Tag Archives: emotional intelligence

Diagnostic Overshadowing [original, now updated]

Source: I had a black dog, his name was depression https://youtu.be/XiCrniLQGYc

I work in a general hospital doing mental health clinical work and education. The two roles overlap. A lot.

A significant part of the job is undiagnosing mental illness. It’s not unusual for us to be asked to see somebody who is emotionally overwhelmed or dysregulated. Sometimes this is in the context of mental health problems, often it’s in the context of significant stress. We don’t want to psychiatricise the human condition. Of course you cry when you’re sad. Of course you’re anxious when, like Courtney Barnett in ‘Avant Gardener‘, you’re not that good at breathing in. Of course you’e frustrated when you’re in pain and/or don’t understand what’s going on.

It’s important to validate understandable and proportionate emotions.

It’s equally important to make sure that somebody who has experienced mental health problems previously doesn’t have every presentation to the hospital/outpatient clinic seen through that lens. That’s called “diagnostic overshadowing”. It’s a real problem.

Diagnostic overshadowing is where physical symptoms are overlooked, dismissed or downplayed as a psychiatric/psychosomatic symptom. It must be one of the most dangerous things that happens in hospitals. The President of the Royal Australian & New Zealand College of Psychiatrists, Professor Malcolm Hopwood, said in May 2016, “I sometimes think that the worse thing a person can do for their physical health is to be diagnosed with a mental health disorder.”

It often comes as a shock to people when they find out that those diagnosed with mental illness die between 10 and 25 years younger than the general public. The next shock comes when discovering suicide accounts for only about 14% of premature death. [source: ‘Please believe me, my life depends on it’: Physical health concerns of people diagnosed with mental illness]

It’s a big deal. About 60% of people who experience mental health problems experience chronic physical health problems too. Poor mental health is a major risk factor for poor physical health, and vice versa. [Source: Australia’s mental and physical health tracker 2018]

Diagnostic overshadowing happens outside of hospitals too. In this example, understandable and proportionate human emotions were misinterpreted as psychopathology. The cascade of events that followed makes for a sobering read:

Questions for Reflection

Assuming that you – the person reading this blog post – is a nurse, midwife or other health professional, I have some questions I’d like you to reflect on.

Have I ever witnessed a person’s mental health history influence how their presenting complaint was investigated or treated?

How does my workplace prevent mental health stigmatising and diagnostic overshadowing?

What can I do to support good holistic patient care, without falling into the trap of diagnostic overshadowing?


Sincere thanks to Bec (aka @notesforreview on Twitter) for giving permission to share her tweets re mental health stigma and diagnostic overshadowing. Her first-hand account is a powerful cautionary tale.

Paul McNamara, 1st October 2018

Short URL meta4RN.com/shadoworiginal

Update as at 15th December 2018

Bec and I tidied-up this blog post and it’s now been published.

See meta4RN.com/shadow

Clinical Care and Clinical Supervision

On Monday 17th September 2018 I’ll be presenting to the Cairns & Hinterland HHS palliative care team regarding clinical care and clinical supervision. It is planned as an interactive session accompanied by visual cues to give the discussion a bit of structure. Consequently, the transcript/dialogue of the presentation can not be included here.  The visual presentation itself doesn’t use powerpoint slides. It uses the prettier (and free!) platform Prezi instead: http://prezi.com/gtsqjgs9zdby

This page serves as a one-stop directory to the online resources used to support the discussion, and as an easy way for me to find the presentation. 🙂

I’m recycling and combining a lot of old ideas for the session (there’s that self-plagiarist vs groovy remix of favourite old songs thing again), so this list below is ridiculously self-referential:

Care goes in. Crap goes out. Ian Miller @ The Nurse Path, 30 May 2017

Emotional Aftershocks (the story of Fire Extinguisher Guy & Nursing Ring Theory) meta4RN.com/aftershocks

First Thyself (the core source of info for the visual aspects of this presentation) meta4RN.com/thyself

Flowchart courtesy of Dr Alex Psirides (aka  on Twitter), ICU, Wellington, New Zealand, sourced here:

Football, Nursing and Clinical Supervision (re validating protected time for reflection and skill rehearsal) meta4RN.com/footy

Hand Hygiene and Mindful Moments (re insitu self-care strategies) meta4RN.com/hygiene

Joseph Heller quote from Catch-22 (1961):
“People knew a lot more about dying inside the hospital, and made a much neater, more orderly job of it. They couldn’t dominate Death inside the hospital, but they certainly made her behave. They had taught her manners. They couldn’t keep death out, but while she was in she had to act like a lady.”

