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Rest rehydrate refuel

Introduction

There will be occasions where nursing staff miss their breaks, but it must never be the norm.

Making sure staff get their breaks isn't just a nice thing to do, it's the law. Anyone a working more than six hours is given an uninterrupted 20-minute break.

That's just the bare minimum. Nursing is a physically and emotionally demanding profession and we need to make sure that everyone has breaks, stays well hydrated and has access to nutritional food. If nursing staff are not enabled to self-care and have a poor working environment, they are more likely to become unwell, burn out or want to leave the job.

We know that low staffing levels can make it feel impossible to take breaks, but we hope this resource can create a space for discussion and offer practical suggestions to make changes in your workplace, starting with you and your team.   

 

Rest

A man sits at a table next to a window. He is drinking a coffee and reading a magazine

In a health care environment where nursing staff are making important and often safety critical decisions about patient care, at-work breaks should be seen as a necessity rather than a luxury.

Physical rest
12-hour or longer shifts and increased patient demands make the need for breaks even more important. Nurses on a 12-hour shift walk on average between four to six miles and such physical demands need a physical rest break.

Mental rest
A rest break is also a stress-reduction measure, particularly where the work is emotionally demanding. It provides an opportunity to network and socialise with other colleagues and rest the mind as well as the body.

Preventing errors and accidents
Errors and accidents are a very real risk for shift workers and the patients they care for. They can happen during a shift or when driving home after a long shift. For community staff who drive during their shift, rest breaks are of additional importance to avoid fatigue-related road traffic accidents.

Rest between shifts
It is important to look at rest breaks within the wider context of shift systems, with adequate recuperation/down time between shifts and days off being equally as important. 

 

The Working Time Regulations 1998 and Working Time Regulations (NI) 2016 ('the regulations') govern the number of hours an employee can work per week, as well as the rest breaks the employee is entitled to; this includes breaks between shifts, annual leave and days off. The key aim of the regulations is to ensure standards of health and safety in the workplace.

Work time includes:

  • job-related training
  • time spent travelling for workers who have to travel as part of their job, for example, community nursing where staff have to travel to patients
  • time spent travelling between home and work at the beginning or end of your working day (if you do not have a fixed work base or you are asked to work from somewhere other than your normal base)
    paid and unpaid overtime where it has been requested
  • time spent on call at the workplace, and
  • any other time that is treated as ‘working time’ under a contract.

It is important that you check your contract and your employers policy to understand what is treated as working time in your organisation.

You are entitled to a minimum break of 20 minutes when your daily working time is more than six hours. This should:

  • be uninterrupted
  • be away from your workstation
  • be during working time
  • not be taken at the start or end of the working day
  • not overlap with your daily rest.

The RCN Working Time and Breaks advice guide gives a great overview as well as highlighting specific aspects such as agency work, night-workers and those fasting during Ramadan.

 

Staff who work more than six hours a day must have a minimum of a 20-minute uninterrupted break away from their immediate workstation.

A 20-minute break is the legal minimum and we believe that nursing staff - who work long hours in safety critical roles - may need two or more longer breaks. Frequent shorter breaks are better for reducing fatigue and improving productivity.

As well as providing the time away from work, employers must provide rest facilities. 

By law, employers must provide suitable, readily accessible facilities to allow you to rest and eat meals. There should be adequate seating (complete with back support) for the number of persons at work likely to use them at any one time. 

These areas should be away from your working environment, but not be so far away that no meaningful rest time can be spent once you have walked there. Canteens or restaurants may be used as rest facilities providing there is no obligation to buy food in order to use them.

Community-based staff should be able to access rest facilities within community bases; this may mean seeking agreement with the building owner. Where there is no agreement to share, community staff should not be penalised for using commercial premises such as cafes during their allotted breaks.

Special provisions need to be put in place for pregnant staff and nursing mothers.

Facilities should be accessible to staff with disabilities.

Rehydrate

A refillable water bottle sits on a wooden table in front of blurred greenery in the background

Dehydration affects concentration and cognitive function and triggers fatigue - essentially, like missed rest breaks, it is not just a wellbeing at work issue but an issue of patient and staff safety.

A study of hydration levels of clinical staff at an NHS hospital found that 36% of participants were dehydrated before they had started their shift. Using urine samples and short-term memory tests, the study also found that 45% of participants were dehydrated at the end of their shift, and that cognition was significantly impaired in dehydrated participants (El-Sharkawy AM et al., 2016). [Check an/or replace reference]

Physical activity, such as being on a busy shift for 12 hours, and environmental temperatures can increase the need to keep hydrated.

