in communication in cancer
care: An interpretative
University of Cagliari, Italy; Universitat Rovira i Virgili, Spain
University of Cagliari, Italy
Cesar Ivan Aviles Gonzalez
University of Cagliari, Italy; Universitat Rovira i Virgili, Spain
University of Cagliari, Italy
Maria Francisca Jimenez Herrera
Universitat Rovira i Virgili, Spain
Background: In cancer care, many clinical contexts still lack a good-quality patient–health professional
communication about diagnosis and prognosis. Information transmission enables patients to make informed
choices about their own healthcare. Nevertheless, disclosure is still an ethically challenging clinical problem
in cancer care. High-quality care can be achieved by understanding the perspectives of others. The
perspective of patients, their caregivers, physicians and nurses have seldom been simultaneously studied.
Objective: To investigate the phenomenon of diagnosis and prognosis-related communication as
experienced by patients, their caregivers, and both their attending nurses and physicians, to enlighten
meanings attached to communication by the four parties.
Methods: A qualitative study using interpretative phenomenological analysis was performed.
Participants and research context: Purposive sampling of six patients, six caregivers, seven nurses and
five physicians was performed in two oncological hospitals in Italy.
Ethical considerations: Local Ethics Committee approved the study. It was guided by the ethical
principles of voluntary enrolment, anonymity, privacy and confidentiality.
Results: Three main themes were identified: (a) the infinite range of possibilities in knowing and willing to
know, (b) communication with the patient as a conflicting situation and (c) the bind of implicit and explicit
meaning of communication.
Conclusion: The interplay of meanings attached by patients, their caregivers, and their attending
oncologist and nurse to communication about diagnosis and prognosis revealed complexities and
Corresponding author: Maura Galletta, Department of Medical Sciences and Public Health, University of Cagliari, SS 554 Bivio per
Sestu, Monserrato, Cagliari 09042, Italy.
Email: [email protected]
2020, Vol. 27(6) 1418–1435
ª The Author(s) 2020
Article reuse guidelines:
ambiguities not yet settled. Physicians still need to solve the ethical tensions in their caring relationship
with patients to really allow them ‘to choose with dignity and being aware of it’. Nurses need to develop
awareness about their role in diagnosis and prognosis-related communication. This cognizance is
essential not just to assure consistency of communication within the multi-disciplinary team but
mostly because it allows and enables the moral agent to take its own responsibilities and be
accountable for them.
Cancer, communication, diagnosis and prognosis, ethics, interpretative phenomenological analysis,
In Western countries, the process of diagnosis and prognosis-related communication in cancer care is
approached as a phenomenon related to information exchanges between patient and clinician and
within healthcare professionals, as well as to the relationships occurring among all the speakers,
This suggests that quality of health professional–patient communication is
linked to the quality of communication and coordination within the team,
and that informal care-
givers also play a crucial role in managing patients’ cancer disease.
Nevertheless, literature high-
lights that many clinical contexts are still lacking a good-quality patient–health professional
communication regarding end-of-life preferences and prognosis disclosure,
and information prefer-
ences for patients with advanced cancer are still unmet.
As information transmission enables patients
to make informed choices about their own healthcare, it can be said that, in cancer care, disclosure
issue is still an ethically challenging clinical problem. Moreover, although there has been advance-
ment in cancer treatments, cancer is still associated with suffering and death. Perceptions and beliefs
surrounding cancer disease still hamper regular interactions and communication.
There is evidence
that the main barriers to effective communication and information sharing are fragmented commu-
nication, uncertainty around patient consent and the unacknowledged existence of overlapping care
On the contrary, prognostic disclosure has been associated with more realistic patients’
expectations of life expectancy,
and discussions on prognosis seem to strengthen the relationship
between patient and oncologist.
Literature has also shown that good collaboration among health
professionals is essential for high-quality care
and that patient-centred care is enhanced by both good
inter-professional communication and acknowledgement of the interdependence of each one’s role.
