ORIGINAL ARTICLE

The PEWTER Study: Breaking Bad News CommunicationSkills Training for Counseling Programs

Kathleen Keefe-Cooperman1 & Devyn Savitsky1 &

Walter Koshel1 & Varsha Bhat1 & Jessica Cooperman2

Published online: 15 September 2017# Springer Science+Business Media, LLC 2017

Abstract The efficacy of teaching communication skills for breaking bad news in graduate-level counseling programs was examined. A structured model, PEWTER (Prepare, Evaluate,Warning, Telling, Emotional Response, Regrouping; Keefe-Cooperman and Nardi 2004),provides a method for this difficult task. Prior to training in using the model, students reportednot feeling adequately trained or comfortable giving bad news. The PEWTER trainingundertaken was significantly related to students’ increased feelings of preparedness andcomfort. Breaking bad news is a universal experience across cultures and the structuredprotocol seems to offer value in helping counselors in training be better prepared for such achallenging task.

Keywords Breaking bad news . Communication . Counselor training . Counseling

Introduction

Providing distressing information is emotionally draining for both the recipient and the persondelivering the news. A counselor strives to help people improve their lives, but watching theoften gut-wrenching reaction of a parent, student or any other person who has just receivedemotionally shocking information can make even the most seasoned specialist struggle. Manyprofessional helpers develop their own method for delivering difficult information throughoutthe course of their careers. Graduate students, however, often receive no training on thischallenging task during their schooling (Nardi andKeefe-Cooperman 2006). Bad news, defined

Int J Adv Counselling (2018) 40:72–87DOI 10.1007/s10447-017-9313-z

* Kathleen Keefe-CoopermanKathleen.Keefe-Cooperman@liu.edu

1 Department of Counseling and Development, Long Island University, 720 Northern Blvd.,Brookville, NY 11548-1319, USA

2 Loyola University, Baltimore, MD, USA

here as any information that affects a person’s view of his or her future (Baile et al2000; Buckman 1992; Nardi and Keefe-Cooperman 2006), is universally likely across cultures.

Counselors must face many possible reactions when giving bad news, and may worry aboutpotential negative outcomes from the communication exchange. The school or mental healthcounselor may fear being unable to intuitively know howmuch information to give. The feelingsand emotions experienced by the counselor can be stressful. The professional maywonder if theysaid too much or too little. The dialog may not even be desired by the person hearing the badnews. Counselees may blame the counselor, or question competency. Repeated instances canresult in compassion fatigue for the school and mental health counselor, whereby the repeatedand ongoing act of being compassionate can lead to professional burnout (Ray et al. 2013).

Difficult conversations can range from news that results in a minor inconvenience to lifechanging events. The counselor’s subjective experience of facing stress related to a conversa-tion is what makes the event challenging. There are many examples of circumstances where acounselor might need to be the person to deliver bad news. Discussions may involve a schoolcounselor telling a parent that their daughter is pregnant or that their youngster is a seriousbully. A mental health counselor may have to share with a husband or wife that their spousehas been diagnosed with a serious mental health issue and needs to be hospitalized. Bothschool and mental health counselors may have to address racial microaggressions at their siteswith students, parents of students, or counselees (Sue et al. 2009). Another example that both aschool and outpatient mental health counselor could face might involve a counselee or studentwho is engaging in self-injurious behavior such as cutting. The mental health counselor orschool counselor may need to discuss with the parents that more involved counseling isneeded, but the parents may insist that they want the child to remain with the current counselor.These are all examples of potentially stressful scenarios for counselors.

An examination of the exchange dynamics between the person communicating distressingnews and the individual/s receiving the information suggests that the stress level of thecommunicator typically increases until the news is given, and then decreases (Ptacek et al.2001). However, the person receiving the news typically experiences an increase in stress uponreceiving the news. Thus, the people involved in the exchange are at different emotional pointsduring the experience, and this needs to be recognized by the counselor to increase sensitivity.

The skill of providing and suitably supporting those receiving upsetting news can beenhanced by breaking down a demanding and complex process into manageable and progres-sive stages of communication. Applying proven counseling skills within the use of a lightlystructured model has the potential to improve the efficacy of imparting all the necessaryinformation, increase the counselor’s ability to respond appropriately to the counselee’sexperience, and result in a greater feeling of control, thereby decreasing stress for thecounselor. Mental health and school counselors are well trained in using proven techniquesto successfully facilitate growth and change. The difficulty of giving bad news is that, althoughcounseling techniques are successfully used, the added dimensionality of stress related to theemotionally charged situation results in additional skills being needed to guide the counselee toa new life path or scenario.

