We've always done it that way

“Oh, but we’ve always done it that way…”

Aren’t habit, custom and tradition marvellously labour-saving devices?!

It doesn’t matter how rational we might seek to be when making a decision that we have time to ponder; during the course of a day, we each have to make hundreds of decisions about small things.

Because we lead busy lives, it is inevitable that we will make some of these decisions without thinking about them at all, thus making use of some of the behavioural shortcuts that are an essential and useful aspect of human nature. This blog post is based on three articles (first published in 2008 and now shared here for a wider audience) in which I sought to explore a few of the issues around what some midwives call the WADI (‘we’ve always done it that way’), syndrome.

Habits

Let’s start by defining a habit as a behaviour pattern which has become repeated so frequently that it has become nearly or completely involuntary. In other words, a habit is something we do without thinking about it. Habits can include anything from the way someone might flick her head to adjust her hair to the three sentences that we say each time we give a particular leaflet out to a pregnant woman. Many of the hand skills that we use frequently become habitual; when is the last time you stopped to think about how to do something that you do regularly, like chopping a carrot, driving round a corner or rubbing a labouring woman’s sacrum?

Once we have learned a habit, we often continue to do it the same way until we encounter the presence of an external factor, such as a student who needs to know what we are doing step-by-step or, perhaps, the desire to change our practice in a particular area because we have discovered another way which we perceive to be better. Even then, habits can be hard to break, for the very reason that they are frequently used and almost involuntary behaviours.

One of the best things about habits is the way that they allow us to efficiently multi-task; you only need to compare the fluidity with which a first-year student midwife and an experienced phlebotomist can converse (or not) with a woman while taking blood in order to see the advantage of developing patterns of behaviour. The potential downside, of course, is that the behaviour that has become a habit may be less than best practice, either because we learned ‘bad’ habits straight off, or because new information has come to light yet we have not adapted our patterns accordingly. The judgement of what makes a habit ‘good’ or ‘bad’, of course, is completely relative; one of the top five bugbears amongst many student midwives is that they have to learn a new way to lay out a delivery pack with each new mentor, yet some midwives find it very useful to arrange things in a certain way because they can then find and pick up exactly what they need without having to look away at the crucial moment!

Customs and Traditions

A custom, then, could be defined as a habit or practice that is common to several people within a group, and a custom may be so important within the group that it is considered to be an unwritten law. Customs common to groups of midwives include the practice of writing down telephone messages or birth records in a particular way in a special book, or the order and form of a shift handover. Although there may be wide variation in how these things are done between different geographical areas, there often exist customs within areas of practice that are carried out for years.

As customs are handed down to new members of a group over time, often by word of mouth or by example rather than as written rules, they become traditions. One of the nicest midwifery-related traditions I ever encountered was in a hospital where the midwives who had worked overnight would make a large pot of tea and coffee each morning and greet each of the arriving midwives with a freshly poured cup of their favourite brew. I quickly learned to get into the habit of putting the kettle on at 6.45am!

Just as with habits, some customs and traditions – perhaps like the morning tea example – are hard to fault, while others are, upon analysis, arguably less beneficial to one or more groups. As Robbie Davis-Floyd proposed (1992), a number of traditions within maternity care have become rituals and we have seen a significant movement to challenge some of the obstetric interventions that have become routine, such as episiotomy, ARM and electronic fetal monitoring. These are important things to challenge, and we need to continue to challenge them, but should we also think about the smaller and less obvious habits, customs and traditions that we have developed?

The Chicken and the Condiments

I once heard a story about a woman (let’s call her Bea) who always cut the legs off whole chickens before she put them in the oven for roasting. One day, when a friend asked Bea why she did this, Bea replied that it was what her mother had always done, so she had assumed that it was the best way to roast a chicken.

The next time she saw her mother, Bea asked about it, and Bea’s mother said the same thing; it was what her own mother had done when she was growing up and she assumed it was for the best. Bea’s grandmother was duly approached and laughingly told her daughter and grand-daughter that, when she was a young mother, her oven had been so small that this was the only way of getting a family-sized chicken to fit inside it. Despite having a modern oven that was probably big enough to cook two chickens, Bea, like her mother before her, had unwittingly continued a fairly unique family tradition that had begun out of necessity.

I was reminded of this story when, after we moved house, my partner quizzed me about why I kept putting the salt and pepper back on the Welsh dresser when this wasn’t, in his view, the most logical location for them. The answer, as you might anticipate from having read the first story, was that the Welsh dresser had been the most convenient spot in the kitchen of our old house, and it hadn’t occurred to me to reconsider my habit of putting them there.

Questioning Traditions

As I noted above, custom, tradition and habit are marvellously labour-saving devices. If we all spent time researching ways of arranging chickens in ovens or considering different locations for condiments after every meal, our lives would probably be a lot less interesting. Many families, groups and cultures (including midwives) develop customs which may well be borne out of things like common sense and necessity, but which may, on occasion, be continued past the time when the reason, need or rationale for their creation has passed. When we are asked why we are doing these things and realise that we can say only that we have always done it that way, however, the next logical step in our thinking is to think about how the custom came about.

