Communicating difficult news in neonatal ICU: an integrative reviewAbstract
Communicating difficult news in neonatal intensive care units is a complex and challenging process that requires sensitivity, technical preparation, and ethics. This study aimed to synthesize and critically analyze recent scientific production on the topic via an integrative literature review. The review was conducted according to PRISMA guidelines and analyzed ten studies published between 2017 and 2025. The findings were organized into four thematic categories. Gaps in professional training, lack of institutional protocols, and the emotional impact on professionals stood out as obstacles to communication. Nevertheless, training in communication skills and the use of protocols for communicating difficult news proved promising in this context. Communicating difficult news in the neonatal intensive care unit environment requires an empathetic, individualized, and culturally sensitive approach, which impacts reception, trust, and quality of care in moments of extreme vulnerability.
Keywords:
Truth disclosure; Intensive care units, neonatal; Medicine
Resumo
A comunicação de notícias difíceis em unidades de terapia intensiva neonatal configura-se um processo complexo e desafiador, que exige sensibilidade, preparo técnico e ética. Este estudo objetivou sintetizar e analisar criticamente a produção científica recente sobre o tema, por meio de revisão integrativa de literatura. A revisão foi conduzida segundo as diretrizes PRISMA e analisou dez estudos publicados entre 2017 e 2025. Os achados foram organizados em quatro categorias temáticas. Destacaram-se como obstáculos à comunicação lacunas na formação profissional, a carência de protocolos institucionais e o impacto emocional nos profissionais. Em contrapartida, treinamentos em habilidades comunicacionais e o uso de protocolos de comunicação de notícias difíceis mostraram-se promissores nesse contexto. A comunicação de notícias difíceis no ambiente de unidades de terapia intensiva neonatal requer abordagem empática, individualizada e culturalmente sensível, a qual impacta no acolhimento, na confiança e na qualidade do cuidado em momentos de vulnerabilidade extrema.
Palavras-chave:
Revelação da verdade; Unidades de terapia intensiva neonatal; Medicina
Resumen
La comunicación de noticias difíciles en unidades de terapia intensiva neonatal es un proceso complejo y desafiante, que exige sensibilidad, preparación técnica y ética. El objetivo de este ensayo fue sintetizar y analizar críticamente la producción científica reciente sobre el tema, mediante una revisión integrativa de la literatura. La revisión se llevó a cabo según las directrices PRISMA y analizó diez ensayos publicados entre 2017 y 2025. Los resultados se organizaron en cuatro categorías temáticas. Se destacaron como obstáculos para la comunicación las lagunas en la formación profesional, la falta de protocolos institucionales y el impacto emocional en los profesionales. Por otro lado, la formación en habilidades comunicativas y el uso de protocolos de comunicación de noticias difíciles se mostraron prometedores en este contexto. La comunicación de noticias difíciles en el entorno de las unidades de terapia intensiva neonatal requiere un enfoque empático, individualizado y culturalmente sensible, que repercute en la acogida, la confianza y la calidad de la atención en momentos de extrema vulnerabilidad.
Palabras clave:
Revelación de la verdad; Unidades de cuidado intensivo neonatal; Medicina
Communication is fundamental in health care, as it favors reception and adherence to treatment 1,2. However, when it comes to difficult news, it raises several challenges for professionals, who need to balance honesty and emotional support in providing information. This is because communicating difficult news involves breaking expectations, beliefs, values, and life projects, which raises several concerns about its impact on physical and mental health 3.
Communicating difficult news is a central to clinical practice and goes beyond the simple exchange of verbal information, encompassing gestures, expressions, and the emotional context in which social interactions occur 4,5. In neonatal intensive care units (NICU), where the clinical scenario is marked by high complexity and vulnerability, the proper management of communication becomes even more critical, since it is an important aspect that influences bonding, trust and decision-making 6.
Difficult communications are frequent in the routine of health professionals and cause challenges, given their complexity and the intense emotional impact involved, especially in NICUs 7. Moreover, the disclosure of serious diagnoses or prognoses can cause discomfort in family members due to the fear of suffering and death, which amplifies their emotional impact. Therefore, professionals who work in this scenario must provide accurate, appropriate and appropriate information to the cultural, emotional and cognitive characteristics of those involved 8.
