Abstract
Background:
Providing information to patients is an essential aspect of care. The way in which such information is transmitted is also important and is affected by different variables. The perceptions of dishonest nursing staff have not been sufficiently discussed to date.
Aim:
The purpose is to explore the reasons for dishonesty in transmitting information to patients.
Design and Method:
In this qualitative content analysis study, data were collected using semi-structured interviews with Twelve Iranian Critical Care Nurses from January 2020 till August 2020. Data were analyzed according to Graneheim and Lundman approach.
Ethical consideration:
The research protocol was authorized by the Ethics Committee of the Medical Sciences University of Tehran (Register number: 95-04-99-33485).
Results:
The findings indicated that dishonesty in giving information to the patients has many reasons. Although lying is not compatible with ethical care, working conditions sometimes forced nurses to hide the truth.
Discussion and conclusion:
Nurses believed honesty was an integral aspect of professional practice, but situational specifics have an effect on whether the truth is told or withheld. Finally, the nurses noticed a big gap between what they want to tell and what they were doing in practice.
Introduction
The exchange of information is important in the relationship between the health-care team (physician and nurse) and the patient. It is essential to provide information in all areas and all patients. It is still much more relevant in places where patients need intensive care because they are in life-threatening situations and need more information. 1
Although it is essential to have information to make informed treatment decisions, historical evidence indicates that patients often have very little information about their symptoms, prognosis, or treatment outcomes.2,3 Various studies have found that the intensive care unit (ICU) and critical care unit (CCU) offer their own particular challenges in giving information to nursing staff.4,5
Since nurses spend more time with patients, they are also the closest health care agent to hospitalized patients; therefore, patients expect nurses to be the first line of giving the right information. Furthermore, the intense nature of care in such settings often results in staff having an increased responsibility to communicate important information to patients and families in an effective manner. 6 Giving accurate information to the patient and honesty between the nurse and the patient is necessary to reduce patients’ stress and allow them to regain a sense of control. As is apparent, ethical nursing care is based on an honest relationship between the nurse and the patient. 7 In nursing ethics literature, the concept of trust and honesty in the nurse–patient relationship is frequently noted. Still, there are also situations where the nurse cannot give the patient the right details, and these conditions prohibit the nurse from telling the truth. 8 The deputy acknowledged that although honesty in providing the information is a moral matter, in some situations and for some reasons, hiding aspects of reality occurs. 9 Tieying et al., 10 however, postulated that while truthful information is a generally recognized ethical concept in nursing care, the dedication of nurses to being honest can be less than ideal and may be influenced by phenomena such as attitude, organizational policies, cultural and religious beliefs.
While medical ethics researchers believe that knowing the truth is necessary for the patient to achieve a successful therapeutic relationship, 11 nurses believe that cultural conceptions of right and wrong on information disclosure differ (e.g. it is not normal for eastern people to offer bad news immediately; the bad news is given gradually, whereas westerners face bad news directly).12 Furthermore, concordance between disclosure of information and the patient’s ability to deal with this information is controversial for nurses. 13 Some research results have shown that too much information can lead to feelings of disappointment, depression, and isolation for the patient, so nurses should not tell the truth.6,11,14
Given the existing ethical challenges of providing patients with information (such as being forced to tell part of the truth, or hiding important information, or lying), especially in ICU and CCU, further investigation in the field of how to give information and truth-telling boundaries is required.
Therefore, the present research was carried out to explain nurses’ experiences of dishonesty in transmitting information to patients in the ICU and CCU and paint a more precise image of what happens in clinical practice.
Methods
Aim and design
This is a qualitative content analysis study. Qualitative content analysis is a research method for making replicable and valid inferences from data to their context to provide knowledge, new insights, a representation of facts, and a practical guide to action. The aim is to attain a condensed and broad description of the phenomenon, and the outcome of the analysis is concepts or categories describing the phenomenon.15,16 The research was conducted in ICU and CCU within five hospitals affiliated (governmental) and supervised (for-profit hospitals) to Tehran University of Medical Sciences, Tehran, Iran. In these hospitals, each nurse was assigned to provide bedside nursing care to three or four patients. These ICU and CCUs provided treatment for medical and surgical problems for patients.
