DIP. DESIGN

Dottorato di ricerca in Design

Coordinatore Prof. Luca Guerrini

Cycle 27

AFFECTING EMOTION THROUGH DESIGN

HOW DESIGN CAN AFFECT THE EMOTION OF WAITING TIME IN HELATHCARECENTERS.

Supervisor I: Marco Maiocchi

Supervisor II: Keiichi Sato

PhD candidate: Zhabiz Shafieyoun

February 2016

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Dedicated to the one I owe my life to him, my dearest Kave

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Acknowledgment

Firstly, I would like to give my special appreciate to my supervisor professor Marco Maiocchi for all ofhis positive energies to make my PhD enjoyable and thanks to his effective advice and big supports.

I would also like to express my gratitude to Professor Keiichi Sato, my second supervisor, I am gratefulby every thing I learned from him and his hardworking attitude, kindness and patience to encourage methroughout the process of my research. Thanks to him to accept me as a research scholar in IIT Instituteof Design and gave me an opportunity to experience different academic atmosphere.

Thanks both of my supervisors for all time and effort that they dedicated to my work.

I would like to express my gratitude to my Co-coordinators Professor Trabucco and Professor Guerrini,throughout all of their support and attention in PhD plan and their special help in every step of my PhD.

I sincerely thanks Simona Murina, she was kind enough to answer all of my questions immediately andmake the PhD process easier.

I would like to thanks to Roberto Mazza. I highly appreciate his support during my study in Institutonazionale dei tumori and Besta Hospital.

I have to thank my dear friend Andre Marouti for his generous effort to help me and being in myside,with positive energy and his infinity kindness.

I thanks my fellow lab-mates for the stimulating discussion and for all the fun we had in the last fouryears.

I am grateful to my dear friends Jerry and Steve to motivate me and encourage me to work harder fortheir unsparing kindness.

My thanks extend to Politechnic of Milan and the Department of Design for giving me the opportunityof studying here. Beside Special thanks to Istituto Nazionale dei Tumori, Besta, Ospedale Maggiore inMilan and San Camillo Hospital in Rome to let me to do my survey in a comfortable and supportiveatmosphere.

Last but not least, I am greatly indebted to my dearest Kave. Though been far, non of this would havebeen possible without unconditional love, support and patience, encouragement and understanding ofhim.

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Table of Content

Abstract

1 – Introduction …...................................................................................................................…. 1

1.2 Statement of the problem ….....................................................................................1

1.3 Research Aim and Objectives …......................................................................….3

1.3.1 Aim.........................................................................................................................3

1.3.2 Objectives.............................................................................................................3

1.4 Thesis Structure …........................................................................................................3

2- Background and History..................................................................................................5

2.1 Waiting Areas.................................................................................................................5

2.1.1 Physical Attraction in waiting areas............................................................6

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2.1.2 Interaction in Waiting area ….................................................................…...7

2.2 Waiting Time..................................................................................................................8

2.2.1 Psychology of wait...........................................................................................9

2.2.2 Factors Affecting Waiting Time..................................................................10

2.2.3 Time Style..........................................................................................................12

2.2.4 Recent Solutions to Reduce Patient Perception of Time …...................12

2.3 Emotion...........................................................................................................................14

2.3.1 Emotional Experience ................................................................................…..16

2.3.2 Categories of Emotion......................................................................................16

2.3.2.1 Categorize last emotions to the Seven Primal Emotion of Panksepp...........20

2.3.3 Design and Emotion..........................................................................................21

2.3.3.1 Sympathetic and Parasympathetic System....................................................21

2.3.4 Scaling of Emotion............................................................................................21

2.3.4.1- Nonverbal Instrument (Objective – Language Independent)....................21

2.3.4.1.1 GEW .…...........................................................................................22

2.3.4.1.2 PrEmo ........................................................................................…..22

2.3.4.1.3 Emo Card…......................................................................................22

2.3.4.1.4 Physiological reaction –ANS (Autonomic Nervous System).................22

2.3.4.1.4.1 Electromyography (EMG)…...............................................................22

2.3.4.1.4.2 Electrodermal Activity…....................................................................22

2.3.4.1.4.3 Skin Temperature ................................................................................22

2.3.4.1.4.4 Blood Volume Pulse (BVP).................................................................23

2.3.4.1.4.5 Electrocardiogram (ECG)….................................................................23

2.3.4.1.4.6 Respiration Sensor..........................................................................…..23

2.3.4.1.4.7 FMRI .............................................................................................…..23

2.3.4.1.4.8 PET.......................................................................................................23

2.3.4.1.4.9 EEG................................................................................................…..23

2.3.4.1.4.10 Eye Tracking .....................................................................................23

2.3.4.1.4.11 Optimal Tracking.........................................................................…..23

2.3.4.1.4.12 Body Tracking...............................................................................…..23

2.3.4.2- Verbal Instrument (Subjective)..................................................................24

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2.3.4.3 Combining Verbal and Nonverbal..............................................................24

2.3.4.3.1 Kansei Engineering ...................................................................24

2.3.4.3.2 QFD........................................................................................25

2.3.5 Emotional Experience …..................................................................................25

2.4 Empathy............................................................................................................................25

2.4.1 Empathy and Quality of Care.........................................................................26

2.5 Humor in Healthcare..................................................................................................27

3. Research Methodology....................................................................................................29

3.1 Ethnographic approach..............................................................................................29

3.1.1 Patient stories …........................................................................................................29 3.1.2 Patient in Waiting area............................................................................................31 3.1.3 Author Experience ….........................................................................................…..33

3.2 Method and procedure: Observation...................................................................34

3.3 Method and procedure: Interview.........................................................................35

3.4 Overview of Observation and Interview..................….....................................36

3.5 Method and Procedure ............................................................................................37 3.5.1 Choice of the Domain...........................................................................................38 3.5.2 Spanning the Semantic Space.............................................................................39 3.5.3 Spanning the Space of Properties......................................................................40 3.5.4 Synthesis ….............................................................................................................43

3.5.5. Results …................................................................................................................43 3.5.6 Discussion …...........................................................................................................47

3.6 Flow Kansei Engineering …..................................................................................483.6.1 How can we affect the user’s emotional reactions?.................................493.6.2 Entering Flow in KE process.........................................................................503.6.3 Choice of Domain.............................................................................................513.6.4 Spanning the Semantic Space........................................................................513.6.5 Spanning the space of properties ….............................................................513.6.6 Synthesis.............................................................................................................513.6.7 Test of Validity..................................................................................................523.6.8. Model Building step........................................................................................523.6.9 The Possible Application of the Method …............................................................533.6.10 Past Experience.....................................................................................................553.6.11 Conclusion............................................................................................................56

3.7 Effect of visual Art in Waiting area..................................................................56

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3.8 Summary …....................................................................................................................62

4. Conceptual Development …..........................................................................................63

4.1 Hypothesis ….................................................................................................................63

4.2 Macro and Micro Interactions..............................................................................64

4.3 Conceptual Framework …......................................................................................65

4.4 Experience Stage Model.........................................................................................66

4.5 BoneFish Analysis...............................................................................................…..71

5. Primary Output......................................................................................................................72

6. Apply Implementation …................................................................................................74

7. Conclusion …...........................................................................................................................77

8.Discussion...................................................................................................................................79

Bibliography ….............................................................................................................................81

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ABSTRACT (ENGLISH)

This study encompassed seven fundamental emotions (as defined by Jaak Panksepp) including FEAR,RAGE, GRIEF, SEEKING, CARE, PLAY and LUST (Panksepp,2012). Based on these sevenemotions I have conducted a survey of 200 cancer patients using the Kansei Engineering method in 4waiting areas in two different hospitals in Milan. Then I used Flow in Kansei Engineering called asFlow Kansei Engineering to propose Flow test. Investigating on the Effect of art in two hospitals inMilan and Rome. Moreover, I have applied a number of well-established design tools like patientjourneys, scenarios, storyboards, personas and interview to complement the surveys. I have usedSemantic Differential Methods in questionnaires (Osgood et al. 1969) and Factor Analysis to analyzedata generated by these participants.

My analysis demonstrated how different aspects of design and social characteristics of waiting areascould influence the emotional experience of their users, and, ultimately, their perceived quality of care.For example, I verified that warm colors, abundance of light, round furniture layout and presence of artworks could enhance patients’ positive emotions.

Long wait as as a problem in waiting areas was analyzed by Bonefish analysis to find the causes. Iproposed a conceptual framework and a model of patient's experience to follow User Experience (UX)in Hospitals, to perform a trustable and comparable method to understand the patient’s perception of ahospital. It might have the potential to become a guideline for every waiting area and waiting time.Finally, I recommended a way of looking through waiting time in hospitals.

KEY WORD: Healthcare design, Empathy, Waiting time, Waiting area, Kansei Engineering, Emotion,Emotional Design

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ABSTRACT (ITALIAN)

Questo studio comprende sette emozioni fondamentali (come definito da Jaak Panksepp) tra cuiPAURA, RAGE, il dolore, la curiosità, la cura, il gioco e la lussuria (Panksepp, 2012). Sulla base diquesti sette emozioni ho condotto un sondaggio su 200 pazienti affetti da cancro utilizzando il metodoKansei engineering in 4 aree di attesa in due ospedali diversi a Milano.Poi ho usato il metodo chiamato come flusso Kansei Engineering per proporre test di flusso. Indagaresugli effetti di arte in due ospedali di Milano e Roma. Inoltre, ho applicato una serie di strumenti diprogettazione consolidati come il percorso di paziente, scenari, storyboard, personaggi edeventualmente colloqui per completare le indagini. Ho usato semantici metodi differenziali aquestionari (. Osgood et al 1969) e il fattore di analisi per analizzare i dati generati da questipartecipanti.La mia analisi dimostrano come i diversi aspetti del design e le caratteristiche sociali delle aree diattesa potrebbero influenzare l'esperienza emotiva dei loro utenti, e, in ultima analisi, la loro qualitàpercepita delle cure. Per esempio, ho verificato che i colori caldi, abbondanza di luce, disposizione deimobili tondo e la presenza di opere d'arte potrebbero migliorare le emozioni positive dei pazienti.Lunga attesa come un problema nelle aree di attesa è stata analizzata mediante l'analisi Bonefish pertrovare le cause. Ho proposto un quadro concettuale e un modello di esperienza del paziente di seguireUser Experience (UX) negli ospedali, per eseguire un metodo affidabile e comparabile a comprenderela percezione del paziente di un ospedale. Si potrebbe avere il potenziale per diventare una linea guidaper ogni zona attesa. Infine, ho raccomandato un modo di guardare attraverso il tempo di attesa negliospedali.

Parole chiave: disegno Sanità, Empatia, tempi di attesa, Area di attesa, Kansei Engineering,Emozione, design emozionale

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1. INTRODUCTION

1.2 Statement of the Problem

The majority of us have had at least a short journey inside a hospital for different reasons and we havecome out with different experiences. All these experiences contribute to the definition of the Hospital.A Hospital is not a place just to get advice and to receive treatments from healthcare professionals butit is a place of communications and interactions among patients, staff and the environment. These threeelements affect each other mentally and physically in a special situation. Paying attention to thepsychological part of user's needs can help us to have a better user experience (Harris et al., 2002).Obviously, it is difficult to create a good mood in a really difficult situation, but it is not impossible.How can Design affect the atmosphere and user's emotin in waiting situations in hospitals?

A hospital is a large building with many units; in order to experiment the use of Design to impact onuser experience, we can zoom in to choose one of the most stressful parts of the hospital. We believethat to find the critical part of the user's journey would be a big step to change atmosphere of thehospitals in positive way. Patient journey starts from arrival to the hospital and finishes after exit. Havea quick look in patient journey and the overall experience of the hospitals reveals that waiting area isone of the most stressful parts of the hospital. Each hospital has a variety of waits, some of them areinside waiting areas and some of them happen in corridors, in lines and in some other stops. We believeaffect on the atmosphere of waiting areas can change the user experience in the whole journey.Hospital care is a part of an important relationship between patient and healthcare provider that needs

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intimacy, empathy and trust. (Ancarani, Di Mauro, & Giammanco, 2009; Lin& Lin, 2010). We knowthat both supportive and appealing setting (place) and friendly and warm professionals (people) havethe capability to affect on patient's emotion and well-being. Environmental and behavioral effect arenot separable and their influence on people are undeniable. Ornella Bonimi in her study found the moststressful part of Istituto Nazionale dei Tumori (a hospital in Milan) is waiting areas. You can see herpie chart below. Corridors are a kind of informal waiting ares which get the first place and then waitingareas are in the second place (Bonomi, 2011). I later chose this hospital as a case study in my survey.Paying attention to waiting areas can help to have a positive mood in the whole Journey. This surveyshows that fifty percent of the anxiety and stress is coming from waiting times. Although the characterof waiting areas are different with different effects on people we can figure out how is the effect ofevery waiting areas in patient’s journey and compare them with each other.

Figure 1- Waiting times are one the stressful part of Instituto Nazionale del Tumori (Bonomi, 2011)

Having satisfying healthcare centers has positive effect on the society. Even it might be a prevention.To promote wellness, healthcare facilities should be designed to support patients in coping with stress.As general compass point for designers scientific research suggests that healthcare environment willsupport coping with stress and promote wellness if they are designed to foster: sense of control; accessto social support; access to positive distraction and lack of exposure to negative distraction (Ulrich;1991). Health theory of Salutogenesis in contrast to the Pathogenic orientation of Healthcare, suggeststhat we shall look for wellness factors instead of risk factors (Aaron, Antonovsky,1982).Make patient's journey easier will be a motivation for people to care their health more and do not justbe in hospital when it is too late. Not only patient but also operators, nurses, doctors and their familyand friends will have benefit of decreasing stress in the hospital. Decline the time of wait decrease theamount of questions about the time then reduce the amount of footwork inside the waiting areas.Changing the experience of wait will affect the whole user experience of the hospital. Emotional affecton waiting areas through design can happen by service design, interior design and behavior design.Regarding the result of our study we can choose the way of influence on patient and waiting time.

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1.3 Research Aim and Objectives

The goal of this thesis is to fill the need of research, to explore: How Design affect on the emotion in waiting areas. How design has emotional impact on waiting time.

1.3.1 Aim To affect on emotion through design in waiting areas of healthcare centers.

1.3.1.1 ObjectivesHow design can affect on: Increasing positive emotion (Care, Joy).Reduceing negative emotion (Fear, Anxiety, Stress).Increasing satisfaction with overall quality of care Improving environmental and behavioral interaction in the waiting areas. Improving experience of wait.Breaking icy atmosphere of the hospital.

