Bending the truth: professionals narratives about lying and deception in nursing practice

\PERGAMON International Journal of Nursing Studies 24 "0887# 181Ð291

S9919Ð6378:87:,*see front matter Þ 0887 Published by Elsevier Science Ltd[ All rights reserved[PII] S 9 9 1 9 Ð 6 3 7 8 " 8 7 # 9 9 9 3 2 Ð 0

{Bending the truth|] professionals| narratives about lying anddeception in nursing practice

A[ Tuckett�Australian Catholic University\ P[O[ Box 136\ Everton Park\ QLD 3942\ Australia

Received 05 February 0887^ received in revised form 8 June 0887^ accepted 0 July 0887

Abstract

The purpose of this study was to capture an insight into the phenomenon of lying as part of the deception employedby a group of practising nurses from a variety of clinical settings[ The importance of this research is that it adds to thelimited knowledge of the range of situations in which nurses use deception[ A case study research approach was utilised[The _ndings presented in this article emphasise the complexity of the subject within a dynamic social context[ The articledescribes the nurses| intention\ role\ the nature of relationships and context and how institutional culture impacts ondisclosure to clients[ Additionally\ it describes how nurses| distinguish lying from other deceptive practices[ These_ndings have relevance for clinical practice and continuing applied ethics research[ Þ 0887 Published by Elsevier ScienceLtd[ All rights reserved[

Keywords] Deception^ Lying^ Benevolence^ Non!male_cence^ Caring

0[ Introduction

Lawyers\ business people\ journalists and advertisersall do it< In everyday life individuals _nd themselvesmaking choices between truthful disclosure and decep!tion[ This study aimed to discover how practising nursesare di}erent[

This article documents only one part of an appliedethics\ qualitative study into the phenomenon of lyingand deception[ The nature of this phenomenon isreported here as employed by practising clinical nurseswithin their professional life[ The complete qualitativestudy further applied an ethical analysis to the responsesof a group of Registered nurses[ This ethical analysis anda subsequent ethical decision making model are explainedelsewhere "Tuckett\ 0886#[

It is within such a context that readers ought to pos!ition this article[ This article aims to describe the datagathering process followed in the study\ provide the

� Tel[] 96!27446113 or 96!27446053^ fax] 96!27446094^ e!mail]a[tuckettÝmcauley[acu[edu[au[

themes identi_ed within the nurses| stories before descri!bing in detail the nature of lying and deception in theirdaily practice[ The article concludes with implications forfurther research[

1[ Review of literature

Do doctors or nurses ever have a right to keep infor!mation from a dying patient< Amongst the literaturethere is evidence that deception by all members of thehealth care team is widespread when caring for cancerpatients "McIntosh\ 0866#[ In the McIntosh "0866# study\nurses and doctors alike routinely utilised vagueresponses\ told half!truths or deceived by omission[ Whilethe doctors {strenuously avoided| lying\ they resorted to{semi!truths| since the false claim of the lie could {reboundon them later| "McIntosh\ 0866#[ The common jus!ti_cation cited by all healthcare workers in McIntosh|s"0866# study was to maintain a client|s hope\ which meantdirect disclosure was to be avoided[

Similarly\ Schrock "0879# reported a {standardised eva!sion of the truth| to dying patients[ Focusing only on

A[ Tuckett:International Journal of Nursin` Studies 24 "0887# 181Ð291 182

nurses\ this study reported that {few nurses lie to patients|\but like their doctor colleagues of the previous study\made use of half!truths and denials to deliberately deceive"Schrock\ 0879#[ The reasons given included^ to preventharm\ promote client well being and to maintain clientcon_dentiality[ A majority of those in Schrock|s studyresorted to half truths and denials because they feltcoerced into doing so because of institutional policy orbecause of a doctor|s order "Schrock\ 0879^ Gillon\0875#[

Further studies of communicating with clients\ supportthe view that nurses use euphemisms "Bond\ 0872#[ Asstudent nurses they are prepared to tell a story which isconsistent rather than accurate "Melia\ 0876# and worryabout inadequate disclosure and telling of untruths in theNeonatal Intensive Care Unit "Miya\ Boardman\ Harrand Keene\ 0880#[

A most recent examination of the use of deception innursing included student and registered nurses workingin medical\ surgical\ community and psychiatric settings"Teasdale and Kent\ 0884#[ The authors of this studyproposed that non!disclosure "as the {titration| of amountof information # is widespread and justi_able "Teasdaleand Kent\ 0884#[ This so!called titration refers to dis!closure to a patient up to and not beyond a certain point[

Somewhat in contrast to other studies\ Teasdale andKent "0884# concluded that deception in nursing is rare[Any deception\ which occurred\ was practised becausenurses attempted to avoid the harmful e}ects of distresson their clients[ Deception was also employed in situ!ations which risked disrupting the ward[ Furthermore\nurses di}ered in their willingness to use deception[ Thus\some nurses practised the dictum] {Truth\ the whole truth|when questioned by their client whilst others respectedthe request of family who asked that information not bedisclosed "Teasdale and Kent\ 0884#[

