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EMPIRICAL STUDIES

Threats to patient safety in telenursing as revealed in Swedish telenurses’ reflections on their dialogues

Marta R€oing DDS, PhD (Researcher)1, Urban Rosenqvist MD, PhD (Professor Em)1 and Inger K. Holmstr€om RN, PhD (Professor)1,2 1 Department of Public Health and Caring Sciences, Health Services Research, Uppsala University, Uppsala, Sweden and

2 School of Health

and Medicine, €Orebro University, €Orebro, Sweden

Scand J Caring Sci; 2013; 27; 969–976

Threats to patient safety in telenursing as revealed in

Swedish telenurses’ reflections on their dialogues

Telenursing is a rapidly expanding actor in the Swedish

healthcare system, as in other Western nations. Although

rare, tragic events occur within this context, and are

reminders of the importance of giving patient safety the

highest priority. As telenurses’ main sources of informa-

tion are their dialogues with the callers, the provision of

safe care can depend on the quality of this dialogue. The

aim of this study was to identify issues that could threa-

ten patient safety in telenurses’ dialogues with callers. As

part of an educational intervention, a researcher visited a

sample of six telenurses five to six times at their work-

place to listen to and discuss, together with the tele-

nurses, their dialogues with callers in stimulated recall

sessions. Each call and the following discussion between

researcher and telenurse was tape-recorded and tran-

scribed as text, resulting in a total of 121 calls. Qualita-

tive content analysis of the reflections and following

discussions revealed that threats to patient safety could

be related to the surrounding society, to the organisation

of telenursing, to the telenurse and to the caller. This

study gives insight into significant problem areas that can

affect patient safety in telenursing in Sweden. Issues that

need to be focused on in telenursing educational pro-

grammes and future research are suggested, as well as

the need for organisational development.

Keywords: telenursing, communication, patient safety,

qualitative content analysis, Sweden.

Submitted 14 October 2011, Accepted 9 October 2012

Introduction

Although rare, events with tragic consequences occur

within the context of Swedish Healthcare Direct (SHD),

the national telephone helpline in Sweden. In 2008, for

example, a mother called about her 3-year-old son, who

was vomiting and had severe stomach pain. The telenur-

ses answering the mother’s first two calls assessed the

boy’s symptoms as gastroenteritis and gave the mother

self-care advice. At her third call, the mother was

referred to the hospital emergency department. However,

the child was dead on arrival at the hospital, and an

autopsy revealed the cause of death to be intestinal

obstruction. In the investigation that followed, the two

telenurses, in individual statements, explained how they

had not felt the need to consult the Computerized Deci-

sion Support System (CDSS) on hand, how they felt

pressured by their employers to keep calls short and not

send patients to hospital emergency departments unnec-

essarily, and how stressful their working conditions were

(1). This case is a reminder of the limitations inherent in

the patient encounter by telephone (2, 3) and of the

importance of giving patient safety the highest priority.

Patient safety is defined as ‘protection from care injury’

and patient safety work as ‘work aiming at enhancing

patient safety by analysing, determining and obviating

causes of risks, adverse events and negative events’ (4).

The nursing profession, with its commitment to protect

the health, safety and rights of the patient, is considered

to be a key actor within the patient safety movement (5,

6). Research on patient safety and telenursing, an emerg-

ing actor in health care, is still rather unexplored, with

many questions left to be answered (7–9).

Telephone advice nursing, including telephone triage,

is defined as the practice of providing ‘a component of

telephone nursing practice that focuses on assessment,

prioritisation and referral to the appropriate levels of

care’ and ‘identifying the nature and urgency’ of a call-

er’s or patient’s needs (10). Adding to this definition, the

process of telenursing, according to Greenberg (11),

includes three phases: gathering information from callers,

cognitive processing of the caller’s problem and output,

Correspondence to:

Marta R€oing, Department of Public Health and Caring Sciences,

Health Services Research, Uppsala University, Box 564, SE-751 22,

Uppsala, Sweden.

E-mail: [email protected]

doi: 10.1111/scs.12016

which consists of ‘all the nursing actions designed to

meet caller needs’. Telenursing is becoming a specialty in

the United States (10). In the UK, it is rapidly expanding

within the context of NHS Direct (12) and in Sweden,

within the context of Swedish Healthcare Direct (SHD).

