Sex-specific associations of depression with inflammatory markers: a systematic review and meta-analysis.

Delivering bad news, particularly in end-of-life care, is one of the most emotionally and ethically demanding responsibilities in nursing. The task becomes even more complex when the recipients are patients’ family members, who often serve as surrogate decision-makers and primary sources of emotional support during the final stages of a loved one’s life [, ]. How distressing information is conveyed can profoundly influence families’ psychological well-being, coping ability, and satisfaction with care []. Despite its critical importance, bad news delivery is inconsistently addressed in clinical practice, especially in cultural contexts where full disclosure of terminal illness is not universally accepted []. In Iran, cultural norms and familial dynamics shape communication practices, and families may prefer to shield the patient from awareness of a terminal diagnosis, placing healthcare providers in ethical tension between patient autonomy and family preferences [, ]. Nurses, who maintain the most continuous contact with patients and families, play a pivotal but often informal role in mediating difficult conversations [, ]. Many nurses report inadequate preparation and lack of standardized protocols for these emotionally charged interactions [, ]. In healthcare, bad news refers to information that significantly alters a patient’s or family’s expectations regarding diagnosis, prognosis, or treatment trajectory, often eliciting strong emotional reactions such as anxiety, sadness, or anger [, ]. In Iran, the delivery of bad news is often physician-centered, and nurses play an important role in clarifying information, supporting families emotionally, and continuing communication after disclosure [, ]. Recent commentaries have questioned the framing of “breaking bad news,” suggesting alternatives like “serious illness communication” or “difficult news” to emphasize patient-centered approaches []. In this study, the term is used operationally to denote information that significantly changes expectations about illness or treatment trajectory. Existing frameworks such as SPIKES, PEWTER(Prepare, Evaluate, Warning, Tell, Emotional Response, Reassure/Refer), ABCDE(Advance preparation, Build a therapeutic environment/relationship, Communicate well, Deal with patient/family reactions, Encourage and validate emotions), and BREAK(Background, Rapport, Explore, Announce, Kindling) offer guidance but were developed primarily for physician–patient communication and are often oncology-focused, limiting their direct applicability to Iranian nursing practice [–]. Iranian healthcare emphasizes family-centered communication, collective decision-making, and spiritual coping, requiring nurses to integrate emotional support, phased disclosure, and culturally sensitive strategies [, ]. Sadat-Hosseini’s “TAT” model (Teamwork, Assessment, Truthfully Communicate) provides an Iranian-Islamic framework incorporating team coordination, spiritual considerations, and gradual disclosure []. However, most existing communication frameworks have been developed primarily in physician–patient contexts and remain largely theoretical, with limited empirical testing in nursing practice (e.g., oncology‑focused models such as SPIKES and ABCDE) [–, ]. Moreover, while several instruments assess clinicians’ knowledge or attitudes toward difficult communication, comparatively few tools specifically measure nurses’ actual communication skills with families of patients nearing end of life []. This study addresses this gap by developing and psychometrically validating a culturally grounded tool and examining relationships between nurses’ demographic and professional characteristics and their competence in delivering bad news. By centering the family and grounding the instrument in indigenous nursing experiences and Islamic ethical principles which emphasize compassion, collective decision-making, and relational care, this work provides both a practical assessment tool and a culturally relevant framework for serious illness communication in end of life care this work provides both a practical assessment tool and a culturally relevant framework for end-of-life communication [, , ].