Learning through difficult disclosures of cancer progression: experiences of physicians and nurses in training

Learning through difficult disclosures of cancer progression: experiences of physicians and nurses in training | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Learning through difficult disclosures of cancer progression: experiences of physicians and nurses in training Julia Kolly, Kristopher Lamore, Louise Haldemann, Benedetta Francieschiello, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8328352/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 06 Feb, 2026 Read the published version in BMC Medical Education → Version 1 posted 10 You are reading this latest preprint version Abstract Objective: Breaking the news of cancer progression is a complex task that requires a balance between clinical accuracy and relational sensitivity. Although research has examined the perspectives of experienced healthcare professionals, little is known about how trainees navigate these consultations. This study aims to explore the experiences of medical and nursing trainees in disclosing disease progression, focusing on communication strategies, emotional impacts, and professional development. Methods: Eighteen semi-structured interviews were conducted with trainees in Swiss hospitals (11 oncologists and 7 nurses). The data were analyzed via thematic analysis. Results: Five themes emerged: professional role perceptions and oncology practices in cancer progression care , the process of disclosing disease progression , perceptions and reactions of patients and their family caregivers, impacts of disease progression disclosure on medical and nursing trainees, and training and development of communication skills . Participants reported developing these skills through experiential learning, noting that formal training and protocols offered limited support. They portrayed disclosure as a carefully prepared, emotionally demanding process that requires clarity, empathy, and teamwork. Trainees described emotional and organizational burdens, which they felt were eased by experience and peer support. Furthermore, they highlighted the variability in patient and family caregiver reactions, which influenced decision-making and underscored the need for flexible, relationally attuned communication. Conclusion: Disclosing cancer progression is a demanding experience for trainees, who described the need to adapt their communication, manage emotional responses, and rely on interprofessional collaboration. Their accounts highlight the central role of experience, supervision, and supportive environments in shaping how they navigate these challenging consultations. medical communication cancer progression psycho-oncology thematic analysis medical education 1. Introduction Recent advances in oncological treatments and increased life expectancy have significantly lengthened and complicated cancer care trajectories. Consequently, patients more frequently undergo successive lines of treatment that prolong cancer care, while cancer remains one of the most prevalent and lethal diseases worldwide (WHO, 2022). Within this context, consultations addressing disease progression due to treatment resistance, alongside the proposal of new therapeutic strategies, are becoming more frequent. It is essential to distinguish progression from recurrence: the former refers to ongoing disease growth despite active treatment, whereas the latter refers to the reappearance of cancer following remission. Progression, often indicative of therapeutic resistance, can arise at various stages of care and across cancer types, necessitating adjustments in treatment strategies (ASCO, 2019). Despite the growing prevalence of these emotionally complex and sensitive consultations, scholarly attention to the communication of progression remains limited (Lelorain et al., 2023; Matthews et al., 2019). Cancer progression is considered bad news, i.e., information that significantly and negatively alters a patient’s perception of their future (Buckman, 1984). Indeed, it is particularly concerning for two reasons: first, it indicates that current treatments are no longer sufficiently effective, requiring a change in therapy; second, this change prompts a reassessment of prognosis, as the most effective treatments are generally administered first (ASCO, 2019). Delivering bad news is a frequent and essential aspect of oncology practice. Healthcare professionals (HCPs) consistently report these encounters as emotionally challenging, requiring both professional expertise and emotional sensitivity (Laranjeira et al., 2021). Literature on breaking bad news in the context of diagnosis, recurrence, and transition to palliative care has revealed the significant psychological burden patients and caregivers (P&Cs) often experience, manifesting as anxiety, depression, hopelessness, uncertainty, and reduced self-efficacy (Chen et al., 2023; Chichua et al., 2023; Chou et al., 2017; Lippe et al., 2020). HCPs themselves are not immune to these negative effects: Matthews et al. (2019) demonstrated that HCPs experience stress, intrusive thoughts, and compromised well-being following difficult conversations, with repercussions sometimes extending into their personal lives. Physiological symptoms, including heightened arousal during such encounters, have also been documented (Studer et al., 2017). Recent findings have suggested that disclosing cancer progression is particularly emotionally taxing and that emotional responses to bad news tend to vary with clinical experience, suggesting that trainees may be particularly vulnerable to negative effects (Kolly et al., 2025; Alwhaibi et al., 2023). Indeed, in prior interviews with HCPs, trainees were consistently identified as particularly vulnerable during consultations involving cancer progression (Kolly et al., 2025). These findings, together with evidence from the literature on the emotional burden of delivering bad news, underscore the need to explore how medical and nursing trainees experience these consultations to inform educational interventions and provide appropriate emotional and pedagogical support. The aforementioned challenges underscore how trainees perceive and engage with their oncology training. Specializing in oncology is rarely a random choice. Faivre et al. (2018) found that the relational dimension of oncology, including intense and diverse patient interactions, is a key motivator for trainees. Nevertheless, delivering unfavorable news remains one of the most challenging aspects of the profession, with trainees often feeling unprepared and emotionally affected (Kotłowska et al., 2022; Laranjeira et al., 2021; Toivonen et al., 2017). Despite the emotional toll, trainees generally recognize the importance of difficult conversations as an integral aspect of their professional role (Julius & McCarthy, 2024; Toivonen et al., 2017). This study to explore how medical and nursing trainees experience consultations in which a change in treatment is discussed due to cancer progression. Our research question was as follows: How do medical and nursing trainees experience consultations in which cancer progression is disclosed? Specifically, we sought to examine the communication strategies employed, the emotional impact of delivering bad news, the support and resources utilized, the influence of family caregivers in these interactions, and how these experiences shape professional identity and learning. 2. Methods 2.1 Study design This qualitative study was grounded in a socio-constructivist paradigm (Chamberlain, 2015) that emphasizes how individuals construct their perceptions of reality through social, cultural, and historical contexts (Santiago-Delefosse & Carral, 2017; Willig, 2013). Semi-structured interviews were selected for their capacity to capture medical and nursing trainees’ perspectives while allowing flexibility in the interview process. This method is well‑suited to exploring complex phenomena (Miles & Huberman, 2003) and enables the emergence of themes that reflect lived realities. The exploratory nature of the topic further justified this methodological choice. The study was conducted in accordance with the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines (Tong et al., 2007). 2.3 Participants Medical and nursing trainees were recruited between June 2024 and September 2025. Eligible participants were at least 18 years old, enrolled in medical or surgical internships or nursing training programs, engaged in clinical activity involving patients with digestive, dermatological, thoracic, or breast cancer, and participated in consultations to announce cancer progression (CACPs) when at least one treatment was still available. No exclusion criteria were defined. Recruitment concluded when data sufficiency was reached, meaning that no new information was redundant between interviews (Clarke & Braun, 2021). The aforementioned cancer types were selected in collaboration with oncologists due to their poor prognoses, marked by aggressive progression and frequent late-stage diagnoses. Thus, treatment resistance and subsequent therapeutic changes are more common in these cases compared with those involving other cancer types (Globocan, 2022; Saini & Twelves, 2021). According to clinical experience and current scientific literature, these cancers are considered likely to progress within one year; depending on the type of cancer, 50–70% of patients are expected to die within 12 months (IARC, 2024; Mani et al., 2024). 2.3 Procedure An invitation to participate in the study was emailed to eligible trainees, accompanied by an informational flyer. Snowball sampling was employed; thus, the invitation was further shared with potentially eligible trainees. Interested individuals were encouraged to contact the sender (JK, LH, BF, or VP) for additional details about the study and to obtain an information letter. Interviews were scheduled upon confirmation of participation. JK, a female PhD candidate in health psychology in the final stages of her PhD, conducted several interviews. JK is trained in semi-structured interviewing and qualitative research methods at the university level; she also trained LH, BF, and VP (Master’s students in psychology) to conduct interviews. All four researchers were involved in data collection. No prior relationship existed between the interviewers and participants. At the start of each interview, the researchers introduced themselves as psychology researchers based in Switzerland studying cancer progression in oncology. Each interview began with the same initial question: “When reviewing the exam results, you observe a progression of the disease for your patient who has advanced cancer. How does the consultation to communicate these results unfold, considering that despite the advanced nature of the cancer, there is still at least one possible line of treatment?” The conversation then explored common themes across both professional groups (medical or nursing trainees), including communication strategies, the emotional impact of delivering bad news, the support and resources used, and the influence of family caregivers during such consultations. Field notes were taken during and after the interviews, which were conducted either via videoconference or in person, depending on participants’ preference. All interviews were audio-recorded using two dictaphones or a videoconferencing platform to ensure data reliability. Transcriptions were completed verbatim, with all identifying information (e.g., names and locations) pseudonymized. Additionally, descriptive data were collected during the interviews, including the participants’ age, gender, profession, years of experience in oncology, and their affiliation with specific cancer units or hospitals. 2.4 Analysis The interviews were analyzed using Braun and Clarke’s thematic analysis method, following an inductive approach (Braun & Clarke, 2006; Clarke & Braun, 2021). This approach enables the breakdown of each interview's narrative structure to identify thematic patterns across the entire dataset (Blanchet & Gotman, 2015). NVivo software (NVivo © 2021 QSR International Pty Ltd.) was used to support the analysis. The process followed six phases: (1) familiarization with the data, (2) generation of initial codes (without abstraction at this stage), (3) identification of potential themes, (4) review of themes, (5) definition and naming of themes, and (6) production of the final report, including illustrative verbatim excerpts. Although the trainees represented two different professions (medicine and nursing), the thematic analysis was conducted without distinction. The thematic grouping was constructed from the discourse of all participants. The nuances present in the discourse were then explicitly outlined in the results. 2.5 Ethical approval This research was conducted in accordance with the protocol, the tenets of the Declaration of Helsinki, the principles of good clinical practice, the Law on Human Research (LRH), the Ordinance on Human Research (ORH), and other relevant local regulations. The study was approved by the Research Ethics Committee of the University of Lausanne (reference n°E_SSP_062022_0000I). 