This report is prepared by Rivensco consulting, as part of the project called “One Minute may a life” 2015-2017, from the analysis of today’s single emergency number 112 in the Cyprus. As is clear from this document, in Cyprus there is still a widespread distribution of emergency services, with some specific initiatives in some areas, and above all, with little awareness. It will provide a general framework of the 112 operation in Cyprus, in Europe and will include psychological perspectives regarding the training of dispatchers who handle the calls.
112 became the single European Emergency number since 1991. The “112” is the European emergency number and people can call at anytime in all EU member states and get immediate assistance from the fire brigade, a medical team or the police. You can call the number 112 with a fixed or mobile phone and it is free of charge everywhere. The Council of the European Union took the decision to introduce the emergency number 112, so that people travelling in Europe don’t need to know all local emergency numbers. The emergency number 112 is easy to remember and it is the only emergency you need to remember in Europe. A specially trained operator will answer any 112 call, who will either deal with the request directly or transfer the call to the most appropriate emergency service depending on the type of emergency services.
112 in Cyprus
The pan-european number of 112 is available in Cyprus in coexistence with the local Emergency number of 199 which used to be the emergency number in the past. It is possible to call 112 from a mobile phone even without a SIM card. 112 calls are answered on average within 16 seconds. The calls are answered in Greek as well as English, Arabic and Russian. According to the latest E-communications household and telecom single market survey, 58% of Cypriots know they can use 112 everywhere in the EU. The European emergency number 112 works alongside 199 as the emergency number in Cyprus.
For disabled people, there is specific help:
- Special equipment is provided to blind people.
- Deaf people can communicate with other telephone customers using a Telefax machine or the SMS. The customer sends his/her message by Telefax (4 digits number) or by SMS to the dedicated number for deaf people, the operator responsible for the above service receives the message, calls the person to whom the message is addressed and reads it out to them.
While there are several contributions in terms of methods and procedures, on the other hand, we perceive the problem of a substantial heterogeneity in protocols, and particularly in the specialized training of emergency service operators. It also seems to prevail a struggle between powers, the organizations involved and the operators themselves, including memberships, rights and duties. There are, extremely, technological inputs to facilitate the emergency call management, or advanced communication systems. The central problem remains, once again, the human factor. In an understandable way, it is revealed a need to adopt unified protocols but at the same time, a formation that is not only purely technical but also and above all psychological.
The report contains different chapters that analyze and especially methods and research on psychological and sociological basis. Starting historical evolution of emergency numbers in Cyprus, to the progressive unification difficulties, the various procedures and protocols adopted valid until the need, common denominator, to deepen the training slope.
The calls are answered by the police department, by specific operators and then are forwarded to the relevant departments. The operators belong to the police force of the Republic of Cyprus and all relevant training and psychological support for their work purposes comes from the training department of the police force.
The introduction of 112 in Cyprus.
In Cyprus the number 112 was introduced in 2009 and along with 199, which used to be the emergency number before operate to transfer any call to the emergency operator. With the establishment in 1991 of the Single European Number 112 for Emergencies (91/396 / EEC), 112 calls have progressively increased since 2009, for a number of reasons:
• Users who use mobile phones are more than 90% of the local population, with almost one mobile line per inhabitant. The number 112 is in the instruction booklets of mobile phones as the only connectable number and is, in fact, the only number without the SIM / USIM card into the telephone.
• Foreign nationals who are in Cyprus and they do not know the different emergency numbers, using your mobile phone or landline, call emergency numbers and, if known, the number 112. With mobile phones, the latest mobile phones, addressed to 112 calls to 999 (UK) or the 911 (USA), without knowledge from the customer of which service is being called.
• There is a growing awareness that the nationwide number for Emergencies in Europe is the number 112, although in Cyprus only 11% of the population knows that 112 can be used everywhere in Europe.
According to Cyprus Police the operator will direct the 112 call to the necessary department of Ambulance, Police or fire Service. The operator will assess the call and direct it to the appropriate service. A summary of different telephone numbers for different services are listed below:
List of Specific emergency numbers in different fields
|Narcotics – Drugs Law Enforcement Unit (Confidential Information)||Tel:||1498|
|Narcotics – Support Against Narcotics Abuse||Tel:||1410|
|Poisoning and Drugs Information – Drug Information & Poison Control Centre||Tel:||1401|
|Violence in the family – Association For the Prevention and Handling of Violence in the Family||Tel:||1440|
|Youth HelpLine – Help Line Youth for Youth||Tel:||1455|
|Officer on duty||Tel:||1499|
|Police – citizens Line||Tel:||1460|
|Report Forest Fires||Tel:||1407|
|Phone number directory||Tel:||11892|
A comprehensive list of emergency numbers can be found at the following link:
Protocol of 112 in Cyprus
The first response of a 112 call takes place at the local police station from the region that the call took place and interconnects the following services
- Local Police stations, or Rapid Response Unit or road safety department
- Health Ministry ambulance service or local hospitals
(Departments Emergency and Accident)
- Fire Department
- electricity authority
- Water supply
- rescue coordination center for air and naval accidents
The protocol for dispatchers in Cyprus aims to get the following important information from callers:
• telephone number from where you are calling
• Precise location (Street, number, etc.)
• Type and severity of the incident
• Data on / victims (eg number, sex, age)
• Identify any risks or difficulties to approach the scene
The idea behind the protocol is to be able to identify the caller and be able to call back and get more information if necessary. It is essential to give your name and address, and your phone number. To avoid confusion, it is necessary to identify the people who have called 112 because the same incident may already have been reported by several people. It is equally important not hang up if you called 112 by mistake. The caller can tell the operator that there is no problem, otherwise it could be sent emergency aid in the field or waste time to confirm that there is no problem.
When should you call 112?
You can call 112 in any emergency where ambulance services are required, the fire brigade or police. For example:
- when you are the victim himself or you have witnessed a serious road accident
- when you see a burning building.
- when you find a home burglary.
You should not call 112 if you require, for example:
- traffic information
- meteorological overview
- general information
Unnecessary calls can cause system overload endangering the lives of those who really need emergency assistance. Telephone pranks can also hinder the prompt handling of real emergencies. Because of the large number of such calls, Belgium, Cyprus, France, Slovenia and the United Kingdom decided to block 112 calls from mobile phones without a SIM card.
The 112 number does not replace existing national emergency numbers, but in most countries, it operates alongside them. However, Denmark, the Netherlands and Sweden have chosen to have as their sole emergency number 112.
In the following paper, by University of Nicosia a review of three healthcare telematic applications in Cyprus are presented. These include a medical system for emergency telemedicine (AMBULANCE and EMERGENCY-112 projects), a diagnostic telepathology network in gynecological cancer (TELEGYN), and a collaborative virtual medical team for home healthcare of cancer patients (DITIS). The problems associated with the deployment of the former two in routine clinical practice as well as the reasons of success of the third project will be briefly discussed. The findings on Emergency Services 112 are presented below:
Ambulance and Emergency-112 Projects - The AMBULANCE and EMERGENCY-112 projects were sponsored by the EU and Cyprus actively participated. The objective of these projects were the development and testing of a portable device allowing emergency telemedicine services between ambulance vehicles and distanced expert physicians via wireless communication. The ultimate goal was to produce a marketable system that will significantly enhance pre-hospital care. The diagnosis at the scene of an emergency and the handling of the case are substantially improved through on-line access to medical specialists, which decreased the time to make the first diagnosis and start the appropriate treatment. Severe or multiple trauma patients were better assessed, while the electronic registration of the patient’s data freed the ambulance personnel of any paper work and helped devoting more time on real emergency care. The system can be further used in directing the management of stacked victims and setting priorities in cases of major incidents (TRIAGE). It can also contribute to directing the transport of victims, thus reducing the time of arrival at the hospital. Although the system was evaluated successfully, both in Cyprus and in other EU countries in 2000, it has not yet been set in routine operation except being partly used in one private hospital in Greece. In Cyprus there are attempts now in collaboration with the Ministry of Health to revitalize this project.
