Nurse Educator
Nurse Educator Vol. 40, No. 5, pp. 254-257 Copyright * 2015 Wolters Kluwer Health, Inc. All rights reserved.
Patient Deception Nursing Students’ Beliefs and Attitudes Drew A. Curtis, PhD This study examined nursing students’ beliefs about indicators of deception and their attitudes toward patient deception. Fifty-eight participants from various nursing programs at a southwestern university completed a Detection of Deception Questionnaire and Attitudes Toward Patient Deception Scale. Findings indicated that nursing students have a number of inaccurate beliefs about deception and possess a number of negative attitudes toward patients who lie. Implications for nursing education are discussed. Keywords: attitudes; deception; lying; nurse-patient relationship; patient deception
A
t the heart of nursing lies the relationship between a nurse and a patient. The nurse-patient relationship is associated with increased patient satisfaction and has a positive impact on care.1 A variable that directly challenges the nurse-patient relationship is deception. Deception is a successful or an unsuccessful deliberate attempt, without forewarning, to create a belief that the communicator considers to be untrue.2,3 This definition of deception has been used in other research.4,5 Deception often damages trust and elicits negative consequences,6,7 even when it is undiscovered.8 Even telling white lies, with the intent of beneficence, may lead to more negative experiences.9 Much of the literature pertaining to deception within health care has focused on the lies told from health care providers to patients.10-12 However, patients also lie.13 This is not surprising given that people lie, on average, about 2 times a day.6 Patients may be deceptive for a variety of reasons, including personal benefit, to protect another person, to gain some advantage, or for psychological or material reasons.3 Faking symptoms of pain to obtain prescriptions14 would be an example of lying for material gain, also considered a self-oriented lie.6 Self-oriented lies may serve to manage impressions,15 such as a patient lying about smoking to portray an image of a healthy nonsmoker. Within health care, being honest is a standard and a norm.16 In fact, nurses are regarded as the most trustworthy health care professionals, and deception from nurses is often viewed as ‘‘bad care.’’17 Nurses are perceived as honest and holding higher ethical standards than other professions for many Author Affiliation: Assistant Professor, Department of Psychology, Sociology, and Social Work, Angelo State University, San Angelo, Texas. The author declares no conflicts of interest. Correspondence: Dr Curtis, Department of Psychology, Sociology and Social Work, Angelo State University, ASU Station 10907, San Angelo, TX 76909-0907 ([email protected]). Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.nurseeducatoronline.com). Accepted for publication: January 24, 2015 Published ahead of print: March 13, 2015 DOI: 10.1097/NNE.0000000000000157
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years.18 Nurses seek to adhere to values and standards of practice, including honesty, evidenced throughout education and training.19,20 Thus, patient deception appears to violate this norm and value, possibly leading to increased negative attitudes toward patients who lie. The effects of deception in health care are amplified because it is often undetected. A meta-analysis found that people are only slightly better than chance (54%) in accurately detecting deception.21 One of the reasons why people are not good at detecting deception is that ‘‘there is nothing like Pinocchio’s nose,’’2 meaning there is not 1 specific behavior that consistently indicates when a person is lying. However, indicators of deception exist, and research has identified behavioral changes in 3 categories: nonverbal, paraverbal, and verbal, resulting in 28 different indicators of deception.3,15,22-24 A variety of professionals’ beliefs about indicators of deception have been examined.3 People rely on their beliefs about lying behaviors when ascertaining the veracity of statements.25 One of the most salient incorrect beliefs about deceptive behavior, found across cultures, is that people look away when lying.26 Because of the impact of deception on relationships, and professionals often holding many inaccurate beliefs about deceptive behavior, the current study examined nursing students’ education, beliefs about indicators of deception, and their attitudes toward patients who lie to nurses. It was predicted that nursing students would report moderate to minimal education in patient deception and that they would hold a number of false beliefs about actual indicators of deception. Considering people’s dislike of being the target of deception and nurses’ emphasis on integrity and trust, it was predicted that participants would hold more negative than positive attitudes toward patients who lie. Lastly, nursing students’ value of honesty was examined.
Method Participants Through convenience sampling, 58 students enrolled in different levels of nursing programs (ie, BSN, RN to BSN, MSN,
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RN to MSN) at a southwestern university were recruited for the study. Of the 58 participants, 52 indicated they had 1 to 26 years (mean [SD], 5.56 [6.46] years) of patient care experience. With the goal to assess nursing students who had clinical experience, only those who had contact with patients were used within analyses. The participants ranged in age from 19 to 52 years (mean [SD], 30.33 [9.54] years). Most participants were female (89%) and represented a range of ethnicities/races, with most (71%) being white. Most participants reported having BSN degrees (65%) and being RNs (64%). Experience and training with deception were measured on a 7-point Likert scale (1 = none, 7 = very much). Participants reported minimal exposure to literature on deception (mean [SD], 1.94 [1.07]), training about patient deception (mean [SD], 1.86 [1.20]), and training related to deception detection (mean [SD], 1.73 [1.07]).