Further a_eld\ writers agree that lawyers "Temby\0883#\ business people "Carr\ 0857^ Wokutch and Carson\0875#\ journalists "Sulch\ 0881# and advertisers "Nelson\0867^ Arrington\ 0871# lie\ blu}\ mislead and use pu}eryto create the illusion of fact from _ction[ It does seemthat nursing stands amidst this world of deception as apractice prone to speaking half!truths\ omitting details\misleading through evasion\ failing to disclose by {fob!bing| o} a client\ simply not telling and:or giving partialinsights by controlled release of information[

Amidst the body of research into lying or deceptionamongst nurses it is necessary to be clear how thisresearch study sets itself apart and adds to this bodyof knowledge[ The importance of this research to theexploration of lying\ deception and truth telling is that itcontributes toward the following concluding rec!ommendation by Teasdale and Kent "0884#[ Thisresearch {increase"s# the knowledge of the range of situ!ations in which deception is used by nurses [ [ [| "Teasdaleand Kent\ 0884#[

2[ Methodology

2[0[ Research questions

The following research questions acted as study objec!tives]

"0# What are the situations nurses describe in which theyare required to make a choice between truth tellingor some other response<

"1# What justi_cation do nurses use for their responseswhen confronted with a situation considered torequire a lie<

"2# What are the perceptions nurses have about lyingor other deceptive practices within their professionallives<

2[1[ Sample

Respondents were sought from two Brisbane Uni!versities*Queensland University of Technology andAustralian Catholic University[ Research participantswere recruited from Post!Registration Nursing Degreeprograms[

The respondents were registered nurses in current clini!cal practice[ No other criteria were enforced[ Groups ofPost!Registration students from each setting were invitedby the researcher to participate[ In this sense\ the sampleevolved from a convenience group "Cohen and Manion\0883# in a respondent!selection\ volunteer capacity"Morse\ 0880#[

In all\ 01 registered nurses were involved in this pro!ject*_ve in the pilot study and seven in the main studygroup[ Of this group of 01\ two were male and the remain!der female[ Clinical experience ranged from 4Ð17 yearsfrom various clinical settings[ A summary of these par!ticipants| demographic details is presented with theirpseudonyms in Table 0[

2[2[ Design

Leininger "0874# recognises qualitative researchmethod as the major method to {{discover essence\ feel!ings\ attributes\ values [ [ [ characteristics and philo!sophical aspects of certain individual life ways||[ Becausethis study aimed to describe justi_cations for\ perceptionsabout\ and situations in which lying takes place\ the quali!tative method to which Leininger "0874# refers clearlyassists with meeting these objectives[

The research utilised a case study method andemployed a pilot study to inform the main study[ Casestudy in this research is understood as {{an in depth inves!tigation of a social unit|| "Parse\ Smith and Coyne\ 0874#[Here\ it is the focus on {nurses as the unit| from whichpotential generalisations might evolve[

The case study method provided an opportunity to

A[ Tuckett:International Journal of Nursin` Studies 24 "0887# 181Ð291183

Table 0Participants| pseudonym and summary of demographic details

Participant Pseudonym Years Present Area"s# of Clinical experienceexperience appointment

0 Oscar 8 Clinical educator ICU\CICU1 Terrence 09 RN level 0 Hospice\ cardiac post operative2 April 00 RN level 0 + 1 Acute general surgical\ midwifery\ paediatrics3 Beth 8 RN level 0 Acute general surgical\ opthalmics\ pain management4 Carmel 07 Clinical nurse consultant Acute general surgical\ midwifery\ psychogeriatrics\

day surgery unit5 Margaret 7 RN level 0 Midwifery\ psychiatric\ paediatrics6 Tanya 02 RN level 0 Casualty\ ICU\ air ambulance7 Wendy 02 RN level 0 + 1 CICU\ Neurosurgical\ medical\ casualty8 Teresa 17 Clinical nurse consultant Paediatrics09 Fiona 01 Clinical nurse consultant Wound management Neurology\ stomal therapist\

"Community# incontinence adviser\ ICU00 Mary 5 RN level 0 Not disclosed01 Toni 03 RN Level 0 Child health\ midwifery

probe and analyse the many facets of a single phenom!enon within a small group of nurses[ Given the limitationsof such a small sample\ a case study of this kind never!theless has the potential to illuminate variables and com!plex processes worthy of further exploration "Isaacs andMichael\ 0863#[

Consequently\ case study is the preferred method whenthe focus is on {{a contemporary phenomenon within areal life context|| "Burns\ 0885#[ A typical technique usedin this type of investigation includes interviewing in anattempt to

gain a picture of the inner:private experience of theindividual\ which seems to constitute the backgroundfor the emergence and existence of a given form ofconduct[ "Blumer\ 0858#[

2[3[ Data gathering

An unstructured interview approach was used in thepilot study[ A criticism of the interview technique fordata gathering is that the researcher may seek out his:herown preconceived ideas[ The unstructured interviewassists with reducing this potential bias[ Data from thepilot informed the semi!structured interviews in the mainstudy group[