1.4 Thesis Structure

How can I make people happy as a designer? Emotional design can be the answer to this question.Patients are a part of the society who needs special care and attention. As we know, patient's journey ina hospital is full of tension and anxiety. Applying emotional design in healthcare centers can be anotheranswer. Hospitals are a part of healthcare centers with different units and wards. People have differentgoals of being in hospitals. Out Patient Department (OPD ) are some Patient who are going to visitdoctors, do a test or radiography and so on in hospital and usually their journey does not last more thena day. and some patient are going to be hospitalize in hospital because of some health problems, theyare In Patient Department (IPD). Observing patients in hospitals and some studies shows us the moststressful part of the hospital is waiting time (Bonomi,2012). OPD patients are usually complainingabout long waits. Even IPD patients have to pass a lot of waits during their journey and they are notsatisfy by that. Our focus is more on OPD patient and their waiting time in healthcare centers. Laterpatient means OPD patient in this study. Quality of wait has straight forward relationship with qualityof care and satisfaction (Arneil, Devlin 2002).Perception of time and actual time are different inwaiting areas. Patients in wait feel time is longer than real. Influence on perception of time is a way todecrease the patient dissatisfaction (Arneil, 2002).Patient in hospital has different type of interaction with the environment and others' behavior.Environmental interactions usually are color, furniture layout, furniture, light, visual art, music, TV,magazine, computer, health information, time information, flier, brochure and nature. Physicalattractions are part of interacting with environment with a big effect on patient satisfaction (Arneil,2002, Ulrich, 1992) Behavioral interactions included other patients, nurses, caregivers, doctors, otherstaff, friends and family. People have a good and bad effect on each other. Feeling respect, care andcomfort has a big effect on the quality of care (Waren, 1994, Waters, 1999). Behavioral effect andenvironmental effect have strong and direct relationship on each other (Zeisel, 1984).Some studies focus on physical attractions significantly and they found it with a big effect on patient

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satisfaction. Using physical attraction to decrease the perception of time has scored in some studies(Aneil, 2002; Dalk 2005; Ulrich 1984) such as presence and absence of a window and a view to thenature and daylight have been proven to affect on patients' emotion (Ulrich, 1984; Verderber, 1986;Wilson, 1972; Rice, Ingram, & Mizan, 2008). Physical attraction was a key in this study to measure patient's emotion in different waiting areas withdifferent interior designs. Measuring patient emotion in different waiting areas happen with differentmethods. I chose Instituto Nazionale del Tumori (INT), Besta hospital, Ospedale magiore in Milan andSan Camillo Hospital in Rome for my study. I started observing patients in hospitals during day and night for more than 300 hours. The aim of theobservation was knowing patient and their feeling in waiting time. Write their stories, drawing andsketching help to know patient better. Use Likert questionnaire in Semantical differential method andKansei Engineering in four waiting areas in two hospitals (INT and Besta in Milan) to know aboutpatient emotion regarding different colors, furniture layouts and materials. I applied KanseiEngineering to evaluate an environment which previously, it was used to be a method for productdesign. The method we chose needed some changes and add a part of positive psychology to it. I added Flow(Csikszentmihalyi, 2014) to the last method and I called it Flow Kansei Engineering with a proposal ofa new survey. To know patient prefer to have useful distractions like music, pictures, paintings inwaiting areas or they prefer to have health education about their disease and their treatment. Later Iproposed to add flow active to the Flow Kansei Engineering to understand patient's emotion in ActiveFlow mode with respect to to Passive Flow mode in waiting area. New design approaches can bepossible after taking the results. Visual art as a physical attractions examined in two hospitals in San Camilo in Rome and INT inMilan. The same questionnaire based on SD methods used for this study. Participants answeredquestions during a painting exhibition in waiting area and they answered the same questions after theexhibition to compare their feeling during and after the exhibition in both hospitals. The result wasinteresting. Macro and Micro interactions in waiting areas gave me the idea of looking at waiting time as a part ofthe patient journey and evaluate it inside patient journey. Based on this idea I proposed a theoreticalframework of user experience in the hospital. Following patient in every step and recording theiremotion reveals the overall patient emotion. Furthermore It shows in which part of the journey peopleare dissatisfy or less satisfy. The information let us find the most critical part of the patient journey.Innext step I am going to reframe my attempt to waiting time and user experience during waiting timeto know the causes of long wait. Dividing patient journey to Flow time, Wait time and Face time andanalyzing the user experience in this three parts separately and together beside analyzing the overalluser experience. The reason of Long wait was analyzed by bone fish analysis. Finding two main causes of long wait wasthe result of the analysis. Then I started to work on improving long waiting time by impacting on thecauses of long waits. Finally looking through the problem in different ways and all results of different studies helped me tohave some assumption for improving waiting time through design. This study has a potential work infuture. Moreover, I will propose a way of looking through the emotional impact on waiting time inhealthcare centers to make it easy for new researchers and designers.

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2. BACKGROUND AND HISTORY

2.1 Waiting AreaThe Waiting area is the most stressful part of the hospital and one of the key parts of healthcarecenters, which can have a considerable impact on the experience of users attending the healthcarecenters. In waiting areas patients and their families more often spend a long time without significantinteractions. The perception of time in waiting areas usually is longer than reality, which can have adirect influence on the amount of stress. Attractiveness of physical environments influence theperception of time, and hence the perceived quality of care (Arneil, 2002). People expect information,care, respect, privacy and comfort in waiting areas (Waren, 1994, Waters, 1999). According to Arneiland Devlin, no studies have been carried out to inquire the effect of physical environment of doctor’swaiting rooms on patient satisfaction, nor in the perceived quality of care before 2002 (Arneil, Devlin2002). Noise, lack of privacy, use of strange equipment, ineffective communication between patientsand staff are significant part of stress factors (Winkle, 1986), which has effect on the treatment process(Ulrich, 1992). Leske talked about the fact that people in waiting time feel numb, hoping forimprovement, scared or being afraid, less in control, walking around and feeling powerless (Leske,1992). Environmental psychology helps us to know the way of changing user's emotion throughDesign. Zeisel says that Environment and Behavior have a straightforward effect on each other.Environment refers to the physical aspects and social characteristics of setting, where people live, work

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and play. Behavior refers to the people's activities, their feelings and their thinking. How people behavemight be the effect of the environment (Zeisel, 1984). Proper design of healthcare centers has beenincreasingly linked with improved emotional experience of users, which in turn is of prime importancefor their healing process, as well as for satisfaction with the care. (Davidson, 1994; Devlin, 1992, 1995;Olsen, 1984; Ulrich,1984). Although the quality of care is a main concept in healthcare today, it is avague one. (Arneill, 2002). According to Omachonu (1990) the quality of healthcare contains of twoparts: quality in fact and quality in perception. Patients’ perceptions have a significant and deep role intheir satisfaction with healthcare. Type of interactions between patients and staff, and patients andenvironment can make a difference for the quality of care. Ulrich believes that poor design can impacton well-being of a patient. The reasons of some negative reactions include the facts that anxiety andstress accompany illness can be due to weak design (Ulrich, 1984).

2.1.1 Physical Attraction in waiting areas

An attractive environment has effect on patient’s health, as evident throughout records of history,Florence Nightingale showed that the variety of the shapes and the brightness of the colors of an objectpresented to the patient had a big influence on their recovery (Dalk and Little 2005). Environmentalobjects include light, noise, temperature, view of nature and windows, sizes and shapes, privacy,colors, textures, furnishing layout and patterns on the wall: each of these elements can have a strongeffect on patient senses. Presence and absence of a window, of a look on the nature and daylight havebeen proven to affect on patients' emotion. (Ulrich, 1984; Verderber, 1986; Wilson, 1972; Rice,Ingram, & Mizan, 2008). In 1984, Ulrich found that the patients who had a view to the nature throughtheir windows, in comparison to the patients with a brick wall view, recovered sooner, and the time oftheir hospitalization was shorter (Arneill, 2002). Also Wilson (1972) did an experiment but for roomswith and without window and he found having a window in the room had a clear effect on decreasingdelirium (Arneill, 2002). In addition, Barrington (1984) says that the connection between the ceilingand window is important too. We can regard the meaning of windows for patients as a peacefuldistraction (Kaplan et al.,1972). Generally, impressions of nature have a positive effect onpsychological aspects (Ulrich 1981). Arneill believes that the environment plays a phenomenal role,even more than patient and staff interaction, to transfer empathy, warmth, and friendliness (Arneill,2002). According to Lakoff, metaphors of empathy and happiness are recognizable in all the parts ofthe world. People have some common signals to understand empathy, happiness and joy (Lakoff,2014), this common language make designer's work easier. A majority of sources has been writtenabout the environmental effects on people’s feelings. Color and illumination are two differentimportant subjects to create pleasure. Dalk believes that the application of colors in the hospitals impacton the first impression of people (Dalk, 2005). Beside all the size of a waiting area should be largeenough. That might be the reason of sitting patients usually in front of the desk to avoid to be forgottenby staff (Yoon, 2010).

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2.1.2 Interaction in Waiting area

Interaction is another considerable part of the hospital. Knowing about different kind of interactions isnecessary to increase positive and decrease negative emotions in waiting area in order to break thepotential icy atmosphere in hospitals, and then affect on the patient’s responses. Patient in wait interactwith environment and other's behavior in the same time and all make the atmosphere of waiting areas .Relationship between patient and healthcare provider has a strong effect on the atmosphere of thehospital. In the last figure patient you can see the environmental and behavioral interactions. Music,Magazine, Game, Computer are some as distraction, Visual art, light, Furniture layout, color, nature,Material and so on as physical attraction and health information and time information as patienteducation that patient interact with them during the waiting time. We can relate all categories ofinteractions to different design fields. Interior Design, Service Design and Interaction Design can affecton the emotion of users in waiting areas. Psychology helps to understand environmental and behavioraleffect on waiting area.

Patient are not alone in waiting areas and they have interact with their friend or families, caregivers,nurses, other patient, doctor, operator and other staff. Their behavior has effect on patient emotion.Knowing about behavioral effect helps to think about behavior change. Behavior Design andpersuasive design is another design field to influence waiting areas atmosphere.

Figure 2- Interaction in hospital

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2.2 Waiting Time

User experience in waiting time in hospitals is one of the tangible issues for most of the people. Peopleinteract with environment and other’s behavior in waiting areas and all these interaction make thestories of waiting areas. Waiting time refer to the time of staying in queue between entering till leaving((Sobolev, Boris, 2008). Factors might affect time to admission can be categorized into four groups:“demands, hospital resources, waiting-list management, and patient characteristics” (Sobolev, Boris,2008). The most frustrating element in waiting time is no control on time (Backer, 2008).

Two simple aspects of waiting time are Objective time and Subjective time. Objective time (Actualtime) measured by watches, clock and chronometers. The mathematical time is able to be added,multiplied and divided. This character of time can be measure an control in waiting time (Larson,1987), and psychological cost part of objective waiting time can be decrease (Carmon, 1995).Subjective time (Perceived time) is based on experience and it is more individual. Subjective time isflexible, changeable and according to the type of activities it will be shorten or extended. How peopleare under or overestimate of time and how information has effect on the perception of time and theoverall satisfaction (e.g.Hornik, 1984; Hui and Tse 1969; Jones and Mowen, 1991; Leclerc, Schmitt,and Dube, 1995; Taylor, 1994; Zakay and Hornik, 1991). Objective and subjective time are two worldview of service providers and customers (Katz, Larson, 1991). Wait can happen before, during andafter the service (Taylor,1994). Katz and Larson in 1991 proposed two ways for service provider tomanage waiting, the first one is related to design a good service and the second one is effect on thecustomer's perception of time (Katz, Larson, 1991), still a lot of services are working in two ways.Taylor recommended a typology of waiting time based on pre-wait and during wait post-wait (Taylor,1994).

According to other studies, waiting has divided in three phases: Pre-process, In process and Post-process (Dube-Rioux, 1989). Pre-process: From the time of arrival to examination. In process: Timebetween entering and leaving examination. Post- Process: After leaving examination area tile exit.Every phases has their characters and different way to face. Another categories of wait explained byJames E. and Julie K, in their study the times in hospitals divided to three separate parts: Flow time,Wait time and Face time. Flow time is the duration between arrival and registration, Wait times is thetime between registration and visit the doctor or examiner; Face time is the time of spending withdoctor or examiner in a office or exam room (Stahl, James E., 2011). We can say flow time is happenin Pre-process, Wait time it happen in In-process and Face time is in Post-process. Figure 2 shows theplace of different waits in patient journey. Although In- process wait time has the main role onperception of time, Length and quality of face time can have a deep efficiency on quality of care andpatient satisfaction (Stahl, James E., 2011). Perceived and actual waiting times are different. De Manet.al did some study in nuclear medicine and they found “perceived total waiting time is lower than theobjective waiting, and perceived waiting time pre- process was considerable lower than the actual time,and perceive waiting time in process was higher than the actual time” (De Man, 2005).Sky and Miles in1997 found the total time in waiting time was the most considerable predictor of patient satisfaction(Sky, 1997).Three phases of waiting can evaluate in two basic psychological and physiological

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reactions (Taylor, 1994). Economical cost and psychological cost are paying during waiting time(Becker, 2008).“People in waiting rooms describe feeling numb, hoping for improvement, being afraid,having no control, walking around like a robot, and feeling powerless”(Yoon, JungKyoon, 2010).

Beside environmental and behavioral effect on patient in waiting areas they have been effected by theircharacters deeply. BMC Health Service has a survey based on the relationship between patient'scharacteristic and their perception of time. They measured the effect on visual environment, hearingenvironment, body contact environment and cleanliness in different type of OPD patients in differenthospitals. They found men are more satisfied than woman about cleanliness.Older patients and followpatient are more satisfied with visual and body contact environment than ew patient. Morning OPDpatient are more satisfied with physical environment than After noon patient (Tsai, Chun-Yen, et al,2007).

People with different characters has different time style. According to Usunier and Valette- Florence(1991-1994) speaking time style consisted to five dimension, “namely, economically of time, pastorientation, future orientation, time submissiveness and feeling of the useless of time” (Usunier andValette- Florence,1991-1994). This five factors has effect on:

a) Customer's reaction to delay (taylor,1990,1994)

b) Wait situation ( e.g Chebat, Filliartut, and Gelinas-Chebat,1995, Maister, 1985)

c) Estimated waiting time (Hornik, 1984) , d) waiting rules (Carmon, 1995).

Agnes in university of Savoy has a study to show us the relationship between different time style andwaiting experience specially in the term of passive and active patient impatience. She found time stylehas influence perceived time but not waiting acceptability (Durrande-Moreau,1999).

2.2.1 Psychology of wait

kraitz believes understanding patients’ concern expectation and request is a key for healthcare policymakers, researchers and clinicians to improve patient satisfaction He says satisfaction explainsSatisfaction has straightforward relation with perception and expectation (Kraitz, 2001). He says theamount of satisfaction depends on the amount perception and expectation can be change, Expectation <Perception gives us Satisfaction but Expectation > Perception result will be dissatisfied. In the otherhand less expectation helps better perception and satisfaction will happen.

Satisfaction = Perception – Expectation (Kraitz, 2001).

Maister (1985) talks about eight influential principles on customers’ satisfaction during waiting times.For instance occupied patients (involved in an activity during their wait) had higher satisfaction levelsand lower gap compared to that of unoccupied patients (sitting idle).

“Unoccupied time feels longer than occupied time.Pre-process waits feel longer than in process waits.Anxiety makes waits seem longer.Uncertain waits are longer than known, finite waits.

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Unexplained waits are longer than explained waits.Unfair waits are longer than equitable waits.The more valuable the service, the longer the customer will wait.Solo waits feel longer than group waits” (Maiser, 1985).

Five necessary conditions was recommended by Rondeau to organize the waiting process:

1-Engage people

Connect new patient with old patient for sharing experience.

2-Decrease patient’s hospital related anxiety

Inform people about time, treatment process and facilities.

3- Improve communication with patient

Non-medical and medical chatting with patient.

4- Ensure quality

Make sure of equal process for every patient

5-Increase interaction between patients in waiting time.

More interaction makes people busier and they put them in groups of patients with same problems(Rondeau, 1998).