Participants
Twelve nurses were purposefully selected to participate in the study. Recruitment began with the first sample who had necessary preconditions and with reaching data saturation ended. Data were sufficiently considered saturated when it was evident that no new information would be obtained. Nurses were recruited from five different hospitals in Tehran, Iran. Inclusion criteria were holding a minimum education level of a bachelor’s degree, plus 3 years of working in an ICU and CCU. Participants with rich experience were purposefully selected to ensure varied workplace exposure to the subject matter at hand.
Data collection
Data collection took place using in-depth semi-structured individual face-to-face interviews from January 2020 till August 2020. In total, 12 semi-structured interviews were carried out with 12 participants. The interviews were guided by questions about their experience providing information to patients, such as: Have you ever been forced to hide the truth or a portion of the truth? When did you not have to tell the truth? How were your feelings and the patient’s feelings? What happened next? What was your motivation for hiding a part of the truth or not telling the truth? Then interviews were continued with probing questions such as would you, please explain it more, what do you mean? Or would you give me an example? Interviews lasted from 40 to 75 min, with an average of 60 min. The interviews were digitally recorded and transcribed verbatim by the corresponding author.
Data analysis
1. Data were analyzed using content analysis according to Graneheim and Lundman’s approach in NVivo software. 16 Data analysis was started by listening to the participants’ voices and continued by repeatedly reviewing the transcribed data. Furthermore, the text was divided into meaning units (about 1600 meaning units) that were condensed. Then, the condensed meaning units based on their importance were abstracted and labeled with codes (such as the request of the patient’s family, the patient’s unwillingness to know, keep the patient calm, the inadequate emotional state of the patient, denial of the patient, lack of mental preparation in the patient, prevention of frustration and destructive effects, maintain motivation and patient hope, the patient’s health, bad patient prognosis, and low patient cultural awareness). Based on comparisons regarding their similarities and differences, 100 codes were sorted into 11 subcategories and 5 categories. These subcategories (based on the codes mentioned above, for example, 1- patient non-acceptance, 2- family reluctance) and categories (based on the subcategory discussed above, for example, considering patient and family preferences) were extracted inductively from the transcripted data. Finally, the theme was created as an expression of the text’s latent content.
Ethical considerations
The research protocol was authorized by the Ethics Committee of the Medical Sciences University of Tehran (Register number: 95-04-99-33485). Participants were told of the study’s goals and methods before giving their consent, as well as reminded of their right to withdraw from the study at any time. Before the interviews, one of the researchers discussed the aims of the study with the participants and received informed consent from the interviewees.
Trustworthiness
Trustworthiness was established following the Guba and Lincoln criteria. 17 Credibility was supported through analyses by three authors and further strengthened by the fact that the first author conducted all of the interviews. The interviews varied in richness and included a wide range of experiences. The non-directive interview style, with the use of opening questions, offered a possibility for the informants to talk about their experiences without restricting themselves. Thus it is hoped that the complexity of the informants’ experiences was expressed and the credibility of the findings enhanced.
Furthermore, the credibility of the data was established through peer-checking and member-checking. A summary of the interviews was returned to the participants, and they confirmed it. Peer-checking was done by all authors and two doctoral candidates in nursing, which resulted in similar findings. Doctoral nursing students were aware of the study plan and played a collaborative role.
Result
Participants in this study were eight female and four male nurses. The participants’ mean age was 34 years, and their working experience in ICU and CCU varied from 3 to 25 years (Table 1). The main theme (a discrepancy between what nurses want to do ethically and what they have to do in the real world) contained 5 categories and 11 subcategories. These five categories include protecting one’s self with three categories (fear of punishment, being expelled, loss of reputation), considering preferences of the patient and their family with two categories (patient non-acceptation, reluctance by family), uncertainty of professional role boundaries with two categories (incomplete role definition, insufficient protocol in giving information), loyalty to colleagues and the organization with two categories (cover-up colleagues’ fault, cover-up organization’s fault), and working conditions for nurses (working overload, resource constrain) (Table 2).
A summary of the participants’ demographic characteristics.
The reasons of dishonesty in providing information to the patients.
