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Can Nudge Theory Be Applied to Hand Hygiene?

By Chris Hermann

Nudge theory has been well documented in behavioral science, economics, politics and other fields. Nudge theory says that simple, small changes in a person’s environment can often have a large impact on the choices they make. Nudges can be used in addition to, or instead of, other methods to impact behavior, such as education, legislation or enforcement.

One commonly-cited example of a nudge is the fact that in Austria, 99% of citizens are potential organ donors. There, organ donation is the default choice – Austrians must opt out if they don’t want to be an organ donor. In the U.S., only about a third of Americans are potential organ donors, because they must opt in instead[1].

Research shows that restaurants that don’t offer trays for customers to carry food to their tables can reduce food waste by up to 50%. By having to juggle their food, drink, napkin and utensils in their hands, customers are less likely to pick up extra food that they won’t end up eating[2].

Finally, a study demonstrated that positioning healthy food at the cash register instead of junk food resulted in more healthy products being sold[3].

What does all this have to do with hand hygiene?

Imagine you’re a busy nurse in a hospital. You’re caring for patients – probably more patients than you should since there’s a nursing shortage. You’re rushing from room to room, and while you know you’re supposed to clean your hands every time you enter and exit a patient’s room (along with other key moments during patient care), sometimes you’re moving so quickly that you forget.

Education is already in place – hand hygiene was covered in your training and there are educational signs posted in the hospital. Legislation is already in place – the hospital has a hand hygiene policy that you’re familiar with. Enforcement is sort of in place – there may or may not be an observer who will intervene if she sees a missed hand hygiene opportunity. Despite all this, you still forget to clean your hands sometimes.

But if there’s a nudge that reminds you to sanitize in the moment…you’ll be much more likely to do so. That’s what our system does. When clinicians forget to clean their hands, our technology’s Real-Time Voice Reminder™ reminds them by saying “Please sanitize” (or whatever you’d like it to say). It’s a small thing, but we’ve seen over and over that this nudge has a very large impact on behavior.

Sound too good to be true? Nudges have been used successfully in healthcare organizations before. The first person to use the term “nudge,” James Wilk, used a handful of simple methods to reduce surgical errors in one hospital by tenfold within a year. These methods ranged from clustering surgeons’ offices together on one hall to developing a protocol for handovers between anaesthetists. These small changes saved an estimated 20-30 lives in the first year[4].

If you’d like to explore how our system typically doubles hand hygiene performance rates and reduces HAIs by up to 75-80%, here’s a brief video about how it works. Or here’s a white paper on How the New Joint Commission Hand Hygiene Standards Could Impact Your Hospital.


[1] Thaler, R. and Sunstein, C. (2009). Nudge. New York, New York, U.S.A.: Penguin Books.

[2] Waldron, J. (2018). It’s All for Your Own Good. [online] The New York Review of Books. Available at: [Accessed 26 Jul. 2018].

[3] Kroese, F., Marchiori, D. and de Ridder, D. (2016). Nudging healthy food choices: a field experiment at the train station. Journal of Public Health, 38(2), p.133.

[4] Cheshire, T. (2018). The Oxford don with tiny answers. [online] Available at: [Accessed 26 Jul. 2018].


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