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Ethical issues in telenursing
During the last decade, the number of call centers for telemedicine has rapidly increased in Sweden.
Telenursing in healthcare brings advantages for both patients and personnel: for example, the improvement of resource- and time allocation and access for patients. However, this technique might also entail ethical difficulties. In this article a range of ethical aspects that are particularly challenging in telenursing are discussed.
Telephone nursing in Sweden
During the last decade, the number of call centres in Sweden has rapidly increased, as well as the number of calls per centre. In 2003, centralisation of telenursing in Sweden started with implementation of a national telephone helpline as a 24-hour nurse-led telephone advice service with one phone number for the entire country. This system has strong similarities with NHS Direct in the United Kingdom and Health Direct in Western Australia. The nurses working at the Swedish call centres sit at computer terminals, wearing headsets, and take calls from the general public. Most calls concern infections such as colds, influenza or diarrhoea, and over 50% of the calls are made on behalf of the ill person, mostly by parents or spouse [5].
Ethics in nursingEthical dilemmas in telenursing
Studies have reported different kinds of ethical dilemmas that nurses encounter in their daily practice [7]. Likewise, increasing ethical dilemmas have been shown to create stress reactions among healthcare personnel. Moral distress can be defined as negative stress symptoms that occur due to a situation where the healthcare provider has identified an ethical dilemma and assumes s/he knows the right thing to do, but institutional constraints hinders him/her from pursuing the desired course of action [8]. Such moral distress has been particularly studied among nurses.
Although telenursing brings great advantages for both patients and personnel in the form of, for example, resource and time allocation and improved patient access, it might also entail ethical difficulties. Kaplan & Litewka [9] have identified privacy, security, confidentiality and autonomy as ethically troubling areas in telemedicine in general, of which telenursing is one branch. We argue, based on an empirical study consisting of interviews with twelve Swedish telenurses [10], that autonomy, integrity, prioritising, information and documentation are ethical aspects that can be particularly challenging in telenursing. In the following section we will discuss each of these aspects in the light of ethical theory.
Autonomy versus beneficenceIntegrity and documentationPriority setting and the healthcare organisationResponsibility and informationEthical competence building in telenursingConclusions
The identified ethical dilemmas in telenursing also occur in other forms of nursing. However, telenursing might be particularly sensitive to ethics. For example, respect for autonomy and obtaining informed consent might be difficult when a woman calls in for her spouse, respect for integrity might be difficult in both the information and the documentation process, and the balancing of giving the patient honest information with the ethical demand to avoid harm, are all examples of ethical dilemmas that telenurses handle in their daily work. Hence, ethical competence building and ethical discussions on a regularly basis are needed for telenurses.