2.6 Informed consent All participants received comprehensive information about the study’s objectives, procedures, potential risks, and benefits, and provided written informed consent prior to participation. Participation was entirely voluntary, and the participants were free to withdraw from the study at any time without consequence. Informed consent was obtained after the participants had read the information sheet, between June 2024 and October 2025. Privacy and confidentiality were ensured through the pseudonymization of all data. 3. Results 3.1 Participant characteristics The recruitment process involved extensive outreach efforts by the research team, including over 100 emails and 80 phone calls to various institutions, ultimately leading to the identification of 33 potential participants. Of these, 12 did not respond, three declined to participate, and 18 agreed to participate in the interviews. There were no dropouts. There were 11 physician trainees and seven nursing trainees, all working in public hospitals in Switzerland. The interviews lasted between 30 minutes and 1.3 hours, with an average duration of 53.6 minutes. The participants’ characteristics are presented in Table 1. The mean age was 30.7 years (range: 24–42 years). The gender distribution was particularly unbalanced among nurses (100% female) and physicians (64% female and 36% male). All but three medical trainees worked full-time. The nursing trainees worked at rates ranging from 60% to 100%. The physicians had an average of 4.09 years of oncology experience (range 1–5), and the nurses had an average of 2.67 years (range 1–5). [Table 1 near here] 3.2 Themes organization Given that most medical and nursing trainees have only minimal CACP consultation experience, their narratives sometimes draw on their wider early experiences in oncology and medicine. Thus, some subthemes may appear less closely tied to CACPs, yet still illuminate how trainees understand these encounters. The participants’ accounts and the thematic organization reflect this process-oriented perspective, encompassing the trainees’ professional roles and practices, communication skills development, the structured disclosure process, the effects of the consultations on the trainees, and the responses of P&Cs. The five identified themes were as follows: (1) professional role perceptions and oncology practices in cancer progression care , (2) the process of disclosing disease progression , (3) perceptions and reactions of patients and their family caregivers, (4) impacts of disease progression disclosure on medical and nursing trainees, and (5) training and development of communication skills. These themes were addressed by all participants. 3.3 Theme 1: Professional role perceptions and oncology practices in cancer progression care This first theme describes how oncology trainees define their roles and specific practices within their field (Table 2). The participants described oncology as a highly complex and multifaceted field that combines scientific rigor with deep human engagement. The discipline’s appeal was linked to the continuous, long-term patient relationships and the interplay among medical, psychological, and social dimensions. The participants emphasized the heterogeneity of cancers, noting that prognosis and therapeutic strategies vary dramatically depending on the tumor type and stage. The participants compared diagnostic disclosure with CACP. Diagnostic disclosure emerged as a particularly sensitive moment that was considered emotionally challenging, marking a transition from perceived health to illness. In contrast, progression announcements were often experienced as less distressing because patients were already engaged in treatment. Similarly, according to the participants’ accounts, discussions about therapeutic goals, especially when shifting from curative to palliative intent, required careful communication to balance honesty with hope. Medical trainees perceived their role as guiding patients through uncertainty by explaining the clinical implications, outlining the next therapeutic options, and clarifying how care would continue despite the change. Nursing trainees highlighted the relational and supportive dimensions of oncology practice in the context of cancer progression. Through active listening, emotional presence, and continuity of care, they provided a stabilizing and empathetic counterpart to the physicians’ technical and decisional roles. Their proximity to patients enabled them to address psychosocial concerns and ensure ongoing support, particularly for those facing the disease alone. [Table 2 near here] 3.4 Theme 2: Process of disclosing disease progression As shown in Table 3, participants described the process of announcing disease progression as a delicate and highly structured communication sequence that combines clinical, emotional, and relational dimensions. Before meeting the patient, the participants reported coordinating with colleagues during multidisciplinary meetings and preparing by reviewing medical data and anticipating patients’ and family caregivers’ reactions. Physician trainees emphasized the importance of being fully informed about the case and mastering the technical aspects of the results, whereas nurse trainees noted that patients often sensed the seriousness of the situation even before the consultation began. The participants highlighted the need for an appropriate setting for the disclosure, ensuring calm and privacy. Consultations could take place in the physician’s office or, for hospitalized patients, at the bedside. The introduction to the discussion varied by professional, with some preferring a direct approach and others beginning by assessing the patient’s emotional state. Explanations of disease progression were often accompanied by the presentation of new therapeutic options, helping physician trainees facilitate a sense of hope. Physician trainees also described strategies for addressing uncertainty, such as using general references to survival statistics without providing precise figures unless requested. Providing support to patients after the disclosure was described as an essential component of the process. Physician trainees frequently offered follow-up appointments to give patients time to process the information, while nurses conducted additional interviews to assess understanding and provide emotional support. The disclosure meeting generally involved the physician, sometimes accompanied by a resident, a nurse, or a family caregiver. The primary responsibility for announcing progression rested with the physician, though junior physicians often worked alongside their supervisors during complex consultations. Given that the interviewees were still in training and had limited experience, they most often attended CACPs as observers or as support to a more senior physician. The nurses described their presence as complementary, focusing on patient comprehension and emotional reassurance. In describing the continuity of care, the participants highlighted the effects of staff rotation and varying levels of familiarity with patients. On the one hand, trainees reported that frequent assignment changes could result in patients seeing different physicians at each consultation. Nurse trainees, on the other hand, often followed the same patients throughout their treatment and hospitalization, enabling them to build relationships of trust and mutual understanding. Some explained that these relationships developed naturally over time and through shared conversations, while others noted that announcing disease progression to a long-term patient could be particularly emotional. [Table 3 near here] 3.5 Theme 3: Perceptions and reactions of patients and their family caregivers As shown in Table 4, the participants described a wide range of emotional, relational, and decision-making experiences related to patients and their family caregivers. Family caregivers were frequently highlighted as crucial sources of support, providing emotional reassurance and practical assistance in understanding medical information. Patients’ reactions to medical announcements were diverse, ranging from anticipation and psychological preparation to shock, relief, emotional concealment, sadness, and anger. The participants reported that these reactions were often shaped by individual coping styles, prior expectations, and perceived quality of communication with HCPs. Participants also discussed the integration of complementary approaches, such as psychological support, hypnosis, or art therapy, particularly when the emotional burden was high. Decision‑making processes varied considerably, encompassing active patient choice, informed deliberation of treatment options, and, in some cases, delegation of decisions to the physician. Participants emphasized the importance of providing comprehensive information while respecting patient autonomy, balancing guidance with support. Overall, participants highlighted the centrality of family involvement, emotional attunement, and flexible, patient-centered decision-making in navigating the clinical experience. [Table 4 near here] 3.6 Theme 4: Impacts of disease progression disclosure on medical and nursing trainees As shown in Table 5, the participants described a wide range of emotional, professional, and relational effects associated with the process of disclosing disease progression. Participants reported diverse emotional reactions and personal adjustments , including fatigue and emotional exhaustion after consultations, particularly when the interaction was intense or when they felt closely connected to the patient. Sadness was a common reaction, though many noted that repeated exposure and clinical experience helped them develop a certain emotional distance over time. Others described their emotions as strongly influenced by the patient’s reaction; moments when patients cried or expressed despair were perceived as particularly difficult. Feelings of frustration, anxiety, and guilt were also reported. Some participants noted that these experiences occasionally affected their private lives, while others emphasized their ability to separate professional and personal spheres and manage emotions through detachment or compartmentalization. The participants also referred to various professional constraints and challenges associated with disclosure. Less experienced physicians often cited a lack of specific training and difficulty managing unexpected questions. Time constraints and institutional pressures limited the opportunity to provide adequate emotional support during consultations. Nurse trainees sometimes described compensating for communication lapses by physicians, while both nurse and physician trainees emphasized the importance of consistent interprofessional communication to avoid giving patients contradictory messages. Emotional identification with patients of similar ages or life circumstances was also described as a significant source of distress. Participants relied on several strategies to cope with these challenges . Experience was often considered a protective factor, helping to reduce emotional intensity and increase confidence. Maintaining emotional distance was perceived as necessary for self-preservation. Some participants found reassurance in the availability of further treatment options or in concrete solutions, such as psychological support for patients. Positive feedback from P&Cs also served as an important source of motivation and validation. Finally, the participants mentioned a range of support mechanisms within and outside the workplace. Many emphasized the value of discussing difficult consultations with supervisors and colleagues as a form of informal debriefing. Sharing experiences with relatives or partners also helped release tension. Some medical trainees reported seeking psychological support when emotional strain accumulated, recognizing it as a necessary resource in sustaining their professional well-being. [Table 5 near here] 3.7 Theme 5: Training and development of communication skills As illustrated in Table 6, participants highlighted diverse approaches to acquiring and refining communication skills in cancer care. Medical and nursing trainees described multiple training modalities, ranging from theoretical instruction, often structured around communication frameworks such as the SPIKES ( S etting, P erception, I nvitation, K nowledge, E motions/empathy, and S trategy/summary) protocol (Buckman, 1984), widely adopted in medical curricula to support the delivery of unfavorable news, to experiential learning through role-playing with simulated patients. Observation of senior colleagues and mentorship during clinical practice also played a key role, allowing learners to internalize effective communication strategies and receive real-time feedback. In addition to structured teaching, participants underscored the importance of learning through practice, including moments of trial and error that foster professional growth and self-reflection. The participants identified a set of core communication skills, including clarity, honesty, empathy, and the ability to tailor their approach to each patient’s emotional and cognitive state. Nonverbal cues, silence, and appropriate physical contact were recognized as integral to establishing trust and conveying compassion. The influence of individual personality traits was also acknowledged to shape communication styles and the degree of emotional engagement. Despite these efforts, participants noted significant limitations in training, particularly its optional or insufficient nature in oncology education. Although communication protocols were reported to provide useful structure, some participants perceived them as overly mechanical, highlighting a “protocol paradox” that can hinder authentic connection and adaptability. The participants described oncology as a field with strong hierarchical structures