Journal of Nursing Management, 2015, 23, 940–944
Are theoretical perspectives useful to explain nurses’ tolerance of suboptimal care? LESLEY PRICE P h D , M S c , B A , R N T , JACQUELINE MCCALLUM E d D ,
RGN
1
, KATHLEEN DUFFY P h D , M S c , B A , R N T , R G N 2, 3 and VALERIE NESS M N , P G C e r t ,
MN, Pgcert, BA, RNT, RGN
BN, RN, RNT
4
1
Lecturer/Researcher in Acute Care Nursing, Glasgow Caledonian University, 2Nursing and Midwifery Practice Educator, NHS Education for Scotland, 3Senior Lecturer and 4Lecturer in Nursing, Glasgow Caledonian University, Glasgow, Scotland, UK
Correspondence Lesley Price Caledonian University A534, Govan Mbeki Building Cowcaddens Road Glasgow G4 0BA UK E-mail: [email protected]
(2015) Journal of Nursing Management 23, 940–944. Are theoretical perspectives useful to explain nurses’ tolerance of suboptimal care?
PRICE L., DUFFY K., MCCALLUM J., NESS V.
Aim This paper explores two theoretical perspectives that may help nurse managers understand why staff tolerate suboptimal standards of care. Background Standards of care have been questioned in relation to adverse events and errors for some years in health care across the western world. More recently, the focus has shifted to inadequate nursing standards with regard to care and compassion, and a culture of tolerance by staff to these inadequate standards. Evaluation The theories of conformity and cognitive dissonance are analysed to investigate their potential for helping nurse managers to understand why staff tolerate suboptimal standards of care. Key issues The literature suggests that nurses appear to adopt behaviours consistent with the theory of conformity and that they may accept suboptimal care to reduce their cognitive dissonance. Conclusion Nurses may conform to be accepted by the team. This may be confounded by nurses rationalising their care to reduce the cognitive dissonance they feel. Implications for nursing management The investigation into the Mid Staffordshire National Health Service called for a change in culture towards transparency, candidness and openness. Providing insights as to why some nursing staff tolerate suboptimal care may provide a springboard to allow nurse managers to consider the complexities surrounding this required transformation. Keywords: cognitive dissonance, conformity, management, nursing, suboptimal care Accepted for publication: 10 March 2014
Introduction There is much written worldwide regarding adverse events and errors. Almost 10 years ago Walsh and Shortell (2004) stated that ‘reports published in the United States, the United Kingdom, Australia, New Zealand, and Canada have focused public and policy attention on the safety of patients and have highlighted 940
the alarmingly high incidence of errors and adverse events that lead to some kind of harm or injury’. More recently the focus has changed. In the UK the publication of the Mid Staffordshire National Health Service (NHS) Foundation Trust Inquiry (2013) highlighted inadequate nursing standards with regard to care and compassion. Of particular concern was the uncovering of a culture of tolerance by staff to these inadequate DOI: 10.1111/jonm.12239 ª 2014 John Wiley & Sons Ltd
Why nurses tolerate suboptimal care?
standards. Significantly, this is an international concern. In October 2007, the New South Wales Parliament in Australia convened a Joint Select Committee to conduct an inquiry into several allegations of inadequate patient care at Royal North Shore Hospital (RNSH) in Sydney (Joseph & Hunyor 2008). They exposed similar problems to those highlighted in the Mid Staffordshire NHS Foundation Trust Inquiry (2013). But what is meant by the term inadequate standards of care? For many years nursing has been developing standards of care where appropriate treatment is specified based on evidence. These are most commonly associated with well-defined elements such as the care required for someone who has a urinary catheter. What appears to be the concern in the above instances is less tangible and relates more to the absence of holistic care that incorporates caring and compassion. Discussions of ‘poor care’ (Giles 2008, Collins et al. 2009, Karstadt 2012, Kmietowicz 2012, Scott 2013) and ‘suboptimal care’ exist in the nursing literature (Scholes 2007, Massey et al. 2009, Quirke et al. 2011). These papers describe incidences and explore the causes of inadequate care but fail to uncover why nurses may tolerate such situations. Our preferred term for use in this article is suboptimal care as it is less judgemental than poor care and is proactive. The dictionary definition of optimal is the ‘best’ and optimum is ‘seeking the optimal (best)’. Therefore, using the term suboptimal care indicates a desire to improve nursing care rather than just describe its occurrence or cause. A number of theoretical perspectives could have been explored, but as our interest in this topic is in exploring why nurses and the nursing profession tolerate suboptimal nursing care, we chose conformity and cognitive dissonance. Both of these concepts are prevalent in the nursing literature. Developing insights from these perspectives may enable nurse managers to understand nurses’ behaviour and thus be able to identify ways of challenging it.
