Emergency rooms are not safe places to make assumptions. That’s why nurses who are unafraid to ask questions can significantly improve the health outcomes for their patients. Elizabeth Even, MSN, RN, CEN, is an emergency department nurse at Northwestern Memorial Hospital in Chicago. She is also associate director, Standards Interpretation, for The Joint Commission, a global driver of quality improvement and patient safety in healthcare.

Paul Quinn: Elizabeth, first of all, thank you for your work on the front lines throughout this pandemic. Apart from ongoing efforts to stay COVID-free, what do you see as the major communication issues for nurses in the ER?

Elizabeth Even: For a new nurse the trauma experience can be intense. There’s a lot of people, it’s loud and there’s a lot going on at the same time. If the nurses in that setting aren’t feeling super confident in the process, they may not feel like they can interject a question during the trauma process.

And that can have huge implications because everyone kind of has their horse blinders on and may be focusing only on the obvious, such as a bad head injury.

But if a nurse notices something else and speaks up, like, “Is this patient pregnant?” it could make a big difference in how care is delivered as well as the patient outcome. 

Paul Quinn: In corporate settings, the failure to ask questions can lead to all kinds of problems. But in healthcare, it’s far more serious considering that neglecting to ask could be potentially life-threatening. 

Elizabeth Even: I used to teach at the medical school. Some of the students felt like they couldn’t ask questions because they were always being graded and were the low man on the totem pole.

I would tell them, Use the patient as your shield. If you feel there’s a question you should ask [a doctor] that’s going to be better for the patient, do it. Because this isn’t about you, it’s about the patient, so you should feel confident to ask on behalf of better care for your patient. Framing it that way empowered them to speak up.

Paul Quinn: That makes sense. A lot of people find it easier to ask on behalf of others. 

Elizabeth Even: It’s good to have an ally, too. If you’re somebody who doesn’t feel confident to ask that person in that moment, find someone who will, because it can change everything.

Paul Quinn: I imagine that you are that ally in many cases?

Elizabeth Even: Sure. People know that I will ask a question in that moment because I’ve been there a long time, I don’t have any problem asking questions. Most senior nurses in the ER have no issues asking questions, getting clarification, and ensuring they understand what is happening and why. 

Paul Quinn: Have you ever been in a position where you’ve felt the need to question a procedure?

Elizabeth Even: There’s a professional courtesy and kind of knowing your place. I wouldn’t question someone on a surgical procedure, for example, because I’m not a surgeon. But there have been plenty of times that I have gone to my ally, the attending ER physician to ask questions about care in an effort to understand it better.

In my everyday practice, though, I would question a medication order or something if my experience has proven it might not be a good idea, as one example. 

Paul Quinn: Is there a particular way you might phrase a potentially challenging question about the proper medication, given the professional respect you mentioned?

Elizabeth Even: I might say something like, “I have a quick question about this,” or “Can you educate me on this?” I play dumb in a way, like, “Isn’t that for this?” or “I’ve never seen it done that way, can you tell me about that?” I try to phrase it in a way that’s not adversarial. It’s “Teach me,” rather than to make them wrong. 

Paul Quinn: I can see that that could be an effective way to bring an issue to their attention by asking rather than making them wrong or accusing. Have you ever asked a question like that and changed a doctor’s actions?

Elizabeth Even: Yes. I had a doctor who ordered a fluid bolus for a patient who had an irregular, rapid heart rate. And it didn’t make any sense to me because their heart was already stressed, so why would we make it work harder with all this fluid?

I was fairly new at the time and I remember asking the doctor, “I don’t know, is this fluid going to help this problem? I’m not sure.” And the doctor, who was also new, looked at me and said, “I don’t know – I thought you knew.”

And so we figured out then that both of us were new and needed to talk to someone who knew the answer, which we did. 

Paul Quinn: So, you asked rather than assumed she was right, which was really an intervention. How might that have turned out for the patient if you hadn’t asked?

Elizabeth Even: It might have been fine, or it might’ve caused more stress on the patient’s heart or caused a decline for the patient. So, that’s another area where I say if you’re not sure, ask.

I tell students, You’re the nurse, you are caring for patients underneath your license so you need to educate yourself and understand why you are doing what you are doing when it comes to carrying out orders. We are the safety double-check prior to the order touching the patient. Do not assume, just ask. People are more likely to speak up when they feel a sense of ownership and responsibility for the patient.

Paul Quinn: I know that medication errors happen at hospitals everywhere. But I imagine that the more that nurses know and take responsibility for their patients, which you promote, the better they’re able to catch medication errors. 

Elizabeth Even: Right. I explain to the new nurses, You have, say, four patients but your team has 24 patients so there’s no way they can know the details of your patient like you do. The team relies on you for information. So, if they order medications that don’t make sense, speak up.

Paul Quinn: It sounds to me like assertiveness is a critical skill for nurses in situations like that. 

