Practice Updates

SAGE Open Nursing

Volume 7: 1–5
Communicating Bad News: Using Role-Play © The Author(s) 2021
Article reuse guidelines:
to Teach Nursing Students sagepub.com/journals-permissions
DOI: 10.1177/23779608211044589
journals.sagepub.com/home/son

Carlos Laranjeira, PhD, MSc, MHN1 , Catarina Afonso,

MSc, CHN2 and Ana Isabel Querido, PhD, MSc, MHN1

Abstract
Receiving bad news can have a profound impact on a patient’s physical, psychological and social well-being. Therefore,
communication of bad news is an essential skill required for health professionals. A good interpersonal relationship based
on trust, empathy, and respect can help the psychological adjustment to end-of-life losses. This study presents a simula-
tion-based learning experience designed to teach communication skills to nursing students who care for palliative patients
and their family members. The authors suggest adopting Gibbs’ reflective cycle during structured debriefing that enables
the students to move logically through the reflective process. A student-centered learning approach can promote responsi-
bility and success in achieving the expected learning outcomes.

Keywords
communication, palliative care, role-play, reflective practice
Received 6 April 2021; Revised received 10 August 2021; accepted 19 August 2021

Introduction and coping suggests that discomfort felt by health profession-

als varies with their experience in giving bad news, percep-
Communication skills in palliative care nursing, more than tion of the disease’s severity, or their partial feeling of
something that occurs naturally, is a complex achievement responsibility for this bad news (Biggs et al., 2017).
like other professional procedures that require intense educa-
Inadequately breaking bad news can result in losing a
tion and practice (Blake & Blake, 2019; Smith et al., 2018). patient’s trust (Bumb et al., 2017), and in extreme cases, a
A particularly important and challenging nursing communi- patient’s suicide (Bumb et al., 2017).
cation skill is the ability to “break bad news” to patients
Communicating bad news is considered a complex task as
and families (ELNEC, 2016). There is a generalized need it requires verbal, paraverbal, and nonverbal communication
for specialized communication skills in nursing care, but skills, but also implies responding to emotional reactions,
these acquire special importance in particularly difficult con-
involving the patient in decision-making, dealing with
texts, such as patients with life-limiting illnesses and pallia- stress (of both the patient receiving the news and the profes-
tive care. sional giving the news), and attempting to give hope when
the situation is dramatic. One of the most common evidence-
based models for delivering bad news is the SPIKES proto-
Background col. Based on robust evidence, this patient-centered protocol
Bad news can be understood as any information that nega-
tively affects a person’s view of the future (Rosenzweig,
2012; Warnock, 2014). Different people may interpret 1
School of Health Sciences of Polytechnic of Leiria, Center for Innovative
similar information as either good, bad, or neutral. The Care and Health Technology (ciTechCare), Leiria, Portugal
2
way of communicating bad news can greatly impact the School of Health Sciences of Polytechnic of Leiria, UCC Arnaldo Sampaio
do ACES Pinhal Litoral, Leiria, Portugal
experience of the disease and death process. If this news is
Corresponding Author:
given incorrectly, it may trigger misunderstandings, pro-
Carlos Laranjeira, School of Health Sciences of Polytechnic of Leiria,
longed suffering, and resentment. In contrast, proper commu- Campus 2, Morro do Lena – Alto do Vieiro, Apartado 4137 2411-901
nication can generate understanding, acceptance, and Leiria, Portugal.
adaptation. Lazarus and Folkman’s (1984) model of stress Email: [email protected]

Creative Commons Non Commercial CC BY-NC: This article is distributed under the terms of the Creative Commons Attribution-
NonCommercial 4.0 License (https://creativecommons.org/licenses/by-nc/4.0/) which permits non-commercial use, reproduction and distribution
of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access page (https://us.sagepub.com/en-
us/nam/open-access-at-sage).
2 SAGE Open Nursing

