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Nudging healthcare professionals towards evidence-based medicine: A systematic scoping review

October 2019
Journal of Behavioral Public Administration 2(2):1-20

DOI:10.30636/jbpa.22.71

License
CC BY 4.0

Authors:

Rosanna Nagtegaal

Utrecht University

Lars Tummers

Utrecht University

Mirko Noordegraaf

Utrecht University

V. J. J. M. Bekkers

Erasmus University Rotterdam

Translating medical evidence into practice is difficult. Key challenges in applying evidence-based medicine are information overload and that evidence needs to be used in context by healthcare professionals. Nudging (i.e. softly steering) healthcare professionals towards utilizing evidence-based medicine may be a feasible possibility. This systematic scoping review is the first overview of nudging healthcare professionals in relation to evidence-based medicine. We have investigated a) the distribution of studies on nudging healthcare professionals, b) the nudges tested and behaviors targeted, c) the methodological quality of studies and d) whether the success of nudges is related to context. In terms of distribution, we found a large but scattered field: 100 articles in over 60 different journals, including various types of nudges targeting different behaviors such as hand hygiene or prescribing drugs. Some nudges – especially reminders to deal with information overload – are often applied, while others - such as providing social reference points – are seldom used. The methodological quality is moderate. Success appears to vary in terms of three contextual characteristics: the task, organizational, and occupational contexts. Based on this review, we propose future research directions, particularly related to methods (preregistered research designs to reduce publication bias), nudges (using less-often applied nudges on less studied outcomes), and context (moving beyond one-size-fits-all approaches).

Applied nudge categories and techniques (based on Münscher et al., 2016)

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Scores Per Category

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ranslating knowledge into clinical practice re-

mains notoriously difficult (Grimshaw, Eccles,

Lavis, Hill, & Squires, 2012). For example, guidelines

take on average more than 17 years to be adopted,

and only about half of the guidelines ever achieve

widespread clinical use (Bauer, Damschroder, Hage-

dorn, Smith, & Kilbourne, 2015). Over the past 20

years, increased attention has been given to reducing

the gap between evidence-based practice and policy.

This has been described using various terms of which

evidence-based medicine (EBM) is commonly used

(Grimshaw et al., 2012). EBM refers to the conscien-

tious, explicit, and judicious use of current best evi-

dence in making decisions about the care of individ-

ual patients (Sackett, Rosenberg, Gray, Haynes, &

Richardson, 1996).

The limited effect of evidence on behavior

might be caused by two challenges in evidence-based

medicine. First, the success of evidence-based medi-

cine has led to an overload of evidence being made

available (Greenhalgh, Howick, & Maskrey, 2014).

Already in 1989, two out of three US physicians

stated that the current volume of scientific infor-

mation was too large (Williamson, German, Weiss,

Skinner & Bowes, 1989). This information overload

makes it impossible for healthcare professionals to

review the best available evidence for each individual

case. In particular, the number of clinical guidelines

is overwhelming. For example, a 24-hour audit in an

acute care hospital identified 3,679 pages of national

guidelines that were relevant to the immediate care of

18 patients (Allen & Harkins, 2005).

Abstract:) Translating"medical"evidence"into"practice"is" difficult."Key"challenges"in" applying"evidence-based"

medicine"are"information"overload"and"that"evidence"needs"to"be"used"in"context"by"healthcare"professionals."

Nudging"(i.e."softly"steering)"healthcare"professionals"towards"utilizing"evidence-based"medicine"may"be"a"fea-

sible"possibility."This"systematic"scoping"review"is"the"first"overview"of"nudging"healthcare"professionals"in"

relation"to"evidence-based"medicine."We"have"investigated"a)"the"distribution"of"studies"on"nudging"healthcare"

professionals,"b)"the" nudges" tested"and" behaviors"targeted ," c) " the" me thodo logica l" qua lity " of" st udies " and" d )"

whether"the"success"of"nudges"is"related"to"context."In"terms"of"distribution,"we"found"a"large"but"scattered"

field:"100"articles"in"over"60"different"journals,"including"various"types"of"nudges"targeting"different"behaviors"

such"as"hand"hygiene"or"prescribing"drugs."Some"nudges"–"especially"reminders"to"deal"with"information"over-

load"–"are"often"applied,"while"others"-"such"as"providing"social"reference"points"–"are"seldom"used."The"meth-

odological"quality"is"moderate."Success"appears"to"vary"in"terms"of"three"contextual"characteristics:"the"task,"

organizational,"and"occupational"contexts."Based"on"this"review,"we"propose"future"research"directions,"par-

ticularly"related"to"methods"(preregistered"research"designs"to"reduce"publication"bias),"nudges"(using"less-

often"applied"nudges"on"less"studied"outcomes),"and"context"(moving"beyond"one-size-fits-all"approaches)."

Keywords:)Nudging,"Healthcare,"Professionals,"Evidence-based"medicine"

Supplements:)Open"data)

Journal of Behavioral

Public Administration

Vol 2(2), pp. 1-20

DOI: 10.30636/jbpa.22.71

Rosanna Nagtegaal*, Lars Tummers*, Mirko Noordegraaf*,

Victor Bekkers†

Nudging healthcare professionals towards evidence-

based medicine: A systematic scoping review

Research Article

* Utrecht University, School of Governance

† Erasmus University Rotterdam, Erasmus School of

Social and Behavioural Sciences

Address correspondence to Rosanna Nagtegaal at

(r.nagtegaal@uu.nl)

under the terms of the Creative Commons Attribution

4.0 International License.

Nagtegaal"et"al.,"2019"

Second, general evidence has to be applied to

individual cases by healthcare professionals (Green-

halgh, Howick, & Maskrey, 2014; Junghans, 2007).

Evidence-based medicine has been criticized for its

emphasis on evidence as opposed to professional au-

tonomy (Greenhalgh et al., 2014). A key stance in

modern EBM is that knowledge should inform

healthcare decision-making, but not necessarily dic-

tate it. This is because, for example, in a very complex

medical situation, a general guideline may do more

harm than good. One can minimize harm by devel-

oping robust evidence-based guidelines that are sen-

sitive to the complexity of patient care, but evidence

should be used in combination with expert

knowledge and patient needs (Dreyfus & Dreyfus,

2005; Sackett et al., 1996). As such, interventions to

promote EBM should not be too restricting and re-

tain the professional’s autonomy to deviate.

Nudges might be a possible solution to the two

evidence-based medicine challenges described above.

A nudge is “any aspect of the choice architecture that

alters people’s behavior in a predictable way without

forbidding any options or significantly changing their

economic incentives” (Thaler & Sunstein, 2008, p. 6).

Most nudges work through automatic cognitive pro-

cesses and by changing the choice architecture of a

decision. An example of a nudge is changing a default

choice, for instance by changing the choice to donate

organs from being “opt in” to being “opt out” (John-

son & Goldstein, 2003). Nudging can ease situations

of information overload by making information eas-

ier to process, for instance by presenting guidelines

in ‘plain English’ (Michie & Lester, 2005). Moreover,

nudges have been claimed to leave room for profes-

sional autonomy as nudging does not remove free-

dom of choice (Sunstein & Thaler, 2003).

Accordingly, it is not surprising that the poten-

tial of nudging healthcare professionals has been rec-

ognized (King, Greaves, Vlaev & Darzi, 2013; Mafi

& Parchman, 2018; Vaughn & Linder, 2018). For in-

stance, The Behavioral Insights Health Project at

Harvard University was launched to improve medical

decisions through tools and research from behavioral

economics (Harvard Law School, 2018). Despite this,

authors of recent nudge experiments claim to be

aware of only a few other experiments nudging

healthcare professionals (Bourdeaux, Davies,

Thomas, Bewley & Gould, 2014; Kullgren, Krupka,

Schachter & Linden, 2018; Meeker et al., 2014a).

Therefore, in this article we conduct a systematic

scoping review to give an overview of reported

nudges that aim to strengthen EBM. Systematic

scoping reviews are used to map what evidence has

been produced as opposed to systematic reviews that

seek the best available evidence to answer a particular

question (The Joanna Briggs Institute, 2015). As such,

systematic scoping reviews are especially suitable

when researching relatively unexplored fields dealing

with broad concepts (Peters et al., 2015). They allow

researchers to ask broad questions but adopt a sys-

tematic approach in mapping the literature. In our

study, we answer the following questions:

1. What is the distribution (journals, countries, year

of publication, usage of nudge terminology) of

studies on nudges aimed at strengthening use of

evidence-based medicine by healthcare profes-

sionals?

2. What nudges, aimed at strengthening the use of

evidence-based medicine by healthcare profes-

sionals, are being applied towards which out-

comes?

3. What is the design and methodological quality

of experiments testing nudges aimed at strength-

ening evidence-based medicine by healthcare

professionals?

