1. Introduction

Bad news is defined as "any news that adversely and severely affects an individual's view of his or her future, providing serious case disclosure to anyone who needs expertise, experience, and compassion" [1]. It is also defined as (situations where there is either a feeling of no hope, a threat to a person's mental or physical well-being, a risk of upsetting an established lifestyle, or where a message is given which conveys to an individual fewer choice in his or her life) [2]. The bad news may be a devastating diagnosis such as metastatic cancer with a poor prognosis and a high mortality rate. It may also include treatment failure or developing drug side effects. There is a wide variety of what can be considered bad news, for example: fetal congenital anomalies, disabilities after trauma, fertility problems, chronic illness, neoplastic disorders, a loved one's death, contagious diseases, or any other conditions that may negatively alter the patient's views of his or her life, hopes, and dreams. Regardless of the content of the bad news, breaking it to the patient and his/her family or guardian is not a simple mission at all. As a result, in medical practice, a global policy and excellent communication skills are required. Despite many articles and theories that have addressed this topic, there are a very limited number of studies with small sample sizes from both medical staff and recipients. There is increasing awareness regarding the importance of breaking bad news in medical societies [3]. Unfortunately, this part of medical practice has not received enough training in the past because medical schools are focused on the scientific part only, whereas communication skills are supposed to be acquired by postgraduates through observation. Breaking bad news is one of the most important and difficult responsibilities in the practice of medicine, although virtually all doctors in clinical practice encounter situations entailing bad news at some point in their medical practice.

2. Methods

2.1 Study Design

Cross-sectional, descriptive hospital-based study.

2.2 Study Area

The study was conducted at Atbara, Ad-damer, and Alsalam teaching hospitals. Atbara teaching hospital is situated in the western north of Atbara town. It's about 14292 meters. It was built in 1904 during the period of the English government. Furthermore, it has wards and referral clinics for surgery, medicine, pediatrics, and obstetrics, as well as a dialysis and diabetes center, casualty, and newly built CCU and ICU. There are about two laboratories and three pharmacies, and other services such as x-rays and ultrasound. Ad-damer teaching hospital is situated in the western south of Ad-damer town. It was built in 1967. It consists of wards and referential clinics for surgery, medicine, pediatrics, and obstetric specialties, a center for dialysis, casualty, and ICU. There is about one laboratory, three pharmacies, and other services such as x-rays and ultrasound.

2.3 Study Period

From the 1st of December 2018 to the 8th of January 2019.

2.4 Study Population

All house officers, medical officers, and registrars work at Atbara, Ad-damer, and Alsalam teaching hospitals during the period from December 1st, 2018 to January 8th, 2019.

2.5 Sample Size

100 doctors.

2.6 The Tool and Technique of Data Collection

Data were gathered through direct interviews with doctors using a closed-ended questionnaire.

2.7 Data Analysis

The data were analyzed by using the statistical computerized program for social sciences, SPSS (version 21).

2.8 Data Presentation

Frequency and percentage descriptive statistics. A formal letter from the department of community medicine to the medical director of Atbara, Ad-damer, and Alsalam teaching hospitals from whom we received verbal consent to conduct the research. We also received verbal consent from the responders after explaining our research objectives.

3. Results

In a descriptive cross-sectional hospital based study, 100 doctors were enrolled to assess their perception toward BBN, fulfilling all inclusion criteria, SPSS version 25 was used for analysis and obtaining the following results. The study revealed that (79%) of participating doctors were younger than 30 years and only (4%) were older than 35 years.70% were females, only (22%) had passed SMSB part 1exam, (73%) were graduated after the year 2015 and only (7%) graduated before the year 2011. The majority of them (47%) were medical officers, (34%) house officers and (19%) registrars. There were participants from several departments: Internal Medicine (28%), Pediatrics (26%), Obstetrics & Gynecology (24%), Surgery (19%) and Family Medicine (3%). Most of the participants (70%) were working at Atabara Teaching Hospital, (23%) in Aldamer TH and (7%) in Alsalam TH, as shown in Table 1.

Table 1: Demography, Qualifications and Job description of study participants.

*Gyn. Gynecology, MBBS (Latin Abbreviation of) Bachelor of Medicine and Surgery, SMSB Sudan Medical Specialization Board, TH Teaching Hospital.