Conformity When thinking about why staff tolerate suboptimal standards of care exploring the social theory of conformity may be helpful. Conformity is a type of social influence where attitudes, beliefs, and behaviours are matched to group norms (Cialdini & Goldstein 2004). Norms are implicit, unstated rules shared by a group of individuals that guide their interactions with others and among society or social groups (Parks 2004). This tendency to conform may result from unconscious influences or direct social pressure. It often does not ª 2014 John Wiley & Sons Ltd Journal of Nursing Management, 2015, 23, 940–944
even need the physical presence of others, as people tend to follow social norms even when alone. The concept of group conformity and its links with belongingness has been discussed throughout the social and psychosocial literature for the last 50 years. Jenness (1932) was the first psychologist to study conformity before being made well-known by Asch’s (1951) line study. This study showed that as more people oppose a subject, individuals become more likely to conform. Conformity has been developed by other psychologists. Maslow’s (1954) seminal work aimed to understand what constitutes human need and he described the significance of belonging to a defined group. Mann (1969) identified three types of conformity: normative (the desire to ‘fit in’ or be liked or scared of being rejected – publically accepts but privately rejects); informational (because of a desire to be correct); and ingratiational (conforming to impress or gain favour). Ingratiational is similar to normative but is motivated by the need for social rewards rather than the threat of rejection. A fourth type of conformity has also been discussed within the literature, namely, identification, to conform to a social role (Kelman 1958). But what does the nursing profession know about nurses and conformity?
Nurses and conformity Informational conformity is often discussed within the context of student nurse behaviour or with regard to newly qualified practitioners. This is because it is common in people who lack knowledge and, therefore, as a result, these individuals look to the group for guidance or are unclear and socially compare their behaviour with the group (Deutsch & Gerard 1955). This usually leads to internalisation, where they accept the views of the group and then adopt them. Ingratiational conformity may be displayed if the reward is a successfully assessed placement, if a student nurse, or promotion, if a registered nurse. Alabaster (2006), in an interpretive study of 10 students, found that although they were confident in their ability to identify and resist negative influences, some degree of conformity was inevitable. LevettJones and Lathlean (2008) conducted a cross-national case study of 18 third-year nursing students’ experience of belongingness when undertaking clinical placements. They also found that students adopted behaviours to improve their likelihood of acceptance and inclusion by nursing staff and did not want to ‘rock the boat’. 941
L. Price et al.
Two studies focusing on new practitioners found similar results. In a grounded theory research project that used in-depth interviews, diary accounts and telephone conversations, Levett-Jones & Lathlean (2008) explored the socialisation and acculturation experiences of six ‘new’ practitioners. These participants stated that they quickly learned that the best way to fit in and be accepted was to comply with established practice and ward routines. At times, the participants questioned practices and attitudes of the registered nurses they worked with but this was rarely voiced. Champion et al. (1998), in a small pilot study, found similar results, that new practitioners adopted the teams’ and institution’s values and norms and modified their behaviours as they rotated through different units in order to be accepted. Some claimed that they made a calculated decision to conform in order to be accepted into the nursing team. The authors suggested that new practitioners learned to ‘fit in’ by becoming what they referred to as ‘chameleons’, changing and continuously adapting to new environments. As can be seen from this discussion the literature appears to suggest that students and new practitioners appear to adopt behaviours consistent with the theory of normative conformity. However, does conformity explain the tolerance of suboptimal care in established nursing teams? Duffy (1995) suggests that nurses are an oppressed group but that often the intergroup conflict (common because of women working together, personality traits, jealousy, ambition and lack of respect) is to blame. Therefore, even though nurses are taught to question practice they allow themselves to be managed by strategies such as correction, criticism, negative feedback and negative reinforcement. Conforming to this social role may explain why nursing teams tolerate suboptimal care. In a case study on a ward with problems (measured by complaints and a concerning level of patient care), Thyer (2003) found that the dominance of the medical model ensured conformity in a bureaucratically hierarchical structure. Conversely, conformity could also be seen as a good thing, especially if it prevents dangerous acts, or means that best practice is followed. However, the literature cited above suggests that it may also be able to explain why suboptimal care is not reported and why it is even practiced in some teams where fitting-in is a priority.