However, the perspectives of patients, caregivers, physicians and nurses have been seldom studied all
communicative interactions have been investigated in some previ-
ous qualitative studies, but they limit the analysis to a portion of the context of care. Interpretative
phenomenological analysis is a qualitative method used in health-related research to understand
human experiences that are essential to the participants. Interpretative phenomenological analysis
contributes to move beyond a biomedical model of the disease to get insights about self-reported
experiences and the meanings that individuals assign to those experiences.
Studies with a multi-
perspective design and adopting interpretative phenomenological analysis are quite recent and still
In our research, we focused on the communication experience by investigating simultane-
ously the perspectives of patients, their caregiver, their attending oncologist and their attending nurse.
This study is part of a larger research aimed to explore communication issues related to diagnosis and
prognosis in oncological wards.
Melis et al. 1419
This study intended to investigate the phenomenon of diagnosis and prognosis-related communication as
experienced by patients, their caregivers, and both their attending nurses and physicians, in order to
enlighten the meanings attached to communication by the four groups of participants.
This study was conducted using an interpretative phenomenological analysis, which is a qualitative research
approach that values ‘a detailed experiential account of the person’s involvement in the context’ (p. 196).
Interpretative phenomenological analysis allows for catching communication meanings through narration
of participants’ experiences within a cultural, social and personal world,
so, it can be said that the method
implies an interpretative approach enriched by descriptive notes.
Following interpretative phenomeno-
logical analysis philosophical roots – that come from Heidegger’s philosophy – meanings are always
created through interactions, including those with researchers.
According to it, the researchers’ pre-
conceived concepts and personal world cannot be kept apart from the investigation, but they can represent
a tool to conduct the analysis.
On this basis, interpretative phenomenological analysis develops a
double-hermeneutic circle where ‘the participants are trying to make sense of their world; the researcher
is trying to make sense of the participants trying to make sense of their world’ (p. 53).
According to the
idiographic focus of interpretative phenomenological analysis, this study explores the perspectives of
individuals in their unique context of life. Besides, this study adheres to interpretative phenomenological
analysis’ request to illustrate and describe themes by a rich reporting of excerpts from participants’
Study inclusion and exclusion criteria
The main inclusion criteria for patients were to be at least 18 years old and being diagnosed with cancer. An
inclusion criterion for nurses was attending on the interviewed patient for at least two shifts. An inclusion
criterion for physicians was attending on the interviewed patient. Caregivers were selected upon indication
of the interviewed patients. General exclusion criteria were to be less than 18 years old and have cognitive
Patients were recruited upon introduction by the interviewer of the research purpose. Eligible nurses
and oncologists were purposively enrolled after the patient. Patients were enrolled based on homo-
geneity of patients’ life expectancy of less than 1 year, according to the attending oncologist. This
selection criterion for patients was used to pursue a fairly homogeneous sample, as suggested by
Smith for interpretative phenomenological analysis studies.
Successively, available caregiver was
selected and the physician and nurse who attended on the patient during his or her disease trajectory
were selected. A total of 24 participants corresponding to six groups of four members each (patient,
his or her caregiver, and his or her attending physician and nurse) were recruited. According to Reid
exploring a phenomenon from multiple perspectives is a kind of triangulation that
can help researchers to develop a more detailed and variegated description of that phenomenon.
Nevertheless, this is possible only with a small sample (5–10 participants).
Therefore, based on
this suggestion, six participants for each role (patients, caregivers, physicians and nurses) are con-
sidered as a very good sample.
Table 1 shows the characteristics of the study participants.
