Report_Valeria Pannunzio_4455203

Effortless interactions
for Emergency Care
designing the LiveSync

Effortless INTERACTIONS
FOR EMERGENCY CARE
Valeria Pannunzio
September 2016
Company: Philips International B.V.
Company mentor: Michael Heesemans
Mentor: Quiel Beekman
Chair: Natalia Romero Herrera
Master Thesis
Design for Interaction
Specialization Medisign
Valeria Pannunzio
Faculty of Industrial Design Engineering
Delft University of Technology

“The practice of medicine is dominated by how we process information, how we record information,
how we retrieve information, and how we communicate information.”
Barnett, Computers in Medicine.
“During the Industrial Age, we used machines to improve our lives by extending the capacity of our muscles.
During the Information Age, we are improving our lives by extending the capabilities of our minds.”
McDonald, Health in the age of tele-cognition.

Thanks
To Natalia, Quiel and Michael for the careful, constant, and thoughtful supervision.
To Gavin, Jeroen, Jacco, Kiran, Christian, Igor, Joe, and the rest of the Philips Design
staff for the trust, the precious advices and the great atmosphere in the office.
To Anne-Marie, Wilma, Rob, and Rocklyn, for believing in the project and for being
so selflessly open: your help constituted the flesh and bones of this thesis.
To Nathan, Rosanne, Andreas, Hayagreev, Tanvi, for the acting, the Dutch, the
clothing and the business training.
To Bharuch, for my very psychophysical balance throughout graduation.
To all of the inhabitants of Heistraat 5, for introducing me into Eindhoven’s life and
for the late night talks.
To Anna, Giulia, Giuggiola, Masiello and Morera, for what Giuggiola said better than
me already.
To my family, for all of the rest.

Abstract
This thesis presents a research and
subsequent design intervention
developed in the context of a Design for
Interaction graduation assignment called
Effortless interactions in Emergency Care.
The design process was characterized by a
strong focus on analysis, and in particular
on user research, which included intense
inquiry activities such as direct observation
of ambulance shifts.
After an iterative conceptualization
phase, a final product idea was detailed
and its interaction tested with real users.
The thesis is concluded with a set of and
conclusion and recommendations.

Glossary
AAAS
Anglo-American System: one of the two
main models of Emergency Medical
Systems together with FGS, or Franco-
German System.
AED
Automated external defibrillator: portable
device that diagnoses life-threatening
cardiac arrhythmias and is able to treat
them through defibrillation.
ALS
Advanced Life Support: set of life-saving
protocols and skills that extend Basic Life
Support (BSL).
BBSL
Basic Life Support: level of medical
care which used for victims of medical
emergency until they can be given more
advanced care.
CCCS
Critical Care Transport: the set of systems
and protocols deputed to the transport
of critically ill patients from one medical
facility to another ensuring comfort and
safety.
COPD
Chronic obstructive pulmonary disease:
group of long term diseases (including
emphysema and chronic bronchitis)
involving a progressive reduction of patients
lung capacity.
DDistributed cognition
An approach to cognitive science research
which takes in consideration the totality
of individuals and artifacts involved in a
particular work practice using the same
methods usually applied to single subjects.
EED
Emergency Department: the department
of a hospital responsible for the provision
of medical and surgical care to patients
arriving at the hospital in need of immediate
care.
ER
Emergency Room: see ED
EMS
Emergency Medical Systems: the set of
systems that provides emergency medical
care.
ePCR
electronic Patient Care Report, software
solutions that allow ambulance
professionals to collect patient information
and care details electronically.
FFGS
Franco-German System: one of the two
possible models of Emergency Medical
Systems together with AAS, or
Anglo-American System.
Flow
The term flow indicates, in positive
psychology, the mental state in which an
individual performing an activity is fully
immersed in a sense focus, involvement,
and enjoyment in the accomplishment of
the task.
TTriage
The process of assessing the priority of a
patient treatments based on the severity
of his or her condition, for instance to
determine the order and priority of patients
approaching the emergency department.
Glossary and initials

Contents
Contents
Acknowledgments 5
Glossary 7
Contents 9
Introduction 11
PRELIMINARY RESEARCH 12
Emergency medical services 14
EMS in the world 18
EMS in the Netherlands 20
Communication in EMS 24
Teamwork in EMS 26
Trends and directions 28
Seamless interactions 30
Preliminary observations 32
USER RESEARCH 36
Research set-up 38
Research methodology 40
Research results 46
CONCEPTUALIZATION 62
Ideation process 64
Measures of quality 66
Problem definition 68
Scope 70
Creative session 72
Preliminary directions 74
Validation with users 76
Direction choosing 78
Future vision 80
EMBODIMENT 84
Features selection 86
Concept description 88
Device interface 90
Application interface 92
Sound design 94
Cycles of use 96
Embodiment focus 97
VALIDATION 99
Desirability validation 100
Feasibility validation 110
Viability validation 112
Conclusions and recommendations 116
REFLECTIONS 118
Reflections on research 120
Reflections on conceptualization 124
Reflections on validation 125
Reflections on overall process 126
REFERENCES & APPENDICES 128
References 130
Appendix I 132
Appendix II 133
Appendix III 138
Appendix IV 140
Appendix V 154
Appendix VI 156
Appendix VII 158
Appendix VIII 160
Appendix IX 162
Appendix X 164
Appendix XI 166
Appendix XII 168
Appendix XIII 172
Appendix XIV 174
Appendix XV 182

Introduction
Assignment brief
Whenever a medical emergency is
reported to the 112 in Europe, a set of
protocols will be triggered.
In case the 112 call center operator
recognizes a medical emergency, an
ambulance will be sent to the patient.
All together, the work of the ambulance
operators represents an highly complex
and, often, very chaotic job. This job is,
moreover, performed under time and,
possibly, emotive pressure (especially in
case of patient’s life threat, or by influence
from emotional reactions of the patient
relatives or friends).
To give a rough overview, the nurses are
expected to be ready to:
• Perform a quick evaluation of the
patient conditions
• Estimate the need for treatments or
other interventions
• Provide the treatment or the
emergency intervention
• Estimate the need for a
transportation to a medical center,
communicate to the destination
Emergency Department the patient
conditions and personal details
• Keep monitoring the patient
conditions and, if necessary, keep
delivering treatment.
The last two operations, are, in particular,
mostly happening simultaneously. In
other words, the crucial moment of
communicating the hospital all of the
information they need (to start gathering
the required professionals and equipment
in time) is expected to be executed
while monitoring the patient conditions
and, often, while executing essential
treatments.
This moment’s importance might look
even more evident, considering that this
first intake information on the patient will
constitute, on the long term, a pivotal data
set for further medical decisions.
The assignment is to develop and test interaction concepts
aimed at empowering emergency care staff to cope with the
high cognitive and interactional demands of their job.
”
”An opportunity exists to facilitate, or
automatize, part of the set of interactions
required to the ambulance staff (e.g. the
collection and delivery of information
from the ambulance units to hospitals
emergency care wards).
The accomplishment of this challenge
would represent a chance to improve the
speed, reliability and quality of existing
emergency care systems, and to alleviate
the cognitive burden and general stress of
the involved emergency care staff.
Asaworldwideleaderinpatientmonitoring
and healthcare information management,
Philips acknowledges this set of problems,
and aims at exploring innovative solutions
for improving the interaction flow of
emergency care professionals.
Introduction

PRELIMINARY RESEARCH
01This first section presents the results
of the introductory phase of the
design process. The goal of this
phase was to examine and familiarize
with the context of Emergency
Medical Services, and to create a
solid theoretical framework on which
to ground the user research. Next,
a general definition on Emergency
Medical Services and the main
concepts associated with it will be
provided, followed by a description
of the Dutch Emergency Medical
Service, its peculiarities, its involved
stakeholders, and its expected future
developments. After that, a closer
look at the process of ambulance
rescuing will be given, with particular
regard to the communicational
aspect. Finally, the results of a
preliminary observation conducted
in an Emergency Department will be
presented. In conclusion, a recap of
the main insights contained of this
section will be provided.
Emergency Medical Services
EMS in the Netherlands
Ambulance nursing
Preliminary observation

14 15
Preliminary Research Emergency medical services
Figure 2 The six branches
of the Star of Life.
1. Early detection
2. Early reporting
3. Early response
4. On-scene care
5. Care in transit
FUNCTIONS
The main functions of EMS are reflected in its
internationally recognized symbol, the Star of
Life (Figure 2).
They include:
1. Detection: A medical emergency is
suspected or detected, by the patient
or by other observers. The first rescuers
on the scene, usually untrained civilians,
acknowledge the problem, assess the
safety threats to themselves and the
others, and take measures to ensure their
safety on the scene.
2. Reporting: A call for professional help is
made and dispatch is connected with the
victim or the first rescuers.
3. Response: The first rescuers provide first
aid and immediate care to the extent of
their capabilities.
4. On scene care: The EMS personnel arrives
on the patient location and provides
immediate care to the extent of their
capabilities on-scene.
5. Care in transit: The EMS personnel
transfers the patient to a medical center
via an ambulance or equipped helicopter.
During the transportation, they provide
medical care to the extent of their
capabilities on the transportation medium.
6. Transfer to definitive care: Specialized
care is provided at the hospital.
Emergency medical
services
Context introduction
definition
Emergency Medical Services, more commonly
known as EMS, are defined as ‘systems that
provide emergency medical care’ (NHTSA, 2015)
This system includes services of coordinated
response and emergency medical care, and
involves multiple professional profiles, both from
private and public institutions.
EMS itself does not exist in isolation, but is
integrated within external services and systems
intended to maintain and enhance population’s
health and safety.
As shown in Figure 1, the EMS operates at
the intersection between health care, public
health and public safety. A combination of the
principles and resources of each is employed in
EMS systems.
Public
Health
Health
Care
Public
Safety
Figure 1 EMS domain
background (adapted from
NHTSA, 2015).
EMS

