Nudging clinicians: a systematic scoping review of the literature

Background: While the quality of medical care delivered by physicians can be very good, it can also be inconsistent and feature behaviours that are entrenched despite updated information and evidence. The “nudge” paradigm for behaviour change is being used to bring clinical practice in line with desired standards. The premise is that behaviour can be voluntarily shifted by making particular choices instinctively appealing. We reviewed studies that are explicit about their use of nudge theory in influencing clinician behaviour. Methods: Databases were searched from April 2008 (the publication date of the book that introduced nudge theory to a wider audience) to November 2018, inclusive. The search strategy and narrative review of results addressed the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews. Results: 22 studies were identified. Randomized trials or pre-post comparisons were generally used in community-based settings; single-site pre-post studies were favoured in hospitals. The studies employed eight intervention types: active choice; patient chart redesign; default and default alerts; partitioning of prescription menus; audit and feedback; commitment messages; peer comparisons; and redirection of workflow. Three core cognitive factors underpinned the eight interventions: bias towards prominent choices (salience); predisposition to social norms; and bias towards time or cost savings. Conclusions: Published studies that are explicit about their use of nudge theory are few in number and diverse in their settings, targets, and results. Default and chart re-design interventions reported the most substantial improvements in adherence to evidence and guideline-based practice. Studies that are explicit in their use of nudge theory address the widespread failure of clinical practice studies to identify theoretical frameworks for interventions. However, few studies identified in our review engaged in research to understand the contextual and site-specific barriers to a desired behaviour before designing a nudge intervention.