4. To what extent is a nudge’s success in strength-

ening evidence-based medicine by healthcare

professionals related to the task, organizational,

and occupational contexts?

The first research question concerns the distribution

of studies on nudging healthcare professionals to-

wards EBM. We aim to show whether studies are

clustered in certain countries or journals, in which

years the studies have been published, if studies use

nudge-related terminology, as well as the usage of

nudge terminology over time.

Answering the second research question will

identify which types of nudges are already frequently

used and which seem to be overlooked. This pro-

vides an overview of currently available studies on

nudges aiming to strengthen evidence-based medi-

cine by healthcare professionals by bundling the

available evidence. Moreover, we provide an inven-

tory that can be used to design experiments to test

nudges aimed at affecting behavior.

It is important to note that our review does not

aim to provide an exhaustive overview of nudge

studies on health care professionals to date. Instead,

our goal is to clarify the current state of nudges re-

lated to evidence-based medicine on health care pro-

fessionals. As such, we focus on studies using nudge

related terminology as well as studies referring to

Journal(of(Behavioral(Public(Administration,(2(2)(

healthcare professionals’ behaviors specifically to

promote EBM or usage of evidence/guidelines.

Our third research question concerns the qual-

ity of, and any indications of, bias in the published

studies. To assess this, we use a quality assessment

tool for multiple study designs (ICROMS) (Zingg et

al., 2016). This assessment of quality can inform fu-

ture research designs and contribute to the method-

ological advancement of experiments in public ad-

ministration (Bouwman & Grimmelikhuijsen, 2016;

James, Jilke & Van Ryzin, 2017; Margetts, 2011).

Our fourth research question concerns the rela-

tionship between the context and a nudge’s success.

We use a statistically significant difference in behav-

ior in favor of the nudge intention as a proxy for suc-

cess. Although nudging has been claimed to be highly

effective (Szaszi, Palinkas, Palfi, Szollosi & Aczel,

2017), some suggest that success might depend on

the context (Gould & Lawes, 2016; Halpern, Ubel &

Asch, 2007; Liao et al., 2016; Mafi & Parchman,

2018). This relates to a key challenge of EBM: leaving

sufficient professional autonomy to allow deviation

depending on the applicability of the evidence in a

specific context. We thus focus on “success” related

to task, organizational, and occupational contexts in

hopes of providing a first step toward informing the-

oretical models and practical decisions on the role of

context in nudging.

The contribution of this study is to provide an

overview of the current scope and methodological

quality of studies on nudging medical professionals,

with the aim of going beyond a one-size-fits-all ap-

proach to nudging by directing attention to the inter-

play between nudges and context (Hallsworth, Egan,

Rutter & Mccrae, 2018; Jones, 2017). This links to a

well-known criticism of the behavioral movement in

public administration research and its study of micro-

phenomena: that it has moved away from macro-

phenomena and big questions (Moynihan, 2018). We

follow the Preferred Reporting Items for Systematic

Reviews and Meta-Analyses (PRISMA) approach

(Liberati et al., 2009) and use the PRISMA Extension

for Scoping Reviews checklist (see Appendix B)

(Tricco et al., 2018).

Theory

Nudging has its origins in behavioral economics. A

core foundation of behavioral economics is that hu-

mans mainly think through two overarching, but in-

terconnected, processes. This is referred to as dual

process theory (Chaiken & Trope, 1999; Evans, 2003;

Evans & Stanovich, 2013). Here we will use the terms

system 1 and system 2 as introduced by Stanovich &

West (2000) to describe these two processes. Dual

process theory has been supported by empirical evi-

dence for separate brain structures (Rangel, Camerer,

& Montague, 2008).

System 1 is described as a universal form of cog-

nition present in both humans and animals (Evans,

2003). As such this system is the oldest of the two.

Associative learning processes form processes in sys-

tem 1. System 1 is generally automatic, fast and non-

deliberative, allowing one to quickly make sense of a

situation and identify how to act (Gawronski &

Creighton, 2013; Kahneman, 2011). This system is

essential in situations of critical survival. The other

cognitive system, system 2, is much younger and is

believed to be present only in humans (Evans, 2003).

This system is somewhat rational and implies slow,

reflective thinking and deliberate decision-making.

System 2 permits abstract thinking that cannot be

achieved by system 1.

System 1 is characterized by the use of heuristics.

Heuristics essentially reduce the complex tasks in as-

sessing probabilities and values to simpler tasks

(Lewis, 2008; Tversky & Kahneman, 1974). These

heuristics are often very helpful and may help health

care professionals to avoid errors, for instance in

medical decision making (Marewski & Gigerenzer,

2012). Heuristics, however, sometimes lead to sys-

tematic errors which are labelled biases (Benson,

2016; Tversky & Kahneman, 1974). Cognitive biases

occur when ‘human cognition reliably produces rep-

resentations that are systematically distorted com-

pared to some aspect of objective reality’ (Haselton,

Nettle, & Murray, 2015, p. 968). An example is con-

firmation bias, which represents the seeking or inter-

preting of information that is in line with existing be-

liefs (Nickerson, 1998).

Here, we are not considering the cognitive pro-

cesses, but rather the techniques designed to affect

decision-making using processes from system 1.

These techniques are often called nudges. For in-

stance, a default might use the status quo bias to

nudge people into staying in a savings plan (Thaler &

Benartzi, 2004). A key characteristic of nudges is that

they do not rule out any option nor change economic

incentives, thereby safeguarding professional auton-

omy. We accompany our description with a nudge

taxonomy. Different taxonomies exist which reflect

different preferences in thinking about nudges (e.g.,

Dolan et al., 2012; Johnson et al., 2012; Michie et al.,

2011; Sunstein, 2014). Münscher, Vetter, & Scheuerle

Nagtegaal"et"al.,"2019"

(2016) developed a nudge taxonomy, with the goal of

creating mutually exhaustive and exclusive sets, on

the basis of 127 documented examples of empirically

tested interventions. We have adopted this taxonomy

because of its systematic approach.

Münscher et al.'s (2016) nudge taxonomy has

three main categories: decision information, decision

structure and decision assistance. Decision infor-

mation refers to changing the way information is pre-

sented without changing the options themselves.

This can, for instance, refer to presenting guidelines

in plain English or providing a social reference point

(Allcott, 2011; Michie & Lester, 2005). Decision

structure is about altering the arrangement of options

and the decision-making format. This amounts to

changing how alternatives are presented. An example

is reducing the number of options that can be easily

selected, or changing the effort needed to make a cer-

tain decision by changing the default (Johnson &

Goldstein, 2003). Decision assistance refers to clos-

ing the intention–behavior gap (Sheeran, 2002). Here,

people are provided with tools aimed at helping them

follow up their intentions. Examples are reminders

and asking people to specify when and where they

will complete an action (Hagger & Luszczynska,

2014).

Methodology

Scope of review

For a study to be included in the review, it had to deal

with nudges that were applied to healthcare profes-

sionals on the individual level to promote evidence-

based medicine. We focused on encouraging deci-

sions that are seen as appropriate, that is, in accord-

ance with evidence (Proctor et al., 2011). Whether an

intervention constituted a nudge was determined us-

ing the taxonomy by Münscher, Vetter, & Scheuerle

(2016). Studies that focused on adherence to practice

guidelines were considered eligible since practice

guidelines are “systematically developed statements

to assist practitioner and patient decisions about ap-

propriate healthcare for specific clinical circum-

stances” (Field & Lohr, 1990, p. 8). We chose to in-

clude guidelines because they offer instructions on

different behaviors related to clinical practice such as

which diagnostic or screening test to order, how to

provide medical or surgical services and hand hy-

https://dataverse.harvard.edu/dataverse/JBPA

giene (Woolf, Grol, Hutchinson & Eccles, 1999). Alt-

hough we have not registered this review, all the

codes used are provided online in JBPA’s Dataverse

Only reports on experiments were eligible for

inclusion. Experiments were seen as comparing the

effects of two or more interventions (The Cochrane

Collaboration, 2018) and included randomized con-

trolled trials (RCT), before and after studies (BA) and

interrupted time series (ITS). Only studies written in

English were considered. We did not impose con-

straints on the year of publication.

Search strategy and study selection

To find eligible studies, we used four methods

(Cooper, 2010). First, we searched the Ovid MED-

LINE, PubMed, and PsycINFO databases using

combinations of the term ‘nudging’ with ‘experi-

ment’, ‘physicians’, ‘guidelines’, or similar terms (pro-

ducing 65% of the total articles retrieved1). The spe-

cific details of this search strategy are shown in Ap-

pendix A. Second, we searched for studies in several

top journals that, according to our first search, pub-

lish articles concerning nudges on healthcare profes-

sionals, namely The Lancet, The British Medical

Journal (BMJ), Annals of Internal Medicine, the Jour-

nal of the American Medical Association (JAMA),

Implementation Science, and BMJ Quality and Safety

(producing 25% of the articles retrieved). Third, we

scanned relevant overview articles including those

identified in the database searches (for example,

Szaszi et al., 2017) to find further eligible studies

(10% of total articles retrieved). Finally, we consulted

experts to check the list of publications and identify

any potentially overlooked studies (1% of total arti-

cles retrieved). The search process was concluded on

May 25th, 2018.

