From darkness to clarity

It was well past midnight. I found myself standing outside a heavy, metal-shelled door in the seclusion unit, equipped with a bunch of keys, and a panic alarm clutched in my damp fingers. Since the start of the shift, the air had been thick with unspoken tension. 

Inside the room was a patient in crisis, recently admitted. A towering young man, irritable, barely contained within the frail seams of a hospital gown, and restless in his isolation. He teetered on the edge of hostility, stoked by the uninviting confines of the room.

In those moments, there are two choices: react or reframe by interacting with the patient via intercom. After taking a measured breath, I tried to redirect his focus. Having got into the habit of reading case notes thoroughly, I remembered his fascination with WWII tanks. I asked him which model he thought was the most powerful on the battlefield, and if he'd ever imagined commanding one himself. His agitation softened as he launched into an animated description of his favourite tanks, their armour, firepower, and tactical prowess, momentarily retreating into the relative safety of his passion. 

That night, I learned firsthand how humour, empathy, and quick thinking can diffuse volatile situations. But I also began to question the support systems in place for staff who navigate the complexities of mental healthcare during night shifts. Working night shifts in a psychiatric setting is challenging for anyone, but for a recent psychology graduate, these hours can feel like an additional layer of unfamiliar risk and vulnerability. From personal safety concerns to the unconventional demands of patient care at night, the experience is both a test of resilience and a call for systemic change in mental health settings.

The challenges 

The night shift setting is a study in contrasts. While daytime work in mental healthcare might involve interactions with a full clinical team, structured therapeutic activities, and a semblance of routine, nighttime mercilessly strips away these familiar safeguards. Fewer staff members, frequent shortages, hours of emptiness and dark silence create an environment that can feel both isolating and precarious. For patients, the absence of stimulation and long hours of darkness often means an exacerbation of symptoms, such as agitation, psychosis, and insomnia. As a result, we regularly encounter patients in their most distressed states.

For female workers, especially, the sense of isolation is amplified by the latent risk of physical threat. Night shifts often feel like a series of calculated moves, where interactions must often be carefully managed to minimise potential conflict. The mind is particularly sensitive to stimuli at night, making even the smallest deviations from the norm in the environment appear more impactful than they would in the clarity of daylight. I recall one colleague describing the apprehension she felt every time she entered the unit alone: 'The patients aren't the problem… but I do often question our protocols. We're left to work without the right tools.' Her exasperation pointed to a larger issue and echoed the words of the rest of the team: the need for more robust support systems during these vulnerable hours.

A system in need of change

Experiences like these have accentuated a critical need for change. In my time working night shifts, despite staff completing the necessary training for their roles, I've seen how understaffed environments, coupled with insufficient security measures, can leave both them and the patients exposed to high-risk situations. Our emergency alarm systems are effective only if staff are nearby to respond and sufficient personnel are present on the ward. Without a structured response plan, these alarms often feel more like symbols of false reassurance than actual safeguards, especially given the often faulty nature of their mechanism. 

Strikingly, training protocols often fail to account for the distinct challenges of the night shift. De-escalation training (typically offered just once a year), is often generalised, lacking the nuance required to handle volatile situations in the dead of night. Just as crucial, the psychological toll of enduring these encounters without sufficient support cannot be overlooked. In moments of high stress, our bodies respond with an adrenaline-fuelled fight-or-flight response, but the recovery from such encounters demands much more than the shallow breathing techniques often promoted in standard training. This is where the support of colleagues becomes indispensable, especially those you can chat with over a cup of tea (stirred with a fork because the spoons have run out).

Beyond immediate safety concerns, there's a broader, ongoing issue: the need for approaches that address the unique emotional challenges faced by all staff in mental healthcare. Both female and male staff can encounter inappropriate comments, lewd behaviour, or even direct threats, yet these experiences are often downplayed as 'part of the job'. In an industry that champions empathy and patient-centred care, there's a glaring need for similar compassion and support for the caregivers themselves.

The cost of compassion fatigue

Working night shifts in mental healthcare isn't just about enduring long hours; it's about maintaining an emotional resilience that can feel increasingly worn with each shift. Compassion fatigue is a widespread issue, and yet on night shifts, these heightened challenges bring a unique intensity. Some nights, there are lighthearted moments: shared laughter with patients, meaningful interactions, and valuable learning points that remind us why we chose this line of work. But on other nights, the emotional toll is undeniable. 

Many of us suffer in silence, internalising the trauma of the patients we care for while wrestling with our safety concerns, often too overwhelmed and pressured by the demands of the environment to take time to reflect and process. For me, this exhaustion was intensified by the implicit expectations placed on mental health workers to appear resilient, composed, and unflinching. There's an unspoken expectation to embody the very qualities we strive to instil in our patients, even while facing our vulnerabilities.

Moving forward: Creating a safer, more supportive environment

Recent news articles depict the pronounced setbacks within existing systems. Reports of children being admitted to inappropriate units, alongside excessive use of restraint and seclusion practices, highlight the need for an unflinching examination of systemic inadequacies, where 'mental healthcare' often feels like a battle both staff and patients must fight to retain their humanity. 

Addressing these challenges requires more than surface-level policy changes; it calls for a cultural shift in inpatient mental healthcare. Firstly, resources and support for night shift staff need reassessment. In cases of understaffing, proactive measures should be implemented to minimise risks and ensure staff safety, bolstered by security protocol improvements to create safer working conditions.

Additionally, regular debriefing sessions and mental health support for staff are essential, beyond handover sessions at the start of shifts. Night shift workers often lack access to support services available only during daytime hours. Providing specific support for night shift staff can offer a relief mechanism from compassion fatigue and a space to process their experiences. 

Lastly, advocacy is needed around the unique challenges faced by mental healthcare staff, particularly on night shifts. Though efforts have been made to address harassment across healthcare, the specific risks faced by all staff in mental healthcare remain under-addressed. All employees, regardless of gender, should feel empowered to report inappropriate behaviour, knowing their concerns will be taken seriously and addressed promptly. Both men and women may feel pressured to take on roles, such as restraining patients, without the opportunity to wait for support to de-escalate appropriately, leading to unnecessary distress for both patients and staff.

Looking back, I see both the resilience required of mental healthcare staff and the pressing need for systemic reform. Moments like that late-night encounter with a patient in crisis are constant reminders of the complexities and nuances of this work. In a profession built on understanding and caring for the vulnerable, isn't it time we extend that same care to the men and women providing this invaluable service?

Disclaimer:
The reflections presented in this article are drawn from my experiences across various mental health settings and are not specific to any particular trust, hospital, or unit. The observations shared are general in nature and should not be attributed to any specific service.

Editor's note: We are planning a 'Night Edition'. If you have any ideas around how Psychology / Psychologists are at play during the night, please reach out on [email protected]