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I S S U E S I N C L I N I C A L N U R S I N G

The faceless encounter: ethical dilemmas in telephone nursing

Inger Holmström RN, PhD

Associate Professor, Department of Public Health and Caring Sciences, Uppsala Science Park, Uppsala University, Uppsala,

Sweden

Anna T Höglund DTheol

Senior Lecturer, Department of Public Health and Caring Sciences, Uppsala Science Park, Uppsala University, Uppsala,

Sweden

Submitted for publication: 22 November 2005

Accepted for publication: 25 August 2006

Correspondence:

Inger Holmström

Uppsala University

Department of Public Health and Caring

Sciences

Uppsala Science Park

SE-751 85 Uppsala

Sweden

Telephone: þ46 18 611 35 69 E-mail: [email protected]

H O L M S T R O M I & H O G L U N D A T ( 2 0 0 7 )H O L M S T R Ö M I & H Ö G L U N D A T ( 2 0 0 7 ) Journal of Clinical Nursing 16, 1865–

1871

The faceless encounter: ethical dilemmas in telephone nursing

Aim. This paper aims to present the findings of a study designed to describe ethical

dilemmas, in the form of conflicting values, norms and interests, which telenurses

experience in their work.

Background. Telephone nursing is an expanding part of health care. Telephone

nurses in Sweden assess care needs, provide advice, support and information, and

recommend and coordinate healthcare resources. Lately, ethical demands on

healthcare professionals in general have increased. The reasons include new bio-

medical competence, an ageing population and constrained resources which have

made priority setting a primary concern for doctors and nurses. When ethical

problems arise, colleagues need open dialogue. Despite this, nurses lack such a

dialogue.

Method. A purposeful sample of 12 female telenurses in Sweden was interviewed

twice during 2004 and 2005. The transcribed interviews were analysed thematically.

Results. Five themes were found: talking through a third party; discussing personal

and sensitive problems over the phone; insufficient resources and the organization of

health care; balancing callers’ information needs with professional responsibility;

and differences in judging the caller’s credibility.

Conclusion. The present study has identified five different themes in which Swedish

telenurses experience ethical dilemmas in their work. This shows how ethical

dilemmas in various forms are present in telenursing. Questions of autonomy,

integrity and prioritizing are particularly highlighted by the participating nurses.

Telenurses in Sweden also experience new ethical demands due to a multicultural

society. Although several of the identified dilemmas also occur in other areas of

nursing we argue that these situations are particularly challenging in telenursing.

Relevance to clinical practice. The work organization should provide opportunities

for ethical competence-building, where ethical dilemmas in telenursing are high-

lighted and discussed. Such a strategy might lead to decreased moral uncertainty and

distress among telenurses, with positive consequences for callers.

� 2007 The Authors. Journal compilation � 2007 Blackwell Publishing Ltd 1865 doi: 10.1111/j.1365-2702.2006.01839.x

Key words: clinical decision making, nursing, nursing ethics, qualitative methods,

telenursing, triage

Introduction

During the last decade the ethical demands on healthcare

professionals have increased. The reasons are, for example,

new biomedical competence, an ageing population and

constrained resources which have made priority setting a

primary concern for doctors and nurses (Moss 1995, Dierckx

de Casterle et al. 2004). Furthermore, new technology and

telenursing are also likely to create new ethical dilemmas.

The encounter by telephone is faceless because the nurse

cannot see the caller and can make decisions based only on

the information the caller chooses to reveal (Coleman 1997).

In addition, the telenurses experience conflicting demands

and a tension between being the patient’s carer and a

gatekeeper for the healthcare sectors (Holmström & Dall’Al-

ba 2002). Situations in telenursing experienced as difficult by

nurses are characterized by uncertainty, communication

difficulties and insufficient resources (Holmström & Dall’Al-

ba 2002, Wahlberg et al. 2003, Forslund et al. 2004).

However, there are few studies to date investigating the

important aspects of ethics in telenursing (Robinson et al.

1997, Malloy 1998).

