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Policy by stealth

17 September 2014 David Bennett

If you’ve ever had that feeling of doing something different without quite knowing why, welcome to the world of ‘nudge’. The principles of nudge were popularized by Thaler and Sunstein in the book Nudge published in 2008.1 Since then a range of professionals have applied these principles to the goal of changing specific human behaviours. Examples of this technique to bring about behavioural change as an alternative to the threat of sanctions  include the provision of information about how many fellow citizens pay their taxes on time and auto-enrolment in company-based pension schemes.

An early application of the nudge approach in public health is represented by the idea of providing mothers with vouchers to encourage breast feeding. Could healthcare professionals also be ’nudged’ into changing their clinical practice? One example is the use of checklists in surgical theatres and intensive care, an idea borrowed from the aviation industry to meet the need to reduce human error as aircraft became more complex machines to operate.2 The introduction of surgical checklists has been documented to reduce mortality, however, adoption of checklists does not occur overnight. In the meantime, it could be argued that ‘unnecessary’ surgical complications and deaths have occurred.

The emergence of evidence-based medicine has been associated with the development of policies and consensus guidelines. As with checklists, the application of new recommendations in routine clinical practice can be delayed. Research into identifying techniques to reduce this delay exist.3 An important step in the process seems to be the identification of barriers to the adoption of specific sets of clinical guidelines. With this in mind, the development of new health policy and guidelines, although an arduous task in itself, should be seen as just one part of the process to improve patient care. Without at the same time researching possible objections to implementation and to make recommendations for the best way to change clinical practice is missing a crucial step.

Now, how do we nudge policy makers into doing this?


1. Nudge. Thaler RH, Sunstein CR. 2008. Available from: http://yalepress.yale.edu/book.asp?isbn=9780300122237.

2. Walker IA, Reshamwalla S, Wilson IH. Surgical safety checklists: do they improve outcomes? Br J Anaesth 2012;109:47-54.

3. Shaw EJ, Thornton J, Chamberlain K and Ayiku L. Factors influencing implementation of clinical practice guidelines: what do users think? GIN poster presentation, Berlin, 2012. Available from: http://www.decide-collaboration.eu/sites/www.decide-collaboration.eu/files/uploads/FINAL-Shaw2-%20poster%202014.pdf.

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