Parents' perceptions of care quality at child health centres: A cross-sectional study from Sweden.

AIM: To examine parents' perceptions of care quality at child health centres. Specific objectives were to examine parents' perceptions of the care received and the subjective importance of such care. Furthermore, to examine the relationship between parents' sociodemographic characteristics and the perceptions of care quality. DESIGN: A cross-sectional study. METHODS: A random sample of parents of children born in Sweden in 2021 participated. Data were collected by the QPP-CHC questionnaire and analysed using descriptive and analytical statistics. RESULTS: The response rate was 19.4%. The targeted sample size of 210 participants was reached as 584 parents responded to the questionnaire. Parents' overall ratings of care quality at child health centres indicated optimal quality with mean values >3. However, various potential improvements areas were identified as needing additional information. These included dental care (m = 2.82), allergy prevention (m = 2.25), breastfeeding (m = 2.97), sleep (m = 2.83), the child's behaviour (m = 2.47) and the child's crying (m = 2.47). Also, parents rated suboptimal quality regarding that the care was based on healthcare routines rather than parental preferences and needs (m = 2.86). Parents born outside of the Nordic countries rated higher care quality than those born in the Nordic countries, as well as parents with a non-academic education. CONCLUSION: Parents want information based on their preferences and needs. Parent's perceptions of areas for improvement are new and important knowledge for registered nurses at child health centres. IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE: The findings indicate that parents feel that insufficient attention is given to areas of care that they perceive as important. Parents' perspectives on the care quality at child health centres is an important component of quality work and might lead to improvements in the care quality at child health centres. REPORTING METHOD: The Strengthening the Reporting of Observational Studies (STROBE) checklist for cross-sectional studies was used to guide reporting. IMPLICATIONS FOR POLICY AND PRACTICE: The findings of this study suggests that parents feel that insufficient attention is given to areas of care that they perceive as important. Parents' perspectives on the care quality at child health centres provides important knowledge which can guide further development of care quality at child health centres. The findings indicate that a family-centred approach that integrates relational and routine-oriented nursing can be a way to ensure that the care is based on parents' preferences and needs. No patient or public contribution.

Feeling Safe in the Perioperative Period: Experiences from Patients Undergoing Orthopedic Day Surgery.

Introduction: Day surgery is often preferred by patients, but it can pose challenges in self-management after discharge. In addition, patients undergoing orthopedic surgery report poorer rates of postoperative recovery than patients undergoing general surgery. Understanding patients' perceptions of feeling safe while undergoing surgery facilitates individualized care and is important since it may affect their recovery. Objective: The aim of this study was to describe patients' perceptions of feeling safe in the perioperative period when undergoing orthopedic day surgery under regional anesthesia. Methods: The design was qualitative and descriptive. Data were collected through a cross-sectional questionnaire containing open-ended questions. Qualitative content analysis with an inductive approach was used for data analysis. Participants' characteristics were presented descriptively. The study population consisted of a consecutive sample of 97 patients who had undergone orthopedic day surgery under regional anesthesia between March and October 2022. Results: The categorization process resulted in the development of two categories describing participants' experience of perioperative feelings of safety when undergoing orthopedic day surgery: having someone near and having a sense of control. The results indicate that the relationship between patients and staff and the perceived feeling of control and participation are factors influencing patients' perception of feeling safe in the perioperative period. Conclusions: In perioperative care, nurses play a vital role in fostering patients' sense of safety by establishing relationships. This ensures that patients can be actively engaged in their own care. Patients also need access to professional and competent staff who strives to add a personal touch and considers their perspective. Since patients undergoing orthopedic day surgery might face a more demanding postoperative recovery than they had initially anticipated, further research is suggested to explore the association between a perceived feeling of safety and postoperative recovery.

Further development of the reflective practice questionnaire.