Instruments The current study implemented 3 instruments. The demographic questionnaire collected information on age, gender, ethnicity and race, education, licensure, certificates, literature read on deception, training in deception, and years of contact with patients. The Detection of Deception Questionnaire (DDQ) was developed by Hart and colleagues23 to measure beliefs about indicators of deception. The questionnaire consisted of 2 items measuring level of confidence in ability to detect deception and how often participants thought patients lie to them on a 7-point Likert scale (from 1 = very rarely to 7 = very often). The remaining 28 items asked participants to indicate whether each of the specific behaviors increase, decrease, or remain the same when patients lie (from 1 = significant decrease in behavior to an anchor of 4 = no change in behavior to 7 = significant increase in behavior). The Attitudes Toward Patient Deception Scale (ATPDS) is a 24-item adaptation of the Therapist Attitudes Towards Deception Scale (TATDS27). The internal consistency of the TATDS is fairly reliable (Cronbach’s ! = .83). The ATPDS was similar to the TATDS but with some items reworded as attitudes toward patients rather than clients. The ATPDS contained 2 subscales: (a) specific and (b) global. The specific subscale consisted of 12 items asking participants to indicate on a 9-point Likert scale how their attitudes would change if a patient’s lie was discovered (from 1 = decrease to an anchor of 5 = no change to 9 = increase; Cronbach’s ! = .91). These attitude items included affective and cognitive labels, such as feeling more angry toward a patient or thinking more negatively about a patient who lied. On the global subscale, participants were asked to rate patients who lie to nurses compared with those who do not lie to nurses across 12 attitudinal items on a 7-point rating scale (from 1 = not very to an anchor of 4 = no change to 7 = very; Cronbach’s ! = .78). Those items asked participants to identify what they thought about patients who lie to nurses, such as whether they were less successful, less likable, or more pathological. To establish a total attitude score, the scores from the specific subscale and global subscale were summed (Cronbach’s ! = .88). Procedure The institutional review board approved the study. An e-mail containing a link to the study, which was conducted online, Nurse Educator
was sent to all nursing students. After consenting to participate in the study, the participants were asked to complete the demographic questionnaire, the DDQ, and the ATPDS. The surveys were available for the span of 1 semester.
Data Analysis Using 1-sample t tests, nursing students’ beliefs about changes in each of the 28 behavioral indicators were analyzed to determine if they differed significantly from a nonbehavioral change anchor. A Bonferroni adjustment (=0.002) was applied to the analyses to avoid an increased type I error due to running multiple t tests. Further, a mixed factorial analysis of variance (ANOVA) was used to analyze RNs’ compared with nursing students’ beliefs of all 28 indicators of deception. One-sample t tests were conducted on attitude items that asked participants to rate how discovering a patient’s lie would affect them to determine if their ratings demonstrated a significant difference from a nonchange anchor of 5 (Bonferroni = 0.004). Furthermore, 1-sample t tests also were conducted on each of the attitude items, asking participants to rate patients who lie to nurses compared with patients who do not lie to nurses (Bonferroni = 0.004). A mixed factorial ANOVA was conducted to examine RNs’ compared with students’ attitudes toward patients who lie to nurses. Lastly, a bivariate correlation was run between age of participants and attitudes toward patient deception. Descriptive analyses were conducted to examine participants’ confidence in detecting patient deception, value of honesty in interacting with patients, and how important honesty is for the nurse-patient relationship, successful treatment, and care.