In Sweden, SHD is staffed exclusively by telenurses. It has

expanded rapidly since 2003 and as of October 2011 con-

nects all of Sweden’s 21 counties (13). The amount of calls

has increased yearly, with 4.5 million calls received in 2010

(14). The main goals of SHD are to increase the patient’s

access to healthcare services, make the use of healthcare

services more effective and enhance patient safety (15).

Thus far, there is no specific education for telenurses

in Sweden. According to Valsecchi et al., (16) Swedish

telenurses are far more autonomous compared to their

British colleagues and also have more responsibilities.

Consequently, while they may have a stronger profes-

sionalism, they are more vulnerable. They are personally

liable for the calls, as it is they and not the organisation

who bear professional responsibility for their assessment

and actions. At worst, a telenurse’s registration or licence

may be withdrawn in case of serious error. Telenurses

have described that they almost always have this threat

in the back of their minds while working (17). In this

respect, they face a complex risk environment (18).

In Sweden, telenurses strive to steer the patient to the

right level of health care (19). They assess the caller’s

symptoms, then recommend appropriate measures, for

example self-care advice, suggest the caller contact a pri-

mary health clinic or send the caller to the hospital

emergency department. Yet, telenurses have expressed

conflicting demands of being both carers and gatekeepers

(17). Although they do not diagnose patients, they do

assess the degree of emergency of a problem over the

phone with someone they cannot see, a ‘faceless encoun-

ter’ (20). As accessibility to the service is an explicit goal,

they are also aware that the call should be as short as

possible. Swedish telenurses do not have any back-up

support from an on-duty physician. They can consult

with each other and also have, to their help, CDSS,

(optional at the start of SHD, now linked to the patients’

records, becoming an implicit requirement), which can

be experienced as both quality assuring and inhibiting for

their work (21). However, the main source of informa-

tion when making an assessment is always the caller.

Hence, the provision of safe care thus depends on the

quality of the dialogue between telenurse and caller (22).

When introducing a new kind of healthcare service,

such as SHD, it is important to investigate issues that

could potentially affect patient safety and to learn from

them. Studies have suggested that current tools, training

and education do not adequately prepare nurses for tele-

nursing work (23, 24). A large research project, with the

intention of developing Swedish telenurses’ competence,

was launched in 2004–2005 (20, 25–27). As part of the

project, telenurses were invited to reflect and comment

on their actual calls in stimulated recall sessions. The

present study reports on part of the project, an educa-

tional intervention, and focuses on the content of the

reflective dialogues in the stimulated recall sessions from

a patient safety perspective.

Aim

The aim of this study was to identify issues that could

threaten patient safety in telenurses’ dialogues with

callers.

Method

This was a descriptive qualitative study, which is a fruit-

ful way to explore peoples’ thoughts, feelings and con-

ceptions (28).

Sampling and participants

All 20 telenurses who at the time were working at one SHD

site in mid-Sweden were informed of the project and asked

to participate. The 12 nurses who agreed were randomly

divided into an intervention group (those who would partic-

ipate in stimulated recall sessions), consisting of six nurses,

while the other six formed the reference group. The telenur-

ses (all female) ranged in age from 39 to 63 years and had

from 4 months to 35 years of experience in telenursing.

Data collection

During 18 months in 2004–2005, all calls to one working

station at the SHD site were recorded. The second author,

a medical doctor with more than 15 years experience of

reflective supervision and extensive clinical experience,

visited the telenurses five to six times at their workplace

during this time for stimulated recall sessions. Similar

stimulated recall sessions have been previously described

in another clinical setting (29, 30). On each occasion, the

telenurse chose one day’s dialogues which she wished to

discuss. These included callers of all age groups with a

large variety of symptoms. Both ‘easy’ and more difficult

and complex calls were first listened to and then dis-

cussed. The sessions were a form of reflection-on-action

as described by Sch€on (31). The researcher (second

author) aimed to enhance a reflective dialogue with spe-

cial reference to patient safety using reflective questions,

giving confirmation and feedback and suggesting inter-

pretations of what was going on in the call. He followed

up with questions that could stimulate reflection on what

the core aspect of the call was and how it was done.

Researcher: How can you handle her [the caller’s] aggressive-

ness?

970 M. R€oing et al.

Telenurse: Well, it’s just to stay calm because I think that

there can be many reasons for callers to be angry.

I heard during the first minute that she had called

before and that she wanted this settled. I knew it

was going to take some time.