The University of Nicosia also has the following Findings
Rapid advances in information technology and telecommunications and their convergence (telematics) are leading to the emergence of a new type of information infra-structure that has the potential of supporting an array of advanced services for health-care. This is commonly called eHealth. In the constant competition for resources in the health sector these new eHealth technologies and applications would not stand much chance if they were not intended to improve the quality of care, directly or indirectly, to help in the cost-containment and better management of the health sector, and to increase competitiveness of the medical informatics industry, including health telematics. Cyprus, although at its early stages in eHealth systems, is actively participating in a number of promising applications covering a spectrum of healthcare processes and services. The objective of this paper is to provide a snapshot of selected eHealth applications, and to discuss their training activities leading to their success or failure.
In Cyprus there was a major effort to introduce a health information system (HIS) in the public hospitals which is considered to have been a partial failure. At the same time several telematics pilot projects were funded and developed but only a few are currently being used and are considered to be successful. We will present the effort to introduce the HIS (the outcome of this project was not what it was expected), and we will also discuss the efforts for a new initiative to introduce a new HIS for the public hospitals which is currently underway. Also, three health telematics projects are presented related to emergency telemedicine, home monitoring, and a satellite-based net-work that can be used for healthcare applications. The training aspects of all these projects are presented along with the reasons for their success or failure. Furthermore, the training activities of the Cyprus Society of Medical Informatics are presented.
The Health Information System of the Ministry of Health
The introduction of the Governmental Health Information System commenced in 1989 as a co-project between the Ministry of Health of the Republic of Cyprus and the East Mediterranean Region Office (EMRO) of the World Health Organization (WHO). Firstly, the Patient Administration System (PAS) module was implemented. The pilot commenced in 1991 at Archbishop Makarios III Hospital in Nicosia and was success-fully completed in 1993. WHO evaluated the results of the pilot implementation at a regional conference in Limassol in June 1993. Subsequently, the Ministry of Health in collaboration with the Department of In-formation Technology Services proceeded with the PAS implementation in the other three district general hospitals which was completed in March 1999. The PAS module was subsequently introduced at three rural hospitals. Other modules besides the pa-tient’s personal and demographic data that have been introduced at the four hospitals are: i) doctor’s register, ii) scheduling for the outpatient department, iii) outpatient en-counters, and iv) in-patient register.
The initial training of users was delayed in relation to the deployment of the system at the first site (Makarios Hospital) which delayed the whole process. The training started with the first group of administrative staff and the nursing personnel followed. To date 760 employees have been trained from all the hospitals, 80% of them are nursing personnel, about 20% administrative staff and a small number are medical staff.
In June 2003, the Ministry of Health and the Department of Information Technology Services of the Ministry of Finance have published an expression of interest (EOI) document for the establishment of a turnkey solution of a ready-made application soft-ware for an Integrated Health Care Information System (IHCIS). The system will cover the clinical, administrative and financial activities of both the New Nicosia General Hospital and the New Famagusta General Hospital. The envisioned system will have the capability for a full electronic patient record, be web-enabled and support the vision of the Ministry of Health for paperless and filmless hospitals. The IHCIS consists of the following 13 modules: Patient Administration, Electronic Health Care Record, Hospital Order Entry, Clinical Laboratory, Radiology/PACS, Billing, Stock Control, Prescription Management, Personnel Management, Blood Bank, Health Smart Card, Histopathology, and Coding and Classification of clinical terms. At present the evaluation of the tenders is in progress, and the deployment of the first phase is expected to be completed by mid 2007.
The tenders shall propose, design, and implement appropriate training packages for each of the modules of the IHCIS listed above and an introductory course regarding the overall system functionality shall be provided to all users. The tender shall pro-vide a detailed plan of the training courses, outlining and justifying the sequence and frequency of the courses, and shall describe the way and practice to ensure a successful training outcome. The tender shall include detailed information for all offered training courses including the following: course name, duration (hrs), location, aims of the training course, course outline, instructors qualifications, and offered certification at the end of the training course.
A detailed list of prospective users has already been prepared for training and includes around a 1000 and 250 users for the New Nicosia and New Famagusta Hospitals respectively. A Train the Trainers methodology will be followed, where a group of ten expert users will be trained and will be responsible for further end user training and first line support in each of the hospitals.
The whole project is expected to take 12 months. It should be noted that this time schedule is considered to be optimistic by a number of officers in the Ministry of Health, based on the rather limited information technology experience of the personnel of the hospitals. However, the plans at present are to proceed as originally scheduled.
Furthermore, the University of Cyprus, in collaboration with the Ministry of Health and the Pafos General Hospital has recently been awarded a new INTERREG III B Archimed Program project entitled “A Mediterranean Research and Higher Education Intranet in Medical and Biological Sciences” . The aim of this project is the development of a medical educational/ research intranet between higher education and research institutions from Greece, Italy and Cyprus, to support the undergraduate educational program, graduate practice and residency and to promote research collaborations by: i) dissemination of web-based lectures and seminars, covering advanced scientific topics and up-to-date technologies, and ii) promotion of research collaborations through web-based shared work-spaces.
Emergency Telemedicine: the AMBULANCE and EMERGENCY-112 Projects
The availability of prompt and expert medical care can meaningfully improve health care services at understaffed rural or remote areas. The provision of effective emergency telemedicine and home monitoring solutions are the major fields of interest of AMBULANCE HC1001 and EMERG-ENCY-112 HC4027 projects that were partially funded by the European Commission/ DGXIII Telematics Application Programme.
The aim of the AMBULANCE project was the development of a portable emergency telemedicine device that supports real-time transmission of critical biosignals as well as still images of the patient using the GSM link. This device can be used by paramedics or not specialized personnel that handle emergency cases in order to provide telediagnosis, long distance support and directions from expert physicians located at an emergency coordination center or a specialized hospital.
The system can be used for different cardiovascular or severe injuries cases. It comprises of two different modules: i) the mo-bile unit, which is located in an ambulance vehicle near the patient, and ii) the consultation unit, which is located at the hospital site and can be used by the experts in order to give directions.
EMERGENCY-112, which was the ex-tension of the AMBULANCE project, aimed to extend the system to an integrated system which would be able to operate over several communication links (Satellite, GSM, POTS, ISDN, LAN, etc. ) and for different cases (ambulance emergencies, rural health center or any other remotely located health center support, navigating ships sup-port and home monitoring). In EMERGEN-CY-112, emphasis was given to maximizing the system’s future potential application, through the utilization of different links (both fixed and wireless), as well as through the increase of the overall system’s usability, focusing on advanced user-interface and ergonomics. The system comprises of two different modules: i) The patient unit which is the unit located near the patient. This unit can operate automatically and has several operating features (depending on the case used). ii) The physician’s unit which is the unit located near the expert doctor. This unit can be either fixed or mobile depending on the place where the expert doctor is located. Diagnostically important data, like ECG, blood pressure, heart rate, oxymetry, temperature, etc., are collected via a biosignal monitor connected to a portable computer at the mobile site and are transmitted through the mobile telephony network (i.e satellite, GSM or UMTS) to the hospital site. Still images of the patient’s position and state are captured through a small camera and trans-mitted. The specialist at the hospital site can observe the signals in real-time, view the images of the patient and mark some interesting areas (whiteboarding), a marking that appears simultaneously at the mobile screen. Thus, he is able to assess the severity of the emergency and through a bidirectional voice communication link can instruct the paramedic how to handle the case. The system is supported by a multimedia database, which stores all information avail-able from the time the system is initialized until the arrival of the patient at the hospital.
