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Background: Keep the patients well and fully informed about diagnosis, prognosis, and treatments is one of the patient’s rights in any healthcare system. Although all healthcare providers have the same viewpoint about rendering the truth in treatment process, sometimes the truth is not told to the patients and instead, healthcare staff use “white lie”. This study aimed to explore the nurses’ experience of white lies during patient care. Methods: This qualitative and descriptive study was conducted during June to December 2018. Eighteen hospital nurses were purposively recruited with maximum variation from ten teaching and public hospitals affiliated to Tehran University of Medical Sciences. Purposeful sampling was used and data were collected by semi-structured interviews that were continued until data saturation. Data was classified and analyzed by content analysis approach. Results: The data analysis in this study resulted in four main categories and eleven subcategories. The main categories included hope crisis, bad news, cultural diversity, and nurses’ limited professional competence. Conclusion: Results of the present study showed that, the use of white lie by nurses during patient care may be due to a wide range of patient, nurse and organizational-related factors. Communication was the main factor that influenced information rendering. Nurses’ communication with patients should be based on mutual respect, trust and adequate cultural knowledge, and also nurses should provide precise information to patients, so they can make accurate decisions regarding their health care.
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Situations of using white lie during patient care: a
qualitative study into nurses’ perspectives
Alireza Nikbakht nasrabadi
Tehran University of Medical Sciences
soodabeh joolaee
Iran University of Medical Sciences
Elham Navab
Tehran University of Medical Sciences
Maryam esmaeilie
Tehran University of Medical Sciences
mahboobe shali ( m.shali@zums.ac.ir )
Tehran University of Medical Sciences
Research article
Keywords: Ethics, White lie, Truth-telling, Nurse, Content analysis
DOI: https://doi.org/10.21203/rs.2.24636/v2
License: This work is licensed under a Creative Commons Attribution 4.0 International License. 
Read Full License
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Abstract
Background: Keep the patients well and fully informed about diagnosis, prognosis, and treatments is one
of the patient’s rights in any healthcare system. Although all healthcare providers have the same
viewpoint about rendering the truth in treatment process, sometimes the truth is not told to the patients
and instead, healthcare staff use “white lie”. This study aimed to explore the nurses’ experience of white
lies during patient care.
Methods: This qualitative and descriptive study was conducted during June to December 2018. Eighteen
hospital nurses were purposively recruited with maximum variation from ten teaching and public
hospitals aliated to Tehran University of Medical Sciences. Purposeful sampling was used and data
were collected by semi-structured interviews that were continued until data saturation. Data was
classied and analyzed by content analysis approach.
Results: The data analysis in this study resulted in four main categories and eleven subcategories. The
main categories included hope crisis, bad news, cultural diversity, and nurses’ limited professional
competence.
Conclusion: Results of the present study showed that, the use of white lie by nurses during patient care
may be due to a wide range of patient, nurse and organizational-related factors. Communication was the
main factor that inuenced information rendering. Nurses’ communication with patients should be based
on mutual respect, trust and adequate cultural knowledge, and also nurses should provide precise
information to patients, so they can make accurate decisions regarding their health care.
Background
In Iran, medical ethics literature and the Patient’s Bill of Rights highlight patients’ right to receive accurate
and complete information about diagnosis, prognosis, and treatments [1-4]. Iran is an Islamic country in
which people are prohibited from telling lies and persuade them to be truthful[5]. Although healthcare
providers and patients have the same viewpoint about truth-telling in the process of treatment[4], there
are sometimes emotional, professional, and cultural barriers to the provision of accurate information to
patients[5]. In any aforementioned circumstances, healthcare providers may inevitably use lies which are
called white lies or therapeutic bs [6].
By denition, a white lie is a deceptive interaction to prevent injury or grief or to protect peoples feelings
[7-11]. History of medicine shows ample evidence in which Greek physicians did not provide information
to patients or provided them with inaccurate information to force them to accept treatments [9].
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Hippocrates’ notes show that truth-telling or accurate information provision to patients about the
outcome of illness can aggravate prognosis [12].
Although telling a lie is an unethical practice, it is not a person-oriented practice and hence, its prevention
and management necessitate interventions to manage its underlying causes [8]. Physicians are the
main information source to the patients and their families [13-16]. Moreover, truth-telling necessitates all
healthcare providers, particularly nurses to be involved in this process [16]. Studies showed that nurses
are in a position that frequently to be forced to hide truths [17, 18]. They sometimes were placed in
situations where truth-telling was impossible and have to use white lies [19].