Ahmady et al. (2014) reviewed models for breaking bad news in the medical field, andfound 14 studies that included specific protocols. These models encapsulated the essentialfeatures necessary for each step of the communication process needed to deliver difficultmedical information. However, professional counseling requires a somewhat different type ofmodel for imparting bad news because of the differences between giving a medical diagnosisand the counseling process as a whole. Counseling can be defined as Ba professional

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relationship that empowers diverse individuals, families, and groups to accomplish mentalhealth, wellness, education, and career goals^ (American Counseling Association n.d.; Kaplanet al. 2014, p. 366). Although there are similarities between the two areas, the process differsfrom that of typical medically-themed models, and requires protocols for breaking bad newsthat are specific to those objectives.

One structured set of guidelines, PEWTER (Prepare, Evaluate, Warning, Telling, EmotionalResponse, Regrouping), has been accepted in both the medical and counseling fields (Keefe-Cooperman and Nardi 2004; Keefe-Cooperman and Brady-Amoon 2012, 2013; Nardi andKeefe-Cooperman 2006). The PEWTER model was developed in 2004 following a review ofthe existing literature, and a realization that a need for a model existed for emergency medicalpersonnel in the field and for counselors (Keefe-Cooperman and Nardi 2004). Ahmady et al.(2014) cited the PEWTER protocol as meeting the rigorous guidelness necessary for successfulcommunication of bad news in the medical field. Further research found that the model waspositively regarded as a communication skills-set in the areas of homicide victim notificationand end of life care (Miller 2008a, b; Watson 2008). Additionally, PEWTER has beensuccessfully applied to the counseling field at professional conferences and in the peer reviewedliterature. The versatility of the model and applicability across settings lends to its acceptance asan effective method for guiding the delivery of bad news. These combined factors suggested anext step involving choosing the PEWTER model to teach graduate students how to facilitatedifficult conversations with counselees.

Incorporating the PEWTER model into the counseling curriculum of graduate programshas the potential to be of benefit to students, because it offers a degree of structure to anuncontrolled stressful situation. Students who have had exposure to the framework can enterthe field of professional counseling more skilled in how to handle difficult discussions, ratherthan having to learn through trial and error. Using a structured protocol has the potential tolessen ambiguity and emotional strain for the student and practicing counselor and improve theoverall experience for all parties involved.

Bad News Communication and the Counseling Field

All bad news brings with it emotional reactions, from mild to life shattering. Receiving badnews about a child can be particularly difficult (Auger 2006). Parents have dreams for theirchildren, and often have trouble viewing their youngsters objectively. Counselors are facedwith providing realistic information, but also want to help the parent/s remain optimistic. Thisdelicate balance can influence the way in which news is given, and sometimes result in theparent/s not fully understanding the impact of the information. Using the previously mentionedexample of an adolescent engaging in self-injurious behavior, the parents may be happy withthe ongoing counselor and not realize the need for more intensive treatment. The counselorcannot always know how the person receiving the bad news will interpret the information, butan effective communication experience may help facilitate the next step after the initialexchange. As an example, parents with more confidence in their ability to engage inproblem-solving might be more likely to action positive coping strategies that will alsoincrease their feelings of effective parenting (Roskam et al. 2008).

Many counselees remember how bad news was given, and have ideas about how theexperience could have gone better. One study showed that inpatient clients with serious mentalhealth issues reported dissatisfaction with how distressing news was presented to them

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(Gallagher et al. 2010). As an example of receiving bad news, those involved in the studyreported confusion upon hearing multiple diagnoses, not getting enough information,experiencing poor communication, and feeling unheard. The individuals indicated a desire toreceive more details, as well as wanting the news to be given in a sensitive manner. Addition-ally, counselees have indicated wanting to be given information in a manner that allowed for anelement of hope (Cleary et al. 2010). Having guidelines helps counselors engage in bettercommunication strategies for such difficult conversations. Structured protocols also have thepotential to ensure that ethical guidelines, like those of the American Counseling Association’sCode of Ethics (2014), for example, are likely to be followed, in general and with regard toproviding such specific information to clients as assessment results.

Cultural Implications

Social issues can be multi-factorial. Adding additional facets of possible racial factors, ethnicidentity, sexuality, religion, emotional, intellectual or physical disabilities, and socioeconomicconcerns to an already difficult task of giving bad news may be so overwhelming for the newcounselor that the conversation becomes unproductive. As an example, Singh et al. (2010)used grounded theory methodology to examine the difficulties school counselors might facewhen advocating for social change in their schools. Seven themes were identified, withinitiating difficult dialogues being one; bringing up subjects that might invoke feelings ofdefensiveness or discomfort for the counselor advocate.

Being sensitive to factors related to diversity adds yet another element to be considered inalready difficult interactions. Counseling students may have difficulty remembering to recog-nize and acknowledge how multiculturalism can impact communication during stressfulexchanges. Counseling students have been found to attribute client problems to the individualwithout taking into account larger contributing societal and discriminatory factors (Bray andBalkin 2013). Incorporating an awareness of social justice issues while imparting bad news toindividuals might be experienced as distracting by counselors-in-training, and add anotherlayer of confusion and possible stress for recipient/s.

