Individuals served by behavioral health programs experience poor health, significant health risks, and a shortened life span (Druss et al., 2018; Parks et al., 2006). Promoting health and wellness has received increased attention in recent years (Olfson et al., 2015). For people with the most serious mental health diagnoses, such as schizophrenia, research indicates that these individuals are 3.5 times more likely to experience early mortality than individuals without the diagnosis (Olfson et al., 2015). Disparities also exist for individuals with more common, less severe, or less persistent mental health concerns. Research findings note that individuals with anxiety or depression die approximately 8 years earlier than individuals without diagnoses (Pratt et al., 2016). In both instances, preventable disease and related health behaviors contribute to the morbidity and mortality disparities facing individuals served by the behavioral health system. Although some approaches and interventions have resulted in positive health outcomes and behavior change, these interventions have had limited reach (McGinty et al., 2016; Naslund et al., 2017; Vancampfort et al., 2017).
Given the great need for strategies for supporting health behavior change, nurses working in behavioral health can benefit from an enhanced understanding of how environments affect health decisions and behaviors and how best to support people to act in ways that will increase their quality of life and lifespan (Chapman et al., 2016). Nudges, or attempts to minimize barriers to consistent performance, can serve as strategies for influencing health habits (Hansen, 2016) by targeting the automatic pathways leading to those habits (Yoong et al., 2020). Nurses are uniquely positioned to implement nudge strategies in behavioral health settings because they are knowledgeable about healthy behaviors and lifestyles and, often, are in a position to influence program policy and to guide and support interventions that are implemented by direct service providers. A recent systematic review of nudge strategies designed to increase health care provider adherence to clinical guidelines (Yoong et al., 2020) found that nudges were at least comparable to other interventions that target evidence-based guidelines for clinician behavior change.
The current article provides a broad overview of the nudge approach, addresses ethical considerations relevant to behavioral health programs, and suggests practical applications of nudges to areas where they can help improve health outcomes.
Environmental Influences on Health-Related Decisions
Individual characteristics influence health choices and health behaviors, such as the knowledge, attitude, and skills necessary for adopting a behavior. However, external factors also influence decision making, as identified in ecological models or frameworks, including physical and social environments and policies (Sallis et al., 2008).
The physical environment influences health choices and behaviors. Some studies found choices about what and how much to eat were affected by cost, what is available and accessible, serving or unit size, serving utensil, and food labels (Larson & Story, 2009; Wilson et al., 2016). The choice to take a walk may be influenced by whether there are sidewalks, traffic, and stores along the walking route (Duncan et al., 2005).
The social environment includes interactions with friends, family, colleagues, neighbors, and others; communication about social norms; and how we think others will perceive and evaluate what we do (McAlister et al., 2008). Social norms for physical activity and nutrition behaviors can predict health behaviors among individuals, independent of available social support (Ball et al., 2010).
Nudges, according to Thaler and Sunstein (2008), change a situation or how decision options are presented to influence the choice a person makes. The key concepts of nudging are “choice architecture” and “libertarian paternalism” (Thaler & Sunstein, 2008, pp. 3 & 5). Choice architecture refers to the structures that influence the choices a person makes, such as which items are first in the buffet line. Nudges redesign choice architecture through structures that make certain choices easier, more appealing, or simply more likely. Libertarian paternalism refers to the idea that someone is deciding which option is best for an individual or larger population (paternalism), although everyone still has free choice related to the decision (libertarian). Free choice exists, but there may be a slight cost or effort required by individuals to make the “poor” choice, with the determination of which option is better being in the hands of the choice architect.
The Ethics of Nudging
Nudges within public policy and broad public health initiatives may raise concerns related to self-determination and real individual benefit (Selinger & Whyte, 2011; Yoong et al., 2020). Mainstream American culture places a high degree of value on self-determination, making manipulation and bribing unacceptable. To a certain extent, some may perceive nudges as manipulations. Incentives used to nudge behavior can be construed as bribes. Thaler and Sunstein (2008) argue that we are all regularly manipulated by our environments—some form of choice architecture is already there. By preserving choice and making the costs and benefits of a given choice only slightly different, choice architects can consciously, and conscientiously, preserve self-determination.
