Patient Satisfaction With

Telephone Nursing
A Call for Calm, Clarity, and Competence
Silje Gustafsson, PhD, RN; Britt-Marie Wälivaara, PhD, RN;
Sebastian Gabrielsson, PhD, RN

ABSTRACT
Background: Studies of patient satisfaction with telephone nursing can provide a better understanding of
callers’ needs and inform the improvement of services.
Purpose: This study described patients’ experiences and perceptions of satisfaction with telephone nursing.
Methods: The design was nonexperimental and descriptive, with an inductive approach. Data were collected
using open-ended questions in a questionnaire that was dispatched to 500 randomly selected callers to the
Swedish Healthcare Direct in Northern Sweden.
Results: Patients’ satisfaction with telephone nursing was related to calm, clarity, and competence. Calm re-
ferred to the nurse remaining calm and composed during the call. Clarity was described as distinct, concrete,
and practical advice on how to act, what to observe, and where to seek further assistance. Competence
referred to both health care knowledge and caring skills.
Conclusion: These aspects of nursing are dependent on each other and on-call telephone nursing services,
which value patient satisfaction need to target all 3.
Keywords: nursing care, patient satisfaction, telenursing, telephone nursing, telephone triage nurse

M any countries have seen the introduction

of telephone nursing call centers expected
to provide accessible, trusted, quality health in-
formation, and advice. According to Kaminsky
et al,1 the aim of telephone nursing is to sup-
port, strengthen, and teach the callers and guide
care seekers to the correct level of care. Tele-
phone nursing reduces costs and the number of
patients seeking care for minor conditions.2 The
frequency of recommendations to self-care is ap-
proximately 30% for persons calling on their
own behalf.2-4 Compliance to telephone nurses’
recommendations is high2,3,5 but dependent on
the level of care recommended by the nurse.
Author Affiliation: Division of Nursing, Department of Health
Science, Luleå University of Technology, Luleå, Sweden.
This study was funded by Luleå University of Technology. The
authors gratefully acknowledge Robert Lundqvist at the county
council of Norrbotten for the help received with this study.
The authors declare no conflicts of interest.
Supplemental digital content is available for this article. Direct URL
citation appears in the printed text and is provided in the HTML and
PDF versions of this article on the journal’s Web site
(www.jncqjournal.com).
Correspondence: Silje Gustafsson, PhD, RN, Division of Nursing,
Department of Health Science, Luleå University of Technology,
SE-971 87 Luleå, Sweden (Silje.gustafsson@ltu.se).
Accepted for publication: January 2, 2019
Published ahead of print: February 25, 2019
DOI: 10.1097/NCQ.0000000000000392
Compliance increases when the recommendation
is a high care level, for example, the emergency
department, or when the recommended care level
is higher than the caller expected.2,6,7
SATISFACTION
In relation to telephone nursing, feeling safe and
secure after the call is the primary factor that
influences patient satisfaction.3 The convenience
and simplicity of telephone nursing have been de-
scribed as important factors influencing satisfac-
tion, as the direct and effective contact and ad-
vice replace long waiting times and unnecessary
journeys to the health care clinic.4,8,9 Satisfaction
is a multidimensional concept, and a single, uni-
versally accepted definition of satisfaction is still
lacking. For the purpose of this study, patient sat-
isfaction was understood as the congruence be-
tween health care service and patient need, de-
sire, or expectation.
Studying patient satisfaction provides impor-
tant information about service factors that need
improvement and creates a better understanding
of patients’ needs.10 This is important informa-
tion that enables organizations and health care
providers to improve services to better match the
needs of the population. Because of the effec-
tive and interpersonal component of patient sat-
isfaction, qualitative evaluations can contribute

E6 www.jncqjournal.com J Nurs Care Qual • Vol. 35, No. 1, pp. E6–E11 • Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Copyright © 2019 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
January–March 2020 • Volume 35 • Number 1
to the body of knowledge by creating a deeper
and more varied understanding of experiences of
satisfaction, as well as validating the findings of
larger, quantitative surveys. The aim of this study
was to describe patients’ experiences and percep-
tions of satisfaction with telephone nursing.
