Helen Osborne: Welcome to Health Literacy Out Loud. I’m Helen Osborne, President of Health Literacy Consulting, founder of Health Literacy Month and author of the book Health Literacy from A to Z. I also produce and host this podcast series, Health Literacy Out Loud.

Today’s podcast looks at the concept of civility, an environment in which patients, family and staff are safe and feel respected.

LouAnn Bala knows a lot about this topic. As Vice President of Content and Clinical Programs at Get Well, LouAnn builds on her experience as a clinical nurse educator and a health coach. Her aim is to improve quality and safety for patients, further the study of alternative and lifestyle medicine approaches and build the case for using technology to improve healthcare delivery.

LouAnn has created numerous patient education materials on topics that include youth mental health and workplace civility.

Welcome, LouAnn, to Health Literacy Out Loud.

LouAnn Bala: Thank you so much, Helen. I’m glad to be here.

Helen Osborne: Civility. I just love that word. I don’t know why. It’s just a word I don’t use a lot, and it has a special charm to me. But I’m not sure I’m using it the correct way. Can you start all of us off with what you mean by the term civility?

LouAnn Bala: Sure. A lot of people think that civility is just about treating others with kindness and respect, about the golden rule, treating others as you would want to be treated. But it actually goes a layer deeper.

It’s really about being present with those around us. I call that having informed conversations, agreeing to disagree respectfully and seeking that common ground.

Helen Osborne: Common ground, I like that. And the respect, too.

LouAnn Bala: Yes.

Helen Osborne: Is it one-sided or is it two-sided?

LouAnn Bala: That’s a great question it’s actually about respecting and learning about our differences.

Helen Osborne: Give us an example.

LouAnn Bala: Sure. Civility actually impacts every form of human interaction. We actually see this as writers, designers, developers and even public servants. How we use messaging really does impact others.

We actually saw a pretty disturbing trend during COVID. That’s probably one of my best examples that I can give.

Helen Osborne: None of us can forget COVID.

LouAnn Bala: I don’t think we’ll be able to forget it for some time. If you can remember, maybe you felt this way. You might’ve felt anxious, depressed or isolated. They actually were as deadly as the virus itself.

Helen Osborne: Really? Those feelings?

LouAnn Bala: Sure. People were not communicating in the traditional way. They were really communicating via screens. You saw this with a lot of the teen population. They were using emojis to replace thoughtful feelings or thoughtful conversation. That can be seen very differently by different types of cultures.

Helen Osborne: It’s not just that look on our face or our expression, or if we move closer to somebody. That was all out of the equation during COVID.

LouAnn Bala: Correct. Exactly.

Helen Osborne: Is that a sample of incivility? I know I would text with my granddaughter and she loved emojis and she’d send me a series of silly ones. But is that a relationship? Is that civility?

LouAnn Bala: It can be. I actually had just read a great report in Gallup’s 2022 Global Emotions Report. I don’t know if you read that.

Helen Osborne: No.

LouAnn Bala: It had a couple really interesting facts in it. It was stating three things. People are having more negative experiences and fewer positive ones.

Helen Osborne: During COVID?

LouAnn Bala: Yes. They’re stressed out, they’re very sad and they’re worried. It’s actually at their highest recorded levels ever. People are not resting, they’re not experiencing joy, and you wonder why this is happening.

I’m going to go back to that emoji conversation for you. Think about it. When you’re communicating via text messaging or you’re communicating via a screen, you’re actually probably multitasking and not so much fully present in that conversation, right?

Helen Osborne: Of course.

LouAnn Bala: You might miss half or more of what that person is trying to tell you or you’re missing that nonverbal communication, and that can actually lead to incivility, misunderstandings, not understanding or respecting each other’s differences.

Helen Osborne: Hopefully the hump of COVID is behind us, but the use of emojis seems here to stay. The multitasking seems just chronic. I seldom do just one thing at a time these days if I’ve got my device in my hand or on my screen. Will that level that prompts incivility stay with us, or are we getting used to it, or is it getting better?