Diversity issues can also add another layer of emotionality to the process of breaking badnews. For example, when working with a Japanese teenager who has just found out that she ispregnant, the need to consider and incorprate an awareness of the larger implications related tobeing an unmarried pregnant teenage girl within a Japanese household makes a stressfulconversation even more complicated. A child’s perception of parental warmth can influenceemotional security (Sart et al. 2016). The significance of any emotionally laden crisis on futurefamilial relations cannot be underscored enough. The reaction of a parent after receivingtroubling news about their child can impact the youth’s emotional security both now and forthe future. The reaction of significant others to troubling news can remain a loaded emotionalreference point, and impact future relationships, and this can also apply between the counselorand the counselee in any ongoing therapeutic relationship.

Racial/ethnic backgrounds may influence the amount and type of information the counseleeprefers to hear. Barclay et al. (2007) wrote on the topic of race and ethnicity related toinformation giving. There seem to be tendencies within African American/Black and EuropeanAmerican clients to typically want detailed information so as to make informed choices, whichis is not always the case for other cultures. Members of the Bosnian culture may not wantinformation to be disclosed and not want the full truth, and traditional Navajo counselees may

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feel that learning the truth can actually cause a bad outcome. As another example, Harper et al.(2009) suggested that counselors should use a strength-based approach when working withBlack males, rather than one that is pathologizing. Recognising and valuing diversity is animportant part of any difficult conversation, as the larger counseling world of engagementbecomes increasingly multicultural (Issari 2006). Counselors also bring their own social issuesto the experience. Counselors-in-training’s feelings of self-efficacy are inevitably impacted bythe scope and likely influence of background factors such as age, gender, religion and racialidentification (Lam et al. 2013), and such feelings can add to already stressful experiences.

The Need for a Model in Counseling Graduate Programs

It has been recognized that the process of giving bad news is important within the counselingfield. For example, Auger (2006) provides a set of comprehensive guidelines for deliveringbad news. Included is the importance of preparing the setting, and specific suggestions on howto deliver the news and respond to reactions. Key counseling skills are included in both thoseguidelines and in the PEWTER model. The guidelines provide a general rule about how tohave a difficult conversation, and include important information. Remembering all the guide-lines, though, can be difficult for emerging counselors during a stressful communicationexchange. Thus, using a set model that organizes guidelines into structured steps may helpthe counselor remember all the important aspects that lead to best possible outcome aftergiving bad news.

The PEWTER model (Keefe-Cooperman and Nardi 2004) provides a clear mnemonic thatsystematically delineates each part of an essential process so that the counselor is able toremain on task during a time of emotional stress and thereby increase feelings of self-efficacy.This is particularly helpful for counselors-in-training, as students can find it overwhelming tothink about finding both the appropriate nonverbal and verbal skills, combined with theappropriate counseling technique to use in difficult situations. This is likely to lead to gapsin the communication process, missed opportunities for clear information sharing, and thepossibility that both parties leave the exchange with feelings of things being left undone orregrets for what was not adequately communicated.

In addition, counselor educators can find value in being able to teach the PEWTER model,as having a clear set of communication guidelines for specific scenarios can adds to theirclinical repetoire for teaching counseling skills. A set protocol for handling distinct situations,such as the PEWTER model, can be easily taught in a variety of courses and be used to helpmeet the standards of the profession.

Teaching a formal protocol for breaking bad news can be an important part of the educationalcurriculum. The PEWTER model provides training needed for delivering distressing informa-tion. A symposium and also an in-depth classroom experience were successfully developed tothoroughly ground graduate students in the rationale for the model, and provided detailedinstruction on each part of the mnemonic. The instructionally-based experiences were modeledafter well-received conference presentations teaching the PEWTER protocol to counselingprofessionals. Students were then provided with real life mental health and school scenarioswhere bad news needed to be provided, and used the steps to deliver the information. ThePEWTERmodel was successfully taught in the space of 2–3 hrs. It is practical as a teaching tooland easily understood by both practitioners and counseling students. Each step of the PEWTERmodel is briefly outlined in Table 1, and more fully explained in the following section.

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The PEWTER Model

P: Prepare

Prepare is perhaps the most complex of all the steps. Not only does preparation involve beingcompetent in being able to apply counseling skills learned during classes, practicum and internshipexperiences, but it also involves being aware of personal thoughts, values, and contributing lifefactors. Preparation can be viewed as both internal and external. The counselor-in-training needs tobe aware of how they view their role in the communication exchange. Do they see themselves as theBmessenger of doom,^ or as a Bguide helping the person on a journey to a new point in life?^ Thisself-view is important as that influences the approach, both verbal and nonverbal, that is likely to bepresented. Attending to self-care is also key, as being tired, distracted, emotionally pressured oroverwhelmed can impact the counselor’s ability to attend and respond effectively.

