MATH233 Unit 3 This assignment features an exponential functio.docx

MATH233 Unit 3
This assignment features an exponential function that is closely
related to Moore’s Law, which states that the numbers of
transistors per square inch in Central Processing Unit (CPU)
chips will double every 2 years. This law was named after Dr.
Gordon Moore.
Table 1 below shows selected CPUs from this leading processor
company introduced between the years 1974 and 2008 in
relation to their corresponding processor speeds of Million
Instructions per Second (MIPS).
Table 1: Selected CPUs with corresponding speed ratings in
MIPS.
Processor
Year
t Years After 1974 When Introduced
Million Instructions per Second (MIPS)
1
1974
0
0.29
2
1978
4
0.33
3
1979
5
0.75
4
1982
8
1.28
5

1985
11
2.15
6
1989
15
8.7
7
1992
18
25.6
8
1994
20
188
9
1996
22
541
10
1999
25
2,064
11
2003
29
9,726
12
2006
32
27,079
13
2008
34
59,455
(Instructions per second, n.d.)

This information can be mathematically modeled by the
exponential function:
Be sure to show your work details for all calculations and
explain in detail how the answers were determined for critical
thinking questions. Round all value answers to three decimals.
1. Generate a graph of this function, , years after 1974, using
Excel or another graphing utility. (There are free downloadable
programs like Graph 4.4.2 or Mathematics 4.0; or, there are also
online utilities such as this site and many others.) Insert the
graph into your Word document that contains all of your work
details and answers. Be sure to label and number the axes
appropriately. (Note: Some graphing utilities require that the
independent variable must be “x” instead of “t”.)
2. Find the derivative of with respect to .
3. Choose a -value between 20 and 34. Calculate the value of
4. Interpret the meaning of the derivative value that you just
calculated from part 3 in terms of the function.
5. If the function is reasonably accurate, for what value of will
the rate of increase in MIPS per year reach 1,000,000 ?
Approximately which year does that correspond to?
6. For the -value you chose in part 3 above, find the equation of
the tangent line to the graph of at that value of . What
information about the function can be obtained from the
tangent line?
7. Using Web or Library resources research to find the years of
introduction and the processor speeds for both the CPU A and
the CPU B. Be sure to cite your creditable resources for these
answers. Convert the years introduced to correct values of and
determine how well the function predicts when these CPUs’

processor speeds occurred.
8. What explanation can you give for the differences observed
in part 7?
References
Desmos. (n.d.). Retrieved from https://www.desmos.com/
Graph 4.4.2. (n.d.). Retrieved from the Graph Web site:
http://www.padowan.dk/
Instructions per second. (n.d.). Wikipedia. Retrieved from
http://en.wikipedia.org/wiki/Instructions_per_second
Intel. (2008). Mircoprocessor quick reference guide. Retrieved
from http://www.intel.com/pressroom/kits/quickrefyr.htm
Laird, J. (2011, January 3). Intel Core i5-2500K review.
Techradar. Retrieved from
http://www.techradar.com/us/reviews/pc-mac/pc-
components/processors/intel-core-i5-2500k-917570/review
Laird, J. (2013, June 3). Intel Core i7-4770K review. Techradar.
Retrieved from http://www.techradar.com/us/reviews/pc-
mac/pc-components/processors/intel-core-i7-4770k-
1156062/review
Mathematics 4.0. (n.d.). Retrieved from the Microsoft Web site:
http://microsoft-mathematics.en.uptodown.com/
Page 2 of 3
Chamberlain College of Nursing NR361 Information
Systems in Healthcare
Telenursing: Is It in My Future?
Guidelines and Grading Rubric
Purpose

The purpose of this assignment is to explore the specialty of
telehealth, and more specifically telenursing, as one example of
the use of technology in various practice settings. Advantages
and disadvantages for the patient and legal and ethical
principles for the nurse of this technology will be explored.
Course Outcomes
This assignment enables the student to meet the following
course outcomes:
CO #2: Investigate safeguards and decision-making support
tools embedded in patient care technologies and information
systems to support a safe practice environment for both patients
and healthcare workers. (PO #4)
CO #6: Discuss the principles of data integrity, professional
ethics, and legal requirements related to data security,
regulatory requirements, confidentiality, and client’s right to
privacy. (PO #6)
Points
This assignment is worth a total of 200 points.
Due Date
Your completed paper is due at the end of Week 4. Submit it to
the basket in the Dropbox by Sunday at 11:59 p.m. mountain
time. Post your questions to the weekly Q & A Forum. Contact
your instructor if you need additional assistance. See the Course
Policies regarding late assignments. Failure to submit your
paper to the Dropbox on time will result in a deduction of
points.
Background
Our text (Hebda, 2013) provides us with a broad perspective on
telehealth. However, the specialty of telenursing is only briefly
discussed. Healthcare is readily embracing any technology to
improve patient outcomes, streamline operations, and lower
costs. This technology includes the use of various applications
based in various environments where registered nurses
indirectly provide professional nursing care.
Scenario
The following scenario serves as the basis for your paper:

You have worked with Tomika for the past five years. Tomika
shares with you that she has resigned and plans to work in an
agency that installs telemonitoring equipment into the homes of
those with chronic illnesses. Nurses monitor the patients using
the equipment with the goal of detecting problems before
patients need to be readmitted to the hospital. Tomika will be
working from her own home, with occasional meetings at the
agency. She would not be visiting her patients in their homes,
but rather would be assessing and interacting with them via
videoconferencing. She tells you that there are still job
openings and encourages you to apply.
You are intrigued by this, and decide to investigate whether
telenursing would be a good choice for you, too. Is telenursing
in your future?
Directions
1. You are to research (find evidence), compose, and type a
scholarly paper that describes telenursing as described above,
and whether it is a good fit for you. Reflect on what you have
learned in this class to date about technology, privacy rights,
ethical issues, interoperability, patient satisfaction, consumer
education, and other topics. Your text by Hebda (2013, Chapter
25) discusses telehealth in detail. However, your focus should
be from the professional nurse’s role in telenursing. Do not
limit your review of the literature to only what you read in your
text. Nurses in various specialties need to know about the
advantages and disadvantages of telenursing as it applies to
their patients. For example, when you discharge a patient from
an acute care setting, will a telenursing service assist that
individual with staying out of the hospital? You may need to
apply critical thinking skills to development of your paper. In
the conclusion of your paper, describe your current employment
situation, and whether a job in telenursing would, or would not,
fit with your career goals and life situation once you graduate
from Chamberlain.
2. Use Microsoft Word and APA formatting to develop your
paper. Consult the Publication manual of the APA, 6th edition if

you have questions, for example, margin size, font type and size
(point), use of third person, and so forth. Take advantage of the
writing service, Smarthinking, which is accessed by clicking on
the link called the Tutor Source, found under the Course Home
tab. Also, review and use the various documents in Doc Sharing
related to APA.
3. The length of the paper should be 4–5 pages, excluding the
title page and the reference page. Limit your references to key
sources.
4. The paper should contain an introduction that catches the
attention of the reader with interesting facts and supporting
sources of evidence, which need to be mentioned as in-text
citations. Keep in mind that APA guidelines state you are not to
call this an “Introduction” but you should include it at the
beginning of your paper. The Body should present the
advantages and disadvantages of telenursing from your
perspective as an employee, and the patient’s perspective as a
recipient of the care nurses provide. The Conclusion and
Recommendations should summarize your findings and state
your position on whether you will apply for a position with the
agency.
NOTE: Review the section on Academic Honesty found in the
Chamberlain Course Policies. All work must be original (in
your own words) unless properly cited. This assignment will
automatically be submitted through Turnitin, a plagiarism
detection system.
Submit the completed paper to the Telenursing: Is It in My
Future? by Sunday, 11:59 p.m. MT at the end of Week 4. Please
post questions about this assignment to the weekly Q & A
Forum so that the entire class may view the answers.
Grading Criteria
Category
Points
%
Description
Introduction

50
25%
The Introduction provides evidence of an information search
including in-text citations of the sources of evidence. It catches
the reader’s attention with interesting facts and supporting
sources.
Body
100
50%
Appropriate headings are used to delineate when the
introduction ends. More than three advantages and three
disadvantages are identified, discussed briefly, and supported
by citations.
Conclusion and Recommendations
25
12.5%
Appropriate headings are used, making clear the conclusion and
recommendations based on solid evidence, privacy rights, and
ethical principles, and so forth. State your current employment
situation, and whether a job in telenursing could be in your
future. Provide pros and cons for this decision.
Scholarly Writing and APA Format
25
12.5%
· Title page, running head, and page numbers. (3 pts.)
· Introduction, body, and conclusion/recommendations sections
are clearly labeled. There is a logical flow between the sections.
(10 pts.)
· Grammar, punctuation, and sentence structure are correct. (2
pts.)
· Citations throughout demonstrate support of student’s ideas
and opinions. (5 pts.)
· Reference page includes all citations. (3 pts.)
· Evidence of spell and grammar check. (2 pts.)
Total
200

100%
A quality assignment will meet or exceed all of the above
requirements.
Grading Rubric
Assignment Criteria
A
Outstanding or Highest Level of Performance
B
Very Good or High Level of Performance
C
Competent or Satisfactory Level of Performance
F
Poor or Failing or Unsatisfactory Level of Performance
Introduction
50 points
Evidence of information search. Catches the reader’s attention
with interesting facts and supporting sources that include
citations to three or more scholarly sources.
46–50 points
Evidence of information search. Catches the reader’s attention
with interesting facts and supporting sources that include
citations to two scholarly resources.
42–45 points
Evidence of information search includes only one citation to
scholarly resource.
No attention catching “hook” noted.
38–41 points
Little or no evidence of information search. No citations
provided and/or there is no attention-catching “hook.”
0–37 points
Body
100 points
More than 3 advantages and 3 disadvantages from a nursing and
a patient perspective are identified and supported by citations.
92–100 points

At least 3 advantages and 3 disadvantages from a nursing and a
patient perspective are identified and supported by citations.
84–91 points
At least 2 advantages and 2 disadvantages from a nursing and a
patient perspective are identified and supported by citations.
76–83 points
Only one advantage and one disadvantage from a nursing and a
patient perspective is identified and supported by citations.
0–75 points
Conclusion and Recommendation
25 points
Conclusion is presented based on cited evidence of how
telenursing affects the patient regarding personal privacy rights,
and ethical principles. Includes current employment situation,
and whether a job in telenursing could be in the student’s future
along with pros and cons for this decision.
23–25 points
Conclusion contains cited evidence for recommendation, but
may lack persuasive use of privacy rights and/or ethical
principles. Includes current employment situation, and whether
a job in telenursing could be in the student’s future but no
rationale for the choice.
21–22 points
Indicates conclusion and recommendation but does not address
privacy rights and/or ethical principles. Includes whether a job
in telenursing could be in the student’s future but no details of
current employment or the rationale for the decision.
19–20 points
Fails to include conclusion or recommendation.
0–18 points
Scholarly Writing & APA Format
25 points
· Title page, running head, and page numbers. (3 pts.)
· Minimum of three sections including the Introduction, Body,
and Conclusions and Recommendations. Each section has at
least three sentences. (10 pts.)