LouAnn Bala: I wish I could say we were actually getting used to it. I think we actually are getting used to it, but I don’t know if it’s for the good. My hypothesis is that it’s not for the good. I believe we need to really start focusing on the mindset behind why this is occurring.

If you look at technology, it’s driving a lot of our interactions. I’m a big fan of technology. I work for a digital technology company.

What we found, though, is that when you’re trying to deliver messages, you really have to consider your audience, how you’re delivering that message, how these tools are being experienced by the other individual, if you’re targeting the correct audience and what kind of information is flowing through those tools. Is it factual? Is it non-factual? Is it a trusted source of information, or is it a social source of information?

Helen Osborne: When you say tools, what are you talking about?

LouAnn Bala: Tools can be everything from an app that you’re using to a healthcare portal, for example.

Helen Osborne: This sounds like health literacy to me.

LouAnn Bala: It absolutely is.

Helen Osborne: Considering your audience, considering the way you’re communicating the message, considering the other person’s experience.

You talked about emojis, and that’s hard. You’ve talked about the setting. That’s hard. The aloneness, our feelings. How can we make this better?

I just want to tell you, LouAnn, who our listeners are. You do so much digital work. You also are a nurse with a clinical background and just a great all-around human being. Please share how we can increase that level of civility, whether we’re meeting with someone in a clinical situation, perhaps in the community, whether it’s through public health or a community organization, or just online and in our lives.

I welcome some tips. All our listeners like to know, “What can I do to make it better today?”

LouAnn Bala: I think the best way for me to answer that question is with a quick story.

I have been in healthcare for a long time, over 25 years, and I’ve gotten to experience quite a few things. The one thing I will take away is that when you have patients that are coming in the hospital, they are often many times walking in frustrated, confused, concerned. They may have a lot of fear that something is either wrong with them or with a loved one, and they can tend to be in a very vulnerable state.

They’re met with all of this different messaging. They have to sign these forms. They are learning all these acronyms that are being thrown at them. They’re seeing a lot of different situations around them, so their situational awareness is very heightened.

When that happens, what we need to do as healthcare workers is recognize those triggers that are occurring.

I use this term, and it can be applied to pretty much any setting. If you’re a librarian in a library, somebody comes in emotional and angry, what do you do? How do you promote civility?

Helen Osborne: I just want to stop there to ask more about triggers. You talked about all the problems that can happen in a hospital. Someone coming in is sick, probably scared. There are noises beeping off. There are all kinds of forms to fill out. There are regulations and protocols, beepers and buzzers. Are those the triggers you’re talking about? Or is that something else?

LouAnn Bala: Absolutely, those can all be triggers. Triggers can be emotional. They can be physical, like pain. They can be emotional, like worry about a child. They can even be situational where there are all kinds of bells and whistles and things that are unfamiliar happening to you at that moment.

Helen Osborne: That’s very helpful. What you’re saying is what we can do to make this better, to create a broader sense of civility, is to recognize these.

LouAnn Bala: Yes.

Helen Osborne: The health clinician goes to this job and is there full-time, so they live with those beepers and buzzers and sterile environments. How can they keep recognizing this when it is what they do every day?

LouAnn Bala: It starts with awareness, taking yourself and putting yourself in the individual’s shoes.

An example that we’ve done with nurses before is actually had them pretend to be a patient. Walk in, pretend to go through filling out a form, look at how they actually use that tool and identify the things around them such as the messaging, the walls, the policies that they might be looking at.

What we found with that is we actually took steps to simplify a lot of the things, like taking the messaging from a very lengthy article about all the things we don’t want you to do when you come into the hospital to, “Do this. Do that.” Very simple, broad messaging.

Helen Osborne: Also, another health literacy principle is really emphasizing what a person can do rather than what they cannot do.