that, in their experience, are often supportive. Junior physicians often delivered difficult news under the supervision of senior colleagues, who provided immediate feedback and assistance when consultations became challenging. Some participants emphasized the reassuring presence and availability of their superiors, whereas others mentioned moments of disagreement or hesitation to speak up due to hierarchical norms. [Table 6 near here] 4. Discussion and conclusion 4.1 Discussion This study provides an in-depth exploration of how medical and nursing trainees experience consultations involving treatment changes due to cancer progression. Our findings underscore the multidimensional nature of these interactions, in which trainees must navigate clinical accuracy, emotional responsiveness, and relational complexity simultaneously. Disclosing cancer progression is not merely the transmission of medical facts but a carefully orchestrated process that involves preparing the patient, communicating clearly and empathetically, and supporting both understanding and emotional adjustment. Trainees’ experiences reveal the need to balance realism with hope, manage their own emotional responses, and coordinate effectively with colleagues, patients, and family caregivers. Although our participants perceived the disclosure of disease progression as less emotionally impactful than the disclosure of the initial diagnosis, disclosing progression remains challenging because it combines the clinical complexity associated with adapting treatment with emotional management. The participants reported that, although patients often anticipate these consultations, the announcements remain emotionally intense and affect trainees’ well‑being. Our results extend previous findings on the importance of preparation, relational knowledge, and follow-up support (Francis & Robertson, 2023; Kolly et al., 2025; Matthews et al., 2019). In contrast to the study by Kolly et al. (2025), which explored the perspectives of experienced oncologists and nurses in CACPs, the present findings reflect the standpoint of trainees. Kolly et al. (2025) reported that HCPs gradually develop confidence and emotional distance through repeated exposure to CACPs; however, the participants in our study described a more uncertain and affectively charged experience. Emotional impacts reported by the participants included anxiety, sadness, frustration, guilt, and a pervasive sense of inadequacy, consistent with the literature on trainees (Kotłowska et al., 2022; Laranjeira et al., 2021; Sobczak et al., 2023). Our participants’ accounts of emotional vulnerability echo findings that inexperienced trainees often struggle with confidence and are strongly affected by patients’ reactions (Gagnerie et al., 2023; Julius & McCarthy, 2024). In our study, however, these experiences emerged in the context of a specific and, to our knowledge, previously unexamined moment in the care trajectory: the announcement of a treatment change within the CACP setting. Although occasional positive emotions, such as gratitude or satisfaction in helping patients, have been noted in some studies (Julius & McCarthy, 2024; Toivonen et al., 2017), our results indicate that these emotions remain secondary to the dominant emotional strain associated with breaking bad news. Our participants all had prior experience in delivering bad news and did not report feeling incapable of doing so, which aligns with studies showing that trainees with previous exposure feel more capable and less apprehensive than those without such experience (Kotłowska et al., 2022; Sobczak et al., 2023). In our study, the participants described relying mainly on peer dialogue, informal debriefing, and occasional support from senior HCPs, as well as personal strategies such as reflection or temporary distancing. The literature similarly indicates that HCPs in training with prior experience tend to use more adaptive coping strategies, seeking support from close others or experienced HCPs and engaging in restorative activities; in contrast, inexperienced trainees more often report non-adaptive or avoidant responses (Sobczak et al., 2023). A more distinctive element in our study is the strong importance participants placed on being honest and transparent with patients about the implications of the treatment change. Several participants explicitly mentioned their effort not to minimize or obscure the situation. This emphasis may reflect broader evolutions in professional training, where emotional literacy, open communication, and ethical clarity are increasingly promoted. Thus, trainees may be more comfortable acknowledging and sharing emotions, along with being more attentive to providing clear and forthright information. Together, these parallels suggest that supportive relationships and accessible guidance are central to how trainees manage the emotional challenges of breaking bad news (Julius & McCarthy, 2024; Preti & Sanatani, 2024). Furthermore, the attitudes observed in our participants indicate generational shifts in openness, transparency, and the integration of emotional competencies into clinical practice. The participants emphasized insufficient formal training and relied on clinical exposure and senior HCP observation. This finding mirrors consistent evidence that observing experienced HCPs deliver bad news helps trainees develop their own approach, while personally delivering bad news remains a pedagogically impactful experience and is associated with greater confidence and lower stress (Kotłowska et al., 2022; Lenkiewicz et al., 2022; Preti & Sanatani, 2024). The sense of inadequate preparation reported by our participants reflects wider concerns documented in the literature, in which many students have been found to consider their training insufficient or poorly timed, often relying on theoretical methods (MacLaine et al., 2021; Polivka et al., 2024; Sherwood et al., 2020). Consistent with our findings, previous studies have also underlined the value of experiential learning, peer dialogue, and supervised practice, with simulation identified as both challenging and highly formative (Gagnerie et al., 2023; Julius & McCarthy, 2024). An important point emerging from our data is the strong willingness among trainees to access supervision and structured support, in contrast with reports from clinical settings indicating that senior oncologists rarely attend optional supervision sessions. This generational difference suggests that the early training period constitutes a critical window for providing guidance. During these years, clinicians are still developing their routines and remain flexible enough to integrate new communicational and emotional skills, and their “still in training” status legitimizes help-seeking. However, later in the professional trajectory, routines tend to be firmly established, and seeking support may be perceived as a sign of weakness in the highly demanding medical environment (Francis & Robertson, 2023; Kolly et al., 2025). This finding underscores the importance of ensuring that supportive structures and supervision are accessible and encouraged during this formative phase. The SPIKES protocol, a six-step communication framework designed to guide clinicians through the structured delivery of bad news, was described as a helpful reference; however, the participants stressed flexible, context-sensitive use, consistent with research indicating that strict adherence may not meet patients’ individual needs (Alves et al., 2023; Marschollek et al., 2019; Ruiz Sancho et al., 2024). This finding aligns with the broader literature showing that SPIKES is one of the most widely used communication protocols in medical training (MacLaine et al., 2021) and that its structured format can improve students’ satisfaction, knowledge, and performance when taught through active, experiential methods (Mahendiran et al., 2023; Mills et al., 2024). However, consistent with our participants’ emphasis on adaptation, several studies highlight that the strict or mechanical application of SPIKES may not meet patients’ needs: perceived adherence is often incomplete, especially in exploring patient understanding, eliciting preferences, and collaboratively planning next steps (Marschollek et al., 2019). Furthermore, research has demonstrated that patients’ expectations and preferences vary widely across psychological, clinical, and sociodemographic factors (Alves et al., 2023; Ruiz Sancho et al., 2024), underscoring the need for a nuanced, individualized approach to the protocol rather than a step-by-step formula (Wild, 2020). Finally, our results suggest that choosing oncology as a specialty and developing a professional identity are dynamic processes shaped by patient care experiences, emotional challenges, and available institutional support. The participants highlighted the appeal of oncology due to long‑term patient relationships, multidisciplinary practice, and meaningful care, findings consistent with those of Faivre et al. (2018) and Julius and McCarthy (2024). The participants also noted that disclosing disease progression, while emotionally demanding, contributes to their professional growth by strengthening their sense of competence and ethical responsibility, in line with studies showing that difficult clinical encounters play a key role in identity formation and emotional resilience (Laranjeira et al., 2021; Novaes et al., 2023; Toivonen et al., 2017). 4.2 Limitations This study has several limitations that should be considered. First, the study was conducted exclusively in public hospitals in Switzerland, limiting the generalizability of the findings to other healthcare systems, cultures, or institutional contexts. Medical practices, including communication training, can differ substantially across countries and even within the same country (de Moura Villela et al., 2020; Julius & McCarthy, 2024; Kotłowska et al., 2022; Polivka et al., 2024). For example, the timing and nature of communication training in medical curricula vary widely, with theoretical courses typically dominating the first years and practical clinical training, including communication skills, introduced later (Kotłowska et al., 2022; MacLaine et al., 2021). Second, the participant sample was predominantly female, particularly among nurses (100%). This gender imbalance may have influenced the experiences and communication strategies reported, limiting the applicability of the findings to a more gender-balanced population, including male HCPs who might perceive and respond to patient interactions differently. Had the sample included more men, we might have observed comparatively less verbal empathy or fewer expressions of emotional vulnerability, given evidence that female physicians tend to self‑report greater empathic concern than male colleagues (although behavioral empathy measures vary) (Surchat et al., 2022). This raises the question of whether the intense relational and emotional engagement described by our predominantly female “young” participants reflects a generational shift, a gender-specific tendency, or their intersection. Finally, several sources of potential bias should be acknowledged. Recruitment and self‑selection biases may have favored participants who are more comfortable with delivering bad news or more motivated to share their experiences, potentially limiting the diversity of perspectives. For example, our team tried to conduct this study in France; however, no medical trainees agreed to be interviewed. Additionally, social desirability bias may have influenced participants’ responses, leading some to emphasize their professional competence rather than discuss difficulties or errors. As noted in our previous study (Kolly et al., 2025), this focus on performance is inherent to medical culture, where expressing emotions or reactions to challenges is often considered inappropriate (Harris & Gilligan, 2022), contributing to a culture of invulnerability (Francis & Robertson, 2023). 4.3 Practice implications The present study highlights several practical implications for improving communication training in healthcare, particularly in oncology. First, there is a clear need to integrate communication training more systematically and to incorporate it as a mandatory component of medical and nursing curricula. Evidence shows that experiential learning methods, such as role-playing, simulated patients, and supervised clinical interactions, are highly valued by students and significantly improve self-efficacy, empathy, and communication skills (Lenkiewicz et al., 2022; Polivka et al., 2024; Przymuszała et al., 2021; Sherwood et al., 2020). Students often prefer active, skill-based learning over passive methods, highlighting the importance of structured opportunities to practice delivering bad news (Novaes et al., 2023). However, pedagogical approaches vary widely across and within countries, suggesting the need for locally adapted yet standardized frameworks for communication training (de Moura Villela et al., 2020; Julius & McCarthy, 2024; Kotłowska et al., 2022; MacLaine et al., 2021; Polivka et al., 2024). Second, communication training should be tailored to specific clinical scenarios, such as disclosing cancer progression, which requires balancing the delivery of bad news with maintaining patient hope through information about potential treatment options (Kolly et al., 2025). Flexibility in applying structured protocols such as SPIKES is recommended, with emphasis on adapting communication to the patient’s emotional state and needs rather than strict adherence to formal steps (Bukowski et al., 2022; Kolly et al., 2025; Polivka et al., 2024). Finally, improving access to support resources is essential for preparing HCPs to manage the emotional burden of disclosing unfavorable medical information. Structured debriefings, mentorship programs, and the availability of psychologists can help students and professionals navigate the psychological stress inherent in delivering bad news (Polivka et al., 2024; Preti & Sanatani, 2024; Sobczak et al., 2023; Steiner-Hofbauer & Holzinger, 2020). Research has shown that integrating emotional management training alongside communication training enhances performance, self-confidence, and resilience, while fostering a culture of reflection and interprofessional collaboration (Novaes et al., 2023; Sobczak et al., 2023). 