Creating and Breaking Habit in Healthcare Professional Behaviours to Improve Healthcare and Health

  • Sebastian Potthoff
  • Nicola McCleary
  • Falko F. Sniehotta
  • Justin PresseauEmail author


Healthcare professionals (HCPs) prescribe, provide advice, conduct examinations, perform surgical procedures, and engage in a range of clinical behaviours. Their clinical actions are characteristically performed repeatedly—sometimes multiple times per day—in the same physical locations with the same colleagues and patients, under constant time pressure, and competing demands. This repetition under pressure in a stable setting provides ideal circumstances for creating contingencies between physical and social cues and clinical actions. HCP behaviour provides an ideal setting in which to advance theory, methods, and interventions to better understand habit formation and habit reversal. Contemporary theoretical and methodological development in the psychology of habit has begun to be applied to understand and promote the formation, breaking, and replacement of habitual behaviour in HCPs. This chapter highlights key theoretical approaches, methods, and intervention techniques that have been applied to conceptualize, measure, develop, and break habit and automaticity in HCPs. These insights have the potential to synergistically contribute novel perspectives to the wider habit literature.


Healthcare professionals Clinical behaviour Dual process models Habit Automaticity Breaking habit Theory 


  1. Adriaanse, M. A., Gollwitzer, P. M., De Ridder, D. T., de Wit, J. B., & Kroese, F. M. (2011). Breaking habits with implementation intentions: A test of underlying processes. Personality & Social Psychological Bulletin, 37(4), 502–513. CrossRefGoogle Scholar
  2. Ajzen, I., Czasch, C., & Flood, M. G. (2009). From intentions to behavior: Implementation intention, commitment, and conscientiousness. Journal of Applied Social Psychology, 39(6), 1356–1372.CrossRefGoogle Scholar
  3. Ash, J. S., Sittig, D. F., Campbell, E. M., Guappone, K. P., & Dykstra, R. H. (2007). Some unintended consequences of clinical decision support systems. Paper presented at the AMIA Annual Symposium Proceedings.Google Scholar
  4. Bateson, M., Nettle, D., & Roberts, G. (2006). Cues of being watched enhance cooperation in a real-world setting. Biology Letters, 2(3), 412–414. CrossRefPubMedPubMedCentralGoogle Scholar
  5. Benner, P. (1982). From novice to expert. AJN The American Journal of Nursing, 82(3), 402–407. CrossRefPubMedGoogle Scholar
  6. Birken, S. A., Powell, B. J., Shea, C. M., Haines, E. R., Alexis Kirk, M., Leeman, J., et al. (2017). Criteria for selecting implementation science theories and frameworks: Results from an international survey. Implementation Science, 12(1), 124. CrossRefPubMedGoogle Scholar
  7. Blackman, D. (1974). Operant conditioning: An experimental analysis of behavior. London: Methuen.Google Scholar
  8. Casper, E. S. (2008). Using implementation intentions to teach practitioners: Changing practice behaviours via continuing education. Psychiatric Services, 59(7), 748–752.CrossRefGoogle Scholar
  9. De Sutter, A. I., De Meyere, M. J., De Maeseneer, J. M., & Peersman, W. P. (2001). Antibiotic prescribing in acute infections of the nose or sinuses: A matter of personal habit? Family Practice, 18(2), 209–213.CrossRefGoogle Scholar
  10. de Vries, M., Witteman, C. L., Holland, R. W., & Dijksterhuis, A. (2010). The unconscious thought effect in clinical decision making: An example in diagnosis. Medical Decision Making, 30(5), 578–581. CrossRefPubMedGoogle Scholar
  11. Drew, P., Chatwin, J., & Collins, S. (2001). Conversation analysis: A method for research into interactions between patients and health-care professionals. Health Expectations, 4(1), 58–70.CrossRefGoogle Scholar
  12. Dreyfus, H. L. (1992). What computers still can’t do: A critique of artificial reason. Cambridge: MIT Press.Google Scholar
  13. Eccles, M. P., Hrisos, S., Francis, J. J., Stamp, E., Johnston, M., Hawthorne, G., et al. (2011). Instrument development, data collection, and characteristics of practices, staff, and measures in the Improving Quality of Care in Diabetes (iQuaD) Study. Implementation Science, 6(1), 61. CrossRefPubMedGoogle Scholar