Ethics deals with questions of how we should lead our lives

and how different actions should be judged. According to

well-established definitions, ethics refers to the theoretical

reasoning over moral practice while morality refers to our

personal opinions of good and bad, right and wrong

(Thompson et al. 2000).

Ethical dilemmas, in the form of conflicting values and

norms (Johnstone 2000: pp. 102–103) in medical practice

have, since the 1970s, often been discussed in relation to four

well-known ethical principles: autonomy, non-maleficence,

beneficence and justice (Beauchamp & Childress 2001).

These principles are mirrored in the International Council

of Nurses’ ethics code (http://www.icn.ch 2006).

Though nursing ethics is known to share its most import-

ant features with medical ethics (Jameton 1984), it also has

its own unique issues and concerns. Nurses are known to

focus on relational ethics, particularly emphasizing the care

aspect. When ethical dilemmas arise, colleagues need open

dialogue. Despite this, nurses emphasize that the most

demanding problems are not being discussed (Sorlie et al.

2003). Ethical dilemmas in nursing concern not only ques-

tions of life and death. Recent studies have investigated the

everyday ethics of nursing, such as how to decide whether a

blood transfusion to one patient should be done before or

after giving a painkiller to another patient (Höglund 2005).

New research also indicates that increasing ethical dilemmas

might lead to stress reactions among healthcare personnel

(Kälvemark et al. 2004, Sporrong et al. 2005). Moral distress,

i.e. a situation where the healthcare giver has identified an

ethical dilemma and assumes he/she knows the right thing to

do, but is hindered by institutional constraints from pursuing

the desired course of action, has been studied, particularly

among nurses (Jameton 1984, Raines 2000).

Telephone nursing in Sweden

The Swedish healthcare system is tax financed and private

healthcare providers are rare. There is a strong emphasis on

equal health care for all. During the last decade the Swedish

healthcare system has undergone major structural changes

and financial cutbacks. These financial cutbacks have resulted

in staff reduction, and increased distress and work-load

among personnel (Arnetz 2001). Simultaneously, the number

of call centres staffed with telenurses in Sweden has rapidly

increased, as well as the number of calls per centre (Wahlberg

2004). The nurses working at the call centres sit at computer

terminals, wearing headsets and taking calls from the general

public about a range of issues. This is highly skilled,

knowledge-intensive work because the telenurses assess care

needs and care level, give advice, support and information,

and recommend and coordinate healthcare resources (Wahl-

berg 2004). Such services have been shown to be safe and

effective in several countries (Marklund et al. 1991, Malloy

1998). Furthermore, telehealth is a cost-effective way to

provide care (Jennett et al. 2003). Most calls are about

infections such as colds, influenza or diarrhoea (Wahlberg

2004). Over 50% of the calls are made on behalf of the ill

person, mostly by parents or spouse (Wahlberg 2004).

According to Swedish law, nurses are obliged to keep a

record of every call (Sahlin 2000). The Swedish call centre

system is currently undergoing changes to become a 24-hour

nurse-led telephone advice service with one phone number

for the entire country. This system has strong similarities

with NHS Direct in the UK and Health Direct in Western

Australia.

Aim

This paper aims to present the findings of a study designed to

describe ethical dilemmas, in the form of conflicting values,

norms and interests, which telenurses experience in their

work.

I Holmström and AT Höglund

1866 � 2007 The Authors. Journal compilation � 2007 Blackwell Publishing Ltd

Method

We chose a qualitative approach because this is a useful

approach to investigate people’s thoughts and experiences

(Patton 1990, Malterud 1998). An inductive approach with

no predetermined categories was used.

Sample and setting

The data collection was carried out between April 2004 and

December 2005 at one call centre in mid Sweden. At the call

centre we did an intervention study and collected a range of

data. The present paper is hence part of a larger study. A

purposeful sample (Patton 1990) of 12 Registered Nurses was

recruited for the study. All were females aged between 35–

63 years. Females comprise about 90% of the Swedish

nursing workforce and no male nurse worked at the time of

the study at the call centre in question. The nurses had a

mixture of clinical backgrounds and between 14–40 years of

clinical experience. The length of working time as telenurses

was between four months and 35 years at the time of the first

interview.