1420 Nursing Ethics 27(6)
The study complies with the principles of the Declaration of Helsinki and the Italian Privacy Law (GDPR
679/2016). The study was approved by the Independent Ethics Committee of the Azienda Ospedaliero-
Universitaria di Cagliari, Italy (Act n.2.27; 25 July 2016). At the enrolment stage, researchers provided
written and oral information about the purpose of the study. Participation was voluntary and anonymous;
confidentiality was assured and guaranteed to all participants. All the interviewees gave their written
informed consent and were informed that they could leave the study at any time without penalty. Pseudo-
nyms were used for all patients in order to preserve anonymity. Moreover, the researchers paid attention to
the participant’s emotional status and respected it by shortening and finishing the interviews when needed.
Data collection procedure
The study was conducted in two oncology departments of two big hospitals from southern Italy. Narrative
interviews were carried out in the departments in which the patients were treated. A researcher expert on the
topic performed interviews from August 2016 to February 2017. A set of interview guiding questions was
developed (see Figure 1), based on previous pilot interviews; questions were used very flexibly in order to
Table 1. Summary of participants’ characteristics.
Patients (n ¼ 6) Caregivers (n ¼ 6) Physicians (n ¼ 5) Nurse (n ¼ 7)
Gender Man ¼ 4; woman ¼ 2 Man ¼ 0; woman ¼ 6 Man ¼ 2; woman ¼ 3 Man ¼ 1; woman ¼ 6
Age 19 years ¼ 1
56 years ¼ 1
63 years ¼ 1
64 years ¼ 1
65 years ¼ 1
77 years ¼ 1
Average age ¼ 57 years
52 years ¼ 1
55 years ¼ 1
62 years ¼ 1
67 years ¼ 1
68 years ¼ 1
72 years ¼ 1
Average age¼62.7 years
40 years ¼ 1
42 years ¼ 1
45 years ¼ 2
55 years ¼ 1
Average age¼45.4 years
36 years ¼ 1
37 years ¼ 1
46 years ¼ 1
47 years ¼ 1
54 years ¼ 1
58 years ¼ 1
59 years ¼ 1
Average age¼48.1 years
Primary school ¼ 2
Secondary school ¼ 2
Master degree ¼ 2
Primary school ¼ 2
Secondary school ¼ 2
Master degree ¼ 2
Tenure Experience as
6 years ¼ 1
12 years ¼ 1
16 years ¼ 2
23 years ¼ 1
Average tenure ¼ 14.6
Experience in an
3 years ¼ 1
10 years ¼ 2
16 years ¼ 1
19 years ¼ 1
20 years ¼ 1
27 years ¼ 1
Average tenure ¼ 15
Breast cancer ¼ 1
Rare cancer ¼ 2
Abdominal cancer ¼ 2
Lung cancer ¼ 1
Minimum: 13 min;
maximum: 60 min
(mean ¼ 35 min)
Minimum: 12 min;
maximum: 48 min
(mean ¼ 24 min)
Minimum: 13 min;
maximum: 26 min
(mean ¼ 17 min)
Minimum: 20 min;
maximum: 68 min
(mean ¼ 39 min)
Melis et al. 1421
elicit the participant’s experience. Prompt questions were used to encourage the interviewees to elaborate
their thought based on their experience. All the performed interviews were audio recorded and verbatim
transcribed, including a brief description of non-verbal aspects of the interviewees.
The patient was always the first one to be interviewed, but it was not always possible to follow a
scheduled sequence for the other participants of the subgroup, because of their unpredictable temporary
unavailability. In any case, all the four parties of each subgroup were interviewed within 2 or 3 days from
each other, except for one group in which the interview time span was of 3 weeks, due to organizational
problems. In a case, two nurses who attended on the same patient desired to be interviewed at the same time;
all the other interviews were conducted separately. During the recruitment process, one physician refused to
be part of the study. Thus, our final sample of 24 participants included six patients, six caregivers, seven
nurses and five physicians.
Data analysis and rigour
Data analysis was conducted according to the procedure indicated by Smith et al.
phenomenological analysis studies. According to this procedure, an inductive approach has been used to
process data. In a first step, each researcher did an attentive reading of each transcript following the
interviews’ chronological order for each group unit (patient, caregiver, nurse and physician). Second, once
an overall sense of the data was gained, each researcher wrote initial textual notes describing any relevant
issue; in the following step, emergent themes were developed by each researcher, via abductive reasoning.