The system was evaluated and verified in Cyprus, Greece, Italy and Sweden. Each pilot recorded certain time indicators, such as time-to-transportation, time-to-start-treatment, time-to-stabilization, etc., in a total of 100 cases in which the system was used and in another 100 cases without using the system, in order for comparative results to be deduced. It was shown that the system provides significant support to the early and specialized pre-hospital patient management and to emergency case survival. The diagnosis at the scene of an emergency, as well as the handling of the case, was substantially improved through on-line access to medical specialists, which decreased the time to make the first diagnosis and start the appropriate treatment. Severe or multiple trauma patients were better assessed, while the electronic registration of the patient’s data freed the ambulance personnel of any paperwork and helped them devote more time to real emergency care.
User training was performed on each site where the base stations and clients of the system were installed. The age of the users ranged from 25 to 50 years. Users were divided into experienced and non-experienced computer users. Training was initially performed using demo cases. This was essential since the system’s main purpose was the support of emergency medical cases. Initial training time for each experienced user was about 30 minutes whereas for inexperienced users it was about one hour. Furthermore the use of the system initially was performed in collaboration with the technical people, thus allowing users to continue their training. A user manual with instructions and installation disks was supplied to the sites.
The results from the system use (except from the initial evaluation phase) were not at the success level we initially expected. In general the system was introduced and used in daily routine in only one hospital which was established when the system was created. This is the Interbalkan Hospital in Thessaloniki, Greece. The emergency health care department was created at the time when the system was finished; the people of the department were trained from the beginning and the system became part of their daily routine. The same department was supporting two isolated areas in the northern part of Greece; a village called “Zoni” and a small island called “Agios Efstratios”. Unfortunately at the other sites in Greece, Italy, and Sweden where the system was installed, the departments were already established and the use of the system was initially delaying the process since many of the users were not computer experts. The final result was rare use of the system.
In Cyprus, although the system was successfully evaluated at the Department of Accident and Emergency at the Nicosia General Hospital, connecting a rural health center and an ambulance, it has not yet been set in routine operation. However, this project will now be revitalized based on a new INTERREG III B Archimed Program project entitled “An INTEgrated broadband telecommunication pilot teleservices-platform for improving health care provision in the Region of MEDiterranean” which has recently been awarded to the University of Cyprus and the Pafos General Hospital . The aim of this project is to develop a plat-form that will enhance the provision of medical services for both citizens and travelers in remote/isolated regions of the southeast Mediterranean, and on board of ships travelling across it. The platform will support ECG and vital signal processing as well as ultrasound imaging and video conferencing functionality.
DITIS: Home Healthcare of Cancer Patients [8-11]
DITIS (ΔΙΤΗΣ, in Greek, stands for: Net-work for Home HealthCare Collaboration) is a system that supports virtual healthcare teams dealing with the home-healthcare of cancer patients in Cyprus. DITIS was originally developed with a view to address the difficulties of communication and continuity of care between the home-healthcare multidisciplinary team (of the Pancyprian Association of Cancer Patients and Friends, PASYKAF) and between the team and the oncologist often over 100 km away. DITIS has through its database and possibility of access via mobile or wire line (computers) offered much more than improved communication. Its flexibility of communication and access to the patient’s history and daily record at all times and from anywhere (e.g. home, outpatients, or even during emergency admission) has offered the team a continuous overall assessment and history of each symptom. DITIS supports the creation, management and co-ordination of virtual healthcare teams, for the continuous treatment of the patient at home. Thus it has offered improved quality of life to the patient, for example by offering the nurses the possibility of immediate authorization to change prescription via mobile devices and the oncologist the possibility of assessment and symptom control without necessarily having to see the patient.
DITIS was initiated in 1999 as a two-year research project and has since been funded by a number of organizations: the Cyprus Research Promotion Foundation, the University of Cyprus, and the Cyprus Association of Cancer Patients and Friends (PASY-KAF). DITIS has also been supported by the Cyprus Telecommunications Authority (CYTA), Cambridge Microsoft Research Labs, NetU consultants Ltd, WinMob Technologies Ltd, Ericsson (through S.A. Petrides Ltd), and the Cyprus Development Bank (CDB). Currently, DITIS supports the activities of PASYKAF, who offer home-care services for cancer patients in Cyprus. Work is underway for a second phase of the project, leading to pan-Cyprian deployment and commercialization.
In this paper a review of selected eHealth applications in Cyprus was presented linked with their success or failure based on their training activities. Different methodologies for training were used ranging from classical approaches like train the trainers, using demo cases followed by personal training, group training, and workshops, to more recent methodologies based on eLearning sessions including teleconsultations. The training was carried out successfully in all cases. However, not all eHealth systems were put into practice successfully, mainly for reasons not related to training.
Cyprus should accelerate its pace in eHealth services for the benefit of the whole healthcare sector. A critical factor in achieving this is training the physicians, the paramedical and administrative staff in emerging information technologies in healthcare. Training these personnel should include concepts like electronic patient record, web-based systems, security, teleworking, and other. Linked with the training, there should be 24-hour support for the medical staff in the hospital, clinical systems, or home care under operation. Furthermore, based on the recommendations of the WHO report on eHealth Tools & Services , Cyprus should invest more on eLearning methods in health sciences, provide wider access to digital libraries and information about evidence-based research within the eHealth domain, and help in the establishment of a network to share experiences internationally. These actions should be promoted taking into consideration recent trends in health informatics education and training based on the introduction of new technologies, including the electronic patient record and prescription , as well as hi-tech imaging, robotics, and genomics and proteomics applications .
Cyprus should prescribe its national action plan in eHealth, aligned with the recently announced EU eHealth action plan . This national plan should pre-scribe the road map leading to the wider spread of information and communication technologies enabling the faster implementation of electronic health records, patient identifiers and health cards, and the faster rollout of high-speed internet access to en-able optimum interactions among health care professionals and with the general public . It is hoped that these efforts will be materialized, thus enabling the offering of better service to citizens.
We can conclude that the emergency number 112 has a good response rate in Cyprus, but more work needs to be done for the operators in order to have all the physical and psychological support they need.
The Role of Psychology Training for the operator 112.
EENA Operations Document – Psychological support of 112 call takers
According to some scientific research, and some interview in Cyprus of people dealing with emergency calls, psychological training can have a decisive role in the dispatcher of Service 112. According to the European Emergency Number Association here are the findings of the main aspects related to the psychological issues of 112 call takers in Europe.
The objective of this Operations document is to describe the main issues related to the psychological aspects, needs and support of 112 call takers, to assemble relevant, currently available information about this issue, to outline some of the ‘best practices’ and evidence based interventions from a system-focused as well as a call taker-focused perspective and inspire further improvements in the systematic creation of a supportive working environment for call takers, whose performance pre-determines the quality and ultimate effectiveness of the potentially lifesaving 112 services.
2 Abbreviations and Glossary1
ALS or Advanced Life Support – is a set of life-saving protocols and skills that extend Basic Life Support to further support the circulation and provide an open airway and adequate ventilation (breathing).
AVL – automatic vehicle location
BLS or Basic life support – is the level of medical care, which is used for patients with life-threatening illnesses or injuries until the patient can be given full medical care at a hospital.