Table 1– Eight Influential Principle on Customer's Satisfaction During Waiting Time ( Maiser, 1985)

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2.2.2 Factors Affecting Waiting Time

Waiting time is dealing with four difference factors, a) Customer's reaction to delay (taylor,1990,1994),b) Wait situation ( e.g Chebat, Filliartut, and Gelinas-Chebat,1995, Maister, 1985) c) Estimated waitingtime (Hornik, 1984) , d) waiting rules (Carmon, 1995). Economically, time is precious and loosing timeof wasting time is facing with regret of loos. “Passive impatience” happen when People have nothing todo and they just pay attention to passage of time, they feel they are in empty time and they feel luckedin this time ( James, 1946). They feel helpless and being under time pressure (Durrande-Moreau,1999). Affect on impatience and perception of time to transfer from emptiness of time called“Active impatience” (Durrande- Moreau,1999). So, waiting experience is included passive impatiencerepresent longer waiting time and active impatience linked with shorter waiting time. Quantitativeindividuals time shows strong economic time mostly by looking at future and qualitative persondisplays low attention to economic time toward past and they prefer to live in present (Prime, 1994).Qualitative people maybe they do not care of being on time and quantitative people's plans would bedisturbed by quick activities. Agnes Durrand assumption is perceived of time for quantitative peopleare more negative than qualitative people (Agnes Durrande- Moreau, 1999).

Although longer waiting time has a negative effect on overall satisfaction, good communication andstrong relationship between patient and staff reduce the negative effect (Miceli and Wolosin, 2004).Length and experience of waiting can effect on the perception of quality of care for patients andvisitors (Arneil& Devlin, 2002). The patients consider waiting as inactive, wasted or lost opportunitytime. It was found patient satisfaction decreased with longer waiting times (Katz 1991, Dansky 1997).Interventions to decrease perception of wait times and increase the perception of service with payingattention patient expectations, can improve patient satisfaction (Olanrewaju, 2011). Relationshipbetween patient and healthcare providers has a strong effect on decrease the perception of time(Anderson, 2007).Majority of the research in this area primarily revolves around three factors: actual waiting time,perceived waiting time, and the gap between them The perceived waiting time is often different fromactual waiting time (Taylor, 1994). This means identifying and improving the variables that influencethe perceptions of waiting could improve patient’s perceptions regarding wait time (Stahl, James E.,2011). Reduce perceived time has a positive effect in patient satisfaction. Figure 4 was published in theJournal of Service Research in November 1999 and it is proposed a model based on actual waiting timeand time style which can be passive impatience of active impatience and all influence on customer’ssatisfaction. So time style has a big effect on user experience in waiting time. They used this model tounderstand people with different time style (actual time, economic time, past oriented and futureoriented) has different experience of waiting time. People with more economic time style are moreactive impatience than others and no more negative. They show short waiting time dose not needinformation system about their wait.

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Figure 4 - A proposal Model of Actual and perceived time (Durrande- Moreau,1999

2.2.3 Time Style

According to Usunier and Valette- Florence (1991-1994) speaking we as a human have different kindof time style including “Namely, Economically, Past orientation, Future orientation, Timesubmissiveness and Feeling of the useless of time” (Usunier and Valette- Florence,1991-1994). Namelyis the real time. The economically time is precious and loosing time of wasting time is facing withregret of loos, Past and Future oriented is living in the past and future and forgeting about current time.“Time submissiveness” define a dutiful and harmonize tendency towards time indicating appointmentand schedules. This is a perceptual of individual relation to time. In psychological dimension of timetalks about how people cope with time and external resources it is divided to motivational aspects ortime related to anxiety ( Usunier, jean-Claude, 2007). Aging has a effect on perception of time, olderpeople being more aware of the time and more concern about the way of spending their time ( Szmigin,Carigan, 2001). Durrande- Moreau and Usunier investigated on the effect of time style on waitingexperience in a service context. Quantitative people contribute to have more negative perception ofwaiting experience than qualitative people ( Durrande, Usunier, 1999).

2.2.4 Recent Solutions to Reduce Patient Perception of Time

The importance of relation between patient satisfaction and waiting time is reason for proposingmultiple strategies to decrease wait times (Weiss, 2003). Feddock, Christopher A., et al found a relationbetween perception of time for patient and the role of physicians. In this survey they specified the roleof spending time with physician in patient satisfaction. Patient with long wait, more than 15 min wait inwaiting room or more than 10 min in exam room, dissatisfied with short time of visiting physician.According to this study physician can decrease the negative effect of waiting time by spending moretime with their patients (Feddock, Christopher A., 2005). We should be considerable about interactionbetween patient and their physicians. Leddy says patient in long waiting time, more than 20 min aremore satisfied in a comfortable and peasant waiting area (Leddy, 2003). We can see in several surveysthe importance of the amount of physician time spending with patient (Dugdal,Epstein, 1999, Gross etal. 1998, Lin et al, 2001). Spending time with patient in one way and being with them in psychosocialissue in another way (Roter, 1997) beside explaining the cause of the patient’s problem (Jackson et al,2001) or non-medical chat with them (Gross, 1998) make people more satisfy.

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Heather Sherwin in 2013 has a study about waiting room “ wait”, waiting room can be a place morethan just for wait. Make more interaction in waiting room between patient, caregiver, physician,doctors, operator and nurses can change passive waiting to active care. For example physician can takeblood pressure of patient during their wait, or they can talk together, fill some questionnaire duringwaiting time, provide patients with education regarding their health, participate patient family in healthquestionnaire. Briefly of his speaking is “using waiting room, to screen, to monitor, and educate couldenhance a patient’s primary health experience, leading to increased patient satisfaction and ownership”.(Heather N.Sherwin, 2013). BMC Health Service Research in one study showed time spend withphysician has a strong effect on patient satisfaction. Reduction in Satisfaction relevant with longwaiting time significantly decrease with increased time spent with physician. Above all thecombination of long waiting time and have a short visit with the doctor has a very low overall patientsatisfaction (Roger T, Anderson, 2007). Investment of time and money- psychological and physicalshould have a significant meaning. In other words, making a good combination of waiting time andvisit time can increase patient satisfaction. Some variable service such as Primary care, health plan ororganization can have a straight effect on patient satisfaction (Roger T, Anderson, 2007). FabianCamacho talkes about “patient willingness” he believes waiting time is an important part of time priceand willing to wait should be increased with patient perception of rising quality of care. Knowing aboutthe amount of “Willing to wait” has effect on patient satisfaction and quality of care (Camacho, 2006).

Table 1-1- Implementation in psychology of wait

Based on mentioned recent solutions, I added one more column to the last table. Every row has anexample of recent solutions to decrease the perception of time based on psychology of wait. Fillquestionnaire and get feed back not only makes patient busy but also give them the feeling of respected(Heather N.Sherwin, 2013).

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In process is wait time in patient journey, talking with physicians in wait time and doing primehealthcare has a good effect in In- Process (Leddy, 2003). Preparing books, flier ,brochure, movies orinformation on the wall help patient education. Patients with an amount of knowledge about theirdisease and the treatment process and side effects have less stress and they are more satisfied (HeatherN.Sherwin, 2013). Informing about the time is another way to give the control of time to patients. Theywill feel better to count down the time to reach their time ((Gilbert, 2009). If the reason of being in thehospital is seeing a doctor and explain about their problem and make a decision about it, the mostimportant part of the journey will be face time and increase the quality of face time will increase thequality of care and increase patient satisfaction (Stahl, James E., 2011). We have not found a study forbeing in a group and being alone yet.

2.3 Emotion

We need to know people's emotions in waiting time in order to be able to impact on them in a positiveway. Before we should know, emotion, being in a mood and personality are three different issues.Briefly, being in a mood is longer period than emotion and personality is longer than mood (Parrot,2000).

Emotions are complex in distinguish and categories.The definition of the term “emotion” has a longhistory, from more than one hundred years ago. Emotion is a multifaceted phenomenon, which includesexpressive reactions, behavioral reactions, physiological reactions and subjective reactions (Desmet,2005).

We have a variety of definitions for emotion in different fields such as psychology, neuroscience,design. You can see some of the definitions blow:

• Emotion as a word “ can be defined as a conscious mental reaction (as anger or fear)subjectively experienced as strong feeling usually directed toward a specific object andtypically accompanied by physiological and behavioral changes in the body” (Merriam,2004)

• Generally speaking, emotions are inseparable part of cognition and are the conscious experienceof affect (Norman, 2007) and Emotions are indispensable part of cognition (Norman,2005).

• Emotion” define as, “disturbance of mind; vehemence of passion, pleasing or painful”

Duchenne de Boulogne (1862) and Darwin (1872) started in the 19th century to define emotion inscience. Emotion has never been statistic but by scientific approach we have had more quantitativelooks on it.

Marco Maiocchi has described the process of emotion's meaning and emotions of users from everysignals. The following figure is shown users have meaning and emotion of all signals by simple andcomplex perception within technical and cultural constrains.

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Figure 5 :The Process of Emtion's Meaning From Signals (Pilan, Maiocchi, 2013)

Desmet proposed a basic model of emotions that are related to human-product interactions andidentified by concern, stimulus, and appraisal (Desmet, 2002). How people have emotional reaction tosignals. Desmet and Hekert introduced a model of product emotion, to respond how emotions areelicited? This model is based on cognitive - functionalist view on emotions. The functionalist approachin emotions can be described as “the felt tendency toward anything intuitively appraised as beneficial,or away from anything intuitively appraised as harmful” (Arnold, 1960). Based on this definition,Desmet says that “emotions pull us toward good stimuli and push us away from bad stimuli” (Desmet,2001). They introduced product emotions based on three approaches to concern:

(1) Goals,

(2) Standards, and

(3) Attitudes (Ortony, Clore, and Collins, 1988), (Desmet, 2001).

• Goals: Three kind of goals define regarding products: utilitarian, social and hedonistic.

• Standards are our expectations, patterns and conventions regarding to things.

• Attitudes are changes in our taste about like or dislike.

Emotional responses to products depends on our goal, standard and the attitudes (Desmet, 2011).

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Figure 6- Desemet Emotional model (Desmet, 2001)

2.3.1 Emotional Experience

The definition of emotion has been changed from passion to desire. Emotions have physical and mentaleffect (Picard, 1997). Touch, sight and sound, taste and olfactory experiences can affect on emotionalexperiences and cognitive emotions. People can experience different emotions in the same situation,based on their background, their experience and their perceptions. By having a look on the history, wecan see how many definitions of emotion exist. “ Emotions change behavior in a short time andquickly, moods can measure by hour or days. Traits are more longer, years or life time. A collection oftraits create personality. All above mentioned factors are changeable. Multiple personalities in differentgroups emphasize different traits and our flexibility (Norman, 2004).

2.3.2 Categories of Emotion

A variety of emotion categories exist in different fields such as psychology, neuroscience and designexcite. In the next figure we summarize different positions of some authors: a lot of scientificapproaches in basic emotions are present in literature, but strongly different from each other. Accordingto Plutchik basic emotions are acceptance, anger, anticipation, disgust, joy, fear, sadness, and surprise(Plutchik,1980). Moreover, he introduces primary, secondary, tertiary emotions.Ekman says there aresix emotions: anger, disgust, fear, joy, sadness and surprise (Ekman 1999). Damasio in 2005 talkedabout primary and secondary emotions both producing changes in body states; but thoughts evoke thesecondary emotion. The emotions that a person feels non-cognitively are primary emotions. Secondaryemotions are produced cognitively (Damasio, 2005). Cannon suggests that different parts of the brain

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can be related to an emotion, for example, the hypothalamus and the limbic system are joined withemotions (Oatley et al, 2006). Bodily experiences we call emotions, consist of two aspects: cognitionand sensation. We know that the body is not separable form consciousness. Russell categorizesemotions in two dimensions. One is the range between pleasant and unpleasant and the other is the rangfrom excitement to calmness (Russell, 2003).

Figure 7- Russel emotional Model ((Russell, 2003)

Gomez believes if a negative emotion follows a positive emotion the result will be an overall ofnoticeably negative experience. This theory also shows that if a positive emotion followed by anotherpositive emotions, it creates a link between positive emotions and the overall experience is positive(Gomez, 2008). Below you can see a chart of different categories of emotions. This chart was made byUgur, Secil one of the PhD graduated of Politechnic of Milan. She worked on embodiment of emotionthrough wearable technology.

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Figure 8- Circumflex of Basic Emotions and Theorists (Ugur, Secil, 2011).

Panksepp defines seven fundamental emotions, fear, rage , grief, seeking, care , play and lust. He saysan emotion is the status deriving from the activation of specific neural circuits by a specificneurotransmitter (Panksepp, 2012). Neuroscientists believe, the human brain has three layers. The innerpart (reptilian) which emotions arise in this part, mainly related to survival emotion such as seeking,fear, anger., the middle part, developed in mammals, which is related to maternal emotions, and theupper part (neocortex) is more related to rational and logic processes. “Nothing is more complex, mysterious, and subject to conflicting theories and interpretations thanhuman emotions” (Denzin, 2007).

· According to Panksepp speaking emotions as one of the mechanisms to increase the survival of thespecies; Based on his words and Darwin theory and some other studies, animal and human bothfeel emotion (Darwin, 1872). As we know Darwin was the pioneer of this approach.

· Panksepp considers every emotion as the activation of a specific part of the brain through aspecific neurotransmitter class, and he says basic emotions are seven. He knows seeking, playand care aspositive emotions with positive- affect and fear, rage and grief as negative emotionswith negative- affect.

· Obviously, above mentioned emotions have effect on physical state such as blood pressure, heart

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rate, and skin conductance.

Nevertheless, the works published by Panksepp don't examine in deep the peripheral nervous system(sympathetic and parasympathetic systems, vagus nerve, etc); those aspects are handled by otherauthors, such as Sapolsky (Sap 2004) and Porges (Porges, 2011). People's emotion are mixing of thesebasic emotions, for example jealousy is mixing of seeking, lust and fear and may be grief (Panksepp1982, 2010c) .

Seven Basic Emotions :

. SEEKING (expectancy): SEEKING trickles our look to search and find the meaning of oursurrounding beside making satisfy our primary needs such as hanger, thirst and find a shelter toprotect ourselves which might leads us to discover some ideas, forecast and models. Seeking isliving under the “brain award system” (Panksepp 2012). One of the most important intuitiveemotional system that stimulate searching, exploring and the reason of being excited to gain thedesires in creatures. SEEKING urge. “In a sense, SEEKING is the “granddaddy” of all theemotional systems. To satisfy LUST, one must seek relationships. To feel tender loving CARE,one must seek to help those who need help, especially babies. To feel full RAGE, one must seekto harm those who would take resources away from you. To respond well to FEAR, one mustseek safety. To make your PANIC/ GRIEF work for you, you must seek out those who wouldsupport your needs. To PLAY with great joy, you must find friends” (Panksepp, 2012). When weare hungry, thirsty, cold or lonely, when we are scared , we care seeking for a solution to answerour needs and desires.. Seeking is a stimuli system for learning to make it an exciting experience.Seeking leads us to feel good by providing a kind of excitment. Peter Milner has called seeking “brain reward system” (Olds & Minler, 1954). Brain dopamine is the fuel of seeking.