In a fourth step, the researchers looked for connections across emergent themes; this process included a first
analysis in which data from each participant were analysed separately, and then they were analysed for each
group unit and across the group units. This process intended to privilege the comparison of the four parties
across the six groups and, at the same time, safeguard the connection of the four participants at the group
level. Moreover, it allowed the researchers to better interpret each single part in relation to the whole and
vice versa. Until this point, the researchers proceeded separately: each researcher produced a list of few
main themes. Then, the researchers met and triangulated their findings conciliating them by retracing back
all the previous steps. This final discussion allowed the researchers to identify the final main themes, by
following a subsumption process. In fact, according to Brocki and Wearden,
in contrast with content
analysis that produces ‘a quantitative analysis of discrete categories from qualitative data’, in interpretative
phenomenological analysis ‘the importance of the narrative portrayal is dominant’, and its aim is to provide
‘a detailed interpretative analysis of themes’ (p. 99).
Data analysis was supported by using Atlas.ti version 7.5.7. To achieve credibility, a constant engage-
ment with the data was maintained throughout the entire data analysis process and a rich amount of
interview quotes has been provided. Confirmability was attained through triangulation of all the steps of
data analysis by the researchers. Transparency was achieved by highlighting the study’s challenges and
Researchers also paid attention to self-reflexivity with respect to their own values and orientation, as it is
required by interpretative phenomenological analysis method. The multi-disciplinary team fostered com-
parison of their personal and professional background and the attention on how those could influence on
different phases of the study. Moreover, the researchers have background and expertise adequate to conduct
this kind of study and to manage potential method bias. Specifically, P.M. is an expert clinical nurse, she
also earnt her master degree in Philosophy and worked for many years with people with cancer. C.I.A.G. is
an expert clinical nurse and worked in mental health contexts. M.G. is psychologist and associate professor
in Nursing. She is PhD and expert of quantitative e qualitative research. M.F.J.H. is associate professor in
Nursing. She is PhD and expert in bioethics. P.C. is full professor, PhD and expert of research in Health
Promotion. Almost all the researchers have been also caregivers of a close relative affected by cancer.
Melis et al. 1423
Operational tools used to foster self-reflexivity were (a) field note – taken after interviews – including
reflections on both feelings and emotions of the interviewer, which were commented with the other
researchers during the data analysis procedure, and (b) audits conducted among the researchers during the
different phases of the study.
The results have identified three main themes: (a) the infinite range of possibilities in knowing and willing
to know, (b) communication with the patient as a conflicting situation and (c) the bind of implicit and
explicit meaning of communication. The first theme is represented in all the four parties and describes the
mix up of cognitive and emotional reactions arousing communication related to diagnosis and prognosis.
The second theme is related to the role of health professionals: how nurses and physicians interpret their role
and how the patient and his or her caregiver perceive it. The third theme concerns an experience of
communication as expression of a personal and intimate world. This theme takes shape in patients and
caregivers as a silent but expected request of recognizance of the existential dimension, and it emerges in
nurses and physicians as a fundamental part of care and cure relationship. Figure 2 summarizes main
perspectives of the four participants for each theme.
The infinite range of possibilities in knowing and willing to know
Patients and caregivers describe their experience about diagnosis and prognosis-related communication as
an experience that admits an infinite range of possibilities in knowing and in the will to know. Angelo,
Daniela and Nella, in fact, describe themselves both as informed and uninformed, willing to be informed
and wanting to know no more. Nella, different from the other two patients who were diagnosed few months
ago, is under treatment since almost 2 years, she values a lot her autonomy and admits that what cost her the
most is to ask for help, she also recognizes to have contrasting feelings and attitude towards communication
and information transmission and says,
The results (for my examinations) were always picked up by me, I read them, but I don’t understand them and I
ask the doctor [ . . . ] I mean [ . . . ] I don’t want to understand them; it’s not that I don’t understand them, that’s
Daniela, who – according to her caregiver – should well understand her health status because she has a
high school–level education, declares a willing to know and recalls all the questions she already asked the
doctors; she refers to have always received a proper answer, but she recognizes that all those questions are
not so significant and concludes,
Even now [ . . . ] I don’t find the courage to ask it [ . . . ] maybe one day I will try to ask it to my oncologist.
