Qualitative Approach to Understanding Barriers to Delivering Difficult News in Sub Saharan Africa- Juniper Publishers
Journal of Surgery- JuniperPublishers
Dear Editor,
Communication, especially delivery of difficult news (DDN), remains a key part of clinical practice. Despite its importance, many medical providers lack the skill and ability to effectively DDN to their patients. Due to lack of data specific to sub-Saharan Africa and to help us develop an appropriate training tool for this geographical area, we sought to explore what challenges and barriers residents at our institution faced when they deliver difficult news to their patients.
Methodology
A qualitative approach using thematic analysis was adopted and a self-administered open ended survey was administered amongst residents currently doing their Masters in Medicine at the Aga Khan University Hospital in Nairobi and Dar es Salaam. The survey was emailed to all the residents within the two campuses using the REDCap software. Two independent researchers identified recurring themes and categorized barriers into either: physician, cultural or institutional. All residents provided written informed consent prior to participation in this study.
Results
A total of 105 residents participated in the survey (response rate 70%). The most frequent physician barriers identified were lack of training opportunities and time to DDN. More than fifty percent of the residents stated that cultural diversity, gender role-play and discussing dying as a taboo subject were the most common cultural barriers. Approximately 4 out of 10 residents faced institutional barriers such as lack of time due to busy schedules especially when on call, lack of private spaces to hold these conversations and limited mentorship/guidance by the faculty when having difficult conversations with patients.
Discussion
Physician barriers: Only 42.1% of the residents in our study had received any formal training in DDN. A study conducted in Nigeria looking at breaking bad news among nurses and physicians showed that only 21% of the respondents had formal training to do so [1]. Similarly, minimal formal training in conducting complex discussions were reported by health care providers in a Tanzanian health care facility [2]. In addition, our resident expressed lack of mentorship and support from faculty members in delivering difficult news to their patients.
Cultural barriers: Our residents felt that the diversity of cultures at our institutions greatly influenced the DDN to their patients, especially if different than their own. Similarly, Periyakoil and colleagues also found that many physicians struggle with end of life conversations especially in patients with a different ethnicity than their own [3]. Female residents at our institution were not taken seriously and struggled with delivery of difficult news compared to their male counterparts. Residents expressed that a majority of patients preferred a male relative be present during DDN. In addition, extended family members, rather than the female spouse, were involved in the decision making process. Our residents also expressed that talking about dying was often seen as taboo for many patients and their families. Further studies are needed to better understand how specific cultures affects effective communication especially in sub-Saharan Africa.
Institutional barriers: Similar to other studies, our residents reported a lack of adequate space and privacy when DDN to patients [2]. Opportunities supported by the institution to train and enhance communication skills were scarce. Similar to other studies, time constraint due to other clinical duties was also reported as a significant barrier [4].
Conclusion
Our study helps shed light on the barriers and challenges our residents face within our institution in delivering difficult news to their patients. This study will help us design and implement effective strategies, unique to sub-Saharan Africa, to better train our resident in DDN to their patients.
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