The researcher recognised the potential sensitivity ofdata[ Con_dentiality and anonymity were two guidingprinciples[ Consequently a single one!time interview waspreferred[ This approach was congruent with Brannen|s"0877# contingencies surrounding the exploration of sen!sitive topics via qualitative means "cited in Lee\ 0882#[

May "0880# acknowledges the di.culty in describing atypical interview pattern within the qualitative researchparadigm[ In this study\ it was necessary to check theusefulness of the solo interview "one!to!one# against thepracticalities of the co!joint interview or focus group"one!to!three# in the pilot phase[

Following the pilot study the researcher concluded thatsolo interviews would be most useful[ Due to the poten!tially sensitive nature of data\ the researcher felt thatthe co!joint interview did not provide for the depth ofexploration possible within the solo interviews[

A further signi_cant variable was the study sample|srecognition of the researcher as a peer[ That is\ becausethe interviewer was identi_ed as a registered nurse\ boththe respondent and interviewer were able to share a com!mon vernacular[ Competence with the nursing language{improve "d# the interactive process| "Hosie\ 0875#[

3[ Establishing auditability and validity

The strategy to establish validity and auditability ofdata involved the taping of interviews\ transcribing andreturning the literal transcript to each respondent forcomment[ In essence\ this process validates the cor!rectness of the transcript[ The data becomes valid andauditable[

Attention was given to the e}ect of {response error|and the potentially threatening questions[ In the case ofresponse error "Borg and Gall\ 0878#\ or what Hosie"0875# described as {reactive in~uences|\ which risk in~u!encing both auditability and validity\ the following wasaccounted for by the researcher]


, The respondent|s predisposition[ "Self!selection was ameans to ensure that those volunteering came forwardwith a willingness to co!operate\ with stories to tell\free from coercion and may have eliminated those withfeelings of anxiety\ guilt or fear about issues sur!rounding lying or deception#\

, The interviewer|s predisposition[ "Written feedbackfrom the respondents indicated that the researcher suc!ceeded in establishing rapport and an atmosphere oftrust# and

, The design of the study[ "Oral and written explanationswere given prior to the study#[ All participants| ques!tions were answered prior to and after interview[ Inter!view duration and location were established to accom!modate participants| lifestyles[

Using the Post Interview Evaluation of Threat ques!tionnaire "Table 1# "Bradburn and Sudman\ 0878# anassessment was made of the perceived ease with whichrespondents felt most nurses would respond to the ques!tions within the interview[ This was done since\ accordingto Bradburn and Sudman "0878#\ questions reported byparticipants as causing them to be {very uneasy| tend tobe under reported or incompletely described[

4[ Data analysis process

For each pilot interview\ data were reduced to a Con!tact Summary Sheet "Miles and Huberman\ 0873#[ These

Table 1Questions for the post interview evaluation of threat "adapted from Bradburn and Sudman\ 0878#

Questions]

Now that we have almost completed the interview\ I would like your feelings about it!Overall\ how enjoyable was it<Which questions\ if any\ were unclear or hard to understand<Which questions\ if any\ did you _nd personal<Using the card provided� I would like your opinion about the questions[ How do you think most nurses would feel about the question"cite question here#<

Responses to the post interview evaluation of threat

Overall response

Margaret Slightly uneasyTanya Slightly uneasyWendy Slight!moderate uneasyTeresa Moderate\ very uneasy "Q7$# onlyFiona Very uneasy "Q7$#\ slight!moderate uneasyMary Not at all\ slightly uneasyToni Not at all\ slightly uneasy

� Participants were asked to evaluate how they felt most nurses would respond as either very uneasy\ moderately uneasy or not at alluneasy[$ Question 7 was reported as {very uneasy| by two participants] How would you respond to a request by a relative not to tell a patienthe is dying from cancer in the situation in which the patient asks] {{Tell me\ am I going to die from cancer<||

sheets were developed after an initial listening and re!listening to the audiotaped interview\ followed by a read!ing and re!reading of the transcript after clari_cationwith the participants[ In this way the data were checkedand re!checked and meaning veri_ed[

Following the practice of data matrix presentation andcoding described by Miles and Huberman "0873#\ datafrom the pilot study were then categorised[ During thiscodi_cation process the researcher depended on {memo!ing| "Miles and Huberman\ 0873#[ Hence\ during thecoding\ preliminary speculation about codes andrelationships between themes were noted on the verbatimtranscripts at the instant they emerged[

At this stage\ following analysis by the researcher\ anattempt was made to check the reliability of the cat!egorisation process[ For this purpose two {assistantresearchers| were used to direct cue sort according to thecodes[ Both {assistants| had experience\ one in edu!cational research the other in nursing research[

The next phase was the establishment of the Guide toInterview questions for the main study group[ Withinan established and reliable categorisation process\ thequestions for the interview aimed to re~ect those theme!s:propositions identi_ed through the pilot study[

