Helen: Welcome to Health Literacy Out Loud. I’m Helen Osborne, president of Health Literacy Consulting, founder of Health Literacy Month and your host of Health Literacy Out Loud.

In these podcasts, you get to listen in on my conversations with some truly remarkable people. You will hear what health literacy is, why it matters and ways all of us can help improve health understanding.

Today I’m talking with Suzanne O’Connor, who is a nurse and has worked for many years in hospital emergency departments, intensive care units and outpatient practices.

Suzanne now consults with clinicians of all disciplines about crisis communication, conflict resolution and working with difficult people. As so many of us know, these skills are essential in healthcare today.

I’ve known Suzanne for many years, and we really do share a lot in common. We not only have a long history of being clinicians, but we’re also now consultants, speakers and active members of the New England chapter of The National Speakers Association.

I am delighted to introduce Suzanne to you. Welcome, Suzanne.

Suzanne: Thank you very much.

Helen: We’re focusing on really hard communication. This came to light even more after the crisis we had in Boston with the bombings after the marathon. That’s why I really wanted to focus on this. You know a lot about crisis communication. What is that?

Suzanne: When people are in crisis, as I saw for many years in the emergency room, they have a hard time hearing, listening, and absorbing because their level of fear and anxiety is very high.

What I try to work on is my non-verbal, open, first impression where I try to put the person at ease because no real communication can happen until there’s a level of confidence.

Helen: You’re talking about a crisis and how hard it is to just listen and hear. Does that mean a tragedy that all of a sudden happened? Or is it more with somebody who is really sick or hearing sad news? What are those crises like?

Suzanne: It’s all of that. It’s delivering bad news.

An example I can give you is that a patient came in having had an overdose. He was slipping into a lower level of consciousness. I had to get out from him as quickly as possible what he took because by the time the toxicology comes around, he could be in serious condition. We didn’t know whether we needed to intubate him.

That’s the kind of stuff I started with. I said, “What did you take? It’s okay. You can trust me. I’m not going to report you to the police. Please open up because this is the best care that we can give if we know what you took.”

Helen: Suzanne, what I’m hearing is that he is in physical crisis at that moment, but you have to communicate as efficiently, quickly and correctly as possible. Is that right? You’re both under a lot of demands at that moment.

Suzanne: That’s right. I think that’s the way healthcare is going. We don’t have a lot of time with a lot of patients. We need to know if they taking their medicine and actually following the regime. I say, “Please be honest with me. It’s okay if you tell me you’re not.”

There’s a lot of trust that has to get established because we want the truth from people. I work hard on developing trust fast. I find that if I share with them that I have good intentions, that I’m going to help them, that it’s a benefit to them to tell me the truth and that it’s going to work better for their care, that’s what seems to work.

As soon as they know that it’s a benefit to them, they seem to be more open and honest. Even though I’m a stranger in crisis, it works well.

Helen: That’s interesting. Building the trust and setting that tone for good communication is something we talk about in health literacy a lot. We need to know who we’re talking to, know where they’re coming from and what their needs are.

You’re talking about this real crisis with quick communication. Then we have to do something to have them be more receptive to the message.

Suzanne: Yes. I find that identifying somebody in their group helps. Maybe it’s a cultural issue. They don’t trust the staff, but they will trust their family member. I try to find the person who is the most influential in the family and get them on board with whatever it is that we’re trying to teach or get the person to learn about.

Once you get somebody from their own family or ethnic group to buy in, or a physician from the same ethnic group or who speaks the same language, it seems to develop rapport very quickly.

I could give you a quick example. In the emergency room, we had a guy that had a large myocardial infarction.

Helen: That’s a heart attack.

Suzanne: Yes. The doctors were focused on getting him to stay and he was refusing. He said, “I don’t know you people. I don’t trust any of you. I just want to put my clothes on and get out of here.” The doctor argued with him. It was going nowhere. He said to me, “Suzanne, you’ve got to get him to stay. If he leaves tonight, he could die.”

The guy was pretty frightened actually because the doctor had said some of that to him too. I went up and said to his wife, “Who influences your husband the most?” She said, “No one. He’s the boss at work and at home. Women do not have any influence over him.” I thought, “Well, there goes me.”