The study selection process is shown in Figure

1. First, we screened 2,322 publications by scanning

the abstracts and titles in a blind manner (i.e. conceal-

ing authors and journals). We checked if our inclu-

sion criteria (such as topic and language) were met

and checked for duplication. Of these 2,322 articles,

377 were deemed potentially eligible and we then

read the full texts of these publications. During the

full text readings, studies were either excluded or

coded in full. The codes used were critically appraised

on multiple occasions and refined accordingly. Tab-

ulations and summaries are based on

Journal(of(Behavioral(Public(Administration,(2(2)(

Figure 1

PRISMA Flow Diagram, Based on Workbooks for Systematic Reviews in Excel

(VonVille, 2018)

Figure 2

Years of Publication and Usage of Nudge Terminology

Records found through database searching

Total number of items identified # of additional items found outside of

from database sear ches database sear ches to be screened for inclusion

k= 2101 k= 221

2322 records identified from

all sources

316 Internal & ex ternal

duplicate citations excluded 1629 titles/ abs tracts excluded

590

507

2006 titles & abstracts screened 432

245 full text articles excluded

377 full tex t r eco rds t o be reviewed 58

32 records not available for review 30

345 full tex t r eco rds revie wed 9

100 publications include d 4

Reporting on

101 studies

Not framed as main effect of nudge

Not a nudge

Not on evidence/guidelines

Records found through other sources

Not on health care profess ional s

Not an experiment

Not a nudge

Incomp lete study

Not framed as main effect of nudge

Not an experiment

Systematic Review

Not on health care profess ional s

Incomp lete study

Not on behaviour

Not on evidence/guidelines

IdentificationScreeningEligibilityIncluded

before 1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

2016

2017

Year

Studies using nudge terminology Total number of studies

Nagtegaal"et"al.,"2019"

these codes. All the included publications are listed

in the Supplement. After this final check, we were left

with 100 publications, which report on 101 studies

and 124 interventions.

Results

Distribution of the studies

We first discuss the distribution of the studies (RQ1).

We found that most studies were conducted in West-

ern countries, with a strong dominance of the United

States (59% of all studies) (e.g. Flanagan, Doebbeling,

Dawson & Beekmann, 1999; Schwann et al., 2011;

Tierney et al., 2005) and 10% in the United Kingdom

(e.g. Bourdeaux et al., 2014; King et al., 2016; Weir et

al., 2013). Only a few studies were from non-Western

countries, such as Kenya (Zurovac et al., 2011) and

Taiwan (Hung, Lin, Hwang, Tsai, & Li, 2008). This

suggests that a Western perspective dominates,

which could have important implications as a country

bias might be present. This might also influence the

external validity of the findings, raising questions as

to how applicable they might be in non-Western set-

tings. Further, we found that all the included studies

were conducted in a single country, indicating a lack

of cross-country comparisons.

The articles included in the systematic scoping

review were published in 64 different journals. Most

were published in healthcare journals such as the

Journal of the American Medical Informatics Asso-

ciation (8%) (e.g., Field et al., 2009; Rood, Bosman,

Van Der Spoel, Taylor, & Zandstra, 2005; Sequist et

al., 2005) and the Journal of the American Medical

Association (8%) (e.g., Dexter, Perkins, Maharry, &

Jones, 2004; Feldstein et al., 2006; Junghans, 2007).

Besides these healthcare journals, articles were also

found in more general behavioral science or imple-

mentation journals, such as in Implementation Sci-

ence (4%) (e.g., Beidas et al., 2017; Kousgaard et al.,

2013; Verbiest et al., 2014). In Figure 2, we show the

publication years and indicate whether nudge-related

terminology was used. We coded a study as contain-

ing nudge terminology if we found terms such as

“nudge”, “behavioral economics” or “choice archi-

tecture”. Figure 2 indicates that there was a peak in

publications around 2007 to 2011, but that nudge ter-

minology was not used until 2013.

Nudges and targeted outcomes

The studies included in our review used various

nudges as shown in Table 1. Our search highlighted

a diverse field with at least four published interven-

tions in every category. Many studies (42%) con-

cerned reminders and/or making information visible

(e.g. Filippi et al., 2003; Förberg et al., 2016; Mur-

taugh, Pezzin, McDonald, Feldman, & Peng, 2005).

Studies in the largest category often used a form of

computerized decision support that provides alerts,

based on available guidelines, about the appropriate-

ness of a certain decision. As Table 1 shows, the

other categories were much less common. For in-

stance, we found only five studies that facilitated

commitment (Casper, 2008; Erasmus et al., 2010;

Kullgren et al., 2018; Meeker et al., 2014; Verbiest et

al., 2014). A detailed description of all the interven-

tions by category can be found in the files for this

article uploaded to the JBPA Dataverse.

We found that the largest category contained in-

terventions aimed at changing prescribing habits

(30%) (e.g. Flanagan et al., 1999; Larsen et al., 1989;

Strom et al., 2010). Other studies were on laboratory

tests or diagnostic image ordering (26%) (e.g. Gill,

Chen, Glutting, Diamond & Lieberman, 2009; Ka-

han, Waitman, & Vardy, 2009; Kucher et al., 2005) or

on hand hygiene (18%) (e.g. King et al., 2016; Kwok,

Juergens, & McLaws, 2016; Nevo et al., 2010). A few

studies addressed other behaviors such as medical

handovers (e.g. Messing, 2015) and providing cogni-

tive behavioral therapy (e.g. Beidas et al., 2017b).

The type of nudge being used seems to be re-

lated to the desired outcomes. Nudges on hand hy-

giene mostly involved changing option-related ef-

forts (36%) (e.g. Chan, Homa & Kirkland, 2013;

Nevo et al., 2010), such as by changing the location

of hand hygiene dispensers. We did not find any

studies on hand hygiene that involved nudges in the

form of making information visible, providing re-

minders, or changing defaults. Studies on prescribing

mostly involved making information visible or

providing reminders (54%) (e.g. Buising et al., 2008;

Hicks et al., 2008; Martens et al., 2007). Changing

prescribing habits was also nudged by providing so-

cial reference points (10%) (e.g. Denton, Smith,

Faust, & Holmboe, 2001; Hallsworth et al., 2016;

Kiefe et al., 2001). Studies related to ordering habits

mostly nudged by making information visible or

providing reminders (51%) (e.g. Bindels et al., 2003;

Lo et al., 2009; Roukema, Steyerberg, van der Lei &

Moll, 2008) but also by changing the range or com-

position of options (18%) (e.g. Kahan et al., 2009;

Poley et al., 2007). No studies on changing option-

related efforts were found related to prescribing or

ordering.

Journal(of(Behavioral(Public(Administration,(2(2)(

Nudges were administered in different types of envi-

ronments. Most were applied in digital environments

(66%), followed by nudges on paper (15%). Some

nudges altered the position or presentation of objects

in the physical environment (6%). The remaining

nudges involved changing the environment, for in-

stance by adding a clean smell (e.g. Birnbach, King,

Vlaev, Rosen, & Harvey, 2013), were delivered by

people, or were delivered in multiple or unspecified

ways. Most nudges (70%) that were applied in digital

environments aimed at changing ordering or pre-

scribing behaviors (e.g. Melnick et al., 2010).

Quality of studies

To answer the second research question, we assessed

the methodological quality of the studies using

ICROMS (Zingg et al., 2016): a single-step approach

for assessing the quality of studies with multiple

study designs. ICROMS provides criteria for as-

sessing the quality of different study designs while al-

lowing scores to be compared. Below, we show the

scores for the different categories in Table 2.

ICROMS scores for all the included studies are in the

JBPA Dataverse files for this article.

For those studies with randomized controlled

trials (RCT), controlled before and after studies

(CBA) and controlled interrupted time series (CITS)

designs, the average score met the minimum required

level. The mean scores in the non-controlled before

and after studies (NCBA) and non-controlled inter-

rupted time series (NCITS) categories were below

the minimum required score, with none of the

NCBA studies meeting the minimum threshold. This

gives an indication of the lower quality of such non-

controlled before and after studies (NCBAs). How-

ever, these numbers only tell part of the story about

Table 1

Applied nudge categories and techniques (based on Münscher et al., 2016)

Nudge category

Number

Example

A. Decision information

A1 Translate information

9 (7%)

Emphasizing consequences for patients of proper hand

hygiene (Grant & Hofmann, 2011)

A2 Make information visible

23 (19%)

Suggesting alternatives when clinicians propose antibiotics

(Meeker et al., 2016)

A3 Provide social reference

point

7 (6%)

Showing general practitioners that they prescribe more an-

tibiotics than their peers (Hallsworth et al., 2016)

B. Decision structure

B1 Change choice defaults

9 (7%)

Changing the default for tests from optional to prese-

lected (Olson et al., 2015)

B2 Change option-related efforts

8(6%)

Putting medical tools in line of sight (hand hygiene dis-

pensers) (Nevo et al., 2010)

B3 Change range or composition

of options

10 (8%)

Grouping tests on order forms or displaying them individ-

ually (Kahan et al., 2009)

B4 Change option consequences

4 (3%)

Asking for accountable justifications (Meeker et al., 2016)

C. Decision assistance

C1 Provide reminders

28 (23%)

Putting reminders on operating room schedules

(Patterson, 1998)

C2 Facilitate commitment

5 (4%)

Hanging poster-sized commitment letters including pho-

tographs and signatures (Meeker et al., 2014)

Other (Multifaceted)

21 (17%)

Providing cues through posters and stickers in a schematic

breast shape with space for recording three mammogra-

phy referrals on charts (Grady, Lemkau, Lee & Caddell,

1997)

Total (n)

124

(This is higher than the number of studies as some studies

addressed multiple nudges.)

Nagtegaal"et"al.,"2019"

study quality. For instance, in many studies key infor-

mation was often not given, making it hard to evalu-

ate the risk of bias.

We now zoom in on specific criteria where there

is clearly room for improvement in the two catego-

ries with the most studies: RCT and NCBA studies.

In RCTs, allocation concealment was generally rated

poorly (57% of the maximum possible score on av-

erage). A solution for this would be to have the allo-

cation carried out centrally by an independent third

party (as in Van Wyk et al., 2008). Moreover, many

studies could suffer from selective outcome report-

ing since, in many instances, no study protocol was

provided and it was not explicitly stated whether

studies were selectively reporting or not (on average,

these studies scored 58% of the maximum possible

score). The situation could be improved by authors

opting to preregister experiments which would also

address publication bias problems (Stern & Simes,

1997).

The NCBA studies scored particularly poorly

with only one study (Creedon, 2005) justifying the

sample chosen or carrying out a baseline measure-

ment to prevent selection bias. Here, researchers

could pay more attention to how their sample might

create a bias in the results, for instance by comparing

sample demographics to the demographics of the

population being studied. Furthermore, very few

studies attempted to justify the lack of a control

group (score of 15% of the maximum possible) and

only one (O’Connor, Adhikari, DeCaire, & Friedrich,

2009) attempted to mitigate the effects of not having

a control group. This indicates that there is a risk of

bias in most studies that use such a design.

Success of nudges by context

Our third research question focused on the contex-

tual conditions under which nudges are successful.

The studies included in our review are highly hetero-

geneous. We, therefore, conducted a narrative syn-

thesis. We used significant changes in behavior in the

preferred direction as a proxy for success (Szaszi et

al., 2017). In addition to the type of nudges that are

successful, we wanted to explore to what extent the

context matters in the success of nudging. Nudges

are potentially dependent on three types of context:

the task, organizational and occupational contexts.

Most studies (65%) reported positive results.

The categories with the highest percentages of posi-

tive outcomes were changing option-related efforts

(88% of studies reported success, for instance Chan

et al., 2013), providing social reference points (71%,

for instance Hong, Ching, Fung & Seto, 1990), and

using a combination of nudges (76%, for instance

Hulgan et al., 2004). The categories with the highest

percentages of mixed outcomes were facilitating

commitment (40%, for instance Kullgren, Krupka,

Schachter & Linden, 2018) and changing choice de-

faults (22%, for instance Ansher et al., 2014). Change

option consequences had the highest percentage of

null outcomes (50%, for instance Beidas et al., 2017),

followed by translating information (44%, for in-

stance Jousimaa et al., 2002). Very few negative ef-

fects were reported (a notable exception being Dex-

ter et al., 2004), which could be due to publication

bias. Further details on the interventions are pro-

vided JBPA Dataverse files for this article.

In terms of context, the task at hand clearly mat-

ters. In the reviewed studies, nudging to promote

hand hygiene was most successful (77%). A reason

for this could be that the need for hand hygiene is

widely accepted (Luangasanatip et al., 2015) and

nudging might be less successful for other outcomes

whose desirability is questioned. For instance, the ef-

fect of action planning on care to encourage smoking

cessation was particularly apparent among GPs who

Table 2

ICROMS Scores Per Category

Design category

Number of

studies

Mean score

(range); max

possible score

Minimum

required

score

Randomized controlled trial (RCT)

70 (68%)

22 (5 – 27); 32

Non-controlled before and after study (NCBA)

17 (17%)

16 (11 – 21); 30

Non-controlled interrupted time series (NCITS)

5 (5%)

19 (10 – 23); 30

Controlled before and after (CBA)

6 (6 %)

18 (10 – 24); 30

Controlled interrupted time series (CITS)

3 (3%)

19 (18 – 19); 30

Total

101 (100%)

N/A

Journal(of(Behavioral(Public(Administration,(2(2)(

had already intended to implement this activity but

had not yet done so routinely (Verbiest et al., 2014).

Mixed results were more commonly found for

nudges related to ordering tests and diagnostic imag-

ing (24% of studies reported mixed results). Sequist

et al. (2005) provide an example of mixed findings in

noting that the success of the intervention they stud-

ied depended on the service being recommended and

the particular disease. This indicates that profession-

als will deviate from the nudging intention if they

find the promoted action inappropriate.

Sometimes nudges are designed so that they

adapt to reflect individual cases. These nudges are

based on algorithms. For instance, in one study IF-

THEN rules were created based on guidelines (Mar-

tens et al., 2007). These rules generate specific re-

minders for relevant cases, but not for others. This

contextualization of the nudge can be beneficial in

reducing problems created by applying general guide-

lines to individual cases. However, such applications

are limited. Martens et al. (2007) further indicated

that they were not certain whether complex recom-

mendations always translated into meaningful re-

minders. Moreover, some physicians rebelled at the

notion of a computer telling them how to manage

their patients (Tierney et al., 2003).

Nudges may well work differently in different

organizational contexts. Our review showed that the

most successful nudges were reported in hospitals

(74% of studies in hospitals report positive results).

A study by Kiefe et al. (2001) noted that physicians

in rural settings were less likely to improve treatment

by responding to feedback. This could be because ru-

ral physicians are more autonomous. Helder et al.

(2012) indicated that not only the organization, but

even the type of unit or shift can influence the results.

They reported an overall positive effect for a screen-

saver intervention, but no effect when calculated for

the night shift alone. They suggest that nudges might

work better in highly visible situations and not so well

when people operate individually.

The effectiveness of nudges depends on the oc-

cupational context, meaning that success depends on

the professional that is working with the nudge. For

instance, academic physicians might be more aware

of guidelines, influencing their reaction to nudges

(Martens et al., 2007; Tannenbaum et al., 2015) and

newly qualified residents might be more susceptible

to nudges than more experienced physicians (Cum-

mings, Frisof, Long, & Hrynkiewich, 1982; Fogarty,

Sturrock, Premji, & Prinsloo, 2013). This is an indi-

cation that public professionals, depending on their

level of professionalization, react differently to

nudges.

Discussion

As far as we are aware, this is the first systematic

scoping review to map studies on nudging healthcare

professionals towards applying evidence-based med-

icine. In this review, we have studied the distribution,

the nudges and the targeted outcomes, the methodo-

logical quality, and the influence of context on the

nudges’ success. Based on our results, we draw four

conclusions. We relate these conclusions to EBM

challenges in dealing with information overload and

applying professional autonomy when applying gen-

eral guidelines to individual cases.

Distribution of studies

Our first research question was about the distribu-

tion (journals, countries, year of publication and

nudge terminology) of studies. We have three main

conclusions. First, most studies are conducted in

Western settings, and all of them in a single country.

This raises questions about the external validity of

the findings. Future studies could be conducted in

other country settings. Second, we found studies in

64 different journals. This emphasizes the need for

scoping reviews such as this one to bundle available

evidence. Third, healthcare professionals ‘have been

nudged’ since 1974. However, nudge-related terms

were not used until 2013, indicating that interven-

tions have only recently been recognized as nudges.

Types of nudges and targeted outcomes studied

Our second research question was about what types

of nudges have been applied and towards which out-

comes. We found that studies testing nudging are

more widespread than often claimed (Bourdeaux et

al., 2014). Some nudges, such as reminders in com-

puterized decision-support systems, are studied more

often than many others, such as using defaults. The

focus on reminders makes sense as reminders ad-

dress the EBM challenge of coping with information

overload: reminders make relevant information easily

available to healthcare professionals at point-of-care.

