Do We Need a Nudge?

Editorial

Do We Need a Nudge?

Rita H. Pickler

ave you heard about “nudge science?” Frankly, until In any event, coming from a behavioral economics per- Hquite recently, I had not, at least not by that name. spective, a relatively new field of study that bridges the gap be- However, I am familiar with practices considered tween economics and psychology, nudge scientists' research nudges by those touting, and in a few cases, decrying, the use about how people make decisions has increased our under- of behavioral economics in health care and, by extension, standing of human behavior. However, how and why does human studies research (Ploug & Holm, 2015). Nudge science nudge science matter to nursing research? is based on the idea that positive reinforcement (a “nudge”)can It has been suggested that nudges can be effectively used influence human motivation and decision making. Marketing in research. For example, participant recruitment is one of strategists do a lot of nudging; I will show my age here, but con- the largest costs and most challenging aspects of conducting sider the influence of the Wheaties cereal box on children's randomized controlled trials; barriers to recruitment can lead breakfast eating habits. Moreover, nudge theory helps explain to a biased sample or an underpowered sample. There are in why consumers make purchasing decisions; this is why so many fact a number of recently published papers about the use of commercials are designed to appeal to who we want to be (e.g., nudges to increase participant enrollment and VanEpps, Volpp, young and beautiful and driving a convertible Mercedes Benz). and Halpern (2016) have created a taxonomy of proposed enroll- Nudge science is embedded in behavioral economics, ment “nudges” that include addressing barriers related to inade- specifically choice architecture, the forces posited to shape quate information, desire for autonomy in making enrollment human decision making. Nudge science, or more specifically, decisions, and resource constraints. Although the VanEpps et al. nudge theory, is the creation of recent Nobel laureate and taxonomy is helpful, the point at which a nudge becomes University of Chicago economist Richard Thaler and his col- coercion is not clear. league, Cass Sunstein (Thaler & Sunstein, 2008). Thaler and Suppose, for example, a principal investigator tells a po- Sunstein posit that a nudge, or positive reinforcement and tential study participant that 20 people have signed up in indirect suggestion, is a better influence on behavior than 1 week for a study. Is that a nudge? Yes, it is; it also seems coer- laws and edicts are. This is because, according to behavioral cive. In fact, there is some argument that nudges diminish the economists, humans generally have flawed judgment and goals of informed consent. However, VanEpps et al. argue that decision making; they (we) are unpredictable and heavily their taxonomy promotes nudges that help potential partici- influenced by who gives them (us) information rather than pants understand relevant information, thus guiding people the content of that information. We like incentives and es- to better-informed decisions. VanEpps and colleagues also pecially those that keep us from harm. Humans also have note that the ethics of consent nudges have not been carefully been shown to be strongly influenced by the behavior of examined. They suggest the need for studies to evaluate the ef- others and most often go with the flow when faced with a fectiveness of various nudges as well as the potential of such decision. Decisions, including going with the flow, are also strategies to create disparities in consents as well as decreased based on what is relevant to us at the moment as well as on understanding about the nature of the research in which the our emotions about the matter being decided. We generally individual has agreed to participate. As Thaler has pointed want to make decisions that are consistent with what peo- out, many commonplace nudges have had very positive results; ple expect of us based on what we have said and done in good signage keeps us from going the wrong way on the free- the past, and we want to feel good about our decisions way, text messages remind us to get our children from school, (Blumenthal-Barby & Burroughs, 2012). Principles of behav- and default options, such as those associated with automatic ioral economics imbue the science of behavior change. This retirement contributions, help us save for the future (Thaler, could be a good thing on many levels if the associated nudges 2018). Yet, the same nudging strategies can be used for less motivate us to engage in activities based on strong scientific noble purposes, including nudging us into research in which evidence of effectiveness that is properly vetted. For although we do not really want to participate or nudging us adopt we could argue that some legally mandated behavioral-based behaviors we would not otherwise choose. initiatives such as car seat belts and bicycle helmets have Researchers are increasingly using nudges to encourage saved lives, generally speaking, it makes sense that a seem- compliance with behavioral interventions—healthy eating, exer- ingly more choice-based approach to behavior change is more cise, and cancer screenings, for example. Behavioral economists effective in our freewill society. argue that influencing decision making to increase study

Nursing Research www.nursingresearchonline.com 1

participants' adoption of health interventions is a good thing, Director, PhD & MS in Nursing Science Programs, The Ohio State Univer- allowing greater opportunity to test the effectiveness of these sity College of Nursing, Columbus. interventions. However, if you need a nudge, be it a monetary The author has no funding or conflicts of interest to disclose. incentive or an alert on your cellphone to be sure you partic- Accepted for publication October 8, 2018. ipate, what happens in the real world when those incentives Corresponding author: Rita H. Pickler, PhD, RN, FAAN, The Ohio State University College of Nursing, 324 Newton Hall, 1585 Neil Avenue, or reminders no longer exist? This question raises concern Columbus, OH 43210 (e-mail: [email protected]). about sustainability of health behavior changes that begin in Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved. “ ” clinical trials and are then translated to the public. It remains DOI: 10.1097/NNR.0000000000000326 unknown whether behaviors supported by nudges in a research study can in fact endure in a world where those nudges are not REFERENCES likely to be available. For me, the question of what happens Blumenthal-Barby, J. S., & Burroughs, H. (2012). Seeking better health when nudging is applied to human studies research or, per- care outcomes: The ethics of using the “nudge”. American Jour- haps, to the translational implications of research results nal of Bioethics, 12(2), 1–10. doi:10.1080/15265161.2011.634481 facilitated by nudges remains unanswered. Ploug, T., & Holm, S. (2015). Doctors, patients, and nudging in the – As a final thought: in this new year, I hope the nudges we clinical context Four views on nudging and informed consent. American Journal of Bioethics, 15,28–38. doi:10.1080/15265161. receive do in fact help us to make better decisions about our 2015.1074303 own personal health and well-being. And, I sincerely hope that Thaler, R. H. (2018). Nudge, not sludge. Science, 361, 431. doi:10. the nudges we give others, in our research and practice, are 1126/science.aau9241 good ones, conceived in thoughtfulness and delivered with Thaler, R. H., & Sunstein, C. R. (2008). Nudge: Improving decisions about the greater good in mind. health, wealth, and happiness. New Haven: Yale University Press. VanEpps, E. M., Volpp, K. G., & Halpern, S. D. (2016). A nudge toward participation: Improving clinical trial enrollment with behavioral Rita H. Pickler, PhD, RN, FAAN, is Editor of Nursing Research, and The economics. Science Translational Medicine, 8(348), 348fs13. doi:10. FloAnn Sours Easton Professor of Child and Adolescent Health, and 1126/scitranslmed.aaf0946