Protecting oneself
Nurses who admitted being dishonest in patient communication (even in part) stated that the main reason was to protect themselves. Fear of punishment, generating a complaint, being condemned and expelled for failure and/or malpractice, and safeguarding job security and reputation, were the primary motivations for concealing the truth:
About two years ago, I had a patient with his sutures bandaged every day. One day, after the dressing was done, I pulled the stitches wrong. The patient, who asked why to remove stitches angrily, had to lie to him that the doctor had ordered it. I was afraid he was going to sue me, and I was going to be reprimanded. (Participant No. 4)
I believe that knowing the truth is the patient’s right, but what happens to my career, which is jeopardized by telling the truth? I recalled a few years ago, I had a patient, he was dizzy, and I forgot to lift the bedside railing; he fell out of bed. I could not tell the truth that I forgot to raise the bedside railing; if I was fired, who would cover my expenses? Or if I was punished and my salary was reduced, then who would take care of me? (Participant No. 3)
Patient and her or his family’s preferences
Individual differences within the patient could also play a part. These included maintaining the patients’ peace, hope, motivation, the patient’s mental unpreparedness for hearing the truth, the patient’s age, and the family’s reluctance to inform the patient of their condition would oblige nurses to hide the truth or lie:
We had a patient who was in CCU and had diabetes. They were referred with sore feet. When the Doctors saw them, they said to the nurse, the foot should be amputated. The patient would constantly ask us, “Will my foot recover?” and “Can I go home soon, because I have a disabled child and I need my foot” Doctors put me in a troubled situation; I could not tell them the truth at that moment. As a nurse, I could not disappoint my patient anymore. I told the patient that you will be healed if GOD wills, but I knew that the foot had to be amputated. (Participant No. 12)
Nurses asserted that pressure from patients’ family members would lead to dishonesty. Family members would ask nurses to withhold certain parts of their knowledge from their ill family member. (Participant No. 1 and No. 7).
Unclear professional boundaries
There was evidence of difficulties regarding awareness of where the boundaries of authority and role lay. Often nurses were unsure about are they allowed to give information to the patient. In some cases, even the nurses did not know who should give the news to the patient because there are no specific instructions: If I tell the truth to the patient, then I would be asked, “Which protocol or guideline justified you telling them that?” There was a situation once a patient asked me about surgical complications, and I was comprehensive in my answer. The doctor came to me and asked me, “Who gave you the authority to discuss that with the patient?..”. these situations make me less inclined to speak plainly, so as not to cause any trouble. (Participant No. 9)
Loyalty to colleagues and the organization
Protecting the healthcare organization and other colleagues were also reasons for concealing the truth. When a medical error has occurred, nurses hide information to protect the medical staff and the organization’s reputation:
Nowadays, patients and their families are clever—they repeatedly ask the same questions and check everything again and again so that they can find some information to use against us. They would end up with lots of information to use. In these instances, to keep the peace, I would withhold the truth. Why should I cause trouble for my colleagues? (Participant No. 2.)
I recall one day having a patient who required oxygen and was admitted to the CCU ward; the patient’s condition was changing. She was using portable oxygen, which ran out unexpectedly. The patient’s blood oxygen saturation decreased gradually. When we used central oxygen, we discovered that it had not yet been repaired, even though, it was supposed to be repaired a few days ago…After the patient awoke after receiving oxygen with a delay, she asked me what had happened and what was wrong…But I couldn’t tell her the truth because I didn’t want to bring the medical center or the ward into disrepute. (Participant No. 11)
Working conditions for nurses
Finally, working conditions were given as reasons for failing to provide information to the patient or lying to them. The situations as resource limitations, heavy workload, working through several hospitals, working consecutive shifts, and nursing shortages resulted in exhaustion, burnout, and nurses’ impatience. All these factors together lead the nurse to lie or not provide all the details to the patient:
I work in a general ward, and there are only three of us nurses, with 18 patients. Do you think that we even have time to greet the patients…not to mention answering the questions and thinking about what we should or shouldn’t say! (Participant No. 8)
I sometimes decide to keep quiet and not tell the truth, only speak in necessary, because of alot of workloads. (Participant No. 10)
Discussion
The results of this study showed that although honesty in providing information and telling the truth is important to nursing staff, despite their verbal acknowledgment of the necessity of maintaining honesty, nurses in some situations cannot observe it. In recent decades, many efforts have been made to provide high-quality services in compliance with the Charter of Patients’ Rights in Iranian hospitals. However, in practice, not only in Iran but also in other countries, nurses face constraints that make meeting ethical standards difficult, if not impossible. Because of these constraints, nurses against their will are forced to keep some information from the patient or to say part of the facts.