In this eld, most studies have been conducted with the aim of examining the attitude of target groups
towards telling the truth in a form of quantitative or literature review. No study was also found in Iran to
use qualitative methods to examine the experiences and perspectives of care providers in the cultural
context of Iran. Yet, there is no in-depth information about the situations in which nurses feel compelled
to tell a white lie. The present study was conducted to address this gap and aimed to explore nurses’
experiences of the situations of telling a white lie during patient care.
Methods
Design
This qualitative descriptive study was conducted during June to December 2018 using conventional
content analysis approach. Qualitative content analysis is a suitable method when the purpose of a study
is to extract the content of a text, as it facilitates the identication and categorization of the information
without changing its meaning[20].
Sample and setting
Study participants were nurses who were working in ten teaching and public hospitals aliated to Tehran
University of Medical Sciences, Tehran, Iran. These hospitals have the highest rate of patient admission
with different diagnoses. Sampling was purposively done with maximum variation in terms of
participants’ gender, educational level, work experience, and work environment. Inclusion criteria were
associate degree or higher in nursing, agreement for participation in the study, being able to communicate
in Persian language and ability to share personal experiences.
Data collection
Data were collected by the rst author through in-depth individual semi-structured interviews. Relevant
eld notes were written before and after interviews by the interviewer and during next interviews for
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clarication. Sample interview questions include; “Can you think of a situation during your patient care
when you did not or could not tell the true to your patient?” “Would you please explain?” “Which tricks did
you use in such situations?” “In what situations during patient care did you use a white lie?” “Would you
please explain your experiences of telling a white lie during patient care?” and “How do you dene telling
a white lie during patient care?”. Interviews were held at participants’ preferred time and place and lasted
between 30–60 minutes. Data collection continued until reaching data saturation after the sixteenth
interview. Two more interviews were also conducted to ensure the data saturation. Interviews were
digitally recorded with voice recorder and transcribed verbatim by the corresponding author.
Data analysis
Data were analyzed through ve-step conventional content analysis method proposed by Graneheim and
Lundman [20]. In the rst step, each interview was transcribed word by word. In the second step, the
interview transcript reviewed several times to obtain a sense of the whole. In the third step, each interview
transcript was considered as the unit of analysis and meaning units were identied and coded. The rst
author analyzed the total data, while the second analyzed half of the textual data. Two authors then
compared the codes, and revised minor disagreements after discussion. In the fourth step, codes grouped
into subcategories according to their conceptual similarities and differences.
.In the fth step, subcategories compared with each other and the latent data content identied and
presented as main categories. The nal four categories were examined by all authors to ensure a clear
difference between categories and subcategories and t the data within each category.
Parts of the audiotape were translated from Farsi into English by an independent translator blind to the
study to check for consistent translation. Data analysis carried out using MAXQDA statistical software
version 2010.
Trustworthiness
Trustworthiness was applied with Guba and Lincoln criteria of credibility, dependability, conrmability,
and transferability [21]. Credibility was established using member- and peer-checking, prolonged
engagement, and maximum variance of participants’ selection. For instance, for member-checking, a brief
report of the ndings was given to two clinical nurses, whom they asked to reect their experiences and
perspectives to the analysis report for researcher assurance. For peer-checking, two qualitative
researchers approved the primary codes and categorizing process. Transferability achieved via the
provision of a rich description of data collection, analysis processes and ndings to allow the readers to
match the ndings with their contexts.
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Results
Participants were twelve female and six male nurses with 37±4.2 year mean age and 13±4.6 years mean
work experience. Totally, in data analysis, 314 codes were generated which further categorized into four
following main categories and 11 subcategories. The mail categories were the crisis of hope, bad news,
cultural diversity, and nurses’ limited professional competence. These categories are presented in table 1
and are explained as follows:
The crisis of hope
Hope is an antidote that makes illnesses and their diculties bearable. Our participants took part in
situations where their clients experienced the crisis of hope after hearing about truths related to their
illnesses. Therefore, they felt compelled using white lies. This category subcategorized into three of loss
of beliefs, lack of motivation for treatments, and death anxiety.