4.4 Conclusion This study explored the experiences of medical and nursing trainees in delivering bad news about cancer progression within Swiss public hospitals. We highlighted how the participants perceived and navigated these challenging situations, noting the strategies they used to communicate with clarity, empathy, and professionalism. The findings showed that while HCPs strive to balance honesty and support, they face difficulties such as limited structured support, a need for mandatory communication training, and reliance on informal peer support to cope with the emotional burden. Overall, the study provides insight into the nuances of delivering news of cancer progression in clinical practice and emphasizes the importance of adaptive, context-sensitive communication strategies. These results highlight actionable areas for improvement, including enhancing training, providing structured support, and fostering team-based approaches to better equip HCPs for these demanding interactions. Declarations Ethical approval This research was conducted in accordance with the protocol, the tenets of the Declaration of Helsinki, the principles of good clinical practice, the Law on Human Research (LRH), the Ordinance on Human Research (ORH), and other relevant local regulations. The study was approved by the Research Ethics Committee of the University of Lausanne (reference n°E_SSP_062022_0000I). Informed consent All participants received comprehensive information about the study’s objectives, procedures, potential risks, and benefits, and provided written informed consent prior to participation. Participation was entirely voluntary, and the participants were free to withdraw from the study at any time without consequence. Informed consent was obtained after the participants had read the information sheet, between June 2024 and October 2025. Privacy and confidentiality were ensured through the pseudonymization of all data. Competiting interests The authors have no competing interests to declare. Consent for publication Written consent for publication of anonymized excerpts was obtained from all participants. Formatting of funding sources This work was funded by the University of Lausanne through the thesis of JK and by the French National Cancer Institute (Institut National du Cancer, grant INCA/16136) in collaboration with the Université de Lille, the SCALab laboratory, the ONCOLille Institute, and the Centre Oscar Lambret, which supports the research chair opsyrii, “Innovations in psycho-oncology and intervention research”. We confirm that all participant identifiers have been removed or disguised; thus, the participants described are not identifiable and cannot be identified from the interview details. Availability of data and materials The datasets generated and/or analyzed during the current study are not publicly available due to the sensitive nature of the interview data and the risk of compromising participant confidentiality. However, the corresponding author may make the data available upon reasonable request and subject to ethical approval. Authors’ contributions SL, KL, and JK contributed to the conception and design of the study. SL and KL served as co‑supervisors for JK’s doctoral research and provided continuous guidance throughout the study and the preparation of the manuscript. The specific roles of each author during the study are outlined in Section 2.3 (Procedure). The manuscript was drafted by the first author, JK, and critically reviewed and revised by SL and KL. References Alves, C. G. B., Ribeiro, A. C. P., Brandão, T. B., Tonaki, J. O., Pedroso, C. M., Rivera, C., Epstein, J. B., Migliorati, C. A., Kowalski, L. P., Mak, M. P., Castro, G., Lopes, M. A., & Santos-Silva, A. R. (2023). Patient's perceptions of oral and oropharyngeal cancer diagnosis disclosure: communication aspects based on SPIKES protocol. 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D., Lowe, N., & Dale, J. (2021). The use of simulation in medical student education on the topic of breaking bad news: A systematic review. Patient Education and Counseling , 104 (11), 2670-2681. https://doi.org/10.1016/j.pec.2021.04.004 Mahendiran et al Mahendiran, M., Yeung, H., Rossi, S., Khosravani, H., & Perri, G. A. (2023). Evaluating the effectiveness of the SPIKES model to break bad news–a systematic review. American Journal of Hospice and Palliative Medicine® , 40 (11), 1231-1260. https://doi.org/10.1177/10499091221146296 Mani, K., Deng, D., Lin, C., Wang, M., Hsu, M. L., & Zaorsky, N. G. (2024). Causes of death among people living with metastatic cancer. Nature Communications, 15 (1), 1519. https://doi.org/10.1038/s41467-024-45307-x Marschollek, P., Bąkowska, K., Bąkowski, W., Marschollek, K., & Tarkowski, R. (2019). Oncologists and Breaking Bad News-From the Informed Patients' Point of View. The Evaluation of the SPIKES Protocol Implementation. 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(2021). « Conversations difficiles avec les patients » — Une expérience clinique structurée et modifiée par objectifs de groupe pour les étudiants en médecine. Revue internationale de recherche environnementale et de santé publique , 18 (11), 5772. https://doi.org/10.3390/ijerph18115772 Ruiz Sancho, E., Pérez Nieto, M. Á., Román, F. J., León Mateos, L., Sánchez Escamilla, F., Enrech Francés, S., Pérez Escutia, M. Á., Juez Mertel, I., Pérez-Segura, P., Aguirre Herrero, A., & Redondo Delgado, M. (2024). Differences in the Communication of Cancer Diagnoses by Different Health Professionals and the Impact of Oncologist Communication on Patients' Emotions. Cancers , 16 (13), 2444. https://doi.org/10.3390/cancers16132444 Saini, K. S., & Twelves, C. (2021). Determining lines of therapy in patients with solid cancers: A proposed new systematic and comprehensive framework. British Journal of Cancer , 125 (2), 155–163. https://doi.org/10.1038/s41416-021-01319-8 Santiago-Delefosse, M., & Carral, M. D. R. (2017). Les méthodes qualitatives en psychologie et sciences humaines de la santé. Dunod. Sherwood, M., Rioux, D., Knight, R., LeBlanc, M., Betsch, T., Giuliani, M., & Caissie, A. (2020). Increasing Undergraduate Exposure to Oncology: the Role of Oncology Interest Groups. Journal of cancer education : the official journal of the American Association for Cancer Education , 35 (5), 997–1001. https://doi.org/10.1007/s13187-019-01554-x Sobczak, K., Trzciński, M., Kotłowska, A., Lenkiewicz, J., Lenkiewicz, O., Przeniosło, J., & Plenikowski, J. (2023). Delivering Bad News: Emotional Perspective and Coping Strategies of Medical Students. Psychology research and behavior management , 16 , 3061–3074. https://doi.org/10.2147/PRBM.S421995 Steiner-Hofbauer, V., & Holzinger, A. (2020). How to Cope with the Challenges of Medical Education? Stress, Depression, and Coping in Undergraduate Medical Students. Academic psychiatry : the journal of the American Association of Directors of Psychiatric Residency Training and the Association for Academic Psychiatry , 44 (4), 380–387. https://doi.org/10.1007/s40596-020-01193-1 Studer, R. K., Danuser, B., & Gomez, P. (2017). Physicians’ psychophysiological stress reaction in medical communication of bad news: A critical literature review. International Journal of Psychophysiology , 120 , 14–22. https://doi.org/10.1016/j.ijpsycho.2017.06.006 Surchat, C., Carrard, V., Gaume, J., Berney, A., & Clair, C. (2022). Impact of physician empathy on patient outcomes: a gender analysis. The British journal of general practice : the journal of the Royal College of General Practitioners , 72 (715), e99–e107. https://doi.org/10.3399/BJGP.2021.0193 Toivonen, A. K., Lindblom-Ylänne, S., Louhiala, P., & Pyörälä, E. (2017). Medical students' reflections on emotions concerning breaking bad news. Patient education and counseling , 100 (10), 1903–1909. https://doi.org/10.1016/j.pec.2017.05.036 Tong, A., Sainsbury, P., & Craig, J. (2007). Consolidated criteria for reporting qualitative research (COREQ): A 32-item checklist for interviews and focus groups. International Journal for Quality in Health Care , 19 (6), 349–357. https://doi.org/10.1093/intqhc/mzm042 Wild, H. B. (2020). There’s no algorithm for empathy. Health Affairs , 39 (2), 339-342. https://doi.org/10.1377/hlthaff.2019.00571 Willig, C. (2013). Introducing qualitative research in psychology (3rd ed.). Open University Press. World Health Organization (WHO) (2022). Https://www.who.int/fr/news-room/fact-sheets/detail/cancer#:~:text=%C3%80%20l’origine%20de%20pr%C3%A8s,le%20cancer%20de%20la%20prostate. (n.d.). Tables Tables 1 to 6 are available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files Table1to6.docx Cite Share Download PDF Status: Published Journal Publication published 06 Feb, 2026 Read the published version in BMC Medical Education → Version 1 posted Editorial decision: Revision requested 26 Dec, 2025 Reviews received at journal 25 Dec, 2025 Reviewers agreed at journal 19 Dec, 2025 Reviews received at journal 18 Dec, 2025 Reviewers agreed at journal 18 Dec, 2025 Reviewers invited by journal 18 Dec, 2025 Editor invited by journal 15 Dec, 2025 Editor assigned by journal 12 Dec, 2025 Submission checks completed at journal 12 Dec, 2025 First submitted to journal 10 Dec, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Introduction","content":"\u003cp\u003eRecent advances in oncological treatments and increased life expectancy have significantly lengthened and complicated cancer care trajectories. Consequently, patients more frequently undergo successive lines of treatment that prolong cancer care, while cancer remains one of the most prevalent and lethal diseases worldwide (WHO, 2022). Within this context, consultations addressing disease progression due to treatment resistance, alongside the proposal of new therapeutic strategies, are becoming more frequent. It is essential to distinguish progression from recurrence: the former refers to ongoing disease growth despite active treatment, whereas the latter refers to the reappearance of cancer following remission. Progression, often indicative of therapeutic resistance, can arise at various stages of care and across cancer types, necessitating adjustments in treatment strategies (ASCO, 2019).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDespite the growing prevalence of these emotionally complex and sensitive consultations, scholarly attention to the communication of progression remains limited (Lelorain et al., 2023; Matthews et al., 2019). Cancer progression is considered bad news, i.e., information that significantly and negatively alters a patient\u0026rsquo;s perception of their future (Buckman, 1984). Indeed, it is particularly concerning for two reasons: first, it indicates that current treatments are no longer sufficiently effective, requiring a change in therapy; second, this change prompts a reassessment of prognosis, as the most effective treatments are generally administered first (ASCO, 2019).\u003c/p\u003e\n\u003cp\u003eDelivering bad news is a frequent and essential aspect of oncology practice. Healthcare professionals (HCPs) consistently report these encounters as emotionally challenging, requiring both professional expertise and emotional sensitivity (Laranjeira et al., 2021). Literature on breaking bad news in the context of diagnosis, recurrence, and transition to palliative care has revealed the significant psychological burden patients and caregivers (P\u0026amp;Cs) often experience, manifesting as anxiety, depression, hopelessness, uncertainty, and reduced self-efficacy (Chen et al., 2023; Chichua et al., 2023; Chou et al., 2017; Lippe et al., 2020). HCPs themselves are not immune to these negative effects: Matthews et al. (2019) demonstrated that HCPs experience stress, intrusive thoughts, and compromised well-being following difficult conversations, with repercussions sometimes extending into their personal lives. Physiological symptoms, including heightened arousal during such encounters, have also been documented (Studer et al., 2017). Recent findings have suggested that disclosing cancer progression is particularly emotionally taxing and that emotional responses to bad news tend to vary with clinical experience, suggesting that trainees may be particularly vulnerable to negative effects (Kolly et al., 2025; Alwhaibi et al., 2023). Indeed, in prior interviews with HCPs, trainees were consistently identified as particularly vulnerable during consultations involving cancer progression (Kolly et al., 2025). These findings, together with evidence from the literature on the emotional burden of delivering bad news, underscore the need to explore how medical and nursing trainees experience these consultations to inform educational interventions and provide appropriate emotional and pedagogical support.