Cognitive dissonance Cognitive dissonance is another theoretical lens through which the question ‘Why do staff tolerate 942
suboptimal care?’ can be explored. Cognitive dissonance is psychological discomfort which is aroused when people are confronted with conflicting ideas, beliefs or values. The theory purports that individuals have a motivational drive to reduce dissonance (Clark et al. 2004), therefore individuals may adapt their ideas, beliefs, values and subsequent behaviour to reduce the dissonance. The theory is attributed to Leon Festinger. In 1957 he published a book called A Theory of Cognitive Dissonance in which he developed his initial version of this social psychology theory. Subsequently Festinger et al. (1964) carried out further research in this area to validate this viewpoint and today cognitive dissonance is one of the most influential theories in social psychology (Gazzaniga 2006). If this theoretical perspective is applied to the question posed above it could be that nursing staff who are continually exposed to suboptimal care have to adapt their ideas, beliefs, values and subsequent behaviour to reduce the dissonance they feel (i.e. that they are unable to maintain the standards they would like), but what evidence exists to support this view?
Nurses and cognitive dissonance Wigens (1997) in a study, utilising grounded theory methodology, sought to understand surgical nurses’ perceptions of the conflict between the tension of delivering individualised patient care and the shift to increased efficiency and throughput of patients with the move to day cases. Reporting only on the interview data from the 10 surgical nurses, which took place within the context of a wider study, Wigens (1997) highlighted that day surgery and shorter stays within general surgical settings created cognitive dissonance for nursing staff. This is because it limited a nurse’s ability to become emotionally involved with patients and to deliver individualised care. Reporting on the various strategies the nurses used to reduce cognitive dissonance, the author reported the use of rationalisation. Wigens (1997) commented that, ‘nurses came to believe that it was alright to routinise care, and reduce emotional labour because the operations were smaller’. Essentially, nurses in the study rationalised their need to give non-individualised care to patients having routine or minor operations. Two forms of rationalisation were reported. Some participants reported increased involvement with a few patients that they felt required individualised care. Others reduced cognitive dissonance by arguing they should maintain equity of care for all patients, so that those patients with increased needs did not receive ª 2014 John Wiley & Sons Ltd Journal of Nursing Management, 2015, 23, 940–944
Why nurses tolerate suboptimal care?
any more care than other patients. Other methods of coping cited by participants included acceptance of the situation, keeping the problem to themselves and looking for good points in any management initiatives that were proposed. Another grounded theory study conducted by Crigger and Meek (2007) explored the psychosocial process that occurs after nurses perceive that they have made a mistake in practice. Drawing on the interview data from 10 registered nurses who described a total of 17 personal mistakes, the authors describe four distinct categories. These were: reality hitting (coming to terms with the reality of the mistake); weighing in (determining the need to disclose or report the mistake); acting (deciding on the best course of action); and reconciling (evaluating the event and moving on). Some nurses did not always disclose the mistakes they had made, consequently various processes of internal rationalisation occurred. Crigger and Meek (2007) described how nurse participants frequently explained their struggle to meet personal and social ideals when they had made a mistake. To reduce the cognitive dissonance experienced, ‘participants often claimed that conditions in which the mistake was made contributed to or caused the error’ also ‘. . .diminishing the degree of harm caused by the mistake was also a way of reducing the incompatibility of being a good nurse and knowing that an error had been committed’ (Crigger & Meek 2007). Nurses who find themselves in the position of working within an environment where the care delivered is suboptimal, as was experienced by the staff at Mid Staffordshire, will undoubtedly experience the psychological discomfort of cognitive dissonance. According to witness statements areas within the Stafford hospital were understaffed and nurses were unable to, and on occasions told not to, provide aspects of care because of the need to reach ‘targets’ (The Mid Staffordshire NHS Foundation Trust Inquiry 2013). Similar to the participants in the studies cited above, it could be argued that staff at Mid Staffordshire adapted their values and subsequent behaviours in order to reduce the cognitive dissonance they were experiencing.
Conclusion Having explored these two theories, this article provides insights into why some nurses tolerate suboptimal nursing care. It has been shown that the theories of conformity and cognitive dissonance can help explain why suboptimal nursing care may remain unchallenged. Nursing students and new practitioners may conform to be accepted by the team and nurses. ª 2014 John Wiley & Sons Ltd Journal of Nursing Management, 2015, 23, 940–944
These situations may be compounded by nurses rationalising their care to reduce the cognitive dissonance they feel as a result of their desire to provide optimum care and their inability to do so. The Mid Staffordshire report (Mid Staffordshire NHS Foundation Trust Inquiry 2013) highlighted the need for a change in culture within the NHS in the UK towards transparency, candidness and openness. Providing insights as to why some nursing staff tolerate suboptimal care may provide a springboard to allow nurse managers to consider the complexities surrounding this required transformation.
