The truth, the whole truth and nothing but the truth? Opinion polls rank nurses as the most trusted professionals in New Zealand. (1) However, in reality, nurses may find that truth telling is not a straightforward matter. Here a nurse explores some of the ethical dilemmas surrounding truth telling in nursing practice.

Most nurses would agree that trust is vital for establishing healthy relationships between the patient, the nurse and family members. Clearly, openness and honesty are essential in any relationship and should be highly valued. Trust, however, will only be evident in a relationship that values truth telling or veracity. (2) Although at face value it may seem that nurses should never tie, it has been suggested there are "shades of honesty" in the real world of nursing. (3)

Code of ethics 

NZNO's Code of Ethics, outlines "veracity" as one of the key moral values all nurses should include in their practice. (4) This code is designed to guide NZNO members, other nurses and the public in determining what is appropriate conduct, and levels of performance in nursing. (4,5) Florence Nightingale suggested nurses needed a code to remind the profession it had a responsibility to maintain certain standards of care. (8) Without a plumb Line on which to gauge our moral standings, we would flounder in the fog of uncertainty, searching for direction. But just how easy is it for nurses to adhere to these values and principles in the current health care environment? How often do we see health literature explore such fundamental ethical issues?

Nurses who face ethical dilemmas in their practice often find their voices are not heard when it comes to collaborative decision making on the issue. Factors such as conflict within the medical team and the existence of hierachial structures can mean the nurse at the coal face is not consulted. Fighting hospital policy and the fear of lawsuits can influence whether the nurse eventually acts by moral choice. This situation can be frustrating and may lead to considerable distress. A nurse who is not able to find resolution to an ethical dilemma, and then act in a way in which she feels morally comfortable, may experience anxiety, feelings of guilt and possibly burnout. It is therefore very important that our leaders and managers include in their nursing education and hospital in-service sessions, teaching that will prepare today's nurses for the complex ethical issues they will encounter. (6)

Surprisingly, the issue of truth telling in the health care setting is a relatively modern concept. in the past, it was considered preferable to keep unpleasant information concerning diagnosis and the progression of a disease from the patient, under the guise of protecting them from unnecessary distress. It was the health professional's responsibility to decide whether the patient should or should not know the truth. At times, the family would insist that their Loved-one should not be told of their prognosis. The patient had no autonomy at all. (2,3,7) Modern legislation, however, recognises the tights of a person to be given true and accurate information about their illness and treatment. The Code of Health and Disability Services Consumers' Rights states that a consumer has the right to 1.(a) "an explanation of his or her condition" and (b) "an explanation of the risks end side effects" of the treatment options. Right 6 also states that, "every consumer has the right to honest and accurate answers to questions relating to services." (4)

The patient's right to know they are dying, stems from their right to respect. After all, is it not their life and their death? Should they not have the right to that knowledge above anyone else? Other ethical questions we might find ourselves asking are: Does a child have the right to know they are dying? Do parents have the right to withhold this information from their child? Does the nurse have the right to disregard parents' wishes, if the child begins to ask searching questions? These are difficult and at times heart wrenching questions requiring soul searching analysis. Each individual case needs to be assessed in its context. (2,8)

Nowadays, it is well recognised by health professionals that by providing a person with the truth about their illness, we are arming them with the information they need to take control of their lives. This enables them to make important Life decisions, plan for their family's future and, at times, seek forgiveness, healing torn relationships, so they can come to a place of peace. (8)

Being denied the truth may be more frightening than having to deal with the issues around death and dying. Often a patient will have picked up enough clues to suspect the worst anyway. Living with uncertainty can have detrimental effects on their mental wellbeing. (8) Evidence has shown that, on the whole, people who are fully informed about their condition summon tremendous strength and, with support, they will eventually be empowered by the truth, enabling spiritual and personal growth. (8,16,17)

The actual process of sharing the painful truth with a patient and theft family is a very difficult task, requiring a great deal of sensitivity about where each individual is at on theft emotional journey. Consideration of the appropriate time, place and just how to tell, is essential.

'Titrating' the truth

In fact, at times it may be necessary to "titrate" the truth into small more palatable doses, allowing time for the words to take affect. This is where the term "shades of honesty" may be applied. It may be necessary, at times, to filter the truth, until the patient is able to cope with the larger, less digestible information. This is an especially important technique to employ when working with children. (2,3,8,)

Although it is primarily the task of the doctor to inform a patient of their prognosis, it is often the nurse who is approached shortly afterwards for an explanation of the implications of this news on the every day life of the patient and their family. Understandably, the nurse may feel frightened and challenged when faced with exposing the truth about a patient's terminal illness. A nurse bearing such news, must share in the initial grief and pain experienced by the receivers. The nurse will need to be there in a supporting role for some time afterwards. This whole process may take its toll on staff.

