Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine 933 Telephone Nursing Stakeholder views and understandings from a paediatric and a gender perspective ELENOR KAMINSKY ACTA UNIVERSITATIS UPSALIENSIS ISSN 1651-6206 ISBN 978-91-554-8746-1 UPPSALA urn:nbn:se:uu:diva-200204 2013 Dissertation presented at Uppsala University to be publicly examined in Auditorium Minus, Gustavianum, Uppsala Universitet, Akademigatan 3, Uppsala, Friday, October 25, 2013 at 09:15 for the degree of Doctor of Philosophy (Faculty of Medicine). The examination will be conducted in Swedish. Abstract Kaminsky, E. 2013. Telephone Nursing. Stakeholder views and understandings from a paediatric and a gender perspective. Acta Universitatis Upsaliensis. Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine 933. 76 pp. Uppsala. ISBN 978-91-554-8746-1. ‘First line healthcare’ is offered via telephone in many Western countries. The overall aim of this thesis is to describe Telephone Nursing (TN) from three viewpoints: telenurses, parents calling for their children, and operation managers. Four empirical studies were conducted. Telenurses described their work in five different ways: ‘Assess, refer and give advice to the caller’, ‘Support the caller’, ‘Strengthen the caller’, ‘Teach the caller’ and ‘Facilitate the caller’s learning’, which all constitute a TN ‘work map’. Authentic paediatric calls between parents and telenurses revealed that 73% of callers were mothers and children were aged between 5 days and 14.5 years. The top three contact reasons were ear and skin problems, and fever, with a median call length of 4.4 minutes. More than half of the calls resulted in referrals and 48% received self- care advice. The likelihood of fathers being given referrals as a result of their call was almost twice as high as that for mothers, while mothers were almost twice as likely to receive self- care advice as fathers. Parents described their degree of worry and trust that influenced their decisions whether to contact SHD or not. Their calls were carefully prepared, and the parent calling often depended on family routine. Parents reported to follow recommendations. Most relied upon their own intuition if further worried, but some indicated they would never seek healthcare unless it was recommended. Operation managers described four main goals of TN work: ‘create feelings of trust’, ‘achieve patient safety’, ‘assess, refer and give advice’, and ‘teach the caller’. Equitable healthcare was regarded as important, whereas health promotion was not considered as part of the goals. Conclusion: The studied TN viewpoints present concordance and discrepancies. Paediatric health calls appear mostly to be a woman-to-woman activity. Telenurses’ increased gender competence might increase TN safety. For that matter, telenurses’ collaboration with parents and making parents aware of holding the ultimate responsibility for their child’s condition is important. Goals of TN work and their relationship with healthcare obligations such as equitable healthcare and health promotion need further clarification. The viewpoints described in this thesis may contribute to the development of TN. Keywords: Children; Equitable Healthcare; Gender; Health Promotion; Managers; Paediatric; Paediatric Health Calls; Parents; Registered Nurses; Telenurse; Telephone Nursing; Qualitative Research Elenor Kaminsky, Uppsala University, Department of Public Health and Caring Sciences, Health Services esearch, Box 564, SE-751 22 Uppsala, Sweden. © Elenor Kaminsky 2013 ISSN 1651-6206 ISBN 978-91-554-8746-1 urn:nbn:se:uu:diva-200204 (http://urn.kb.se/resolve?urn=urn:nbn:se:uu:diva-200204) To Alfrida, Helga, Orvar and all other children Research is to see what everybody else has seen, and to think what nobody else has thought. (Albert Szent-Gyorgyi) List of Papers This thesis is based on the following papers, which are referred to in the text by their Roman numerals. I Kaminsky, E., Rosenqvist U. & Holmström, I. (2009). Telenurses’ understanding of work: detective or educator? Journal of Advanced Nursing; 65(2):382-390. II Kaminsky, E., Carlsson, M., Höglund, AT. & Holmström, I. (2010). Paediatric health calls to Swedish telenurses: a descriptive study of content and outcome. Journal of Telemedicine and Tele- care; 16(8):454-457. III Kaminsky, E., Carlsson, M., Röing, M., Holmström, I. K. (2013). ‘If I didn´t trust Swedish Healthcare Direct, I would never call’ - views of making pediatric health calls. Clinical Nursing Studies; 1(3):57-69. IV Kaminsky, E., Carlsson, M., Holmström, I. K., Larsson, J., Fredriksson, M. Goals of telephone nursing work - the managers’ perspectives. A qualitative study on Swedish Healthcare Direct. Under review Reprints were made with permission from the respective publishers. Contents Prologue ........................................................................................................ 11 Introduction ................................................................................................... 13 Telephone Nursing internationally and in Sweden .................................. 15 A professional area in nursing ............................................................. 16 Nursing Care via Telephone ..................................................................... 17 A recognised phenomenon for nurses .................................................. 17 Support for decisions ........................................................................... 17 Recommended time frame ................................................................... 18 The Nursing Process and a model for Telephone Nursing .................. 19 Telephone Nursing Education .................................................................. 20 Paediatric Telephone Nursing .................................................................. 21 Talking to someone other than the person in need .............................. 21 The paediatric patient .......................................................................... 22 The parent caller ....................................................................................... 22 Operation managers at SHD ..................................................................... 23 Equitable healthcare ................................................................................. 24 Health promotion ...................................................................................... 25 Theoretical framework ............................................................................. 25 Competence theory .............................................................................. 26 Gender theory ...................................................................................... 27 Rationale for this thesis ............................................................................ 28 Overall and specific aims .............................................................................. 29 Specific aims ............................................................................................ 29 Methods ........................................................................................................ 30 Design ...................................................................................................... 30 Setting ...................................................................................................... 30 Participants and data ................................................................................. 31 Data collection .......................................................................................... 32 Data analysis ............................................................................................ 33 Ethical considerations .............................................................................. 36 Findings ........................................................................................................ 37 Study I ...................................................................................................... 37 Study II ..................................................................................................... 39 Study III ................................................................................................... 39 Study IV ................................................................................................... 42 Discussion ..................................................................................................... 44 Summary of findings ........................................................................... 44 Telephone Nursing ‘work map’ ........................................................... 45 Gender aspects of paediatric health calls ............................................. 46 Inequitable call outcome ...................................................................... 48 Worry and trust .................................................................................... 49 Telephone Nursing professionalism .................................................... 50 Future studies ....................................................................................... 52 Methodological considerations................................................................. 52 Conclusions ................................................................................................... 56 Clinical implications ....................................................................................