Loss of beliefs
Patients’ beliefs may change during illness. Awareness of bitter truths may challenge or change their
beliefs. Beliefs, in turn, affect patients’ perceptions of health and illness. According to the participants, a
white lie helps nurses reduce the importance of negative situations and supports patients’ beliefs.
When we inform them about the bitter truths, they lose their faith in treatments, dietary regimen, and even
religion and God (P. 14).
Lack of motivation for treatments
In case of serious illnesses or lifetime treatments, motivation is a key factor affecting treatment success
and patient adherence to treatments. Our participants referred to tell a white lie or to avoid truth-telling as
strategies for maintaining patients’ motivation.
A question which patients always ask is, “Will I recover from this disease?” The answer is sometimes
“No”. But who can give this answer forthrightly? It will be associated with motivation loss. Thus, we need
to use answers like, “Go ahead; it may get better. The science is advancing” (P. 11).
Death anxiety
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Awareness of imminent death can cause an acute psychological crisis for patients and reduce their
collaboration and motivation. Moreover, death anxiety can negatively affect hope and quality of life. All
these situations may require healthcare providers to tell a white lie.
Family members may warn us about the fact that their patient fears cancer and ask us not to tell him/her
the truth. Thus, we should use other words in these cases to prevent patient anxiety or fear over death
from affecting his/her hope. For instance, we may use words such as gastric ulcer or tumor instead of the
word cancer (P. 13).
Bad news
One of the most challenging situations of using a white lie is when nurses want to give patients and
family members bad news. In these situations, nurses may resort to telling a white lie due to their lack of
knowledge about strategies for giving bad news, concern over damages to nurse-patient relationships,
unfamiliarity with patients’ morale and emotions, and fear over patients’ strong emotional reactions.
Situations in which nurses preferred to tell a white lie for giving bad news were related to the diagnosis of
a serious illness, treatment ineffectiveness, and signicant losses.
News about the diagnosis of a serious illness
Getting informed about diagnoses that are publicly equated with an imminent death makes these
dicult situations even more challenging and may shock patients and families. In these situations,
nurses may use a white lie to minimize the effects of the shock associated with hearing about a piece of
bad news.
Particularly, in the case of the diagnosis of cancer, multiple sclerosis, and similar serious illnesses, we
need to play with words to avoid telling the truth about the diagnosis (P. 9).
News about treatment ineffectiveness
Long-term chemotherapy courses, major surgeries, and extensive treatments may cause patients to
perceive that they are approaching recovery. However, when treatments are ineffective, nurses face
challenges and diculties in telling patients about treatment ineffectiveness and may resort to white-lie-
telling.
When futile treatments are continued, patients may conclude that they are achieving recovery. They may
ask us about treatment effectiveness. At that moment, we cannot tell them about treatment failure (P. 10).
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News about signicant losses
Signicant losses such as loss of a child, an organ, or a family member are very stressful for patients and
their family members. Nurses who give news about signicant losses to patients and family members
may face unexpected emotions such as shock, anger, belief loss, deep grief, and guilt. Accordingly, they
may primarily tell a white lie to reduce such emotions.
When a patient dies and we want to inform his/her family members over the phone, we cannot directly
tell them that the patient has died; rather, we just tell them that the patient is not in good condition and
ask them to quickly refer to the hospital (P. 2).
Cultural diversity
People with different cultures and ethnicities have different methods for disclosing information about
illness-related realities and have different rituals for dealing with reality. Besides culture and ethnicity,
each person has a unique method for dealing with reality. The two subcategories of the cultural diversity
main category were the patient’s culture and organizational culture.
Patient’s culture
Nurses need to provide care to patients from different cultures. Because of their cultural beliefs, patients
have their unique behaviors, some of which may not be in line with treatment goals. Thus, nurses may
sometimes feel compelled to tell a white lie to achieve treatment goals.
There was a child in our ward with a nasogastric tube in place and a “Nothing by mouth” order. His family
members brought us an admixture from their home city and believed that the admixture could treat their
child. They rmly insisted on the gavage of the admixture while the child should not receive anything by
mouth due to his medical conditions. Finally, we had no option but to tell the family that we had given the
food to their child (P. 16).
Organizational culture
Moreover, organizational culture, values, and beliefs affect their behaviors. According to our participants,
organizational culture and policies may require them to tell a white lie.
Even in case of the diagnosis of serious illnesses, we are not allowed to tell the families anything until the
physicians inform them. In those situations, we answer patients’ questions without referring to reality (P.