Background: This article provides an update of the Reflective Practice Questionnaire (RPQ). The original RPQ consisted of 40-items with 10-sub-scales. In this article, the RPQ is streamlined into a 10-item single reflective practice construct, and a 30-item extended version that includes additional sub-scales of confidence, uncertainty/stress, and work satisfaction. Methods: A total of 501 university students filled out an online questionnaire that contained the original Reflective Practice Questionnaire, and two general measures of reflection: The Self-Reflection and Insight Scale, and the Rumination-Reflection Questionnaire. Results: Based on factor analysis, the RPQ was streamlined into a brief 10-item version, and an extended 30-item version. Small positive correlations were found between the RPQ reflective practice measure and the two measures of general reflection, providing discriminant validity evidence for the RPQ. The RPQ was found to be sensitive to differences among industries, whereas the general measures of reflection were not. Average reflective practice scores were higher for health and education industries compared to retail and food/accommodation industries.

The telephone nursing dialogue process: an integrative review.

BACKGROUND: Telephone nursing involves triage, advice, and care management provided by a nurse over the telephone. The telephone nursing dialogue process has been used clinically in telephone nursing in Sweden for several years to structure the communication and ensure a safe assessment and advice. Studies are needed to determine whether there is sufficient scientific evidence to support the method. AIM: To describe the scientific basis of the phases of the telephone nursing dialogue process. DESIGN: This was an integrative review. METHODS: The literature searches were performed in August 2023, in the PubMed, CINAHL, Cochrane Database of Systematic Reviews and SwePUB databases. Sixty-two articles were included. Data was sorted deductively according to the five phases of the telephone nursing dialogue process and categorized inductively to form subcategories describing the content of each phase. RESULT: All five phases in the telephone nursing dialogue process were supported by a range of articles (n = 32-50): Opening (n = 32), Listening (n = 45), Analysing (n = 50), Motivating (n = 48), and Ending (n = 35). During the opening of the call, the nurse presents herself, welcomes the caller and establishes a caring relationship. In the listening phase, the nurse invites the caller to tell their story, listens actively and confirms understanding. During the analyzing phase, the nurse gathers, assesses, and verifies information. In the motivating phase, the nurse reaches a final assessment, informs the caller, gives advice and creates a mutual agreement and understanding while supporting the caller. Ultimately, the nurse ends the call after checking for mutual agreement and understanding, giving safety-net advice, deciding on whether to keep monitoring the caller and rounding off the call. CONCLUSION: The phases of the telephone nursing dialogue process as described in the scientific literature are well aligned with the theoretical descriptions of the telephone nursing dialogue process.

Perception of feeling safe perioperatively: a concept analysis.

PURPOSE: The purpose of this study was to explore the concept of feeling safe, from the patient perspective, in a perioperative context. METHOD: The eight-step concept analysis approach proposed by Walker and Avant was utilized to examine the attributes of feeling safe. Uses of the concept, defining attributes as well as antecedents, consequences and empirical referents are presented to describe the concept. Case examples are provided in order to assist the understanding of the defining attributes. RESULTS: Feeling safe is defined as: a person that does not feel worried or threatened. Three attributes were identified: Participation, Control and Presence. Knowledge and Relationship are the antecedents of feeling safe, while Feeling Acknowledged and Trust are the consequences. Empirical referents are explored in order to find a way to measuring the perceived feeling of safety. CONCLUSION: This concept analysis underscores the importance of including patients' perceptions in traditional patient safety work. Patients who feel safe perceive that they participate in their care, that they are in control, and that they feel the presence of both healthcare staff and relatives. The perceived feeling of security could, by extension, promote the postoperative recovery of patients undergoing surgery by positively affect the process of recovery.

Strategies for a safe interhospital transfer with an intubated patient or where readiness for intubation is needed: A critical incidents study.

INTRODUCTION: The number of interhospital transports with intubated patients or where intubation readiness is required is increasing in Sweden and globally. Specialist nurses are often responsible for these transports, which involve numerous risks for critically ill patients. AIM: The aim of this study was to describe nurse anaesthetists' and intensive care nurses' strategies for safe interhospital transports with intubated patients or where intubation readiness is required. METHOD: A qualitative study was conducted using the critical incident technique. During March and April 2020, 12 semi-structured interviews were conducted with nurse anaesthetists and intensive care nurses. Data were analysed according to the critical incident technique, and a total of 197 critical incidents were identified. The analysis revealed five final strategies for safe interhospital transport. RESULTS: Participants described the importance of ensuring clear and adequate information transfers between caregivers to obtain vital patient information that enables the nurse in charge to identify risks and problems in advance and create an action plan. Stabilising and optimising the patient's condition before departure and preparing drugs and equipment were other strategies described by the participants, as well as requesting assistance or support if questions or complications arose during transport. CONCLUSION: Transports with intubated patients or where intubation readiness is required are complex and require systematic patient-safety work to ensure that strategies for increasing patient safety and decreasing risks are visible to the nurses in charge, that they are applied, and that they are, indeed, effective.