  14. Evans, J. S. B. (1989). Bias in human reasoning: Causes and consequences. Hillsdale: Lawrence Erlbaum Associates, Inc.Google Scholar
  15. Evans, J. S. (2008). Dual-processing accounts of reasoning, judgment, and social cognition. Annual Review of Psychology, 59, 255–278. CrossRefPubMedGoogle Scholar
  16. Fischer, J. E., Steiner, F., Zucol, F., Berger, C., Martignon, L., Bossart, W., et al. (2002). Use of simple heuristics to target macrolide prescription in children with community-acquired pneumonia. Archives of Pediatrics & Adolescent Medicine, 156(10), 1005–1008.CrossRefGoogle Scholar
  17. Flodgren, G., Eccles, M. P., Shepperd, S., Scott, A., Parmelli, E., & Beyer, F. R. (2011). An overview of reviews evaluating the effectiveness of financial incentives in changing healthcare professional behaviours and patient outcomes. The Cochrane Library.Google Scholar
  18. Fuller, C., Michie, S., Savage, J., McAteer, J., Besser, S., Charlett, A., et al. (2012). The Feedback Intervention Trial (FIT)—Improving hand-hygiene compliance in UK healthcare workers: A stepped wedge cluster randomised controlled trial. PLoS One, 7(10), e41617.CrossRefGoogle Scholar
  19. Gardner, B. (2014). A review and analysis of the use of ‘habit’ in understanding, predicting and influencing health-related behaviour. Health Psychology Review, 1–19. CrossRefGoogle Scholar
  20. Gardner, B., Abraham, C., Lally, P., & Bruijn, G. J. (2012). Towards parsimony in habit measurement: Testing the convergent and predictive validity of an automaticity subscale of the Self-Report Habit Index. International Journal of Behavioural Nutrition and Physical Activity, 9, 102.CrossRefGoogle Scholar
  21. Gardner, B., Phillips, L. A., & Judah, G. (2016). Habitual instigation and habitual execution: Definition, measurement, and effects on behaviour frequency. British Journal of Health Psychology, 21(3), 613–630.CrossRefGoogle Scholar
  22. Gardner, B., & Tang, V. (2013). Reflecting on non-reflective action: An exploratory think-aloud study of self-report habit measures. British Journal of Health Psychology, 19(2), 258–273.CrossRefGoogle Scholar
  23. Giguère, A., Légaré, F., Grimshaw, J., Turcotte, S., Fiander, M., & Grudniewicz, A., et al. (2012). Printed educational materials: Effects on professional practice and healthcare outcomes. The Cochrane Library.Google Scholar
  24. Glisson, C., Schoenwald, S. K., Hemmelgarn, A., Green, P., Dukes, D., Armstrong, K. S., et al. (2010). Randomized trial of MST and ARC in a two-level evidence-based treatment implementation strategy. Journal of Consulting and Clinical Psychology, 78(4), 537.CrossRefGoogle Scholar
  25. Godin, G., Belanger-Gravel, A., Eccles, M., & Grimshaw, J. (2008). Healthcare professionals’ intentions and behaviours: A systematic review of studies based on social cognitive theories. Implementation Science, 3, 36. CrossRefPubMedGoogle Scholar
  26. Gollwitzer, P. M. (1999). Implementation intentions: Strong effects of simple plans. American Psychologist, 54, 493–503.CrossRefGoogle Scholar
  27. Gollwitzer, P. M., & Sheeran, P. (2006). Implementation intentions and goal achievement: A meta‐analysis of effects and processes. Advances in experimental social psychology, 38, 69–119.Google Scholar
  28. Grimshaw, J. M., Eccles, M. P., Steen, N., Johnston, M., Pitts, N. B., Glidewell, L., et al. (2011). Applying psychological theories to evidence-based clinical practice: Identifying factors predictive of lumbar spine x-ray for low back pain in UK primary care practice. Implementation Science, 6(1), 55.CrossRefGoogle Scholar
  29. Hagger, M. S., Luszczynska, A., de Wit, J., Benyamini, Y., Burkert, S., Chamberland, P.-E., et al. (2016). Implementation intention and planning interventions in Health Psychology: Recommendations from the Synergy Expert Group for research and practice. Psychology & Health, 31(7), 814–839. CrossRefGoogle Scholar
  30. Handoll, H. H. G., Elliott, J., Iheozor-Ejiofor, Z., Hunter, J., & Karantana, A. (2016). Interventions for treating wrist fractures in children. Cochrane Database of Systematic Reviews, (12).
