Nurses' attitudes toward truthful communication with patients with cancer. A Greek study

Knowledge and training among nursing students regarding the conspiracy of silence in palliative care: A participatory action research

AIM

To develop and implement specific training based on the knowledge and management of conspiracy of silence among nursing students.

BACKGROUND

Conspiracy of silence refers to the concealment of information from a patient on the family's request, under the influence of a paternalistic culture that seeks to protect the patient.

DESIGN

Participatory action research.

METHODS

Was conducted in the following stages: reconnaissance (focus groups); planning, action and observation (theoretical sessions); and reflection (analysis of care plans). The focus group consisted of six fourth year and eight second-year students. The intervention was conducted with 42 s-year students and a total of 93 s-year students participated in the resolution of the clinical case. The study was conducted between October 2022 and June 2023 at the Faculty of Nursing, University of Valencia. For data analysis, the process described by Carrillo et al. (2011) was followed, involving coding and the creation of categories and subcategories.

RESULTS

The focus group deficiencies were detected in the students' learning of palliative care competence, breaking bad news and the conspiracy of silence (reconnaissance stage). Therefore, an intervention was conducted to reinforce these knowledge areas, specifically addressing the conspiracy of silence (planning, action and observation stages). The resolution of the case showed how students with training approached the situation more comprehensively, including the family and proposed activities that were consistent with managing the situation (reflection stage).

CONCLUSIONS

An active feedback process was successfully established, where the students' feedback helped create specific training on oncological palliative care and provided the students with tools to manage the conspiracy of silence. The results underscore the importance of providing students with training in palliative care and managing conspiracy of silence, through therapeutic communication training, active training or enhancing emotional intelligence. This training is essential for cultivating the attitudes and skills required to deliver high-quality palliative care.

Disclosing the undisclosed: are radiographers and healthcare scientists required to communicate a provisional diagnosis when asked?

Patients need to be given the relevant information to be able to give informed consent, which might require the disclosure of a provisional diagnosis. Yet, there is no duty to give information to a patient if that patient is aware that this information exists but chooses not to request it. Diagnostic radiographers and healthcare scientists are often responsible for ensuring that patients have given informed consent for the investigations they undertake, but which were requested by other clinicians. Here we examine if they have a duty to disclose a patient's provisional diagnosis made by a referring clinician if the patient asks for this information as part of the informed consent process to a diagnostic investigation. We first consider aspects of UK law, professional guidance and salient ethical principles, emphasising that while professional codes of practice highlight the need to act in the patient's best interest, they do not require giving patients information they do not require for the examination or have not requested. We then propose that diagnostic radiographers and healthcare scientists placed in such a position use a 'minimally necessary disclosure' framework. This framework fulfils their commitment to their patient and the principle of veracity, while respecting the boundaries of their professional duties. The framework ensures that enough detail is given to the patient for them to be able to give informed consent, while shouldering the diagnostic professional from making a full disclosure, which is the duty of the referring clinician.

Cancer patients' awareness of extent of disease: anxiety, depression, quality of life

OBJECTIVE

In Asian cultures, the belief that full disclosure would harm the patient's health would lead to non-disclosure. The study aimed to determine whether making patients aware of the extent of their disease will lead to psychological morbidity and poor quality of life (QOL).

METHODS

This was a cross-sectional study among 195 patients with stage 4 cancer who were aware of their cancer diagnosis at the medical oncology, radiation oncology and palliative care units at an academic cancer centre. Participants were asked about their cancer stage, treatment goal and if they prefer to know their life expectancy. They answered the 14-item Hospital Anxiety and Depression Scale and 27-item validated Functional Assessment of Cancer Therapy-General questionnaires. Determination of the association of patients' awareness of the extent of the disease with psychological status and QOL was analysed using univariate and multivariate statistics.

RESULTS

About three-fourths of patients with cancer knew they had an advanced disease, but very few were aware that the current treatments they were taking for their cancer would not cure them. No association between awareness of the extent of the disease and psychological morbidity was found. Still, those aware of the advanced disease had significantly higher QOL scores for social well-being.

CONCLUSIONS

This study revealed that physicians should not hesitate to communicate the cancer diagnosis and prognosis to patients, as the disclosure was not associated with psychological morbidity. Open communication between physicians, patients and their families on the extent of the disease could empower patients to make informed decisions about their treatment, engage in advance care planning and seek the necessary support.

Translation and cultural adaptation of the Greek integrated palliative care outcome scale (IPOS): challenges in a six-phase process

AIM

To translate and culturally adapt IPOS to the Greek population.

METHODS

A four phases- sequential study, which included verification of conceptual equivalence, double forward- backward translations and conceptual cognitive debriefing. Focus group interviews used 'think aloud' and 'verbal probing' techniques. Interviews were audio-recorded, transcribed verbatim and thematically analyzed using predefined categories. Purposely sampled from two oncology and palliative care units in Athens.

RESULTS

The Integrated Palliative Care Outcome Scale was well accepted by both patients and health professionals. Overall comprehension and acceptability of the scale were good. The comprehension and judgement challenges identified in the pre-final version were successfully resolved in the cognitive interviewing phase. Five out of the seventeen translated items of the scale were modified after cognitive debriefing. Comprehension difficulties were identified with specific terms (e.g., energy/feeling depressed) and with some answer options. Severity of symptoms and not their impact was a common difficulty. A judgement challenge was reported in relation to 7-days recall and fluctuation of symptoms. Layout concerns in relation to length of questions were also stated. All questions were considered important and none as inappropriate.

