Table 1 Important obstacles and prerequisites in telenurses’ work environment according to the findings in Round 1 (the interviews) presented alphabetically order

1

All of the working hours monitored

…all of their working hours were monitored and evaluated regarding number of answered calls, number of referrals and how long they had been logged off their work station.

2

Cognitive fatigue

…cognitive fatigue, the long working periods with the high level of concentration their work involved exhausted them. 8-h shift was perceived as far too long, and for this reason several of the participants had chosen to work part time.

3

Collaboration with other sites

…collaboration with other sites (regions) within SHD increased call length.

4

Disturbing sounds

…disturbing sounds such as loud voices disrupted concentration, taking attention away from the caller.

5

High employee turnover

…high employee turnover and subsequent shortage of staff were perceived as an obstacle because it was difficult to recruit new colleagues.

6

Lack of possibilities for development (professionally)

…lack of possibilities for development and opportunities for continuing education were perceived as low.

7

Lack of possibilities to discuss and reflect with colleagues

…lack of possibilities to discuss and reflect with colleagues

8

Lack of support and appreciation from managers

…lack of support and appreciation from managers, especially when something went wrong, e.g. when they received complaints from other healthcare providers or callers.

9

Lack of understanding and being exposed to critic from other healthcare providers

…lack of understanding and becoming exposed to critic from other healthcare providers regarding their assessments of callers’ care needs

10

Lacking availability among other healthcare providers

…lack of availability to other healthcare providers and they often encountered callers who were frustrated over other healthcare providers’ lack of availability.

11

Lacking availability to the callers’ medical charts

…they lacked availability to the callers’ medical charts and hence important medical information

12

Limited career opportunities

…limited career opportunities within their workplace.

13

Limited possibilities to socialize with colleagues,

…limited possibilities to socialize with colleagues, lunch and coffee breaks were almost always taken alone and opportunities for spontaneous socialization with colleagues were few.

14

Long telephone queues

…how long telephone queues were experienced as stressful and made them try to shorten calls to decrease waiting time, but this strategy increased their sense of insecurity.

15

Low possibility to affect work situation

…low possibility to affect their work situation, calls were automatically forwarded to them

16

Management did not avail themselves of the knowledge and experience

…management did not avail themselves of the knowledge and experience of employed telenurses

17

No feedback on one’s own calls

…feedback on one’s own calls was inadequate and scarce.

18

No occupational health services

…some did not have occupational health services and reported having no one to turn to regarding work stressors and associated problems

19

No opportunity for recovery during the work shift

…no opportunities for recovery during the work shift, it was almost impossible to just sit back for some minutes and rest when all of their working hours were being monitored.

20

Periodical repetitively work

…in some respects, the work was periodical repetitively, especially in periods of outbreaks of, e.g., influenza and gastroenteritis.

21

Problems with availability to an interpreter

…problems with availability of interpreter occurred as callers to SHD sometimes not are native speakers of Swedish.

22

Sedentary work cause physical strain

…their sedentary work caused physical strain and several experienced neck and shoulder pain

23

Solitary work

…how being a telephone advice nurse was solitary work; they worked alone at their computer using headsets without interacting with colleagues.

24

Technical problems

…technical problems with telephone equipment, computers and software aggravated the participants’ work.

25

The CDSS

…the CDSS was described as undesirable; it contained so much information that it was difficult to find specific information. Searching took time and attention away from the callers.

26

Unclear guidelines and lack of structure at the workplace

…they perceived problems with unclear guidelines and lack of structure at the workplace.

27

Working within a production-steered business with demands for efficiency

…they perceived their work environments to be like working within a production-steered business with demands for efficiency.

28

Wrong kind of calls

… they sometimes had to handle the wrong kind of calls, e.g., calls regarding opening hours at pharmacies, administrative questions regarding medical bills, etcetera

Items of Prerequisites

Example of content

The participants described how:

29

All calls to SHD were recorded and that the content of each call was clearly documented

…the fact that all calls to SHD were recorded and that the content of each call was clearly documented was described as valuable and as contributing to having a sense of control.

30

Being able to call callers back

…being able to call callers back to follow up on their condition. This increased participants’ feelings of control and reduced their anxiety about making incorrect assessments.

31

Being able to choose the size of their workroom

…being able to choose the size of their workroom, e.g. decide whether they wanted to sit alone or with colleagues was desired

32

Being able to focus on one caller at a time

…having one patient at a time gave a feeling of control, whereas in traditional care they were supposed to manage several patients at the same time.

33

Calm and pleasant environment

…working in an environment without disturbing sounds and pleasant surroundings .

34

Collegial support

…a permissive atmosphere with possibilities for social interactions with colleagues enabled collegial support, which was described as essential to their work, especially after handling difficult calls.

35

Education and observation possibility

…having possibility to education and observation strengthened telenurses and developed their professional skills.

36

Health and wellness training/massage

… was appreciated and eased the physical strain caused by their work.

37

Joint coffee and lunch breaks

…joint coffee and lunch breaks provided an important chance for social interaction.

38

Possibility to adjust the workstation

…possibility to adjust the workstation e.g., to stand up and work, was regarded as important in avoiding/preventing physical strain.

39

Possibility to influence work time

…those given the possibility to influence their work time felt this was important since it enabled them to work when it suited their private and family life.

40

Regular feedback on one’s own calls

…regular feedback on one’s own calls was a prerequisite for professional development. Listening to one’s own calls with a coach allowed them to observe and reflect on their communication with the callers and develop their communicative skills.

41

Stimulating work

…they perceived a stimulating work, every call was an unexpected challenge and every caller was unique. The callers often expressed their appreciation, and the participants described how they felt they could help the callers in important ways.

42

Structure and support from the “Call dialogue

…the “Call dialogue” helped to focus on the callers’ problem and ensure that nothing important had been left out

43

Structure and support via CDSS

…the CDSS gave participants access to structure and support, hence as a tool to structure the call and support their assessments through the system.

44

Support from management

…support from management was an important prerequisite and created a feeling of security, as they knew they always had someone to turn to, especially when they were exposed to criticism from other healthcare providers.

45

Technical support 24/7

…adequate and professional technical support 24/7