\u003c/p\u003e\n\u003cp\u003eThe aforementioned challenges underscore how trainees perceive and engage with their oncology training. Specializing in oncology is rarely a random choice. Faivre et al. (2018) found that the relational dimension of oncology, including intense and diverse patient interactions, is a key motivator for trainees. Nevertheless, delivering unfavorable news remains one of the most challenging aspects of the profession, with trainees often feeling unprepared and emotionally affected (Kotłowska et al., 2022; Laranjeira et al., 2021; Toivonen et al., 2017). Despite the emotional toll, trainees generally recognize the importance of difficult conversations as an integral aspect of their professional role (Julius \u0026amp; McCarthy, 2024; Toivonen et al., 2017).\u003c/p\u003e\n\u003cp\u003eThis study to explore how medical and nursing trainees experience consultations in which a change in treatment is discussed due to cancer progression. Our research question was as follows: \u003cem\u003eHow do medical and nursing trainees experience consultations in which cancer progression is disclosed?\u0026nbsp;\u003c/em\u003eSpecifically, we sought to examine the communication strategies employed, the emotional impact of delivering bad news, the support and resources utilized, the influence of family caregivers in these interactions, and how these experiences shape professional identity and learning.\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003e2.1 Study design\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis qualitative study was grounded in a socio-constructivist paradigm (Chamberlain, 2015) that emphasizes how individuals construct their perceptions of reality through social, cultural, and historical contexts (Santiago-Delefosse \u0026amp; Carral, 2017; Willig, 2013).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSemi-structured interviews were selected for their capacity to capture medical and nursing trainees\u0026rsquo; perspectives while allowing flexibility in the interview process. This method is well‑suited to exploring complex phenomena (Miles \u0026amp; Huberman, 2003) and enables the emergence of themes that reflect lived realities. The exploratory nature of the topic further justified this methodological choice. The study was conducted in accordance with the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines (Tong\u0026nbsp;et\u0026nbsp;al.,\u0026nbsp;2007).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e2.3 Participants\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMedical and nursing trainees were recruited between June 2024 and September 2025. Eligible participants were at least 18 years old, enrolled in medical or surgical internships or nursing training programs, engaged in clinical activity involving patients with digestive, dermatological, thoracic, or breast cancer, and participated in consultations to announce cancer progression (CACPs) when at least one treatment was still available. No exclusion criteria were defined. Recruitment concluded when data sufficiency was reached, meaning that no new information was redundant between interviews (Clarke \u0026amp; Braun, 2021).\u003c/p\u003e\n\u003cp\u003eThe aforementioned cancer types were selected in collaboration with oncologists due to their poor prognoses, marked by aggressive progression and frequent late-stage diagnoses. Thus, treatment resistance and subsequent therapeutic changes are more common in these cases compared with those involving other cancer types (Globocan, 2022; Saini \u0026amp; Twelves, 2021). According to clinical experience and current scientific literature, these cancers are considered likely to progress within one year; depending on the type of cancer, 50\u0026ndash;70% of patients are expected to die within 12 months (IARC, 2024; Mani et al., 2024).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e2.3 Procedure\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAn invitation to participate in the study was emailed to eligible trainees, accompanied by an informational flyer. Snowball sampling was employed; thus, the invitation was further shared with potentially eligible trainees. Interested individuals were encouraged to contact the sender (JK, LH, BF, or VP) for additional details about the study and to obtain an information letter. Interviews were scheduled upon confirmation of participation.\u003c/p\u003e\n\u003cp\u003eJK, a female PhD candidate in health psychology in the final stages of her PhD, conducted several interviews. JK is trained in semi-structured interviewing and qualitative research methods at the university level; she also trained LH, BF, and VP (Master\u0026rsquo;s students in psychology) to conduct interviews. All four researchers were involved in data collection. No prior relationship existed between the interviewers and participants. At the start of each interview, the researchers introduced themselves as psychology researchers based in Switzerland studying cancer progression in oncology.\u003c/p\u003e\n\u003cp\u003eEach interview began with the same initial question: \u003cem\u003e\u0026ldquo;When reviewing the exam results, you observe a progression of the disease for your patient who has advanced cancer. How does the consultation to communicate these results unfold, considering that despite the advanced nature of the cancer, there is still at least one possible line of treatment?\u0026rdquo;\u003c/em\u003e The conversation then explored common themes across both professional groups (medical or nursing trainees), including communication strategies, the emotional impact of delivering bad news, the support and resources used, and the influence of family caregivers during such consultations. Field notes were taken during and after the interviews, which were conducted either via videoconference or in person, depending on participants\u0026rsquo; preference. All interviews were audio-recorded using two dictaphones or a videoconferencing platform to ensure data reliability. Transcriptions were completed verbatim, with all identifying information (e.g., names and locations) pseudonymized. Additionally, descriptive data were collected during the interviews, including the participants\u0026rsquo; age, gender, profession, years of experience in oncology, and their affiliation with specific cancer units or hospitals.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e2.4 Analysis\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe interviews were analyzed using Braun and Clarke\u0026rsquo;s thematic analysis method, following an inductive approach (Braun \u0026amp; Clarke, 2006; Clarke \u0026amp; Braun, 2021). This approach enables the breakdown of each interview\u0026apos;s narrative structure to identify thematic patterns across the entire dataset (Blanchet \u0026amp; Gotman, 2015). NVivo software (NVivo \u0026copy; 2021 QSR International Pty Ltd.) was used to support the analysis. The process followed six phases: (1) familiarization with the data, (2) generation of initial codes (without abstraction at this stage), (3) identification of potential themes, (4) review of themes, (5) definition and naming of themes, and (6)\u0026nbsp;production of the final report, including illustrative verbatim excerpts.\u003c/p\u003e\n\u003cp\u003eAlthough the trainees represented two different professions (medicine and nursing), the thematic analysis was conducted without distinction. The thematic grouping was constructed from the discourse of all participants. The nuances present in the discourse were then explicitly outlined in the results.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e2.5 Ethical approval\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research was conducted in accordance with the protocol, the tenets of the Declaration of Helsinki, the principles of good clinical practice, the Law on Human Research (LRH), the Ordinance on Human Research (ORH), and other relevant local regulations. The study was approved by the Research Ethics Committee of the University of Lausanne (reference n\u0026deg;E_SSP_062022_0000I).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e2.6 Informed consent\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll participants received comprehensive information about the study\u0026rsquo;s objectives, procedures, potential risks, and benefits, and provided written informed consent prior to participation. Participation was entirely voluntary, and the participants were free to withdraw from the study at any time without consequence. Informed consent was obtained after the participants had read the information sheet, between June 2024 and October 2025. Privacy and confidentiality were ensured through the pseudonymization of all data.\u003c/p\u003e"},{"header":"3. Results","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003e3.1 Participant characteristics\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe recruitment process involved extensive outreach efforts by the research team, including over 100 emails and 80 phone calls to various institutions, ultimately leading to the identification of 33 potential participants. Of these, 12 did not respond, three declined to participate, and 18 agreed to participate in the interviews. There were no dropouts. There were 11 physician trainees and seven nursing trainees, all working in public hospitals in Switzerland. The interviews lasted between 30 minutes and 1.3 hours, with an average duration of 53.6 minutes.\u003c/p\u003e\n\u003cp\u003eThe participants\u0026rsquo; characteristics are presented in Table 1. The mean age was 30.7 years (range: 24\u0026ndash;42 years). The gender distribution was particularly unbalanced among nurses (100% female) and physicians (64% female and 36% male). All but three medical trainees worked full-time. The nursing trainees worked at rates ranging from 60% to 100%. The physicians had an average of 4.09 years of oncology experience (range 1\u0026ndash;5), and the nurses had an average of 2.67 years (range 1\u0026ndash;5).\u003c/p\u003e\n\u003cp\u003e[Table 1 near here]\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e3.2 Themes organization\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eGiven that most medical and nursing trainees have only minimal CACP consultation experience, their narratives sometimes draw on their wider early experiences in oncology and medicine. Thus, some subthemes may appear less closely tied to CACPs, yet still illuminate how trainees understand these encounters.\u003c/p\u003e\n\u003cp\u003eThe participants\u0026rsquo; accounts and the thematic organization reflect this process-oriented perspective, encompassing the trainees\u0026rsquo; professional roles and practices, communication skills development, the structured disclosure process, the effects of the consultations on the trainees, and the responses of P\u0026amp;Cs. The five identified themes were as follows: (1) \u003cem\u003eprofessional role perceptions and oncology practices in cancer progression care\u003c/em\u003e, (2) \u003cem\u003ethe process of disclosing disease progression\u003c/em\u003e, (3) \u003cem\u003eperceptions and reactions of patients and their family caregivers, (4) impacts of disease progression disclosure on medical and nursing trainees, and\u003c/em\u003e (5) \u003cem\u003etraining and development of communication skills.\u003c/em\u003e These themes were addressed by all participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e3.3 Theme 1: Professional role perceptions and oncology practices in cancer progression care\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis first theme describes how oncology trainees define their roles and specific practices within their field (Table 2). The participants described oncology as a highly complex and multifaceted field that combines scientific rigor with deep human engagement. The discipline\u0026rsquo;s appeal was linked to the continuous, long-term patient relationships and the interplay among medical, psychological, and social dimensions. The participants emphasized the heterogeneity of cancers, noting that prognosis and therapeutic strategies vary dramatically depending on the tumor type and stage.\u003c/p\u003e\n\u003cp\u003eThe participants compared diagnostic disclosure with CACP. Diagnostic disclosure emerged as a particularly sensitive moment that was considered emotionally challenging, marking a transition from perceived health to illness. In contrast, progression announcements were often experienced as less distressing because patients were already engaged in treatment. Similarly, according to the participants\u0026rsquo; accounts, discussions about therapeutic goals, especially when shifting from curative to palliative intent, required careful communication to balance honesty with hope. Medical trainees perceived their role as guiding patients through uncertainty by explaining the clinical implications, outlining the next therapeutic options, and clarifying how care would continue despite the change.\u003c/p\u003e\n\u003cp\u003eNursing trainees highlighted the relational and supportive dimensions of oncology practice in the context of cancer progression. Through active listening, emotional presence, and continuity of care, they provided a stabilizing and empathetic counterpart to the physicians\u0026rsquo; technical and decisional roles. Their proximity to patients enabled them to address psychosocial concerns and ensure ongoing support, particularly for those facing the disease alone.