Data collection

Open-ended interviews were carried out twice by the first

author (I.H.) at the nurses’ workplace. The interviews

focussed on the professionals’ personal experiences of the

patient encounter by telephone. Through seeking concrete

descriptions the focus was maintained. The informants

were asked about their difficulties at work and their

experiences of ethical dilemmas. The interviews lasted 45–

90 minutes and were audio-recorded. A second interview

round was carried out with the same telenurses one year

after the first interview to expand and refine findings.

However, no new theme emerged from the second inter-

view.

Ethical considerations

The study was approved by the Regional Ethics Committee.

Further, as the interviews covered questions of ethical issues

which might be experienced as sensitive by the informants,

great caution and ethical awareness was regarded when

performing the interviews. Following the ethics of scientific

work the informants were included after informed consent.

The participation was voluntary and the results have been

presented in a way that guarantees the informants’ confiden-

tiality. The ethical considerations concerning the study are

thus fulfilled.

Data analysis

The interviews were transcribed verbatim and processed as

text and a thematic stepwise analysing method, as outlined by

Malterud (1998), was used. The first step was to read through

each interview several times to get a good grasp of the whole,

and to identify narratives about ethical dilemmas. The second

step was to identify meaning units, for example:

The rules can be that this type of patient should not get an urgent

appointment… today I think that the patients are guided back and forth between different caregivers. When I, in turn, should refer them

to someone else I sometimes get a bad conscience. They have tried to

contact a bunch of different caregivers… I feel, it feels bad.

The third step was to code the separate meaning units, in the

example above as: a tension between following the rules and

one’s own professional nursing values. Finally, in the fourth

step, the content of these abstracts was condensed and

grouped into themes. The above excerpt exemplified thus:

insufficient resources and the organization of health care. The

analysis of the texts was conducted by the first author (IH)

while the second author (ATH) acted as co-reader.

Rigour in qualitative studies

We tried to follow the quality criteria credibility, depend-

ability, confirmability and transferability outlined by Guba

and Lincoln (1989). Credibility means to be thorough in data

collection and analysis. Dependability means consistency and

that the research process should be described so that it is easy

to follow. Confirmability refers to the notion that the

research should convincingly show how the results are

grounded in the material by, for example, quotes. Finally,

transferability means that the results can be readily commu-

nicated and useful to others.

Results

Five different themes of ethical dilemmas in telenursing were

found: talking through a third party, discussing personal and

sensitive problems over the phone, insufficient resources and

the organization of health care, balancing callers’ informa-

tion needs with professional responsibility, and differences in

judging the caller’s credibility. In the following, each theme

will be illustrated through the use of direct quotations.

Talking through a third party

This theme concerns the conflict between the patient’s

autonomy and the caller’s, as well as the nurse’s wish to do

Issues in clinical nursing Ethics in telenursing

� 2007 The Authors. Journal compilation � 2007 Blackwell Publishing Ltd 1867

good for the patient. As stated in the introduction, it is not

unusual in telenursing that the caller is not the actual patient.

Although the nurses describe that they try to get to talk with

the patient when possible, they also clearly state that talking

to a friend or relative to the patient might cause ethical

dilemmas. Such difficult situations are, for example, when

adults call for help to take measures for other adults, such as

a wife calling for her husband or a parent calling for a grown-

up child. Sometimes the nurses encounter callers who want to

make a doctor’s appointment for a relative without the

relative’s prior knowledge. The nurses deal with these

problems by trying to persuade the caller to talk to the

family member and to share their worries:

I then asked her if she was aware that she was actually lying to her

husband and said: Isn’t it better for you to share this worry with your

husband instead of sharing it with me? Then you can share each

other’s worries about his symptoms instead. To sort of… make her

rethink this matter…. (nurse 1)

In addition, the nurses expressed how ethical dilemmas

sometimes arise in relation to issues of independence for the

patient, as well as of integrity and autonomy in cross-cultural

encounters. Such conflicts are often due to differing gender

norms. Given that the patient might come from a culture

where gender norms are hierarchically ordered and marked

by female subordination, the woman is sometimes not

allowed to contact the Swedish healthcare system herself

even though she is the patient. Instead, her husband as the

‘head of the family’ makes the call.

