Research article

Nursing Ethics 17(1) 3950 The Author(s) 2010 Reprints and permission: http://www. sagepub.co.uk/journalsPermission.nav 10.1177/0969733009350952 nej.sagepub.com

A phenomenological study of nurses understanding of honesty in palliative care

Eva Erichsen

ping University, Norrkoping, Sweden Vrinnevi Hospital, Norrkoping, Sweden and Linko

Elisabeth Hadd Danielsson

Linkoping University, Norrkoping, Sweden

Maria Friedrichsen
Vrinnevi Hospital, Norrkoping, Sweden, Linkoping University, Norrkoping, Sweden and Stockholm Sjukhem Foundation, Stockholm, Sweden

Abstract Honesty is essential for the care of seriously ill and dying patients. The current study aimed to describe how nurses experience honesty in their work with patients receiving palliative care at home. The interviews in this phenomenological study were conducted with 16 nurses working with children and adults in palliative home-based care. Three categories emerged from analyses of the interviews: the meaning of honesty, the reason for being honest and, finally, moral conflict when dealing with honesty. The essence of these descriptions was that honesty is seen as a virtue, a good quality that a nurse should have. The nurses ethical standpoint was shown in the moral character they show in their work and in their intention to do good. This study could help nurses to identify different ways of looking at honesty to promote more consciousness and openness in ethical discussions between colleagues and other staff members. Keywords communication, honesty, nursing, palliative care, phenomenology

Background
Palliative care is multiprofessional care for people with severe, life-threatening disease. It is a holistic practice that focuses on all dimensions of patients and their families and the competence available for optimal care. The aim is to improve quality of life and make the end of life dignified. This demands high professional skills: to be able to develop relationships, make complex decisions, be supportive and preserve integrity.1 A model for palliative care nursing was developed in the 1990s, describing significant nursing interventions such as respecting, connecting, empowering, doing for, finding meaning and preserving integrity.2 These interventions highlight the importance of interpersonal care, especially honesty, which has been rated as most important by patients in their judgement of the quality of the care given.3 Building relationships is essential in palliative care and the ethical principle of telling the truth is valued highly. Truth telling and honesty are often intertwined in the literature.46 Truth telling is defined as the essence of an open and trusting relationship.2

Corresponding author: Eva Erichsen, Linkoping University, Faculty of Health Sciences, Department of Social and Welfare Studies, AVC, Campus Norrkoping, 601 74 Norrkoping, Sweden. E-mail: eva.erichsen@lio.se
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Honesty, on the other hand, refers to facts, metaphors, ethics and communication.1,7,8 From a medical point of view, the concept of honesty is discussed when providing information about a terminal disease and patients awareness of the diagnosis and prognosis.9 There have been several studies on honesty when breaking bad news to terminally ill patients.4,10,11 From a nursing perspective, a study was conducted on nurses aim to give honest information, to explain and to help patients to understand palliative care.4 There is also debate on how nurses can be honest and yet give hope.12 How honesty between nurses and patients can affect care, according to our knowledge, is a subject not yet studied. However, the opposite concept, caring dishonesty, has been investigated, when it was shown that nurses were reported to avoid telling the truth to patients in order to evade a confrontation.13 The nurses wanted to be diplomatic and believed that patients and their spouses could not handle the truth. Nurses do not use the term lying; instead, their use of white lies has been reported. This term was used in one study by nurses as a way of not harming patients and avoiding dishonesty.13 Metaphors are another powerful and tactful way of speaking that uses figurative language to say one thing but mean another.14 Since honesty is often mentioned as an essential component of palliative care, it is important to clarify the meaning of this concept in relation to nursing. Up until the present time we have not found any empirical analysis of the concept of honesty in the literature that could explain some of the vagueness in its definition. However, honesty is part of virtue or character ethics. Tenets of this kind of ethics are a moral character, moral goodness, moral education and moral motivation.15 Armstrong15 argues that, in nursing, a virtue is a character trait, habitually performed, which disposes a nurse to act, think and feel in morally excellent ways. It is an ethics of being rather than doing, even though it is action guiding. Virtue ethics is also about taking account of the context and to behave appropriately in particular circumstances.16 To be a good nurse requires excellence in skills, theoretical knowledge and moral virtue. It is important to identify ways of defining and describing honesty in order to obtain scientific knowledge about it. An empirical study could help nurses to improve their self-awareness and provide guidance in meetings and conversations with patients, spouses and colleagues.10 The aim of this study was therefore to describe nurses experiences of honesty in their work in palliative home-based care.

