The Art of Breaking Bad News: Awareness, Practice, and Training of Spikes Protocol among oral Healthcare Professionals on Oral Cancer

Abstract

Background:

Effective communication is a skill for oral healthcare professionals, particularly while delivering bad news to patients. Structured approaches such as the SPIKES protocol can reduce patient anxiety, improve satisfaction, and support patient-centered care. While the SPIKES protocol is well recognized and increasingly practiced worldwide, in India, its awareness, practice, and training remain limited.

Aim:

To assess the awareness, application, and training needs related to the SPIKES protocol among oral healthcare professionals in Indore, India.

Materials and Methods:

A descriptive and cross-sectional survey was conducted between April and June 2024 at the Government College of Dentistry, Indore. A total of 200 oral healthcare professionals completed a validated, structured questionnaire with 18 items divided into three domains: professional background, awareness and use of the SPIKES protocol, and training needs.

Results:

Overall, 72% of participants agreed that following a structured protocol is essential when delivering bad news. Awareness of the SPIKES protocol was reported by only 38%, and among them, <20% had applied it in practice. A significant majority (84%) expressed the need for formal training in communication skills and the SPIKES protocol, with postgraduate students showing the highest demand (P < 0.05).

Conclusion:

Awareness of the SPIKES protocol among oral healthcare professionals in India remains low, and its practice is also limited. At the same time, the strong demand for formal training highlights the need for immediate action. Incorporating SPIKES training modules, simulation-based teaching, and structured communication skill workshops into both undergraduate and postgraduate curricula are essential to ensure patient-centered cancer care.

Introduction

Buckman has defined “any news that drastically and negatively alters the patient’s view of her or his future” as bad news.[1] Oral health professionals, irrespective of their speciality, often come across scenarios during their day-to-day practice where they are the provider of unfortunate news to their patients and their attenders. “You have cancer.” These three words, though short, can alter a patient’s life as well as a family forever.[2] Breaking bad news to a patient is one of the most emotionally challenging and psychologically significant moments in the doctor–patient relationship.[3] This task requires not only clinical knowledge but also deep empathy, emotional intelligence, and communication skills. Delivering bad news with clarity and empathy has a lasting impact on how patients cope and respond. If bad news is broken poorly, feelings of mistrust, anger, fear, and blame are common reactions.[4]

In India, oral healthcare professionals regularly encounter patients with oral potentially malignant disorders and oral cancers that require proper communication.[5] However, most receive little to no training in structured communication protocols. Many protocols are available to deliver bad news, some of which can be identified by acronyms such as SPIKES, ABCDE, SCOPE, and BREAKS.[6] Of all the protocols described to break bad news, SPIKES is the most popular and most commonly recommended.[1,6] Despite its popularity, it has not been studied extensively in India, and little data are available on its awareness, especially among oral healthcare professionals.[5] Recognizing this gap, the present study aims to evaluate the awareness, practical use, and availability of training in the SPIKES protocol among oral healthcare professionals from various sectors in India.

Materials and Methods

Study design and setting

A descriptive, cross-sectional questionnaire survey was conducted between April 2024 and June 2024, at the Government College of Dentistry, Indore, Madhya Pradesh. The study aimed to assess the awareness, practice, and training needs related to the SPIKES protocol among oral healthcare professionals involved in the management of oral cancer.

Study population and sampling

The target population included dentists, dental specialists, postgraduate students, and faculty involved in direct patient care, recruited from hospitals, government institutions, and private dental clinics across Indore. A total of 200 participants were selected using a combination of convenience and snowball sampling, ensuring a representative distribution of experience levels and practice settings but may introduce the sampling bias and limit the generalization of results. Sample size was calculated after reviewing the literature and it was done using G power software.

The inclusion criteria were oral healthcare professionals with at least 6 months of clinical experience. The exclusion criteria included healthcare professionals currently not engaged in clinical practice or those who declined participation.

