Care erosion in hospitals: Problems in reflective nursing practice and the role of cognitive dissonance

• Cognitive dissonance theory helps understanding care erosion in hospitals.
• Failing critical reflection in health care is at the basis of care erosion.
• Restoration of care levels in troubled hospitals should emphasise restoring health care workers ability to self-correct.
• Nurse educators can help prevent care erosion by addressing the care erosion mechanism, and promoting nursing values and critical reflection.

SummaryCare erosion – gradual decline in care level – is an important problem in health care today. Unfortunately, the mechanism whereby it occurs is complex and poorly understood. This paper seeks to address this by emphasising problems in reflective nursing practice. Critical reflection on quality of care which should drive good care instead spawns justifications, denial, and trivialisation of deficient care. This perpetuates increasingly poor care levels. We argue that cognitive dissonance theory provides a highly effective understanding of this process and suggest for this approach to be incorporated in all efforts to address care erosion. The paper includes a detailed discussion of examples and implications for practice, in particular the need to restore critical reflection in nursing, the importance of embracing strong values and standards, and the need for increased awareness of signs of care erosion.