Members frequently complain of not being able to access drinking water whilst at work. In a survey of RCN members, 25% of participants reported that they were not allowed to have water on the wards or at the nurses' station while at work. Members responding to the RCN's staffing survey (Royal College of Nursing, 2017) also reported that the pressure of work leads to the inability to drink, go to the toilet and eat. 

It is the duty of employers to ensure staff have access to drinking water, the time to rehydrate and go to the toilet.

 

Refuel

A nurse in uniform holding a plastic lunch box with a healthy wrap. The picture does not show their face.

As with hydration, nutrition is a basic human need and as with public health initiatives for general population, many health care organisations are focussing on the promotion of healthy eating and maintenance of healthy weights for staff.

Food is energy and during a physical shift where nursing staff are on their feet for long periods, it is important to have both time to eat, and access to, nutritional food that releases energy slowly.

Good nutrition is particularly important for night shift workers, as night shift work has been associated with digestive problems, obesity and poorer health outcomes (Health and Social Care Information Centre, 2014) [check and/or replace reference]. Shift workers should be able to access healthy food options and/or store, refrigerate and reheat foods brought in from home during a night shift.

As with access to rest facilities, community-based staff should be able to access somewhere to eat their food, free from contamination. Where there is no agreement to share, community staff should not be penalised for using commercial premises such as cafes during their allotted breaks.

Where employers provide food for staff as part of their reward and benefits package, these should be healthy and nutritious and suitable for the staff being catered for.

Making the case for improvements

A post it with "take a break" written and a heart shape

Shift work, long working hours and a lack of rest breaks, all exacerbated by low staffing levels, can make it challenging for nursing staff to self-care and look after their own health and wellbeing.

We know that there is a link between good staff health and wellbeing and improved patient outcomes. A report commissioned by NHS Employers (Danson 2014) [check and/or replace reference] concluded that there is now a substantial amount of evidence that the experiences of staff are associated with the care provided to patients. 

Unhappy, unwell and burned out staff are also likely to want to leave nursing.  It makes sense, and is less expensive to retain and take care of the staff we have, than to recruit, train and place new ones and that is aside from the unprecedented vacancy rates we continue to experience.

In 2018, a Health Select Committee report (House of Commons, 2018) [check and/or replace reference] looking at the the nursing workforce and factors such as retention recognised the importance of nurses being able to take breaks and having access to facilities to make food and drink near their place of work. It's a simple action that can make a big difference to the working lives of nursing staff.

Diagram of Maslow's Hierarchy of Needs. It is represented as a triangle with a wide base and point at the top. The triangle is divided into 5 sections horizontally which represent the five steps up the hierarchy. From the bottom up they are: Physiological needs; safety needs, belongingness and love needs, esteem needs and, finally, self-actualisation at the top. The 5 elements are also grouped into three woth physiological and safety needs being labelled as 'basic needs' (and also fundamentals of nursing care). Belongingness, love and esteem needs are labelled as 'psychological needs'. Self-actualisation is labelled as 'self-fulfilment needs.

Nursing staff will be familiar with Maslow's Hierarchy of Needs (see diagram) and its application to patient care. 

Physiological needs such as food, water, warmth and rest are the base of the pyramid. Along with safety needs they are known as 'basic needs' but we also consider them as the fundamentals of nursing care.

But how about application to the nursing workforce?

Nursing staff also have these basic needs when at work, how can we ensure they get them?

Having drinking water on the wards is an infection control and health and safety risk

In the majority of circumstances, having individual labelled water bottles with lids or drinking cones/ disposable cups for staff to use will pose no risk to staff or patients. Bottles should be stored in a clean area, and not in the patient areas, and disposed of or cleaned at the end of the shift. There may be restrictions during an outbreak such as norovirus, although managers should still ensure that staff can access drinking water. There may also be restrictions on receptacles or hot drinks in areas where there is a high risk of violence (for example, the hot drink/receptacle could be used as a weapon) or a risk of burn to vulnerable individuals such as in paediatric units. A local risk assessment should determine this.

It doesn't look professional for nurses to be drinking water in clinical areas 

Being professional means following the Nursing and Midwifery Council's code and ensuring that you are looking after your own health, ensuring it doesn't impact on patients and modelling good health behaviours to encourage your patients to drink fluids. Where patients are nil by mouth and have no IV fluids, discretion is needed when drinking but it should not lead to bans on drinking water in clinical areas. Staff should assess where it is appropriate to drink and not clutter the nurses' station or other communal areas, which can be problematic for cleaners.