· Grammar, punctuation, and sentence structure are correct. (2
pts.)
· Citations throughout demonstrate support of student’s ideas
and opinions. (5 pts.)
· Reference page includes all citations and no errors in format
are noted. (3 pts.)
· Evidence of spell and grammar check. (2 pts.)
23–25 points
· Minimal error in APA title page noted.
· Minimal errors in grammar, spelling, punctuation, and/or
sentence structure noted.
· Citations are present but not in correct format.
· References are present, with minimal errors in format.
· Minimal red or green wavy lines within document.
21–22 points
· Some errors in APA title page noted.
· Some errors in grammar, spelling, punctuation, and/or
sentence structure noted.
· Citations are present but not in correct format.
· References are present, with some errors in format.
· Some red or green wavy lines within document.
19–20 points
· Multiple errors in APA formatting.
· Multiple grammar, spelling, and punctuation errors noted.
· Citations are missing.
· References are missing or incomplete.
· No evidence of proofreading prior to submitting paper.
0–18 points
Total Points Possible = 200 points
NR361 Telenursing: Is It in My Future? Guidelines 11-17-14
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1

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Application of telenursing in nursing practice: an integrative
literature review
Valtuir Duarte de Souza Junior RN, Ms, Isabel Amélia Costa
Mendes
RN, PhD, Alessandra Mazzo RN, PhD, Simone de Godoy RN,
PhD
PII: S0897-1897(15)00103-2
DOI: doi: 10.1016/j.apnr.2015.05.005
Reference: YAPNR 50672
To appear in: Applied Nursing Research
Received date: 25 August 2014
Revised date: 18 April 2015
Accepted date: 9 May 2015
Please cite this article as: Duarte de Souza, V. Junior, Costa
Mendes, I.A., Mazzo, A.
& de Godoy, S., Application of telenursing in nursing practice:
an integrative literature
review, Applied Nursing Research (2015), doi:
10.1016/j.apnr.2015.05.005
This is a PDF file of an unedited manuscript that has been
accepted for publication.
As a service to our customers we are providing this early
version of the manuscript.
The manuscript will undergo copyediting, typesetting, and

review of the resulting proof
before it is published in its final form. Please note that during
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errors may be discovered which could affect the content, and all
legal disclaimers that
apply to the journal pertain.
http://dx.doi.org/10.1016/j.apnr.2015.05.005
http://dx.doi.org/10.1016/j.apnr.2015.05.005
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literature review
Valtuir Duarte de Souza-Junior, RN, Ms
a
, Isabel Amélia Costa Mendes, RN, PhD
a*
,
Alessandra Mazzo RN, PhD
a
, Simone de Godoy RN, PhD
a
a
University of São Paulo at Ribeirão Preto College of Nursing -
WHO Collaborating
Centre for Nursing Research Development, Brazil.
Av. Bandeirantes, 3900 Campus Universitário - Bairro Monte
Alegre Ribeirão Preto -
SP – Brazil CEP: 14040-902. Telephone: +55 (16) 36023469
Fax: +55 (16) 3602-0518.
*
Corresponding author.
E-mails

Souza-Junior: [email protected]; Mendes: [email protected];
Mazzo: [email protected]; Godoy: [email protected]
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literature review

Abstract
Aims and background: Telenursing is the use of technological
resources and
communication systems to encourage the development of
nursing. Its efficiency has
been demonstrated to help countries overcome barriers to
healthcare. This study
investigates the current telenursing strategies utilized in nursing
practice, as found in the
literature.
Method: Integrative literature review of the application of
telenursing, using the
descriptors: telenursing, nursing care and communication
means, in Portuguese, English
and Spanish, between 2003 and 2013.
Results: Telenursing is found particularly in care through
telephone use for health
services and orientations. The country with the largest number
of research publications
was the United States with 14 (37.8%), followed by Canada and
the United Kingdom.
Final Considerations: It could be verified that telenursing is
growing, in view of its

presence in different countries, with strong evidence and
benefits of its use. It proves to
be an efficient tool to help countries overcome geographical
barriers and provide health
care information to the population.
Keywords: Telenursing; Telephone; Internet; Nursing Care;
Communications Media
Introduction
The expansion of communication media creates different
possibilities for the use
of new tools in various knowledge areas in an attempt to
enhance the effectiveness of
their processes and competencies, contributing to scientific
development. In health,
these resources are used choosing the terminology according to
the scientific area’s
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focus, such as in the case of telehealth, telemedicine and
telenursing. Telehealth
technologies permit nurses to expand care to anyone who needs
it, wherever they are.
Telenursing is a strategy that enhances nursing activities,
allowing the professionals to
use it to guide and monitor patients and populations in light of
their needs. It facilitates
access, saving time, resources and promoting greater self-care
possibilities (ICN, 2007).
Through telenursing, the development of nursing and health in
general can be
accelerated, using these technologies and communication

systems in the field of
teaching, research and care. In teaching, in a study undertaken
in the United States
concerning the implementation of the Virtual Clinical
Practicum, teleconferencing
technology was used to permit nursing students’ real-time
interaction with patients and
preceptors at kilometers of distance. The study showed
satisfactory results through the
expansion of clinical experiences and the opportunity for
critical reflection and
dialogue. The patients who participated in the research project
were satisfied with their
virtual experiences, mainly seeing them as a complement to the
information gained
from traditional health services (Grady, 2011). The use of
telenursing in research was
evidenced in a Canadian study about the perceptions of families
who received telehealth
care. To overcome the geographical distance between the
participants and the research
team, the video system of the telehealth network was used to
hold interviews (Sevean,
Dampier, Spadoni, Strickland, & Pilatzke, 2009).