CONCLUSION

This study demonstrated face and content validity and acceptability of the Integrated Palliative Care Outcome Scale in the Greek context. Cognitive Interviewing proved valuable in refining concepts within the specific cultural context.

CLINICAL IMPLICATIONS

The IPOS outcome measure tool is now being used routinely in a palliative care service in Athens and is currently used to evaluate service outcomes.

Oncology nurse perceptions about life expectancy discussions: a cross-sectional study exploring what patients want to know, and why doctors don't disclose

Background: Sensitive and patient-centred discussion about life expectancy has clear benefits for patients with advanced cancer and their families. The perceptions of oncology nurses about disclosure of life expectancy, and the barriers to disclosure, have rarely been explored. Objectives/Aims/Hypotheses: To examine oncology nurses' perceptions of the: (1) proportion of patients with advanced cancer who want, receive and understand estimates of life expectancy; (2) reasons why doctors may not provide estimates of life expectancy. Design: Cross-sectional survey. Methods: Australian oncology nurses who were members of a professional society or worked at a participating metropolitan cancer centre were emailed a link to an anonymous online survey. Participants provided socio-demographic characteristics and their perceptions about the proportion of patients with advanced cancer who (a) want, (b) are provided with, (c) receive and (d) understand estimates of life expectancy, as well as the reasons estimates of life expectancy may not be provided. Results: A total of 104 nurses participated. While 51% of nurses perceived that most patients (>75%) want to be provided with an estimate of their life expectancy, 63% of nurses reported that <50% of patients were provided with an estimate. Further, 85% of nurses indicated that <50% of patients understand the estimate. The most frequent reason nurses perceived doctors did not provide an estimate of life expectancy was because the doctor didn't have an accurate idea of life expectancy (80.8%). Almost one-fifth of nurses (18.3%) thought that doctors did not provide estimates because they felt it was not their responsibility to do so. Conclusions: Strategies to ensure a patient-centred approach to life expectancy discussions with patients with advanced cancer are urgently needed. Impact statement: Oncology nurses perceive that many patients with advanced cancer are not provided with an accurate estimate of their life expectancy and few understand the information provided to them.

Novice Nurses' Communication Skills When Addressing Aggression in Individuals Experiencing Psychosis: The Role of Emotional Regulation Capacity

Effective nursing practice is linked to a nurse's ability to regulate emotions and effectively communicate with patients. Novice nurses can feel unprepared when approaching individuals with psychosis who show aggressive behaviors. The current descriptive correlational study aimed to examine relationships among novice nurses' emotional regulation (ER) capacity, length of service, and communication skills, and investigate the predictive capacity of ER on communication skills in dealing with aggression among individuals with psychosis. A convenience sample of 133 novice nurses was obtained. Nurses who had been working for 19 to 24 months demonstrated significantly higher overall communication skills than those who had been working for 12 to 18 months and those who had been working <12 months (mean = 45.05 [SD = 10.89], mean = 41.43 [SD = 12.16], and mean = 38.44 [SD = 9.33], respectively; p = 0.03). In addition, a strong positive correlation was detected between ER strategies and communication skills. ER strategies were identified as independent precursors of novice nurses' communication skills. Incorporating ER and communication skills training in mental health nursing curricula is recommended. [Journal of Psychosocial Nursing and Mental Health Services, xx(xx), xx-xx.].

Experiencing communication related to knowing the cancer diagnosis and prognosis: A multi-perspective interpretative phenomenological study

PURPOSE

To understand the phenomenon of communication related to knowing the diagnosis and prognosis, by exploring the perspectives of patients with advanced cancer and those of their caregivers, physicians and nurses.

METHODS

Drawing upon a multi-perspective design, a total of 27 semi-structured interviews involving four different groups of stakeholders (7 patients, 7 caregivers, 6 physicians, and 7 nurses) -who were linked by a carer-cared relationship-were conducted in two Oncology Departments of two Italian hospitals. Interpretative Phenomenological Analysis was used to interpret the participants' narratives.

RESULTS

Two overarching themes were identified: The first theme "the «what is it?» and the «what will happen to me?»" illustrates the two different paths of communication of diagnosis and prognosis. The second theme "Matching and mismatching in identifying the others as speakers" shows that not each of the four parties recognizes the others as reciprocal speakers on topics related to diagnosis and prognosis, although all of them display reciprocal communication interactions.

CONCLUSIONS

Communication related to diagnosis and prognosis is often handled by health professionals without a comprehensive and integrated understanding of the communication approach. There is a correspondence between the nurses' perception of their extraneousness to the diagnosis and the prognosis related communication, and the descriptions and perceptions of the nurse's role reported by the other participants. Understanding how the different groups of stakeholders reciprocally interact and influence each other, can help to identify potential positive resources and detect hindrance in the implementation of an effective patient-centered approach, while avoiding silo cultures.

A preliminary study of the effectiveness of cancer communication skills training for interdisciplinary staff

BACKGROUND

Studies have emphasized that the disclosure of a diagnosis and prognosis is the doctor's responsibility, but little attention has been given to the importance of interdisciplinary cooperation.