A Study of Self-Care Practice in Routine Radiotherapy Care: Identifying Differences Between Practitioners and Non-Practitioners in Sociodemographic, Clinical, Functional, and Quality-of-Life-Related Characteristics.

OBJECTIVES: The objective of this study was to describe self-care practice during radiotherapy for cancer and to identify potential differences between practitioners and non-practitioners of self-care regarding sociodemographic, clinical, functional, and quality-of-life-related characteristics. METHODS: In this descriptive study, 439 patients (87% response rate) undergoing radiotherapy responded to a study questionnaire regarding self-care, sociodemographic, clinical (eg, experienced symptoms), functional, and quality-of-life-related characteristics. RESULTS: Of the 439 patients, 189 (43%) practiced at least one self-care strategy, while 250 (57%) did not. In total, the patients described 332 self-care practices, resulting in 14 different categories of self-care strategies. The 5 most common indicators of practicing self-care were fatigue, general wellbeing, psychological symptoms, nausea, vomiting and improving physical condition. The 5 most common self-care strategies were physical activity, increased recovery, healthy eating, distraction, and skincare. Patients who were married, were older than 69, patients with less education than university education, patients undergoing a combination of internal and external radiotherapy, patients experiencing fewer than 8 symptoms, and better quality of life, practiced self-care to a lower extent than did other patients. Functional capacity did not differ between self-care practitioners and non-practitioners. CONCLUSION AND IMPLICATIONS FOR PRACTICE: Of the patients undergoing radiotherapy, slightly less than half practiced self-care during an ordinary week of radiotherapy. Because older and less-educated patients were less likely to practice self-care, cancer care practitioners should consider paying particular attention to helping such patients with their self-care practice.

Mothers' strategies for creating positive breastfeeding experiences: a critical incident study from Northern Sweden.

BACKGROUND: Positive breastfeeding experiences positively influence subsequent attitudes towards breastfeeding, and increase mothers' confidence, self-efficacy, motivation and intention to breastfeed. However, the strategies that mothers find useful and effective for creating positive breastfeeding experiences remain largely unknown. The aim of our study was thus to describe experience-based knowledge from mothers about strategies for creating positive breastfeeding experiences. METHODS: The study followed a qualitative design involving the critical incident technique. Data were collected with an online survey containing open-ended questions that was administered to a Sweden-based parenting group on Facebook in September 2018. Ultimately, 340 incidents from 176 women were identified as offering strategies for creating positive breastfeeding experiences. Data from the written replies were extracted as textual units, condensed and categorised until categories were mutually exclusive, which resulted in six categories. RESULTS: Participating women were on average 31.2 years old and the median number of children per participant was two. Mothers' strategies for creating positive breastfeeding experiences generally included being calm and accepting that initiating breastfeeding takes time and can be difficult initially. Participants described feeling close to the baby by maintaining skin-to-skin contact and being present in the moment by taking time to appreciate the child and the breastfeeding situation, and temporarily forgetting about the world and simply being with the child in the here and now. Participants advocated baby-led breastfeeding and following correct techniques. They also described the importance of keeping an effortless mindset about breastfeeding to prevent perceiving breastfeeding as a compulsion. Mothers described acquiring knowledge about breastfeeding so that they could be prepared if breastfeeding problems occurred and getting support from professionals and family was described as significant for having a positive breastfeeding experience. Caring for oneself and one's body, with aids if necessary, were described as important strategies, as were having a positive attitude and a strong desire to breastfeed. CONCLUSION: Because positive breastfeeding experiences and support are predictors of future breastfeeding initiation and duration, assisting women in creating positive breastfeeding experiences is important. Asking mothers to formulate strategies that they find useful could facilitate breastfeeding by making their approaches more conscious and visible.