A comprehensive national helpline system for healthcare has
existed in Sweden
since 2003, where nursing staff attends to approximately four
million telephone calls
from the population each year. International studies show
satisfactory results of
telenursing in screening access. Telenursing has served as the
entry door to other health
services, accomplished with safety, effectiveness and
acceptance from the population
(St George, Cullen, Gardiner, & Karabatsos, 2008).
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Research has revealed that, as a result of the increase in the
elderly population
and the number of bedridden people suffering from chronic
conditions, telenursing
should be used in care as a tool to support care delivery.
Telenursing makes it possible
to address excessive demand and mitigate difficulties posed by
geographical distances
and transportation issues (Kawaguchi, Azuma, & Ohta, 2004).
To expand the
development of this resource and extend its benefits to different
populations as needed,
considering professionals as well as patients and community
groups, the scientific
production profile of the use of telenursing needs to be verified.
This research project focuses on how telenursing is applied,
observing the
technological tools used to develop intervention strategies. The

use of telenursing is
examined in professional and student education, in patient
teaching and in care delivery
to patients. In addition, the countries that publish most of the
research on telenursing are
noted, as well as the evidence levels attained in that research,
so as to better assess the
impact of these studies in nursing. Thus, the aim in this study
was to investigate, in the
literature, the current telenursing strategies utilized in nursing
practice.
Method
Research developed through an integrative literature review of
the Medical
Literature Analysis and Retrieval System online (MEDLINE),
Latin American and
Caribbean Health Sciences Literature (LILACS) and Web of
Science databases. The
integrative literature review is a resource that seeks a detailed
understanding of a
phenomenon based on existing studies. Data obtained through
different research designs
are grouped to enhance the conclusions that research provides.
For the appropriate use

of this method, the methodological phases need to be carefully
established:
identification of the research problem; inclusion and exclusion
criteria; definition of the
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information under analysis; assessment of the selected studies;
and interpretation and

synthesis of the data (Torraco, 2005; Mendes, Silveira, &
Galvão, 2008).
The guiding question used was: “Where and how has telenursing
been applied?"
The following descriptors, derived from LILACS, were defined
for the search:
telenursing, nursing care and communication media. The
languages searched were
Portuguese, English and Spanish. The search identified 187
publications, whose titles
and abstracts were read. As a result, 56 publications were
selected and the full versions
of these were read. From the articles reviewed, 37 met the
following inclusion criteria:
studies published in the last ten years (2003 to 2013); written in
English, Spanish or
Portuguese; having a focus on telenursing as a strategy for
nursing care. To analyze the
articles, a tool was used based on Ursi and Galvão (2006). The
following data were
identified: year of publication; journal; place of study; method;
evidence level according
to Stetler et al. (1998); technology used; target population;
theories used to support

telecare; and main outcomes.
The strategies were classified according to four main
characteristics: Educational
Strategy (ELS)- use of telenursing as a teaching resource for
students and/or
professionals; Educative strategy (EES) – the nursing
intervention contains educative
material for patient consultation; Monitoring system (MS) – the
intervention contains
components to monitor and transfer patients’ vital data to
professionals; Care
management (CM)- the intervention involves telecare by trained
professionals as a
support strategy in healthcare management for patients and/or
family members.
As far as quality of evidence is concerned, the studies can be
divided into four
levels of quality. Those quality levels are: level 1 – meta-
analysis of controlled studies;
level 2 – studies with experimental design; level 3 – quasi-
experimental studies; level 4
– non-experimental research; level 5 – case reports, program
assessment; level 6 –

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opinions of authorities or expert committees (Stetler et al.,
1998). The presentation and
analysis of the data is accomplished descriptively (Polit, Beck,
& Hungler, 2004).
Results

The publications analyzed included one thesis and scientific
papers. Among the
publications, one was a meta-analysis and eight were
randomized clinical trials. In
regard to the language used, one was available in Portuguese,
one in all three languages,
one in Spanish and the remainder in English. The data
concerning year, publication
vehicle, place of study, tool, target population, theories used in
telecare in the studies,
strategies and the quality levels of the studies’ evidence are
displayed in Table 1.
Table 1- Year, publication vehicle, place of study, tool, target
population, theories used
in telecare in the studies and the quality levels of the studies’
evidence
The strategies and main outcomes are displayed in Table 2. In
seven of the
publications analyzed, telenursing strategies were present in the
studies in the form of
care delivery to the population. This care delivery is part of the
country’s national health
services.

Table 2 – Strategies and main study outcomes
Discussion
Telenursing is a booming area, as shown by the increase in the
number of studies
performed and the presence of research developed in different
countries, with strong
evidence regarding the benefits of its use. Among the
publications analyzed, one was a
N* número da publicação
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thesis and the rest were scientific papers. It is clear that English
is the main language for
much of the published research. English also affords greater
international visibility to
those countries where English is not the primary language.
Concerning the locations of the studies, the majority were
concentrated in
developed countries (86.5%), particularly the United States with
14 (37.8%), followed
by Canada and the United Kingdom with five (13.5%) each
(Table 1). The countries’
level of technological development impacts the use of these
technologies in science to
expand healthcare professionals’ competencies. If we take into
consideration that
telenursing is a strategy to direct and monitor patients and
populations, facilitating their
access, saving time, resources and promoting self-care (ICN,

2007), the countries that
would most benefit from its use would be exactly those with
fewer resources.
As regards the tools used in the telenursing strategies, the tool
present in most of
the studies was the telephone for patient care, aiming to support
healthcare management
(Table 1). This greater use of the telephone may be associated
with the greater mastery
of its use as a technology, as the telephone attained popularity
before other resources.
Several countries include telephone care as a strategy to
maximize their care
systemization and the search for health services as carried out
by their populations
(Price, & Mckay, 2000; Rodriguez-Gazquez, Arredondo-
Holguin, & Herrera-Cortes,
2012).
Care delivery through audio calls requires greater competency
from nurses to
hold interviews, as they lose the possibility of using visual
assessment for decision-
making (Fincher, Ward, Dawkins, Magee, & Willson, 2009).
Mobile phone use also

