Self-reported Attitudes of NHS sTaff About Christmas (SANTA-C) Study: A comparison of specialities
It is generally accepted that NHS staff are on Father Christmas’ nice list, but this has never been formally studied. This study aims to determine critical differences in festive attitudes of NHS staff working in different specialities.
A mixed quantitative and qualitative observational study. Data was collected from a self-reporting survey of 213 members of staff in a UK district general hospital in the UK via an online questionnaire in December 2020.
The primary outcome was the self-reported prediction of the likelihood of being on the naughty or nice list (or non-belief in such a list). Secondary outcomes included measures of festive home decoration (timing of decoration and type of tree), enjoyment of key Christmas activities (Secret Santa, Brussel sprouts, and Christmas hats), and Christmas jumper ownership. They preferred Christmas media (favourite film and song).
Approximately half of the respondents considered themselves likely to be on the ‘nice list’ (49%), with a third (33%) reporting their expected list status as ‘too close to call’; 8% did not believe in the existence of such a list. There was general uniformity across different clinical areas in staff perception of position on the naughty or nice list. For example, staff working in paediatrics were significantly more likely to own more Christmas jumpers (p=0.006) and to enjoy participating in ‘Secret Santa’ (p=0.03).
The results of this study suggest that despite previously suggested differences in personalities amongst staff working in different specialities, we are united regarding the Christmas spirit. It is hoped that staff who felt their appearance on Santa’s nice list was too close to call woke to full stockings on Christmas morning.
In the 2020 Ipsos Mori Survey, 60% of respondents predicted that NHS staff would be on Father Christmas’ nice list – the highest rating of all public figures presented and above that of the late Captain Sir Tom Moore (49%).1 Given that historically different personality types have been drawn to different medical and nursing specialties,2,3 there may be differences in the proportion of staff who are lucky enough to find themselves on the nice list. A previous study has used rule-breaking tendencies amongst doctors as a marker of likelihood of ‘naughty’ status and concluded that 92% of doctors working in surgical specialties were likely to be on the naughty list in comparison to only 50% of those working in critical care.4 We felt that openly asking healthcare staff about their status on Father Christmas’ list (as such individuals are sure to know from previous years) was likely to be the most accurate way of gathering this information, and also gave us the opportunity to assess where there may be other differences or similarities in the festive spirit. Functional MRI has previously suggested the presence of a ‘Christmas Spirit’ network in several cortical areas of the brain.5 We hypothesised that cognitive differences in healthcare staff working in different specialities might translate into differences in Christmas Spirit. When it comes to Christmas attitudes are we really all that different, or are we united in our festivity?
Recruitment and survey
A prospective survey was sent to staff members in our district general hospital via email in December 2020. Due to variable distribution by ward managers and further informal dissemination amongst staff, it is impossible to determine the number of staff reached by the survey and, therefore, the response rate. The survey could be completed on trust or personal devices, and all questions, including respondent demographics, were optional.
The primary outcome was expected status on the naughty or nice list. Due to the large number of specialities represented among respondents, we compared the three largest groups (Urgent and Emergency Care, Paediatrics, and Surgery) to assess possible differences between specialities. Secondary outcomes included measures of home festive decoration (timing of decoration and type of tree), enjoyment of key Christmas activities (Secret Santa, Brussel sprouts, and Christmas cracker hats), Christmas jumper ownership, and preferred Christmas media (favourite film and song).
Responses for the three largest speciality groups were compared using the Kruskal-Wallis test, due to the non-parametric nature of the data. For the primary outcome, those reporting being on the nice list were given a score of +1, those on the naughty list -1, and those too close to call a score of 0. Rates of non-belief between specialities were compared using Fisher’s exact test. The large number of different answers provided for favourite Christmas film and song prohibited any meaningful statistical analysis of these responses and a descriptive analysis was therefore carried out for these questions. As levels of missing data were very low (n=2 [1%] for primary outcome) no statistical techniques were used to adjust for or to impute missing data.
Statistical analyses were conducted using Stata version 12 and Clinstat.
There were 213 responses to the online questionnaire (Table 1). Respondents were more likely to be female (82%), and 25-34 years was the most frequent age group. The sample included 86 doctors (43%), 97 nurses/allied health professionals (47%), and 23 non-clinical staff (11%). More than two-thirds of respondents worked over Christmas, defined as any shifts worked on Christmas Eve, Christmas Day or Boxing Day.