16 17
Emergency medical services
Basic Life Support (BLS)
WHO HOwWHAT NOTWHat
• Trained medical
personnel
• Citizen volunteers
• Often: Firefighters
and police
• ABC (Airways,
Breathing,
Circulation) control
and support
• CPR
(cardiopulmonary
resuscitation)
• Artificial respiration
• Bleeding Control
• Use of AED
(Automated External
Defibrillator)
• Drugs
administrations
• Invasive procedures
• Support the basic
functions of life-
threatened patients
until they can be
given full medical
care
Advanced Life Support (ALS)
• Physicians
• Nurses
• Often: Medical
Technicians
• All of the BLS
protocols
• Tracheal intubation
• Rapid sequence
intubation
• Cardiac monitoring
• Cardiac defibrillation
• Transcutaneous
pacing
• Intravenous
cannulation
• IIntraosseous
infusion
• Surgical
cricothyrotomy
• Needle
cricothyrotomy
• Medication
administration
• Cardiac Life Support
• Diagnosis
• Surgery
• Use of ICU
equipment
• Support the basic
functions of life-
threatened patients
including invasive
procedures
and specialized
equipment
Critical care transport (CCT)
• Trained Nurses
• Often: Respiratory
Therapist (RT).
• All of the ALS
protocols
• Use of ICU
equipment (e.g.
Automatic Transport
Ventilators (ATV) for
ventilator dependent
patients).
• Diagnosis
• Surgery
• Transport critically
ill patients from one
medical facility to
another ensuring
comfort and safety.
Figure 4 Summary of
the three main levels of
Emergency Care
c
y
Medical Emergency recognition
Access to special number
Dispatch
First responder
Basic Life Support
Advanced Life Support
Air or ground transportationEmergency Department
Specialty Care
Patient rehabilitation
Prevention awareness
Public education
Communication Systems
Medical Direction
Integration of Health Services
Informational Systems
EMS Research
Legislation and regulation
Finances System
Human Resources
Figure 3 Protocols and
sub-systems connected to
EMS (adapted from NHTSA,
2015).
Protocols
Even though EMSs organizational structures
can vary significantly from country to country,
common practices can be recognized above the
differences. The scheme in Figure 3 provides
only an outline of the complexity of the chain of
actions pertaining EMSs.
The outer circle represents the chain of protocols
activated one after the other in response to a
medical emergency. In the center of the circle,
are the sub-systems working ‘behind the scene’
to support the outer circle’s elements. The red
section represent the phases more closely
pertaining emergency medical services.
Levels of care
Emergency Medical Services worldwide are
provided using large spectrum a of methods.
As a generalization, they can be categorized into
three main levels of service: Basic Life Support
(BLS), Advanced Life Support (ALS), Critical Care
Transport (CCS).
A summary of the features of each care level is
provided in Figure 4.
Preliminary Research

18 19
Emergency medical services
Anglo-american system Franco-german system
scoop and run stay and stabilize
Clinical governance: In most FGSs, pre-hospital
specialists are only authorized to provide care
in presence of a physician. In many parts of the
world (e.g. France, Belgium, Luxembourg, Italy,
Spain, Brazil), they can rely on a permanent
Online Medical Supervision.
Conversely, in AAS, pre-hospital staff is given
authority to provide care and to make clinical
decisions. This authority is built on the basis of
offline protocols and, only if needed, by voice
consultations with online physicians. Both the
protocols and the permissions given to the
pre-hospital staff is provided by one or more
physicians charged to establish the emergency
medical directive for a specific region.
From this point on, the Anglo-American model
will be addressed as the project target context,
mainly in consideration of large application
potential on the global scale (as shown in
Figure 5). Furthermore, as the research at the
basis of this project will be conducted in close
collaboration with hospitals in the Netherlands,
the Dutch model will be analyzed and used as a
reference framework.
Nevertheless, the peculiarities of the different
models will be kept in consideration during later
project stages, and the possible validity of the
generated solution in Franco-German systems
will be discussed.
EMS in the world
Context introduction
Models of care
Many possible differences could be recognized
in the provision of EMS care on a global scale.
The most fundamental one is perhaps the
division into physician-centered systems
and systems revolving around pre-hospital
specialists (typically emergency medical
technicians or paramedics). Usually, these two
models are identified after their culture of origin:
the Franco-German System (FGS) or the Anglo-
American System (AAS). As explained in clearer
terms, ”The key differences between the AAS
and the FGS are that in the AAS, the patients
is brought to the doctor, while in the FGS, the
doctor is brought to the patient.” (Dick WF, 2003)
Overall, it can be stated that if AAS system
guarantee overall service efficiency, FGS take
greater care of the systems effectiveness.
Operational consequences of these two different
approaches can be identified at the levels of:
Involved professional figures: in FGS, doctors
respond directly to all medical emergencies
requiring more than first aid. In AAS, doctors are
very rarely involved in pre-hospital interventions,
and ambulances are usually equipped with
trained nurses, paramedics and emergency
medical technicians.
Ambulance equipment: in FGS, ambulances are
typically more extensively equipped, and high-
speed transport tends to be avoided. In AAS,
their equipment is reduced and the patient is
usually transported sooner to a Medical Center.
F
Franco-german
undeveloped or unknown
combination of two systems
Anglo-american
shifting towards anglo-american
Figure 5 Emergency
Medical Systems models
around the world

20 21
PATIENT
AMBULA
N
CE
CONTROLROOM(MKA)
PRIV
ATECARRIERS
Withstanders
REGIONA
LAM
BULANCESERVICE(RAV)
Dutch Ambulance
Institute (NAI)
Health Insurance
Companies
Ambulance service
licence provider
Ministry of Health
(VWS)
Sector organization
Ambulance Netherlands
(AZN)
Foundation Training
Ambulance
Assistance (SOSA)
N
ATIONALAUTHORITIES
European Committe
for Standards
Dispatch
Center Operator
Philips
AM
BULANCE
S
UPRANATIONALAUTHORITIES
EMERGENCY WARD
Emergency
physicians
Emergency
nurse
Physicians
assistants
Specialty
doctors
Medical
directors
Pharmacy
staff
Technicians
Medicine
students
Nursing
staff
Therapists
Clerical staff
IT staff
Janitorial
staff
Equipment
supplier
Triage
nurse
Medical
Manager
Equipment
supplier
Medical devices
manufacturer
Hospice
Mental
healthcare
Nursing
home
GP’s
Firefighters
Police
Home
care
HOSPITAL
Office staff
Dispatch
nurse
Driver
Nurse
Figure 6 Stakeholders
map in Dutch Emergency
Medical Systems.
Source: Kommer GJ. (2010);
Over Ambulancezorg Nederland
(2016).
Stakeholders/institutions
Contexts
Direct connections
Mapping the stakeholders
The Dutch model
The Netherlands are one of the few non-British
countries in Europe following an AAS model.
As shown in Figure 6, Ambulance Services
are provided by private carriers, coordinated
by an ambulance control room (Meldkamer
Ambulancezorg or MKA) and operating under
contract of the regional ambulance services
(Regionale Ambulancevoorzieningen or RAV’s).
The quality standards of these services are
regulated both by National and European
authorities. The ambulance control rooms,
accessible by the special number 112, are staffed
with operators with a nursing background trained
to give instructions to the caller (the patient itself
or others bystanders). The ambulance control
room can also rely on a direct connection with
colleagues from the Police and the Fire Services.
In addition, the ambulance carriers cooperate
with a chain of healthcare providers such as
general practitioners, domestic care services,
mental healthcare services, nursing homes, and
hospitals.
Within hospitals, Emergency Departments are
deputed to manage the arrival of critically ill
patients. A dispatch nurse answering to calls
from the ambulances ensures everything is
prepared for the patients arrival. The first figure
the patient encounters is usually the triage nurse,
assessing the patient conditions before the visit
of an emergency physician. The Emergency
Department is also attended by several types
of medical technicians and nurses with different
backgrounds. The Emergency Department is also
part of the bigger hospital ecosystem, involving a
broad spectrum of professional figures.
Stakeholders influence
The Dutch Ministry of Health (VWS) determines
the available sector’s macro budget, currently
525 million euros (Over Ambulancezorg
Nederland, 2016). Ambulance care is financed
from health insurance premiums, whose policies
are regulated by the Dutch Healthcare Authority
(Nederlandse Zorgautoriteit or NZa).
Health insurers, together with the board of GHOR
(Geneeskundige Hulpverleningsorganisatie in de
Regio), advise the Ministry of Health in granting
ambulance services licenses. Furthermore,
insurers must negotiate the cost of the service
with the ambulance services.
In turn, private ambulance carriers will stipulate
contracts with medical devices manufacturers
for equipping their ambulances: this relation
can be mediated by one or more intermediate
suppliers. The control room, conversely, is of
public responsibility, and is financed by the
region of competence board.
Conclusions
The Emergency Care sector represents a
stratified and highly regulated market. Decisions
in this field are a summation of the interests of
multiple parties, both private and public.
Specific overall market requirements are:
• Cost effectiveness and reliability, as
investments are taken on the basis of
a limited budget and performances are
monitored.
• Compatibility with technologies used in
connected systems, as services work in
coordination.
• Compliance to National and European
regulations.
EMS in the Netherlands

