Can ‘nudge’ help IBA delivery?

17 Dec

IBA works to reduce risky drinking, but despite significant efforts, regular good quality IBA delivery seems some way off. However there may be some simple ‘nudges’ for supporting IBA delivery that are being overlooked. nudge

‘Nudge theory’ became popular following the Coalition Government’s favour for policy approaches that did not restrict choice or require legislation. It set up a ‘nudge unit’ and its controversial public health responsibility deal. However reports have warned that nudge alone is not enough to change behaviour at population level, though it may have a useful role to play.

IBA itself is not really a ‘nudge’, it is a more conscious and collaborative form of intervention. ‘Nudges’ are more about changing the environment to affect non-conscious decision making. Popular ‘nudge’ examples include placing healthier food choices in more visible places or designing buildings with stairs more accessible than the lifts. In an Amsterdam airport, an image that looked like a fly embossed in the men’s urinals apparently resulted in an 80% reduction in ‘spills’ by focusing the men’s aim! Use of incentives may also be considered ‘nudging’, but there has been lots of debate over what may be ‘nudge’, ‘shove’ or ‘push’.

However, policy and actions to encourage IBA delivery by front-line roles is often in line with ‘nudge’ theory. For instance, incentives and recording systems may mean that screening (identification) tools,  like the AUDIT, may pop up on a nurse’s computer screen. Or GP practices collect a payment when offering IBA to new patients when they register.

Incentives may have gone some way to initiating IBA delivery, but have not proved enough in isolation. We need to make front line role’s work environments as conducive to doing IBA as possible. For example, having resources as easily accessible as possible. Having to print off screening tools or leaflets each time is off-putting and time consuming.

Some areas have produced ‘IBA packs’ for front line roles. Packs typically include all the tools and materials needed for IBA and posters or local referral options. Having resources already printed out makes it more likely for roles to initiate IBA and offer appropriate information. Ordering free alcohol materials from the DH orderline is not the easiest of processes.

There could be other ‘nudges’ we are missing out on. In some hospitals all staff have been given a credit card sized lanyard with the three AUDIT-C questions to wear alongside their staff badge. Roles often cite concern over asking patients about their alcohol use. Perhaps wearing a badge stating “I try to ask all patients about their alcohol use” could ease this pressure and remind them about IBA.

Just as reports have found for nudge in general, it’s not the solution, but it may be a part of it.

2 Responses to “Can ‘nudge’ help IBA delivery?”

  1. Niamh Fitzgerald December 18, 2013 at 10:11 am #

    Interesting post James. And some good ideas for helping practitioners feel more comfortable about asking – I like the lanyard idea (though am wondering why for alcohol, but not all the other things they are asked to screen for and how many lanyards can they wear?!!).

    As you say part of the solution but I wonder if more like tinkering – because I think in hospitals particularly the big things that make IBA happen are more important. These I would say are:

    – The hospital management, senior clinicians, and staff’s own line managers/team leaders all believe in, expect, and support IBA delivery.
    – IBA delivery is monitored and reported on a regular basis and each hospital is accountable for delivery (e.g. to local NHS CCG or board). What gets measured gets done.

    The rest of the stuff – training, resources, reminders, nudges – all help – but delivery won’t become normal unless it is built into systems, measured and reported. So what you’re saying about prompts on electronic systems is important – but are the screening fields mandatory to complete? The nudge becomes an on-screen stranglehold you can’t get out of without doing as it asks!

    • James Morris January 16, 2014 at 11:45 pm #

      Thanks Niamh. I think we need as many of these things as poassible all acting together to get routine, good quality IBA. We can rank them in order of importance but some of them are push and some are pull factors. Each setting will have its own unique barriers and opportunities – adding in nudges to places that have the systems set up may really give it a ‘boost’..

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