provides a stepwise framework for difficult situations that the patient, and his/her family. Moreover, empathic commu-
involve bad news (Kaplan, 2010). Each letter represents a nication skills necessarily demand active listening, which
phase in a six-step sequence. will help the nurse explore the patient and family’s percep-
S = Setting up the interview. This first stage includes tion of the illness or disease trajectory (Rosenzweig, 2012).
arranging the physical setting to provide privacy, allowing For effective person-centered care to commence, continue,
the involvement of significant others, and the self-preparation and achieve success, the nurse and patient should have a
of the professional—including self-awareness (negative feel- good interpersonal relationship. This requires valuing
ings and communicating skills). oneself, promoting moral integrity and reflective ability,
P = Perception. In this stage, by asking open-ended ques- and knowing oneself—as the result of reflection—and
tions, the focus should be on assessing the patient’s informa- about values of others and their place in the relationship
tion, feelings, and expectations. (Rønning & Bjørkly, 2019). For nurses to achieve compe-
I = Invitation to disclose and discuss information, assum- tency in conveying bad news, they must develop instruments
ing that not all patients express the desire for full information that fully respond to this type of intervention.
about their condition. In this step, we ask the patient what The role of nurses in breaking bad news is largely unac-
information they desire, how much details they want, and knowledged and undervalued. However, they play an impor-
how they prefer information to be disclosed. tant role in this regard, for instance, by providing information
K = sharing Knowledge and information, starting by and helping patients prepare for, receive, understand, and
warning the patient there is bad news. In this phase, commu- cope with bad news. Breaking bad news for the first time
nication techniques should be used to help the patient process can be a terrifying prospect for students and novice nurses
the information. Information should be given in small because they can feel guilt or a sense of failure that they
amounts, in short sentences, and plain language, rather than have not “fixed things” for patients—even when they know
medical jargon. that is an unrealistic expectation of their own role or ability
E = Emotions. Addressing the patient’s emotions with to influence outcomes. Evidence shows that undergraduate
empathic responses, by identifying a patient’s primary nursing students are inadequately prepared to deliver pallia-
emotion and the reason for the emotion, and expressing the tive care (Kirkpatrick et al., 2017). Hence, examining the
connection between the reason and the emotion. Nonverbal impact of EOL simulations with newly graduated nurses is
communication is well accepted when the patient’s emo- needed to address this known gap. Palliative care education
tional response is intense. needs to focus on two key elements: self-directed and
S = Summarize. In this last step, it is important to sum- problem-based learning. Both can produce clear benefits by
marize the situation and align with a patient’s knowledge, increasing critical thinking, problem-solving, and communi-
expectation, and hopes. Establishing a clear strategy for the cation at multiprofessional levels. If ill-trained, nurses can
future with regard to the clinical situation will lessen uncer- face many problems during clinical practice. They are often
tainty and the patient’s anxiety toward the future (Kaplan, expected to understand the needs of the patient and family
2010). members and tend to provide additional information after
Communication about EOL care issues, in accordance patients speak with the doctor, and their responses foster
with the readiness and preferences of the patient and their rel- communication among all parties (Smith et al., 2018).
atives is essential. This task facilitates a person-centered Several publications highlight the importance of commu-
interaction with the patient (Hafskjold et al., 2015). nication techniques when delivering bad news to patients
“Person-centeredness” has become an increasingly familiar with life-limiting illness and their family members
term within health and social care globally and has been (Bousquet et al., 2015; Bumb et al., 2017). Despite the avail-
used to describe the standard of care that places the patient/ able evidence, many nurses feel inadequately trained to com-
client at the center of care delivery (McCance et al., 2011). municate bad news to patients and families in their practice.
The concept of person-centered care includes both the phys- In nursing education, training communication skills using
ical and psychosocial environment (Bökberg et al., 2019). simulations has been revealed as more crucial—than
Such care is created jointly as healthcare professionals merely teaching therapeutic techniques to increase self-
engage a particular patient through a genuine dialogue to confidence among nursing students—when communicating
understand the person’s experience of their situation (Öster- therapeutically with patients and families (Blake & Blake,
lind & Henoch, 2021). Evidence suggests that there is a need 2019). Despite this, there are few studies about learning exer-
to improve person-centered palliative care, which should cises for nursing students on how to break bad news (Erawati,
focus on both the person’s suffering and their capability 2017). Training with well-developed exercises is crucial to
(Bökberg et al., 2019; Ohlen et al., 2017). reach competency in this challenging situation.
Good communication is the key to a dignified response to This article presents a pilot role-play simulation con-
all of the sick person’s dimensions. Communication is ducted in a Portuguese undergraduate nursing program
present, to a greater or lesser degree, in all interactions, con- with senior students during an EOL simulation. Based on
stituting a permanent, albeit invisible link between the nurse, the study carried out by Mariolis and McKew (2020), the
Laranjeira et al. 3