Nevertheless, other nudging forms can also mitigate

information overload. Nudges could for instance

make existing guidelines easier to use by simplifying

their format (John & Blume, 2018; Michie & Lester,

2005).

Apart from information overload, nudges target

‘irrational’ behavior by healthcare professionals and

Nagtegaal"et"al.,"2019"

10"

use cognitive biases to change behavior. For instance,

nudges can facilitate commitment to close the inten-

tion–behavior gap or change defaults in ordering sys-

tems (Ansher et al., 2014; Kullgren et al., 2018).

These nudges might be especially useful when barri-

ers other than information overload have been iden-

tified. For instance, for fairly general guidelines about

hand hygiene, the location of hand hygiene dispens-

ers has been described as a main barrier to compli-

ance by nurses (Sadule-Rios & Aguilera, 2017). There

are, however, only a few related studies and further

research is needed.

Furthermore, the nudges studied mainly focus

on outcomes related to ordering, prescribing, and

hand hygiene. Future research could test existing

EBM nudges in less researched areas, such as admin-

istration and medical handover. In designing new

studies, one should be aware that some nudges are

more applicable to certain behaviors than others. For

instance, it is not surprising that we did not find any

studies using a default-type nudge to encourage hand

hygiene since having clean hands by default is

unachievable. In comparison, we also found few

studies reminding healthcare professionals to wash

their hands – a nudge that seems highly feasible. Fur-

ther, even without actively nudging, the design of

current systems might have an influence on per-

formative behaviors. Choice architecture is always

present and, if options are not displayed, this will in-

fluence the choices people make (Tannenbaum et al.,

2015). Therefore, we would encourage critical re-

views of existing choice architectures (Vaughn &

Linder, 2018).

Methodological quality of studies

Our third research question focusses on assessing

methodological quality. The methodological analysis

indicated that many studies were only of moderate

study quality. Researchers could improve methodo-

logical quality to reduce the risk of bias and simulta-

neously increase the validity of the study outcomes.

We would urge quality improvements by making

small changes, such as ensuring allocation conceal-

ment is carried out by a third party, and also by mak-

ing larger changes, such as by preregistering experi-

ments. In terms of non-controlled before and after

studies, more attention should be paid to the poten-

tial bias introduced by sample selection, and the

omission of a control group should always be justi-

fied. Moreover, we often found studies were unclear

as to what choices had been made, and why. Collec-

tively, we should therefore strive to increase our re-

porting standards. We suggest using reporting guide-

lines and checklists, such as the Consolidated Stand-

ards of Reporting Trials (CONSORT) statement

(Moher et al., 2010).

Nudges in different task, organizational and

occupational contexts

In our fourth research question, we highlight the role

of three contextual conditions for success: task, or-

ganization and occupation. We first note that 65% of

published studies report success (i.e. statistically sig-

nificant improvements). This could be due to publi-

cation bias, which is characterized by an aversion to

publishing studies with null results (Ferguson &

Heene, 2012). Here, we suggest preregistering exper-

iments as a partial solution (Nosek & Lakens, 2014).

Nevertheless, the 65% of ‘successful’ studies in this

paper is considerably below the 83% successful inter-

vention rate reported in a more general systematic

scoping review of nudges (Szaszi et al., 2017). We can

offer two reasons for this. First, publication bias

could be less widespread in studies dealing with evi-

dence-based medicine than studies about nudges in

general. Second, it could be that nudges are less suc-

cessful in EBM due to other factors such as study

design or contextual factors. We summarize the in-

fluence of task, organizational, and occupational con-

texts below.

First, we see that the targeted task is important

in determining the success of a nudge. This could be

because tasks that are widely accepted, such as hand

hygiene, are more suitable to nudging. Related to this,

some outcomes would seem less appropriate to

nudging. In a clinical context, appropriateness de-

pends to a large extent on outcomes. For example,

Patel, Volpp, & Asch (2018) state that reducing the

default duration of opioid prescriptions may make

sense in acute conditions, as often seen in an emer-

gency department, but may be inappropriate for cli-

nicians caring for patients with chronic pain. This ex-

ample further stresses the importance of carefully

considering the behaviors being nudged.

Some nudges present contextualized infor-

mation based on algorithms. This diminishes the

problem of using general guidelines in individual

cases, as nudges become customized to specific clin-

ical scenarios. The question is, to what extent should

nudges be contextualized for specific tasks? Evi-

dence-based medicine has been criticized for overly

focusing on algorithmic rules that oversimplify clini-

cal realities (Greenhalgh et al., 2014). In line with this,

Journal(of(Behavioral(Public(Administration,(2(2)(

11"

complex clinical realities might not always be suitable

for nudges, as nudges always involve some form of

simplification, either through IF-THEN rules or by

targeting a quite general outcome such as reduced an-

tibiotic prescribing (‘Thou should not prescribe anti-

biotics for cases of flu’). Here, we see that EBM

nudging suffers from a similar problem to that of ap-

plying heuristics: simplifying complex realities can be

beneficial, but not all situations can be easily simpli-

fied. We would therefore advise practitioners and au-

thors to consider nudge–task fit and assess impres-

sions of the complexity and appropriateness of the

targeted behaviors with specialized healthcare pro-

fessionals.

Second, the organizational context seems to

have an influence. Physicians in a large city hospital

have been found to react differently than a rural phy-

sician (Kiefe et al., 2001). Nurses during the night

shift might not be influenced by nudges that are ef-

fective during the day shift (Helder et al., 2012). More

research is needed on how working autonomously, in

teams, and/or under various levels of visibility can

make nudges more or less effective.

Third, the occupational context is important.

Less experienced doctors are, for instance, more in-

clined to accept a default than experts (Fogarty et al.,

2013; Martens et al., 2007). More information on the

interplay between professionalism and nudges would

be useful. In terms of algorithms, it has been shown

that if people are experts, or believe they are experts,

they tend to follow decision rules less often and as a

result perform worse (Arkes, Dawes, & Christensen,

1986). Does the same occur if ‘experts’ override

nudges such as default options, or are these experts a

necessary counterforce to the nudge? Overall, we see

a need for future research to focus on the implica-

tions of task, organizational, and occupational con-

texts for nudges and thus to move away from a one-

size-fits-all view of nudging. Instead, the focus

should be on how the context of public professionals

matters in nudging (Jones, 2017).

Limitations

The present review has several limitations. First, we

cannot be certain that this review covers all nudges

related to evidence-based medicine by healthcare

professionals. In systematic scoping reviews, the

trade-off between breadth and comprehensiveness is

often reported as a challenge (Pham et al., 2014).

Our search strategy focused on behavioral aspects in

healthcare, seeking studies referring to nudge-related

terms and studies referring to healthcare profession-

als’ behaviors to promote EBM. In this sense, our

study encompasses an already broad spectrum of

studies that goes beyond those using nudge terminol-

ogy but might nevertheless have overlooked studies

using other terms (Szaszi et al., 2017). Especially for

reminders, there is already a large body of literature

(for an overview see Cheung et al., 2012). Our find-

ings could also be skewed due to publication bias. We

attempted to address this by explicitly asking experts

to add unpublished studies, but it is possible that

some relevant studies have been overlooked.

Second, the heterogeneity of the studies meant

that we could not conduct a meta-analysis. Instead,

we have provided a systematic scoping review (Szaszi

et al., 2017). We recognize that even though hetero-

geneity is a strong argument against conducting

meta-analyses, our systematic scoping review is lim-

ited because it does not consider effect size, sample

and other relevant measures (Ioannidis, Patsopoulos,

& Rothstein, 2008). Moreover, in this study we use a

statistically significant difference in behavior in the

direction of the nudge intervention as a proxy for

success. Future research could also carry out meta-

analyses of specific categories in those areas where

there is sufficient homogeneity in the published stud-

ies. For some nudging categories, such as reminders,

meta-analyses of their effects on healthcare profes-

sionals already exist and provide more detailed infor-

mation on their effectiveness (Cheung et al., 2012).

Other nudging categories, such as using defaults,

need additional studies with similar designs in order

to assess their effectiveness with healthcare profes-

sionals.

Third, ‘success’ can also be evaluated in terms

of other outcomes. O’Connor et al. (2009) for in-

stance stated that while most changes in order sets

were beneficial, order set changes were also associ-

ated with an unintended overall increase in ordering

night-time sedation. Tierney et al. (2003) noted that

physicians and pharmacists found the nudge intru-

sive and time consuming. Although such issues are

beyond the scope of this review, these reports high-

light the importance of not only studying significant

differences, but also evaluating the impact on profes-

sionals’ attitudes and unintended negative conse-

quences.

Fourth, we categorized interventions in the

choice architecture category we found most fitting.