  31. Helfrich, C. D., Rose, A. J., Hartmann, C. W., van Bodegom-Vos, L., Graham, I. D., Wood, S. J., et al. (2018). How the dual process model of human cognition can inform efforts to de-implement ineffective and harmful clinical practices: A preliminary model of unlearning and substitution. Journal of Evaluation in Clinical Practice, 24(1), 198–205. CrossRefPubMedPubMedCentralGoogle Scholar
  32. Hofmann, W., Friese, M., & Wiers, R. W. (2008). Impulsive versus reflective influences on health behavior: A theoretical framework and empirical review. Health Psychology Review, 2(2), 111–137. CrossRefGoogle Scholar
  33. Hrisos, S., Eccles, M., Johnston, M., Francis, J., Kaner, E. F., Steen, N., et al. (2008). Developing the content of two behavioural interventions: Using theory-based interventions to promote GP management of upper respiratory tract infection without prescribing antibiotics# 1. BMC Health Services Research, 8(1), 11.CrossRefGoogle Scholar
  34. Ivers, N., Jamtvedt, G., Flottorp, S., Young, J. M., Odgaard-Jensen, J., French, S. D., et al. (2012). Audit and feedback: Effects on professional practice and healthcare outcomes. The Cochrane Library.Google Scholar
  35. Johnston, D., Bell, C., Jones, M., Farquharson, B., Allan, J., Schofield, P., et al. (2015). Stressors, appraisal of stressors, experienced stress and cardiac response: A real-time, real-life investigation of work stress in nurses. Annals of Behavioral Medicine, 50(2), 187–197.CrossRefGoogle Scholar
  36. Kenealy, T., & Arroll, B. (2013). Antibiotics for the common cold and acute purulent rhinitis. The Cochrane Library.Google Scholar
  37. Kwasnicka, D., Presseau, J., White, M., & Sniehotta, F. F. (2013). Does planning how to cope with anticipated barriers facilitate health-related behaviour change? A systematic review. Health Psychology Review, 7(2), 129–145. CrossRefGoogle Scholar
  38. Lally, P., & Gardner, B. (2013). Promoting habit formation. Health Psychology Review, 7(Suppl. 1), S137–S158. CrossRefGoogle Scholar
  39. Lally, P., van Jaarsveld, C. H. M., Potts, H. W. W., & Wardle, J. (2010). How are habits formed: Modelling habit formation in the real world. European Journal of Social Psychology, 40(6), 998–1009. CrossRefGoogle Scholar
  40. Linder, J. A., Doctor, J. N., Friedberg, M. W., Nieva, H. R., Birks, C., Meeker, D., et al. (2014). Time of day and the decision to prescribe antibiotics. JAMA Internal Medicine, 174(12), 2029–2031. CrossRefPubMedPubMedCentralGoogle Scholar
  41. MacKinnon, D. P., Lockwood, C. M., & Williams, J. (2004). Confidence limits for the indirect effect: Distribution of the product and resampling methods. Multivariate Behavioral Research, 39(1), 99–128.CrossRefGoogle Scholar
  42. Magnabosco, J. L. (2006). Innovations in mental health services implementation: A report on state-level data from the US evidence-based practices project. Implementation Science, 1(1), 13.CrossRefGoogle Scholar
  43. McCleary, N., Francis, J. J., Campbell, M. K., Ramsay, C. R., Eccles, M. P., Treweek, S., et al. (2017). “Better” clinical decisions do not necessarily require more time to make. Journal of Clinical Epidemiology, 82, 173.CrossRefGoogle Scholar
  44. Ouellette, J. A., & Wood, W. (1998). Habit and intention in everyday life: The multiple processes by which past behavior predicts future behavior. Psychological Bulletin, 124(1), 54.CrossRefGoogle Scholar
  45. Potthoff, S., Presseau, J., Sniehotta, F. F., Breckons, M., Rylance, A., & Avery, L. (under review). Exploring the role of competing demands and routines during the implementation of a self-management tool for type 2 diabetes: A theory-based qualitative interview study.Google Scholar
  46. Potthoff, S., Presseau, J., Sniehotta, F. F., Elovainio, M., & Avery, L. (2017). Planning to be routine: Habit as a mediator of the planning-behaviour relationship in healthcare professionals. Implementation Science, 12, 24.CrossRefGoogle Scholar
  47. Potthoff, S., Rasul, O., Sniehotta, F. F., Marques, M. M., Beyer, F. R., Bryant, A., et al. (under review). The relationship between habit and healthcare professional behaviour in clinical practice: A systematic review and meta-analysis.Google Scholar
