The most common approach to changing behavior is to say to people, “Please do X.” Please warm the newborn. Please wash your hands. Please follow through on the twenty-seven other childbirth practices that you’re not doing. This is what we say in the classroom, in instructional videos, and in public-service campaigns, and it works, but only up to a point.
Then, there’s the law-and-order approach: “You must do X.” We establish standards and regulations, and threaten to punish failures with fines, suspensions, the revocation of licenses. Punishment can work. Behavioral economists have even quantified how averse people are to penalties. In experimental games, they will often quit playing rather than risk facing negative consequences. And that is the problem with threatening to discipline birth attendants who are taking difficult-to-fill jobs under intensely trying conditions. They’ll quit.
The kinder version of “You must do X” is to offer incentives rather than penalties. Maybe we could pay birth attendants a bonus for every healthy child who makes it past a week of life.... [snip]
...Besides, neither penalties nor incentives achieve what we’re really after: a system and a culture where X is what people do, day in and day out, even when no one is watching. “You must” rewards mere compliance. Getting to “X is what we do” means establishing X as the norm. And that’s what we want: for skin-to-skin warming, hand washing, and all the other lifesaving practices of childbirth to be, quite simply, the norm.
To create new norms, you have to understand people’s existing norms and barriers to change. You have to understand what’s getting in their way.The most affecting portion of the Gawande article is too long to excerpt (imagine that, for this blog!), but I will try to present a summary: Gawande talks to a nurse, Seema, who acted as a trainer for a much more experienced labor and delivery nurse in India. The experienced nurse did not do any of the recommended items for childbirth: the room was not disinfected, vital signs of the mother and newborn were not checked, no emergency supplies were prepared, the infant's vital signs were taken with a hand instead of a thermometer and kangaroo care (the warming of the infant by skin-to-skin contact with the mother) was not performed.
After Seema pointed out these issues, the experienced nurse was unhappy, but she and Seema went to the hospital's organization to get some of the issues (room cleaning, equipment like a thermometer (!)) dealt with. Seema kept visiting the nurse, and kept talking to her and getting her to change her behavior through conversation, not through demand or incentive. Gawande followed up with the experienced nurse months later, and asked why Seema was effective:
“Why did you listen to her?” I asked. “She had only a fraction of your experience.”
In the beginning, she didn’t, the nurse admitted. “The first day she came, I felt the workload on my head was increasing.” From the second time, however, the nurse began feeling better about the visits. She even began looking forward to them.
“Why?” I asked.
All the nurse could think to say was “She was nice.”
“She was nice?”
“She smiled a lot.”
“That was it?”
“It wasn’t like talking to someone who was trying to find mistakes,” she said. “It was like talking to a friend.”After I read this article, it is difficult not to think about our issues with academic chemical safety. It seems to me that universities rely too much on "Please do X" (please wear your PPE, please don't do that 3 kilogram azide reaction) and "You must do X" (you will wear your PPE! or we will fire you!).
In an ideal world, there would be space in a university for chemical safety educators who would do the work that Seema was doing: he or she would visit labs repeatedly (note that Seema visited at least 4 or 5 times!), befriend students, point out errors in practice and convince, not hector or harangue. I note that said chemical safety educator's job would be harder -- the experienced nurse could see the fruits of her labor, and be convinced that the new way was better. If a chemical safety educator does their job, nothing happens. (I've floated a similar idea in the past about using mid-career chemists for similar positions; I still think it's a good idea.)
The problem with this approach, of course, is that it's extremely labor-intensive and time-intensive; in the U.S., that means that it's money-intensive as well. There are a lot of other reasons why it might not work; I'd be interested in hearing others' thoughts about my policy notional. Readers?