\u003c/p\u003e\n\u003cp\u003e[Table 2 near here]\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e3.4 Theme 2: Process of disclosing disease progression\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAs shown in Table 3, participants described the process of announcing disease progression as a delicate and highly structured communication sequence that combines clinical, emotional, and relational dimensions.\u003c/p\u003e\n\u003cp\u003eBefore meeting the patient, the participants reported coordinating with colleagues during multidisciplinary meetings and preparing by reviewing medical data and anticipating patients\u0026rsquo; and family caregivers\u0026rsquo; reactions. Physician trainees emphasized the importance of being fully informed about the case and mastering the technical aspects of the results, whereas nurse trainees noted that patients often sensed the seriousness of the situation even before the consultation began.\u003c/p\u003e\n\u003cp\u003eThe participants highlighted the need for an appropriate setting for the disclosure, ensuring calm and privacy. Consultations could take place in the physician\u0026rsquo;s office or, for hospitalized patients, at the bedside. The introduction to the discussion varied by professional, with some preferring a direct approach and others beginning by assessing the patient\u0026rsquo;s emotional state. Explanations of disease progression were often accompanied by the presentation of new therapeutic options, helping physician trainees facilitate a sense of hope. Physician trainees also described strategies for addressing uncertainty, such as using general references to survival statistics without providing precise figures unless requested.\u003c/p\u003e\n\u003cp\u003eProviding support to patients after the disclosure was described as an essential component of the process. Physician trainees frequently offered follow-up appointments to give patients time to process the information, while nurses conducted additional interviews to assess understanding and provide emotional support.\u003c/p\u003e\n\u003cp\u003eThe disclosure meeting generally involved the physician, sometimes accompanied by a resident, a nurse, or a family caregiver. The primary responsibility for announcing progression rested with the physician, though junior physicians often worked alongside their supervisors during complex consultations. Given that the interviewees were still in training and had limited experience, they most often attended CACPs as observers or as support to a more senior physician. The nurses described their presence as complementary, focusing on patient comprehension and emotional reassurance.\u003c/p\u003e\n\u003cp\u003eIn describing the continuity of care, the participants highlighted the effects of staff rotation and varying levels of familiarity with patients. On the one hand, trainees reported that frequent assignment changes could result in patients seeing different physicians at each consultation. Nurse trainees, on the other hand, often followed the same patients throughout their treatment and hospitalization, enabling them to build relationships of trust and mutual understanding. Some explained that these relationships developed naturally over time and through shared conversations, while others noted that announcing disease progression to a long-term patient could be particularly emotional.\u003c/p\u003e\n\u003cp\u003e[Table 3 near here]\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e3.5 Theme 3: Perceptions and reactions of patients and their family caregivers\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAs shown in Table 4, the participants described a wide range of emotional, relational, and decision-making experiences related to patients and their family caregivers.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFamily caregivers were frequently highlighted as crucial sources of support, providing emotional reassurance and practical assistance in understanding medical information. Patients\u0026rsquo; reactions to medical announcements were diverse, ranging from anticipation and psychological preparation to shock, relief, emotional concealment, sadness, and anger. The participants reported that these reactions were often shaped by individual coping styles, prior expectations, and perceived quality of communication with HCPs.\u003c/p\u003e\n\u003cp\u003eParticipants also discussed the integration of complementary approaches, such as psychological support, hypnosis, or art therapy, particularly when the emotional burden was high. Decision‑making processes varied considerably, encompassing active patient choice, informed deliberation of treatment options, and, in some cases, delegation of decisions to the physician. Participants emphasized the importance of providing comprehensive information while respecting patient autonomy, balancing guidance with support. Overall, participants highlighted the centrality of family involvement, emotional attunement, and flexible, patient-centered decision-making in navigating the clinical experience.\u003c/p\u003e\n\u003cp\u003e[Table 4 near here]\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e3.6 Theme 4: Impacts of disease progression disclosure on medical and nursing trainees\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAs shown in Table 5, the participants described a wide range of emotional, professional, and relational effects associated with the process of disclosing disease progression.\u003c/p\u003e\n\u003cp\u003eParticipants reported diverse \u003cstrong\u003eemotional reactions and personal adjustments\u003c/strong\u003e, including fatigue and emotional exhaustion after consultations, particularly when the interaction was intense or when they felt closely connected to the patient. Sadness was a common reaction, though many noted that repeated exposure and clinical experience helped them develop a certain emotional distance over time. Others described their emotions as strongly influenced by the patient\u0026rsquo;s reaction; moments when patients cried or expressed despair were perceived as particularly difficult. Feelings of frustration, anxiety, and guilt were also reported. Some participants noted that these experiences occasionally affected their private lives, while others emphasized their ability to separate professional and personal spheres and manage emotions through detachment or compartmentalization.\u003c/p\u003e\n\u003cp\u003eThe participants also referred to various \u003cstrong\u003eprofessional constraints and challenges\u003c/strong\u003e associated with disclosure. Less experienced physicians often cited a lack of specific training and difficulty managing unexpected questions. Time constraints and institutional pressures limited the opportunity to provide adequate emotional support during consultations. Nurse trainees sometimes described compensating for communication lapses by physicians, while both nurse and physician trainees emphasized the importance of consistent interprofessional communication to avoid giving patients contradictory messages. Emotional identification with patients of similar ages or life circumstances was also described as a significant source of distress.\u003c/p\u003e\n\u003cp\u003eParticipants relied on several \u003cstrong\u003estrategies to cope with these challenges\u003c/strong\u003e. Experience was often considered a protective factor, helping to reduce emotional intensity and increase confidence. Maintaining emotional distance was perceived as necessary for self-preservation. Some participants found reassurance in the availability of further treatment options or in concrete solutions, such as psychological support for patients. Positive feedback from P\u0026amp;Cs also served as an important source of motivation and validation.\u003c/p\u003e\n\u003cp\u003eFinally, the participants mentioned a range of \u003cstrong\u003esupport mechanisms\u003c/strong\u003e within and outside the workplace. Many emphasized the value of discussing difficult consultations with supervisors and colleagues as a form of informal debriefing. Sharing experiences with relatives or partners also helped release tension. Some medical trainees reported seeking psychological support when emotional strain accumulated, recognizing it as a necessary resource in sustaining their professional well-being.\u003c/p\u003e\n\u003cp\u003e[Table 5 near here]\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e3.7 Theme 5: Training and development of communication skills\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAs illustrated in Table 6, participants highlighted diverse approaches to acquiring and refining communication skills in cancer care.\u003c/p\u003e\n\u003cp\u003eMedical and nursing trainees described multiple training modalities, ranging from theoretical instruction, often structured around communication frameworks such as the SPIKES (\u003cstrong\u003eS\u003c/strong\u003eetting, \u003cstrong\u003eP\u003c/strong\u003eerception, \u003cstrong\u003eI\u003c/strong\u003envitation, \u003cstrong\u003eK\u003c/strong\u003enowledge, \u003cstrong\u003eE\u003c/strong\u003emotions/empathy, and \u003cstrong\u003eS\u003c/strong\u003etrategy/summary)\u0026nbsp;protocol (Buckman, 1984), widely adopted in medical curricula to support the delivery of unfavorable news, to experiential learning through role-playing with simulated patients. Observation of senior colleagues and mentorship during clinical practice also played a key role, allowing learners to internalize effective communication strategies and receive real-time feedback. In addition to structured teaching, participants underscored the importance of learning through practice, including moments of trial and error that foster professional growth and self-reflection.\u003c/p\u003e\n\u003cp\u003eThe participants identified a set of core communication skills, including clarity, honesty, empathy, and the ability to tailor their approach to each patient\u0026rsquo;s emotional and cognitive state. Nonverbal cues, silence, and appropriate physical contact were recognized as integral to establishing trust and conveying compassion. The influence of individual personality traits was also acknowledged to shape communication styles and the degree of emotional engagement.\u003c/p\u003e\n\u003cp\u003eDespite these efforts, participants noted significant limitations in training, particularly its optional or insufficient nature in oncology education. Although communication protocols were reported to provide useful structure, some participants perceived them as overly mechanical, highlighting a \u0026ldquo;protocol paradox\u0026rdquo; that can hinder authentic connection and adaptability.\u003c/p\u003e\n\u003cp\u003eThe participants described oncology as a field with strong hierarchical structures that, in their experience, are often supportive. Junior physicians often delivered difficult news under the supervision of senior colleagues, who provided immediate feedback and assistance when consultations became challenging. Some participants emphasized the reassuring presence and availability of their superiors, whereas others mentioned moments of disagreement or hesitation to speak up due to hierarchical norms.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e[Table 6 near here]\u003c/p\u003e"},{"header":"4.\tDiscussion and conclusion","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003e4.1 Discussion\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study provides an in-depth exploration of how medical and nursing trainees experience consultations involving treatment changes due to cancer progression. Our findings underscore the multidimensional nature of these interactions, in which trainees must navigate clinical accuracy, emotional responsiveness, and relational complexity simultaneously. Disclosing cancer progression is not merely the transmission of medical facts but a carefully orchestrated process that involves preparing the patient, communicating clearly and empathetically, and supporting both understanding and emotional adjustment. Trainees\u0026rsquo; experiences reveal the need to balance realism with hope, manage their own emotional responses, and coordinate effectively with colleagues, patients, and family caregivers.\u003c/p\u003e\n\u003cp\u003eAlthough our participants perceived the disclosure of disease progression as less emotionally impactful than the disclosure of the initial diagnosis, disclosing progression remains challenging because it combines the clinical complexity associated with adapting treatment with emotional management. The participants reported that, although patients often anticipate these consultations, the announcements remain emotionally intense and affect trainees\u0026rsquo; well‑being. Our results extend previous findings on the importance of preparation, relational knowledge, and follow-up support (Francis \u0026amp; Robertson, 2023; Kolly et al., 2025; Matthews et al., 2019).