Implications for nursing management One of the concerns of the public inquiry into standards of care at Mid Staffordshire NHS Foundation Trust (2013) was that ‘a completely unacceptable standard of nursing care was prevalent at the Trust’. The inquiry found that this was because of inadequate staffing levels and poor leadership. This situation had been on going and led to a decline in the professionalism of the nurses and the tolerance of suboptimal nursing care. Cognitive dissonance and conformity explain that there is a tendency for nurses to conform and seek to minimise their cognitive dissonance by tolerating the prevailing culture, even if it is one of suboptimal care. Raising awareness of these theoretical perspectives may allow nurse managers to consider the complexities surrounding such situations. Nurse managers could also apply these theories in practice by facilitating discussions with the nurses or providing an external facilitator in situations where lack of support or leadership has precipitated tolerance of suboptimal care. This would give the nurses an opportunity to understand their own behaviour or the behaviour of the nursing team. A transparent, candid and open discussion of the challenges facing staff and their reactions to them, in light of an understanding of cognitive dissonance and conformity, could create a no-blame culture where staff would be willing and enthusiastic to go on to discuss ways of addressing suboptimal care. Exploring nurses’ and nursing teams’ experiences, and their reaction to them, as a basis for discussing their values and beliefs about care could be the stimulus required to identify how these values and beliefs could be upheld in their current practice. This would encourage nurses to take ownership for the proposed changes and embed them into their practice, thus transforming the culture of suboptimal care. Although this paper explored two theories it is acknowledged that there are others that may be useful to consider. Cognitive dissonance and conformity 943
L. Price et al.
were chosen because there was a body of evidence investigating their application to nursing. This body of evidence was relatively small but there is sufficient evidence to suggest that these theories may be relevant to the development of a more caring culture across the NHS. In addition to the use of the theories in practice, nurse managers could also collaborate with higher education institutions to research the contribution of the theoretical perspectives of cognitive dissonance and conformity to the improvement of care. The role that experienced nurses and nurse managers play within a culture of suboptimal care is under-represented in the literature and is an area of practice that warrants further investigation.
Source of funding The authors did not receive any funding for this paper.
Ethical approval Not required as it is not primary research and no data collection from human participants has occured. It is a review of two theories and their application to nursing management.
References Alabaster E.S. (2006) Students’ ideals for nursing older people in practice. International Journal of Older People Nursing 1, 66–74. Asch S.E. (1951) Effects of group pressure upon the modification and distortion of judgments. In Groups, Leadership and Men (H. Guetzkow ed). Carnegie Press, Pittsburgh, PA. Champion B., Amble N. & Keatinge D. (1998) Fitting in: Becoming an Insider: A Nursing Perspective. Nurses Registration Board of New South Wales, Newcastle. Cialdini R.B. & Goldstein N.J. (2004) Social influence: compliance and conformity. Annual Review of Psychology 55, 591–621. Clark E., McCann T.V., Rowe K. & Lazenbatt A. (2004) Cognitive dissonance and undergraduate nursing students’ knowledge of, and attitudes about, smoking. Journal of Advanced Nursing 46 (6), 586–594. Collins B., Brown M., Strachan-Hall E. & Barron D. (2009) Blowing the whistle on poor care and practice. Nursing Management 16 (3), 11. Crigger N.J. & Meek V.L. (2007) Towards a theory of self-reconciliation following mistakes in nursing practice. Journal of Nursing Scholarship 39 (2), 177–183. Deutsch M. & Gerard H.B. (1955) A study of normative and informational social influences upon individual judgment. Journal of Abnormal and Social Psychology 51, 629–636. Duffy E. (1995) Horizontal violence: a conundrum for nursing. Collegian 2 (2), 5–17.