EC – European Commission
EU – European Union
ICF – International Classification of Functioning
MS – Member State
PSAP – Public Safety
AN Answering Points
UN – United Nations
WHO – World Health Organization
3 Call taking from a psychological perspective
- The role of the call taker – tasks and factors affecting performance
The emergency setting related to 112 call-taking brings a set of questions to the fore — how do workers in an emotionally charged setting, with features of vivid and interruptive experiences that possibly interrupt decision making, interact with standard operating procedures that are supposed to provide the necessary stability and support, so that recurring decisions can be made under similar conditions? How do the call takers relate to the emotional landscape of emergency call taking and the callers’ emotional expressions? How do they cope with related stress? How do call takers make decisions, use intuitive and emotional capabilities to complement or challenge rational aspects of the available decision-support systems? How do they use rational and formal procedures as well as non-formal, intuitive and emotionally based, individual processes to make their decisions and how can they be effectively supported in the decision-making process? These questions require a reflection in an organizational context, in order to identify limitations to the development of situation-specific expertise, obstacles for organizational learning and tools for effective on-job call taker support.
The 112 service chain defines the basic framework of tasks and thus the context, in which we can start searching for answers to these and other relevant questions – in modern dispatch systems, the call taker will fill a number of critical functions.3 These functions are determined by and will vary in relation to the defined service chain at organizational level.
The Emergency Alarm Sequence:
The response interval of the public:
- The incidence occurs
2) The emergency call is made
The emergency response interval:
- The call is answered by the service
- A need is identified
- A priority is decided
- A response is defined
- The response/resource is dispatched
- Assistance may be given online if indicated
- The call is terminated
In most systems, the telephone remains almost a singular point of access for those needing assistance, but the deployment of new alerting mechanisms such as public access defibrillators, personal safety alarms and vehicle monitoring systems represent new challenges for call takers processing incoming emergency calls at the PSAPs.
The responsibility of the call taker involves the triage of incoming calls, providing expert systematized caller interrogation, in order to determine the likely severity of the problem, illness or injury, so that the most appropriate type of response by emergency services is triggered. All calls are prioritized, in the case of injuries or illness by the medical symptom/condition acuity. This process may be further complicated by panic-stricken callers who scream, cry, or make unreasonable demands. The trained call taker uses interpersonal and crisis management skills to sort through these distractions, taking control of the conversation, calming the caller, and extracting the necessary information. This inquiry begins with the obvious questions regarding the situation or the patient. The questioning will continue until the call taker is able to qualify (a potentially life-threatening) condition, to which the closest appropriate response can be triggered, dispatching required emergency service’s resources (such as a paramedic-staffed ambulance service, fire and rescue service or police units).
When this occurs, the call taker will continue the questioning, attempting to gather additional relevant information, useful to determine response speed, the type of resources dispatched, or the type of equipment that the rescue services units will bring to the site when they arrive. In most cases, this ‘pre-alert’ function will not be required, and the resource will simply be dispatched when all of the required information has been gathered. Ultimately, the decision on how to proceed, or when to interrupt the established process, requires the judgment of the call taker handling the call. Otherwise, the manner in which this questioning proceeds is often governed by protocols, or by decision-support software.
The third function, relevant in some selected cases (depending on the specific emergency services organisation and its service chain), is the selection and assignment of the most appropriate type of response resource, (such as an ambulance), from the closest or the most appropriate location, depending on the nature of the problem, and ensuring that the crew of the response resource receive all of the appropriate information. The call taker is responsible for the management and work assignment (in some cases physicians and supervisors provide the work direction) for all of the response resources in the system. In many cases, the call taker is responsible for managing multiple response resources simultaneously and providing first aid guidance (basic or advance life support) or other potentially live saving advice to the caller. This requires a constant level of awareness of the location and status of each resource, so that the closest available and appropriate resource may be sent to each call, but also effective communication skills, a sound knowledge base (training) enabling the call taker to provide active support to the caller facing an emergency.
The call taker is generally also responsible for providing information support to the responding resources. This may include call-backs to the call originator to clarify information. It may involve clarifying the exact location of the emergency/patient, or sending a bystander to meet the ambulance and direct paramedics to the patient. It may also include requests from the onsite rescue services crew to provide support resources, such as additional ambulances, rescue equipment, or a helicopter. The call taker also plays a key role in the safety of staff onsite. They are the first with the opportunity to assess the situation that the crew is responding to, will maintain contact on the scene in order to monitor crew safety, and are frequently responsible for requesting emergency police response to ‘back up’ paramedics when they encounter a violent situation. PSAPs are often responsible for monitoring the status of local hospitals, advising paramedics on which hospitals are accepting ambulance patients, and which are on ‘re-direct’ or ‘divert’. In many cases, they may also be responsible for notifying the hospital of incoming patients on behalf of the response resource crew.
Finally, the call taker ensures that the information regarding each call is collected in a consistent manner, for both legal and quality assurance purposes. In most jurisdictions, all records, including both patient care and dispatch records, and also recordings of dispatch radio and telephone conversations, are considered to be legal documents. Dispatch records are often a subject of interest in legal proceedings, particularly with respect to the initial information obtained, statements made by the caller, and response times for resources. The gathered information may be at some point demanded by a criminal court or civil court or a public inquiry and may have to be produced as evidence. It is not uncommon in some jurisdictions for call takers to be summoned to court, in order to provide evidence regarding their activities. As a result, there is frequently a legal requirement for the long-term storage of such information, and the specific requirements are likely to vary by both country and jurisdiction. As a direct result of these two factors, there is a requirement for all call information to be collected and stored in a regular, consistent, and professional manner, and this too, will often fall to the call taker, at least in the initial stages.
Multi-tasking is the central feature of call taking and dispatch work. Numerous factors and barriers can affect the realisation of these tasks, including decision-making under time constraints, quality of available support in management of resources and decision-making, effective communication, coordination, cooperation and mutual awareness within a broader team of involved specialists. As a result, the psychological factors at an individual level such as interpersonal skills, adaptive behaviour and coping strategies play an important role.
Decision Making in Emergency Settings
Making fast decisions at the same time as making complex analytic decisions may imply quality tradeoffs. Moreover, fast and analytic decision making draws on different assumptions of how information is processed. Even though reason-based and non-reason-based conceptualisations may be grossly oversimplified depictions of these phenomena, they have earned attention across research programs (cf. Kahneman, 2003; Sloman, 1996) and it has also been brought up in the emergency room context (cf. Coget & Keller, 2010).7
Decision-making can be hampered and stress-levels increased by lack of available resources and institutional support (call overload, insufficient staffing, decisions about priority status, shortage of ambulances, precision imperative, absence of down time)8 and these factors are more closely analysed in the section 4 of the document related to the ergonomics of the call taking.
- Psychological aspects of emergency call taking
Emergency call takers listen to callers describing mundane problems but also to callers describing severe accidents, agony and deaths. The emergency setting is further complicated by having to perform triage quickly, but without the possibility of seeing the patient. The setting rests on an imperative of speedy management—there is little possibility of postponing or reconsidering a decision. At the same time, the model of communication (telephone) may cause an overflow or lack of information, resulting in an uncertain and ambiguous decision-making setting.
Thus emergency call takers need to possess multiple competencies in terms of medical, technical, and emotional skills but also have access to continuous education (training) and psychological support. A Swedish study9 described the setting of emergency call taking as an uncertain setting, filled with communication difficulties and insufficient resources. Further related research found that individual skills, knowledge, experience, sensitivity, insight, empathy and intuition helped bridge the difficulties related to the call taking tasks
The tasks of the call taker consist of interconnected processes, administered in a cooperative work situation, with an awareness of dealing with clients in potentially life threatening situations, which ultimately results in an increased sense of responsibility and higher pressure to perform.
Processing of an emergency call requires a sequence of complex cognitive, emotional and behavioral reactions by the call taker collecting key information about the emergency, often in an emotionally and socially complex situation. The situation analyses require a process of synthesis, abstraction, specification and prioritization of acquired information in the context of a decision-making process.
A seemingly simple task of call taking requires a fast, effective and flexible coordination of mental processes. Each call places a rather high demand on the exact perception of the sensory systems (mainly hearing and sight), good coordination of sensory perception and fine motor skills, which are used in listening and the parallel work with the computer, concentration and quick division of attention, spatial orientation (in working with maps), imagination, ability to memorize quickly, the ability to differentiate heard facts from own interpretations. Synthetic and analytical thinking as well as logic are required for the mentioned tasks.
