Contributor – Elodie Alves de Carvalho
“The most important thing in communication is hearing what isn’t said.” – Peter Drucker.
Joining a nursing team in an Oncology Day Hospital means, on a daily basis, providing care in contexts of profound vulnerability. Within this setting, the communication of bad news emerges as an inevitable and deeply challenging dimension of clinical practice, requiring nurses not only to demonstrate technical competence but also sensitivity, empathy, and presence.
Statements such as “There is nothing more that can be done, Nurse…” or “What will happen to my child?” are part of the everyday reality of nursing practice and confront us with the human dimension of suffering. In such moments, communication is not merely about conveying information; it is about knowing how to embrace pain, acknowledge silence, sustain uncertainty, and remain present with the patient, family, or caregiver.
The literature reinforces this complexity. Warnock et al. (2010) state that communicating bad news is a demanding process for nurses, making it essential to clarify and value their role in this context. In oncology, this competency becomes even more relevant given the high emotional burden associated with diagnosis, treatment, and prognosis.
In Portugal, the relevance of this topic is further reinforced by the growing prevalence of cancer in the population. According to the report Portugal: Country Cancer Profile 2025 (OCDE, 2025), cancer is the second leading cause of death in the country, and its incidence is projected to increase by 20% by 2040. The same report also highlights that cancer mortality in Portugal has been declining more slowly than the European Union average, and that the prevalence of the disease increased by 27% between 2010 and 2020. Against this background, oncology nursing is practised in a highly complex setting in which communicating bad news, managing suffering, and supporting patients and their families assume particular importance.
Communicating bad news constitutes a challenge that requires technical, emotional, and interpersonal competencies. Nurses must be prepared to communicate bad news sensitively and effectively. It is within this context that Hildegard Peplau’s Theory of Interpersonal Relations assumes particular relevance. Developed in the 1950s, this middle-range theory focuses on the relationship between nurse and patient (Tomey & Alligood, 2004). Rather than merely carrying out interventions, the nurse is understood as an active partner in the therapeutic process, capable of helping the person understand their experience, cope with emotions, and adapt.
Peplau describes four phases: orientation, identification, exploitation, and resolution. The theory’s application in the oncology setting provides a concrete framework for communicating bad news in a more effective, empathetic, and patient-centred manner (George, 2000).
In the orientation phase, the nurse initially assumes the role of a stranger, receiving the patient without judgment and seeking to understand what they know and their main concerns. Questions such as “What have you been told so far?” or “How have you been feeling since receiving this news?” help identify the person’s starting point. This phase is essential for helping the patient feel heard, thereby initiating the development of a trusting relationship that reduces initial anxiety and allows communication to be adjusted to the patient’s actual and perceived needs, positioning the nurse as a resource person.
In the identification phase, the therapeutic relationship deepens, and the patient no longer sees the nurse as a stranger but rather as a source of support and security. At this stage, the nurse assumes the role of a counsellor, creating a safe space for the patient to express fears, doubts, and distress. For example, when the patient expresses fear, empathetic listening helps the patient feel understood and supported. This approach is essential for reducing anxiety and reinforcing the trust needed to face the illness process.
In the exploitation phase, the nurse assumes the roles of leader and teacher, helping the patient mobilize resources, clarify needs, and participate actively in their illness. When confronted with difficult news, such as the transition to palliative treatment, it is important to explore the impact of this information on the person’s life, listen to their concerns, and jointly identify strategies for support and adaptation. This phase values the patient’s active participation and promotes a greater capacity to adapt to illness and treatment.
Finally, in the resolution phase, the patient gradually acquires greater autonomy and integrates strategies that enable them to cope better with their condition and prognosis. In many cases, they learn to adapt to the new reality, seek help in a timely manner, and optimize their daily life. This does not mean the absence of suffering, but rather the possibility of adaptation. The nurse remains present, but the patient feels more confident and autonomous.
Peplau’s theory not only promotes interaction with the patient but also emphasizes the development of a solid therapeutic relationship based on empathy and clear communication. In this way, nurses can provide more humanized and effective care, particularly in emotionally challenging situations such as communicating bad news. According to (Salida Johari et al., 2023), applying this theory in nursing improves communication between nurses and patients, fostering an environment of trust and emotional support during difficult moments.
However, this process is not without challenges. The emotional impact of bad news affects not only patients and families but also nurses themselves. Anxiety, helplessness, fear, and insecurity may lead to stress and emotional exhaustion. According to Peplau, nurses must develop interpersonal competencies and self-awareness to address this emotional burden (Tomey & Alligood, 2004).
Nurses also face difficulties conveying information clearly and sensitively. Choosing the right words can be difficult, as can the fear of increasing the patient’s suffering, which may lead nurses to hesitate when communicating bad news. Nevertheless, in the orientation phase described by Peplau, the patient feels welcomed and prepared to receive difficult information.
In addition, the lack of training in communicating bad news is another difficulty. Communicating in this context requires preparation, reflection, and practice. Tools are needed that enable nurses to communicate with clarity, empathy, and confidence. Peplau emphasizes the educational role of the nurse not only in relation to the patient but also to the professionals themselves.
Communicating bad news in the Oncology Day Hospital is complex and emotionally challenging for nurses. The application of Hildegard Peplau’s Theory of Interpersonal Relations is essential for providing effective emotional support, as its principles help nurses communicate more sensitively and empathetically, overcoming emotional and technical difficulties. However, it is crucial to invest in continuing education and research on best practices so that nurses feel safer and better prepared in challenging moments. Case simulation, as well as the creation of spaces for sharing and reflection, may constitute important strategies for developing communication and relational competencies.
Thus, Hildegard Peplau’s Theory of Interpersonal Relations continues to prove current and relevant in nursing by reinforcing the importance of interpersonal relationships, empathy, and communication. In a context in which it is often not possible to change the course of disease, it remains essential to care for the way one is present, listens, and communicates. Even in the face of suffering, nursing can remain a place of encounter and support, ensuring humanized and excellent care for the oncology patient.
Sources
George, J. B. (2000). Teorias de enfermagem: Os fundamentos à prática profissional (4a edição). Artmed editora.
OCDE. (2025). Country Cancer Profile 2025. https://www.oecd.org/content/dam/oecd/en/publications/reports/2025/02/eu-country-cancer-profile-portugal-2025_699bde59/46c3a9e0-en.pdf
Salida Johari, Abd Razak Zakaria, & Umi Kalsum Mohd Salleh. (2023). The Application of Peplau’s Theory Approach to Improve Interpersonal Relationship and Communication Skills between the Nursing Students’ and the Patients. JournalofChemicalHealthRisks. https://jchr.org/index.php/JCHR/article/view/2914/2043
Tomey AM & Alligood MR. (2004). Teóricas de Enfermagem e a sua obra: Modelos e Teorias de Enfermagem (5a edição). Lusodidacta.
Warnock, C., Tod, A., Foster, J., & Soreny, C. (2010). Breaking bad news in inpatient clinical settings: Role of the nurse. Journal of Advanced Nursing, 66(7), 1543–1555. https://doi.org/10.1111/j.1365-2648.2010.05325.x
About Elodie Alves de Carvalho
I have been a nurse since 2007. Since 2022, I have been a member of the Oncology Day Hospital team at ULS Santa Maria, where I practise. I am currently pursuing a master’s degree in nursing, specializing in Community Nursing, with a focus on Community Health Nursing and Public Health Nursing, at the Faculty of Health Sciences and Nursing of the Universidade Católica Portuguesa, Lisbon. This post was prepared as part of the Nursing Theories course unit, under the supervision of Professor Zaida Charepe (PhD, Associate Professor).