Behavioural (*nudge*) insights – part 3

One of the sessions I attended was titled ‘You are the doctor’ this was a session on patient safety and I was more than intrigued to see what the behavioural insights world had to add to the work that we all do on patient safety.  Would I find any additional insights, would I find a new way of looking at patient safety?

The session was led by one of the behavioural insights team (BIT) Michael Hallsworth, and the speakers were;

  • Marjorie Stiegler @DrMStiegler (her twitter profile says she is a doctor from the US who also explores medical decisions, patient safety and error via human factors and cognitive psychology)
  • Dominic King @digitalstitched (his twitter profile says he is a clincal lecturer in surgery, behavioural economist and digital health enthusiast at Imperial College)
  • Peter Jaye an emergency department consultant who I quote “usually gets home at 1 in the morning from work” so I suspect is way too busy to be on twitter!

There was an introduction into patient safety which quoted the Health Foundation as the source for the 10% adverse event rate (which in itself I found fascinating that (a) is this what happens with original research that people tend to quote the last person who said it and (b) I didnt know why it bothered me so much).

The audience members were told that they would see a series of videos and that they would be ‘making the decisions’ – in reality I am not sure how much the audience decided but it was a neat way of trying to immerse an audience into the difficult world of medical decision making.  The context was accident and emergency, the viewpoint was from a junior doctor.  It was the video equivalent of simulation training without the added addrenaline increase and total embarrassment when you make the wrong decision in front of people who are ‘assessing’ (judging) you.

The conference programme said ‘you will see how making decisions can be a matter of life of death (yes we got that) and how we can ensure they are made better (unfortunately no we didnt get that).  There was some discussion about training, education, decision support systems, teamworking and the fact that in healthcare we are working with different team members every day, attitudes between doctors and nurses, use of titles (do you call your consultant by their first name or Doctor, Professor, etc) and hierarchy.

I was left wondering where this intervention could be applied in the NHS and if it was, what difference would it make? It probably would be useful to try it out on different audiences; e.g. show it to frontline clinicians – (a) one separated into doctors only and (b) one for the multidisiciplinary team – to test out whether it is a useful way of helping people understand the behaviour, culture, human factors and system factors that affect patient safety and whether you learn this better amonst your peers or amongst the representative ‘healthcare team’. To make it even better for me it should include an additional aspect of applying new knowledge into practice. The take away stuff people can actually put into practice tomorrow.

Having been to mainly patient safety type conferences over the last 20 years or so being at a ‘new’ topic conference opened my eyes to conferences in a way that I wouldn’t have got if I had attended yet another patient safety one. A specific blog on conferences will be coming soon.  In summary conferences provide you with a certain level of information, understanding and insight so that you can appreciate the subject but more importantly you do not gain enough knowledge so that you can apply that knowledge into practice.  It is a window into the subject matter but nothing more.  In other sessions I attended even those that described their own research in relative detail, I could still not quite understand how to put this information into practice. Perhaps I am missing the point.  Perhaps applied social psychology or behavioural economics is different for and unique for every area it tries to effect.  So there is nothing that is generalisable (apart from make it easy and get the evidence).  I shall let you know when I have read all the reports I referred to in Part 1!

Behavioural (*nudge*) insights – part 2

Returning to my attendance at this behavioural insights conference.

Speakers included those well known to this niche field:

  • Richard Thaler the co-author of the original ‘Nudge
  • Iris Bohnet, Professor of Public Policy at Harvard
  • Stephen Pinker an experimental psychologist who specialises in psycholinguistics – most recent book ‘The Sense of Style
  • Robert Cialdini – who wrote ‘Influence: the psychology of persuasion
  • Daniel Kahneman a psychologist noted for his work on psychology of judgment and decision-making, as well as behavioral economics, for which he was awarded the 2002 Nobel Memorial Prize in Economic Science – (he was not in person but provided a televised interview from the US)
  • Dan Ariely – a professor of psychology and behavioural economics at Duke University – his latest book ‘The honest truth about dishonesty
  • Elizabeth Dunn – academic and author of Happy Money
  • Eldar Shafir – behavioral scientist, and the co-author of Scarcity: Why Having Too Little Means So Much

Standout comments included:

  • How we look and dress, determines whether people think we are rich or poor and if we are deemed rich we are also assumed to be more competent – an opinion that is apparently formed in seconds (Eldar Shafir)
  • Panel interviews are simply useless in picking the right people (iris Bohnet)
  • Aim to change environments not minds (Iris Bohnet)
  • if you want people to change behaviour or practice or you want to influence them to do something different from what they are doing now, don’t offend them, don’t do something which embarrasses them.  Many people think you have to challenge or create conflict or be critical – however what behavioural psychologists have found is that it is important not to do something that makes others appear to be the ‘loser’, to lose face, or to have their status or reputation diminished as a result of your actions – it would be better if you work out who has the potential to lose from the change you want to happen and you figure out what you can do to mitigate the consequences of that (Daniel Kahneman)
  • Figure out resistance; what is preventing people from doing the thing you want them to do? can you compensate their potential loss and decrease resistance? (Daniel Kahneman)
  • Try to find out whether you are being successful fairly quickly, don’t persevere too long if it does not appear to be working; be bold and stop (Daniel Kahneman)
  • People spend too much time reading the literature and too little time on ‘real life’ (Daniel Kahneman)
  • Teaching people about the different biases (outcome base, confirmative bias and so on) is not useful at all; much better to introduce the subject area and encourage people to reflect and recognise when they could be wrong, when they could be biased and could behave differently as a result – enable people to live it; structure their thinking (Daniel Kahneman)
  • Role models really do matter Iris Bohnet)
  • Get a non-expert to check everything you write – when you have too much knowledge you find it impossible to write for those who have no knowledge – it is hard for you to ‘undo’ your knowledge and are not able to figure out what people do and don’t need to know (Stephen Pinker)
  • Reciprocality – if you want people to change their behaviour, you should ‘give’ first and only then ask for something in return; the ‘gift’ should be meaningful, unexpected, tailored and personalised (Robert Cialdini)
  • People lie all the time (implications for incident reporting and incident investigation) (Dan Ariely)
  • People don’t like to ‘tell on others’; loyalty is a strong factor (again implications for safety) however trust is eroding in society (Dan Ariely)
  • There is a place for paternalism – when things are so important, that for people and society it is right that people are told what to do e.g. drink driving legislation (Dan Ariely)
  • In respect of ‘happiness’ the myth of a midlife ‘crisis’ is true for both genders – apparently we are ‘happy’ in our 20s, or happiness decreases throughout our 30s, 40s, and 50s and starts to increase from 60s – to a return to happiness in our 70s! This finding has been identified in both humans and apes – which means the causal or contributory factors are most likely to be ‘natural’ rather than societal.(Andrew Oswald)
  • Evolutionary theory could help predict how we behave in different contexts (Nicola Raihini)
  • Giving to others is correlated with feeling happier which in turn has been found to be correlated with a decrease in blood pressure over time – especially if that ‘giving’ is meaningful, targeted and personalised (Elizabeth Dunn)

More to follow!

Behavioural (*nudge*) insights – part 1

I have just attended the 2015 Behavioural Insights conference in London.  Just to be clear I am new to this stuff, I am not a social psychologist, a health economist or an expert in behavioural insight. in fact up until a few weeks ago I didn’t know that there was a Behavioural Insights Team (referred to as *BIT* by all) who have been around for the last five years and describe themselves as ‘a social purpose company which is partly owned by the Cabinet Office’.  BIT have just completed an update report for 2013 – 2015 which explains what they do and what they have done over the last 2 years.  This and other publications can be found at:

Once I have had a chance to read the report I will share some snippets via this blog.

In the meantime I thought I would share what I (with all my own personal bias and lack of understanding) learnt and how I think it could relate to patient safety.  Part 1 describes my initial thoughts after the first morning.

Validation:  so it turns out that we are not alone in the patient safety world with our implementation struggles – there was a lot of agreement that ‘turning theory into practice is difficult”

Key themes:  Make it easy and provide the evidence (to show the change makes a difference or not).  Also don’t preach, don’t force yourself on people, be pragmatic and foster a culture of testing before simply adopting

  • Clearly we must do the same with safer practices

Replication:  this appeared to be a preoccupation by many – any findings, no matter how brilliant they appear to be must then be tested by replicating the study elsewhere – but make sure you involve those that did the original work in order to be truly  collaborative

  • This reminded me of our ongoing mantra related to the implementation of the surgical checklist and the view that it is more successful if ‘tested’ locally, adapted for the specific set of theatres and teams and only then embedded into practice when people feel it fits the ‘way they do things where they are’

Ethics:  another preoccupation – is it ethical to *nudge* people to behave differently, when is it ethical, when is it not?

  • Again – when we introduce a ‘safer practice’ or we focus on one harm at a time – we should also consider the ethics of working on one thing rather than another and whether the safer practice may solve a problem for some but not all – are we behaving ethically?

Defaults:  something ‘nudgers’ (is that a term) talk about a lot… apparently we are influenced by the default settings or simply too lazy to change them and this can mean we are ‘nudged’ to behave in a particular way.  Think about when you set up your new smart phone and you get a variety of options to accept or not – who doesn’t think that the default settings must be set for the most optimum use of that particular smart phone or it feels to daunting to change them.

  • So when we think about complex technical equipment in healthcare are the default settings supporting safety, minimising risk, preventing harm?

More to follow….