  48. Powell, B. J., Waltz, T. J., Chinman, M. J., Damschroder, L. J., Smith, J. L., Matthieu, M. M., et al. (2015). A refined compilation of implementation strategies: Results from the Expert Recommendations for Implementing Change (ERIC) project. Implementation Science, 10(1), 21.CrossRefGoogle Scholar
  49. Prasad, V., & Ioannidis, J. (2014). Evidence-based de-implementation for contradicted, unproven, and aspiring healthcare practices. Implementation Science, 9, 1.CrossRefGoogle Scholar
  50. Preacher, K. J., & Hayes, A. F. (2008). Asymptotic and resampling strategies for assessing and comparing indirect effects in multiple mediator models. Behavior Research Methods, 40(3), 879–891.CrossRefGoogle Scholar
  51. Presseau, J., Francis, J. J., Campbell, N. C., & Sniehotta, F. F. (2011). Goal conflict, goal facilitation, and health professionals’ provision of physical activity advice in primary care: An exploratory prospective study. Implementation Science, 6, 73. CrossRefPubMedGoogle Scholar
  52. Presseau, J., Grimshaw, J. M., Tetroe, J. M., Eccles, M. P., Francis, J. J., Godin, G., et al. (2015). A theory-based process evaluation alongside a randomised controlled trial of printed educational messages to increase primary care physicians’ prescription of thiazide diuretics for hypertension [ISRCTN72772651]. Implementation Science, 11(1), 121.CrossRefGoogle Scholar
  53. Presseau, J., Johnston, M., Heponiemi, T., Elovainio, M., Francis, J. J., Eccles, M. P., et al. (2014). Reflective and automatic processes in health care professional behaviour: A dual process model tested across multiple behaviours. Annals of Behavioral Medicine, 48(3), 347–358. CrossRefPubMedGoogle Scholar
  54. Presseau, J., Sniehotta, F. F., Francis, J. J., & Campbell, N. C. (2009). Multiple goals and time constraints: Perceived impact on physicians’ performance of evidence-based behaviours. Implementation Science, 4, 77. CrossRefPubMedGoogle Scholar
  55. Reyna, V. F. (2008). A theory of medical decision making and health: Fuzzy trace theory. Medical Decision Making, 28(6), 850–865. CrossRefPubMedPubMedCentralGoogle Scholar
  56. Reyna, V. F., & Brainerd, C. J. (2002). Fuzzy-trace theory and false memory. Current Directions in Psychological Science, 11, 164–169.CrossRefGoogle Scholar
  57. Reyna, V. F., & Brainerd, C. J. (2007). The importance of mathematics in health and human judgment: Numeracy, risk communication, and medical decision making. Learning and Individual Differences, 17(2), 147–159. CrossRefGoogle Scholar
  58. Reyna, V. F., & Brainerd, C. J. (2011). Dual processes in decision making and developmental neuroscience: A fuzzy-trace model. Developmental Review, 31(2–3), 180–206. CrossRefPubMedGoogle Scholar
  59. Schoenwald, S. (2010). From policy pinball to purposeful partnership: The policy contexts of multisystemic therapy transport and dissemination. Evidence-Based Psychotherapies for Children and Adolescents, 2, 538–553.Google Scholar
  60. Shapiro, S. L., Astin, J. A., Bishop, S. R., & Cordova, M. (2005). Mindfulness-based stress reduction for health care professionals: Results from a randomized trial. International Journal of Stress Management, 12(2), 164.CrossRefGoogle Scholar
  61. Shojania, K. G., Jennings, A., Mayhew, A., Ramsay, C., Eccles, M., & Grimshaw, J. (2010). Effect of point-of-care computer reminders on physician behaviour: A systematic review. Canadian Medical Association Journal, 182(5), E216–E225.CrossRefGoogle Scholar
  62. Skinner, B. F. (1963). Operant behavior. American Psychologist, 18(8), 503.CrossRefGoogle Scholar
  63. Sniehotta, F. F. (2009). Towards a theory of intentional behaviour change: Plans, planning, and self-regulation. British Journal of Health Psychology, 14(Pt 2), 261–273. CrossRefPubMedGoogle Scholar
  64. Squires, J., Presseau, J., Francis, J., Bond, C. M., Fraser, C., Patey, A., et al. (2013). Self-formulated conditional plans for changing health behaviour among healthcare consumers and health professionals. Cochrane Database of Systematic Reviews, (12).
