Social Science & Medicine 286 (2021) 114321

Contents lists available at ScienceDirect

Social Science & Medicine

journal homepage: www.elsevier.com/locate/socscimed

Effectiveness of nudges as a tool to promote adherence to guidelines in

healthcare and their organizational implications: A systematic review
Onyi Nwafor a, *, Rahul Singh a, Cassie Collier b, Dereck DeLeon c, Jim Osborne d, Jon DeYoung c
a
University of North Carolina at Greensboro, North Carolina, USA
b
University of Houston, Texas, USA
c
Cone Health, Greensboro, NC, USA
d
Triad Healthcare Network, Greensboro, NC, USA

A R T I C L E I N F O A B S T R A C T

Keywords: The shift in the United States in recent years toward value-based healthcare delivery models has brought
Adherence to guidelines renewed pressure on healthcare organizations to improve adherence to clinical and administrative guidelines
Nudges designed to deliver high quality care at lower costs. However, getting clinicians to adhere to these guidelines
Choice architecture
remains a persistent problem for many organizations. The use of nudges has emerged as a popular intervention in
Behavioral economics
Literature review
healthcare settings to promote adherence to both sets of guidelines. This systematic review aims to assess the
empirical evidence base on the use of various types of nudges and their effectiveness as a tool to promote this
adherence and to identify the boundary conditions under which they are effective. In our assessment of 83
empirical studies, we found compelling evidence that nudges are an effective tool for promoting adherence to
guidelines. However, much of this evidence relies heavily on studies focused on three types of nudges (increasing
salience, providing feedback, and default). Other types of nudges (anticipated error reduction, structuring of
complex problems, and understanding mapping) received far less attention. We also found that this literature is
primarily focused on whether nudge interventions work, with little consideration for organizational issues such
as cost effectiveness, impact on healthcare workers, and disruptions of established workflows and routines. We
offer observations and recommendations on how research at the intersection of organizational studies and health
services can improve our understanding of nudge interventions.

1. Introduction antibiotics is associated with unnecessary risk of adverse drug events,

The shift in the United States in recent years toward value-based
healthcare delivery models has brought renewed pressure on health­
care organizations to improve adherence to clinical and administrative
guidelines designed to deliver high quality care at lower costs. Under
these models, revenue is generally tied to reported metrics of clinical
quality in such a way as to ensure clinicians adhere to evidence-based
clinical practice guidelines and standards of care while also ensuring
documentation of all relevant details (Ellis, 2018). However, getting
clinicians to adhere to both the clinical guidelines to improve care and to
administrative guidelines to improve nonclinical outcomes remains a
persistent problem for many healthcare organizations (Lorenzetti et al.,
2018; O’Reilly-Shah et al., 2018).
For example, inappropriate or unnecessary prescription of
increased healthcare costs, and the prevalence of antibiotic resistant
bacteria (Fleming-Dutra et al., 2016; Meeker et al., 2014). Yet, despite
published clinical guidelines and decades of efforts to change prescrib­
ing patterns, the problem of unnecessary prescription of antibiotics
persists in many healthcare settings (Meeker et al., 2016). According to
governmental agencies such as the United States Agency for Healthcare
Research and Quality (AHRQ) and the Centers for Disease Control and
Prevention (CDC), nearly one in four antibiotic prescriptions in the
United States are unnecessary and each year, at least 2 million people
are infected with antibiotic-resistant bacteria, about 23,000 people die
as a result, and antibiotic resistant infections contribute about $20
billion to direct healthcare costs (AHRQ, 2019; CDC, 2021).
The use of nudges, either alone or as part of multicomponent in­
terventions, has shown promise in promoting adherence to both clinical

* Corresponding author. Bryan School of Business and Economics, University of North Carolina at Greensboro, 516 Stirling Street, Greensboro, NC, 27412, USA.
E-mail addresses: o_nwafor@uncg.edu (O. Nwafor), r_singh2@uncg.edu (R. Singh), cacollier2@uh.edu (C. Collier), dereck.deleon@conehealth.com (D. DeLeon),
Jim.Osborne@conehealth.com (J. Osborne), jon.deyoung@conehealth.com (J. DeYoung).

