried out by using existent personnel; minimal expense was incurred. The residents thought the course was valuable and effective, although no statistically significant change in the communication skills of residents could be demonstrated.Conclusions:
The area of physician-patient communication can be taught in a structured fashion during residency. Programs should be devised to meet the changing needs of training during residency and should incorporate the unique strengths of individual institutions.(Arch Pediatr Adolesc Med. 1996;150:638-642)
It was hypothesized that reluctance to communicate bad news (the MUM effect) is partially due to communicators assuming that recipients do not want to be told bad news. In a design in which news (Good versus Bad) and recipient desire to hear the news (Low versus. Not Expressed versus High) were independently manipualted, 60 male Ss were given the choice of transmitting or not transmiting the news (an aptitude score). Greatest news transmission was to recipients perceived as having high desire to hear (p .005). Potential recipients of good news were assumed to have high desire to hear more often that were potential recipients of bad news (p=.30). The MUM effect was replicated (p .50).
The common sense notion that people will be more reluctant to communicate information which is negative rather than positive for the recipient was tested under conditions that would rule out the following variables as determinats of this difference: the recipient's prior behavior toward the communicator, specified present or anticipated role relationships and/or interaction, a unit relation between communicator and message, and obvious anticipated rewards and punishments as a consequence of transmission (or non-transmission). Even when these factors were controlled for the hypothesized effect was obtained $(p<.001)$ . The difference in communication rates as a function of whether the news was good or bad was discussed in terms of some of the costs which might inhere in the communication situation per se and of other variables which might moderate the relationship.
Male college students were induced either to assist or not to assist their partner under conditions where they had previously established a norm of assistance or nonassistance. They then were in formed of either a bad news (experimen tal group) or a good news (control group) message intended for their partners. As predicted, subjects who learned of good news transmitted more completely/ spontaneously than those who learned of bad news (p < .001). Greater transmission of bad news by subjects who initially agreed to assist their partner (p < .025) was explained in terms of Ss perception of the role relationship betuveen Ss in the experimental situation. The finding that the effects of both actual (behavioral) assistance, which resulted in a marginally significant increase in the transmission of bad news (p < . 10), and the establishment of a norm of assistance were additive in their effect on the transmission decision is explained in terms of increasing salience of the social responsibility norm.
HIV disease is a slow, progressive immunological disorder. As there is neither a cure nor a vaccine, morbidity and mortality arising from HIV infection will continue to challenge health care providers, including those who counsel these patients. Psychological preparation for ‘bad news’ and support for those whose health is deteriorating is an important task in HIV counselling. This paper describes what may be considered bad news for people living with HIV, how to prepare them for unwelcome changes in their medical condition and how to give bad news, should the need arise.
This chapter focuses on pervasive bias on the part of communicators to encode (transmit) messages that are pleasant for the recipient and to avoid encoding those that are unpleasant (termed as the “MUM” effect). The hypothesized MUM effect appears to have considerable intuitive validity: “Of course people don't like to give others bad news!” Nevertheless, although anecdotal evidence is plentiful, the search of the empirical literature revealed no straightforward demonstration of, nor explicit attempt to demonstrate, the effect. The chapter attempts to define it more precisely and to demonstrate its existence unambiguously. An unambiguous demonstration of the MUM effect should not be linked with obvious extrinsic differential rewards associated with telling good or bad news, nor should news valence be dependent on the recipient's prior behavior. The chapter reviews evidence attesting to its generality, empirically examine a number of hypotheses generated to account for it, and some implications have been suggested.
In recent studies of the structure of affect, positive and negative affect have consistently emerged as two dominant and relatively independent dimensions. A number of mood scales have been created to measure these factors; however, many existing measures are inadequate, showing low reliability or poor convergent or discriminant validity. To fill the need for reliable and valid Positive Affect and Negative Affect scales that are also brief and easy to administer, we developed two 10-item mood scales that comprise the Positive and Negative Affect Schedule (PANAS). The scales are shown to be highly internally consistent, largely uncorrelated, and stable at appropriate levels over a 2-month time period. Normative data and factorial and external evidence of convergent and discriminant validity for the scales are also presented. (PsycINFO Database Record (c) 2010 APA, all rights reserved)
The factors that affect the latency period between attracting a target person's attention and delivering either good or bad news were examined. The subjects were 66 (34 female, 32 male) Canadian university students. Three hypotheses were confirmed: There was a longer latency period for bad news than for good news, women had a longer latency period for bad news than for good news and a longer latency period for delivering either bad news or good news than men did, and there was a longer latency period when women delivered bad news to a man than when women delivered bad news to a woman.
