Nudging healthcare professionals in clinical settings: a scoping review of the literature

Abstract

Background Healthcare organisations are in constant need of improvement and change. Nudging has been proposed as a strategy to affect people’s choices and has been used to affect patients’ behaviour in healthcare settings. However, little is known about how nudging is being interpreted and applied to change the behaviour of healthcare professionals (HCPs). The objective of this review is to identify interventions using nudge theory to affect the behaviour of HCPs in clinical settings. Methods A scoping review. We searched PubMed and PsycINFO for articles published from 2010 to September 2019, including terms related to “nudging” in the title or abstract. Two reviewers screened articles for inclusion based on whether the articles described an intervention to change the behaviour of HCPs. Two reviewers extracted key information and categorized included articles. Descriptive analyses were performed on the data. Results Search results yielded 997 unique articles, of which 25 articles satisfied the inclusion criteria. Five additional articles were selected from the reference lists of the included articles. We identified 11 nudging strategies: accountable justification, goal setting, suggested alternatives, feedback, information transparency, peer comparison, active choice, alerts and reminders, environmental cueing/priming, defaults/pre-orders, and education. These strategies were employed to affect the following 4 target behaviours: vaccination of staff, hand hygiene, clinical procedures, prescriptions and orders. To compare approaches across so many areas, we introduced two independent dimensions to describe nudging strategies: synchronous/asynchronous, and active/passive. Conclusion There are relatively few studies published referring to nudge theory aimed at changing HCP behaviour in clinical settings. These studies reflect a diverse set of objectives and implement nudging strategies in a variety of ways. We suggest distinguishing active from passive nudging strategies. Passive nudging strategies may achieve the desired outcome but go unnoticed by the clinician thereby not really changing a behaviour and raising ethical concerns. Our review indicates that there are successful active strategies that engage with clinicians in a more deliberate way. However, more research is needed on how different nudging strategies impact HCP behaviour in the short and long term to improve clinical decision making.

Battling Bias in Primary Care Encounters: Informatics Designs to Support Clinicians

“…Digital nudges were recommended as a solution for reminding clinicians of patient characteristics not noted in the EHR; to provide real-time alerts to encourage patient engagement and to recognize when communication may be problematic. Research on the use of nudges as interventions in healthcare settings have predominately focused on objectives related to medication management and changes to clinical care procedures such as scheduled inpatient blood pressure checks rather than on patient-provider communication[ 47 ]. Guided reflection could be used to engage other healthcare staff in processing communication feedback through meetings, clinical consult groups, or in-clinic observations or practice settings such as the use of standardized patients.…”

Can we nudge to reduce the perioperative low value care? Decision making factors influencing safe practice implementation

“…Designing initiatives to reduce LVC and improve decision making should be planned following behavioural sciences approach, like behavioural economics (i.e., Nudge), that emphasise the importance of the stakeholders’ perspectives (i.e., public, patients and clinicians) to redesign systems to facilitate higher-value care [65,66 ▪▪ ,67 ▪ ].…”

A Qualitative Description of Clinician Free-Text Rationales Entered within Accountable Justification Interventions

“…Interventions informed by behavioral science embedded within the electronic health record (EHR) have been utilized in quality improvement efforts within primary care, and some have been effective. 1 2 Accountable justification alerts are one such behavioral intervention that led to a reduction in inappropriate antibiotic prescribing for acute respiratory infections. 3 4 5 Accountable justification alerts prompt a clinician who is ordering a potentially guideline-discordant test or treatment to enter a free-text rationale for why their clinical decision should override the presented clinical guideline or recommendation.…”