Some other patients, like Sergio, Piero and Mario, present their decision to receive limited medical
information as a shared decision with their oncologists and relatives. Mario, who is very young, is aware that
he does not exactly know what is happening to his body, but he values this ignorance as the price to ‘stay
calm’. He knows that his disease is a very serious one: he tells that he has been diagnosed more than 2 years
ago and has undergone several chemo treatments. He explains his choice like this:
I prefer to be like this [ . . . ] because if I would know more I would have more worries . . . and maybe this could
worsen my condition [ . . . ] maybe [ . . . ] better not to know anything and have minimal details that only can
1424 Nursing Ethics 27(6)
Other patients, like Sergio, who is already retired, show difficulty to conciliate what they have been told
and what they know. He is attending the oncological ward since few months and concludes his interview by
Sooner or later, I should know the truth, only that [ . . . ] I’m afraid of truth [ . . . ] do you understand?
But previously he had already admitted that
They [the doctors] said me that [ . . . ] they told me clearly [ . . . ] do you understand? He called me in his office –
there was my wife too – and when he said it [ . . . ] the world fell on me! Do you understand?
Many caregivers also describe communication related to diagnosis and prognosis as an experience of
contrasting willing and feelings and as a knowledge not possible to confine into the opposite poles of
knowing or not knowing. Nella’s caregiver describes her loved one’s attitude towards communication as the
display of contrasting behaviours, but she does not interpret it as an inconsistency:
Of course there is an inconsistency [ . . . ] but I’m not sure whether it is an inconsistency; you would like to know
more and more because you would like to discover that [ . . . ] your worries are excessive [ . . . ] that after all [ . . . ]
the situation can be seen in a [ . . . ] way . . . , but if you are searching more, you’re afraid to discover the contrary.
So, you prefer to stay in a limbo in which you would like to know, but you can’t.
Caregivers recognize that patient needs to know what is happening, but at the same time, they underlie
that patient also seeks and needs continuous reassurance. In the caregivers’ stories, the patient’s character
and the emotional costs of knowledge appear to be important factors to understand the patient’s attitudes
and to decide which communication approach is more suited for him or her. Angelo’s caregiver declares that
her loved one and she are perfectly aware of the seriousness of his health conditions because they were
informed of the advanced stage of his disease by the oncologist. Nevertheless, to the question if she
considers it is better to know or not to know, she answers,
I don’t know, I don’t know: knowing too much is upsetting, but maybe knowing too little is also upsetting. Who
can say which the right measure is? In between knowing and not knowing there are an infinite range of
The theme of the various degree of knowledge emerges in physicians’ narratives (and in some of the
interviewed nurses) either as the patient’s capacity to understand the real meaning of the information
received by physicians or a partial information received by them. Physicians refer this capacity as the
patient’s will to confront himself or herself with bad news. Concerning that point, Sergio’s physician says,
It has been the head physician to tell him that the surgery he underwent couldn’t eradicate the tumour. Therefore,
he knows the diagnosis, namely a disease that is not cured by the surgery but that is still there and that is a quite
severe disease, because his liver has been affected. I told him that he had to be treated just by chemo and by oral
therapy. So, it has not been told anything unreal [ . . . ] if one should tell all and everything [ . . . ] I don’t believe
that this would be the rightest thing to do [ . . . ] I don’t know [ . . . ] anyway, the patient understands what he wants
to understand! Anyway, the patient was thoroughly informed of the disease.