The task of call taking integrates several professions and places high demands on the mental processes, condition and personality of the call takers. The complexity factors of the call taker tasks 11 can be divided into
- mental workload and decision-making, based on possibly unreliable information, potentially conflicting requirements, realising activities with potentially damaging effect on other people, the employer (own organisation) or the call taker,
- interpersonal complexity, due to the necessity of obtaining trust and cooperation of various agents (stakeholders), emotional distress,
- demand factors related to time and energy, especially related to tasks with very limited time available for their completion and limited or no space for correction of mistakes.
Stress factors in call taking can include:
- feelings of helplessness in critical situations with limited ability to influence the situation of the caller facing an emergency and emotional strain of extreme situations (such as incidents with children dying, mass emergencies and incidents with many severely injured, incidents involving own family members),
- competing demands for executing rapid and precise assessments while working with a limited environment in relation to the decision-making autonomy and information availability, with constrained decision-making capacity by working within a frequently unsupervised, non-visual access environment, relying on secondary (potentially inaccurate) information delivery, (a common experience is “being reprimanded for dispatching too little or too much help”),
- frequent emergency line abuse, conversational difficulties with callers with limited capacity for conveying accurate information, complicated by rapidly shifting features of the emergency scene,
- frequently disrupted functioning of support systems (such as communication lines, call centre software) without back up options, outdated equipment
- lack of necessary resources (such as ambulances) available to be deployed to an emergency,
- problems in the organisation of work, overload of tasks, perceived inadequate working conditions, perceived inadequate remuneration, compromised work place relationships, physically confining and isolating workspace (and the resulting inability to relieve stress physically and socialise with colleagues) and lack of available quiet space,
- inadequate formal training and preparation for tasks and the arising insecurity and problems in decision-making,
- enduring lack of public acknowledgment for the work of emergency call takers (media attention is usually focused on rescue units onsite) and the resulting less robust social support (demonstrated for example by negative citizen responses) as well as perceived underestimation of the degree of stress that dispatchers face and lack of recognition in the part of management (sometimes based on the assumption, that call taker-dispatcher stress is negligible to paramedics or other onsite rescue services staff stress).
Literature on occupational stress among emergency personnel emphasizes the direct contact with distress, injury, violence and death as central causes of stress.13 The tension between competing exigencies of call takers (dispatchers) to act instantaneously while simultaneously not overstepping decision-making power, combined with inadequate resources contribute to escalating powerlessness and cumulative stress levels. 14 The sense of responsibility is complicated by their role as intermediaries between the distressed, frequently panicked and incoherent public and paramedics. Based on these factors and research results15 its possible to conclude, that the work of emergency call takers represents a set of complex tasks, challenging the endurance of call-takers and carry along relatively high stress factors and thus a risk of burnout.
As illustrated on the above graph, an increase in stress results in an increase of productivity
– up to a point, after which things go rapidly downhill.
However, that point or peak differs for each of us, so one needs to be sensitive to the early warning symptoms and signs that suggest a stress overload is starting to push him/her over the hump.
Such signals also differ for each individual and can be so subtle that they are often ignored until it is too late. Not infrequently, others are aware that one may be headed for trouble before the affected person.
Given the demands of the job, the common experience is that call takers are being much more comfortable providing help than requesting it or making use of it once it’s offered. Therefore it is recommendable to include relevant topics such as recognition of signs of depression and burnout but also the difference between critical incidents related stress and cumulative stressors which are characteristic of the call takers’ daily work environment into the formal training programme.
In order to avoid unwanted impact on human resources and institutional capacities, these identified stress factors require systematic attention at institutional level of PSAPs. In an ideal setting, they should translate to the development, implementation, evaluation and maintenance of stress management programmes in work settings (of the PSAPs), with a clearly defined purpose of the programme, delineated individual and organisational goals and defined mechanisms of organisational support to the programmes, which are to be integrated into existing occupational health and safety strategies.
Stress management methods at individual level can include methods like muscle relaxation, meditation, biofeedback and cognitive strategies, taught to employees as a means of reducing psycho-physiological and subjective distress providing the individual with skills for recognizing and coping with work related stress.18
The Croatian experience shows that call takers should be qualified to manage the stress to which they are exposed. It is important for every call taker to have a psychological baseline data (psychological test results). In Croatia, once a year, testing of call takers is conducted to determine how they manage with stress. They are taught different relaxation techniques that can be applied at work and at home. Quality supervision is significantly affected by the reduction of stress. The Croatian PSAP management recommends, based on gained experiences, conducting analyzes of the impact of stress on the call takers after each demanding stressful event in the presence of a psychologist and that each centre 112 should have a Stress management plan. Psychologist should also be available to each call taker.
The development of stress management programmes at (PSAPs) institutional level should be based on a complex analyses of the exposure of employee target groups (such as call takers) to stress factors in the defined settings and task context, the work setting ergonomics and result in comprehensive actions, embedded in the institutional human resources management strategies.
- Psychological load in the work performance of emergency call takers
The role of the 112 call takers and dispatchers is critical to the outcome of emergency calls and thus the psychological load related to their work performance requires systematic attention. If we assume the psychological load refers to the subjective (mental and emotional) responses of employees (call takers) to the requirements of their job, the level of this load depends on the difficulty of task, the impact of both the internal and the external working environment and individual capabilities. 112 call takers are exposed to various factors increasing the psychological load of their work including:
- The essence of their tasks, processing dozens of emergency calls per working shift, carrying legal responsibility and the resulting increased pressure not to make mistakes;
- Work place related factors like noise, inadequate circulation of air, work place set up;
- Socio-pathological factors in social interaction, conflicts and frustrating experiences with callers (for ex. abusing the emergency line and thus increasing the work load of call takers, abusive, intoxicated or vulgar callers) or with team members (with conflicting agenda or expectations, such as frequent and/or inadequate questioning the relevance of the call takers dispatch decisions by rescue units crews sent onsite);
- Limited or no availability of adequate outlets for the expression of difficult emotions, effective, proximal and non-intrusive supervision as well as lack of social support in general.
Individual capabilities, including motivation, and the ascribed value to the role/performed tasks influence performance, both in positive and negative ways.
- Most common psychological problems of call takers
Given the unique features of call taking (dispatch) work as compared to paramedic work (e.g. its status as the first point of entry for emergency calls; its role as the conduit for information between civilians and emergency workers; its limited intervention status and its sedentary nature), there are implications for both empirical explorations of call taker stress and intervention development.
Despite the numerous similar stressors faced by both paramedics and dispatchers, chronic and/or traumatic stress may be experienced differently in the context of dispatch work. For instance, while paramedics might struggle with lingering visual images from a difficult call, call takers might be left with auditory reminders. That is, involuntary recollections resulting from calls might take the form of auditory reverberation
Moreover, visual images that may be elicited by listening, in the absence of verifiable visual information, may lead to different symptoms and may require different intervention possibilities. A recent unpublished UK project comparing paramedics and call takers (dispatchers) has begun to explore some of these issues. Similar levels of intrusive visual imagery were reported by dispatchers and paramedics, and dispatchers who presented with post-traumatic symptoms exhibited false visual re-experiencing symptoms22. Notably, visual imagery ability was a moderator of the relationship between post-traumatic symptoms and call-related visual imagery among dispatchers in particular. This suggests potential differential intervention pathways for paramedics versus dispatchers.
The lack of control imposed by the call taking (dispatch) role in providing on-the-scene, hands-on help, may also elicit a specific type of second-guessing about decision accuracy or sense of helplessness that may be different from the kind of struggles paramedics report in relation to retracing their decision-making for a call.
