NUDGING from AUTOMATIC to REFLECTIVE

NUDGING

The "Nudge" theory was coined by economist Richard Thaler in 2008 with the release of his book "Nudge: Improving Decisions About Health, Wealth and Happiness", written with Cass Sustein. Their definition is: “A nudge, as we will use the term, is any aspect of the choice architecture that alters people’s behaviour in a predictable way without forbidding any options or significantly changing their economic incentives."

Far before Richard Thaler defined the term, however, examples of nudging have altered behaviours in history. An early example was put in place in 1919 when an American highway in Michigan had a white line put down the middle of the road in order to avoid car collisions. Something that has been prominent throughout all these examples is their simplicity. The Nudge theory follows a hybrid approach to influencing human behaviour as it is rooted in a combination of Behavioural Economics, Psychology and Political Theory. A classic nudge follows three traditions in psychology, as outlined by Dr David Halpern, CFO of the Behavioural Insights Team, at the LSE lecture on "Inside the Nudge Unit: how small changes can make a big difference":

1. Experiential and Perceptual e.g. looking for change, contrast, edges

2. Social Psychology e.g. how we behave and interact with each other

3. Cognitive Psychology e.g. how people think and make decisions

Nudging aims to create predictable behavioural outcomes through the premises of how the human brain perceives the world and makes decisions. The foundation of the nudge theory is based on a phenomenon known as Dual Process Theory (DPT). This is the separation between the automatic and reflective systems in our brain. As stated in the introduction, humans are primarily set in the automatic system as it conserves the most energy. This system controls most of our behaviour, however, those behaviours are often unconscious, fast and associative. In essence, this system is the 'auto- pilot' mode.

The second system, reflective, follows the opposite approach, as it is conscious thought, slow, analytical and consumes a great deal of energy. The reflective system requires more energy as it works by creating hypotheses based on prior experiences and knowledge before acting. This system can be activated by will, but it takes a lot more consideration and can only process a fraction of alternatives compared to that of the automatic system. This is why the reflective system tends to only be activated when presented with an odd, rare or potentially dangerous situation. It has to be prompted and 'awoken', so to speak. These two systems work side-by-side, aiding humans to conserve energy and make decisions. There are three main factors, however, that cause rifts in the partnership:

• The reflective system remains unaware of the problem

• The automatic processes provide us with the wrong response

• The reflective system provides us with the wrong response

For my Master’s dissertation titled “Nudging: From Automatic to Reflective”, I explored the theory of nudging and developed a case study on how behavioural design can be implemented to improve Barts Health NHS Trust's waste management. My thesis earned me a Distinction and motivated me to work for one of the world’s leading environmental consultancies.

The purpose of this dissertation is to demonstrate the importance of behavioural design and how it can go hand in hand with hospital waste management in order to enhance the triple bottom line: people, planet and profit. Incorporating the nudge theory to sustainability strategies is becoming increasingly relevant to companies today, as it has the potential to decrease a multitude of social, economical and environmental concerns we face. The research methodology was a practice based case study comprising of a series of interviews with experts within the field and fieldwork at the Barts Health NHS Trust, in collaboration with Barts Health, SKANSKA and the Carbon Trust. Through this research and inspired by Sille Krukow's case study, I have proposed a nudge to improve waste management and reduce cross contamination in Barts Health.

INTRODUCTION

The reason for why there is a gap between how we wish to behave and how we actually act is because humans operate under two systems: the automatic and the reflective. “Biologically we are coded to conserve as much energy as possible, and thus prefer to spend most of our time governed by the automatic system.” This results in passive decision-making, which normally does not benefit us in the long run. With our ever-increasing population, it is imperative to form more sustainable habits in order to address environmental concerns and lack of resources for the over 7 billion people on our planet. Hospitals are natural candidates for sustainable design as the public buildings place high demands on resources. They have a significant impact on the environment and economy due to their large consumption of energy and water and massive producers of waste. An estimated 40,000 people are hospitalised every day in the UK alone, which results in staggering amounts of carbon dioxide emissions. Carbon dioxide emissions attributable to the NHS in England are greater than the annual emissions from all aircraft departing from Heathrow Airport. Although actions have been put in place to reduce carbon emissions from hospitals, at present, there is still little information or guidance available regarding a hospital's visual environment, with specific focus on behavioural design. Being the fifth largest employer in the world , even the smallest changes to the National Health Service can have an enormous impact on the environment due to the massive scale. I chose to focus my research project on Barts Health NHS Trust, the largest Trust in England, as it can act as a microcosm of the NHS. Even within the Trust, which is comprised of 6 hospitals, there are variations between the hospitals and even in the hospitals themselves. This makes the Trust an interesting case study as it provides insights into prospective challenges the NHS might face with incorporating design solutions across various sites.