Following each main study interview\ the researcherimmersed himself in the audiotaped data as per the pro!cesses described for the pilot data[ Finally\ dominantthemes were isolated as the framework upon which toexplore meaning[


5[ Findings

Stemming from the previously cited research questions\a total of _ve themes emerged[ Although each theme isexamined as an entity unto itself\ such representation isdeceptive[ That is\ the themes cannot exist as exclusivesets of data[ Rather\ they tend to interlock and overlap[The themes woven together in this way emphasise thecomplexity of the subject within a dynamic social context[

In brief\ the _ve themes were]

, Intention\ Motivation and Justi_cation[That is\ what was the purpose or inducement to act by\and the reason for\ the chosen response<

, An Ethic ascribed to Role[It was apparent each nurse|s perception of their roleimpacted on their decisions\ actions and reasoning[

, Relationships\ persons and place[Clearly\ participants acknowledged the context\ natureof relationships and situation as an in~uence on adecision to deceive[

, Lying*deception dichotomy[That is\ what distinguishes\ if anything\ one from theother in practice<

, Culture of the institution[Participants perceived the workplace culture as impact!ing on their decisions and consequent actions whenconfronted with a deception or lie choice situation[ Asummary of these themes is presented in Table 2[

5[0[ Intention\ motivation and justi_cation

Nurses in this research unanimously opt for a lie ordeception when such is perceived to improve the client|s

Table 2An overview

Objective Themes Insights

Objective Three 0[ Lying!deception dichotomy[ Lying is a misleading statement\ never a misleading silence\ look\evasion[

Lying or deception with intention to bene_t:prevent harm 7client ~ourishes[

Act "lying# is understood in its context and according to therelationship in which it exists[

Objective Two 1[ Intention\ motivation and justi_cation[ Lying as a choice\ improve client|s status[A caring response can mean not revealing the whole truth[

Objective Two 2[ An ethic ascribed to role[ {{The Law|| coerces:forces nurses to lie or deceive[{{The Law|| means nurses withhold information[May require nurses lie when asked to by a client or client

relative : control[Objective Three 3[ Culture of the institution[ Managerial styles and ward social order : propensity to

{cover up| lie[Objective Two 4[ Relationships\ persons and place Relationships fundamental to nurses| moral reasoning[

Lie:deception|s intent is not to mislead per se but aims todo good[ Aiming to do good by a lie risks client trust[

well being[ That is\ the lie or deception is used to bene_tthe client or to prevent or diminish harm[ Nurses in thisgroup justi_ed their actions by the same reasoning asnurses in the study by McIntosh "0866#\ Schrock "0879#\Bond "0872# and Teasdale and Kent "0884#[

For this group\ conditions can and do exist in practicewhen the maxim\ {the truth the whole truth and nothingbut the truth|\ is not the most caring[ A commitment tocare in some unique circumstances may mean not reveal!ing the whole truth[

Perhaps one of the most revealing stories was about aclient with Alzheimer|s disease[ Tanya admitted that afalse response\ a diversion "suppresso veri# or not answer!ing the question would have been a better response]

I was in a Nursing Home "caring for a# woman whohad Alzheimer|s and she said] {{Oh\ where is my hus!band<|| and I had been told that this lady had been awidow for about 04 years and I|d looked at thiswomen and said to her] {{Oh sweetie\ your husbanddied 04 years ago|| and the woman|s grief was instan!taneous[ It was like I was delivering the news forthe _rst time about her husbands death and I feltdevastated [ [ [ and I thought\ {{Oh my God\ now Ihave this mourning woman [ [ [|| and in hindsight [ [ [ ifthat ever happens to me again I might just say] {{He|sout in the garden or he|s gone away or he|ll be back||only because I know that they|ll forget about it in acouple of minutes [ [ [ If you delivered the truth to " theAlzheimer patient# it might be really devastating forthem [ [ [ I mean\ I have never forgotten about that [ [ [ Ithink I might just divert them and not answer thequestion next time[


Tanya believed her way of speaking to the Alzh!eimer:dementia client and some critically ill:dying clientsas appropriate since {{it won|t cause them any harm||[She proposed that {{they wouldn|t su}er from what I|vesaid||]

Its only because I know that it|s for their well beingand I know in my heart that I am not manipulatingthem\ I just know they won|t su}er from what I|vesaid[ I know it won|t cause them any harm [ [ [ I knowthat if I tell them the truth*I mean\ I just keep think!ing of the Alzheimer|s lady [ [ [ someone who is dyingand they say] {{Am I dying|| and I think] {{Well on aphysiological level\ yes you are [ [ [ but I think on aspiritual and intellectual level we|re still talkingso [ [ [ you|re not||*so that|s the only justi_cation thatI can get away with [ [ [ And just get away with in asense that I don|t really feel like I|m lying[ I feel likeI|m helping them because I|m there\ right beside them

Another nurse\ Mary\ said that most of her patients areelderly*{{you know\ 54 plus||[ She said because of thisshe {{bends the truth||]