Hypothesized that an individual's reluctance to communicate news that is bad for the recipient (the MUM effect) is partially due to guilt associated with not sharing the other's fate. A 2 * 2 design (similar vs. dissimilar fate and good vs. bad news for the recipient) was employed. 72 female undergraduates were given the opportunity to communicate under the guise of a "learning experiment." Each specific prediction was substantiated: Good news was communicated more frequently (p < .05) than bad news; Ss in the bad news-dissimilar fate condition experienced the most guilt, and communicated the news less frequently than either bad news-similar fate S (p < .05) or good news-dissimilar fate Ss (p < .01). (PsycINFO Database Record (c) 2012 APA, all rights reserved)
With the increased popularity of qualitative research, researchers in counseling psychology are expanding their methodologies to include mixed methods designs. These designs involve the collection, analysis, and integration of quantitative and qualitative data in a single or multiphase study. This article presents an overview of mixed methods research designs. It defines mixed methods research, discusses its origins and philosophical basis, advances steps and procedures used in these designs, and identifies 6 different types of designs. Important design features are illustrated using studies published in the counseling literature. Finally, the article ends with recommendations for designing, implementing, and reporting mixed methods studies in the literature and for discussing their viability and continued usefulness in the field of counseling psychology. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
‘Breaking bad news’ within a paediatric setting: an evaluation report of a collaborative education workshop to support health professionals
Aims of Project. To evaluate a workshop to prepare health professionals for breaking bad news in the paediatric setting.
Background. Breaking bad news can be difficult for health professionals, and it seems that few receive specific training for undertaking this challenging task. Latterly, however, there have been reports of training programmes being developed to prepare health professionals for breaking bad news, although most focus upon meeting needs of medical staff only. While doctors have a uniquely important role in breaking bad news it is evident that other health professionals, most frequently nurses, can be equally involved in this encounter. Accordingly, nurses and other professionals need training to recognize the contribution that they can make in ensuring sensitive and effective bad news disclosure.
Design. A one-day, multi-professional, experiential training workshop.
Method. Forty-five participants, mainly nurses (34, 76%) and doctors (10, 22%), attended one of five breaking bad news workshops set up for staff working in a range of paediatric settings including Accident and Emergency and Intensive Care. Each of the workshops was facilitated by three facilitators from varied backgrounds. Using an experiential design, participants were supported to explore and reflect upon breaking bad news issues, which also included engagement with actors to act out realistic bad news scenarios. Debriefing, using a positive learner-centred model of feedback, provided the main platform for promoting learning. Following the workshop, participants completed an evaluation questionnaire, seeking their perceptions of the effectiveness of the workshop in enhancing knowledge and communication skills.
Data Analysis. Atlas.ti, a qualitative computer data analysis software program was used to explore the evaluation comments made by participants, resulting in the generation of common themes.
Findings. Seven themes, including development of practice, the value of sharing, benefit of feedback, and team work, emerged from responses. All responses indicated that the workshop had been beneficial and an effective training method, with most participants (40 of 89%) indicating that they would strongly recommend their colleagues to attend a similar workshop.
Conclusion. The educational approach reported is considered by participants to be beneficial in preparing health professionals for breaking bad news in a collaborative way.
College students (N= 90) completed a questionnaire designed to assess their recollection of a time that they delivered bad news. Responses were provided about whether each of 72 possible characteristics of such transactions occurred in addition to the impact each had on the ease of delivering the news. Participants also provided information about the stress associated with the process and their perceptions of the anxiety experienced by the receiver of the news. Three important findings emerged: (a) there was substantial diversity in the type of bad news that givers recalled transmitting; (b) students reported a wide variety of experiences associated with the bad-news process, with a sizable cluster of these experiences seeming to typify such transactions across students and news type; and (c) the level of stress associated with the bad-news process was generally high, and it was associated with what students thought about and did during the transaction.