LouAnn Bala: One hundred percent.

Helen Osborne: In healthcare, there always are things not to do, but we can often reframe it. Rather than, “Don’t lift anything too heavy,” it is, “You can lift up to five pounds, which is about the weight of a bag of flour,” or something like that. I’m just giving it as an example to reframe a negative message into a more positive one.

LouAnn Bala: That is what civility is all about, Helen.

Helen Osborne: Oh, it is?

LouAnn Bala: You hit the nail on the head.

Helen Osborne: Look at our messaging in healthcare, role-play it and try it out.

When I think about that sometimes, I try to put myself in another situation, an unfamiliar, stressful situation. For me, it’s technology. The computer is all kaflooey. Even this podcast we’re recording, I have to support it all. I am not a whiz at this technology. I’m okay at it, and I can find that very stressful.

When I encourage people to be thinking about stress in their own workplace, where they are so familiar with it, think of a time that you find very stressful.

LouAnn Bala: That is 100% correct. I have been the nurse on the side of the emergency room with a patient yelling and screaming my name because they need somebody to come in the room right now.

They may not know that I’m working with a doctor to get their dose of pain medication, or I’m on the phone with somebody understanding what this next patient is coming in with. They don’t have the understanding of that. They just know that they’re in pain right now.

We’ve done a lot of education not only with the nursing team, but with all of the healthcare staff, to talk about how to de-escalate situations like that.

Helen Osborne: How do you? If someone is in pain or has to go to the bathroom, they want LouAnn now. They don’t care that you have five other patients or whatever you’re doing, right?

LouAnn Bala: That’s correct.

Helen Osborne: How do you de-escalate it?

LouAnn Bala: You typically have to finish the thing that is most important that you’re doing right now, and then you go into the room or you work with another individual to help to de-escalate.

But it really starts with respecting people’s personal space, respecting where they’re at, at the moment, being with them and present at the moment. “I understand you need to go to the bathroom. I’m going to get somebody to take care of that right now.” Being present and really empathetic with that individual is huge.

Helen Osborne: You don’t have to reveal too much about you. You have, for lack of a better word, a cranky patient who’s on your case about everything. Is that the other side of the incivility? Is that person not being polite and respectful to you?

LouAnn Bala: We are in a very interesting situation that requires us to take a step back, stop and listen, and, again, be with that patient where they are at, at the moment.

They may be showcasing incivility toward us, but the way that you get somebody to de-escalate can be as simple as sitting down with that individual to fully listen to them, to nod, to use body language that is open versus trying to stand up and hover over that patient.

There are a lot of simple things. You go back to the use of emojis. I’m going to go back there, Helen. Emojis can’t communicate that human touch, that human aspect.

Helen Osborne: That’s true.

LouAnn Bala: A lot of what we talk about with civility with face-to-face humans is really using that body language, those things that you can do to be open and present.

You can’t always do that with technology, but there are some simple tips that I could give.

Helen Osborne: Sure. I want to hear about the tips, and in technology. That’s your world now.

LouAnn Bala: That’s my world.

Helen Osborne: You live in the world of emojis, LouAnn.

LouAnn Bala: I know. It’s funny we just had a conversation about that, whether or not to use them.

Helen Osborne: How can we demonstrate civility and show it to others?

LouAnn Bala: When we’re thinking about applying it to technology, you have to think about your technology becoming what we call human-centered. Big word, but it simply means using the right images, considering the meaning of words, considering the depth and breadth of how you’re trying to communicate in situations.

I have a philosophy at Get Well that is specific around our ability to communicate education. It is not just through the education itself. It’s through the actual user design. How am I going to click to get to where I need to go? Is it easily navigated?

What do I do for the patient that only wants to learn small bits and only has the capacity to learn small bits right now versus the person that really wants to go in-depth further and learn more about their condition or about what they’re about to experience?