simulation was designed to help nursing students develop sometimes the urgency of other people’s perspectives that
communication skills necessary to care for patients receiving are not always included in the decision-making process.
palliative and EOL care, and their families. The pedagogical The aim is not only to teach students to become aware of
approach had three main learning objectives: (a) improve the different dimensions in decision making, but also to
student ability to break bad news and build their confidence encourage them to think about what a framework for respon-
in that ability, (b) increase use of empathic communication sible action might look like.
(understanding the patient’s perception) to decrease uncer- A case vignette of a patient with palliative care needs was
tainty and patient anxiety; and (c) help students reflect on created. Manuel is a 38-year-old white man who presents
the experience. constant and intense headaches, accompanied by uncontrol-
lable vomiting, delirium, and blurred vision. He was diag-
nosed with an end-stage brain tumor. His prognosis was
Method poor, and his wife was called so she could be present and
provide support when he received the diagnosis. Sofia exhib-
Participant Recruitment
ited signs of stress and anxiety about the severity of her hus-
The participants of this study were fourth-year students in the band’s health problems. Understandably, both Mr. Manuel
seventh semester (n = 30) from a palliative care nursing and his family were devastated.
course. Participation was mandatory and students had no pre-
vious experience with role-play simulation. The simulation
was conducted in September 2020 and took place during Findings
three separate theoretical-practical classes, each with ten stu- Most of the students were females (n = 22) aged between
dents. Student participation implied no additional compensa- 18 and 25 years. During the debriefing session, students
tion. The authors obtained consent from each participant to felt positive about their experience and performance, indicat-
collect notes during the debriefing process and to use the pro- ing that the simulation had promoted the development of cog-
ject’s results. nitive (consolidation of theoretical knowledge), interpersonal
(facilitation of therapeutic alliance), and affective (explora-
tion of feelings) competencies. The intention of reducing
Role Assignment and Procedures the patient’s and family’s suffering and despair triggered
Before each role-play, three students were randomly attrib- various feelings among students, such as failure, anxiety, dis-
uted the role of a nurse, patient, and family member. appointment, impotence, nervousness, sadness, pity, com-
Students who were not assigned an active role observed the passion, revolt, and anguish. For that reason, students
simulation and helped their peers on request. The exercise described conveying bad news as a complex process that
was followed by a debriefing period, when all students pro- required nurses to have a deep sensitivity, empathy, profes-
vided feedback with the aid of a facilitator. Three nursing sionalism, and severe training. They accepted that one may
educators (the authors) supervised student performance and not always be able to provide the best answer to a patient’s
took notes. Each session lasted 30 min and was followed needs—because it is also a singular and intense experience
immediately by a 20-min reflective thinking session for the nurse—but that they must properly develop their com-
(debriefing). munication skills (whether verbal or nonverbal) to provide
the best support for the sick person and their family, while
moving away emotionally from those who expect their
Clinical Scenario support. Besides, descriptions of teamwork represent a
The simulation laboratory was organized to mimic the reality pivotal experience for many students. Collaboration with
of a clinical environment. Before the simulation activity, the peers during simulation provided insight into what teamwork
authors provided the role-players with a detailed script should entail.
including dialogue, the clinical nature of the illness, and
behaviors to be dramatized. Besides, the authors underwent
a prebriefing session with each group of students, providing
Discussion
guidelines on the simulation environment and indicating After each role-playing session, there was a group discussion
student objectives. During the simulation, the students were and a debriefing with a facilitator, using a participant-
expected to: (a) use principles of effective nursing communi- centered positive feedback model (Abualhaija, 2019).
cation skills in palliative care, such as breaking bad news; (b) Students were encouraged to explore and reflect on issues
implement the SPIKES communication model; (c) respond related to the communication of bad news using Gibbs’
empathically to emotional distress; and (d) collaborate with reflective cycle. The use of a model such as Gibbs’ cycle
peers by using the decision-making process and applying enables the student to move logically through the reflective
the course concepts in a real-life situation. In these role-play process and provides a structured approach. It offers a frame-
sessions, students could learn about the legitimacy, and work to examine experiences, and considering its cyclic
4 SAGE Open Nursing