· RAGE (anger): Disappointed seeking, seeking with no achievement create frustration then rage,trend to quick reactions. Rage can change to jealousy and hatred. Anger can be the cause of Rageand some times it happen for protecting ourselves. Jim Averill’s (2010) definition states that“anger refers to an emotional state that involves both an attribution of blame for some perceivedwrong and an impulse to correct the wrong or prevent its recurrence; aggression is an attempt tocoerce another into taking, or refraining from, some action against his or her will and not for hisor her own good”. Rage system can increase aggression dramatically. Many frustrations arecoming from difficult times, increasing difficult time is a cause of human anger. Generallyfemale have less anger than males. Difference in sex circulating hormones is a part of the reasonof sex difference. Testosterone has influence on aggression and it is promote male dominancetendencies. Social rejections are another causes of aggression ( Panksepp, 2012)

· FEAR: leads creatures to survive, pain, threat and forbid. Freezing and flight are two objectiverelated to Fear. Pain is fear stimulation. Becoming afraid of conditional stimulus are simplyhappens. Symptoms of expecting anxiety are rapid heartbeat, sweating, gastrointestinal upset, andincrease muscle tension which are characterizing Fear. Experience and a memory of a fear inchildhood can be a reason of fear in adulthood. Weak people like children have more fear, becausethey feel not having the power to resist danger. Some times children put themselves in danger likegoing up of a ladder that's because they still do not understand the particular danger.There is closerelationship between Fear and Rage and both associated with fight responses and flight responses,both happen in a kind of danger (Panksepp, 2012).

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· PANIC or Grief ( sadness): separation distress, social loss, grief, loneliness, specifically for theabsence of maternal care Grief is one of the reason of depression and this is an emotion you havenever wished. We can say grief is “the dark side of our capacity for love and Play”. Stresschemical arouse the grief system. Panksepp talks about new treatment of depression and heintroduces it in three ways :

First, use of “ safe opioid” to reduce psychological pain and depression (in process method).

Second, deep Brain Stimulation of Seeking System to evaluate capacity for enthusiasm.

Third, the genetic analysis of Play- Increase the amount of social joy in the brain to classify newneuro- chemistries to help positive social feelings.

Care can decrease the grief. When we hold a chicken in our hands and give the feeling of safe andcomfortable place to it, we decrease the feeling of loneliness. Panic/ Grief might be the strongestemotional resonance to assist empathic devotion (Panksepp, 2012)

· LUST(sexual excitement) : involves sex and sexual desire; Lust linked with different homeostaticand sensory affective mechanism like other emotional system. Negative emotions such as Fear ofGrief decrease sexual arousal but mild pain some times increase it. Loving relationship withsexual satisfaction seems a to be a reason of happiness and longer life. In biological level, brain'ssexual organization may not match well with sociocultural identity. Furthermore, people can bein “ mismatching” bodies and minds. Males and females have different approaches to Lust andtheir attractions are different. Sexual desire is the reward of Seeking System and it helps toincrease Dopamine ( Panksepp, 2012).

· CARE (nurturance): maternal nurturance;

Human motherhood is a miracle. The role of extending families have been changed with the passageof time. Care reduces Grief and Grief reduces Play, this is the interrelationships between Care,Grief and Play. The positive effect of Care is rising dopamin in the brain (Panksep, 2012). In factwithout maternal care and psychic of Panic, empathy would not exist ( Panksepp, 1998:Watt,2007). Care can be sexual and non sexual emotional system. Oxycontin is one of theimportant maternal chemical (Peterson et al. 1982; Keverne & Kendrick, 1994) in more quantitiesin female brains than male brains (Jirkowski et al., 1988).

· PLAY (social joy) : Play, joy. Playful activities bring great joy. Panksepp says this is difficult todefine Play chose the five criteria of Gordon Burghardt (2005) which summarized it in a singlesentence “ “Play is repeated, incompletely functional behavior differing from more seriousversions structurally, contextually, or ontogenetically, and initiated voluntarily when the animalis in a relaxed or low-stress setting” (Panksepp, 2012).

Panksepp has affective feeling for every seven primal emotions. Affective feeling of Seeking isEnthusiasm , Rage/ Pissed- off, Fear/Anxiety, Lust/ Horny, Care/ Tender & Loving, Panic/Lonely &Sad and Play/ Joyous. He is talking about them in Ted Talk and he mentioned about all in his bookseperatley (Panksepp, 2012).

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2.3.2.1 Categorize last emotions to the Seven Primal Emotion of Panksepp

Categorize last emotions in the last chart in a new chart (blow) based on seven basic emotions ofPanksepp shows Lust is one of the emotions with no attention in other's classifications and Fear thenGrief and Seeking are noticed more. It seems positive emotions from Panksepp speaking have thincolumns between all other emotions. Widest column is related to Grief, it means we found moreemotions under the meaning of grief to situate in this group.

Table 2- Basic Emotions Under Panksep's Category of Emotion

2.3.3 Design and Emotion

According to Norman design has three levels, Visceral, Behavioral and reflective. Each part helps toshape the experience. Visceral is about initial reactions of people to design. What nature does isVisceral. Interpretation of emotional signals of environment use in visceral level. Behavioral level isabout use, with not too much attention to apprentice (Norman, 2004). Functional can introducebehavioral level which needs understanding people. Good behavioral can be the base of design.Reflective is about variety sides of design such as culture, meaning of product and message (Norman,2004). Smith and Kirby talked about level of processing in appraisals; 1) Direct perception which dosenot need the activation of mental presentation (Viscersal level). 2) Automatic response based on thebackground and memories outside of the consciousness ( Behavioral level). 3) Conscious reasoning( Reflective level) (Smith and Lirby, 2001). These levels are comparable with three level of perception1- Simple perception, 2- Complex perception and 3- metaphors (Lakoff, 2003).

Desmet says two other approaches are introduced between different appraisals, thematic andcomponential. The first approach is a short distribution of an overall meaning of a situation. Forinstance for joy overall meaning is a progress to achieve a goal (Lazarus, 1991). In the second onefocus is on every steps and different aspect of situation as appraisal component ( Roseman, 2001;Scherer,2001) both approaches should be understood for designing emotion (Desmet, 2009). Desmetbelieves design for happiness should play with these four features of human: Talent and skills,

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contribution, personal value, pleasure (Desmet, 2011). “The importance of emotion and contextinvolved during interaction with artifacts or environments is also activated within activitytheory”( Gomez, 2008)

2.3.3.1 Sympathetic and Parasympathetic System

Before start to talk about scaling of emotion, talking briefly about sympathetic and parasympatheticsystems can be useful. There are two major branches in automatic nervous system. The Sympatheticand Parasympathetic. The sympathetic system evaluate for active responses such as heart rate,respiration. The Parasympathetic branch approves in passive situation such as the slow heart rate. It isalso sensitive in emotional changes and it advocate, sexual arousal, salivation and tears (Panksepp,2012).

2.3.4 Scaling of Emotion

According to Rodaway, sensation and cognition are two dimensions of perception (Rodaway, 994).Sensation is the relationship between human body and the environment with five different senses.Cognition is a mental process. Human body shows emotion in different ways in verbal and nonverbalcommunications. Methods have been developed to scale emotions based on their verbal and nonverbalmanifestations and physiological reactions:

2.3.4.1- Nonverbal Instrument (Objective – Language Independent)

Nonverbal instruments are language independent and can be used in all cultures. In addition nonverbalinstruments are more objective than subjective which is not relay on participant own assessment( Desmet, 2005). These instrument approach a limited set of basic emotions such as fear and rage(Cacioppo et al. 2001) and the instruments can not enter to the field of measuring mixing of emotion(Desmet, 2005). Facial expression, vocal, postural expression and gesture shows emotions in nonverbalcommunications. Desmet presented a non-verbal self-report instrument to measure 18 positive andnegative emotions specified by product design. (Desmet, 1999) Ekman found out that each emotion isassociated with a particular pattern of expression (Ekman, 1994). Facial Action Coding System (FACS;Ekman & Friesen, 1978), and the Maximally Discriminative Facial Moving Coding System (MAX;Izard, 1979) are measuring facial and vocal reactions. Facial Expression Analysis Tool (FEAT; Kaiser& Wehrle, 2001) automatically codes videotaped facial actions. Vocal instruments are based ontheories which are linked patterns of vocal cues to emotions (e.g. Johnstone & Scherer, 2001). Theseinstruments measure the effects of emotion in multiple vocal cues such as average pitch, pitch changes,intensity color, speaking rate, voice quality, and articulation (Desmet, 2005).

2.3.4.1.1.GEW

Geneve Emotion Wheel is a new instrument for measuring emotional reactions to objects, events andsituation. GEW is invented by Schere, Shuman, Fontain and Soriano in 2013. (sherer, 2005), (Sheresr,2013).

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2.3.4.1.2.PrEmo

The PrEmo tool is invented by Desmet (Desmet, 2005) to evaluate emotional reactions of customerswith respect to given product based on non-verbal self-reporting of 14 emotions which seven of themare positive and others are negative. Positives emotions are: desire, pleasant surprise, inspiration,amusement, admiration, satisfaction, fascination and negatives emotions are: indignation, contempt,disgust, unpleasant surprise, dissatisfaction, disappointment, and boredom. Fourteen emotions isdepicted with animated cartoon characters, expressing the emotion through dynamic facial, bodily, andvocal expression. The animated cartoons are made based on the Ekman (1994) who found the facialexpressions of basic emotions (fear and joy) which are recognized calculable and obviously acrosscultures (Desmet, 2005).

2.3.4.1.3 Emo Card

Emo card is a solution to characterize emotions by using pictograms instead of words. Desmet dividesthe emotions into 8 different categories, and represents each emotion through two facial expressions, offemale and male faces. Figure X shows these 16 emocards of the 8 introduced emotional expressions(Desmet, 2011)

2.3.4.1.4 Physiological reaction –ANS (Autonomic Nervous System)

Blood pressure responses, skin responses, brain waves, heart responses, and pupillary responses. EEG,ECG, FMRI, PET helps us to record physiological reactions.

Fear is an emotions with many physical reactions such as increasing heart rates, breathing faster, driermouth, tense muscles, wet palms which are mediated by controlling heart muscle, smooth muscle, andexocrine glands (Kandel, Schwartz, and Jessell, 2000).Thanks to technology for helping us torecording, measuring and comparing these physical reactions. Researchers in the affective computingfield are most active in ANS instruments are IBM’s emotion mouse (Ark, Dryer, & Lu, 1999) AffectiveComputing Group at MIT designed a range of wearable sensors (e.g. Picard, 2000).

2.3.4.1.4.1 Electromyography (EMG)

EMG helps us to have some data about muscle tensions. High muscle tension happen in stressfulsituation (Wei, 2013).

2.3.4.1.4.2 Electrodermal Activity

Electrodermal activities are related to Skin Conductivity (SC) or Galvanic Skin Response (GSR).Sweat in palms increase under stressful situations but unfortunately out side temperature can easilyinterfere on the result, so it needs reference measurements and calibration (Lykken, and Venables,1971). 2.3.4.1.4.3 Skin Temperature

Measuring skin temperature is easy. Skin temperature decrease in stressful situation, mainly because ofthe contraction of the blood vessels because of the muscle tension.

2.3.4.1.4.4 Blood Volume Pulse (BVP)

The Blood volume pulse measures the amount of blood currently running though the vessels sitedunder a photoplethysmograph (PPG) . BVP measures the vasoconstriction of the participant and his/herheartbeat rate which are higher and faster under stress (Kandel, Schwartz, and Jessell, 2000).

2.3.4.1.4.5 Electrocardiogram (ECG)

The ECG signal represents contractile activity of the heart. It can be recorded on the surface of the

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chest or on the limbs. ECG can be used to measure heart rate (HR) and inter-beat intervals (IBI) todetermine the heartbeat rate variability (HRV). A low HRV shows a state of relaxation, whereas anincreased HRV shows a potential state of mental stress or frustration (Haag, Goronzy, Schaich, andWilliams, 2004).

2.3.4.1.4.6 Respiration Sensor

Respiration sensors measure how deep and fast a person is breathing. Fast and deep breathing showsexcitement, anger, fear or joy. Rapid and shallow breathing shows tense Slow and deep breathingshows a relaxed resting state or states of withdrawal, passive like depression or calm happiness.

2.3.4.1.4.7 FMRI

The Functional Magnetic Resonance uses an MRI scanner to measure the blood oxygenation achievinginformation the amount of stimulation in which part of the brain. The changes amount of oxygenationassociated with the underlying synaptic activity. (Ariely, and Berns, 2010; Khalid, and Helander, 2006;Reimann, Zaichkowsky, Neuhaus, Bender, and Weber, 2010 )

2.3.4.1.4.8 PET

Positron Emission Tomography (PET) is a highly specialized imaging technique to know brainfunctions and body's biological function.

2.3.4.1.4.9 EEG

EEG uses electrodes applied to the scalp and measures changes in the electrical field of the brain regionunderneath. Jenkins, Brown, and Rutterford (2009). EMG, TMS are other kind of measuring emotionswhich are working with Magnetic.

2.3.4.1.4.10 Eye Tracking

Eye tracking records eyes movements with a special contact lens, mirror and magnetic field sensor(Robinson, 1963). The measurement of eye movement can happen in horizontal, vertical and torsiondirections Duchowski, 2007). Eye tracking has been used on research in Psychology, visual system andcognitive linguistic.

2.3.4.1.4.11 Optimal Tracking

Optical tracking, light reflects from the eyes then recorded by a video camera or a kind of opticalsensor. Then the information will be analyzed to extract eye rotation from changes in reflections(Crane, Steele, 1985)

2.3.4.1.4.12 Body Tracking

In body tracking interaction between product and user will be tracked in the body (Slater, and Usoh,1994). Hand tracking is a part of bodytracking by infrared tracking systems like the Vicon and Elitesystem (Murradius, Goulermas, and Fernando, 2003; Ferrigno, and Pedotti 1985) or by fluorescentgloves and Kinect cameras (Xia, Chen, and Aggarwal, 2011).Nowadays, i capturing the movement andthe posture of users is possible. Yacoob and Davis made a dictionary for converting motions of edge ofthe mouth, eyes and eyebrows, to a linguistic, frame, mid-level representation (Yacoob, Davis,1994).

2.3.4.2- Verbal Instrument (Subjective)

Nonverbal instruments have some limitation and it leads us to use self reported instruments to knowsubjective feeling. Verbal instruments are a solution to the problems associated to nonverbalinstruments. These instruments can have response for all kind of emotions and have a ability of using

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for mixing emotions but it can not be used for every cultures in the same way. Furthermore, translatingemotion word from one language to another language is difficult. Pictogram is a solution which isbeing used instead of words recently ( Desmet, 2005). Questionnaire and Interview are introduced asverbal instrument. Following you can see some example of verbal instruments.

2.3.4.2.1 Self-Assessment Manikin (SAM)

Bradly Land developed Self-Assessment Manikin (SAM)as a non-verbal visual assessment technique.SAM measures arousal, pleasure and dominance held by user's affective reaction to different stimuli.(Margaret m., 1994) has been used in different design studies. The self-assessment manikin is apictorial representation of a semantic differential scale in three dimensions : Valence, Arousal, andDominance (Lang, 1985).

2.3.4.3 Combining Verbal and Nonverbal

These instruments can cover the gap of each instrument lonely. Mixing Nonverbal and Verbalinstruments can create better customer satisfaction. Below you can see some of the methods whichmeasures emotions with both instruments.

2.3.4.3.1 Kansei Engineering

Briefly, Kansei is a Japanese word which depicts senses, human preferences, feelings etc. HaradaPresented “Kansei Engineering,” as a research-based design method to identify and quantify therelationship between product design and the emotional responses of product users Harada,1999).Kansei Engineering is a technology and methodology on design development level, which translates“Kansei”, (that is, senses, human preferences, feeling, images etc.) of a person into a concrete product(Takagi, 2004). The data in Kansei engineering is obtained from a collection of adjectives (which aretreated as kansei words) that help to construct the semantic space for the design of a product, it haseight different types. As an overall goal Kansei is translating human emotions into appropriate productphysical design elements, which contain size, shape, color and texture, in the remainder of this paperwe try to group and assign these words to human feelings. Later you will see how we use Kansei wordscombined with defined taxonomy of the emotions for purpose of understanding the perceptions andemotions felt by persons in Waiting areas.

