Effects of an education program on attitude about these difficult conversations

Nurses’ knowledge and communication skills enhance informed decision-making for patients with cancer. Discussions with patients and families about a cancer diagnosis or recurrence typically involves prognosis, including estimates of the likelihood of a cure and survival. Without these conversations, patients must make decisions about care goals and end-of-life care without a proper understanding of their prognosis. High-quality prognosis communication supports hope, trust, satisfaction with medical care, and peace of mind.

Physicians typically lead prognosis-related conversations, but bedside nurses also participate in these discussions with patients and their families. Frequently, however, clinicians avoid these complex conversations due to the difficulty of finding a balance between hope and honesty. Research indicates that oncology nurses are more likely to deliver bad news than do nurses in other specialties. Communication involving prognosis isn’t always the nurse’s focus due to knowledge deficits regarding a case.

Determining what the patient knows and what they want to know can help nurses initiate prognosis-related conversations. An educational intervention implemented at Riverview Medical Center in Redbank, New Jersey, aimed to enrich nurses’ efforts, knowledge, skills, and confidence in explaining prognosis-related information.

Who participated

To determine differences in nurses’ attitudes about prognosis-related conversations with oncology patients before and after an education intervention, I used a one-group descriptive pre- and post-intervention study design. A convenience sample of 38 oncology nurses who work on four oncology units at the medical center chose to participate. The participants ranged in age from 23 to 62 years with a mean of 37.3 years (SD=11.52). Most of the participants had 1 to 5 years (56.2%) of experience working as a nurse, held a bachelor of science in nursing degree (82%), and worked as full-time staff nurses (71%) on the day shift (61%); 24% held a national oncology certification. (See Participant characteristics.)

How the intervention worked

Intervention objectives included empowering nurses through an education module to have prognosis-related conversations and understanding why having difficult conversations can help patients and their families make goals-of-care and end-of-life decisions. Using a 15-minute, visually appealing PowerPoint presentation with voiceover, the intervention focused on communication in terms of process, prognosis, verbal and nonverbal conveyance, trust, relationships, and outcome.

Participants also received information related to strategies for building a trusting relationship and creating a therapeutic environment. Other topics included tips and techniques regarding the importance of timing, the environment, eye contact, and physical touch as well as multiple daily discussions with both the patient and family.

Methods

Participants completed the Prognosis-Related Communication in Oncology Nursing instrument before and after the presentation. This validated and reliable instrument has the Cronbach’s alpha for the total scale of 0.75, which is deemed acceptable for new instruments.

Higher scores on the MD communication subscale indicate that the nurse agrees that the physician they work with generally discloses prognostic information to patients, does so early in the course of the disease, and generally keeps the nurses involved in such discussions. A higher score on the RN role subscale implies that nurses feel well-equipped and comfortable initiating and responding to prognosis-related discussions with patients and families. Lower scores on the decision-making subscale suggest that nurses identify prognosis-related communication as assistive and integral for helping patients make care decisions.

What the results revealed

Results suggest that an educational intervention on prognosis-related discussions significantly impacted nurses’ attitudes about their role in this communication with patients and their families (P=<.001). Because nurses serve as a constant presence at the bedside, patients and families frequently ask them questions about the patient’s prognosis and its implications. Nurses’ participation in these conversations can help support patients and their families in goals-of-care and end-of-life decision making. (See Intervention results.)

The education session focused on the nurse, their role and responsibilities, and the courage and compassion required for difficult conversations. Nurses received information about tools to enhance their awareness of all aspects of communication, including how to establish a therapeutic atmosphere, maintain awareness of who’s present in the room, remain mindful of their own body language, and develop trust. They also learned how to read the room regarding whether to proceed with the discussion or defer it to another time.

Empowerment through education

Nursing schools don’t teach about end-of-life and prognosis-related communication, which can lead many nurses to avoid these discussions in practice. Education empowers nurses by providing them with the knowledge and skills needed to navigate difficult conversations. Providing nurses with this educational intervention empowers them to have conversations about difficult situations, goals of care, and prognosis, which can positively influence the patient and family experience.

Margaret Valenti is the manager of oncology at Riverview Medical Center in Red Bank, New Jersey.

American Nurse Journal. 2025; 20(6). Doi: 10.51256/ANJ062538

References

Kirca N, Bademli K. Relationship between communication skills and care behaviors of nurses. Perspect Psychiatr Care. 2019;55(4):624-31. doi:10.1111/ppc.12381

Mehta AK, Wilks S, Cheng MJ, Baker K, Berger A. Nurses’ interest in independently initiating end-of-life conversations and palliative care consultations in a suburban, community hospital. Am J Hosp Palliat Med. 2018;35(3):398-403. doi:10.1177/1049909117704403

Newman AR, Helft PR. Reliability and validity of a tool to assess oncology nurses’ experiences with prognosis-related communication. Oncol Nurs Forum. 2015;42(1):64-73. doi:10.1188/15.onf.64-73

Pehrson C, Banerjee SC, Manna R, et al. Responding empathically to patients: Development, implementation, and evaluation of a communication skills training module for oncology nurses. Patient Educ Couns. 2016;99(4):610-6. doi:10.1016/j.pec.2015.11.021

Key words: cancer prognosis, difficult conversations, communication skills