He also asked the telenurses ‘What did you think of

the call we have just listened to? Are you satisfied with

it?’ Each session lasted around 60 minutes. A total num-

ber of 121 dialogues were listened to and discussed

(Table 1). One telenurse only participated in two ses-

sions, as she changed her place of work. The dialogues

between telenurse and caller and the following stimu-

lated recall sessions were recorded and transcribed as

text.

Ethical considerations

This study was approved by the Regional Ethics Commit-

tee at the Faculty of Medicine. The telenurses were

informed about the study in writing and orally at an

information meeting held by the third author. Callers

were informed by a recorded message when they called

SHD. They could agree or decline participation by press-

ing different buttons on their telephone. Both telenurses

and callers were guaranteed confidentiality and informed

that they were free to withdraw from the study at any

time.

Analysis

The analysis was conducted by the first author (who,

although a healthcare professional, had no previous

experience of telenursing), with both the second and

third authors (who had experience of previous telenur-

sing work) acting as co-readers. Data were analysed by

qualitative content analysis inspired by Graneheim &

Lundman (32), with focus on a systematic analysis of the

visible and apparent components of the text. Reading

through the text was the first step in the analysis. Signifi-

cant text or meaning units were identified and then

coded by the first author. With the help of computer

software program Atlas.ti, the codes were compared for

similarities and differences and sorted into categories

(Table 2). The analysis was presented to the second and

third authors for their judgments as to whether the anal-

ysis and identification of safety threats was reasonable

based on what had been read in the dialogues and

discussions.

Results

Threats to patient safety identified in the analysis are

summarised and labelled as four main categories as fol-

lows: Safety threats related to the surrounding society;

safety threats related to the organisation; safety threats

related to the telenurse; safety threats related to the

caller (Fig. 1). A description of each category and subcat-

egories, illustrated by quotations from the discussions,

follows. Some safety threats were discovered and/or dis-

cussed by the telenurses and researcher in the stimulated

recall sessions, while others were revealed by the authors

during the analysis.

Safety threats related to the surrounding society

Expectations from the public on the service of telenur-

sing for ‘instant access’ could contribute to feelings of

stress among the telenurses. Patient safety could also be

related to media coverage, for example about the side

effects of medications, or ongoing infections in the popu-

lation, which could result in an increased amount of calls

from anxious callers.

Researcher: What was your diagnosis here? What did you

decide on?

Telenurse: Simply speaking a sore throat.

Table 1 Overview of sessions with tutor

Telenurse

Number of

sessions

with tutor

Total number of

dialogues listened

to and discussed.

1 6 30

2 2 7

3 6 24

4 5 20

5 5 15

6 6 25

Table 2 Examples from the data analysis demonstrating coding and categorizing of significant statements

Meaning unit Codes Sub-categories Category

‘You should never expect all the callers to be satisfied with the

advice you have given and if it happens it shouldn’t affect your

self-confidence. Somehow if you don’t feel good you can easily

get upset by these type of calls. You really have to be stable

to work with telephone advice’.

Reacting to

demanding

callers

Caller’s behaviour Safety threats

related to the caller

Threats to patient safety in Swedish telenursing 971

Researcher: Was it connected to the fact that there were a lot of

virus infections going around and so many

children had similar problems?

Telenurse: Yes, and also that so many had called that day

with similar symptoms, that’s why.

Safety threats related to the organisation

The telenurses described the stress of telenursing, how it

feels to work under pressure, be constantly monitored

and not have time for in-depth discussions with callers.

Telenurse: During stressful periods, when you have many

calls in the queue and we are only a few nurses, it

stresses me out to see this [the clock]….

Researcher: Can’t you cover it?

Telenurse: I wish I could.

Researcher: You see the clock and you see the queue?

Telenurse: Yes.

Researcher: And you have to answer each and every call….

Engaging in health promotion and educating callers in

self-care over the telephone was considered to be almost

impossible due to organisational demands to keep calls as

short as possible.

I don’t have the time to educate about such things, I

don’t have the time. Sometimes I need to educate and

I take it for granted that most callers have a basic

understanding about how the body works, but I don’t

know. Many, mainly young people, don’t and I can

tell from talking to them that they don’t know where

kidneys are located or how the body works.

Long working shifts and problems with technical

equipment made some feel as if they had no control over

their work environment.

The way you hear with different headsets varies. If I

use a headset with foam I hear so poorly and I have

to strain myself to be able to hear properly.