OBJECTIVE

Therefore, this study examined and compared the effectiveness of cancer communication skills training (CST) for doctors and interdisciplinary staff in Taiwan.

METHODS

This study utilized a quasi-experimental design. The participants were 124 oncology professionals who participated in cancer CST. These 124 professionals included a group of 65 doctors and a group of 59 interdisciplinary professionals, both of which received the same CST. After the participants have received CST, the changes in their disease disclosure skills were evaluated.

RESULTS

Significant pretest-posttest differences were observed in the overall truth-telling scores for both groups (doctors: t = 6.94, P < 0.001; interdisciplinary professionals: t = 7.71, P < 0.001) and in different constructs. However, in many items, the doctors demonstrated no progress after receiving the training (P > 0.05), whereas the interdisciplinary professionals demonstrated significant progress (P < 0.05). In particular, the doctors' scores for 'disclosing information in a monotonous tone' showed significant retrogression (P < 0.05). There were no significant differences in the overall truth-telling scores of the two groups with regard to pre- and post-CST (P > 0.05 and P > 0.05, respectively), and there were also no significant differences in the four sub-scales' scores.

CONCLUSION

The CST for interdisciplinary professionals improved their cooperation and communication skills.

Mothers' preferences toward breaking bad news about their children cancer

Background:

The responsibility of breaking bad news (BBN) to patients is one of the most difficult tasks of a medical profession.

Aim:

The current study aimed to investigate the preferences of mothers of children with cancer about BBN.

Materials and Methods:

In this cross-sectional study was conducted in Mashhad during years of 2016, 62 mothers of children with cancer at Dr-Sheikh hospital were recruited by convenience sampling and completed a questionnaire including demographic data and 20 questions about the mothers’ preferences to BBN. Data displayed as percent by SPSS V20 software.

Results:

Mothers preferred that BBN conducted by their child's doctor (93.5%), with an emotional and compassionate way (83.9%), and in a private setting (90.3%). Be told completely about the process of diagnosis (98.4%), meet people with similar conditions (83.9%), receive psychological (85.5%), and religious (79%) support after getting bad news, being in touch with a close relative (82.3%) and applying another term-like malignancy instead of cancer (95.5%).

Conclusion:

We tried providing helpful information for developing national guidelines about how to breaking news in Iran, by doing this study.

Nurses' Perceptions of Diagnosis and Prognosis-Related Communication: An Integrative Review

BACKGROUND

Disclosure of diagnostic and prognostic information has become the standard in the United States and increasingly around the world. Disclosure is generally identified as the responsibility of the physician. However, nurses are active participants in the process both intentionally and inadvertently. If not included in initial discussions regarding diagnosis and prognosis, the nurse may find it challenging to openly support the patient and family.

OBJECTIVE

The aim of this study is to synthesize published literature regarding nurses' perceptions and experiences with diagnosis and prognosis-related communication.

METHODS

The Whittemore and Knafl method guided the integrative review process. Electronic databases including Cumulative Index to Nursing and Allied Health Literature, Health Sciences in ProQuest, PubMed, and Web of Science were used to review the literature from 2000 to 2015. Constant comparison methods were used to analyze the data and develop themes.

RESULTS

Thirty articles met all of the inclusion criteria and were included in this review. Several themes emerged from the data, including the nurse's role in the process of diagnosis and prognosis-related communication, barriers and difficulties related to communication, and positive and negative outcomes.

CONCLUSIONS

Nurses play an integral role in the process of diagnostic and prognostic disclosure. Further exploration of both physician and patient perceptions of the nurse's role are needed. Interprofessional training regarding diagnosis and prognosis-related communication is essential to promote collaboration and better empower nurses in this process.

IMPLICATIONS FOR PRACTICE

Nurses should aim to purposefully partner with physician colleagues to plan and participate in diagnostic and prognostic discussions. Nurses should identify opportunities to improve their knowledge, understanding, and comfort with challenging conversations.

Diagnosis, disease stage, and distress of Chinese cancer patients

BACKGROUND

The objective is to assess how cancer patients know about their diagnosis what they know about their real stage, and the relationship between cancer stage and psychological distress.

METHODS

A questionnaire including the Distress Thermometer was delivered to 422 cancer inpatients. Multivariate logistic regression analysis was used to estimate odds ratios (OR) and 95% confidence intervals (CI).

RESULTS

Most of patients (68.7%) knew the bad news immediately after diagnosis. Half of patients knew their diagnosis directly from medical reports. Nearly one third of patients were informed by doctors. Cancer stages, which patients believed, differed significantly from their real disease stages (P<0.001). Over half of patients did not know their real disease stages. Patients with stage I-III cancer were more likely to know their real disease stage than patients with stage IV cancer (P<0.001). Distress scores of cancer patients were determined by the real cancer stage (P=0.012), not the stage which patients believed.

CONCLUSIONS

Although most of participants knew the bad news immediately after diagnosis, less than half of them knew their real disease stage. Patient with stage I-III cancer was more likely to know the real disease stage and had a DT score <4 than patient with stage IV disease.

