Editorial Value dissonance in nursing: Making sense of disparate literature 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 com- fortably meets published academic requirements regarding, for example, analysis and evaluation. However, the assignment vigor- ously 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 es- say 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 If the latter, then normative, non-academic and possibility unpublished marking criteria may be used in grading assignments.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 place- ment. 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student undertakes a literature review and discovers that the ward practice for caring for intravenous cannu- lae is outdated.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 accom- plishment 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 pa- tients 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 dis- sonance 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 institu- tions, individuals and groups. Thus, in the first vignette, for the nurse lecturer, academic values are pitted against professional val- ues. 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 associ- ated with institutions (social structures) and role positions. Thus, academia valorises critical thinking skills, nurse regulating bodies (speaking for ‘the profession’) promote particular versions of pro- fessionalism and employers sponsor managerialism or pragma- tism. 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, his- torically 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 psy- chologically experienced. At this individual level, the lecturer in the first vignette might want to promote the academic respectability of nursing by encour- aging 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’ autono- mous 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 simi- lar 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 0260-6917/$ - see front matter Ó 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.nedt.2010.01.012 Nurse Education Today 30 (2010) 595–597 Contents lists available at ScienceDirect Nurse Education Today journal homepage: www.elsevier.com/nedt