I|d bend the truth to alleviate their anxiety\ make themfeel good a bit[ Perhaps give them hope [ [ [ The olderpopulation just have no idea about their body [ [ [ andthey|re probably more optimistic about things and ifyou bend the truth and make it sound a little bit betterthen [ [ [ they won|t throw the bundle in[

Perceptively Mary evaluated both the short and long!term e}ects of bending the truth in cases motivated bygiving individuals hope]

The two situations mentioned could not be classed asmorally correct[ Instead that could be morally usefulin the short term[ The lies used are to hopefully makethe patient feel better*a feeling of hope[ But\ longterm\ the lies are not allowing the patient to face thereality of the situation[

5[1[ An ethic ascribed to role

Nurses in the study perceive {{the law|| as coercingthem into lying[ Two points can be made about thisperception[ Firstly\ this perception accords with the studyby McIntosh "0866# and Bond "0872# in which the nursesbelieved it to be the doctor|s prerogative to disclose[Secondly\ it follows that this perceived legal restraintmeans that nurses are withholding information from theirclients[

Directives usually from doctors and the CNC "ClinicalNurse Consultant# were a feature whilst discussing the

management of the terminally ill[ In this situation Tonirevealed]

[ [ [ [ where we|ve been told] {{Don|t you dare tell himhe|s got cancer|| I mean your job is on the line if youdo for a start but I still think its a tremendous lie [ [ [

Wendy acknowledged this impact of the outside auth!ority and perceptions about the nurse|s legal rights]

When someone is going for a C[A[T[ scan and youjust say {{No you|re not;|| you might say so becauseyou|re too busy to explain at a time when you|ve gotother things on your mind[ That|s a deliberate lie [ [ [ [

Wendy continued]

Whereas when you know in your mind exactly whatthe truth is and you have to withhold it from them\your conscience is playing on you and your thinking]{{Oh God\ I can|t say anything||\ so the feeling insideis {{I|m deceiving this person|| but it|s because I haveto until such time as I|m permitted to say[

The nature of the work of nurses is such that frequentlyanother requests them to conceal the truth or to managethe disclosure of the truth on another|s behalf[ Charac!teristically\ either the family of a client\ believing it bestnot to reveal the whole truth will ask the nurse to lie ordeceive the client[ Similarly\ the client\ wishing to protectthe family from {{hurtful truth||\ will demand that thenurse lie about the client|s condition[

Wendy described this predicament inherent in her rolewhen communicating prognostic information over thetelephone]

Maybe a relative of a patient rings up and they say]{{I don|t want you to tell them that I phoned [ [ [ I don|twant them to worry|| and so I don|t say anything [ [ [Then through the course of the shift the patient says]{{Did my wife ring today<|| and I say] {{Oh; No [ [ [ nothey didn|t ring|| [ [ [ and you can walk away and youthink {{I feel really awful because they have rung butshe doesn|t want "him# to worry "and# she doesn|twant "him# to know they|ve phoned||[ Quite often inthe critical care environment that happens or\ even\the patient will say] {{Look\ if my wife rings [ [ [ if myfamily rings don|t let on that I|m really\ reallyunwell*just tell them I|m _ne\ O[K[<|| Or even whenrelatives ring up to make an inquiry about how apatient is [ [ [ their rhythm is a bit unstable\ they mighthave been bleeding and we say] {{Oh*yes\ they|restable|| because we don|t want to say on the phone]{{Well actually the blood pressure is a bit low\ at themoment the heart rate is irregular and they|re bleed!


ing*we|re thinking about re!transfusing at themoment [ [ [ ||

Another nurse\ Toni\ believed that situations do arisewhen the {{total good|| is served by the lie[ She makes thisclear when confronted with the asthmatic child]

I have been "in# that "putting medication in chocolatesyrup# situation before and sometimes I|ve answeredhonestly and said] {{Yes\ and its good for you\ I wantyou to take "it#|| and somehow you get them to takeit[ Other times if you admit it [ [ [ my concern is alwaysthat if this child doesn|t take the Prednisone "and# hasa serious asthma attack how are you covered legally<You know [ [ [ and so sometimes in thosesituations [ [ [ with young children |cause Mum andDad aren|t there and this medication has to get intothem [ [ [ The lesser of the two evils in that situation isto ensure that the child gets the medication that theyneed and their health bene_ts[

The {{wink|| of an eye from a parent is taken as ana.rmative directive to resort to a lie[ Toni acknowledgesthe directive from the child|s parents as suitable for sayingto the asking child] {{No "the medication# wasn|t "in thesyrup#||[ Toni admits]

If you know the parents and you|ve got an idea as towhether they are supportive of the child having "thePrednisone# or not [ [ [ if they wanted the kid to haveit but really didn|t want him to know*like they mightgive you a wink [ [ [ so they|re basically saying] {{No||"don|t say# then you|d probably go ahead and say]{{Oh\ no "the medication# wasn|t "in the syrup#||[