Results When students were asked to indicate whether particular behaviors change when people lie to them, most of them held accurate beliefs for 6 of the 28 behavioral indicators of deception: smiles, latency, pitch, answer length, logical consistency, description of feelings, and describing interactions with others (see Table, Supplemental Digital Content 1, http://links.lww.com/NE/A218). For example, students correctly identified that logical consistency tends to decrease and vocal pitch tends to increase when people are deceptive. There were no differences between students and nurses in their accuracy in determining indicators of deception (F1, 44 = 0.14, P = .71). When students were asked how they would respond when they discovered that a patient had lied to them, most indicated they would form more negative attitudes toward the patient, for example, liking the patient less, not wanting to interact with the patient, and viewing the patient as less successful and less likable (Tables 1 and 2). Of 24 attitude items, students held 13 negative attitudes and no positive attitudes toward patients who lie. There were no differences between students and RNs regarding their attitudes toward patients who lie (F1, 45 = 0.99, P = .75). Lastly, there was no relationship between participants’ age and their attitudes toward patients who lie to nurses (r = j0.17, df = 43, P = .28). Students reported moderate confidence in detecting patient deception (mean [SD], 3.72 [1.42]). They also indicated that honesty with patients is valued highly (mean [SD], 6.51 [0.93]), is very important for the nurse-patient relationship Volume 40 & Number 5 & September/October 2015
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Table 1. Nursing Students’ Attitudes Toward Discovering a Patient’s Lie (Specific Attitudes Scale) Attitude Item
Mean (SD)
Liking the patient Being angry at the patientb Patient as a bad personb Thinking negatively of patientb Judging patient harshlyb Desire to interact with patient Enthusiasm to work with patient Judging patient as a good patient Speaking poorly of patientb Trusting the patient Thinking positively about patient Viewing patient as sincere
3.73 5.42 5.23 5.54 5.31 3.88 3.63 4.02 5.15 2.34 3.56 2.79
a
t
(1.47) j5.99a (1.47) 1.96 (1.71) j1.36 (1.35) 2.78a (1.17) 1.85 (1.48) j5.26a (1.42) j6.69a (1.34) j4.95a (1.05) 0.96 (1.51) j12.09a (1.46) j6.83a (1.50) j10.19a
Attitude Change Decrease No change No change Increase No change Decrease Decrease Decrease No change Decrease Decrease Decrease
P < .004. Reverse coded.
b
(mean [SD], 6.69 [0.72]), and is highly important for successful treatment and care (mean [SD], 6.63 [0.79]).
Discussion The current study explored patient deception in nursing and found that students and nurses have a number of incorrect beliefs about deceptive behavior. Some of these incorrect beliefs include believing that people avoid eye contact or look away when lying. These findings are parallel to research from other fields.27,28 One reason for the findings may be that beliefs about deception are deeply rooted in our lives. People often hold incorrect beliefs about deception that reflect cultural constructions of the liar stereotype.2,26 Another reason could be the lack of education and training in deception. Nursing students reported minimal training in patient deception, its detection, and exposure to the literature. These findings appear among psychotherapists as well.27 Students in nursing programs may receive minimal education in patient deception because of the importance of developing clinical skills and competencies.29,30 Deception emerges as a topic in medical ethics; however, it has been argued that the dynamics of deception extend beyond medical ethics.11,17 Regarding attitudes, nursing students possess a number of negative attitudes toward patients who lie. These attitudes may be due to their dislike of being lied to and perceiving liars as unpleasant.31 The resultant attitudes also may be related to professional values and normative practice.16,17 Participants in this study reported that they valued honesty in interacting with patients and thought patient honesty was important for the nurse-patient relationship and for treatment. It is important to note that not all attitudinal changes were negative toward patients who lie. The findings offer implications for education and practice. The risk for nurses is that inaccurate beliefs may lead to incorrectly assuming a patient is lying and then not liking or trusting that patient. As a result, the patient may receive reduced care or treatment, as attitudes can be predictive of future behavior.32 Nursing programs need not create interrogators but rather increase attention to dynamics of deception 256
in the nurse-patient relationship. Thus, education about being poor judges of deception21 in conjunction with learning about actual indicators of deception may prevent incorrectly labeling lying behaviors. Discussing attitudes toward patient deception may increase awareness of interpersonal issues, which may affect trust within the nurse-patient relationship.1 Education about deception within nursing may be delivered in various formats. Because of participants reporting minimal familiarity with deception literature, 1 possibility may be to include a selection of deception literature in existing courses. Students can then discuss key issues or questions related to patient deception. Another possibility might be to introduce a workshop that reviews actual indicators of deception and discuss the impact of attitudes toward patient deception on practice behaviors. Recently, the use of a deception workshop with physical therapy students has been shown to improve accurate beliefs about indicators of deception and reduce negative attitudes toward patient deception.33 The study is limited in that it is unclear as to what degree negative attitudes may affect practice. Negative attitudes may diminish desire to interact with a patient, as reported in the current study, but it may not have a significant effect on care or treatment. In other words, a patient who is lying may get sufficient but not exceptional care. Future research is encouraged to examine the effects of attitudes on various aspects of practice. Researchers may also seek to investigate the qualitative aspects of nursing students and professionals’ experiences of patient deception. Overall, the current study revealed that nursing professionals do not have a unique professional advantage in identifying indicators of deception, and they possess a number of negative attitudes toward patients who lie. However, the findings serve to augment educational programs toward best practices, competencies, and quality care through shedding light on deception within health care. It is important for nursing professionals to realize that patients who lie do not have a single behavioral cue, such as a ‘‘Pinocchio’s nose.’’ Understanding the multiple facets of deception and attitudes toward patients who lie will strengthen nursing education and practice.
