Taking the biscuit: defining excessive quantities of free refreshments in a healthcare library

Evidence suggests that complementary hot drinks and biscuits benefit an overworked and highly stressed healthcare workforce. But when signage in healthcare libraries asks patrons not to consume “excessive” quantities of free hot drinks and biscuits, how much is too much? Tabner and colleagues explore this resource allocation conundrum

As the festive season approaches, temperatures plummet, days shorten, and healthcare workers see glimmers of time off around the holidays, some might consider the provision of unlimited free hot drinks and biscuits a welcome token of appreciation; this is particularly the case for National Health Service staff, who are often felt to be underpaid and undervalued. 1 2 A chance observation of signage in a hospital library requesting that patrons avoid "excessive" consumption of free hot drinks and biscuits (fig 1) does, however, raise the question: if some people take more than others in a system constrained by both finances and logistics, might some staff end up getting the short end of the teaspoon? As sweet (and seemingly bottomless) as the ubiquitous communal box of Quality Street 3 may be, the term "excessive" in the context of free refreshment consumption is open to interpretation. The Oxford English Dictionary defines excessive as "exceeding what is right, proportionate, or desirable," 4 suggesting that individuals may apply their own values and judgments. Interpretations may therefore vary depending on appetite, taste, income, the proximity of snacks to beverages, psychological determinants (eg, stress and guilt), and myriad factors not yet considered. But how much is too much? Furthermore, who judges etiquette in such situations, and how might opinions differ between staff members? One of the current authors described regularly succumbing to Bentham's Panopticon effect, 5 where behaviour is modified to avoid that uncomfortable feeling of being perceived as greedy by others.
From the comfort of a hospital library and buoyed by a seemingly endless supply of (free) hot beverages and biscuits (snack size, multiple varieties), the authors developed a 15 item online survey to establish the quantities of free refreshments healthcare staff believed represented excessive consumption during a single visit to a hospital or academic library. Over a four week data collection period the survey was completed by 1874 healthcare workers and academics, more than half (51%) of whom were doctors.
In a chance encounter with free hot drinks in a single library visit, respondents would take a mean of 3.32 drinks before considering it excessive. This is slightly higher than the mean number of hot drinks respondents consume over a typical day when left to supply their own refreshments (3.04), with coffee the drink of choice for just over half (51%) of them.
The highest number of acceptable free hot drinks varied by choice of drink. Respondents who preferred to drink free coffee would consume more cups in a visit than those who preferred to drink free tea (mean 3.44 v 3.29). Respondents with a preference for free hot whisky (n=2), if available, represented an important outlier (mean eight free drinks before considering it excessive). Department or specialty also appeared to have an impact on the number of free drinks deemed excessive-general practitioners, for example, would consume more free hot drinks than staff working in emergency departments (mean 3.67 v 3.22). General practitioners would also consume more than staff working in all other departments or specialties (mean 3.67 v 3.28).
Regardless of beverage choice, respondents considered taking more than a mean of 2.25 packets of free biscuits to be excessive. This varied by role, with doctors having a slightly higher threshold for acceptable number of packets taken than non-doctors (mean 2.35 v 2.14). The number of packets perceived to be excessive also varied by time in role, with increasing time in role associated with a decreasing proclivity for free victuals (<2 years: mean 2.89, 2-5 years: mean 2.36, 5-8 years: mean 2.30, > 8 years: mean 2.16. Although UK respondents considered more than 2.20 packets of biscuits to be excessive, those based elsewhere (n=122) had a higher cut-off point (mean 2.97). 1481 (79%) of the overall survey sample would accept a free doughnut, and even 36 of the 88 who would not take any free biscuits would still be tempted by this alternative sweet treat.
Free text comments from respondents (box 1) offer some insight into the sentiment, current mood, and sense of humour of healthcare workers.

So much more than taking the biscuit
Office workers have previously identified free hot drinks as a more important workplace benefit than free support for mental health, and free coffee is associated with improved morale and productivity. 6 Against the backdrop of flagging NHS staff morale and a cost of living crisis, limiting the availability of biscuits and hot drinks is certainly not in the holiday spirit. Responses to our survey imply that most staff have a reasonable self-imposed biscuit threshold and would hardly drink the library dry, so setting restrictions may achieve nothing other than fostering resentment and may even counterintuitively increase consumption (box 1).
Although no formal cost effectiveness evaluation was carried out, back-of-a-biscuit-wrapper calculations (fig 2) were performed using cost data from a university caterer and workforce data from The King's Fund. 7 Given the growing diversity in milk types available and the wide range of milk volume used per hot drink, milk costs were excluded from these calculations. Given the current concerns over the morale, recruitment, and retention of NHS staff, 9 the estimated £21.7bn cost of a potential staff exodus, 10 and the well documented challenges facing providers of healthcare and social care, 9 11 -43 the provision of free hot drinks and biscuits could be a worthy and cost effective expense.
As a target for cost saving initiatives, limiting free refreshment consumption is really scraping the biscuit barrel (although some limits on hot whisky availability may be necessary), and implementing, or continuing, perks that improve staff morale seems justifiable. The authors therefore suggest that healthcare employers should allow biscuits and hot drinks to be freely available to staff, and they should leave these grateful recipients to judge for themselves what constitutes reasonable consumption.
Contributors: AT conceived the project in a caffeine induced moment of clarity. AT and GJ constructed the first draft of the data collection tool, and KH, HB, CW, and ST revised it before dissemination. SS processed and collated the survey responses, and all authors contributed to interpretation. AT, GJ, KH, and SS contributed to the first draft of the manuscript, with the remaining authors and our patient and public involvement contributors revising it critically for content. All authors reviewed and approved the final version of the manuscript. AT and GJ are guarantors. The corresponding author attests that all listed authors meet authorship criteria and that no others meeting the criteria have been omitted.
Funding: Despite the importance of the survey question and the anticipated impact of the project's findings, no funding was sought during the planning of this study. University Hospitals of Derby and Burton Library and Knowledge Service provided sufficient quantities of complementary hot beverages and biscuits to ensure that the authors were able to complete the work within the required timescales; this is not felt to be a conflict of interest given authors did not provide data for the survey. In their proper jobs, however, KH and SS are supported by the National Institute for Health and Care Research Applied Research Collaboration South West Peninsula. The views expressed in this publication are those of the authors and not necessarily those of their employing institutions.
Karen Trifunovic designed the sign from which this project was conceived. This project would not have been possible without the indulgence of the Royal Derby Hospital Library.
Ethical approval: Not required. The host library was contacted and approved use of the photographs; the sign was originally approved by CW, an author of this manuscript. The potential risks to researchers through inadvertent supra-therapeutic caffeine consumption during study activities were considered; given researcher caffeine consumption at baseline, these risks were deemed negligible. Survey responses were anonymous.
Data sharing: Data will be made available upon reasonable request to the corresponding author; biscuits will not. A limited data set is available on OSF (https://osf.io/5qw8b).