Moreover, the self-selection process that might be operating in choosing to become a paramedic versus a dispatcher may also have implications for how emergency work-related stress is experienced and managed. Although some have performed both roles at different points in their career, for the most part these are discrete positions.
- Individual coping strategies
The difference between experiences that result in stimulating stress and those that result in distress is determined by the disparity between an experience (real or imagined) and personal expectations and resources to cope with the stress. Reactions to call taker load and stress can be adequate, inadequate or pathological and can, under certain circumstances, result in acute stress reaction, post-traumatic stress disorder or burn-out syndrome
Call taker coping strategies in disaster management context
Disasters may range from severe to minor and having an awareness of the potential deployment environment, conditions, duties, and constrains (including possible limits to the ability to communicate to or assist own family members) can prepare a call taker to cope more effectively in these mentally challenging situations.
The working conditions in a disaster area may vary depending on the type of disaster, the length of time that has passed since the disaster, and the magnitude of the emergency response effort. The nature of the disaster deployment and the role assumed by the call taker will vary, as will the degree of coping skills necessary to overcome stress and fatigue. Stress and fatigue may easily progress to depression and, in some cases post-traumatic stress disorder.
Research into the coping strategies used by and found effective by emergency responders has generally focused on law enforcement and fire department responders. An important factor related to call takers is their dynamic working conditions, with adaptability and flexibility identified as the key considerations in working effectively in disaster areas.
Nevertheless, research has found the following general strategies have been effective in relieving and preventing stress in disaster management context: 25
- Sleep/work schedule – Maintain these schedules as best as possible. If you are “off” take advantage of the time to rest, exercise, or to otherwise relax.
- Nutrition – Eat at regular intervals and eat healthy to the most extent possible.
- Exercise – Walk or engage in some other form of exercise to “de-stress”.
- Avoid Alcohol/Drugs – These not only jeopardize job performance, but also increase stress after intoxication.
- Humor – The use of humor is often a natural expression to relieve stress and to make the best of a situation. However, there may be times when humor is inappropriate.
- Breaks – Take adequate breaks with your team and other call takers. The diversion from work and the opportunity to talk with others in a similar situation will help relieve stress.
- Think About Other Things – Take a “mental vacation” and think about non-work-related and pleasant events.
- Take a Deep Breath and Relax – Take a deep breath and remember you have the strength, training, and experience to handle the situation. If you act calm, you will start to feel calm.
- Remember, It Could Be Worse – Regardless of how bad things may seem, it could always be worse. As a result, this perception may enable you to reduce the stress and to appreciate the situation better.
- Talk to Others – Talk to others in your team or from the PSAP. Discuss what has occurred, what is occurring, and what will happen.
- Out of Place, Out of Mind – Some people deal with stress better alone and by withdrawing from others, while others may need to talk to someone. Others can simply ignore the current situation and dedicate their efforts to helping more.
Professional and Peer-Assistance
Depending on the nature of the deployment and disaster, the emotional impact of active engagement in disaster management may necessitate professional and/or peer assistance. Under some disaster related circumstances, it might be necessary for call takers to assist another temporary, alternate, or permanent PSAP when assistance is needed and this represents an extra challenge. The mental preparation for disaster deployment is an integral component of pre-deployment. The ability to recognize the characteristics of disaster areas and the associated stress typically resulting from working in these areas, as well as different coping strategies can have a significant impact on a call takers ability to function in a disaster area.
Changes in sleep, appetite, relationships, recurring dreams, or other indicators of depression may be signs of long-term emotional trauma and should be seen as signals to seek support. The long-term consequences for failing to seek help, if necessary, can lead to a number of physical and mental illnesses. Unfortunately, rescue services professionals (including call takers) are often very independent and rarely acknowledge the need for help.
- Psychological intervention possibilities
Most commonly used tools of intervention include:
- Critical Incident Stress Management, which is an intervention protocol developed specifically for dealing with traumatic events. It is a formal, highly structured and professionally recognized process for helping those involved in a critical incident to share their experiences, vent emotions, learn about stress reactions and symptoms and given referral for further help if required. It is not psychotherapy. It is a confidential, voluntary and educative process, sometimes called ‘psychological first aid’. First developed for use with military combat veterans and then civilian first responders
(police, fire, ambulance, emergency workers and disaster rescuers), it has now been adapted and used virtually everywhere there is a need to address traumatic impact in people’s lives. There are several types of interventions that can be used, depending on the situation. Variations of these interventions can be used for groups, individuals, families and in the workplace and include:
Debriefing is a proactive intervention involving a group meeting or discussion about a particularly distressing critical incident. Based on core principles of crisis intervention, the CISD is designed to mitigate the impact of a critical incident and to assist the persons in recovery from the stress associated with the event. The CISD is facilitated by a specially trained team which includes professional and peer support personnel. Also called Critical Incident Stress Debriefing (CISD). Ideally it is conducted between 24 and 72 hours after the incident, but may be held later under exceptional circumstances.
Defusing is an intervention that is a shorter, less formal version of a debriefing. It generally lasts from 30 to 60 minutes, but may go longer and is best conducted within one to four hours after a critical incident. It is not usually conducted more than 12 hours after the incident. Like a debriefing, it is a confidential and voluntary opportunity to learn about stress, share reactions to an incident and vent emotions. The main purpose is to stabilize people affected by the incident so that they can return to their normal routines without unusual stress. Where appropriate, a formal debriefing also be required.
Grief and Loss Session is a structured group or individual session following a death and assists people in understanding their own grief reactions as well as creating a healthy atmosphere of openness and dialogue around the circumstances of the death.
Crisis Management Briefing is a large, homogeneous group intervention used before, during and after crisis to present facts, facilitate a brief, controlled discussion, Q & A and info on stress survival skills and/or other available support services. May be repeated as situation changes.
Critical Incident Adjustment Support provides multi-faceted humanitarian assistance to individual, families or groups for coping with the aftermath of an incident and overcoming the ongoing impact of a death or injury.
Pre-Crisis Education provides a foundation for CISM services. It includes incident awareness, crisis response strategies and develops stress management coping skills that can prevent major problems should an incident occur. It takes the form of an employee handbook, e-book and/or workshops and training seminars.
Individual crises intervention – while dealing with crisis, both personal and societal, there are five basic principles outlined for intervention. Those affected by crises are initially at high risk for maladaptive coping or immobilization, thus intervening as quickly as possible is imperative. Resource mobilization should be immediately enacted in order to provide them with the tools they need to return to some sort of order and normalcy, in addition to enable eventual independent functioning. The next step is to facilitate understanding of the event by processing the situation or trauma. This is done in order to help the victim gain a better understanding of what has occurred and allowing him or her to express feeling about the experience. Additionally, the counselor should assist the victim(s) in problem solving within the context of their situation and feelings. This is necessary for developing self-efficacy and self-reliance. Helping the victim get back to being able to function independently by actively facilitating problem solving, assisting in developing appropriate strategies for addressing those concerns, and in helping putting those strategies into action. This is done in hopes of assisting the victim to become self-reliant. An example of an intervention program based on crises intervention principles is the Assessment Crisis Intervention Trauma Treatment (ACT) model of crisis intervention developed by Roberts as a response to the September 11, 2001 tragedy.28
- Trainings, workshops
The potential benefits of crises related training include:
- staff members becoming more confident in their ability to manage crisis situations, increasing their confidence as a team in handling crisis situations;
- staff members and supervisors adopting a more consistent approach to callers in crisis, thus providing higher quality support/service;
- staff members obtaining increased knowledge of crisis intervention and management techniques;
- selected supervisory staff members obtaining basic and sophisticated techniques to conduct effective and long-lasting training programs, benefiting the human resources of the PSAP.
- Peer and supervision support programmes
The concept of psychological support based on peer assistance is relatively new, and one which has developed from industrial settings. In essence, assistance is offered by a group of specially trained employees so to assist their co-workers in coping with personal or job related problems. While peer support programs may seem similar to the earlier developed self help movement, in fact they are quite different. Peer support programs focus on everyday experiences of everyday typical people. The helpers are themselves employees who can relate to other employees of their common trade, profession or working environment. Peer support programs are preventative in their orientation and they encourage people to seek assistance in the early stages of a problem. Peer programs are ultimately based on the premise that people who experience a common circumstance or find themselves in a common predicament can, by virtue of their understanding, facilitate recovery in others. 29
The mission of a peer support programme is to provide fellow PSAP personnel psychological and emotional support through pre-incident education, spousal/family support, on-scene support and demobilization intervention, post-incident defusing or one-on-one interaction. The peer support team would/should be comprised of agency members who have been specially trained in crisis intervention and stress management techniques and who work in conjunction with mental health professionals who specialize in providing support to emergency service personnel. 30
- Mental health services
Like other members of the general population, emergency call takers (similar to first responders of onsite rescue services) may have pre-existing mental health conditions that are exacerbated by emergencies or they may develop new mental health conditions as a result of constant exposure to emergencies. Yet, the emergence or aggravation of mental health conditions may occur at higher rates when compared to the general population, because of the stresses associated with their duties.
31 If emergency call takers have access to mental health screenings, they may be more likely to receive timely diagnoses and treatment. Therefore, mental health screening should, ideally, be offered, especially after exposure to situations or emergencies perceived as potentially traumatizing for those involved.
The barriers to such resource utilization may stem both from perceived or actual stigma associated with revealing specific symptoms such as anxiety, depression or intrusive thoughts and from a belief that their disclosure would undermine one’s ability to perform the job.32 Research results advocate for integrated models for dealing with occupation stress that addresses both personal and organization features. Rather than viewing stress management as an individualized, privatized problem of the employee, coping can be conceptualized as an organizational or joint venture. 33
This approach is also compatible with the finding that resilience in response to even deeply disturbing events is the rule rather than the exception for the majority of individuals. 34 It is important to underscore, however, that this propensity for natural recovery can be either facilitated by appropriately-timed and calibrated, supportive responses or undermined by their absence. Intrusive interventions or those incongruent with the recipient’s needs may be potentially even more damaging than the doing nothing.35
Work-related stress can be both exacerbated and mitigated by institutional factors. Issues such as decision-making latitude, scheduling, stress-leave policies, and peer and management support repeatedly emerge as central and frequently outweigh concerns over specific critical incidents36. The organizational structure can, thus, be appropriately galvanized to build prevention and intervention approaches that foster both individual and organizational resilience.37
4 Ergonomics of call taking
- Call taker perspective
The profession of call takers is being taken up by staff with varying educational profiles across Europe. Scope of experiences, the knowledge base and professional skills of a call taker have a direct impact on the performance of the complex set of tasks and the quality of support provided to the callers and rescue services involved in intervention.
Their tasks are carried out in a sheltered environment of (restricted access) call centers with special regime and 24h/365 day per year operations. They work in 8 or 12 hour shifts, followed by a defined period of rest (which varies from 12, 24 to 48 hrs). According to general experience (data collected in research activities in Slovakia), the defined periods of rest are often shortened due to participation on educational activities, other jobs or overtime needs due to other staff illnesses.
According to some studies38 addressing the relation between the length of the working shift and performance indicators, it is not generally recommended to exceed an 8 hours shift of call takers, as 40 working hour weeks showed lowest impact on absences, highest level of performance and employee satisfaction. The practice in defined length of call taker shift varies across European PSAPs. Breaks during working hours vary in length and frequency, according to the general experience they are rather short and tend to be sporadic.
The tempo of the task performance cannot be defined by the call taker him/herself as it depends to a large extent on the frequency and type of emergency calls, specifics of the situation to be managed and the interaction of the call taker with the caller and other stakeholders involved in the response.
The most immediate work settings of the call takers are defined by the computer work station and the physical organization of the emergency call centre (its operations room). The work station usually consists of an ergonomic chair and table, a computer station with multiple screens and specialized computer software, tele-and radio-communication equipment, hard copy manuals and maps.
According to research the call takers most often complain about problems associated with increased noise, long-term use of headsets, swelling feet due to lengthy sitting and complicated interaction (communication) with other team members due to the working stations placement.39 Thus call centre ergonomics are another crucial factor determining the well/being and performance of call takers.
- Call centre ergonomics
Call centers have a unique working environment characterized by working practices that can present hazards, and systems of work that differ from those of other computer-based office jobs and can potentially influence the wellbeing and performance of call takers. Creating an ergonomically correct call centre can help workers avoid such discomforts and injury. Ergonomics can be used to improve the well-being and productivity of workers by ensuring that workstations and work methods are designed to meet their needs and capabilities and thus conducting ergonomic analyses of the emergency call centre and addressing potential hazards and risks systematically is highly recommendable.
Ergonomics match the task, tool and environment to fit the needs of people and the work they do, with the Endeavour to adapt the working environment to the anatomical and physiological requirements of the body of a working individual by the utilization of all available measures. The performance of ergonomic analyses for workplaces is justified by the fact that the safe and comfortable conditions for employees are required and crucial for their performance and thus the quality of provided services and ergonomic methods and techniques are also applied in the rationalization of work processes. The obtained results can be used to facilitate the implementation of organizational changes in the PSAPs.
Psychological load together with fatigue resulting from physical discomfort are important factors of work performance. 40Call centre workers usually need to sit for extended periods of time doing several tasks on the computer and phone. The advent of technology in call centers has brought speed and accuracy, however, with all its benefits, technology in the call centre can also take a toll on workers in the form of physical ailments, such as muscle soreness, lower back pain, eye fatigue and more serious conditions like repetitive strain injuries (such as the carpal tunnel syndrome) and work stress related psychological problems.41
- Policy context
Basic framework is provided by the national legal frameworks (such as Occupational Health and Safety Acts) and human resources management standards, setting out the legal and institutional obligations for various parties (in particular, employers and employees) in the workplace.42 The purpose of the legislation is to prevent injury and illness in the workplace.
Examples of the regulations include the obligation of employers to ensure that:
- Sufficient workspace is provided to allow persons to work safely;
- Floors and surfaces are constructed and maintained to minimize the possibility of slips, trips and falls; and
- Persons are not hindered and able to move safely around a place of work.
In relation to employees:
- A safe workplace, and safe means of entry to and exit from the workplace
- Use of equipment, machinery or chemicals that are safe, when used properly
- A safe and healthy working environment, and safe and healthy methods and procedures (systems) for working
- Adequate information, instruction, training and supervision to be provided for all workers
- Adequate facilities and first aid for employees made available
- A process for consultation with workers
- Processes for identifying hazards, assessing risks and eliminating or controlling those risks put in place.
- Potential Hazards
Any workplace may present hazards to a worker’s physical and/or psychological health and safety. Although the following list does not address every hazard within call centers, it provides a framework for identifying and managing workplace hazards. Each workplace may present hazards unique to that workplace. It was developed through consultation with industry and a review of call centre literature, reflects the nature of the work carried out by call centre operators, the work environment of call centers, and workers compensation claims data. The list identifies factors that may give rise to hazards in the workplace, due to poor design or other causes. They include:
- Workstation design and ergonomics (including problems related to shared work stations)
- Working space
- Telephone headset use
- Background noise
- Manual handling tasks (including repetitive keyboard tasks)
- Psychological environment.
- Risk management process44
The risk management process provides employers with the information they need to make decisions about how best to avoid or control the impact of workplace hazards. The process is comprised of a four-step cycle:
- Identification of hazards in the work place
Hazards associated with call centers can arise in many broad contexts and can be related to:
- Manual tasks (e.g. working postures, repetition and duration)
- Work environment (e.g. workstation, psychological factors, lighting)
- Noise (e.g. background noise, headset use)
- Plant (e.g. equipment, machinery, appliances)
- Substances (e.g. chemicals)
- Energy (e.g. Electricity, electro-smog exposure)
When looking for hazards employers should consider:
- The suitability of workers’ equipment and their work location
- How people use equipment and materials
- How people might be affected by noise, fumes, lighting, and other environmental factors
- The potential for people to be hurt by equipment, machinery or tools
- The potential for people to be affected by chemicals and other substances used in the workplace.
- Assessment of risks
Assessment is conducted to determine the likelihood of an incident arising from the identified hazard, and the severity (i.e. seriousness) of the outcome if an incident did occur.
In assessing the risk, it is recommended to:
- Review the available health and safety information relevant to the hazard
- Identify the factors contributing to its risk, including:
– The work environment
– The capability, skill, experience and age of the people ordinarily doing the work
– The system of work being used
– Any reasonably foreseeable abnormal conditions
- Identify what records are necessary.
- Risk control
This is achieved by deciding and applying what needs to be done to remove or control the risks to health and safety. Measures can include:
- Elimination: In a call centre, excessive keying to record large amounts of data may give rise to the risk of musculoskeletal injury as a result of overuse of soft tissue in the neck, shoulders, back, hands and/or wrists. Employers may decide that this information can be entered in other ways that requires less keying, for example by using improved software design.
- Substitution: Replace the hazard with a less hazardous option. For example, replace a work process, material or equipment. In a call centre, the chemical currently used to clean/disinfect headsets might be replaced with another cleaning fluid that gives rise to less risk than the current chemical being used.
- Isolation/Engineering: Isolate the hazard from people by making changes to the work environment or practices so that exposure is minimized, or redesign equipment or work practices so that work can be done differently. For example, office resources such as photocopiers, printers and faxes may be creating excessive background noise affecting employees. The employer should relocate such office equipment to a separate area away from employees.
- Administrative Controls: Reduce the risk by improved supervision, instruction, training, job rotation or adjusting rosters, etc. For example, employers should introduce regular breaks away from calls into call centre rosters to reduce the exposure of employees to risks of physical and psychological injury.
In a call centre, you can apply ‘substitution’ to control ‘prolonged static working postures’ by redesigning the job and furniture or equipment to encourage changes in posture. This control measure should be supplemented by training (i.e. administrative control) to ensure employees have a good understanding of the risks associated with the identified hazard and how job redesign can control exposure to the risk.
To ensure that control measures operate effectively, you should consider the following:
- Develop safe work procedures to ensure employees know how to do the job properly and safely
- Communicate and consult with employees and others about the control measures and the reasons for their implementation
- Provide training for employees, particularly where changes in work procedures occur as a result of the implementation of the control measures
- Supervise employees to verify that the control measures are effective and that they are following procedures
- Maintain the control measures to ensure their ongoing effectiveness.
- Also, specify review and maintenance procedures for new controls as part of routine practice.
- Monitoring and review of measures. Monitoring and review of measures can be realized by consulting with the employees to ensure they are working to identify and doing other ways of things.
Here are some things employers need to consider when monitoring and reviewing control measures:
- Are they in place?
- Are they being used?
- Are they being used correctly?
- Are they working?
Hazards may change from time to time as the workplace and procedures change. Employers should thus set up a routine of periodic hazard checks (e.g. performing regular inspections and safety audits) and establish a date to review the entire risk management process. It is crucial to recognize the importance of organizational climate for both contributing to and mitigating the effects of occupational stress for emergency call takers. 45 The emphasis on management and organizational features as significant and often more common sources of chronic stress than operational demand and acute stressful incidents is a further argument in support of systematic attention, focused on the workplace ergonomics and organizational management.
5 Challenges and issues for 112 services – Economic context
There is emerging evidence that emergency call takers (dispatchers) regularly experience a range of both daily stressors and critical incidents that are similar to those faced by their communications operator counterparts and other emergency frontline workers. They also report additional stressors that are specific to the nature and scope of their work. The occupational stress literature increasingly points to the centrality of organizational factors in both exacerbating and mitigating the effects of such stressors.
Given the individual and organizational costs, there is an urgent need to include this employee target group in empirical, theoretical and intervention efforts that address these issues. Suggestions drawn from research indicate that the organizational structure of PSAPs can be a powerful conduit for change in reducing distress and improving employee morale and performance and this is an important factor of institutional and economic sustainability of the 112 systems.
6 EENA Recommendations to stakeholders
Recommendations for possible improvements at institutional/PSAP level
The central question is what can be done to enhance support of the call takers, while the focal point for the organization is the individual capability of conducting triage. The organization thus seeks to help call takers by providing organizational routines, which are manifested in decision-support systems, to help them navigate this uncertain and ambiguous setting.
Competent Authorities can introduce non-intrusive supervision and peer support mechanisms Emergency Services at the PSAP
- Enable participatory definition of performance targets for call takers
- Establish a psychological intervention plan
- Provide specially designed furniture, adjusted to emergency call taking specifics and ergonomic studies at PSAPs
- Make stress management tools/programmers available
- Establish risk management plans and critical incidents management support
- Provide active support and focused psychological training for call takers
- Ensure special security procedures are implemented to make the
- PSAP facility resistant to attack or threat, both physical and technological
- Accept psychological support and training
- Participate in the definition and setting of performance targets
- Comply with security procedures
- Actively developing own coping strategies
- Provide feedback to management
- Actively using decision-making support tools (protocols)
7 EENA Requirements
|Employee safety checklist including ergonomic PSAP||compulsory|
|Call taker supervision mechanisms||compulsory|
|Provision of psychological call taker training||compulsory|
|Provision of psychological call taker support||compulsory|
|System of critical incidents management support||compulsory|
Potentially helpful resources – Employer Safety Checklist for Call Centers
This checklist is based on the potential hazards identified in the Guidelines. It is not a comprehensive list of all hazards within call centers. If a box is not ticked, something should be done about that issue
|Have employees been educated/trained to recognize poor ergonomic risk factors (i.e. awkward postures, repetitive and sustained movements, and forces) associated with Occupational Overuse Syndrome (OOS)?|
|Have employees been trained in the correct adjustment of workstation furniture to enable them to achieve neutral postures|
|Is the seat height adjustable for the range of users within the workforce?|
|From a seated position, can the height of the chair be easily adjusted?|
|From a seated position, can the backrest be easily adjusted for height and angle?|
|Is the seat pan width and depth adequate and comfortable when sitting?|
|Do employees’ elbows avoid hitting the backrest and armrest (if provided) when performing their job?|
|Can the computer screen be adjusted for height and viewing distance from the seated position?
|Is the desk height adjustable between 580mm & 730mm?|
|If ‘no’, is there a height adjustable chair and footrest available to achieve neutral postures (as shown in Diagram 1)?|
|Is the desk depth sufficient for the computer screen, keyboard, and document holder?|
|Is the desk wide enough for the task?|
|Is the top surface non-reflective?|
|Is there adequate leg space under the desk?
|If necessary, do employees have the choice of using footrests to achieve correct lower limb postures?|
|If necessary, do employees have the choice of using document holders?
|Telephone headset use|
|Is the background noise level low enough that operators do not have to turn up the volume of their headsets?|
|Are the operators’ headsets free from sudden bursts of loud noise, such as line interference?|
|Are operators provided with individual headsets?|
|Is there a system of maintaining and exchanging faulty headsets?|
|Are the headsets cleaned on a regular basis, and cleaned prior to issuing to another operator|