permits information exchange through text messaging. Internet
connections offer the
possibility of accessing different resources. These possibilities
are further expanded
with the availability of mobile phones (McCann, Maguire,
Miller, & Kearney, 2009).
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Various evidences exist for the use of telephone care to guide
healthcare. In the
United States, a study by Hannan (2013) showed that telecare to
help postpartum
patients proved to be an easy, safe, low-cost and effective
intervention that improved the
health outcomes of mothers and children and reduced spending
on healthcare. In
another study in the United States by Battaglia (2013),
telephone care provided to
psychiatric patients to lead them to quit smoking was a feasible
strategy. In Malaysia, in
a study by Tahir and Al-Sadat (2013), telephone calls to support
breastfeeding were
shown to be an effective resource, increasing exclusive
breastfeeding rates in the first
month postpartum.
The association of multiple technological resources can also
present good
results, like the study undertaken in Norway by Jelin, Granum
and Eide (2012) in which
telephone care with educative support through the web was used
for care delivery to

fibromyalgia patients, helping with counseling and support for
these patients’ chronic
pain. The dissemination of computers and access to the Internet
permits the use of
technologies, through computers and other devices with Internet
access. For example,
websites, video calls, videoconferencing, audio calls and text
messages can be used in
combination with one another. Until a short time ago, this
required a specific tool for
each system. Technological evolution, however, entails
unlimited possibilities for
telenursing usage every single day. (Dale, Caramlau, Sturt,
Friede, & Walker, 2009).
A study that, in part, verified which Facebook groups on
diabetes were the
largest identified that patients and family members use these
spaces to search for
information on the disease, in addition to experience-exchange
among the subjects for
care and emotional support (Greene, Choudhry, Kilabuk, &
Shrank, 2011). Regarding
the use of Skype as an assessment tool in orthopedics in patients
after surgical

correction of a collarbone fracture, outpatient assessments
followed by the same
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procedure performed via distance instruction through Skype
showed no difference,
suggesting that this resource can be used for clinical
assessments. The patients found

assessment via Skype to be more convenient due to the time and
resources saved (Good,
Lui, Leonard, Morris, & McElwain, 2012).
In regard to the target population (Table 1), it was observed that
telenursing is
fundamentally important to attending to situations or conditions
where patients
experience greater self-care management difficulties. This is
mainly the case for patients
with chronic illnesses like diabetes or heart failure, where there
are difficulties
maintaining treatment.
Among the publications studies, some presented details of the
theoretical
background used to support telenursing strategies (Table 1),
including the studies by
Amoako, Skelly and Rossen (2008), Dale et al. (2009), and
Lange et al. (2010), who
presented the use of cognitive-behavioral and motivational
theories and techniques to
assess patients’ perceptions of their health conditions. The
theories and techniques were
further intended to support patients in coping with their
conditions, in order not to

restrict their actions and information exchange, making the
dialogue therapeutic. A
theory can help reach a better interpretation of the reality in
question and is fundamental
to elaborating strategies designed to achieve the objectives the
professionals proposed.
The evidence levels that the studies attained were as follows
(Table 1): level 4
(43.2%), level 3 (32.4%), level 2 (21.6%) and level 1 (2.7%).
The use of these
classification systems is important to helping nurses make
decisions based on scientific
evidence. The more research with strong scientific evidence is
developed using
telenursing, the further it will be consolidated as a part of
nursing practice.
The telenursing strategies found in the studies were classified
as follows:
Educational strategy (ELS); Educative strategy (ES);
Monitoring system (MS); Care
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management (CM). In 35 (94.6%) of the publications (Table 2),
the strategies were fully
or partially focused on Care Management, in which the nurses
delivered telecare to
patients to support their healthcare. In seven (18.9%) of these
CM strategies, the care
was provided as part of the nation’s health service. In the
remainder, the researchers
developed them for the sake of research interventions. To give
an example, in Chile in

2005, a telecare service was implemented for the population;
the service, called Health
Answers, provides information in health and education,
functions 24 hours a day and for
the entire country, involving medical and nursing professionals
(Ministerio de Salud,
2011; Romero, Angelo, & Munoz Gonzalez, 2012).
In some studies, the strategies can be classified in more than
one category (Table
2). According to a study developed in Japan that associated an
Educative Strategy with
a Monitoring System and Care Management, in home care for a
type 2 diabetes patient,
a laptop connected to the Internet was used with e-mail, texts
and videos. The patients’
data were included in a database, accessed by nurses or
physicians. The patient was
offered a website to access the material available on type 2
diabetes control. The
patients measured their own blood pressure and pulse with the
help of a device and the
data were transmitted to a server at the health center. The
results were positive for the

control of patients’ capillary glucose, glycated hemoglobin and
blood pressure
(Kawaguchi, Azuma, & Ohta, 2004).
In another study by Jönsson and Willman (2008), which
associated an Educative
Strategy with Care Management for care delivery to patients
being treated for lower
limb wounds, two intervention components were associated in
the telenursing strategy.
One was educative, using a web application with information on
health treatment to be
accessed by patients and caregivers, and another part used
resources through an internet
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connection for communication between patients and nurses,
supporting health care
management. The nurses and patients were very receptive of the
system.
A telenursing strategy was developed in the United Kingdom,
associating a
Monitoring System with Care Management, involving the
construction of a mobile
telephone system to monitor chemotherapy toxicity symptoms in
cancer patients. The
system helped the patients to communicate with the nurse about
the effects of
chemotherapy in real time, when they received help for care
management. The patients
reported increased safety and reduced severity of adverse
treatment effects (McCann,
Maguire, Miller, & Kearney, 2009).