22 23
Ambulance rescuing
Process features
Out of the outlined journey, some
considerations can be taken regarding
characteristics and peculiarities of the
overall process.
One initial observation is that all of the
complex sets of protocols, taking place
before the patient stabilization, happen in
a situation of time pressure. More in depth,
it is to be noticed how each and every stage
is chained, and every time delay in one step
has a cascade effect on the whole process.
To this end, the transitions between one
stage and the other (steps 2,4,5,6,8) appear
as sensitive moments whose fluidity is
crucial to ensure optimal process speed.
All of these transitions rely on a common
operational framework shared between the
workers.
This operational framework is, in traditional
EMS literature (Artman et al, 1999), often
articulated on the three perspectives of:
• Mutual awareness (every operator is
aware of the role and competences of
the other)
• Joint situation assessment
(the degree of severity of the
medical emergency is assessed
in collaboration between several
operators)
• Co-ordinated use of technology
(operators can rely on a common
technical infrastructure).
Failures under any of these perspectives are
recognized to result in increased delays, or
even incidents, in every dynamic complex
system relying on the efforts of multiple
individuals.
A final important consideration regarding
the journey is that most of the interactions
happening between the operators are
constituted by exchanges of information
(steps 1,2,4,5,6,7,9). Information, in fact,
appears to be the fuel activating and
powering every step of the whole medical
emergency management process.
To this end, is it beneficial to denote how
effective and precise communication plays
a delicate but pivotal role in ensuring
patient’s safety throughout the rescue
process. According to Shelton and Sinclair
(Shelton et al, 2016), communication
failures still constitute the main cause for
adverse events in healthcare.
To provide a more complete overviewon the
topic, the next chapter has been reserved
to the description of how information is
generated and propagated within EMSs.
H
OSPITA
L
PRE-ARRIVAL ARRIVAL ON SITE PATIENT TRANSPORT ARRIVAL AT E.D. FIRST AID AT E.D. OUT OF E.D.
PATIENT
DISPATCH
CENTER
OPERATOR
AMBULANCE
NURSE
AMBULANCE
DRIVER
A
M
BULANC
E
E.D.
CO
NTROLRO
OM
DISPATCH
NURSE
TRIAGE
NURSE
OTHER E.D.
STAFF
(nurses,
physicians,
technicians)
HOSPITAL
STAFF
1
2 3
4
5
6
7
8 9 10
A medical emergency is reported to
the special number. The operator
gives first instructions.
1
2
3
4
5
6
7
8
9
10
If necessary, the operator calls
an ambulance providing it with
emergency details and location.
The ambulance crew assesses
the case, provides first aid and, if
necessary, boards the patient.
The ambulance crew informs the
dispatch nurse on the arrival and gives
an overview on the patient conditions.
The dispatch nurse requests other ED
staff members to prepare equipment
or teams for the patient arrival.
The ambulance nurse hands the
patient to the triage, providing a vocal
update about the patient conditions.
The triage nurse labels the patient
with a priority code.
The patient’s acute situation is
treated and, if needed, the patient is
moved to another department.
The ambulance nurse fills a report
with the details of the case and hands
it in to his own center.
The patient is given full medical
assistance and is eventually
dismissed.
Not just driving patients
Ambulance rescuing
Process baseline
Every medical emergency is unique, and requires
different approaches and competences.
However, to ensure consistency and quality
of care, standard protocols regulate the way
medical professionals collaborate with each
other.
To give an overview on these praxes, a general
patient journey for a complete emergency
intervention, from special number call to patient
dismissal, is here described in ten steps.
The involved professionals are listed on the
left column, and their moments of activity in
the journey are highlighted in red. Vertical lines
indicate moments in which the stakeholders
interact or collaborate with each other.
H
OSPITA
L
PRE-ARRIVAL ARRIVAL ON SITE PATIENT TRANSPORT ARRIVAL AT E.D. FIRST AID AT E.D. OUT OF E.D.
PATIENT
DISPATCH
CENTER
OPERATOR
AMBULANCE
NURSE
AMBULANCE
DRIVER
A
M
BULANC
E
E.D.
CO
NTROLRO
OM
DISPATCH
NURSE
TRIAGE
NURSE
OTHER E.D.
STAFF
(nurses,
physicians,
technicians)
HOSPITAL
STAFF
1
2 3
4
5
6
7
8 9 10
Figure 7 Stakeholders activity
throughout the emergency
intervention.

24 25
Ambulance rescuing
1
2
3
4
The story
”no reason to
doubt”
A customer was in a restaurant
when he suddenly started to
show breathing difficulties
The ambulance nurse supposed
he could have been suffering from
a heart attack
The physician who visited him
said he had seen ‘no reason to
doubt’ the patient was having an
heart problem and treated him
accordingly, with no success
A later dissection of the patient’s
body found a piece of steak in
his throat, suggesting choke as a
cause of death.
Reported in Hughes, 1980
Process effectiveness
The described multi-step passage of
information, as a communicational method in
EMS, presents undoubted advantages. In fact,
filtering information by relevance is a priority
in Emergency Management, in which time
constrains are extreme and fast decision has a
life-saving value.
Still, as in every decisional process based on the
judgment and experience of individuals, risks
correlated to human error are a possibility, and
their possible impact has to be carefully taken
into consideration.
To provide an overview on this impact, the
main threats associated to the presented
communicational chain are hereby listed in order
of increasing estimated hazard.
• Information freezing
The initial emergency categorization
made by the call center operator is
often maintained as a basis for the
case evaluation throughout the whole
chain, even when not appropriate.
Also, the information collected by the
ambulance crew during their presence
on the scene is all of the data that will
ever be collected about the emergency
scenario, as no later inspection or hearing
of testimonies is performed. In the moment
the crew leaves the scene, the information
regarding the scene is said to be ‘frozen’
(Hughes, 1980). Finally, the communication
from the ambulance to the hospital during
transportation is not designed for ongoing
updates, even though the severity of a
patient could not be a stable factor at all.
• Information loss
Information regarded as irrelevant by one
actor, and therefore left out of the chain,
could potentially constitute a point of
interest for the diagnosing doctor.
• Misinterpretation chain
As the judgment of each operator on the
chain influences the way the information
will be communicated to the next one,
an initial misinterpretation could have a
cascade effect. In this chapter’s story, a
case is reported in which this phenomenon
brought to death of a patient.
The ambulance nurse gives
only a quick recap of all of
the case information to the
triage nurse, who mostly
assimilates what could
help in assessing the case
severity
The triage nurse assimilates
the given information and
forms her own idea of the
patient status
The emergency physician
receives only a summary
of this resulting pack of
information and proceeds
with a diagnosis
The ‘Chinese whispers’
Communication in EMS
Informational
process
In an old but still very relevant research,
inspecting communications within ambulance
journeys from a semiotic perspective, David
Hughes demonstrated the notable amount
of information leaking and degradation in
emergency care. As he affirms:
‘From the patient standpoint, there is a
sequence of contacts with persons that collect
the information necessary at their stage of the
patient passage, and then communicate only a
fraction of that information to the next person
on the chain’ (Hughes, 1980).
This extract could perhaps be better unfolded
by following the narration illustrated in Figure 8,
which describes how the information is collected
and treated in an abstract emergency case
scenario.
In this scenario, the information is likely to
evolve multiple times before reaching the
doctor who will perform a diagnosis. What the
doctor will receive is in fact the result of multiple
re-interpretations of raw data from several
professionals, each applying their experience
and ‘typified knowledge’ to the case.
Initial emergency
information are given by
the caller
The call center operator
gives this information
translated in medical terms
to the ambulance crew
The ambulance nurse
records his own impressions
and evaluations and
collects testimonies by
witnesses Out of what the witnesses
say, the ambulance nurse
assimilates mainly what
could help him in taking
decisions on the short term.
Figure 8 Data set evolution in
the first stages of emergency
care

26 27
Ambulance rescuing
Also, in distributed cognition terms, artifacts
are not only examined for the efficiency they
accomplish their main function with, but also in
relation to their role as coordination tools.
Due to its appropriateness to describe and
evaluate Emergency Medical Systems,
distributed cognition has been largely applied to
this context (Furniss, 2006). An overview of the
collaborations among stakeholders contributing
to distributed cognition in ambulance nursing,
including the main cognitive artifacts used, is
offered in Figure 9.
As it can be seen, an inefficiency in any part of
the network would constitute a direct damage to
the quality of the overall cognitive aim, defined
as:
• Reaching optimal awareness on the
emergency case, and
• Providing the most appropriate care.
While some artifacts are explicitly designed for
coordinating the distributed team (e.g. phones),
other constitute a cognitive source that needs
to be consciously assimilated and transformed
into meaning by team members (e.g. instant
measuring instruments information has to be
processed, remembered and communicated by
the ambulance nurse) before being introduced
in the cognitive network.
In this sense, shared cognition principles would
suggest that enabling an automatic availability
of these information to other team members
would be a way to improve the coordination of
the overall team. The potential value of such
an intervention will be examined further during
the user research and, possibly, considered as a
design opportunity.
Informational channels
After the information content and the dynamics
have been described, a last perspective under
which communication in EMS could be the
discussed is the informational channels.
Observing Figure 9 again, we can see how the
exchanges of data in the system happen under a
number of different forms, both verbal and non-
verbal: phone calls, face-to-face, written text,
color coding are only some of the examples.
Notably, some of these forms are volatile and
leave no trace, while others allow for long-term
storage. This diversity is considered to result
from an ongoing change in nursing common
practices evolving from paper-based to digital
systems (Wilson, S. 2009), and from overriding
practical needs, in particular speed and clarity.
Under this perspective, there is little surprise that
the two main communication channels active
in ambulance nursing are the visual and the
auditory one.
In a recent study (Zaborowski, 2015) investigating
how ambulance nurses prefer to receive
information, 86% of the interviewed selected the
auditory channel as their favorite medium, while
14% chose the visual one. On the other hand, the
same set of participants reported to experience
frequent problems connected to the usage of
the auditory channel to communicate. In fact,
72% of the overall group identified noise as a
frequent cause of disturbance in long-distance
voice communications. This might explain why,
when asked which communicational systems
were in their opinion the fastest and most
unambiguous ones, the proportions changed:
80% of the participants still chose auditory,
while 20% opted for visual.
All in all, these results seem to outline the
presenceofaneedfor faster,moreunambiguous,
and undisturbed channel than the ones currently
available. This possible problem area will be kept
in consideration for further validation with users.
CONCLUSIONS
Mapping processes connected to ambulance
rescuing brought to an acknowledgment of the
crucial importance of communication.
Therefore, the features of communication in
ambulance rescuing were analyzed under
several aspects. The main insight from these
analyses are summarized as:
• The communications between
stakeholders in EMS happen under many
forms and by mean of several channels,
but they always rely on a same codified
language.
Emergency Management as distributed cognition
Teamwork in EMS
Informational
dynamics
As we have seen, a typical EMS informational
chain encapsulates acts of conscious mental
activities, as the way individuals in the chain
think, understand, learn and remember has
certain effects on the information itself. In
cognitive ergonomics literature, a framework
often used to describe these type of systems is
the model of distributed cognition.
This model lies on the principle of analyzing
cognition as if it was not a phenomenon
‘bounded to the individual brain’ (Resnick, 1991),
but rather a team activity, in which different
elements (minds and artifacts) contribute to an
overall cognitive process.
Evaluating systems in terms of distributed
cognition or individual cognition could differ
drastically: for instance, ‘an individual optimal
performance may be suboptimal, in relation
to the overall goal shared by the whole team’
(Artman, 1998).
Figure 9 Cognitive channels in
ambulance nursing
Phone
PATIENT
Bystanders
Control Room
Operator
Emergency
physicians
E.R.
nurse
Triage
nurse
Dispatch
nurse
Driver
Nurse
Computer-based
decision system
Instant medical
measurements
Colour coded
triage system
Traffic flow, signals,
car interface
Extensive medical
measurements
Arrivals overview
monitor
Phone, transceiver,
portable radio
Voice
Stakeholders
Cognitive
artifacts
Phone Phone, transceiver,
portable radio
Phone, transceiver,
portable radio
VoiceVoice
Voice Voice