METHODS
This was a nonexperimental and descriptive
study with an inductive approach. The Swedish
Healthcare Direct (SHD) is the largest health
care provider in Sweden and was made fully op-
erational in all counties in 2013. The SHD com-
prises 3 services—an on-call telephone nursing
service, a state-owned Web site, and a platform
for e-services where patients can manage their
health care contacts. The on-call telephone nurs-
ing service consists of nurses providing an assess-
ment of care needs, advice, and guidance to the
correct level of care. The Web site contains peer-
reviewed medical information and advice and
has 90 million visits per year, a number that in-
creases by 10% every year. The platform for e-
services enables patients to contact their health
care providers and receive digital care, as well as
gathering information about all of their health
care contacts.11
Participants and setting
A random selection was made of 500 callers to
the SHD in Northern Sweden during the first
week of March 2014, a third of the total number
of callers in that week (n = 1500). Participants
received a questionnaire by post with an infor-
mational letter enclosed, and a reminder was sent
2 weeks after primary dispatch. A total of 225
persons returned a completed questionnaire, giv-
ing a response rate of 45.6%. Five questionnaires
were returned unopened because of the wrong
address, and 2 study participants were deceased
after the call to the SHD. The regional ethical re-
view board of Umeå reviewed and approved this
study (DNR: 2010-225-31).
Data collection
Data were collected using open-ended questions
in a questionnaire. The construction of the ques-
tionnaire has been described elsewhere.3 The
open-ended questions follow the exact wording
of the modified Quality from the Patient Per-
spective questionnaire for telephone nursing.12
Participants were asked to describe what they
found satisfactory (n = 98); if they were unsat-
Copyright © 2019 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
www.jncqjournal.com E7
isfied, they were asked to describe the reason
for dissatisfaction (n = 7) and provide sugges-
tions for improvement (n = 66). A panel of 4
experienced multidisciplinary senior researchers
and 2 statisticians critically reviewed the ques-
tionnaire, including the open-ended questions.
A total of 123 different persons responded to
the questions, and 171 written answers were re-
ceived. Median length of the written answers was
11 words (interquartile range, 4-23).
Data analysis
Participants’ answers were analyzed using qual-
itative content analysis. This is a method for
systematic analysis of written and verbal com-
munication that allows for making replicable
and valid abductive inferences from texts.13 Fol-
lowing Krippendorff,13 content was understood
as being created during the process of reading
and analyzing the text in a specific context that
is continuously reconceptualized, directing and
redirecting the analysis.
We thus performed the analysis as a system-
atic, stepwise, iterative process. First, partici-
pants’ answers were read as a whole with the
aim in mind. The material generated 220 textual
units. These were then coded and organized
into categories independently by the first and
last authors, respectively, and the 2 sets were
compared, discussed, and synthesized, forming
a third set. The original answers were then read
again, and additional revisions made to the
wording and content of categories and codes.
Graneheim et al14 suggest that qualitative con-
tent analyses differ in degree of abstraction and
interpretation. This analysis resulted in 3 main
categories and 12 subcategories on a descriptive
level. The main categories reflect some level
of abstraction, whereas the subcategories are
concrete and closer to the original text. After
categorization, a quantitative word frequency
count was performed to identify the number of
positive and negative statements relating to each
main category.
RESULTS
Following patients’ experiences and suggestions,
patients’ satisfaction with telephone nursing can
be described as dependent on engaging with
calm, clear, and competent nurses (Table). A to-
tal of 127 positive statements were made about
the SHD, and 44 statements commented on the
SHD in negative terms (see Supplemental Digital
E8 Patient Satisfaction With Telephone Nursing
Table. Analysis of Patients’ Experiences
and Perceptions of Satisfaction With Tele-
phone Nursing
Main
Subcategories Categories
That the nurse
listens before asking questions Calm
and giving advice
gives time and inspires calm
gives clear and concise advice on Clarity
what to do and what to observe
facilitates and coordinates care
is easily accessible
is knowledgeable and professional Competence
with great medical competence
gives a correct medical
assessment and advice
takes symptoms seriously and
avoids risks
is welcoming and supporting and
strives to help
is committed and compassionate
shows warmth and understanding
respects the patients’ knowledge
Content, Table, available at: http://links.lww.
com/JNCQ/A549).