Evidence from both the Western and Middle Eastern medical literature revealed that, while the Western medical literature prioritizes patient autonomy and corresponding truth-telling, the weight of evidence from the Middle East suggests high variability between and within individual countries, patient–physician relationships, organizational policy, and families regarding truth-telling practices and preferences. 2 A common reason for nondisclosure in both studies is protecting the patients from distressing information. Other factors include contextual limitations like organizational climate, multi-faceted role, lack of time due to work overload, and so on, prevent nurses from doing what they want in practice, despite knowing all of the standards of care and ethics. 18 In our study, nurses believed that dishonesty in providing information was due to the following reasons: protecting herself/himself, the patient, her or his family’s preferences, unclear professional boundaries, loyalty to colleagues and the organization, and working conditions. We’ll go over the explanations one by one.
Accordingly, the first reason for being dishonest in providing information was emerged as protecting themselves. In the study of Ghena et al., 19 results show that when nurses make a mistake, for example, forget to take patients’ drug, they would hide it from the patients for fear of punishment and do not put their occupational future at risk. Also, Zolkefli 7 has argued that non-disclosure or dishonesty is commonplace in patient care, doctors and nurses see it as part of their self-protection. According to the findings of this study, when nurses are forced to lie in self-defense, they suffer from a guilty conscience, and this remorse is always with them. Nurses themselves identify these situations as a particularly challenging aspect of their job, leading to burnout and moral distress.
Another reason for hiding the truth from patients was considering the preferences of the patients and their families. In their opinion, avoiding telling the truth can be used as an honest caring action in order to protect a loved one. We understood that sometimes, nurses are forced not to say the truth to safeguard patients; perhaps it is a supporting strategy. Like our results, Desborough et al. 11 found that the main reason for not telling the truth is nurses’ concerns about the patient’s critical condition and illness. Also, we found that nurses’ goal was to maintain patients’ motivation, hope, and spirit to fight for recovery. In Borjalilu et al., 20 a nurse discussed their experiences of hiding a diagnosis of a type of cancer from a child due to his or her parents’ request and considered it as the worst experience during his or her career. In another study, Gallagher discussed, dishonesty can be justified on empirical grounds since some patients are distressed and become frustrated when they are received more specialized information than they desire. 21 Sometimes the nature of the data is the main reason for hiding because it is challenging to spread bad news or provide highly specialized information to patients in critical condition. Deciding on telling or hiding the truth is an ethical challenge requiring knowledge of ethical principles. 22 Nurses should have an understanding of ethical reasoning to preserve their patients’ rights without compromising their own moral conscience.
Indeed, this study’s participants reported uncertainty of professional role Boundaries as a significant barrier to sharing information with patients. This implies that, in view of the ambiguity of professional role boundaries, truth-telling will seem to be difficult, and that, before the nurses’ authorities are clear, they may fail to say the truth to patients and their families because they will not be deemed qualified to provide information and respond to the patients. Furthermore, In some cases, the nurses stated that the doctors asked them not to give information without consulting them. Vaismoradi et al., regarding the nurse-physician relationship, stated that usually, nurses are not independent in making their clinical decisions, and physicians expect them to ask for their permission before doing anything. This lowered self-esteem and led to an expedient-oriented behavior, resulting in the patient’s deprivation of therapeutic information. 23 During the study, we understood that physicians would ask nurses not to provide any information to the patients without coordinating with them. If patients asked them any questions, they should avoid answering them. Gallagher and their colleagues named this kind of dishonesty as professional dishonesty.24,25 In order to eliminate or reduce professional dishonesty related to the lack of clear boundaries, the role of nurses in providing the information must first be clearly defined so that they do not have ambiguity in answering.