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Festinger L. (1957) The Theory of Cognitive Dissonance, Stanford University Press, Stanford, CA. Festinger L., Riecken H.W. & Schachter S. (1964) When Prophecy Fails: A Social and Psychological Study of a Modern Group that Predicted the Destruction of the World, Harper Collins, New York, NY. Gazzaniga M.S. (2006) Leon Festinger: lunch with Leon. Perspectives on Psychological Science 1 (1), 88–94. Giles H. (2008) Exploring the links between the lack of nursing leadership and poor care. Kai Tiaki Nursing New Zealand 14 (4), 18–19. Jenness A. (1932) The role of discussion in changing opinion regarding a matter of fact. Journal of Abnormal and Social Psychology 27, 279–296. Joseph A.P. & Hunyor S.N. (2008) The Royal North Shore Hospital inquiry: an analysis of the recommendations and the implications for quality and safety in Australian public hospitals. Medical Journal Australia 188 (8), 469–472. Karstadt L. (2012) Is poor care cause for concern in nurse education? British Journal of Nursing 21 (11), 689. Kelman H.C. (1958) Compliance, identification, and internalization three processes of attitude change. Journal of Conflict Resolution 2 (1), 51–60. Kmietowicz Z. (2012) High job vacancy rates in hospitals and nursing homes underpin poor care, says watchdog. British Medical Journal 345, e7990, 15. Levett-Jones T. & Lathlean J. (2008) ‘Don’t rock the boat’: nursing students’ experiences of conformity and compliance. Nurse Education Today 29, 342–349. Mann L. (1969) Social Psychology. Wiley, New York, NY. Maslow A.H. (1954) Motivation and Personality. Harper & Bros, New York, NY. Massey D., Aitken L.M. & Chaboyer W. (2009) What factors influence suboptimal ward care in the acutely ill ward patient? Intensive and Critical Care Nursing 25, 169–180. Mid Staffordshire NHS Foundation Trust Inquiry (2013) Independent Inquiry into Care Provided by Mid Staffordshire NHS Foundation Trust, January 2005–March 2009, Vol. 3. The Stationery Office, London. Parks C.D. (2004) Group Norms. Encyclopaedia of Leadership. SAGE publications. Available at: http://www.sagepub.com/ northouseintro2e/study/chapter/encyclopedia/encyclopedia7.1.pdf, accessed 4 February 2014. Quirke S., Coombs M. & McEldowney R. (2011) Suboptimal care of the acutely unwell ward patient: a concept analysis. Journal of Advanced Nursing 67 (8), 1834–1845. Scholes J. (2007) Suboptimal care 10 years on. Nursing in Critical Care 12 (6), 259–260. Scott G. (2013) Evidence proves poor care is about numbers. Nursing Standard 27 (18), 1. Thyer G.L. (2003) Dare to be different: transformational leadership may hold the key to reducing the nursing shortage. Journal of Nursing Management 11, 73–79. Walsh K. & Shortell S.M. (2004) When things go wrong: how health care organizations deal with major failures. Health Affairs 23 (3), 103–111. Wigens L. (1997) The conflict between ‘new nursing’ and ‘scientific management’ as perceived by surgical nurses. Journal of Advanced Nursing 25 (6), 1116–1122.
ª 2014 John Wiley & Sons Ltd Journal of Nursing Management, 2015, 23, 940–944
Are theoretical perspectives useful to explain nurses’ tolerance of suboptimal care? LESLEY PRICE P h D , M S c , B A , R N T , JACQUELINE MCCALLUM E d D ,
RGN
1
, KATHLEEN DUFFY P h D , M S c , B A , R N T , R G N 2, 3 and VALERIE NESS M N , P G C e r t ,
MN, Pgcert, BA, RNT, RGN
BN, RN, RNT
4
1
Lecturer/Researcher in Acute Care Nursing, Glasgow Caledonian University, 2Nursing and Midwifery Practice Educator, NHS Education for Scotland, 3Senior Lecturer and 4Lecturer in Nursing, Glasgow Caledonian University, Glasgow, Scotland, UK
Correspondence Lesley Price Caledonian University A534, Govan Mbeki Building Cowcaddens Road Glasgow G4 0BA UK E-mail: [email protected]
(2015) Journal of Nursing Management 23, 940–944. Are theoretical perspectives useful to explain nurses’ tolerance of suboptimal care?
PRICE L., DUFFY K., MCCALLUM J., NESS V.
Aim This paper explores two theoretical perspectives that may help nurse managers understand why staff tolerate suboptimal standards of care. Background Standards of care have been questioned in relation to adverse events and errors for some years in health care across the western world. More recently, the focus has shifted to inadequate nursing standards with regard to care and compassion, and a culture of tolerance by staff to these inadequate standards. Evaluation The theories of conformity and cognitive dissonance are analysed to investigate their potential for helping nurse managers to understand why staff tolerate suboptimal standards of care. Key issues The literature suggests that nurses appear to adopt behaviours consistent with the theory of conformity and that they may accept suboptimal care to reduce their cognitive dissonance. Conclusion Nurses may conform to be accepted by the team. This may be confounded by nurses rationalising their care to reduce the cognitive dissonance they feel. Implications for nursing management The investigation into the Mid Staffordshire National Health Service called for a change in culture towards transparency, candidness and openness. Providing insights as to why some nursing staff tolerate suboptimal care may provide a springboard to allow nurse managers to consider the complexities surrounding this required transformation. Keywords: cognitive dissonance, conformity, management, nursing, suboptimal care Accepted for publication: 10 March 2014
Introduction There is much written worldwide regarding adverse events and errors. Almost 10 years ago Walsh and Shortell (2004) stated that ‘reports published in the United States, the United Kingdom, Australia, New Zealand, and Canada have focused public and policy attention on the safety of patients and have highlighted 940
the alarmingly high incidence of errors and adverse events that lead to some kind of harm or injury’. More recently the focus has changed. In the UK the publication of the Mid Staffordshire National Health Service (NHS) Foundation Trust Inquiry (2013) highlighted inadequate nursing standards with regard to care and compassion. Of particular concern was the uncovering of a culture of tolerance by staff to these inadequate DOI: 10.1111/jonm.12239 ª 2014 John Wiley & Sons Ltd
Why nurses tolerate suboptimal care?