28 29
Trends and directions
DATA
ANALYTICS
TECHNOLOGICALTRENDS
SOCIO-POL
ITICALTRENDS
ECONOMICAL TRENDS
PERSONAL
HEALTH
WEARABLES
INTERNET
OF
THINGS
DIGITAL
HEALTH
SPECIALIZED
CARE
LABOR
DEMAND
BUDGET
CUTS
GROWING
COSTS
RISK
COSTS
PERFORMANCES
MONITORING
Data storing,
processing and
algorithms discover
patterns leading to
new insights and a
glance into the
future.[1]Everything can
and will be
connected in the
near future.[1]
Healthcare costs are
growing faster than the
economy. Innovations
focuses largely on costs
reduction instead
of quality
improvement.[9]
There is a
growing demand
of labor in the
healthcare
sector.[8]
A small portion of
specialized hospitals will
offer highly complex care.
Regional hospitals will
focus more on delivering
chronic and acute care.
Cooperation between the
different care institutions is
key to success.[5]
Political
restructuring in
the upcoming years
will need to cut 1.4 bn
€ by simplifying
institutions
structures.[9]
Risk costs are
moving from the
governmental
budget (macro level)
to the insurance
budget (micro
level).[8]
POLICE/
FIREMEN
Police
and firemen
are being required
to do more (e.g.
increased adoption
of AED
[6]
GP
AUTHORITY
The GP will be
given responsibility
for delivering more
care which is now
done in the
hospital.[7]
DIGITAL
SOLUTIONS
There is a
growing need of
digital solutions
in healthcare.
[1]
Long distance
consultations
and care are
becoming more
feasible.[2]
Individual
health monitoring
allows people to
act upon a
personalized
health plan.[4]
Medical
equipment
deterioration will
be tracked remotely
to prevent sudden
failures [3]
Wearables make
it possible to
measure and monitor
the user and its
environment.
[1]
1. Brookman, D. (2014). Introducing experience domains. Connecting the Dots, (1).
2. ICT trends voor zorginnovatie. (n.d.). Retrieved September 23, 2015.
3. Mwanza, B. G. and C. Mbohwa (2015). “An Assessment of the Effectiveness of Equipment Maintenance Practices in Public Hospitals.” Procedia
Manufacturing 4: 307-314.
4. Phelps, M. (2013, November 26). 10 megatrends shaping healthcare. Retrieved September 23, 2015.
5. Dantuma, E. (2015, March 15). Verbeteren door te verbinden. Retrieved September 23, 2015.
6. Blom, M. T. (2014). “Improved Survival After Out-of-Hospital Cardiac Arrest and Use of Automated External Defibrillators.” Circulation(130:00-00): 1.
7. Gevolgen miljoenennota 2016 voor zorg & welzijn . (n.d.). Retrieved September 23, 2015.
8. Trends en ontwikkelingen Gezondheidszorg. (n.d.). Retrieved September 23, 2015.
9. Rabobank cijfers en trends: Gezondheidszorg (n.d.). Retrieved September 23, 2015.
Figure 10 Upcoming trends
in Dutch Emergency Medical
Systems. Sources:
right
now
in a few
years
later
on
Looking ahead in EMS
Recognizing and understanding
trends in healthcare is a key
component of planning a successful
innovation strategy.
Several expected trends from the economical,
socio-political and technological domain have
been profiled in Figure 10 that could have a
direct impact on the near future of Emergency
Medical Systems.
Technology
Big innovations expected to stream the future
of health tech (such as digital health, data
analytics, wearable medical sensors and in
general individual health monitoring) all contain
a potential big value in the field of Emergency
Care.
Other trends, such as Internet of Things, even
though not originally generated in the medical
field, could find several possible applications
in EMS: for instance, unlocking the possibility
of monitoring remotely the operational status
of emergency medical equipment to prevent
unexpected failures.
Economy
On the economical side, several challenges will
be presented to innovators in the coming years,
due to the growing labor and equipments costs
on one side, and on public budget cuts on the
other one.
On top of this, some market key characteristic
are migrating: risks costs, for instance, are
becoming less and less a public concern and
more a responsibility of insurance companies.
Society and politics
For what concerns the Netherlands, a shifting of
responsibilities in the medical field is expected
to happen on many layers. On the institutional
level, a rearrangement of hospital systems is
going to aim at centralizing clinical specialties in
highly-focused centers.
On the professional level, roles are mutating:
general practitioners will increasingly be
assigned tasks previously carried out in hospital
environments. Also, policemen and firefighters
crews will be more and more equipped with
automated external defibrillators (AED)
and trained to intervene in certain medical
emergency situations.
On the organizational level, the increasing
digitalization of protocols and communications
will expand into new areas, while the solutions
that are already implemented will evolve and
start to merge with each other.
Conclusions
It is expectable to observe, in the near future,
a shift towards digitalization for many aspects
of Emergency Care: medical data collection,
delivery and analysis, equipments performances
monitoring, health management. Moreover,
most of the upcoming interventions in
Emergency Care are likely to be primarily aimed
at reducing operations time, budget and medical
staff labor, rather than improving service quality.
Therefore, future solutions for this context will
be able to rely on digital infrastructures broader
than the ones currently available, and their
adoption will be mainly determined by their
impact on systems overall cost efficiency.

30 31
However, the several advantages of voice
command, such as being contact-free,
automatically converting speech into text, and
being natural and intuitive even for technology
laymen, are now making this principle attractive
for the most different applications.
Some of the most interesting examples are
surgery (Taylor et al, 2008), driving and navigation
aids (Figure 11), and military applications
(Weinstein, (1995).
motion detection
The translation of movements happening in
the analog world into digital data is a vast field,
embracing various contexts and expanding on
different layers of complexity.
On the most simple level, we can find for instance
digitizing pens, translating hand drawing or
writing into digital images or text. This permits
to digitally store and share information created
by mean of a tangible, universally familiar
interaction.
More advanced is the technology permitting
to control a system by contact-less body
movements, such as the one implemented in
Microsoft’s Kinect (Figure 12). Eye-tracking
devices, spotting the position and motion
of pupils, can also be used as a human-
machine interface, as it happens in the case of
paralyzed people talking with the aid of speech
synthesizers.
On the cutting edge level of this topic, many
expectations are reserved to the upcoming
Google’s project Soli, (Figure 13) using motion
and gesture recognition to track traditionally
tactile commands (pressing buttons, rolling
knobs, shifting slides) without the need for any
direct physical interface.
Augmented reality
Although not defining a new way to impart
commands per se, augmented reality constitutes
a future trend in human-computer interactions.
This technology allows for integration of
computer-generated sounds, video, graphics
into the view of a real world environment. This
view could be mediated by a screen framing the
scene (Figure 14), by head-mounted sets or
glasses, by contact lenses (Bernstein, 2012), or
even by direct integration in the human retina
(Tidwell et al., 1995). Often, augmented reality
devices include speech and gesture recognition.
bCIs
On the extreme side of contact-less interactions,
there is a technological niche enabling users
to impart orders to devices directly with their
minds. Those Brain-Computers Interfaces (or
BCIs) capture complex brain cortex signals and
translate them back into effective actions.
Initially developed for restoring capabilities of
disabled people, this technology has recently
expanded into other contexts, such as gaming
(Figure 15).
Figure 13 Examples of
Google’s Project Soli
movement recognition.
Figure 15 Mindflex, a
game controlled by brain
concentration and relaxation.
Figure 14 MRI data shown live
on a LCD screen during needle
insertion in orthopedic surgery.
Seamless interactions
Inspirations and latest developments
Seamless
interactions
In an increasingly connected world, seamless
digital interactions are becoming a solution for
optimizing human complex task performances,
saving time and allowing multitasking.
Ways to achieve seamlessness in the content of
interactions are under constant development:
digital interfaces are striving to provide less
but more relevant information to the user, by
making use of adaptive and predictive systems.
Next to this, radically new ways of physically
operating digital systems are becoming reality.
These new interaction forms could provide
interesting application in Emergency Medical
Systems, an environment in which commands
velocity, effortlessness and integrability with
other simultaneous tasks would constitute a
solid advantage.
Therefore, four breakthrough technological areas
have been selected, from the most widespread
to the less common one, to portrait a picture
of the solutions being developed in different
domains for a common target: enabling users to
access the digital world with less effort.
voice commands
Talking to machines has become by now an
everyday reality, mostly by virtue of voice-
activated assistants such as Apple’s Siri or
Microsoft’s Cortana.
In the voice command patent registered by
Apple Inc, it is indicated that ‘typical speech
recognition applications include voice dialing,
call routing, domotic appliance control, simple
data entry and speech-to-text processing.’ (van
Os et al., 2010).
Figure 11 Using voice activated
commands in a Ford Explorer.
Figure 12 Microsoft Kinekt
allows players to control avatars
by simple body motion.

