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Do We Need a Nudge?

Pickler, Rita H.

doi: 10.1097/NNR.0000000000000326

Rita H. Pickler, PhD, RN, FAAN, is Editor of Nursing Research, and The FloAnn Sours Easton Professor of Child and Adolescent Health, and Director, PhD & MS in Nursing Science Programs, The Ohio State University College of Nursing, Columbus.

The author has no funding or conflicts of interest to disclose.

Accepted for publication October 8, 2018.

Corresponding author: Rita H. Pickler, PhD, RN, FAAN, The Ohio State University College of Nursing, 324 Newton Hall, 1585 Neil Avenue, Columbus, OH 43210 (e-mail:

Have you heard about “nudge science?” Frankly, until quite recently, I had not, at least not by that name. However, I am familiar with practices considered nudges by those touting, and in a few cases, decrying, the use of behavioral economics in health care and, by extension, human studies research (Ploug & Holm, 2015). Nudge science is based on the idea that positive reinforcement (a “nudge”) can influence human motivation and decision making. Marketing strategists do a lot of nudging; I will show my age here, but consider the influence of the Wheaties cereal box on children's breakfast eating habits. Moreover, nudge theory helps explain why consumers make purchasing decisions; this is why so many commercials are designed to appeal to who we want to be (e.g., young and beautiful and driving a convertible Mercedes Benz).

Nudge science is embedded in behavioral economics, specifically choice architecture, the forces posited to shape human decision making. Nudge science, or more specifically, nudge theory, is the creation of recent Nobel laureate and University of Chicago economist Richard Thaler and his colleague, Cass Sunstein (Thaler & Sunstein, 2008). Thaler and Sunstein posit that a nudge, or positive reinforcement and indirect suggestion, is a better influence on behavior than laws and edicts are. This is because, according to behavioral economists, humans generally have flawed judgment and decision making; they (we) are unpredictable and heavily influenced by who gives them (us) information rather than the content of that information. We like incentives and especially those that keep us from harm. Humans also have been shown to be strongly influenced by the behavior of others and most often go with the flow when faced with a decision. Decisions, including going with the flow, are also based on what is relevant to us at the moment as well as on our emotions about the matter being decided. We generally want to make decisions that are consistent with what people expect of us based on what we have said and done in the past, and we want to feel good about our decisions (Blumenthal-Barby & Burroughs, 2012). Principles of behavioral economics imbue the science of behavior change. This could be a good thing on many levels if the associated nudges motivate us to engage in activities based on strong scientific evidence of effectiveness that is properly vetted. For although we could argue that some legally mandated behavioral-based initiatives such as car seat belts and bicycle helmets have saved lives, generally speaking, it makes sense that a seemingly more choice-based approach to behavior change is more effective in our freewill society.

In any event, coming from a behavioral economics perspective, a relatively new field of study that bridges the gap between economics and psychology, nudge scientists' research about how people make decisions has increased our understanding of human behavior. However, how and why does nudge science matter to nursing research?

It has been suggested that nudges can be effectively used in research. For example, participant recruitment is one of the largest costs and most challenging aspects of conducting randomized controlled trials; barriers to recruitment can lead to a biased sample or an underpowered sample. There are in fact a number of recently published papers about the use of nudges to increase participant enrollment and VanEpps, Volpp, and Halpern (2016) have created a taxonomy of proposed enrollment “nudges” that include addressing barriers related to inadequate information, desire for autonomy in making enrollment decisions, and resource constraints. Although the VanEpps et al. taxonomy is helpful, the point at which a nudge becomes coercion is not clear.

Suppose, for example, a principal investigator tells a potential study participant that 20 people have signed up in 1 week for a study. Is that a nudge? Yes, it is; it also seems coercive. In fact, there is some argument that nudges diminish the goals of informed consent. However, VanEpps et al. argue that their taxonomy promotes nudges that help potential participants understand relevant information, thus guiding people to better-informed decisions. VanEpps and colleagues also note that the ethics of consent nudges have not been carefully examined. They suggest the need for studies to evaluate the effectiveness of various nudges as well as the potential of such strategies to create disparities in consents as well as decreased understanding about the nature of the research in which the individual has agreed to participate. As Thaler has pointed out, many commonplace nudges have had very positive results; good signage keeps us from going the wrong way on the freeway, text messages remind us to get our children from school, and default options, such as those associated with automatic retirement contributions, help us save for the future (Thaler, 2018). Yet, the same nudging strategies can be used for less noble purposes, including nudging us into research in which we do not really want to participate or nudging us adopt behaviors we would not otherwise choose.

Researchers are increasingly using nudges to encourage compliance with behavioral interventions—healthy eating, exercise, and cancer screenings, for example. Behavioral economists argue that influencing decision making to increase study participants' adoption of health interventions is a good thing, allowing greater opportunity to test the effectiveness of these interventions. However, if you need a nudge, be it a monetary incentive or an alert on your cellphone to be sure you participate, what happens in the real world when those incentives or reminders no longer exist? This question raises concern about sustainability of health behavior changes that begin in clinical trials and are then “translated” to the public. It remains unknown whether behaviors supported by nudges in a research study can in fact endure in a world where those nudges are not likely to be available. For me, the question of what happens when nudging is applied to human studies research or, perhaps, to the translational implications of research results facilitated by nudges remains unanswered.

As a final thought: in this new year, I hope the nudges we receive do in fact help us to make better decisions about our own personal health and well-being. And, I sincerely hope that the nudges we give others, in our research and practice, are good ones, conceived in thoughtfulness and delivered with the greater good in mind.

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Blumenthal-Barby J. S., & Burroughs H. (2012). Seeking better health care outcomes: The ethics of using the “nudge”. American Journal of Bioethics, 12(2), 1–10. doi:10.1080/15265161.2011.634481
Ploug T., & Holm S. (2015). Doctors, patients, and nudging in the clinical context–Four views on nudging and informed consent. American Journal of Bioethics, 15, 28–38. doi:10.1080/15265161.2015.1074303
Thaler R. H. (2018). Nudge, not sludge. Science, 361, 431. doi:10.1126/science.aau9241
Thaler R. H., & Sunstein C. R. (2008). Nudge: Improving decisions about 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 economics. Science Translational Medicine, 8(348), 348fs13. doi:10.1126/scitranslmed.aaf0946

behavioral economics; nursing research; nursing science

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