Nudges are not value-free because the choice architect has determined that one option is better than another. Social control drives nudges when the values that determine better or best options are primarily related to policy and population health, rather than to the needs and preferences of any given individual. Some nudges may have the primary purpose of reducing government expenditures, with the target behavior not providing a significant individual benefit. For example, nudges to increase recycling may save money in the municipal budget but may not translate into significant savings for each taxpayer. The person who, by default, gets signed up as an organ donor may not acquire any tangible real benefit (Quigley, 2013).
Three practice principles for creating ethical nudges can help ensure the preservation of true choice while avoiding manipulation that could be considered unethical. The first principle is that options must be available. This means that individuals can exercise free choice and are not restricted by limited options, such as a ban on a behavior. For example, an organization may prohibit smoking, which might be a wise policy decision but is not a nudge.
The second principle is that there must be a clearly good or better choice from among the available options. The clearly good or better choice would be the option grounded in sound scientific evidence for health behavior promotion. Yet, what is perceived as a good or better choice may vary culturally. Although it is important for nudges to support people in making what is objectively a healthier choice, the design of nudges needs to take into consideration various cultural influences regarding a person's own goals and values and how that may impact what is perceived of as a good or better choice. Although there may be cultural differences, for example, regarding what a healthy or ideal body type looks like, there is an abundance of research on the benefits of physical activity for promoting a healthy long life. Robust research supports the conclusion that regular physical activity contributes to feeling well and to living longer, making increasing physical activity a potential target for nudging (Quigley, 2013). Some long-term outcomes are widely accepted across cultures, such as wellness and longevity, with most people wanting to feel well. People may find a nudge acceptable, or even desirable, if it moves them toward goals they value (Junghans et al., 2015). Moving people toward physical activity as a better or good choice will likely be an acceptable nudge. Choosing physical health, for many, will be a clear good choice. Rather than nudging people to a choice of weight loss, for example, values may better support a nudge toward overall physical health, which most people will see as a good or better choice.
The third principle is that, to remain ethical, nudges must involve only a slight cost for the worse choice or a slight incentive for the better choice. They do not entail powerful or coercive rewards, disincentives, or punishments. These costs or incentives are not extreme. For example, a tax for highly sweetened beverages serves as a nudge that may change behaviors, such as imposing a slight cost for the worse choice—in this case, sugary soda. The first tax on sugary drinks in the United States was only one cent per ounce of the beverage, a small added cost, yet sales of these beverages decreased approximately 10% in the first year the tax was levied (Silver et al., 2017).
Types of Nudges
Nudges can influence choice using a variety of approaches, including information, prompts, priming, opt-out programs, incentives, and environment redesign.
Information ensures people are aware of alternatives and/or have the facts they need to choose among those alternatives.
Prompts are reminders of a desired behavior at or near the moment of making a choice.
Priming refers to cues that make people sensitive to a particular option. This can occur through posters or other items in an environment that provide a subtle influence in the direction of the better choice.
Opt-out programs have a default of signing everyone up for something, whereas “opt-in” choices mean a person must take some action to sign up. Whether due to inherent inertia, external barriers, or other factors, “opt-out” choices result in many more people enrolled in the desired option (Thaler & Sunstein, 2008). Automatic enrollment sidesteps the barriers to taking the actions needed to enroll.
Incentives provide another way of nudging, either through added cost for the worse choice or some payment or added positive benefit for the better choice.
Environment redesign places the better choice or option within view or first on a list, or otherwise highlights it in some way. Sometimes, simply rearranging choices to make some more obvious can have the desired effect of shifting behavior.