https://doi.org/10.1016/j.socscimed.2021.114321
Received 2 March 2021; Received in revised form 13 August 2021; Accepted 15 August 2021
Available online 18 August 2021
0277-9536/Published by Elsevier Ltd.
O. Nwafor et al.
and administrative guidelines (Yoong et al., 2020). Nudges are defined
as subtle changes in how choices are presented that can significantly
influence a decision maker’s behavior in predictable ways without
restricting choices or changing economic incentives (Thaler and Sun­
stein, 2008). For example, in order to reduce inappropriate or unnec­
essary antibiotic prescriptions, clinicians’ choices can be influenced if
they are presented with preset options (i.e., defaults) in an electronic
order entry system.
From a policy-making perspective, nudges are attractive because
they influence behavior without the use of regulatory processes or
economic incentives. From an organizational perspective, nudges are
attractive because they involve relatively cheap, small, and generally
palatable adjustments to operational workflows (Gill, 2018). And unlike
alternative strategies to promote adherence to guidelines such as system
reengineering and business process redesign or training and education,
nudges do not have disadvantages such as imposing workflow re­
strictions that may disrupt the way clinicians perform their tasks.
Moreover, once implemented, nudges are likely to perpetually influence
behavior without additional reinforcement. Consequently, behavioral
changes are less likely to decline to baseline levels over time as is the
case with other interventions such as training and education (Kaiser
et al., 2019; Stander et al., 2019).
These advantages of nudges have inspired a growing number of
research projects that have investigated their effectiveness in promoting
adherence to guidelines in healthcare. In turn, the growing popularity of
nudge-based studies has resulted in two attempts that we know of to
provide a systematic review of the evidence base for their effectiveness
(Nagtegaal et al., 2018; Yoong et al., 2020). Although these reviews
made important contributions, they were limited by their research ap­
proaches. For example, whereas Nagtegaal et al. (2018) conducted a
scoping review that described the reviewed material without critically
appraising individual studies or rigorously synthesizing evidence from
different studies to assess their organizational implications, Yoong et al.
(2020) reviewed literature review articles and thus did not examine the
original research studies. These two approaches raise questions about
the research implications of difficult tradeoffs between the breadth
(covering all available material) and depth (detailed analyses and ap­
praisals of a smaller number of studies) of the articles reviewed (Arksey
& O’Malley, 2005). Moreover, the application of nudges has been
examined across a variety of contexts—different care settings (e.g.,
primary care vs. emergency departments), task types (e.g., clinical vs.
administrative tasks), provider-level demographic groups (e.g., nurses
vs. physicians or experienced vs. inexperienced clinicians), and adopted
different units of randomization (e.g., patient, unit, or organizational
levels). However, existing reviews have made little attempt to synthesize
and identify associations between the efficacy of nudges (or lack
thereof) and the contexts in which they were applied. Without such
considerations, our knowledge of the effectiveness of nudges to promote
adherence to guidelines is likely to remain limited.
Management research in fields such as organizational theory, orga­
nizational behavior, management information systems, and operations
management emphasizes that decision-making and behavior depend
largely on context or situational settings in which workplace phenomena
occur (Cooper et al., 2014; Joshi and Roh, 2009). For example, clinicians
in different care settings characterized by different levels of workloads
or urgency of care (e.g., emergency room vs. primary care) may make
different decisions when exposed to the same intervention. Likewise,
individual attributes such as experience and task attributes (e.g., clinical
vs. administrative tasks) have been shown to affect decision-making and
behavior (McElroy and Dowd, 2007; Speier et al., 2003). Further,
because nudges are not monolithic—in the sense that they are of
different types—and their implementation often triggers new situations
that decision makers may experience differently (Thaler and Sunstein,
2008), different types of nudges may generate different responses
among decision makers.
These responses could also differ by work contexts, likely resulting in
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Social Science & Medicine 286 (2021) 114321
person-situation variations in the efficacy of different nudge types
(Johns, 2006). Moreover, because organizations tend to have resource
constraints (e.g., time, money, skills) that must be balanced against
competing priorities and different nudge types impose different de­
mands on organizational resources, nudges are likely to unintendedly
affect organizational processes and performance outcomes over and
above their effects on adherence to guidelines.
All these aspects of nudges suggest that their effects on adherence to
guidelines may differ according to factors such as type, organizational
context, tasks, and clinicians’ attributes. They may also result in unin­
tended consequences that can enhance or diminish their overall benefits.
Thus, if we are to better understand the efficacy of nudges as a tool to
promote adherence to guidelines and to inform managers of appropriate
application conditions for these interventions, we must identify oppor­
tunities to integrate ideas from the foundational fields of nudges—­
psychology and behavioral economics—with organizational theories.
Such endeavors should provide insights into how to effectively design
and implement nudges in organizations; they also should provide a
framework through which researchers can identify mechanisms that
explain the effects of nudges on behavioral and organizational out­
comes. Cross-fertilization of these research disciplines could also shed
light on spillover effects, unintended consequences on organizational
processes, and how to manage them.
Accordingly, our primary objective here is to present a systematic
review of studies that have assessed the effectiveness of various kinds of
nudges in improving clinicians’ adherence to guidelines. In addition to
assessing the evidence base on the effectiveness of nudges for this pur­
pose, we also have undertaken to identify whether the contexts in which
nudges are applied affect their effectiveness. Achieving this primary
objective requires a focus on studies that have quantitatively assessed
behavioral changes in adherence to guidelines because of nudge in­
terventions. A secondary objective is to identify research opportunities
at the intersection of foundational theories for nudges and organiza­
tional fields that may advance our understanding of how to design and
implement nudges that effectively promote adherence to guidelines and
also inform theory-guided explanations for the organizational impact of
nudges. Achieving this secondary objective requires careful assessment
of the scientific evidence of the effects of nudges across different
contexts.
Our study departs from its predecessors in notable ways. Unlike their
focus primarily on adherence to clinical guidelines, our focus is on both
the clinical and administrative guidelines involved in delivering
healthcare. This dual focus is necessary to ascertain if the same nudges
that are effective with adherence to clinical guidelines are equally
effective with adherence to administrative guidelines. Second, we have
gone beyond the previous research that was mostly preoccupied with
atheoretical approaches narrowly focused on behavioral outcomes and
sought insight into the conditions under which nudges promote adher­
ence to guidelines. We also have assessed the organizational impacts and
issues associated with implementation of these nudges, topics largely
unaddressed in previous research. In pursuing a more holistic approach
to designing and implementing nudges in healthcare, we aim to identify
opportunities for cross-fertilization of theoretical ideas from the well-
established literature in psychology, behavioral economics, and orga­
nizational behavior and theory. This approach should also provide re­
searchers and practitioners with broader perspectives to use in assessing
and explaining the effectiveness of nudges in healthcare environments.
Our study makes two major contributions to the literature. First is
our synthesis of a fragmented body of work and our identification of
conditions under which nudges are likely to improve adherence to
guidelines. Such a synthesis and assessment of the varieties of nudges
available and the conditions under which they work best is essential to
effective design of nudges. Without a comprehensive assessment of the
variety of nudge interventions available and the conditions under which
they are effective, it is difficult to design effective interventions and
challenging to identify contextual factors that determine their success or
O. Nwafor et al. Social Science & Medicine 286 (2021) 114321

failure. Thus, we provide a repository of evidence on the use of nudges to Table 1

promote clinicians’ adherence to clinical and administrative guidelines. Common examples of cognitive biases and heuristics that can be exploited to
Second, by advocating for a holistic approach in investigating the promote adherence to guidelines.
effectiveness of nudges, we also contribute to the literature by identi­ Cognitive Bias/ Description Possible Application to
fying key knowledge gaps that can be filled by cross-disciplinary Heuristic Promote Adherence to
research at the intersection of health services research and organiza­ Guidelines