External factors, such as the physical setting are also crucial. Finding as private a setting aspossible is important, as is freedom from distractions and interruptions (e.g., turning off cellphone notifications). The set-up of the physical space is also vital related to the distancebetween the counselor and the person/s receiving the news. Buckman (2001) generallyrecommends a physical distance of two to three feet for difficult communications, but careneeds to be taken so as to make physical adjustments possible as needed.

The counselor should review any records prior to the arrival of the person/s receiving thenews, as well as considering the likely meaning of the information. Knowing what to say in amanner that can be easily understood by a lay person is important, without being patronizingor overly simplistic. Factors should be considered that could influence the timing of themeeting, such as in regard to religious practices. For example, scheduling the the meetingmight involve avoiding a time or date when religious practices or work circumstances mightmake things difficult. The counselor must always take into account the counselee’s culturalbackground and personal circumstances in this regard (ACA 2014). Familiarizing oneself withpossible areas that might impact the communication process is key.

Table 1 PEWTER protocol for breaking bad news

Step Techniques

(P) - Prepare Attending to the physical setting, self-awareness of personal factors thatmay influence the exchange, reviewing the records, taking into accountcultural factors.

(E) – Evaluate Determine what the counselee suspects or understands aboutthe situation prior to telling the bad news. Open-ended questionsare especially important. Noting verbal and nonverbal cues.

(W) – Warning Giving a brief statement that indicates bad news is to follow,and allowing a short pause for the counselee to begin to prepare mentally.

(T) – Telling The counselor breaks the bad news in a genuine manner andis sensitive to the reactions of the person getting the bad news.

(E) – Emotional Response The counselor is attuned to how the counselee is receivingthe news, and must be prepared to either end the meetingif needed so as to reconvene when the counselee is bettersituated to continue, or proceed if the receiver is ableto continue. Assessing supports that are available is appropriate at this stage.

(R) – Regrouping The counselor works to help the counselee determine howto next proceed. Referrals and supportive systems maybe provided. Remaining genuine and compassionate is key.

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E: Evaluate

Many individuals often suspect that a problem exists. People may be hesitant to broachconcerns, or they may avoid mentioning concerning thoughts out of the hope that the issuegoes away. Evaluating what the counselee suspects or understands about the situation prior totelling the bad news allows misinformation to be corrected. For example, parents of a childwho is about to receive a Conduct Disorder diagnosis may have already entered their child’sproblem behaviors into an Internet search, and are just waiting for the words to be spoken thatmake the feared diagnosis a reality. Ascertaining the likely thoughts prior to giving the badnews allows for a shared platform from which to move forward.

Open-ended questions are vital to this step. The counselor can ask something like thefollowing when the counselee gives an indication that knowledge of a problem is present, BWeknow there have been a lot of difficulties up to this point, what do you think is going on?^ Incases where it is unknown if the person receiving the bad news has any idea that something iswrong, the counselor can query, BHave you noticed anything lately that has been concerning?^

Nonverbal communication is also important, as both the counselee and the counselorpresent their own cues as well as see cues exhibited by the other. Three distinct areas of thisdifficult discussion will be influenced by nonverbal communication (Roter et al. 2006): boththe giver and receiver of bad news have emotions, both show emotions and both will interpretwhat the other’s emotions represent. The counselor must be aware of their nonverbal presen-tation, as this can hinder or facilitate communication.

W: Warning

TheWarning is a significant part of the communication process. Although quite brief, it allowsfor the counselee to begin processing that bad news is coming. The warning may be as simpleas, BI have some difficult news to share with you.^ A brief pause is then taken whereby thereceiver of the news begins to experience a cognitive and emotional shift. This allows theindividual to begin to contemplate that something is wrong and opens their mind to hearingwhat that news might be.

T: Telling

Telling is the center of the process for breaking bad news, and is the point where the counselorimparts the information. This is a challenging step because the presenter of the informationmay be feeling the highest level of stress at that point (Ptacek et al. 2001). The previous threesteps have helped set the stage for what could be termed ‘the point of no return’. The counselormust exhibit genuineness and be present in the moment. Avoiding technical jargon is key. Theprofessional may understand what ‘school reorientation’ represents, but the parents may neverhave heard of the term. Using inductive reasoning may be helpful.

The counselor can list the observations and/or facts and then the central difficulty. Provid-ing details of the behaviors and the rationale often will be in line with what the recipient hasnoted, and will result in a higher level of acceptance of the problem. The tone of voice is alsoimportant, and care should be taken to speak in a gentle and compassionate manner. Watchingthe person receiving the bad news will help direct the counselor as to whether furtherexplanation of the bad news is required. Presenting information in chunks might also bevaluable, as is checking with the individual to assure that they understand what is being said.