Living Close to the Water (re #dyingtoknowday and emotional intelligence) meta4RN.com/water 

Nurses, Midwives, Medical Practitioners, Suicide and Stigma (re the alarming toll of those who undertake emotional labour) meta4RN.com/stigma

Nurturing the Nurturers (the Pit Head Baths and clinical supervision stories) meta4RN.com/nurturers

Sample Clinical Supervision Agreement (no need to reinvent the wheel – start with a wheel that works and tailor it to your needs) meta4RN.com/sample

Woody Allen quote from Without Feathers (1975)
“I’m not afraid of death; I just don’t want to be there when it happens.”


That’s it. Please feel free to play with the pretty prezi: prezi.com/gtsqjgs9zdby

Also, as always, please feel free to leave comments in the section below.

Thanks for visiting.

Paul McNamara, 2nd September 2018

Short URL: meta4RN.com/care


Perinatal Mental Health Workshop Links + Resources 2018

When you’re doing education sessions, it’s handy to have the links/resources in one place. It makes info much easier to share.

This is a quick and dirty updated and cutdown version of a 2014 blog post called Perinatal Mental Health Workshop Links and Resources. Anyway, with no further ado:

Mental Health Care in the Perinatal Period: Australian Clinical Practice Guideline
It handy to know how to find the October 2017 guideline and companion documents

Using the Edinburgh Postnatal Depression Scale

Tips for midwives, child health nurses, Indigenous health workers and other clinicians

Perinatal Jargon Busting
If you haven’t already, get your head around the lingo, and maybe become Facebook friends with Perry Natal 🙂

Nurturing the Nurturers
Info about guided reflective practice/clinical supervision as a self-care mechanism for health professionals

Nurses, Midwives, Medical Practitioners, Suicide and Stigma
This companion piece to “Nurturing the Nurturers” presents alarming data about the high suicide rate amongst nurses and midwives compared to other professions

Still Face Experiment
Edward Tronick’s demonstration of how infants respond to changes in interaction from primary caregivers is often cited in infant mental health education

Here’s Looking at You – Connecting with Bubs Our Way
This is a terrific video to use/share with parents-to-be or new parents.
The only people on screen and doing the talking are Aboriginal and Torres Strait Islanders, which makes a welcome change. 🙂

Circle of Security
The current “go to” model of attachment theory and affective neuroscience.

Head to Health
Find the right Australian digital mental health resources for the family you’re working with (includes info sheets, websites, apps + helplines)



That’ll do for the quick and dirty 2018 version. You’re welcome to browse the more detailed 2014 version here, but be warned: there’s quite a few dud/dead links there now. 😦

You’re also very welcome to share this page, the resources above and/or leave a comment below.

Thanks for dropping-in.

Paul McNamara, 12 July 2018

Short URL: meta4RN.com/perinatal

Post Script

Whiteboard from the perinatal and infant mental health session with CQU Student Midwives on 13 July 2018


Diabetes and Emotional Health

This page is in support of an education session I’m doing at EXPOsing diabetes Cairns on Saturday 9th June 2018.


EXPOsing diabetes is a one-day educational event for people living with type 1 and 2 diabetes.

This event will equip you with the knowledge you need to live well with diabetes.

The day consists of interactive and engaging presentations from health professionals who work closely in the area of diabetes. You will come away from the day feeling more confident, motivated and more empowered to live well with your diabetes.
[Source: www.diabetesqld.org.au/get-involved/what’s-on/2018/june/exposing-diabetes-cairns.aspx]


Paul McNamara is a Fellow of the Australian College of Mental Health Nurses. He has been working in Cairns since 1995. Paul’s day job is providing mental health support and education to general hospital patients and staff.


The presentation itself can be accessed via prezi.com/user/meta4RN or by clicking on the image below:

Key Messages, References + Further Info

The session is an oral presentation, so I don’t intend to replicate all of the content here.

Collated below are some of the key messages of the presentation, the references/evidence I’ve used, and how to access further info.

“It’s a Fine Line” – Myth vs Reality meta4RN.com/fineline

About 20% of us will experience mental health problems in any given year [source: 2007 National Survey of Mental Health and Wellbeing].

About 45% of us will experience mental health problems in our lifetime [source: 2007 National Survey of Mental Health and Wellbeing].

Up to half of us with diabetes will experience mental health problems in our lifetime [source: Diabetes Australia].

Anxiety and depression are the most common mental health problems [source: Mindframe].

Depression, anxiety and other mental problems are usually multifactorial. A good way to understand this is to consider the biopsychosocial model of mental health [source: Engel 1977].

Australia has introduced the idea of “stepped care” to respond to mental health matters [source: Northern Queensland Primary Health Network].