tional studies. Few theory-based explanations exist to guide the more in- Affect heuristic A mental shortcut that Providing physicians
depth research investigations needed to advance beyond simple obser­ allows people to reach information about the cost of
decisions quickly by relying medications and their
vations of “what nudges work” to a contextually situated understanding
on their emotions (affect). relative benefits at the time
of “when nudges work”, while expounding on their relative effects of prescription order entry to
across various actors or settings. Throughout our discussion, we have curb healthcare costs by
highlighted several avenues future research can take to address these evoking a negative affect
gaps in the literature. Our conclusions inform healthcare administrators associated with expensive
choices.
and policymakers of the importance of adopting much broader per­ Anchoring effect Decision-makers’ tendency Implementing a pop-up alert
spectives on the use of nudges to promote adherence to clinical and to insufficiently adjust their within an EHR systems that is
administrative guidelines and put forward research directions in this assessments of a situation activated at the time of
area. based upon previously prescription order entry with
presented external the following sample
information (the “anchor”), message:
2. Background leading to assessments that “Ideally we would like our
remain closer to the anchor physicians to consider
2.1. Nudges than they would have been prescribing Drug A because it
without the anchor. has been proven to be effective
in treatment of various
The concept of nudges originated in the behavioral economics bacterial infections.”
discipline and in recognition that when faced with prediction problems, This starting information
decision makers often rely on simple heuristics or rules-of-thumb. This serves as an anchor that
sort of reliance tends to result in cognitive biases, or predictable dis­ influences subsequent
decisions.
tortions in decision-making that can ultimately result in suboptimal
Availability A mental short-cut in which Use of text, color, pictures,
outcomes (Thaler, 2018; Tversky and Kahneman, 1974). For example, heuristic decision-makers rely on animation, and location to
although it seems rational that clinicians operating under value-based immediate examples or influence which information
payment models would choose to adhere to care standards and guide­ previous events that are easy or action is readily available
lines designed to improve patient outcomes and the practice’s revenue, to recall. in memory and, in turn, the
choice alternative that a
they often fail to do so. This failure may be because they do not perceive
decision-maker will
a clear cause-and-effect relationship between their individual actions ultimately adopt.
and the benefits, which generally occur in the future. Bandwagon effect Decision-makers’ tendency Nudging physicians toward
However, because when faced with new options, decision makers to adopt an activity or preferred decisions by
behavior because they providing them with
prefer to choose the status quo alternative—resulting in a status quo bias
perceive that everyone else is information at the time of
(Samuelson and Zeckhauser, 1988), clinicians can be influenced to make doing it. prescription order entry
the desired decision by the inclusion of an opt-out default setting among about the proportion of other
their choices. Presenting choices with opt-out default settings exploits physicians in a health
decision makers’ innate preference for the status quo by leaving the network who choose lower
cost drug alternatives.
default option unchanged. Thus, defaults can be leveraged as nudges to
Loss/Gain framing Decision-makers’ tendency Providing physicians with a
promote behavior that accords with guidelines. effect or loss to choose a decision option gain-framed message to
The general premise behind nudges as a tool to change behavior is aversion bias based on whether the promote hand hygiene rather
that the way choices are presented, framed, or labeled influences what is decision option highlights than a loss-framed message
positive features (i.e., gains) (e.g., a message that
chosen and then acted on. Specifically, nudges work by exploiting de­
instead of negative features emphasizes the benefits of
cision makers’ cognitive limitations, biases, and behavioral tendencies (i.e., losses). hand hygiene rather than the
in a way that promotes nonrational behavior (Hansen, 2016). Table 1 risks of non-compliance).
provides examples of common types of biases and heuristics that deci­ Status quo bias/ Decision-makers’ preference Physicians may be required
sion makers can exhibit and how they can be exploited to promote Path of least for the current state of affairs to opt-out of a default order
resistance effect (baseline) because of the set.
adherence to guidelines.
perception that any change
from the baseline is less
2.2. Types of nudges advantageous.

In their seminal work, Thaler and Sunstein (2008) offered a cate­

factors such as decision makers’ experience, education, efficacy, and
gorization of nudges based on the implementation techniques available
task attributes with organizational attributes to provide alternative ex­
to a choice architect to address various cognitive limitations. These are
planations for behavioral outcomes (Rousseau and Fried, 2001). Johns
increasing salience of information or incentives (IS), understanding
(2006) suggested that context can manifest itself in numerous way­
mapping (UM), default choices (DF), providing feedback (PF), error
s—including the salience of situational features, a cross-level effect, or in
reduction (ER), and structuring complex choices (SC). These categories
the shaping of meaning—and create “situational opportunities for, and
are defined in Table 2.
constraints against, organizational behavior” (Johns, 2006, p. 387). For
example, decision-making and actions may be influenced by individuals’
2.3. Nudges in context
agency, their understanding of tasks and why the tasks are important to
the organization, or whether the decisions are made individually or with
Prior research suggests the pivotal role of context in influencing
peers (Baker and Mechtel, 2018; Yukl et al., 1999). Decision-making
behavioral choices. Context has been defined as the situational setting in
may also be influenced by organizational climate or culture, resource
which workplace phenomena occur (Joshi and Roh, 2009). Context links