  65. Stanovich, K. E., & West, R. F. (2000). Individual differences in reasoning: Implications for the rationality debate? Behavioral and Brain Sciences, 23(5), 645–665. CrossRefGoogle Scholar
  66. Strack, F., & Deutsch, R. (2004). Reflective and impulsive determinants of social behavior. Personality and Social Psychology Review, 8(3), 220–247. CrossRefPubMedPubMedCentralGoogle Scholar
  67. Strack, F., & Deutsch, R. (2014). The reflective—Impulsive model. In J. W. Sherman, B. Gawronski, & Y. Trope (Eds.), Dual-process theories of the social mind (pp. 92–104). New York, NY, US: Guilford Press.Google Scholar
  68. Strack, F., Werth’, L., & Deutsch, R. (2006). Reflective and impulsive determinants of consumer behavior. Journal of Consumer Psychology, 16(3), 205–216. CrossRefGoogle Scholar
  69. Tannenbaum, D., Doctor, J. N., Persell, S. D., Friedberg, M. W., Meeker, D., Friesema, E. M., et al. (2015). Nudging physician prescription decisions by partitioning the order set: Results of a vignette-based study. Journal of General Internal Medicine, 30(3), 298–304. CrossRefPubMedGoogle Scholar
  70. Thomas, R. E., Vaska, M., Naugler, C., & Turin, T. C. (2015). Interventions at the laboratory level to reduce laboratory test ordering by family physicians: Systematic review. Clinical Biochemistry, 48(18), 1358–1365. CrossRefPubMedGoogle Scholar
  71. Treweek, S., Francis, J. J., Bonetti, D., Barnett, K., Eccles, M. P., Hudson, J., et al. (2016). A primary care Web-based Intervention Modeling Experiment replicated behavior changes seen in earlier paper-based experiment. Journal of Clinical Epidemiology, 80, 116–122.CrossRefGoogle Scholar
  72. Verbiest, M. E. A., Presseau, J., Chavannes, N. H., Scharloo, M., Kaptein, A. A., Assendelft, W. J. J., et al. (2014). Use of action planning to increase provision of smoking cessation care by general practitioners: Role of plan specificity and enactment. Implementation Science, 9(1), 180. CrossRefPubMedGoogle Scholar
  73. Verplanken, B., & Melkevik, O. (2008). Predicting habit: The case of physical exercise. Psychology of Sport and Exercise, 9(1), 15–26.CrossRefGoogle Scholar
  74. Verplanken, B., & Orbell, S. (2003). Reflections on past behavior: A self-report index of habit strength. Journal of Applied Social Psychology, 33(6), 1313–1330.CrossRefGoogle Scholar
  75. Wood, W., & Neal, D. T. (2007). A new look at habits and the habit-goal interface. Psychological Review, 114(4), 843–863.CrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2018

Authors and Affiliations

  • Sebastian Potthoff
    • 1
  • Nicola McCleary
    • 2
    • 3
  • Falko F. Sniehotta
    • 4
    • 5
  • Justin Presseau
    • 2
    • 3
    • 6
    Email author
  1. 1.Department of Nursing, Midwifery and HealthNorthumbria UniversityNewcastle upon TyneUK
  2. 2.Centre for Implementation Research, Clinical Epidemiology Program, Ottawa Hospital Research InstituteOttawaCanada
  3. 3.School of Epidemiology and Public Health, University of OttawaOttawaCanada
  4. 4.Institute of Health and SocietyNewcastle UniversityNewcastle upon TyneUK
  5. 5.Fuse, The UK Clinical Research Collaboration Centre of Excellence for Translational Research in Public HealthNewcastle upon TyneUK
  6. 6.School of Psychology, University of OttawaOttawaCanada

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