A similar ethical dilemma arose when participants ex-

pressed concern about how to handle the situation of young

girls of non-Scandinavian origin, who might risk being at the

centre of cultural clashes. The nurses in the study express

how this can raise ethical dilemmas; they want to do what is

in the best interest for the girl, but without violating the

integrity of the family:

Well there was this young woman, just a girl, sixteen years old… She

had some gynaecological symptoms… her Swedish was absolutely fluent but her parents were immigrants and had totally different

cultural values. I advised her to see a doctor but she said she didn’t

dare to… couldn’t do that because then her parents would be

accompanying her. And she had had an abortion some time ago, and

of course they didn’t know about that… And she was really

devastated and had no one to turn to. (nurse 4)

Discussing personal and sensitive problems over the phone

Nurse 12 stated that, in one way: ‘The whole telenursing

service could be regarded as unethical’ because the nurse

could never be sure of the caller’s identity. The caller gives a

name and a social security number, but the nurse cannot

know for sure that it is the right person she is talking to.

Because of this, the nurse always gave little information when

questioned about previous calls and illnesses, documented in

the patient’s record. Furthermore, because she cannot see the

caller’s face, she cannot read the caller’s reactions such as

embarrassment as easily as she might do face-to-face.

The documentation of sensitive information in the patient’s

record is in this perspective a problematic issue, as described

by the nurses, especially regarding psychiatric illness or

venereology/gynaecology. If the nurse advises the patient to

have a test for a sexually transmitted disease (STD), she is

often unsure of what to write in the record. The nurses may

deal with these problems by just noting ‘referral’ in the

record. This is a correct but uninformative notation:

Another problem is the documentation in itself. To use the right

expressions… how to write about sensitive things. Well, it can be for instance venereology symptoms and contagious… if you refer them

for an STD test, or… how much do you actually write in the record about that referral? It can be very sensitive…. (nurse 1)

Insufficient resources and the organization of health care

This theme is about instant prioritizing between patients that

the nurse cannot see. The nurses express ethical concerns

about the organization of the Swedish healthcare system.

Some callers are described to be ‘falling through the safety

net’ as though they do not ‘fit’ into the healthcare system.

This makes the priority setting of faceless callers even more

difficult. The nurses give the example of a person with stress-

related symptoms who is advised by their GP’s office to

contact the call centre for an appointment to the GP on call.

However, the telenurse has to tell the caller that the GP on

call only handles acute conditions and that stress-related

symptoms and burn-out cannot be characterized as acute as

both develop over time. Consequently, the nurse has to refer

the caller to the psychiatric clinic instead even though she

knows that the clinic will probably inform the caller to

contact his/her GP’s office. The nurses consider this as

extremely unethical and they do not wish to be a part of this

game:

Today… they do not feel well and there is no one to turn to. No place

to go. They are suffering, they are in the middle of a divorce or

something. They haven’t slept for nights. They are walking around

like zombies, and yet they have to go to work. And they call

everywhere to get an appointment, but they are always referred….

(nurse 10)

I Holmström and AT Höglund

1868 � 2007 The Authors. Journal compilation � 2007 Blackwell Publishing Ltd

Balancing callers’ information needs with professional

responsibility

This theme is strongly connected to the previous one.

Balancing the caller’s information needs and right for

appropriate information with the risk of giving information

that might overwhelm the caller, not knowing anything about

the faceless caller is walking a fine line. If a patient calls for

what they believe is merely for some self-care advice, the

nurse might realize that the symptoms presented are signs of a

serious illness. The nurse feels that she cannot confront the

caller by saying for instance: ‘I think you have an advanced

cancer’; yet, she has to make the caller realize the severity and

urgency of the symptoms:

It is very hard indeed to know what and how much to say in these

cases. You cannot follow a standardized procedure or check-list.