For information about prevention or early intervention with mental health problems, often the “best fit” will be online info via headtohealth.gov.au and/or via one of the apps available via the same website [source: Northern Queensland Primary Health Network].

If the online/app route doesn’t help, or if you’re experiencing symptoms of mental health difficulties, you should chat with your GP about it. S/he will discuss treatment and support options with you, which may include medication and/or referral to one of the local speciality services. It’s a good idea to book a longer appointment with your GP to discuss mental health stuff: neither you or your GP will want to feel rushed [source: Northern Queensland Primary Health Network].

If the above options haven’t helped, the mental health problem is complex, severe or urgent, it’s outside of business hours, and/or your questions would best be answered by a local specialist mental health professional, phone the Cairns Acute Care Team on 1300 64 2255 (1300 MH CALL) [source: Queensland Health].


Many thanks to Claire Massingham, Events Coordinator @ Diabetes Queensland for inviting me to present at EXPOsing diabetes Cairns. Thanks also to Endocrinologist Dr Luke Conway for making the suggestion to Claire.

A quick clarification: although this web page has info about how to access mental health support, it’s my personal web site. I can’t offer direct support or referrals from here. Please access further info and/or support via the options listed above.

That said, I welcome comments in the comments section below.

Thanks for visiting. 🙂

Paul McNamara, 2nd June 2018

Short URL: meta4RN.com/diabetes




#WeNurses Twitter Chat re Communication and Compassion

On 21st December 2012 (Cairns time) nurses from the United Kingdom and Australia came together on Twitter using the #WeNurses hashtag. The planned Twitter chat was used to discuss issues raised by the much-publicised death of a nursing colleague – Jacintha Saldanha.

This curated version of the Twitter chat demonstrates nurses using social media in a constructive manner, and responding to the issues surrounding Jacintha’s passing with thoughtfulness and grace. This was in sharp contrast to the shrill, insensitive and ill-informed way the matter was discussed elsewhere on social media and in mainstream media in the UK and Australia.

I’ve used sub-headings in red to structure the chat as per the themes that emerged.

WordCloud created from the full transcript of the #WeNurses Twitter chat

Preliminary Information.













Setting The Tone.



Communication and Confidentiality.





















Mobile Phones.
















Social Media.






Individualising Communication & Confidentiality.










WiFi for Hospital Patients.






















Prank Call.









Targeted Crisis Support.






Clinical Supervision (aka Peer Supervision, aka Guided Reflective Practice).









Supportive Workplaces.




















Preventative/Early-Intervention Resources.





The 6Cs (Care, Compassion, Competence, Communication, Courage & Commitment).






Integrating Defusing Emotions into Clinical Practice.








Finishing-Up: Key Learnings.










Closing Remarks.

















These Tweets were initially compiled using a social media aggregation tool called Storify

Unfortunately, Storify is shutting-down on 16 May 2018 and all content will be deleted.

I’m using my blog as a place to mimic/save the Storify pages I created and value.

End Notes

This archive of Tweets relate directly to two blog posts I wrote at the time. If you’re interested in elaboration re the context at the time, please visit these pages:
Questions of Compassion meta4RN.com/questions-of-compassion
WeNurses: Communication and Compassion meta4RN.com/WeNurses

As always, please use the comments section below for any feedback/questions.

Paul McNamara, 3rd April 2018

Short URL: meta4RN.com/Chat

My White Privilege

As far as I know it started with Cory Bernardi. On 31 January 2018 Cory wrote these two untruths, amongst others:
1. “The nursing and midwifery board, from 1 March this year, will insist their members acknowledge “white privilege” on demand.”
2. “Nurses must acknowledge white privilege and voice this acknowledgment [sic] if asked – which is compelled speech.” Source www.corybernardi.com/nursing_bruised_egos

Neither of these statements are remotely true.

When Cory and his political party repeatedly Tweeted the lie, I was really irritated that nurses were being intentionally misrepresented by non-nurses, and responded:


Please do not trust me because I’m a nurse.
Please do not mistrust Cory because he’s a politician.
Please read the actual policy yourself.
Read it and make up your own mind. The relevant section is a one-pager:

Nursing and Midwifery Board of Australia (01/03/18) Code of conduct for nurses, via http://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Professional-standards.aspx

See how it says nothing at all about white privilege? You’d think that would be the end of the story. But no.

A few weeks later another non-nurse started trotting out the same nonsense as Cory Bernardi. This time it’s a bloke called Graeme Haycroft chatting to Peta Credlin on SkyNews. Graeme was on TV representing an organisation called Nurses Professional Association of Queensland (NPAQ). He acknowledged that his organisation was the only one that was fighting the new code of conduct, and that the Australian Health Practitioners Registration Authority and all the mainstream nursing unions have agreed to it. Graeme also acknowledged that he was quoting from the glossary of the code, not the code itself. Nevertheless Graeme and Peta broadcast the lie that nurses and midwives would need to stop and discuss their white privilege with their Aboriginal and Torres Strait Islander patients, before providing any clinical care [source].