Nursing leaders and managers can provide structures, frameworks and support to guide their workers in ethical decision making. The issues of rights, duty and the implications of a course of action, need to be ascertained. Collaboration at these times with senior staff can provide the nurse with the confidence and support they need. (2,6)

Former director of nursing at Auckland District Health Board, Mia Carroll, writes in an article on nursing leadership that leaders in present and future health care settings need to model ethical behaviour like never before. She suggests there needs to be strong values that guide decision making, and that leaders need to pull in ideas from a range of people, so diverse viewpoints are considered. It is also important to ensure there is time and space for collaboration and reflection on ethical issues. This is particularly important when patients' lives will be affected by the outcomes of this decision making. The pooling of a variety of viewpoints is especially valid when ethical dilemmas are being weighed in the minds of a nursing team. (9) If Mia Carroll is correct in her suggestion that ethical behaviour needs to be modelled from the top down, (9) then New Zealand hospital chief executives may need to look at why they are falling behind other countries such as Canada, the United States (US), Australia and the Untied Kingdom (UK) in being honest about the rates of medical errors in their establishments. It has been reported that 25 percent of New Zealand chief executives would not release the medical error rates in their hospitals. These chief executives stated that only seven percent of their physicians would be willing to disclose data on medical errors, compared to 30 percent of US physicians and 35 percent of UK being in favour of releasing data. (10)

A report on "hiding" errors points out that if the public perceive they are not being told the truth, and that errors are being covered up, then this will only incite a larger number of people to lodge complaints. This will, in turn, lead to lawsuits and a lowering of the public perception of the quality of our health system. The avoidance of the truth and the presence of dishonesty breeds mistrust. Despite the fact that New Zealand has one of the most supportive structures in the world to deal with medical errors, there is a reluctance by chief executives and district health boards to disclose information. (10)

The unfortunate consequence of this dishonesty, is that when errors are not acknowledged, they cannot be appropriately dealt with. This means there is no way of ensuring they do not recur. Nursing leaders and managers need to promote a safe environment for their staff, one that fosters a culture of learning from mistakes, rather than one of accusation and blame. A regular meeting of staff members to review errors made on the ward, can be run anonymously and encourage teamwork. Discussion should be encouraged to discern ways to avoid the same mistakes in the future. (10,11)

One common error made by nurses is medication administration. Such an error will result in the nurse feeling vulnerable and upset. Not only are they concerned about how the mistake will affect the patient, they also worry about the implications on their careers if they are disciplined. By admitting to the mistake, they may be ridiculed by other nurses or even worse, lose the trust of their patients. The outcome of this distress is that often the nurse will hide the truth when the patient seems to be unaffected. Many ethical questions arise in these instances: Should the nurse tell the truth and disclose the error? Will telling the patient, cause more harm than good? If the patient isn't ton and they find out later, will the outcome be an erosion of trust? (12)

Hidden mistakes

As mentioned earlier, hidden mistakes mean problems with procedures are not recognised. This eventually has an impact on the quality of care delivered to our patients. Nurses need to be supported and encouraged by management when they disclose an error. They are then in a position to learn from their mistakes and can hopefully help to identify ways in which a similar event can be avoided. (12) This process can help to alleviate feelings of guilt associated with the event. (13)

There are four identified guiding principles needed to implement safe medication delivery. These include beneficence, nonmaleficence, fidelity and veracity. (12) When the focus is on changing the unsafe practice and not on punishing the offender, staff will be able to exhibit these guiding principles without fear of the consequences. (12,13)

Another situation where nurses may fear telling the truth, is in the area of whistleblowing. This term is used when someone publicly exposes the truth about unsafe or unlawful work practices. In a nursing context, these "practices" may be endangering the patient or the public at Large. (8,12)

The act of whistleblowing is not taken lightly. Nurses realise they are accountable for their own standards of practice and professionalism, but they also have a sense of a wider responsibility to their profession. This responsibility will at times present the nurse with difficult moral choices, meaning they will have to decide whether to tell the truth about a colleague's poor standards of care or, in some cases, acts of cruelty. (8,12)

The ethical questions that may arise include: At what point do I disregard my professional loyalty? Do I want to live with the consequences of betraying a co-worker? Will the good relationships I have with the rest of the staff be destroyed if I go public? How will this affect my career? Will I lose my job? Will I be accused of interfering?