5[2[ Relationships\ persons and place

Nurses interviewed in this research\ in their delib!eration about a lie or deception option\ considered thenature of the relationship they were in as fundamental totheir moral reasoning[ This is an outcome congruent withGilligan|s "0871# ethic of care[

They lie or deceive not to mislead per se\ while reco!gnising this as an outcome[ Rather they aim to do goodfor their client\ and recognise that\ paradoxically\ in aim!ing to do good they risk the loss of client!nurse trust[

Without exception\ those interviewed tended to bein~uenced in their option to lie by a consideration of theperson\ place and the nature of the relationship[ Thatis\ they weighed up the consequences and articulated ajusti_cation for the lie or deception based on the con!text:situation in which the nurse was operating at a givenmoment in time[

Teresa clearly deliberates about the lie choice mindfulof the relationship*be it with a colleague or family mem!

ber or in the nurse!client relationship[ What she does isestablish a di}erent relationship with each person]

[ [ [ I|ve been very hard and fast "about# {{Don|t everlie about anything||\ but sometimes "within# a personalrelationship discretion is the better part of valour andin order not to hurt others sometimes you step backfrom being blatantly truthful [ [ [ [

I had a colleague who died of cancer [ [ [ she had adaughter and a son and she had no husband [ [ [ nowthe daughter was not telling her that she wasdying [ [ [ it had come through friends and colleaguesthat this daughter was not talking to her mother aboutdying [ [ [ but I couldn|t go along with what theywanted [ [ [ because my relationship with that friendwas more important than what the daughter and sonwere wanting\ so I went to her this day [ [ [ and saidgoodbye to her [ [ [ "I#t was just a very privilegedmoment to be as honest as that and say goodbyeand I think she appreciated it and I think she|d beensurrounded by dishonesty and "she died within a cou!ple of days# I hoped the family found that they coulddo the same[

Additionally\ Wendy disclosed when confronted with arequest from a dying patient "{{Am I dying of cancer<||#whose wife has requested her husband not be told]

There is a _ne line between telling the patient theanswer they want to hear and what I think is best forthem to hear[ We must use discretion and decide whatis appropriate at the time for the sake of the patientand wife[

The nurse decides what a client or relative should know{{at the time|| mindful of {{what is best for the sake of theother persons||[ This reasoning is linked to intention[Nurses in this study resort to the lie or deception whenin a given context the consequences are the prevention ofharm and:or the maximisation of client bene_t or wellbeing[ This action accords with caring as {{an oversightwith a view to protection|| "Wolf\ 0875#[

An additional perception about lying as it exists forthe nurse and within the nurse!client relationship is thee}ect the lie has on trust and rapport[ Paradoxically\nurses in this study who choose to lie or deceive areconcerned about its deleterious e}ect on trust[

Wendy acknowledges the e}ect lying has on rapportbetween the client and nurse]

[ [ [ [ you won|t establish as good a rapport with thepatient[ If they are not aware that you|ve told the liethen they|re none the wiser so they don|t know[ Butyou know so I might not feel as comfortable aboutinteracting with that patient[


Fiona added that the experience of being lied to impactedon the relationship between the agent who lied andherself\ saying]

"Y#ou don|t have any trust for them [ [ [ "Y#ou learn tokeep your mouth shut a bit[ You tend to withdraw abit as well[

Nurses| recognise there is a danger that communicationwill become impotent\ all trust lost and the nurse!clientcloseness destroyed when the client becomes aware of thefalsehood[

5[3[ LyingÐdeception dichotomy

According to the participants of this study\ in the realmof clinical nursing practice\ lying is understood only as amisleading statement and never an omission\ silence orevasion that otherwise may mislead[ For these nurses\ alie can only be spoken[

Margaret maintains there is a distinction between {{nottelling the truth|| and {{missing out bits||[ She identi_edlying as the former whilst the latter as {{not lying*but itcould be conceived as dishonesty||]

Lying is not telling the truth[ Lying is when you speakand you tell something that|s not true[ If you miss abit out [ [ [ that might not be lying*it|s still not tellingthe truth but it|s not exactly lying[ Lying is somethingyou have to do as in you change the story and youspeak the story[

Furthermore]

Not telling or not answering or avoiding the questionis not lying*but it could be conceived as dishonesty[

Teresa di}erentiates between {{bending the truth|| and{{avoiding telling the whole truth||[ For her\ lying is bend!ing the truth whilst avoiding telling the whole truth is to{{step back from being blatantly truthful [ [ [ [|| She said]

[ [ [ bending the truth is lying*telling only as much asis necessary to answer the question is not "and#[ [ [ I|ve been very hard and fast "about# {{Don|t everlie about anything||\ but sometimes "within# a personalrelationship discretion is the better part of valour andin order not to hurt others sometimes you step backfrom being blatantly truthful[ [ [ [

Explicit herein is that incomplete disclosure or omittingto disclose is not lying[ Teresa claimed that]

I wouldn|t be lying if I didn|t tell her[ If I didn|t tell heranything I|m not lying[ Not telling is not lying [ [ [ [ [ [