Nudges in Behavioral Health Programs
During any given day, individuals served by nurses in behavioral health programs make many health-related decisions that might respond to nudges (Table 1). For example, a sedentary lifestyle is far too common, eating well can be a challenge, smoking is prevalent, and routine medical care often is not used as needed. For many complex reasons that are beyond the scope of the current article, individuals served by behavioral health programs seem to select unhealthy choices and often lack adequate support and resources for making healthier choices. In addition, everyone, regardless of diagnosis or disability, makes choices that are not always rational (Potthoff et al., 2019). Helping people walk more, choose water instead of soda, smoke less or quit, establish a healthy sleep routine, and access regular medical and dental care can improve the quality of life and lifespan for this population. These healthy behavior changes can also reduce the frequency or severity of psychiatric symptoms (Cavazos-Rehg et al., 2014; Dash et al., 2016).
Examples of Daily Health-Related Decisions
Factors contributing to poor health and poor health choices include poverty and unemployment, symptoms, trauma, limited education, medication side effects, substance use, social withdrawal, hopelessness and powerlessness, and low self-efficacy (Blanner Kristiansen et al., 2015; Center for Health Care Strategies, 2017; Moore et al., 2015; Price et al., 2016; Twyford & Lusher, 2016). Financial, social, and emotional challenges can be barriers to medical care, screening, and preventive services. Even with the support of health care professionals and a better understanding of the health decisions they make, people served by behavioral health agencies may not overcome all these systemic and ecological challenges. Although nudges will not and cannot plausibly serve as interventions that will address and overcome all of these deeply rooted issues and disparities, they may increase awareness, motivation, and support enough to prompt better choices for individuals with behavioral health conditions, helping foster improved health outcomes.
Suggested Nudges for Behavioral Health Programs
Nudges can be used within behavioral health programs to increase positive and healthy behavior change (Woodend et al., 2015). The first category, program-based nudges, focuses on the organization's physical and social environment to target behavior change for service users and/or service providers. As these nudges aim to support the achievement of desired personal health and wellness goals for the target population, their design, implementation, and evaluation need to include stake-holder involvement to avoid ethical concerns. Collaboration with people using services and staff when considering how to design program nudges is essential to ensure that the nudges match their needs, goals, and desires.
The second category, person-based nudges, involves helping individuals self-nudge, that is, where they choose and design modifications within their environments to facilitate the behavior change needed to achieve a desired personal health and wellness goal.
Behavioral Health Program Environments
The first step to helping people make healthier choices is to identify the desired behaviors that are likely to benefit individuals using the services and staff. Next, observe the environment for factors that may influence those behaviors, including factors such as the current program culture, policies, procedures, and choice defaults. Finally, implement small changes in the environment to make better choices easier, such as adding a tiny cost (e.g., time or effort costs; Thaler & Sunstein, 2008) to help override a less healthy choice.
Because environments inherently contain choice architecture (Thaler & Sunstein, 2008), behavioral health program environments already have opportunities for nudging (Table 2). In considering how to create environments and implement practical nudges, it is important to remember to allow for and support choice while avoiding harsh or punitive approaches or interventions that may seem shaming to participants. Instead, it is best to provide supports to increase awareness and motivation for choosing healthier options, such as in the examples below.
Examples of Nudges for Behavioral Health Programs
Prompts, Priming, Information, and Other Cues. Health-related displays of healthy food and people exercising are low-cost nudges. Ideally, these displays will depict people, foods, and activities that reflect local cultural diversity. Changing displays and postings monthly will continue to draw attention. A common prompt is a sign by the elevator that says, “Why not take the stairs?” Priming does not specify the better choice. For example, in one study, a food lab was designed with “a green ambience of plants” (Friis et al., 2017, p. 5). In that study, the environmental changes in this “restaurant” resulted in decreased calorie intake. One information nudge is posting “stop light” information (Massachusetts General Hospital, 2019) on food options, in which a graphic design indicates that green means “choose often,” yellow means “choose less often,” and red means “there is a better choice.”