Postoperative Recovery: Experiences of Patients Who Have Undergone Orthopedic Day Surgery.

PURPOSE: Day surgery is a common phenomenon and is associated with several benefits including cost-effectiveness. However, patients are required to manage their postoperative recovery at home. Patients undergoing orthopedic surgery are a particularly vulnerable group, and their postoperative recovery requires further investigation. This study aimed to describe the experiences of postoperative recovery of patients who had undergone orthopedic day surgery. DESIGN: A qualitative and descriptive study design was used METHODS: Participants were selected purposefully and included 18 orthopedic day-surgery patients who underwent surgery in October and November 2020. Semi-structured interviews were conducted from December 2020 to February 2021. All interviews were recorded and transcribed verbatim. The transcribed data were analyzed using qualitative content analysis with an inductive approach. The process of analysis was done in several steps and resulted in four categories FINDINGS: Four categories that described the postoperative recovery experiences of patients who underwent orthopedic day surgery were developed: (1) Questions arose when I got home; (2) I wanted confirmation that I was on the right path; (3) I felt lonely and dependent on others; and (4) I strove to find a balance between activity and rest CONCLUSIONS: For most patients, there was no follow-up after day surgery. However, patients expressed a desire for confirmation that their recovery process was within the normal trajectory. Most of the recovery takes place at home, leading to feelings of loneliness and highlighting the need for support from healthcare providers and close relatives. A phone call from a nurse after surgery might offer support, reduce feelings of loneliness, and promote a sense of safety. This study highlights the importance of systematic follow-up following orthopedic day surgery.

Parents' strategies and advice for creating a positive sleep situation in the family.

AIM: The aim of this study was to describe the experience-based knowledge of parents of children aged 0-3 years for creating a positive sleep situation in the family. DESIGN: This study has a qualitative design. Data were collected using an online survey and analysed using the critical incident technique. METHODS: The study participants were recruited through an announcement posted in parenting groups on a social media platform in September 2018. A total of 93 parents answered the questionnaire; 76 of the parents matched the study's selection criteria, and their responses were included in the analysis. RESULTS: The results are presented from the two main questions in the survey: "Strategies for creating a positive sleep situation" and "Advice to new parents regarding sleep". Having routines and reading the child's signals were important strategies, as were creating good conditions for sleep and making sure the child was well-fed and content at bedtime. Winding down and giving the child closeness and touch was described as important, and some parents would co-sleep to soothe the child quickly and create a sense of security and belonging. Parents' most frequent advice to other parents was to accept the situation and to let go of the idea that the child should sleep without waking up in a separate bed or room. CONCLUSION: Personal preferences and needs are likely to vary among individuals, and it is important that nurses tailor sleep advice in accordance with families' preferences and needs, taking individual variations and views into account.

Development and psychometric evaluation of the Feeling Safe During Surgery Scale.

AIM: The aim of this study is to develop and psychometrically test the Feeling Safe During Surgery Scale. DESIGN: The study design was non-experimental and cross-sectional. METHOD: The evaluation followed classical test theory, and the instrument was evaluated regarding reliability, construct validity and content validity. For the reliability analysis, a postal questionnaire consisting of the 16 items of the scale was dispatched in March 2020 to a consecutive sample (N = 242) of patients who had undergone hip or knee replacement arthroplasties with regional anaesthesia. Five experts in nursing care evaluated the content validity of the scale. RESULT: Internal consistency was 0.841. Three items were excluded due to deficits in reliability, resulting in a 13-item scale. A principal component analysis revealed a two-dimensional solution, labelled internal and external aspects of feeling safe. Two items were rephrased to improve clarity and content validity. The average content validity for the scale was 0.88, indicating acceptable content validity.

Reflective capacity in nurses in specialist education: Swedish translation and psychometric evaluation of the Reflective Capacity Scale of the Reflective Practice Questionnaire.