Doesn’t that sound unbelievable?

Well, that’s because it is.

Don’t trust me because I’m a nurse.
Don’t mistrust Graeme because he’s setting-up a business.
Read the actual policy yourself.

NPAQ describes itself as an alternative to the Queensland Nurses and Midwives Union, which is the Queensland branch of Australia’s largest union: the Australian Nursing and Midwifery Federation. At the end of the SkyNews segment it becomes clear what Graeme’s interest in this matter is. Remember, he’s not a nurse. He’s described as the founder of NPAQ. Graeme makes it very clear that he’s making a pitch for more members to join NPAQ instead of the union. It’s just that he’s misrepresenting the truth to do so. The little rascal.

OK, got it.

Graeme needs a lever to make his business work. That’s probably all we need to know about him and NPAQ.

But the lie is a contagion. The media is its vector.

The lie was spread on South Australia’s Today Tonight, it pops-up in news.com.au and affiliates  some UK papers, and via a Melbourne political blogger & illustrator who explained her understanding thus: “…nursing staff are required to acknowledge white privilege using dialogue & communication.”

Aha! Now I see the problem!
Yoda they are reading like.
Backwards talking are they.
Twisted are the words being.

The actual excerpt from the glossary (that is: the glossary, not the policy) reads “…cultural safety provides a de-colonising model of practice based on dialogue, communication, power sharing and negotiation, and the acknowledgment of white privilege.” Turning the words around backwards creates a slightly different meaning. That’s what Cory, Graeme and Peta have done. The little rascals.

Look, these people have pretty good language skills. I don’t think they’re stupid. I don’t think they’re making an naive error. I think their actions are intentional. I think they are intentionally misrepresenting a single phrase in the glossary as a policy instruction. I think they’re being loose with the truth. I reckon they’re as dodgy as.

Even if they not dodgy, they’re the wrong people to be commenting.

Cory Bernadi is not a nurse.
Graeme Haycroft is not a nurse.
Peta Credlin is not a nurse.
The various journalists who repeated the lie are not nurses.

Yet each of them have taken it upon themselves to speak on behalf of nurses and about nursing policies that nurses were consulted and collaborated on.

It’s infuriating!

I’ve been muttering into my iPad thinking/saying things like, “Keep your uninvited uninformed opinions to yourselves you irritating bunch of arseclowns!”

And that’s when the penny dropped.

That’s when I realised that Cory, Graeme, Peta and the journos were giving me a lesson in white privilege.

I was getting angry that these people dared to speak on my behalf, on my area of experience and expertise, without consulting with me or others from my nursing background.

How dare they?

It’s as if they don’t respect nurses. It’s as if they don’t really understand nurses, the nursing world view, our nursing political systems or our nursing culture.

I’m not used to shabby treatment like that. White blokes like me with a steady job don’t get much practise in being patronised, belittled or having our opinions hijacked in the mainstream media.

The mainstream media is much more likely to misrepresent Aboriginal and Torres Strait people (looking at you Sunrise). They’re not alone: refugees, Africans, Muslims and Asians cop their fair bit of flack too (looking at you Pauline Hanson). It goes further: women who dress too slutty or not sexily enough, or are too skinny, too fat, too bossy, or too opinionated will also cop it in the media – especially if they have one of those race or religion things going on as well.

But not me. I’m a white employed male. I don’t usually cop that crap.

What Cory, Graeme and Peta have done is they’ve given me a small taste of what it’s like to have your self-identity misappropriated and misrepresented. They’ve shown me what it’s like when non-nurses assume the voice of nurses. These three, and others, talking about- and over- nurses gives me a small taste of how disempowering and degrading it would be to have that happen all the time.

The discredited rants of Cory, Graeme and Peta will be a brief flash-in-a-pan, and I probably didn’t need to get angry. However, they have helped me to reflect. It has given me a small insight into how it must be a nagging irritation for those who often have their identities misappropriated and misrepresented.

I acknowledge that I have privileges as a white employed man. I don’t take those privileges for granted, and am grateful for my good fortune. #countingmyblessings

Although Cory, Graeme and Peta have amplified my insight, I don’t intend to thank them. I still think they’re as dodgy as.



NPAQ are trying a fear argument now (see Twitter). It needs rebuttal.