An experiment was conducted to determine whether reluctance to transmit an overheard message intended for a stranger depends on (1) fear of negative evaluation by that stranger and (2) fear of the message's anticipated consequences for him. It was reasoned that a messenger would fear negative evaluation if he were identified by the recipient. The hypothesis that bad news would be transmitted less completely and spontaneously than good news was supported. Unexpectedly, anonymity did not interact with news content. Instead, greater communication occurred under nonanonymity than under anonymity. These findings, along with some supportive correlational data, are reinterpreted from an attribution-theoretical viewpoint.
Teaching on the theme of ‘breaking bad news’ was selected for special development as part of an introductory course on communication skills for preclinical medical students in 1987. Eight parents of handicapped children and three patients terminally ill with neoplastic diseases cooperated in a series of semi-structured group discussions in which students were encouraged to interact with patients and children. The patients/parents readily assumed the role of teachers and where it was possible, they participated in similar sessions the following year.
Analysis of questionnaires indicated that the plan had proved acceptable to patients, relatives and students. Follow-up of student opinion one year later indicated that students felt they had derived benefit from these opportunities to learn first-hand from patients and parents of handicapped children.
In recent studies of the structure of affect, positive and negative affect have consistently emerged as two dominant and relatively independent dimensions. A number of mood scales have been created to measure these factors; however, many existing measures are inadequate, showing low reliability or poor convergent or discriminant validity. To fill the need for reliable and valid Positive Affect and Negative Affect scales that are also brief and easy to administer, we developed two 10-item mood scales that comprise the Positive and Negative Affect Schedule (PANAS). The scales are shown to be highly internally consistent, largely uncorrelated, and stable at appropriate levels over a 2-month time period. Normative data and factorial and external evidence of convergent and discriminant validity for the scales are also presented.
A British senior registrar in medical oncology discusses the major difficulties encountered by physicians in disclosing unfavorable diagnoses and prognoses to patients. These difficulties are attributed to an unwarranted assumption by the physician of responsibility for the disease itself; to fears arising from personal reactions to illness, death, and expression of emotions; and to a lack of training in coping with the nonmedical aspects of serious illness. The author suggests that, with only minor changes in the curriculum, instruction in communication can be integrated into orthodox medical education.
Pediatric residents should learn to manage family crises such as informing parents that their child has a potentially life-threatening illness. Unfortunately, few training programs prepare residents to counsel parents of a child with cancer. An experiential parent crisis counseling program has been developed at the Children's Hospital National Medical Center in Washington, DC; this program has demonstrated that pediatric residents, with limited instruction, can be taught to give bad news to parents using effective information-giving and interpersonal skills.
This paper investigates the effects of three different role models in teaching trainee nurses to cope with the sensitive task of communicating a traumatic event to patients or their relatives. This is a long-standing problem with a high level of dissatisfaction within the field of nurse training. This study, in contrast to other studies of telling bad news (TBN), has focused on the person who gave rather than received bad news. This study also reinforces the view that role play and role modelling are not only effective learning methods in nurse training but are natural methods of learning in the profession. Student nurses are constantly exposed to other people's attempts at caring. Eighteen student nurses were randomly selected from a total student intake of 66 students for study in depth. Nine main skills were identified in a TBN task. Six student nurses were exposed to negative examples of a novice telling bad news, six to an expert model doing it and six to both models. The results showed that nurses learned quickly from role models, whether it was the negative instance of a poor model or the positive instance of an expert model or a combination of both. No significant difference in effectiveness between the three models was observed. The findings are discussed with reference to implications for nursing education in general.
