Tag Archives: emotional intelligence

Crisis? What Crisis?

I’m a nurse. Every day at work somebody is in crisis.

Every. Single. Day.

People have life threatening injuries and illnesses. People experience suicidal ideation and sometimes act on those thoughts. People experience delirium, dementia and psychosis – they lose touch with reality. People behave in unexpected and challenging ways.

All of these people are in crisis. They are having the worst day(s) of their life.

When you are part of the clinical team trying to help out these people it’s always useful to acknowledge and clarify the nature of the person’s crisis. It’s surprising what the individual’s perception of the crisis is. I’ve met a person who was desperately unwell – ICU unwell – who’s subjective crisis was that the cat was home alone without anyone to feed it. That was the crisis she wanted me to respond to. I’ve met quite a few people who need urgent medical/surgical interventions, but who perceive their biggest crisis as being unable to smoke a cigarette right now. I’ve had the peculiar privilege of spending time with people who have survived suicide attempts, who have experienced a crisis related to abuse, financial problems, relationship breakdown, and loss of job/role/independence/sense-of-self. An existential crisis in mind, body and spirit.

All of these people are in crisis. It is their crisis.

It is important to ascribe ownership. The nurse/midwife/physician/other clinician is not experiencing the crisis; they are responding to the crisis. We (the clinicians) have not been immunised against crises, but we do have the responsibility to do whatever we can to not get overwhelmed by them. Also, truth of the matter is, I’m not sure how long you would last if you responded to every day at work as an adrenaline-filled, too-busy-to-wee, emotional rollercoaster. That be the road to burnout and breakdown, my friend.

So, what do we do?

We use Jedi Mind Tricks, pithy sayings and clinical supervision. That’s what we do.

Clinical Supervision
I’ve written about clinical supervision before (here and here). Despite the name, it’s not about scrutiny. Clinical supervision is about reflecting on clinical practice with a trusted colleague, and asking simple questions of yourself: what did I do?; what were the outcomes?; how did I feel?; what lessons did I learn?.

The idea of clinical supervision is to acquire and refine clinical skills.

Pithy Sayings
A lot of us use and repeat pithy sayings such as the ED adage: “In the event of a cardiac arrest [or any other patient crisis for that matter], the first pulse you should take is your own.”

If you recognise your own anxiety you’re more capable of managing it. Intentional slow breathing is an excellent intervention for this. You can do it while you’re scanning the patient/file/environment.

Breath. Slowly.

It is not a crisis. A crisis is when there’s a fire, storm-surge, tsunami, earthquake or explosion that requires evacuation of staff and patients. If the hospital is not being evacuated it’s not a crisis. It’s just another day at work.


Jedi Mind Tricks
The other thing I like to do when feeling anxious is impersonate a calm person. It’s like a Jedi mind trick. “This not the anxious nurse you’re looking for. This is a calm nurse.”

When impersonating a calm person  I conjure-up a person who was a CNC when I was a student nurse at the Royal Adelaide Hospital. Part of the apprenticeship model of nursing education at the time was to give students experience in RN roles. I had been thrown into the Team Leader role on a day when the neuro ward was especially busy. There were emergency admissions, a stack of post-op patients – two of whom were really unwell, a person dying in the side room, and an inexperienced unqualified overwhelmed drongo (me) coordinating the whole thing. We were in trouble. We needed more nurses and a proper team leader.

I sought-out the CNC – a smart-as-a-whip young woman not much older than me (i was quite youngish 25 years ago). The CNC spent all of about 5 minutes with me prioritising the ward’s workflow:

  • “First things first. No need to shower/clean anyone unless they’re incontinent.” There goes about 50% of the morning’s workload in an instant.
  • “Don’t bother with routine 4-hourly obs unless the person looks unwell. Only the post-op patients and the clinically unwell patients need their obs done.” There goes another 10% of the work.
  • “Let’s get Fiona (the most experienced and skilled nurse on the shift) to look after the two dodgy post-op patients and nobody else.” The biggest concern was instantly taken care of.
  • “Bring all the nurses in here (a cramped nurses station overlooking 2 bays of 6 patients each) and tell them the plan. Make sure they all drink water and coordinate their breaks.” Got it. To look after the patients you need to look after the nurses.
  • “After you’ve told the nurses the plan, tell the patients/visitors who aren’t critically unwell the plan. They’ll understand we’re abnormally busy if we tell them.” Open, honest communication? Who’d have thought?
  • “Slow down your breathing. Use your humour. You’ll be fine. Come and grab me if you need.” My racing thoughts slowed. Panic evaporated.