METHODS

EMPIRICAL DATA

I collected empirical data from both primary and secondary sources. From a three-month work placement at Carbon Trust, I was able to gain insights into statistical data on Barts Health waste management due to the Waste Management Standard awarded by Carbon Trust and their collaboration with SKANSKA. The statistics from the waste management data were useful in gaining an economic perspective as well as scope of how much annual waste the Trust produces and what improvements have already been put in place.

INTERVIEWS

I conducted informal interviews with various experts in the field including Fiona Daly, Environmental Manager of Barts Health, Catherine Burrows, Environmental Waste Manager of SKANSKA, Lazar Armianov, Senior Client Manager of Carbon Trust Certification, Joseph Williams who leads the Carbon Trust behaviour change work and Sara Flyvebjerg, Art Director of INDEX: Design to Improve Life® and previous Service Designer of iNudgeyou Development.

FIELDWORK & OBSERVATION

In order to understand the current waste management policies and practices at Barts Health I was fortunate enough to gain access to Whipps Cross Hospital for fieldwork, in which I shadowed a waste management training session as well as an auditing process. During my fieldwork, I paid particular attention to the placing of bins, the labelling and user-experience. It was vital to focus on the user, that being the staff, in order to understand their perception of medical waste management training and the difficulties they face during the current waste segregation process.

SURVEY

In order to determine if there was a staff-driven interest in sustainability and to ascertain what barriers they encounter during their day-to-day practice with regard to waste disposal, I also applied a survey. Through mapping my user research I was able to identify the unique challenges faced by Barts Health.

RESEARCH

In addition, I have also utilised external literature provided by SKANSKA and Carbon Trust as secondary sources to support my primary findings. From analysis of both primary and secondary research I was able to design and prototype a potential solution by applying the nudge theory.

PESTEL

I have analysed the solution scenario by applying a PESTEL model, in order to discover what Political, Environmental, Social, Technological, Economical and Legal implications my solution scenario has from a macro-environment perspective.

STAKEHOLDER ANALYSIS

Finally, I have applied a stakeholder analysis in order to discover who the key stakeholders are, their stakes in the company and how they will be impacted by the strategy. I selected a stakeholder analysis as it evaluates what the value propositions are and therefore draws attention to the benefits of the strategy. This has assisted in the conclusion of my thesis by outlining how the solution might help solve some of the barriers Barts Health faces through their current waste management strategy.

DELIMITATION

Although the improvement of waste management is important throughout the entire NHS, I have selected to focus my research dissertation on Barts Health NHS Trust due to the geographic location, their size, as they are the largest Trust in England, as well as the massive strides they have taken in improving sustainability through behaviour change in recent years. This makes it a particularly interesting case study to analyse as it provides guidelines for how other Trusts could improve their waste management. The project also allowed me to explore how implementing a nudge could help spur Barts Health towards achieving their goal of being the most sustainable NHS trust by 2020. A limitation I encountered during my research is that of the 6 hospitals of Barts Health, I was only able to obtain access for fieldwork at Whipps Cross Hospital. I have therefore selected this hospital to be the 'pilot site' for the prototype, which is fitting, as it is one of the least advanced in terms of waste management out of the 6 hospitals. Under the timeframe and due to the varying nature of the hospitals, it was more valuable for me to select one to focus on in more detail. The bureaucratic nature of hospitals and limited access is why I have only discussed a broad overview of the suggested implementation for my solution scenario; the finer details of the strategy are not essential to answering my problem formulation. Ideally, I would have tested my prototypes in their intended settings to assess their effectiveness, but administrative barriers meant it was beyond the scope of this thesis. I have chosen not to include any cultural probes or forecasting/backcasting, as with nudging it is imperative to have a more scientific approach with statistics and measurements. This is another reason why I have focused on waste management, which can be measured objectively, as opposed to something more subjective like mood and emotions, which are not easily measured against an original baseline.

RESEARCH

BARTS HEALTH NHS TRUST

Formed in 2012, through the merger of the Barts and The London NHS Trust and three other London-based NHS Trusts, Barts Health is the largest NHS Trust in England. Barts Health NHS Trust comprises of 6 hospitals - Royal London, The Chest, St Bartholomews, Newham, Whipps Cross and Mile End. With an annual turnover of over 1.25 billion pounds, the Trust employs 15,000 staff and delivers healthcare to over 2 million patients a year . Barts Health has ambitious goals of becoming the most sustainable NHS Trust in England and reducing their impact by 15% per patient by 2020. Although the Trust is a massive producer of waste, Barts Health has already made massive strides in improving their waste management processes. The Trust, which disposes of 6,000 tones of waste a year, has eliminated all of its waste from landfill since October 2013, increased recycling by 384% and saved the NHS over 700,000 pounds. These efforts have not gone unnoticed, as Barts Health was the first NHS Trust in England to receive the Carbon Trust Waste Management Standard. The standard aims to focus organisations to examine their resource use and environment impact, evaluating and measuring their use of the waste hierarchy.