Table 2. Nursing Students’ Attitudes Toward Patients Who Lie to Nurses (Global Attitudes Scale) Attitude Item Successful Pathologicalb Weakb Compliant Predictable Pleasant Lazyb Awkwardb Knowledgeable Intelligent Likable Adjusted
Mean (SD) 3.29 4.47 3.96 2.55 3.23 3.59 4.00 4.30 4.00 3.94 3.45 3.19
(1.30) (1.33) (1.47) (1.42) (1.63) (1.34) (1.21) (1.27) (1.41) (1.29) (1.38) (1.57)
Attitude Change
t a
j4.28 2.41 j0.20 j6.95a j3.22a j2.09 0.00 1.61 0.00 j0.34 j2.75a j3.53a
Not very successful No change No change Not very compliant Not very predictable No change No change No change No change No change Not very likable Not very adjusted
a
P < .004. Reverse coded.
b
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Acknowledgment The author thanks Rachel Curtis for reviewing the manuscript.
References 1. Dinc¸ L, Gastmans C. Trust in nurse-patient relationships: a literature review. Nurs Ethics. 2013;20(5):501-516. 2. Vrij A. Detecting Lies and Deceit: The Psychology of Lying and the Implications for Professional Practice. New York: John Wiley & Sons Ltd; 2000. 3. Vrij A. Detecting Lies and Deceit: Pitfalls and Opportunities. 2nd ed. New York: John Wiley & Sons Ltd; 2008. 4. Granhag P, Stro ¨ mwall L. Research on deception detection: past and present. In: Granhag P, Stro ¨ mwall L, eds. The Detection of Deception in Forensic Contexts. New York: Cambridge University Press; 2004:3-12. 5. Hart CL, Fillmore DG, Griffith JD. Indirect detection of deception: looking for change. Curr Res Soc Psychol. 2009;14:134-142. 6. DePaulo B, Kashy D, Kirkendol S, Wyer M, Epstein J. Lying in everyday life. J Pers Soc Psychol. 1996;70(5):979-995. 7. Schweitzer ME, Hershey JC, Bradlow ET. Promises and lies: restoring violated trust. Org Behav Hum Decis Processes. 2006; 101(1):1-19. 8. Sagarin BJ, Rhoads KvL, Cialdini RB. Deceiver’s distrust: denigration as a consequence of undiscovered deception. Pers Soc Psychol Bull. 1998;24(11):1167-1176. 9. Argo JJ, Shiv B. Are white lies as innocuous as we think? J Consumer Res. 2012;38(6):1093-1102. 10. Jackson J. Truth, Trust and Medicine [e-book]. New York: Routledge; 2001. 11. Olsen DP. Ethical issues: putting the meds in the applesauce. Am J Nurs. 2012;112(3):67-69. 12. Fallowfield LJ, Jenkins VA, Beveridge HA. Truth may hurt but deceit hurts more: communication in palliative care. Palliat Med. 2002;16(4):297-303. 13. Burgoon M, Callister M, Hunsaker FG. Patients who deceive: an empirical investigation of patient-physician communication. J Lang Soc Psychol. 1994;13(4):443-468. 14. Jung B, Reidenberg MM. Physicians being deceived. Pain Med. 2007;8(5):433-437. 15. DePaulo BM, Lindsay J, Malone B, Muhlenbruck L, Charlton K, Cooper H. Cues to deception. Psychol Bull. 2003;129(1):74. 16. Huddle TS. Honesty is an internal norm of medical practice and the best policy. Am J Bioethics. 2012;12(3):15-17. 17. Wolf ZR. Nursing practice breakdowns: good and bad nursing. Medsurg Nurs. 2012;21(1):16-36.
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18. Nurses top honesty and ethics list for 11th year. Gallup Poll Web site. Available at http://www.gallup.com/poll/145043/nurses-tophonesty-ethics-list-11-year.aspx. Published December 3, 2010. Accessed June 4, 2014. 19. Baxter PE, Boblin SL. The moral development of baccalaureate nursing students: understanding unethical behavior in classroom and clinical settings. J Nurs Educ. 2007;46(1):20-27. 20. Langone M. Educational innovation. promoting integrity among nursing students. J Nurs Educ. 2007;46(1):45-47. 21. Bond CF Jr, DePaulo BM. Accuracy of deception judgments. Pers Soc Psychol Rev. 2006;10(3):214-234. 22. Akehurst L, Ko ¨ hnken G, Vrij A, Bull R. Lay persons’ and police officers’ beliefs regarding deceptive behaviour. Appl Cogn Psychol. 1996;10(6):461-471. 23. Hart CL, Hudson LP, Fillmore D, Griffith J. Managerial beliefs about the behavioral cues of deception. Individ Differ Res. 2006; 4(3):176-184. 24. Sporer SL, Schwandt B. Paraverbal indicators of deception: a metaanalytic synthesis. Appl Cogn Psychol. 2006;20(4):421-446. 25. Forrest JA, Feldman RS, Tyler JM. When accurate beliefs lead to better lie detection. J Appl Soc Psychol. 2004;34(4):764-780. 26. The Global Deception Research Team. A world of lies. J Cross Cult Psychol. 2006;37(1):60-74. 27. Curtis DA. Therapists’ Beliefs and Attitudes Towards Client Deception [doctoral dissertation]. Denton, TX: Texas Woman’s University; 2013. 28. Hart CL, Fillmore D, Griffith J. Deceptive communication in the workplace: an examination of beliefs about verbal and paraverbal cues. Individ Differ Res. 2010;8(3):176-183. 29. Armstrong GE, Spencer TS, Lenburg CB. Using quality and safety education for nurses to enhance competency outcome performance assessment: a synergistic approach that promotes patient safety and quality outcomes. J Nurs Educ. 2009;48(12): 686-693. 30. Williams K, West EA. Approaches to nursing skills training in three countries. Int Nurs Rev. 2012;59(2):230-236. 31. Miller RS, Perlman D, Brehm SS. Intimate Relationships. 4th ed. New York: The McGraw-Hill Companies, Inc; 2007. 32. Bentler PM, Speckart G. Models of attitude-behavior relations. Psychol Rev. 1979;86(5):452-464. 33. Curtis DA, Huang H-H, Nicks K. Beliefs and attitudes toward patient deception: an intervention for change. Paper presented at: 61st Annual Meeting of the Southwestern Psychological Association; April 2015; Wichita, KS.