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Figure 9 : Choices of Route to Reach the Kansei (Lokman and Nagamachi, 2009).

2.3.4.3.2 QFD

QFD is Quality Function Deployment, a mothed which was invented in Japan in early seventies(Akao,1994). This is a systematic approach to the desire and need of customer in product. QFD is beingused for translating Customer's desire to product for satisfying the users (Rosenthal, 1992). QFD hasfour phases, product planing, product design, process planing and process control.

2.3.5 Emotional Experience

User experience is associated with wide range of meaning. (Battarbee, 2003, Forlizzi, J.,2000, Kerne,A., 1998, Mäkelä, A. & Fulton Suri, 2001). Understanding user experience from interacting withenvironment, product and behavior and knowing about their feeling are necessary for design.Nowadaysmost contemporary emotional theories have a look on emotion as cohehrent, organized and functionalsystem (Smith & Kirby, 2001). Emotions build our position in our environment, pulling us to specificpeople, objects, actions, and ideas, and pushing us away from others (Frijda, 1986). Positive emotionspull us to products and negative emotions will push us from them. ( (Desmet, 2002).

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2.4 Empathy

Daniel Goleman psychologist and inventor of emotional intelligence says, without empathy a person is"emotionally tone deaf" (Goleman, 2006). According to Roman Krznaric Empathy is the most popularconcept nowadays and we have two kinds of Empathy. One is Affective Empathy and the other isCognitive Empathy. Affective Empathy is a mirror respond for instance when a baby cry other babiesare starting to cry with no reason. Cognitive Empathy is being in other people's shoes and have look onthe world from their point of view.

Empathy can be learned (Krznaric, 2014). Sympathy and compassion are two confusions for people touse instead of empathy. The definitions make them clear. General speaking Sympathy is mentionedabout an “emotional repose that was not shared.” Compassion means to suffer with another”,sympathetic emotional responses compassion like mercy or tenderness are a kinds of compassion(Krznaric, 2014). Empathy and Compassion are introduced as the aspects of Healing of Art. Increasingor decreasing a part and not doing well can be a kind of problem in Health care centers and I can affectthe treatment process. According to high sensitivity in the hospital Healing Art wil have more preciousand meaningful meaning.

We know Jaak Panksepp as a Neuroscience in this paper “Toward a cross-species understanding ofempathy” in June 2013 is speaking about how empathy is created in Mammalian brain. Jaack believesthe result would help to know about the origin of human empathy (Panksepp, 2013). Furthermore,Krznaric define empathy in a simple way, he says “ empathy is the art of stepping imaginatively intothe shoes of another person, understanding their feelings and perspectives, and using that understandingto guide your actions” (Krznaric, 2014). Moore is a designer who is famous for her “empathic model”.She looks through other people eyes. She says “Empathy is a constant awareness of the fact that yourconcerns are not everyone’s concerns and that your needs are not everyone’s needs, and that somecompromise has to be achieved moment by moment. I don’t think empathy is charity, I don’t thinkempathy is self-sacrifice, I don’t think empathy is prescriptive. I think empathy is an ever-evolving wayof living as fully as possible, because it’s pushing your envelope and pushing you into new experiencesthat you might not expect or appreciate until you’re given the opportunity(Krznaric, 2014)”. Empathyis not a new subject and we can find the foot print of empathy even in our old novels and stories, in themiddle of difficulties people some times helped each other empathetically. “How can we expand ourEmpathetic potential?” this is the question for Roman who spent the last dozen years to find theanswer. He mentioned that the capacity of empathy is a hidden talent in human beings.

Roman introduced six habits of highly empathic people :

Habit 1- Shift on your Empathetic Brain

Habit 2- Make an imagination of other people's life.

Habit 3- Explore life and cultures

Habit 4- Tracking off emotional masks

Habit 5- Travel by Media, Art and literature.

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Habit 6- Provoke a revolution of empathy (Krznaric, 2014).

Jefferson Scale Empathy

Mirror Neuron system (MNS ) and Perception Action Model (PAM)

Empathic engagement at the biological level is synchronize between some prosocial endogenousneuropeptides and hormonal change. Furthermore the set of neuron as the Mirror Neuron System(MNS) is discharged by observing performing the acts (Rizzolati, 1969) & (Heinrichs, 2008). MNSplays a significant role in understanding the other's experience, it can be lead to empatheticcommunication (Hojati, 2013). Paterson and Waal are formulated Perception Action Model (PAM) in2002. Facial expression triggers the observer to have a similar facial mimicry (Peterson, 2002).Anthropologists found out that empathetic thinking supports moral codes in different cultures. We canfind some some relation between empathy and morality. Keith Payne says why are we less empatheticto large numbers of victims than single ones? Karina Schumann, Jamil Zaki found empathy can belearned as an skill. Micheal Inzlicht found some people less feel empathy during an experiment hisexample is powerful people. Sukhvinder obhi found that brain activity matches with lower empathy(even in the short time) in high-power roles. This high power people might have less persuasive tointeract with others (Krznaric, 2014).

2.4.1 Empathy and Quality of Care

Empathy in healthcare centers is defined as a main cognitive associated with patient's experience,concern, pain and suffering and a purpose to help. We can feel the difference between Empathy andSympathy in this definition (Hojati, 2013). In Additional Empathy has a cognitive essence and becauseof that even in surplus is always has benefit for patient care (Hojati, 2011) We talked about MSN andPAM before and we believe both mechanisms MSN and PAM provide to understand patient's emotionand situation better to make a good empathic relationship (Hojati, 2013). The connection betweenPAM, MNS and empathy protected by knowing unconscious mimicry, transmissible yawning, heartrate synchronization and skin response among interactions (Hojati, 2013).

2.5 Humor in Healthcare

Using Humor as a medicated technology is a new popular topic with old roots. There is a proverb inIranian culture saying, “ Laugh is the treatment for all kinds of pain”. Humor has been accepted as apositive physical and psychological effect in different situations (Steven, 2011). In Oxford dictionaryHumor is defined as “that quality of action, speech, or writing which excites amusement; oddity,jocularity, facetiousness, comicality, fun”. Humor can be in comedy films, a perception, or responsesuch a laugher. “Humor involves cognitive, emotional, behavioral, psychophysiological, and socialaspects” (Martin, 2000).

One study in Mayo clinic shows Laugh has short term and long term benefits, the short terms benefitsstimulate many organs, relief stress, pacify tension and long term benefits improve immune system,soothing pain, increasing personal satisfaction and improving the mood (Decker, 2015). Literaturereview on humor and Laughter displays positive psychological changes on the immune system, heartdisease and cardiac rehabilitation (Steven, 2011). Release tension, improve coping and well being and

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simplification relationship and communications are the benefit of Humor in Healthcare (Nuttman-Shwartz, 2010). According to Berk humor decrease anxiety, tension and depression (Brek, 2001).

The work of Clown Doctors and Elder Doctors are based on humor. Clown doctors are providing aplayful and joyful atmosphere for patient. Clown doctors give emotional support and create a strongempathetic relationship (Dormann, 2015). Elder Clown usually wear a small token, a red nose, specialmake up, a lab coat and a stethoscope. They use some technique for juggling, magic and singing withpatient. The juxtapose of being clown in the hospital and “ Medical Clowning” with a paradox inmeaning are enough to break the barrier of pain and distress (Raviv, Amnon, 2014) (Warren, Bernie,2013). Humor can be verbal and non verbal. Verbal humor such as singing, music, dancing and someactivities with facial expression, body posture, gesture and movement. Non-verbal humor can works forpatient with less cognitive ability when communication is not easy (Warren, Bernie, 2013). Dormannproposed three type of therapeutic agent, as comic relief, as comic parents, and as virtual clowns as anew perceptual design based on Humor in healthcare (Dormann, 2015). Humor medicated technologyhas many potentials for future investigation. Create local and international applications, virtual clownsand games are some on going projects.

Our goals and the result of laugh in Healthcare are so close to each other. Using Humor in waiting areacan be a future project. Humor is in Play category of our emotions. By increasing Play in waiting areawe can have a better feeling.

Nowadays Humor therapy is used to reduce chronic and acute pain. Distraction is used for pain controland humor is a kind of distraction technique (Melzack, 1967). Laughter and humor are association withpleasant emotional meanings (Ruch, 1993). Humor strengthen abdominal muscles, increase lungcapacity and immunoglobulin ( Martin, 1988)(Wanzer, Melissa,2005). Humor is a cause of reductionof cortisol and increase epinephrine (Brek, 2001) and increase endorphin which is a pain killer by itself(Haig, 1988). Using humor consistently has an effect of reducing pain and has a beneficial in healthoutcomes (Mahony, 2001). Ferrell et al believe pain management beside humor is more influential(Ferrell, Betty R., 1993). Subjective Happiness measure is a method to measure happiness(Lyubomirsky, 1999).

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3. RESEARCH METHODOLOGY

3.1 Ethnographic approach

3.1.1 Patient stories

Knowing users and living in their shoes helps us in having an empathetic way to design. Living withpatient in the same situation and observe them in one way and being one of them on the other sidemake the situation more clear and touchable. Observation starts by being in a hospital during day andnight. Almost 300 hours in a month spent in hospital to observe people. Instituto Nazionale del Tumori(INT) in Milan was the environment to visit, a hospital with eight floors including hospice, pediatric,wards for hospitalization different kind of cancer patient before and after surgery, a garden in the roofwith some benches for sitting, a meditation room and a church. I had a tour in all parts of the hospitaland I spent my two days in hospitalize ward- this is the place with incurable patients. I wrote the storyof hospitals during these time, I did not use camera because it could be an object to make a distancebetween me and patient. I was with formaluniform with a tag on my pocket, the same as other staff inthe hospital. I am sharing some of the stories so that you can read to know the atmosphere of thehospital better.

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There were two types of rooms in the wards. One in the east side with two bedrooms and one in thewest side with four bedrooms. People could keep privacy by using curtains , curtains were hangingfrom roof and pulling them was enough to protect the bed from other people views but no protect fromthe sounds. Each room had a TV in the corner which was not comfortable for everyone to watch it or toavoid watching it. Rafaela was a woman with hearing problems and she watched TV with a loud voiceand beside her was Giovanni without paying attention to TV. He was busy with his kindle and sometimes played cross-words and nothing more. Both had surgery and not in a good mood, Giovanni hadsome visitors some times and Rafaela was a person with no visitor. Rafaela had a surgery in her throatand her face was not in a good shape and could not talk clearly, she called me with some words andshowed me that she had problem with her bandage - You know I was with uniform- I called the nurseand I stood beside her by taking her hand, she needed care, she pressed my hand respecting to decreaseor increase of her pain. The nurse was so nice. She started to make some joke and being humble.Rafaela gave me a precious smile which is in my pocket yet. All the time Giovanni was busy with hisbook and he did not like any interaction. While his wife came inside, his face was blowing up and thecurtain was closed. Nights were combined with pain, sleep, alarms, going to rest rooms, snoring,somemoaning and sometimes quiet. Sometimes I could find a patient near the coffee vending machine notbeing able to sleep for chatting and having something to drink and sometime stealthy smoking cigarettein the balcony. Night was going to be finished with no stop in the sound of wheels. Wheels of everycontainer to carry medicine, food, bedsheet and patients wheelchairs or beds. Morning have beenstarted very early with the voice of a prioress and changing shifts of staff with the buzz of “Ciao Ciao”.Rush in the morning was a kind of confusion if you looked the whole but for patient on the bed wasjust new drugs, new visits by doctors and one day closer to discharge.

They prepared their questions to break the hierarchy of patient, doctors and nurses. The time to achieveto the top of the pyramid, a precious short time to talk with doctors who were their angles and patientsbelieved they knew every thing about their disease.

Smile was not always the key for transferring good emotions and sometimes was rejected by patients.There were patients with deep pain or introvert characters, with more need to be in private areas, theycan be compared with the patient who choose a corner in the waiting rooms to avoid contacts andinteractions.

Francesca was a young girl with no request and sometimes she put herself in a trouble by not asking.She tried to come down from the bed very hardly, it took half an hour then she took her coin andwalked to the Coffee vending machine every step with noisy breathing, ten steps was enough for her toloose her energy. She was on her knee beside the wall but no stop. So she got her coffee and she wassatisfied by doing it all by herself. I saw the sparkle in her eyes.

You can have picture of a man with lung cancer in light blue formal dress of the hospital after thesurgery in the balcony with deep puff of cigarette. How is this picture? Freedom in the hospital? let himdo all he wants at the end of life? Hidden part of the hospital? Neglecting? I could find an answer if Icould speak with him, but he had no voice to speak.

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3.1.2 Patient in Waiting area

I spent some days in different waiting areas in INT to observe people. People get used to sit for a longtime and they make themselves busy in some ways. The character of waiting area has effect on user'sbehavior. The waiting area of radiology and mammography was designed by SIP Lab group inPolitechnic of Milan. The majority of the users were female. The first impression of this waiting roomwhich made it different from other waiting rooms was Warm colors. You could see some sculpturesand paintings around with a guide book to explain the artworks in the room. At the end of the journeyyou would find a notebook to write your idea about your time in this waiting area or a waiting area asan exhibition. To know about the people's feeling you can follow the stories. The first step, new way ofinterior design makes newcomers surprised. People are looking around with smile. Guide book isinteresting for users they turn over the pages and sometimes they talk together about one of theartworks. Even follow patient still looking on painting and some time they read the guid book. Alarmsand numbers get attention of people to avoid loosing their turn. Furniture layout is in front of the board,TV and reception. Warm color of the chairs, warm materialand warm light made this place friendlierand warmer. It seems this interior design bring smile to people. . TV and the board of the numbersannouncement are on the same wall and along the patient's view. This area is one of the waiting areaswhich I did some surveys to know the emotion of people and compare it with other waiting areasatmosphere. Observing shows this waiting area is more social and using mobile, tablet, newspaper andsome personal distraction is less than others and people are not walking and shaking their feet. Briefly,the signs of anxiety and stress was less evident. The size of waiting area might affect people's behavior.Following, you can see the pictures of this waiting area.

Figure 10- Radiotherapy waiting area in INT This is 3: 06pm of July 2012, I am in the main waiting area of INT hospital. People are looking aroundand sometimes they feel they are forgotten. Full of noise but boring I can call this place boring room oryawning room. People are talking together, some of them are sharing their journey in the hospital and

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some are sharing their treatment process. There are some people who are almost silent with anewspaper or book to be by themselves and other group who are walking, watching board, clock andaround several times. Most of them are shaking their feet, drinking coffee or water and they are waitingimpatiently to visit the doctor. They catch every staff who pass to ask a question. They love to controltheir time. Often I could hear their loud breathing. Boards and alarms are controlling them them, theycould not neglect the alarms. Cellphones and tablets or kindle are a solution to not thinking of time andsometimes they are used to avoid interaction with others. In general they are facing with hidden paininside, which dose not let them to be patient. Chewing gum, making noise, moving, walking, shakinghands and legs, reading book and newspaper, playing with cellphone or tablet, playing cross-words aresome common visible activities in waiting areas which we can put them in some emotional categories.

This waiting area has day light and people are sitting around on metal chairs and reception is in themiddle of the circle. Some months of a year there is an exhibition in this area. The walls are almostwhite with some pale paintings of nature. There are some doors around with a number on top of themwhich invite patients one by one to visit the doctors. You can see the figures of this waiting area blow.