SKANSKA PARTNERSHIP

These impressive results can be attributed to the drive towards cultural change within the staff and educating the importance of correctly segregating the waste streams. This has been achieved through the partnership with waste contractors, SKANSKA and the implementation of a new behavioural change program. Over the past two years, more than 5,000 staff members have been trained on waste segregation and over 180,000 individual bin audits have been carried out, resulting in improving compliance by almost 400%. There is clearly good communication between the Trust and SKANSKA. Fiona Daly, Environmental Manager at Barts Health NHS Trust, said: “It was important for us, when tendering the waste management service, that we chose a partner who fully aligned with our values, drove innovation and bought into our vision for a sustainable healthcare future. Our partnership with Skanska has already delivered excellence in data collection and reporting, quality assurance, compliance improvements and innovative solutions."

BACKGROUND OF BEHAVIOURAL CHANGE PROGRAM

Liam Hogg, SKANSKA's then appointed Waste Manager, who put the programme in place said: “Previously we emptied the waste into the incinerator and all you got out was black ash. But with the autoclave we could see what came out the other end, and there were all sorts of things, like chocolate boxes and daffodils. So yes, the NHS was paying to sterilise bunches of flowers.”

For more on that, download my thesis below.

CRITIQUE

A critique of Nudging is that some users may find the approach to be manipulative. Rainford and Tinkler argued at a lecture at LSE on Designing for nudge effects: how behaviour management can ease public sector problems, Innovating through design in public sector services seminar series: "Critics of nudge and libertarian paternalism argue that attempts to change people’s lifestyle choice are potentially patronising and condescending and embody excessive state interference. The use of public authority to change citizens’ behaviours, even if the altered behaviours are better for the citizens themselves, violates spheres of privacy, integrity and autonomy... The state ought not to patronise people, by singling out a subset of the population and treating them as if they lacked the full use of reason".

In defence of Nudging, Thaler and Sunstein note that "there is no such thing as neutral design and as such, the anti‐nudge position is unhelpful – a literal nonstarter". Indeed, "once you know that every design element has the potential to influence choice, then you either close your eyes and hope for the best, or you take what you know and design programs that are helpful". The important thing to remember about Nudging is that it serves as a signpost to suggest a path towards a particular direction, rather than re-paving the entire road. It's a nudge, not a shove.

Perhaps the true difficulty lies in confusion over what determines a nudge. A nudge, if used correctly, should be; voluntary, avoidable, easy or passive and low cost. In addition, as opposed to other types of behavioural steering such as target marketing, the nudge should always promote the alternative most aligned with the long-term goals of the person who is being nudged. As expressed by Thaler and Sunstein, a nudge should "only get designed to help people live according to their best interests". This requires a nudge to be transparent, as the intended outcome as well as its reason should be available to the person being nudged.

That is not to say there are not valid and important ethical concerns that have been raised surrounding the potential misuse of the human subconscious. These ethical aspects are important issues for designers to reflect upon when proposing a new contribution to society through design. It becomes especially urgent as the use of design thinking is evolving into realms of solving public and societal concerns.

The Behavioural Insights team or "Nudge Unit", which put in place by Prime Minister David Cameron in 2010, proposed in a report on health policy suggestions of ways to nudge people into making better decisions for their health. The report argued: “The Government cannot address these issues successfully using heavy- handed legislation to rebalance our diets, change our desire to drink too much alcohol on a Friday night, or make our lives more active. But in a number of areas, there are often cost-effective ways of encouraging behavioural change that are less intrusive and will lead to better results for individuals and for society.”

Using targeted designs to change how people behave has the power to influence social, environmental or cultural issues in positive ways. Dan Formosa of Smart Design believes that designing behaviour is the “agenda for the future” as “design is easy, the person is really the problem. We need more psychologists”.

In the words of Mari Hunnes, in 'Nudging How Human Behaviour Is Affected by Design': "As choice architects get greater insight into these facts it should be possible to design environments that make choosing for our own greater good a more frictionless, straightforward way of life. When understanding how the human brain functions, it becomes clear that the way our environment is built today, it is often easier to make choices that prevent us from reaching a beneficial behaviour, than actually making the right decisions for future wellbeing."