32 33
Preliminary observation
A less evident but as interesting discovery was
constituted by the number of paper-based
reminders and decision aids available in different
areas. Among others, the following were spotted:
• Emergency department timeout checklists,
hanging on the back of beds carrying
patients.
• Folders of laminated paper sheets,
providing guidelines for choosing
equipment in pediatric cases (tables age-
size- suggested device).
• A paper template hanging in the trauma
room, filled in by the dispatch nurse,
containing basic information about the
upcoming case for when the trauma
team is preparing. The data provided in
the moment of the observation included:
mechanism of injury, blood type and a
rough severity evaluation.
• All over the Department, laminated
booklets of approved protocols and
decisional flowcharts for different medical
emergencies were available.
This abundance of hard copy material was
explained with the urge for having the needed
information immediately available in case of
indecision. In other words, this amount of paper
served as a way to diffuse potentially crucial
information in the Department environment, to
be as close as possible to the operators working
on the case if needed.
Procedures
Astriking initial impression about the Department
regarded the dynamism and variety of working
personnel.
As testified by the dispatch nurse, shifts of
doctors are frequent, and the main continuity is
given by the nurses. A consequence of this is that
emergency teams could be formed of people
who have never met each other before.
The same dispatch nurse, when asked about
the kinds of information wanted when receiving
a call, stressed the importance of personal
data such as name and age in order to start the
internal procedures. The availability of this piece
of data, interestingly, was also mentioned as an
issue by the ambulance nurse (see quotes)
roles
A talk with the dispatch nurse pointed out a
number of unforeseen tasks falling under her
responsibilities; for instance, she mentioned how
many calls are coming from families and friends
of missing people, rather than from ambulances
or emergency control rooms.
Regarding the psychological attitude toward
her works, she stressed out the difficulty of not
letting empathy arise when receiving ‘bad news’.
In her opinion, operators feel the impulse to react
emotionally to accidents as everyone else. This
emotional component of the work experience
will be kept in consideration, and investigated
further in the user research.
Other discoveries about roles and responsibilities
within the Emergency Department concern:
• The ambulance driver, being occasionally
deputed to manage the call to the hospital
instead of the ambulance nurse
• The central role of triage nurses, and
their usually extensive background (often
including more nursing experience than
everyone else in the Department).
Conclusions
The visit constituted an essential preparation
for the user research. Topics suggested after for
further exploration are:
• Evaluating the staff issues and effort
required for circulating in the Department,
as the ambulance bike might suggest the
need for increased mobility.
• Inspecting the frequency and modality
of use of the paper checklists, reminders,
information sheets.
• Observe consequent shifts paying
attention at teamwork aspects (e.g.
are there any problems in finding
professionals?)
• Investigate about the emotional distress of
Emergency Department workers
• Map the main roles and responsibilities of
each professional role
“
The
quotes
”no time for
talking”
In fifteen minutes everything can
change. Sometimes there’s no
time for communicating
Sometimes they (the dispatch
nurse, ed.) ask about the name
and I’m busy figuring out if there’s
a cardiac arrest
We can do ECGs, we have some
basic equipment, and then we
only care about going to the
right hospital and tell them - I’m
coming in 10 minutes with an
infarction.
Ambulance nurse direct testimonies, 2016
“
“ “
“ “
Approaching the field
Preliminary
observation
the visit
To get a closer look at the targeted context
before the setup of the user research, a brief visit
to the Utrecht Hospital Emergency Department
was executed. The observation was limited to
the department main area, the trauma room,
the triage room, the resuscitation room, the call
dispatch area and the ambulances garage.
Brief, unstructured talks with the emergency
department dispatch nurse, an ambulance
nurse and other professional figures were also
possible.
The main first impressions and discoveries
collected in the Departments will be presented in
the categories of artifacts, procedures and staff
members roles. In addition, the main highlights
of a brief talk with an experienced ambulance
nurse are offered in this chapter’s quotes.
Artifacts
A surprising discovery in the passage leading
to the ambulances garage was the existence
of an ambulance bike, equipped with first aid
instruments and used to move quickly within
the department itself. This constituted a sort of
confirmation of the busy and rapid atmosphere
dominating in the Department.
Figure 16 Entrance of the
Utrecht University Hospital’s
Emergency Department
Figure 17 Garage of Utrecht
University Hospital’s Emergency
Department

34 35
Overall conclusions
Targeted context
The main informations collected on the context of Emergency Medical Services
concerned:
• Functions of EMS and presentation of the main concepts associated with it
• Basic differences in the way EMSs are organized in different countries
• General description of rescues dynamics
market peculiarities
Some characteristics of the Dutch Emergency Services market have been defined as:
• Compatibility with existing technologies and compliance to European
Regulations as strict prerequisites.
• Cost effectiveness and reliability as key market drivers.
future scenarios
Trends expected to shape the future of Emergency Medical Services are:
• Digitalization
• Time, budget and labour optimization
While trends relevant to the topic of effortless interactions are:
• Voice commands
• Motion detection
• Augmented reality
• Brain-computer interfaces
Acknowledged problems
Reported issue, concerning the whole rescue chain system, have been listed as:
• The informational chain in ambulance nursing allows for data freezing, loss or
misinterpretation.
• Existing communicational supports usability seem to be suboptimal from the
point of view of ambulance nurse.
AREAS OPEN FOR EXPLORATION
Relevant directions for further research were recognized in:
• Mapping the main roles and responsibilities of each EMS professional role
• Investigate the interactional and emotional demand of the main EMS
professional figures
Overall conclusions
Literature Research
A desk research concerning the past and present studies on the existing theoretical
frameworks and reported problems in Emergency Medical Services was executed.
pest analysis
An analysis taking into consideration the political, economical, social and technological
most relevant trends in the context of Emergency Medical Services was performed.
distributed cognition
The framework of Distributed Cognition, defined in cognitive science as an approach
to cognitive analysis taking into consideration the totality of individuals and
communicational artifacts as a unit, was presented and adopted for describing the
Emergency Medical Services system.
direct observation
An unstructured, informal observation of a Dutch Emergency Department was made.
?
Preliminary research
theoretical framework
Preliminary research
methods
STAKEHOLDERS MAPPING
An investigation of the existing relevant figures involved in the context of Dutch
Emergency Medical Services was carried out.

36 37
Preliminary research methods
USER RESEARCH
02This report presents the results of
the second phase of the design
process. The goal of the second
phase is to get to know the targeted
user group, to examine its context
in greater depth, and to collect data
to support the further generations
and selection of ideas. Next, a
description of the user research set
up and methodology will be given,
followed by a description of the main
deliverables resulting from these
research methods. The research
results are divided into a rescue
workflow model, a set of characters,
a time analysis, a set of experience
factors, and a framework describing
the notion of flow in ambulance
nursing. Finally, a problem
definition, summarizing all of the
previous insights into an actionable
proposition for the Conceptualization
phase, is offered.
Research set up
Research results
Problem definition

38 39
Research set-up
2. Ambulance nursing context
2.1. What are the main tasks and activities
performed by ambulance staff? How much
time do they take?
2.2. What are the main parties ambulance
staff interacts with? How?
2.3. What are the main stress generators/
motivating and rewarding factors for
ambulance staff?
2.4. What’s on the top of ambulance staff’s
mind while performing a rescue?
2.5. What does ambulance staff think it
would make their job easier?
3. Emergency Medicine domain
3.1 What are the most improvable areas in
Emergency Medicine according to domain
experts?
research depth
Upon the corpus of research methods
available, a classification was introduced in
techniques revealing what people ‘say and
think’, what people ‘do and use’ and what
people ‘know, feel, and dream’, (Sanders
and Stappers, 2012).
As the methods for accessing deeper
levels of knowledge coincide with the
more challenging ones in terms of time
and resources, a deliberate selection was
made on what types of stakeholders to
analyze more in depth (see Figure 18). The
main focus of the research was maintained
on the ambulance staff, identified as
ambulance nurse and driver.
Other stakeholders, such as the Emergency
Department staff, were included in the
research main scope but excluded from
in-depth generative research methods.
Finally, stakeholders involved in decision
making but far from the product-service
application context were only interviewed
on specific subjects.
research breadth
As stated in the preliminary research
chapter, the Anglo-American model of
emergency care constitutes the project
main targeted context. Consequently,
a particular focus on users working in
countries following this system (see Figure
5 for an overview) was maintained.
In particular, all of the research off-line
methods were executed in the territory of
the Netherlands, and the results obtained
were integrated with on-line questionnaires
directed to USA and Canadian ambulance
workers (see Figure 19).
participant
recruitment
Contacts were attempted using both formal
and informal media, such as e-mails,
phone calls, social media (facebook,
linkedin), specialized blogs and magazines
as well as personal social connections. The
company existing connections with medical
specialists were made available as well.
Out of eight hospitals contacted to
gain access to Emergency Department
workers, only three ever reacted: two
of these reactions brought to an actual
collaboration, while the third response
arrived too late to be included in the
operative project planning.
Out of the twelve organizations contacted
to get access to Ambulance Services
employees, only five reacted. Out of
this five, two organization decided not
to participate in the research, while the
remaining three demonstrated interest in
the topic and confirmed their willingness in
getting involved in the project.
Astherecruitmentconstitutedarichlearning
process in the field of project management,
some overall recommendations concerning
the seeking of participants in the medical
field has been drafted for future reference
in Appendix I.
Online
questionnaires
Interviews with
experts
Cultural probes
& interviews
Direct
observations
?
?
?
?
?
?
?
Figure 19 Geographical
distribution of the research
Approach and framework
Research set-up
Tools Generative session
Booklets Booklets
what people
methods
knowledge
stakeholders
say
& think
do & use
interviews
observations
generative
techniques
know, feel, dream
explicit
observative
tacit
latent
Medical
directors
Triage
nurses
Dispatch
nurses
Emergency
physicians
Other ED
workers
Ambulance
nurses
Ambulance
drivers
Figure 18 Research depth for
context stakeholders
Research objectives
The collection of data from the users was
conducted using generative research
methods, with special regard on qualitative
information such as feelings, attitudes, and
perceptions.
This approach was chosen for a twofold
purpose:
• to construct a non-superficial view
on the wishes and problems of the
people involved in the context of use,
and
• to create a ground for the designer to
truly empathize with the end users.
It is now widely recognized that designers
and researchers that put effort in
developing an empathic understanding
of their targeted users are more likely to
produce designs that fit the users needs
better (Van Doorn, Gielen et al., 2014A; van
Doorn, Gielen et al., 2014B).
Moreover, the chosen style in the
collaboration with the research target
group was inclusive and participatory.
In fact, involving the stakeholders as
experts of their own domain is expected
to produce better and more meaningful
designs, services and experiences (Sanders
and Stappers, 2012).
This was believed to be even more true
in a context such as ambulance nursing,
characterized by an high degree of domain-
specific experience and knowledge.
Altogether, the objective of the user
research was defined as to inform and
inspire the designer on the topic context
factors, implications, opportunities and
problems.
research questions
To organize and articulate the research,
a set of research questions were defined,
concerning both the specific topic and the
targeted context, as well as the bigger
domain of Emergency medicine.
1. Interactions in Ambulance Nursing
1.1. What are the main interaction and
cognitive demands related to ambulance
nursing?
1.2. Who performs them, how, when and
why?
1.3. What are the main artifacts ambulance
nurses interact with during their job?
1.4. What are the most desirable
interaction qualities in ambulance
rescuing?
User Research