I was introduced to this definition of cultural safety as a student nurse (1988-1991). It’s a good fit for nursing. It’s a humble, nurturing mindset. Nurses understand that pain, nausea, kindness and cultural safety are all subjective patient experiences.

Wait. There’s more.

There are better credentialed and more articulate responses to this matter than mine,

Recommended references/readings include:

  1. Tara Nipe (25/03/18) On the matter of privilege (this is the blog that I wish I wrote: it’s much clearer and more succinct than mine)
  2. Joint statement by the Australian Nursing and Midwifery Federation, the Australian College of Nursing, the Australian College of Midwives and the Congress of Aboriginal and Torres Strait Islander Nurses and Midwives (23/03/18) Cultural safety: Nurses and midwives leading the way for safer healthcare 
  3. Ruth DeSouza via Melissa Sweet/croakey (26/03/18) Busting five myths about cultural safety – please take note, Sky News et al 
  4. Janine Mohamed, CEO @CATSINaM (24/03/18) Cultural safety matters – the conversation we need to keep having
  5. Media Watch (26/03/18) White privilege outrage
  6. Luke Pearson (24/03/18) The truth behind the Nursing Code of Conduct lie
  7. Sarah Stewart (29/03/18) Fake news and lies! Nurses, midwives and white privilege 


Thanks for reading.

As always your comments are welcomed in the section below.

Paul McNamara, 28 March 2013

Short URL: meta4RN.com/white

+update on 29/03/18 re typos + references/recommended reading

+update on 30/03/16 as rebuttal to NPAQ

Phatic Chat: embiggening small talk.

Small talk is a big deal.

Small talk is the oil that keeps the machinery of interpersonal relationships running smoothly.

Small talk even has its own name. It’s called “phatic chat”.

Phatic chat has been described as “A type of speech in which ties of union are created by a mere exchange of words”  by Bronislaw Malinowski (no relation to Barry Manilow). This is why I think it’s important that us health professionals be intentional about phatic chat.

Every, “Hello. My name is…” and “How are you today?” serves to create a working relationship between people. Health professionals rely on working, therapeutic relationships.

Academics (god bless their cotton socks) have even gone to the effort of researching and naming 12 functions of phatic communication (source):

(1) breaking the silence
(2) starting a conversation
(3) making small talk
(4) making gossip
(5) keeping talking
(6) expressing solidarity
(7) creating harmony
(8) creating comfort
(9) expressing empathy
(10) expressing friendship
(11) expressing respect
(12) expressing politeness

When we think about phatic chat in the health care setting, it’s not just a social lubricant, we can also see it as a stand-alone form of therapy. Think of phatic chat as the nonspecific factors of psychotherapy

BTW: “nonspecific factors of psychotherapy” an actual thing, let me google that for you: here

Phatic chat/the nonspecific factors of psychotherapy show the person that there is someone who is interested in them and their concerns. It helps people feel understood, accepted and respected. In my current gig – providing mental health support in the general hospital – I often get told by patients how good it is to be nursed by someone who is good at phatic chat.

It’s easy to imagine, isn’t it? Who would you rather attend to your vital signs, IV antbiotics, wound dressings, and pain relief in hospital: a friendly person who chats and listens, or someone unfriendly and officious who just goes about the tasks at hand? There’s more than one way to prime an IV line.

It sounds simple, and (to my ear anyway) pretty patronising. However, it’s clear that many clinicians do not routinely engage in phatic chat.

You may already know the story of Kate Grainger. Briefly, for those who don’t, Kate was a doctor in the UK who tweeted her experience of living with a terminal illness. One of the many observations she made was that it was refreshing, but actually pretty unusual, for hospital staff to introduce themselves by name and role when they came to see you in your hospital bed. That observation lead to this tweet:

That simple idea has been one of Kate’s greatest legacies (she died in 2016).

If you’re not familiar with the #hellomynameis story, I urge you to visit the hellomynameis.org.uk website for more info.

#hellomynameis = a very successful campaign promoting phatic chat in healthcare

I live and work a long way from the UK. Although I don’t wear a #hellomynameis badge, I borrow heavily from the idea that phatic chat is important, and toss-in a few more Aussie-fied ways to go about using it in the hospital setting. As argued above, phatic chat is important for building relationships and can be therapeutic in and of itself. Sometimes to be culturally safe you need to try a little harder to facilitate trust and rapport. With that in mind. here’s 4 ideas that usually (not always) work for me:


“Are you Cyril? G’day my name is Paul McNamara, I’m a nurse with the psych team here at the hospital. Is it OK if we sit down and have a bit of yarn?”


Shaking hands is a respectful thing to do. I always offer a handshake when introducing myself to patients (they’re often surprised!).

