Value dissonance in nursing: Making sense of disparate literature
Article Outline
- Three vignettes
- Value dissonance
- Value dissonance: an ordering and structuring concept
- Conclusion
- References
- Copyright
Three vignettes
Consider a University nurse lecturer marking assignments. The lecturer is confronted by an essay that provides a well argued and thoughtful perspective on the topic under consideration. It comfortably meets published academic requirements regarding, for example, analysis and evaluation. However, the assignment vigorously challenges and contradicts professional values and ideals concerning ‘essential’ nurse attitudes or behaviours. As a member of the University Faculty should the lecturer solely reward the essay for demonstrating academic credibility and critical thinking or, as a member of a professionally regulated body, should the lecturer require that students accept and demonstrate ‘professional values’ in written work? If the latter, then normative, non-academic and possibility unpublished marking criteria may be used in grading assignments.
Alternatively, imagine a student nurse going out into placement. The student has been prepped and encouraged by University staff to think critically about practice experience and, accepting the roles of adult learner and autonomous practitioner, the student carries a reflective and questioning attitude into the workplace. During placement the student undertakes a literature review and discovers that the ward practice for caring for intravenous cannulae is outdated. Evidence suggests that more frequent observations and documentation will reduce the incidence of phlebitis, but ward staff are unwilling to engage in questioning their current practices. Here, as both recent and ‘historic’ literature attests (e.g. Levett-Jones and Lathleen, 2009, Kramer, 1974), it would not be surprising if the student found herself in a culture that merges understandable managerial demands for a quiescent and biddable workforce with traditional nursing norms that valorise ‘doing’ and task completion over scholarly thoughtfulness, engaged scepticism and a willingness to embrace the new.
Finally, a nurse manager in an accident department is struggling to meet government targets for waiting times regarding transfer out of the department. A great deal rides on the successful accomplishment of these targets and, to ensure that it can truthfully be said that patients are not being kept waiting on a trolley in the department, the nurse manager instigates a policy of moving patients into a corridor. Nurses caring for these patients object that the practice is unsafe and undignified, but the manager – subject to competing pressures – insists, desperate to avoid the financial and other penalties which would accompany failure to meet the targets.
Value dissonance
These vignettes are not examples of the oft-quoted theory–practice divide, rather they are stylised examples of events that, we suggest, illustrate or embody ‘value dissonance’ – a concept that links together and structures a variety of otherwise disparate debates in nursing and healthcare. Further, not only does value dissonance tie together issues that outwardly appear discreet, we also assert that many of nursing’s long-term ‘problem’ topics cannot be understood at all unless the normative and evaluative rupture at their core is realised.
Examples of the concept’s ordering and structuring capability are given below. However, to be clear, value dissonance occurs when two or more values or value sets come into conflict and, whilst only people can experience emotional dissonance, value or ideational conflict can be evidenced between and within institutions, individuals and groups. Thus, in the first vignette, for the nurse lecturer, academic values are pitted against professional values. In the second, for the student, academic values conflict with employment and ‘ward’ values, and in the third, for the registered nurse manager, professional and employment values diverge. In these examples, values and ideas (cultural structures) are associated with institutions (social structures) and role positions. Thus, academia valorises critical thinking skills, nurse regulating bodies (speaking for ‘the profession’) promote particular versions of professionalism and employers sponsor managerialism or pragmatism. However, to suggest that social structures ‘valorise’, ‘promote’ or ‘sponsor’ cultural values is problematic. Values and ideas may exist a priori ‘in the library’ (Archer, 1995); however, historically and socially situated agents – individuals or groups – are required to embody or take up these values or ideas in pursuance of objectives or interests before they make themselves felt in the world. It is in individual embodiment that value dissonance is psychologically experienced.
At this individual level, the lecturer in the first vignette might want to promote the academic respectability of nursing by encouraging unfettered debate and critical enquiry whilst simultaneously wanting to protect traditional professional or vocational values. The student may want to embrace the role of ‘innovative’ autonomous adult learner and recognise that organisational and collegiate demands reasonably limit this autonomy. And the nurse manager may want to care properly for the patients in the department while simultaneously recognising the pragmatic need to meet targets (from a US perspective Kramer (1974) analogously describes similar instances of ‘Professional–Bureaucratic’ conflict). Circumstance may allow conflict to be avoided – it is not inevitable – and conflict need not be articulated or identified even when present. However, in each of the vignettes, perfectly legitimate and understandable ideals or value sets may generate incommensurable demands within individuals and thus described value dissonance is:
a distressing mental state in which people find themselves doing things that they do not highly value, or having opinions that do not fit institutional norms or fit with the opinions of those who monitor or enforce them. (Bruhn, 2008, p. 21).
Value dissonance: an ordering and structuring concept
Inter-institutional conflict, the product of value dissonance, surfaces in a number of guises. For example, whereas employers understandably want nurses to exit training competent in the performance of a wide range of practical and possibly advanced skills (e.g. IV cannulation or defibrillation) (Kilstoff and Rochester, 2003), University lecturers frequently emphasise the development of more intangible intellectual accomplishments (e.g. ‘critical thinking’). Nurse education does, of course, combine practical and theoretic elements. However, since curriculum time is a finite resource, tensions have been noted between the ‘pull’ of employer and academic demands (Roberts and Johnson, 2009) and, we suggest, at root here are very real normative differences – or value dissonances – about what the essence of nursing is or should be.