40 41
Research set-up
Figure 20 Direct observation of
an ambulance shift
Research methodology
A diversified toolbox
data collection tools
To fit the research specific needs (such
as type of stakeholders, kind of desired
data, geographical positioning, time
constrains) several data gathering methods
were generated and applied. To better
understand the research outcomes
reliability and relevance, an overview on
their characteristics and usage is here given.
Online user research
The online side user research included two
main resources, being:
1. The scanning of EMS professional
fora and blogs, from which to gather
a taste of the professional life of
ambulance workers. In particular,
ems1.com, a leading website serving
the Emergency Medical Services
community worldwide and counting
more than 130,000 registered
members, was routinely visited.
2. A set of questions was released
on Quora.com, a website in which
experts answer on public doubts. The
questions were formulated both for
gathering information and for testing
questions formulations, checking the
best ways of receiving interesting
answers. For instance, the question
‘What is a superpower that could help
ambulance paramedics to do their job
better?’ revealed potential to unlock
ambulance workers creativity, and
was re-used in the cultural probes.
The set of questions and the received
answers are available in Appendix II.
Direct observations
The research included three observations
of Emergency Care work environments:
A preliminary observation in the Utrecht
Hospital Emergency Department, a two
hours visit at the Witte Kruis Ambulance
Center in den Haag, and the direct
observation of an ambulance crew for a
whole shift in the RAV Brabant Midden-
West-Noord ambulance center in Tilburg.
As the first observations details were
disclosed in the Preliminary Research
section, a brief description of the remaining
two will be here provided.
1. The visit at the Witte Kruis was
guided by the Center Manager, who
explained the main functions of the
center and of the operators peformed
in it. Then, the Manager presented the
main types of Ambulances and their
equipment to the researcher in the
Ambulance garage. The presentation
was rather interactive, and insights
on the most frequently registered
problems and issues related to
Ambulance Rescuing were already
collected. As pictures in the center
were not allowed to preserve the
privacy of the workers, extensive
notes about the conversation were
written during and immediately after
the visit.
2. The observation of the Ambulance
crew at work took place in TIlburg
and lasted for a whole shift (07.30-
16.30). The researcher worn a
regular paramedic uniform and was
equipped with the bib usually worn
by paramedics in training not to be
confused with actual emergency
workers. The researcher followed
the crew in each step of their day, as
well as in every phase of the rescues.
Audio and video records of the
environment were only allowed if not
involving patients or non-participant
staff. Consequently, the researcher
carried an agenda on which to take
note of relevant observations in every
moment of the shift. The note was
attached to a watch, (Figure 20) to
keep track of the time spans taken for
every activity on the shift. A resulting
timeline of the shift, complete of
a brief description of each call, is
provided in Appendix III. In addition,
special attention was reserved to
elements relevant to contextual
design models (as described Beyer
& Holtzblatt, 1997) in particular
cultural, workflow, physical, and
artifacts model. This research method
constituted, in addition, a rich source
of opinions from other workers, as
talks and debates with the whole
ambulance center active staff were
possible in the coffee room during off
times.
??
User Research

42 43
Research set-up
Cultural probes
Cultural probes, as first described by Gaver
(1999), are a user centered research approach
based on self-documenting. Their aim is to
reveal users’ personal perspectives to enrich
design and support empathy.
This method was chosen in consideration of the
multiple advantages for the hereby presented
research, as:
• The adequacy to unveil personal issues
as well as tacit and latent knowledge of
ambulance staff.
• The advantages for the participants to
permit a prolonged reflection on the
topic, united to optimal adaptability to
the participant schedule - a particularly
delicate factor in researching with
ambulance workers.
• The convenience for the participants of
being conducted in the original language
of the participants (Dutch), factor that
would have not be possible in face-to-face
interviews.
To elicit personal involvement, the formulation
of the probe exercises was always made in first
person. For instance, the booklet title was ‘my life
as an ambulance nurse’, and the five ‘exercises’
(one per day) structured in thematic areas, were
named, respectively:
1. What do I do?
2. How do I work?
3. How do I like it?
4. How many things do I do/ how much time
does it take?
5. What would I want better?
The exercises were translated as much as
possible into visual and tangible artifacts,
through the use of graphic templates and
stickers enclosed in the booklet. (Figure 21). In
total, five booklets were sent by regular mail to
participants located in various locations in the
Netherlands (Figure 19). Apart from the booklet
itself, the envelope included instructions for the
use of the probe, researcher contact details, and
a pen. The content of these booklets in English is
available in Appendix IV.
The recollection of the probes, which the
researched followed in person, constituted an
occasion to perform direct interviews to each
participants. The interviews were used as a
follow-up on the probe completion as well as a
confirmation of the main insights generated by
the probes. Also, the interviews could benefit
from the application of the event reconstruction
method (ERM), a tool introduced by Grube,
Schroer, Hentzschel and Hertel to measure job
satisfaction in occupational psychology (Gribe,
2008) and based on questions on a job situation
previously recalled by the participant, aimed at
defining the kind of experience felt in that very
moment.
Figure 21 Exercises from the
cultural probe booklet
User Research

44 45
Research set-up
Research
landscape
Desk
research
Ambulance center
observation
Online
questionnaires
?
Online
questionnaires
?
Ambulance shift
observation
Cultural
probes
Follow-up
interviews
Research
methods
The literature
research constituted a
scanning of the publicly
available information on
the topic.
The ambulance center
observation confirmed
part of the information
given by the previous
methods, and opened
spaces for new
explorations.
E.D.
observation
The preliminary
observation in the
Emergency Department
suggested new directions
for further research.
The online questionnaire
questions gave personal,
in-depth insights both
about observed
phenomena and new
topic aspects.
The observation of the
ambulance crew shift
gave confirmations and
nuances to what already
drafted, plus offered
clarifications on of many
topic aspects suggested
by the online
questionnaires.
The cultural booklets in
form of probes sent to six
participants deepened
and broadened the most
interesting areas outlined
by the previous research.
The follow-up interview
made to the booklets
participants confirmed,
broadened connected
the data contained in the
booklets.
1.
2.
3.
4.
5.
6.
7.
Gaveinputto
t
he
set-up of...
Expert
talks
The talks with EMS
experts could benefit
from all of the knowledge
collected in the previous
stages, and contributed
to put this knowledge
into a broader and more
critical perspective.
8.
Figure 22 Usage of the
different research methods
to map the targeted
context.
tools systematization
The building of the data gathering tools
constituted an iterative process in itself.
In fact, each method constituted a basis for the
others, and contributed in mapping the design
space in a different direction.
The graph presented in Figure 22 describes,
metaphorically, the way in which each data
gathering tool contributed in adding new
elements to the picture of the examined context,
as well as how it gave inputs - and suggested
new exploration areas - for following research
activities.
Experts talks
Three talks with Emergency Department
expert workers and/or researchers were
conducted as a conclusive context analysis.
These talks, coming after the field research
activities, could benefit from some early
working results (list of categorized quotes and
list of problems), upon which the experts could
provide their view.
The talks were rather informal and interactive.
More than providing specific answers to
research questions, their main value consisted
in integrating the specific, small-scale results
drafted from the field research with a much
broader perspective on Emergency Care present
and future needs. Extensive minutes of these
meetings are provided in Appendix V.
Frank Goethals
Innovator in Health &
Healthcare at UMC Hospital in
Utrecht
Talk highlights
• IT systems of Ambulances
and Emergency Wards
should be able to
communicate more
efficiently.
• A direct connection from
ambulances to response
teams in the hospital could
constitute a value from the
point of view of Emergency
Ward staff.
Juanita Haagsma
Research coordinator for
Emergency Department of
the Erasmus MC Hospital in
Rotterdam
Yuri van der Does
Emergency Physician and
Researcher at Erasmus MC
Hospital in Rotterdam
Jeroen Zewald
Emergency Physician,
Medical Manager and Head
of Emergency Department at
Reinier de Graaf Hospital in
Delft.
Talk highlights
• Face-to-face
communication about the
patient state is always
preferable.
• Pictures of patients ID’s,
if sent in advance to the
Emergency Department,
could speed up
administrative procedures
of about 5 to 10 minutes
per case.
Talk highlights
• Emergency Departments in which Emergency Physicians are
usually working face less problems in arranging and managing
response teams.
• Much overcrowding of the Emergency Ward is caused by
difficulties in redirecting stabilized patients to definitive care.
Stable patients might have to be transported back home or
to other hospitals, but the Meldkamer would not allow for
Ambulances to be used in non-emergency cases.
• “If you want to become millionaire, invent a unified information
system that covers all of the emergency patient journey”.
User Research