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Table 2 to contextual conditions in existing research, little effort has gone into
Types of nudges. systematically reviewing the influence of context on the efficacy of
Nudge Category Definition Example of Nudge as nudge interventions. Thus, our understanding of the relative effective­
Behavioral Intervention ness of nudges in improving adherence to guidelines across different
Increasing salience Involves providing Use of text, color, animation, contextual conditions remains limited. Our systematic review attempts
of information or information that increases or alerts to make a decision to close these gaps by assessing nudges and the contexts in which they
incentives (IS) the prominence, option more salient. were applied. Our goal is to create a repository of empirical evidence
noticeability, or that guides policymakers and healthcare administrators in developing
conspicuousness of
information or an incentive
and implementing nudge interventions that promote guideline-
associated with decisional concordant behavior and also to identify opportunities for future
alternatives. research.
Understanding Involves simplification Use of a flowchart or
mapping (UM) (mapping) of the decision tree that
3. Methodology
relationship between a summarizes major guideline
decision maker’s choice recommendations for all
alternatives and the kinds of therapeutics and This review conforms to the Preferred Reporting Items for Systematic
outcomes associated with practices for a clinical Reviews and Meta-Analyses (PRISMA) guidelines (Moher et al., 2009).
those alternatives condition
Default choices (DF) Involves choice settings Physicians may be required
that place the desired to opt-out of a default order
3.1. Search strategy and study selection
choice alternative along the set.
path of least resistance. The We searched the Embase, Medline/Pubmed, Scopus, and Web of
path of least resistance Science databases to identify studies suitable for inclusion in this review.
refers to the choice
Additionally, we searched the Cochrane Library and reference lists of the
alternative that will apply if
decision makers do not take featured systematic reviews as a source of data. Our search strategy
active steps to change them combined search terms from three themes: (i) clinician (OR physician,
Providing feedback Involves providing decision Providing physicians nurse, resident, healthcare worker or professional) AND (ii) nudg* (OR
(PF) makers information about information about their choice architecture, feedback, default); AND (iii) adherence (OR
the consequences of their individual compliance rate
behaviors in order to against a guideline and how
compliance) to guidelines. Studies were deemed eligible for inclusion if
influence future behavior. their compliance rates rank they: (a) were written in English; (b) were published between 2010 and
in comparison to those of 2020; (c) used a quantitative empirical research design (descriptive or
other physicians in the case studies were excluded); (d) focused on a nudge intervention; (e)
network in order to elicit
included adherence to guidelines as an outcome variable (studies eval­
peer comparisons.
Error Reduction Involves the use of prompts Clinicians are required to uating intention to adhere were excluded); and (f) included physicians,
(ER) and “forcing functions” that accept or decline an order for nurses, residents, and/or healthcare professionals as subjects.
are designed to reduce the immunization with an The initial search from all sources yielded 1558 articles, a predict­
occurrence of common acknowledgment reason ably large number that was reduced to 1532 articles after duplicates
errors. They often include before entering new
active choice methods that information in a patient’s
were removed. Further scanning of titles and, if necessary, the abstracts
require clinicians to take chart. of each article ultimately reduced the number of studies eligible for full-
certain actions before a text screening to 123 records. Of these, 40 were excluded as not meeting
final task is completed. the inclusion criteria, resulting in 83 articles deemed appropriate for
Structuring complex Involves partitioning Structuring choices about a
data abstraction. Four research team members working independently
choices (SC) choice alternatives and cancer screening guideline
attributes into vivid around such issues as timing, and in duplicate performed the full-text screening. Any discrepancies
categories that can frequency, and invasiveness; were discussed and resolved by consensus. Fig. 1 illustrates the selection
influence allocations and providing explanations process.
involving simultaneous of screening choices to
choices. increase physicians’
understanding of the
3.2. Data abstraction
guideline (Purnell et al.,
2015). Using a standardized form created in Excel as a data abstraction tool,
details of the 83 included studies were then coded according to the
following broad categories: (a) publication details (author, journal, date
endowments, leadership, and managerial support (Ghoshal and Bartlett,
of publication); (b) study setting (location, care setting); (c) study design
1994). These factors influence behavior through a combination of in­
(sample size, level of analysis, analytic method, treatment and control
dividual psychological processes, personality traits, and social roles that
group, moderators, outcome measures); (d) description of nudge inter­
define normative behaviors and expectations as well as individual role
vention; and (e) effectiveness of nudge intervention used. We also coded
identities (Matsumoto, 2007). They also influence behavior through
data regarding conceptual issues such as the conceptual and operational
social processes enabled by the organizational environment. Addition­
definitions of nudges used in the studies as well as whether the studies
ally, the influence of these individual and situational factors on
were guided by theories from behavioral economics—the foundational
decision-making may vary when the level of analysis changes from in­
fields of nudges—or any other behavioral theories. All reviewers inde­
dividuals to groups or organizations (Klein and Kozlowski, 2000). As
pendently extracted data from a common random sample (10%) to
such, it is important to examine the role of context in decision-making
assess reviewers’ agreement regarding the dimensions of extraction and
and behavioral change studies.
quality of the study. Thereafter, two pairs of reviewers working inde­
Researchers have examined the effectiveness of nudges in promoting
pendently and in duplicate used the data extraction tool to retrieve data
guideline-concordant behavior across a variety of settings, levels of
from the remaining (90%) articles.
analysis, task types, and so forth. Nevertheless, most of these studies
have not considered how variations in contextual settings may impact
3.3. Assessment of risk of bias
the effectiveness of nudge interventions to improve (or impede) adher­
ence to guidelines. Unsurprisingly, given the lack of consideration given
During the data abstraction stage, we concurrently used the