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E: Emotional Response

Individuals differ, not just in terms of personality traits that affect thoughts and feelings, butalso in how they respond to being given bad news. Being attuned to the Emotional Responseallows for the next leg of the communication journey to begin. At this point, the counselormust conduct a self-appraisal to ensure they are presenting appropriately. Both nonverbal andverbal cues could be misinterpreted. A slight smile could be interpreted as a smirk. This is alsowhen the emotional stress level of the counselee often begins to peak, while the stress level ofthe counselor concurrently begins to decrease. This needs to be remembered so as to remainaware of the counselee’s presentation.

Some people may not be able to proceed at this time due to the overwhelming nature of theinformation. The counselor should always ascertain if a break or another appointment entirelyis needed. The individual may want to reconvene at another time so as to involve other people,or be incapable of continuing at that moment due to emotionality.

This is the point as well where positive community and familial supports should beconsidered. For example, reaching out to a religious leader could be encouraged if the personprofesses a sense of spirituality and affiliation with a house of worship. Assessing familial,friends and other resources may be appropriate.

R: Regrouping

Regrouping represents the final point in the PEWTER process. This is not the end, but thebeginning of the next journey for the person. The counselor works at this point to help thecounselee determine how to next proceed. This can be accomplished by helping the counseleefind resources, such as a reputable support group, or a site where additional services might befound to ease the strain of the bad news. Printed material could also be part of the process andthese might contain relevant phone numbers or websites.

Instilling hope, whenever possible and however small an amount, is an inherent part in thisphase of communication. Being hopeful represents new and frequently revised goals that theindividual begins to work toward (Bruininks and Malle 2005). Hope might represent suchthings as a discussion of the efficacy of techniques for reducing acting out behaviors for ayouth with an Autism Spectrum Disorder, the access to special needs services that may bepresent at a new site, or what counseling techniques have proven effective for treatment of aserious mental health issue.

The biggest contributing factor to the success of the last phase continues to be thecounselor. Remaining genuine and showing compassion while using professional communi-cation techniques is key to facilitating ongoing interaction. This will create a memory for thefuture on which the person might look back on and realize that they were not alone during atime of crisis. The counselor in training who learns to use effectively the PEWTER model willenter the profession with a greater sense of confidence and self-efficacy.

A Need in Counseling for a Tested Structured Protocol

A review of the research literature within the field of counseling found information on theimportance of breaking bad news, and suggestions on how to improve a difficult situation(Auger 2006; Cleary et al. 2010; Gallagher et al. 2010; Roskam et al. 2008). However, there is

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a lack of tested systematic protocols for providing distressing information in the counselingfield. The theoretical PEWTERmodel addresses the need for a systematic mnemonic structure,but has not been researched in the field. This important topic may also be under-addressed intraining programs (Milton et al. 2016). Additionally, it is unclear as to how students perceivetheir level of preparedness for giving bad news. There is a need to study the efficacy of atraining program focusing on breaking bad news, and designed for the counseling field. Thisleaves an important gap in the counseling literature base.

Purpose

The purpose of the current study was to consider the efficacy of a training for graduate studentsin the counseling field for communicating bad news using the structured protocol PEWTER(Keefe-Cooperman and Nardi 2004). Several hypotheses were tested (a) that counselingstudents do not feel adequately prepared or comfortable giving bad news; (b) that counselingstudents will show a significant improvement in their feelings of preparation and comfort levelafter the training; and (c) that teaching a structured protocol results in increased knowledge andfeelings of competence for graduate students when giving bad news.

Method

Participants

Participants were 63 graduate students who had registered for one of two symposia focusingon developing communication skills using the PEWTER model. The symposia were adver-tised on campus as well as via email, and were free. All of the students were enrolled in aMaster’s degree program in counseling accredited by the Council for Accreditation ofCounseling & Related Educational Programs (CAREP). The study group was composed offifty-seven women and six men, and all listed their primary language as English. The majorityof students were in their twenties or early thirties (85%), with 12.7% listing their age as beingbetween 35 and 44, and 1.6% being 45 or older. Race/ethnicity was reported as follows:European-American or White (n = 43, 68.3%), Latino or Hispanic (n = 11, 17.5%), Black orAfrican American (n = 6, 9.5%), Asian or Asian American (n = 1, 1.6%), and Other (n = 2,3.2%). Fifty of the students reported being single or never married (79.4%), and 13 stated theywere either married or in a domestic partnership (20.6%). The bulk of the participants (n = 58,92.1%) were currently either interning or completing a practicum at a counseling site.