Questionnaire development and validation

A structured, self-administered questionnaire comprising 18 items [Table 1] was developed after a comprehensive literature review and consultation with experts in dental education and medical ethics. The questionnaire was organized into three major sections:

Table 1.

The comparison of the responses for the questionnaire

Questions	Responses	Count (%)	P
Time in the specialty area (years)	<5	154 (77.0)	<0.001**
	From 5–10	32 (16.0)
	From 10–20	9 (4.5)
	>20	5 (2.5)
Locus of professional activity	Dental office	50 (25.0)	<0.001**
	Specialty center	4 (2.0)
	Hospital	100 (50.0)
	University	46 (23.0)
Sector of professional activity	Public service only	93 (46.5)	<0.001**
	Private service only	51 (25.5)
	Both public and private services	56 (28.0)
How often do you find yourself in situations where you need to deliver bad news to patients?	Frequently	49 (24.5)	<0.001**
	Occasionally	66 (33.0
	Rarely	73 (36.5)
	Never	12 (6.0)
Frequency of professional contact with cancer patients	<1 patient/year	51 (25.5)	0.011*
	1–5 patients/year	52 (26.0)
	10–20 patients/year	32 (16.0)
	>20 patients/year	65 (32.5)
When delivering bad news, do you follow a specific method or protocol?	Yes	75 (37.5)	0.456
	No	63 (31.5)
	Sometimes	62 (31.0)
Are you aware of the SPIKE protocol on breaking bad news	No I am not aware	148 (74.0)	<0.001**
	Yes I am aware	42 (21.0)
	I am aware but do not practice	10 (5.0)
How useful do you think a SPIKE protocol could be in delivering bad news?	Very useful	182 (91.0)	<0.001**
	Not very useful	16 (8.0)
	not useful	2 (1.0)
How important do you think it is to create a comfortable environment before discussing difficult news with a patient? (Step 1: Setting up the interview)	Very Important	172 (86.0)	<0.001**
	Neutral	22 (11.0)
	Not very important	6 (3.0)
	Not important at all	0
How beneficial do you think it is to assess a patient’s understanding of their condition before delivering news? (Step 2: Assessing the patient’s Perception)	Very beneficial	174 (87.9)	<0.001**
	Neutral	20 (10.1)
	Not very beneficial	4 (2.0)
	Not beneficial at all	0
Do you think patients should be given the option to choose how much detail they want to know about their condition? (Step 3: Obtaining the patient’s Invitation)	Strongly agree	80 (40.4)	<0.001**
	Agree	73 (36.9)
	Neutral	28 (14.1)
	Disagree	15 (7.6)
	Strongly disagree	2 (1.0)
How important is it to use simple and clear language when explaining a patient’s medical condition? (Step 4: giving knowledge and information)	Very important	178 (89.0)	<0.001**
	Neutral	22 (11.0)
	Not very important	0
	Not important at all	0
When delivering bad news, how crucial is it to respond empathically to a patient’s emotional reactions? (Step 5: Addressing the patient’s Emotions	Very crucial	164 (82.0)	<0.001**
	Neutral	36 (18.0)
	Not very crucial	0
	Not crucial at all	0
How helpful do you think it is to provide a clear plan and summary after delivering bad news? (Step 6: Strategy and Summary)	Very lpful	184 (92.0)	<0.001**
	Neutral	13 (6.5)
	Not very helpful	3 (1.5)
	Not helpful at all
Would you be interested in receiving training on the SPIKE protocol or a similar structured approach for delivering bad news?	Yes	147 (74.2)	<0.001**
	Maybe	51 (25.8)
In your opinion, what is the most challenging aspect of delivering bad news to patients?	Managing the patient’s emotional response	98 (49.0)	<0.001**
	Finding the right words	56 (28.0)
	Ensuring patient understanding	43 (21.5)
	Time constraints	3 (1.5)
Do you believe that a structured protocol like SPIKE could improve patient satisfaction and outcomes?	Strongly agree	102 (51.0)	<0.001**
	Agree	79 (39.5)
	Neutral	17 (8.5)
	Disagree	2 (1.0)
	Strongly disagree	0
What additional resources or support would you find helpful in improving your skills in delivering bad news?	Training workshops	107 (53.5)	<0.001**
	Online courses	50 (25.0)
	Mentorship programs	23 (11.5)
	Simulation exercises	20 (10.0)

*P<0.05 (Significant). **P<0.001 (Highly Significant)

• Professional Background and Frequency of Delivering Bad News (Questions 1–5)

• Awareness and Use of the SPIKES Protocol (Questions 6–14)

• Training Needs and Perceived Challenges in Delivering Bad News (Questions 15–18).