In our results, the next explanation for dishonesty was loyalty to colleagues and the organization. In the study of Ghena et al., of the nurses said that if my colleagues made a mistake and the patients had irreversible issues, the system would ask us not to inform the patients so that the patients’ confidence in my colleagues and the medical team would not be shattered. I accepted it and did not say anything in order to advocate for my colleagues. 19 Also, Carter et al., Ko et al. and the findings of our study indicated that Nurses usually saw themselves as responsible not only to their medical colleagues but also to their healthcare organizations. These responsibilities may conflict with ethical issues such as truth-telling in nursing and medical malpractice cases.18,26 Although nurses are aware of ethical issues and there are many ethical guidelines for nurses, despite nurses’ agreement on ethical issues, they occasionally face specific organizational issues that harm the organization’s credibility. For example, one interviewee stated that after twenty years of working in the same place, it becomes your second home, causing you to be loyal and indebted to it, as far as you decide, if you noticed a mistake, do not say anything to protect your organization or even hide the information. It seems to overcome such ethical issues, familiarity with various approaches to ethical decision-making is beneficial.27,28
The last reason for dishonesty that the nurses mentioned was the hard-working conditions for nurses. These conditions include exhaustion and heavy workload, a large number of patients, insufficient number of nurses, and so on. Ervin et al. 12 in their study, found that there was a disparity between the number of staff and the number of patients, that working shifts would run out of human resources, and that the vast number of nursing procedures would leave nurses with little time to speak to patients and provide them with enough information. Also, Marc et al. and our study’s results pointed out that difficult working conditions and early burnout force caregivers to spend less time with patients. Furthermore, nurses understand that by not giving all of the information to patients in the above situations, they can free up time to care for other patients during their service period. 29 Nurses who reported such experiences under difficult working conditions believed they were assisting other patients and that not providing all of the information to the patients would not harm them. 30
Conclusion
Truthfulness is an ethical norm and characteristic of professional behavior. It is always considered a concern for the nurses. Nurses believe that honesty and truthfulness are a part of ethical care, although it might have risks and threats for them. In fact, it is the conditions and necessity of each situation that would lead them toward telling or hiding the truth or lying; as mentioned discussion, we would call this, The gap between what nurses want to tell and what they have to do in practice. Finally, the nurses acknowledged that the gap between knowledge and clinical practice causes work tension, remorse, burnout, and resignation. This means nurses know that truth-telling is an ethical principle. Still, sometimes the conditions such as protecting one’s self, the condition of the patient and their family, the uncertainty of professional role boundaries, loyalty to organization and colleagues, and working conditions make them refuse to say all or part of the truth.
Summary Statement
What is already known about this topic? Nurses’ honesty or dishonesty continues to remain a challenging issue across critical and intensive care units. Although studies have been done on giving or hiding information or not telling the truth in some wards, we still know far less about why nurses are dishonest, especially in the critical and intensive care units. What this paper adds: (research findings/ key new information).
What this paper adds:
Our findings show that, while honesty is important for nursing staff in providing information and telling the truth, some nurses indicated that, despite verbal acknowledgment of the importance of maintaining honesty, a variety of factors and reasons discussed in this article can affect the information shared with patients.
The implications of this paper:
This subject is important because it is a prerequisite to know about the experiences of critical care nurses on dishonesty to help us do morally driven care.
Knowing the reasons for not being honest between critical and intensive care nurses in a specific situation help to perform a new study on how to eliminate obstacles so that such experiences will not be repeated in the future.
Implications for future practice
This subject is important because it is a prerequisite to know about critical care nurses’ experiences on dishonesty to help us do morally driven care. Knowing the reasons for not being honest between critical and intensive care nurses in a specific situation, help to perform a new study on how to eliminate obstacles so that such experiences will not be repeated in the future.
Limitation
In this study, the possibility of nurses’ self-censorship in expressing their experiences may have occurred. When they know what is right and wrong, they try to conceal their opposing thoughts and actions and attribute failures to environmental factors.
Footnotes
Author contributions
I confirm that all of the authors (R.N., M.K.H., M.A.H., D.M.) had authorship Criteria. They had same contribution in whole parts of this article such as, study conception and design, data collection, data analysis and interpretation, and drafting of the article. Each author had participated sufficiently in the work to take public responsibility for the content.
Conflict of interest
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Ethical approval
approval was obtained from ethical committee of Tehran University of Medical sciences. Register number is 95Ethical-04-99-33485.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research supported by Nursing and Midwifery Care Research Center, Tehran University of Medical Sciences (grant number 95-04-99).