Barriers to exposing the truth

These questions highlight the dilemma nurses face when weighing up the pros and cons of whistleblowing. The fear of damage to their career and working relationships, are barriers to exposing the truth about unsafe practice. (8,14) The Government passed the Protected Disclosures Act in 2001. This law protects whistle-blowers from the ramifications that may result from the exposure of unsafe or unlawful practices within their organisation. This Act is designed only to be used when there has been failure to address the wrongs through normal workplace processes. Instances where nurses may be forced to use the protection this Law provides, would be in the case of gross misuse of public funds, when patients or the public are at risk of harm, or in cases of serious abuse, neglect or cruelty. (15)

Again, it is paramount that health managers have policies in place that will protect the nurse and address whistleblowing issues. If an institution is not providing frameworks that uphold the principles of the code of ethics, then it is not an ethically responsible organisation. If nurses are not supported in their endeavours to speak out and act as patient advocates, then this profession will never be a "voice" that is heard and taken seriously in health care. (14) Ultimately it is the moral climate that exists in society that will inevitably influence the morals and ethics of health professionals. (8) Nevertheless, nurses need to recognise that their chosen profession will always demand a high standard of moral and ethical behaviour because their work so directly affects humankind. Therefore it is important they recognise that truthfulness is a crucial principle to apply in the field of medical ethics. (7)

I would like to conclude on a more personal note. Have I answered the question in the title of this article or have I, instead, posed even more ponderous questions for the reader? The issues surrounding truth telling are too numerous to number and the answers are unfathomable at times. I would therefore like to quote some wise words written by psychiatrist and author of the best-selling book, The Road Less Traveled, M. Scott Peck, that I believe will help any nurse who is genuinely seeking the answer to the question: Do I tell the truth, the whole truth and nothing but the truth?

"What rules, then, can one follow if one is dedicated to the truth? First, never speak a falsehood. Second, bear in mind that the act of withholding the truth is always potentially a lie, and that in each instance in which the truth is withheld o significant moral decision is required. Third, the decision to withhold the truth should never be based on personal needs, such us the need for power, a need to be liked, or the need to protect one's map from challenge. Fourth and conversely, the decision to withhold the truth must always be based entirely on the needs of the person or people from whom the truth is being withheld ... " (16)

He goes on to remind us that to assess another person's needs is such a responsible task that it requires an attitude of genuine Love and caring for the other person. He finishes by pointing out that generally we tend to underestimate a person's capacity to cope with the truth. By denying them the chance to use the truth, we deny them the chance to grow as people. (16)

It is the responsibility of all health workers, from managers to those at the coalface of clinical practice, to adhere to the principles of truth and veracity. Structures and frameworks need to be put in place to aid and protect staff when they face ethical dilemmas. Any decisions made that have the potential to negatively affect others, deserve deliberation from a moral and ethical perspective. This deliberation is more effective if a variety of viewpoints are considered, before decisions are made. The nurse has the right to be heard, along with the other members of the medical team, because ultimately, she is the patient's advocate--an awesome role deserving recognition.

References

(1) Listener, (2001) Turf war: who will see you now--the doctor or the nurse? New Zealand Listener; November 24, p38.

(2) Richarson, J. & Webber, I. (1995) Ethical Issues in Child Health Care. London: Mosby.

(3) Day, L.J. & Stannard, D. (1999) Developing trust and connection with patients and their families. Critical Cure Nurse; 19: 3, 66-70.

(4) Burgess, M.E. (1999) A Guide to the Law for Nurses and Midwives (2nd ed.). Auckland: Longman.

(5) Gunn, D. (1997) Bearing the burden of professional duty. Kai Tiaki Nursing New Zealand, 3: 10, 11.

(6) Rodney, P. & Starzomski, R. (1993) Constraints on the moral agency of nurses. The Canadian Nurse; October, 23-26.

(7) Seedhouse, D. (1992) Ethics: The Heart of Health Cure. Chichester: Wiley.

(8) Boyd, K., Melia, K.M. & Thompson, I.E. (1994) Nursing Ethics. (3rd ed.) Edinburgh: Churchill Livingstone.

(9) Carroll M. (2002) Nursing leadership: A personal perspective, in E. Papps (Ed.) Nursing in New Zealand: Critical Issues Different Perspectives. Auckland: Prentice Hall.

(10) Stuart, J. (2003) Hiding errors risk flood of complaints. New Zealand GP. Auckland: Adis International.

(11) New Zealand GP (26/11/03). Errors up but rate down. Auckland: Adis International.

(12) Erlen, J.A. (2001) Medication errors: ethical implications. Orthopedic Nursing; 20: 4, 82-85.

(13) Hall, 3.K. (2003) Legal consequences of the moral duty to report errors. JONA'S Healthcare Low, Ethic5 and Regulation; 5: 3, 60-64.

(14) Light, C. (2001) Whistleblower protection: returning the healthcare profession to the advocate role. Kansas Nurse; 76: 6, 1-4.

(15) The Treasury, New Zealand Government (2001, January). Whistleblowing: making a disclosure of serious wrongdoing under the Protected Disclosures Act 2000. Available (online) at http://www.treasury.govt.nz/careers/tsypda-policy.pdf.

(16) Balzer Riley, J. (2000) Communication in Nursing. (4th ed.) St Louis: Mushy.

Shona Philpott, RN, BHSc (Nursing), is undertaking the new graduate programme at Whangarei Base Hospital. She has just completed six months in operating theatre and is now working in an orthopaedic ward.