Participation of patients in healthcare decisions has become as a key principle of modern clinical practice, reflecting a transition toward patient-centered care and collaborative decision-making. Respect for patient autonomy acknowledges the individual’s ability to make informed choices about diagnostic procedures, treatments, and other healthcare interventions, including the right to refuse suggested care. Although this principle is recognized both ethically and legally, a patient refusal of care poses considerable difficulties for healthcare providers, especially nurses, tasked with protection patient safety, enhancing well-being, and providing high- quality care.

Patients may decline care, which can include refusing medications, diagnostic tests, nursing procedures, rehabilitation activities, or other treatment options. Rejection can be conveyed through spoken words or through non-verbal actions like retreating, resisting, or not adhering to treatment plans. Existing research shows that the rejection of care is affected by various factors, such as fear, anxiety, pain, fatigue, cultural beliefs, past negative experiences with healthcare, insufficient comprehension of treatment, and distrust in healthcare providers (Backhouse et al., 2022; Featherstone et al., 2019). These elements frequently occur together, making the rejection of care a complicated clinical and ethical issue that requires individualized evaluation and effective communication

Nurses often face ethical dilemmas when patients refuse care, as their responsibility to protect patients and avoid harm can clash with the obligation to respect patient’s independent decisions. Balancing the principles of autonomy, beneficence, non- maleficence, and respect for human dignity can be especially difficult when declining treatment could lead to significant clinical outcomes. These circumstances can create emotional strain, hesitation, and moral distress among nurses, particularly when they believe that respecting a patient’s choice might compromise health results (Haahr et al., 2020; Aljabery et al., 2024; Arash et al., 2024).

Therapeutic communication is generally recognized as one of the most effective methods for handling patient refusals of treatment. Active listening, empathy, clear explanations, and shared decision- making can help healthcare professionals identify patient’s uncertainties, clarify misunderstandings, and strengthen trust within the nurse- patient relationship. Rather than trying to influence patients through authority, communication strategies that acknowledge patient’s values and preferences are more likely to facilitate informed decision- making and improve patient satisfaction (McCabe, 2004; Lown et al., 2009).

In the Lebanese healthcare system, nurses operate in a setting marked by financial limitations, staff shortages, institutional demands, and increasing demands for healthcare services. These contextual challenges might exacerbate ethical decision-making and restrict opportunities for organized education and institutional support concerning the management of patient refusal of care (Bou Sanayeh & El Chamieh, 2023). Although the practical importance of this issue, evidence detailing nurses experiences, communication methods, ethical dilemmas, and educational requirements concerning patient refusal of care in Lebanon.

Closing this knowledge gap is crucial for enhancing nursing education, reinforcing institutional policies, and encouraging ethical clinical practice. Comprehending how nurses react to patients declining care could assist healthcare organizations in creating evidence- based approaches that promote both patient independence and quality nursing care.

Therefore, this study aimed to investigate nurse’s experiences with patient refusal of care in Lebanese hospitals by inspecting the frequency and forms of refusal met in clinical practice, the perceived reasons for refusal, communication and management strategies adopted by nurses, the ethical challenges they experience, and their observed training and institutional support needs.

Materials and Methods Study Design

A descriptive and analytical cross-sectional study was conducted to observe nurse’s experiences regarding patient care refusal in hospitals in Lebanon. The research examined the prevalence and types of patient refusal, perceived reasons for decline, nursing management approaches, ethical challenges, and identified training requirements.

Study Setting and Participants

The research focused on registered nurses employed in various hospitals and clinical departments throughout different Lebanese governorates. Eligible participants were nurses actively involved in direct patient care and willing to participate voluntarily in the study. Nurses who were not involved in clinical practice at the time of data collection were excluded.

Sampling and Data Collection

A non-probability snowball sampling technique was used to recruit participants. Data were collected between August 12, 2025, and October 7, 2025, using a structured online questionnaire distributed electronically through professional networks and social media platforms. Participation was voluntary, anonymous, and based on informed consent obtained before questionnaire completion.

The final sample consisted of 180 registered nurses. Study Instrument

Data were collected using a structured questionnaire designed to assess:

•            Sociodemographic and professional characteristics.

•            Frequency and forms of patient refusal of care.

•            Perceived reasons for patient refusal.

•            Nursing responses and communication strategies.

•            Ethical challenges encountered during refusal situations.

•            Perceived training needs and institutional support.

Statistical Analysis

Data were analyzed using the Statistical Package for the Social Sciences (SPSS). Descriptive statistics, such as frequencies and percentages, were used to summarize the characteristics of participants and the study variables. Associations between categorical variables were examined using Pearson's Chi-square test or Fisher's exact test when appropriate. Statistical significance was established at a p-value of less than 0.05.