Calm
Participants found it positive when the nurses
tuned in and listened first before they started
asking questions and giving advice. Participants
found it reassuring to know that there was some-
one at hand to consult when needed, without
feeling that they were taking up someone else’s
time. Callers described that, when the nurse
spoke calmly, it would inspire confidence and
ease distress. When the nurse remained calm and
composed, callers felt reassured and safe: “The
welcoming reception and the feeling of reassur-
ance after the call with what felt like knowl-
edgeable and calm staff” and “Being able to re-
ceive advice without feeling that you are stealing
someone else’s time.”
The assessment received could sometimes be
perceived as overly dramatic, causing fear and
concern. Some callers had experience of talking
to nurses who did not listen and stressed the im-
portance of allocating enough time for conversa-
tion. They also called for a greater focus on lis-
tening to the callers: “Listen better to the caller
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Journal of Nursing Care Quality
about their symptoms and not just read from the
hospital records.”
Clear
Callers appreciated nurses offering clear, con-
crete, and practical advice delivered in a confi-
dent manner. Information received when calling
telephone nurses was expected to be trustworthy
and was of high quality. Callers described being
satisfied when being instructed how to act, what
to observe, and where to seek further assistance.
For example, patients stated: “The nurse made
us feel calm and gave clear instructions on how
to monitor our child during the night until the
primary care clinic would open.”
Patients wanted the information to be straight-
forward and the advice to be personalized and
action-oriented. They wanted more information
about self-care interventions so that they could
be self-reliant instead of simply being sent some-
where else. Receiving more information about
medications, particularly side effects, was also
mentioned: “[I] would like to get more infor-
mation/tips about what to do to relieve my
symptoms instead of just being sent somewhere
else.”
Callers expressed satisfaction when the nurse
facilitated and coordinated care, for instance,
by connecting them with other health care
providers. This could include calling for an
ambulance and calling ahead to the emergency
department to give information. Accessibility of
the SHD was not only highly valued but also a
source of dissatisfaction. Callers described being
frustrated when they had been put on hold.
Participants expressed satisfaction with short
waiting times and a rapid service that was easily
accessible. A need was found for improvements
in the organization of the telephone nursing, in-
cluding reducing waiting time, improving the in-
structions for redialing, and making sure the tele-
phone call was actually connected. Participants
suggested the opportunity of sending a picture
by MMS to the nurse for assessment, as they
found it sometimes hard to explain in detail
what they saw over the telephone.
Competence
Participants expressed satisfaction with receiv-
ing a careful examination and an accurate as-
sessment by a skilled nurse with high medical
competence, which produced a feeling of com-
fort and safety after the call. The respondents
January–March 2020 • Volume 35 • Number 1
wanted some kind of “diagnosis”; they wanted
to hear the nurse’s opinion about their symp-
toms, possible cause of their symptoms, and rea-
soning underlying the recommendation to either
seek medical care or practice self-care. One pa-
tient commented: “I would like nurses to ex-
plain what causes the symptoms, like receiving a
diagnosis.”
Many praised the nurses’ clinical skills and
found them competent, knowledgeable, and
professional. Yet, respondents pointed out the
need for nurses’ skills to be increased to improve
confidence, as it was seen as negative when the
nurse seemed insecure or faltering. Some people
had experienced receiving a wrong assessment
and advice, causing difficulty in relying on
the expertise and assessments of the nurses. It
was important for the nurse to consult with
someone if unsure, and respondents stressed
the importance that telephone nurses should
be registered nurses with specialist competence.
One patient stated: “They should recommend
that you seek emergency care if there is any
doubt about anything…. Neither the nurse
nor the patient should feel that they are doing
something wrong if the patient seeks medical
care.”
Callers were satisfied when they were received
in a kind and friendly manner and the nurse was
welcoming and supporting. Callers stressed the
importance of being met with compassion and
described feeling safer when they felt that the
nurse genuinely cared about them and wanted to
help. Compassion from the nurse inspired con-
fidence, and taking the time to follow up their
situation was appreciated. The importance of
nurses respecting the callers’ knowledge about
their own bodies and conditions was stressed,
and it was important that the nurses listened to
the patients and trusted their knowledge about
their own health: “I think you have to be care-
ful, taking every call seriously; no symptom can
be too small to be taken into account.”