We, nurses and patients alike, had a good shift. All the vital stuff was done. It wasn’t a crisis. It was a day at work.

I haven’t seen that CNC (her name is Lee Madden) since 1992, but I think of her every now and then. Whenever I see a crisis unfolding or see/feel anxiety rising, I wonder, “What would a calm person do?” and conjure an image of Lee floating serenely into the space. I channel Lee’s reassuring smile and clear understanding of priorities, and do my best to behave in the way she modelled to an impressionable overwhelmed student nurse.

Crisis? What crisis? I’m impersonating a calm person.



As always, you’re welcome to leave comments below.

Paul McNamara, 5th September 2015
Short URL: meta4RN.com/crisis

Living Close to the Water

August 8th is “Dying To Know Day” – an annual day of action dedicated to bringing to life conversations and community actions around death, dying and bereavement. More info about that here: www.dyingtoknowday.org


The first time I read “Field Notes on Death” by Lea McInerney was two years ago when I stumbled across it via the #DyingToKnowDay hashtag. It is a beautiful, poignant piece of writing, where Lea draws on her experience growing-up Catholic in the 1960s/70s, and later becoming a nurse. I’ve re-read Field Notes on Death four or five times over the last couple of years. I re-read it again this morning. Just as I did every other time, I quietly started crying about three quarters of the way through.

I cry too easily. I have been terribly embarrassed by this on many occasions. It’s not that I don’t think men shouldn’t cry, it’s just that I think I cry too easily. Too easily for my liking anyway.

A couple of things happened recently which make feel slightly less embarrassed.

One was seeing the generous, open display of grief shown by Adelaide Football Club players and staff after the death of the team’s coach. For those not familiar with Australian Rules Football, the players are mostly “blokey blokes”. They are men so manly they make other men question their manliness. They’re fit and fearless. Tonka trucks are nowhere near as tough.

These manly young men wept openly in public. Not embarrassed. Not ashamed. They have never been more inspiring. Never been better role models.

The other thing happened at work. I met a lady who was referred because of postnatal depression. My job involves listening mostly, but I ask questions too, in the hope of gaining an understanding of what support strategies would be most useful. When I asked her whether she had been more tearful than usual, she responded:

Where I grew up we have a saying that translates into English as “lives close to the water”. It refers to people who are sensitive. People who cry easily.
I have always lived close to the water. 

It’s a lovely metaphor. Doesn’t everyone want to live close to the water? That’s where you’ll see some of the most beautiful views.


Trinity Inlet, Cairns

In Closing

Field Notes on Death is a great read. I intend to re-read it and re-share it every year on #DyingToKnowDay. I thoroughly recommend it to anyone, and think nurses and other health professionals who are exposed to end of life care/issues will find it especially useful.

In case you missed the subtle hyperlinks to “Field Notes on Death” above, here is the full URL: https://griffithreview.com/articles/field-notes-on-death/ 



Thanks for reading. As always your comments are welcome below.

Paul McNamara, 8th August 2015
Short URL:  http://meta4RN.com/water


“It’s a Fine Line” – Myth vs Reality

Every now and then somebody trots out a phrase like, “It’s a fine line between madness and sanity” (or words to that effect). It makes me cringe a little every time I hear it.

This version of “It’s a Fine Line” paints an unrealistic and unkind picture. It creates an impression that anyone who is “sane” (whatever that is) could, in a random moment, cross a line and become “insane” (whatever that is). It also creates an impression that jumping back across the line should be just as quick, just as fateful. This version of “It’s a Fine Line” is a dopey dichotomy – it divides humans into two tribes. It creates an illusion that you can only be one thing or the other, but could not be a bit of both or somewhere in-between.

Rubbish. It’s a passé cliché. It’s a myth.


There is not a fine line to cross. There is a fine line that we all slide along – first one way, then the other.

When it comes to mental health all of us travel somewhere along a fine line that connects the extremities of “very well” to “very unwell”. We all are on the same line; we are not all on the same section of the line at the same time.


If we are lucky we will spend most of the time somewhere along the continuum between the middle and the “very well (thanks)” point at the end. 100% “sane” (whatever that is) is not achievable. If it is achievable, it’s not achievable 100% of the time. Even the Dalai Lama would have bad days.

Nelson Mendela seemed better put together than most of us (in a healthy-mind-kind-of-way, that is). Was Nelson Mandela 100% sane 100% of the time? Nope. None of the heroes of humanity and none of us ordinary peeps are 100% sane 100% of the time. We are not statues on Easter Island. We are human. We all change. We are all affected by what we experience. We all have good days and bad days.

