The equipment and personnel required to perform this skill:

This skill is developed by practising nursing skills and manipulation skills when the nurse is working with a patient (standardised patient)

Description of the clinical situation:

When to Use SPIKES:

  • Cancer diagnoses
  • Poor prognosis discussions
  • Treatment failure announcements
  • Transition to hospice care
  • Unexpected complications

The order in which the skill is performed:

  • S - SETTING UP the Conversation
    • Goal: Create a physically and emotionally safe environment.
    • Key Actions:
      • Choose a private room with tissues available
      • Sit down at patient's eye level (reduces power imbalance)
      • Minimize interruptions (silence phones)
      • Include important family members per patient's wish
      • Time management: "We need about 20 minutes. Is this a good time?"
    • Example:
      • A surgeon preparing to discuss metastatic findings: "Mrs. Kim, I'd like to discuss your test results in detail. Would you prefer your daughter to join us? Let's move to a quieter room."
  • P - Assessing PATIENT'S PERCEPTION
    • Goal: Understand what the patient already knows/feels.
    • Techniques:
      • Ask open-ended questions: "What have you been told about your condition so far?", "What were you expecting the scan to show?"
      • Listen for emotional cues (sighs, clenched fists)
      • Identify health literacy level through their vocabulary
      • Critical Insight: This step reveals misconceptions. A patient might say: "The pain is just arthritis, right?" → Shows complete lack of suspicion about cancer.

  • I - Obtaining INVITATION
    • Goal: Respect patient autonomy in receiving information.
    • Approaches:
      • Direct ask: "How would you like me to share the results? Some people want all details, others prefer a summary."
      • Cultural adaptation:
        • In some Asian cultures: "Would you like me to discuss this with your son first?"
        • Handle denial gently: "I sense you're not ready. We can pause and talk tomorrow."
    • Red Flag Scenario:
      • Patient interrupts: "Just tell me - is it serious?"
      • Response: "I will explain everything. First, is it okay if I share this step-by-step?"
  • K - Giving KNOWLEDGE (Information)
    • Goal: Deliver clear, compassionate information.
    • Best Practices:
      • Warning shot: "I'm afraid the news isn't what we hoped for..."
      • Simple language: Avoid "metastatic adenocarcinoma" → "The cancer has spread"
      • Small chunks: Pause after each piece of information
      • Avoid false hope: "While not curable, treatments can help you feel better"
      • Use diagrams: Sketch tumor locations
    • Word-for-Word Example:
      • "The biopsy shows breast cancer [pause]. It's spread to your bones [pause]. This means we focus on controlling it rather than curing it [pause]. I know this is a lot to take in."
  • E - Addressing EMOTIONS
    • Goal: Respond empathetically to emotional reactions.
    • Common Reactions & Responses:
      • Silence: "I see this is overwhelming. Would you like me to pause?"
      • Anger: "You're right to feel upset. This isn't fair."
      • Tears: Pass tissues silently; avoid interrupting grief
      • Denial: "I hear you doubting the results. Would a second opinion help?"
  • S - STRATEGY & SUMMARY
    • Goal: Collaboratively plan next steps.
    • Execution:
      • Check capacity: "Are you ready to discuss options?"
      • Offer choices: "We can try chemotherapy, focus on comfort, or get another opinion."
      • Concrete next steps: "I'll schedule a PET scan for Thursday and introduce you to our pain specialist."
      • Summarize: "To confirm: we'll start radiation Monday to shrink the tumor causing your back pain."
      • Leave the door open: "What questions might you have later?"
SPIKES in Action: Complete Case Study
  • Scenario: 58M with pancreatic cancer metastasis.
    • 1. Setting: Nurse prepares family conference room with water and chairs in a circle.
    • 2. Perception: "John, what do you understand about your jaundice?" → Reveals he blames it on "bad food."
    • 3. Invitation: "Would you like me to explain the CT results now or wait until your wife arrives?"
    • 4. Knowledge: "Unfortunately, the tumor has spread to your liver. This explains the yellow skin." (Shows liver diagram.)
    • 5. Emotions: Responds with stunned silence. MD waits 90 seconds before: "This is a lot to process. How are you feeling?"
    • 6. Strategy: "Our priority is relieving your nausea. I recommend a hospice nurse visit tomorrow to discuss home support."