However, we found the choice architecture catego-

ries by Münscher, Vetter, & Scheuerle (2016) to be

not entirely exclusive of each other. Therefore, we

Nagtegaal"et"al.,"2019"

12"

advise scholars looking for interventions in a partic-

ular category to review the related categories in the

JBPA Dataverse files for this article as well. Despite

these limitations, we do believe that we have shed

new light on the scope of the nudging field and iden-

tified possible avenues for future research.

Conclusions

The aim of this research was to expose the current

state of research on nudge interventions designed to

promote evidence-based medicine by healthcare pro-

fessionals. We found more than a hundred studies in

over sixty journals and identified ten distinct nudging

categories associated with outcomes ranging from

hand hygiene to prescribing. Moreover, we found

that nudges have been used since the 1970s, despite

nudge terminology not appearing until 2013. Re-

minders that deal with information overload are used

the most often. However, further studies on less re-

ported nudge categories that could also mitigate in-

formation overload, such as the effect of simplifying

existing guidelines, are required. We also need more

studies that explore outcomes beyond hand hygiene,

image ordering and prescribing, as well as assess-

ments of current choice architectures. Our method-

ological assessment identified considerable room for

improvement in the identification of success,

through better study design and more detailed re-

porting, with suggestions made related to allocation

concealment and preregistration. Future research

should also consider the roles of task, organizational,

and occupational contexts in theoretical models re-

garding the design of nudges, thereby moving be-

yond one-size-fits-all approaches.

Funding

Lars Tummers acknowledges funding of NWO

Grant 016.VIDI.185.017. Furthermore, he acknowl-

edges that this work was supported by the National

Research Foundation of Korea Grant, funded by the

Korean Government (NRF-2017S1A3A2067636).

Notes

1. Percentages are rounded.

2. References included in the systematic review

and cited in this article. Note that not all publi-

cations included in our review have been cited.

For a full list of all included articles, see the files

for this article uploaded to the JBPA Dataverse.

Acknowledgement

We would like to thank our colleagues at the Utrecht

University School of Governance, as well as review-

ers and peers at IQ Healthcare, NIG 2018, WINK

2018 and EGPA 2017 for giving feedback on earlier

versions of this manuscript.

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Appendix

Appendix A – Search strategy

Specific search

((nudge or nudging ‘’choice architecture’’ or ‘’behavioural economics’’ or ‘’behavioural economics’’)

and (health care or healthcare or medical) and (practitioners or doctors or nurses or clinicians or sur-

geons) and (guidelines or ‘’evidence based medicine’’)).af. and (experiment* or trial or interven-

tion).ab. – Ovid Medline, PsychINFO

Broad search

(‘’choice architect*’’ OR nudg* OR

ehavior*)) AND (health care OR healthcare OR medic*))

AND (experiment* OR trial OR intervention)) AND (practitioners OR doctors OR nurses OR cli-

nicians OR surgeons) AND (guidelines OR ‘’evidence based medicine’’)[all] – PubMed

Appendix B – PRISMA statement for scoping reviews

Preferred Reporting Items for Systematic reviews and Meta-Analyses Extension for

Scoping Reviews (PRISMA-ScR) Checklist

SECTION

ITEM

PRISMA-ScR CHECKLIST ITEM

REPORTED

ON PAGE #

TITLE

Title

Identify the report as a scoping review.

ABSTRACT

Structured

summary

Provide a structured summary that includes (as applica-

ble): background, objectives, eligibility criteria, sources

of evidence, charting methods, results and conclusions

that relate to the review questions and objectives.

INTRODUCTION

Rationale

Describe the rationale for the review in the context of

what is already known. Explain why the review’s ques-

tions/objectives lend themselves to a scoping review

approach.

Objectives

Provide an explicit statement of the questions and ob-

jectives being addressed with reference to their key ele-

ments (e.g., population or participants, concepts and

context) or other relevant key elements used to con-

ceptualize the review questions and/or objectives.

METHODS

Protocol and

registration

Indicate whether a review protocol exists; state if and

where it can be accessed (e.g., a Web address) and, if

available, provide registration information, including

the registration number.

Journal(of(Behavioral(Public(Administration,(2(2)(

19"

SECTION

ITEM

PRISMA-ScR CHECKLIST ITEM

REPORTED

ON PAGE #

Eligibility

criteria

Specify characteristics of the sources of evidence used

as eligibility criteria (e.g., years considered, language

and publication status) and provide a rationale.

Information

sources*

Describe all information sources in the search (e.g., da-

tabases with dates of coverage and contact with au-

thors to identify additional sources), as well as the date

the most recent search was executed.

Present the full electronic search strategy for at least

one database, including any limits used, such that it

could be repeated.

Appendix A

Selection of

sources of

evidence†

State the process for selecting sources of evidence (i.e.,

screening and eligibility) included in the scoping re-

view.

Data charting

process‡

Describe the methods of charting data from the in-

cluded sources of evidence (e.g., calibrated forms or

forms that have been tested by the team before their

use, and whether data charting was done independently

or in duplicate) and any processes for obtaining and

confirming data from investigators.

Data items

List and define all variables for which data were sought

and any assumptions and simplifications made.

Supplement

Critical ap-

praisal of in-

dividual

sources of

evidence§

If done, provide a rationale for conducting a critical ap-

praisal of included sources of evidence; describe the

methods used and how this information was used in

any data synthesis (if appropriate).

3, 7-8

Synthesis of

results

Describe the methods of handling and summarizing

the data that were charted.

RESULTS

Selection of

sources of

evidence

Give numbers of sources of evidence screened, as-

sessed for eligibility and included in the review, with

reasons for exclusions at each stage, ideally using a flow

diagram.

Characteris-

tics of

sources of

evidence

For each source of evidence, present characteristics for

which data were charted and provide the citations.

Supplement

Critical ap-

praisal within

sources of

evidence

If done, present data on critical appraisal of included

sources of evidence (see item 12).

Supplement

Results of in-

dividual

sources of

evidence

For each included source of evidence, present the rele-

vant data that were charted that relate to the review

questions and objectives.

Supplement

Nagtegaal"et"al.,"2019"

20"

SECTION

ITEM

PRISMA-ScR CHECKLIST ITEM

REPORTED

ON PAGE #

Synthesis of

results

Summarize and/or present the charting results as they

relate to the review questions and objectives.

5-9

DISCUSSION

Summary of

evidence

Summarize the main results (including an overview of

concepts, themes and types of evidence available), link

to the review questions and objectives, and consider

the relevance to key groups.

9-11

Limitations

Discuss the limitations of the scoping review process.

11-12

Conclusions

Provide a general interpretation of the results with re-

spect to the review questions and objectives, as well as

potential implications and/or next steps.

FUNDING

Funding

Describe sources of funding for the included sources

of evidence, as well as sources of funding for the scop-

ing review. Describe the role of the funders of the

scoping review.

JBI = Joanna Briggs Institute; PRISMA-ScR = Preferred Reporting Items for Systematic reviews

and Meta-Analyses extension for Scoping Reviews.

* Where sources of evidence (see second footnote) are compiled from, such as bibliographic data-

bases, social media platforms, and Web sites.

† A more inclusive/heterogeneous term used to account for the different types of evidence or data

sources (e.g., quantitative and/or qualitative research, expert opinion and policy documents) that

may be eligible in a scoping review as opposed to studies. This is not to be confused with infor-

mation sources (see first footnote).

‡ The frameworks by Arksey and O’Malley (6) and Levac et al. (7) and the JBI guidance (4, 5) refer

to the process of data extraction in a scoping review as data charting.

§ The process of systematically examining research evidence to assess its validity, results and rele-

vance before using it to inform a decision. This term is used for items 12 and 19, instead of "risk of

bias" (which is more applicable to systematic reviews of interventions), to include and acknowledge

the various sources of evidence that may be used in a scoping review (e.g., quantitative and/or quali-

tative research, expert opinion and policy documents).

From: Tricco AC, Lillie E, Zarin W, O'Brien KK, Colquhoun H, Levac D, et al. PRISMA Extension

for Scoping Reviews (PRISMA-ScR): Checklist and Explanation. Ann Intern Med. ;169:467–473.

doi: 10.7326/M18-0850

Please mind the gap between guidelines & behavior change: A systematic review and a consideration on effectiveness in healthcare

Article

Full-text available

Oct 2024
HEALTH POLICY

Acquisition and Promotion of Critical Online Reasoning Skills - Analyses among Students in Professional/Practical Year/Studies in Medicine, Law, and Teaching

Thesis

Full-text available

Nov 2024

Anika Kohmer

This dissertation explores the development and promotion of critical online reasoning (COR) skills among medical students in their clinical year, as well as law and teacher education trainees in Germany. Given the challenges posed by digitalization and the accompanying increase in online information, the ability to identify and critically evaluate trustworthy information is deemed essential for evidence-based practice in these professions. Through four sub-studies, the current state of COR competencies, as well as the need and feasibility of targeted digital training interventions, are examined. The findings highlight the necessity for better integration of COR into academic curricula and indicate that targeted digital training programs can be promising approaches to enhancing these skills.