Some described having experienced a lack of
compassion from the nurse and that their con-
cerns were not understood. This made them per-
ceive the nurse as being cold and uninterested
in their situation, resulting in feelings of rejec-
tion. Being shifted further to other caregivers was
frustrating: “My feeling is that they will do just
about anything to keep the patient from going to
the primary care clinic or hospital.”
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www.jncqjournal.com E9
DISCUSSION
The aim of this study was to describe patients’
experiences and perceptions of satisfaction with
telephone nursing. The results describe the im-
portance of calm, clarity, and competence. Ar-
guably, all these aspects of nursing are dependent
on each other and thus on-call telephone nursing
services need to target all 3.
Participants described that a nurse who con-
veys calm made them feel reassured and safe.
A common reason for calling telephone nursing
services was a need for reassurance related
to uncertainty and concern about symptoms.
The severity of symptoms, new and unfamiliar
symptoms, or persisting or worsening symptoms
generate feelings of uncertainty and stress.8,15
A trusting relationship was reassuring, and
personal presence in the encounter with the
telephone nurse was identified as an important
factor that promoted feelings of safety and secu-
rity. Distance technology imposes demands on
the nurse to convey a sense of personal presence
and togetherness during the conversation with
the caller.8,9 According to Kaminsky et al,16
speaking slowly and listening carefully facilitate
communication and inspire calm. The presence
of a nurse is reassuring, and the presence need
not be physical.17 Patients are reassured when
nurses have a quiet, warm tone to their voices.17
In relation to our findings, this implies that
the nurse reassures the care seeker through a
calm presence and clear communication and
by displaying competence and care. Thus, tele-
phone nurses “being calm” demonstrate how
fundamental interpersonal aspects of nursing
remain relevant regardless of context.
Our findings demonstrated a need for clear,
concrete, and practical advice delivered in a
confident manner. Callers requested information
and advice about their situation and wanted to
know what to do, what to observe, and where
to go if the symptoms worsened. According to
Kaminsky et al,1 telephone nursing comprises an
important function to teach the caller about
health matters and facilitate learning. The nurse’s
pedagogical role is carried out with the intention
of empowering callers to perform self-care and
encouraging them to seek further information
when needed, thus contributing to their learn-
ing. Thus, the emphasis on the importance of
clear advice might reflect an expectation that
telephone nursing should facilitate learning and
E10 Patient Satisfaction With Telephone Nursing
autonomous decision-making rather than simply
telling callers what to do.
The results describe patients valuing the clin-
ical competence of telephone nurses and call-
ing for a higher level of knowledge among these
nurses. This underlines the importance of tele-
phone nurses having specialist education tar-
geted at telephone nursing. Although perceiving
the nurse as unsure or unaware of the partic-
ular circumstances of their situation can result
in reduced trust from patients, the emphasis on
nurses’ competence should not be interpreted as
patients expecting nurses to have all the answers.
On the contrary, participants described that the
nurse consulting colleagues for advice and de-
cision support generated trust in nurses’ assess-
ments, consistent with the findings of Kaminsky
et al.18 In this regard, our results also point to the
importance of what Roland et al19 label “safety-
netting,” that is, providing the caller with infor-
mation on warning symptoms and how further
health care can be accessed, as well as follow-
ing up the outcome of care. Our findings sug-
gest that, from the perspective of patients, safety-
netting might increase trust in the competence of
telephone nurses and in the advice given. Partic-
ipants also stressed the importance of not being
made to feel that they were wrong to seek medi-
cal care.