The Nurse's Role in Difficult Conversations:
While the physician often delivers the initial diagnosis, the nurse is crucial in:

  1. Preparing the patient for the conversation.
  2. Being present to provide immediate support.
  3. Reinforcing and clarifying information afterward.
  4. Providing emotional support and managing reactions.

  5. Coordinating care and resources.

Scenario 1: Reinforcing a New Diabetes Diagnosis

Context: You are a student nurse on a medical ward. Mr. Ben Carter, a 45-year-old man, has just been told by the doctor that he has Type 2 Diabetes. The doctor has left the room, and Mr. Carter looks overwhelmed.

1. S - Setting:

  • Ensure the patient's room is private. Pull up a chair next to his bed. Have a box of tissues handy.

2. P - Perception:

  • You: "Mr. Carter, I saw Dr. Smith was just in to speak with you. That can be a lot to take in. What is your understanding of what he shared with you?"

  • Patient: "He said I have diabetes. My dad had it. I just... I don't even know what I'm supposed to do now."

3. I - Invitation:

  • You: "It's completely normal to feel overwhelmed. Would it be helpful if we sat for a few minutes and went over the main points again? We can talk about what happens next."

4. K - Knowledge:

  • Reinforce Simply: "Yes, the tests confirmed Type 2 Diabetes. It's a condition where your body needs help managing sugar levels."

  • Focus on Next Steps: "The most important thing to know is that this is very manageable. Our first step here will be for you to meet with the diabetic educator and a nutritionist. They are experts in helping people create a simple plan."

5. E - Emotions:

  • Observe: He sighs deeply and looks at his hands. "I just feel like I failed."

  • Empathize: "I hear that worry, and it's a very common feeling. But this is not about failure. This is about learning new ways to take care of your health, and we have a whole team to help you."

6. S - Strategy & Summary:

  • "So, our strategy for today is simple. I'll schedule those meetings with the educator and nutritionist for you. For now, the best thing you can do is write down any questions that pop into your head, and we can answer them together."

  • Check: "How does that plan sound to you?"

Scenario 2: Supporting a Patient After a Fall with Injury

Context: Ms. Evelyn Gray, an 80-year-old resident in a long-term care facility, fell out of bed. An X-ray revealed a fractured wrist. The physician has informed her she needs to be transferred to the hospital for casting. She has mild cognitive impairment and is anxious.

1. S - Setting:

  • Sit with her in her room after the doctor leaves. Speak clearly and calmly.

2. P - Perception:

  • You: "Ms. Gray, that was a scary fall. The doctor mentioned your wrist is hurt. What do you remember about what he said?"

  • Patient: "He said I broke it. Do I have to go to the hospital? I don't want to go! I want to stay here."

3. I - Invitation:

  • You: "I understand you're worried about leaving. Is it okay if we talk about what will happen at the hospital and how we'll get you back home safely?"

4. K - Knowledge:

  • Explain Simply: "Yes, the X-ray showed a small break. The hospital has a special team that will put a light cast on your wrist to protect it and help it heal. It won't take very long."

  • Reassure: "I will help pack your things, and a staff member will go with you. We've already called your daughter. This is just a short trip to get your wrist fixed, and you will be coming back here to your room tonight."

5. E - Emotions:

  • Observe: She is agitated and pulling at her sheets.

  • Empathize: "I can see this is making you very anxious. It's okay to be nervous about something new. My job is to make sure you're safe and comfortable through all of this."

6. S - Strategy & Summary:

  • "So, the plan is: we'll get you ready, you'll take a short ride to the hospital to get your cast, and then you'll come right back. I will be here when you get back to help you get settled."

  • Check: "Can you tell me what's going to happen next?"

Scenario 3: Explaining a Change to Palliative Comfort Measures

Context: You are assisting with the care of Mr. John Davies. The physician and family have made the decision to transition from curative treatment to palliative comfort measures. The family has asked you to help explain this to the patient in simple terms.

1. S - Setting:

  • In the patient's room. Sit close to him. Ensure he is physically comfortable.