Power napping doesn't work, it just makes you more tired

Power naps are short periods of sleep. A short nap of around 20 minutes is more beneficial than a longer sleep. Minimising napping time to around 20 minutes will prevent sleepers from entering a deeper cycle of sleep; this may make them drowsy and even more tired, and it may be harder to come round from. Power napping may not work for everyone but there is robust scientific evidence that it reduces fatigue and improves performance.

I've told my staff to take their breaks - it's not my problem if they don't take them

The Working Time Regulations 1998 require employers to ensure that staff are able to take their breaks. Managers also have additional delegated responsibility to ensure the safety of their staff and the patients they care for. Every effort should be made to ensure staff are able to take their breaks and actively encouraged to do so.

Taking action

Anyone and everyone can make a difference in creating a safe and healthy workplace where nursing staff can take their breaks in appropriate nearby spaces and have access to water and nutritious food.

Rest

  • Take your rest breaks. Don't feel guilty - a rest break is not a luxury but there for patient safety as well as yours.
  • When you can't take a break and you are concerned that tiredness may be impacting on patient safety, raise it with your manager and fill in an incident form. If this is too time-consuming you could keep a tally of missed breaks over a stretch of working days and complete one from rather than a new one each time.
  • Where you, or your colleagues are regularly missing breaks, raise concerns with your manager and RCN workplace reps.
  • Consider if you might benefit short 20 minute 'power naps'. They might not suit everyone, but can help as a way of coping with fatigue, particularly during a night shift or a long shift. Avoid sleeping for longer than 20 minutes though as that can leave you less refreshed and less alert.

Rehydrate

  • Come onto shift well hydrated and ensure you drink enough fluids, especially during hot weather.
  • Check if you are dehydrated against our urine colour chart.
  • If you are not able to access drinking water, speak to your manager or raise it with your RCN workplace reps. 

Refuel

  • Don't go to work hungry as that can lead to unhealthy choices later in the shift.
  • If you know access to food may be difficult, for example if the hospital shops/canteen are closed, or you are on the road, bring in some additional healthy snacks such as almonds, bananas or similar non-refrigerate foods.
  • During shifts, avoid heavy, fatty or spicy meals and stick to snacks and easily digestible foods

  • Eating for Endurance is an article by nutritional therapist Nicola Moore specifically for nursing staff.

Listen to this fantastic episode of The Nursing Handover podcast where the hosts have a frank discussion about self-care as healthcare professionals. They explore how the work environment and a selfless 'giving' psyche gets in the way and how to make changes to move you forward in the right direction.

Model behaviours for members by ensuring you drink enough fluids, take your breaks and record when you aren't able to.

Raise awareness

  • Promote and signpost to our Rest, Refuel, Rehydrate information
  • Ask for hydration and breaks to be a standing item for team meetings and huddles

  • Order some RCN 'Am I hydrated?' posters and lanyard cards with urine colour charts. The laminated posters are ideal for placing in staff toilet areas to help prompt staff to drink more fluid. Posters and cards are available for all RCN members to order from RCN publications.

Consult with staff and other unions

  • Find out if there are any barriers to drinking fluid and find out what would make it easier for staff to drink more fluid on a shift.
  • Ask colleagues how they feel about the rest breaks and the accessibility of, and facilities within, rest areas.
  • Use the RCN Nursing Workforce Standards and the Health and Safety Checklist to identify any improvement work that could be undertaken in your workplace. 
  • Talk to reps from other unions and try, where possible to work together to support the health and wellbeing of all staff.

Take action

  • Talk to managers at a local level about what improvements could be made. Charitable/endowment funds often include support for staff health and wellbeing and so can be a good source for funding to refurbish areas and provide equipment and furniture.
  • Discuss with your branch and share best practice. Real examples of changes and good practice are a fantastic influencing tool for persuasive conversations
  • If you have general concerns around poor practice or trends, the staff partnership forum or committee is a good place to take those concerns.
  • Read the 'Taking action' section in our Ask.Listen.Act resource which will help you to plan your steps

If you have serious concerns for the immediate safety of staff or patients, speak to a senior manager immediately. If the situation impacts on patient care, you have a duty under the NMC professional code and standards to escalate this through normal reporting procedures.

