Clinical Skills & Placement Hub

Difficult Conversations & Breaking Bad News

What lectures rarely teach you — compassion, clarity, and courage.

Breaking bad news is very often not a taught skill. It comes with practice. It comes with compassion. And it comes with patience — especially if you are about to be part of telling a patient they have a terminal diagnosis.

There are methods to follow, yes — frameworks that help structure the conversation and guide you through. But ultimately it comes down to you as a person. Whether you can confidently stand in that situation, sit with someone’s pain, and be present when everything changes. That is what this page is about — not just the steps, but the heart behind them.

Before You Speak — Prepare Yourself

You cannot support someone else if you are not steady yourself. Before you even walk through the door:

• Know what is being said. Ask the doctor or lead clinician what the news is, in plain terms. If you do not understand it, you cannot support them through it.
• Know who is there. Does the patient know anything already? Are family present? Is there someone they want with them? Has an interpreter been arranged if needed?
• Check the space. Private, quiet, no interruptions. Put phones away. Sit at eye level — not standing over them. This is not something you do at the bedside with curtains half-closed.
• Check yourself. Take one breath. Remind yourself: it is okay to be nervous. It means you care. But be calm enough that they can hold onto you.

A Framework to Guide You — SPIKES

There is a widely used, evidence-based approach called SPIKES. It gives you a structure to lean on when your own feelings want to take over. It is not a script — it is a map. Every person and every conversation will be different, but these six steps keep you on course:

Letter	What It Means	How to Do It
S	Setting Up	Private room, sit together, introduce everyone, explain roles — “We’ve come to talk through what is happening, and what it means for you.”
P	Perception	Ask what they already understand: “What have the doctors told you so far?” This tells you where to start — and corrects misunderstandings gently.
I	Invitation	Ask how much they want to know: “Some people want every detail, some prefer just the main points — what would suit you best?” Respect their answer.
K	Knowledge	Give the information — start with a warning shot: “I’m afraid I have some difficult news.” Use plain language. No jargon. Pause. Let it land. Do not rush to fill the silence.
E	Emotion	Acknowledge and respond to feelings — “I can see how incredibly hard this is.” Sit with them. Do not say “I know how you feel.” You don’t. Just be there.
S	Strategy	Summarise what happens next — “We will support you every step of the way. We will see you again tomorrow, and your nurse is here whenever you need us.” Give them something steady to hold onto.

In the Room — What It Actually Looks Like

Looking After Yourself Too

You will carry these moments with you. That is not a weakness — it is proof you care. But you cannot pour from an empty cup.

References & Evidence Sources

1. NMC (2018, reissued 2024): The Code — Professional standards of practice — Communicating clearly and honestly, respecting autonomy and dignity
2. Baile WF et al. (2000): SPIKES — A Six-Step Protocol for Delivering Bad News — Academic model widely adopted in UK clinical practice
3. Royal College of Nursing (2022): Breaking Bad News — Clinical Practice Guidelines — Empathy, preparation, and person-centred communication
4. NICE NG18 (2015, updated 2023): End of Life Care for Adults — Communication, honesty, and involving patients and families in decisions
5. General Medical Council: Good Medical Practice — Communication and Decision Making — Shared guidance for all clinical professionals