Default Choices and Opt-Out Programs. In many programs that serve meals, options are limited and often high in fat and carbohydrates. In the default choice example, healthier options might be offered as the default, with the less healthy options available only upon request. For example, a burger might automatically come with a salad or side of broccoli. To preserve choice, patrons could still get fries or chips but would need to ask and possibly pay a small surcharge to choose the item(s) not on the default menu. Predetermined portion sizes offer another default choice. For example, large, pre-packaged portion sizes of healthy foods and small portion sizes of less healthy options could be provided, where people could take as many pre-packaged options as they wished (Friis et al., 2017). Another “opt-in” relates to flu vaccines, with the default choice involving scheduling a flu shot for employees and people using program services, who maintain the ability to opt-out of their shots by canceling the appointment. One study found that people who were pre-scheduled were more likely to get flu shots than those who were only prompted to make an appointment (Chapman et al., 2010).
Incentives. Some incentives for healthy choices may already exist, which creates an opportunity for nurses to learn about them and share that information. For example, in one state, using SNAP benefits for fruits and vegetables gets shoppers a coupon for their next grocery store purchase (Washington State Department of Health, 2020). Offering an incentive for a good or better choice is another way to nudge. Monetary rewards (contingencies) have shown promise of success when they have been used to support addiction recovery, smoking cessation, and medication adherence (Petry et al., 2012; Rash et al., 2017). However, incentives may raise ethical issues and can backfire by making the good option appear so undesirable that someone must pay you to do it (Gneezy et al., 2011).
Redesigning the environment can affect food choices, such as putting healthy foods first and in front in a cafeteria display (Arno & Thomas, 2016). Such changes are generally simple and low cost. A clubhouse, familiar to the current authors, changed their canteen offerings so the chocolate was not on the top of the counter. It was moved under the counter where it could not be seen but was still available if someone asked. Within a few weeks, chocolate purchases dropped to zero (M. Clair, personal communication, March 4, 2016).
Changing an environment to promote physical activity, such as creating sidewalks or moving the location of the elevator, may be too complex or costly for many organizations. However, adding an exercise space may provide a choice or may prompt a person to consider exercise in a low-cost manner. Similarly, providing information about local walking routes and walking tips may be a useful nudge that is accessible for many providers. Offering free pedometers, discount coupons for sneakers, walking groups, friendly competitions, and team goals may be affordable and practical ways to nudge people toward more physical activity.
Supporting Person-Based Self-Nudges
We believe a commitment to self-determination and empowerment means educating people about the powerful influence of the environment and about how they can become their own choice architects. Any person can modify a personal physical environment to support health decisions and behaviors, creating self-nudges that allow freedom and choice, as well as personal responsibility. Nurses and other health care professionals can be aware of and role model self-nudges. Nurses can play an important role by offering encouragement and opportunities for self-determination, while recognizing that assisting people to make healthy choices may require a lengthy process, including helping people see their many daily choices in ways that will not leave them feeling ashamed, embarrassed, or judged about their past choices (Cook & Jonikas, 2002). Nurses can help people using services to increase awareness of the power of environmental influences, combined with greater hope and self-efficacy, to open the door to considering the tool of self-nudges.
Behavioral health programs should support everyone in making wellness goals and plans, both service users and service providers, including nurses. Self-nudges (Table 3) fall into approximately the same categories as nudges implemented by someone else, including prompting, incentives, and environmental redesign. Once a person chooses a goal, self-nudges can be incorporated as action steps in the person's service plan.