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn contrast to the study by Kolly et al. (2025), which explored the perspectives of experienced oncologists and nurses in CACPs, the present findings reflect the standpoint of trainees. Kolly et al. (2025) reported that HCPs gradually develop confidence and emotional distance through repeated exposure to CACPs; however, the participants in our study described a more uncertain and affectively charged experience. Emotional impacts reported by the participants included anxiety, sadness, frustration, guilt, and a pervasive sense of inadequacy, consistent with the literature on trainees (Kotłowska et al., 2022; Laranjeira et al., 2021; Sobczak et al., 2023). Our participants\u0026rsquo; accounts of emotional vulnerability echo findings that inexperienced trainees often struggle with confidence and are strongly affected by patients\u0026rsquo; reactions (Gagnerie et al., 2023; Julius \u0026amp; McCarthy, 2024). In our study, however, these experiences emerged in the context of a specific and, to our knowledge, previously unexamined moment in the care trajectory: the announcement of a treatment change within the CACP setting. Although occasional positive emotions, such as gratitude or satisfaction in helping patients, have been noted in some studies (Julius \u0026amp; McCarthy, 2024; Toivonen et al., 2017), our results indicate that these emotions remain secondary to the dominant emotional strain associated with breaking bad news.\u003c/p\u003e\n\u003cp\u003eOur participants all had prior experience in delivering bad news and did not report feeling incapable of doing so, which aligns with studies showing that trainees with previous exposure feel more capable and less apprehensive than those without such experience (Kotłowska et al., 2022; Sobczak et al., 2023). In our study, the participants described relying mainly on peer dialogue, informal debriefing, and occasional support from senior HCPs, as well as personal strategies such as reflection or temporary distancing. The literature similarly indicates that HCPs in training with prior experience tend to use more adaptive coping strategies, seeking support from close others or experienced HCPs and engaging in restorative activities; in contrast, inexperienced trainees more often report non-adaptive or avoidant responses (Sobczak et al., 2023). A more distinctive element in our study is the strong importance participants placed on being honest and transparent with patients about the implications of the treatment change. Several participants explicitly mentioned their effort not to minimize or obscure the situation. This emphasis may reflect broader evolutions in professional training, where emotional literacy, open communication, and ethical clarity are increasingly promoted. Thus, trainees may be more comfortable acknowledging and sharing emotions, along with being more attentive to providing clear and forthright information.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTogether, these parallels suggest that supportive relationships and accessible guidance are central to how trainees manage the emotional challenges of breaking bad news (Julius \u0026amp; McCarthy, 2024; Preti \u0026amp; Sanatani, 2024). Furthermore, the attitudes observed in our participants indicate generational shifts in openness, transparency, and the integration of emotional competencies into clinical practice.\u003c/p\u003e\n\u003cp\u003eThe participants emphasized insufficient formal training and relied on clinical exposure and senior HCP observation. This finding mirrors consistent evidence that observing experienced HCPs deliver bad news helps trainees develop their own approach, while personally delivering bad news remains a pedagogically impactful experience and is associated with greater confidence and lower stress (Kotłowska et al., 2022; Lenkiewicz et al., 2022; Preti \u0026amp; Sanatani, 2024). The sense of inadequate preparation reported by our participants reflects wider concerns documented in the literature, in which many students have been found to consider their training insufficient or poorly timed, often relying on theoretical methods (MacLaine et al., 2021; Polivka et al., 2024; Sherwood et al., 2020). Consistent with our findings, previous studies have also underlined the value of experiential learning, peer dialogue, and supervised practice, with simulation identified as both challenging and highly formative (Gagnerie et al., 2023; Julius \u0026amp; McCarthy, 2024).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAn important point emerging from our data is the strong willingness among trainees to access supervision and structured support, in contrast with reports from clinical settings indicating that senior oncologists rarely attend optional supervision sessions. This generational difference suggests that the early training period constitutes a critical window for providing guidance. During these years, clinicians are still developing their routines and remain flexible enough to integrate new communicational and emotional skills, and their \u0026ldquo;still in training\u0026rdquo; status legitimizes help-seeking. However, later in the professional trajectory, routines tend to be firmly established, and seeking support may be perceived as a sign of weakness in the highly demanding medical environment (Francis \u0026amp; Robertson, 2023; Kolly et al., 2025). This finding underscores the importance of ensuring that supportive structures and supervision are accessible and encouraged during this formative phase.\u003c/p\u003e\n\u003cp\u003eThe SPIKES protocol, a six-step communication framework designed to guide clinicians through the structured delivery of bad news, was described as a helpful reference; however, the participants stressed flexible, context-sensitive use, consistent with research indicating that strict adherence may not meet patients\u0026rsquo; individual needs (Alves et al., 2023; Marschollek et al., 2019; Ruiz Sancho et al., 2024). This finding aligns with the broader literature showing that SPIKES is one of the most widely used communication protocols in medical training (MacLaine et al., 2021) and that its structured format can improve students\u0026rsquo; satisfaction, knowledge, and performance when taught through active, experiential methods (Mahendiran et al., 2023; Mills et al., 2024). However, consistent with our participants\u0026rsquo; emphasis on adaptation, several studies highlight that the strict or mechanical application of SPIKES may not meet patients\u0026rsquo; needs: perceived adherence is often incomplete, especially in exploring patient understanding, eliciting preferences, and collaboratively planning next steps (Marschollek et al., 2019). Furthermore, research has demonstrated that patients\u0026rsquo; expectations and preferences vary widely across psychological, clinical, and sociodemographic factors (Alves et al., 2023; Ruiz Sancho et al., 2024), underscoring the need for a nuanced, individualized approach to the protocol rather than a step-by-step formula (Wild, 2020).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFinally, our results suggest that choosing oncology as a specialty and developing a professional identity are dynamic processes shaped by patient care experiences, emotional challenges, and available institutional support. The participants highlighted the appeal of oncology due to long‑term patient relationships, multidisciplinary practice, and meaningful care, findings consistent with those of Faivre et al. (2018) and Julius and McCarthy (2024). The participants also noted that disclosing disease progression, while emotionally demanding, contributes to their professional growth by strengthening their sense of competence and ethical responsibility, in line with studies showing that difficult clinical encounters play a key role in identity formation and emotional resilience (Laranjeira et al., 2021; Novaes et al., 2023;\u0026nbsp;Toivonen\u0026nbsp;et\u0026nbsp;al.,\u0026nbsp;2017).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e4.2 Limitations\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study has several limitations that should be considered. First, the study was conducted exclusively in public hospitals in Switzerland, limiting the generalizability of the findings to other healthcare systems, cultures, or institutional contexts. Medical practices, including communication training, can differ substantially across countries and even within the same country (de Moura Villela et al., 2020; Julius \u0026amp; McCarthy, 2024; Kotłowska et al., 2022; Polivka et al., 2024). For example, the timing and nature of communication training in medical curricula vary widely, with theoretical courses typically dominating the first years and practical clinical training, including communication skills, introduced later (Kotłowska et al., 2022; MacLaine et al., 2021).\u003c/p\u003e\n\u003cp\u003eSecond, the participant sample was predominantly female, particularly among nurses (100%). This gender imbalance may have influenced the experiences and communication strategies reported, limiting the applicability of the findings to a more gender-balanced population, including male HCPs who might perceive and respond to patient interactions differently. Had the sample included more men, we might have observed comparatively less verbal empathy or fewer expressions of emotional vulnerability, given evidence that female physicians tend to self‑report greater empathic concern than male colleagues (although behavioral empathy measures vary) (Surchat et al., 2022). This raises the question of whether the intense relational and emotional engagement described by our predominantly female \u0026ldquo;young\u0026rdquo; participants reflects a generational shift, a gender-specific tendency, or their intersection.\u003c/p\u003e\n\u003cp\u003eFinally, several sources of potential bias should be acknowledged. Recruitment and self‑selection biases may have favored participants who are more comfortable with delivering bad news or more motivated to share their experiences, potentially limiting the diversity of perspectives. For example, our team tried to conduct this study in France; however, no medical trainees agreed to be interviewed. Additionally, social desirability bias may have influenced participants\u0026rsquo; responses, leading some to emphasize their professional competence rather than discuss difficulties or errors. As noted in our previous study (Kolly et al., 2025), this focus on performance is inherent to medical culture, where expressing emotions or reactions to challenges is often considered inappropriate (Harris \u0026amp; Gilligan, 2022), contributing to a culture of invulnerability (Francis \u0026amp; Robertson, 2023).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e4.3 Practice implications\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe present study highlights several practical implications for improving communication training in healthcare, particularly in oncology. First, there is a clear need to integrate communication training more systematically and to incorporate it as a mandatory component of medical and nursing curricula. Evidence shows that experiential learning methods, such as role-playing, simulated patients, and supervised clinical interactions, are highly valued by students and significantly improve self-efficacy, empathy, and communication skills (Lenkiewicz et al., 2022; Polivka et al., 2024; Przymuszała et al., 2021; Sherwood et al., 2020). Students often prefer active, skill-based learning over passive methods, highlighting the importance of structured opportunities to practice delivering bad news (Novaes et al., 2023). However, pedagogical approaches vary widely across and within countries, suggesting the need for locally adapted yet standardized frameworks for communication training (de Moura Villela et al., 2020; Julius \u0026amp; McCarthy, 2024; Kotłowska et al., 2022; MacLaine et al., 2021; Polivka et al., 2024).\u003c/p\u003e\n\u003cp\u003eSecond, communication training should be tailored to specific clinical scenarios, such as disclosing cancer progression, which requires balancing the delivery of bad news with maintaining patient hope through information about potential treatment options (Kolly et al., 2025). Flexibility in applying structured protocols such as SPIKES is recommended, with emphasis on adapting communication to the patient\u0026rsquo;s emotional state and needs rather than strict adherence to formal steps (Bukowski et al., 2022; Kolly et al., 2025; Polivka et al., 2024).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFinally, improving access to support resources is essential for preparing HCPs to manage the emotional burden of disclosing unfavorable medical information. Structured debriefings, mentorship programs, and the availability of psychologists can help students and professionals navigate the psychological stress inherent in delivering bad news (Polivka et al., 2024; Preti \u0026amp; Sanatani, 2024; Sobczak et al., 2023; Steiner-Hofbauer \u0026amp; Holzinger, 2020). Research has shown that integrating emotional management training alongside communication training enhances performance, self-confidence, and resilience, while fostering a culture of reflection and interprofessional collaboration (Novaes et al., 2023; Sobczak et al., 2023).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e4.4 Conclusion\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study explored the experiences of medical and nursing trainees in delivering bad news about cancer progression within Swiss public hospitals. We highlighted how the participants perceived and navigated these challenging situations, noting the strategies they used to communicate with clarity, empathy, and professionalism. The findings showed that while HCPs strive to balance honesty and support, they face difficulties such as limited structured support, a need for mandatory communication training, and reliance on informal peer support to cope with the emotional burden.