Revealing a cancer diagnosis to patients: attitudes of patients, families, friends, nurses, and physicians in Lebanon-results of a cross-sectional study

BACKGROUND

Disclosure of a cancer diagnosis to patients is a major problem for physicians in Lebanon. Our survey aimed to identify the attitudes of patients, families and friends, nurses, and physicians regarding disclosure of a cancer diagnosis.

METHODS

Study participants included 343 physicians, nurses, cancer patients, families, and friends from clinics in two major hospitals in Lebanon. All completed a 29-item questionnaire that assessed, by demographic group, the information provided about cancer, opinions about the disclosure of the diagnosis to cancer patients, perceived consequences to patients, and the roles of family, friends, and religion.

RESULTS

Overall, 7.8% of the patients were convinced that cancer is incurable. Nearly 82% preferred to be informed about their diagnosis. Similarly, 83% of physicians were in favour of disclosing a cancer diagnosis to their patients. However, only 14% of the physicians said that they revealed the truth to the patients themselves, with only 9% doing so immediately after confirmation of the diagnosis. Disclosure of a cancer diagnosis was preferred before the start of the treatment by 59% of the patients and immediately after confirmation of the diagnosis by 72% of the physicians. Overall, 86% of physicians, 51% of nurses, and 69% of patients and their families believed that religion helped with the acceptance of a cancer diagnosis. A role for family in accepting the diagnosis was reported by 74% of the patients, 56% of the nurses, and 88% of the physicians. All participants considered that fear was the most difficult feeling (63%) experienced by cancer patients, followed by pain (29%), pity (8%), and death (1%), with no statistically significant difference between the answers given by the participant groups.

CONCLUSIONS

The social background in Lebanese society is the main obstacle to revealing the truth to cancer patients. Lebanese patients seem to prefer direct communication of the truth, but families take the opposite approach. Physicians also prefer to communicate the reality of the disease at the time of diagnosis, but in actuality, they instead disclose it progressively during treatment. Faith is helpful for acceptance of the diagnosis, and families play a key role in the support of the patients. An open discussion involving all members of society is necessary to attain a better understanding of this issue and to promote timely disclosure of a cancer diagnosis.

Information preferences regarding cure rates and prognosis of Austrian patients with advanced lung cancer

INTRODUCTION

Due to concerns about patients' wellbeing, open end-of-life communication is associated with reservation. Furthermore, sociocultural differences must be considered. The objective of this pilot study was therefore to investigate the information preferences of Austrian patients regarding cure rates and prognosis.

PATIENTS AND METHODS

The information preferences of 50 advanced lung cancer patients were assessed at their first visit to the Department of Radiation Oncology, Medical University of Vienna. Preferences in terms of content (cure rates and/or prognosis) and depth of the information (additional quantitative estimates) were addressed. After the individually adapted medical consultation, patients' satisfaction with the consultation and the emotional responses to the information were evaluated.

RESULTS

The majority of patients (76 %) requested information about cure rates and/or prognosis; nearly half of these (47 %) wanted additional quantitative estimates. Neither sociodemographic variables, disease characteristics, nor time since diagnosis had an impact on the information preferences. The individually adapted medical information showed no overall negative influence on the emotional responses; only patients receiving prognostic information had significantly higher distress scores after the consultation. High satisfaction with the individually adapted medical consultation was reported by 92 % of patients.

CONCLUSION

Austrian physicians may offer end-of-life communication and directly ask patients about their information preferences, since patients seem able to decide whether or not prognostic information would overwhelm their emotional capacity and therefore to accept or reject the invitation. The disclosure of cure rates and/or prognosis with or without quantitative estimates-according to the patients' preferences-shows overall no negative impact on emotional reactions. The individually adapted consultation results in high patient satisfaction. Nevertheless, prognostic information may lead to higher distress.

Experiences of truth disclosure in terminally ill cancer patients in palliative home care

OBJECTIVE

The aim of this study was to explore the experiences and preferences of terminally ill cancer patients regarding truth telling in the communication of poor prognoses.

METHOD

We recorded and transcribed interviews with 45 patients who knew their cancer was terminal, and analyzed their responses hermeneutically.

RESULTS

Patients identified three different modes of truth: (1) the absolute objective truth that they are dying; (2) the partial truth about their condition including some facts but not all of the details; and (3) the desired truth, originating in the patient's own beliefs about a healthy or better life. Coping strategies were related to patients' preferred mode of truth: (1) facing the truth in order to take action; (2) facing some parts of the truth in order to maintain hope; and (3) hovering between facing and avoiding the truth. In their struggle for existential survival, patients used different coping strategies, changing from one to another depending upon the circumstances.

SIGNIFICANCE OF RESULTS

Varying use of different coping strategies impacts on patient preferences concerning communication about bad news with their doctors. Truth-telling entails more than merely providing information related to the forthcoming death. It also concerns how physicians or other healthcare staff can support the patient's existential survival by fine-tuning the communication of "truth" according to the individuals' preferences.

Truth-telling to patients' terminal illness: what makes oncology nurses act individually?

PURPOSE

Nurses encounter the challenge of truth-telling to patients' terminal illness (TTPTI) in their daily care activities, particularly for nurses working in the pervasive culture of family protectiveness and medical paternalism. This study aims to investigate oncology nurses' major responses to handling this issue and to explore what factors might explain oncology nurses' various actions.

