FNPs Handling Difficult Conversations with Patients

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fnps may have to discuss difficult information with patients


As primary-care providers, family nurse practitioners (FNPs) have an opportunity to form close bonds with patients and help them through chronic and acute conditions. In doing this work, FNPs may have to deliver difficult information regarding abnormal lab results, disease progression or life-limiting illnesses.

Honest and forthcoming information is vital to providing patients with the best care possible. But in delivering the information, FNPs must be careful not to cause additional stress. Effective and accurate communication skills are essential to working as an FNP, Margaret Quinn Rosenzweig, the author of “Breaking bad news: A guide for effective and empathetic communication,” stated. She said bad news is defined as any information that negatively alters the recipient’s view of the future.

“One of the most important components in the repertoire of NP communication skills is the ability to ‘break bad news’ to patients and families,” Rosenzweig said. “The NP cannot judge what constitutes bad news and should be aware of this with any news that has the potential to alter an individual’s view of themselves or their future.”

In relaying sensitive information, all healthcare professionals, including those entering online master’s in nursing programs and MSN careers, are encouraged to follow a multi-step protocol, called SPIKES, that helps initiate conversations.


SPIKES originated in the early 2000s after researchers noticed a gap between how healthcare workers relayed bad news and what patients heard.

In the landmark study, “SPIKES—A Six-Step Protocol for Delivering Bad News: Application to the Patient with Cancer,” the authors said breaking bad news is a complex task that includes responding to the patient’s emotional reactions and handling the involvement of multiple family members.

“The complexity of the interaction can sometimes create serious miscommunications such as patient misunderstanding about the prognosis of the illness or purpose of care,” the authors said. “Poor communication may also thwart the goal of understanding patient expectations of treatment or involving the patient in treatment planning.”

As a step-wise method, SPIKES is based on well-established principles of counseling and communication. The acronym represents each part of the provider-patient communication process:

Setting up a meeting

In addition to using an area that is private and free from distractions, healthcare providers should take care to sit and make eye contact with the patient. The patient’s family or significant others should be included in the discussion if the patient chooses.

Assessing the patient’s Perception

Clinicians should start the discussion with open-ended questions that invite the patient into the process. For example, the difficult conversations can be started with “What have you been told about your medical situation so far?” or “What is your understanding of the reasons we did the MRI?” Based on the details, clinicians can assess what the patient knows, correct misinformation and adjust the bad news to the patient’s level of understanding.

Obtaining the patient’s Invitation

Clinicians should also determine how much information the patient wants regarding the diagnosis by asking questions that include, “How would you like me to give the information about the test results?” or “Would you like more details about the diagnosis?” Patients who do not want information immediately may want more in the future.

Providing information and Knowledge

In the discussions, providers should use nontechnical words and tactful phrasing, provide factual information about the disease and allow the patient to ask questions at any point. Through this, patients may have a better understanding of the options, including therapeutic alternatives with a focus on pain control and symptom relief.

Addressing the patient’s Emotions with empathy

Since patients respond to bad news in different ways, providers should find techniques to provide empathetic responses before moving on to new topics. The expressions of understanding and compassion should aim to soothe the patient, reduce the feeling of emotional isolation and validate feelings.

Determining a Strategy and summary of events

Providing a clear path forward may alleviate the patient’s uncertainty and anxiety. Through shared decision-making, the clinician and patient should formulate a plan for the future. Clinicians should acknowledge the patient’s hopes and fears and correct any unrealistic expectations.

In addition, study authors advised all clinicians to use flexible approaches to accommodate their patients’ differing reactions.

When it comes to FNPs specifically, other studies have found SPIKES principles helpful. In “Role of Nurse Practitioners in Delivering Bad News,” author Betty R. Ferrell, RN-Ph.D., said all NPs, including those working in palliative care, can benefit from using SPIKES.

“NPs are key members of interdisciplinary palliative care teams in both inpatient and outpatient settings,” she said. “In these roles, NPs are increasingly involved in communicating with patients and families, including breaking bad news.”

FNPs and Difficult Conversations

Indeed, as FNPs continue to gain full practice authority across the country, they will be facing more situations where they have to deliver bad news. An advantage of working as an FNP is the chance to build relationships and provide ongoing support.

As a growing number of RNs seek MSN careers, including as FNPs, they will be filling roles as primary care providers. RNs who are seeking careers as FNPs are encouraged to take online master’s in nursing classes so they can effectively apply their learned communication skills to everyday practice.

At Duquesne University, students learn essential communication skills that translate into clinical competencies. The online master’s in nursing and online postmaster’s certificate programs provide opportunities for RNs to work as FNPs in hospitals, medical centers and private practice.


About Duquesne University’s Online Master of Science in Nursing in Family (Individual Across the Lifespan) Nurse Practitioner Degree Program

Duquesne University’s online master’s in nursing programs are designed to meet the needs of RNs who are seeking to advance their careers. The coursework is presented entirely online so RNs can maintain their careers and personal lives while pursuing their educational goals.

Duquesne University’s online MSN FNP program prepares graduates for the American Academy of Nurse Practitioners Certification Board (AANPCB) and American Nurses Credentialing Center (ANCC) Family Nurse Practitioner certification examinations. The university’s School of Nursing has been repeatedly recognized as a leader in nurse education. The program boasts a 100% pass rate on the 2018 AANPCB FNP certification exam. For more information, contact Duquesne University today.



Breaking bad news: A guide for effective and empathetic communication: HHS Public Access

SPIKES—A Six-Step Protocol for Delivering Bad News: Application to the Patient with Cancer: The Oncologist

Role of Nurse Practitioners in Delivering Bad News: Medscape