Method
For this study, a qualitative, phenomenological method, according to Giorgi, was chosen. This method is specifically aimed at understanding consciousness and subjectivity. An experience, according to Husserl, is something that occurs before a reflection over it is made.1719 Giorgi points out that consciousness shows itself through human experiences and intuition. Intentionality is consciousness of a phenomenon in transition, which is experienced by the body and through intersubjectivity, through all the senses, and gives openness to everything a person experiences.20 Phenomenology is a descriptive approach that demands knowledge of bracketing (i.e. putting aside previous knowledge about a phenomenon and not letting it interfere with the phenomenon itself). The authors pre-understanding refers to their experiences from working in palliative care, both with children and adults, where honesty is an important subject, although few reflect upon it. The authors also have experience of working as university lecturers.

Sample
The informants in this study were nurses, recruited from two different hospitals in one county in southeast Sweden with approximately 400 000 inhabitants. They worked for an organization providing advanced teambased home care using staff nurses, nurses, physicians, physiotherapists, occupational therapists and social workers. The patients can receive team support in their homes within 30 minutes for 24 hours a day. Purposive sampling was used. Heads of units were asked to choose nurses to represent variation in nurses working

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Table 1. Participants demographic data Characteristic Education Registered nurse Work experience in nursing (years) 1 29 1015 1625 2630 3140 Experience in palliative home-based care (years) 1 2-5 6-10 Specialist education Palliative care course District nurse Paediatric nurse No. 16

2 0 6 4 3 1

1 8 7

2 1 8

experience with different types of patients, both children and adults, and in different kinds of relationships in families and between siblings and spouses. The participants were 16 female nurses working in palliative home care with children and adults. Their total clinical experience varied from one to 34 years, six months to 10 years of which was in palliative care (Table 1). Ethical guidelines were followed regarding individual informed consent, confidentiality and voluntariness. The nurses were informed both orally and in writing that participation was voluntary. None of the nurses declined. They were also assured that all data collected would be confidential, that their interviews would be read only by the authors, and that all data would be kept in a safe.

Data collection
The data were collected at the nurses workplace, in a selected undisturbed location adjacent to each unit, by means of tape-recorded open interviews with follow-up questions. The first two authors (EE, EHD) conducted and transcribed all the interviews verbatim. The interviews lasted for between 30 and 90 minutes. In order to encourage informants to focus on the concept, all the interviews commenced with the question: Do you think honesty is important?

Analysis
The analysis was conducted in four steps (Table 2): 1) Reading the transcribed material to obtain a sense of the whole, of the context, and to become familiar with the data. 2) Identification of meaning units: In order to see the descriptions as described by the informants, previous knowledge was actively put aside and the most important statements were selected.

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Table 2. Analysis example of steps 24 Expressed meaning units Honesty wins in the long run; I believe in that, above all as a person. I believe it is important to be honest, even though its hard sometimes and you have to tell things to parents. Transformed meaning units Theme

The nurse experiences that one should The content is that you should be be honest because this is experienced as honest because it wins in the long important in the long run, even if it is run. difficult.

It will show ... in your body language if The nurse experiences that dishonesty youre not honest and then there is the will be found out. trust ... it has to show in the patients trusting you ... ... an 11-year-old girl who is going to die The nurse experienced that it was from a disease and we were not allowed difficult not to be able to be honest. to talk about it in their home ... that made our work difficult ... but we had to respect the parents wishes ...

A reason for being honest is that dishonesty will be exposed and thereby affects a relationship of trust. Problems and conflicts may arise when honesty is not permitted.

3) Transformation: All meaning units were transformed to make their content explicit. They were then compared to find sources of variation or agreement. Similar meaning units were grouped together. By using free imaginative variation, every descriptions specific meaning was raised to a more general trans-situational statement (Table 3), here described as a theme.17 4) The structure of the experience: All these variations were then studied to explore the phenomenon and explicitly to express a structure of meaning, which is the essence of the phenomenon.20 All the transformed meaning units were synthesized into an overarching statement, the essence, to describe the lived experience of honesty. Last, the subjective life-world perspective was transformed into scientific language from its meaning within the discipline of nursing. Scientific knowledge should be systematically and methodologically sampled correctly for reliability. For this reason, a third researcher (MF) took part in the data analysis by reading all the transcribed interviews and comparing them with the analysis procedure and the results. The researchers discussed differences until agreement was reached.