\u003c/p\u003e\n\u003cp\u003eOverall, the study provides insight into the nuances of delivering news of cancer progression in clinical practice and emphasizes the importance of adaptive, context-sensitive communication strategies. These results highlight actionable areas for improvement, including enhancing training, providing structured support, and fostering team-based approaches to better equip HCPs for these demanding interactions.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research was conducted in accordance with the protocol, the tenets of the Declaration of Helsinki, the principles of good clinical practice, the Law on Human Research (LRH), the Ordinance on Human Research (ORH), and other relevant local regulations. The study was approved by the Research Ethics Committee of the University of Lausanne (reference n\u0026deg;E_SSP_062022_0000I).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInformed consent\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll participants received comprehensive information about the study\u0026rsquo;s objectives, procedures, potential risks, and benefits, and provided written informed consent prior to participation. Participation was entirely voluntary, and the participants were free to withdraw from the study at any time without consequence. Informed consent was obtained after the participants had read the information sheet, between June 2024 and October 2025. Privacy and confidentiality were ensured through the pseudonymization of all data.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompetiting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no competing interests to declare.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten consent for publication of anonymized excerpts was obtained from all participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFormatting of funding sources\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was funded by the University of Lausanne through the thesis of JK and by the French National Cancer Institute (Institut National du Cancer, grant INCA/16136) in collaboration with the Universit\u0026eacute; de Lille, the SCALab laboratory, the ONCOLille Institute, and the Centre Oscar Lambret, which supports the research chair opsyrii, \u0026ldquo;Innovations in psycho-oncology and intervention research\u0026rdquo;. We confirm that all participant identifiers have been removed or disguised; thus, the participants described are not identifiable and cannot be identified from the interview details.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and/or analyzed during the current study are not publicly available due to the sensitive nature of the interview data and the risk of compromising participant confidentiality. However, the corresponding author may make the data available upon reasonable request and subject to ethical approval.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSL, KL, and JK contributed to the conception and design of the study. SL and KL served as co‑supervisors for JK\u0026rsquo;s doctoral research and provided continuous guidance throughout the study and the preparation of the manuscript. The specific roles of each author during the study are outlined in Section 2.3 (Procedure). The manuscript was drafted by the first author, JK, and critically reviewed and revised by SL and KL.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eAlves, C. G. B., Ribeiro, A. C. P., Brand\u0026atilde;o, T. B., Tonaki, J. O., Pedroso, C. M., Rivera, C., Epstein, J. B., Migliorati, C. A., Kowalski, L. P., Mak, M. P., Castro, G., Lopes, M. A., \u0026amp; Santos-Silva, A. R. (2023). 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Five ways to get a grip on the personal emotional cost of breaking bad news. \u003cem\u003eCanadian medical education journal\u003c/em\u003e, \u003cem\u003e15\u003c/em\u003e(3), 97\u0026ndash;99. https://doi.org/10.36834/cmej.78228\u003c/li\u003e\n \u003cli\u003ePrzymuszała, P., Marciniak-Stępak, P., Cerbin-Koczorowska, M., Borowczyk, M., Cieślak, K., Szlanga, L., ... \u0026amp; Marciniak, R. (2021). \u0026laquo; Conversations difficiles avec les patients \u0026raquo; \u0026mdash; Une exp\u0026eacute;rience clinique structur\u0026eacute;e et modifi\u0026eacute;e par objectifs de groupe pour les \u0026eacute;tudiants en m\u0026eacute;decine. \u003cem\u003eRevue internationale de recherche environnementale et de sant\u0026eacute; publique\u003c/em\u003e , \u003cem\u003e18\u003c/em\u003e (11), 5772. https://doi.org/10.3390/ijerph18115772\u003c/li\u003e\n \u003cli\u003eRuiz Sancho, E., P\u0026eacute;rez Nieto, M. \u0026Aacute;., Rom\u0026aacute;n, F. J., Le\u0026oacute;n Mateos, L., S\u0026aacute;nchez Escamilla, F., Enrech Franc\u0026eacute;s, S., P\u0026eacute;rez Escutia, M. \u0026Aacute;., Juez Mertel, I., P\u0026eacute;rez-Segura, P., Aguirre Herrero, A., \u0026amp; Redondo Delgado, M. (2024). Differences in the Communication of Cancer Diagnoses by Different Health Professionals and the Impact of Oncologist Communication on Patients\u0026apos; Emotions. \u003cem\u003eCancers\u003c/em\u003e, \u003cem\u003e16\u003c/em\u003e(13), 2444. https://doi.org/10.3390/cancers16132444\u003c/li\u003e\n \u003cli\u003eSaini, K. S., \u0026amp; Twelves, C. (2021). Determining lines of therapy in patients with solid cancers: A proposed new systematic and comprehensive framework. \u003cem\u003eBritish Journal of Cancer\u003c/em\u003e, \u003cem\u003e125\u003c/em\u003e(2), 155\u0026ndash;163. https://doi.org/10.1038/s41416-021-01319-8\u003c/li\u003e\n \u003cli\u003eSantiago-Delefosse, M., \u0026amp; Carral, M. D. R. (2017). \u003cem\u003eLes m\u0026eacute;thodes qualitatives en psychologie et sciences humaines de la sant\u0026eacute;.\u0026nbsp;\u003c/em\u003eDunod.\u003c/li\u003e\n \u003cli\u003eSherwood, M., Rioux, D., Knight, R., LeBlanc, M., Betsch, T., Giuliani, M., \u0026amp; Caissie, A. (2020). Increasing Undergraduate Exposure to Oncology: the Role of Oncology Interest Groups. \u003cem\u003eJournal of cancer education : the official journal of the American Association for Cancer Education\u003c/em\u003e, \u003cem\u003e35\u003c/em\u003e(5), 997\u0026ndash;1001. https://doi.org/10.1007/s13187-019-01554-x\u003c/li\u003e\n \u003cli\u003eSobczak, K., Trzciński, M., Kotłowska, A., Lenkiewicz, J., Lenkiewicz, O., Przeniosło, J., \u0026amp; Plenikowski, J. (2023). Delivering Bad News: Emotional Perspective and Coping Strategies of Medical Students. \u003cem\u003ePsychology research and behavior management\u003c/em\u003e, \u003cem\u003e16\u003c/em\u003e, 3061\u0026ndash;3074. https://doi.org/10.2147/PRBM.S421995\u003c/li\u003e\n \u003cli\u003eSteiner-Hofbauer, V., \u0026amp; Holzinger, A. (2020). How to Cope with the Challenges of Medical Education? Stress, Depression, and Coping in Undergraduate Medical Students. \u003cem\u003eAcademic psychiatry : the journal of the American Association of Directors of Psychiatric Residency Training and the Association for Academic Psychiatry\u003c/em\u003e, \u003cem\u003e44\u003c/em\u003e(4), 380\u0026ndash;387. https://doi.org/10.1007/s40596-020-01193-1\u003c/li\u003e\n \u003cli\u003eStuder, R. K., Danuser, B., \u0026amp; Gomez, P. (2017). Physicians\u0026rsquo; psychophysiological stress reaction in medical communication of bad news: A critical literature review. \u003cem\u003eInternational Journal of Psychophysiology\u003c/em\u003e, \u003cem\u003e120\u003c/em\u003e, 14\u0026ndash;22. https://doi.org/10.1016/j.ijpsycho.2017.06.006\u003c/li\u003e\n \u003cli\u003eSurchat, C., Carrard, V., Gaume, J., Berney, A., \u0026amp; Clair, C. (2022). Impact of physician empathy on patient outcomes: a gender analysis. \u003cem\u003eThe British journal of general practice : the journal of the Royal College of General Practitioners\u003c/em\u003e, \u003cem\u003e72\u003c/em\u003e(715), e99\u0026ndash;e107. https://doi.org/10.3399/BJGP.2021.0193\u003c/li\u003e\n \u003cli\u003eToivonen, A. K., Lindblom-Yl\u0026auml;nne, S., Louhiala, P., \u0026amp; Py\u0026ouml;r\u0026auml;l\u0026auml;, E. (2017). Medical students\u0026apos; reflections on emotions concerning breaking bad news. \u003cem\u003ePatient education and counseling\u003c/em\u003e, \u003cem\u003e100\u003c/em\u003e(10), 1903\u0026ndash;1909. https://doi.org/10.1016/j.pec.2017.05.036\u003c/li\u003e\n \u003cli\u003eTong, A., Sainsbury, P., \u0026amp; Craig, J. (2007). Consolidated criteria for reporting qualitative research (COREQ): A 32-item checklist for interviews and focus groups. \u003cem\u003eInternational Journal for Quality in Health Care\u003c/em\u003e, \u003cem\u003e19\u003c/em\u003e(6), 349\u0026ndash;357. https://doi.org/10.1093/intqhc/mzm042\u003c/li\u003e\n \u003cli\u003eWild, H. B. (2020). There\u0026rsquo;s no algorithm for empathy. \u003cem\u003eHealth Affairs\u003c/em\u003e, \u003cem\u003e39\u003c/em\u003e(2), 339-342. https://doi.org/10.1377/hlthaff.2019.00571\u003c/li\u003e\n \u003cli\u003eWillig, C. (2013). \u003cem\u003eIntroducing qualitative research in psychology\u003c/em\u003e (3rd ed.). Open University Press.\u003c/li\u003e\n \u003cli\u003e\u003cem\u003eWorld Health Organization (WHO) (2022). Https://www.who.int/fr/news-room/fact-sheets/detail/cancer#:~:text=%C3%80%20l\u0026rsquo;origine%20de%20pr%C3%A8s,le%20cancer%20de%20la%20prostate.\u003c/em\u003e (n.d.).\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 to 6 are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"medical communication, cancer progression, psycho-oncology, thematic analysis, medical education ","lastPublishedDoi":"10.21203/rs.3.rs-8328352/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8328352/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eObjective:\u003c/strong\u003e Breaking the news of cancer progression is a complex task that requires a balance between clinical accuracy and relational sensitivity. Although research has examined the perspectives of experienced healthcare professionals, little is known about how trainees navigate these consultations. This study aims to explore the experiences of medical and nursing trainees in disclosing disease progression, focusing on communication strategies, emotional impacts, and professional development.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e Eighteen semi-structured interviews were conducted with trainees in Swiss hospitals (11 oncologists and 7 nurses). The data were analyzed via thematic analysis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e Five themes emerged: \u003cem\u003eprofessional role perceptions and oncology practices in cancer progression care\u003c/em\u003e, \u003cem\u003ethe process of disclosing disease progression\u003c/em\u003e, \u003cem\u003eperceptions and reactions of patients and their family caregivers, impacts of disease progression disclosure on medical and nursing trainees, and\u003c/em\u003e \u003cem\u003etraining and development of communication skills\u003c/em\u003e. Participants reported developing these skills through experiential learning, noting that formal training and protocols offered limited support. They portrayed disclosure as a carefully prepared, emotionally demanding process that requires clarity, empathy, and teamwork. Trainees described emotional and organizational burdens, which they felt were eased by experience and peer support. Furthermore, they highlighted the variability in patient and family caregiver reactions, which influenced decision-making and underscored the need for flexible, relationally attuned communication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e Disclosing cancer progression is a demanding experience for trainees, who described the need to adapt their communication, manage emotional responses, and rely on interprofessional collaboration. Their accounts highlight the central role of experience, supervision, and supportive environments in shaping how they navigate these challenging consultations.\u003c/p\u003e","manuscriptTitle":"Learning through difficult disclosures of cancer progression: experiences of physicians and nurses in training","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-22 16:23:52","doi":"10.21203/rs.3.rs-8328352/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-12-26T11:14:48+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-25T12:13:41+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"221348551486799316536959001708474496248","date":"2025-12-19T11:44:55+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-18T20:39:02+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"183409898007203402209350619858318637137","date":"2025-12-18T19:30:29+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-12-18T11:35:51+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-12-15T09:48:00+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-12-12T23:31:17+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-12-12T23:31:02+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Medical Education","date":"2025-12-10T13:53:56+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"53138aca-d2f8-43f0-8819-a29a9fd6eba0","owner":[],"postedDate":"December 22nd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-02-09T16:10:19+00:00","versionOfRecord":{"articleIdentity":"rs-8328352","link":"https://doi.org/10.1186/s12909-026-08688-9","journal":{"identity":"bmc-medical-education","isVorOnly":false,"title":"BMC Medical Education"},"publishedOn":"2026-02-06 15:57:03","publishedOnDateReadable":"February 6th, 2026"},"versionCreatedAt":"2025-12-22 16:23:52","video":"","vorDoi":"10.1186/s12909-026-08688-9","vorDoiUrl":"https://doi.org/10.1186/s12909-026-08688-9","workflowStages":[]},"version":"v1","identity":"rs-8328352","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8328352","identity":"rs-8328352","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}