4
O. Nwafor et al.
Fig. 1. PRISMA flow diagram.
Cochrane Risk of Bias Assessment tool (Higgins et al., 2011) to rate
studies for bias related to the randomization process, deviation from
intended intervention, missing outcome data, measurement of outcome,
and selective outcome reporting. Any discrepancies noted by indepen­
dent reviewers were discussed until consensus was reached.
4. Results
4.1. General study characteristics
Table S-1 in the online supplement presents a descriptive summary of
the 83 studies identified in our search. Of the 83 studies in the final
review, 41 (49.39%) were conducted in North America (U.S. with
45.78% and Canada with 3.61%). Twenty-seven (32.53%) were from
Europe (the U.K., Denmark, Germany, Norway, Switzerland, the
Netherlands, Spain, and Sweden); two were from Australasia (2.40%),
and five studies (6.02%) were reported from non-Western nations
(Argentina, Ghana, Hong Kong, Iran, and Kenya). The location was not
reported for eight studies (9.64%).
Regarding issues related to the conceptual and operational defini­
tions of nudges used in the studies as well as whether the studies were
guided by theories from behavioral economics or any other behavioral
theories, we found that 24 studies (28.92%) offered definitions of either
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Social Science & Medicine 286 (2021) 114321
the term “nudge”, the specific nudge interventions studied, or their
behavioral foundations. Of these, 11 studies conceptually defined the
term “nudge” while two studies conceptually defined the term “choice
architecture”. The remaining studies that provided any conceptual
definitions focused on specific types of nudges or their behavioral
foundations: six studies each conceptually defined various kinds of
feedback, two studies conceptually defined defaults, and one study each
defined behavioral prompts, psychological priming, and reminders.
Regarding the operational definitions used in the included studies,
we found that nudges were operationalized using various strategies
identified in Thaler and Sunstein (2008) framework. We elaborate on
the use of these strategies later on in Section 4.2. We also found that 21
of the 83 included studies were guided by theories of behavioral eco­
nomics. One study each relied on theory from the health belief model,
theory of motivated reasoning and confirmation bias, and theory of
planned behavior. Table S-2 in the online supplement provides a
descriptive summary of the conceptual and operational definitions of
nudges employed in the included studies as well as an indicator of
whether the studies relied on theories from behavioral economics or any
other behavioral theories.
The included articles used various study designs. Forty (48.19%)
were randomized controlled trials (RCT); 20 (24.1%) were noncon­
trolled before and after studies (NCBA); 8 were controlled before and
O. Nwafor et al.
after studies (CBA); five adopted a controlled interrupted time series
design (CITS); four studies each adopted a controlled clinical trial (CCT)
and noncontrolled interrupted time series design (NCITS); one study
each was based on simulation analysis (SIM) and statistical process
control (SPC) methods. Summary graphs of study distributions by
location and study design are shown in panels (a) and (b) of Fig. 2,
respectively.
Overall, 63 studies (75.90%) of the 83 reviewed reported success in
improving clinicians’ adherence to clinical and administrative guide­
lines; eight studies (9.64%) reported no success in improving adherence.
The other 12 studies (14.46%) reported mixed results.
4.2. Types of nudge strategies used
We examined researchers’ uses of the six nudge types identified in
Thaler and Sunstein (2008)—and introduced earlier as IS, UM, DF, PF,
ER and SC—as interventions to promote clinicians’ adherence to
guidelines. Our review showed that extant research has examined the
use of all six nudges strategies to promote adherence to guidelines.
Fig. 2. General characteristics of included studies.
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Social Science & Medicine 286 (2021) 114321
However, in 23 of the studies (27.71%), the intervention involved a
combination of nudge strategies (e.g., IS in combination with DF or PF),
but some other studies involved the use of a nudge strategy as part of
multicomponent intervention—which we defined as an intervention
combining nudge and nonnudge strategies (e.g., IS used in conjunction
with training). Most studies we reviewed (77.11%) used the various
nudge strategies as single-component interventions, but others (20.48%)
used them as part of multicomponent interventions.
Increasing the Salience of Information (IS). The most frequently
used nudge strategy was IS, increasing the salience or prominence of
information or incentive used to direct subjects’ attention to the desired
choice that conformed to guidelines. It was used in 50 (60.24%) of the
studies and used alone in over a third of them (34.94%) and combined
with PF in 18 (21.69%) as well as with ER, DF, and SC in one study
(1.2%) each. Of the 29 studies that used IS alone, 24 (82.76%) reported
successful results, and one reported mixed results. When used in
conjunction with other choice architecture strategies, including PF (18
studies), two-thirds of the studies (66.67%) reported success, and five
(27.78%) reported mixed results. Taken together, of the 50 studies that
O. Nwafor et al.
used IS as a choice architecture strategy, either alone or in conjunction
with other nudge strategies, 37 (74.00%) reported success, six reported
a lack of success (12.00%), and seven (14.00%) reported mixed results.
Providing feedback (PF). Providing feedback, the choice architec­
ture strategy in which decision makers are nudged toward choices by
receiving information about past performance, was another popular
intervention investigated. Its use was examined in 35 of the studies
(42.17%). Of these, it was used as the sole intervention in 15 (18.07%)
and used in combination with DF in two studies (2.41%). As previously
mentioned, it was also used in combination with IS in 18 (21.69%)
studies. In the 15 studies that used PF alone, 11 studies (73.33%) re­
ported improved adherence to guidelines by care providers. In those
studies in which feedback was used in conjunction with IS, 66.67% re­
ported success. However, when combined with DF in the two studies we
reviewed, results were mixed, with one study reporting success and the
other reporting that the combination of DF and PF was not successful.
Default Choices (DF). Eight of the 83 studies (9.64%) investigated
the efficacy of DF to nudge participants into improving adherence to
guidelines, and all of them reported success. Users often do not change
DF, which can allow choice architects to significantly influence
conformance through careful choices in the default options they present
to decision-makers. However, in three of these studies, DF were used in
combination with other nudges. Two studies combined DF with PF with
mixed results in which one was successful and the other was not; another
study unsuccessfully combined DF and IS.
Other choice architecture strategies. Other choice architecture
strategies, including ER, SC, and UM, were investigated less frequently
in the studies we reviewed. Only five (4.82%) of the 83 investigated ER
by itself. Four of these reported success in improving adherence to
evidence-based guidelines, and one reported mixed results. One study
(1.20%) investigated ER in conjunction with IS and reported improved
compliance with evidence-based guidelines. Two studies investigated
SC. One reported success, and the other reported mixed results. In one
study, researchers investigated the use of SC along with IS and found
mixed results. In the one study in which it was used, UM was reported as
a successful strategy for improving adherence to guidelines. Fig. 3 pre­
sents a graphical summary of the success rate of the different nudge
strategies.
Fig. 3. Success rate of nudge interventions.
7
Social Science & Medicine 286 (2021) 114321
4.3. Study context
Settings. Fifty of the studies (60.24%) were conducted in inpatient
settings, 30 (36.14%) were conducted in outpatient settings, and one
(1.20%) was performed in a health system that included both types of
facilities. Two studies (2.41%) used a framed (i.e., vignette-based)
experimental design approach and as such, did not capture real-world
behavioral changes. The outpatient settings in the studies were gen­
eral primary care facilities, specialized primary care facilities, and
community health centers. The inpatient settings consisted of general
and specialist hospitals and long-term care facilities. Most of the studies
conducted across both care settings—inpatient (70%), outpatient
(83.33%) and both settings (100%)—reported improved adherence to
guidelines by care providers. Panel (a) of Table 3 summarizes these
findings.
Task Type. The outcome measure of interest for all included studies
was behavioral change with respect to adherence to guidelines. The
guidelines could pertain to clinical or administrative tasks. Like Rebuge
and Ferreira (2012), we defined clinical tasks as those directly linked to
a patient and executed according to a diagnostic-therapeutic cycle
comprising observation, reasoning, and action; administrative tasks are
generic organizational process patterns that support medical treatment
processes in general. Administrative tasks aim to coordinate medical
treatment among different people and organizational units. Examples of
clinical tasks include diagnostic and therapeutic procedures performed
for a specific patient. Examples of administrative tasks include processes
such as patient scheduling, medical order entry, and result reporting.
Seventy (84.34%) of the reviewed studies assessed adherence to
guidelines related to clinical tasks, and 12 studies (14.46%) assessed
adherence to guidelines related to administrative tasks. One study
(1.20%) examined adherence to both clinical and administrative
guidelines.
Most of the studies that considered clinical tasks focused on adher­
ence to evidence-based guidelines for the treatment of specific diseases
(e.g., Geary et al., 2020; Schnoor et al., 2010), but the majority of the
study studies that considered administrative tasks focused on guidelines
that promote documentation (e.g., Holt et al., 2010) and selection of
lower cost drugs, treatments and procedures, or supplies (e.g., Langley
et al., 2018; Olshan et al., 2019; Patel et al., 2014; Offodile et al., 2020).
O. Nwafor et al. Social Science & Medicine 286 (2021) 114321