AIM: This study aimed to test the validity and reliability of the Swedish version of the Reflective Capacity Scale of the Reflective Practice Questionnaire in a nursing context. DESIGN: Non-experimental and cross-sectional. METHODS: The instrument was translated from English to Swedish using a translation and back-translation procedure. Data for the validity and reliability analysis were collected from Registered Nurses in specialist education (n = 156) at two Swedish universities. RESULTS: The Swedish version of the Reflective Capacity Scale of the Reflective Practice Questionnaire is a valid and reliable instrument that assesses the reflective capacity of healthcare practitioners. Our findings suggest a unidimensional structure of the instrument, excellent internal consistency and good reliability. CONCLUSION: The Swedish version of the Reflective Capacity Scale of the Reflective Practice Questionnaire has a degree of reliability and validity that is satisfactory, indicating that the instrument can be used as an assessment of reflective capacity in nurses.

Quality indicators in telephone nursing - An integrative review.

AIM: The aim of this study was to identify factors that indicate quality in telephone nursing. DESIGN: An integrative literature review. METHOD: A literature search was performed in October 2018, in the PubMed, CINAHL, Cochrane Library, Academic Search, PsycINFO, Scopus and Web of Science databases. A total of 30 included were included and data that corresponded to the study's aim were extracted and categorized along the three areas of quality as described by Donabedian (Milbank Quarterly, 83, 691), namely structure, process and outcome. RESULTS: The analysis revealed ten factors indicating quality in telephone nursing (TN): availability and simplicity of the service, sustainable working conditions, specialist education and TN experience, healthcare resources and organization, good communication, person-centredness, competence, correct and safe care, efficiency and satisfaction. TN services need to target all ten factors to ensure that the care given is of high quality and able to meet today's requirements for the service.

Patients' Experiences of Pain and Postoperative Nausea and Vomiting in the Early Postoperative Period After an Elective Knee Arthroplasty.

PURPOSE: The aim of this study is to explore patients' experience of pain and postoperative nausea and vomiting (PONV) in the early postoperative period after knee arthroplasties. DESIGN: This is a retrospective cohort study with a quantitative approach. Data from patients registered in the Swedish Perioperative Registry were used. We used the Strenghtening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines for cross-sectional studies. METHODS: Data were collected from patients (N = 439) undergoing knee arthroplasties. The analysis was performed with descriptive and analytic statistics. FINDINGS: The findings indicate that women experienced significantly higher levels of pain than men and suffered significantly more often from PONV. However, the relationship of postoperative pain and PONV was not significant. There was also no significance for the relationship among postoperative pain, PONV, and age. CONCLUSIONS: Care needs to be sensitive to differences in experiencing pain and PONV depending on sex or gender bias, with a goal of increasing the equality in care.

The Impact of Preoperative Patient Anxiety on Postoperative Anxiety and Quality of Recovery After Orthopaedic Surgery.

PURPOSE: To study how preoperative anxiety affects postoperative recovery in orthopaedic surgery based on two specific issues: does preoperative anxiety affect postoperative anxiety, pain, and nausea in the postanesthesia care unit (PACU) and does preoperative anxiety affect the quality of recovery. DESIGN: This was a nonexperimental quantitative observational study. METHODS: Patients (N = 37) were included through consecutive selection. Anxiety, pain, and nausea were measured preoperatively, 30 minutes after arrival at PACU and before discharge from PACU. Three days after discharge, participants completed the Quality of Recovery Questionnaire by telephone. FINDINGS: There was a significant correlation between preoperative anxiety and anxiety in PACU as well as anxiety, sadness, and depression 3 days after discharge from PACU. CONCLUSIONS: Patients who experience preoperative anxiety also experience anxiety in PACU. The quality of recovery 3 days after surgery is also affected by preoperative anxiety. Patients experience continued anxiety as well as sadness and depression.

Patient Satisfaction With Telephone Nursing: A Call for Calm, Clarity, and Competence.

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 referred 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.

Factors Influencing Early Postoperative Recovery After Laparoscopic Cholecystectomy.