Flaws in the healthcare organisation, for example lack

of collaboration between telephone call centres and pri-

mary healthcare centres, doctor’s demands regarding

which patients should be referred to them, and how

nobody wanted to take responsibility for patients, made

work harder for the telenurses.

Unfortunately, since primary care clinics do not work

as they should, many [patients] call directly to us

because they can’t get through to their own primary

clinics. The truth is that patients are supposed to turn

to their primary clinics first. We say to the patients

that ‘we understand it is hard to reach your clinic by

phone, but you have to try’. If daytime primary care

worked better, if they were easier to call to, we would

not have to waste time on such administrative details.

It’s not good for the patients, for us, or anybody.

Safety threats related to the telenurse

Some telenurses appeared to be aware of the risk of gath-

ering partial information from callers.

I can feel unsure about how far to go when asking

certain patients about their problems, or maybe not

going deep enough with others. That’s what I think.

Did I cover everything? Am I doing the right thing?

Could I have asked more?

At times, instead of a more in-depth exploration of the

caller’s symptoms, the telenurses simply accepted the

callers’ ideas about what was wrong with them.

Researcher: What do you think that was?

Telenurse: I am 100% sure it was chickenpox and the reason

she called was because her son had it 2 years ago

and she didn’t want to end up looking like him.

Figure 1 Patient safety threats in Swedish telenursing as revealed in stimulated recall sessions.

972 M. R€oing et al.

Researcher: Are you sure?

Telenurse: She sounded so certain, so I believed her.

Researcher: What could it be? Where was the rash?

Telenurse: She seemed so sure it was chickenpox, so I didn’t

ask. I was certain she knew, since her kids had

had it. I had no doubts at all.

A recurring issue was the tendency among the telenur-

ses to focus mainly on ‘here-and-now’ aspects, which

often made them gather insufficient background

information.

Researcher: Well, I have another concern here. Did she [the

caller] have any other illnesses? We don’t know

about that, do we?

Telenurse: No, I didn’t ask.

Researcher: I was thinking, maybe she had some kind of

kidney disease?

Telenurse: Hmm. It’s true, we don’t know that….

Some telenurses revealed their concern about the lack

of feedback about given advice. As a result, they could

feel a need for closure and a desire to follow up on call-

ers, for safety reasons.

Sometimes I think I could have taken in certain call-

ers who had really wanted to come, but I had told

them to wait and see. So I called them back and

they were surprised to hear from me, since every-

thing was OK. But I had worried about them. Many

of my colleagues feel the same way. They wonder if

they could have handled certain calls differently.

Relying on past and personal experience was a strategy

used by some telenurses when assessing callers’ symp-

toms. At times, they could prefer to rely on past profes-

sional experience, even though they had access to

support literature and CDSS (which at the time was

optional to use).

We have special support literature when it comes to

children, which I think is well written and which I

use sometimes. But many times I don’t feel I need

to, since I used to work in a pediatric emergency

ward.

In assessing callers’ symptoms and problems, telenurses

could also refer to personal, private experience. However,

they seemed to think that this was only positive and

could not see any potential risks in doing so.

A lot depends on what I have experienced in my

own life and in the lives of my family members.

And it’s the same for my colleagues, I know that.

Sometimes I think that the patients don’t know that

my advice is not based on education, but on the fact

that somebody in my family has had the same symp-

toms. I see it as something positive.

Some appeared to refer to past personal experience

when advising callers as well.

Sometimes I think it’s good for callers to know that

even we nurses can have problems. In this case I

know that I too can have a cough when I catch a

cold that almost kills me for 5 weeks in a row. I

know exactly what I’m talking about. I realize we

are not supposed to refer to ourselves, but it just

slipped out, since I recognized the caller’s symptoms.

All the telenurses commented on the uncertainty due

to their inability to see the caller in person.

It’s like reading a book. You have the picture in

front of you and that’s what I do when I have a

patient on the phone….make my own picture and

hopefully the picture is right. But it can be wrong.

Safety threats related to the caller

Another issue brought up by the telenurses was the call-

er’s behaviour. Callers could be angry or demanding, or

very anxious.

You can never be sure how much information call-

ers can take in, even though you know you’ve done

your best. It’s so hard and it depends a lot on how

stressed and worried or distracted they are when

they call.

Understanding and communicating with callers with

language problems was perceived to be problematic, took

time and could also create uncertainty.