The initial draft was reviewed for content and face validity by a panel of five subject-matter experts, including oral medicine specialists and experts in health communication. Feedback from the panel was used to refine the questions for clarity and relevance. The revised version underwent pilot testing with 20 oral healthcare professionals to assess comprehension, flow, and time to completion. Responses from the pilot were excluded from the final analysis. The final questionnaire was administered in English.

Data collection procedure

Upon obtaining informed consent, the final version of the questionnaire was distributed digitally as a Google Form via E-mail and WhatsApp to maximize reach and accessibility, using a secure and anonymous link. Participation was voluntary, and confidentiality was assured. Reminders were sent at 2-week intervals to enhance response rates until the target sample size was achieved.

Statistical analysis

The statistical analysis was done using the Statistical Package for the Social Sciences (SPSS) software, v. 22 (IBM, Chicago, US). The difference between the responses of the questionnaire was calculated using the Chi-square test. The difference will be considered as significant, when the P value is below 0.05 and highly significant if the P value is below 0.001.

Results

The results obtained are tabulated in Table 1 showing responses which were found statistically significant with P < 0.001** and confidence interval of 95%.

When asked about whether they ever heard about the SPIKES protocol two third of the respondents were not aware of such protocol [Figure 1]. However, they felt that it would be very useful in delivering bad news to patient in an appropriate manner [Figure 2]. This reflects that while awareness remains limited, the necessity of structured guidance for sensitive communication is strongly acknowledged as the framework resonates with the routine challenges including managing emotional responses, accommodating cultural norms, and addressing the active involvement of family members in decision-making.

Figure 1.

Awareness of the SPIKE protocol on breaking bad news

Figure 2.

How useful do you think a SPIKE protocol could be in delivering bad news?

Majority of the respondents showed interest to get trained in the SPIKES protocol and felt that the most challenging aspect of delivering bad news to patients was managing the patient’s emotional response. According to respondents, additional resources or support like training workshops (53.5%) are helpful in improving your skills in delivering bad news.

In the current Indian scenario, there is a growing need for interventions and programs tailored to enhance the competence in breaking bad news. To bridge this existing skill gap, a structured educational reform is the need of the hour emphasizing on the role of communication as a determinant in patient care.

Discussion

Our study provides valuable insights into the communication practices of oral healthcare professionals across a range of healthcare environments, including hospitals, dental offices, and academic institutions. By capturing responses from both public and private sectors, we ensure the findings reflect the broad applicability of structured communication training throughout the oral healthcare system. Importantly, a significant proportion of our participants was early-career professionals with <5 years of experience, offering a perspective that is both current and relevant to the evolving landscape of clinical practice.[7]

According to our study data, approximately one in four oral healthcare professionals frequently face the emotionally challenging task of delivering bad news to patients. Furthermore, 32.5% of participants reported managing more than 20 cancer patients per year, indicating frequent exposure to situations requiring sensitive communication and empathetic dialogue. These results highlight the urgency of equipping practitioners, regardless of their workplace setting or years of experience, with the skills and protocols necessary for effective, compassionate communication.[8]

Our study found that only about one-third of oral healthcare professionals consistently follow a specific protocol when delivering bad news, while the majority remain unaware of the widely recommended SPIKES communication framework.[9] Notably, despite this low familiarity, there is strong consensus on the protocol’s value in guiding difficult conversations. This gap likely reflects limited formal training in communication skills within dental education and continuing professional development, a trend supported by similar findings in other settings. Qutob et al. reported low awareness and use of the SPIKES protocol among dental professionals, although most agreed it improves communication.[5] Curtin and Sweeney emphasized its value in dental education to enhance the skills in delivering bad news.[10]

When comparing these findings internationally, studies such as Curtin et al.[10] show that structured SPIKES training significantly increases confidence and competence among dental students in Western contexts, highlighting a clear gap between Indian practices and global standards. This underscores the need to critically interpret the limited awareness and practice in India, considering factors such as curriculum design, clinical exposure, and cultural differences in patient communication.