Don’t worry infection control peeps, I’ve got that covered: meta4RN.com/hygiene

Three (this is my second favourite: I stole it from Professor Ernest Hunter)

Make a cup of tea for the patient. Even if they say “no thanks”, let them know that you’re making one for yourself anyway, so are happy to make them one while you’re at it. Take instructions on how the person likes it . Apologise if you make it too hot/strong/weak or spill it. Sip yours when they’re talking: if for no other reason, it let’s them know you’re not about to interrupt.

This might be the best journal article ever written by a psychiatrist:
Hunter, E (2008) The Aboriginal tea ceremony: its relevance to psychiatric practice. Australasian Psychiatry, 16:2, doi: 10.1080/10398560701616221
Despite the paper’s title, the same demonstrations of humbleness, politeness and respect work for whitefellas too.

Four (this is my favourite: I made this one up myself)

I nearly always use when Google Maps when introducing myself to people who have come to the hospital from out of town. “Oh you’re from Aurukun? I’ve been to Wujal Wujal, Laura and Hope Vale, but I’ve never been there. Do you mind if we use this map on my phone to see where you live?” It’s nearly always a great way to break the ice, especially when meeting with someone from a different culture. It sets the right tone of showing that you’re interested and approachable.

I’m lucky to work in a place where I meet with Aboriginal and Torres Strait Islander people all the time. By getting the Aboriginal/Torres Strait Islander person to show me around their community on a map, I’m acknowledging/demonstrating that they know stuff that I don’t know, and I’m prepared to learn from them. Sometimes I’m a bit more skilled at using the Google map app on my phone, so I get to show the person how I can be helpful, in a kind and respectful way. It probably doesn’t hurt that we’re both looking at the map together and working on the same task (it demonstrates that we can work together, and you don’t want to rush into making a heap of eye contact with someone you’ve just met). While we’re using the app to find their house, the local school, favourite fishing or camping spot, and other landmarks we’re getting to know each other a bit. I’m not left in that clumsy position of being accidentally too pushy, too intrusive, too task-orientated.

Spending a few minutes establishing rapport is what phatic chat is all about. The phone/map app is just a prop, but it’s a great prop.

In Closing

That’s it.

A while back I had a gig educating uni students. One of the best tricks-of-the-trade when in a uni lecturer role is to introduce people to words they have not heard before. This makes you look cleverer than you really are, and lends an illusion of credibility.

So, with that in mind, my call-to arms for health professionals is this:

Let’s embiggen phatic chat!
It’s a perfectly cromulent thing to do. 🙂


The phrase/notion of “phatic chat” as a defence against the forces that seek to turn nurses into unempathetic box-ticking robots came to my attention via Professor Eimear Muir-Cochrane’s keynote presentation at the ACMHN 39th International Mental Health Nursing Conference, held in Perth, Western Australia, 22nd-24th October 2013.

Storify of the keynote here: storify.com/meta4RN/zero

Follow Professor Eimear Muir-Cochrane on Twitter here: @eimearmuirc


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

Paul McNamara, 12th October 2017

Short URL meta4RN.com/phatic



Nurse can’t take Pulse. Seriously.

This week in Australia ABC TV screened Episode 1 of a new medical drama called “Pulse“. It is said to be inspired by a true story of a transplant patient who became a doctor. Sounds cool, right? Well, it isn’t. From my perspective it’s pretty crappy, even for TV fiction. I started my career as a nurse in 1988. I’m not fond of nurses being ignored or misrepresented. Pulse does both. In spades.

Following are four reasons why I can’t take Pulse seriously (complete with Episode 1 timings, for those who want to check via iView):

1.  The cast. 

See how in the cast photo there are nine doctors and two nurses?

source: http://www.tvtonight.com.au/2017/06/gallery-pulse.html – I’ve added the labels

How does that compare to the actual health workforce in Australia?

In 2014 there were 610,148 registered health practitioners. Over half of these (352,838) were nurses or midwives – over 3 times the size of the next largest group [source: www.aihw.gov.au/workforce]. So, if we put gender-mix aside for a moment (about 90% of Australia’s nurses are female, about half of our new doctors are female) this would be a more accurate visual representation of what a real-life Australian health drama cast photo should look like:

source: http://www.tvtonight.com.au/2017/06/gallery-pulse.html – I’ve duplicated the original and added the labels

2. The patient is critically unwell, but the nurses are nowhere to be seen.   

At about 7:00 into Episode 1 there is a large group of doctors (no nurses) at the bedside of a patient. One doctor asks (referring to the patient), “What’s her oxygen saturation?” Another doctor looks around bewildered and is the prompted by yet another doctor to use the oximeter. He does and (instantly!) announces that O2Sa is 88% (this is spookily low for most people).