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Nurse Educator Vol. 40, No. 5, pp. 254-257 Copyright * 2015 Wolters Kluwer Health, Inc. All rights reserved.
Patient Deception Nursing Students’ Beliefs and Attitudes Drew A. Curtis, PhD This study examined nursing students’ beliefs about indicators of deception and their attitudes toward patient deception. Fifty-eight participants from various nursing programs at a southwestern university completed a Detection of Deception Questionnaire and Attitudes Toward Patient Deception Scale. Findings indicated that nursing students have a number of inaccurate beliefs about deception and possess a number of negative attitudes toward patients who lie. Implications for nursing education are discussed. Keywords: attitudes; deception; lying; nurse-patient relationship; patient deception
A
t the heart of nursing lies the relationship between a nurse and a patient. The nurse-patient relationship is associated with increased patient satisfaction and has a positive impact on care.1 A variable that directly challenges the nurse-patient relationship is deception. Deception is a successful or an unsuccessful deliberate attempt, without forewarning, to create a belief that the communicator considers to be untrue.2,3 This definition of deception has been used in other research.4,5 Deception often damages trust and elicits negative consequences,6,7 even when it is undiscovered.8 Even telling white lies, with the intent of beneficence, may lead to more negative experiences.9 Much of the literature pertaining to deception within health care has focused on the lies told from health care providers to patients.10-12 However, patients also lie.13 This is not surprising given that people lie, on average, about 2 times a day.6 Patients may be deceptive for a variety of reasons, including personal benefit, to protect another person, to gain some advantage, or for psychological or material reasons.3 Faking symptoms of pain to obtain prescriptions14 would be an example of lying for material gain, also considered a self-oriented lie.6 Self-oriented lies may serve to manage impressions,15 such as a patient lying about smoking to portray an image of a healthy nonsmoker. Within health care, being honest is a standard and a norm.16 In fact, nurses are regarded as the most trustworthy health care professionals, and deception from nurses is often viewed as ‘‘bad care.’’17 Nurses are perceived as honest and holding higher ethical standards than other professions for many Author Affiliation: Assistant Professor, Department of Psychology, Sociology, and Social Work, Angelo State University, San Angelo, Texas. The author declares no conflicts of interest. Correspondence: Dr Curtis, Department of Psychology, Sociology and Social Work, Angelo State University, ASU Station 10907, San Angelo, TX 76909-0907 ([email protected]). Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.nurseeducatoronline.com). Accepted for publication: January 24, 2015 Published ahead of print: March 13, 2015 DOI: 10.1097/NNE.0000000000000157
254
years.18 Nurses seek to adhere to values and standards of practice, including honesty, evidenced throughout education and training.19,20 Thus, patient deception appears to violate this norm and value, possibly leading to increased negative attitudes toward patients who lie. The effects of deception in health care are amplified because it is often undetected. A meta-analysis found that people are only slightly better than chance (54%) in accurately detecting deception.21 One of the reasons why people are not good at detecting deception is that ‘‘there is nothing like Pinocchio’s nose,’’2 meaning there is not 1 specific behavior that consistently indicates when a person is lying. However, indicators of deception exist, and research has identified behavioral changes in 3 categories: nonverbal, paraverbal, and verbal, resulting in 28 different indicators of deception.3,15,22-24 A variety of professionals’ beliefs about indicators of deception have been examined.3 People rely on their beliefs about lying behaviors when ascertaining the veracity of statements.25 One of the most salient incorrect beliefs about deceptive behavior, found across cultures, is that people look away when lying.26 Because of the impact of deception on relationships, and professionals often holding many inaccurate beliefs about deceptive behavior, the current study examined nursing students’ education, beliefs about indicators of deception, and their attitudes toward patients who lie to nurses. It was predicted that nursing students would report moderate to minimal education in patient deception and that they would hold a number of false beliefs about actual indicators of deception. Considering people’s dislike of being the target of deception and nurses’ emphasis on integrity and trust, it was predicted that participants would hold more negative than positive attitudes toward patients who lie. Lastly, nursing students’ value of honesty was examined.
