A little while ago, I had the privilege of reading Calling IN: A Less Disposable Way of Holding Each Other Accountable by Ngọc Loan Trần. The essay is well written and thought provoking, and brought a new idea to the way I practice feminism and activism. I keep thinking back to this essay and what it could mean in my personal life. What if we brought Trần’s idea of “Calling In” to nursing? Could we find a method of speaking to each other that comes from a place of concern and love? When speaking from that place of concern, could we use language and tone in such a manner that lateral violence and bullying on our hospital units is decreased? Could we actively support one another to improve our patient care without bringing someone to tears? I think we could.

From the essay:

“Most of us know the drill. Someone says something that supports the oppression of another community, the red flags pop up and someone swoops in to call them out.

But what happens when that someone is a person we know — and love? What happens when we ourselves are that someone?

And what does it mean for our work to rely on how we have been programmed to punish people for their mistakes?

I’ll be the first person and the last person to say that anger is valid. Mistakes are mistakes; they deepen the wounds we carry. I know that for me when these mistakes are committed by people who I am in community with, it hurts even more. But these are people I care deeply about and want to see on the other side of the hurt, pain, and trauma: I am willing to offer compassion and patience as a way to build the road we are taking but have never seen before.” (Trần)

While Trần’s essay deals primarily with actions within the activist community, I see a lot of parallels with nursing. A good example is shift report. Generally, report is a smooth transition, performed by thousands of nurses each day to get one shift in and another shift out. Everyone’s goal is to get through report quickly so the oncoming nurse can get to work and the offgoing nurse can get some sleep. Report isn’t always seamless, and a big part of that comes from nurses. There are nurses who approach report aggressively, and by the time the offgoing nurse has finished, that nurse feels like they have been through a battle. This is lateral violence.

There are nurses who seem to look for mistakes and consider themselves blameless. Now, we are all going to make mistakes, and because we all make mistakes, we are all going to FIND mistakes. Some mistakes are big, and have a lot of people involved. Some mistakes are small, and are the result of action or inaction by one individual. Regardless of the level of mistake, we should never berate one another or treat one another in a hostile fashion. Rather, we should deal with the mistake, and if we are in the presence of someone who has made a mistake, we should not talk to them as if they did not have a nursing education. We should keep in mind that this is our co-worker, someone we trust and have worked with as a team member. We should tailor our language and our tone to maintain professionalism, patient confidence, and the relationship of trust we have built as members of the patient care team.

When another nurse is aggressive during a nurse to nurse interaction, it is lateral violence. When a nurse is aggressive toward a CNA or other member of ancillary staff, it is BULLYING. This happens to CNAs more often than nurses are willing to admit. It can happen as a result of stress. It can happen as a result of miscommunication, but it happens. We need to be aware, as nurses, of the potential we all hold to be bullies on our units, and to watch our tone, watch how we delegate, and to be aware when our CNAs simply cannot handle one additional task, and that we need to do something ourselves. We are ALL working hard. When viewing bullying by a nurse to ancillary staff, it is important to speak up and stop the bullying behavior. Trần’s idea of “calling in” gives us a new technique to use when we see bullying behavior in a co-worker for whom this behavior Is abnormal. What is causing the behavior today? What can we do to stop the behavior and save the relationship between the nurse and the ancillary staff?

So what is the difference between calling out and calling in?

Trần works to define (and states this is a work in progress):

1) “The first part of calling in is allowing mistakes to happen.”

(Now, in nursing, if we see a medical error about to happen, if we see a safety issue, we should always speak up. I am not advocating that we allow preventable medical or safety errors to happen. In nursing, we should be aware that mistakes will happen and we will have to deal with them, but it is how we deal with mistakes that either brings us closer together or pulls us apart)

2) Think about “what makes my relationship with this person important?”

            Are they a long time co-worker? Are they a new graduate? Are we friends? Do we know they’ve been having a rough time lately? What do we know about our co-worker that makes them valuable?

How do we start these conversations? Again, Trần has put a great deal of thought into this, and nurses do not need to stretch far to see how Trần’s model could be used to decrease lateral violence and bullying on our units:

“I start “call in” conversations by identifying the behavior and defining why I am choosing to engage with them. I prioritize my values and invite them to think about theirs and where we share them. And then we talk about it. We talk about it together, like people who genuinely care about each other.”

Additionally:

“I picture “calling in” as a practice of pulling folks back in who have strayed from us… Calling in as a practice of loving each other enough to allow each other to make mistakes; a practice of loving ourselves enough to know that what we’re trying to do here is a radical unlearning of everything we have been configured to believe is normal.”( Trần)

Trần discusses how we have “configured to believe it’s normal to punish each other and ourselves without a way to reconcile hurt.” This is where nursing needs to look up and examine itself closely as a profession. Too often do we see a mistake and rather than deal with it quietly, we mention it to our co-workers. We say “someone was having a bad day” or make comments that lead others to believe our fellow nurses are now not as trustworthy as they might be. Comments like these undermine nursing as a profession. They undermine the teamwork on our units, and they break down the relationships among nurses.

It should not be “normal to punish each other.” Instead, when a mistake is noted, deal with it. If the mistake needs to be reported, do so quietly and efficiently without involving others, if possible. If you need to involve someone, involve someone who will also be discreet. Offer your fellow nurse a shoulder, support them if they need to take a moment for self-care. Be aware of the signs of compassion fatigue or burnout.

By incorporating the idea of “calling in” rather than calling out, we can decrease the incidence of lateral violence and bullying on our units. We can make our workplace more professional, and less stressful. We can encourage each other to participate in self-care to stay mentally and physically healthy. We can be better nurses, and we can elevate the nursing profession.

I would like to address the issue of “calling in vs. calling out” as it relates to ancillary staff. If a nurse finds an error made by a CNA, “calling in” can still be very useful, but nurses need to remember the potential for bullying in these situations. There are different power dynamics involved with nurse-CNA interactions than with nurse-nurse interactions, and the potential for harm here must be acknowledged. Remember how humiliating it can be to be “called out” at the nurse’s station, in a patient’s room, and afford all of your co-workers the same respect, and do not use these power dynamics to better yourself, but to better all staff.