Among the strategies verified in the studies, 35 (94.6%) used
telenursing as a
form of patient care (Educative Strategy, Monitoring System
and Care Management).
Two studies (5.4%) concerned professional education
(Educational Strategy) and one
involved nursing students and other professionals. In view of
the increasing number of
publications that appear as the years progress in this review,
this result can be perceived
as a trend toward research development in care.
As an example of an educational strategy, telenursing used in
continuing
education is shown in a Brazilian study that covers the use of
technological resources to
train nursing professionals, in which 30 auxiliary nurses
received training for
intramuscular injection at a hospital. The training was supplied
through a lecture taught
by means of videoconferencing, followed by in-class theoretical
and practical training
(Godoy, Mendes, Hayashida, Nogueira, & Marchi Alves, 2004).
The use of

technological resources for continuing education in healthcare
is an important
professional qualification strategy, contributing to the
development of the Unified
Health System (Mendes et al., 2007; Mendes, et al., 2011).
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The study results show the effective use of telenursing, but

some measures need
to be improved, such as knowledge, mastery and familiarity
with the technologies used
in the strategies, mainly by the users. When they start a
telenursing strategy, patients can
initially experience difficulties. After adaptation to the system,
though, adherence and
the search for this type of care increase. The same is the case
for patient participation in
a telenursing intervention: at first, patients may not have much
to say and may
experience difficulties using the system. After adaptation
occurs, acceptance may be
good, offering excellent health management outcomes (Hodgins,
Ouellet, Pond, Knorr,
& Geldart, 2008; Kawaguchi, Azuma, & Ohta, 2004).
The selection of the patient groups that need this type of care is
fundamental to
the success of the intended objectives. Health professionals
made telephone calls to
promote blood pressure control in hypertensive patients in a
study in the United States,
based on the blood pressure levels transmitted to the health
professionals from a

telemonitoring device inside the patient’s home. The individuals
with poor blood
pressure control showed better intervention outcomes,
indicating the importance of
identifying individuals who will benefit further from these
telecare strategies (Bosworth
et al., 2011). The professionals responsible for the interventions
presented should be
knowledgeable and have the skills needed to conduct telecare,
showing their
receptiveness and valuation of respect and ethical conduct. The
patients’ compliance
with telephone recommendations is related to nurses’ interactive
roles, showing the
latter’s need to develop communication skills in order to hold
the telephone
consultations, in addition to skills and knowledge concerning
healthcare related to the
diseases in question (Purc-Stephenson, & Thrasher, 2012).
Telenursing is expanding, showing positive results especially as
a strategy to
guide and monitor patients and populations. Its application
facilitates health care access

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and saves time and resources, particularly in situations or
diseases where the patients
experience greater care management difficulties, as is often the
case for chronic
illnesses. For telenursing in patient care to be efficient, a solid
legal background needs

to be constructed in each country, so that it can be structured as
a nursing specialty and
be included among the health services offered.
Final Considerations
Telenursing is a promising field for the incorporation of
possibilities and
strategies for nursing activities in research, teaching and care. It
is an efficient strategy
to help countries overcome healthcare barriers and bring
information about healthcare to
populations. Telenursing helps to promote primary care and
enhance rehabilitation and
health maintenance processes. This contributes to complement,
further and intensify the
integration of healthcare systems, emphasizing patients with
chronic conditions who
experience greater treatment difficulties. The studies analyzed
in this review, involving
research developed in 13 countries and a target population
mainly suffering from
chronic conditions, demonstrate the importance of telenursing
to complement the access
to and universal coverage of health systems.

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Table 1- Year, publication vehicle, place of study, tool, target
public, theories used in
telecare in the studies and the quality levels of the studies’
evidence
N* Year Vehicle Place Tool Target
Public

Use of
theoretical
support
LE
#
1 2013 Journal of Clinical Nursing USA Telephone Postpar
tum
-
2
2 2013 International Journal of
Nursing Studies
Taiwan Monitoring
system/Tele
phone
Heart
failure
Meleis’
Theory of

Transition
s (Meleis
et al.,
2000). 3
3 2013 Journal of the American
Psychiatric Nurses
Association
USA Telephone Mental
disorde
r due to
post-
traumat
ic
stress
Transtheor
etical
Model by
Prochaska

and
DiClement
e (1982).
Motivatio
nal
Interview
(Miller, &
Rollnick,
2002;
Parker,
Pederson,
&
Bergmark,
2007;
Resnicow
et al.,
2002). 3
4 2013 International Journal of

Nursing Studies
Malaysia Telephone Breastf
eeding
-
2
5 2012 Patient Education and
Counseling
Canada Telephone General
and
pediatri
c
patients
-
1
6 2012 Pain Management Nursing Norway Telephone Women
with
fibrom
yalgia

Cognitive-
Behavioral
Therapy
based on
Mindfulne
ss
(McCrack 4
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en,
Vowles,
Gregg, &
Almada,
2010).
7 2012 Journal of Advanced
Nursing
United
Kingdom
Telephone Pregna
ncy
-
4
8 2012 Revista Latino-Americana
de Enfermagem

Colombia Telephone Heart
failure
-
2
9 2011 Telemedicine and E-Health USA Videophone Family
caregiv
er of
palliati
ve care
patients
-
4
10 2011 Nursing Education
Perspectives
USA Videoconfer
encing
equipment
Nursin

g
student
s
-
3
11 2011 Archives of Internal
Medicine
USA Monitoring
system/Tele
phone
Hypert
ension
-
2
12 2010 Biblioteca Digital de Teses
e Dissertações da UERJ
Brazil Website Health
team

-
4
13 2010 Revista Médica de Chile Chile Telephone Type 2
diabete
s
Motivatio
nal
interview
(Barr
Taylor et
al., 2003;
Stacey et
al., 2003). 3
14 2010 Journal of Telemedicine
and Telecare
Sweden Telephone Pediatri
c
patients

-
4
Counseling
USA Telephone Ulcerat
ive
colitis
Approach
of
cognitive
and
emotional
reactions
according
to the
study by
Leventhal
(1992).