Method Participants Through convenience sampling, 58 students enrolled in different levels of nursing programs (ie, BSN, RN to BSN, MSN,
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RN to MSN) at a southwestern university were recruited for the study. Of the 58 participants, 52 indicated they had 1 to 26 years (mean [SD], 5.56 [6.46] years) of patient care experience. With the goal to assess nursing students who had clinical experience, only those who had contact with patients were used within analyses. The participants ranged in age from 19 to 52 years (mean [SD], 30.33 [9.54] years). Most participants were female (89%) and represented a range of ethnicities/races, with most (71%) being white. Most participants reported having BSN degrees (65%) and being RNs (64%). Experience and training with deception were measured on a 7-point Likert scale (1 = none, 7 = very much). Participants reported minimal exposure to literature on deception (mean [SD], 1.94 [1.07]), training about patient deception (mean [SD], 1.86 [1.20]), and training related to deception detection (mean [SD], 1.73 [1.07]).
Instruments The current study implemented 3 instruments. The demographic questionnaire collected information on age, gender, ethnicity and race, education, licensure, certificates, literature read on deception, training in deception, and years of contact with patients. The Detection of Deception Questionnaire (DDQ) was developed by Hart and colleagues23 to measure beliefs about indicators of deception. The questionnaire consisted of 2 items measuring level of confidence in ability to detect deception and how often participants thought patients lie to them on a 7-point Likert scale (from 1 = very rarely to 7 = very often). The remaining 28 items asked participants to indicate whether each of the specific behaviors increase, decrease, or remain the same when patients lie (from 1 = significant decrease in behavior to an anchor of 4 = no change in behavior to 7 = significant increase in behavior). The Attitudes Toward Patient Deception Scale (ATPDS) is a 24-item adaptation of the Therapist Attitudes Towards Deception Scale (TATDS27). The internal consistency of the TATDS is fairly reliable (Cronbach’s ! = .83). The ATPDS was similar to the TATDS but with some items reworded as attitudes toward patients rather than clients. The ATPDS contained 2 subscales: (a) specific and (b) global. The specific subscale consisted of 12 items asking participants to indicate on a 9-point Likert scale how their attitudes would change if a patient’s lie was discovered (from 1 = decrease to an anchor of 5 = no change to 9 = increase; Cronbach’s ! = .91). These attitude items included affective and cognitive labels, such as feeling more angry toward a patient or thinking more negatively about a patient who lied. On the global subscale, participants were asked to rate patients who lie to nurses compared with those who do not lie to nurses across 12 attitudinal items on a 7-point rating scale (from 1 = not very to an anchor of 4 = no change to 7 = very; Cronbach’s ! = .78). Those items asked participants to identify what they thought about patients who lie to nurses, such as whether they were less successful, less likable, or more pathological. To establish a total attitude score, the scores from the specific subscale and global subscale were summed (Cronbach’s ! = .88). Procedure The institutional review board approved the study. An e-mail containing a link to the study, which was conducted online, Nurse Educator
was sent to all nursing students. After consenting to participate in the study, the participants were asked to complete the demographic questionnaire, the DDQ, and the ATPDS. The surveys were available for the span of 1 semester.
Data Analysis Using 1-sample t tests, nursing students’ beliefs about changes in each of the 28 behavioral indicators were analyzed to determine if they differed significantly from a nonbehavioral change anchor. A Bonferroni adjustment (=0.002) was applied to the analyses to avoid an increased type I error due to running multiple t tests. Further, a mixed factorial analysis of variance (ANOVA) was used to analyze RNs’ compared with nursing students’ beliefs of all 28 indicators of deception. One-sample t tests were conducted on attitude items that asked participants to rate how discovering a patient’s lie would affect them to determine if their ratings demonstrated a significant difference from a nonchange anchor of 5 (Bonferroni = 0.004). Furthermore, 1-sample t tests also were conducted on each of the attitude items, asking participants to rate patients who lie to nurses compared with patients who do not lie to nurses (Bonferroni = 0.004). A mixed factorial ANOVA was conducted to examine RNs’ compared with students’ attitudes toward patients who lie to nurses. Lastly, a bivariate correlation was run between age of participants and attitudes toward patient deception. Descriptive analyses were conducted to examine participants’ confidence in detecting patient deception, value of honesty in interacting with patients, and how important honesty is for the nurse-patient relationship, successful treatment, and care.