On the one hand, you shouldn’t make the patient extremely upset,

but on the other hand, you cannot minimize the problem either –

it’s walking a fine line both ethically and as a fellow human.

(nurse 3)

All the interviewed nurses express that the triaging function is

often a jeopardy, but only having telephone contact with the

patient, or the caller, means that the nurse only has one single

source of information, that is, the caller’s wording and voice.

It also means handing over considerable responsibility to the

caller and relying on the caller’s own ability to make sound

judgements:

This mother seemed like a normal mum to me… I thought that I’d thoroughly explained to her how to proceed. I told her that the baby

had to see a doctor today… something made me call her again before

I left my shift. And she was very happy for my call, and I heard from

her description that her baby was in a much worse condition. She had

called to the local GP but they had no acute appointments left – and

then she just did nothing…. (nurse 2)

Differences in judging the caller’s credibility

The nurses differ in the way they perceive the callers’

credibility and right to care. The call described below also

shows how some nurses’ values were considered to be

different from those of their colleagues. One nurse had had

a call from a young woman who had seen a gynaecologist.

This male doctor had been so brutal that the woman had

haematomas in her genitals. She wanted to be examined by

another doctor to document the bruises because she wanted

to press legal charges against the gynaecologist. The nurse

was shocked by the young woman’s story and had never

encountered such a ‘case’ before. She discussed what meas-

ures to take with her colleagues and discovered that some of

them questioned the young woman’s story and, moreover,

that their ethical values differed from hers:

And I realised that this is what often happens to rape victims… they

get their credibility questioned just like her… They (the fellow nurses) said: it can’t be that bad and is she like, you know, a bit weird or

something? And I thought of this young woman who had had this

horrible experience…. (nurse 9)

Discussion

The results of our study show five different themes in which

the nurses experience ethical dilemmas when working as

telenurses. Questions of autonomy, integrity and prioritizing

are highlighted by the participating nurses. These are central

ethical values in all types of care and are found in many forms

in the present study. While Malloy (1998) underscores the

legal risks for telenurses, these risks are not mentioned by the

present informants. This is probably because the Swedish

healthcare setting is different from the American one. As

stated in the introduction, the Swedish healthcare system is

tax-financed and not insurance based. Hence, all citizens have

equal access to the same type of care. This provides a

structure in which economics is separated from nurse–patient

relationship. Legal charges against doctors and nurses are

rare. However, Malloy (1998) points out the ethical conflict

arising for the nurse when a standardized protocol advises

one course of action but her experience, knowledge and

intuition tell her that something else would be more appro-

priate. This is supported within the present study as findings

suggest that the lack of resources and the organization of

health care seem to hinder the nurses from acting in the best

interests of the callers.

This tension between caring for the individual patient, or

caller, and the care for the population as a whole, is well

known (Rogers 2002). As described above, moral distress

comes from recognizing the ethically appropriate action, but

not being able to take it. The more nurses experience moral

distress, the more they are likely to become burned out and

abandon their profession (Severinsson 2003), which some

nursing students already see as a future risk (Holmström &

Larsson 2005). Knowles et al. (2002), in their study of NHS

Direct, indicate that telenurses experience stress, pressure and

also monotony in their work. Furthermore, the present study

confirms Malloy’s (1998) discussion about confidentiality,

privacy and decision-making as ethical dilemmas within

telenursing. Hence, moral distress seems to be an issue even

within telenursing.