Procedures

The study had received full approval by the university IRB committee prior to the symposiabeing advertised. Students were given a questionnaire packet and asked to first complete aconsent form as well as a pre-workshop questionnaire upon their arrival to the symposium.Care was taken to advise the participants that completing the questionnaire packet wasvoluntary. Included was demographic information as well as questions focusing on perceptionsof giving bad news, perceived self-efficacy, expectations of counselee responses after hearingtraumatic information, and level of comfort with performing the task. Another questionnaire

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was given following the symposium to determine differences in student perceptions afterlearning and practicing the PEWTER model.

A five point Likert-type scale was used for both questionnaires to allow each participant toexpress how much they agreed or disagreed with statements. Answer choices were Bstronglyagree (5),^ Bagree (4),^ Bneutral (3),^ Bdisagree (2)^ and Bstrongly disagree (1).^ A higheroverall mean score indicated more agreement with the statement, and the reverse was true forlower mean scores. Students were also asked six questions before the symposium that assessedtheir views about breaking bad news.

Training Program

The training was developed by the research team using instructional material from wellreceived PEWTER symposia presented at national conferences (Keefe-Cooperman andNardi 2004; Keefe-Cooperman and Brady-Amoon 2012). The presentation was bothdidactic and experiential, with information and exercises presented in clearly timedsegments so as to remain on task. After showing a video clip from a popular televisionshow focusing on bad news, the presenters first defined bad news (as stated earlier) forthe audience so as to ensure a common reference point. A small group exercise was thenconducted whereby participants shared personal communication strategies and ap-proaches found helpful in daily life and/or when at counseling internship/practicum/worksites. This helped the students feel that they had the beginning experiences and skillsupon which to build greater competency.

The presenters segued to the didactic lecture focusing first on the stressors faced by thecommunicator of difficult information, and then the emotional strain of the personreceiving the news. The difference in stress levels between the two parties was highlight-ed and explored. The PEWTER model was introduced at this point, and each step of themnemonic clearly explained.

The participants were then asked to work in dyads for a case example exercise. Casescenarios were developed based on actual stories provided by working counselors. Situationswere outlined involving bad news that was emotionally difficult for both the counselor and thecounselee. Two scenarios were provided and students were free to choose the most applicable,based on whether they were focused in either school or clinical mental health counseling. Theschool counseling case scenario involved one participant having to tell the role playing parentthat their child was pregnant. The clinical mental health scenario involved a discussion with acounselee at a supposed large medical site at which the counselor worked as part of a team thatthey had been diagnosed with HIV. Each practice session was timed so as to ensure thesymposium stayed on schedule. Both members of the dyad switched roles, and each played thecounselor and counselee.

Students then reconvened to the larger group setting and verbally processed their experi-ence with the presenters leading the discussion. The first topic question focused on how theyfelt prior to giving the difficult news. The second centered on the experience of using thePEWTER model. An open topic discussion then followed in which participants askedquestions and delved deeper into the experience of giving bad news. Self-maintenance andcoping techniques were provided at the end of the symposium so as to stress the importance ofself-care for the counselor, and as a means of avoiding professional burnout linked to ongoingwork in the area of emotional distress. Select references were also given. Finally, a post-symposium questionnaire was completed.

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Results

Results by Hypothesis

Pre- and Post-Symposium Questionnaire Comparisons

A number of questions were asked of the participants in regard to their pre- and post-workshopself assessments (see Tables 2 & 3). Paired-samples t tests were calculated to compare meanscores in regard to what were regarded as three specific key questions. The questions wereregarded as key because they specifically addressed the student’s perceived skills and comfortlevels before and after the symposium. Other pre-workshop questions dealt with prior knowl-edge and experiences, and the other post-workshop questions focused on aspects of awarenessand confidence considered gained.

All statistical assumptions for the paired-samples t test were examined and met. Specifi-cally, the dependent variables (responses) were measured on a continuous scale, the indepen-dent variable (participants pre-post) consisted of two categorical Bmatched pairs,^ there wereno significant outliers in the differences between the two sets of scores, and the distribution ofthe differences in the dependent variables between the two related groups were approximatelynormally distributed.

The mean pre-workshop score on the first key question (Q.4 Table 2; Q.11 Table 3) (‘I feelprepared with my current skill/education level to deliver bad news’) was 2.70 (SD = .85,SE = .11), while the mean post-workshop score was 4.02 (SD = .61, SE = .07). This differenceof 1.32 points (95% CI 1.10–1.54 points) was statistically significant, t(62) = −11.928,p < .001. The mean pre-workshop score on the second key question (Q.5 Table 2; Q.12Table 3) (‘I am comfortable delivering bad news’) was 2.75 (SD = .86, SE = .11), while themean post-workshop score was 4.44 (SD = .62, SE = .78). This difference of 1.69 points (95%CI 1.44–1.96 points) was statistically significant, t(62) = −13.139, p < .001. Finally, the meanpre-workshop score on the third key question (Q.6 Table 2; Q.13 Table 3) (‘I feel comfortableknowing a client’s/student’s response to bad news may be intense, emotional, or seeminglyinappropriate’) was 3.30 (SD = .94, SE = .12), while the mean post-workshop score was 4.08(SD = .55, SE = .69). This difference of .78 points (95% CI .51–1.04 points) was statisticallysignificant, t(62) = −5.857, p < .001.

