Editorial

Nursing Ethics
1–2
The ethics of ‘Nudge’ ª The Author(s) 2018
Article reuse guidelines:
sagepub.com/journals-permissions
in professional education 10.1177/0969733018802643
journals.sagepub.com/home/nej

Ann Gallagher, Julia Brennan and Colin Loughlin

University of Surrey, UK

In the 1700s, Frederick the Great of Prussia had a dilemma. His people were in danger of starvation and they
were resisting one nutritious food on offer, complaining: ‘the things have neither smell nor taste, not even
the dogs will eat them, so what use are they to us?’ Frederick tried threats to begin with – anyone who
refused to plant the crop in question would have their noses and ears cut off. And then he tried another
approach. He ordered his soldiers to mount a visible guard around the fields where the crop was grown so his
people would be aware of the high esteem in which the crop was held. Before long, they were stealing and
planting the ‘royal crop’ and the potato became the salvation of the Prussian people. Frederick’s change of
tactic is highlighted as one of the earliest examples of a shift from ‘shove’ to ‘nudge’.1
The academic beginnings of nudge theory are credited to a book by Thaler and Sunstein2 in 2008. The
theory was embraced by politicians and policy-makers leading to the setting up of the Behavioural Insights
Team or ‘Nudge Unit’ in the United Kingdom.1 The approach has been embraced in public health, markets,
medicine and even in public toilets. The positioning of a fake fly in the Amsterdam airport urinals, an
example of what has become known as ‘choice architecture’, is cited by Thaler and Sunstein. The fly,
strategically placed in the urinals, reduced spillage by 80%.2
How then might nudge theory impact on some of the challenges encountered in professional education? Is an
educator well-placed to be a ‘choice architect’? How might we discern between ethical interventions that come
under the umbrella of ‘nudge’ and those that would be better described as ‘shove’, manipulation or coercion?
We three authors are involved in a range of educational initiatives – face to face, online and blended
approaches – designed to enhance student engagement with professional education.
It will come as no surprise to readers that students do not always engage as well as hoped and are not
always as enthusiastic about educational innovations as educators are. Some educational innovations which,
for example, use online teaching materials are under-used and accessed only near assessment time.
So what to do? Could we use some of the insights from nudge theory to encourage more engagement?
Which strategies are ethical? And which are unethical?
It might be argued that ethical nudge strategies include those which are respectful of student autonomy,
those which are beneficial in promoting learning and those which are fair. It might be argued that unethical
strategies are those which are disrespectful of student autonomy, those which are harmful, those which are
overly burdensome and coercive and those which are unfair.
In professional education, such as with undergraduate nurse education programmes, student autonomy is
curtailed, whether or not ‘nudges’ are used, so that learning outcomes are achieved and regulatory require-
ments are met. Students are required to read (or listen) and reflect on professional knowledge, they are
required to engage in educational activities at the university and to complete assessments to demonstrate
that they are able to apply knowledge to health and social care practices.

Corresponding author: Ann Gallagher, International Care Ethics Observatory, School of Health Sciences, Faculty of Health and
Medical Sciences, University of Surrey, GU2 7XH, Guildford, UK.
Email: a.gallagher@surrey.ac.uk
2 Nursing Ethics XX(X)

To help students achieve their goals, it seems to us that a continuum of ‘nudging’ is discernible, from
weak to strong nudging. On the weak end of the continuum, the assumption may be that students are
autonomous adult learners and all that is required is for them to receive module handbooks (which may
be online) with guidance as to what is required in terms of attendance and assessment.
On the middle of the nudge continuum, professional educators could draw on previous work in the
United States which suggests that there is value in setting up a system where automatic, personalised text
messages are sent to students to remind them of looming course deadlines.3 The message also has links to
tutor details and required documents. Another ‘nudge analytics’ approach is to include guidance in feedback
as to how students might improve their performance.4,5 Engagement with some of the nudge frameworks
appears to have potential, for example, the EAST framework (easy, attractive, social and timely)1 and
insights from the MINDSPACE report.6
Other ‘middle-of-the-continuum’ nudge strategies that might promote fuller engagement with the con-
tent of professional education courses could include: using face-to-face sessions to remind students of the
value of online material in relation to health and social care practices; weekly email messages to students
reminding them of the online resources available to develop their knowledge; and another might be to
introduce peer review of formative assignments so students become accustomed to more regular reflections
on the course content.
On the ‘strong’ end of the nudge continuum, students could be rewarded publicly for engagement and,
perhaps, penalised for lack of engagement. The latter may then veer into negative or unethical nudging
whereby students are manipulated, for example, ‘everyone else on your course is doing it, why aren’t you?’7
Nudges designed to elicit emotional responses or which would include the disclosure of personal informa-
tion such as test scores are likely to be unethical.
We need more innovative approaches to professional education, and time and space in organisations for
reflection on what makes it more likely that students will engage meaningfully with course content –
especially with the increase of online and blended components of university courses. There appears to
be value in educators considering their role as ‘choice architects’ and potential for discussion as to which
approaches are ethical and which are not. Perhaps more could be done, following the lead of Frederick the
Great, to emphasise that professional education is a privilege, it has high esteem and those who avail of it
should be eager to engage with a view to the fruits of their labour contributing to exemplary ethical care?
Creativity is called for to develop engagement strategies, perhaps drawing on nudge theory. We need
always to reflect on the aims of our educational endeavour and on what success might look like.

References
1. Halpern D. Inside the nudge unit: how small changes can make a big difference. London, UK: Penguin Random
House, 2015.
2. Thaler RH and Sunstein CR. Nudge: improving decisions about health, wealth and happiness. London: Penguin
Books, 2008.
3. Dynarski S. Helping the poor in education: the power of a simple nudge, https://www.nytimes.com/2015/01/18/
upshot/helping-the-poor-in-higher-education-the-power-of-a-simple-nudge.html
4. Field J. Improving student performance using nudge analytics. In: Proceedings of the ERIC – international con-
ference on educational data mining, Madrid, 26–29 June 2015.
5. Carmean C and Mizzi P. The case for nudge analytics. Educ Quarter 2010; 33(4): 4772.
6. The Behavioural Insights Team. The MINDSPACE Report, https://www.behaviouralinsights.co.uk/publications/
mindspace/
7. Lane DJ and Gibbons FX. Am I the typical student? Perceived similarity to student prototypes predicts success.
Person Soc Psychol Bullet 2007; 33(10): 1380–1391.