Figure11 - Main waiting area in INT Figure12 – Small waiting area in INT

Picture in the left is the main waiting area that we talked above. The picture in the right is one of thesmall waiting areas in INT. This waiting area is located in the middle of some ways to go to mainwaiting area and the place for blood test. People are passing through this waiting room. There is daylight here and you can see some plants . You can find some people sitting in this area and most of themare busy by looking around. People with different diseases and different behaviors may entertain them.People usually choose the last row to sit, it seems they feel safer to be far from the crowd. Metal chairsin some rows are not friendly but it can be good for people who are interested in communicating. Thissmall area has a lot of noise and activity. In the next picture you can see a waiting area in Bestahospital. This area is decorated by painting. Furniture layout dose not help people to see paintings . Thecolors are whiter. This is an open waiting area too. People are passing this area to enter the other wardsand units. In front the people, there is a big open area and in the left there is a TV and the board. Coldair is one of the biggest differences in this waiting area. In winter people are sitting in this area withtheir coats on, you can see in the picture too. This is because it is located close to the main door of thehospital. This area has white light and day light. The atmosphere seems colder than other areas. Using

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metal for the furniture and putting them in a line helps to increase coldness. Walls are not caringpeople. People sit separately and they are not interested on talking to each other . I feel they just wantto escape this area. Their desire is to finish waiting time as soon as possible.

Figure 13 - Waiting area in Besta

Patient feelings and their physical appearance have effect on others. Patient with no good appierencebecause of disease try to hide themselves from others' eyes. Waiting area can be an area to share feelingand decrease loneliness even if they do not talk to each other. Sometimes being in WA is necessary andhelpful for people to share their treatment process and the amount of pain.

Daniella is one of the patients in the main WA she has covered her face and I can only see her eyes andunder the scarf she has a suction in her neck. She has pale skin and other patients are not comfortable tohave eye contact with her. Being in waiting time for people who are not in a good shape is moredifficult, all the time they feel other people's eyes on them and sometimes they do not feel fine by anykind of Sympathy.

3.1.3 Author Experience

Trying to be in the other peoples' shoes as a designer is helpful to understand the users but when Ibecame on of them with a long wait in waiting areas, I found the big difference in the way ofunderstanding. I diagnosed by breast cancer and the next step was meeting the doctor to make adecision. Being in waiting time for the first week after diagnosing was the most difficult wait for me.None of the physical attractions were interesting for me but one warm smile could change my mood. Iremember once a kid with an I-pad in her hand who watched Tom and Jerry was the most usefuldistraction not only for me but also for the other patients . Second week of my treatment was muchbetter. First week, I was trying to accept my disease and that was the most difficult part of the process.The second week I accepted it and the third week and after that I learnt to live with it and later I found Ican live with it with happiness. First week I loved to find people with the same problem to know aboutthe rest as soon as possible. Being in waiting area helped me to find some people more or less with thesame problem to talk. They were survivors and that was the best optimistic thing I could see and Icould learn from them. Surprisingly I became one of the patient in main waiting area in INT, The placewhich I did hours of observation and wrote the patient story. Main waiting area was colder and lesssupportive for me when I was a patient there. Furniture layout did not help me to know patients andtalk to them. Waiting time was longer than every time even before I had a mammogram in this area.

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Patient emotion has a straight forward effect on their perception of time and the level of disease andtreatment has a big effect on their emotion. I can say my cancer leads my emotion and it took time forme to handle it by myself. Obviously this is a part of humanity and different experience for eachindividual person.

3.2 Method and procedure: Observation Basic emotions help us to categorize all our observations. Every act is coming from one or moreemotion and we can categorize them by emotions. Shaking legs is an example which belongs to Fear orRage category and looking around belongs to Seeking category.

Patient Journey

Patient's journey is the result of shadowing patient in the hospital. Figures below show the Out PatientDepartment (OPD) with a short journey or In Patient Department (IPD) with a long journey. In both ofthem multiple waits are visible, Short journey and long journey with different characters but stress iscommon between them specially during wait.

Figure 14- OPD Patient Journey

Figure 15- IPD Patient Journey

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3.3 Method and procedure: InterviewInterview with 100 patients during waiting time for radiology in Instituto Nazionale dell Tumori (INT)and Ospedale Majore in Milan-Italy. Interview was based on open questions to know:

•The feeling of people in waiting time.•Their recommendation and complaining about waiting time and waiting area.•Find the relation between the length of wait and user’s feeling.•Effect of physical attractions and distractions on perception of time.

Figure 16 - Age distribution among subjects in Interview

Figure17 -Sex distribution among subjects in Interview

Most people who were interviewed were older than 45 years old. We found less young patients than oldpatients. The majority of patients were female but not with a big difference.

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Most of the patients were surprisingly satisfied about waiting room, they talked about color andpainting and they said these are fine but some thing we expected is better service. Some patient did nothave look around even and they said there is no difference between colors for us we need to visit doctorsooner. Some of them feel bored and tired of sitting a long time but they answered questions politelyand they tried to be helpful. One of the patients told us this is a public hospital and I do not need a highquality service and I am just here for some hours I should respect the people who are working hereevery day for us. Based on the observation and interviewing and using seven basic emotions ofPanksepp we made the chart blow. It says about the amount of emotions in every step of patients'journey for OPD patients. Later we will use the result of the observation and interviews in Bonefishanalysis and User Experience in hospital.

3.4 Overview of Observation and Interview Based on Seven Basic Emotions

Figure18- Patient emotion in every step of patient journey based on Observation

Lust is deleted from our Seven Emotions because it is not considerable specially for patient. Seekingand Fear are the highest and then fear and Rage. Negative emotions are higher than positive emotions.Wait 2, 4 , and 3 are more negative than wait 1. Patients in all the journey are looking for next step andthe way of doing the current step. Seeking is a part of the journey with highest rate in arrival, wait forexamination and wait for result. Interaction between human and Machine make the radiotherapy moreunknown and scary. Grief has more up and down comparing to other emotions. Care and Play have theless rate of emotion. We believe improving these two positive emotions can help to have the positiveatmosphere in the hospital. How can we increase Play and Care by Design? Create more Physicalattraction? Create more useful distractions? Changing behavior? Later you will see some studies toanswer these questions.

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Figure 19 - Effect of increasing Positive emotions in whole journey

3.5 Method and Procedure in Physical Attraction in Waiting areas

Environmental Effect on Emotion In Waiting Areas Based on Kansei Engineering and AffectiveNeuroscience.

As we said in previous chapter, Arneil and Devlin found the relation between attractive environmentand perceived quality of care (Arneil,Devlin, 2002). Patient’s experience in healthcare system besideinterpersonal relations and interactions with staff included courtesy, competence and communication.(Powers and Bendall Lyon, 2002). Every small design has effect on the mood and morale of medicalstaff. Maslow in 1956 said people are more positive in beautiful rooms (Maslow & Mintz, 1956).

I did a survey about the “Environmental Effect on Emotion in Waiting Areas Based on KanseiEngineering and Affective Neuroscience” As my aim is to assign emotions to physical properties of thespace I opted for emotional model from general research in Affective Neuroscience which describes 7primary-process emotions: SEEKING (expectancy), FEAR, RAGE, LUST, CARE, GRIEF (sadness)and PLAY (social joy). We described these emotions which are similar for all mammals (Panksepp,1998) and we can understand them as being both positive (desirable) and negative (not desirable) foreach person. When referring to the waiting areas, we will use this taxonomy of emotions as our modelfor structuring the collected Kansei words which we will explain further.

You can find the definition of kansei and Kansei Engineering in last chapter. For this study, KanseiEngineering (KE) type “I” was used. We opted for KE model proposed by Simon Schutte, which wasfeasible in our facilities. This model is a 6-step process and is used in our previous study to link productemotions with product properties (Shafieyoun, Koleini Mamaghani, 2010). In this dissertation we applythe same model, however, we use it for the physical environment and in particular, the waiting area.We follow Shutte who anticipated that the “future growth of Kansei Engineering and the application ofnew areas make it necessary to allow the integration of more tools and methods from other areas”(Schutte, 2005).

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Figure 20 - KE model proposed by Schutte (2005).

3.5.1. a. Choice of the Domain

Our study subjects were 200 patients who were diagnosed with cancer. Fifty patients for each four WAs were distinguished in two hospitals (Istituto Nazionale dei Tumori and Bestain Milan, Italy).

Figure21- Age distribution among subjects

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3.5.2. b. Spanning the Semantic Space

In our study, we use Kansei words (KWs) to describe the environment of the WAs by obtaining 650adjectives (KW). We collect them from magazines, Internet, books, papers, and dictionaries, as well aspersonal observations where adjectives have been collected by spending one week during both day andnight inside the hospital. In the next step, we used manual expert method by the designer’s choice toperform the word structuring (Table 1). We grouped 325 of them and finally to 24 which we classifiedinto 6 out of 7 primary-process emotions. Some of these KWs are presented in Tables 1 and 2 below.We excluded LUST as it did not apply to the hospital 2.1. environment. For each of the emotions weobtained an average of 4 Kansei Words, which we believe are the nearest representatives to theemotion definition in Affective Neuroscience (Panksepp, 1998).

Table3- Manual Expert Method of structuring the Kansei Words (from left to right)

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Table 4- Final 24 Kansei Words structured per 6 emotions from Affective Neuroscience

3.5.3 c. Spanning the Space of Properties

We chose four WAs, which had easier access for performing our study. It is worth mentioning that patients inthese areas were suffering from cancer. These areas had diverse characters (as depicted in the Table 3 and inFigures 3 to 6) for the purpose of revealing similarities and differences in patients’ perception. Each WA had thecapacity of 50 persons waiting to be accepted for medical check.

Table 5 : Characteristics of the Waiting Area (WA)

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Figure 22- Waiting Area 1

Figure 23- Waiting Area 2

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Figure 24 - Waiting Area 3

Figure25- Waiting Area 4

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3.5.4 d. Synthesis

We ascribed KW’s to WA’s by using the Manual Expert Method, as it is the oldest and being accepted as havingmore accessible tools (Shutte, 2005). Our study participated 200 patients and we performed a total of 600surveys in 4 WA’s. The distribution of patients was equal for each of the WA’s, having 50 patients per room.Each patient had 3 types of surveys and a task to match 24 KW (short listed above in Table 2). The same KWswere used for each of the 3 surveys: color, furniture layout and materials. Survey was based on semanticdifferential method with 7- point empty spaces ranging 1-3 (not so good), 4 neutral and 4-7 (very good).

Figure 26- An example of 7-Point Scale used throughout the survey

After collecting the participants’ answers, in next step we asked 10 designers to perform the same structure of 3surveys (additional 30 surveys), however by imagining an ideal WA.

3.5.5. Results

Below are survey results of all 4 WAs and Ideal WA. We observe that in Ideal WA “Beautiful”, “Friendly”,“Nice”, “Active”, “Alive” and “Dynamic” Kansei Words have higher rates.

Figure 27- An Ideal Waiting Area seen by designers

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Figure 28 - All Waiting Areas seen by participants

The data was treated with factor analysis with the purpose of semantic structuring. This was done inSPSS (Statistical Package for Social Sciences), which is a commercial statistical software. The inputdata were the mean values for the 24 KW’s describing each of the 4 WAs and including an ideal WA.We used this method as the factor analysis to simplify this raw data and to reveal connections betweeneach of the WAs. Results below demonstrate new categories of KW by performing factorial analysis. AllKWs were reduced to five factor-words: Gloomy, Friendly, Active, Confusing and Agitated which had thehighest loading in more than one analysis. Factor 1 (Gloomy) for color are: “Tranquil”, “Calm”,“Quiet”, “Boring”, “Sleepy”, “Dozy” and “Depressed”. We can observe that there are no adjectives +4in Ideal WA. Factor 2 (Friendly): “Nice”, “Funny”, “Beautiful” and “Friendly” are +4 in ideal WA.According to the amount of Kansei Rating in 4 WAs we can observe that WA 1 have +4 rating in theseadjectives. Factor 3 (Active) “Alive”, “Active” and “Dynamic” we observe +4 in Ideal WA and WA 1having all of this adjectives +4. Factors 4 and 5 respect the similar trend. Finally, we find out that thecolor of WA 1 has been perceived friendlier and have more positive emotion for users. Results belowdemonstrate a comparison of an average participants’ of 1-7 ranged values among all 3 attributes:color, furniture layout and material.

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Table 6 - Kansei words per Color(* Adjectives 4+ are rating for Ideal Waiting Area)

Conversely, Factor 1 in Table 6 is “Slow” and includes “Hateful”, “Tranquil”, “Quiet”, “Slow” and “Apathetic”which has no +4 adjectives however having instead 3 adjectives (“Hateful” and“Apathetic” and “Slow”), whichare less than 1 in Ideal WA. We can also observe that the WA’s 2 and 3 have +4 rating of Kansei in theseadjectives. In addition, in Table 7 we observe the results of negative emotions in WAs. Table below shows WAs1 and 3 as favorite selection for furniture layout.

Table7- Kansei words per Furniture Layout(* Adjectives 4+ are rating for Ideal Waiting Area)

Under the word "Material" we consider any material in environment, which can be tangible material in furnitureor a wall texture. We can see in table below that users chose WA1 as the best WA in case of material.

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Table 8- Kansei words per Material(* Adjectives 4+ are rating for Ideal Waiting Area)

We believe that decreasing negative emotion and increasing positive ones in new WAs would be possible byknowing better the perception of people. Though, we can depict negative elements of each WA by choosingadjective less than 1 in Ideal WA and +4 in our WAs. The result is shown in the table below. We mergedSEEKING with GRIEF; SEEKING is a mother emotion (Panksepp, 1998), which serves as a channel to enhanceother ones. Results below depict comparison of Kansei Words of four WAs with negative and positive adjectivesfor three characteristics: color, furniture layout and material. In overall, WA1 has more positive emotions for allthree factors. WA3 has a friendly Furniture Layout but other factors dominate negative emotions. By analyzingthe character of WAs we obtained a better insight in perception of participants.

Table 9- Kansei words with 7 Panksepp’s Emotions per WA

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3.5.6 Discussion

This study applied Kansei Engineering (KE) type I to design a waiting area (WA) for two hospitals inMilan, Italy. The majority of participants used in our study have been diagnosed with cancer. Theresults of this study were qualified by using factor analysis of user’s perception of the WA. KE type Iwas used because it was compatible with available resources. Our study shows that the WA1 is the bestsample of Positive emotion according to color, furniture layout and materials, whereas WAs 2 and 3have more negative emotions. It is also notable that WA1 resembles a private room with a warm color(decorations, paintings and sculptures) where the texture of furniture is warm and friendly. Patientsprefer warm colors instead of bright colors (Devlin, Arneil 2003). Based on our on-field observation,people generally sit next to each other and enjoy by sharing their feelings during the waiting time inWA1. We also observed that people in WA1 had a more expressed feeling of respect. Our studysuggests that using artworks in WA can stimulate PLAY. Textures and warm colors can providesatisfaction by provoking CARE. It is also obvious that a furniture layout can enhance more SEEKINGin this WA. According to our findings, Was 2 and 3 included negative signals among the participantsthat could be attributed to cold colors and the usage of metal for furniture as well as by the dispersionof furniture. This implies that these two remaining WAs together with other characteristics reported inliterature are being in general more negative. Therefore, by understanding increased positive feedbacksin WA1 against findings in literature review we have a potential candidate for PLAY/CARE WA.Comparing an ideal environment to the results of our research study underpins how it is possible todecrease negative and increase positive emotions in a WA. Our future step is to perform a validity testas well as to propose a concrete design model. After completing comparison with other cases whichused KE method, we figured out negative elements of WAs besides positive ones which can be used todecrease the impact of negative emotions and increase positive ones in designing the new environment.A recent study conducted by Ebru Ayas, Jorgen Eklund and Shigekazu Ishihara (Ayas, 2008) used KEmethod to design WA. They applied CA (Correspondence Analysis) and X2 independency testsanalyses in SPSS and Rough Set (RS) method to extract decision rules between Kansei in ROSEsoftware. They used interviews in their survey with closed questions. Obviously, this method is not ausual method for designing the environment but it seems possible to propose a new approach in KEtype I in Design Environment.