Table 3
Nudge intervention success rates in various contexts.
Total Successful Mixed Evidence Not Successful

(N) (N) (%) (N) (%) (N) (%)

(a): Nudge intervention success rate by study setting

Inpatient 50 35 70.00% 8 16.00% 7 14.00%

Outpatient 30 25 83.33% 4 13.33% 1 3.33%
Inpatient & Outpatient 1 1 100.00% – – – –
Framed Experiment 2 2 100.00% – – – –
(b): Nudge intervention success rate by task type

Clinical 70 54 77.14% 11 15.71% 5 7.14%

Administrative 12 8 66.67% 1 8.33% 3 25.00%
Clinical and Administrative 1 1 100.00% – – – –
(c): Nudge intervention success rate by level of analysis

Individual Level 60 45 75.00% 8 13.33% 7 11.67%

Group Level 11 9 81.82% 2 18.18% – –
Organizational Level 11 8 72.73% 2 18.18% 1 9.09%
Network Level 1 1 100.00% – – – –

Among the studies that considered clinical tasks, over 77% found
various nudges effective in promoting adherence to guidelines, and
two-thirds (67%) of the studies focused on administrative tasks found
the various nudge strategies to be effective in promoting adherence to
guidelines. Panel (b) of Table 3 summarizes these findings.
Levels of Analysis. Although the subjects of the studies were clini­
cians (physicians, nurses, physician assistants, residents, medical stu­
dents, and fellows), the outcome variables in the reviewed studies were
analyzed at various levels. Sixty (72.29%) were analyzed at the indi­
vidual level; 11 studies each (26.50%) were analyzed at the group and
organizational levels, respectively. One study (1.20%) considered the
impact of the intervention on outcomes for the entire health network
that the care providers belonged to. Panel (c) of Table 3 summarizes
these findings.
4.4. Risk of bias
As previously mentioned, we used the Cochrane Risk of Bias
Assessment tool (Higgins et al., 2011) to rate studies for bias stemming
from the randomization process, deviation from intended intervention,
missing outcome data, measurement of the outcome, and selective
outcome reporting. Forty studies were rated as low risks for bias arising
from the randomization process, 22 raised some risk concerns, and 21
were rated as high risks. As for deviations from intended interventions,
49 studies had low risks of bias, 27 had some risk concerns, and seven
were rated as high risks. For missing outcome data bias assessment, 63
studies had low risk, 16 had some risk concerns, two studies had no
information, and two had high risk. For measurement of outcome data
assessment, 47 studies had low risk of bias, 32 had some risk concerns,
and four were rated as high risks. For the assessment of selective
outcome reporting, 18 studies had low risk of bias and 65 studies had
some risk concerns. A graph summarizing the risk of bias assessment is
presented in Fig. 4, and the risk of bias assessments for each study is
provided in Figure S-3 in the online supplement.
Overall, we found that for most of the 83 studies we reviewed, the
risk of bias for the five outcomes assessed were high. Major factors
contributing to the high risk of assessment rating include the inclusion of
several nonrandomized studies that adopted quasi-experimental de­
signs, lack of similarity of groups at baseline levels, lack of statistical
measures to reduce confounding, and lack of information on pre-
specified plans.
4.4.1. Publication bias concerns
The Cochrane Risk of Bias Assessment tool assesses the risk of bias in
each study included in a systematic review, including selective outcome
reporting bias—or bias that arises because the reported result is selected
from among multiple intervention effect estimates that were calculated
by the trial investigators. It does not deal with publication bias arising
from the selective reporting of results either because of non-publication
of whole studies or suppression of a subset of outcomes based on their
direction, magnitude, or statistical significance (Sterne et al., 2019).
Several studies have highlighted that positive outcome studies are more
likely to be published than negative or null outcome studies, thereby
rendering findings from the reviews that are based on these studies
susceptible to publication bias (Harriman and Patel, 2016). The litera­
ture suggests two broad strategies to ameliorate publication bias con­
cerns (Page et al., 2021). First, reviewers can expand the scope of search
beyond traditional databases of published articles to include “gray
literature” such as unpublished government or institutional reports,
regulatory documents, and unpublished datasets. The general idea
behind this approach is that by searching multiple sources for study
inclusion, reviewers are able to include research findings that are
ostensibly unaffected by selective non-reporting. Alternatively, re­
viewers can restrict their analysis to studies that were registered prior to

Fig. 4. Risk of bias summary plot.