In addition, Piero’s and Sergio’s nurses consider awareness disconnected by any kind of intellectual
capacity. Piero’s nurse is working in an oncological ward since many years; she loves to talk with patients
and thinks that almost all her patients know their diagnosis but, at the meantime, notices,
1426 Nursing Ethics 27(6)
In our ward there were physicians that didn’t understand any (!) [ . . . ] I mean, once they have become patient,
they, that were physicians and nurses [ . . . ] well, once they were admitted in our ward, they forgot to be
physicians, they forgot all the staff they studied [ . . . ] like if they knew nothing.
Communication with the patient as a conflicting situation
The interviewed physicians talk about their communication approach as an information-giving to let the
patients know what is going on: the diagnosis and the therapeutic course they should undergo. This
information transmission is perceived as something that they need to modulate because it is also a potential
harm to patients’ psychological well-being. This position is well presented by Mario’s physicians, an expert
oncologist, who explains his communication approach with his young patient:
I believe that we have been quite detailed [ . . . ] in one case and in the other, that is both towards the patient and
towards his relatives. It is a situation in which the psychological implications are very heavy [ . . . ] and [ . . . ] the
[ . . . ] let’s say that the fuzziness that we have maintained in providing information to the patient is motivated by
the need not to create an excessive psychological distress that could lead him to dismiss therapy.
On this basis, physicians consider as a duty to inform the patient about his or her diagnosis, but they also
maintain that it is upon them to decide, case by case, the extension and the timing of information. They
declare to generally conform to the norm to inform the patients in order to obtain their informed consent to
therapies, but they also take into account that knowledge has the power to provoke huge emotional reactions
such as hope or despair. These reactions are deemed a big resource or, vice versa, an insurmountable
obstacle to treat and cure the patient. A practice solution adopted by most physicians to both preserve hope
in patients and fulfil their duty to inform the patients is to avoid talking about prognosis if not requested. The
conflictual situation is so approached by Daniela’s physicians:
I think it’s essential to know [ . . . ] but it’s evident that not anybody can bear the information so I think
information should be, how to say it, adjusted upon emotional sensitivity, upon the patient’s capacity to manage
this kind of information but, anyway information should be given to patients in a complete way, absolutely! but
one can be less explicit about prognosis, especially with regard to the advanced stages of the illness.
Only Nella’s physician, by highlighting a correspondence between the missed knowledge of prognosis
by the patient and the missed knowledge of the patient’s will about end-of-life care by the physician, speaks
of physicians’ ethical responsibility in conciliating contrasting urgencies and needs implicated in diagnosis
and prognosis-related communication. She explains,
[ . . . ] what is still problematic [to make the patient understand] [ . . . ] is the choice [ . . . ] between not to do
anything, because actually there is no chance to get anything better and therefore [ . . . ] just to undergo palliative
care, or undergo therapies until the last days. This issue, perhaps, was not faced with my patient. In some patients,
this may be due to a communication problem, I mean, the difficulty to make the patient understand it and help
him/her to make an aware choice, while preserving his/her dignity.
All the nurses state that they usually do not investigate if the patient knows or does not know his or her
diagnosis and …
Delivering a high-quality product at a reasonable price is not enough anymore.
That’s why we have developed 5 beneficial guarantees that will make your experience with our service enjoyable, easy, and safe.
You have to be 100% sure of the quality of your product to give a money-back guarantee. This describes us perfectly. Make sure that this guarantee is totally transparent.Read more
Each paper is composed from scratch, according to your instructions. It is then checked by our plagiarism-detection software. There is no gap where plagiarism could squeeze in.Read more
Thanks to our free revisions, there is no way for you to be unsatisfied. We will work on your paper until you are completely happy with the result.Read more
Your email is safe, as we store it according to international data protection rules. Your bank details are secure, as we use only reliable payment systems.Read more
By sending us your money, you buy the service we provide. Check out our terms and conditions if you prefer business talks to be laid out in official language.Read more