I have worked with people who have been really unwell psychiatrically. People who have experienced “3D” in a not-so-good way. That is, these 3 Ds:
1. Dysregulated emotions
2. Disordered thoughts
3. Disturbed perception
When this combination happens people are prone to experiencing psychosis (ie: loss of contact with reality). I have not kept count of the people I’ve worked with who have experienced psychosis – certainly hundreds, probably thousands. However, I’ve never met someone who is 100% “insane” (whatever that is) 100% of the time.

People who experience mental illness are on the same line as everyone else. On occasions they spend some time closer to the difficult “very unwell at the moment” end of the mental health continuum than they would like. They are not statues on Easter Island. They are human. They all change. They are all affected by what they experience. They all have good days and bad days.

Of course, these things are true of us all. Don’t believe me? Try substituting “they” with “we” in the paragraph above.

The “It’s a Fine Line” Myth divides us. The “It’s a Fine Line” Reality is much different, much better.

There is a fine line. It does not separate us, it connects us.

We are all sliding along the same fine line.



Thanks for reading this far. As always, your comments are welcome below.

Short URL: http://meta4RN.com/fineline

Paul McNamara, 1st October 2014

A Blog About A Blog About Suicide

I’m going to keep this short.

On the eve of the second anniversary of the meta4RN.com blog we (guest writer Stevie Jacobs and I) have finally released her powerful, gutsy post “These words have been in my head and they needed to come out (a blog post about suicide).” I thought by opening up meta4RN.com to occasional guest posts I would save myself some time and effort. Ha! Stevie’s post has had the longest, most difficult gestation of all of the posts on this blog.

Why? It’s not because of Stevie’s writing – she writes very well – It’s because of the content.

It’s because we don’t know how to talk about suicide.

mindframe I remember as a 14  year old learning about suicidal ideation via the famous Hamlet soliloquy which starts: “To be, or not to be, that is the question…” Shakespeare didn’t seem to be as afraid as getting the tone/message wrong as Stevie Jacobs and I have been.

Luckily, we don’t have to navigate this tricky territory without a map. Mindframe – Australia’s national media initiative – have some very handy tips aimed (mostly) at media. They also have info for universities, the performing arts, police and courts. It would be silly to replicate all their information here – cut out the middle-man and visit the Mindframe website:

The only thing I want to make sure is included here is that we, the health professionals, remain mindful of responsible use of language in social media, including blogs (and Facebook, Twitter, Instagram etc) . Melissa Sweet of croakey (the Crikey health blog) has used the term “citizen journalist” to refer to us non-journos who are active on social media. I have shied-away from that label because I have zero knowledge/pretensions of being a journalist. However, when it comes to talking about mental health and/or suicide, I reckon that those of using social media as health professionals should take some ownership of the “citizen journalist” tag.

Health professionals are used to being informed by evidence-based guidelines, right? That’s what the Mindframe guidelines are. They are guidelines for how language should be used by journalists. Those of us who are blogging/Tweeting/Facebooking/whatever can, if we choose to be safe and ethical, abide by the same code of good practice (here).

Let’s watch our language.

Let’s edit and re-edit.

Let’s reflect and think about our impact. Let’s do that slowly.

Let’s be safe. ethical and kind.

Let’s do no harm.

Let’s follow the Mindframe guidelines when we’re blogging about mental health and/or suicide.


That’s it. Thanks for visiting.

If you haven’t done so already, visit Stevie Jacob’s guest post here: meta4RN.com/guest02 My favourite part is the middle part (the meat in the sandwich?) which is honest, powerful, raw and gutsy. I hope/think that the edits made have been in keeping with the Mindframe guidelines. If  not, that is my responsibility. Please let me know and I will fix it as soon as possible.

Paul McNamara, 23rd September 2014

Short URL: meta4RN.com/mindframe


Many nurses and midwives are so adept at swearing that they can make truckies blush. Sailors and sportsmen gather at their feet to learn the fine art of uttering profanities.

There is, however, a small rightious subset of health professionals who are absolutely determined to take offence every time a patient gets a bit sweary.  These people seem to have no tolerance for the use of vulgar, foul language to express and relieve stress or pain.