8
O. Nwafor et al.
their inception, or at least prior to the availability of their results (an
“inception cohort”). The general idea behind the inception cohort
approach is that if all relevant results are available for prospectively
registered studies, then there should be no bias due to missing or
selectively reported results (Berlin and Gersi, 2005; Page et al., 2021).
While useful, both approaches suffer serious limitations. Limitations
of the expanded search approach include difficulty identifying unpub­
lished data that researchers have chosen not to disclose, difficulty
interpreting regulatory documents, and long delays between request and
receipt of unpublished data from researchers and regulatory agencies
(Isojarvi et al., 2018; Page et al., 2021). The major limitation of the
inception cohort approach is that the precision of the literature review
may be low if there exist only a few studies prospectively registered
studies addressing the review question (Page et al., 2021).
Given the limitations of both approaches and the heterogeneity in
study designs which limits the applicability of a statistical assessment,
we found it reasonable to compare study findings from the complete
sample of included studies (n = 83) against findings from an inception
cohort to assess whether results from both groups differed in a way that
might be indicative of serious publication bias or selective reporting. We
generated an inception cohort by searching all included studies to
identify those that were prospectively registered in clinical trial regis­
tries (Berlin and Gersi, 2005; Page et al., 2021). Of the 83 studies, 18 (or
21.69%) were pre-registered. A comparison of the prespecified study
plans of the preregistered studies with completed reports showed no
evidence of selective reporting of key outcomes. Therefore, one can be
reasonably assured that the evidence from our inception cohort has low
sensitivity to publication bias. A comparison of the success rates of the
inception cohort vs. the complete sample of included studies showed
that the success rates of both samples have relatively similar distribution
patterns and that most nudge intervention studies tend to be successful
(see Table S-4 in the online supplement). However, because of the
relatively small size of our inception cohort, it is reasonable to conclude
that the risk of publication bias still remains in our synthesis of the
literature.
5. Discussion
Our review of the literature on the use of nudge interventions to
promote adherence to clinical and administrative guidelines reveals that
researchers have examined all six nudge strategies identified in the
Thaler and Sunstein (2008) framework. In decreasing order, the fre­
quency of investigations into the interventions was: IS, PF, DF, ER, SC,
and UM. We found this evidence base on the effectiveness of nudges to
be compelling. However, we note that much of this evidence relies on
studies predominantly focused on increasing the salience of information
presented, providing feedback, and/or defaults either individually and
in conjunction with one another (75 of the 83 studies or 90.36% we
reviewed used IS, PF, and DF, either individually or in combination with
other nudges).
This finding suggests continuing uncertainty about how well other
nudge interventions (i.e., ER, SC, and UM) work to promote adherence
to guidelines. Further, although our review also indicates that re­
searchers demonstrate a preference toward studying the impact of
increasing the salience of information feedback and defaults, it did not
reveal the rationale for this significant preference, either by clinicians,
healthcare organizations or by the researchers themselves. Some in­
terventions are plausibly easier to incorporate into workflow processes,
clinical decision support systems, or other electronic health record
(EHR) applications, thus making these nudges more attractive as in­
terventions to promote adherence to guidelines. However, because of
the preference for the IS, DF, and PF nudge strategies in the literature,
other strategies that may be equally effective techniques for behavioral
change remain under-researched. This suggests an opportunity for re­
searchers to examine the relative efficacy of understudied nudge stra­
tegies in their role as choice architecture strategies to effect improved
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Social Science & Medicine 286 (2021) 114321
adherence to guidelines.
The prevalence of some nudge strategies, and conversely the lack of
research attention to others, also raises the question of whether exoge­
nous factors are in play that encourage or deter researchers and
healthcare organizations from investigating their effects on improving
adherence to guidelines. Our review of the literature did not answer this
question. For example, are there organizational capabilities or con­
straints that systematically influence the decision to adopt certain
nudges, and do these organizational factors have performance conse­
quences? Without research that examines the organizational perspective
and its influence on adherence to guidelines, our knowledge of the
relative efficacy of various nudge strategies remains incomplete. Some
nudges may be more popular than others because of their minimal dis­
ruptions on clinical or administrative workflows. Although this may
make them easier to implement, we do not know the relative efficacy of
these strategies in improving adherence to guidelines. Thus, the trade­
offs between efficacy and ease of implementation may lead to subopti­
mal choices of nudge interventions.
Organizational research emphasizes concepts such as tradeoffs,
contingencies, and unintended consequences. These convey the notion
that an intervention that results in desirable outcomes in one area (e.g.,
improved adherence to guidelines) may result in detrimental outcomes
in another (e.g., alert fatigue or job dissatisfaction). Our review of the
literature revealed a lack of consideration of these concepts, with the
notable exception of Offodile et al. (2020). They investigated the impact
of nudges on guidelines to reduce the cost of supplies used for surgical
operations as well as an assessment of whether the expected cost
reduction had any negative impacts on quality. Without a holistic
investigation of the organizational implications of nudge strategies,
healthcare organizations may overstate their benefits or not consider
impacts in other areas. The lack of attention to these organizational is­
sues presents researchers with an opportunity to use complexity and
contingency theories, among others, to study the organizational impact
of using nudge strategies to improve adherence to guidelines.
In investigating the efficacy of nudge strategies to improve adher­
ence to healthcare guidelines, researchers have studied their impact by
incorporating them into the decision environment in numerous ways.
For example, to study the impact of IS, some researchers have used text,
color, pictures, animation, and location to ensure the information or
action is readily available in memory and, in turn, subsequently avail­
able to influence the alternative decision that a decision maker will ul­
timately make (Meeker et al., 2014). Others used the physical
positioning of medical supplies to promote their usage (Caris et al.,
2018; Chan et al., 2013) and framed messages to influence a choice of
action (Page et al., 2011). Even among broad approaches to information
presentation (e.g., visual cues, physical positioning; and framing), we
found considerable differences across studies.
For example, when attempting to increase salience by framing, re­
searchers have highlighted the positive features of tools or procedures (i.
e., gains) instead of their negative features (i.e., losses) to exploit the loss
aversion cognitive bias. They have also attempted to increase salience by
providing information in a manner that anchors a certain choice or ac­
tion against a benchmark (e.g., peer performance) as a way to bring to