standards. Significantly, this is an international concern. In October 2007, the New South Wales Parliament in Australia convened a Joint Select Committee to conduct an inquiry into several allegations of inadequate patient care at Royal North Shore Hospital (RNSH) in Sydney (Joseph & Hunyor 2008). They exposed similar problems to those highlighted in the Mid Staffordshire NHS Foundation Trust Inquiry (2013). But what is meant by the term inadequate standards of care? For many years nursing has been developing standards of care where appropriate treatment is specified based on evidence. These are most commonly associated with well-defined elements such as the care required for someone who has a urinary catheter. What appears to be the concern in the above instances is less tangible and relates more to the absence of holistic care that incorporates caring and compassion. Discussions of ‘poor care’ (Giles 2008, Collins et al. 2009, Karstadt 2012, Kmietowicz 2012, Scott 2013) and ‘suboptimal care’ exist in the nursing literature (Scholes 2007, Massey et al. 2009, Quirke et al. 2011). These papers describe incidences and explore the causes of inadequate care but fail to uncover why nurses may tolerate such situations. Our preferred term for use in this article is suboptimal care as it is less judgemental than poor care and is proactive. The dictionary definition of optimal is the ‘best’ and optimum is ‘seeking the optimal (best)’. Therefore, using the term suboptimal care indicates a desire to improve nursing care rather than just describe its occurrence or cause. A number of theoretical perspectives could have been explored, but as our interest in this topic is in exploring why nurses and the nursing profession tolerate suboptimal nursing care, we chose conformity and cognitive dissonance. Both of these concepts are prevalent in the nursing literature. Developing insights from these perspectives may enable nurse managers to understand nurses’ behaviour and thus be able to identify ways of challenging it.
Conformity When thinking about why staff tolerate suboptimal standards of care exploring the social theory of conformity may be helpful. Conformity is a type of social influence where attitudes, beliefs, and behaviours are matched to group norms (Cialdini & Goldstein 2004). Norms are implicit, unstated rules shared by a group of individuals that guide their interactions with others and among society or social groups (Parks 2004). This tendency to conform may result from unconscious influences or direct social pressure. It often does not ª 2014 John Wiley & Sons Ltd Journal of Nursing Management, 2015, 23, 940–944
even need the physical presence of others, as people tend to follow social norms even when alone. The concept of group conformity and its links with belongingness has been discussed throughout the social and psychosocial literature for the last 50 years. Jenness (1932) was the first psychologist to study conformity before being made well-known by Asch’s (1951) line study. This study showed that as more people oppose a subject, individuals become more likely to conform. Conformity has been developed by other psychologists. Maslow’s (1954) seminal work aimed to understand what constitutes human need and he described the significance of belonging to a defined group. Mann (1969) identified three types of conformity: normative (the desire to ‘fit in’ or be liked or scared of being rejected – publically accepts but privately rejects); informational (because of a desire to be correct); and ingratiational (conforming to impress or gain favour). Ingratiational is similar to normative but is motivated by the need for social rewards rather than the threat of rejection. A fourth type of conformity has also been discussed within the literature, namely, identification, to conform to a social role (Kelman 1958). But what does the nursing profession know about nurses and conformity?