nature, lends itself particularly well to repeated experiences, regard to their impact on the long-term learning of nursing
allowing students to learn and plan based on good or bad past students. Comparing effects on student anxiety, self-
experiences (Jayatilleke & Mackie, 2013). The process awareness, and emotion regulation of active versus observer
includes six steps, namely: (a) describing the experience; roles in undergraduate nursing EOL care simulations would
(b) expressing feelings and thoughts about the experience; also be useful.
(c) evaluating the experience; (d) making sense of the situa-
tion; (e) concluding what was learned and could have been
performed differently; and (f) elaborating an action plan to Implications
deal with similar situations in the future, based on high- A comprehensive palliative care curriculum focused on com-
quality evidence in palliative care. petency development should be the goal of every nursing
Overall, students acknowledged that they felt nervous and school worldwide. Education and training on how to break
lacked self-confidence in their abilities to communicate bad news, in particular with role-playing exercises, can
effectively, in accordance with previous research by Blake allow students to experience and understand a patient by
and Blake (2019). According to these authors, students feel experiencing their viewpoint (Blake & Blake, 2019). The
more confident and comfortable while communicating bad student, thereby, develops a greater capacity for treating
news after the experience in simulation classes. However, others with the respect and understanding required in pallia-
students indicated that the number of hours dedicated to sim- tive care nursing (Rønning & Bjørkly, 2019). This pedagog-
ulation is short, and more simulation classes are needed to ical exercise does not eliminate or decrease the educator’s
improve the sense of self-efficacy and self-confidence in role, but rather should promote collaboration and facilitation
communicating sensitive issues, such as breaking bad news. between educator and learner. McCabe and O’Connor (2014)
In our simulation experience, students felt more prepared stressed that a student-centered learning approach includes
to meet the patient’s bodily and biological needs than their four critical criteria: active accountability for learning, auton-
spiritual and psychosocial needs. This illustrates how physi- omous knowledge construction, proactive management of
cal and mental health care can often be disconnected and the learning experience, and educators as facilitators.
underlines the need for a more integrated approach
(Daset al., 2016). These results are similar to those of
Mariolis and McKew (2020), who noted that lessons Conclusion
learned within simulation experiences could influence trans-
fer to practice and enable communication with patients and Communication is, therefore, essential to build a relationship
their relatives. Furthermore, students reported that effective based on trust between patients and health professionals. This
feedback is also important for learning, which can occur is particularly relevant in the case of distressing news because
when contrasting personal perception of their performance coping strategies can only be promoted if skillful communi-
with another person’s perception. They also understood the cation takes place (Mariolis & McKew, 2020; Rønning &
value of teamwork, as it facilitated the decision-making Bjørkly, 2019). Compassionate communication can be fos-
process. Effective teamwork gave students chances to tered if it is viewed as a technique inherent to the profes-
examine the patient’s situation and the nursing interventions sion—one that requires considerable expertise and
that should be taken (Handeland et al., 2021). Rønning and prudence, and that must be developed and shaped to
Bjørkly (2019) outlined how role-play prepares nursing stu- become an integral part of the performance of health profes-
dents for complex clinical scenarios and helps them to switch sionals. Although health professionals rely on a standard pro-
from “an individual- and symptom-oriented focus to a focus tocol to transmit bad news, they should consider each patient
on interpersonal relationships” (p. 417). Placing the student as a unique individual with particular biopsychosocial char-
at the center of the feedback process may influence the acteristics inserted in a specific environment.
dynamic of the interaction, and in turn, the outcome of
learning. Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to
the research, authorship, and/or publication of this article.
Limitations
Despite these promising findings, some limitations should be
Funding
highlighted. First, the study had a small sample size and par-
ticipants were selected by convenience sampling. Similarly, The authors received no financial support for the research,
authorship, and/or publication of this article.
we conducted a pilot study where the results may not be gen-
eralized to real-life clinical scenarios. Although the results
suggest that role-playing could be effective for learning out- ORCID iDs
comes of nursing students, further studies should compare Carlos Laranjeira https://orcid.org/0000-0003-1080-9535
the role-play method with other training methods—with Ana Isabel Querido https://orcid.org/0000-0002-5021-773X
Laranjeira et al. 5