I have to explain in a different way than I would

with a Swedish mother. I have to know if the caller

understands what I mean. Sometimes I ask…’do you

understand what this word means’….because it isn’t

at all for sure they do. That’s why such calls are

longer.

Some conditions were almost impossible to assess over

the telephone, as callers could not always describe their

symptoms effectively. The situation could be even more

difficult when somebody called on behalf of the patient,

which happened quite often.

It’s very difficult when someone else tries to describe

how something looks and how somebody feels. Most

often the picture is completely different when you

speak directly to a person.

Discussion

Issues that could affect patient safety in telenursing,

revealed during the stimulated recall sessions, appeared

to be present in all three phases of the telenursing pro-

cess: gathering information, cognitive processing and out-

put (11). Most striking were the descriptions of how the

telenurses did not seem to explore background informa-

tion when gathering and assessing callers’ symptoms. The

telenurses’ reflections also brought to light possible

Threats to patient safety in Swedish telenursing 973

threats to patient safety related to the surrounding soci-

ety and technical equipment, which have not been men-

tioned in research to date.

Some of the patient safety threats identified in this

study can be addressed by the organisation, while others

may be related to a telenurse’s understanding of work. In

a phenomenographic study, Kaminsky (27) showed five

different ways a group of 12 telenurses understood their

work. Understanding the work of telenursing as ‘assess-

ing, referring and giving advice’ to the caller was com-

mon to all of the telenurses in the study. ‘Supporting’

the caller implied genuine caring for the callers,

‘strengthening’ the caller implied increasing a caller’s

self-confidence, ‘teaching’ the caller involved checking to

see whether instructions were understood and ‘facilitat-

ing the caller’s learning’ involved tailoring an individual

teaching process for each caller (27). Applying these

ways of understanding to the telenurses in the present

study, it is possible that telenurses with ‘supporting’ as a

way of understanding were more vulnerable to the

uncertainty of handling calls adequately or lack of feed-

back about given advice. It is interesting that the threats

to patient safety discussed by the telenurses in the pres-

ent study, such as lack of in-depth exploration of caller’s

symptoms, or relying on personal experience when

assessing symptoms are part of the first way of under-

standing ‘assessing, referring and giving advice’, which,

according to Kaminsky (27), is part of the first care level

of telenursing, meant to provide medical safety.

Another factor contributing to threats to patient safety

in this study may have been the heightened sense of

uncertainty which seemed to pervade every aspect of

telenursing work. The notion of uncertainty in health

care is not new. Studies have described how uncertainty

is both pervasive and inescapable in health care and how

nurses as well as physicians make decisions without all

relevant information or knowledge of positive outcome

of the decisions (33, 34). As a response to uncertainty,

nurses rely heavily on knowledge from their own experi-

ence, the experience of others and intuitive knowledge

and are trained to do so (33, 34). This suggests that the

telenurses’ reflections in this study may have been in

accordance with their basic formal training in and/or

understanding of nursing.

In contrast to physicians, nurses have no formal training

and education in medical interviewing, considering differ-

ential diagnoses or deriving medical diagnoses. The ques-

tion at this point is the perceived need for practice based

on biomedical information in telenursing, with its height-

ened state of uncertainty. How much is necessary to guar-

antee safety? This may depend on the urgency of the

situation (35). In matters of lesser urgency, as for example

when a caller needs a referral or self-care advice, a tele-

nurse’s decision needs to be based on biomedical informa-

tion, even though the content of the telephone dialogue

may require a degree of intuitive reasoning and a contex-

tualised view of the caller’s problem. In situations of high

urgency (where a caller is in need of immediate attention),

competence in recognising critical biomedical symptoms

should be in the forefront to secure patient safety.

This confirms the value of following medical protocols

in computerised decision support systems (21, 36), yet

they are not the final solution. Protocols are standar-

dised, and there may always be exceptions when proto-

cols cannot be followed. Each caller is unique, situations

vary, and even telenurses appear to vary in their clinical

decision-making when using CDSS (18). And using a

CDSS based on incomplete information from callers can

be a very real threat to patient safety. Many studies have

already shown a need for specifically adapted training for

telephone consultations (24, 37–39).

Organisational factors may also have contributed to

potential threats to patient safety in this study. Were the

telenurses’ inconsistencies in collecting and assessing

information from callers due to stress? If so, the telenurses’

comments and reflections on their interactions with callers

and their work conditions in this study need to be taken

seriously. Many of the issues brought up by the telenurses,

such as their working conditions, including stress at work,

the importance of a functioning healthcare organisation

and difficulties in not being face-to-face with callers have

been described and are in accordance with previous

research on telenursing in Sweden (17, 40, 41).