Nurses and conformity Informational conformity is often discussed within the context of student nurse behaviour or with regard to newly qualified practitioners. This is because it is common in people who lack knowledge and, therefore, as a result, these individuals look to the group for guidance or are unclear and socially compare their behaviour with the group (Deutsch & Gerard 1955). This usually leads to internalisation, where they accept the views of the group and then adopt them. Ingratiational conformity may be displayed if the reward is a successfully assessed placement, if a student nurse, or promotion, if a registered nurse. Alabaster (2006), in an interpretive study of 10 students, found that although they were confident in their ability to identify and resist negative influences, some degree of conformity was inevitable. LevettJones and Lathlean (2008) conducted a cross-national case study of 18 third-year nursing students’ experience of belongingness when undertaking clinical placements. They also found that students adopted behaviours to improve their likelihood of acceptance and inclusion by nursing staff and did not want to ‘rock the boat’. 941
L. Price et al.
Two studies focusing on new practitioners found similar results. In a grounded theory research project that used in-depth interviews, diary accounts and telephone conversations, Levett-Jones & Lathlean (2008) explored the socialisation and acculturation experiences of six ‘new’ practitioners. These participants stated that they quickly learned that the best way to fit in and be accepted was to comply with established practice and ward routines. At times, the participants questioned practices and attitudes of the registered nurses they worked with but this was rarely voiced. Champion et al. (1998), in a small pilot study, found similar results, that new practitioners adopted the teams’ and institution’s values and norms and modified their behaviours as they rotated through different units in order to be accepted. Some claimed that they made a calculated decision to conform in order to be accepted into the nursing team. The authors suggested that new practitioners learned to ‘fit in’ by becoming what they referred to as ‘chameleons’, changing and continuously adapting to new environments. As can be seen from this discussion the literature appears to suggest that students and new practitioners appear to adopt behaviours consistent with the theory of normative conformity. However, does conformity explain the tolerance of suboptimal care in established nursing teams? Duffy (1995) suggests that nurses are an oppressed group but that often the intergroup conflict (common because of women working together, personality traits, jealousy, ambition and lack of respect) is to blame. Therefore, even though nurses are taught to question practice they allow themselves to be managed by strategies such as correction, criticism, negative feedback and negative reinforcement. Conforming to this social role may explain why nursing teams tolerate suboptimal care. In a case study on a ward with problems (measured by complaints and a concerning level of patient care), Thyer (2003) found that the dominance of the medical model ensured conformity in a bureaucratically hierarchical structure. Conversely, conformity could also be seen as a good thing, especially if it prevents dangerous acts, or means that best practice is followed. However, the literature cited above suggests that it may also be able to explain why suboptimal care is not reported and why it is even practiced in some teams where fitting-in is a priority.
Cognitive dissonance Cognitive dissonance is another theoretical lens through which the question ‘Why do staff tolerate 942
suboptimal care?’ can be explored. Cognitive dissonance is psychological discomfort which is aroused when people are confronted with conflicting ideas, beliefs or values. The theory purports that individuals have a motivational drive to reduce dissonance (Clark et al. 2004), therefore individuals may adapt their ideas, beliefs, values and subsequent behaviour to reduce the dissonance. The theory is attributed to Leon Festinger. In 1957 he published a book called A Theory of Cognitive Dissonance in which he developed his initial version of this social psychology theory. Subsequently Festinger et al. (1964) carried out further research in this area to validate this viewpoint and today cognitive dissonance is one of the most influential theories in social psychology (Gazzaniga 2006). If this theoretical perspective is applied to the question posed above it could be that nursing staff who are continually exposed to suboptimal care have to adapt their ideas, beliefs, values and subsequent behaviour to reduce the dissonance they feel (i.e. that they are unable to maintain the standards they would like), but what evidence exists to support this view?
Nurses and cognitive dissonance Wigens (1997) in a study, utilising grounded theory methodology, sought to understand surgical nurses’ perceptions of the conflict between the tension of delivering individualised patient care and the shift to increased efficiency and throughput of patients with the move to day cases. Reporting only on the interview data from the 10 surgical nurses, which took place within the context of a wider study, Wigens (1997) highlighted that day surgery and shorter stays within general surgical settings created cognitive dissonance for nursing staff. This is because it limited a nurse’s ability to become emotionally involved with patients and to deliver individualised care. Reporting on the various strategies the nurses used to reduce cognitive dissonance, the author reported the use of rationalisation. Wigens (1997) commented that, ‘nurses came to believe that it was alright to routinise care, and reduce emotional labour because the operations were smaller’. Essentially, nurses in the study rationalised their need to give non-individualised care to patients having routine or minor operations. Two forms of rationalisation were reported. Some participants reported increased involvement with a few patients that they felt required individualised care. Others reduced cognitive dissonance by arguing they should maintain equity of care for all patients, so that those patients with increased needs did not receive ª 2014 John Wiley & Sons Ltd Journal of Nursing Management, 2015, 23, 940–944
Why nurses tolerate suboptimal care?