PURPOSE: To study the factors influencing early postoperative recovery after laparoscopic cholecystectomy. DESIGN: A nonexperimental retrospective study. METHODS: The study was performed using records from all patients who had undergone laparoscopic cholecystectomy at a hospital in Northern Sweden in 2017 (219 patients in total). Nonparametric data were analyzed using Spearman's rho, Mann-Whitney U test, and logistic regression. Parametric data were analyzed using Pearson's correlation, an independent t test, and analysis of variance. FINDINGS: The length of stay in the postanesthesia care unit was not predicted by factors such as age, gender, body mass index, American Society of Anesthesiologists classification, postoperative nausea and vomiting, premedication, or type of surgery. Younger age and high classification level were significant predictors of pain during rest and pain when in motion. No significant predictors of postoperative nausea were found. The majority of study participants experienced little or no pain or nausea. The documentation of pain, nausea, and premedication was inadequate in many cases. CONCLUSIONS: Nurses in postanesthesia care units should work to preventively identify and address patients' medical and emotional needs so that optimal conditions for postoperative recovery can be provided.

Key Factors for Successful General Anesthesia of Obese Adult Patients.

PURPOSE: To study nurse anesthetists' experiences of key factors for successful airway management in general anesthesia of adult obese patients. DESIGN: The study was a qualitative observational study with a descriptive approach. METHODS: Eight semistructured interviews were conducted. Data were analyzed using the critical incident technique. FINDINGS: Five key factors for successful general anesthesia of adult obese patients were identified. These factors were preparing and planning the anesthesia, optimizing patient position, optimizing ventilation through proper preoxygenation and increasing positive end-expiratory pressure, quickly securing the airway, and working in teams. CONCLUSIONS: Knowledge of key factors that facilitate and improve the anesthesia care of obese patients is important to provide safe and quality anesthesia to this patient group as obese patients often have small margins and urgent situations can quickly arise. This knowledge enables the nurse anesthetist to be one step ahead and to be ready to take action if complications occur.

Difficult Airways: Key Factors for Successful Management.

PURPOSE: To describe anesthetic nurses' experiences of key factors for the successful management of difficult airways in adult patients. DESIGN: This study had a qualitative observational and descriptive design following the critical incident technique. METHODS: Twelve experienced anesthetic nurses were interviewed. FINDINGS: We identified five key factors for the successful management of difficult airways: identification of the difficult airway, creating a plan of action, remaining calm and focusing on the task, technical skills, and using the equipment. Identification of the difficult airway implies preassessment with standardized methods and actively observing for signs indicative of a difficult airway. Having all equipment available at bedside during induction and creating a backup plan increases the action force in unexpected situations. A calm and methodical work procedure facilitates the management of the difficult airway as well as selecting techniques and equipment according to the patient and situation. CONCLUSIONS: Reflective practice can aid the anesthetic nurse in drawing on experience and remaining calm in acute situations.

Modeling the effects of telephone nursing on healthcare utilization.

BACKGROUND: Telephone nursing is the first line of contact for many care-seekers and aims at optimizing the performance of the healthcare system by supporting and guiding patients to the correct level of care and reduce the amount of unscheduled visits. Good statistical models that describe the effects of telephone nursing are important in order to study its impact on healthcare resources and evaluate changes in telephone nursing procedures. OBJECTIVE: To develop a valid model that captures the complex relationships between the nurse's recommendations, the patients' intended actions and the patients' health seeking behavior. Using the model to estimate the effects of telephone nursing on patient behavior, healthcare utilization, and infer potential cost savings. METHODS: Bayesian ordinal regression modeling of data from randomly selected patients that received telephone nursing. Inference is based on Markov Chain Monte Carlo (MCMC) methods, model selection using the Watanabe-Akaike Information Criteria (WAIC), and model validation using posterior predictive checks on standard discrepancy measures. RESULTS AND CONCLUSIONS: We present a robust Bayesian ordinal regression model that predicts three-quarters of the patients' healthcare utilization after telephone nursing and we found no evidence of model deficiencies. A patient's compliance to the nurse's recommendation varies and depends on the recommended level of care, its agreement with and level of the patient's prior intention, and the availability of different care options at the time. The model reveals a risk reducing behavior among patients and the effect of the telephone nursing recommendation is 7 times higher than the effect of the patient's intended action prior to consultation if the recommendation is the highest level of care. But the effect of the nurse's recommendation is lower, or even non-existing, if the recommendation is self-care. Telephone nursing was found to have a constricting effect on healthcare utilization, however, the compliance to nurse's recommendation is closely tied to perceptions of risk, emphasizing the importance to address caller's needs of reassurance.