References Jayatilleke, N., & Mackie, A. (2013). Reflection as part of continu-

Abualhaija, N. (2019). Using constructivism and student-centered ous professional development for public health professionals: A
learning approaches in nursing education. International literature review. Journal of Public Health, 35(2), 308–312.
Journal of Nursing and Health Care Research, 5(7), 1–6. https://doi.org/10.1093/pubmed/fds083
https://doi.org/10.29011/IJNHR-093.100093 Kaplan, M. (2010). SPIKES: A framework for breaking bad news to
Biggs, A., Brough, P., & Drummond, S. (2017). Lazarus and patients with cancer. Clinical Journal of Oncology Nursing,
Folkman’s psychological stress and coping theory. In 14(4), 514–516. https://doi.org/10.1188/10.CJON.514-516
C. L. Cooper, & J. C. Quick (Eds.), The handbook of stress Kirkpatrick, A., Cantrell, M.A., & Smeltzer, S. (2017). Palliative
and health: A guide to research and practice (pp. 351–364). care simulations in undergraduate nursing education: An integra-
Wiley Blackwell. tive review. Clinical Simulation in Nursing, 13(9), 414–431.
Blake, T., & Blake, T. (2019). Improving therapeutic communica- https://doi.org/10.1016/j.ecns.2017.04.009
tion in nursing through simulation exercise. Teaching and Lazarus, R., & Folkman, S. (1984). Stress, appraisal, and coping.
Learning in Nursing, 14(4), 260–264. https://doi.org/10.1016/j. Springer-Verlag.
teln.2019.06.003 Mariolis, T., & McKew, C. (2020). Using simulation to improve
Bökberg, C., Behm, L., Wallerstedt, B., & Ahlström, G. (2019). care of the critically ill mental health patient at the end of life.
Evaluation of person-centeredness in nursing homes after a pal- Nursing Education Perspectives, 41(1), 52–53. https://doi.org/
liative care intervention: Pre- and post-test experimental design. 10.1097/01.NEP.0000000000000426
BMC Palliative Care, 18(1), 44. https://doi.org/10.1186/s12904- McCabe, A., & O’Connor, U. (2014). Student-centered learning:
019-0431-8 The role and responsibility of the lecturer. Teaching in Higher
Bousquet, G., Orri, M., Winterman, S., Brugière, C., Vernueil, L., & Education, 19(4), 350–359. https://doi.org/10.1080/13562517.
Revah-Levy, A. (2015). Breaking bad news in oncology: A 2013.860111
metasynthesis. Journal of Clinical Oncology, 33(22), 2437– McCance, T., McCormack, B., & Dewing, J. (2011). An exploration of
2443. https://doi.org/10.1200/JCO.2014.59.6759 person-centredness in practice. Online Journal of Issues in Nursing,
Bumb, M., Keefe, J., Miller, L., & Overcash, J. (2017). Breaking bad 16(2), 1. https://doi.org/10.3912/OJIN.Vol16No02Man01
news: An evidence-based review of communication models for Ohlen, J., Reimer-Kirkham, S., Astle, B., Hakanson, C., Lee, J.,
oncology nurses. Clinical Journal of Oncology Nursing, 21(5), Eriksson, M., & Sawatzky, R. (2017). Person-centred care
573–580. https://doi.org/10.1188/17.CJON.573-580 dialectics-inquired in the context of palliative care. Nursing
Das, P., Naylor, C., & Majeed, A. (2016). Bringing together phys- Philosophy, 18(4), e12177. https://doi.org/10.1111/nup.12177
ical and mental health within primary care: A new frontier for Österlind, J., & Henoch, I. (2021). The 6S-model for person-centred
integrated care. Journal of the Royal Society of Medicine, palliative care: A theoretical framework. Nursing Philosophy,
109(10), 364–366. https://doi.org/10.1177/0141076816665270 22(2), e12334. https://doi.org/10.1111/nup.12334
End-of-life Nursing Education Consortium (ELNEC) (2016). Rønning, S., & Bjørkly, S. (2019). The use of clinical role-play and
End-of-Life Nursing Education Consortium (ELNEC) fact reflection in learning therapeutic communication skills in mental
sheet. Retrieved November 18, 2020, from http://www.aacn. health education: An integrative review. Advances in Medical
nche.edu/elnec/about/fact-sheet. Education and Practice, 10, 415–425. https://doi.org/10.2147/
Erawati, E. (2017). Learning practice of a breaking bad news exer- AMEP.S202115
cise by nursing student. New Trends and Issues Proceedings on Rosenzweig, M. (2012). Breaking bad news: A guide for effective
Humanities and Social Sciences, 4(2), 80–85. https://doi.org/10. and empathetic communication. The Nurse Practitioner, 37(2),
18844/prosoc.v4i2.2733 1–4. https://doi.org/10.1097/01.NPR.0000408626.24599.9e
Hafskjold, L., Sundler, A. J., Holmström, I. K., Sundling, V., van Smith, M., Macieira, T., Bumbach, M., Garbutt, S., Citty, S.,
Dulmen, S., & Eide, H. (2015). A cross-sectional study on Stephen, A., & Keenan, G. (2018). The use of simulation to
person-centred communication in the care of older people: The teach nursing students and clinicians palliative care and
COMHOME study protocol. British Medical Journal open, end-of-life communication: A systematic review. American
5(4), e007864. https://doi.org/10.1136/bmjopen-2015-007864 Journal of Hospice and Palliative Medicine, 35(8), 1140–
Handeland, J., Prinz, A., Mari, E., & Fossum, M. (2021). The role of 1154. https://doi.org/10.1177/1049909118761386
manikins in nursing students’ learning: A systematic review and Warnock, C. (2014). Breaking bad news: Issues relating to nursing
thematic metasynthesis. Nurse Education Today, 98, 104661. practice. Nursing Standard, 28(45), 51–58. https://doi.org/10.
https://doi.org/10.1016/j.nedt.2020.104661 7748/ns.28.45.51.e8935