Differences across specialities
There was no significant difference in healthcare workers’ perceptions as to their position on Father Christmas’ naughty or nice list (Table 2). Just under half of the respondents predicted that they were on Father Christmas’ nice list. Only one in ten reported they would likely be on the naughty list, whilst a third (33%) felt that it would be “too close to call’. A minority of respondents (8%) did not believe such a list exists (‘non-believers’). 14% of those working in surgical specialities reported that they were non-believers compared to only 5% of those working in paediatrics and 4% in ED or urgent care but this did not reach statistical significance (P=0.10). There was no significant difference in type of Christmas tree (real or artificial), the timing of decoration, enjoyment of Brussel sprouts, or likelihood of wearing a cracker hat.
Healthcare staff working in paediatrics reported enjoying participating in Secret Santa more than those in other specialities (p = 0.03), with an average ranking of 4/5 on the Likert scale. They owned significantly more Christmas jumpers (p=0.006), with 9% owning five or more. In comparison, almost a third of staff in surgical specialities stated that they owned no Christmas jumpers, and none owned more than three.
Ninety-seven per cent of respondents (n=206) recorded a favourite Christmas film. Home Alone (17% of all respondents), Elf (17%) and Love Actually (13%) were firm favourites across specialities. Arthur Christmas and the Polar Express were more highly favoured amongst those working in Paediatrics, and the Die Hard series was popular amongst those in surgical specialities.
Eighty-seven per cent (n=185) of respondents stated a favourite Christmas song. In total, 51 songs were mentioned. There was slight variation across specialities, with the same five songs appearing in the top five favourites across the board.
The festive season is for many people a time for celebration with friends and family. For NHS staff working in emergency care, already feeling the disproportionate impact of winter pressures, there is a rise in presentations from over-enthusiastic celebrations, decorating-related injuries, and the ingestion or insertion of Christmas-related items.6–8 Our results do not suggest that staff working in urgent care or the emergency department feel disproportionately less festive because of this. In fact, overall, our results show when it comes to Christmas attitudes, healthcare workers are more similar than we might have otherwise expected.
We were encouraged to see that around half of NHS staff expected to be on the nice list, with only a tenth of participants expecting to receive a lump of coal in their Christmas stocking. However, a third of the participants felt their expected status was too close to call. This may reflect the uncertainty that the Covid-19 pandemic has brought to individuals and the NHS, with participants erring on the side of caution in their responses to avoid disappointment on Christmas morning.
This study has shown, however, that healthcare staff working in paediatrics enjoy participating in Secret Santa more than other staff and are likely to own more Christmas jumpers than their non-paediatric colleagues. Our study was not able to explore the reasons for these differences. Further research to ascertain whether paediatric wards are a more accepting place to wear Christmas jumpers, whether staff working in paediatrics are better gift-buyers or have more active ‘Christmas Spirit’ neuronal networks than their colleagues would be helpful. It is interesting to note that the Home Alone series of films is less popular amongst Paediatricians. It is quite possible that the careless attitude towards supervision of children and clear safeguarding concerns demonstrated in these films is not enjoyed by those working primarily with young people.
An unexpected finding in this study was that 1 in 12 participants and 1 in 7 of those working in surgery did not believe that a naughty or nice list exists. This could imply a lack of belief in Santa Claus himself, which is of concern given that Santa’s very existence depends on belief. We would suggest that steps are taken within NHS Trusts to monitor rates of unbelief closely to ensure the long-term survival of Santa.
Our study has several limitations. It relies on self-reporting and has small sample sizes within each speciality. It is likely that those individuals on the naughty list may have had less inclination to participate in a Christmas-related survey. It is also important to consider that individuals on the naughty list may have had concerns that they could be identified by the demographic information provided, and may have been less likely to respond or amend their responses to avoid potential judgement from their peers. There is also an over-representation of participants working in Paediatrics and Urgent and Emergency Care, likely reflecting a higher response rate amongst those working in the same specialities as the study authors.
It is not known how the SARS-CoV-2 pandemic could have impacted these results. The essential role played by healthcare workers may have changed individual perceptions as to one’s ‘niceness, and the changes in winter pressures felt across the hospital may have also impacted festive spirit. It is also possible that the pandemic will have changed Father Christmas’ attitude to healthcare workers in general, and those who considered themselves likely to be on the naughty list based on previous years’ experiences might have found themselves pleasantly surprised. Further follow up studies would be needed to investigate this. The recent bestowment of the George Cross on the NHS from Her Majesty the Queen for “courage, compassion and dedication” will surely have gone some way to reassure NHS staff that they are deserving of the general public’s confidence in their position on the nice list.
1 Ipsos MORI. Santa’s list polling 2020. 2020.
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