Ethical Considerations

Participation in the study was voluntary and anonymous. All participants provided informed consent electronically before completing the questionnaire and were informed of their right to withdraw at any time without consequences.

Results

Participant Characteristics

A total of 180 registered nurses participated in the study. The sociodemographic characteristics of the participants are presented in Table 1.

The study population was predominantly female (71.7%, n = 129), whereas male nurses represented 28.3% (n = 51). Participants represented different age categories, with the largest proportion being younger than 25 years (38.3%, n = 69). Nurses aged 25–34 years accounted for 22.8% (n = 41), while those aged 45 years and above represented 22.2% (n = 40). Participants aged 35–44 years constituted the smallest age group (16.7%, n = 30).

Regarding professional experience, approximately one-third of the participants (31.7%, n = 57) reported more than ten years of nursing experience. Nurses with less than one year of experience represented 27.2% (n = 49), followed by those with one to five years of experience (26.1%, n = 47) and six to ten years of experience (15.0%, n = 27).

Geographically, the majority of participants were employed in hospitals located in Mount Lebanon (45.0%) and Beirut (26.7%), while the remaining participants were distributed across the other Lebanese governorates.

Table 1: Sociodemographic characteristics of the participants

Frequency and Forms of Patient Refusal of Care

Patient refusal of care was commonly encountered among participating nurses. Overall, 87.8% of respondents indicated that they had experienced at least one situation involving patient refusal during their clinical practice, suggesting that refusal of care represents a frequent component of nursing care in Lebanese hospitals.

Among the different forms of refusal, verbal refusal was the most frequently reported (60.0%), followed by partial refusal (41.1%). Nurses noted that refusal was commonly associated to technical nursing procedures (30.6%), and medication administration (26.1%), suggesting that refusal often occurs during standard clinical tasks requiring patient cooperation.

These results show that patient refusal extends beyond complete rejection of treatment and foften encompasses selective refusal of certain nursing interventions.

Perceived Reasons for Patient Refusal of Care

Participants identified several factors contributing to patient refusal of care.

The most commonly reported reason was fear and anxiety (53.3%), followed by pain (38.9%) and fatigue (36.1%). These findings indicate that emotional and physical discomfort were perceived as the primary contributors to refusal of healthcare interventions.

Over 50% of the nurses (50.6%) indicated that patients did not provide any explanation for declining care. This finding indicates that healthcare professionals often need to handle refusals without fully understanding patient’s reasons or worries.

Other noted reasons were seen less frequently, further highlighting the complex nature of patient refusal.

Nursing Responses and Communication Strategies

Participants reported using a variety of approaches when managing patient refusal of care.

Communication strategies represented the most frequently adopted interventions. Specifically, 71.1% of nurses reported providing additional explanations regarding the proposed intervention, while 62.4% reported using active listening to better understand patients' concerns and encourage dialogue.

Respecting patient autonomy was highlighted as a key management approach, with 35.6% of participants indicating that they respected the patient's choice after confirming sufficient information was given.

In general, the results indicate that nurses focused mainly on communication methods instead of coercive strategies when addressing patient refusal.

Training and Perceived Competence

Despite the high occurrence of patient refusal observed in clinical settings, there seemed to be a lack of formal education on how to handle refusal of care.

Almost (63.9%) of participants indicated that they had never received formal education or professional training related to patient refusal of care.

Aligned with this finding, only 18.3% viewed themselves as proficient in handling refusal situations, indicating a significant educational deficiency among working nurses.

These results emphasize a gap between how often nurses face patient refusals and their sense of readiness to handle these situations successfully.

Inferential Analysis

Inferential statistical analyses were conducted to examine associations between nurses' demographic and professional characteristics and selected aspects of patient refusal of care. The results are summarized in Table 2.

A statistically significant association was identified between age and the frequency of encountering patient refusal (p = 0.002), suggesting that experiences with refusal varied across age groups.

Formal training was significantly associated with nurses' perceptions of the impact of patient refusal on the nurse–patient relationship (p < 0.001), indicating that education may influence how nurses perceive and respond to these situations.

Significant associations were also observed between clinical service and the management strategies adopted by nurses (p < 0.05). Furthermore, the geographical region in which nurses practiced was significantly associated with the reported forms of patient refusal (p < 0.05).

The statistically significant associations identified in this study suggest that demographic, educational, and workplace characteristics may influence nurses' experiences and responses to patient refusal of care.

Table 2. Inferential analysis (SPSS output summary)