Currently, there are several communication protocols that contribute to the improvement of skills in handling difficult news 9,10, even in clinical scenarios of intense emotional distress. However, additional challenges exist when considering NICUs, including work overload, lack of time and space for sensitive conversations, lack of specific training in communication, and high emotional impact, both for professionals and family members involved 11. Moreover, defense mechanisms in response to stress can elicit affective distancing reactions by professionals, which compromise trust, care quality and, consequently, communication 12.
Considering the context presented and the relevance of communicating difficult news in the NICU, the study aimed to synthesize and critically analyze the scientific production on the subject to elucidate the communicational challenges present in this care scenario.
Method
This is an integrative literature review, conducted according to the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 13. The methodological path was based on the question: what is the evidence available in the scientific literature on the communication of difficult news in the context of neonatal intensive care units?
The inclusion criteria adopted were original articles that addressed the communication of difficult news between health professionals and family members in the context of NICUs, published in Portuguese, English, or Spanish between January 2015 and April 2025. Literature reviews, editorials, letters to the editor, opinion articles, dissertations, theses, abstracts of scientific events, and non-scientific trials were excluded, as well as studies conducted in pediatric or adult intensive care units and duplicate studies.
The PubMed, MEDLINE, Embase, Web of Science, Cochrane Library and LILACS databases were searched. Medical Subject Headings (MeSH) and Health Sciences Descriptors (DeCS) descriptors were used, conjugated by the Boolean operator “and”, according to the following data search strategy: “(Communication) and (Neonatal Intensive Care Units) and (Newborn)” for the search in the LILACS database; and “(Communication) and (Intensive Care Units, Neonatal) and (Infant, Newborn)” to search the other databases.
The identified articles were imported into the Rayyan platform, and the authors manually deleted duplicates. Subsequently, the selection and screening of studies occurred in two stages, conducted by two independent and double-blind reviewers: the first stage consisted of screening by reading titles and abstracts, while the second stage involved the full reading of the pre-selected articles, with strict application of the eligibility criteria. In cases of divergence, a third reviewer was consulted.
Data extraction was performed independently, using a standardized form that included the following information: title, authorship, year of publication, country of publication, methodological design, study objectives, characteristics of the participants, main findings related to the communication of difficult news, conclusions and recommendations of the studies in the communicational context in the NICU.
The synthesis of the data was conducted qualitatively and narratively, and the results were grouped into thematic categories, prioritizing the following aspects: emotional implications; barriers to communication; prior training and skills development; and cultural, ethical, and relational aspects involved. Quantitative data, when available, are shown descriptively.
Results
The systematic search in the databases found 1,371 articles. After the removal of 265 duplicates, 1,106 studies were selected for evaluation of titles and abstracts, of which 1,082 were excluded after applying the eligibility criteria. The remaining 24 articles were read in full, and reading resulted in the final inclusion of ten studies. The selection process is represented in the PRISMA flowchart (Figure 1).
PRISMA flowchart of the search, selection and screening of the studies included in the review.
The ten articles included, which are described in Chart 1, were published between 2017 and 2025, with a concentration in the last five years. Most studies were was conducted in Brazil (n=4), followed by the United States of America (n=2), France (n=1), Israel (n=1), Germany (n=1), and Canada (n=1). Regarding methodological designs, the studies had different approaches, with a predominance of qualitative studies of a descriptive nature (n=7), followed by randomized controlled trials (n=1), cross-sectional (n=1) and quantitative (n=1). Regarding aims of the studies, emphasis was observed on investigations on knowledge, skills and impacts on the communication of bad news in NICUs, which addressed not only the point of view of health professionals, but also of parents.
Description by title, authorship, year of publication, country, methodological design, and aim of the study of the articles included in the review
Chart 2 shows that the main data extracted from each study enabled a thematic analysis that resulted in the organization of the findings into four main axes related to the management of communication of bad news in the neonatal context: emotional implications; barriers to communication; prior training and skills development; and cultural, ethical, and relational aspects.
