Nudges from the Edge of Health
MY NUDGE STORY
Seven years ago, Sheena Iyengar came to talk to us at the Foundation about her book, The Art of Choosing. It was one of my first introductions to ideas like choice architecture, defaults and nudges. Her talk was as fascinating as it was informative — replete with stories from her research and the work of others (including my old professor, Barry Schwartz) about how relatively simple changes could have profound impact in people’s health and well being.
Among her stories, one has stuck with me all these years later. Sheena told us about a research study that looked at how a nudge during one of life’s most unbearable moments alleviated grief and even provided some level of mercy and grace. It involved end of life decisions for children who were on life support systems with no chance of recovery. In the United States, the default is for parents to make the final decision on when to discontinue life support. Parents are given some guidance from doctors but it is more passive than in other countries like France. The default there is that doctors take responsibility for the decision. They don’t ask, they tell parents that this is the plan and unless there are objections, they will terminate life support.
It turns out, by putting the weight of that decision squarely on their own shoulders, medical providers remove a bit of the weight from the already unbearable burden on the parents. This nudge had not only a one time impact, but over time, researchers found that for parents whose providers made the decisions for them, incidences of complicated grief were dramatically decreased and parents were better able to cope with their loss. A lifetime of “what if” questions no longer haunting them might explain improved future life outcomes they observed for these parents (like lower divorce and suicide rates).
As a mother of three children, it is hard to fathom what it must be like to be faced with that decision, and the idea that a simple nudge in provider behavior could provide ANY measure of relief was so compelling. And as someone who runs a group that is constantly looking to the edges for ideas on how to improve people’s well-being — the idea had real implications for our work to improve health and healthcare.
Around the time of Sheena’s talk, we began to make investments exploring how ideas from behavioral economics might enhance the impact of our foundation’s work. During a six year partnership with the Penn Center for Health Incentives and Behavioral Economics we learned quite a lot about what does and doesn’t work when applying nudges in healthcare.
I had previously written about our learning here.
The behavioral economics initiative, led by David Asch and Kevin Volpp is emblematic of much of our work. The Pioneer team at the foundation looks to the cutting edge of other fields in order to push us to the cutting edge of our own. This requires us to meet new people and look in unexpected places and ask new questions
So with that as context, here are six questions from the edge of health that may challenge our ideas around nudging.
1) WHO DO WE NUDGE? As we think about the role of nudges in healthcare, we should carefully consider: whose behavior should we nudge? Doctor? Nurse? Nurse Practitioner? Patient? Family? Healthcare Administrator? Insurer? And so on and so on. It’s not always clear what the right answer is and it depends on how you think about well-being and agency.
One thing that I didn’t mention about Sheena that you may or may not know is that she is blind. I tell you this because during our discussions she mentioned that while societies’ default might be to help restore vision, she herself if confronted with a choice to “see” said she would probably refuse. This is a huge lesson in humility and checking our own biases at the door when we presume to know who to nudge and towards what end.
2) WHEN DO WE NUDGE: Our healthcare system is largely a responsive system. A patient presents herself with a health challenge, or there is an outbreak of a disease or a public health issue arises.
This is not unusual. In fact in most systems, there are workflows and defined protocols that are triggered by events and become established over time — eventually becoming the accepted default. Studies that show up to 80% of patients forget what their doctor tells them right after they leave the office. They don’t understand their homework they need to do to stay well. Why would we not send them the information they need before they come to the doctor’s office, so the precious time they have with their provider could be used answering their questions and internalizing their feedback. Maybe it’s time to change the default of when we nudge.
3) WHAT WE NUDGE: This question of “what we nudge” is a logical starting point when looking to identify nudge opportunities. Governments, HR departments and healthcare systems have nudged organ donations, prescription drug practices and conversations about cost. Yet more opportunities abound. As Dr. Mitesh Patel recently noted in Managed Care Magazine, “What most people fail to recognize is that we were already being nudged. Now we have a chance to think strategically about it.”
We’ve recently made some investments exploring the role of sound and health and have discovered that it is an area ripe for nudging. Through a grant to PRX, we supported a two-part mini series on the popular podcast 99% Invisible with Roman Mars, one of which focused specifically on Sounds and Hospitals. Download and have a listen. What you hear could inspire what you nudge next.
4) WHERE DO WE NUDGE: The question of where we nudge also reveals tremendous opportunities. Increasingly we all recognize that so much of our health is impacted by factors outside of our healthcare system — in places where we live, learn, work, play and pray.
What nudges could we be making in schools, grocery stories, factories and communities? Think it’s hard to get permission to nudge in church? I once heard of a church that, in order to nudge its congregation towards healthier lifestyles, installed scales near where congregants walked into the church and banned bake sales!
5) HOW DO WE NUDGE: Next is the question of asking how can we nudge? It can be as simple as changing the default setting in an online form or changing the shelf location of healthy food. But the reality is that sometimes a nudge requires a little more of a lift to guarantee the healthy outcome we want to see in the world.
Several years ago, my teammates and I noticed the convergence of two trends: The growing maker movement, and a continuation of a long running trend of nurses being a source of innovation within our healthcare system. Through a project called MakerNurse, that nudges nurses to turn more of their inspiring thoughts into practice. required more than a change in a form or single practice. It required the creation of space, an allocation of time and a giving of permission. Sometimes a nudge also requires a push, we need to provide more resources to make the nudge take hold.
6) WHY DO WE NUDGE: Perhaps the most important question is one I’d like to ask for your help with?
WHY should we nudge?
- Do we nudge to reduce costs? Do we nudge to improve efficiency?
- Do we nudge to minimize bad outcomes? Do we nudge to maximize positive outcomes?
- Do we nudge to make the healthy choice the easy choice? Or do we nudge to make the unhealthy choice the hard choice?
- Do we nudge to improve healthcare? Do we nudge to build a culture of health?
There are no right or wrong answers, but those of us who are working to improve health in any setting — do have to choose. Ideas are more plentiful than the time and resources you have to execute them. We are all constantly challenged to prioritize — and developing a nudge strategy is no different.
A critical aspect of building a Culture of Health is health equity, which in essence means we all have the basics to be as healthy as possible. Within the health care system this means centering patient care around patients’ needs and goals.
Outside of the hospital walls, it means that no one’s prospects for good health are limited by where they live, how much money they make, or discrimination they face.
To achieve health equity, we need to address these barriers and shift values so seeking to be healthy is a part of everything we do… so much so that we don’t even think about it.
Which brings us back to the question of “why nudge?”
At the Robert Wood Johnson Foundation, we’re interested in nudges that can bring us closer to achieving health equity.
We’ve recently launched an online tool called www.shareyourhunch.org. I’d ask that you take a few minutes and share any hunches you might have about how we can all nudge towards a world where we all have the opportunity to live our healthiest lives possible.
Let me close where I began.
Seven years ago, I heard a woman share some ideas about nudges. What she said changed the way I thought about choices, end of life decisions and human behavior. I will not hold this post to that same standard but I do hope that I have given you some food for thought and perhaps planted a few questions that will keep you thinking long after you’ve finished reading this.
This article was excerpted from a talk I gave at the University of Pennsylvania Nudges in Healthcare Symposium held by the Center for Health Incentives and Behavioral Economics. You can learn more about the event and watch the full talk below beginning at the 2:35 mark:
