Emotional Study in Service Experience:Waiting in a Hospital Waiting Room by Kwan Phonghanyudh

Emotional Study in Service Experience: Waiting in a Hospital Waiting Room Kwan Phonghanyudh Supervisors: Prof. Birgit Mager and Prof.Andreas Wrede MA Integrated Design 2009-2011 Kรถln International School of Design Fachhochschule Kรถln

Emotional Study in Service Experience: Waiting in a Hospital Waiting Room

Emotional Study in Service Experience: Waiting in a Hospital Waiting Room Kwan Phonghanyudh Köln International School of Design MA Integrated Design 2009-2011 University of Applied Sciences Cologne Fachhochschule Köln Faculty of Cutural Sciences Fakultät Kulturwissenschaften Supervisors Prof. Birgit Mager: Service Design Prof.Andreas Wrede: Design and Identity

Abstract

This research studies emotion in service consumption and factors that elicit them, in relation to the dimension of service experience, based on the context of waiting in a hospital waiting room. There are two phases of field research; First phrase â&#x20AC;&#x201C; Exploration: gathering general information about an area of study: Emotional study in a waiting room of a health care provider. There are three methods used during this phrase: general interview with health care customers, observation in eight waiting rooms of different health care providers and questionnaire with responses from 81 participants. After this phrase, types of emotion and factors in health care experienced were identified. Second phrase â&#x20AC;&#x201C; Case specific: field research at an outpatient waiting room of the Clinical Immunology (Aufenhaltsraum Wartezimmer, Immunologische Ambulanz), St. Josef Hospital, Bochum. There are four methods used during this phrase: hidden observation at the waiting room of a clinic, questionnaires with responses from 84 participants, interview with hospital staff and deep interview with nine patients with the use of three different tools: emotion and factor cards, emotional Graph and color card and co-creation: story telling. The result indicates two types of emotion in service experience: existing emotion and emotion elicited during service experience, which are elicited by three different types of factor: factors related to dimensions of service experience at a certain service provider, factors related to an area of service and factors related to an individual. These findings provided more knowledge in an area of service design concerning emotional aspect of favorable customer experience. However, for further research the same studies should be repeated in a different type of service provider in order to make a comparison.

Contents

Abstract

Introduction

Literature Review Service Business Service Experience Introduction A definition of service experience Dimensions of service experience 09 Emotion in service experience Introduction Definition of emotion Emotion in this study (Emotion in service experience) Describing Emotion Terms related to emotion Affect vs Emotion, Mood vs Emotion, Feeling vs Emotion, personality vs Emotion) Emotion measurement method 19 Health Care Experience 21 Emotion in health care experience 22 Waiting in health care experience - Types of waiting in health care - Impact of waiting in health care on patient 25 Emotion in waiting room 04 05 06

Contents 27

Research Methodology

First Phase: Gathering general information about the topic: emotional study in waiting room of different health care provider. 29 Introduction 29 Methodology 29 1. General interview: (Method/Objective/Process/Finding) 34 2. Observation: (Method/Objective/Process/Finding) 39 3. Questionnaire: (Method/Objective/Process/Finding) 49 Conclusion 51 Proposal for the 2nd phase: case specific 29

53 Second 53 60 60 64 84 89 99

Phase: Case specific field research â&#x20AC;&#x201C; clinical immunology (Immunologische Ambulanz), St. Josef Hospital Introduction Methodology 1. Observation: (Method/Objective/Process/Finding) 2. Questionnaire: (Method/Objective/Process/Finding) 3. Interview with hospital staff: (Method/Objective/ Process/Finding) 4. Deep interview with patient Conclusion

106 106 109

Research Summary Emotion in service experience (based on the case study: Analysis of methodology used for study emotion in service experience

111

Bibliography

117

Acknowledgement

Introduction

This research, “Emotional study in service experience: Waiting in a hospital waiting room”, studies the emotions that a customer experiences during a service consumption and factors that elicit them, in relation to a service experience. The aim is to contribute more knowledge in the area of service design concerning emotional aspects of favorable customer experience. In the competitive service market, creating a favorable experience by focusing on customer’s emotion is believed to be a very importance strategy for a company to differentiate itself among others in the same market, due to its influence on customer’s perception towards a service quality, his or her level of satisfaction, the relationship between customer and service provider and future retention. In this research, “Waiting in a hospital waiting room” is used as an area of study. Waiting is a chronic problem in health care that only seems to get worse day by day due to a raising aging population, increase demand of health care services, higher patient expectation and an advancement of technology. It is a common situation that not only affects patients but also hospital staff. While waiting, patients and their companions often mentioned experiencing many emotions such as stress, frustration and anxiety due to different factors such as unidentified health problem, unknown treatment procedure and anticipation of a response from medical staff, long waiting time, and the environment of a waiting room. As a result, patients are often unsatisfied and have negative perceptions toward the quality of the health care institute, which sometimes leads to an early departure from the treatment or a switch of health care provider. On the other hand, patients with positive emotion often have a promising outcome after treatment and are more likely to return to the same hospital.

Introduction

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Introduction

The acquired data from the research does not only provide a better understanding of emotions that a customer experiences throughout a service consumption and factors that elicit them, but also points out a possible direction that service design can implement to create a favorable customer experience by enhancing positive emotion, and coping with negative emotion. The research consists of three sections. The first section is a literature review of related books and papers, aims to provide a background knowledge about the topic. The second section is the research methodology, divided into two phrases, First phrase – Exploration: gathering general information about an area of study “Emotional study in a waiting room of a health care provider” and Second phrase – Case specific: field research at an outpatient waiting room of the Clinical Immunology (Aufenhaltsraum Wartezimmer, Immunologische Ambulanz), St. Josef Hospital, Bochum. The last section is the summary of the research.

Introduction

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Literature Review -4-

1. Service Business 2. Service Experience 3. Emotion in service experience 4. Health Care Experience 5. Emotion in health care experience 6. Waiting in health care experience 7. Emotion in waiting room

Literature Review

Service Business The Service Sector, which includes different types of businesses such as turism (hotels), gastonomy (restaurants), entertainment, transportation, banking, education and health care, has been growing in a rapid rate. According to Mager (2007), importance to service and information has become a foundation of the Western economic for the past thirty years. There are many factors that influence this phenomenon, such as, an increase in investment in service businesses especially in big companies, an advancement of technology that enable more opportunity for creating a suitable service and last but not least, a possibility to provide more options that would correspond with an individual need of clients besides providing only product (Moritz 2005). Nowadays, service sector represents approximately sixty three percent of the world gross domestic product (GDP) while the industry sector only represents around thirty-one percent1. As the service business market is booming, many companies are shifting themselves from being product companies to product-service companies (Moritz 2005). However, the act of doing so is not as easy as it sounds as there are big differences between characteristics of product and service. While products are usually tangible objects that can be stored and normally consumed by a customer after the production, services, on the other hand, are intangible, heterogeneous, perishable and inseparable of a production and consumption (Parasuraman, Zeitaml, and Berry, 1985, Moritz 2005, and Edvardsson 2005). Therefore, with all of these features combined, customers often refer to service consumption as an â&#x20AC;&#x153;experienceâ&#x20AC;?, which is embbed in the mind of the customers.

Literature Review: Service Business

1. https://www.cia.gov/ library/publications/ the-world-factbook/geos/ xx.html

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Service Experience Introduction An increasing number of service companies and a shift from product manufacturing company to product-service company led to a very competitive market. Companies are looking for ways to add value, differentiate themselves among others in the same market, retain and attract customers. As a result, many service companies are focusing on creating a favorable â&#x20AC;&#x153;service experienceâ&#x20AC;? as it is believed to be one of the major attribute that customers use to distinguish an average service from an excellent one. (Edvardsson, Enquist, and Johnson 2003).

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Definition of service experience Service experience is defined as a direct experience between a customer and a service provider throughout the service process. It includes how customers are treated and the interaction between them and organization, staff and facilities. Most of the time, customers involved in co-creating an experience as services are produced and consumed simultaneously (Johnston and Clark, 2005). According to Johnston and Clark, (2001), the aspect of the service/ customer experience include: - The degree of personal interaction - The responsiveness of the service organization - The flexibility of customer-facing staff - Customer intimacy - The ease of access to service personnel or information system - The extent to which the customer feels valued by the organization - The courtesy and competence of customer-facing staff - Interaction with other customers.

Literature Review: Service Experience

They can elicit varieties of emotions, both positive and negative, influences customers’ perception towards a service, which determines an assessment of service quality, the satisfaction level and future behavior. With positive experience, customers tend to be satisfied, be loyal, repurchase and revisit. On the other hand, opposite reaction, such as complaints and service abandonment, will occur when customers have negative experiences, which are often embed in a memory and pass on to other customers via word of mouth (Johnston and Clark 2005, Keillor et al, 2004). Therefore, it is very important for service providers to understand the needs of customers in order to create a preferable experience and add unique and personalized value to the service.

Dimensions of service experience During the past 20 years, there have been many empirical researches about different dimensions that would influence customers and also the staff on their service experience. (Bitner 1992, Bonin, Turley and Milliman (2000), Edvardsson 2005) Bitney (1992) introduced “Servicescape”, the term is a combination of service and landscape, refers to the physical environment which have a powerful impact on customer’s perceptions of the service quality and his/ her satisfaction level. It can elicit emotion, stimulate cognitive response and create physical response of both employees and customers. All these internal responses affect the social interaction between and among customer and staff and also affect their reaction to the service; approach or avoid. Approach behavior includes all positive behavior such as desire to stay, explore, work and affiliate, while avoid behavior are the opposite (Mehrebian and Russel 1974, and Bitner 1992). According to Bitner (1992) customers and employees perceive the environment holistically, as a composite of three dimensions: 1. Ambient Conditions: include background characteristics of environment such as temperature, lighting, noise, music and scent. They affect five senses. 2. Spatial Layout and Functionality: Spatial layout refers to the ways in which machinery, equipment and furnishing are arranged, the size and shape of them and the spatial relationship among them. Functionality refers to the ability of the same items to facilitate performance and the accomplishment of goals. 3. Signs Symbols, and Artifacts: refer to signage displayed on the exterior and interior of the structure. They are used as label, giving directions or communicate rules of behavior and a firm image.

Literature Review: Service Experience

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However, servicescape is only emphasized on physical environment and neglect the importance of customer as a co-creator of services. Later, Edvardsson et. al (2005) proposed another model, â&#x20AC;&#x153;Experience Roomâ&#x20AC;?, with six dimensions of service experience, which underlines the importance of the social interaction dimension (Pareigis, Edvarsson, and Enquist, 2011). 1. Physical Artifacts: physical sign, symbols, products and infrastructures. 2. Intangible Artifacts: nonphysical infrastructure, mental images, brand reputation, norms and values. 3. Technology: The nature and role of the equipment that customer interacts with, either positively or passively, not limited only to information and communication technology (ICT). It involves how service processes and carried out. 4. Customer Placement: the position of the customer in the service. 5. Customer Involvement: roles taken and enacted by the customers. 6. Interaction with Employee: the way customers contact with service provider.

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In conclusion, service providers need to be aware of every dimension of its organization, as customer often looks for clues that concern function and quality of a service (Berry, Carbone, and Haeckel 2002). Therefore, each of them needs to be carefully designed in order to create a favorable experience and the highest level of costumer satisfaction.

Literature Review: Service Experience

Emotion in Service Experience Introduction Emotion is one of the major components in a service experience. Throughout a journey, many customers reported to experience complex varieties of emotions, both positive and negative such as, angry, annoyance, frustration, happiness, pleasure and enjoyment. Emotions can elicit at any period of a service experience and sometime still present even after the consumption has ended (Wong 2004, Westbrook and Oliver 1991) Emotions can be used as an important indication of an over all service experience. They often remain in the memory of customers, which affect how customers categorize different services, how they perceive a service quality, their level of satisfaction, their relationship with a service provider and their future behavior (Wong 2004). In the book â&#x20AC;&#x153;Satisfactionâ&#x20AC;? (1997), Oliver mentioned that there is a connection between positive emotion and a higher level of customer satisfaction and an increasing of a repurchasing intention, while negative emotions, on the other hand can cause a customer to abandon a service. Furthermore, in an article Wong (2004) stated that the tendency of being loyally to the service is related to the feeling of enjoyment during the service experience. Therefore it is vey important to understand different emotions that take place during a service experience and factors that provoke them, in order to create a preferable service experience.

Literature Review: Emotion in Service Experience

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Definition of Emotion There are many ways that emotions are defined by psychologists according to different theories. From the evolutionary perspective, emotions are function as a survival mechanism of the species and individual (Desmet 2002), which adaptive to events that an individual considers harmful or beneficial to his or her safety and basic needs (Scherer 2005). Many psychologists in this field of study such as Ekman (1971), Izard (1977), Plutchik (1980) Tomkins (1984) and Frijida (1986) proposed a list of “basic” emotions (see Table 1). These lists of emotions are universally experienced; they exist in all cultures and also some of the higher organism. At the same time they can be recognized through different facial expressions. (Ortony and Turner 1990, Richins 1997)

Table 1

A List of Basic Emotions

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Ekman (1971)

Izard (1977)

Plutchik (1980)

Tomkins (1984)

Frijida (1986)

Anger Disgust Fear Sadness Joy Surprise

Anger Disgust Fear Joy Surprise Interest Distress Contempt Shame/Shyness

Anger Disgust Fear Sadness Joy Surprise -

Anger Disgust Fear Joy Surprise Interest Distress Contempt Shame

Surprise Interest -

Guilt

Expectancy Acceptance

Table 1: Example of the list of basic emotions mentioned by psychologists based on evolutionary theroy

Wonder Sorrow Desire Happiness

Another group of psychologists lead by Arnold (1960) proposed the “appraisal theory”, which is a subjective, cognitive evaluations of the personal significance of a situation, object, or event. According to the book “Cognitive science perspectives on personality and emotion” (1997), van Reekam and Scherer mentioned that potentially emotion-eliciting events include an individual’s perception of change in environment, individual’s perceived pleasantness or unpleasantness of the event, the importance of an event to an individual’s concern, the notion of who or what caused the event, the estimated ability to deal with the event and its consequences and the evaluation of individual’s own actions in relation to moral standards or social norms. However, type and intensity of emotions elicited by specific events vary among individual depending on his or her perception and evaluation. Furthermore, it is also affected by the individual’s personality, culture, concept of self-image and mood (van Reekam and Schere 1997, Scherer 1999) Literature Review: Emotion in Service Experience

Emotion in this study (Emotion in service experience) According to Westbrook and Oliver (1991) â&#x20AC;&#x153;Consumption emotion refers to the set of emotional responses elicited specifically during product usage or consumption experiencesâ&#x20AC;? In this study, based on appraisal theory, emotion is defined as a response to an evaluation of an external or internal stimulus event throughout a service experience, which is perceived to be significant to the individual. According to Scherer (2005), external event refers to a natural phenomenon or behavior of other people or animals, while the internal refer to oneâ&#x20AC;&#x2122;s own behavior, instantaneous neuroendocrine and physiological changes, memories and images that come to mind. Emotions can be very brief, lasting for a couple of seconds, or at most minutes with a relatively high intensity and tend to change rapidly due to a spontaneous evaluation of different external or internal stimulus event. (Ekman 1984, Scherer 2005) (see Figure 1). Figure 1

A Diagram Explaining Emotion in this Study Personal Evaluation of a significant external or internal stimulation event. Figure 1: This diagram explains emotion in this study: a response to an evaluation of an external or internal stimulus event

Internal Stimulus Event Emotion

External Stimulus Event

Literature Review: Emotion in Service Experience

Internal

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Personal Evaluation of a significant external or internal stimulation event.

For a service experience, external events are connected with a service delivery process and an organization of a service provider, which includes a social interaction; between customer and employee, among customers themselves, and also an impact of the physical environment. Internal events are connected with one’s personality, previously existing mood, memory about past experiences and existing relationship with an organization and staff. The response of the evaluation can either be behavior reactions, expressive reactions, physiological reactions or subjective feelings (Desmet 2002). 1. Behavior reactions: approach – avoid (see service experience) 2. Expressive reactions: facial, vocal and postural expression (happy – smile, anger - raised voice and compressed lips, fixed stare, contracted eyebrows and brisk movements) 3. Physiological reactions: the change in activity in automatic nervous system (increase in heart rate) 4. Subjective feeling: the emotional state that one is in at the moment (see emotion vs feeling)

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In conclusion, costumer may elicit various emotions though out different phases of a service experience depending on his or her personal evaluation of internal and external stimulus event. A certain occasion may provoke totally opposite emotions between two different people. Furthermore, an expression and a reaction of emotion is also varies among customers.

Describing Emotion Emotions can be described as discrete emotion expression (ex. happy, sad, angry, fear), or represented in structural dimensions underlying emotion categories such as pleasantness/unpleasantness, relaxation/ action, or calmness/excitement (Westbrook and Oliver 1991). For example, basic emotions by Izard (1977) and Ekman (1971) are accounted as discrete emotions, each emotion on both lists can be treated individually as the origin of language, the emergence of word and the expression can easily be distinguish from one another (Scherer 2005). However, psychologists tend to use dimension as an approach to structure an evaluation of self-report emotion, to represent the cognitive structure and to make them easier to understand by all group of people (Russell 1980). In addition, studies (Schlosberg 1952 and Russell 1980) show that emotions are best represented as a circle with two dimensions: ‘pleasant-unpleasant’ and ‘high arousal/ activation-low arousal/activation’. It also believed to be corresponded with the semantic different rating of emotional terms (Russell 1980).

Literature Review: Emotion in Service Experience

In the “Circumplex of Emotion” by Russell (1980) (see Figure 2), two axes represent each dimension; the horizontal axis represents “pleasantunpleasant” and the vertical axis represents “high arousal/activation-low arousal/activation”. According to the figure, the circle is divided into 8 octants which all fill a circle in the following order: pleasure (0°), excitement (45°) arousal (90°) distress (135°) displeasure (180°) depression (225°), sleepiness (270°) and relaxation (315°). Figure 2

“Circumplex of Emotion” by Russel (1980) Arousal (90°)

Displeasure (180°)

High Activation

Distress (135°)

Unpleasant

Pleasant

Low Activation

Depression (225°)

(45°) Excitement

(0°) Pleasure

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(315°) Relaxation

(270°) Sleepiness

Emotions are placed into the circle according to their dimensions (see Figure 3), based on Desmet (2002), adapted from Russell (1980) and Watson and Tellegen (1985) Even though emotions can be defined within these two dimensions, Desmet (2002) claims that it is not enough to differentiate one emotion from another as some of the emotions fall in the same octant but they are completely different emotions. (ex. fear – anger)

Literature Review: Emotion in Service Experience

Figure 2: Circumplex of Emotion (Russell 1980), emotions are differentiated with two dimensions: Unpleasant - Pleasant and High arousal - Low arousal

Figure 3

“Circumplex of Emotion”, Based on Desmet (2002) adapted fom Russell (1980) and Watson and Tellegen (1985) Astonished Stimulated Distressed

Active Aroused

Fearful

Surprised

Anxious

Intense

Jittery Nervous

Unhappy

Elated Excited

(1)

Lively Peppy

Happy Delighted

(6)

Unpleasant

(5)

Pleasant

Low Activation

Dull Tired Drowsy Sluggish Bored Droopy

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High Activation

(7)

Miserable Sad Grouchy Gloomy Blue

Euphoric

(8)

Annoyed

Figure 3: Circumplex of Emotion (Desmet 2002), example of emotion words placed on the circle according to their dimensions.

Enthusiastic

(4) Quiet Tranquil Still Passive Inactive Idle

(3)

(2)

Glad Cheerful Warmhearted Pleased

Relaxed Content At rest Calm Serene At ease

Terms that Related to Emotion Literatures on emotion in every field of study (e.g. psychology, consumer behavior, sociology) often mention terms such as “affect”, “emotional trait”, “feeling”, “mood” and “personality”, which sometimes are mistaken with the word “emotion” or used interchangeably in everyday language. However, based on psychological theory, there are relations and differences between each of them.

Affect vs Emotion

Affect is a general term that refers to an evoked internal feeling state, which include feeling, emotion and mood (Ellis and Moore 1999)

Literature Review: Emotion in Service Experience

Mood vs Emotion There are three main differences between emotion and mood: duration, intensity and cause of existence. Emotion often lasts for a short period of time, no longer than minutes with a relatively high intensity (Ekman 1984, Scherer 2005) while mood can last from several hours to several days with less intensity (Desmet 2002, Ellis and Moore 1999). In addition, mood is more subtle, able to emerge without any specific causes and relates more to the surrounding (Scherer 2005, Ellis and Moore 1999, Frijida 1994). Unlike emotion, which is only elicited by a particular reason and one is usually able to identify a cause of his or her emotion (Desmet 2002). However, there is a connection between mood and emotion. The type and intensity of emotions is subject to change when mood is present. For example, when one is in an irritable mood, he or she tends to be angry easier than a person in a happy mood. (Frijida 1994).

Feeling vs Emotion

Even though emotion and feeling can be described by using same terms such as happy, sad, fear and shame, there are differences between both of them. Damasion mentioned in an interiew with Lenzen (2005), in Scientific American, that feeling is a result of a brain interpretation of emotion, which usually happens consciously after one becomes aware of his or her physical change. For example, when one is afraid of something, he or she experiences many physical reactions such as heart beating fast and mouth becomes dry, which occur unconsciously. As a result, when he or she becomes aware of these physical changes, as an emotional reaction, then he or she experiences a feeling of fear.

Personality vs Emotion

Personality can be described as a combination of individual characteristics that account for his or her consistent pattern or feelings, cognition, and behavior. (Weinstein, Capitanio and Gosling, 2008) According to the book “Handbook of Personality: Theory and Research”, one of the most common trait taxonomy that is used to explain personality dimension is “the Big Five”, which is derived from the analysis of the terms that people use to described themselves and others. It consists of five dimensions: 1.Openness/Originality/Open-Mindedness: breadth, depth and complexity of an individual’s mental and experiential life. A person who is an Openness usually has wide interest is imaginative, intelligent, curious, creative, sophisticate, artistic, inventive and resourceful. Literature Review: Emotion in Service Experience

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2. Conscientiousness/Constraint/Control of impulse: Socially prescribed impulse control that facilitates task and goal directed behavior. A person who is a Conscientiousness usually thinks before acting, follows norms and rules, organizes and prioritizes task, is efficient, reliable and responsible. 3. Extraversion/Energy/Enthusiasm: an energetic approach to the social and material world. A person who is an Extraversion usually sociable, outgoing, enthusiastic, assertive, dominant, talkative, adventurous and has a positive emotion. 4. Agreeable/Altruism/Affection: prosocial and communal orientation toward others with antagonism. A person who is an Agreeable is usually warm, tender-mindedness, trusting, helpful, kind, sympathetic, generous, forgiving, friendly and sensitive. 5. Neuroticism/Negative emotionality/Nervousness: contrasts emotional stability and even-temperedness with negative emotionals such as feeling anxious, nervous, sad and tense. A person who is a Neuroticism is usually moody, worrying, emotional, unstable, self pitying and despondent. Personality is considered one of the factors that differ individual tendency to experience specific emotions. For example, in a similar situation, a person who is an Neuroticism is more likely to experience a negative emotion when compared to a person who is an Extraversion. -16-

Emotional study (Emotional measurement method) For more than thirty years, researchers from different area of study such as psychology, sociology, consumer behavior, and designer, have been proposing many methods for studying emotions. They can be categorized into three different groups: (Parrott and Hertel 1999, p. 73) 1. Self-report: verbal self-report and visual self-report. Example of methods: DES: Differential Emotion Scale (Izard, 1977), EPI: Emotional Profile Index (Plutchik, 1980), PAD: Pleasure-Arousal-Dominance (Mehrabien and Russel, 1974), CES: Consumer Emotion Set (Richin, 1997), PANAS: Positive/Negative Affect Schedule (Watson, Cark and Tellegen,1988), SAM: Self Assessment Manikin (Lang 1980), PrEmo (Desmet, 2002) 2. Behavioral and Cognitive Indices: detect behaviors and cognitive patterns that are associated with emotions. Example of methods; psychomotor retardation and facial expression such as gaze aversion or blushing in case of embarrassment. 3. Psychophysiological Indices: include a study of the nervous system (neuroscience) and the brain image. Examples of method: a measure of heart rate, blood pressure, skin conductance, finger temperature and respiratory and eye movement variability, EMG electromyographic

Literature Review: Emotion in Service Experience

Out of all methods listed above, verbal self-report is considered the most common for studying emotion in a service experience. For example, Edwardson (1998) used a set of questionnaire, “service experience survey”, to measure customers’ recall of emotions in service encounters, and Vinager and Neves (2007) used DESII scale for assessing patient emotion over service health care experience. Not only because it is the most convenient in comparison to other methods, but also inexpensive and more flexible due to the fact that it doesn’t require any specific equipment or expertise. However, there are many criticisms toward the use of this method. One of them is, emotion sometimes occurs unconsciously (antecedent appraisal process) and is usually hard to define. As a result, individual might not be aware of its existence or is unable to distinguish it. In addition, self-report is normally conducted after the whole experience is completed. Therefore, responses from participants are more likely to depend on their cognition interpretation and recall memory of the experience, which might be different from their actual emotions. In some cases, participants may alter their responses in order to construct a rational reason for their emotions or make it correspond with the researcher’s expectation. Therefore, the use of some research tools such as questionnaire is believed to have an influenced on participants’ responses. (van Reekum and Scherer 1997, Parrott and Hertel 1999). -17-

Despite all the criticism, self-report is the only method that allows participants to verbalize their emotions that occur consciously, which is believed to be very significant for the service experience as they remain in customers’ memories, affect how they perceive the service and their post purchase consumption. (Oliver 1996)

Literature Review: Emotion in Service Experience

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Area of study: Waiting in a Hospital Waiting Room

Literature Review

Health Care Experience Heath care is a complex service organization, made up of a combination of different systems, which involve a number of stakes holders such as administrator and manager, medical practitioner (doctor, nurse), hospital staff, patients and companion/care giver (friends and family). A number of health care providers, both hospital and clinic, often focus on improving their operational system or implementing advance technology for diagnosis and a treatment of diseases in order to enhance their service quality. However, in order to differentiate themselves among health care providers, not only the medical aspect needs to be improved but also the non-medical aspect of service as well. Many studies showed that patients have difficulty in evaluating the medical aspect of the service, therefore he or she often take every non-medical aspect of an entire range of service providers into account for his or her judgment over an overall quality of the service. Handschieff J. mentioned that customers take medical competence for granted, because it is easier for them to judge how they were treated by health care organization and staff (e.g. how friendly a welcome is, how complaints and suggestions are handled, how pro-active services are implemented) than their healing process. Based on the definition of service experience (see p.10), health care experience refers to how health care customers (patient, companion, visitor) experience every dimension of a health care throughout a health care consumption. It starts even before his or her arrival at a health care institute and ends long after a visit. It involves, for example, how one heard about the service, ease of access, responsiveness and competence of staff (assurance and empathy), interaction between customer and physical environment, equipment and facilities of the health care institute and interaction among health care customers themselves (Gabbott and Hogg 1996). Health care experience varies depending on different type of health care providers (hospital, clinic) and the different roles of health care customers (patient, companion, visitor). For example, an experience when going to the dentist for a wisdom tooth removal is not going to be the same as visiting a friend at a hospital. In addition, memorable experience is a key to a hospital sucLiterature Review: Health Care Experience

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cess as it improves treatment outcome and patients’ perception of service quality, which affect their future retention (van Thiel, Janssen and Fonteijn (2009). Recently, awareness on creating favorable patient experience has increased in many health care providers. Not only “Patient-centered” is listed as one of the six aims for improving health care quality in 21st century by the Institute of Medicine (IOM), but it was also already implemented in many hospitals. For example, the Kaiser Permanente hospital, in the United States, carried out the “Total Health Environment program” in order to find out all problems and difficulties in a total health care experience by conducting observation and interviews with all participants including doctors, nurses, other hospital staff, patients and companion, and Odense University Hospital (OHU), Denmark, started the “Patient Hotel”, which aims to deliver a better experience for patients, relatives and staff by offering a safe, flexible, and service-oriented alternative to traditional hospitalization (Park 2009).

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In conclusion, Ericson (2009) mentioned that it is important to take every dimension of health care experience in consideration, not only tangible touchpoints but also emotional as well. An effective experience must be designed to provide appropriate information, empowering patients with a sense of control, and create an atmosphere of trust and care along with anticipating patient’s expectations.

Literature Review: Health Care Experience

Emotion in Health Care Experience The fundamental of a health care service is associated with “well-being” and “cure” of individual, (Gabbott and Hogg 1996), which includes many activities that concern a life threatening and life-changing events of oneself or his or her love one. (Brunton 2005) Thus, emotion, such as anxiety, despair, anger, happiness, hope, compassion, joy, fear and distress, is an inevitable part of a health care experience of everyone who is involved, especially patients (Brunton 2005). It influences patient perception of service, which affects his or her treatment and recovery process. Patients with positive emotion often have a promising outcome after treatment while patients with negative emotion have greater risk of an unfavorable result, and these lead to a demand of different medical care carried out by hospital staff. Most of the time negative emotion happens when patient’s expectations are not fulfilled. It usually relates to all aspects of a health care service, from waiting time, amount of time visiting, medical care process, response from hospital staff to facility provided, which is subject to change throughout an experience. Thomas (2003) mentioned in “Anger: the Mismanaged Emotion” that anger can be caused by feeling of vulnerability, loss of control, intrusive procedure, inefficiency of system, a receipt of bad news about a disease and lack of competent staff. In addition, negative emotion, such as stress and anxiety, can also be elicited by poorly-designed health care setting due to lack of physical comfort, incongruence with individual needs and unfamiliar character of an environment. At the same time, a well-design physical environment can be a source of coping resources. (Leather, Beale, Santos, Watts and Lee 2003). In conclusion, it is important for medical staff to understand patient emotions during every phase of health care experience and also the cause of them, in order to provide a favorable service, which reduces negative emotions and create positive ones.

Literature Review: Emotion in Health Care Experience

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Waiting in Health Care Experience Introduction

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Waiting is an unavoidable problem in health care due to increasing demand because of growing in population of elderly, improving in technology, higher patient expectation and higher incidence of lifestyle diseases. It is associated with delays, expectation, putting off and pause (Suzanne 2001), which health care customers (patient, companion, visitor) often associate as an indication of a service quality that affect his or her satisfaction. Empirical studies show that patientâ&#x20AC;&#x2122;s satisfaction increase when actual waiting time is less than expected, while waiting longer than expected may contribute to dissatisfaction. (Leddy, Kaldenberg, Becker 2003) In general, waiting is caused by uneven supply and demand, which is caused by a poorly organized health care system, characterized by a lack of flow in the system and long service time. That can be caused by shortage of health care staff or lack of cooperation among hospital staff, and results in queuing problems.

Types of waiting in health care There are three different types of waiting in health care (Fogarty and Cronin 2008) (see figure 4).

Literature Review: Waiting in Health Care Experience

1. Patients waiting for outpatient appointment across a wide variety of disciplines: refers to the period between a patient not feeling well or suspect oneself of having any kind of disease and a visit to a health care provider (hospital, clinic). It can be eliminated if a patient goes directly to a health care provider. However, some health care providers require patient to make an appointment in advance. 2. Waiting for diagnosis: refers to the period after a patient has arrived at the health care provider (hospital, clinic), and waiting for a diagnosis or a treatment or any health care activities (e.g. blood testing, X-ray) in a waiting area provided. 3. Waiting for treatment phases: refers to the period between a diagnosis and a treatment. During this phase, patient has already met a doctor and known what kind of disease he or she is experiencing along with the treatment procedure. The waiting may be caused by unreadiness of patient’s health condition or insufficient health care supply (e.g. medical staff, facilities, equipment). It usually takes place in the areas of cancer treatment, coronary care, organ transplant or elective surgery of all types. In case of a long waiting period, patient’s physical or mental condition may affect his or her social life. For example, patients were unwilling to make plans and gave up many social activities. Note: This research is only focusing on a “waiting for diagnosis phase” -23-

Waiting for diagnosis (1)

Pre-Treatment Sick

Waiting

Going to Hospital

Welcome (Register)

Waiting

Diagnosis

(3) Waiting for outpatient appointment

(2) Waiting for treatment phase

Waiting

Treatment

Post Treatment (personal) Figure 4

Three different types of waiting in healthcare Figure 4: The diagram show different phases of a patients’ journey and the different types of waiting in healthcare.

Literature Review: Waiting in Health Care Experience

Post Treatment (at hospital)

Post-Treatment

Impact of waiting in health care on patient Waiting in health care may result in a number of physiological and psychological consequences, which have both negative and positive effects on a patient. Some patients report that waiting provide them time to prepare and adapt oneself, physically and mentally, to a treatment (Suzanne 2001). However, most patients mention experiencing many negative physiological consequences: intensification of pain, worsening of the condition of the sympton, and several psychological consequences: the feeling of psychological distress, such as anxiety, frustration, anger and depression. In addition, waiting leads to negative patientâ&#x20AC;&#x2122;s perception toward the quality of a health care provider as it signals poorly organized process, which may cause an early departure from a treatment or a switch of health care provider.

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Literature Review: Waiting in Health Care Experience

Emotion in a Waiting Room Waiting room is a main area where patient and his or her companion spend their time before a diagnosis or a treatment. It is often perceive as a place of desperation, impotence, senseless and destructive, a “nightmare bureaucracy where health care customer are physically contained within alienating bureaucratic structures and a liminal space where hope paused” (Strathmann and Hay 2009). However, it is considered one of the major features in the beginning of the health care experience, which has a lot of influence on the following medical activity. Therefore, it is very important for the waiting room to both elicit positive emotion (e.g. please, satisfied) and cope with negative emotion (e.g. stress, anger, anxiety) of a patient. According to Fogarty and Cronin (2008), patients experiences negative emotion, such as stress, anxiety, anger and frustration, while waiting for a diagnosis or treatment as result of feeling uncertain and powerless due to an unidentified health problem, unknown treatment procedure and anticipation of a response from medical staff to his or her need. Furthermore, events such as a long waiting time, a delay of an appointment, a poorlydesigned interior, an unfair or unclear waiting system, or incompetent staff, may intensify those negative emotions. However, they vary among individual owing to context and reason of visiting (Leddy, Kaldenberg and Becker 2003). However, there are different methods to cope with negative emotions. For example, making waiting bearable and perceived shorter than it really is by providing a comfortable waiting area with a lot of facilities (e.g. television, music, magazine, drinking zone)(Leddy, Kaldenberg and Becker 2003). Ulrich (1991) mentioned “a theory of supportive design”, a basis of a health care environment that help dealing with stress and promote wellness, which consists of three components: 1. Health care facilities should provide sense of control with respect to physical-social surrounding 2. Health care facilities should provide access to social support 3. Health care facilities should provide access to positive distractions in physical surrounding

Literature Review: Emotion in a Waiting Room

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At the same time, a receptionist can help calm a patient down from fear, upset, frustration and anger of being paused or stopped from a treatment by reassuring the patient that he or she will care for the patient until a physician is available (Emotional labor) (Strathmann C.M. and Hay M. C. 2009). In conclusion, it is essential to identify different emotions of patients that take place in a waiting room and factors that provoke them, both by an external stimulus event and internal stimulus event (see emotion in this study p.11), in relation to dimensions of a health care experience (see dimension of service experience p.7) in order to provide an appropriate health care service that would maintain or enhance positive emotion and cope with negative emotion, which will result in a favorable health care experience.

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Literature Review: Emotion in Waiting Room

Research Methodology The research is divided into 2 phases: First phase – Exploration: gathering general information about the topic “Emotional study in a waiting room of a health care provider” Second phase – Case specific: field research – Clinical Immunology (Immunologische Ambulanz), St. Josef Hospital, Bochum

Research Methodology

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Timeline

Figure 3

Research Methodology

Research Methodology Timeline Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Oct

First Phrase -28-

Creating tools Field Reseach Data analysis

Second Phrase Improving/ creating tools Field Reseach Data analysis

Research Methodology: Timeline

First Phase: Exploration

First Phase: gathering general information about the topic â&#x20AC;&#x153;Emotional study in a waiting room of a health care providerâ&#x20AC;?

Introduction Not only health care systems vary from country to country, but also health care providers. The purpose of the first phase is to understand waiting situations in different health care providers concerning emotions that people who are involved in health care (patient, companion, visitor and health care staff) experience while waiting in any health care providers and factors that elicit them. This basic understanding will determine research methods and tools used in a field research of the second phase, a case specific.

Research Methodology: A field research of the 1st phase was conducted in a two-months period (March - May 2011) 1. General interview with hospital staff, patients and companions 2. Observation in waiting rooms of different health care providers 3. Questionnaire 1. General interview with hospital staff, patients and companions.

Method: A personal interview was carried out with eleven people who are involved in a health care service: three health care staff, six patients and two companions. Each participant was asked to describe emotion that they experienced while a waiting in any health care provider and the factor that elicited them.

Research Methodology: First Phase

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Objective: 1. Gain more insight about the topic, including general information about health care system and differences between each type of health care provider. 2. Find out the emotions that the participants recall from their memories and the factors that provoked them in relation to service experiences, in order to acquire a set of factors, which will be used in a 2nd phase. Process: 1. Conduct a personal interview 2. Data analysis 1. Conduct a personal interview A personal interview was conducted during a one-month period (March - April 2011). The date and place of the interview were held on requested of each participant. They were asked to recall any waiting experience in any health care provider and responded to the question â&#x20AC;&#x153;Please describe any waiting experience in any type of health care providers, which you encountered strong emotionsâ&#x20AC;?.

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2. Data analysis From the interviews, participants used many emotional terms, such as frustrated, excited, worried, satisfied, stressed, bored, fear, afraid, calm, relax, normal, anxious, nervous, and angry, when describing their waiting experience in different health care providers. A waiting experience in hospital is often associated with strong and negative emotional terms such as angry, worried, stressed and fear, while a waiting experience in clinic is often associated with emotional term such as calm, relax, satisfied. These different emotions were caused by several factors such as unfair waiting system, staff lack of competence and personal health condition. The list of factors mentioned by all the participants are categorized into two groups according to a source of event that elicit emotion (see emotion in this study p.11). 1. Internal stimulus event 2. External stimulus event Internal stimulus event factor Internal events are connected with oneâ&#x20AC;&#x2122;s personality, existing mood, memory about past experience and existing relationship with an organization and employee.

Research Methodology: First Phase

1. Personality Participantsâ&#x20AC;&#x2122; personality such as introverted and extroverted, affect their emotion in the waiting room. One of the participants mentioned that she likes to be by herself, so she was annoyed when there were people trying to talk to her. 2. Existing mood Existing mood has effect on how participants elicit emotions. Participants reported being able to tolerate a long wait when they were in a good mood. 3. Health condition (good/bad/unknown) 3.1 Personal health condition 3.2 Health condition of friends and families There is a correlation between their health condition and the emotions that they experienced; the severer the condition the stronger negative emotions the participants experiences. For example, they experienced strong negative emotions when there were physical sign of severe symptom such as bleeding, swelling or participants were suffering from pain. In case of regular health check up, participants often feel calm and relax. Further more, participants were likely to experience strong negative emotions such as worried, anxious, stress, nervous and fear, when the cause of sickness was unknown. 4. Memory about a past health care experience (personal experience related to all aspect of health care) Personal experience has a lot of influence on emotions elicited in a current experience, one participant mentioned always being afraid waiting for dentist owing to a bad experience in his childhood. Further more, participants tend to use past experiences as a standard and often set up their expectation according to it. For example, one participant mentioned getting angry because the waiting time at the hospital â&#x20AC;&#x153;Aâ&#x20AC;? is much longer than an other hospital that he used to visit. 5. Existing relationship between patient and health care provider; organization and health care staff A good relationship with health care provider (organization, health care staff) often leads to a positive emotion while waiting for the service (e.g. satisfaction, pleased). Participants mentioned feeling more relax and comfortable when going to a doctor who is kind, gave a good treatment and a good advice during the last visit. On the other hand, participants mentioned feeling unhappy, concerned or hesitant when visiting a doctor who is not friendly or gave a poor response, which sometimes result in postponing the visit or switching a provider.

Research Methodology: First Phase

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External stimulus event factor 1. Waiting time (perception of the waiting time) There is a strong relationship between waiting time and elicited emotion. Not only long waiting (even with appointment) often leads to boredom, but also anxiety and nervousness owing to a fear of being forgotten by health care staff. However, participants reported to be very happy when the waiting time is shorter than ten minutes, and still satisfied if it does not exceed one hour.

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2. Waiting room 2.1 Facility in waiting room (refer to any tangible object) Even though there are different varieties of facilities available in a waiting room such as refreshment area, reading material and entertainment devices, participants often mentioned feeling frustrated as a result of experiencing physical restrain owing to a restriction of space and unable to perform normal activities. However, some mentioned reading magazine and drinking water, juice or coffee, helped to cope with stress and be more relaxed. At the same time, the interior design of a waiting room can also elicit emotion. Some participants felt uneasy and awkward when having to sit facing others in a U- shaped seating arrangement or sitting too close to another people. At the same time, some were angry at a poorly designed chair with fixed armrest, which makes it impossible to lie down when suffering from pain. 2.2 Atmosphere of the waiting room (related to five senses) Participants mentioned that loud ambient noises, such as loud talking voice, a crying baby and a construction sound from a site near by, and also strong smells, such as perfume from other people in the waiting room caused irritation. At the same time, insufficient lighting or poorly designed lighting lead to depression, difficulty when reading and headache. 3. Interaction 3.1 Between patient and companion Participants reported receiving emotional support from companion. Conversations between them made participants more relaxed and more secure. 3.2 Between patient and other people in the waiting room Some participants reported enjoying a conversation with other patients during waiting, while some felt uneasy, uncomfortable or annoyed. Most of the time elicited emotions depended on the people that they met, the conversation they had and their current mood.

Research Methodology: First Phase

4. Performance of health care staff Performance of staff is one of the factors that elicited a variety of emotions. Participants reported being satisfied when health care staff were able to respond to their request and fulfill their needs. On the other hand, they were angry and frustrated when health care staff were not able to fulfill their requirement or made mistakes. Further more, lack of feedback or response from staff often leads to fear and worriness of being forgotten. In addition, participants mentioned feeling angry when staff didnâ&#x20AC;&#x2122;t speak politely and react with a negative attitude and felt intimidated, shame and embarrassing if staff asked a very critical or personal question. At the same time, misunderstanding of technical terms used by staff often leads to anxiety as health condition is perceived to be more severe. On the other hand, participants reported feeling calm, relaxed and less stressed when received empathy from staff. 5. Waiting system Participants felt frustrated if the waiting system was complicate, unfair and not transparent. However, relations between emotions and factors are not always one to one. Most of the time, an emotion was elicited by a combination of many factors. For example, a participant felt angry, because she was at the hospital for the first time therefore she was not used to the waiting system and it was complicated and she had to wait for a long time while suffered from pain. In addition, external stimulus event factors can intensify or help cope with emotions elicited by internal stimulus event factors. For example, a participant reported being very anxious when the cause of a health condition was unknown (internal stimulus event factor), but later she was less anxious and more relaxed after receiving a warm welcome from a hospital staff (external stimulus event factor) Note: Individual differences such as gender, age, religion, cultural background and education, are not taken into consideration when analyzing this list of factors

Research Methodology: First Phase

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2. Observation in waiting rooms of different health care providers

Method: Hidden observation was carried out in eight waiting rooms of different health care providers: three hospitals, dental clinic, ophthalmology clinic, internal clinic and gynecology clinic, by using observation sheets, in order to better understand the situation. Note: The amount of time spent per each observation varied from one to three hours depending on the situation.

Objective: 1. Gain more insight about health care systems and services of different health care providers. 2. Gain more insight about physical environment and provided facilities in waiting areas of different health care providers. 3. Find out a general behavior of patients in a waiting room and the influence of the given facility on their behaviors. 4. Find out interactions between patients and other people who are involved in the process such as companions, other patients and staff.

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Process: 1. Creating an observation sheet 2. Using the observation sheet to collect the data while conducting a hidden observation in eight waiting rooms of seven health care providers 3. Data analysis 1.Creating an observation sheet An observation sheet was used as a guideline in every observation in order to easily compare and interpret the results. It contains the following information: - General information about the visit (date, time, location) - General information about a physical environment of the waiting room (room size, color of walls and ceilings, seating arrangement, type of chair, number of seat, provided facilities) - General information about an atmosphere of the waiting room (room temperature, source of lighting, ambient sound/sound, scent) - Average number of people in the waiting room at a specific time (every 15 minute) - General behaviors of the people in the waiting room - Personal comments about the waiting room and behavior of people - Specific events that take place - Detailed observation of patients and companions throughout the waiting experience (precise behaviors, register time, total waiting time)

Research Methodology: First Phase

2. Use the observation sheet to collect the data while conducting a hidden observation in eight waiting rooms of seven health care providers Hospital 1. University Hospital of Cologne: General, Visceral und Thoracic Surgery (Universität Köln Klinikum: Allgemein, Viszeral und Tumorchirurgie)

2. University Hospital of Cologne: Emergency Department (Universität Köln Klinikum: Zentrale)

3. Maria-Hilf Hospital : Emergency Department (Maria-Hilf-Krankenhaus : Notfallaufnahme)

4. Hospital Augustinerinnen: Emergency Department (Krankenhaus der Augustinerinnen: Notfallaufnahme)

Clinic 1. Internal Medicine Clinic (Fachärztin für Innere Medizin)

Research Methodology: First Phase

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2. Ophthalmology Clinic, Maus (Augenzentrum, Maus)

3. Dental Clinic, Dr. E. Lieman (Dental clinic Zahnartzpraxis, Dr. E. Lieman)

4. Gynaecology, Ursula Schmidt (Gyn채kologie, Ursula Schmidt)

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3. Data analysis

There are several distinctive dimensions of health care service regarding waiting experience between hospital and clinic, such as, the physical environment of waiting room, interaction of staff, waiting time and a health condition of patient, which influence behaviors and interactions of people in the waiting room (see Table 2).

Picture 1: Sample of the filled observation sheet

Research Methodology: First Phase

Table 2

Observation analysis: Comparision between hospital and other health care institute Hospital

Other Health Care Institute

Waiting time

Wide range of waiting time from 10 min. to more than 3 hours (even with an appointment)

Average no longer than 30 minutes

Waiting room

Poorly design, bad lighting (felt headache after sitting for a while), material and furniture used for the interior makes it looks cheap and dirty. One has no magazine and newspaper or water provided. There is a children’s zone with small chair and table but only a few toys and no books.

Waiting room is well-designed, comfortable atmosphere. Magazine and newspaper are provided together with a drinking zone. Out of four, only one place has children’s zone, there are many toys and books.

-37Picture 1: A waiting room for Allgemein, Viszeral und Tumorchirurgie: Universität Köln Klinikum

Picture 2: A waiting room at Augenzentrum

Interaction with staff

Less contact with staff, which seem busy and in a hurry.

Easy access to staff, which are always available, friendly and welcome.

General Behavior

People seemed worried, hesitated and bored. Most of them read books/ magazines or engage themselves with personal devices, such as mobile phone, game and camera. Some just sit still looking around the room or with their eyes close. Often go out to toilet, get a drink and snack or go walk around outside the waiting area for a while. Some ask staff for their turn and complain to staff of with other patient after waiting for longer than one hour. Kids normally running around, playing at the children’s zone and sometimes cry.

People perceived to be more relax and calm. They often occupy themselves with book and magazine or have a conversation with their companion. Sometimes drink the water that was provided. Some listen to music and put make up on. They rarely leave the waiting area.

Research Methodology: First Phase

In addition, behaviors of subjects in the waiting room are categorized into four categories according to the underlying intentions: 1. An act of engaging oneself While waiting, subjects tended to occupy themselves with different types of activities such as reading newspaper, book and magazine, talking to their companions, looking around the room or at other people in a waiting room, playing in a provided area, listening to music, or putting make up on. According to â&#x20AC;&#x153;the psychology of waiting linesâ&#x20AC;?, Maister (2005) mentioned that occupied time feels shorter than unoccupied time, therefore an act of engaging oneself with these behaviors would make the subjects feel that a perceived waiting time is shorter than the actual waiting time 2. Compensating behavior for the long waiting Many behaviors were not intended to be conducted because of their main purpose but to compensate for long waiting hours. For example, a subject drank coffee and water from a refreshment area not because he or she was thirsty but to utilize a provided facility in order to compensate for their long waiting time.

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3. Physical reaction While waiting subjects may feel powerless and uncertain or experience psychological distress such as anxiety, frustration, anger and depression, which lead to physical reactions such as going to toilet more often than usual, asking hospital staff about his or her turn to gain more control in the situation and complaining about a long waiting with other people in the waiting room to feel relieved from negative emotions. 4. An act of escaping Poorly designed interior and unpleasant atmosphere of a waiting room lead to an act of escaping, such as going to toilet, going outside, and going out to get coffee, as an excuse for a short escape from the space. For example, subjects went outside to get a coffee not because he or she was thirty but to change the atmosphere and get out of the same environment. Note: Individual differences such as gender, age, religion, cultural background, personality and education, are not taken into consideration when analyzing the observation data.

Research Methodology: First Phase

3. Questionnaire

Method: The questionnaire in both paper and online format was handed/sent out within a three-weeks period (14h April 2011 â&#x20AC;&#x201C; 3rd March 2011). Objective: 1. Find out emotions that participants experienced while waiting in any type of health care providers 2. Find out the relationship between type of health care provider and emotions that participants experienced while waiting 3. Find out the relationship between reason of a visit and emotions that participants experienced while waiting Process: 1. Creating the questionnaire sheet in two formats (paper and online) 2. Handing/sending out questionnaires in both formats 3. Data analysis

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Picture 2: Sample of the filled questionnaire sheet.

1. Creating the questionnaire sheet in two format (paper and online) 1.1 The information aimed to be acquired from the questionnaire - General information about the participant (age, gender) - A name of the health care provider that often visit - The time of the last visit - The reason of a visit - Emotion that experienced

Research Methodology: First Phase

1.2 Selecting the emotion words The list of emotions in the questionnaire based on three emotion theories. 1. The primary emotion by Plutchik (1980): fear, anger, joy, sadness, acceptance, disgust, expectancy, surprise 2. The fundamental emotion by Izard (1977): anger, disgust, fear, joy, surprise, interest, distress, contempt, shame/shyness, guilt 3. The circumplex of emotion by Watson and Tellegen (1985): enthusiastic, euphoric, elated, happy, pleased, joy, relaxed, calm, serene, passive, inactive, idle, tired, drowsy, bored, sadness, gloomy, melancholy, anxious, nervous, annoyed, strong, active, aroused The repeated emotion words were eliminated before they were translated to German language based on the paper “Emotionen von Berufsschülern bei selbstreguliertem Lernen – Eine Interventionsstudie” by Grieder, Sandra K. (2006) and placed into the circumplex of emotion (Russell 1980) in order to define the dimension of each word. As a result, there were a total of 35 emotion words (see Figure 5).

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Note: There are many measuring methods based on these three theories. EPI (Emotional Profile Index) method based on the primary emotion, DES I and DES II (Differential Emotion Scale) based on the fundamental emotion and PANAS: Positive/ Negative Affect Schedule method based on the circumplex of emotion. These emotion measuring methods, especially DES and EPI, are commonly used in consumer research (Westbrook and Oliver 1991).

2. Handing/sending out questionnaires in both formats Within a three-weeks period (14h April 2011 – 3rd March 2011), the paper questionnaire was handed out to people in the city of Cologne while the online questionnaire were randomly sent out to people in any area of Germany. 3. Data analysis There were a total of 81 participants responded to both format of questionnaires (paper and online): 50 male, 30 female and 1 unknown. The different clusters of the frequently responded emotions can be seen when the collected data from questionnaires was categorized by different types of health care providers, and reason of visit. Furthermore, besides the provided lists of 35 emotions, participants also mentioned other emotions: Wütend (angry), Deprimiert (depressed), Ohnmächtig (powerless), Unzufrieden (dissatisfied), Genervt (annoyed), Besorgt (worried), Trostlos (discomfort), Unruhig (disturbed) and Gestress (stressed).

Research Methodology: First Phase

Figure 5

The 35 emotion words in the questionnaire placed on the Circumplex of emotion (Russel 1980) Stark (Strong) Aktiv (Active) Erregt (Aroused) Überrascht (Surprise) Erwartung (Expectancy)

Traurig (Sad) Niedergeschlagen (Gloomy) Schwermütig (Melancholy) Verachtung (Contempt) Scham (Shame)

High Activation

Gequält (Distress) Furcht (Fear) Ängstlich (Anxious) Ekel (Disgust) Ärger (Anger) Nervös (Nervous) Verärgert (Annoyed)

Unpleasant

Glücklich (Happy) Zufrieden (Satisfied) Fröhlich (Joy) Freude (Enjoyment) Interessiert (Interest)

Pleasant

Low Activation

Müde (Tired) Schlaff (Drowsy) Langweilig (Bored)

Begeistert (Enthusiastic) Euphorisch (Euphoric) Übermütig (Elated)

Entspannt (Relaxed) Ruhig (Calm) Gelassen (Serene) Akzeptanz (Acceptance)

Passiv (Passive) Inaktiv (Inactive) Untätig (Idle) Figure 5: 35 emotion words used in the questionnaire, both in English and German, placed on the CIrcumplex of emotion according to their dimensions

The collected data from questionnaires was categorized into three groups: categorized by age of the participants, categorized by reason of a visit (feeling sick or having disease, body examination or health check-up and as visitors or companions) and categorized by type of health care providers (hospital and other health care provider) (see Table 3). Note: The emotions responded from the collected data is placed on a circle with two dimensions “pleasant-unpleasant” and “high arousal – low arousal”, based on “Circumplex of Emotion” (see Describing Emotion p.12-14) in order to make it easier to distinguish and compare the result as a cluster of emotions with the same dimension.

Research Methodology: First Phase

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Table 3

The result of the questionnaires. Categorize by age (years) Total Male Female Unknown

Under 20

Male Female

1 -

20 - 30 Male Female

30 - 40 Male Female

40 - 50 Male Female

50 - 60 Male Female

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81 50 30 1

Categorize by Reason of Visiting 1. Feeling sick or having disease (Illness, Operation, Emergency)

22 12 10

Over 60

Male Female

5 1

Unknown

Total

Male Female Unknown

14 2 1

Total

3. As visitors or companions

10 1 5 -

26 14

2. Body examination or health check-up

17 18

Male Female

Categorize by Type of Healthcare 1. Hospital Male Female

33 16

Total

2. Other health care providers (Augenartz, Hausartz, Frauenärztin Praxis, Zahnartz, Internist, etc)

Male Female

3 2

Total

3. Unknown

Male Female

3 10

Male Female

4 5

Total

4. Ohters (Others, Unknown)

Male Female

7 1

Total

Table 3: The result of the questionnaire represents the number of the responses from participants according to the different catagories.

The diagram (see Figure 5) represents all emotions that participants reported experienced while waiting in any type of health care providers. Size and darkness of letters represent a frequency of responses: the bigger and darker a letter is the more frequent the emotion was responded by the participants. Bored, expectancy, nervous, anxiety, angry, tired and clam are seven most mentioned emotions. According to the circumplex of emotion, participants associated with emotions that are “Unpleasant-Excited”: nervous, anxiety, angry, “Unpleasant-Calm”: bored, “Neutral-Excited”: expectancy and “Neutral-Calm”: calm.

Research Methodology: First Phase

Figure 5

Diagram showing all emotions responded by participants. Total Participants

Male Female Unknown

50 30 1

Frequency of Response Group Group Group Group Group Group Group Group Überrascht (Surprise)

0 1-3 5-6 10-12 14-17 20-21 27-30 39

Aktiv (Active)

Erregt (Aroused)

Ängstlich (Anxious) Gequält (Distress)

1 2 3 4 5 6 7 8

Erwartung (Expectancy)

Furcht (Fear)

Ärger (Anger)

High Activation

Nervös (Nervous) Verärgert (Annoyed)

Ekel (Disgust) Traurig (Sad) Niedergeschlagen (Gloomy) Schwermütig (Melancholy)

Unpleasant

Begeistert (Enthusiastic)

Zufrieden (Satisfied) Pleasant

Low Activation

Müde (Tired)

Interessiert (Interest) Freude (Enjoyment)

Scham (Shame)

Langeweile (Bored) Schlaff (Drowsy)

Übermütig (Elated)

Fröhlich (Joy)

Ruhig (Calm) Akzeptanz (Acceptance)

Gelassen (Serene) Entspannt (Relaxed)

Inaktiv (Inactive)

Untätig (Idle) Passiv (Passive) Figure 5: All the emotion responded by the participants were placed in Circumplex of emotion with different sizes and darkness of letters representing the frequency of response.

Research Methodology: First Phase

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Categorization by reason of visit

The diagrams (see Figure 6, Figure 7, Figure 8) represent emotions responded by participant when categorized the collected data by reason of visit. Participants reported being bored, nervous, expectancy, anxiety, tired, angry and clam when visiting any type of health care providers due to feeling sick or having disease (see figure 6). At the same time, participants who visited any type of health care providers because of a body examination or health check-up, mentioned being relaxed, bored, expectancy, serene, nervous, calm and interest, (see figure 7). Furthermore, when visiting any type of health care providers as a visitor or companion, participants mentioned anxiety, expectancy, bored, tired, nervous, and interest, (see figure 8). Figure 6

Diagram showing all emotions mentioned by participants in visiting any kind of health care provider due to illness or disease. Total Participants

Male Female

26 14

Frequency of Response Group Group Group Group Group Group Group Group

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Aktiv (Active)

Gequält (Distress)

Überrascht (Surprise)

1 2 3 4 5 6 7 8

0 1 24610 13 21

3 5 8 - 12 - 15

Erregt (Aroused)

Ängstlich (Anxious) Erwartung (Expectancy) Furcht (Fear) High Activation

Ärger (Anger)

Nervös (Nervous) Ekel (Disgust)

Verärgert (Annoyed)

Traurig (Sad)

Scham (Shame)

Niedergeschlagen (Gloomy)

Unpleasant

Übermütig (Elated) Begeistert (Enthusiastic)

Pleasant

Schwermütig (Melancholy)

Müde (Tired)

Interessiert (Interest) Freude (Enjoyment) Fröhlich (Joy)

Low Activation

Langeweile (Bored)

Zufrieden (Satisfied)

Schlaff (Drowsy)

Inaktiv (Inactive)

Ruhig (Calm)

Akzeptanz (Acceptance)

Gelassen (Serene) Entspannt (Relaxed)

Untätig (Idle)

Passiv (Passive) Figure 6: The emotions responded by participants that visit any kind of health care provider because of illness or having a disease were placed in Circumplex of emotion with different sizes and darkness of letters representing the frequency of response.

Research Methodology: First Phase

Figure 7

Diagram showing all emotions mentioned by the participants in visiting any kind of health care provider for body examination or health check up. Total Participants

Male Female Unknown

14 5 1

Frequency of Response Group Group Group Group Group Group Group Group

1 2 3 4 5 6 7 8

0 1 2 3 4 6-7 8 9

Überrascht (Surprise)

Erwartung (Expectancy) Furcht (Fear)

High Activation

Ängstlich (Anxious)

Ärger (Anger)

Nervös (Nervous) Ekel (Disgust)

Verärgert (Annoyed) Traurig (Sad)

Niedergeschlagen (Gloomy)

Unpleasant

Pleasant

Schwermütig (Melancholy)

Müde (Tired)

Low Activation

Langeweile (Bored)

Zufrieden (Satisfied) Interessiert (Interest)

Ruhig (Calm)

Akzeptanz (Acceptance)

Entspannt (Relaxed)

Inaktiv (Inactive)

Gelassen (Serene)

Untätig (Idle)

Passiv (Passive) Figure 7: The emotions responded by participants that visit any kind of health care provider body examination or health check-up were placed in Circumplex of emotion with different sizes and darkness of letters representing the frequency of response.

The different clusters of responded emotions can be seen when comparing three reasons of a visit with one another. Based on the circumplex of emotion, patients reported experiencing emotions that are more “Unpleasant-Ecited”: nervous, anxiety, angry, when visiting any health care providers owing to feeling sick or having a disease, while those who were visiting for body examination or health check-up experienced emotions that are more “Pleasant-Calm”: relaxed, serene, calm. In addition, participants who were visitors or companions, reported experiencing emotions that are “Unpleasant-Excited”: anxiety, the same as participants who were visiting because of feeling sick or having disease, but participants who were visitors or companions experienced less emotions that are “Unpleasant-Calm”: bored, tired.

Research Methodology: First Phase

-45-

Figure 8

Diagram showing all emotions mentioned by the participants in visiting any kind of health care provider as a company or a visitor. Total Participants

Male Female

3 10

Frequency of Response Group Group Group Group Group Group Group Group

1 2 3 4 5 6 7 8

0 1 2 3 4 5 6 8

Aktiv (Active)

Aroused (Erregt)

Gequält (Distress)

Erwartung (Expectancy)

Ärger (Anger)

Verärgert (Annoyed)

Furcht (Fear)

Nervös (Nervous)

Ekel (Disgust)

Traurig (Sad)

Niedergeschlagen (Gloomy)

High Activation

Ängstlich (Anxious) Unpleasant

Interessiert (Interest) Pleasant

Zufrieden (Satisfied)

Schwermütig (Melancholy)

Langeweile (Bored) Müde (Tired) Schlaff (Drowsy)

Low Activation

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Ruhig (Calm) Akzeptanz (Acceptance)

Gelassen (Serene) Inaktiv (Inactive)

Untätig (Idle) Passiv (Passive)

Figure 8: The emotions responded by participants that visit any kind of health care provider as a company or visitor were placed in Circumplex of emotion with different sizes and darkness of letters representing the frequency of response.

Research Methodology: First Phase

Categorization by type of health care provider

The diagrams (see Figure 9, Figure 10) represent emotions responded by participant when categorized the collected data by type of health care provider. When visited a hospital regardless of reason, participants reported being bored, anxiety, expectation, nervous, tired and anger, (see figure 9), while reporting experienced bored, calm, relaxed, passive, serene, expectation, interest and expectancy when visited other type of health care providers regardless of reason (see figure 10). Figure 9

Diagram showing all emotions mentioned by participants that visited a hospital. Total Participants

Male Female

33 16

Frequency of Response Group Group Group Group Group Group Group Group

Aktiv (Active)

Aroused (Erregt) High Activation

Ärger (Anger)

Nervös (Nervous)

Shame (Scham)

Verärgert (Annoyed)

Traurig (Sad)

Niedergeschlagen (Gloomy)

Unpleasant

Übermütig (Elated) Begeistert (Enthusiastic)

Interessiert (Interest) Pleasant

Zufrieden (Satisfied) Freude (Enjoyment)

Schwermütig (Melancholy)

Müde (Tired)

Low Activation

Langeweile (Bored) Schlaff (Drowsy)

3 5 7 10 - 16 - 22

Erwartung (Expectancy)

Furcht (Fear)

Ekel (Disgust)

0 1 246814 20

Überrascht (Surprise)

Ängstlich (Anxious) Gequält (Distress)

1 2 3 4 5 6 7 8

Inaktiv (Inactive)

Fröhlich (Joy)

Ruhig (Calm) Akzeptanz (Acceptance)

Gelassen (Serene) Entspannt (Relaxed)

Untätig (Idle) Passiv (Passive)

Figure 9: The emotions responded by participants that visit a hospital were placed in Circumplex of emotion with different sizes and darkness of letters representing the frequency of response.

Research Methodology: First Phase

-47-

Figure 10

Diagram showing all emotions mentioned by participants that visited any type of health care providers, except a hospital. Total Participants

Male Female

17 14

Frequency of Response Group Group Group Group Group Group Group Group

1 2 3 4 5 6 7 8

0 1 2 3 4 5-6 7-9 13

Erwartung (Expectancy)

Distress (Gequält)

Niedergeschlagen (Gloomy)

Unpleasant

Zufrieden (Satisfied) Freude (Enjoyment)

Langeweile (Bored) Schlaff (Drowsy)

Interessiert (Interest) Pleasant

Müde (Tired)

Low Activation

-48-

High Activation

Ärger (Anger) Ängstlich (Anxious) Nervös (Nervous) Verärgert (Annoyed)

Ekel (Disgust)

Inaktiv (Inactive)

Ruhig (Calm)

Akzeptanz (Acceptance) Gelassen (Serene)

Entspannt (Relaxed)

Untätig (Idle)

Passiv (Passive) Figure 10: The emotions responded by participants that visit any type of health care ptoviders, besides a howpital were placed in Circumplex of emotion with different sizes and darkness of letters representing the frequency of response.

There is a distinctive difference between the cluster of emotions responded by participants when visited a hospital and any health care providers. According to the circumplex of emotion, the participants who visited hospitals experienced more “Unpleasant-Excited” emotions: anxious, annoyed, nervous, while the participants who visit the other types of health care provided experienced more “Pleasant-Calm” emotions: relax, calm. In conclusion, reason of a visit and type of health care provider are considered factors that affect emotion experienced in the waiting room.

Research Methodology: First Phase

Conclusion of field research in first phase: Emotional study in a waiting room of a health care provider From the field research, a participant experiences variety of emotions while waiting in a waiting room of a health care provider. These emotions are elicited by several factors, such as reason of visit, type of health care provider, health condition, waiting system and performance of hospital staff. Besides categorizing by using stimulus event, (see general interview: data analysis p.32-33) these factors can also be classified into two groups in relation to health care experience: 1. Related to health care experience: waiting time, waiting room, interaction with other health care customer, performance of staff and waiting system. This group of factors is related to every dimension of a health care experience (see dimension of service experience p. 7-8), therefore it varies among different type of health care provider depending on its organization and operational system, including number of staff and variety of medical activities. 2. Non-related to health care experience: personality, existing mood, health condition, memory about a past health care experience This group of factors correspond to individual differences such as gender, age, occupation, cultural background and religion. However, the degree of influence of both groups of factors on eliciting any emotions varies among each individual depending on his or her evaluation of each factor. For example, participant “A” reported “angry” when a hospital staff was unable to answer her question, while participant “B” did not report any emotions relating to the same matter. In addition, from the perspective of a health care provider, non-related health care experience factors are uncontrollable and are always more or less influenced by emotions that a health care customer had previously. Nevertheless, health care providers can improve the waiting experience by emphasizing on the factors that related to health care experience, which may result in reducing the intensity of existing negative emotions.

Research Methodology: First Phase

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Research methodology From the field research in the first phase, every method (general interview, observation, questionnaire) has it own advantage and limitation in finding out different emotions that participants experienced during waiting in a health care provider.

-50-

General interview was a good starting point to gain more in sight about the topic as a number of emotions and factors were mentioned randomly according to participantsâ&#x20AC;&#x2122; recalled memories. Therefore, some participants may not remember an exact emotion, mix up between different experiences, or have bias when reported. At the same time, emotional terms, or terms that were used to describe were very random depending on their habit of speaking, which make the data collected from the interviews difficult to compare. Furthermore, a meaning of some emotion words are varied among different cultures, in case the participants are from different cultural backgrounds, and meanings of the same word may not be the same. For example, emotion word reported by German speaking participant may have a slightly different meaning from when the same word was reported by an English speaking participant. In addition, one of the important issues that influence the outcome of an interview is the location where the interview was conducted. Participants tend to be more relaxed and engage more with the topic when having a conversation in a private and comfortable place. Observation is a good way to understand a situation from a subject point of view, to be a part of a real situation and experience it at the same time. However, it is difficult to interpret a behavior of an individual only by observing. Misunderstanding the reason of behavior and interaction among participants can lead to error findings. Questionnaire is very efficient for gathering large amount of basic data in order to see an overview of a topic. However, it is a one-way communication, some participants can easily misunderstand or misinterpret the questions. Furthermore, the time spent and the attention paid when answering varies among different participants.

Research Methodology: First Phase

Proposal for the 2nd phase: case specific A field research in the 2nd phase is case specific, conducted at a certain department of a hospital, in order to control a type of health care provider and narrow down reasons of a visit of the subjects, and emphasize on emotions that the subjects experience in a waiting room in relation to dimensions of a health care experience, such as waiting time, physical environment of a waiting room interaction with companion or other people in the waiting room and performance of staff. In addition, the findings from every method indicate that, when comparing between both health care providers, participants experienced more negative emotions, such as anxious, angry, nervous, when visited a hospital, while experienced more positive emotions, such as calm and relaxed when visiting a clinic. Therefore, conducting a field research in the second phase at a hospital will allow to indentify factors that elicited negative emotions, which is necessary for improving a current health care experience or creating favorable experience in the future. For the methodology, it remained the same as the first phase (observation, questionnaire) but instead of a general interview, a deep interview with a hospital staff and patients was conducted in order to gain more insight about a situation and a subjectâ&#x20AC;&#x2122;s point of view. A research tool (card) was used to aid the participant during the interview. Moreover, the questionnaire will be redesigned to make it more precise and case specific oriented. It was more focusing on identifying a relationship of each specific emotion and factors that elicited it.

Research Methodology: First Phase

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03 St. Josef Hospital, Bochum 04 Signage displays the building plan of St. Josef Hospital 05 The lobby in the main building of St. Josef Hospital 03

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Research Methodology: Second Phase

Second Phase: Case Specific Second phase: a field research – Clinical Immunology (Immunologische Ambulanz), St. Josef Hospital, Bochum

Introduction The second phase was conducted at an outpatient waiting room of clinical immunology, under the department of dermatology, venereology, allergy (Aufenhaltsraum Wartezimmer, Immunologische Ambulanz, Kilnik Für Dermatologie, Venerologie und Allergologie). It was a continuation of the first phase, which emphasizes on defining the type of emotions that patients experience while waiting in a specific waiting room and factors that provoke them in relation to a service dimension. The finding of the second phase is aimed to contribute more knowledge to the area of emotional study in service experience. General Information about Clinical Immunology (Immunologische Ambulanz)

The clinical immunology (Immunologische Ambulanz) is under the department of dermatology, venereology, allergy (Kilnik Für Dermatologie, Venerologie und Allergologie), located at 4th floor of the “A” building, St. Josef Hospital. There are approximately 600 patients in total. It responds for patient with disease related to the immune system. The majority are those with HIV, sexually transmitted disease (STD), Hepatitis (C and D), Cirrhosis. Besides that, there are also some with other skin disease, or a liver problems. There are ten hospital staff working in the clinic; one main female specialist for skin and sexually transmitted disease (STD), six internists and two nurses; one male and one female. However, the internists alternate every day, each one is only responsible for one specific day per week, except Friday when there are two internists. The working hour is Monday to Friday, from 8.00 to 17.00. In the morning (8.00-12.30) is a medical-activities time, available for patients to come for treatment and check up, while the afternoon is for the hospital staff to fill out a paperwork concerning patient’s

Research Methodology: Second Phase

-53-

data and heath insurance. In addition, the clinic is open extra on the second Tuesday of every month, from16.00 to19.00 for patients who have trouble visiting in the morning. The numbers of patients visiting the clinic vary during the week with an average of 30 patients per day. Most of them are existing patients with an approximately of 2-3 new patients per week. General information about patient

The patients in the clinical immunology vary with age; under 20 â&#x20AC;&#x201C; over 70, and nationality: German, Russian, African. Most of them are German between 30-60 years old. The majority, 80 percent, of the patients is male and many of them are homosexual. However, there are also heterosexual male and female. Most of the patients visit the clinic by themselves, nevertheless, some comes with their family or partner (in some cases they are both infected) especially when they are expecting bad news. The patient journey at clinical immunology

The journey of patients at clinical immunology are different according to their disease and a severity of the disease. (see Figure 11) -54-

Figure 11

The process of new patient at clinical immunology Contact Clinical Immunology to make an appointment (Note: usually done by family doctor (Hausarzt))

1st visit to the clinic for an examination or a blood testing and a short meeting with the doctor.

2nd visit with the doctor for consulting and discussing a treatment plan

(Note: Patient recieves a booklet about the disease and a contact to AIDS-Hilfe Bochum (in case of HIV patient))

(up to 3 days waiting period depending on an existing appointment) Note: In case of HIV, a person may come in the same day

Regular visit according to the treatment plan, including a yearly total health examination. (Note: It varies among individual according to his or her disease and the severity of the disease.)

(3-week waiting period due to the complete result from the blood testing and clinical examination)

Figure 11: A new patientâ&#x20AC;&#x2122;s journey at ckinical immunology

Research Methodology: Second Phase

For the treatment procedure, HIV patient who have to take medicines are required to visit the clinic every month, while those with a normal health condition are visiting every three months for blood testing. A side effect of the medicine may lead to diarrhea or coughing. However, it is very rare that patient have to come earlier then their regular routine due to the result of their blood test. A therapy for patient with hepatitis C takes 48 weeks. They are required to come every two weeks in the first 3-4 month for a complete blood count and a clinical examination. During the treatment the patients may experience depression, anemia and feeling very weak. Most of the time the treatment process can be complete within the clinic. However, sometimes patients are required to visit other departments for X-ray, ECG and proctology test or a yearly complete examination. Hospital staff and patients with negative emotion

Negatives emotions of patients are caused by the following factors: 1. The disease An HIV patient may experience a variety of emotion during different phases. At the first visit, patients may be anxious and afraid, depending on how much they are aware of being infected. In case it is a new information, patients may have a strong reaction (e.g. crying) and lose their will of living. After a certain period of time, patient be would be able to carry on with their life, regularly visit the clinic every three months are that become a part of their routine. 2. The treatment The side effect of the treatment process may lead to psychological distress. For patients with HIV, some of the side effects are diarrhea, nausea, depression, anxiety, weight lost and fat loss in arms, legs, or face, therefore when they experience these symptom, they are afraid concerning their health condition. 3. The service process (mostly related to paper work) Patients reacted angry when their needs are not fulfilled, which may be caused by a complexity of processes or the patient himself was not aware of the procedure. The most common case was that they did not have transfer papers (Ă&#x153;berweisung) with them, therefore, they could not proceed with the treatment. Note: Individual differences such as gender, age, religion, cultural background, personality and education, are not taken into a consideration.

Research Methodology: Second Phase

-55-

Each hospital staff has his or her own way of dealing with negative emotions of the patients depending on each staff ’s personality and relationship between them and the patient. In general, a nurse often shows empathy to the patients, tries to comfort and calm them down by talking to them or accompanying them and offering them something to drink in the waiting room along with inviting them to the breakfast on Thursday with other HIV patient and AIDS-Hilfe in case they need someone to talk to. During the treatment, the doctors often listen to their problem, spend more time with them, try to fix the problem if possible and take the treatment slowly step by step. In addition, staff often contact AIDS-Hilfe for further support for the patients. Physical environment of the outpatient waiting room of clinical immunology (Aufthenhaltsraum Wartezimmer, Immunologische Ambulanz)

Direction to a Treatment Room

Entrance from Elevator

Floor Plan: Clinical Immunology (Imunologische Ambulanz) 4th Floor, “A” Building St. Josef Hospital, Bochum

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Clinical Immunology (Immunologische Ambulanz)

Entrance from Staircase

Figure 12: Floor Plan of clinical immulogoly with three entrances labled.

Waiting Room (Auftenhaltsraum Wartezimmer)

Waiting Area in a Hallway

1m.

Entrance from Other Department Figure 12

Floor plan of Clinical Immunology (Immunologische Ambulanz) Research Methodology: Second Phase

The outpatient waiting room of clinical immunology located at 4th floor of the â&#x20AC;&#x153;Aâ&#x20AC;? building directly under the roof, therefore, a part of the ceiling is slanted. The approximate size is 16.25 square meters with a dimension of 6.50 (length) x 2.50 (width) x 2.80 (height) meters (see figure 12).

-5706 Entrance to clinical immunology from a staircase (a view from a staircase)

The walls of the waiting room are white with a gray stripe in the middle, while the floor has an orange and blue color. There is one window and two sets of three fluorescence lights, normally unused. The waiting room is equipped with eleven leather chairs, three tables, a computer, a television, a coffee machine, a coat hanger, many posters and a wall covered with a big bulletin board and a lot of booklets providing information such as a medical treatment, facts about disease and upcoming events. Besides that, there are also kitchen appliances such as sink, stove, refrigerator and dishwashing machine, which are regularly used by hospital staff. Besides sitting in the waiting room, patients and his or her companion also have an option to sit at the waiting area in a hallway, there are 2 seats and one table provided.

Research Methodology: Second Phase

07 Entrance to clinic immunology from a staircase (a view from inside the clinic) 08 Register area and hallway of clinical Immunology 09 Provided waiting area in a hallway of clinical immunology 10 Entrance to clinical immunology from an elevator (a view from a waiting room)

11 12

14 17 19 15 16

-5811 Entrance of the waiting room and drinking zone 12 Drinking zone and coat hangers 13 Seating and different notice in a waiting room 14 Seating arrangement in the waiting room 15 Information board and kichen facilities 16 Entrance of a waiting room and an information board

17 Seating arrangement for Thursday breakfast 18 Computer corner 19 Window in a waiting room 20 Poster 21 Information booklet 22 Information board

Research Methodology: Second Phase

Picture 23: Seating arrangement for Thursday breakfast

Every Thursday from 9.00 – 12.00, there is a breakfast (Donnerstag Frühstück) prepared by the AIDS-Hilfe Bochum, which is open for everyone in the clinical immunology including, patient, his or her companion and hospital staff. On this day, chairs and tables are rearranged to form a big dining table and the waiting room is filled with a number of people, both volunteers and patients; some come because of an appointment with a doctor while some just come for breakfast.

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24-26 Different notice in a waiting room

Research Methodology: Second Phase

Research methodology 1. Hidden Observation 2. Questionnaire 3. Interview with hospital staff 4. Deep interview with patients Note: During every process of the field research at the hospital, no photos of patients or hospital staff could be taken, due to a privacy agreement. 1. Hidden Observation

Method: Hidden observation in a waiting room was carried out in five days, (Monday 1st, Wednesday 3rd Friday 5th, Wednesday 10rd and Friday 12th of August 2011) five hours per day (8.00 â&#x20AC;&#x201C; 13.00), by using observation sheet. Note: A set of observation sheets is the same as the one used in the first phase.

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Objective: 1. Observe the general behavior of patients in a waiting room and the influence of the given facility on their behaviors. 2. Observe the interaction between patients and other people who are involved in the process such as companions, other patients and staff. Data Analysis:

Picture 27: Sample of the filled observation sheet

Research Methodology: Second Phase

1 . Analysis of the physical environment of the waiting room The physical environment of the waiting room The size of the waiting room is quite small, its narrowness and slant ceiling leads to an uncomfortable feeling when sitting facing another people. It is poorly designed with an unpleasant atmosphere, bad ventilation and lack of natural light due to lack of window; it is a bit dark especially on a cloudy day. Although the door remains open, still feel like being captured in a tight space. Furthermore, the language used in some notices is not appropriate. Note: The construction noise is very loud due to a construction in the ground floor.

The privacy of the waiting room Even though this waiting room is an enclosed space, there is no privacy given. It seems like a multipurpose room, conceptually divided into two zoning; the seating area for patients and companions, and the shared facility area includes a coffee machine, sink, stove, dishwashing machine and refrigerator, which are used by hospital staff and AIDS Hilfe volunteers to prepare the Thursday breakfast. From time to time, staff will come into the waiting room to prepare coffee, putting something in the dishwashing machine or getting something from the refrigerator. Besides that, sometimes the waiting room was used as a meeting room, patients and his or her companion have to leave the room and wait outside at a waiting area in a hallway. Furthermore, the door is always open, therefore, people inside the waiting room are able to hear a phone rings or a conversation between staff and other patient. 2 . General information about patient + waiting room + waiting time According to the observation, the number of people in the waiting room varies throughout the week. However, the average of total people in the waiting room is thirteen per day and the ratio between male and female is 4:1. Patients usually come by themselves, nevertheless, around 30 percent of them were accompanied by other people (in some cases, companion is also a patient) (see table 4). Most of the time, the waiting room is quiet, not every patient spent his or her waiting in the waiting room, some spent their total waiting time outside or went directly to a treatment room after registration. As a result, at a certain time, there is an average of one person in the waiting room while the highest number was five people. In addition, the average time spend in the waiting room per each person is 20 minutes, while the maximum is 55 minutes, depending on his or her treatment process. For example, in case of blood testing, patients may go directly to the treatment room, while for a complete blood count, patients have to wait about one hour and a half due to the preparation of material. Research Methodology: Second Phase

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Table 4

The result of an observation at Clinical Immunology Mon 1st Count Percent

Fri 5th Count

Percent

Wed 10th Count Percent

Fri 12th

Total

Average

Count

Percent

Count

Total people in a watiting room

23.88

14.92

26.98

16.42

19.40

Male

22.64

15.09

24.53

15.09

22.64

28.57

14.28

28.57

21.43

7.14

Female Visiting the clinic by himself or herself

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Wed 3rd Count Percent

27.5

22.5

12.5

27.5

Visiting the clinic with a companion

15.38

30.77

23.08

15.38

Average number of people in the waiting room

Maximum number of people in a waiting room at a certain time

Approximate average time spend in the waiting room

Maximum time spend in a waiting room

Note: The time spent in a waiting room is not equal to waiting time since many patients left the room before they got called for treatment and the total number of people in a waiting room is not equal to the total number of patients per day because not every person in a waiting room is a patient, some are companions, and also some patient spent their total waiting time outside or went directly to a treatment room after registration.

Some patients returned to the waiting room several times because they had to take other tests (e.g. a complete blood count, X-ray) or to wait for a result from a laboratory before proceeding with a next step. Note: Thursday is not in a consideration due to a breakfast with Aids-Hilfe Bochum.

3. General behavior of patient and companion while waiting in the waiting room While waiting, patients and companions tended to change their behaviors from time to time. The following is the list of behavior: List of behaviors 1. Interacting with personal belonging Patients and companions frequently engage themselves with personal electronical devices (e.g. mobile phone, laptop) and reading material (e.g. book, paper, newspaper) Research Methodology: Second Phase

2. Interacting with physical environment of the waiting room and provided facilities Patients and companions often use provided facilities. Many of them drink coffee, water and read a magazine or an information booklet, while a few use a computer. (Some take an information booklet with them) 3. Changing physical movement: Patients and companions tend to alternate their physical movement - Going in and out of the waiting room - Looking around the waiting room, including looking up at a poster and ceiling, looking down at the floor and closeing the eyes. - Standing still or walking around the waiting room. Most of them stop and look at a poster, a notice or an information booklet. 4. Interacting with other people in the waiting room 4.1 Interacting with companion Patients often talk to his or her companion, frequently mention about objects in the waiting room, such as computer, coffee machine and poster, and very rarely complain about the waiting room. Besides that, very seldom there was also a physical interaction such as holding hand. 4.2 Interaction with other people in the waiting room Patients who come alone rarely talk with other people in the waiting room, unless someone starts a conversation or asks a question. 5. Interacting with hospital staff An interaction in the waiting room is usually between a patient and a nurse, not a doctor. The nurse usually stays at a register area unless patients have trouble with a coffee machine. Besides that, whenever there are not many patients in the clinic, he would come in and have a conversation with a patient, especially with a new patient. However, patients often left the waiting room to talk with staff at a register area and remain outside. 6. Behavior related to medical treatment process Sometimes patients are required to filled in a paper, related to their health condition and treatment. Note: Individual differences such as gender, age, religion, cultural background, personality and education, are not taken into consideration when analyzing the observation data.

Research Methodology: Second Phase

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2. Questionnaire

Method: The questionnaire was handed out within a two-weeks period (1st August 2011 â&#x20AC;&#x201C; 13th August 2011) to a patient before he or she was going to the treatment room. Objectives: 1. Find out specific emotions and their intensity that patients associated while waiting. 2. Find out the cause of each emotion and how patients cope with them. 3. Find out factors that would influenced his or her pleasant waiting experience.

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Process 1. Creating a questionnaire sheet 2. Hand out questionnaires 3. Data analysis 1.Creating a questionnaire sheet 1.1 The information that aimed to acquire from the questionnaire - General information about the visit (date, time) - General information about the participant (age, gender, existing/ new patient) - The pleasant/unpleasant level of an experience - Emotions that a participant experience during waiting - Detail about each Emotion (intensity, pattern, cause, coping strategy, color) - Factors that would create a pleasant waiting experience 1.2 The selection of the emotion words The selection of emotion words in the questionnaire is based on the result of emotion words test with native German speaking and the finding of the questionnaire in the first phase (see Questionnaire: data analysis) - Emotion words test with native German speaking. The 35 emotion words from the preliminary questionnaire were based on three psychology theories, therefore some of them are unfamiliar and not common for everyday use (Richins 1997). Furthermore, according to Clore, Ortony, and Foss (1987), affective words considered an emotion word must not involve words related to nonvalenced cognitions (e.g. interest, surprise), physical and bodily state (e.g. tired, drowsy) and objective description (e.g. isolated, terrible) (Richins 1997). Research Methodology: Second Phase

Therefore, emotion words test were conducted with eight native German speaking in order to select a new set of 10-12 emotion words, by eliminating non-emotion, unfamiliar, uncommon and similar words. During the test, participants were asked to describe how they associate with each word and grouped words that have a similar meaning.

According to the collected data, participants pointed out several nonemotion words (see table 5) along with dentifying many sets of similar emotion words (see table 6). Table 5

Result of the emotion words test: A set of similar emotions Similar Emoions Traurig (Sad) - Schwermütig (Melancholy) Übermütig (Elated) - Überrascht (Surprise) Enjoyment (Freude) - Joy (Fröhlich) - Glücklich (Happy) Relaxed (Entspannt) - Serene (Gelassen) - Calm (Ruhig) Ärger (Anger) - Verärgert (Annoyed) Verachtung (Contempt) - Verärgert (Annoyed) Furcht (Fear) - Ängstlich (Anxious) Müde (Tired) - Schlaff (Drowsy) - Niedergeschlagen (Gloomy) Passiv (Passive) - Inaktiv (Inactive) - Untätig (Idle) Begeistert (Enthusiastic) - Euphorisch (Euphoric) Begeistert (Enthusiastic) - Übermütig (Elated)

Note: The set of similar emotions depending on each individual lexicon. Most of them usually have same dimension (lay in the same octant in circumplex of emotion).

Research Methodology: Second Phase

30 28-30 picture from emotion words test with eight native German speaking

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Table 6

Result of the emotion words test: Emotion vs Non-Emotion

Table 6: 35 emotion words from the questionnaire in the first phrase and its -66- description in relation to how eight native German speaking from an emotion words test associate with it.

Emotion

Description

Aktiv (Active)

non-emotion (physical and bodily state)

Akzeptanz (Acceptance)

non-emotion

Ängstlich (Anxious)

emotion

Ärger (Anger)

emotion

Begeistert (Enthusiastic)

emotion

Ekel (Disgust)

emotion

Entspannt (Relaxed)

non-emotion (physical and bodily state)

Erregt (Aroused)

inappropriate (sexual related)

Erwartung (Expectancy)

non-emotion

Euphorisch (Euphoric)

emotion

Freude (Enjoyment)

emotion

Fröhlich (Joy)

emotion

Furcht (Fear)

uncommon

Langeweile (Bored)

emotion

Gelassen (Serene)

non-emotion (physical and bodily state)

Glücklich (Happy)

emotion

Inaktiv (Inactive)

non-emotion (physical and bodily state)

Interessiert (Interest)

non-emotion

Müde (Tired)

non-emotion (physical and bodily state)

Niedergeschlagen (Gloomy)

inappropriate (used as slang)

Nervös (Nervous)

emotion

Passiv (Passive)

non-emotion (physical and bodily state)

Gequält (Distress)

inappropriate (used as slang)

Ruhig (Calm)

non-emotion (state of mind)

Scham (Shame)

emotion

Schlaff (Drowsy)

non-emotion (state of mind), uncommon

Schwermütig (Melancholy)

uncommon

Stark (Strong)

non-emotion (physical and bodily state)

Traurig (Sad)

emotion

Übermütig (Elated)

non-emotion

Überrascht (Surprise)

non-emotion

Untätig (Idle)

non-emotion (physical and bodily state)

Verärgert (Annoyed)

emotion

Verachtung (Contempt)

inappropriate (too strong)

Zufrieden (Satisfied)

emotion Research Methodology: Second Phase

Participants mentioned that this list of words relate to feeling (Gefühl) and can be used to describe a situation, however, not all of them are emotion. Some of them refer to physical and bodily state (e.g. Relaxed (Entspannt), Serene (Gelassen), Inaktiv (Inactive), Müde (Tired)), state of mind (e.g. Schlaff (Drowsy), Calm (Ruhig)) or are used as a description of an emotion. For example, “Niedergeschlagen (Gloomy)” would be used to describe “Taurig (Sadness)” Besides that, they also reported that some of the words are no longer used or uncommon, such as Furcht (fear), Schlaff (Drowsy) and Schwermütig (Melancholy), while some are inappropriate due to its meaning or daily usage. For example, the word “Verachtung (Contempt)” is too strong, “Erregt” (Aroused) is a sexually related word, “Gequält (Distress)” means torture and “Niedergeschlagen (Gloomy)” is a slang for punch. In addition, every word should be written in the same form, either noun or adjective, however, participants reported to associate better when it was written in an adjective form. - Emotions from the finding of the questionnaire in the first phase The emotions responded by the participants who visit a hospital according to the result of the questionnaire applied in the first phase were ranked according to its frequency. The selection of new emotion words set was, which consists of nine emotion words, was based on the finding from the emotion words test (mentioned above) (see Table 7). 1.3 Selection of Factors The factors used in the questionnaire were selected from the finding of an interview in the first phase (see first phase: general interview, data analysis p. 30-33 and conclusion of the first phase p.49) based on its relevance to a health care service. As a result, waiting time, waiting room, interaction with staff, performances of staff, waiting system and health condition were chosen. 2. Handing out the questionnaire to the patients The questionnaires were handed out within a two-weeks period (1st August 2011 – 13th August 2011) to patients who visited Clinical Immunology (Immunologische Ambulanz) before he or she was going to the treatment room.

Research Methodology: Second Phase

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Table 7

Result of the selection of emotion words for the questionnaire

-68-

The list of the emotions from the 1st phrase, ranks according to its frequency

Elimination of emotion words based on the result of the emotion words test

A new set of emotion words for the questionniare

Langeweile (Bored)

Langweilig (Bored)

Ängstlich (Anxious)

Erwartung (Expectancy)

Nervös (Nervous)

Ärgerlich (Anger)

Müde (Tired)

Ekelig (Disgust)

Ärger (Anger)

Verärgert (Annoyed)

Interessiert (Interest)

Zufrieden (Satisfied)

Erregt (Aroused)

Fröhlich (Joy)

Untätig (Idle)

Gestresst (Stressful)

Ruhig (Calm)

Furcht (Fear)

Gelassen (Serene)

Ekel (Disgust)

Entspannt (Relaxed)

Inaktiv (Inactive)

Niedergeschlagen (Gloomy)

Verärgert (Annoyed)

Passiv (Passive)

Traurig (Sad)

Schwermütig (Melancholy)

Zufrieden (Satisfied)

Schlaff (Drowsy)

Aktiv (Active)

Akzeptanz (Acceptance)

Gequält (Distress)

Überrascht (Surprise)

Freude (Enjoyment)

Begeistert (Enthusiastic)

Fröhlich (Joy)

Scham (Shame)

Übermütig (Elated)

Euphorisch (Euphoric)

Glücklich (Happy)

Stark (Strong)

Verachtung (Contempt)

Note: Every emotion word is written in adjective form and “Gestresst (stressed)” was added as it was often mentioned by the participant when referred to emotion that they experienced while waiting in the hospital from a field research in the first phrase.

Research Methodology: Second Phase

3. Data Analysis

Picture 31: Sample of the filled questionnaire

General information about the collected data There were 84 patients who responded to the questionnaire: 68 male and 16 female. Almost all of the participants are existing patients except one who visited the Clinical Immunology (Immunologische Ambulanz) for the first time. (see Figure 13). Approximately sixty percent of the participants reported having a pleasant or very pleasant experience and about thirty percent reported having a normal experience, while less than ten percent reported unpleasant or very unpleasant (see Figure 14). While waiting in the waiting room, a number of participants reported experienced Zufrieden (Satisfied), Langweilig (Bored) and Nervös (Nervous), some of them mentioned Gestresst (Stressful), Fröhlich (Joy) and Ängstlich (Anxious), while a few experienced Ärgerlich (Anger), Ekelig (Disgust) and Verärgert (Annoyed) (see Figure 15). In addition, besides provided lists of emotions, participants also reported experiencing: Entspannt (relaxed), Gut gelaunt (in a good mood), Müde (tired), Notwendig (necessary), Dankbar (thankful), Kalt (bleak), Neutral (neutral) and Normal (normal) According to the collected data of the questionnaire, short waiting time is considered the most significant factor for a pleasant experience, while high performance and friendly staff, a well-designed waiting room, variety of available facility in the waiting room and social interaction with companion or other people in the waiting room were also often mentioned. The factors that perceived to be less important are being well-informed about a waiting situation, well-designed waiting system (see figure 16). Furthermore, “to be on time” is a factor mentioned by one of the participant besides the provided factors.

Research Methodology: Second Phase

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Figure 13

Result of the questionnaire: Participant Information Participants

Count

Percent

Male 68 81 Female 19% Figure Female13 16 19 Total of the questionnaire: 84 Result Participant Information

Participants

Age (years Male Female 20 - 29 Total

Figure 13: General data about questionnaire participants

-70-

Count

old)68

male female Age 30 - (years 39 old) 20 - 29 male male female female 40 - 49 30 - 39 male male female female 50 - 59 40 - 49 male male female female 60 -- 59 69 50 male male female female Over 70 60 - 69 male male female female

16 84

Male 81%

Percent

Count81 Percent Female 19%

9 9 Count 16 914 92 37 16 29 148 2 15 37 11 29 84 156 114 42 61 41 2-

11 13.24 Male 81% Percent 19 11 20.59 13.24 50 - 59 years old 10.53 60 - 69 years old 18% 44 7% 19 Over 70 years old 42.65 20.59 1% 50 50 - 59 years old 10.53 20old - 29 years old 18 60 - 69 years 18% 44 11% 7% 16.18 Over 70 years old 42.65 1% 40 - 49 years old 5025 44% 20 - 29 years old 18 7 11%30 - 39 years old 10.29 16.18 10.53 40 - 49 years old 25 19% 44% 7 1 10.29 1 30 - 39 years old 10.5319%

Over 70 1 1 First visit to the clinical immunology male 1 1 female Yes No

First visit to the clinical immunology Yes No

1 83

1.2 98.8

Count Percent

1 83

Figure 14

Count Percent

1.2 98.8

Result of the questionnaire: The pleasantness of the experience Figure 14

Result of the questionnaire: The pleasantness of the experience Count Percent

Figure 14: Participantsâ&#x20AC;&#x2122; responses about the pleasantness of their experience

1- unpleasant 2 13 unpleasant 2 4 3 5 4 6 5 7 6 8 7 9 8 10 - pleasant 9 10 - pleasant

4 Count 4 3 - 1 3 11 1 15 11 6 15 18 6 11 18 1114 14

1, 4.8% 3, 3.6% 4.8 10, 16.9% 4, 1.2% Percent 1, 4.8% 3, 3.6% 4.83.6 5, 13.3% 10, 16.9% 4, 1.2% - 1.2 3.613.3 5, 13.3% 9, 13.3% 1.2 18.1 13.3 9, 13.3% 7.2 6, 18.1% 18.1 21.7 7.2 6, 18.1% 13.3 21.7 8, 21.7% 16.9 13.3 7, 7.2% 16.9

8, 21.7%

7, 7.2%

Research Methodology: Second Phase

Figure 15

Result of the questionnaire: Emotion experienced while waiting in the waiting room at clinical immunology

Ängstlich (Anxious)

Ekelig (Disgusting)

High Activation

Gestresst (Stressful)

Nervös (Nervous) Verärgert (Annoyed)

Ärgerlich (Angry) Unpleasant

Pleasant

Fröhlich (Joyful)

Low Activation

Langweilig (Bored)

Emotion (Total 129) Zufrieden (Satisfied) Langweilig (Bored) Nervös (Nervous) Gestresst (Stressful) Fröhlich (Joyful) Ängstlich (Anxious) Ärgerlich (Angry) Ekelig (Disgusting) Verärgert (Annoyed) Sonstiges (Others) Kalt, Müde, gut gelaunt, Dankbar, Normal

Zufrieden (Satisfied)

Count

Percent

50.6

44.6

39.8

19.3

18.1

13.3

3.6

Note: The emotions responded from the collected data is placed on a circle with two dimensions “pleasant-unpleasant” and “high arousal – low arousal”, based on “Circumplex of Emotion” (see Describing Emotion p…), in order to make it easier to distinguish and compare the result as a cluster of emotions with the same dimension is presents.

Research Methodology: Second Phase

Note: Each participant may select maximun 3 emotions -71-

Figure 16

Result of the questionnaire: The factor that would create a pleasant waiting experience List of factors

Count

Percent

Short waiting time

67.1

Social interaction while waiting - with companion - with other patient

25 24 11

32.9 18.4 14.5

Privacy while waiting

23.7

Well-designed waiting room

46.1

39.5

Well-informed about a waiting situation

22.4

Well-designed waiting system

14.5

(nice wall color, comfortable chair, plant, good lighting)

Variety of available facility in the waiting room (recreation zone, kid zone, entertainment ex.television, magazine)

(easy to understand, fair, transparent)

-72-

High performance and friendly staff

56.6

Others to be on time, eaiting and drinking

3.9

Note: Each participant may select maximun 3 factors Figure 16: Participants’ responses about the factor that would create a pleasant waiting experience.

Emotions and factors The first part of the data analysis is based on three groups of emotions (see figure 17) 1. “Unpleasant-Excited” Emotion 2. “Unpleasant-Calm” Emotion 3. “Pleasant-Average” Emotion 1. “Unpleasant-Excited” Emotion Nervös (Nervous), Gestresst (Stressful), Ängstlich (Anxious), Ärgerlich (Angry), Ekelig (Disgust), Verärgert (Annoyed) This group of emotions is very often mentioned caused by factors related to health condition, such as having a life-threatening disease, afraid of being infected, or having disease, health condition is not good, unstable or unknown and lack of information about the treatment process. At the

Research Methodology: Second Phase

same time, waiting time is occasionally mentioned due to long waiting or time pressure from another appointment (e.g. work). Environment/atmosphere of a waiting room was also mentioned by 16 percent of the participants, one of them reported a poorly designed lighting system. Out of all participants only one participant mentioned, waiting system, while none mentioned performance of hospital staff and interaction/relationship with hospital staff. Besides the provided factors, 10 percent of the participants also mentioned others factors such as his or her personality, a personal reason, bad past experience about the treatment and difficulty accessing the the clinic. Figure 17

Three groups of emotion placed on the circumplex of emotion “Unpleasant Excited”

High Activation

Ängstlich (Anxious) Ärgerlich (Angry) Ekelig (Disgusting) Gestresst (Stressful) Nervös (Nervous) Verärgert (Annoyed) Unpleasant

Pleasant

Fröhlich (Joyful) Zufrieden (Satisfied)

Low Activation

“Unpleasant Calm” Langweilig (Bored)

“Pleasant Average”

Figure 17: 9 emotion words used in the questionnaire, both in English and German, placed on the CIrcumplex of emotion according to their dimensions

2. “Unpleasant-Calm” Langweilig (Bored) According to the collected data, 57 percent of the participants mentioned that this group of emotion was caused by waiting time. Some explained that they have to wait long even with an appointment and there was no conversation or entertainment while waiting. Besides that, half of the participants mention environment/atmosphere of a waiting room due to its poorly designed interior and lack of distraction. Participants rarely mentioned waiting system. While only one participant mention health condition, performance of hospital staff and interaction/relationship with hospital staff.

Research Methodology: Second Phase

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Figure 18

Result of the questionnaire: Emotions and factors, a comparison between 3 groups of emotion Unpleasant-Excited

Participants Male Female Total

Factor

Count Percent 43 12 55

78.18 21.81

Count Percent

1. Health condition 2. Waiting time 3. Environment/atmosphere of a waiting room 4. Waiting system 5.Performance of hospital staff 6. Interaction/relationship with hospital staff 7. Others

29 17 9 1 10

52.73 30.90 16.36 1.82 18.18

Unpleasant-Calm Count Percent 24 4 28

85.72 14.28

Count Percent 1 16 14 3 1 1 3

3.57 57.14 50 10.71 3.57 3.57 10.71

Pleasant-Average Count Percent 33 8 41

80.49 19.51

Count Percent 19 19 16 11 26 26 5

46.34 46.34 39.02 26.83 63.41 63.41 12.20

Factors that provoked the emotion 1. Gesundheitszustand (Health condition) 2. Wartezeit (Waiting time) 3. Umfeld/Atmosphäre im Wartezimmer (Environment/atmosphere of a waiting room) 4. Wartesystem (Waiting system)

-74-

3.57%

57.14% 50% 10.71%

5. Kompetenz des Personal (Performance of hospital staff)

3.57%

6. Umgang mit dem Personal (Interaction/relationship with hospital staff)

3.57%

7. Sonstiges (Others)

10.71%

Note: Each participant may select maximun 3 emotions

In addition, in order to cope with a negative emotion either “unpleasant excite” or “unpleasant clam”, participants reported distracting themselves by using an electronical device (e.g. smart phone, computer), reading a book or a magazine, talking to other people, drinking coffee and thinking of other things. However, a lot of them accepted it, stayed clam, and tried to go through with it, while some of them did nothing and ignored it. Furthermore, a few of them mentioned that an intensity of negative emotion can be lower when time passed, or the staff is good. 3. “Pleasant-Average” Zufrieden (Satisfied), Fröhlich (Joyful) Two-thirds of the participants reported experiencing Fröhlich (Joy) and Zufrieden (Satisfied) because of the performance of hospital staff and interaction/relationship with hospital staff. They referred to staff as having a high performance, friendly and helpful. Furthermore, 47% of the parResearch Methodology: Second Phase

ticipants mentioned their health condition (stable, good) and waiting time (short), while 39% mentioned environment/atmosphere of a waiting room (good, beautiful and laid back atmosphere). Waiting system was reported by some of the participants (27 percent) as it is well organized; with an appointment the waiting time is short. A few participants mentioned other factors beside the provided list such as nice atmosphere, interaction with other people, specific staff and existing mood. The following graphs represent the detail of each emotion and the factors that elicited it, based on the collected data from the questionnaire, “Unpleasant-Excited”: Nervös (Nervous) (see Figure 19), Gestresst (Stressful) (see Figure 20), Ängstlich (Anxious) (see Figure 21), Ärgerlich (Angry) (see Figure 22), Ekelig (Disgust) (see Figure 23), Verärgert (Annoyed) (see Figure 24), “Unpleasant-Calm”: Langweilig (Bored) (see Figure 25), “Pleasant-Average”: Zufrieden (Satisfied) (see Figure 26), Fröhlich (Joy) (see Figure 27). Figure 19

Result of the questionnaire: Emotions and factors, Nervös (Nervous)

Nervös (Nervous), “Unpleasant-Excited” Participants Male Female Total

Count Percent 19 5 24

79.17 20.83

Age (years old) Count Percent 20 - 29 30 - 39 40 - 49 50 - 59 60 - 69 Over 70

5 4 10 3 2 -

8.33 16.67 41.67 12.5 8.33 -

Factor 1. Health condition 2. Waiting time 3. Environment/atmosphere of a waiting room 4. Waiting system 5.Performance of hospital staff 6. Interaction/relationship with hospital staff 7. Others - I am always nervous - Relating to the blood test - The fear of neeldle, will I have a blackout?

Count Percent 14 8 2 5

58.33 33.33 8.33 20.83

Factors that provoked the emotion 1. Gesundheitszustand (Health condition)

58.33%

2. Wartezeit (Waiting time)

33.33%

3. Umfeld/Atmosphäre im Wartezimmer (Environment/atmosphere of a waiting room)

8.33%

4. Wartesystem (Waiting system) 5. Kompetenz des Personal (Performance of hospital staff) 6. Umgang mit dem Personal (Interaction/relationship with hospital staff) 7. Sonstiges (Others)

20.83%

Figure 19: Factors mentioned by participants who experiencing Nervös (Nervous) while waiting in the waiting room of clinical immunology.

Figure 24 Research Methodology: Second Phase

Result of the questionnaire: Emotions and factors, Verärgert (Annoyed)

Verärgert (Annoyed), “Unpleasant-Excited”

-75-

Figure 20

Result of the questionnaire: Emotions and factors, Gestresst (Stressful)

Gestresst (Stressful), “Unpleasant-Excited” Participants Male Female Total

Count Percent 9 3 12

75 25

Age (years old) Count Percent 20 - 29 30 - 39 40 - 49 50 - 59 60 - 69 Over 70

1 2 6 2 1 -

8.33 16.67 50 16.67 8.33 -

Factor

Count Percent

3 1. Health condition 3 2. Waiting time 3 3. Environment/atmosphere of a waiting room 4. Waiting system 5.Performance of hospital staff 6. Interaction/relationship with hospital staff 3 7. Others - Private problem, work problem - I was confuse and couldn’t find my way to the clinical immunology because of a construction, the stairway was closed - I am usually stress

25 25 25 25

Factors that provoked the emotion 1. Gesundheitszustand (Health condition)

25%

2. Wartezeit (Waiting time)

25%

3. Umfeld/Atmosphäre im Wartezimmer (Environment/atmosphere of a waiting room)

25%

4. Wartesystem (Waiting system) 5. Kompetenz des Personal (Performance of hospital staff)

-76-

6. Umgang mit dem Personal (Interaction/relationship with hospital staff) 7. Sonstiges (Others)

25%

Figure 25

Figure 20: Factors mentioned by participants who experiencing Gestresst (Stressful) while waiting in the waiting Result of the questionnaire: Emotions and factors, Langweilig (Bored) room of clinical immunology.

Langweilig (Bored), “Unpleasant-Calm” Participants Male Female Total

Count Percent 24 4 28

85.72 14.28

Age (years old) Count Percent 20 - 29 30 - 39 40 - 49 50 - 59 60 - 69 Over 70

4 10 11 2 1 -

14.28 35.71 39.29 7.14 3.57 -

Factor

Count Percent

3.57 1 1. Health condition 57.14 16 2. Waiting time 50 14 3. Environment/atmosphere of a waiting room 10.71 3 4. Waiting system 3.57 1 5.Performance of hospital staff 3.57 1 6. Interaction/relationship with hospital staff 10.71 3 7. Others - Sometimes I feel time prossure - We live in a stress world, we are under pressure - I was bored for a while before I started a converstaion

3.57% 57.14% 50% Research Methodology: Second Phase 10.71%

3.57%

Figure 21

Result of the questionnaire: Emotions and factors, Ängstlich (Anxious)

Ängstlich (Anxious), “Unpleasant-Excited” Participants Male Female Total

Count Percent 8 2 10

80 20

Age (years old) Count Percent 20 - 29 30 - 39 40 - 49 50 - 59 60 - 69 Over 70

1 5 3 1 -

10 50 30 10

Factor 1. Health condition 2. Waiting time 3. Environment/atmosphere of a waiting room 4. Waiting system 5.Performance of hospital staff 6. Interaction/relationship with hospital staff 7. Others

Count Percent 9 1 1 -

90 10 10 -

Factors that provoked the emotion 1. Gesundheitszustand (Health condition)

90%

2. Wartezeit (Waiting time)

10%

3. Umfeld/Atmosphäre im Wartezimmer (Environment/atmosphere of a waiting room)

10%

4. Wartesystem (Waiting system) 5. Kompetenz des Personal (Performance of hospital staff)

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6. Umgang mit dem Personal (Interaction/relationship with hospital staff) 7. Sonstiges (Others) Figure 22

Figure mentioned by participants Ängstlich(Angry) (Anxious) while waiting in the waiting Result21: ofFactors the questionnaire: Emotions who and experiencing factors, Ärgerlich room of clinical immunology.

Ärgerlich (Angry), “Unpleasant-Excited” Participants Male Female Total

Count Percent 5 5

100 -

Age (years old) Count Percent 20 - 29 30 - 39 40 - 49 50 - 59 60 - 69 Over 70

2 1 1 1

40 20 20 20

Factor 1. Health condition 2. Waiting time 3. Environment/atmosphere of a waiting room 4. Waiting system 5.Performance of hospital staff 6. Interaction/relationship with hospital staff 7. Others

Count Percent 40 80 40 -

2 4 2 -

Factors that provoked the emotion 1. Gesundheitszustand (Health condition)

40%

2. Wartezeit (Waiting time)

80%

3. Umfeld/Atmosphäre im Wartezimmer (Environment/atmosphere of a waiting room)

40%

Research Methodology: Second Phase

4. Wartesystem (Waiting system)

5. Kompetenz des Personal (Performance of hospital staff) 6. Umgang mit dem Personal

(Waiting system) 5. Kompetenz des Personal (Performance of hospital staff) 6. Umgang mit dem Personal (Interaction/relationship with hospital staff) 7. Sonstiges (Others) Figure 22

Result of the questionnaire: Emotions and factors, Ärgerlich (Angry)

Ärgerlich (Angry), “Unpleasant-Excited” Participants Male Female Total

Count Percent 5 5

100 -

Age (years old) Count Percent 20 - 29 30 - 39 40 - 49 50 - 59 60 - 69 Over 70

2 1 1 1

40 20 20 20

Factor

Count Percent

1. Health condition 2. Waiting time 3. Environment/atmosphere of a waiting room 4. Waiting system 5.Performance of hospital staff 6. Interaction/relationship with hospital staff 7. Others

40 80 40 -

2 4 2 -

Factors that provoked the emotion 1. Gesundheitszustand (Health condition)

40%

2. Wartezeit (Waiting time)

80%

3. Umfeld/Atmosphäre im Wartezimmer (Environment/atmosphere of a waiting room)

40%

4. Wartesystem (Waiting system)

-78-

5. Kompetenz des Personal (Performance of hospital staff) 6. Umgang mit dem Personal (Interaction/relationship with hospital staff) 7. Sonstiges (Others)

Figure 22: Factors mentioned by participants who experiencing Ärgerlich (Angry) while waiting in the waiting room of clinical immunology.

Research Methodology: Second Phase

Figure 23

Result of the questionnaire: Emotions and factors, Ekelig (Disgusting)

Ekelig (Disgusting), “Unpleasant-Excited” Participants Male Female Total

Count Percent 1 1

100 -

Age (years old) Count Percent 20 - 29 30 - 39 40 - 49 50 - 59 60 - 69 Over 70

100

Factor

Count Percent

1. Health condition 2. Waiting time 3. Environment/atmosphere of a waiting room 4. Waiting system 5.Performance of hospital staff 6. Interaction/relationship with hospital staff 7. Others

1 1 -

100 100 -

Factors that provoked the emotion 1. Gesundheitszustand (Health condition)

100%

2. Wartezeit (Waiting time) 100%

3. Umfeld/Atmosphäre im Wartezimmer (Environment/atmosphere of a waiting room) 4. Wartesystem (Waiting system) 5. Kompetenz des Personal (Performance of hospital staff)

-79-

6. Umgang mit dem Personal (Interaction/relationship with hospital staff) 7. Sonstiges (Others)

Figure 23: 28 Factors mentioned by participants who experiencing Ekelig (Disgusting) while waiting in the waiting room Figure ofResult clinicalof immunology. the questionnaire: Factors and emotions, the factors responded

by participants as a cause of an emotion experienced while waiting in a waiting room Total number of emotion responded by 68 participants Total number of factor responded by 68 participants Participants Male Female Total

Count Percent 55 13 68

80.88 19.12

Age (years old) Count Percent 20 - 29 30 - 39 40 - 49 50 - 59 60 - 69 Over 70

7 15 29 11 5 1

10.29 22.06 42.65 16.18 7.35 1.47

129 238

Factor 1. Health condition 2. Waiting time 3. Environment/atmosphere of a waiting room 4. Waiting system 5.Performance of hospital staff 6. Interaction/relationship with hospital staff 7. Others

Count Percent 47 54 42 16 29 28 22

36.43 41.86 32.55 12.40 22.48 21.70 17.05

Factors that provoked the emotion 1. Gesundheitszustand (Health condition)

36.43%

2. Wartezeit (Waiting time)

41.86%

3. Umfeld/Atmosphäre im Wartezimmer (Environment/atmosphere of a waiting room)

32.55%

4. Wartesystem (Waiting system)

12.40%

Research Methodology: Second Phase

7. Sonstiges (Others)

20.83%

Figure 24

Result of the questionnaire: Emotions and factors, Verärgert (Annoyed)

Verärgert (Annoyed), “Unpleasant-Excited” Participants Male Female Total

Count Percent 1 2 3

33.33 66.67

Age (years old) Count Percent 20 - 29 30 - 39 40 - 49 50 - 59 60 - 69 Over 70

1 1 1 -

33.33 33.33 33.33 -

Factor

Count Percent

1 1 2

33.33 33.33 66.67

Factors that provoked the emotion 1. Gesundheitszustand (Health condition) 2. Wartezeit (Waiting time)

33.33%

3. Umfeld/Atmosphäre im Wartezimmer (Environment/atmosphere of a waiting room) 4. Wartesystem (Waiting system)

-80-

33.33%

5. Kompetenz des Personal (Performance of hospital staff) 6. Umgang mit dem Personal (Interaction/relationship with hospital staff) 7. Sonstiges (Others)

66.67%

Figure 24: Factors mentioned by participants who experiencing Verärgert (Annoyed) while waiting in the waiting room of clinical immunology.

Research Methodology: Second Phase

(Waiting system) 5. Kompetenz des Personal (Performance of hospital staff) 6. Umgang mit dem Personal (Interaction/relationship with hospital staff) 7. Sonstiges (Others)

25%

Figure 25

Result of the questionnaire: Emotions and factors, Langweilig (Bored)

Langweilig (Bored), “Unpleasant-Calm” Participants Male Female Total

Count Percent 24 4 28

85.72 14.28

Age (years old) Count Percent 20 - 29 30 - 39 40 - 49 50 - 59 60 - 69 Over 70

4 10 11 2 1 -

14.28 35.71 39.29 7.14 3.57 -

Factor

Count Percent

3.57% 57.14% 50% 10.71%

5. Kompetenz des Personal (Performance of hospital staff)

3.57%

6. Umgang mit dem Personal (Interaction/relationship with hospital staff)

3.57%

7. Sonstiges (Others)

10.71%

Figure 25: Factors mentioned by participants who experiencing Langweilig (Bored) while waiting in the waiting room of clinical immunology.

Research Methodology: Second Phase

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Figure 26

Result of the questionnaire: Emotions and factors, Zufrieden (Satisfied)

Zufrieden (Satisfied), “Pleasant-Average” Participants Male Female Total

Count Percent 24 5 29

82.76 17.24

Age (years old) Count Percent 20 - 29 30 - 39 40 - 49 50 - 59 60 - 69 Over 70

10.34 13.79 41.38 20.69 10.34 3.45

3 4 12 6 3 1

Factor

Count Percent

1. Health condition 2. Waiting time 3. Environment/atmosphere of a waiting room 4. Waiting system 5.Performance of hospital staff 6. Interaction/relationship with hospital staff 7. Others - I am in a good mood - Nice atmosphere - I like to talk to people in the waiting room, (sometimes I meet someone I know) but normally not many there

11 14 11 8 18 18 3

37.93 48.28 37.93 27.59 62.06 62.06 10.34

Factors that provoked the emotion

-82-

1. Gesundheitszustand (Health condition)

37.93%

2. Wartezeit (Waiting time)

48.28%

3. Umfeld/Atmosphäre im Wartezimmer (Environment/atmosphere of a waiting room)

37.93%

4. Wartesystem (Waiting system)

27.59%

5. Kompetenz des Personal (Performance of hospital staff)

62.06%

6. Umgang mit dem Personal (Interaction/relationship with hospital staff)

62.06%

7. Sonstiges (Others)

10.34%

Figure 26: Factors mentioned by participants who experiencing Zufrieden (Satisfied) while waiting in the waiting room clinical immunology. Figureof27

Result of the questionnaire: Emotions and factors, Fröhlich (Joyful)

Fröhlich (Joyful), “Pleasant-Average” Participants Male Female Total

9 3 12

Age (years old) 20 - 29 30 - 39 40 - 49 50 - 59 60 - 69 Over 70

Count Percent 75 25

Count Percent 1 1 7 2 1 -

8.33 8.33 58.33 16.67 8.33 -

Factor

Count Percent

5 5 5 3 8 8 2

41.67 41.67 41.67 25 66.67 66.67 16.67

41.67% 41.67% Research Methodology: Second Phase

41.67% 25%

5. Kompetenz des Personal (Performance of hospital staff)

62.06%

6. Umgang mit dem Personal (Interaction/relationship with hospital staff)

62.06%

7. Sonstiges (Others)

10.34%

Figure 27

Result of the questionnaire: Emotions and factors, Fröhlich (Joyful)

Fröhlich (Joyful), “Pleasant-Average” Participants Male Female Total

9 3 12

Age (years old) 20 - 29 30 - 39 40 - 49 50 - 59 60 - 69 Over 70

Count Percent 75 25

Count Percent 1 1 7 2 1 -

8.33 8.33 58.33 16.67 8.33 -

Count Percent 5 5 5 3 8 8 2

41.67 41.67 41.67 25 66.67 66.67 16.67

Factors that provoked the emotion 1. Gesundheitszustand (Health condition)

41.67%

2. Wartezeit (Waiting time)

41.67%

3. Umfeld/Atmosphäre im Wartezimmer (Environment/atmosphere of a waiting room)

41.67%

4. Wartesystem (Waiting system)

25%

5. Kompetenz des Personal (Performance of hospital staff)

66.67%

6. Umgang mit dem Personal (Interaction/relationship with hospital staff)

66.67%

7. Sonstiges (Others)

16.67%

Figure 27: Factors mentioned by participants who experiencing Fröhlich (Joyful) while waiting in the waiting room of clinical immunology.

Note: The other responses related to the detail of emotion (a frequency, an intensity, the graph, color) are not mentioned here because many patients did not answer and reported having trouble interpret the question.

Research Methodology: Second Phase

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Total

3. Environment/atmosphere of a waiting room 4. Waiting system 5.Performance of hospital staff 6. Interaction/relationship with hospital staff 7. Others

Age (years old) Count Percent 20 - 29 30 - 39 40 - 49 50 - 59 60 - 69 Over 70

100

1 -

100 -

Factors and emotions part of the data analysis is based on provided factors. 1. Health condition 100% 1. Gesundheitszustand (Health condition) 2. Waiting time 2. Wartezeit (Waiting 3. Environment/atmosphere of a waiting room time) 4. Waiting system 100% 3. Umfeld/Atmosph채re im Wartezimmer (Environment/atmosphere of a waiting room) 5. Performance of hospital staff 4. Wartesystem 6. Interaction/relationship with hospital staff second Factors that provoked the The emotion

(Waiting system)

5. Kompetenz des Personal hospital Based on (Performance of staff)

the collected data, 68 participants (out of a total of 84) each emotion. The factor that was most waiting system was the least mentioned.

mentioned the factors that elicited 6. Umgang mit dem Personal (Interaction/relationship with hospital staff) mentioned was waiting time while Sonstiges (see 7.Figure 28). (Others)

Figure 28

Result of the questionnaire: Factors and emotions, the factors responded by participants as a cause of an emotion experienced while waiting in a waiting room Total number of emotion responded by 68 participants Total number of factor responded by 68 participants Participants -84-

Male Female Total

Count Percent 55 13 68

80.88 19.12

Age (years old) Count Percent 20 - 29 30 - 39 40 - 49 50 - 59 60 - 69 Over 70

7 15 29 11 5 1

10.29 22.06 42.65 16.18 7.35 1.47

129 238

Factor

Count Percent

1. Health condition 2. Waiting time 3. Environment/atmosphere of a waiting room 4. Waiting system 5.Performance of hospital staff 6. Interaction/relationship with hospital staff 7. Others

47 54 42 16 29 28 22

36.43 41.86 32.55 12.40 22.48 21.70 17.05

Factors that provoked the emotion 1. Gesundheitszustand (Health condition)

36.43%

2. Wartezeit (Waiting time)

41.86%

3. Umfeld/Atmosph채re im Wartezimmer (Environment/atmosphere of a waiting room)

32.55%

4. Wartesystem (Waiting system)

12.40%

5. Kompetenz des Personal (Performance of hospital staff)

22.48%

6. Umgang mit dem Personal (Interaction/relationship with hospital staff)

21.70%

7. Sonstiges (Others) Figure 28: All factors that was mentioned by questionnaire participants

17.05%

Research Methodology: Second Phase

The following graphs represent the detail of each factor and participants’ emotions that were elicited, based on the collected data from the questionnaire; Health condition (see Figure 29), Waiting time (see Figure 30), Environment/atmosphere of a waiting room (see Figure 31), Waiting system (see Figure 32), Performance of hospital staff (see Figure 33), Interaction/ relationship with hospital staff (see Figure 34). Figure 29

Result of the questionnaire: Factors and emotions, Health condition

Gesundheitszustand (Health condition) Count 47 Percent 36.43% Emotion

Figure 29

Count Percent

9 19.15 Ängstlich Result of (Anxious) the questionnaire: Factors and emotions, Health condition Ängstlich (Anxious)

High Activation

Ärgerlich (Angry) 2 4.26 Gestresst (Stressful) Ekelig (Disgusting) 1 2.13 Gesundheitszustand (Health condition) Count 47 Percent 36.43% Gestresst (Stressful) 3 6.38 Ärgerlich (Angry) Ekelig (Disgusting) Nervös (Nervous) 14 29.79 Unpleasant Pleasant Count Percent Emotion Fröhlich (Joyful) Verärgert (Annoyed) 9 19.15 Ängstlich (Anxious) Langweilig (Bored) 1 2.13 Ängstlich (Anxious) Ärgerlich (Angry) 2 4.26 Gestresst (Stressful)Langweilig (Bored) Fröhlich (Joyful) 5 10.64 Ekelig (Disgusting) 1 2.13 Zufrieden (Satisfied) 11 23.40 Gestresst 3 6.38 Ärgerlich (Angry) Ekelig (Disgusting) Sonstiges (Stressful) (Others) 1 2.13 Nervös Unpleasant Pleasant - gut (Nervous) gelaunt (in a good 14 mod) 29.79 Fröhlich (Joyful) Verärgert (Annoyed) Langweilig (Bored) 1 2.13 Langweilig (Bored) Figure 29: All emotons that5 participants mentioned experiencng while waiting in a waiting room of the clinical imFigure 30 Fröhlich (Joyful) 10.64 munolo that were elicit from condition. Result of the questionnaire: Factors and emotions, Waiting time Zufrieden (Satisfied) 11 health 23.40

Nervös (Nervous)

High Activation Low Activation

Nervös (Nervous)

Zufrieden (Satisfied)

Low Activation

Sonstiges (Others)

Zufrieden (Satisfied)

2.13

- gut gelaunt(Waiting (in a good mod) Wartezeit time) Count 54 Percent 41.86%

Emotion Figure 30

Count Percent Ängstlich (Anxious)

Ärgerlich (Angry)

7.40

Nervös (Nervous)

Ärgerlich (Angry) Ekelig (Disgusting) Wartezeit (Waiting - time)- Count 54 Percent 41.86% Verärgert (Annoyed)

Zufrieden (Satisfied)

Unpleasant

Pleasant

Fröhlich (Joyful)

Ängstlich (Anxious)

Gestresst (Stressful)

Langweilig Nervös (Bored) (Nervous) Verärgert (Annoyed)

Ärgerlich (Angry)

High Activation Low Activation

Zufrieden (Satisfied)

Unpleasant

Langweilig (Bored)

Pleasant

Fröhlich (Joyful)

Low Activation

Gestresst (Stressful) 3 5.56 Nervös (Nervous) 8 14.81 Count Percent Emotion Verärgert (Annoyed) 1 1.85 1 1.85 Ängstlich Langweilig(Anxious) (Bored) 16 29.63 Ärgerlich (Angry) 4 7.40 Fröhlich (Joyful) 5 9.26 Ekelig (Disgusting) Zufrieden (Satisfied) 14 25.93 Gestresst 3 5.56 Sonstiges (Stressful) (Others) 2 3.70 Nervös - gut (Nervous) gelaunt (in a good 8 mood)14.81 Verärgert (Annoyed) 1 1.85 - Dankbar (thankful) Langweilig (Bored) 16 29.63 Fröhlich (Joyful) 5 9.26 Zufrieden (Satisfied) 14 25.93 Figure 31 Sonstiges (Others) 2 3.70 Result of the questionnaire: Factors - gut gelaunt (in a good mood) - Dankbar (thankful)

High Activation

Result of (Anxious) the questionnaire: Factors and emotions, Waiting time Gestresst (Stressful) 1 1.85 Ängstlich

and emotions, Environment/atmosphere of a waiting room

Umfeld/Atmosphäre im Wartezimmer Count 42 Percent 32.55% (Environment/atmosphere ofmentioned a waiting room)while Figure 30: All emotons that participants experiencng waiting in a waiting room of the clinical imFigure 31that were elicit from waiting time. munolo Result of the questionnaire: Factors and emotions, Environment/atmosphere of a waiting room Count Percent Emotion

Ängstlich (Anxious)

2.38

Ängstlich (Anxious)

Gestresst (Stressful)

Nervös (Nervous) Emotion

Verärgert (Annoyed) Ängstlich Langweilig(Anxious) (Bored)

7.14

4.76

1 14

2.38 33.33

Nervös (Nervous) Ekelig (Disgusting) Ärgerlich (Angry)

Count Percent Unpleasant

High Activation

Umfeld/Atmosphäre im Wartezimmer Ärgerlich (Angry) 2 4.76 Gestresst (Stressful) Ekelig (Disgusting) Research Methodology: Second 1Phase 2.38 Count 42 Percent 32.55% (Environment/atmosphere of a waiting room)

Zufrieden (Satisfied) Pleasant

Fröhlich (Joyful)

-85-

Activation

Langweilig (Bored)

Langweilig (Bored) 16 29.63 Fröhlich (Joyful) 5 9.26 Zufrieden (Satisfied) 14 25.93 Sonstiges (Others) 2 3.70 - gut gelaunt (in a good mood) - Dankbar (thankful)

Figure 31

Result of the questionnaire: Factors and emotions, Environment/atmosphere of a waiting room

Umfeld/Atmosphäre im Wartezimmer (Environment/atmosphere of a waiting room) Count 42 Percent 32.55% Emotion

Count Percent

Ängstlich (Anxious)

Gestresst (Stressful) Nervös (Nervous) Ekelig (Disgusting) Ärgerlich (Angry)

High Activation

1 2.38 Ängstlich (Anxious) Ärgerlich (Angry) 2 4.76 Ekelig (Disgusting) 1 2.38 Gestresst (Stressful) 3 7.14 Nervös (Nervous) 2 4.76 Verärgert (Annoyed) Langweilig (Bored) 14 33.33 Fröhlich (Joyful) 5 11.90 Zufrieden (Satisfied) 11 26.19 Sonstiges (Others) 3 7.14 - gut gelaunt (in a good mood) - Kalt (cold) - Dankbar (thankful)

Unpleasant

Zufrieden (Satisfied) Pleasant

Low Activation

Langweilig (Bored)

Fröhlich (Joyful)

Figure 31: All emotons that participants mentioned experiencng while waiting in a waiting room of the clinical immunolo that were elicit from environment/atmosphere of a waiting room.

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Figure 32

Result of the questionnaire: Factors and emotions, Waiting system

Wartesystem (Waiting system) Count 16 Percent 12.40% Emotion

Count Percent -

Verärgert (Annoyed)

High Activation

Unpleasant

Zufrieden (Satisfied) Pleasant

Fröhlich (Joyful)

6.25 18.75 18.75

Langweilig (Bored)

Low Activation

Ängstlich (Anxious) Ärgerlich (Angry) Ekelig (Disgusting) Gestresst (Stressful) Nervös (Nervous) Verärgert (Annoyed) 1 Langweilig (Bored) 3 Fröhlich (Joyful) 3 Zufrieden (Satisfied) 8 Sonstiges (Others) 1 - gut gelaunt (in a good mod)

6.25

Figure 33

Figure 32: All emotons that participants mentioned experiencng while waiting in a waiting room of the clinical imResult of the questionnaire: Factors and emotions, Performance of hospital staff munolo that were elicit from waiting system.

Kompetenz des Personal (Performance of hospital staff) Count 29 Percent 22.48% Emotion

Count Percent -

3.45

27.59

62.07

6.90

Unpleasant

Langweilig (Bored)

Zufrieden (Satisfied) Pleasant

Low Activation

High Activation

Ängstlich (Anxious) Ärgerlich (Angry) Ekelig (Disgusting) Gestresst (Stressful) Nervös (Nervous) Verärgert (Annoyed) Langweilig (Bored) Fröhlich (Joyful) Zufrieden (Satisfied) Sonstiges (Others)

Research Methodology: Fröhlich (Joyful) Second Phase

18.75 50 6.25 6.25 18.75 18.75

6.25

Verärgert (Annoyed)

Langweilig (Bored) Unpleasant

Langweilig (Bored)

Zufrieden (Satisfied) Pleasant

Fröhlich (Joyful)

Low Activation

Zufrieden (Satisfied) Sonstiges Figure 33 (Others)

6.25 18.75 -

Activation Low Activation

Ärgerlich (Angry) Verärgert (Annoyed) 1Ekelig (Disgusting) Langweilig(Stressful) (Bored) 3Gestresst Fröhlich (Joyful) 3Nervös (Nervous) Zufrieden (Satisfied) 8 Verärgert (Annoyed) 1 Sonstiges (Others) 1 Langweilig (Bored) 3 - gut gelaunt Fröhlich (Joyful) (in a good mod) 3

- gutof gelaunt (in a good mod) Factors and emotions, Performance of hospital staff Result the questionnaire: Figure 33 Kompetenz

des Personal (Performance of hospital staff) Count 29 Percent 22.48% Result of the questionnaire: Factors and emotions, Performance of hospital staff Emotion

Count Percent

Kompetenz des Personal (Performance of hospital staff) Count 29 Percent 22.48% Ängstlich (Anxious) -

High Activation

Ärgerlich (Angry) Ekelig (Disgusting) Emotion

Count Percent ---

-3.45 27.59 62.07 -

Unpleasant

Langweilig (Bored)

Unpleasant

27.59

Langweilig (Bored)

62.07

Zufrieden (Satisfied) Pleasant

Fröhlich (Joyful)

Zufrieden (Satisfied) Pleasant

Fröhlich (Joyful)

Low Activation

6.90 3.45

High Activation Low Activation

Gestresst -Ängstlich (Stressful) (Anxious) Nervös (Nervous) Ärgerlich (Angry) -Verärgert (Annoyed) -Ekelig (Disgusting) Langweilig (Bored) 1Gestresst (Stressful) Fröhlich(Nervous) (Joyful) 8Nervös Zufrieden (Satisfied) 18 Verärgert (Annoyed) Sonstiges 2 Langweilig(Others) (Bored) 1 - gut gelaunt Fröhlich (Joyful) (in a good mood) 8 - Dankbar (thankful) Zufrieden (Satisfied) 18

Sonstiges (Others) 2 6.90 - gut33: gelaunt (in a good Figure All emotons thatmood) participants mentioned experiencng while waiting in a waiting room of the clinical imFigure 34 - Dankbar (thankful) munolo that were elicit from performance of hospital staff.

Result of the questionnaire: Factors and emotions, Interaction/relationship with hospital staff Figure 34 Umgang

mit dem Personal

Result of the questionnaire: Factors and emotions, Interaction/relationship hospital staff Count 28 Percentwith 21.70% (Interaction/relationship with hospital staff)

Umgang mit dem Personal Count Percent Emotion

64.29

Langweilig (Bored) Unpleasant

Langweilig (Bored)

Zufrieden (Satisfied) Pleasant

Fröhlich (Joyful)

Zufrieden (Satisfied) Pleasant

Fröhlich (Joyful)

Low Activation

18 Zufrieden (Satisfied) 1 Sonstiges (Others) - gut gelaunt (in a good mood)

Unpleasant

Count 28 Percent 21.70%

High Activation Low Activation

Ärgerlich (Angry) Count Percent Emotion Ekelig (Disgusting) --Gestresst (Stressful) Ängstlich (Anxious) --Nervös (Nervous) Ärgerlich (Angry) -Verärgert (Annoyed) Ekelig (Disgusting) 13.57 Langweilig(Stressful) (Bored) Gestresst 828.57 Fröhlich (Joyful) Nervös (Nervous) 18 64.29 Zufrieden (Satisfied) Verärgert (Annoyed) 1 3.57 1 3.57 Sonstiges (Others) Langweilig (Bored) 8 28.57 - gut gelaunt Fröhlich (Joyful) (in a good mood)

High Activation

(Interaction/relationship with hospital staff) Ängstlich (Anxious)

3.57

Figure 34: All emotons that participants mentioned experiencng while waiting in a waiting room of the clinical immunolo that were elicit from interaction/relationship with hospital staff.

From the graphs, it can be seen that every factor elicited Zufrieden (Satisfied) and Fröhlich (Joy), while “Unpleasant-Exctied” emotion such as nervous and anxious, were often elicited by health condition and occasionally elicited by waiting time. Langweilig (Bored) is strongly elicited by waiting time and environment/atmosphere of a waiting room. Further more, performance of hospital staff and interaction/relationship with hospital staff elicited exactly the same emotion.

Research Methodology: Second Phase

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3. Interview with hospital staff

Method: A personal interview with four hospital staff was conducted on 16st â&#x20AC;&#x201C; 17th August 2011. Note: Hospital staff was welcome to refuse to answer any question, and terminate interview at any moment. Furthermore, no photo of staff was taken during the interview.

Objective: 1. Gain more insight about the Clinical Immunology, including general information about patient and staff, medical activities and service delivery process. 2. Get an overview of the current waiting situation and system. 3. Understand staff point of view, especially their problems and needs on their daily working routine. Process: 1. Conducting a personal interview with four hospital staff 2. Findings -88-

1. Conducting a personal interview with four hospital staff A personal interview was conducted with two nurses, and two doctors (a specialist for skin and sexually transmitted disease (STD) and an internist) who were in charge on the certain day. The interview was conducted in German languages by a German native speaker, design students of KĂśln International School of Design (KISD). 2. Finding Hospital staff perception towards the current service delivery process. Physical setting Clinical immunology is quite old and small in size. There is not enough room for the treatment and examination. The register room is also small, patient data and different kinds of document are stored there, therefore it is always busy and filled with both hospital staff and patients. There is no private space between patient and staff for registering, consequently, the patientâ&#x20AC;&#x2122;s data can be heard by other patients in the room. Besides that, the floor plan needs to be rearranges, some of the rooms need to be switches in order to create a better work flow.

Research Methodology: Second Phase

Appointment system. Even though many patients schedule an appointment in advance according to their treatment plan, some come directly without an appointment, due to an urgency of their health condition. However, this affects an existing schedule, and leads to a longer waiting time for other patients. Medical equipment The regular treatment for a patient can be complete in the clinic. Nevertheless, there are some cases that required medical equipment from other department. For example, when patient experience chest pain, it is hard and take long to organize an Electrocardiography (ECG) from other department to the clinic. Note: Most of the data from the interview hospital staff are mentioned in the general information about Clinical Immunology (see p.53-56) and conclusion of a field research in the second phase (see p.99) 4. Deep Interview with patients

Method: Conducting a 30-minutes personal interview in German language with volunteering patients before or during his or her treatment, within three-days period (15stâ&#x20AC;&#x201C; 17th August 2011). During the interview, different types of cards, such as emotional cards, factor cards and story telling cards, were used to aid the participants. Note: Participant was welcome to refuse to answer any question, and terminate interview at any moment. Furthermore, no photo of staff was taken during the interview.

Objective: 1. Gain more insight about the participantsâ&#x20AC;&#x2122; experiences. 2. Find out in detail about the emotions that the participants recall from their memories and the factors that provoked them in relation to service experiences. 3. Gain more insight about patient opinion about dimensions of a pleasant experience. Process 1. Creating research tools, including pilot test and improvement 2. Conducting an interview with volunteering patients during his or her visits 3. Data Analysis

Research Methodology: Second Phase

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1. Creating research tools, including pilot test and improvement The purpose of the tools - To create an interactive movement and a relaxed interview atmosphere - To aid a participant in recalling his or her memory - To gain more insight about each emotion

There are three sets of tools used in this interview:

32 Emotion cards

-90-

33 Factor cards 34 Emotion graph and color cards 35 Two types of emotion graph

1.1 Emotion card and factor card The list of emotion word and factors word are the same as those in the questionnaire. There is one set of emotion card, and three sets of factor cards. Each participant was asked to select maximum three emotions and the factors that caused it. 1.2 Emotion graph and color card The color cards are based on the colors mentioned in the questionnaire. The blank graph label “intensity” on the y-axis and “waiting time” on the x-axis, to indicate intensity and pattern of each emotion while waiting. Research Methodology: Second Phase

Each participant was asked to select the color for each emotion, and drew a graph explain the pattern of the emotion while waiting. Note: There was a change in a emotion graph on the second day of the interview. Two lines indicated a register period and a treatment period were added because participants on the first day tended to mention and compare the intensity of their emotion before and after the waiting time when they were drawing the graph.

1.3 Co-creation: story telling “my pleasant waiting experience at clinical immunology”

-91Picture 36: Sample of Co-creation story telling card

The story telling listed every step of a patient’s journey from “not feeling well” to “getting called for the treatment”. The story cards provided up to four options per each step. Each participant was asked to create his or her own pleasant experience that would eliminate negative emotions or enhance positive emotion from the story card or suggested his or her own scenario. List of steps in patient journey Step 1: Not feeling well Step 2: Way finding to the Clinical Immunology Step 3: Registration Step 4: Waiting area 4.1 Waiting Space 4.2 Seating arrangement 4.3 Room Interior Step 5: While waiting 5.1Waiting time 5.2 Interaction with hospital staff Step 6: My turn Research Methodology: Second Phase

2. Conducting an interview with volunteering patients during his or her visits Patients who visited the clinic during 15th – 17th August 2011, were informed about the interview by hospital staff. Those who agreed to participate were brought to the private room where the interview was conducted according to the following steps:

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1. Introduction a) Please give a general information about yourself and the visit (age, gender, date, time) b) Described today’s experience at the clinic, what you like or dislike about it? 2. Emotions in waiting experience a) Select maximum 3 emotions from the emotion cards and factors that provoke each of them. b) Draw a graph represents a pattern of each emotion. (a change of level of intensity throughout the waiting time) c) How did you cope with the emotion? 3. Co-creation: story telling “my pleasant waiting experience at clinical immunology” a) Complete every step of the journey by selecting from the provided story cards or create their own. b) Explain how the new scenario can eliminate prior negative emotion and enhance prior positive emotion. Note: The interview was conducted in German languages by Lena Hammes, BA Integrated Design student at Köln International School of Design (KISD).

3. Data analysis There were nine patients who participated in the interview: eight male and one female, from different ages. Note: Most of the data from the interview are mentioned in conclusion of a field research in the second phase (see p.99).

Emotion Pattern According to the collected data, participants experienced a variety of emotions during waiting and each of them has its own pattern. Waiting time is a major factor that influences the change in pattern. There is a correlation between a level of intensity of the “Pleasant-Average” emotions, Zufrieden (Satisfied) and Fröhlich (Joy), and waiting time; the longer the wait, the lower the intensity of a positive emotion. For the “UnpleasantCalm” emotion, Langweilig (Bored), the level of intensity tends to stay the same or increase in a steady rate. However, there is no specific pattern for the “Unpleasant-Excited” emotions.

Research Methodology: Second Phase

36-40 Sample of filled emotion graph from a deep interview with patients

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Nervös (Nervous), Gestresst (Stressful), Ängstlich (Anxious), Ärgerlich (Anger), Ekelig (Disgust), Verärgert (Annoyed), it usually depends on the factors that caused each of them and individual differences. For example, paticipant no.8 reported “Nervös (Nervous)” is a part of his personality, there fore it stays the same throughout the waiting time, while participant no.3 reported that the intensity of Nervös (Nervous) suddenly decreases at a certain point and continues to decrease throughout the waiting time. Furthermore, many participants reported hospital staff and other people in the waiting room could influence the level of intensity of their emotion. For example, participant no.9 mentioned that talking with staff make him less bored while waiting and participant no.4 mentioned talking with other people in the waiting room about the disease makes him less stress and less scared. He described it as a “treatment before treatment”. In addition, emotions that were caused by a treatment or a waiting time, such as Nervös (Nervous) and Langweilig (Bored), suddenly decreased when the treatment began.

Research Methodology: Second Phase

“My pleasant waiting experience at clinical immunology”

The created journeys were different among each participant depending on personal differences, personal interest, his or her usual behaviors and past experience. Nevertheless, an important dimension mentioned by most participants was an interaction with hospital staff and other people in the waiting room. Registering with staff, available access to staff and getting call from the waiting room by staff assured the feeling of safe and care, which is very essential for the health care experience. At the same time, participant mentioned a conversation with other people can distract them from getting bored and help them coped with stress.

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Picture 42: Participant No.1’s response in a deep interview

In addition, participants’ selection for an interior design and the seating arrangement of the waiting room is very subjective. While some participant preferred calm environment, others prefer a room with a lot of distraction.

Research Methodology: Second Phase

Picture 43 Participant No.2â&#x20AC;&#x2122;s response in a deep interview

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Picture 44: Participant No.3â&#x20AC;&#x2122;s response in a deep interview

Research Methodology: Second Phase

Picture 45: Participant No.4â&#x20AC;&#x2122;s response in a deep interview

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Picture 46: Participant No.5â&#x20AC;&#x2122;s response in a deep interview

Research Methodology: Second Phase

Picture 47: Participant No.6â&#x20AC;&#x2122;s response in a deep interview

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Picture 48: Participant No.7â&#x20AC;&#x2122;s response in a deep interview

Research Methodology: Second Phase

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Picture 49: Participant No.8â&#x20AC;&#x2122;s response in a deep interview

Picture 50: Participant No.9â&#x20AC;&#x2122;s response in a deep interview

Research Methodology: Second Phase

Conclusion of a field research in the second phase: Emotional study in a waiting room of the Clinical Immunology (Immunologische Ambulanz)

1 . Different types of patients Although every patient requires the same level of care, the combination of individual difference such as gender, age, personality, cultural background, nationality, occupation, along with relationship with staff and familiarity with medical activities, lead to individual service preferences. Patients can be broadly classified into two types: 1.1 Isolated This type of patient prioritizes self-privacy, has a distance relationship with staff and does not need social interaction between other patients. The clinic is a place to receive a medical treatment only. While waiting, this type of patient often keeps themself apart from other people by sitting separately or engage themself with personal object, such as mobile phone, and reading material provided. His or her negative emotion may easily elicit when privacy is violated, while intensity in level of positive emotion may increase when the privacy is ensured. 1.2 Sociable This type of patient likes to interact with other people in the clinic, both patient and staff. They often have a close relationship with staff and join the Thursday breakfast. Besides receiving medical treatment, the clinic is a part of their social life, where they can be in touch with other people. While waiting, this type of patient tend to be around other people in the waiting room and start a conversation, otherwise they would wait outside near the registration area and talk with staff. His or her intensity level of negative emotion, such as Langweilig (Bored), may increase when there is no social contact, while communicating with other people and staff may decrease intensity in level of negative emotion and increase intensity in level of positive emotion. Note: Individual service preference may be different in each visit due to his or her existing mood.

Research Methodology: Second Phase

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2. Emotions that patients experienced while waiting in the waiting room of the clinical immunology and the factors that provoked them. While waiting in a waiting room, patients experience various emotions; “Unpleasant-Excited”: Nervös (nervous), Gestresst (stressful) and Ängstlich (anxious), “Unpleasant-Calm”: Langweilig (bored), and “Pleasant-Average”: Zufrieden (satisfied) and Fröhlich (joy), which varies in pattern and intensity level. These emotions may be elicited before or during the service experience depending on factors that provoke them. The factors that elicited emotions experienced while waiting in the waiting room of the clinical immunology can be categorized into three groups: 2.1 Factors related to dimension of health care experience at the clinical immunology: waiting time, environment and atmosphere of the waiting room, waiting system, performance of hospital staff, interaction/relationship between patient and hospital staff, access to the service and memory of the past experience at the clinical immunology. 2.2 Factors related to the area of health care: health condition and personal reason or condition resulted from the past experience 2.3 Factors related to an individual: personality/personal character, existing mood, personal reason/condition -100-

2.1 Factors related to dimension of health care experience at the clinical immunology An emotion elicited by this group of factor is a result of the patient’s evaluation of the service that he or she received at the clinical immunology while waiting in the waiting room, which include his or her memory of the past visit. a) Waiting Time The waiting time in the clinical immunology is different depending on a patient medical activity. For example, a patient can proceed with a blood testing directly after registration, but may have to wait up to one and a half hour for a complete blood count. An average waiting time for a regular treatment when patient has an appointment is less than 20 minutes, while those without an appointment may have to wait up to 45 minutes. A long waiting for a regular treatment is caused by many reasons, such as a prior patient taking longer than usual (e.g. new patient), an existing schedule is being pushed back due to patient without appointment or a doctor is occupied in some other business. In addition, waiting time is the most mentioned factor as a cause of all types of emotions experienced while waiting. Besides that, the duration of the waiting affects an intensity level of emotion. In general, the intensity level of the“Pleasant-Average” emotion, Zufrieden (Satisfied) and Fröhlich Research Methodology: Second Phase

(Joy), tend to gradually decrease when the waiting is long, while an intensity level of the “Unpleasant-Calm” emotion, Langweilig (Bored), tend to stay the same or gradually increase. However, there is no common pattern for “Unpleasant-Excited” emotion, it varies from patient to patient depending on the factors that elicited it. Even though eliminated waiting time is the best solution, it is impossible to manage, therefore, providing a distraction while waiting or informing an approximate waiting time may help patients to perceive that a waiting time is shorter than it actually is. b) Environment and atmosphere of the waiting room There are two waiting area in the clinical immunology; a waiting room and a provided waiting area in the hallway, however, this factor is only referred to a physical environment of the waiting room. Even though it was mentioned as a cause of all types of emotion: “Unpleasant-Excited”, “Unpleasant-Calm” and “Pleasant-Average”, Langweilig (Bored) and Zufrieden (Satisfied) are the two most frequently mentioned. The emotion that were elicited by this factor are usually based on individual preference and his or her past experience. A number of patients who experienced Langweilig (Bored) mentioned that the waiting room is poorly designed (e,g, small, old, outdated), lack of provided facility for distraction and lack of privacy, while others, who experienced Zufrieden (Satisfied), mentioned that they like the waiting room due to its nice atmosphere, along with a provided information booklet and a coffee machine. In addition, patient who experience “Pleasant-Average” emotion, often associate the environment/atmosphere of the waiting room with other activities and his or her own memory about things that happened in the waiting room, such as Thursday breakfast. A well-designed interior of a waiting room, with a clearly defined zoning and a lot of entertainment for distraction may decrease the intensity level of Langweilig (Bored). In addition, some patients mentioned that calm atmosphere of a waiting room may help them cope with a “UnpleasantExcited” emotion such as Gestresst (stressful). c) Waiting system The waiting system in clinical immunology is very simple. It is based on an appointment schedule, in which each patient receives a 30-minute time slot. A patient is required to call the clinic to make an appointment for his or her visit in advance, even when a patient is planning to visit in the same day due to urgency of his or her health condition. On the day of a visit, a patient may go directly to the clinical (clinic?), registers themself with a nurse at a register area and wait in a provided area, either in a waiting room or in a hallway, until he or she is called by a nurse or a doctor. In case of a patient visiting without an appointment due to urgency of his or her health condition, the staff may take care of him or her right away if Research Methodology: Second Phase

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a treatment process does not require a lot of time, otherwise they have to wait until there is a time available. However, a visit of a patient without an appointment often pushes back an existing schedule, which lead to a longer waiting time for a patient with an appointment. Even though there is no visible indication of a waiting time or a waiting queue, none of the patients referred to the waiting as unfair or not transparent. A waiting system is the least mentioned factor as cause of emotion experienced while waiting. Most patients are familiar with the process, they often mentioned “Fröhlich (Joy)” and “Zufrieden (Satisfied)” when they come with an appointment and do not have to wait long. Note: There are only a few serious emergency case in the clinical immunology, such as broken condom, which very rarely happens. Most of the patients visiting the clinic without an appointment usually experience a diarrhea and a heavy cough as a side effect of the medicine, which is not considered a serious case.

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d) Performance of staff Performance of staff is the most mentioned factor (together with performance of staff) as a reason for “Pleasant-Average” emotion. It assures a safety feeling as if they are in a good hand. Patients mentioned nurses have a high social competence: are friendly and have a sense of humor, while doctors have a high medical competence: are specialized in a specific area. For an existing patient, a memory of his or her visit and the stage of health condition are indications of the performance of the staff, which they often associate with the interaction/relationship with staff. (this phrase is unclear) e) Interaction/relationship with staff An interaction between patient and staff is based on their relationship, which is different among each individual depending on his or her personality (both patient and staff) and the number of times he or she visit the clinic. In the case of patients with chronic disease, the relationship usually develop over time due to the treatment process, which requires a regular visit and detail about personal life. The close relationship with the doctor makes the patient more relax and feel good during the treatment, which influences a pleasant emotion in the next visit. Interaction/relationship with staff is the most mentioned factor (together with performance of staff) as a cause of “Pleasant-Average” emotion. Some patients mentioned staff remember them by name and they were taken care individually with empathy. In addition, interaction/relationship with staff may increase or decrease the intensity level of an emotion. For example, an intensity level of Nervös (Nervous) that were caused by an unclear health condition gradually decreased when talking to staff or suddenly decreased when a doctor picked him up and accompanied him to the treatment room.

Research Methodology: Second Phase

Note: One of the reasons that may contribute to a close relationship between patient and staff is because a main doctor is a woman and one of the nurses is homosexual.

f) Access to the clinical immunology St. Josef Hospital, Bochum, is a big hospital consisting of many buildings, which were constructed during different periods of time. The clinical immunology is located at the 4th floor of an “A” building, an old building in the back of the hospital. The way finding to the clinic is very complex due to its location and lack of signage. Furthermore, patients may be reluctant to ask at the reception desk because of a concern for his or her privacy about the disease. A participant mentioned a difficulty from the way finding elicited “Unpleasant-Excited” emotions such as Gestresst (stressful) and Verärgert (annoyed), which remained throughout the waiting time. Note: During the period of field research, there was a construction at a ground floor of an “A” building, therefore, patients and companions had to access the clinic through a basement or the first floor of the main building, instead of going directly.

g) Memory of the past experience at the clinical immunology Memory of the past experience at the clinic, including how he or she was treated, perceived quality and relationship with staff, has a lot of influence on a participant’s expectation and attitude toward the current experience at the clinic. For patient with chronic disease, his or her emotion, especially the “Pleasant-Average”, at the current service experience depends a lot on a memory of a past experience. Regular visits at the clinic and familiarity with the system and staff lead to a better understanding and a tolerance when an undesired event takes place, which usually lower the tendency to experience a negative emotion while waiting. For example, a participant mentioned in an interview that he understands if other patient needs a bit more time to consult with the doctor in order to handle the problem, therefore, waiting is not a problem for him.

2.2 Factors related to an area of health care

a) Health Condition Besides being the most mentioned factor as a cause of the “Unpleasant-Excited” emotion, health condition also elicited the “Pleasant-Average” emotion. In general, the intensity level of “Pleasant-Average” emotion and “Unpleasant-Excited” emotion depends on the stage of individual health condition. For example, patients experienced “Fröhlich (Joy)” when his or her health is in a good condition. Even though 90 percents of patients are in a stable health condition, they may experience other “UnpleasantExcited” emotions caused by the medical treatments and the result of the

Research Methodology: Second Phase

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medical examination. When the process of a treatment is unknown or the patient personally has a bad experience related to the treatment, “Unpleasant-Excited” emotion, such as Nervös (Nervous) or Ängstlich (Anxious), may be elicited. At the same time, when the health condition is unknown or unclear, patients reported experiencing “Unpleasant-Excited” emotions while waiting due to a concern about the severity of the result. However, “Unpleasant-Excited” emotions are usually gone or suddenly decrease when the treatment begins or the result is known. Informing a patient about the medical process and the stage of his or her health condition in advance may help to prepare the patient and lower the intensity of his or her “Unpleasant-Excited” emotion. b) Personal reason or condition resulted from the past experience at other health care providers Patients may develop a certain perception or a personal condition toward health care based on his or her past experience at any health care providers, which more or less affect his or her emotion experienced while waiting at the clinical immunology. For example, patient reported experienced “Unpleasant-Excited” emotion; Ängstlich (Anxious) and Nervös (Nervous) due to fear of needle and getting a blackout.

2.3 Factors related to an individual

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a) Personality/Personal character Personality and personal character influence a tendency for an individual to experience a certain emotion more often than others with different personality or character. An emotion elicited by this factor tends to constantly remain with an individual. At the same time, other factors can easily contribute to an increase of an intensity level of an emotion. Participant who mentioned that nervousness is a part of his character, reported always nervous wherever he is, either at home or at the waiting room of the clinic, and nothing can be done to cope with it. However, a high performance staff and a conversation with other people in the waiting room can prevent an intensity level to increase. b) Existing mood An existing mood influences a tendency for an individual to experience a certain emotion more often than others without any mood or in a different mood. In addition, it is subject to change from time to time. However, from the collected data, participants only mentioned being in a good mood and feeling happy as a cause of experiencing “PleasantAverage” emotion while waiting.

Research Methodology: Second Phase

c) Personal reason/condition (not related to health care experience) Personal reason/condition such as private problems also affect emotions that patients experienced while waiting. For example, participants mentioned experiencing â&#x20AC;&#x153;Gestresst (stressed)â&#x20AC;? due to a work problem and having to secretly visit the clinic during working hour. In conclusion, an emotion, including its pattern and level of intensity that a patient experiences while waiting is different among each individual depending on his or her evaluation of the significance of each factor. Usually, the relationship between those two is not one to one, therefore, one emotion may be caused by many factors and one factor may elicit many emotions at the same time. Note: Although the purpose of this research is not to indicate an importance of a pleasant experience, a number of patients had pointed out its influence on their retention and their perception of the service quality.

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Research Methodology: Second Phase

Research Summary Emotion in service experience (An assumption of the research summary about emotion in service experience is based on a field research of a second phrase-a case specific: waiting in waiting room of a clinical immunology (Immunologische Ambulanz)) A customer experiences a number of emotions during his or her service experience, which are elicited by different types of factors. -106-

1. Different types of emotion in service experience (based on internal and external stimuli event) Emotion in service experience can be categorized into two types. 1.1 Existing emotion 1.2 Emotion elicited during service experience. 1.1 Existing emotion This types of emotion are usually elicited before service experience as a result of an internal stimuli event (see emotion in this study p.11-12), such as personality, existing mood, a memory of the past experience, and an existing relationship with service provider and information from media and word of mouth. An existing emotion has a lot of influence on a tendency of an individual to elicit a certain type of emotion along with its pattern and level of intensity, during a service experience. 1.2 Emotion elicited during service experience This type of emotion may beelicited at any point during a consumption experience as a result of an individual evaluation of a significant external event (see emotion in this study p.11-12), which in this case refers to dimensions of a service experience such as physical environment, interaction with other people and staff, and a service delivery process.

Research Summary: Emotion in Service Experience

Note: The effect of emotion elicited during service experience on a future customer behavior and his or her retention of a service is not possible to conclude from this research.

2. Different types of factor that elicit emotion in service experience. The factors that provoke existing emotion and emotion elicited during service experience can be categorized into three groups: 2.1 Factors related to dimensions of service experience at a certain service provider. An emotion elicited by this group of factor is a result of consumer evaluation of the service that he or she received at a certain service provider during past experiences and throughout a current consumption of service. Memories of past experiences usually set up a standard and an expectation for a current experience, therefore, when a consumption of a service is over, a memory of a current experience then combines with memories of past experiences to set up a new set of standard and an expectation for a next visit. In case of a new customer, expectation and standard may be based on customerâ&#x20AC;&#x2122;s past experience at other service providers in the same area of service (mentioned below). a) During the current experience of the service experience such as physical environment, interaction with other customer or staff during service experience and a service delivery process. b) Memory of the past experience and relationship with a service provider such as close/distant relationship with staff, familiarity with service delivery process and perception of service quality. 2.2 Factors related to an area of service An emotion elicited by this group of factor is usually an existing emotion, which results from a customer memory of his or her past experience of a service that he or she received at any service providers in the same area of service or personal condition related to his or her need or familiarity with an area of service. This type of factor may influence customer to develop a certain perception and attitude toward an area of service. a) Past experience related to service provided by other service provider such as a bad/good experience related to a service delivery process (e.g. black out because fear of needle) b) Personal reason or condition related to service such as individual background (e.g. work as staff at other hospital) and individual need from a service (e.g. a condition of health)

Research Summary: Emotion in Service Experience

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2.3 Factors related to an individual An emotion elicited by this group of factor is usually an existing emotion, which has no connection to any service providers or any area of services. This group of factor influences a tendency for an individual to experience a certain emotion during a service experience more often than others. At the same time, other types of factors can easily contribute to an increasing of an intensity level of an emotion. a) Individual differences such as personality (e.g. openness, neuroticiem), existing mood (e.g. good, bad) b) Personal reason or condition not related to service (e.g. personal problem) According to the list of factors mentioned above, although only â&#x20AC;&#x153;Factors related to dimensions of service experience at a certain service providerâ&#x20AC;? is controllable by a certain service provider, a creation of a preferable customer experience is essential for compensating negative emotions that may be elicited by other types of factors.

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Research Summary: Emotion in Service Experience

Analysis of methodology used for studying emotion in service experience A study of emotion in service experience is very complex, therefore a combination of different methods is needed. A self-report method such as interview, questionnaire or cultural probe is suitable for acquiring data related to different types of customers emotions and factors that provoke them. The selection of method should be based on a context of a service experience and the use of different tools to aid a participant during a selfreport process is also recommended. However, one of the major issues that need to be concerned is the time when the self-report method is conducted: during a service experience or when a service experience is over. Furthermore, other methods, such as hidden observation, interview or co-creation game with staff or stakeholders are also recommended in order to gain more insight about a current situation and a service providerâ&#x20AC;&#x2122;s perspective, which lead to better understanding of the participants responses from the self-report method. Note: The self-report process in this research was only conducted during a service experience, therefore an affect of the different period of time that a self-report method is conducted is not possible to identify. -109-

Research Summary: Analysis of Methodology

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Acknowledgement

Prof. Birgit Mager and Prof. Andreas Wrede Dr. Anja Potthoff and Eric Sybertz, along with all of the hospital staff at Immonologische Ambulanz, St. Josef Hospital, Bochum Anja Wolff and Elisabeth Fischer My family and friends : Suraphong Phonghanyudh, Araya Phonghanyudh, Ayudh Phonghanyudh, Samara Tanaka, Na young Koh, Peter Velz, Arthid Boonsa, Athikom Srirathum, Marissa Maghavipata, Waytiga Threamthrakanpon, Voramon Agrasuta, Pattira Chiempricha, Lenka Petzold, Michelle Christensen, Florian Conradi, Hiroe Yoshihama, Jaclyn Le, all MA friends and my thai friends Translator and Interviewer: Oliver SSuerp, Tam Minh Lien, Lena Hammes, Patrik Frauzem and Jeannette Weber All of the participants in the research, especially patients at Immonologische Ambulanz and Miriam Becker

Acknowledgement

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Declaration This is to declare that I wrote this thesis by myself â&#x20AC;&#x201C; in case of group work I marked the part of the thesis produced by me â&#x20AC;&#x201C; and that I used only thoses quotes, sources and aids indicated in my thesis. All quotations used by me are explicitly marked.

Place, Date

(Kwan Phonghanyudh)