Elizabeth Even: Yes. I was reading about a situation at a hospital where a provider was ordering blood thinners and the nurses either weren’t looking at the labs that showed that the levels were already too high or didn’t feel comfortable in asking so they continued to give the medication to the patient. There was really no critical thinking and patients had worse outcomes because of it.

Paul Quinn: We’ve been talking about nurses and the importance of asking questions. How about patients? What is the patient’s responsibility for speaking up in their own healthcare?

Elizabeth Even: I am a huge advocate for not ever going to [medical facilities] alone if you can help it. I know it seems silly to bring a friend or family member if you come in for a relatively small thing. But if you’re in pain, you’re not paying attention, you’re overwhelmed—there’s so many things you could miss but that someone else could catch. It helps to have a second set of ears with you. They can help ask questions or clarify things. I’m a huge proponent for that.

Paul Quinn: There are a few times that I’ve been the advocate for someone in the hospital, and it really is a critical role. What other advice do you have for patients?

Elizabeth Even: Asking questions is taking care of yourself. So many times when patients come in to see us, it is clear that they simply did not understand what they needed to do at home to take care of themselves or nobody explained to them what symptoms were normal so they came back in to get evaluated even when it wasn’t necessary. 

I always say to patients, Ask us all of the questions now, because the minute you walk out of this hospital it’ll be almost impossible to get a hold of the emergency team. We’re not like your regular doctor where you can just call us. We’re shift workers, so the team you saw three days ago is not going to be available. 

Patient advocacy is always on a continuum. Some patients are very familiar with the healthcare system or they’ve researched it. And then there are patients that have 100% faith in the providers, “I’m in your hands, you guys have got this.” They don’t ask any questions, they’re just along for the ride.

And then there are people in the middle that might not feel very confident to ask or they’re in denial, or medicated. There’s so many different reasons they might not ask.

Paul Quinn: How does a patient even know what to ask hospital staff about their health care, especially if they’ve never been in this position before? You have to be somewhat informed in order to even know the right questions to ask, right?

Elizabeth Even: Right. We [nurses] are good at asking if patients have questions. But that’s like the mechanic asking me about my car problem. I may not have familiarity with the problem, so I don’t have the basis to ask the right questions. So that’s often what I’ll coach patients on is what questions they should be asking and why, because they don’t know.

Paul Quinn: That’s an issue with a lot of professions. The expert knows what they know but often forgets that lay people don’t know what they know, and a lot of mistaken assumptions get made. (see “You Didn’t Ask is a Lousy Excuse for Withholding Information”)

Elizabeth Even: And I think the piece we forget is that what’s basic common knowledge to us is not common knowledge to people who are not in our field. If I were to ask my cousin, who’s a lawyer, a simple question, to me it’s anything but simple. But to him it’s no big deal, it’s something that he just knows in his practice.

I equate that to the medical profession. Friends and family members text me questions and they’re apologetic, but it’s not really a big deal for me to answer because it’s basic information for me by the nature of what I do.

Paul Quinn: What are the most important questions you ask in patient education? 

Elizabeth Even: When I discharge a patient I ask them three questions. The first is, What did we just talk about? Because I want to hear from them what they heard me say. Sometimes they miss something or I need to clarify.

Second: What do you need to do next? This can be wound care or calling for follow-up or picking up prescriptions or really anything related to why they came in. 

Third: When are you going to follow up? [based on the recommended followup] If they can’t answer a question, we go over it again. When I talk to nurses, I emphasize the importance of getting into a routine so these questions become automatic. 

When you are busy you default to routine — when you do not even need to think about something, you are more likely to do it.  Sadly, patient teaching at discharge is often very abbreviated. 

Paul Quinn: Northwestern is known as a teaching or academic hospital. In your experience, are questions more common or expected at teaching hospitals?

Elizabeth Even: In a teaching hospital, the attending physicians are talking to the residents because they’re in training. And the nature of that environment is a lot of talking because there’s active teaching going on all the time. And so the smart resident will talk to the nurses as well. 

We see a different side of patients that the physicians may miss and we always have the inside scoop.  Patients tend to tell the nurse more than they will tell the doctor at times.

In a community nonteaching hospital you have attending physicians, no residents, and the nursing staff. It’s a very different feeling and generally a lot less communications in comparison. There you might have more hierarchy, and less question asking. 

Paul Quinn: So, for nurses and patients the message is the same — when in doubt, speak up and ask questions. Because as you said, it can change everything. Thanks for sharing your insights on this, Elizabeth.

Elizabeth Even: It’s my pleasure. I’ve always had a passion for communication, but there are few areas where it’s as important as in emergency medicine.  

Elizabeth Even is the author of Shift Your Mindset, Your Job, Your Life: A Guide for Nurses. Visit her website, StraightTalkRN.com or contact her directly at hello@straighttalkrn.com.

Paul Quinn is author of a nearly completed book about asking as a life skill.