Results When students were asked to indicate whether particular behaviors change when people lie to them, most of them held accurate beliefs for 6 of the 28 behavioral indicators of deception: smiles, latency, pitch, answer length, logical consistency, description of feelings, and describing interactions with others (see Table, Supplemental Digital Content 1, http://links.lww.com/NE/A218). For example, students correctly identified that logical consistency tends to decrease and vocal pitch tends to increase when people are deceptive. There were no differences between students and nurses in their accuracy in determining indicators of deception (F1, 44 = 0.14, P = .71). When students were asked how they would respond when they discovered that a patient had lied to them, most indicated they would form more negative attitudes toward the patient, for example, liking the patient less, not wanting to interact with the patient, and viewing the patient as less successful and less likable (Tables 1 and 2). Of 24 attitude items, students held 13 negative attitudes and no positive attitudes toward patients who lie. There were no differences between students and RNs regarding their attitudes toward patients who lie (F1, 45 = 0.99, P = .75). Lastly, there was no relationship between participants’ age and their attitudes toward patients who lie to nurses (r = j0.17, df = 43, P = .28). Students reported moderate confidence in detecting patient deception (mean [SD], 3.72 [1.42]). They also indicated that honesty with patients is valued highly (mean [SD], 6.51 [0.93]), is very important for the nurse-patient relationship Volume 40 & Number 5 & September/October 2015
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Table 1. Nursing Students’ Attitudes Toward Discovering a Patient’s Lie (Specific Attitudes Scale) Attitude Item
Mean (SD)
Liking the patient Being angry at the patientb Patient as a bad personb Thinking negatively of patientb Judging patient harshlyb Desire to interact with patient Enthusiasm to work with patient Judging patient as a good patient Speaking poorly of patientb Trusting the patient Thinking positively about patient Viewing patient as sincere
3.73 5.42 5.23 5.54 5.31 3.88 3.63 4.02 5.15 2.34 3.56 2.79
a
t
(1.47) j5.99a (1.47) 1.96 (1.71) j1.36 (1.35) 2.78a (1.17) 1.85 (1.48) j5.26a (1.42) j6.69a (1.34) j4.95a (1.05) 0.96 (1.51) j12.09a (1.46) j6.83a (1.50) j10.19a
Attitude Change Decrease No change No change Increase No change Decrease Decrease Decrease No change Decrease Decrease Decrease
P < .004. Reverse coded.
b
(mean [SD], 6.69 [0.72]), and is highly important for successful treatment and care (mean [SD], 6.63 [0.79]).
Discussion The current study explored patient deception in nursing and found that students and nurses have a number of incorrect beliefs about deceptive behavior. Some of these incorrect beliefs include believing that people avoid eye contact or look away when lying. These findings are parallel to research from other fields.27,28 One reason for the findings may be that beliefs about deception are deeply rooted in our lives. People often hold incorrect beliefs about deception that reflect cultural constructions of the liar stereotype.2,26 Another reason could be the lack of education and training in deception. Nursing students reported minimal training in patient deception, its detection, and exposure to the literature. These findings appear among psychotherapists as well.27 Students in nursing programs may receive minimal education in patient deception because of the importance of developing clinical skills and competencies.29,30 Deception emerges as a topic in medical ethics; however, it has been argued that the dynamics of deception extend beyond medical ethics.11,17 Regarding attitudes, nursing students possess a number of negative attitudes toward patients who lie. These attitudes may be due to their dislike of being lied to and perceiving liars as unpleasant.31 The resultant attitudes also may be related to professional values and normative practice.16,17 Participants in this study reported that they valued honesty in interacting with patients and thought patient honesty was important for the nurse-patient relationship and for treatment. It is important to note that not all attitudinal changes were negative toward patients who lie. The findings offer implications for education and practice. The risk for nurses is that inaccurate beliefs may lead to incorrectly assuming a patient is lying and then not liking or trusting that patient. As a result, the patient may receive reduced care or treatment, as attitudes can be predictive of future behavior.32 Nursing programs need not create interrogators but rather increase attention to dynamics of deception 256
in the nurse-patient relationship. Thus, education about being poor judges of deception21 in conjunction with learning about actual indicators of deception may prevent incorrectly labeling lying behaviors. Discussing attitudes toward patient deception may increase awareness of interpersonal issues, which may affect trust within the nurse-patient relationship.1 Education about deception within nursing may be delivered in various formats. Because of participants reporting minimal familiarity with deception literature, 1 possibility may be to include a selection of deception literature in existing courses. Students can then discuss key issues or questions related to patient deception. Another possibility might be to introduce a workshop that reviews actual indicators of deception and discuss the impact of attitudes toward patient deception on practice behaviors. Recently, the use of a deception workshop with physical therapy students has been shown to improve accurate beliefs about indicators of deception and reduce negative attitudes toward patient deception.33 The study is limited in that it is unclear as to what degree negative attitudes may affect practice. Negative attitudes may diminish desire to interact with a patient, as reported in the current study, but it may not have a significant effect on care or treatment. In other words, a patient who is lying may get sufficient but not exceptional care. Future research is encouraged to examine the effects of attitudes on various aspects of practice. Researchers may also seek to investigate the qualitative aspects of nursing students and professionals’ experiences of patient deception. Overall, the current study revealed that nursing professionals do not have a unique professional advantage in identifying indicators of deception, and they possess a number of negative attitudes toward patients who lie. However, the findings serve to augment educational programs toward best practices, competencies, and quality care through shedding light on deception within health care. It is important for nursing professionals to realize that patients who lie do not have a single behavioral cue, such as a ‘‘Pinocchio’s nose.’’ Understanding the multiple facets of deception and attitudes toward patients who lie will strengthen nursing education and practice.
