This study explores the possibility of combining national health system objectives of health promotion and equitable healthcare
 with an efficient telephone healthcare service. It deals with how managers of the organisation Swedish Healthcare Direct (SHD) view the goals of telephone nursing (TN) work and whether health promotion and equitable healthcare are included in these goals. Health promotion refers to the process of planned actions that enable people to increase control over, and to improve, their health and well-being, physically, mentally and socially
. Equitable healthcare implies that people with the same needs should have the same services and access to healthcare, regardless of residence, gender, age, social group, and so on
. Since parent gender was recently found to play a role for the outcome in paediatric health calls
, implying that sick children are not treated equally due to the gender of the parent making the call on their behalf, this aspect of equitable healthcare was used as an example in the study.
TN in Sweden is, as in many other countries, an expanding healthcare area, accessible on a 24/7 basis. The calls are free of charge, except for the cost of the call. Swedish healthcare is otherwise tax financed and patients pay a maximum yearly fee of approximately €120 (1100 SEK) for their healthcare. After 2013, when nationally completed, SHD is probably Sweden’s largest healthcare provider. Callers connect directly to telenurses at the nearest county or region through the national number, 1177. In total, there are 1100 employed telenurses at 33 workplaces. The telenurses are encouraged to keep calls 7–9 minute long
 and use a decision support tool (DST) designed as a checklist based on caller symptoms
. Reported call outcome for self-care versus referral to other healthcare providers is approximately 50/50
[6–8]. Callers are however free to seek primary and emergency care irrespective of telenurse recommendations. The estimated number of calls is 0.6 per person and year for the 9.5 million Swedish inhabitants. This offers telenurses rich opportunities for health promotion as intended by the law. In paediatric health calls, which account for nearly half of the six million yearly SHD calls, investments of health promotion are likely to ensure long-lasting value. This, due to the young age of persons calls are made for (children age 0–17), facing a long life profiting from early health promoting activities.
TN is a special kind of healthcare as the nurses at SHD never see the callers
. The care is regulated in the same way as other forms of Swedish healthcare provisions, one consequence being that the nurses are not allowed to diagnose illnesses
. The most important regulations can be found in the Health and Medical Services Act
. For example, the law requires SHD to produce “good health and healthcare on equal terms for the entire population” and work to “prevent ill health”. The preventive aspect is also present in national guidelines for healthcare and in several other documents
[11–15] with the central message that health promotion should systematically be integrated into all aspects of healthcare as a natural component in the chain of care.
The repeatedly mentioned objectives of SHD are to increase access to healthcare, increase citizens’ sense of security and increase the effectiveness of healthcare services
[4, 10]. The tasks for telenurses as described by SHD include to ’answer questions, assess care needs, give advice and refer callers to an appropriate level of care’. Yet, telenurses themselves describe their work to be more relational
 and also mention supporting, strengthening and teaching callers, as well as facilitating their learning, which imply that they have a more comprehensive understanding of telephone nursing work. This last aspect of their work implies a potential for health promotion, provided that the caller receives self-care advice, one of the most common measures of health promotion
, and not just a referral to another provider of care. In Sweden, mothers received twice as much self-care advice for their sick children compared to fathers, according to a recent study
. The discrepancy was not explained by any difference in the seriousness of the children’s condition, neither was it related to the child’s gender. Thus, contrary to the law’s intention as regards health promotion and equitable healthcare, health promotion is distributed unequally. If and how SHD intends to meet the requirements of the law remains unclear.
As a service, SHD is intended to lead to ’increased access to healthcare, increased public sense of security and an efficient healthcare service’
. These organisational goals are likely to affect how managers view the goals of TN work
. The investment in SHD is part of the New Public Management (NPM) reform trend, associated with objectives of efficiency, cost control and performance evaluation. NPM objectives in healthcare have been linked to changes in the nurse manager role: from leading and supporting nurses who deliver care to policy implementation, quality measures, budgetary matters, etc. Because all calls are monitored, managers at SHD can supervise and control the telenurses’ work performance (length of calls, quality of the conversation etc.) in detail
[19, 20]. Thereby they can have a strong impact on the culture of for example health promotion
. The question whether telenurses are being encouraged to prioritise health promotion in situations of stress
[22, 23] and shortage of time
 has thus far gone unanswered. Most of the managers are qualified registered nurses (RNs) and are hence concerned by, for example, the ICN ethical code for nurses
 and the Swedish ‘Competence description for registered nurses’
. Consequently, they may have difficulties in balancing these dual roles
[24–26]. In practice, managers at SHD have to determine a way for the service to be efficient without losing caring aspects or long-term investments in callers (e.g., health promotion). Furthermore, according to Winblad
, the extent to which health professionals take actions to fulfil political intentions such as systematic health promotion depends on whether they are 1) able to carry out the policy goals, 2) whether they understand the intentions behind the goals and the actual rules; and whether they are 3) willing to carry out the tasks to reach the policy goals. Whether they are able is e.g. conditional on the organisational structure and prerequisites for carrying out the policy; whether they understand e.g. on knowledge and interpretation of the policy; and whether they are willing on e.g. the correspondence to professional codes and ethics. The managers’ perceptions are discussed in relation to this tripartite model.
Against this background, this study aimed to explore and describe what SHD managers perceive as the primary goals of TN work and how they view health promotion and equitable healthcare implementation at SHD. Do the managers strive to match the legal goals of health promotion and equitable healthcare with SHD goals of efficiency and productivity?