Clearly\ Teresa recognises lying as an utterance*aspeech act whilst other actions are deceptions[

5[4[ Culture of the institution

The social dynamic of the work life in which a nurseoperates was described by some as authoritarian\ insen!sitive\ intolerant and di.cult[ Nurses in this group admitthat lies were told occasionally to cover up mistakes inwards whose environments were characterised by thesedescriptors[

Teresa and Mary propose a work place in which thereis no option for lying\ but suggest it require the inte!gration of nurses into a collaborative\ non!authoritarianmanagement practice[ The establishment of a work cul!ture that encourages {{honesty and transparency||depends on managerial style and personality[ Nurses inthis study look for superiors who are sensitive to theirneeds\ tolerant of their humanness\ able to use each teammember|s skills maximally and encourage individual selfgrowth[

Teresa believed that a work environment could onlyfacilitate honest practice when the organisation was sup!portive and inclusive of sta} in decision making]

We [ [ [ need those "in# the workplace*in a ward orteam who acknowledge and support each other andvalue each other as individuals for doing things intheir own way and [ [ [ valued for their special skills ortheir special attributes [ [ [ [

In her discussion about {{honesty in the culture||\ Teresaidenti_ed the {{authoritarian and defensive organ!isational culture|| as failing to be aware of and failing toencourage sta} participation in decision making[ Thus aworkplace that encourages honest practice is sensitive tothe practitioners in that organisation[

Mary described the ward manager of her place of workas an individual that promotes open and honest clinicalpractice in the following way]

supportive\ acts to solve problems\ "is a# listener [ [ [ [isnot looking over our shoulders [ [ [ she|ll know whatkind of day you|ve had [ [ [ [

Mary claimed the {{need to lie|| by a practitioner dimin!ishes relative to {{experience and knowledge||[ The agent|spropensity to lie depends on self assurance[ Hence]

the more comfortable you feel in your job and positionat work "which# comes from experience in nursingover a number of years*the less you need to lie[ Theknowledge you gain from experience facilitates this[

Her honest work environment becomes one in whichthe practitioners are comfortable with their jobs[


Additionally\ as a {{cultural group|| nurses admit tobeing a party to information control which amounts towithholding information and incomplete disclosure"refraining from telling the whole truth#[ Wendy claimsnurses as a {{cultural group|| acknowledge and participatein the role of information gatekeepers amongst them!selves and their clients[

[ [ [ {{We|re doing some tests[ [ [ [ I|m not at liberty toanswer any of the questions||*that he needs [ [ [ Tospeak to his doctor about that[ [ [ [ I don|t feel as aregistered nurse\ until all the results have comethrough [ [ [ |till a decision has been made betweenmedical sta} [ [ [ nursing sta} and the family [ [ [ wellone of the reasons I|m not doing it is\ I might get intotrouble from the doctor [ [ [ the doctor might not evenof said to any of the nurses] {{Don|t tell this patient||but I think its like\ its kind of understood in thatclinical environment and at hand over {{Listen\ thisman doesn|t know yet so don|t say any!thing|| [ [ [ Nurses make it known to one another andunderstood when they know\ whether it is advisableto divulge information at hand over[ It|s not lying by{{saying nothing at all|| because you haven|t com!mitted yourself either way to a response to {{What|sgoing on<||

6[ Discussion

Above all else\ the participants choose to lie or deceiveand\ for that matter\ tell the truth only when the clientbene_ts or is prevented from harm[ Generally\ thesenurses do not hold to the absolute maxim of {the truth\the whole truth and nothing but the truth|[ These nursesgive precedence to a notion of caring as indicative ofthe virtues of benevolence and non!male_cence[ Caring\indicative of these virtues\ has previously been describedas compassionate "May\ 0883#[ Situations and relation!ships exist when to care deeply about another may meannot revealing the whole truth[

Nurses are in an unenviable position within their dailyclinical lives[ External authorities to which they do havea responsibility regularly seek responses that\ _rstly\ maynot complement each other and secondly\ may requirethe nurse to lie or deceive[ Australian law does notadequately provide nurses with a clear directive aboutthe handling of client information[ The law may be clearin its guidance for doctors*allowing them to withholdinformation "not reveal the whole truth#*but it failsto give independent\ unambiguous guidance to nurses[Rather\ it is most apparent in practice that nurses arevery often coerced into lying or deceiving their clients"either by withholding information or denial#[ Thisoccurs either because a doctor requests that they not

reveal prognostic information to the client\ or becausenurses interpret the law and ward social order as dictatingthe reality that only doctors tell[

The nurses in this study do not necessarily reject thein~uences of an outside request to lie or deceive whenthe request originates from one deeply involved in thesituation[ It is suggested\ in fact\ that an adherence to theabsolute maxim for truth telling may fail to respond\in these cases\ in both an ethical and caring way[ Byacknowledging the request by the client or the client|srelatives not to tell another something\ and thus resortingto a lie or deception to accede to this request\ the nursecares enough to allow the requesting agent some controlof the situation[