METHODS

A pilot quantitative study was designed to describe full-time nurses' (n = 70) truth-telling experiences at an oncology centre in Taipei. The potential influencing factors of nurses' demographic data, clinical characteristics, and truth-telling attitudes were also explored.

RESULTS

Most nurses expressed that truth-telling was a physician's responsibility. Nevertheless, 70.6% of nurses responded that they had performed truth-telling, and 20 nurses (29.4%) reported no experience. The reasons for inaction were "Truth-telling is not my duty", "Families required me to conceal the truth", and "Truth-telling is difficult for me". Based on a stepwise regression analysis, nurses' truth-telling acts can be predicted based on less perceived difficulty of talking about "Do not resuscitate" with patients, a higher perceived authorisation from the unit, and more oncology work experience (adjusted R² = 24.1%).

CONCLUSIONS

Oncology care experience, perceived comfort in communication with terminal patients, and unit authorisation are important factors for cultivating nurses' professional accountability in truth-telling. Nursing leaders and educators should consider reducing nursing barriers for truth-telling, improving oncology nurses' professional accountability, and facilitating better quality care environments for terminal patients.

Disclosing the truth: a dilemma between instilling hope and respecting patient autonomy in everyday clinical practice

BACKGROUND

While medical ethics place a high value on providing truthful information to patients, disclosure practices are far from being the norm in many countries. Transmitting bad news still remains a big problem that health care professionals face in their every day clinical practice.

AIMS

Through the review of relevant literature, an attempt to examine the trends in this issue worldwide will be made.

METHOD

Various electronic databases were searched by the authors and through systematic selection 51 scientific articles were identified that this literature review is based on.

RESULTS

There are many parameters that lead to the concealment of truth. Factors related to doctors, patients and their close environment, still maintain a strong resistance against disclosure of diagnosis and prognosis in terminally ill patients, while cultural influences lead to different approaches in various countries. Withholding the truth is mainly based in the fear of causing despair to patients. However, fostering a spurious hope, hides the danger of its' total loss, while it can disturb patient-doctor relationship.

Factors associated with nurses’ opinions and practices regarding information and consent

This cross-sectional survey aimed to investigate nurses’ opinions and practices regarding information and consent in the context of a large Italian teaching hospital and to explore potential influences of gender, age, university education, length of professional experience, and care setting. A questionnaire was administered to 282 nurses from six different care settings (Emergency Room, Emergency Medicine, Surgery, Hematology–Oncology, Geriatrics, and Internal Medicine). Overall, 84% (n = 237) of nurses returned the questionnaire (men: 24%; mean age: 36.2 ± 8 years; university degree: 35%; mean length of professional experience: 12 ± 8.2 years). Most respondents regularly informed patients about medications and nursing procedures and asked for consent prior to invasive procedures, but some provided information to relatives instead of patients. Lack of time or opportunity was the main difficulty in informing patients. The work setting was the foremost factor significantly associated with participants’ opinions and practices. Further investigations are needed to confirm these findings in similar and other care settings.

Should culture affect practice? A comparison of prognostic discussions in consultations with immigrant versus native-born cancer patients

OBJECTIVE

Poor prognosis is difficult to impart, particularly across a cultural divide. This study compared prognostic communication with immigrants (with and without interpreters) versus native-born patients in audio-taped oncology consultations.

METHODS

Ten oncologists, 78 patients (31 Australian-born, 47 immigrants) and 115 family members participated. The first two consultations after diagnosis of incurable disease were audiotaped, transcribed and coded. 142 consultations were included in the analysis.

RESULTS

Fifty percent of doctor and 59% of patient prognostic speech units were not interpreted or interpreted non-equivalently when an interpreter was present. Immigrant status predicted few prognostic facts, and oncologist characteristics no prognostic facts, disclosed. Oncologists were significantly less likely to convey hope to immigrants (p=0.0004), and more likely to use medical jargon (p=0.009) than with Australian-born patients. Incurable disease status and a limited life span were commonly acknowledged, generally with no timeframe provided. Physical issues were discussed more commonly than emotional aspects.

CONCLUSIONS

While culture did not appear to influence doctor speech, interpreters filtered or blocked much prognostic communication.

PRACTICE IMPLICATIONS

Initiatives to empower all patients to attain needed information, optimise communication when an interpreter is present and train cancer health professionals in culturally appropriate care, are urgently required.

Intentions of nurses and nursing students to tell the whole truth to patients and family members

AIMS AND OBJECTIVES

To investigate the intentions of nurses and nursing students to telling the truth to patients and families, based on the Theory of Planned Behavior which examines intention to perform behaviours.

BACKGROUND

In recent decades, the perception that patients have a moral and legal right to truthful and reliable information has become dominant. However, the study of telling the truth to non-oncology patients has received scant attention and little is known about the intention of nurses and nursing students to tell the truth.

DESIGN

A cross-sectional design.

METHODS

We used a scenario-based questionnaire, illustrating eight different situations in which nurses/nursing students are asked to tell the truth to a patient or family member regarding a devastating disease with which the patient is afflicted. Data were analysed using the Mann-Whitney U-test and ridge regression.