Results The meaning of honesty

All the nurses had problems when they tried to define the word honesty. Lying was defined as the clear opposite to honesty, but to adjust the truth or not tell everything was not considered to be dishonest. When they were talking about honesty they referred to this in encounters with patients and family members and during communication about death, the future, progress of the disease and reality. They also expressed honesty as caring actions, risks, and why and what to do in certain situations. They had learned that the truth of today could change and look different tomorrow.

A basic human need. All the nurses experienced honesty as essential, something basic that all humans
tried to achieve, expected and required in their meetings with others. The nurses were striving for it and

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Table 3. Themes and their meaning units Theme The meaning of honesty Meaning unit A basic human need A way of behaving A quality Prerequisite for good care Dishonesty will always be exposed in the end Expectations

The reason for being honest

Moral conflict when dealing with honesty

were disappointed if they felt the opposite: dishonesty. This was considered important, especially in the care of vulnerable and terminally ill patients.
I need honesty from other human beings; I really have that need. Maybe that is why I have the need to be honest to others.

A way of behaving. The nurses experienced that honesty was a way of behaving and acting at work as well
as in their private lives. Some claimed that patients should be told the truth about the reality of their illness by giving facts that they could check out for themselves They were of the opinion that this was best for all parties in the long run, even if patients or family members might initially feel hurt. This was something they would have to go through anyway.
When I give information to patients about our organization then I have to be direct and ask what they want from this care. I ask them to tell me about their experiences of the disease. At the same time I compare their experience to the physicians letter of referral. If it doesnt match, I tell them what the physician has written and confront them with that. Im so straightforward that I tell them that: You wont be getting better.

Other nurses said that they had to adapt to patients and/or family members view of the truth and be careful and sensitive in their judgement of when the time was right to be honest. They did not feel that this kind of behaviour was dishonest or that they were lying. They could still be honest in expressing half of the truth, not telling the patients and/or family members exactly everything.
In a way maybe you could say that you withhold certain things, but Im not dishonest because of that! But if I was going to withhold something, I would do so because I think its for the patients best.

A quality. The nurses also expressed their opinion that honesty was a quality, an ability to feel and understand others situation and needs. This quality was experienced as a feeling that could be felt instinctively by others. They experienced that they acted in an honest way according to their own mind, based on an ability to feel empathy. They wanted to do their very best for patients. Some nurses described it as a gut-feeling of what, when and how they should or could be honest.
No, I dont ask the patient how honest they want us to be. Maybe I should? I havent thought about it! Well, I cant describe it any other way than a sort of ... I felt this ... this feels good ... in my gut!

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The reason for being honest Prerequisite for good care. The most important reason why the nurses claimed that honesty was important
was that it created the prerequisite for good care. Honest information was said to be the basis of all good caring relationships because it built up rapport, and created trust, confidence and a sense of security. Mutual trust was experienced to be the ultimate caring relationship. Honesty made patients and families feel more involved in the care, for example, because they dared to ask the nurses all kinds of questions. The nurses actively worked towards these goals but were not sure if the patients shared them. They experienced that good care could not be provided without a good relationship.
Wanting to be honest is about creating security and trust. That is why you are honest. You want to inform the patients, they have the right to know, to get understandable information. You want to create a relationship and confidence. What I say must be honest; otherwise they wont believe me.

Honesty was also believed to give patients hope.

I think that honesty, even bad news, may give patients more hope. People know the facts and theres hope in being more prepared. If I was a patient I would like to know how things worked. And then I can have some hope of having a good end, instead of not knowing anything.

Dishonesty will always be exposed in the end. The nurses described honesty as something that all the
patients required and, if someone was dishonest, this would be revealed in the end and would result in angry and distrustful patients and family members who did not have faith in the health care system. It affected trust, confidence and the relationships between nurses and patients. Distrust made care complicated and, if it was broken, it was considered very hard to repair.
I come back to this bit about creating trust! I come back to that all the time! I cant say that you will have more hope or that Ill create trust just at this moment. But I figure, in some way, that well have more contact with each other in the future ... That you ... well, that youll be able to trust me!