Assessing a behavioral nudge on healthcare leaders’ intentions to implement evidence-based practices

Article

Full-text available

Nov 2024
PLOS ONE

Importance Leaders of healthcare organizations play a key role in developing, prioritizing, and implementing plans to adopt new evidence-based practices. This study examined whether a letter with peer comparison data and social norms messaging impacted healthcare leaders’ decision to access a website with resources to support evidence-based practice adoption. Methods Pragmatic, parallel-group, randomized controlled trial completed from December 2019 –June 2020. We randomized 2,387 healthcare leaders from health systems, hospitals, and physician practices in the United States, who had previously responded to our national survey of healthcare organizations, in a 1:1 allocation ratio to receive one of two cover letter versions via postal mail (all) and email (for the 60.6% with an email address), accompanying a report with their survey results. The “nudge” letter included messaging that highlighted how an organization’s results compared to peers using text, color, and icons. Both nudge and control letters included links to a resource website. We interviewed 14 participants to understand how the letter and report impacted behaviors. Results Twenty-two of 1,194 leaders (1.8%) sent the nudge letter accessed online resources, compared to 17 of 1193 (1.4%) sent the control letter (p = 0.424). Nine of the 14 interviewed leaders stated that viewing the letter (regardless of version) and accompanying report influenced their decision to take a subsequent action other than accessing the website. Seven leaders forwarded the report or discussed the results with colleagues; two leaders stated that receiving the letter and report resulted in a concrete practice change. Conclusions Receiving cover letters with a behavioral nudge did not increase the likelihood that organizational leaders accessed a resource website. Qualitative results suggested that the survey report’s peer comparison data may have been a motivator for prioritizing and delegating implementation activities, but leaders themselves did not access our online resources.

Developing implementation strategies through Intervention Mapping: Introducing new medical quality indicators in Swiss long-term care facilities

Presentation

Nov 2024

Background and aims: Routine data on medical quality indicators (MQIs) underpin the continuous improvement of care quality. Since 2019, the Swiss Federal Insurance Law (LAMal, Art. 59a) mandates all long-term care facilities (LTCFs) to collect MQI data, which are published by the Federal Office of Public Health. To enhance quality monitoring and improvement, new quality themes (pressure ulcers, advance care planning, medication review) were proposed. As part of the National Implementation Programme NIP-Q-UPGRADE, this study aims to develop implementation strategies for the potential introductory implementation of the new MQIs. Method: Intervention Mapping (IM), a participatory and ecological framework guided approach, was used for the strategy development. A stepwise protocol was followed to develop and evaluate strategies for introducing the new MQIs. Based on a contextual analysis, behaviour-change techniques were selected to address determinants of desired outcomes. Results: Key determinants identified for successful implementation of the new MQIs were awareness, knowledge, outcome expectation, and perceived feasibility. Target groups included nurses, LTCF directors, physicians, and other stakeholders at organisational and societal levels. These findings informed the development of a logic model of change with desired outcomes, guiding the selection of theory-based behaviour-change techniques. Examples are educational materials using Advanced Organisers (presenting an overview) to strengthen understanding, Use of Imagery (e.g. diagrams) to improve knowledge retention, and Environmental Re-evaluation (encouraging realising the impact of one’s behaviour) to shape outcome expectation. Discussion and Conclusion: Mapping target groups and determinants ensured stakeholder engagement. The use of IM demonstrated potential to develop effective implementation strategies for new MQIs in LTCFs. This approach facilitated explicit actions at individual and environmental levels, promoting sustainable MQI use to enhance care quality and residents' health outcomes. Keywords: long-term care facility, Intervention Mapping, theory- and evidence-based implementation strategy design, quality indicators.

The Use of Nudge Strategies in Improving Physicians’ Prescribing Behavior: A Systematic Review and Meta-analysis

Article

Sep 2024

Background Nudges have been proposed as a method of influencing prescribing decisions. Purpose The purpose of this article is to 1) investigate associations between nudges’ characteristics and effectiveness, 2) assess the quality of the literature, 3) assess cost-effectiveness, and 4) create a synthesis with policy recommendations. Methods We searched health and social science databases. We included studies that targeted prescribing decisions, included a nudge, and used prescribing behavior as the outcome. We recorded study characteristics, effect size of the primary outcomes, and information on cost-effectiveness. We performed a meta-analysis on the standardized mean difference of the studies’ primary outcomes, tested for associations between effect size and key intervention characteristics, and created a funnel plot evaluating publication bias. Synthesis We identified 21 studies containing 25 nudges. In total, 62 of 85 (73%) outcomes showed a statistically significant effect. The average effect size was −0.22 standardized mean difference. No studies included heterogeneity analyses. We found no associations between effects and selected study characteristics. Study quality varied and correlated with study design. A total of 7 of 21 (33%) studies included an evaluation of costs. These studies suggested that the interventions were cost-effective but considered only direct effects. We found evidence of publication bias. Limitations Heterogeneity and few studies limit the possibilities of statistical inference about effectiveness. Conclusions Nudges may be effective at directing prescribing decisions, but effects are small and health effects and cost-effectiveness are unclear. Future nudge studies should contain a rationale for the chosen nudge, prioritize the use of high-quality study designs, and include evaluations of heterogeneity, cost-effectiveness, and health outcomes to inform decision makers. Moreover, preregistration of the protocol is warranted to limit publication bias. Highlights Nudging as a method to improve prescribing decisions has gained popularity during the past decade. We find that nudging can improve prescribing decisions, but effect sizes are mostly small, and the size of derived health outcomes is unclear. Most studies use feedback and error-stopping nudges to target excessive opioid or antibiotic prescribing, making heterogeneity analyses across nudge types difficult. Further research on the cost-effectiveness of nudges and generalizability is needed to guide decision makers considering nudging as a tool to guide prescribing decisions.

Polypharmacy and Deprescribing

Chapter

Aug 2024

Polypharmacy contributes to medication-related harm. Medication-related harm accounts for approximately 9% of hospital admissions worldwide, and it is estimated that many of these hospitalisations are preventable. It is therefore important to consider significant opportunities which can be used to reduce the burden of medication-related harm. These opportunities could involve the provision of timely and effective interventions, which include shared decision-making and a person-centred approach when undertaking reviews, where deprescribing may be an outcome as well as starting medications, to ensure optimised treatment. Strategies to avoid inappropriate polypharmacy, as a whole system and integrated approach by various members of the healthcare team, could also be considered as important interventions to reduce medication-related harm. This chapter will discuss why polypharmacy is on the increase and why it is important to consider appropriate and inappropriate polypharmacy as well as the significance of deprescribing. It will describe why a person-centred prescribing and management of multimorbidity approach are important to consider during all stages of the medication management process.

Integrating Scholarly Evidence and Personal Experience in Health Information Technology-Enabled Evidence-Based Patient-Care Practices: Challenges, Opportunities, and Outcomes

Article

Feb 2024

Scholarly evidence and personal experience are two prominent sources of knowledge informing patient-care practices in hospitals. In evidence-based patient-care practices, jointly applying both forms of knowledge is challenging due to the divergent preferences of administrative personnel versus frontline providers towards these knowledge sources and the limited understanding of how to combine these knowledge sources effectively despite divergent preferences. Health information technologies (HITs) tend to influence this challenge by simultaneously imprinting a standardized practice based on scholarly evidence while also allowing workarounds based on personal experience. We apply a theoretical framework, integrating cognitive information processing theory and agency theory, to the context of HIT-enabled evidence-based patient-care practices to investigate the circumstances that enable joint consideration of scholarly evidence and personal experience in value-adding versus value-depleting ways in these practices. Our findings reveal the salience of outcome uncertainty and of the prior stored knowledge of administrative personnel versus frontline providers in enabling joint considerations of the two types of knowledge and the value-adding versus value-depleting outcomes that result.

