Breaking Bad News: A Contextual Model For Pakistan

Original ArticleBreaking Bad News:A contextual model for PakistanLubna Baig1, Sana Tanzil2, Syeda Kauser Ali3,Shiraz Shaikh4, Seemin Jamali5, Mirwais Khan6ABSTRACTObjectives: The purpose of the study was to identify the sequence of violence that ensues after breaking badnews and develop a contextual model of breaking bad news and develop a model contextual for Pakistan.Methods: A qualitative exploratory study was conducted using Six FGDs and 14 IDIs with healthcare providersworking in the emergency and the obstetrics and gynecology departments of tertiary care hospitals ofKarachi, Pakistan. Data was transcribed and analyzed to identify emerging themes and subthemes usingthematic content analysis.Results: Impatience or lack of tolerance, lack of respect towards healthcare providers, unrealisticexpectations from healthcare facility or healthcare staff were identified as main reasons that provokedviolence after breaking bad news. A conceptual five step model was developed to guide communicationof bad news by the health care providers. On initial testing the model was found to be effective in deescalation of violence.Conclusion: Communication of bad news requires application of specific approaches to deal with contextualchallenges for reducing violence against healthcare.KEYWORDS: Breaking bad news, Communication, Health care providers, Violence.doi: https://doi.org/10.12669/pjms.346.15663How to cite this:Baig L, Tanzil S, Ali SK, Shaikh S, Jamali S, Khan M. Breaking Bad News: A contextual model for Pakistan. Pak J Med Sci.2018;34(6):1336-1340. doi: https://doi.org/10.12669/pjms.346.15663This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0),which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.1.2.3.Prof. Dr. Lubna Baig, MBBS, MPH, MMEd FCPS, PhD,Dr. Sana Tanzil, MBBS, FCPS,Dr. Syeda Kauser Ali MBBS, MHPE, PhD,Aga Khan University, Karachi, Pakistan.4.Dr. Shiraz Shaikh, MBBS, FCPS,5.Dr. Seemin Jamali, MBBS, MPH,Jinnah Post Graduate Medical Centre,Karachi Pakistan.6.Dr. Mirwais Khan, MBBS, MPH,International Committee of Red Cross,Islamabad, Pakistan.1,2,4: APPNA Institute of Public Health,Jinnah Sind Medical University,Karachi, Pakistan.Correspondence:Prof. Lubna Baig,Pro-Vice Chancellor,Dean APPNA Institute of Public Health,Jinnah Sindh Medical University,Karachi, Pakistan.Email: lubna.baig@jsmu.edu.pk***Received for Publication:May 19, 2018Revision Received:May 30, 2018Accepted for Publication:September 20, 2018Pak J Med SciNovember - December 2018INTRODUCTIONDuring past few decades Pakistan has seen anincrease in the number of incidents of violencetargeting the general population.1,2 The country hasalso observed a considerable increase in violenceagainst healthcare mostly targeting healthcareproviders (HCPs), ambulances and hospitals.3,4There is a political will to effectively reduce theseincidents not only against the healthcare providersbut also the general public.A multicenter study conducted in Karachi, in2015 found that 66% of HCPs had experienced orwitnessed at least one incidence of violence in last12 months.5 The study also identified that verbalabuse was the most prevalent type of violenceagainst healthcare providers. Relatively higherincidents have been reported from departmentsinvolved in provision of acute care particularlyEmergency and Obstetrics and GynaecologyVol. 34 No. 6www.pjms.com.pk1336