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18).
Nurses’ limited professional competence
Besides the characteristics of patients, healthcare organizations, and other healthcare providers, nurses’
limited professional competence also affected their use of white-lie-telling. This main category included
three subcategories, namely limited communication skills, limited professional knowledge, and limited
professional experience.
Limited communication skills
Communication is the core of nursing care. In dicult situations when nurses are the only accessible
source of information for patients, limited communication skills may require them to use a white lie.
Sometimes, patients ask questions that I don’t know how to answer. In these situations, I attempt to
provide good answers; however, occasionally I cannot manage the situation and cannot tell the truth
without annoying the patient. Thus, I may feel compelled to use a white lie (P. 12).
Limited professional knowledge
Medical and nursing sciences continuously advance and change. Sometimes, nurses do not have
adequate knowledge about patients and their treatments and hence, may nd themselves in situations
that require them to use a white lie.
Sometimes, I may not know the answers to patients’ questions. In such situations, I may have no option
but to use a white lie. Of course, this is not true for critical situations (P. 15).
Limited professional experience
Experience helps nurses understand which information should be given to patients and which strategies
should be used for giving information. Novice nurses are more prone to situations that force them to use
a white lie.
More experienced nurses have magic sentences which are neither a lie nor direct answers to patients’
questions. At the beginning of my work, I didn’t have experience and told the truth to the patients directly.
Such direct truth-telling caused negative consequences. After a while, I sometimes felt compelled to use a
white lie to answer some patients’ questions (P. 6).
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Discussion
This study explored nurses’ experiences of the situations of using white lie during patient care. Our
ndings showed that nurses might feel compelled to use a white lie during patient care due to factors
such as the crisis of hope, bad news, cultural diversity, and nurses’ limited professional competence.
Hope crisis is one of the main categories of this study. Although nurses experienced fear of hope crisis in
case when they were obliged to tell a bitter truth, other studies including Seyedrasooly et. al have shown
neutral effects on patients' hope and quality of life of the patient in truth disclosure situations [22]. In
Apatira et. al (2008) study, overall, 93% (166 of 179) of surrogates felt that avoiding discussions about
prognosis is an unacceptable way to reduce death anxiety and maintain patients’ hope [23]. In another
study, awareness of bad news had no effect on treatment motivation or patients’ beliefs. Patients and
their families were concerned about how to report bad news [24] To overwhelm this concern, techniques
such as information provision about available diagnostic procedure and treatments, supporting systems
and allocating enough time based on each patient’s personal needs should be taken [25].
Bad news is the second main category of telling a white lie during patient care to reduce or avoid patients'
reactions. Patient reactions to bad news are not predictable and may include anger, crying, denial, verbal
abuse, threatening behaviors, bargaining, and silence. Management of all these reactions requires great
communication skills [26]. Bagherian et. al showed that nurses were reluctant to tell bitter truths to
patients and did not have the necessary abilities to do so [27]. Also, Gauthier et. al showed further
reasons for white lie use in bad news break like caregivers’ negative feelings, time management, accurate
information provision, and ability to provide logical answers to patients’ and their families’ questions by
the nurses [28].
Culture is another factor that force the nurses to use white lie. In this study culture has been reected in
different areas of medical, nursing, organizational and patient personal aspects. White lies have been
used to achieve therapeutic goals where abovementioned cultural aspects stood as an obstacle against
these goals. However, based on Iranian and Islamic culture, telling the truth is a religious virtue and
strongly recommended. This principle signies the importance of patients dignity and latitude [29], and
highlights the nursing supporting role against bad news harms. Despite this religious and national virtue,
nurses' experiences showed that cultural limitations and differences made truth-telling an intricate task
especially in patient critical situations. Truth-telling to patients seems to be easy in countries such as the
United States[30], while in Asian and southeastern European countries that would be dicult and requires
more advanced communication skills. So, given the impact of culture on the acceptance of truth, medical
and nursing educational authorities need to develop strategies to improve nurses’ competence in truth-
telling and patient informational provision.
In addition to organizational and patient-related factors, nurses’ limited professional competence also
contributed to their use of white lie during patient care. Our ndings also showed nurses related factors
for white lie use such as limited communication skills, professional knowledge, and professional
experience. The ability to understand patients’ wordings and their insights about treatment modalities
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together with appropriate physical, emotional, and social environment all can help to establish rational
and effective communication techniques and facilitate truth-telling to patients and their families [31].