Description by authorship, characteristics of the participants, main findings, conclusions and recommendations of the final articles included in the review
Emotional functions
Studies reveal that communicating bad news in the NICU has an intense emotional impact on both professionals and family members. Camilo and collaborators 19 highlight that this process is seen by nurses as unpleasant, complex, and arduous, with the main challenge being the feeling of powerlessness for not being able to deal with the emotional overload, especially in situations of neonatal death. Despite the difficulties, the participation of the nursing team is indispensable, especially in offering support to family members in the post-communication period. Also, Koch, Rosa, and Bedin 15 reinforce that the sociocultural representations of death intensify the symbolic load of bad news, and that the psychological impact associated with this process amplifies emotional discomfort among professionals.
Nevertheless, the way news is communicated can directly influence the experience of family members. Kukora and collaborators 22 highlight that inadequate communication can have deleterious effects in the long term, compromising parents’ trust in the team and causing prolonged parental suffering, since parents keep vivid and lasting memories derived from the way they received difficult news.
Wege and collaborators 20 show that the professionals’ perception of empathy and in-depth knowledge of the case directly contribute to the parents’ emotional support. However, Cheng and collaborators 21 emphasize that emotional responses are heterogeneous, since there are those who feel oppressed when communication is restricted to the objective presentation of facts, without the offer of emotional support. Nevertheless, others prefer a more direct and factual approach and interpret expressions of empathy as generic or artificial.
Barriers to communication
The absence of adequate training, technical preparation and institutional protocols was pointed out as the main barrier to effective communication. Pirrello and collaborators 18, when evaluating the dimensions involving communications about critical care in the NICU, found that there is difficulty in adapting the communication of bad news to parental expectations, due to legal, ethical and emotional aspects.
Haim-Eli, Benbenishty and Wruble 23 also demonstrated that the communication process does not occur in a systematic and uniform way, largely due to the lack of institutional protocols. Moreover, the lack of prior knowledge about the patient/family, personal concerns about the level of clinical knowledge, and self-confidence in handling bad news add to these barriers. In a complementary way, Koch, Rosa and Bedin 15 reinforce that many professionals do not use or even acknowledge the validity of protocols for the communication of difficult news. Moreover, they also describe emotional factors as barriers to this process.
Cheng and collaborators 21 show that NICU residents face barriers in learning difficult conversations, since the hierarchy of the profession, which assigns the responsibility for communication to the most experienced physician, limits the active participation of residents and reduces learning opportunities, which highlights gaps in practical training in communication.
Prior training and skills development
Specific training in communication of difficult news is one of the needs most emphasized in the studies analyzed. Haim-Eli, Benbenishty and Wruble 23 point out that the lack of educational curricula aimed at the development of skills for the communication of bad news contributes to a disjointed and not always efficient performance among multiprofessional health teams.
In this context, Koch, Rosa and Bedin 15 reinforce the incorporation of this theme in a systematic way in undergraduate and graduate courses, given that adequate preparation has a direct impact on effective communication. Likewise, Pirrello and collaborators 18 and Marçola and collaborators 17 show that a structured medical education, with the inclusion of communication skills, associated with professional training and the use of specific protocols, is essential to qualify communication between health professionals and family members, especially in sensitive contexts such as the NICU.
Moreover, Bowen and collaborators 16 report that the implementation of other communication training programs, such as workshops with practical simulations, demonstrates positive results not only in terms of technical competence, but also the empathy of the professional in the neonatal ICU, which shows that the simulated practice contributes significantly to technical and emotional preparation.
Cultural, ethical, and relational aspects
Communicating difficult news in the NICU context requires not only technical mastery and communication skills, but also an understanding of the context in which communication takes place. Cabeça and Sousa 14 identified that communication is qualified when it considers both the context in which the news is transmitted and the individual experiences and relationships established between professionals and family members, so that it requires adaptations to the beliefs, cultures and values of the interlocutors.