This paper presents the evaluation of a Breaking Bad News course run for three groups of medical students (fourth and fifth year from the London Hospital Medical College and fourth year from St Bartholomew's Hospital Medical College). The course, which is student centred, uses group discussion, videotape presentations and role-play including actors. All teachers, clinicians and human science tutors, had been through a staff training programme on teaching methods. At the end of the course, students' knowledge of important principles in giving bad news had increased, particularly in relation to interpersonal communication; they were more confident in their ability to break bad news well; and the course learning methods were highly rated. The course was just as well received by fourth year as by fifth year students and several said they would like more of this training. The evaluation shows that if reservations about role-play can be overcome then this experiential learning is highly valued by students.
To design a structured curriculum concerning issues of communication with patients and families for use during training of pediatric residents.
The stimulus for this initiative arose from residents perceived need for such a program and the realization that a structured approach to communication techniques did not currently exist in our residency and, in fact, in many undergraduate and graduate medical education curricula.
Our program was designed to address complex and difficult areas in physician-patient interaction, including how to deliver "bad news," deal with hostile parents, and speak to children about serious illness; the psychosocial aspects of death and dying were also covered in the program. Various teaching techniques were used. We attempted to assess residents' response and alteration in behavior consequent to the program.
The program was successfully incorporated into the training of our residents and was carried out by using existent personnel; minimal expense was incurred. The residents thought the course was valuable and effective, although no statistically significant change in the communication skills of residents could be demonstrated.
The area of physician-patient communication can be taught in a structured fashion during residency. Programs should be devised to meet the changing needs of training during residency and should incorporate the unique strengths of individual institutions.
PROGRAM OBJECTIVE: To teach medical students to break bad news to patients and their families empathically and competently.
Seven teaching hospitals affiliated with the University of Toronto since 1987.
All medical students in their third preclinical year.
The course presents a 6-point protocol to guide students in breaking bad news and comprises 2 half-day (3-hour) teaching sessions. Each session incorporates a video presentation, a discussion period and small-group teaching, consisting of exercises followed by 4 different role-playing scenarios conducted with the use of standardized patients. The course was evaluated through 2 questionnaires, 1 administered before and 1 after the course, which measured changes in the students' attitude and strategy. Questionnaires were administered during 5 of the years since the course was started. A total of 914 precourse and 503 postcourse questionnaires were completed, of which 359 matched pairs of precourse and postcourse questionnaires were analysed to study any changes due to the course.
Precourse questionnaires showed that 68% of the students had thought about the task of breaking bad news often or very often. Of the 56% of students who had seen clinicians performing this task, 75% felt that they had seen good examples. The proportion of the students who had a plan for how to conduct such an interview rose from 49% before the course to 92% after it, and the proportion who felt they might be reasonably competent in breaking bad news rose from 23% before the course to 74% after it.
The subject of breaking bad news is important to medical students, and it is practicable to design a course to teach the basic techniques involved. Most students perceive such a course as enjoyable and useful and find that it increases their sense of competence and their ability to formulate a strategy for such situations.
To evaluate a culture-specific videotape on how to 'break bad news' and another videotape produced by a western university, and to determine if the language of presentation influenced the students' perceived abilities to execute basic skills.
Third year medical students at the Faculty of Medicine, the University of Hong Kong.
Longitudinal study with experimental design.
Two instructional tapes on breaking bad news; one using Chinese speaking role models and one using English.
In both groups, self-efficacy summed scores increased from 26.8 (95% CI = 25.9-27.7) at the pre-test to 29.0 (95% CI = 28.4-29.6). The biggest changes occurred in perceived self-efficacy regarding specific skills. However, students using the Chinese tape rated skills as more useful than those using the English tape.
The videotapes were useful in teaching communication skills. Culturally relevant audiovisual materials were more effective.
Reviews of the literature on how to convey bad news to patients with serious diseases have identified a paucity of empirically based information to guide clinicians in undertaking this difficult task. In 1994, consensus guidelines for clinicians that incorporated the views of medical oncologists, general practitioners, surgeons, nurse consultants, social workers, clergy, human-rights representatives, cancer patients, hospital interns, and clinical directors of medical schools were developed in Australia. Since then, the guidelines have been published widely and incorporated into other documents outlining recommendations for the best practices. The most recent version of the guidelines on breaking bad news is reported in this article. Revisions based on feedback from key groups, including medical schools and clinicians, and on comparisons of the views of breast cancer patients with their providers' views on the importance of each recommendation in the guidelines are included, and suggestions for future research are detailed.