What can be done? Can implementation of a more

vertical organisation with back-up support from on-duty

physicians or experienced nursing colleagues help to

ensure patient safety? Are the demands for efficiency

reasonable? One might wonder if constant monitoring of

the telenurse’s work and calls in queue is contra-produc-

tive, creates stress and is a potential threat to patient

safety. The organisation needs to provide prerequisites

and support for telenurses to work in the safest way pos-

sible. Organisational resources such as physician support

have been pointed out to be essential to promote a safe

telenursing process (11). And, without feedback, telenur-

ses are working in a vacuum, which limits their possibili-

ties for professional growth (11, 42). It should thus prove

important to develop not only the technical and organi-

sational aspects of telenursing, such as CDSS, but also

aspects such as systematised feedback and communica-

tion (in particular telenurses’ listening skills, their inter-

pretation of information and verification with callers)

(42, 43). Even so, many questions remain. From the per-

spective of patient safety, which style of communication

is most suitable in this clinical setting?

Methodological considerations

This qualitative study followed the quality criteria of cred-

ibility, dependability, confirmability and transferability as

974 M. R€oing et al.

outlined by Guba and Lincoln (44). Credibility means to

be thorough in data collection and analysis. Dependability

means consistency and that the description of the research

process is easy to follow. Confirmability refers to the

notion that the research convincingly shows how the

results are grounded in the material by, for example,

quotes. Finally, transferability means that the results can

be readily communicated and useful to others.

A possible weakness may be that the study is based on a

small sample of telenurses in one telenursing centre.

However, 121 stimulated recall sessions were analysed,

which provided rich data. The findings describe telenur-

ses’ reflections on their dialogues together with the second

author, a male physician, and there is a risk that gender

and power issues might have influenced the discussions.

While it may appear that he asked leading questions or

steered the interviews at times, these stimulated recall ses-

sions were meant to enhance reflection on the part of the

telenurses. A possible strength may be the different back-

grounds of the authors, as their varied perspectives

resulted in numerous discussions as to the presence and

extent of any preunderstanding on the part of the second

author during the recall sessions and analysis process.

The telenurses’ reflections could also have been influ-

enced by the way they understood their work or by their

personal values and biases, as previously mentioned. As

there are variations in ways of understanding telenursing

(27) and as values and biases are unique to individuals,

it is possible that other threats to safety, not discovered

in the present study, exist. It is hard to speculate as to

why eight of the twenty telenurses did not want to par-

ticipate. In contrast to a single interview, participation in

an intervention may have been perceived as too time-

consuming or demanding. The fact that the nurses were

randomly divided into a reference and intervention

group may have resulted in more experienced (or alter-

nately less experienced) telenurses in the same groups.

Fortunately, this was not the case in the group of tele-

nurses who agreed to participate.

Admittedly, there have been changes in SHD since it

started in 2003. Most important, all telenurses working

in the SHD now work systematically with CDSS. Even

so, these finding can be transferred to other settings,

where nurses provide advice on their own, for example

in primary care clinics or doctors’ offices, without support

or guidelines, both in Sweden and internationally.

Conclusion

This study has shown that issues affecting patient safety

could be present throughout the whole process of tele-

nursing: the gathering of information, the cognitive pro-

cessing and the output. The most striking threat to safety

was that telenurses did not seem to explore background

information when gathering and assessing callers’ symp-

toms, while other possible threats to patient safety could

be related to the surrounding society and technical

equipment. Areas to be focused on to improve patient

safety are organisational development and telenursing

education. As communication appears to be the key to

safe care, the communication between telenurse and

caller needs further research and different communica-

tion models should be tested in large-scale studies before

implementation in clinical practice.

Author contributions

IKH and UR designed the study, IKH obtained funding,

UR conducted the intervention, MR conducted the analy-

sis and drafted the manuscript, IKH and UR acted as co-

readers in the analysis and commented on the drafts.

Ethical approval

Ethical approval was granted by the Regional Ethics

Committee at the Faculty of Medicine, Uppsala Univer-

sity, Dnr 02-366.

Funding

Grants were received from the Swedish Research Council

(Vetenskapsr�adet) Dnr 522-2005-7461 and the Faculty of

Medicine, Uppsala University, Sweden.

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