46 47
Research results
ideas
problems
experience
factors
rescue
workflow
characters
Figure 23 Analysis on
the wall
Research results
Data analysis and outcomes
data analysis
methodology
Analysis on the wall
Analysis on the wall (as described in Sanders and
Stappers, 2012) was selected as the preferred
data analysis method.
This was chosen in consideration of the
heterogeneity of the collected data, and of the
capacity of the technique to be compelling and
involving. The analysis was divided into three
stages:
Preparation
From the previously presented research tools,
the following results were printed and kept
visible on a wall:
• Labeled quotes from the online user research.
• Labeled pictures and videos from the
observations.
• Translated booklets (including drawings and
time-lines from the originals).
•Labeledtranscriptsfromthedirectobservations,
from the follow-interviews with booklet fillers
and from the interviews with experts.
In addition, empty templates for characters and
rescue workflow were prepared. These templates
were laid on a large table together with empty
sheets for ‘problems’ , ‘ideas’ and ‘experience
factors’.
Execution
The researcher scanned and reviewed all of
the research results. The appropriate pieces
of information were placed into the empty
templates (characters, rescue workflow,
experience factors, problems, ideas). In addition,
the rescue workflow included special insights
concerning ‘data points’, or moments whose
importance was regarded as particularly
important for the exchange of information in the
rescue workflow.
The whole analysis was video recorded, in order
to be able to retrieve key insights and pertaining
data sources if necessary.
Elaboration
An additional synthesis process was executed
on each of the filled templates, whose content
was worked out, integrated and refined until
reaching the form of a research deliverable.
This stage constituted, for the first time in
the project, an opportunity to go beyond the
descriptive stage and deepen the research focus,
taking into consideration the implicit meanings
of the collected data.
In particular, the interpretation and confrontation
of quotes concerning positive or negative
experiences of the ambulance nurses brought
to the identification of a number of contextual
experience factors.
All of the deliverables resulting from the analysis
on the wall are presented in the next paragraphs.
User Research

48 49
Research results
PRE-ARRIVAL ARRIVAL ON SITE PATIENT TRANSPORTATION
Activities:
• Assessing emergency severity
• Collecting data
• Reassuring the caller
Relevant data:
• Emergency type and severity
• Patient position and accessibility
• Patient name
• Scene safety
Control room
operator
Activities:
• Checking severity level
• Confirming destination
Relevant data:
• Emergency type and
severity
• Patient position and
accessibility
• Patient name
• Scene safety
Ambulance
nurse
Activities:
• Calling the emergency
number
Relevant data:
• Ambulance arrival time
Patient
Activities:
• Checking route
Relevant data:
• Traffic and weather
conditions
accessibility
“One of the most stressful aspects is not
knowing what you are going to get.”
“Sure, uncertainty can be stressful...but it’s
also what I love about it: the adrenaline
rush”
Ambulance
driver
What is
it?
Where
to go?
What will I
find?
What could we
need?
Will the scene be
safe to proceed?
What
happened?
Who is here?
How are the
vital signs?
What it’s
better to do
next?
Which hospital to go?
Is the patient willing and
the family informed?
How are the vital
signs?
Is the patient
comfortable?
How fast should
we go?
Is my working
diagnosis right?
Is the treatment working? How a
vital signs evolving? Is the patie
comfortable and calm? Do I hav
the data for the handover?
Activities:
• Receiving updates about the
case
Relevant data:
• Case updates
• Next steps
• Need for additional
emergency staff or equipment
Control room
operator
Activities:
• Carrying equipment
• Assessing scene safety
• Assessing patient’s vitals
• Collecting scene information
Relevant data:
• Emergency background
• Vitals, additional exams
• Patient medical history
• Patient consent to proceed
Ambulance
nurse
Activities:
• Answering to ambulance
staff questions (if conscious)
Relevant data:
• What happened and how
severe is it,
• Will it go better
• What will happen next.
Patient
Activities:
• Assisting nurse
Ambulance
driver
Activities:
case
Relevant data:
• Case updates
• Next steps
Control room
operator
Activities:
• Administer treatment and
checking its efficacy
• Communicating with the
destination hospital
Relevant data:
• Patient anagrafic details
Ambulance
nurse
Activities:
• Answering to
ambulance staff
questions (if conscious)
Relevant data:
• What happened and
how severe is it,
• Which hospital am I
going to.
Patient
Activities:
• Communicating with the
destination hospital (only in
extreme conditions )
Relevant data:
• Estimated arrival time
conditions
Ambulance
driver
Activities:
• Answering to call from
ambulance
• Preparing E.R. staff for the
patient arrival
Relevant data:
• Estimated arrival time
severity
• Needed staff and
equipment to gather
• Patient anagraphic
details
E.R.
dispatcher
Activities:
• Answering to E.R
staff questions (if
conscious)
Relevant data
• What happened an
how severe is it
• What is going to
happen next.
Patient
Activities
and data
What’s in
people
mind
Ambulance
nurses
experience
Ambulance nurse
Ambulance driver
E.R. dispatcher
Triage nurse
Emergency physician
Other wards staff
“If we have to take a decision such as
leaving the patient home we have to be
sure. And how can we? We have very
limited means. Can be a hard time.”
“When the situation is not clear,
this could be a tough moment.
We’re analyzing a lot of factors in a
short time ”
“I let my eyes work and assess
the situation.”
“I see that things are going better, that
the treatment works or I’m giving
support to his emotional problems.”
“You have to keep watching the patient,
the patient is the first thing”
“Always a hassle to get
someone on the stretcher and
take all the equipment and
stuff back to the ambulance.”
“Sometimes you know that
nothing is going on, but it
doesn’t feel right to leave.”
“Sometimes they ask me the name and
I’m busy figuring out if it’s a cardiac arrest ”
“The orientation phase
and I’m doing good!”
“The most problematic situations are the
ones in which the patient doesn’t want to
come to the hospital. It’s unclear what to
do.”
“We're focused on the priorities - airway, breathing,
and circulation. Things are happening so fast,
there's really no conscious thought ”
“The ride can be quite
unpleasant if it is an out of
control patient. In this case, I
even feel relief if they get
unconscious.”
”The absolute number one
thing on my mind is the safety
of myself and my crew.”
Legend
Police, firemen, withstanders
Hospital,
general practitioner
Data exchange point
(flowing from lower stakeholder
to upper stakeholder, e.g.
ambulance to control room)
Data exchange point
(flowing from upper stakeholder
to lower stakeholder, e.g. patient
to ambulance)
Possible additional
stakeholders
Communication
media in use
Phone Transceiver
(both portable and
built-in ambulance)
Pager Computer Direct conta
Fireman Paramedic | 23 years of experience
Ambulance nurse | 23 years of experience
Paramedic | 29 years of experience
FIreman Paramedic | 23 years of experience
Ambulance nurse | 26 years
Ambulance nurse | 26 years of experience Ambulance nurse | 21 years of experience
What happens on
and behind the scenes
of ambulance rides
Emergency
rescue
workflow
Control room operator
Patient
PRE-ARRIVAL
Activities:
• Collecting data
Relevant data:
• Patient name
• Scene safety
Control room
operator
Activities:
Relevant data:
severity
accessibility
• Patient name
• Scene safety
Ambulance
nurse
Activities:
number
Relevant data:
Patient
Activities:
• Checking seve
• Checking rout
Relevant d
• Traffic and we
conditions
• Patient positio
accessibility
Amb
drive
Activities
and data
Patient
Control room
operator
Ambulance nurse
Ambulance driver
E.R. blue line
Triage nurse
Emergency physician
Other wards staff
Activities:
• Collecting data
Relevant data:
• Patient name
• Scene safety
Control room
operator
Activities:
Relevant data:
severity
accessibility
• Patient name
• Scene safety
Ambulance
nurse
Activities:
number
Relevant data:
Patient
Activities:
• Checking route
Relevant data:
conditions
accessibility
Ambulance
driver
What is
it?
Where
to go?
What will I
find?
Wha
nee
Will
safe
Activities
and data
What’s in
people
mind
Ambulance driver
E.R. blue line
Triage nurse
Emergency physician
Other wards staff
Activities:
• Collecting data
Relevant data:
• Patient name
• Scene safety
Control room
operator
Activities:
Relevant data:
severity
accessibility
• Patient name
• Scene safety
Ambulance
nurse
Activities:
number
Relevant data:
Patient
Activities:
• Checking route
Relevant data:
conditions
accessibility
rush”
Ambulance
driver
What is
it?
Where
to go?
What will I
find?
What could we
need?
Will the scene be
safe to proceed?
What
happened?
Who is
here? How
are the vital
signs? What
it’s better to
do next?
Activities:
case
Relevant data:
• Case updates
• Next steps
Control room
operator
Activities:
Relevant data:
Ambulance
nurse
Activities:
Relevant data:
severe is it,
Patient
Activities:
• Assisting nurse
Ambulance
driver
Fireman Paramedic | USA | 23 years of experience
Acti
• Rec
case
Rele
• Cas
• Nex
Activities:
• Answering to
ambulance staff
Relevant data:
how severe is it,
going to.
Patient
Activities
and data
What’s in
people
mind
Ambulance
nurses
experience
Emergency physician
Other wards staff
limited means. Can be a hard time.”
Paramedic | Netherlands | 26 years of experience
short time ”
the situation.”
someone on the stretch
take all the equipment a
stuff back to the ambula
Paramedic | Netherlands | 19 years of e
doesn’t feel right to leave.”
do.”
“We're focused on the priorities - airway,
breathing, and circulation. Things are
happening so fast, there's really no
conscious thought ”
Paramedic | USA | 29 years of
experience
Legenda
Data exchange point
(flowing from lower stakeholder
to upper stakeholder, e.g.
ambulance to control room)
Data exchange point
(flowing from upper stakeholder
to lower stakeholder, e.g. patient
to ambulance)
Possible additional
stakeholders
Communication
media in use
Pho
Activities:
• Collecting data
Relevant data:
• Patient name
• Scene safety
Control room
operator
Activities:
Relevant data:
severity
accessibility
• Patient name
• Scene safety
Ambulance
nurse
Activities:
number
Relevant data:
Patient
Activities:
• Checking route
Relevant data:
conditions
accessibility
rush”
Ambulance
driver
What is
it?
Where
to go?
What will I
find?
What could we
need?
Will the scene be
safe to proceed?
Activities:
case
Relevant data:
• Case updates
• Next steps
Control room
operator
Activities:
• Assessing scene saf
• Assessing patient’s
• Collecting scene inf
Relevant data
• Emergency backgro
• Vitals, additional ex
• Patient medical his
• Patient consent to
Ambula
nurse
Activities:
Relevant data:
severe is it,
Patient
Activities
and data
What’s in
people
mind
Ambulance
nurses
experience
Patient
Control room
operator
Ambulance nurse
Ambulance driver
E.R. blue line
Triage nurse
Emergency physician
Other wards staff
the situation.”
“The most problem
ones in which the p
come to the hospit
do.”
Paramedic | Netherlan
“We
bre
hap
con
Para
expe
Police, firem
PRE-ARRIVAL ARRIVAL ON SITE PAT
Activities:
• Collecting data
Relevant data:
• Patient name
• Scene safety
Control room
operator
Activities:
Relevant data:
severity
accessibility
• Patient name
• Scene safety
Ambulance
nurse
Activities:
number
Relevant data:
Patient
Activities:
• Checking route
Relevant data:
conditions
accessibility
rush”
Ambulance
driver
What is
it?
Where
to go?
What will I
find?
What could we
need?
Will the scene be
safe to proceed?
What
happened?
Who is
here? How
are the vital
signs? What
it’s better to
do next?
Activities:
case
Relevant data:
• Case updates
• Next steps
Control room
operator
Activities:
Relevant data:
Ambulance
nurse
Activities:
Relevant data:
severe is it,
Patient
Activities:
• Assisting nurse
Ambulance
driver
Activities:
• Receiving update
case
Relevant dat
• Case updates
• Next steps
Contro
operat
Activities:
• Answering to
ambulance staff
Relevant data:
how severe is it,
going to.
Patient
Activities
and data
What’s in
people
mind
Ambulance
nurses
experience
Patient
Control room
operator
Ambulance nurse
Ambulance driver
E.R. blue line
Triage nurse
Emergency physician
Other wards staff
short time ”
the situation.”
“I
th
su
Par
someone on the stretcher and
take all the equipment and
stuff back to the ambulance.”
do.”
“We're focused on the priorities - airway,
breathing, and circulation. Things are
happening so fast, there's really no
conscious thought ”
Paramedic | USA | 29 years of
experience
Police, firemen, withstanders
Hospital,
general practi
Ambulance journey workflo
Figure 24 Sample from
the rescue workflow model
Data points
The contact points between
parties involved in the rescue
are depicted as intersections
between colored lines. The
exchanges of information
are represented by arrows
flowing from the sender to the
receiver’s line.
Quotes
Direct quotes from the
participants give a more
vivid tint to the
description.
communication
devices
The devices used by each
role in each rescue stage are
represented by icons.
thoughs
Images of the rescue,
accompanied by though
bubbles, provide a degree of
immersion into the context. emoticons
Expressions and quotes from
participants were used to
explain experience flow peaks
and falls.
Rescue
workflow
Model description
Part of the user research results were
processed into a model narrating the main
phases of an average ambulance rescue
process. The process was described on
several levels, advancing from a simple
description of the performed actions to a
deeper view into the underlying mental
processes.
The levels of description are:
• Stakeholders involvement
• Relevant activities and data
• Mental landscape
• Positive and negative experiences
trends (for ambulance nurses only).
This model is given the operative name
of ‘rescue workflow’, due to its feature
of describing not a real case, but rather a
sequence of operations usually performed
in sequence in ambulance rescues,
disregarding from the type of medical
emergency.
With ‘average ambulance rescue process’ is
meant that unusual events that could occur
are excluded from the journey. As these
shouldn’t be neglected, they are hereby
listed in order to be taken into account in
the further design process.
These events are:
• Decision of the ambulance nurse
to not bring the patient to the
Emergency Department (often in
agreement with the patient general
practitioner).
• Patient refusal to be treated or
transported.
• Patient decease.
In addition, it is necessary to specify that
the model only describes an emergency
rescue, while ambulance services ordinarily
perform planned transportation (e.g.
hospital to hospital or home to hospital).
A detailed explanation of the graph
structure and partition is offered in Figure
24, while the full model is available online
at goo.gl/VrzWod.
In alternative, the full model can also be
visualized by scanning the QR code in this
page with a compatible mobile device.
Model relevance
The goal of the rescue workflow consists
in gaining both a rich and broad overview
on the average ambulance rescue. Due
to its narrative structure, it is regarded
as a suitable support for illustrating the
basic functioning of ambulance rescues to
inexpert listeners.
In addition, the model is meant to highlight
and contextualize part of the identified
problems and context factors.
Main insights
An overview of the overall rescue workflow
could bring to a number of contextual
observations.
The first ones concern the organization
of the teamwork among the parties,
showing the ambulance team as the core
of the action, the hospital personnel as a
receiving apparatus, and the control room
operator as an off-site organizer of the
whole operation. The emergency patient
experiences a discontinue succession of
transfers, each characterized by a different
environment, reference figure, quality of
care and level of emotional support.
On the second level of the model, it is
relevant to denote the large spectrum of
communication devices used by the parties
across the rescue stages.
In the level of mental processes, which was
mostly built after the results of the ERM
(event recollection method), it appears
that nurses are constantly updating their
knowledge on the case and anticipating
the next steps.
The last level, describing the nurses
experience, interestingly describes how the
most negative experience for the nurses
seems to be the decision making for an
uncertain case.
Overall, the trend of negative and positive
experiences appears in the graph more
often mirrored than parallel, suggesting
that same situations could bring to opposite
reactions for different individuals and
different emergency types. The ride to the
case scene, for instance, was reported to
be a moment of excitement and adrenaline
rush (positive) by some participants, and
a moment of anguish for the uncertainty
of the destination scenario (negative)
by others. This suggested the need for
a more comprehensive and articulated
examination of the factors determining
the good or bad rescue experience of
ambulance nurses, which was therefore
reserved a separate model (presented later
in the chapter).
As an exception for this ambiguity in
ambulance nurses responses, it is to notice
how the trip to the hospital represents
a consistent rise in the mood of the
ambulance nurses both for negative and
positive experiences.
User Research