Surgical appropriateness nudges: Developing behavioral science nudges to integrate appropriateness criteria into the decision making of spine surgeons

Article

Full-text available

Apr 2024
PLOS ONE

Background Substantial variation exists in surgeon decision making. In response, multiple specialty societies have established criteria for the appropriate use of spine surgery. Yet few strategies exist to facilitate routine use of appropriateness criteria by surgeons. Behavioral science nudges are increasingly used to enhance decision making by clinicians. We sought to design “surgical appropriateness nudges” to support routine use of appropriateness criteria for degenerative lumbar scoliosis and spondylolisthesis. Methods The work reflected Stage I of the NIH Stage Model for Behavioral Intervention Development and involved an iterative, multi-method approach, emphasizing qualitative methods. Study sites included two large referral centers for spine surgery. We recruited spine surgeons from both sites for two rounds of focus groups. To produce preliminary nudge prototypes, we examined sources of variation in surgeon decision making (Focus Group 1) and synthesized existing knowledge of appropriateness criteria, behavioral science nudge frameworks, electronic tools, and the surgical workflow. We refined nudge prototypes via feedback from content experts, site leaders, and spine surgeons (Focus Group 2). Concurrently, we collected data on surgical practices and outcomes at study sites. We pilot tested the refined nudge prototypes among spine surgeons, and surveyed them about nudge applicability, acceptability, and feasibility (scale 1–5, 5 = strongly agree). Results Fifteen surgeons participated in focus groups, giving substantive input and feedback on nudge design. Refined nudge prototypes included: individualized surgeon score cards (frameworks: descriptive social norms/peer comparison/feedback), online calculators embedded in the EHR (decision aid/mapping), a multispecialty case conference (injunctive norms/social influence), and a preoperative check (reminders/ salience of information/ accountable justification). Two nudges (score cards, preop checks) incorporated data on surgeon practices and outcomes. Six surgeons pilot tested the refined nudges, and five completed the survey (83%). The overall mean score was 4.0 (standard deviation [SD] 0.5), with scores of 3.9 (SD 0.5) for applicability, 4.1 (SD 0.5) for acceptability, and 4.0 (SD 0.5), for feasibility. Conferences had the highest scores 4.3 (SD 0.6) and calculators the lowest 3.9 (SD 0.4). Conclusions Behavioral science nudges might be a promising strategy for facilitating incorporation of appropriateness criteria into the surgical workflow of spine surgeons. Future stages in intervention development will test whether these surgical appropriateness nudges can be implemented in practice and influence surgical decision making.

The management of bias and noise in public sector decision-making: experimental evidence from healthcare

Article

Feb 2024

Cui prodest ? Nudging prosocial behavior among healthcare professionals

Article

Jan 2024

PRISMA extension for scoping reviews (PRISMA-ScR): Checklist and explanation

Article

Full-text available

Sep 2018

Scoping reviews, a type of knowledge synthesis, follow a systematic approach to map evidence on a topic and identify main concepts, theories, sources, and knowledge gaps. Although more scoping reviews are being done, their methodological and reporting quality need improvement. This document presents the PRISMA-ScR (Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews) checklist and explanation. The checklist was developed by a 24-member expert panel and 2 research leads following published guidance from the EQUATOR (Enhancing the QUAlity and Transparency Of health Research) Network. The final checklist contains 20 essential reporting items and 2 optional items. The authors provide a rationale and an example of good reporting for each item. The intent of the PRISMA-ScR is to help readers (including researchers, publishers, commissioners, policymakers, health care providers, guideline developers, and patients or consumers) develop a greater understanding of relevant terminology, core concepts, and key items to report for scoping reviews.

A great schism approaching? Towards a micro and macro public administration

Article

Full-text available

Feb 2018

Donald P. Moynihan

As an emerging field, behavioral public administration (BPA) has spurred important new research, documenting human biases and heuristics in public sector contexts. In doing so, it has embraced Herbert Simon’s call to draw from psychology to understand administrative behavior. To fulfill its potential, BPA should also pursue another goal of Simon: a normative aspiration toward design science, using its powerful analytical techniques to solve, and not just document, real administrative problems. Another challenge for BPA is understanding where it fits in the constellation of public administration research. One critique of BPA is that a focus on micro-level behavior leads to a neglect of big questions that were once central to public administration. But this tension may also signal the possibility of a productive division of labor, with a micro and macro public administration that addresses distinct questions, but which are connected by common research concepts

How best to nudge taxpayers? The impact of message simplification and descriptive social norms on payment rates in a central London local authority

Article

Full-text available

Feb 2018

Behavioral insights or nudges have yielded great benefits for today’s public administrators by improving the quality of official messages and increasing revenue flows. In the absence of a large number of studies suitable for meta-analysis, less is known about the external validity of these interventions, their range of impact, and the exact matching of the behavioral cue to the client group and context. Factorial designs and repeated interventions, as in the study reported in this article, can add insight through respectively comparing interventions and analyzing their impacts over time. This randomized controlled trial tests whether simplification and/or a descriptive social norm can increase payment of local taxes in a central London local authority. In the first wave, a factorial design on a targeted group of residents, simplification increased the number of people paying by four percentage points, whereas the social norm did not change behavior. In wave two of the study, which was carried out across all households, the descriptive social norm backfired, reducing the rate of payment. The heterogeneous nature of the target population and the exact wording of the social norm are discussed as possible reasons for these results.

Feasibility and acceptability of two incentive-based implementation strategies for mental health therapists implementing cognitive-behavioral therapy: a pilot study to inform a randomized controlled trial

Article

Full-text available

Dec 2017
IMPLEMENT SCI

Background: Informed by our prior work indicating that therapists do not feel recognized or rewarded for implementation of evidence-based practices, we tested the feasibility and acceptability of two incentive-based implementation strategies that seek to improve therapist adherence to cognitive-behavioral therapy for youth, an evidence-based practice. Methods: This study was conducted over 6 weeks in two community mental health agencies with therapists (n = 11) and leaders (n = 4). Therapists were randomized to receive either a financial or social incentive if they achieved a predetermined criterion on adherence to cognitive-behavioral therapy. In the first intervention period (block 1; 2 weeks), therapists received the reward they were initially randomized to if they achieved criterion. In the second intervention period (block 2; 2 weeks), therapists received both rewards if they achieved criterion. Therapists recorded 41 sessions across 15 unique clients over the project period. Primary outcomes included feasibility and acceptability. Feasibility was assessed quantitatively. Fifteen semi-structured interviews were conducted with therapists and leaders to assess acceptability. Difference in therapist adherence by condition was examined as an exploratory outcome. Adherence ratings were ascertained using an established and validated observational coding system of cognitive-behavioral therapy. Results: Both implementation strategies were feasible and acceptable-however, modifications to study design for the larger trial will be necessary based on participant feedback. With respect to our exploratory analysis, we found a trend suggesting the financial reward may have had a more robust effect on therapist adherence than the social reward. Conclusions: Incentive-based implementation strategies can be feasibly administered in community mental health agencies with good acceptability, although iterative pilot work is essential. Larger, fully powered trials are needed to compare the effectiveness of implementation strategies to incentivize and enhance therapists' adherence to evidence-based practices such as cognitive-behavioral therapy.

A Systematic Scoping Review of the Choice Architecture Movement: Toward Understanding When and Why Nudges Work

Article

Full-text available

Dec 2017
J BEHAV DECIS MAKING

In this paper, we provide a domain-general scoping review of the nudge movement by reviewing 422 choice architecture interventions in 156 empirical studies. We report the distribution of the studies across countries, years, domains, subdomains of applicability, intervention types, and the moderators associated with each intervention category to review the current state of the nudge movement. Furthermore, we highlight certain characteristics of the studies and experimental and reporting practices that can hinder the accumulation of evidence in the field. Specifically, we found that 74% of the studies were mainly motivated to assess the effectiveness of the interventions in one specific setting, while only 24% of the studies focused on the exploration of moderators or underlying processes. We also observed that only 7% of the studies applied power analysis, 2% used guidelines aiming to improve the quality of reporting, no study in our database was preregistered, and the used intervention nomenclatures were non-exhaustive and often have overlapping categories. Building on our current observations and proposed solutions from other fields, we provide directly applicable recommendations for future research to support the evidence accumulation on why and when nudges work. Copyright

PROPHYLAXIS FOR DEEP VEIN THROMBOSIS IN SURGICAL PATIENTS

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Jun 2005

The Cambridge handbook of psychology and economic behaviour, second edition

Book

Jan 2018

A. Lewis

There has recently been an escalated interest in the interface between psychology and economics. The Cambridge Handbook of Psychology and Economic Behaviour is a valuable reference dedicated to improving our understanding of the economic mind and economic behaviour. Employing empirical methods - including laboratory and field experiments, observations, questionnaires and interviews - the Handbook provides comprehensive coverage of theory and method, financial and consumer behaviour, the environment and biological perspectives. This second edition also includes new chapters on topics such as neuroeconomics, unemployment, debt, behavioural public finance, and cutting-edge work on fuzzy trace theory and robots, cyborgs and consumption. With distinguished contributors from a variety of countries and theoretical backgrounds, the Handbook is an important step forward in the improvement of communications between the disciplines of psychology and economics that will appeal to academic researchers and graduates in economic psychology and behavioral economics.

Thoughtless design of the electronic health record drives overuse, but purposeful design can nudge improved patient care

Article

Mar 2018

Nudge Units to Improve the Delivery of Health Care

Article

Jan 2018

Key information and important choices are constantly being presented in health care. Yet often the frames or default options used are selected without attention to strategic goals. Creating a nudge unit in a health care system can lead to consistently better decisions.

Low-value care: An intractable global problem with no quick fix

Article

Jan 2018

Nudging healthcare professionals towards evidence-based medicine: A systematic scoping review

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