I didn’t take that personally. I approached him and said, “I really want to help you.” I asked if there was a son or daughter that had influence. She said no, but she did say that the physician he has gone to for 12 years has good rapport with him.

Helen: That’s not the one in the emergency room.

Suzanne: No. Everybody was a stranger. He was bolting basically. He was putting his clothes on. I said, “Can I get your physician on the phone just for you and him to talk to each other about this issue and see what he has to say?” I bought some time. He said, “Okay, I’ll sit still.”

I got the doctor on a portable phone and brought it over to him in the trauma area. They had this quick, three-minute conversation and he ended smiling. He said, “He said to me, ‘Stop giving theses nurses and doctors a hard time. Wait for me. I’m coming in the morning and you and I can discuss any issues about your heart.’”

Helen: In those few minutes in that conversation, you brought in that trusted person. Did the person stay in the hospital?

Suzanne: He did, and he was smiling. It took only three minutes. That was the magic of it. Everybody else was arguing with him for about an hour. Once he got the trusted physician who said, “Come on, I’ll see you in the morning. Go to bed, sleep well tonight and we’ll talk about it,” that was the turning point.

Helen: What a wonderful story and what wonderful work that you did with that. I’m interested in knowing what we in health literacy can do about other times where there might be a crisis.

We’re not all nurses or in emergency rooms. There are other times that we have to give urgent information, such as in an environmental disaster. How do we communicate that clearly?

Suzanne: I think what you do is state your intention and ask questions. Don’t tell the person what to do, but say, “I’m here for you. I want to help you. Let me see what I can do.” Give them options because they’re very frightened. Say, “Here’s something I can help you with right now.”

Maybe there’s somebody you want to take their tuberculosis medicine and they’re refusing or having any kind of resistance. What seems to work is saying, “I have your best intention to help you through this. Don’t worry. I’m with you.”

I find that’s what really works. People instantly say, “They’re coming from an authentic place of caring and empathy.” That seems to bring people closer to somebody who’s a real stranger. In crisis, you’ve got to get a lot of information from somebody and keep them calm enough so they can think clearly.

Helen: It sounds like you’re setting the tone of calmness. You’re letting them know you have their best intention. The caring and empathy certainly seems to come through not just with your tone, but with your words.

When it gets to that actual message itself, what suggestions do you have for all of us who have to do this really hard communication?

Suzanne: I say go step by step, give small bits of information and describe in a factual way something that’s happening.

For instance, with diabetes you would say, “You need to be on insulin because your levels are really high.” If someone’s drinking really heavily, you say, “I’m concerned about you because your liver enzymes are very high. This is what they should be and this is what yours are.”

When you give them some facts and their exact data, rather than talk in generalizations that alcohol isn’t good for you or whatever, it seems like they buy it better, especially if you can look on the computer or the iPad and say, “Here are your exact numbers,” or, “This is why I believe you need to go on insulin. This is your blood sugar level.”

Helen: Make it somehow personally relevant to that specific individual. Is that something that takes a long time to be able to do, or can you do that pretty efficiently?

Suzanne: Pretty quickly, especially with the technology we have now. IPads are at the bedside. When people see, “Here’s your fracture. This is why you need surgery or an extra pint of blood. It’s because your hemoglobin is so low. Here’s your case with your name up here,” it’s almost like opening their medical record in front of them. I find that it builds quick rapport.

A fact is a fact. They don’t seem to get defensive on a fact. If you say, “You’re pretty sick, I think you should stop drinking,” they say, “No, I’m not that sick.” If you put the numbers and the facts out there, the facts can stand alone and they don’t create the tension and the resistance that a generalization would.

Helen: That’s really interesting. What if somebody comes in with their own set of beliefs or facts that may not be supported by the data out there about drinking or something? Maybe a person has their own story about that and it’s not the same as the medical model.

Suzanne: That is true. They have their own perception of how sick they are and what they need. I think you just explore that. Stephen Covey said, “Seek first to understand before being understood.”

What I do with resistance is instead of defending and digging in with my opinion, I say, “Tell me more about your thoughts on alcohol or hypertension medication. What is your concern about taking that? I need to know more. That’s really interesting.”