2. P - Perception:

  • You: "Mr. Davies, your family and the doctor had a long talk today about how you've been feeling. What are you feeling right now?"

  • Patient: "Tired. Just so tired of all this."

3. I - Invitation:

  • You: "I hear that. The most important thing now is your comfort. Is it okay if we talk about how we can best help you feel more peaceful?"

4. K - Knowledge:

  • Explain the Shift: "The doctor has talked with your family, and everyone agrees that the best plan is to focus entirely on making you feel as good as possible. This means we will be experts at managing your pain and making sure you're not feeling short of breath."

  • Focus on Care: "We are not stopping care. We are changing our goal to your comfort. We will be right here with you."

5. E - Emotions:

  • Observe: He nods slowly and closes his eyes.

  • Empathize: "It can be a relief to hear that the goal is now your comfort. It's okay to rest. We will handle everything."

6. S - Strategy & Summary:

  • "So our new plan is simple: my number one job is to keep you comfortable. I will check on you often. If you feel any pain or discomfort at all, you tell me, and I will fix it right away."

  • Check: "Does that sound like a good plan to you?"

Scenario 4: Preparing a Patient for a Difficult Procedure (IV Insertion)

Context: A young adult, Ms. Chloe Smith, is admitted for dehydration and is very anxious about needles. You need to insert an IV.

1. S - Setting:

  • Approach her calmly. Have all your equipment prepared but out of immediate sight.

2. P - Perception:

  • You: "Hi Chloe, I need to start an IV to give you the fluids the doctor ordered. I know sometimes people have worries about needles. How are you feeling about it?"

  • Patient: "I hate them. I always look away. I'm really bad with this."

3. I - Invitation:

  • You: "Thank you for being honest. That helps me help you. How would you like to get through this? Do you want me to talk you through it, or would you prefer distraction?"

4. K - Knowledge:

  • Explain What to Expect: "I'll be very quick. First, I'll clean your arm, which will feel cold. Then you'll feel a quick poke, less than a second. After that, the hard part is over."

  • Give Control: "You can definitely look away. You can take deep breaths. Would you like to watch a video on your phone while I do it?"

5. E - Emotions:

  • Observe: She is breathing quickly and looks tense.

  • Empathize: "I can see your breathing has gotten faster. That's a normal nervous reaction. Let's take three slow breaths together before we start."

6. S - Strategy & Summary:

  • "Okay, so our strategy is: you'll look at your phone, I'll do a quick countdown, and it will be over before you know it. I'll tell you every step so there are no surprises."

  • Check: "Are you ready to try?"

Scenario 5: Discussing a Non-Medical Urgent Issue (Financial/Social Worry)

Context: During your assessment, Mr. Arthur Lowe, a sweet, elderly man, confides in you that he is worried about how he will pay for his new medications and get to his follow-up appointments. He has no family nearby.

1. S - Setting:

  • During a quiet moment in his room. Sit down. This shows you have time for him.

2. P - Perception:

  • You: "Mr. Lowe, you mentioned being worried about the cost of your medicines and getting to the doctor. Can you tell me a bit more about that?"

  • Patient: "Yes, well, my pension is small, and the bus is hard for me with my walker. I don't know what I'll do."

3. I - Invitation:

  • You: "These are really important worries, and I'm glad you told me. Would it be okay if we brought in our social worker? She is a miracle worker with these exact problems."

4. K - Knowledge:

  • Provide Reassurance: "You are not alone in this. Many patients have these concerns, and there are resources to help. Our social worker can help find programs to reduce medication costs and arrange for medical transport to your appointments."

  • Manage Expectations: "She may not have all the answers today, but she will know exactly where to start."

5. E - Emotions:

  • Observe: He looks relieved but still hesitant, as if he's being a burden.

  • Empathize: "I can see a bit of relief, and maybe still some worry. It's okay to ask for help. That's what we're here for. Letting us know about this is a really positive step."

6. S - Strategy & Summary:

  • "So, the plan is: I will page our social worker, Maria, and ask her to come see you today. She will talk with you about your options. Does that sound like a good next step?"

  • Check: "Is it alright if I give her a call now?"


Last modified: Thursday, 11 September 2025, 3:01 PM