3.6 Flow Kansei Engineering

Qualifying Conscious and Unconscious Behavior to Gain Optimal Experience in Kansei Engineering

Last survey gave the idea of testing useful distractions as a part of physical attractions. Based on ourliterature reviews reducing the difference between perceived time and actual time can have a positiveeffect on patient's satisfaction. Informing about the time of waiting is noticeable of patient satisfactiontoo. Environment transfer Empathy, Warmth and Friendliness (Arneill, 2002). Useful distraction suchas television or magazine in waiting space, indoor and outdoor views, patient- education resources,give people a choice of what they can do during waiting time has been shown to help to reduce stressand anxiety (Hosking & Haggard, 1999). According to Oermann providing patient education resourceis not correlated with patient satisfaction in waiting area (Oermann, 2003: Oerman, 2002) and Feddockthinks usual distraction seems do not improve patient satisfaction in long waiting time (Feddock,Christopher A., et al, 2005). Patients choose their seat in front of the reception to avoid being forgotten

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(Becker, 2008). Quality of care, Quality in fact and Quality in perception should be measured to knowhow people feel (Becker, 2008). Obviously, perception of time in waiting time for Doctors, Nurse,Patient, staff, family or caregivers is different (Boris, 2007).Flow Kansei Engineering test was proposed as a qualifying conscious and unconscious behavior to gainoptimal experience in Kansei Engineering.The general tendency of design is that being based on humanand the aim of Kansei engineering is to follow the structure of emotions based on human behaviors. Aswe know, Kansei appears in individual emotions and is able to create different feelings in human mind(Nagamachi, 2010) where Flow is a teleonomy of the self (Csikzentmihaly, 2014). However, Designhas a convergent and divergent relation with needs and desires. Accordingly, designers are obliged tomeet user’s desires but the implicit needs of such an emotional experience are difficult, partly becausepeople express their emotions both consciously and unconsciously. Analyzing the relationship betweenKansei and Flow, activities can have optimal behavior output. This article provides a new approach,which can be applied to capture the emotions of users and proposes a new framework of KanseiEngineering (KE) to handle the optimal experience of people besides their needs in a various tangiblefield such as interior and product design. In this study we use the KE Model of Schutte because it isunderstandable and compatible with new tools. We use Flow in semantic and properties space and wecreated a Flow space during the synthesis step of this level.

Figure 29- Choices of route to reach the Kansei (Lokman and Nagamachi, 2009).

3.6.1 How can we affect the user’s emotional reactions?

The amount of skills and challenges are forming the user’s emotional reaction. As presented in Figure 4,Flow is a function of counterbalance between challenge level and skill level when both are aboveaverage for the individual in that, low skill and high challenge generates anxiety and high skill and lowchallenge result relaxation. Flow helps people to overcome problems and to bring exhilarating feelingof transcendence into their lives (Csikszentmihaly; 2013). Entering Flow depends on developing abalance between perceiving activities, capabilities and opportunities (Nakamura, 2002). In addition,attention plays a key role in entering and staying in Flow mode. Remaining in Flow mode can only beguaranteed by keeping the balance between skills and challenges. The duration of remaining in Flowmode is the most widely used system for measuring the autotelic personality (Nakamura, 2002).

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Figure 30- Csikszentmihalyi's Flow mode ( Mihaly, 1997)

According to Csikszentmihaly the joy of movements such as dance, exercise, Yoga, sex, listening tomusic, tasting and hundreds of separate functions do correspond to Flow experience (Csikszentmihaly,2002). He believes that joy of thinking, working, enjoying solitude and being with other people,communication and creativity have the ability to enter people into Flow mode. Measuring Flow is asubjective state based on self-report interviews, paper-and-pencil measures, Flow Questionnaires andthe Experience Sampling Method (ESM) (Delle Fave and Massimini, 2004; Jackson and Marsh, 1996).Flow and design projects Several art museums have integrated Flow principles during their exhibitionsdesign and buildings, including the Getty Museum in Los Angeles. Flow principles have informedproduct design, at Nissan USA, for example, with the goal of making the use of the product moreenjoyable (Nakamura, 2002).

3.6.2 Entering Flow in KE process

We believe that the customer’s point of view is not considered enough to achieve satisfaction in newdesign. Doing the KE test while the participants who are in their Flow mode, can lead us to new designbased on people’s happiness. Being in a good mood and using user’s skills to make a deep challengewith products provide an appropriate status in achieving better results. In order to get a valuable resultbesides entering the participants in their Flow mode, we need to keep them in that condition. MeasureKansei of users during their flow by all aforementioned measures of Kansei and Semantic Differential

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Method (SD) developed by (Osgood et al. 1969) are available to assist us in this evaluation. You knowabout KE type one, We choose this model and merged it with the Flow concept. We describe the newapproach of KE based on above stated literature reviews and link it with Flow concept to form a newmeasuring system called Flow Kansei Engineering (in future, FKE).3.6.3 Choice of Domain

The choice of a target group is informed by the market and the particular new product. MeasuringFlow helps us to know our user better and to make a better consequently results in developing a moresuitable Kansei word (KW) collection. We also need to measure flow in order to choose the optimalway to enter our users in the Flow. The results of qualitative interview help us to prepare aquestionnaire based on the keywords such as whether, how often, in what specific activity and context.The goal is to compose a picture of the typical subjective experience when things are going well. Wecan create a questionnaire depending on our research goals to use ESM. ESM helps to change acomplex subject to simple one and gain more results about the condition of individual Flow. Duringmeasuring Flow we can gain a lot of KW.

3.6.4 Spanning the Semantic Space

Kansei measure is a part of this step to collect KW. We measure Kansei alongside with measuringFlow. We know about the interest of users and we find how we can enter them in Flow mode. Being inFlow can change the result of Kansei measure for users, which is reflected in their physiologicalresponses, behaviors and actions, and facial and body expressions and words. When Shuttee introducedthis method he mentioned, “Unfortunately, all the presently available measuring methods are externalmethods interpreting different body expressions”. Applying Flow concept we might grasp and measureKansei and develop interpretations of customer’s emotions. SD Method is the best solution to gainmetric parameters during this process. In order to collect KW, we use magazines, literature, results ofmeasuring Flow, ideas, Internet as well as the result of Kansei measures and further observation. Wordreduction can be done by factor analysis, cluster analysis or manually. We can embrace the modelproposed by Schutte and use collection, selection and compiling to help us organize the process(Schutte, 2004).

3.6.5 Spanning the space of properties

This space is similar to semantic space. Same as before, we can follow three steps of collecting,selecting and compiling to choose the product samples related to our KW (Schutte, 2004). A widerange of sources such as product samples can be selected by considering the future of product. Productshould have a potential to be linked with user’s Flow. In this space we can ask about the properties ofideal products from users or designers.

3.6.6 Synthesis

This step includes merging the Semantic space and Space of properties. We use the result of theprevious levels to make a suitable situation to use participants’ skills and make achallenge with our product range. In measuring Flow we define the span of high level and high skills.Different methods can be used in entering the participants in their Flow mode. For instance we can ask

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an architect to draw the product (paying attention to his/her skills) or in case of a music lover we canplay several music and ask for linking one of them with the product. Writing a poem, making asculpture, playing with the product, taking some photos and so on are all methods toenter users in their Flow mode. During the time of Flow mode, we can ask them to use their skills togive their ideas about the characteristic of ideal product. Then ask them to answer the SDquestionnaire. This method prepares a situation to make a deep relation between user and product,make a pleasurable time by entering them in Flow mode and gain the result from their optimalexperience. Furthermore, the time of keeping in Flow mode is important. In some of KE studies basedon Schutte model the picture is used instead of the original product. For example, Grimsaeth used themethod of Schutte to design battery drills. They presented 23 battery drill samples in pictures(Grimsaeth, 2005). We used the same methodology as the one applied in our previous study to designtable for art students at Art University of Tabriz in Iran. We presented 10 pictures of various tables toour participants (Shafieyoun, Koleini Mamaghani and Jahanbakhsh, 2010). Pictures were in highquality and three dimensional. The participants were skilled in visualization and capable of consideringthree-dimensional shapes.In some surveys, products were used as prototypes and people had the opportunity to touch and usethem. For example, Shang et al. used twenty-four real telephone samples presented to 40 subjects (20designers and 20 users) for subjective evaluation to analyze the subject perception (Hsu, 2000).However, we know that Kansei measure with tangible products can possibly be more precise comparedto tests with intangible products (pictures). Obviously, the emotional engagement with productshappens in Flow and it leads to gain more trustable results. The results can be analyzed using factor andcluster analysis. We can use SPSS and EXCEL software to do that.

3.6.7 Test of Validity

Newly developed models can be tested in the same circumstances that we have described above:entering participants in Flow and asking them to investigate our new model and answering our newquestionnaire in SD method.

3.6.8.Model Building steps

After gaining the satisfactory result we will have a new design of the product.

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Figure 31- Flow KE model based on Schutte model (2005).

3.6.9 The Possible Application of the Method

Our group is working with the Istituto dei Tumori di Milano, a relevant public cancer research andtherapy center since January 2012. In the past, we provided and implemented some proposals, rangingfrom a new interior design, new way of finding signals, new patients communication, new info pointsand so on. Our attention has been specifically dedicated to the waiting rooms. We use KE in one of ourongoing projects to design new waiting room. Now we proposed a test based on the methods above-mentioned, which is a future project. The proposed test is just related to the waiting areas in theHospital, with about 100 users. Before starting the test we have to know about the challenges ofpatients and their attractions. We have to use ESM for measuring Flow mode. We collect KW andmake a questionnaire based on both of them.

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This test is organized into three phases:

1. In the first phase, we will go in ordinary waiting area and we will measure the related Kanseiwith no test, by SD questionnaires. In this phase we will observe which activities patients use todistract themselves from the waiting situation.

Figure 32 - Waiting area with no useful distraction

2. In the second phase, we will prepare a situation to encourage patients in the waiting area tomake them concentrate on their disease and will observe their behavior. We will measure therelated Kansei after the test, by using SD questionnaires.

Figure 33- Waiting area with Useful distraction (Passive Flow)

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3. IIn the third phase of the test, we will introduce a useful distraction, such as the ones applied inthe first test. We will evaluate the user’s Kansei before and after the test, by using observationsand SD questionnaires.

Figure 34 - Waiting area with Useful distraction (Educate patient)

The results of this test provide useful method for a better understanding of user’s emotion and itprovides design suggestions to the relevance of introducing useful distractions into that particular site.In the mean time the tests are intended to engage in alternative, more positive experiences. Each testwill show us which parameters increase the level of user satisfaction and which parameters decrease it.Implications: users are our test groups not their caregivers. They do not need to be aware of being in atest at first, therefore we have to know which day we can catch at least twenty people in waiting area.Waiting room has to have at least one window and a TV and the possibility to close the door. Payingattention to weather, time and the day are important. A gloomy day is not a good choice. Briefly weneed as normal position as possible.

3.6.10 Past ExperienceThe proposal comes from previous experiences, not formalized and then scarcely measured, thatsuggested us to prepare the proposed method. In different areas we provided different new “signals” inthe environment, and observed the different behaviors of patients and staff, depending on the changeswe had done. The above mentioned intervention were done in any waiting situation (i.e. in waitingrooms, but also in examinations or therapy rooms, when time was needed, without any possible parallelactivity), and mainly related to:

· Disguise of analysis or therapy machines (e.g. NMR equipment) to transform them fromaggressive equipment to “toys”;

· Decoration of the walls with a rich and dense collection of paintings;

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· Availability of books, also to be carried home, as in a book-crossing service;

· Availability of crosswords puzzles, and so on.

We compared the behaviors of the users in usual and “equipped” areas, and were able to observe:

· Reduction of anxiety;· Distraction;· Increase the number of smiling people” (or, in general, more relaxed facial expressions;· Increase positive feelings toward the institution and the staff.In the other words, they entered very quickly and positively in their Flow mode.

3.6.11 Conclusion

We developed a method to incorporate unconscious behavior in KE by integrating possibilities thatFlow offers in KE. It seems that one of the advantages of this method besides promoting health andhappiness in society is the usage of less advanced and low cost technology to measure Kansei. TheFKE method is cheaper and easier to apply to different domains and measuring the emotion is done bythe participants themselves and not by an external device. By entering persons in Flow mode, we canhelp them in better understanding and transmitting their own emotions. Then, we measure their Kanseiunconsciously. Psychology and sociology are inseparable parts of KE. For this study, we used KE typeI and the feasibility of using other types of KE warrants further investigation. We can do the samesurvey for KE and FKE and compare the results to show the amount of user’s satisfaction andhappiness. Result can show the amount of user satisfaction and the amount of happiness. Grimsaethperformed a project in KE Type I and he argued that KE is a time consuming method. We alreadyknow that our suggested FKE is even more time consuming in any case, it depends on our ability tokeep participants in their Flow mode which can change their perception of time. Obviously, thismethod is not so simple and use of Flow concept to measure Kansei needs very high perception andpatience of users.

3.7 Effect of visual Art in Waiting area

Visual art has been used in hospital not only as a part of physical attractions but also as a usefuldistraction. In May 2013, a special Exposition of Artworks, named “When Art meets Care”, wasorganized in the main Reception and Waiting Hall of Oncological Center INT, Istituto dei Tumori(Milan - Italy), introducing the paintings of a Japanese Painter, Tetsuro Shimizu, who was also apatient of the Hospital. He drafted the artworks of his project “Immunity” during his admission and hecompleted them at home, when recovered. The paintings tell the story of the successful fight againstcancer done by the Artist. The impact on mood of users due to the presence of the exhibition was testedby a proper survey, herein illustrated. Our study subjects were 400 individuals (some patients who arediagnosed with cancer, some who are investigating the illness and their caregivers). They wererecruited in the main waiting room during exhibition and after that, to know how is the effect ofpainting in the mood of people. The Painter emphasizes the concept of impermanence (Mujo inJapanese). Having a look on his artistic language, we found this concept coming from Japanese cultureis fundamental: irregular shapes of frame, cuts, slits, depression are mixed with vibrate and unstablecolor make the character of his work. Figure x is one of his work in INT.

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Figure 35- Painter ( Tetsuro Shimizu) and one of his painting

Figure 36- A main Waiting Room in Instituto Nazionale dei Tumori –Milan, Italy during an exposition

I prepared questionnaire based on Semantic Differential Method (SD) to discover how much this

exhibition can change the environmental effect of the hospital. Participants fill the questionnaire during

the exhibition and after the exhibition and it helped me to compare them together.

In the first stage, our study subjects were around 200 participants which presented in three days main

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waiting room of INT. Between 200 questionnaire which were divide 153 questionnaires were valid. In

the second stage among 200 questionnaire,165 were valid. Figure 37 and 38 show dispersion of age in

two parts of the survey are approximately close to each other. The majority of them are more than 58

years old and the amount of rest are almost half of them. In the second test population of young people

are more with respect to the first test.