RESULTS

The sample included 150 participants, 110 registered nurses and 40 third year nursing students, with a response rate of 87%. The results show that nurses and nursing students intend to tell the whole truth even if this is not easy for them. Nurses more than students think that it is important to tell the whole truth and intend to do so. Head nurses tend to tell the truth more than staff nurses. For nurses, the components of the Theory of Planned Behaviour predicted intention to tell the truth, whereas among students subjective norms were the only predictor of intention.

CONCLUSION

The Theory of Planned Behaviour is a powerful predictor of nurse intention to tell the whole truth to patients and their families. Students perceive social pressure as the most important incentive of their intention to tell the truth.

RELEVANCE TO CLINICAL PRACTICE

Nurses and nursing students should receive additional training in dealing with various situations involving truth telling.

A survey of emotional difficulties of nurses who care for oncology patients

Nurses who care for dying patients are under pressure emotionally because of their beliefs and values about death as well as the emotions and reactions of the patients and their families. This study examines the emotional difficulties of nurses caring for oncology patients in Turkey. The study used a descriptive survey design. The participants were 157 nurses from three medical oncology units in Ankara. Results showed that nurses had difficulty in talking to oncology patients about end-of-life issues and found that caring for dying patients affected their personal lives. This study also showed that the length of nurses' work experience had no effect on their feelings and perceptions toward terminally ill patients. However, the nurses who had more work experience were more likely to report difficulty in talking to patients. Most of the nurses expressed feelings of inadequacy and hopelessness about pain management and treatments.

Telling the truth: Turkish patients' and nurses' views

The objective of this study was to investigate nurses' communications with patients, particularly regarding getting accurate and truthful information about their medical diagnosis and prognosis. This survey research involved 166 nurses and 435 patients at the Osmangazi University Hospital, Turkey. Although 90% of the nurses said that patients should be informed about their diagnosis, only 66% of the patients said they wanted to be told this information. For those who wanted to be informed, how they should be informed is also discussed.

Truth-telling in discussing prognosis in advanced life-limiting illnesses: a systematic review

Many health professionals (HPs) express discomfort at having to broach the topic of prognosis, including limited life expectancy, and may withhold information or not disclose prognosis. A systematic review was conducted of 46 studies relating to truth-telling in discussing prognosis with patients with progressive, advanced life-limiting illnesses and their caregivers. Relevant studies meeting the inclusion criteria were identified by searching computerized databases (MEDLINE, EMBASE, CINAHL, PsychINFO and Cochrane Register of Controlled Trials) up to November 2004, with handsearching of studies, as well as inclusion of studies satisfying selection criteria reported in 2005 by the authors. The reference lists of identified studies were hand-searched for further relevant studies. Inclusion criteria were studies of any design evaluating communication of prognostic information that included adult patients with an advanced, life-limiting illness; their caregivers; and qualified HPs. Results showed that although the majority of HPs believed that patients and caregivers should be told the truth about the prognosis, in practice, many either avoid discussing the topic or withhold information. Reasons include perceived lack of training, stress, no time to attend to the patient's emotional needs, fear of a negative impact on the patient, uncertainty about prognostication, requests from family members to withhold information and a feeling of inadequacy or hopelessness regarding the unavailability of further curative treatment. Studies suggest that patients can discuss the topic without it having a negative impact on them. Differences and similarities in findings from different cultures are explored.

Communication Strategies and Cultural Issues in the Delivery of Bad News

Good communication is a fundamental skill for all palliative care clinicians. Patients present with varied desires, beliefs, and cultural practices, and navigating these issues presents clinicians with unique challenges. This article provides an overview of the evidence for communication strategies in delivering bad news and discussing advance care planning. In addition, it reviews the literature regarding cultural aspects of care for terminally ill patients and their families and offers strategies for engaging them. Through good communication practices, clinicians can help to avoid conflict and understand patients' desires for end of life care.

Discrepant perceptions about end-of-life communication: a systematic review

Little research has compared the perceptions of health professionals (HPs), patients, and caregivers about the communication of prognostic information. The objectives of this literature review were to determine 1) patient and caregiver perceptions of levels of information received about prognosis and end-of-life (EoL) issues regarding a life-limiting illness; 2) patient perceptions of and factors related to their understanding and awareness of prognosis; 3) HPs' perceptions of patients' wishes about disclosure of prognosis and factors related to their decision whether to disclose; and 4) concordance between HPs and patients/caregivers regarding the information given by HPs about prognostic and EoL issues. Relevant studies meeting the inclusion criteria were identified by searching computerized databases (MEDLINE, EMBASE, CINAHL, PsychINFO, Cochrane Register of Controlled Trials [Central]) up to November 2004. The reference lists of identified studies were hand searched for further relevant studies. Inclusion criteria were studies of any design evaluating communication of prognostic information that included adult patients with an advanced, life-limiting illness; their caregivers; and qualified HPs. Fifty-one studies were identified. There was a large discrepancy between patients/caregivers and HPs regarding the amount of information they believed had been given. Patients' understanding and awareness of information received conflicted with the HPs' perceptions of patients' understanding and awareness of the information that had been given. HPs tended to underestimate patients' need for information and overestimate patients' understanding and awareness of their prognosis and EoL issues. HPs need to repeatedly check patients' understanding and preferences for information.

