White-coat syndrome and why environment matters


It’s great to see the growing appreciation of why context and environment matters in driving behaviour change.

And perhaps one of the better demonstrations of how our environment affects us in big and emotional ways is through what’s known as white-coat syndrome. This is a tendency for people’s blood pressure to rise when in a doctor’s office. It can affect about 20 to 25 per cent of patients (me included). What’s worse, if the doctor doesn’t consider this phenomenon, it can lead to incorrect diagnosis and unnecessary treatment for hypertension. But if the doctor is aware, steps can be taken to either take the elevated readings into consideration, or adopt different approaches that seek to relax the patient.

The lesson here is that without taking the impact of the environment into account, the wrong conclusion – and solution – can be adopted. If we don’t see the bigger picture when it comes to changing behaviour, millions of dollars can be wasted around the world trying to get people to adopt healthier activities. As argued by Philip Graves in Consumer.ology and Faris Yakob in his Uncovering Hidden Persuaders paper, we give too much weight to the power of attitudes. The evidence suggests that while attitudes might help indicate our intentions, they don’t always reflect what we do. This is because so much of our behaviour depends on the context – the who or what that surrounds us.

When we start to walk in the shoes of our audience, and understand how the things around them impact how they feel and what they do, we start asking the right questions, observe more deeply and challenge how we use research. This leads to inspired thinking, insights and ideas that have the potential to make a tangible difference. The positive examples are endless, but here’s a few that grabbed my attention recently.

  • A shopping cart nudge that understands the shopping environment and powers of social norms to give us a little bump.
  • A solution in healthcare that I wrote about a few weeks back
  • An approach out of Kenya aimed at getting bus drivers to reduce their reckless driving
  • A workplace safety solution highlighted in Switch by the Heath Brothers. It encouraged more workers to wear safety glasses – not by hammering away with an awareness message – but by replacing the glasses with designs that were  less embarrassing and almost cool
  • Malcolm Gladwell’s presentation on how the wearing of seatbelts were finally normalized in the US.

Understanding our environment, how we interact with it, and how it changes what we think, feel and do can lead to powerful solutions. It can serve us well as we tackle some of the biggest behavioural challenges of our society today – from obesity, smoking rates, binge drinking and much more…

The red vest

One of the behaviour change examples I’ve referenced a lot when talking about the need to consider the wider environment comes from Switch. In it, the Heath Brothers describe the efforts used by Becky Richards, the Adult Clinical Services Director at Kaiser South San Francisco hospital.

Nurses who were distributing medication had a higher then average error rate. Rather then assuming this was a training or attitude issue with the nurses (it wasn’t), Richards observed that during the administration of medication, nurses were being distracted by doctors and others who would ask for their help.

So her solution focused not on the nurses, but those around them. In a pilot project, nurses administering the drugs were asked to wear a red vest, while at the same time, others within the hospital were instructed not to interrupt nurses when they were wearing the vest. At the end of the 6 month trial, error rates had dropped by 47%. It was adopted as a permanent process across the entire hospital – and in the 1st month, error rates dropped by 20% overall.

It’s a simple yet inspiring story that drove real behaviour change. To me, it’s a great reminder of how clearing a path to change can come from looking up and out, rather than simply at the individual.