clinicians’ attention the cost of prescriptions or to reduce unnecessary
tests and procedures, all with the ultimate goal of reducing healthcare
costs (Fogarty et al., 2013; Offodile et al., 2020). As research into the use
of nudge strategies matures, studies of the relative effectiveness of
various nudge strategies are likely to emerge. Such studies should pro­
vide further guidance on which nudge strategies can be implemented to
improve clinical practices with the least burden on clinicians, in­
terruptions to workflow, or cost requirements. Such research is currently
not available.
We also found that no matter the approach used to incorporate
nudges into the decision environment, their integration into various
EHR applications, such as computerized physician order entry systems
(CPOE), appeared to be the dominant mode of implementation. For
O. Nwafor et al.
example, IS interventions were mostly implemented by building visual
cues and alerts into EHR systems (e.g., Maidlow et al., 2019). Given the
popularity of EHR systems as a vehicle for the implementation of nudge
strategies, it is important to also consider that these systems have
brought numerous unintended adverse consequences to healthcare or­
ganizations. These include disruptions of work processes, burdensome
documentation, and cognitive overload (Gephart et al., 2015; Vander­
hook and Abraham, 2017).
Thus, a significant need exists for research into the extent to which
nudges ameliorate or exacerbate these adverse events, the strategies or
workarounds used to minimize these unintended consequences, and the
effects of the workarounds on the efficacy of nudge interventions. For
example, alerts and reminders that prompt specific actions are often
implemented in EHR systems to nudge clinicians to undertake specific
courses of action (Dexter et al., 2001). However, evidence suggests these
alerts are often overridden (Van Der Sijs, 2006) because of
alert-fatigue—a phenomenon in which too many alerts may engender
cognitive overload and subsequent failure of a decision maker to
recognize the relevance of the alert to the current citation.
These challenges highlight the opportunities for researchers to use
research from other disciplines, such as psychology, human-computer
interaction and information systems, to provide richer understandings
of how to design choice architecture interventions in a way that in­
creases their effectiveness in improving adherence to guidelines in
healthcare environments.
As previously mentioned, most studies (75.90%) reported that
nudges were successful in promoting adherence to guidelines. The high
success rate was observed across task types (i.e., clinical vs. adminis­
trative); research contexts (i.e., inpatient vs. outpatient settings); levels
of analysis (i.e., individuals, teams, or organizations) and whether they
were applied alone or in combination with other interventions. This
finding leads us to competing conclusions. On one hand, the high success
rate of nudge interventions may suggest strong empirical evidence exists
to support the notion that nudges are generally effective in promoting
adherence to guidelines. Given the advantages of nudges over
commonly used alternatives, such as training and financial incentives,
this finding makes a compelling case for healthcare administrators to
consider nudges as the intervention of choice to effect behavioral
change. On the other hand, the high success rate in our sample could
stem from researchers’ tendency to report only successful interventions
while underreporting unsuccessful ones. Although our study took steps
to account for the threat of publication bias or selective non-reporting,
we note that publication bias remains a potential threat in all areas of
research—including qualitative research, primary quantitative studies,
narrative reviews, and quantitative review—and no single approach
eliminates it nor is there an approach without limitations. Under­
reporting of unsuccessful nudge interventions, including the reasons for
failure, means that researchers miss an opportunity to learn from un­
successful strategies. Thus, significant gaps remain in our knowledge
and ability to evaluate the effectiveness of nudge interventions.
A relatively small number of studies (21.68%) investigated the effi­
cacy of nudges as part of a multicomponent intervention where the
nudges were combined with nonnnudge interventions. For example, PF
was frequently used as part of multicomponent intervention studies and
was combined with training interventions, organizational changes (e.g.,
renewed leadership commitment), and expanded opportunity for pa­
tient engagement (e.g., Rodriguez et al., 2015; Stewardson et al., 2016;
Yeun et al., 2011). In these studies, when PF was used as part of a
multicomponent intervention, its success rate appeared to be worse than
when it was used alone. However, the relatively small number of studies
that employed multi-component interventions demands caution in how
we interpret the superiority of multicomponent interventions to
improve adherence to guidelines. In the aggregate, both single and
multicomponent studies reported high success rates, 73.85% and
83.33%, respectively. Because most interventions tended to be suc­
cessful, our review suggests that it is unclear whether multicomponent
10
Social Science & Medicine 286 (2021) 114321
interventions provide additional benefits. As such, the decision of
whether to design and implement single component vs. multicomponent
nudge interventions should be based on other organizational charac­
teristics and resource constraints (e.g., financial and time constraints),
strategic goals and timelines, physicians’ readiness to adopt/implement
interventions, and so forth. Thus, the intersection of organizational
studies and medicine represents a significant opportunity to advance our
knowledge of nudge interventions in healthcare.
5.1. Limitations
Although the studies we reviewed provided important insights on
how nudges can be used to improve adherence to guidelines in health­
care settings, we observed significant inconsistencies in the definitions
of nudges in terms of the underpinnings of these interventions in the
theories of behavioral economics. This resulted in definitional in­
consistencies that complicated the comparisons of nudge strategies
across studies, a difficulty that should be considered a limitation of our
study. Moreover, many studies we reviewed examined either multiple
nudge interventions or treated them as part of a multicomponent,
making it difficult to isolate the effects of distinct types of nudges.
5.2. Conclusion
Three major points emerge from the foregoing discussion, and these
present opportunities to advance research at the intersection of orga­
nizational studies and healthcare: (1) There is a narrow focus on un­
derstanding whether specific nudges work, and too little research
attends to the organizational conditions under which they work, which
leads to a paucity of holistic investigation in this area; (2) To fully un­
derstand the effectiveness of nudges on individuals (e.g., patients and
clinicians) and healthcare organizations, it is necessary to provide
contextual assessments of nudges in use; and (3) The literature will
benefit greatly from cross-fertilization of ideas from related disciplines
such as information systems, psychology, organizational behavior, and
organizational theory, all of which could be very useful in identifying
contextualized explanations of where, why, and under what conditions
some nudges outperform others in improving adherence to guidelines.
These disciplines have a longstanding tradition of using robust theories
to identify relevant task, individual, and organizational level factors that
can advance a more nuanced and contextualized understanding of the
effectiveness of nudge strategies to improve adherence to evidence-
based guidelines.
Appendix A. Supplementary data
Supplementary data to this article can be found online at https://doi.
org/10.1016/j.socscimed.2021.114321.
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