Preparation for cancer care: Perceptions of newly qualified health care professionals

The present paper is derived from a larger survey which examined the perceptions of recently qualified health care professionals' experience on evidence-based practice, team working and cancer care. This study reports solely on the findings relating to cancer care. The perceptions of recently qualified professionals in relation to their initial educational input on issues such as confidence, anxiety, communication skills and practice in cancer care as well as adequacy of support, professional supervision and use of reflection were gathered using a cross-sectional postal survey design. A total of 50 graduates from each professional category in nursing, occupational therapy, physiotherapy, and social work were sampled yielding a total sample of 200. Eighty-five questionnaires were returned yielding a response rate of 43%. Twenty-eight (33%) respondents stated that they were currently involved in working with people with cancer. These were as follows: 5 nurses, 8 physiotherapists, 9 occupational therapists and 6 social workers. Despite the low response rate, the findings suggest that health care professionals' educational input and experiences of working with people with cancer were overall positive; for example, in the respondents' confidence, communication skills, decrease in anxiety and application of knowledge gained in classroom to professional practice. Moreover, most respondents learnt about caring for cancer patients through practice rather than classroom teaching. A high percentage (i.e. 64%;18) across all groups felt supported when caring for people with cancer and reported receiving professional supervision as well as being able to actively reflect on their practice. The implications for education and practice were discussed particularly as there have been few studies conducted in relation to the specific needs and collaborative learning of these health care professional groups.

Being asked not to tell: nurses' experiences of caring for cancer patients not told their diagnosis

AIMS AND OBJECTIVES

The aim of the primary research was to investigate the impact of the nurse-patient relationship on clinical learning and subsequently clinical practice. Coincidently, 32 participants, all Registered Nurses in Hong Kong, provided details of nurse-patient encounters involving withholding of a cancer diagnosis.

BACKGROUND

The changing face of clinical practice and cancer care has fuelled discussion and debate around disclosure or non-disclosure of the diagnosis of cancer, global consensus on this issue still does not exist. In different countries there is marked variation in how and what a patient may be told about their diagnosis and prognosis. There is considerable variability in the reported rate of cancer diagnosis disclosure across studies and countries. Being asked not to tell a patient their diagnosis of cancer presents many problems for nurses caring for those patients. The issue of non-disclosure directly affects nurses and their clinical practice.

METHODS

This paper reports one of the findings of a large international qualitative study informed by phenomenology into the perceptions of nurses about caring for a patient with a diagnosis of cancer.

RESULTS

Responses from participants revealed considerable difficulties for nurses when caring for patients who were not informed of their diagnosis. They recounted having learned from the encounters but remarked on the negativity of the experience. They discussed their inability to act decisively in the past situations but expressed hope that they had found a resolve to act in future.

RELEVANCE TO CLINICAL PRACTICE

Although, overwhelmingly, participants doubted they would actually be able to change the reality of practice. The identified care episode and the nurse-patient relationship, according to participants, did change their clinical practice but often not for the better.

Healthcare providers' priorities for cancer care: A Delphi study in Greece

Cancer is a major problem globally and effective cancer care services are needed to lessen its burden on the community. In Greece, oncology health services provision is not located efficiently, resulting in few patients receiving high-quality care. Furthermore, shortages of health professionals and underdeveloped services such as primary care, home care and palliative care have aggravated the problem. The absence of a national cancer registry means that the extent of cancer incidence cannot be evaluated effectively. Dissatisfaction with the Greek NHS is well established, despite the reforms proposed by consecutive Greek governments. It remains that limited research exists in the area of cancer services and cancer care. The aim of this study was to identify the key areas of cancer care and services that needed to be developed or improved in Greece and their prioritisation within the Greek healthcare system. A Delphi technique was used to collect data from a sample of 30 healthcare providers, in three rounds. The response rate for each round was over 77%. The priorities for healthcare providers were focused on staff shortages, working conditions, pain management, home care, day units and communication. Based on the priorities provided by the participants and supporting literature, it is suggested that a national cancer registry, the employment of nurses to develop primary care, home care, day care and palliative care services need to be established. Furthermore, education in communication skills and the redistribution of the bio-medical technology are needed in order to provide more effective cancer services in Greece. More research is needed to validate the actual level of cancer services provided in Greece.

Family centred decision making and non-disclosure of diagnosis in a South East Asian oncology practice

AIM

To audit the extent of non-disclosure of cancer diagnosis (NDD) in South-East Asian patients referred to a Western trained oncologist, and determine the factors associated with this pattern of decision-making.

METHODS

Over a 12-month period, all new patients referred to a single radiation oncologist's practice were prospectively audited at time of the initial consultation. Data obtained included patient demographic features, tumour details, proposed treatment and decision-making process. A shared decision-making consultation was attempted but if there was a persistent request by family to avoid disclosure, then a family-centred model was adopted. Patient autonomy was maintained by formally asking desire to participate in decision-making process, and subsequent permission then sought to involve family members as surrogates. Treatment aim, predicted median survival and NDD was recorded at end of consultation. Endpoints of patient NDD and non-discussion of prognosis were audited over a 12-month period, and factors potentially associated with these endpoints were assessed.