From an organizational perspective it is important to

note that nursing ethical dilemmas are systematic and the

Issues in clinical nursing Ethics in telenursing

� 2007 The Authors. Journal compilation � 2007 Blackwell Publishing Ltd 1869

problem is not of the individual nurse but of the system

(Hardingham 2004). Addressing ethical issues in today’s

fast-paced healthcare system is not easy. However, Moss

(1995) has stated that ethics should be top priority, as a

guardian against chaos and loss. The work with ethics in

the healthcare system can take many forms. One strategy

that has shown to be efficient is to develop so called

‘ethical rounds’, i.e. institutionalized ethics discussions on

authentic patient cases, in hospital settings. Recent studies

have argued that such rounds are a working strategy to

handle moral distress (Hansson 2002, Kälvemark et al.

2004). Such ethical discussion forums have, hitherto,

mostly been practiced in hospital clinics but might be a

suitable model even in the setting of telenursing. Forslund

et al. (2004) argue that guidance, education and feedback

would give telenurses increased sense of security and

reduce stress. In addition, an increased ethical competence

that might come out of the work with institutionalized

ethical discussions may lead to a decrease of moral

uncertainty and thereby also prevent moral distress.

Almost all of the identified ethical dilemmas found in

telenursing can also be found in other areas of nursing.

However, we argue that, because the patient encounter in

telenursing is over the telephone, it is particularly sensitive to

ethical demands. For instance, documentation is particularly

sensitive when the nurse cannot be completely certain of the

identity of the caller. What if she is not talking to the right

person? Coleman (1997) argues for a streamlined and

simplified documentation of triage calls, to optimize nurse–

caller understanding and reduce the risk of legal action

against telenurses.

This study also indicates the need for continued research

within the field of telenursing and ethics. First, these results

could generate hypotheses and serve as a starting point for a

large scaled survey. Secondly, a future study might compare

the ethical dilemmas experienced by male and female nurses,

as the present study only includes female nurses. Previous

research has indicated that men and women differ in their

moral reasoning (Gilligan 1982, Tong 1998). Men are

supposed to reason out of rights and women out of a

readiness to care for others. This pattern has been noticed

also in healthcare settings (Zickmund 2004). Because some of

the dilemmas described in this study were due to gender

norms, it is reasonable to assume that male nurses to some

extent would experience other ethical dilemmas than their

female colleagues. Finally, one important theme of ethical

dilemmas in telenursing originated from cross-cultural

encounters. These dilemmas concerned primarily balancing

the respect for autonomy with the integrity of the patient’s

cultural tradition. It also concerned communication problems

and differing gender norms. These issues will be the focus of a

future paper.

Limitations

The study was qualitative and did not include a representa-

tive sample of telenurses. We do not claim that the results

could be generalized to a larger population. To study

frequencies, a quantitative approach with a large-scale survey

would be useful. In addition, the context (public primary

health care) and culture (Swedish/European) might have

influenced the results. However, we propose that the present

study is relevant for telenurses in general.

Conclusion

The present study identified five different themes in which

Swedish telenurses experience ethical dilemmas in their

day-to-day work. This shows how ethical dilemmas in var-

ious forms are present in telenursing. Questions of auto-

nomy, integrity and prioritizing are particularly highlighted

by the participating nurses. Possibilities for ethical com-

petence building and reflection seems to be needed also in

telenursing.

Relevance to clinical practice

The present study indicates that call centres need to develop

the ethical competence of their personnel. The work organ-

ization should provide opportunities for ethical competence

building, where ethical dilemmas in telenursing are highligh-

ted and discussed. Such a strategy might lead to decreased

moral uncertainty and distress among telenurses, with pos-

itive consequences for callers.

Acknowledgements

We are indebted to the telenurses who willingly shared their

experiences with us. A special thanks to Sara Holmström for

invaluable help with transcriptions and administrative work.

Grants were received from The Swedish Research Council

(Vetenskapsrådet), The Swedish Council for Social Research,

the Research and Development Unit for the Elderly (ÄNV),

Northwest Stockholm County Council and the Faculty of

Medicine, Uppsala University.

Contributions

Study design: IH; data analysis: IH, ATH; manuscript

preparation: IH, ATH.

I Holmström and AT Höglund

1870 � 2007 The Authors. Journal compilation � 2007 Blackwell Publishing Ltd

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