any more care than other patients. Other methods of coping cited by participants included acceptance of the situation, keeping the problem to themselves and looking for good points in any management initiatives that were proposed. Another grounded theory study conducted by Crigger and Meek (2007) explored the psychosocial process that occurs after nurses perceive that they have made a mistake in practice. Drawing on the interview data from 10 registered nurses who described a total of 17 personal mistakes, the authors describe four distinct categories. These were: reality hitting (coming to terms with the reality of the mistake); weighing in (determining the need to disclose or report the mistake); acting (deciding on the best course of action); and reconciling (evaluating the event and moving on). Some nurses did not always disclose the mistakes they had made, consequently various processes of internal rationalisation occurred. Crigger and Meek (2007) described how nurse participants frequently explained their struggle to meet personal and social ideals when they had made a mistake. To reduce the cognitive dissonance experienced, ‘participants often claimed that conditions in which the mistake was made contributed to or caused the error’ also ‘. . .diminishing the degree of harm caused by the mistake was also a way of reducing the incompatibility of being a good nurse and knowing that an error had been committed’ (Crigger & Meek 2007). Nurses who find themselves in the position of working within an environment where the care delivered is suboptimal, as was experienced by the staff at Mid Staffordshire, will undoubtedly experience the psychological discomfort of cognitive dissonance. According to witness statements areas within the Stafford hospital were understaffed and nurses were unable to, and on occasions told not to, provide aspects of care because of the need to reach ‘targets’ (The Mid Staffordshire NHS Foundation Trust Inquiry 2013). Similar to the participants in the studies cited above, it could be argued that staff at Mid Staffordshire adapted their values and subsequent behaviours in order to reduce the cognitive dissonance they were experiencing.
Conclusion Having explored these two theories, this article provides insights into why some nurses tolerate suboptimal nursing care. It has been shown that the theories of conformity and cognitive dissonance can help explain why suboptimal nursing care may remain unchallenged. Nursing students and new practitioners may conform to be accepted by the team and nurses. ª 2014 John Wiley & Sons Ltd Journal of Nursing Management, 2015, 23, 940–944
These situations may be compounded by nurses rationalising their care to reduce the cognitive dissonance they feel as a result of their desire to provide optimum care and their inability to do so. The Mid Staffordshire report (Mid Staffordshire NHS Foundation Trust Inquiry 2013) highlighted the need for a change in culture within the NHS in the UK towards transparency, candidness and openness. Providing insights as to why some nursing staff tolerate suboptimal care may provide a springboard to allow nurse managers to consider the complexities surrounding this required transformation.
Implications for nursing management One of the concerns of the public inquiry into standards of care at Mid Staffordshire NHS Foundation Trust (2013) was that ‘a completely unacceptable standard of nursing care was prevalent at the Trust’. The inquiry found that this was because of inadequate staffing levels and poor leadership. This situation had been on going and led to a decline in the professionalism of the nurses and the tolerance of suboptimal nursing care. Cognitive dissonance and conformity explain that there is a tendency for nurses to conform and seek to minimise their cognitive dissonance by tolerating the prevailing culture, even if it is one of suboptimal care. Raising awareness of these theoretical perspectives may allow nurse managers to consider the complexities surrounding such situations. Nurse managers could also apply these theories in practice by facilitating discussions with the nurses or providing an external facilitator in situations where lack of support or leadership has precipitated tolerance of suboptimal care. This would give the nurses an opportunity to understand their own behaviour or the behaviour of the nursing team. A transparent, candid and open discussion of the challenges facing staff and their reactions to them, in light of an understanding of cognitive dissonance and conformity, could create a no-blame culture where staff would be willing and enthusiastic to go on to discuss ways of addressing suboptimal care. Exploring nurses’ and nursing teams’ experiences, and their reaction to them, as a basis for discussing their values and beliefs about care could be the stimulus required to identify how these values and beliefs could be upheld in their current practice. This would encourage nurses to take ownership for the proposed changes and embed them into their practice, thus transforming the culture of suboptimal care. Although this paper explored two theories it is acknowledged that there are others that may be useful to consider. Cognitive dissonance and conformity 943
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were chosen because there was a body of evidence investigating their application to nursing. This body of evidence was relatively small but there is sufficient evidence to suggest that these theories may be relevant to the development of a more caring culture across the NHS. In addition to the use of the theories in practice, nurse managers could also collaborate with higher education institutions to research the contribution of the theoretical perspectives of cognitive dissonance and conformity to the improvement of care. The role that experienced nurses and nurse managers play within a culture of suboptimal care is under-represented in the literature and is an area of practice that warrants further investigation.
Source of funding The authors did not receive any funding for this paper.
Ethical approval Not required as it is not primary research and no data collection from human participants has occured. It is a review of two theories and their application to nursing management.
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