Out of office – the ethics of taking a break

I’M writing this column on the bank holiday weekend in August, following a blissful fortnight on holiday away from my desk, emails and meetings. At the same time as I was retreating from work, many will have been starting new roles, or even their clinical careers.

The rotation that characterises clinical training and practice in the NHS is at its dizzying peak in the summer. Many of those in new jobs will have been asked to anticipate and book their leave well in advance of even locating the loos and coffee. Others will have started their roles anxious that a long-planned weekend for a significant event or travel for a special occasion may not be compatible with the demands of the rota.

Some may have left their previous jobs having been unable to take the leave to which they were entitled, feeling exhausted and far from ready for the demands of changing to a new job, with its concomitant stresses and pressures.

Leave is a particular currency in the NHS. It preoccupies those charged with organising rotas and shifts. It can rarely, if ever, be taken without considering others, and the extent to which it meets an individual’s circumstances and preferences vary widely.

Moral assumptions and judgements attach to leave and its management. Reasons may be weighed for their ‘acceptability’ when people ask for, or take, leave. Categories are applied to different types of absence to distinguish between different circumstances, including sickness, studying and the curiously-named ‘compassionate’ leave.

Holidays are rarely timed without reference to the needs of the service. Sometimes the demands of the service are invoked by those in power to exert pressure on a junior colleague to work even when leave is agreed. Those who are unwell describe feelings of guilt or even shame when they are unable to come to work. When they return, they may be required to explain their vulnerability to someone whom they have never met in language that claims to be about supporting them back to work, but hints at judgement about whether the sickness leave is ‘justifiable’.

As well as periods of leave, breaks can be elusive in the clinical setting, even for basic human functions and needs. Time to eat, to go to the loo, to draw breath, to see daylight, to think and to talk to colleagues is increasingly hard to find. The pace is relentless and to take a break can be impossible, with efforts to step out even for a moment being interrupted by bleeps and calls.

In professions concerned with care for others and health, the system too often promotes indifference and illness. Wellbeing initiatives abound, the discourse about resilience rumbles on and yet staff are unable to meet their own most fundamental needs.

When the absence of breaks causes breakdown, the moral tone is harsh and finger-wagging; exhorting those in pain to complete forms, attend interviews and plan their distress better or ideally avoid it all together.

I am saying nothing that will not be familiar to readers who work in clinical settings. Moreover, many people have written about the difficulties of working in the NHS at a time of demand, pressure and complexity. What is perhaps not said often or explicitly enough, is that this is an ethical issue. It is not merely a matter of bureaucracy or organisational culture. A people plan may be a good start, but it is how we engage with the people that counts. That engagement is an inherently ethical task.

We need to be clear that holidays and even the shortest breaks in working days have moral force. They exist because we see the humanity of our colleagues. The entitlement to a holiday and a break conveys that someone matters; that the system in which they work owes a duty of care to its staff as well as to the patients it serves. Breaks acknowledge the effort, commitment and contribution an individual makes to the collective.

Time away from work has morally positive consequences, enabling people to think, restore, regroup and return to work able to provide the best care. To protect and ensure that staff take holidays and breaks is to avoid ethical dissonance between the rhetoric of ‘wellbeing’ and the realities of moral distress, burnout and breakdown.

Too often the language of morality is invoked to manipulate and minimise the moral power of holidays and breaks. Assumptions, judgements and apparent disregard for others too often imbue the language, processes and procedures that dominate our approach to human beings. Taking a break is a moral good for professionals and for patients.

Imagine if, instead of being yet another category to tick on an absence form, we recognised that all leave is not only compassionate leave, but ethically essential.

Deborah Bowman is Emeritus Professor of Bioethics, Clinical Ethics and Medical Law at St George’s, University of London