The nurses experienced that others would expose them if they acted dishonestly. Avoiding eye contact and uncertain body language exposed them and they were convinced that patients and their spouses could see that. They described that they couldnt hide if this occurred.
... quite clearly, actually, you can feel the tension, you see the body language, you see it in their eyes, in their facial expression. Often when I come into a room I can feel if there are people sitting round a table, feel the mood. You can see the different people if they keep distance. You can feel distance in a different way than in others.

Expectations. The nurses felt expectations of them to be honest emanated from different sources, such as the community, the health care system, the team and themselves. These expectations were sometimes frightening and, in certain situations, they felt they didnt have the courage to be honest. Others described that being honest was part of their profession and they had no problems with it. Honesty was not an issue for discussion between nurses and patients, and the expectations mostly came from the nurses themselves.
I have the experience that you would like to know. You dont have to know everything. But, surely, youd like to know, wouldnt you? For all of a sudden you may be deprived of your time on this earth. I think that is the worst thing that can happen.

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Moral conflict when dealing with honesty

The nurses experienced that there were times when they felt forced to act against their own desire to be honest. They felt dishonest when they failed to understand or explain the benefits of treatment when no improvement or relief was observed. Sometimes there were problems within the team, for example, when they were unsure if the physicians were unaware of a lack of improvement, didnt have the courage to stop the treatment, or had a reason for continuing the treatment that was unknown to the nurses. Conflict could also arise when the nurses knew more about patients than the patients themselves, and when they were uncertain and did not know how much they could say. All the nurses experienced that it was the doctors task to inform and explain about diagnosis, prognosis and medical treatments.
Somewhere, somebody has to be honest and say that now we cant do any more for you. If you say that and the next minute you say that maybe there is someone somewhere else that might be able to do something, that gives them contradictory messages. What are they to believe then?

Sometimes family members explicitly told the nurses not to tell a patient how ill the person really was. This forced the nurses to act against their own moral judgement and they were not always sure what was the right thing to do. They had to put aside their wish to be honest, to protect and support out of respect for the patient. Some nurses described their own need for honesty and their objections to being dishonest regardless of a patients needs. Others felt that they had to have a feeling for patients need for honesty, without prioritizing their own feelings.
Often these questions arise when the spouses are there. Often the question comes from the spouses. How long has she got? Then there is the opposite, which I experience as even more frustrating! When the spouses say, Dont tell the patient that she is sick or is going to die! What can you do? It is so difficult!

The nurses also felt uncertain when meeting patients from different cultures. In these situations they did not know how to act because honest information could be experienced as most inappropriate by family members. With the intention of keeping hope alive, sometimes certain information was withheld from patients and spouses. If the doctor had this conversation together with patients, spouses and nurses, it would make it easier for them to act honestly later.
We had a family where I would say that they were lying to us several times. But for them they werent lying; I can see that now. It was acceptable in their culture to do that, but not in mine

The essence: honesty is a virtue, of doing good

The essence of the findings was that honesty is a virtue. The nurses explained their actions from an ethical point of view by motivating their conduct using human values. One has to be an honest person, and this is taken for granted without any question, argument or discussion. It is societys values. You should act on the principle that what you expect for yourself you would do for others. The nurses wanted the consequences of their actions to lead to good things, both for themselves and for the patients. They assumed that others also experienced their acts as good, despite the fact that they had never evaluated this. The principle that one cares for others as one would wish to be cared for was the uncontradicted rule.

Discussion The problems of defining honesty

This study has shown that palliative care nurses had problems with defining honesty. They expressed different opinions about honesty, using opposites like dishonesty and the consequence of it in caring relationships.