Examples of Self-Nudges
Poor health and early death are real issues for individuals served by behavioral health programs. Nurses working in behavioral health settings can support the wellness goals, barriers, and resource needs of the people they serve to help them access services and strategies for health improvement. Program-based nudges and individual self-nudges are approaches that may contribute to positive health behavior. As more people in a behavioral health agency, including nurses, focus on their wellness, social norms and expectations shift, observed behaviors serve as prompts, and the culture and policies change to provide a new choice architecture. When nurses consider planning to incorporate nudges, collaboration with people using services will be essential. Nurses can play an important role in promoting healthy lifestyles that individuals desire. Behavioral health relates to well-being and involves the prevention, treatment, and recovery associated with mental health conditions and substance use disorders. Nurses working in behavioral health settings are in unique positions to help create environments that encourage health-promoting behaviors to mitigate risk factors, improve quality of life, and add years to the lives of the people they serve.
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Examples of Daily Health-Related Decisions
|Physical activity||Should I take the stairs or the elevator?|
|How close should I park to the grocery store?|
|Should I go to the gym?|
|How long should I work out once I get to the gym?|
|Should I keep working at the computer or take a stand-up break?|
|Eating well||Do I hit the snooze button or get up and have breakfast?|
|Should I drink water, coffee, soda, or juice?|
|Will I take a piece of candy from the receptionist's desk?|
|What do I choose from the vending machine?|
|How much sugar do I put in my tea?|
|Access screenings and medical care or prevention services||Am I going to get a flu shot?|
|Should I tell my doctor about…?|
|Do I need an annual physical exam this year?|
|Shall I floss or just brush my teeth?|
|Do I fill this prescription or wait and see how I feel next week?|
|Health habits||Will I wash my hands after using the toilet?|
|Do I cover my mouth when I cough?|
|Do I go to bed now or stay up to watch the weather?|
|Will I take a smoke break now or wait a while longer?|
|Do I have another beer?|
Examples of Nudges for Behavioral Health Programs
|Physical activity||Post signs to prompt using the stairs|
|Provide a map of local walking routes, with stores marked|
|Provide pedometer and offer sessions on how to use|
|Arrange discounts for gym membership and sports equipment|
|Organize an agency-wide exercise challenge|
|Eating well||Replace some of the candy dishes with healthier snack options|
|Put salad first in the lunch buffet, before the sandwiches and chips|
|Make water free and easily available; charge for soda or juice|
|Locate healthiest options in the vending machine at eye level|
|Put posters of fruits and vegetables in the kitchen|
|Access screenings and medical care or prevention services||Organize a health fair|
|Sign everyone up for a free flu shot appointment|
|Prompt everyone to get an annual physical exam|
|Leave small packages of dental floss in the restrooms|
|Arrange transportation and support for medical appointments|
|Health habits||Discuss health habits (non-judgmentally) during assessments|
|Provide information on hand washing and other prevention tips|
|Offer smoking cessation programs to everyone|
|Schedule sleep education programs the month before daylight savings time|
|Make sleep diaries and other health journals available|
Examples of Self-Nudges
|Physical activity||Prompt myself to walk using a phone or other alarm|
|Keep my sneakers by the door where I will see them|
|Use phone to track steps and daily physical activity|
|Choose a desirable destination for walking|
|Combine social activities with exercise|
|Pay my change jar each time I exercise; cash in for a reward|
|Eating well||Keep a full bottle of water within reach all day|
|Place fruit out on the counter|
|Hide high-calorie snacks|
|Take a small portion, rather than eat from the box or bag|
|Put chopped vegetables for salads at eye level in the refrigerator|
|Access screenings and medical care or prevention services||Reward myself after getting a screening test or vaccination|
|Schedule next year's physical at the end of this year's appointment|
|Keep my vitamins and morning pills by the coffee maker|
|Add my next prescription refill date to my calendar|
|Ask my doctor for a flu shot reminder call or postcard|
|Health habits||Wash hands for 20 seconds|
|Put a picture of someone I love in my cigarette pack|
|Set personal rules (e.g., no smoking or no soda at home)|
|Get nice smelling soap so I enjoy washing my hands|
|Watch evening TV only after cleaning my teeth after dinner|
|Set a timer to turn off a living room lamp before bedtime|