In all, dilemma between truth-telling or white lie use is an ethical challenge that cannot be overwhelmed
only with improved personal ability. To reach this goal, organization supportive atmosphere may drive
nurses to cope with ethical challenges of white lie use in the patient care setting. Malloy et. al suggests
that nurses’ work environment can affect their attitudes toward ethical issues and their ethical decision-
making [32]. Organizational support and nurse leaders’ supportive behavior play a key role in nurses’
productivity and their ethical performance promotion [33].
Limitations
One of the limitations of this study was that, it was limited to hospitals aliated to Tehran University of
Medical Sciences. Further studies in other therapeutic settings can provide valuable data from other
nurses which can lead to more generalized ndings. This study also only addressed the perspectives and
experiences of nurses, and the patients' own experiences and perspectives were not investigated, which
limited the more comprehensive examination of the use of white lies in the patient care process.
Therefore, it is recommended to consider patients' opinions and experiences in future studies.
Conclusion
This study suggests that a wide range of patient-oriented, nurse-related, and organizational factors may
require nurses to use a white lie during patient care. Nurses need to develop their communication skills
and experiences to establish effective communication with patients and their families to provide them
with accurate information. Communication needs to be established based on adequate patients’ cultural
knowledge and organization supportive actions. Our ndings highlight the importance of truth-telling and
effective communication skills to reduce white lie use for information provision in different medical
setting especially in dilemmatic situations. This study can be used as the basis for further quantitative
and qualitative studies of white lie use and its consequences in patient care setting.
Declarations
Ethics approval and consent to participate
This paper is part of the co-desponding author’s Ph.D. thesis approved by the Ethics Committee of Tehran
University of Medical Sciences, Tehran, Iran (code: IR.TUMS.VCR.REC.1397.568). In the beginning of the
interviews, interviewees received information about the aim of the study and signed the informed consent
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form for participation. Condentiality and voluntarily withdrawal from the study were approved by the
study conductors.
Consent for publication
Not Applicable
Availability of data and materials
Data were available by contacting the corresponding author.
Competing Interests
The author(s) declare no potential conicts of interest with respect to the research, authorship, and/or
publication of this article.
Funding
The author(s) disclosed receipt of the following nancial support for the research, authorship, and/or
publication of this article: This study was funded by Tehran University of Medical Sciences.
Authors’ contributions
A.N. and S.J. contributed in designing the study and collected the data, which was analyzed by E.N and
M.E, the nal report and article were written by M.Shali and it was read and approved by all the authors.
Acknowledgment
This article came from the co-responding author’s Ph.D. dissertation in nursing. The authors would like to
thank the Research Administration of Tehran University of Medical Sciences, for their scal support. We
also express our gratitude to the nurses and colleagues for their cordial help.
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Table 1
Table 1. Situations of using a white lie during patients care
Subcategories Categories
Loss of beliefs The crisis of hope
Lack of motivation for
treatments
Death anxiety
News about the diagnosis of a
serious illness
Bad new s
News about treatment
ineffectiveness
News about significant losses
Patient’s culture Cultural diversity
Organizational culture
Limited communication skills Nurses’ limited professional
competence
Limited professional knowledge
Limited professional experienc e
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Background: Truth telling is found as one of the most important issues in physician-patient communication and all of the physicians are concerned with it in some way. As disclosure (or truth reticence) would cause ethical or legal problems, this study aimed to assess the attitude of patients and physicians about truth telling. Methods: In this descriptive study, 50 physicians and 150 patients with cancer were envolved in Isfahan, Iran. Two standardized attitude questionnaires were used for physicians and patients. Data were analyzed by SPSS software. Findings: About 88% of patients and 90% of physicians agreed truth telling for patients in early stage of cancer. 78% of patients and 72% of physicians were agreed truth telling for patients with terminal stage cancer. Both physicians and patients were agreed frankness in telling the diagnosis; they separated no effect for patient socioeconomic condition on truth telling. In both groups, doctor was the best person for telling the cancer diagnosis. Doctor office and quiet and undisturbed room were the best places for truth telling in patients and physiciansviewpoints, respectively. Conclusion: Noticing the obtained results in our society culture, the majority of patients and physicians had positive attitude about truth telling to patients in different stages of cancer.
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