Editorial: Cross my heart and hope to die: the use of pledges in health care

Making a promise is one of the oldest human-specific mechanisms aimed at fostering cooperation and trust (Baumgartner et al. 2009). A promise is a commitment characterised by the will to do, or not do something. Promises (for consistency, we use ‘promise’, but in some instances particularly when referring to policy, we use the term ‘pledge’) can be either a public or a private matter. Examples of public pledges are marriages and civil ceremonies and the requirement of new UK citizens to take citizenship oaths. Private promises, on the other hand, may take the form of New Year’s resolutions or a promise to repay a debt or loan. We are all accustomed to making promises in one way or another. It is likely that we have all made the symbolic gesture of crossing our hearts and hoping to die, indicating our intention to keep the promise. From a scientific perspective, pledging has attracted some interest over the past few decades, particularly from the disciplines of psychology and social science. For example, Moriarty (1975) demonstrated that people more readily intervened to stop a theft (a portable radio taken from a beach towel) when they had committed themselves in advance to guard the radio. More precisely, bystanders who agreed to watch the victim’s portable radio were more likely to stop the staged robbery when they had made a promise. The results suggested that this act of promise increased responsiveness and altered behaviour. A recent UK-based randomised controlled trial conducted by Cotterill et al. (2010) sought to evaluate the effects of making a pledge, and also whether pledges are more successful if made public. The results from a sample of over 11,000 respondents suggested that asking individuals to promise the donation of a book to charity caused more people to donate than if they received a campaign letter without being asked to pledge (8·1 vs. 7·2%). The number of book donations increased further when individuals were advised that the list of donors would be published locally (8·8%). Collectively, these studies demonstrate the effects of making promises in terms of increasing responsiveness and changing behaviour. But what is the relevance of this for healthcare? Inspired by a recent radio documentary on the subject of promises, we have reflected on the implications of pledging in nursing. More precisely, we have pondered their place as a commitment device in terms of encouraging patients/service users’ engagement with services. Despite the benefits that this approach might hold, it is as yet relatively unchartered territory in nursing literature. We are going to venture into that territory by describing the characteristics of promises and the conditions under which they are most successful. Pacta sunt servanda, the Latin phrase for ‘agreements must be kept’, is arguably the oldest principle of civil and international law and is an important characteristic of a pledge. Making a promise figuratively involves entering an agreement or commitment. Promises are more likely to be kept when they are voluntary, based on reciprocity, captured in written form and made in the presence of a support system (McKenzie-Mohr & Smith 1999, BBC 2010). Furthermore, people are more likely to stick to a promise if it is about an issue they were already concerned about before they were asked to make a promise (Hallaq 1976). It also matters who we make the promise to and how much we care about what they think of us (BBC 2010, Cotterill et al. 2010). As indicated earlier, it also makes a difference if a promise is accompanied by publicity (Cotterill et al. 2010). This may explain the existence of a bank of promises website where people can make a promise public or have it printed on a bank note to be sent to a chosen recipient (http://www.bankofpromises.co.uk). Psychologically, promises are made out of a desire to be consistent, that is, aligning our behaviour and our self-view. If we make promises we want to keep them, because we have a strong internal pressure to behave in a way that is consistent with how we see ourselves. Cognitive dissonance theory tells us that people feel discomfort if there is inconsistency in their understandings, and therefore they have strong motivations to avoid holding inconsistent views (Cotterill et al. 2010). The breaking of promises is associated with increased cerebral activation. This is suggestive of emotional conflict owing to suppression of the honest response (Baumgartner et al. 2009). The characteristics and conditions we have discussed are relevant to making pledges in a healthcare context. Use of pledges in healthcare is a new concept and has only recently begun to attract the attention of policy makers globally. For example, in Canada, the government has pledged to reduce long waiting times for health services in the form of ‘waiting time care guarantees’ (Joshi et al. 2006). Similarly, the recent report by the Prime Minister’s Commission on the Future of Nursing and Midwifery (2010) recommends that all nurses and midwives in the UK must declare their commitment to society and service users in a pledge to provide high quality, compassionate care. The pledge is intended to complement the Nursing and Midwifery Council Code of Practice, the NHS Constitution and other professional codes. It is hoped that such a pledge will restore public trust in the profession and make nurses act as ‘role models’ for society (Gainsbury 2010). The concept of nurses being required to make a pledge for the benefit of their patients may be laudable. However, it has stimulated us to question whether healthcare service users ought to make pledges too, by way of demonstrating commitment to their care. There are some problems with this approach as we will explore later, but at this point we will use coronary heart disease as an illustrative example of the place of pledges in healthcare. Despite evidence from meta-analyses of randomised controlled trials supporting the effectiveness of cardiac rehabilitation programmes, studies routinely report that 30–60% of eligible patients do not attend. This is despite the fact that participating in these programmes has been shown to decrease morbidity and mortality (Jolliffe et al. 2004). Given the health benefits to patients and financial savings to the health service, we have played with the idea of implementing a system in which service users pledge to fully engage with their care. We accept that asking patients to make promises carries with it a number of implications. In the spirit of respecting autonomy, the notion of patients having to promise to engage with healthcare services raises power and ethical concerns around the risk of coercion and manipulation. There is also the issue that some patients – the diehards – do not have the intention of engagement and will thus be ‘forced’ to make a white promise – in just the same way as we make white lies. In other words, despite the promise they will fail to engage. Another criticism is that given the physiological affects of breaking promises, this could result in emotional conflict. Finally, this approach does not tackle the root problem of lack of engagement in the first place. To address some of these issues, we will return to the conditions for successful promises highlighted earlier. A significant consideration was that of reciprocity. Promises are only effective if made in agreement with another person and if undertaken voluntarily. For this reason, coercion and compromised autonomy become less salient because making a promise cannot be prescribed authoritatively. Making a promise is not a panacea. It cannot address the multifaceted factors influencing a person’s non-engagement with services. However, psychological evidence suggests that human beings have a propensity towards wanting to keep their promises. With this in mind, it may be that for some individuals – the fence sitters – making a promise voluntarily could tip the scales in favour of their engagement. These are the people for whom pledges may be effective, because unlike the ‘diehards’ who never intend on engaging, the promise could be the catalyst for increased responsiveness and changed behaviour. After all, we know that promises have this effect. Returning to the example of cardiac rehabilitation, metaphorically crossing the heart and hoping to die could be crucial in determining an improved health outcome. To draw the discussion to a close, it is noteworthy that making promises takes very little time and costs nothing. The human and financial benefits, however, could prove to be immeasurable. We have used cardiac rehabilitation as an exemplar regarding the potential use of patient promises in nursing. It is for the reader to make transferability judgments beyond this context and indeed to assess the overall usefulness of pledging. The claims we have made may be putative, but our intention has been to merely highlight some of the issues surrounding patient promises as a stimulus for discussion and debate.

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