Among the 100 participating doctors, only (46%) had been trained about breaking bad news, first person to receive bad news were a patient in only (30%), (50%) family and (20%) were both patient and family. (56%) of participating doctors were comfortable to discuss diagnosis issue with family or patient, (24%) were not and (16%) were not sure. Most of the study participants (77%) told the patients everything about diagnosis, while (18%) didn't and (5%) were not sure about. (26%) informed the patients about diagnosis in single visit. (47%) of participating doctors took patient hope before, while (25%) didn't and (28%) were not sure. (49%) of study participants relied on relatives’ consent to inform patient about diagnosis, (42%) did not rely on, while (9%) were not sure about. (41%) of participating doctors told patient diagnosis and prognosis, (15%) avoided difficult questions from patients, (14%) tell patient truth only if patient ask, (21%) refer the patient to another doctor, while (9%) lied to the patients. (66%) of study participants thought that patients didn't want to know about diagnosis, (16%) of thought the reverse, while (18%) were not sure. Most of participating doctors (77%) were depressed about breaking bad news, while (17%) were not and (6%) were unsure. (81%) of study participants explained bad prognosis but (60%) of them gave false hope and remaining (21%) didn't, (17%) gave false hope to terminal patients. (60%) told patients about their final diagnosis, while (28%) avoided that, and (12%) were not sure about. (21%) of study participants used a multi bed hospital room to deliver bad news, while (64%) didn't and (15%) were not sure. (65%) of participating doctors prepared the patients for bad news, (28%) didn't and (7%) were not sure about. The majority of study participants (89%) gave follow-up plan and hope, the rest either didn't (4%) or were unsure (7%). Only (26%) of participating doctors knew about breaking bad news policy, while (48%) didn't know and (26%) were unsure. As shown in Table 2.

Table 2: Training, Perception and Practice regarding Breaking Bad News.

The most age group trained on breaking bad news was older than 35 years (75%), followed by younger than 25 years (51%), then (25 < 30) years old (44%), and the least trained age group was (30 < 35) years; only (35%). Male participants were more trained with (56%) versus (41%) for female doctors. Registrars were the most trained with (70%) followed by house officers (50%) then medical officers (36%). Study participants from family medicine were all trained (100%) then surgery (51%), obstetrics (50%), pediatrics (46%) and least trained were Participants from internal medicine with (32%). As shown in Table 3.

Table 3: Correlation of Demography, Clinical Position and Specialty with Breaking Bad News Training.

4. Discussion

To the best of the author's knowledge, this is the first study in the perception of doctors in breaking bad news in the River Nile State and in Sudan as a whole, assessing the perception and experience of the doctors in breaking bad news.

There are few studies regarding this issue in developing countries especially Africa, in one study conducted in southeastern Nigeria regarding breaking bad news in clinical setting between health professionals, they found that only 22.1% of health professionals received formal training about BBN, they concluded that large proportion of respondents in this study were incompetent in BBN, as they showed low level of training and little knowledge about BBN concept and policies [4]. The results of this study demonstrate that more than half of doctors didn't have training in breaking bad news due to lacking of the training programs in Sudan, in contrast to the similar study done at comprehensive cancer center, at King Fahad Medical City, Riyadh, Saudi Arabia [5] which reveled about 70% of their doctors had training in breaking bad news. In a survey conducted among patients in tertiary care hospitals in Pakistan, most respondents (40.5%) stated that it is absolute right to know about breaking bad news [6]. The current study showed about 50% of doctors preferred to discuss diagnosis issues with close relatives rather than the patient because they felt more comfortable and easier to handle it with them, and this finding is in agreement with a similar study performed in the Qassim region and published at Oman Medical Specialty Board [7]. In our study showed 77% of doctors feeling depressed after breaking bad news and describe that's more stressful situation, 60% of study group when explaining bad prognosis, they gave false hope to the patient and their families. More than 60% of our doctors preparing and informing their patients about bad news in multi visits, trying to reduce the psychological impact. Our hypothesis is there may be big limitation in awareness, training and implementation of principles of breaking bad news. The purpose of this study is to evaluate the perception of doctors in breaking bad news in Atabra, Ad-damer and Alsalam teaching hospitals through a cross-sectional descriptive hospital-based study conducted in Atabra, Ad-damer and Alsalam teaching hospitals from December 2018 to January 2019. This study is novel and constitute a basis for further studies and work up concerning breaking bad news in River Nile State and across Sudan.

5. Conclusion

From this cross-sectional study, we concluded that there is good relationship between the level of training and the clinical position of doctors. Also, our study showed that the obstetricians and pediatricians were well-trained rather than other specialties. Half of doctors thought that the family should be told first about bad news. Unfortunately, the majority of doctors didn't hear about the global policy of breaking bad news.

Acknowledgment

The authors are grateful and deeply indebted to their family members, friends, colleagues for their unconditional support and encouragement.

Conflicts of Interest

The authors have no conflicts of interest to declare.

Ethical Statement

The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Contributions

(I) Conception and design: All authors; (II) Administrative support: All authors; (III) Provision of study materials or patients: All authors; (IV) Collection and assembly of data: All authors; (V) Data analysis and interpretation: All authors; (VI) Manuscript writing: All authors; (VII) Final approval of manuscript: All authors.

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