Table 2 Graduate students' perceptions of giving bad news prior to training

Pre-symposium questionnaire responses Mean score (SD)

1. I have thought about the process of delivering bad news. 3.73 (.97)2. I feel the topic of delivering bad news was adequately discussed during my

training/education.2.49 (.84)

3. I have previous training in delivering bad news. 2.06 (.98)

Key Questions for paired-samples comparison4. I feel prepared with my current skill/education level to deliver bad news. 2.70 (.85)5. I am comfortable delivering bad news. 2.75 (.86)6. I feel comfortable knowing a client’s/student’s response to bad news

may be intense, emotional, or seemingly inappropriate.3.30 (.94)

Students answered each question using a 5 point Likert scale ranging from BStrongly Disagree^ to BStronglyAgree^

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Effectiveness of the PEWTER Training

Additional post-workshop questions and mean scores (Q.1–Q 10) can be found inTable 3. The graduate students reported that the PEWTER model helped them in regardto delivering bad news (M = 4.22), feel confident in their ability to break bad news(M = 3.94), clarify questions for clients (M = 3.90), warn the client/student of the badnews (M = 3.92), and present information related to bad news (M = 4.08). Increasedawareness was rated highly in several areas, including the preparations needed to givebad news (M = 4.44), and the need to evaluate client/student knowledge of the situationprior to giving bad news (M = 4.41). Greater recognition of the importance of vocaltones and use of language was noted (M = 4.48). Overall, students felt that the PEWTERmodel was a practical method that could be used at school or mental health counselingsites (M = 4.59), and that they felt more comfortable in regard to delivering bad newsafter the workshop (M = 4.30).

Discussion

The present study was to our knowledge, an unprecedented attempt to evaluate the value of thePEWTER model. This is the first known study assessing student perceptions of giving badnews, implementing a communication skills training seminar related to giving bad news, andassessing feelings of competence after learning the PEWTER model. The findings suggest thatincorporating the PEWTER model in counseling graduate programs could be practical andalso of value. Results of this study support the hypotheses that students find the topic ofproviding distressing news to be a difficult one, and that the PEWTER model provides avaluable structure for the rather daunting process.

Table 3 Graduate students' perceptions of giving bad news after the PEWTER training

Key post-symposium questionnaire responses Mean score (SD)

1. The PEWTER model helped me deliver bad news. 4.22 (.71)2. I now feel confident in my ability to break bad news. 3.94 (.62)3. I feel more confident in my ability to clarify any questions the client asks of me. 3.90 (.69)4. I am more aware of the preparations needed to give bad news. 4.44 (.62)5. I am more aware of how I need to evaluate the client’s/student’s knowledge

of the situation prior to giving bad news.4.41 (.66)

6. I feel confident in my ability to warn the client/student of the bad news. 3.92 (.68)7. I feel more confident in presenting the information relating to bad news. 4.08 (.55)8. I have greater recognition of the need to use simple, everyday speech

when breaking bad news, and to modulate my tone of voice.4.48 (.56)

9. I felt that the PEWTER model is practical and can be usedin my clinical/school practice.

4.59 (.58)

10. I feel more comfortable delivering bad news after this workshop. 4.30 (.66)

Key Questions for paired-samples comparison11. I feel prepared with my current skill/education level to deliver bad news. 4.02 (.61)12. I am comfortable delivering bad news. 4.44 (.62)13. I feel comfortable knowing a client’s/student’s response to bad

news may be intense, emotional, or seemingly inappropriate.4.08 (.55)

Students answered each question using a 5 point Likert scale ranging from BStrongly Disagree (1)^ to BStronglyAgree (5)^

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Distinguishing features of this present study include applying a set protocol for breakingbad news, and making the PEWTER model available in the graduate school setting forcounselors in training. This study also provides a teaching method that enhances counselingcurricula, and meets the foundational standards of accrediting bodies such as CACREP. Theresults may encourage discussions on how to mediate the difficult task of giving possibly life-changing information using PEWTER, and what that means within the role of a counselor.

Student Perceptions of Giving Bad News

Graduate students in counseling programs are schooled in communication skills, but worryabout their ability to give bad news in a competent manner. The scores reflect that studentstypically felt unprepared to have difficult discussions. Students viewed the process of having adifficult discussion as a stressful experience and this supports previous findings (Nardi andKeefe-Cooperman 2006; Ptacek et al. 2001). The findings show that this topic is an importantone for counseling students. Giving bad news is something that students usually have thoughtabout, but have not been adequately prepared to address.