In this same perspective, Camilo and collaborators 19 and Wege and collaborators 20 emphasize that effective communication begins with the recognition of the subjectivity of each family and the singularities of each newborn. In addition, Marçola and collaborators 17 demonstrate that the way information is transmitted can profoundly influence the experience of suffering, so that professionals, in addition to the technical content, are required to be sensitive, continuous care and attention to the life trajectory of the families, even after the news is communicated.
Moreover, cultural elements exert a significant influence on this process. Kukora and collaborators 22 point out that cultural and relational values strongly influence the way news is received and interpreted, even impacting trust in the professional. Haim-Eli, Benbenishty and Wruble 3 They highlight specific cultural barriers, such as taboos associated with the communication of bad news, establish a block not only in the transmission, but also in the understanding of the information. Therefore, the professional must be attentive and be able to promote communication in an accessible and effective way.
Discussion
The NICU is a scenario of vulnerability, where uncertainty and the imminent risk of death require that communication transcend the mere exchange of clinical information and be established as an ethical imperative of care. The analysis of the literature reveals, however, a persistent tension between technological sophistication and the fragility of human relationships and highlights gaps that compromise the ethics and humanization of care.
One of the most critical findings refers to the asymmetry of power and the violation of parental autonomy. The frequent exclusion of parents from clinical dialogues and the lack of validation of their understanding suggest the persistence of a paternalistic model, in which the team holds the knowledge and the decision. The excessive use of technical language and the strategy of “softening” serious news violate the principle of veracity. Instead of protecting, this opacity generates distrust and prevents parents from exercising truly free and informed consent, fundamental for shared decision-making 24,25.
From the perspective of human dignity, signs of dehumanization and impersonality are observed, such as the non-use of the baby’s name or gender by the team. This conduct reduces the newborn to an object of intervention and ignores the otherness of the family, increasing psychic suffering and weakening the bond of trust necessary to cope with grief and illness 26. The literature reinforces that empathic communication is not simply desirable, but a mechanism of non-maleficence, as the way the news is transmitted can be iatrogenic and aggravate family trauma 14,20,27.
In the context of justice and institutional responsibility, the absence of structured protocols and the heterogeneity in communication conducts generate inequity in care. The lack of standardization, added to the low integration between professional categories (especially between physicians and nurses), fragments care and compromises patient safety. The adoption of communication tools and the definition of difficult news flows are therefore ethical measures necessary to ensure team cohesion and clarity of information 23,28.
Finally, moral distress, insecurity and fear of family reaction, reported by both resident physicians and experienced nurses, denounce failures in academic training, which prioritizes technique to the detriment of relational skills. Health communication should be seen as an essential “soft technology.” Investing in continuing education and emotional support for the team is, therefore, a double care strategy: it protects the professional from illness and ensures that families receive ethical, compassionate, and humanized care 15,16,19,21.
Final considerations
The communication of difficult news in the NICU transcends the sphere of technical procedure; it constitutes the ethical foundation on which the care relationship between team, family and patient is built. This study shows that such a practice requires more than technical preparation; it requires a moral competence that integrates emotional balance, communicative skills, and a deep understanding of the human dimension of suffering.
The literature review found that, although professionals recognize the importance of an empathetic approach, significant gaps in training persist, characterized by the incipience of active listening and low personalization of information. When communication is flawed, the parents’ ability to understand the clinical picture and participate, in a free and informed way, in decisions about the newborn is compromised, violating the principle of informed consent.
Thus, the central contribution of this study lies in demonstrating that the humanization of care is not an accessory, but an ethical imperative. Strategies such as the adoption of structured protocols and the strengthening of the multidisciplinary team should be seen as tools to ensure the dignity of the family and mitigate the vulnerability inherent to the NICU context.
Going beyond the purely welfare approach in favor of a true ethical dialogue is thus urgent. This requires investments in training starting from undergraduate studies and in institutional policies that value family-centered communication. By exercising self-criticism and improving relational competence, professionals not only improve the technique, but also reaffirm the NICU’s commitment to the defense of life in its human and relational fullness.
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Data availability:
All data used or generated in this study are described and presented in full in the body of the article.
Edited by
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Editor in charge:
Dilza Teresinha Ambrós Ribeiro
All data used or generated in this study are described and presented in full in the body of the article.
