NHS managers should be aware of a famous theory in social psychology called cognitive dissonance. It has become one of the most dominant ways of accounting for many puzzling behavioural phenomena in the world of academic psychology, yet it remains relatively obscure outside the field.

The idea behind cognitive dissonance is that we like to think of ourselves as rational, reasonable and consistent beings. Therefore, if we notice our behaviour is inconsistent, we will tend to modify our attitudes to bring consistency back into the frame.

This drive for consistency is so powerful that it can have a massive effect, though often an unconscious one, on our attitudes and behaviour.

Cognitive dissonance theory has a wide range of applications. For example, it accounts for the puzzling tendency of those who work in hazardous industries to ignore safety regulations more than those who do not work in dangerous environments.

Cognitive dissonance theory says that those in dangerous occupations must experience dissonance between their choice to work in such a hazardous area and their understandable fear of injury. It is impossible to reconcile your decision to turn up to work with the idea that you are a rational, intelligent person.

Reducing dissonance in this context takes the form of mentally minimising the probability of injury in your own mind.

Cognitive dissonance works the other way for those outside the industry. If the industry is well paid, those who do not work in it will reason that it is better not to take the big rewards because it is too dangerous.

Waiting times

Cognitive dissonance also argues that the longer we wait for something, the more likely we are to believe that the wait was worth it as a way of maintaining our view of ourselves as sensible people who would not wait forever for something trivial. The converse also applies - as a general rule, when something is too easily available and no wait is required, we tend to mentally reduce its value (doctors may want to consider deploying this finding in their waiting rooms).

Basically, then, the more something costs us in money, waiting time, or whatever the personal cost, the greater the need to positively justify our actions, and so alter our appreciation of its value.

The implications of cognitive dissonance theory for the NHS are multifold, including the fact that managers tend to reconcile two conflicts - that of trying to deliver high-quality patient care with balancing the budget. Cognitive dissonance theory would predict that after a while, dissonance reduction might lead managers to dehumanise patients and not be overly concerned about them as individuals. Alternatively, it might cause them to de-prioritise balancing the budget.

The reality is that conflicts like these induce stress that managers need to be aware of. They need to become more aware of the impact of cognitive dissonance on themselves.

For example, is it possible that some nurses - particularly those who work in terminal or palliative care - may come to have lowered inhibitions over administering euthanasia and therefore come to harbour a completely contrasting attitude to death compared with the general population?

When a nurse is pictured on the front page of the national press accused of killing elderly patients, many may ask how this can occur in a caring profession. But the psychological mechanisms involved in this kind of crime may in fact be surprisingly widespread in the profession and could involve cognitive dissonance.