50 51
Research results
Ambulance driver
• Not only a driver, but a partner.
Emergency physician
• A relief from responsibility, but also a
source of concern.
“The
patient
is the first
thing”
Characters
who is operating in
emergency rescues
Ambulance
nurse
About others
E.R. dispatch nurse
• Usually a flawless cooperation,
occasionally a reason of overload.
“Whatever I’ve been into, my partner was
there with me.”
“They don’t read what we send,
sometimes they don’t listen to us”
“Sometimes they ask for the name and
I’m busy figuring out if there’s a cardiac
arrest”
Key responsibilities
• Collecting information from the
scene and the patient
• Providing care in transfer
• Selecting and applying life support
protocols
• Managing all communications with
the hospital
• Providing a complete handover to
the E.R staff
• Reporting all relevant rescue data
+ Freedom, adrenaline, working with the
people
+ Special relationship with colleagues
and drivers
+ Offering support to the ones who
need it the most
- Protocol uncertainties, non-cooperative
patients
- Time pressure, responsibilities overload
- Time wasting incidents, lengthy
procedures
- Traumatic events, physical distress,
mental burnout
“If I’m afraid of forgetting things, I
write them on my gloves.”
“Everything in EMS is about
documentation. If it’s not on the
report, it didn’t happen”
“ I am their strenght when they don’t
have none.”
“The sad part is people lie to
paramedics for the stupidest reasons.”
• Faster, more flexible bureaucracy
• Reliable, real time data collection,
‘better memory’
• Easier access to patient information
• Easier decision making
• Faster, easier and more effective
communication with hospital and control
room
• More advanced and complete
diagnostic equipment
• Clear tools for assessing scene safety
• Improved legal protection
• Reduced physical effort
“I wish I could speed up the
administrative work”
“I have to fill up all of these forms that
are not even relevant to my case”
“Patients lie, forget, cannot respond
and we don’t have many other
sources.”
• Problem solving mindset
• Cold blood
• Social and communication skills
“You have to know how to
gain the patient trust”
Goals and motivations Wishes
Stress sources
Key qualities
Characters
Model description
A separate model was chosen to describe
the features and peculiarities of the
different professional roles involved in
ambulance rescues.
This model was obtained by collecting
insights generated from several research
methods, in particular direct observations
of the driver-nurse partnership and from
direct interviews with experts.
The five characters outlined with this
method are presented in the next pages.
Model relevance
The characters descriptions include the
professional role’s key responsibilities,
wishes, goals and motivations as well as
problems and stress source. In addition, a
summarized view of the relationship of each
character with others is provided, to give
a glimpse of the harmonies and tensions
shaping the hidden levels of teamwork in
the emergency care domain.
Quotes from the participants are included
in the model, to clarify and sustain the
reported fundings. This model will be
used to orientate later stages choices, for
instance regarding possible desirable side
effects for users different from ambulance
nurses.
Main insights
Among the most interesting insights
outlined from the characters, we observe
several points of contrasts between
stakeholders priorities and mutual
expectations.
In particular, a breakdown of influence is
reported between the role ofthe ambulance
nurse and the one of the emergency
physician or the triage nurses, especially
in case of delays in the patient acceptance
in the hospital, or when the expectation of
the paramedic of being carefully listened
is not fulfilled. Not unequivocally positive
are also the feelings of the ambulance
nurse towards the control room operator,
sometimes defined as ‘distant from the
battlefield’.
Key responsibilities
• Responding to the emergency calls
and directing the rescue operations.
• Collecting all of the initial
information for the rescue, including
patient location and accessibility,
emergency severity level, patient
personal details,
• Keeping track of the ambulances
position, state and availability.
+ Adrenaline, sense of responsibility
+ Monitoring and managing remotely an
highly complex system.
+ Physically safer use of a nursing
background
- Time pressure
- Unclear patient location or emergency
type
- Language barriers
- ‘Frequent fliers’
• Automatic identification of mobile
phones position
• Automatic translation from every
language
• Problem solving mindset
• Fast thinking
• Cold blood
• Emotional support attitude
• Multitasking
Goals and motivations Wishes
Stress sources
Key qualities
“I’m the
calm voice
in the storm”
Characters
who is operating in
emergency rescues
Control room
operator
User Research

Report_Valeria Pannunzio_4455203

Report_Valeria Pannunzio_4455203

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