Inter-institutional conflict may also occur between members of the same community. Thus, Thompson (2009) notes important disparities between the academic ‘respectability’ of Faculty nursing staff in UK and North American Universities and this, we believe, in part points towards the existence of important value differences between nursing and nurse lectures at an international level – i.e. academic values are ‘embedded’ more fully in North America’s concept of nursing than in the UK.
Alternatively, intra-institutional value dissonance may be apparent between nurse lecturers within single institutions. In the UK the formidable ‘double act’ of Thompson and Watson have, over several years, singly and jointly challenged the legitimacy and telos of nursing’s presence within higher education by, we suggest, articulating aspects of lecturer value dissonance. Thompson (2009), in particular, identifies a small but telling constellation of issues that suggestively hint at internal fracture or value conflict amongst Faculty staff.
We read Thompson (ibid) and Watson and Thompson (2004) as, at the extremes, identifying fault lines that divide nurses who embrace traditional scholarly or University ideals regarding the purpose of higher education – ideals that can be considered elitist – from those who, equally traditionally, validate bedside ‘practice’ and the centrality of ‘care’ and ‘vocation’ (of ‘training’) over academic pretensions. (Similar tensions are recognised elsewhere – e.g. see Björkström et al. (2005) for a Swedish perspective.) These two orientations – academic and practice/vocational based values – need not conflict and we would not want to assert an overly bi-polar separation between these orientations. Nevertheless, lecturers who embody these evaluative perspectives do disagree over, for example, the purpose of the educative process or the relative importance of practice and theoretic ‘learning’.
Value dissonance, as a structuring and ordering concept, can also ‘scaffold’ an explanation of complex inter- and intra-institutional relationships. For example, we note that contradictory values associated with what might broadly be defined as nurse autonomy and control or prescription, differentiate employers from Universities and regulatory bodies.
Thus, in their use of declamatory language (you “must”) employers pragmatically generate policy documents that limit nurse autonomy – although, as Bail et al. (2009) recognise in a recent Australian study, the use of such directive and infantilising terms may well be perceived as ‘insulting’ (p. 1463) to competent and skilled practitioners. On the other hand, Universities and regulatory bodies tend to elide or muddle discordant claims. For example, within the University autonomous behaviour is promoted in policies based upon humanistic theory that require students to take on the mantle of adult learners and autonomous thinking is encouraged by higher education’s endorsement of academic scepticism and the development of analytic skills which deny argumentative closure. However, student autonomy is restricted when prescriptive and controlling demands require, for example, attendance in the theoretical or taught component of University education.
Likewise professional regulatory bodies such as the UK’s Nursing and Midwifery Council (NMC) also tend, within their codes, to make declamatory claims (you “must” – NMC, 2008) whilst simultaneously commissioning and to some extent therefore endorsing documents that sponsor autonomous practice (e.g. see Longley et al., 2007, p. 35: “education... must prepare nurses to work.. [with] high levels of autonomy”). And this apparent dichotomy or inconsistency – between “you must” and “be autonomous” – is recognised by the same NMC when they note that pre-registration education needs to “balance prescription with autonomy” (NMC, 2004, p. 48).
It is perhaps unsurprising that nurses can find themselves enmeshed in the tensions deriving from competing sets of values. Our examples illustratively suggest competing value sets arising in education and employment. However, individual nurses embody a range of values and when, for example, these derive from cultural or religious influences these values can run counter to professionally sanctioned norms. Further, if somewhat less palatably, nurses may hold political opinions or affiliations that sit outside professional values and, for example, in the UK, the NMC has issued guidance regarding membership of legal political parties of the far right.
Values clearly matter very much to nursing as it transforms itself and its practices. A glance at text books from only a generation ago reveals that values are plastic over time and it should be noted that, as with other aspects of education, it is possible that outdated concepts continue to be embraced by senior cohorts of practicing nurses. As Chiarella (2002) reminds us, it was only in 1973 that obedience to the doctor was removed from the International Council of Nurses code of ethics at the behest of Canadian student nurses and it was not until 10 years later that UK nurses had their first Code of Professional Conduct.
Conclusion
Ideational or value dissonance is the common denominator that links together each of the examples used here. Admittedly, these examples might be accused of being somewhat ‘strained’ or unrealistic. We recognise that, presentationally, somewhat crude bi-polar contrasts have been used to ‘make the point’ and, to restate, even when evident putative tensions need not flare up in realised conflict. That said, we propose that if the concept of value dissonance captures a real relationship, if it does indeed order and structure a variety of otherwise singular debates, then engagement with this concept may, in the educational field, fruitfully assist lecturers in a process of self understanding. Significantly, the UK’s professional regulatory body is now committed to degree only programmes, a move that will bring English practice into line with other developed nations and similar professions. And, it might be argued that this change will, in itself and over the next few years, heighten the amount or degree of ‘academically’ related value dissonance. That said, internationally, the development of nursing Masters and Doctoral level programmes is becoming more commonplace and, as the ‘pool’ of more academically qualified nurses grows, we suggest that similar conflicts – between idealised academic and traditional non-academic nursing values – will be played out and chronicled across developed nations. In understanding future trends and conflicts we propose that value dissonance will remain centre stage.
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PII: S0260-6917(10)00024-9
doi:10.1016/j.nedt.2010.01.012
© 2010 Elsevier Ltd. All rights reserved.
