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

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