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The social language of palliative care (patient centred, holistic) shapes what individual carers say.21 In one study nurses found it difficult to express their values.22 Maybe this is why the nurses in the present study had problems with defining honesty. Instead, they used ethics for their reasoning. Only a few studies have explored this concept even though it is essential in nursing. In the palliative care literature, honesty is found as a sub-subject under communication23 or truth.4 The only available definitions are those from dictionaries, where one meaning is uprightness in character and actions.5 This is close to the nurses descriptions in the current study, in which they emphasized honesty as an essential need for all human beings and as a guiding rule to live by. Truthfulness and honesty are natural virtues essential to all categories of health care.24 In virtue ethics, honesty is one essential concept. However, in virtue ethics there is no cardinal principle such as duty or utility from which we can derive secondary moral rules. There is rather a concern with what sort of people we must be if we are to achieve the good life.16 It is difficult to know what honesty means when research is lacking, but it is still an important, implicit and undiscussed phenomenon in clinical practice that seems to be one of the most central parts of nursing communication and ethics. Our study, based on nurses experiences, suggests that honesty is a virtue, of doing good. Malloch is one of the few who have studied the concept of white lies. These could be expressed in order to avoid harm to patients but also with nurses intention to evade telling the unpleasant truth. Most white lies, however, do more harm than good because they can be misunderstood as the truth.13 The nurse participants in the current study also agreed that little white lies could make them feel sincerely honest, in spite of not saying everything, in a positive way.

The importance of providing honesty

The nurses reasons for being honest were that honesty was expected from them as professionals, that a lie would be exposed anyway, and that they wanted to provide good care of high quality. Their thoughts seemed to be influenced by virtue ethics, in which a virtue such as honesty is a trait of character that is socially valued and expected.25 Dishonesty, the nurses feared, could lead to a loss of trust between themselves and patients and their spouses. A feeling of trust, security and co-decision making was considered as good care by patients receiving palliative treatment.26 Orem suggests that nurses should support a patient in achieving optimal health and provide an environment in which patients can develop despite their illness.27 Nurses seem to know that patients need trust and expect honesty, but at the same time they more or less voluntarily withhold facts in order to promote patients well-being. The crucial questions is: what is in patients best interests versus the nurses own interests? Nurses fundamental assumptions need to be addressed openly for improvements in palliative care. Even though nurses try to ease the suffering of patients from their own personal understanding of life,28 an ethical question must be asked: what is an honest action and what is not? Honest relationships can be achieved through mutual agreement and must be clarified to overcome patients uncertainty and vulnerability. Being honest is a challenge and a powerful tool that demands sensitivity.29 Moral wisdom is one phenomenon in virtue ethics that includes moral sensitivity. This is an admirable quality that allows a nurse to assimilate a wide range of information, act upon it and respond to patients needs in a morally good way.15 A moral act is judged as good if the receiver experiences it as such. By using informed consent, patients ability to evaluate and understand information can be realized.30 Whether the intentions of honesty are perceived as a benefit or a hindrance to the receiver was not a subject for evaluation or reflection in this study. Structured reflection in practice can help nurses to perceive a more profound aspect of caring31 and explain their life-world assumptions. The use of morality may help nurses to highlight the values and needs of patients.8 Moral imagination is about putting oneself in another persons position.15 Communication between caregivers facilitates nurses subsequently being honest in their communication.32,33 Decisions are based on information but studies indicate that information can be understood in different ways, depending on who you are and what you decide to listen to.10 Patients need to receive information that is understandable to them and then make their own

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HONESTY

T R U T H

VIRTUE

L I E S

Figure 1. Model showing the relationship of honesty to truth and lies

decisions.34 Communication as a subject has been reported to be missing from nursing training,35 although development in this area is progressing.36,37

The clinical problem of being honest

Some moral conflicts emerged from the data; for example, when spouses expressed the wish that nurses did not talk about the illness in patients homes. This made nurses feel uncomfortable but they respected the spouses wishes. In palliative care, spouses are of great importance and a natural part of the care.1 They may want to avoid psychological stress for both the patients and themselves, to be able to maintain their positive thinking and maybe avoid telling patients what they really know.38,39 Avoiding telling the truth can be used as an honest caring action in order to protect a loved one.7 Despite nurses knowledge, it is impossible to predict how a certain disease will develop in a particular patient.40 The respondents in this study said that they informed patients according to what they estimated they had the strength to bear and absorb. The nurses looked upon themselves as patient interpreters and advocates. This is not in accordance with the ethical principle of respecting patients autonomy.41 Hutchings also points out that nurses role as patients advocate could result in benevolent paternalism if it is not reflected upon.14 To achieve a morally good helping relationship between patients and nurses it is also important to have compassion, courage, respect, patience, tolerance and trustworthiness.15 This could be achieved through a structured model for reflection, which could help nurses to deepen their knowledge about nursing so that taken-for-granted phenomena become explicit.31

What needs to be done?

In the current study, a model was developed to illustrate how honesty could be described in relation to truth and lies (Figure 1), which can be seen as two opposite poles or as contrasts on each side of an adaptable virtue. In addition, Aristotle described virtues as a mean; truth is noble and praiseworthy and falsehood is mean and culpable.42 Virtue is a fundamental character that nurses must have and which shapes their actions. Honesty can be adapted to a righteous truth or to a white lie, depending on nurses judgement of a situation and based on their own qualities and virtues. According to Swedish law, health care judgements should be

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made based on science and well-tried experience.43 The virtue of being honest becomes very important when patients are frail and in a dependent state.44 Research on how patients and spouses experience honesty in a caring context would elucidate this phenomenon further. There is a need to develop a humbler approach to every individual, who will possess expert knowledge about themselves and therefore should be met with accordingly. Denying patient autonomy can be harmful to patients and distressful for nurses.45

Conclusion
The essence of the phenomenon of honesty turns out to be a virtue. This study implies that virtue ethics appears to be a subject that is in need of improvement in palliative care nursing. Human beings want to be honest and do good deeds. Our life-world affects our virtues, ethical reasoning and feelings. Ethical discussion could contribute to increased knowledge and awareness of the subject. Owing to the nurses experiences of honesty, it becomes clear that the meaning of honesty is highly individualistic. This emphasizes the importance of nurses being honest in caring situations, which may be achieved by putting aside their own assumptions and through open and honest communication with respect to patients autonomy and identifying their preferences. This study showed that feelings and intuition are good qualities but can also create uncertainty and ethical conflict. Conflict of interest statement The authors declare that there is no conflict of interest. References
1. Johnston B. Overview of nursing developments in palliative care. In: Lughton J, Kindlen M eds. Palliative care: the nursing role. London: Churchill Livingstone, 1999: 126. 2. Davies B, Oberle K. Dimensions of the supportive role of the nurse in palliative care. Oncol Nurs Forum 1990; 17: 8794. 3. Britto M, DeVellis RF, Hornung RW, DeFriese GH, Atherton HD, Slap GB. Health care preferences and priorities of adolescents with chronic illness. Paediatrics 2004; 114: 127280. 4. Stanley KJ, Zoloth-Dorfman L. Ethical considerations. In: Ferrell RB, Coyle N eds. Textbook of palliative nursing. New York: Oxford University Press, 2001: 66381. 5. Encyclopedia Britannica Online Academic Edition. (n.d.) Retrieved 31 July, 2007, from: http://search.eb.com/ dictionary?vahonesty&queryhonesty 6. Oxford Reference Online Premium. (n.d.) Retrieved 31 July, 2007, from: http://www.oxfordreference.com/views/ ENTRY.html?subviewMain&entryt22.e6632 7. Tuckett AG. On paternalism, autonomy and best interest: telling the (competent) age-care resident what they want to know. Int J Nurs Pract 2005; 12: 16673. 8. Marshall PL. End of life care: ethical issues. Kansas Nurse 2001; 7: 47, 1112. 9. Bruera E, Portenoy RK. Truth telling and reciprocity in the doctorpatient relationship: a North American perspective. (Topics in palliative care vol. 5.) New York: Oxford University Press, 2001. 10. Friedrichsen M, Strang P, Carlsson M. Cancer patients interpretation of verbal expression when given information about ending active tumour treatment. Palliat Med 2002; 16: 32330. 11. Gold M. Is honesty always the best policy? Ethical aspects of truth telling. Int Med J 2004; 34: 57880. 12. Begley A, Blackwood B. Truth-telling versus hope; a dilemma in practice. Int J Nurs Pract 2000; 6: 2631. 13. Malloch K. The white lies of leadership: caring dishonesty? Nurs Adm Q 2001; 25(3): 6168. 14. Hutchings D. Communicating with metaphor: a dance with many veils. Am J Hospice Palliat Care 1998; 15: 28284. 15. Armstrong A. Towards a strong virtue ethics for nursing practice. Nurs Philos 2006; 7: 11024.

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