Motivatio
nal
interview
(Rollnick, 3
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Miller, &

Butler,
2007).
Cognitive-
behavioral
techniques
(Beck,
2000).
16 2009 Scandinavian Journal of
Caring Sciences
Sweden Telephone General
populat
ion
-
4
17 2009 Journal of Clinical Nursing Canada Website Rural
commu
nity
-

4
18 2009 Journal of Clinical Nursing Norway Telephone Post-
stroke
patients
-
2
19 2009 Oncology Nursing United
Kingdom
Mobile
telephone
Young
cancer
patients
in
chemot
herapy
Medical
Research

Council
(MRC)
complex
interventio
n-
evaluation
framework
(Campbell
et al.,
2000). 4
20 2009 Association of Operating
Room Nurses journal
USA Telephone Postop
erative
patients
after
arthros
copy

Meleis’
Theory of
Transition
s (Meleis
et al.,
2000). 4
21 2009 The Journal of the
Association of Nurses in
AIDS Care: JANAC
USA Telephone HIV
patients
Transtheor
etical
Model by
Prochaska
and
DiClement
e (1982).

Motivatio
nal
interview
strategies.
Cognitive-
behavioral
strategies. 4
22 2009 Patient Education and United Telephone Type 2
Bandura’s 2
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A
N
U
S

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Counseling Kingdom diabete
s
Theory of
Self-
Efficacy
(1977).
Motivatio
nal
interview
(Anderson
, &
Funnell,
2000; Dale
et al.,

2007).
23 2009 European Journal of
Cancer Care
United
Kingdom
Mobile
telephone
Cancer
patients
in
chemot
herapy
-
2
24 2009 Journal of Gerontological
Nursing
USA Telephone
/Videophon

e
Parkins
on
Orem’s
Self-Care
Theory
(2001). 2
25 2008 Telemedicine Journal and
E-Health
Sweden Website/Vid
eophone
Patients
with
wounds
-
3
26 2008 Australian Family
Physician

Australia
and New
Zealand
Telephone General
populat
ion
-
4
27 2008 Canadian Journal of
Cardiovascular Nursing
Canada Telephone Heart
failure
patients
-
4
28 2008 The American Journal of
Managed Care
USA Telephone Psychia

tric
patients
Cognitive-
behavioral
counseling
(Azrin, &
Teichner,
1998).
Motivatio
nal
interview
(Kempet
al., 1996;
Kemp et
al., 1998). 3
29 2008 Western Journal of Nursing
Research
USA Telephone Type 2

diabete
s
Counselin
g and
behavioral
change
theories
(Cormier, 3
A
C
C
E
P
TE
D
M
A
N
U
S
C

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IP
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ACCEPTED MANUSCRIPT
&
Cormier,
1991;
Eagan,
1998).
30 2008 The Canadian Journal of
Nursing Research
USA Website Rural
women
with
chronic
illnesse
s
-

3
31 2008 European Journal of
Oncology Nursing
United
Kingdom
Mobile
telephone
Nurses
-
3
Counseling
The
Netherlan
ds
Website Patients
with
cardiov

ascular
disease
s
Self-
regulation
theory
(Johnson,
1999).
4
33 2007 Journal for Specialists in
Pediatric Nursing
USA Telephone Pediatri
c
postope
rative
patients
-
4

34 2005 Journal of Advanced
Nursing
Canada Telephone Postop
erative
patients
after
heart
surgery
-
4
35 2004 Oncology Nursing Forum USA Videophone Cancer
patient
with
new
stoma
-
3
36 2004 Journal of Telemedicine

and Telecare
Japan Website Type 2
diabete
s
-
3
37 2003 Health Services Research Canada Telephone General
populat
ion
-
4
N* publication number
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#
the quality levels of the studies’ evidence
A

C
C
E
P
TE
D
M
A
N
U
S
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ACCEPTED MANUSCRIPT
Table 2 – Strategies and main study outcomes
Strategies N* Main Outcomes
ELS
10 Effective clinical nursing teaching method, permitting the
students’ interaction with

clinical situations through videoconferencing.
12 The strategy permitted overcoming geographical and time
barriers, granting conditions
for the individuals to develop knowledge according to their own
needs and conditions.
ES/MS/CM 36 The telenursing system showed to be an effective
strategy and demonstrated significant
results regarding patients’ glucose, glycated hemoglobin and
blood pressure levels.
ES/CM
3 Care management through telehealth to quit smoking was a
feasible and high-fidelity
strategy. The participants were motivated to change their
smoking behaviors.
8 The intervention studied positively affects the self-care of
heart failure patients.
25 The virtual communication between patients and nurses
represents a fundamental
resource for health care at home. The nurses and patients were
very receptive of the

system, with good results for real-time communication, even in
patients of advanced
age.
30 The intervention showed improvement in the participants’
social support and self-
efficacy, besides reducing solitude and improving the ability to
manage the chronic
disease.
32 The program showed to be feasible, reducing the levels of
the risk factors associated
with the development of cardiovascular diseases.
MS/CM
2 Traditional nursing care combined with telehealth care
significantly reduced the family
caregiver’s burden, mainly in the stress domain related to their
caregiver role, and
improved family functioning.
11 The interventions showed global moderating effects but the
effects were stronger

among individuals with bad blood pressure control. The study
indicates the importance
of identifying individuals who will more probably benefit from
this care.
19 The system shows the chemotherapy patients’ symptoms in
real time. Various potential
benefits of the system were identified, including the potential to
promote self-care and
improve the communication between young people and health
professionals.
23 The patients showed positive experiences in the use of the
symptom monitoring system
related to chemotherapy toxicity. It permits the identification of
early effects to
accomplish the necessary interventions, enhancing the safety
and reducing the gravity
of the effects.
31 The nurses demonstrated positive perceptions in the use of
the toxicity-monitoring
system related to chemotherapy in cancer patients. Real-time
monitoring permits the
rapid identification of symptoms, with the possibility of early
and more appropriate
interventions.