The findings of our study clearly indicate that oral healthcare professionals recognize the importance of each step in the SPIKES protocol, even if they do not formally follow it. A large majority viewed core components as highly valuable – 86% believed creating a comfortable environment is very important, 87.9% found assessing the patient’s perception highly beneficial, and 89% emphasized the use of simple, clear language when sharing information. Similarly, 82% considered empathetic responses to patient emotions crucial, while 92% stressed the need to provide a clear plan and summary after delivering bad news. Furthermore, 77.3% supported giving patients autonomy in deciding how much information they wish to receive. This strong alignment with the principles of structured communication may reflect healthcare professionals’ intuitive understanding of compassionate care, even in the absence of formal training. It is likely that many professionals do not actively apply the SPIKES protocol not because they disagree with its approach, but because they are unaware of its structured steps or have not received adequate training in applying them systematically. Limited emphasis on communication skills in dental education and clinical mentorship may contribute to this gap, highlighting the need for structured, protocol-based training to bridge the difference between recognition and consistent practice.[11]

Our study reveals a strong willingness among oral healthcare professionals to improve their communication skills, with most participants expressing interest in structured training such as the SPIKES protocol. This likely stems from growing recognition of the emotional and ethical complexities involved in breaking bad news an area where many professionals feel underprepared due to limited exposure in undergraduate curricula.[10]

The greatest challenge identified was managing patients’ emotional responses, followed by difficulties in finding the right words and ensuring patient understanding. These challenges may arise because dental education tends to prioritize clinical and technical training, often overlooking the emotional dynamics of patient care and the need for structured communication frameworks.[12]

Despite limited formal training, most professionals agreed that using a structured approach could improve patient satisfaction and outcomes. This suggests an intuitive understanding of the value of empathetic, stepwise communication, even among those unfamiliar with the SPIKES protocol. It may also reflect their real-world experiences, where a lack of structure can lead to misunderstandings or distress during difficult conversations.[11]

Preferred resources for skill development included training workshops, online courses, mentorship, and simulation-based exercises. These preferences may reflect a desire for interactive and practical learning methods that can be immediately applied in clinical settings, especially given the emotionally charged nature of such interactions.[8]

These findings align with earlier studies: Qutob et al. (2024) observed that while many dental professionals lacked familiarity with the SPIKES protocol, they valued its potential in improving communication.[5] This highlights the need to integrate structured communication training into dental education and continuing professional development not only to enhance patient outcomes, but also to equip professionals with the skills and confidence to navigate emotionally sensitive conversations more effectively.

To bridge the gap with international practices, India should incorporate structured communication training, such as the SPIKES protocol, into undergraduate and postgraduate dental curricula. Interactive workshops, role-playing, and simulation-based exercises can equip students with practical skills to handle emotionally sensitive conversations effectively. In addition, continuing professional development programs should include formal modules on breaking bad news to ensure practicing professionals remain competent and confident. Incorporating these measures will align Indian dental education with international standards and enhance patient-centered care.

Conclusion

Awareness and practical application of the SPIKES protocol among oral healthcare professionals in India remain limited, despite clear recognition of its importance in effectively delivering bad news. This gap highlights a pressing need for immediate action to address the communication skills deficit in this critical area of patient care. The strong and consistent demand for formal training underscores the necessity to integrate structured communication education, including SPIKES protocol modules, simulation-based learning, and skill-building workshops, into both undergraduate and postgraduate dental curricula.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.