Table 2. Nursing Students’ Attitudes Toward Patients Who Lie to Nurses (Global Attitudes Scale) Attitude Item Successful Pathologicalb Weakb Compliant Predictable Pleasant Lazyb Awkwardb Knowledgeable Intelligent Likable Adjusted
Mean (SD) 3.29 4.47 3.96 2.55 3.23 3.59 4.00 4.30 4.00 3.94 3.45 3.19
(1.30) (1.33) (1.47) (1.42) (1.63) (1.34) (1.21) (1.27) (1.41) (1.29) (1.38) (1.57)
Attitude Change
t a
j4.28 2.41 j0.20 j6.95a j3.22a j2.09 0.00 1.61 0.00 j0.34 j2.75a j3.53a
Not very successful No change No change Not very compliant Not very predictable No change No change No change No change No change Not very likable Not very adjusted
a
P < .004. Reverse coded.
b
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Acknowledgment The author thanks Rachel Curtis for reviewing the manuscript.
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18. Nurses top honesty and ethics list for 11th year. Gallup Poll Web site. Available at http://www.gallup.com/poll/145043/nurses-tophonesty-ethics-list-11-year.aspx. Published December 3, 2010. Accessed June 4, 2014. 19. Baxter PE, Boblin SL. The moral development of baccalaureate nursing students: understanding unethical behavior in classroom and clinical settings. J Nurs Educ. 2007;46(1):20-27. 20. Langone M. Educational innovation. promoting integrity among nursing students. J Nurs Educ. 2007;46(1):45-47. 21. Bond CF Jr, DePaulo BM. Accuracy of deception judgments. Pers Soc Psychol Rev. 2006;10(3):214-234. 22. Akehurst L, Ko ¨ hnken G, Vrij A, Bull R. Lay persons’ and police officers’ beliefs regarding deceptive behaviour. Appl Cogn Psychol. 1996;10(6):461-471. 23. Hart CL, Hudson LP, Fillmore D, Griffith J. Managerial beliefs about the behavioral cues of deception. Individ Differ Res. 2006; 4(3):176-184. 24. Sporer SL, Schwandt B. Paraverbal indicators of deception: a metaanalytic synthesis. Appl Cogn Psychol. 2006;20(4):421-446. 25. Forrest JA, Feldman RS, Tyler JM. When accurate beliefs lead to better lie detection. J Appl Soc Psychol. 2004;34(4):764-780. 26. The Global Deception Research Team. A world of lies. J Cross Cult Psychol. 2006;37(1):60-74. 27. Curtis DA. Therapists’ Beliefs and Attitudes Towards Client Deception [doctoral dissertation]. Denton, TX: Texas Woman’s University; 2013. 28. Hart CL, Fillmore D, Griffith J. Deceptive communication in the workplace: an examination of beliefs about verbal and paraverbal cues. Individ Differ Res. 2010;8(3):176-183. 29. Armstrong GE, Spencer TS, Lenburg CB. Using quality and safety education for nurses to enhance competency outcome performance assessment: a synergistic approach that promotes patient safety and quality outcomes. J Nurs Educ. 2009;48(12): 686-693. 30. Williams K, West EA. Approaches to nursing skills training in three countries. Int Nurs Rev. 2012;59(2):230-236. 31. Miller RS, Perlman D, Brehm SS. Intimate Relationships. 4th ed. New York: The McGraw-Hill Companies, Inc; 2007. 32. Bentler PM, Speckart G. Models of attitude-behavior relations. Psychol Rev. 1979;86(5):452-464. 33. Curtis DA, Huang H-H, Nicks K. Beliefs and attitudes toward patient deception: an intervention for change. Paper presented at: 61st Annual Meeting of the Southwestern Psychological Association; April 2015; Wichita, KS.
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