In 1994, the Oregon Health Sciences University instituted an integrated course (Principles of Clinical Medicine; PCM) of classroom and outpatient clinic experience designed to give first- and second-year medical students a head start in clinical skills. During their third year, the students have been periodically evaluated by objective structured clinical examinations (OSCEs). Part of the OSCE assesses the student's skills in giving bad news by means of role playing. Assessment criteria fall into those measuring knowledge and those evaluating humanistic skills.
To evaluate whether formal instruction in giving bad news leads to an improvement in a medical student's skills, the bad-news portions of the OSCE scores of third-year medical students taught by the old curriculum (OC) were compared with those of third-year students who had taken PCM.
While bad news knowledge scores did not differ significantly between the two groups of students, the average bad-news humanistic score was significantly better for the PCM group (85% vs 79%; p = 0.05). There was no significant difference in average scores for either knowledge or humanistic skills between male and female students in the PCM group. The benefit of PCM regarding delivering bad news was also reflected by a survey of attending physicians who had taught students under both the old and the new curricula. The majority of those surveyed scored students' skills in related areas better after PCM.
Formal instruction in the first two years of medical school improved students' humanistic skills as they relate to the delivery of bad news.
Because most patients now want to know the truth about their diagnosis and prognosis, the ability to discuss the cancer diagnosis, disease recurrence, or treatment failure, and to solicit patients' views about resuscitation or hospice care, are important verbal skills for oncologists and other oncology health care providers. Moreover, the ability to clearly articulate a treatment plan or elicit patient preferences for treatment are a prerequisite to informed consent. Despite these imperatives, clinicians do not routinely receive training in key communication skills that could enable them to accomplish these tasks. A body of literature is available, however, that identifies communication strategies that can (1) facilitate the establishment of a close rapport with the patient, (2) identify the patient's information preferences, (3) ensure comprehension of key knowledge and information, (4) address the patient's emotions in a supportive fashion, (5) elicit the patient's key concerns, and (6) involve the patient in the treatment plan. In this article, we use dialogues between a physician and a hypothetical patient with advanced ovarian cancer to illustrate how communication techniques can be applied to accomplish these goals. We identify important benefits of the use of these techniques for both the physician and patient, and pose several questions regarding the training of physicians in this area.
The challenge of teaching good communication skills and psychotherapy to medical students was addressed through development of a clerkship seminar that stressed the practical application of psychotherapeutic techniques to the difficult and/or psychiatric patient. Clinical vignettes from television programs such as "ER" were used to illustrate encounters with extremely emotional or personality-disordered patients. Students also examined the dynamic meaning of these encounters, their own countertransference, and their ability to tolerate emotional interchanges with such patients. In addition, the vignettes were used to examine and apply Buckman's model for breaking bad news to patients who have undergone a significant loss. Seventy-two third-year medical students participated and completed pre- and post-seminar questionnaires to assess their knowledge and attitudes toward psychotherapeutic techniques. Students significantly improved in knowledge of countertransference, boundary setting, and how to break bad news. Attitudes toward breaking bad news and recognizing strong countertransference also improved. Some differences in post-seminar knowledge and attitudes were found between male and female students.
Previous research has shown that physicians experience incompetence and difficulty in dealing with patients' feelings after they have broken bad news to them. During the past 10 years, we have implemented a longitudinal training program targeting these issues. The present article describes this training and discusses its contribution to doctors' skills at approaching distressed patients. In order to cope with breaking bad news to patients and their families, physicians should be skilled at crisis intervention and communication techniques. They should also be aware of their personal attitudes and emotional reactions when breaking bad news. Each session encompassed these areas, as well as the most prominent issues arising when breaking bad news. In a 1-5 Likert scale, the course received an overall score of 4.47 (S.D. 0.51). Participants noted that they had gained relevant communication skills for future patient encounters.
Giving bad news Behavioral medicine in primary care
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- T S H Dent
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The teaching of crisis counseling skills to pediatric residents: A one-year study
- L S Jewett
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- L A A Champion
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