I always try to find one thing that I can agree to. If they say to me, “I’m not going to take these pills every day. I have to pay co-pays and it’s expensive.” I might say to them, “You’re right. Money is an issue, especially now with the economy. I do agree with that. Money is a concern.”

Then I will also say, “I really want you to get the best care. I’m worried if money gets in the way of the best care for you.” I always give them a feeling that it’s definitely customizing the information for them.

I deflect the resistance by almost dancing with them rather than resisting them and digging in. I go with them with their fear and anxiety about the medication.

You need to unravel the fear and stay in dialog with people. That’s what I learned to be really helpful for me. I don’t let them go silent or become aggressive.

Helen: Just tell us a little bit about that.

Suzanne: You know when you’re losing rapport and you’re no longer in dialog with somebody. They start rolling their eyes or shutting down and don’t seem to be listening. They give you a lot of non-verbal communication that they’re just not interested in what you have to offer.

As soon as that happens, I say, “Hey, what happened?” What I say in my own head is, “Somehow we lost the dialog.” They got into silence or aggression and started to withdraw, which would be the silence, or they start getting angry and say, “I just can’t do this anymore. Please don’t tell me anymore.”

Then I say, “I’m really sorry. I didn’t mean to upset you.” You try to restore safety before you go back into the dialog, if they’ll allow you to. That’s what I do. I say, “My intention is not to upset you. I brought this up for this reason.”

I always call people by name many different times in the conversation. I say, “John, I really do want to help you. I’d hate to see you leave here tonight not understanding something about your personal health.

Helen: Suzanne, one practice consistently recommended in health literacy is using the teachback to make sure your message is understood. Do you ever use that strategy?

Suzanne: Yes, I use it all the time. I think you have to do the teachback in small increments. When they’re in crisis, they can’t absorb too much information too fast.

Rather than give a 15-minute dialog about why they need something, I would stop every three or four minutes and say, “What is it that you’ve heard, just so that I’m clear? Sometimes I’m not so clear. How did you hear what I just said? Can you say it in your own words?”

I always put the onus on myself that I might not be clear. It’s always incremental steps of giving bad news or information that’s going to make them more fearful. I just go very slowly.

I also gather my help from the family members they really trust. I always have a second person there so that the teaching can be resonating with at least two to three people so we don’t lose the content because they’re so anxious to leave or get out.

Helen: You’re doing exactly what those of us who have been doing health literacy for a long time talk about. You’re able to do it in that moment. You may not have a lot of time to do it. You’re doing this when a person may be at the hardest time of their whole life. They could be newly injured, scared or sick.

You’re organizing your information and presenting it in context of their life. You’re giving facts, undoing misconceptions and confirming understanding. That’s the true essence of health literacy.

I know that you do this, and you do it well. It must be very hard work. What gets you excited to keep doing it day after day?

Suzanne: I find that the longer you do something like this and the more you see trust and results and people actually developing a rapport with you, even though they’re still pretty nervous, I just find it a great challenge. If I can bring somebody’s anxiety from a 10 down to a five, feel I’ve succeeded. At least they got something.

I’ll also give them something in writing. I’ll also give them my phone number to call me at any time if they want to review this again because it’s often hard to absorb this when you’re in the middle of a crisis.

Repetition is the key, and being available to them again and again. I also have taped some of my teaching with people and said, “Here’s a cassette that you may want to use. This might be helpful. You can hear it again and again.”

If it’s delivering bad news, sometimes they need to share it with their family. They can say, “Here’s exactly what the person said to me.”

Helen: I just want to tell you we’re putting that into place because people can listen to this podcast again and again.

You’ve offered so many very practical strategies we all can be using to help our communication go from a five to 10 when it comes to communicating clearly in a crisis. Thank you, Suzanne, for sharing this with all of the listeners of Health Literacy Out Loud.

Suzanne: It’s been a pleasure. Thank you.

Helen: I learned so much from talking with Suzanne O’Connor about communicating clearly in a crisis, and I hope that you learned a lot too. But health literacy isn’t always easy. For help clearly communicating your health message, please visit my health literacy consulting website at www.HealthLiteracy.com.

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Please share the word about health literacy. Tell your colleagues and friends. Together, let’s let the whole world know why health literacy matters. Until next time, I’m Helen Osborne.