On one antenatal ward, for instance, the women who are having their labour induced are admitted into in bay 6. When I visited this hospital to speak at a study day, I was taken on a tour and a couple of the midwives joked about how the Trust enforced an exercise regime on the midwives, because bay 6 was the furthest room from the midwives’ station and they were forever running back and forth on ‘induction days’ in order to check CTG printouts. No-one could explain why bay 6 was used for this when other identical and closer bays existed until we raised the question generally. A midwife who had worked at the hospital for many years remembered that, when the ward was first built, the midwives’ station had previously been at the other end of the ward … right next to bay 6.

Another hospital tradition I encountered (and which has subsequently been addressed) was the holding of a labour ward ‘handover’ session in front of a board where the names and details of women were recorded. The problem with this tradition was that, when the custom began, visiting hours were restricted, the layout of the ward was different and the board and handover were private. A complaint caused the staff to realise that this was no longer the case and that, if confidentiality was to be maintained, the tradition needed to change as a result of the reorganisation of other aspects of the environment.

Taking Positive Action

As I said last month, these issues are rarely black and white, and, moreover, there are many examples of traditions which benefit everyone concerned. One example might be the use of sticky butterflies on women’s notes to let midwives know when a woman has lost a baby; even a midwife who is new to a particular unit has a good chance of knowing what one of these stickers means because they are used throughout the UK.

It is not, then, tradition (or custom or habit) per se which is the problem, but the inappropriate use, development or passing on of patterns which may no longer be beneficial is something that we should perhaps all be aware of. As I’ve discussed in here, one of the most important questions that we can consider is how a particular tradition came about, but there are other questions that are just as important

The Daily Clash of Theory and Habit

Right now, somewhere in the world, there probably exists a midwife who is being challenged by a student. The midwife has just done something (almost certainly with good intentions) that the student thinks may not be the ‘right’ or ‘best’ way of doing it. Perhaps the student learned something different from a lecture, book, tutor or previous mentor. The student is passionate about being with women and also has the best of intentions. The midwife, however, may well feel threatened by the challenge.

We can all feel threatened when challenged about our habits, for lots of reasons. Although we can value someone as a person while being less certain about the value of an aspect of their behaviour in a particular situation, this distinction may be forgotten by one or both people in the midst of conversation. On a practical level, we have busy lives (especially in practice) and there is often enough to do without having to continually think about why we are doing something and debate the relative merits of other ways of doing it. In any case, many practice-related habits are too complex to be easily labelled as “good” or “bad” and, even if you somehow find time to think about all of this, popular wisdom says it takes a month to acquire a new habit. It’s a wonder that anything ever changes!

Why have we always done it that way?

So, humans develop habits in order to save time and make life easier and more ordered. Habits are not intrinsically bad but we all probably have habits that could benefit from being reconsidered. While there is a sense in which taking time out to think about habits and customs on a regular basis sort of goes against the whole reason for developing them in the first place, I believe that there can be huge value in looking at our habits, whether this is as a result of being challenged or because we are looking for ways to improve our practice.

So how and where do we start? Some of the most common habits that we develop as midwives include:

Developing a ‘patter’ of things we say at certain times; when handing out a leaflet about the triple test, when giving information about an intervention such as vitamin K or as we prepare for an abdominal examination.
Doing or arranging things in a particular way; laying out a delivery pack in a particular order, taking notes during handover in a set format or teaching something in the same way to every student.
Performing hand skills (such as taking blood or giving injections) the same way every time or asking each woman to get into a particular position each time we carry out a vaginal examination.
Writing ‘set pieces’; when we record the results of an examination or the details of the birth, third stage and early postnatal period.

All of these habits confer benefits in that they save us time and enable us to work efficiently, yet the potential downsides include that we may not be placing as much emphasis on individualised care as we think we are, that we miss opportunities to improve what we are doing or that we may omit important details. As I discussed last month, it is sometimes possible to trace the story of how a habit developed over time, and doing so may sometimes cause us to realise that the habit is no longer useful. (Or it may cause us to realise that it remains very useful!)

Some of the most important things that we can ask ourselves include:

Why did I begin doing this? (The initial reason may have passed).
Is this useful, beneficial, kind and/or supported by evidence? (However, many of the kindnesses that midwives do for women, such as mopping hot brows, have not been researched, so there is a need to be discerning here!)
Is this in alignment with the ideals I hold as a midwife?

That last question is, to me, perhaps the most important message. We are all trying to do our best, and habits, customs and traditions are only human. No-one is perfect, and I don’t know of one midwife who would claim to be. I also don’t think there is any shame at all in realising that we are doing something that is not in alignment with our ideals only because we have always done it that way. The key may in being able to smile at our humanity and see if we can’t find a better habit to adopt in time for the next generation of students to challenge.