The fact is that nurses are the ones who are usually at the bedside, and are the ones who monitor the progress/deterioration of a patient, including measuring vital signs regularly. This monitoring would have been very frequent in someone who has low oxygen sats. The nurses would have the info on hand, and most likely would have been discussing care options with the doctors. Maybe the Pulse scriptwriters haven’t heard about multidisciplinary health teams, and don’t know that Australia’s largest union is the Australian Nursing and Midwifery Federation (ANMF) [source: anmf.org.au].

3. When you do finally see/hear the voice of a nurse it’s just two gossipy snippets. 

At about 8:40 the nameless character listed in the credits as “Scrub Theatre Nurse” (played by Lara Lightfoot), stands around doing nothing while the doctors perform surgery. Her role seems to be solely to deliver these two consecutive bits of dialogue:

“I heard from the head of department there’s an MVA that didn’t make it upstairs. There may be a potential donor.”

“The head of surgery is retiring, right? Guess they’ll be looking for a replacement.”

It’s important to note that Scrub Theatre Nurse is not depicted as actually doing anything (other than gossiping). For the non-nurses out there, please be reassured that your tax dollars are not being wasted on employing nurses to just stand around in operating theatres doing bugger-all. The roles and skills of peroperative nurses are many and varied: visit the Australian College of Perioperative Nurses website www.acorn.org.au and/or follow their link to “A day in the life of a preoperative nurse“.

Logo from @ACORN_org Twitter page

4. The only other two lines of nurse dialogue portray her as an unprofessional unethical antisocial bitch 

Carol Little RN (played by Penny Cook) has just two lines of dialogue, as below:

At about 13:00 Carol Little RN says to Dr Tabb Patel (in front of the patient and another doctor): “This time do not catheterise the cliterous, intern.” Lead character Dr Frankie Bell (correctly) advises the intern that female catheterisation is usually a nurse’s role and that the nurse was bullying him. Carol Little’s behaviour is not just a breach of common decency, but also of about 27 different aspects of the codes of conduct and ethics that set the standards for all health care workers, nurses included.

At about 17:30 lead character Dr Frankie Bell enquires on the whereabouts of a man who was meant to be receiving haemodialysis. In reply Carol Little RN gets her only other line of dialogue: “Do I look like a fucking concierge?” Is that verbal abuse or just lalochezia? The former, I think.

It’s interesting that Australians have voted nurses as the most ethical and honest profession for 23 consecutive years (1994-2017) [source: www.roymorgan.com], but the Pulse scriptwriters think otherwise.


Look, Pulse is just TV fiction. The hilariously fanciful depiction of lead character Dr Frankie Bell leaving hospital to jump on her bicycle and visit the home of a dialysis patient who didn’t show-up for treatment, then stay at his bedside overnight after he receives a kidney transplant is evidence enough of creative imaginations at work. Pulse is not pretending to be a documentary. It is very clearly just another hospital TV drama. An old formula, acted well, shot beautifully, just scripted awfully.

I guess it’s not really all that important whether people watch Pulse or ignore it in the big scheme of things. My bias is such that I’d rather watch Australian TV than imported shows – it’s good for us Aussies to hear our own voices and see our own stories on the telly. However, this isn’t anything like an Australian story. Bananas in Pyjamas does a better job of portraying an Australian reality.

I will not bother watching any more episodes of Pulse because it insults nurses and nursing. Nevertheless, we should give credit where credit is due. In one simple seven-word sentence the Pulse scriptwriters managed to capture the sentiment of what it feels like to be a nurse who is angry about their skills being misunderstood, underestimated and devalued:

Dialogue scripted for the character Carol Little RN in Episode 1 of “Pulse”


Thanks for reading my first outing as a television critic. As always, your feedback is welcomed in the comments section below.

Paul McNamara, 22nd July 2017

Short URL: meta4RN.com/pulse


First Thyself

First Thyself – Surviving Emotionally Taxing Work Environments

On 28th April 2017 I’ll be presenting a session at the Ausmed “Breaking Point: Ice & Methamphetamine Conference” in Cairns. More info about the conference here: https://www.ausmed.com.au/course/ice-methamphetamine#overview

The nature of nursing will mean that we are likely to be are exposed to a range of challenges.

Feeling unsafe, witnessing violence, tragedy and dealing with trauma are some examples.

This emotionally taxing environment can result in tension with colleagues, family and friends.

This session will begin day two of the conference by creating an opportunity to discuss the following:

What are the professional implications of working in challenging areas of nursing and healthcare?

How can we maintain unconditional positive regard?

Why self-care matters and how to practice what we preach!

What’s all this then?