Lubna Baig et al.departments.5,6 Another multicenter cross-sectionalsurvey of trainee physicians working in emergencydepartments of nine major tertiary care hospitalsin Pakistan found that 76.9% of the physicianshad experienced some kind of violence.7 Thecommonest reasons cited for increased violenceon healthcare by patients’ attendants in Pakistaninclude; unreasonable expectations of patientsand their families, poor quality of healthcareservices and lack of trust on healthcare providers.Moreover, lack of education among general publicand poor security measures in hospital and failureto communicate important information effectivelyto patients and their attendants has also been citedas reasons that incite violence on health ation of health related information topatients and their families can reduce violenceagainst healthcare.7-9 However, most of the peopleare reluctant to communicate any potentiallydisturbing or stressful information; consideringit to be “Bad News”.10,11 Breaking bad news maylead to disappointment, distress and aggression inthe receiver(s) and has a high potential to provokeviolence depending on contextual factors.10,11A qualitative study of experiences of healthcareproviders regarding breaking bad news analyzedbad and good experiences separately and identifiedthat interpersonal communication skills andspecific training of healthcare providers regardingbreaking bad news predominantly influencedoutcomes of breaking bad news.12 The previousmodels of breaking bad news ignore the specificsocial context and have limited usability incountries like Pakistan.11,13 Hence, it is not onlyimportant to understand the reasons and context ofviolence against healthcare in response to breakingbad news but also the positive experiences ofhealth care providers (HCPs) that helped mitigatethose situations. This study was conducted todevelop a contextual model for effective and safercommunication of bad news in settings with highpotential for violence against healthcare.METHODSA qualitative exploratory study was conductedin August, 2016 in tertiary healthcare settings ofKarachi to identify the reasons for violence related tobreaking bad news and suggestions of participantsin its management. Six Focus Group Discussions(FGDs N 45) and 14 in depth interviews (IDIs,N 14) were conducted with purposive sampling ofHCPs working in the departments of Emergency,Pak J Med SciNovember - December 2018Obstetrics and Gynecology and Medicine of sixpublic and private sector hospitals which includedJinnah Postgraduate Medical Centre, CivilHospital, Ziauddin Hospital, Sindh GovernmentHospital-Korangi, Sindh Government HospitalLyari and Sindh Government Hospital-Malir. Therespondents included; doctors, nurses, residents,dispensers and paramedics from seven public andprivate tertiary care hospitals. Using theoreticalsampling the data collection was stopped whensaturation was reached.Semi structured interview guides were used afterpre-testing. All the FGDs and IDIs were videorecorded and audio-taped. Data was transcribedand translated into “English” by a languageexpert. The transcripts of IDIs were discussedwith the respondents to ensure the reliability andauthenticity of the data.Data was analyzed using thematic contentanalysis. Both ‘manifest content’ (visible, obviouscomponents) and ‘latent content’ (underlyingmeaning) of the text were analyzed. The principalinvestigator (PI) and two co-investigators analyzedthe data independently to identify codes andthemes, which were finalized with consensus.Ethical approval for the proposed study wasobtained from Institutional Review Board (IRB)of Jinnah Sindh Medical University and relevanthealth care settings. Informed consent was takenfrom all study participants before the IDI or FGD.RESULTSThe study identified a number of reasons forviolence against healthcare in response to breakingbad news. The causes of violence were classified asclient and provider related causes. The client relatedcauses included impatience or lack of tolerance, lackof respect towards healthcare providers, unrealisticexpectations from healthcare facility or healthcarestaff. A HCP from emergency department of apublic sector hospital mentioned;“Violence occurs when people become emotional inresponse to adverse health outcomes “, (EmergencyMedical Officer)The provider-related causes included: badattitude of HCPs towards patients and attendants,lack of timely communication, inability to counselpatients/attendants and appropriate preparation forundesirable outcomes. One study participant said;“Incompetency to counsel patients and theirfamilies and bad attitude of doctors with staff andattendants causes violence in healthcare settings”.(Nurse Supervisor)Vol. 34 No. 6www.pjms.com.pk1337

Breaking Bad NewsThe study participants suggested variousstrategies to help reduce violence in healthcaresettings related to receiving bad news. Training incommunication especially breaking bad news wassuggested by most participants a postgraduatetrainee said;“Training of health care providers in communicationskills may help in reducing violence”.Most of the healthcare providers emphasizedthat violence in healthcare settings can be reducedby implementing specific patient-communicationprotocols. Based on the themes and subthemesemerging from data analysis a context specifictraining module was developed to train HCPs foreffective and safer communication of sensitiveinformation or breaking bad news. This modeloffers a contextualized stepwise approach tobe used by healthcare providers for effectivecommunication of bad news while ensuringhealthcare providers safety as well. Currently, thismodel is being implemented in some tertiary careteaching hospitals of Karachi and the effectivenessof the entire training on de-escalation of violencewas found to be effective which also included themodel on breaking bad news.14DISCUSSIONThis is the first study which specifically exploredways to effectively manage breaking bad newsin the local context. Our study identified lack ofcommunication skills and empathic attitude amonghealthcare providers that resulted in violenceagainst healthcare. This is in concurrence with thestudy done in Pakistan with residents related tobreaking bad news.15 Previous studies have shownthat empathic attitude of healthcare providersBox 1: Details of breaking bad news model proposed to reduce violence in healthcare settings of Pakistan.Pak J Med SciNovember - December 2018Vol. 34 No. 6www.pjms.com.pk1338