RESULTS

Over a 12-month period 369 new patients were referred to the oncologist's practice. Forty per cent were >65 years, 84% Chinese race, and 66% non-English speaking. Lung (33%) and breast (32%) primaries were prominent. Forty-seven per cent were managed with palliative intent and 24% had expected median survivals of <6 months. NDD was recorded in 66 patients or 17% of the patient group. Quantitative discussion of prognosis was avoided in 36.8% of patients. On univariate analysis advanced patient age (p<0.001, OR=9.6, 95% CI 4.9-18.9), female sex (p=0.035, OR=1.8, 95% CI 1.04-3.1), non-English speaking (p<0.001, OR=21.4, 95% CI 5.1-89.1), palliative treatment aim (p<0.001, OR=5.9, 95% CI 3.1-11.2) and short expected median survival (p<0.001, OR=4.0, 95% CI 2.3-7.1) were associated with NDD. Advanced patient age (p<0.001, OR=7.9, 95% CI 3.6-17.5), female sex (p<0.001, OR=6.4, 95% CI 2.8-14.7), non-English speaking (p=0.010, OR=7.4, 95% CI 1.6-33.3) and palliative treatment aim (p=0.010, OR=3.3, 95% CI 1.3-8.0) remained significantly associated with NDD on multivariate logistic regression analysis.

CONCLUSIONS

A high rate of desired NDD is evident in this Asian oncology population when a family-centred model to medical decision making is used. This data confirms that NDD and the model of decision making remains a significant ethical issue.

Patterns and barriers in information disclosure between health care professionals and relatives with cancer patients in Greek society

The issue of whether, how and how much to tell cancer patients concerning diagnosis is still approached in various ways across different countries and cultures. The health care team-patient relationship is a triangle consisting of the health care professionals, the patient and the family. Each part supports the other two and is affected by the changes that happen in the triangle. The objective of the study was to investigate the communication context through which health care professionals and families with cancer patients interact. In Greece, physicians have the tendency to tell the truth more often today than in the past, although the majority still disclose the truth to the next of kin. Nurses in Greece are considered to be the most suitable health care professionals for the patients to share their thoughts and feelings with. Nevertheless, the decision on information disclosure lies with the treating physician. In Greek society the patient's family plays an important role in the provision of care and information disclosure. They often decide on the patient's behalf.

Communicating prognosis in cancer care: a systematic review of the literature

Prognosis is an issue that most doctors and patients describe as difficult to discuss and the best way of presenting prognostic information to optimise patient understanding, psychological adjustment and decision-making is uncertain. A systematic review of the literature was conducted with the aim of clarifying the current available knowledge of patient preferences, clinician views and current practice regarding the communication of prognosis. Eleven primary research questions guided organisation of the review findings, which were: patient preferences for prognostic information and preferred style of communicating prognosis; disclosure of prognosis to family members; physicians' views on communication of prognosis; current practice of delivering prognostic information; patient understanding and awareness of prognostic information; cultural differences in preferences and understanding; impact of prognostic information on patient outcomes; and interventions to facilitate prognostic discussion. Predictors of patient preferences for and understanding of prognostic information were also summarised. Studies are summarised under the subcategories according to the participants' disease stage. It was found that the majority of the published research has been conducted in the early stage cancer setting providing mostly descriptive evidence, and there is little evidence of the best method of communicating prognosis or of the impact of prognostic information on patient outcomes.

Cancer information disclosure in different cultural contexts

The relationship between truth telling and culture has been the subject of increasing attention in the literature. The issue of whether, how and how much to tell cancer patients concerning diagnosis is still approached differently depending on country and culture. The majority of physicians tell the truth more often today than in the past, in both developed and developing countries, but most of them prefer to disclose the truth to the next of kin. Nurses in Anglo-Saxon countries are considered to be the most suitable health-care professionals for the patients to share their thoughts and feelings with. Nevertheless, in most other cultures the final decision on information disclosure lies with the treating physician. Regardless of cultural origin, the diagnosis of cancer affects both family structure and family dynamics. In most cases patients' families, in an effort to protect them from despair and a feeling of hopelessness, exclude the patient from the process of information exchange. The health-care team-patient relationship is a triangle consisting of the health-care professional, the patient and the family. Each part supports the other two and is affected by the cultural background of each of the others as well as the changes that occur within the triangle.

The "Palliative Care Quality of Life Instrument (PQLI)" in terminal cancer patients

BACKGROUND

This paper describes the development of a new quality of life instrument in advanced cancer patients receiving palliative care.

METHODS

The Palliative Care Quality of Life Instrument incorporates six multi-item and one single-item scale. The questionnaire was completed at baseline and one-week after. The final sample consisted of 120 patients.

RESULTS

The average time required to complete the questionnaire, in both time points, was approximately 8 minutes. All multi-item scales met the minimal standards for reliability (Cronbach's alpha coefficient > or =.70) either before or during palliative treatment. Test-retest reliability in terms of Spearman-rho coefficient was also satisfactory (p < 0.05). Validity was demonstrated by inter-item correlations, comparisons with ECOG performance status, factor analysis, criterion-related validation, and correlations with the Assessment of Quality of Life in Palliative Care Instrument (AQEL), and the European Organisation for Research and Treatment of Cancer (EORTC) Core Quality of Life Questionnaire (QLQ-C30, version 3.0).

CONCLUSION

The PQLI is a reliable and valid measure for the assessment of quality of life in patients with advanced stage cancer.