The curriculum of the graduate program involved in this study was approved by CACREP,and was found to address adequately all standards upon last review by the accrediting body.Even with the program having met the highest standards of the counseling profession, thisemotionally laden task was considered to be inadequately addressed. Student perceptions werelinked to a positive reception for a structured protocol, and were representative of the similarneeds of medical students (Garg et al. 1997; Liénard et al. 2010). It would seem clear then thatcounseling students want greater guidance on how to break bad news.

Post-PEWTER Training

The level of preparation felt by counselor students was significantly higher following thePEWTER training. Students felt a significantly greater degree of comfort with the thought ofgiving bad news following the symposium, as compared to their degree of comfort prior to thetraining. They also indicated a greater level of comfort regarding the likely response by clients/students to bad news. Trainees were additionally more comfortable with the realization thatsomeone receiving bad news might display a reaction that could be intense, emotional or evenseemingly inappropriate.

The effectiveness of this training for counseling students is similar to that for medicalstudents (Liénard et al. 2010; Park et al. 2010). A common theme across the professions is aconcern by developing professionals about how to behave in difficult situations. The differ-ences between the trainings are profession-specific, with some contrasts between a medicalmodel versus a counseling model. However, seemingly, all students in training benefit fromskills workshops that improve their ability to break bad news. Using a set protocol that isspecific to a line of work, such as PEWTER for counseling, may make a difficult andcomplicated process easier for emerging professionals.

Effectiveness of the PEWTER Training

Counseling students reported that the PEWTER model training was beneficial in helping themto deliver bad news. Students gained greater realization of the steps needed prior to tellingsomeone potentially negative information. On average, an increased level of confidence was

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exhibited regarding the ability to engage in difficult conversations, and provide a warningabout the upcoming bad news. The PEWTER model training facilitated a successful methodfor presenting the information. Students felt that the model itself could be used effectively inboth the school and mental health settings.

The PEWTER model has been positively put forth as a communication skills-set in theareas of school and mental health counseling, homicide victim notification and end of life care(Keefe-Cooperman and Brady-Amoon 2013; Miller 2008a, b; Nardi and Keefe-Cooperman2006; Watson 2008). This study adds to the larger field of research by showing that there is aneed for a structured communication model, as demonstrated by the success of PEWTER, inthe graduate school area of counseling. This training is easily transferable to other countries,with only minimal cultural adaptation needed. Involving more of a wellness focus may beneeded (Jacob et al. 2016).

The PEWTER training provided graduate students with perceived skills necessary to breakbad news and a valuable resource that builds upon curricula and enhances student learning,and educators are likely to benefit by offering a valuable framework that seemed well received.The large array of factors addressed during the PEWTER model meet many of the standardsput forth by CACREP, and appear to add to the efficacy of the educators, program andprofession as a whole. The PEWTER protocol can also help meet CACREP standards(2016), including enhancing ethical practice, social and cultural diversity, human growth anddevelopment, counseling and helping relationships, assessment and testing, and programevaluation. Teaching the PEWTER model has the potential to enhance the skills of graduatestudents in counseling, and contribute to the highest standards for the profession.

Limitations

This study has several limitations and the results should be interpreted with appropriatecaution. First, the majority of participants identified as white and female. This limits thegeneralizability of the findings. Second, the study was based entirely on self reporting, whichobviously falls short of being able to assess skills in action. Collecting other methods oftreatment efficacy, such as observer ratings of student skill during the role play would havebeen a stronger test of the efficacy of the intervention. Students voluntarily signed up for thesymposium, and, accordingly, may have been predisposed to an acceptance of the model.Also, it is unclear as to the length of time the assessed worth of the PEWTER training remains.

We recommend that future researchers consider ways to address these limitations andexpand the knowledge and effectiveness of the PEWTER model. It is recommended that thelength of retention for the PEWTER model skills be assessed using a longitudinal study. Astudy of the PEWTER model in clinical/school settings is also recommended to assess realworld differences in perception. The model was developed in the U.S., and cultural adaptationof it and the training should also be explored for other countries.

Conclusion

It is an inescapable fact that counselors will have to give bad news, and the situation mayinvolve individuals with whom the counselor has no pre-existing contact. Without a structuredprotocol such as PEWTER, unschooled and ill-prepared counselors are likely to be left to

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develop this skill through trial and error. The PEWTER protocol provides a fresh approach toteaching graduate students in counseling programs how to break bad news. Students seem tofind the PEWTER training both beneficial and gratifying, and experience a greater perceivedlevel of control and effectivess in regard to the task.

Compliance with Ethical Standards The authors certify that they have no affiliations with or involvement inany organization or entity with any financial interest (such as honoraria; educational grants; participation inspeakers’ bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and experttestimony or patent-licensing arrangements), or non-financial interest (such as personal or professional relation-ships, affiliations, knowledge or beliefs) in the subject matter or materials discussed in this manuscript.

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