The interpersonal aspects of telephone nurs-
ing are further emphasized. Our results describe
how compassion from the nurse inspired confi-
dence and indicated a caring competence. It has
been argued that the emotional understanding
of nursing, “to care for,” has been devalued in
the modern society.20 Previous research describes
that, when the design of telephone nursing ser-
vices focuses on somatic symptoms, telephone
nurses are left without support in dealing with
callers’ emotional and mental health needs.21
According to Ström et al,4 callers might actu-
ally prefer emotional interaction before seeking
knowledge from the telephone nurse. In our re-
sults, participants also stressed the importance of
nurses trusting the patients’ stories and knowl-
edge of their own bodies. This is consistent with
the findings of Murray and McCrone,22 who
found that seeing the patient as a person rather
than a case and listening to the patient’s con-
cerns developed trust between the patient and the
caregiver. Conveying caring competence reduces
worry and feelings of vulnerability and leads to
increased trust.23
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Journal of Nursing Care Quality
Our results specifically describe nurses taking
the time to follow up on a patient’s situation
as a caring act. Offering monitoring calls has
been described by parents of children with gas-
troenteritis as comforting, as they generate a feel-
ing of shared responsibility. According to Kvilén
Eriksson et al,9 monitoring calls creates a sense
of personal contact and connectedness and en-
ables parents to share their worries and concerns
with a nurse. The feeling of not being alone, and
the security of having someone to talk to, has
been found to engender feelings of confidence
and reassurance.8,9
Our findings illustrate how the telephone
nurse’s gatekeeping function might shine
through in the encounter. Telephone nurses
are exposed to criticism, and their competence
and referrals can be questioned by both callers
and colleagues in other sectors of the health
care system.24 Understanding how patients per-
ceive and value telephone nurses’ competence is
especially important, as previous research has
shown that the tendency to seek health care
increases when callers feel unsecure or when
they feel unsatisfied with the care received.8,16
Consequently, satisfaction with the interper-
sonal interaction with the nurse is positively
correlated with self-care behavior.2,5 Our results
not only stress the importance of telephone
nurses being competent but also demonstrate
how this competence must be about putting
patients’ needs first—even if that means having
to admit your own limitations by seeking advice
from colleagues or dealing with uncertainties by
“safety-netting” or referring patients.
Strengths and limitations
Validity in qualitative research assesses whether
the research findings represent a credible in-
terpretation of the original data.25 To reduce
the risk of confirmation bias, the authors per-
formed the first step of analysis separately, thus
triangulating the analysis. The data collected
were written down by the respondents, which
meant that the text was relatively condensed, fa-
cilitating the striving to stay close to the original
text.
Reliability pertains to the stability of data
collection.25 The sampling of study participants
in this study was random, and 123 different re-
spondents contributed data that formed the ba-
sis of the analysis. The questions that formed the
January–March 2020 • Volume 35 • Number 1
basis for data collection were obtained from a
validated and tested questionnaire.12 A limita-
tion in satisfaction research is the phenomenon
of positively skewed ratings of satisfaction. To
reduce the risk of social desirability bias and to
gain a broader view, we also sought experiences
of dissatisfaction and thus asked for sugges-
tions for improvement. The questionnaire was
anonymous, and no personal information could
be linked to the answers. Experiences and per-
ceptions of satisfaction from respondents with
a language other than Swedish are not repre-
sented in the material, as non-Swedish speak-
ers would not have been able to understand
the questions in the questionnaire. The ques-
tionnaire was distributed within 2 weeks of
the call to the SHD, which implies a low risk
of recollection bias. However, the callers al-
ready knew the outcome of care, which could
have affected their experiences with the nurse
both positively and negatively, depending on the
outcome.
CONCLUSIONS
This qualitative study adds to a limited but grow-
ing body of knowledge on telephone nursing
building on patients’ experiences and percep-
tions. Our findings suggest that satisfaction in-
creases when engaging with nurses who are calm,
clear, and competent. In the clinical setting, this
implies that the nurse needs to convey a sense of
calm, as well as communicating with the caller
in a clear and understandable manner. Nurses
need a high level of medical knowledge, as well
as a caring competence to adequately address
patients’ needs. To identify and meet patients’
needs, nurses should embrace the relational and
emotional aspects of care. Competent nurses al-
low themselves to acknowledge and act when
unsure by consulting colleagues or safety-netting
through referral to other services. The findings of
this study validate the quantitative findings from
previous studies and provide an understanding
of the nuances of callers’ experiences of satisfac-
tion with telephone nursing.
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