It’s creating that layered information within the technology, giving that user choices consistent with what we call their readiness state. That readiness state can be impacted by those things that we’re talking about with triggers, pain.

It’s not the first thing on my mind to go educate myself when I’m in severe pain. I might only need to know the first few things that are going to keep me safe versus the entire litany of everything I need to know about the surgery that I’m about to go through.

Helen Osborne: That’s really interesting there. We’ve been kind of teasing back and forth about emojis, but really what do you want to tell us about the use of visuals? Emojis are just a very abbreviated part. Do they represent ideas or emotions? I’ve only seen goofy ones from my granddaughter.

LouAnn Bala: I laugh because I have often had this conversation with executives across the country. Why is it that humans can spend hours on Facebook, TikTok and YouTube, but they can’t watch a three-minute education video?

Again, this is my perspective. I’ve come to the thought process that this is because of how industry is actually guiding us and how it is becoming part of our learned environment, meaning that you are used to seeing those apps that provide that scrolling feature, or the active use of adding an emoji or a thumbs up or thumbs down to something.

Taking some of those industry best practices of what get people to do that and applying that to the healthcare tools where we want people to educate themselves is super important. That’s what we’re doing right now within our tools.

Helen Osborne: That’s great. Wow, all these great tips.

As you were talking about adding civility in technology, I’m remembering a podcast I did, and I’ll have a link to this on your Health Literacy Out Loud web page, about respecting your reader. That’s in our written materials, so how you set the tone, how you invite the reader to want to read. It sounds like comparable concepts in there.

That was an interview with Karen Schriver, who’s very well-known. I have so much respect for her.

Briefly, I don’t know if you have much to say about this, but it’s out in the community, about civility in the community with people we don’t know, whether someone is at a community organization, such as a librarian with a patron coming in, to someone just sitting next to us at the coffee shop or on public transportation.

This seems to be a difficult area these days. How can we bring in a greater sense of civility when we’re in the public and we don’t know the people we’re talking with?

LouAnn Bala: It all starts with ourselves, our human connectedness. You can still apply the same kinds of techniques that I was talking about, like being willing to sit down and be present with somebody, understanding what it is they’re going through.

Seeking to understand your differences, seeking to learn more about those individuals and being open, I think, are key.

In our tools or even when I’m trying to communicate a message, for example, on something important that might be super complex, I use storytelling. Storytelling can be one of the absolute best tools in your toolbox.

Helen Osborne: I love those. Thank you for all of these. This is health literacy in action.

This is also what this podcast is about. Here you are, a real voice. We can hear your calmness. We can certainly listen to your bio and respect all that you’ve done before, but your voice carries a lot.

Indeed, interviews like this, even though it’s audio only, really are a form of storytelling. You’re sharing a story with listeners. I hope that they take that story and share it in their lives.

LouAnn Bala: Thank you.

Helen Osborne: LouAnn, thank you so much. You are fully present and I certainly have that sense of civility from you. I thank you so much for sharing these great tips and strategies with listeners of Health Literacy Out Loud. We’ll have even more information on your Health Literacy Out Loud web page. Thank you.

LouAnn Bala: Thank you so much, Helen. It was a pleasure.

Helen Osborne: As we just heard from LouAnn Bala, it’s important to consider civility in all the many ways we communicate. Civility is not only about how we explain or teach a message, but also our presence and how we listen to others. But doing this is not always easy.

For help clearly communicating your health message, please take a look at my book, Health Literacy from A to Z. Feel free to also explore my website, www.HealthLiteracy.com, or contact me directly at helen@healthliteracy.com.

New Health Literacy Out Loud podcasts come out the first of every month. You can get them all for free by subscribing at www.HealthLiteracyOutLoud.com, or wherever you get your podcasts.

Please help spread the word about health literacy. Together, let’s tell the whole world why health literacy matters.

Until next time, I’m Helen Osborne.

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