A nurse fails to reveal the whole truth at a particularinstant in time for the sake of another person[ At aparticular instant in time means that at some furthermoment in time the complete truth may be revealed[ Thenurse as primary carer makes an assessment about thedisclosure of information and its potential harmfule}ects[ For the sake of another emphasises the nurse|sfocus on intent[ It is important to consider the di}erencein intent when a nurse chooses to lie or deceive at a givenmoment for the client|s sake or chooses to lie or deceiveas an overall guide to practice[

The very fact that nurses recognise the e}ect lying ordeception may have on the nurse*client relationshipwhilst they are striving to minimise client su}ering\ high!lights the moral conundrum of the nurse|s role[ Which isthe way they ought to respond< Nurses may lie or deceivewhen the client|s well being is at stake even when theyforesee the unintentional e}ect such an act has on trustand rapport[ Their misleading at an instant in time in theknowledge that this may a}ect trust is to be recognisedas a {{momentary lapse into untruth and concealment"which# are understandable and common human fail!ings|| "Jordan\ 0884#[ This is not the sustained lying ordeception of an agent with a pathological disposition noris it the intricate untruth spanning some twenty or moreyears "Jordan\ 0884#[ Rather\ nurses respond the waythey do "in most cases\ not all# because they care[

An additional aim of this research was to test in prac!tice the idea that silence and:or a non!verbal act canintentionally mislead another to believe what is false tobe true or vice versa[ That is\ lying as an unspoken false!hood is inclusive when silence or a false declaration intendto mislead another into believing that which is false to betrue[ When intention is regarded as pivotal in the moraldistinction between lying and other deceptive practicesboth silence and an utterance have equal potential toproduce misleading beliefs[ According to all the par!ticipants\ intention is pivotal in their justi_cation for lyingand their propensity to lie or deceive[ However\ whenthey spoke of intention they focused on the preventionof harm and the promotion of the client|s well being[Contrary to the way lying is usually de_ned\ these nurses


tended to be mostly concerned for the ill client in termsof the virtues of bene_cence and non!male_cence[

In practice at least\ it appears that neither silence nora non!verbal act are recognised as a lie[ The clinical nurseidenti_ed by this research places an emphasis on whatshe does rather than on what she doesn|t do[ In thenurse|s view\ only by committing herself to speech doesshe lie[ The failure to fully or properly disclose the wholetruth through silence\ omission\ evasion or withholdinginformation is not recognised as a lie but rather as adeception or as misleading[ Thus\ it must be concluded\in their view nurses lie less than they deceive[

The way to eliminate lies or deceptions was obvious tothose respondents who confessed to the problem[ Theyclaimed that ward social order must accept that nursesare not infallible or\ alternatively\ clarify the expectationsof practice to include acceptance of\ and tolerance for\human error[

It follows that these nurses do not lie by saying nothingat all[ Rather\ this becomes a case of withholding infor!mation or incomplete disclosure[ What is said need notbe a false set of claims\ but clearly what is said is not the{whole| truth[ This practice _nds support in Teasdale andKent|s "0884# observation that]

Doctors and nurses frequently see it as part of theirprofessional responsibility to {titrate| the amount ofinformation they give to patients[

These authors believe that this {{non!disclosure|| can bejusti_ed on empirical grounds\ as some clients becomedistressed when they receive more information than theydesire[ Furthermore\ Teasdale and Kent "0884# note thatdeception in the euphemistic guise of misleading {{infor!mation management||\ is harder to justify and rarelyacknowledged in public[ This failure to publicly admit todeception is noted by Gillon "0875# who concedes that{{in practice if not in print*doctors tend to deceive pat!ients with fatal disease||[

7[ Conclusion

The study successfully captured an insight into thephenomenon of lying as part of the deception employedby a small group of practising nurses from a variety ofsettings[ It revealed that dimensions of deception andlying are complex located within a dynamic socialcontext[

Research _ndings indicated that Registered nurses "a#make a clear distinction between lying and deception\ "b#will choose to lie or deceive for the client|s bene_t anddepending on the situation\ and "c# place an emphasis onthe relationship with another when choosing to lie\deceive or tell the truth[ Participants acknowledge that

their role and institutional culture of their workplacesin~uence decisions about lying and deception[

These _ndings will contribute towards an ongoingappraisal of what constitutes a caring response withinthe nurseÐpatient relationship[ Additionally\ the study|s_ndings allow for the development of a model for ethicalpractice that is mindful of the good\ the right and thevirtuous[ Further systematic qualitative inquiry is necess!ary from the point of view of the patient[ The _ndingsfrom such a study will contribute to a more complete setof ideas about care:caring and potential ethicalresponses[

Acknowledgements

The author would like to thank Ms Fiona Bogossian\Australian Catholic University and Dr Margaret McAl!lister\ Gri.th University\ Queensland for their valuablecomments and suggestions[

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Bending the truth: professionals narratives about lying and deception in nursing practice