There is emotional release to be had when uttering indecent or filthy words. The phenomenon of emotional release through swearing even has a name: “lalochezia” – a word formed from the Greek lalia (speech) and chezo (to relieve oneself). Sources 1 + 2 lalochezia


Words only have the power that we ascribe to them. As a judge sitting on cases regarding obscene language charges said, the use of swear words in Australia is very common in music, poetry, drama and literature, by ordinary people in the street, and by those in the corridors of power. The notion that they cause offence is an individual’s decision to react, not because of the rarity or harshness of the words themselves. Source 3.

Anyway, if we are fair dinkum about being patient-focused then swearing can be very useful. Swear words are great adjectives – think of them as something akin to the pain scale. Instead of using the ” 0 = no pain and 10 = worst pain imaginable” routine, some of our patients will use their own qualitative and quantitative pain scale. It might include descriptors like “no worries”, “a bit of an ache”, “painful”, “bloody painful”, “really bloody painful”, “bastard of an ache”, “as painful as fuck”, etc.

Maybe its those dopey “zero tolerance” signs (and the dopey attitudes they engender) that make some clinicians react to swear words as if they are weapons. As I have argued previously (see meta4RN.com/zero), we should have zero tolerance for zero tolerance and not spend so much time and effort trying to shut-down people from expressing their distress. Swearing not only communicates emotions but, as per the definition of “lalochezia”, acts as a pressure valve for those emotions. In clinical practice we should not be too quick to try turn off that pressure valve – it may prevent an explosion.

Suggested Further Reading Stone, T. E. and Hazelton, M. (2008), An overview of swearing and its impact on mental health nursing practice. International Journal of Mental Health Nursing, 17: 208–214. doi: 10.1111/j.1447-0349.2008.00532.x http://onlinelibrary.wiley.com/doi/10.1111/j.1447-0349.2008.00532.x/abstract

Print (PDF version): LalocheziaPrint

End As always, comments are welcome.

Paul McNamara, 12th July 2014
Short URL: http://meta4RN.com/lalochezia

Football, Nursing and Clinical Supervision

When I started this blog in September 2012 I made a half-joke that watching Adelaide play in the AFL can inform clinical practice (see Number 8 meta4RN.com/about).

Well, as it turns out, this is absolutely true. Please let me explain. 


The Adelaide Crows, like all elite sporting teams, spend a lot of time preparing to play. For those unfamiliar with Australian Rules Football (AFL) it’s a fast, free-flowing, physical game that is played weekly during the winter months. Here’s a sample of play:

A game of AFL is played over four quarters, each lasting approximately 30 minutes (nominally each quarter is 20 minutes, but the clock stops when the ball is out of play). So, any player who stays on the ground for every moment of the game will play for two hours.

Guess how much time the player spends preparing for that two hours.

Crows warm-up at training. From left, Jarryd Lyons, Ian Callinan, Daniel Talia and Taylor Walker. Picture: Sarah Reed via Herald Sun.

Crows warm-up at training. From left, Jarryd Lyons, Ian Callinan, Daniel Talia and Taylor Walker. Picture: Sarah Reed via Herald Sun.

Think about what goes into preparation: recovery from the previous game, keeping-up and improving fitness levels, practicing individual skills, practicing team skills, discussing and developing team strategies, having coaches give feedback on what you did well and what areas could be improved, developing on-ground leadership and communication skills, nurturing confidence in yourself and your team-mates, learning about the team you’ll be playing against next week. The list goes on.

My brother, Bernie McNamara, has seen the Adelaide Crows up-close and personal over the last few years. Bern says that typically during the season a player will have about 25 contact hours each week with the club, and be expected to do about 10 hours of preparation away from the club.

So, each week, a diligent AFL player will spend  about 35 hours preparing for no more than 2 hours play.

How does that preparation:work ratio compare for clinicians?


It’s not just the explicit hands-on knowledge that counts, it’s also very important that we make time for thinking-about, discussing and reflecting on our clinical roles. Clinicians, like footballers, have a desire to improve, but we may have to fight for support to do so. As noted at a recent seminar regarding clinical supervision, “in a time of austerity, high caseloads and increasing problems, the organisation is often satisfied with a ‘good enough’ (work task) rather than seeking excellence. This tends to reduce supervision to a control function rather than aspiring to best practice.” Source: Talking about supervision: conversations in Bolzano and London 

I have written about clinical supervision previously (in “Nurturing the Nurturers” meta4RN.com/nurturers), but perhaps undersold it – some have commented that it seems like a feel-good exercise for clinicians. There’s more to it than that.