  • Model behaviours for both patients and peers by ensuring you drink enough fluids and take your breaks
  • Check in with staff to ensure they are able to take their breaks and arrange cover for those who are having difficulty due to case load. This includes community-based staff.
  • Use of team huddles during a shift can help identify nursing staff who may be in need of support in order to take a break. Where practicable, allow a degree of autonomy to plan their own breaks. 
  • Consider how you can ensure staff have easy access to drinking water. This could be tap water or piped filtered water. 
  • Personal reusable water bottles are great, but make sure you have space to keep them where they are in easy reach but your working area remains safe and uncluttered. Hydration stations with a storage area and water supply can be used to keep areas clear and create easy access. 
  • Consider the needs of community staff and ensure they have access to areas to top up water bottles. 
  • Be especially vigilant during hot weather and look out for staff who may be more vulnerable to dehydration such as those who have long-term conditions or are pregnant/breast feeding.
  • Do your team have facilities, away from the ward to take a rest break and either purchase or prepare hot food? If not, consider exploring how you could access hospital charitable/ endowment funds for equipment such as a fridge or microwave to allow staff to bring in healthy foods from home.

'Am I hydrated?' Poster campaign

RCN poster that features the title "Am I hydrated" and a urine colour chart

We have produced an A4 poster that has a urine colour chart to assess your level of hydration. It is laminated which makes it perfect for the back of toilet doors.

There is also a smaller version of the chart printed onto card that can fit into your staff pass holder.

Members, Reps, and RCN staff can order the posters and cards via email at publications@rcn.org.uk or by calling 03457726100 (option 5 / Mon-Fri 10:00-16:00).

Quote the following publication numbers:

  • 011974 - Am I hydrated? poster
  • 011973 - Am I hydrated? cards 


     

Petition your employer

Members and reps can use the resources below to find out about your legal right to facilities at work, along with petition and letter templates to present to your employer to call for improvements.

As set out in the Workplace (Health, Safety and Welfare) Regulations (Northern Ireland) 1993 and The Workplace (Health, Safety and Welfare) Regulations 1992. Employers must provide:

  • Drinking water: There must be a readily accessible supply of drinking water (Regulation 22)
  • Facilities to rest and eat: Employers must provide fully accessible suitable facilities to allow you to rest and prepare/purchase and eat hot meals. These areas should be away from your working environment, with adequate seating (Regulation 25)
  • Changing facilities and lockers: Fully accessible changing rooms should be provided for workers who change into special work clothing. This should include include showering facilities and have secure facilities for staff to store their clothing. (Regulation 23 and 24)
  • Sanitary and washing facilities: Washing facilities should have running hot and cold or warm water, soap and clean towels or other means of cleaning or drying. Where the work results in contamination of the skin by hazardous or offensive materials, suitable and sufficient showers should also be provided for staff to use. (Regulation 20 and 21)

Before you start your petition

  • If you are not an RCN representative, contact your local RCN Branch and let them know what you are planning. They will either link you up to your local rep, or signpost you to someone at your local RCN office.
  • Read the Welfare Rights section and download our Know your rights: Welfare facilities at work factsheet.

The petition letter

Members will be adding their signature to a letter which will outline

  • The issue or situation
  • The impact or consequences if no action is taken
  • The action you want taken

We've created a Welfare facilities model letter you can use or adapt. 

Gathering signatures

We suggest setting a benchmark of 50% of affected/eligible staff signing before the petition letter is sent. Explain this to members and that more signatures means more impact.
Members will be signing a petition that you attach to the letter. This does not have to be complex.
You can download our Welfare Facilities Petition template, or create one of your own. 

Presenting the petition

Consider how you will present the petition. If it is a local issue that can be actioned by a manager, you may wish to send the letter and await a response. If this is an ongoing issue that needs pressure and influence, you may consider other more public tactics to draw attention to your action. 
[Ask Miles/Duncan to review]

References

El-Sharkawy AM, Bragg, D, Watson, P, Neal, K, Sahota, O, Maughan, RJ, Lobo, DN (2016) Hydration amongst nurses and doctors on-call (the HANDS on prospective cohort study).
Clinical Nutrition; 35: 4, 935-942

Royal College of Nursing (2017) Safe and Effective Staffing: Nursing Against the Odds. Available at www.ren.org.uk (accessed 4 January 2018)

Health and Social Care Information Centre
(2014) Shift Work available at www.nhs.uk/news/2014/12December/Pages/Shift-workers-more-likely-to-report-poor-health.
aspx (accessed 4 January 2018)

Dawson J (2014) Staff Experiences and Patient Outcomes: What do we Know? A Report Commissioned by NHS Employers on Behalf of NHS England. Available at www.nhsemployers.org
(accessed 4 January 2018)

House of Commons (2018) The Nursing
Workforce, Second report of the Health Committee Session 2017-19 available at www.parliament. uk/business/committees/committees-a-z/commons-select/health-committee/ publications/ (accessed 5 February 2018)

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