Impact of telephone nursing education program for equity in healthcare

The concept of ‘gender’ came into practise in the 1970s, in order to being able to analyse differences between men and women that were not related to the biological sex [24, 25]. In the 1980s, West and Zimmerman [26] introduced the concept “doing gender” and since then researchers within this field mostly refer to gender as something that is constantly constructed in interaction between human beings. Early gender research focused on the construction of femininity, with the aim of understanding and changing women’s subordination in patriarchal societies. Since the 1990s, theories of masculinity have also been developed, for example by Connell [27, 28], who argued that masculinity and femininity are contextually and relationally constructed, so that in the same context, several forms of masculinity (and femininity) can be found, hierarchically ordered in relation to each other. The most valued form of masculinity in a Western context was defined by Connell as ‘hegemonic masculinity’ [27, 29], characterised by being constructed as superior to femininity. Hegemonic masculinity is normative rather than normal; even though few people might live up to these idealized images, men are required to position themselves in relation to them. In analogy with Connell, Schippers [30] identified a “hegemonic femininity”, i.e., the most valued form of femininity in a Western context, which guarantees the dominant position of men and the subordination of women. Further, Lyons [31] has argued that hegemonic femininity is marked by being caring and acting responsibly towards other people.

“Doing health” has shown to be an important aspect of “doing gender” [32]; for example, hegemonic masculinity can be reinforced by men being reluctant to seek healthcare [33‐36]. In Western countries, men are likely to die at younger age and suffer more frequently from heart attacks and mortality from cancer than women [37]. Furthermore, men have unhealthier behaviours than women, for instance, through a higher extent of excessive drinking, unsafe sex and taking less health preventive actions [34]. This is also related to a failure or delay in men’s care- seeking when ill. Ideal femininity is upheld by the opposite health behaviour; that is, taking care of one’s own and other family members’ health and seeking healthcare in time [31].

Macintyre and Hunt [38] have pointed out that gender, along with socio-economic factors, as well as ethnicity, age and sexuality, are important markers of how groups and individuals are positioned in a society. This implies that gender is a dimension of social life that interacts – or intersects – with other factors, such as ethnicity, race, age, sexual orientation or identity and social class. This has also been pointed out by Connell [27]. Also within healthcare research, the concept of ‘intersectionality’ has been frequently used and acknowledged [39‐42]. Wamala et al. [43] found that perceived discrimination due to more than one social category increased the risk of refraining from seeking healthcare, despite an experienced need.

Telephone nurses from two different sites in Sweden were asked to participate in the study. The sites were strategically chosen, since they were similar in size and in number of employed (30–40) nurses. One site functioned as intervention group and the other as control group, which implies that samples in the same group were from the same working place and that the participants were not blinded to the intervention.

Permission to perform the study was given by the respective head of the sites. All telephone nurses working on the sites were asked to participate and they were included after individual informed consent. All in all, 72 nurses participated in the baseline measurement (32 in the intervention group and 40 in the control group). In the intervention seminar 19 nurses participated. In the follow-up evaluation 60 nurses participated (25 in the intervention group and 35 in the control group). All 25 nurses in the intervention group who answered the follow-up questionnaire were analyzed together, although only 19 of them participated in the seminar that was part of the intervention. This is due to the fact that they had all received information about the literature and had access to the web-based lecture, also those who did not take part in the seminar because of various reasons (illness, work load etc.).

The questionnaire was developed by the research group and is described elsewhere [44, 45]. It measures three aspects of power orders or intersects, namely, gender, age and ethnicity. It included descriptions of twelve fictive persons, of different age and born in Sweden or outside Europe, and of male or female gender. The following fictive persons were included:

The items concerned assessment of the likelihood of whether the fictive person had called SHD, whether or not s/he was recommended a doctor’s appointment when calling, whether s/he had a high quality of life, power of own life and had experienced discrimination. Each participant was asked to assess two of the fictive persons, randomly selected. This gave 66 different combinations ((12x11)/2). The participants were also asked to give comments to their assessments, using free text.

The base-line questionnaire was distributed to the intervention group and the control group on workplace meetings in fall 2014. The follow-up questionnaire was distributed to both groups on workplace meetings in May and June 2015, i.e., approximately six months after the intervention.