Clinical supervision is a key component in providing high quality services with positive outcomes for those who use health services. Clinical supervision promotes a well trained, highly skilled and supported workforce, and adds to the development, retention and motivation of the workforce. High quality clinical supervision also contributes to meeting performance standards, meeting the expectations of consumers/carers/families and goes a long way towards developing a learning culture in a changing health care environment. Source: ClinicalSupervision

Clinical supervision guidelines are very modest compared to the preparation:work ratio of AFL footballers. Clinical supervision requires nothing like the investment of 35 hours of preparation for 2 hours of play, instead, it’s something like 1 hour of preparation for every 80 or 160 hours of work.

Are nurses, midwives and other clinicians worth the expense?

I’ve been thinking about this tweet lately:

I’m wondering whether we can tweak that sign a little – maybe something like this:

The Financial Perspective: “We can’t afford to spend money on nurses and midwives sitting around talking, thinking and reflecting.”

The Patient Safety Perspective: “We can’t afford not to.”



As always, your feedback/comments are welcome.

Paul McNamara, 27th April 2014

Trying to Stay Focused

PatientFocused Some days it feels like a cruel conspiracy.

Those are the days when it feels like the time and space I have made to speak one-to-one to the patient* is in the middle of a sports arena. The patient and I walk into the middle of the empty playing surface and make our preparations for meaningful discussion, for emotional catharsis, for education, for counselling, for disclosure, for discovery, for therapy.

Then the grandstands of the arena start filling with people with loud voices. These people are not providing frontline care, so we would like to think of them as supporters. However, they all seem to think of themselves as coaches. They each have their own special area(s) of interest and shout well-meaning advice from their seats in the grandstand.

It gets very rowdy and distracting. SystemsFocused So many supporters coaches. So many systems**.

Systems are what makes airlines so safe – apparently that’s why hospitals have become so system-focused over the last couple of decades. I think it is a bit silly that public health systems try so hard to align themselves with profit-making airline systems. The cost of a regional hospital redevelopment ($454m) is about the same cost as two Boeing 787s (source), However, they serve very different purposes: the hospital is filled with critically ill people aiming to become less unwell or die with dignity. Commercial jets are filled with tourists and business people going on a planned journey. The hospital is a place of unknowns: discovery, diagnosis, treatment, trials and strong, unpredictable human emotions. A commercial jet is a trumped-up bus that travels at a scheduled time on a scheduled route between clearly defined destinations, carrying only people who are wealthy and healthy enough to travel long distances.

Hospitals and airlines have such very different clients, expectations, control and outcomes – can they really teach-each other much about systems?

Nevertheless, I understand the rationale for systems, and will make no effort to argue against them. Still, wouldn’t it be nice if there was one healthcare system? As it stands in my workplace, the emergency department has a system (EDIS) that does not speak to the ICU system (MetaVision), which does not speak to the general hospital system (ieMR), which does not speak to the mental health system (CIMHA). And that’s just within one hospital – imagine how fragmented it gets when we start thinking of the primary healthcare and rural/remote outpatient sectors.

I understand that some of these systems, some of these competing demands, are very important – but not all of them are. For example, it is not important that a clinician spend time away from their patients to transpose a bit of information that is in one hospital system into another hospital system –  this is a matter of dumb systems.

Which is why nurses and other clinicians know that sometimes the safest, most compassionate, and most ethical thing to do is to turn their back on the distractions created by dozens of disjointed systems, and make the priority to simply be with the patient.

Why? Because we are trying to stay focused – patient focused.

*Clarification re using the word “Patient”

In mental health over the last couple of decades nomenclature has changed from “patient” to “client” to “consumer” or “service user”. I understand the rationale for this – it is to move away from the passive (i.e.: “patient” as someone that the “expert” diagnoses and fixes) to participant (i.e.: “informed “consumer” of a service). In my current role I provide mental health assessment, support and education in a general hospital – the people I see are, in this context, first-and-foremost medical/surgical/obsetric hospital inpatients. It is these people’s physical health that had them admitted to an acute general hospital as “patients”, hence my use the word here.

**All the systems named in the “Systems Focused” cartoon are real, as is the claim that using each one is VERY IMPORTANT.

Tech Tip

I used an easy-to-use iPad app called Notes Plus to draw the cartoons. As you can see, my artistic skills have pretty-much plateaued since kindergarten, as has my spelling. Nevertheless, I think the cartoon might have been a little better and a lot easier to draw if I had used a stylus – that’s what I would recommend if you plan to do something similar.


As always, your thoughts/feedback is welcome in the comments section below.

Paul McNamara, 6th April 2014