Nudging for Care: Practical applications of behavioural science

This article originally appeared in the Canadian Hospice Palliative Care Association's Publication AVISO in both English and French.

Behavioural science - the body of research largely comprised of the distinct but related fields of psychology and behavioural economics - has become an increasingly popular policy approach since the launch of the UK Government’s Behavioural Insights Team in 2010. In Canada, labs have been set up across provincial and federal jurisdictions to help government better design and implement social programs.

Insights from this body of literature can offer a window into how people behave in various choice environments, resulting in interventions to curb harmful personal choices, or to ‘nudge’ people towards better choices that improve outcomes for themselves and society. Less publicized, however, are the practical applications of behavioural science outside policy realms. How can behavioural interventions be used to increase drug adherence in home-care settings, or reduce administration of certain classes of medication?

Fortunately, over the last decade, numerous studies have documented nudge effects across various settings. Combined with data from controlled experiments, we can draw conclusions about how hospice and palliative care might benefit from behavioural approaches to service design and delivery.

In complex operating environments like healthcare, caregivers are regularly inundated with sights and sounds (one estimate by the Acoustical Society of America found that the average hospital produces 135 alarms per patient, per day, about one every 11 minutes). This can make identifying cases of clinical deterioration a challenge. The Australian state of New South Wales sought to reduce preventable deaths caused by ‘unintentional blindness’ due to cognitive overload.

To combat this problem, the Between the Flags program was developed to provide caregivers with an easy-to-read, colour-coded ‘track and trigger’ chart, which enables vital signs to be graphically recorded. Observations recorded in the ‘yellow zone’ trigger a clinical review of the patient, while those in the ‘red zone’ trigger a rapid response. An interim report from 2013 found that 70% of staff agreed or strongly agreed that the Between the Flags program assisted with earlier detection and management of patients at risk.

Over-prescription of medication is also being addressed through behavioural approaches. Public Health England sought to address this problem by utilizing social norms to influence physicians to prescribe less. By telling physicians that they were prescribing particular classes of medications 80% more than other practices in their local area, Public Health England saw a 3% decrease in those prescriptions in the first 6 months alone. Similar approaches could be used to curb over-administration of antipsychotics to dementia patients for example, a known correlate of physical risks including infection and heart failure.

To date, hundreds of biases and cognitive shortcuts have been identified by researchers, making possibilities for service improvement virtually limitless. Recent studies have shown that patients in clinical settings are over-reliant on ‘system 1’ thinking - the fast, and largely automatic decision making process that can result in short-sighted behaviour. By identifying these mental shortcuts, we can better design processes to ensure patients and their families are acting in their own best interests. Designing for how people behave, rather than how we think they behave, can be used to improve intake forms, boost program compliance, or serve as the lens through which we analyze other procedural or service-related issues.

It is important to note however that many variables can affect the success of an intervention. Early testing and measurement on a smaller scale can help to identify which approaches are most effective before full scale roll-out. Behavioural interventions also require a ‘light touch,’ ensuring that nudges are effective, while simultaneously preserving individuals’ abilities to choose for themselves. When utilized properly, behavioural approaches offer scalable, cost-effective solutions to many challenges. In fact, a recent OECD report on Behavioural Insights and Public Policy showed that fewer than 3% of respondents indicated that interventions came at ‘substantial’ cost. All it takes is a nudge in the right direction.