CM
1 Telephone call monitoring as nursing practice to support low-
income mothers in care
for their first child showed to be an easily-applicable, safe, low-
cost and effective
intervention that improved the health outcomes of mothers and
children and reduced
the spending on health.
4 Telephone counseling for breastfeeding, offered by trained
nurses, showed to be
effective to increase the breastfeeding rate in the first month
postpartum.
5 The patient’s adherence to telephone screening
recommendations was influenced by the
interactive role of the patients’ perceptions and the quality of
the provider’s
communication. The need for communication skills training is
highlighted in the
context of patient-centered telephone consultations.
A

C
C
E
P
TE
D
M
A
N
U
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ACCEPTED MANUSCRIPT
6 The patients experienced the monitoring program as
motivating support, with relations
of trust and detachment with the therapist. The program can
help with counseling and
support for patients in chronic pain.
7 Telephone care to pregnant women demands clear, friendly
and respectful orientations,
showing the professionals’ confidence and receptiveness.

9 Potential value was perceived in video contact to provide
access to non-verbal
communication and visual emotion, which can be used for care
delivery.
13 The results show that the care model used, combined with
habitual care, shows to be
effective for the control of glycated hemoglobin, reducing the
emergency consultations
and enhancing the self-efficacy in individuals’ control of their
disease.
14 The mothers were more prone to accepting self-care
counseling by telephone, while
different father who received the counseling did not accept the
orientations and visited
another health service.
15 Compliance levels with telephone counseling to cope with
emotional and cognitive
reactions of a chronic disease were high in comparison with
traditional health
treatment.
16 The patients identified the professional helpline as reliable
and easy to access in daily
life, promoting self-care and permitting reflections and

manifestations of feelings.
Presents effective outcomes when the nurse is calm, friendly
and transmits respect and
confidence.
17 Telehealth video technology as a health care mode was well
received among patients
and family members in rural / remote communities. The benefits
of telehealth extend
not only to patients and family members, but also to care
providers and the health
system.
18 The intervention group showed significant results after six
months with regard to
quality of life and exercise frequency in comparison with the
control group. Telephone
monitoring after discharge is an easy intervention that permits
individual information
provision and support at a moment of stress for the patient.
20 The continuing contact between patients and nurses helped
the patients to cope with the
recovery experience between 12 and 24h after knee arthroscopy.
21 Telephone counseling furthered a high compliance rate with
antiretroviral therapy and

can be an effective care strategy in different contexts.
22 The telehealth intervention is feasible to help patients with
treatment in general, but no
change was found in the physiological and psychological data
verified. It is important
to identify the patients who will benefit more from this type of
care.
24 The intervention showed to be easy to access by the nurses
and offering greater patient
satisfaction. Through the videophone, further information can
be verified for self-
management counseling and identification of physical capacity
and mood changes.
26 The telephone care service, established as health care
screening for the population,
already represents an important component with good
acceptance of the population.
27 Telephone care by trained nurses for heart failure patients
represents a fundamental role
to support medication therapy management.
28 The psychiatric patients who participated in the research
attended emergency services
less frequently than the control group and presented lower rates

of hospitalizations and
visits to the emergency service in comparison with the previous
year.
29 The intervention group showed improvement in the self-care
and social adjustment
components, reducing treatment-related uncertainties.
33 Telephone monitoring of pediatric patients in the
postoperative phase of spinal surgery
permitted closer contact between nurse and patient, building an
important relationship
that permits the identification of factors that may be related to
pain coping, supporting
its management.
34 Telephone intervention can support health promotion for
patients after discharge from
coronary artery bypass graft surgery, stimulating the patients
towards self-care.
35 The patients who participated in the intervention group after
the hospital discharge
showed a better nurse-patient relation and less cases of
colostomy bag change. The
strategy reduces costs and enhances patient satisfaction.
37 Telephone counseling in health service delivery should be

done carefully and involve
trained professionals. Many patients seem to interpret the
orientations mistakenly.
N* publication number
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]
© 2012 The Authors
Scandinavian Journal of Caring Sciences © 2012 Nordic
College of Caring Science 969
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.
© 2012 The Authors

College of Caring Science
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
© 2012 The Authors
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.
© 2012 The Authors
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
© 2012 The Authors
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
© 2012 The Authors
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.
References
1 V�ardfokus – tidning f€or V�ardf€orbun-
det (Journal of the Swedish

Association of Health Professionals.
http://vardforbundet.se/Vardfokus/
tidningen/2010/Nr-3-2010-3/13/
(last accessed 21 July 2012).
2 Derkx HP, Rethans JJ, Maiburg BH,
Winkens RA, Muijtjens AM, van
Rooij HG, Knottnerus JA. Quality of
communication during telephone
triage at Dutch out-of-hours cen-
tres. Patient Educ Couns 2009; 74:
174–8.
3 Pettinari CJ, Jessopp L. “Your ears
become your eyes”: managing the
absence of visibility in NHS direct.
J Adv Nurs 2001; 36: 668–75.
4 Socialstyrelsen – Termbank (National
Board of Health and Welfare term
bank). http://app.socialstyrelsen.se/

termbank/QuickSearchBrowse.aspx/
(last accessed 21 July 2012).
5 Richardson A, Storr J. Patient safety:
a literature [corrected] review on the
impact of nursing empowerment,
leadership and collaboration. Int Nurs
Rev 2010; 57: 12–21.
6 Pashley HS. Personal nursing care
experiences provide lessons on
patient safety. AORN J 2011; 94:
194–8.
7 Ernesater A, Engstrom M, Holm-
strom I, Winblad U. Incident report-
ing in nurse-led national telephone
© 2012 The Authors

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