Participants were twelve female and six male nurses with the mean age of 37±4.2 years old and the mean work experience of 13±4.6 years. Totally, in data analysis, 314 codes were generated which further categorized into four following main categories and eleven 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 difficulties 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 telling white lies. This category subcategorized into three: 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 illness or lifetime treatment, motivation is a key factor affecting treatment success and patient adherence to treatments. Our participants referred to tell a white lie or 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).
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).
One of the most challenging situations of telling a white lie is when nurses want to give patients and family members bad news. In these situations, nurses may choose to tell 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 significant losses.
News about the diagnosis of a serious illness
Getting informed about diagnoses that are publicly equated with an imminent death makes these difficult situations even more challenging and may shock patients and families. In these situations, nurses may tell 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 difficulties 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).
News about significant losses
Significant losses such as loss of a child, an organ, or a family member are very stressful for patients and their family members. Nurses who break the news about significant 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).
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 are the patient’s culture and organizational 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 the 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 firmly 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).
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. 18).
Nurses’ limited professional competence
In addition to 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 difficult situations when nurses are the only accessible source of information for patients, limited communication skills may require them to tell 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 find 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 tell 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).