“First Thyself” is planned as an interactive session accompanied by visual cues to give the discussion a bit of structure. Consequently, the transcript/dialogue of the presentation can not be included here.  The visual presentation itself doesn’t use powerpoint slides. It uses the prettier (and free!) platform Prezi instead: prezi.com/skmu0lbnmkm5/first-thyself/#

This page serves as a one-stop directory to the online resources used to support the discussion.

I’m recycling and combining a lot of old ideas for the session (there’s that self-plagiarist vs groovy remix of favourite old songs thing again).

Here is the online presentation: Prezi

Here are the resources and references used in the presentation:

Emotional Aftershocks (the story of Fire Extinguisher Guy & Nursing Ring Theory) meta4RN.com/aftershocks

Football, Nursing and Clinical Supervision (re validating protected time for reflection and skill rehearsal) meta4RN.com/footy

Hand Hygiene and Mindful Moments (re insitu self-care strategies) meta4RN.com/hygiene

Lalochezia (getting sweary doesn’t necessarily mean getting abusive) meta4RN.com/lalochezia

Nurse & Midwife Support nmsupport.org.au  phone 1800 667 877
– we have specifically targeted 24/7 confidential support available

Nurses, Midwives, Medical Practitioners, Suicide and Stigma (re the alarming toll of those who undertake emotional labour) meta4RN.com/stigma

Nurturing the Nurturers (the Pit Head Baths and clinical supervision stories) meta4RN.com/nurturers

Spector, P., Zhiqing, Z. & Che, X. (2014) Nurse exposure to physical and nonphysical violence, bullying, and sexual harassment: A quantitative review. International Journal of Nursing Studies. Vol 50(1), pp 72-84. www.sciencedirect.com/science/article/pii/S0020748913000357

Zero Tolerance for Zero Tolerance (a reframing of reducing aggression) meta4RN.com/zero

It’s OK if you forget everything about today’s talk, just don’t forget that there is 24 hour support available via 1800 667 877 or https://nmsupport.org.au


Please have a play with the pretty Prezi prezi.com/skmu0lbnmkm5/first-thyself/#

Thanks for visiting. As always your comments are welcome.

Paul McNamara, 30 March 2017

Short URL: meta4RN.com/thyself



The Hearing-Voices/Car-Driving Metaphor

A while ago I met a lady who had a fantastic way of describing and understanding her experience of auditory hallucinations/psychosis. It goes a bit like this:

My body’s a car. I’m the driver.

In the back seat are the voices. They’re like naughty kids, always chatting away amongst themselves. Often they’re taunting me. 

Usually I can just ignore them and get on with driving the car.

However, every now and then the voices get real loud.

It’s distracting. Driving becomes difficult and that’s when I’m most likely to drive badly or, if I’m unable to concentrate properly, I could even crash the car. 

It’s pretty scary, but I usually don’t have to come into hospital at that point. I just need more support to get control back, and maybe a change to my medication. 

The worst time for me is when the voices get so distracting that I can’t focus on driving at all. I turn to the voices in the back seat and try to get them to shut up. But they’re like naughty kids yelling and jumping around the car, and I can’t get them to stop. 

I take my seatbelt off and turn to face them, then somehow – I don’t even notice it happening – one of the voices will slip into the driver’s seat and take over control of driving the car.

Thats when it gets REALLY dangerous.

I’m not out of control – it’s worse than that – I have lost control entirely. I haven’t even got my hands on the steering wheel anymore, and I can’t reach the brakes. 

That’s when I need to come into hospital.

At the time I met this lady she was make a tentative recovery from one of these acute episodes of psychosis. On admission she had been experiencing command auditory hallucinations, paranoid delusions, racing thoughts and suicidal ideation.

When we met the intensity of these symptoms was settling. The lady’s articulate insight helped us both communicate effectively when she had a relapse in symptoms. To keep her safe we needed to stop her from leaving the hospital, and provide an increased level of supervision/support. To get a shared understanding of this I was able to return to the lady’s metaphor:

I’m worried that you’re at risk of losing control of the car again. What I’m planning to do is take the keys away for now, and hand them back to you when you’re safe to drive again. 

That’s a good way to think about using the Mental Health Act – it’s a mechanism to decrease risk/stop people from a foreseeable crash if they’ve lost the capacity to drive. 

However, the real story here is about the intelligence, insight and articulate communication of a young woman who experiences symptoms of psychosis.

An impressive person, and a fantastic metaphor. 

Hopefully other people will be able to make use of this lady’s metaphor as a way to understand psychosis/hearing voices. 


Thanks for visiting. As always your comments/feedback is welcome below.

Paul McNamara, 20th February 2017.

Short URL: meta4RN.com/car