The intervention used can be described as complex, in that it consisted of several interacting components [46]. Complex interventions are characterized by the difficulty of behavior that is required by those delivering and receiving it, as well as by the number of groups and outcomes and the degree of flexibility the intervention permits. Key questions concern whether the intervention is effective in everyday practice, what the active ingredients are and how they are exerting their effect [46]. The interacting components used in the present study intervention were 1) web-based lecture; 2) literature reading; and 3) seminar. Hence, it consisted of reading, listening and reflecting alone and in group settings.

The web-based lecture covered aspects that have been described under “Theoretical framework” above. Based on statistics of inequality in healthcare, Connell’s theory of hegemonic masculinity [27‐29] and the concept of “doing gender” [26] in relation to “doing health” [32] were introduced. The literature consisted of three chapters from a Swedish anthology on “gender vertigo” [47] and critical norm theory, edited by the Swedish Association of Health Professionals [48]. The chapters addressed the function of socially constructed norms in society, e.g., gender norms; theories on constructions of masculinity, and research on racism as a result of discriminatory norms.

Flexibility in how the intervention was performed was permitted and the design and performance were based on theory [46]; in this case gender and intersectionality theories. Further, the educational intervention was designed according to principles for adult learning [49]. Knowles [50] first identified the characteristics of adult learning, stressing that it should acknowledge the participants’ autonomy, experience and knowledge. The teaching should be goal oriented, relevant, and practical and the participants be treated with respect in a cooperative learning climate. Further, our intervention also acknowledged principles of the adults’ willingness to learn, that they learn by doing and from practical and realistic problems (http://​www.​literacy.​ca/​).

Information of the educational intervention was given both orally and in written to the participants in the intervention group on a workplace meeting in fall 2014. It encouraged them to watch the web-based lecture on inequalities in healthcare and read three chapters in the literature on gender and intersectionality in health.

The seminar was led by two of the authors (ATH and EK) and lasted for about three hours. It was performed twice in fall 2014, covering half the intervention group at a time, in order to fit the work schedule for the telephone nursing site. In the seminar, participants were first allowed to reflect on the web-based lecture and the recommended literature, followed by group discussions on these matters. Thereafter, authentic case examples were discussed in smaller groups. At the end of the session, the participants were asked to fill out a short evaluation form of the educational intervention, covering questions on how participants viewed the literature, the lecture and the seminar.

Data from the questionnaires were analyzed through descriptive and comparative statistics, using SPSS version 22. The mean (M) was calculated for each assessed person for each item. The assessments were ranked from lowest likelihood to highest likelihood; thus 12 ranked positions were possible. A Good life-index was also calculated. This combined the questions: quality of life, power of own life and experience of discrimination. The assessment for the item “Experience of discrimination” was reversed when the index was calculated. The reliability/homogeneity of the Good life-index was calculated with Cronbach’s alpha-coefficient [51, 52].

Approval for the study was sought at the Regional Ethics Review Board (Dnr 2014/130). The Board found, however, that according to Swedish legislation no formal approval of the project was needed. Throughout the project, the ethics of scientific work as outlined in the Declaration of Helsinki [53] were followed. Permission to perform the study was given by the respective head of the sites. The study concerned the encounter between telephone nurse and caller, with focus on power interactions related to factors such as gender, age and ethnicity; hence, the issue could be regarded as sensitive. In order to handle these ethical challenges, much effort was put on information and the consent process. The nurses were informed both orally and in writing about the study and were included after informed consent. Information emphasized that participation was voluntary and possible to withdraw at any time. Likewise, it was stressed that data would be handled confidentially and that no workplace would be identifiable in the reporting of results.

Every participant assessed two fictive persons before the intervention and two after the intervention. The same pairs of fictive persons were assessed in the intervention and the control group. In Table 12 the number of assessments is presented. The same assessment in both measurements indicated that the respondents assessed that the two fictive persons had been treated equally. Different assessments in the two measurements indicated non equal treatment. The answers in the two groups were almost the same, but with a slight tendency to fewer equal assessments for the questions about calling SHD and probable experience of discrimination.