Figure 37- sex distribution among subjects with and without exhibition in waiting room- INT

Figure 38- Age distribution among subjects with and without exhibition in waiting room- INT

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Figure 39 - Emotional effect of waiting room during and after painting exhibition

The result shows people are more agitated in waiting room during the exhibition. Compare between theenvironment with and without exhibition shows play and care are increased in waiting room during theexhibition. It can be because of some question which will have during exhibition and people areinterested to see the painting and speaking about it. This exposition made waiting room more activeand friendly and we can see Play and Care are increased during exposition. Considering theenhancement of agitation during exhibition we can refer it to the character of paintings and being moredynamic atmosphere in the waiting area.

I repeated the same survey with the same questionnaire in San Camillo Hospital in Rome the waitingarea is the main waiting area with cancer patient. This study had 200 participants to answerquestionnaires during the exhibition and after the exhibition. Below you can see the paintinginstallation in two pictures. During the exhibition the majority of participants were between 48-57 butafter the exhibition all ages were equally present. Ratio of men and women are almost the same. Thesurvey has done during 6 days. The first there days were during the exhibition and the second threedays were 2 weeks after the exhibition. Amount of daily patient in San Camilo Hospital was less thanINT and that was the reason of longer time for this study. The charts blow show the age and sexdistribution of participants.

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Figure 40- Painting Installation in waiting area in San Camilo Hospital in Rome- Italy

Figure 41- Painting Installation in waiting area in San Camilo Hospital in Rome- Italy

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Figure 42- sex distribution among subjects with and without exhibition in waiting room- San Camilo Hospital

Figure 43- Age distribution among subjects with and without exhibition in waiting room – San Camilo Hospital

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Figure 44 - Emotional effect of waiting room during painting exhibition

This chart shows the emotional effect of the exhibition on patient. The results show people's feelingdoes not change. Considering the enhancement of monotone mood during exhibition we can refer it tothe place of installation. As we expected, bringing exhibition as a new uncommon event in WA shouldincrease Play (Active, Moving and Dynamic) but the result shows no changes in the amount of Playand even other emotions. People have not a lot of interaction in paintings and the installation was notmotivating them to walk and look around to know them better or they could understand them from theirseats.

Summary

Emotional effect of physical attraction in waiting areas was measured based on Kansei Engineering.Although usually Kansei Engineering uses in product design, use it in environmental effect on userswas successful and was a reason to propose a new Kansei Engineering approach- Flow KanseiEngineering. Useful distraction and educate patient will examine by enter patient in active flow modeand passive flow mode. Based on above I found warm color, round furniture layout and warm materialin my case study (Besta and INT in Milan) are increasing quality of care and satisfaction.

Survey visual art as a part of physical attraction in waiting areas during and after an painting exhibitionin INT in Milan and San Camilo in Rome showed the character of paintings and installation has amajor effect on patient emotions. In these two case studies in INT patient were more active and agitatedduring the exhibition and in San Camilo that was not a difference between patient emotion with andwithout exhibition in waiting areas.

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4. CONCEPTUAL DEVELOPMENT4.1 Hypothesis

Increasing positive emotions theoretically has positive effect on the whole user experience. Based onthis theory, increasing positive energy is enough and we do not need to think about negative emotionsand try to eliminate them. This is a rule when people laugh they can not cry. Raise positive emotionreduce negative emotions by itself. I took the blow chart of Chapter 3. In this chart, I increase positiveemotions with changing number purposely to show how it would be the changed visually.

Figure 45 - Hypothesis of Increasing Positive Emotions to Change the Atmosphere of the Hospital.

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4.2 Macro and Micro Interactions In chapter 3 you see different studies to know about the way of increasing positive emotion in waitingtime by design. Analysis based on the result of these studies makes the new achievements and newmethods to investigate in waiting area. We can examine waiting areas with or without waiting context.Macro and Micro levels are used in one study in QUT in 2008 about emotional driving experience formtheir point of view Micro level includes the interactions between driver and vehicle and Macro level isinteraction between driver- vehicle and external environment (Gomez, 2008). We can extend it to thewaiting area, then micro level would be interaction between patient and environment- behavior inwaiting area and macro level can be interaction between patient and the whole journey in the hospital.

Figure 46 - Micro Interaction in WA. Figure 47 - Macro Interaction in WA.

Based on Macro interaction in waiting area we proposed conceptual frame work in waiting area to do the study with waiting context in the whole patient journey.

4.3 Conceptual Framework

A conceptual frame of User Experience (UX) in Hospitals helps me to perform a trustable andcomparable method to understand the patient’s perception of a hospital. It might have a potential to bea guideline for every waiting time. The foundation of knowing people in waiting areas is being awareof patient’s mood in every step of their Journey. I proposed measure changing user’s feeling based onthe time and their activities. Their age, gender, stress of work, disease and daily life events are somenotable variables for measuring their emotions.

Our target is Out Patient Department (OPD). According to Gomez, Triangulation approaches includinginterviews, observations and think-aloud protocols. (Gomez, 2008). I observed OPD patients inInstituto Nazionale del Tumori (INT) in 300 hours during the day and night. We follow them from theirarrival till departure. According to our observation, the first step of patient’s journey for doingMammography in INT after arrival is wait. They have to wait for starting their process of booking then

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they will have another experience of waiting for doing Mammography. This is the beginning, they willgo to the radiology and they will wait for an exam. Wait has not finished yet they have to wait to gaintheir result. All this process will be accompanied by changes in their mood and the overall mood wouldbe their experience of the hospital. The conceptual framework investigates User Experience in everystep. Knowing user’s emotion in each part of their journey will give us a potential of discovering themost painful part of the process and the effect of time in their satisfaction. The Conceptual frame wouldgive us some data data usable in service design, emotional design, interior design and furniture design.It depends on how we want to influence on user’s emotion to make it better. Therefore, we will have anopportunity to effect on them by entering in passive and active Flow tests. Comparing the results willshow us how can we increase the quality of care.

Figure 48 - A Sample of Conceptual Explanation of User Experience.

Table 10 - User Experience and Patient Emotion in the Hospital.

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4.4 . Experience Stage Model

User experience in the whole journey shows patients activities during their journey and the effect ofeach step on them. In the top of the chart is hospital activities to answer patient’s desire and needs andbelow is patient activities during their journey. As you see, following patient starts from registrationand they will have less activity. In every step patient enter, see the space then understand it then start todo some activities. These are repeating in all steps. First, patient search for a hospital based on theirdisease they have a look in quality, amount of payment and insurance. Distance and transport areanother important factor to be considered. After selecting a hospital they should register. Usuallyhospital gives some options for registration such as on line registration, physical presence in thehospital or register by phone. Patient choose one of them depending on their abilities. Record the timeand date in calendar and find the best way to reach the hospital will happen after registration. Enter tothe hospital, check in and pass the flow time to enter the main area which is wait time, in this areapatient should wait after second check in to be called. Usually they get some numbers in second checkin and they should pay attention to numbers. In some hospitals, they give a vibrator to patient in waittime. Wait time will be finish by vibration or alarm or some times they will be called by name. Visitingthe doctor is next step and it is the beginning of face time. In figure 48, you can find one step before seethe doctor and this is see a nurse. In figure I improved our user experience in the whole journey byknowing them better. Nurses usually asks about patient history and they are doing vital test. Patientanswer questions and help them during vital test and some times they have some documents likeprevious test or X-rays to show to nurses. Visit the doctor is the most important and affective part ofthe journey. Patient will be checked by doctors to diagnose or control. Patient and doctor make adecision together about the next step. Prescription is the result of the all conversation and checking.Prescription tells patient what they should do in next step. Next step can be a new test or radiography,following a treatment then go back to the doctor. decide about a surgery and so on. Based onprescription patient are planning a new journey. Below you can see User Experience in Flow time,Wait time and Face time. User experience in Flow time shows in 5E- Entice (Arrival), Enter, Engage,Exit and Extend. These categories helps us to compare these three Times together. Engage in all thesethree categories of time in patient journey has more activities. Flow time is the first part of the patient journey with more activities. Patient after enter to the hospitalthey looki for the information desk to ask about the address of the intended place. Then should followsign to arrive there. First step is check-in they should talk with an operator show ID and answerquestions and then they will have the number to go to the next stop. In European hospital paymenthappen in this part of the journey but in American bills are coming in front of the door after exit. Next stop is the start of the Wait time, Patient enter the main area, they meet another operator and showthe number to them and answer questions and some times they have a case in the hospital (For followpatient) that will be check. Patient should find a place to sit and wait to be called. During the wait,some patient talk to other people and some of them prefer to stay by themselves. Some people with noactivity get bored sooner than some people who make themselves busy by reading books or magazines,playing crosswords or speaking with others and so on. Wait time is passing longer than other parts ofthe journey. Wait time will be finished with calling a number.

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Figure 49- Overall User Experience in Hospital.

Figure 50- User Experience in Flow time

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Figure 51- User Experience in Wait time

Figure 52- User Experience for Face Time

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Patient step in to the doctor office. In some hospitals patient enter to a smaller waiting area beforemeeting the doctor. They will see a nurse in this place, vital tests and medical chat and show the patientmedical history are the activities of this area. Later on, patient will see the doctor, they will talk to thedoctor about their problem then they will be examined by the doctor and again medical conversationabout the problem. Some time doctor decide about the disease and just say the result to the patient andthe way of the treatment but some times doctor and patient should decide together about the next step.For example when people went to the doctor with backache, after checking the doctor send them to doMRI and ask them to rest for a week, and do some exam after decreasing the pain. Pain killer can bethe prescription. In other cases for example patient with low stage of breast cancer, after examinationdoctor explain them about the problem and the ways to solve the problem and start the treatment.People can decide about Lumpectomy, Mastectomy or depends on the genetic test to doubleMastectomy. Patient and doctor make a decision together. Usually patient are coming out of the officewith a prescription in their hand and the next plan in their mind. They are going to ask questions for thenext step and then they will leave the hospital. They will carry the whole experience to the next visit. In every step Engage seems the most complicated and unknown part for both new and follow patient.New patient sometimes are confused in Enter too because of not being familiar with the Environment.The last chart is the User Experience with more detail . I explained about it before.

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4.5 BoneFish Analysis

Bonefish analysis is a diagram which is created by Karou Ishikara in 1968 . This method is based oncauses for a specific problem. Observing, interviewing and literature reviews made the causes of longwait in hospital.

(1) (e.g.Hornik, 1984; Hui and Tse 1969; Jones and Mowen, 1991; Leclerc, Schmitt, and Dube, 1995; Taylor, 1994; Zakay and Hornik, 1991)

(2) (Rice Ingram, & Mizan, 2008; Arneill, 2002; Dalk and Little 2005, Ulrich, 1984; Verderber, 1986; Wilson, 1972;)

(3) (Melzack, 1967, Kaplan et al.,1972; Oermann, 2003: Oerman, 2002)(4) (Leddy, 2003)

Figure 53- Bonefish Analysis for Long waitin in Hospital

We found the main reasons of long waiting time are not being on time and unpredictable patient.Unpredictable patient happen in face time. The right of patient does not let us to limit face time. Facetime is the most precious time for patient and the reason of being in hospital. Not being on timehappens in wait time and persuading patient to be on time is possible. Influence on patient can be a partof persuasive design. How can we effect on patient to change their behavior to be on time. Userexperience and changing behavior can help us.Bonefish analysis is talking about causes and reasons of a problem. The Long Wait in the hospitalwhich you see in the left part at the head of the fish is the main problem. I analyzed three levels of timein hospital, Flow time , Wait time and Face time. This analysis is based on my observation in more thanone month and some literature reviews. The chart shows the main problem of long waiting

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is unpredictable patient which is happening in Face time and patient and doctor both play a role in it.Not being on time is another cause which happen in Wait Time. Not being on time is not happeningjust because of patients delay it can be caused by something from the first step of the journey.The duration of Face time will be changed based on the communication between patient and doctor, thetype and the level of disease, age, disability, education and maybe sex and we call it unpredictablepatient. Face time control is not easy. Patient should be satisfied when they leave the doctor's office.They come to the hospital and spend all the time to achieve the Face time. Although we can not put atime limitation, we can think about a tolerance for this time. Not being on time is a cause with morepotential to change.

4.6 Result

One time patients are pros of a hospital. Being one time helps better organization about the time. Mostof the time patient with delay expect to be called in the middle of other patient as soon as possible. Itcan be more difficult when two appointments are close to each other. Being late not only waves everystep of patient journey but also has effect on the other patients’ time. Every steps in the hospital needs to be on time to decrease the wait time. People need to move fast fromone step to another and keeping them in a long time in one step make them tired. Keeping themovement in wait time can help to decrease the perception of time. Small waits are more acceptablethan long ones.Patient are more satisfied in flow time than wait time and they feel better by being more active. Activepatient comparing to passive patient are more satisfied in the hospital. Creating some activities inwaiting time to make patient busy is a good way to change the negative effect of long wait . Passivepatient always have a look on their watch and they feel passing time but active patient focus on theiractivities instead of passing time.Patient with different types of disease and different levels of treatment have different face time. Theyare unpredictable patient with a big effect on long wait. Long face time has effect on wait time.Patient’s time is linked together and one change is the reason of other changes. On the other handpatient with more experience in the hospital are more familiar with the reason of long face time and itis more understandable for them. They usually accept it. Even their expectation is not as high as newpatient.

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5. PRIMARY OUTPUT

Analysis of the current situation of hospital to achieve the target of breaking icy atmosphere in waitingarea. Then finding the possibilities for improvement through design was the first aim of this study. Myethnographic approaches included observation and interviews was the first attempt to make thequestion clear. Observations and interviews in most of the wards in hospital and follow OPD and IPDpatient showed me the most stressful part of the hospital is waiting time. To improve the currentsituation I need to focus on waiting areas. Waiting time appeared as a key in patient journey. OPDpatient with a short journey is the target.

Following patient in waiting areas and talking to them lead me to focus on interactions in waiting area.Interaction between patient and environment, on the other hand environmental effect was measured byphysical attractions in waiting areas. Color, material and furniture layout was inquired as an empatheticapproach in waiting area. Warm colors gave people friendly and active feeling. Circle furniture layoutmake the area more dynamic and nice. Warm texture support people and keep the balance betweenfeeling active and calm. These are means to increase Play and Care. Play and Care are two positiveemotions which by increasing them the amount of satisfaction will be increased.

Entering flow in our survey is helpful to make useful distraction for patient specially if we use activeflow. Active flow means patient are doing some activities to enter themselves in flow mode andPassive flow means we make some activities to enter them to their flow mode, such as music in waiting

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area. People need to modify waiting areas from a passive area with no attraction to an active area withsome useful attraction. Changing the color, light and make it warmer and change the cold material ofseats to the warm material and set both kind of furniture layout in round and line to give the options ofbeing alone or being in a group to patient. All above can be useful to make patient satisfy and decreasethe perception of long wait.

Visual art as a part of physical attraction and as a useful distraction is one of the objects to makepassive flow in waiting areas. Depends on how much visual art can impact patient's emotions.. Visualart in this study was painting. In one of the selected waiting areas (WA1) in second attempt was full ofpaintings but these paintings were a part of the wall and always were there. In my new survey, wemeasured the emotion of people and their ideas about the waiting area during an exhibition and afterthe exhibition in two hospitals in Rome and Milan. In this case we did not find a big difference betweenpatient feeling during and after the exhibition. Even in one of the areas people were more agitated. Thecharacter of paintings and the installation are two important factors. This type of paintings could notincrease positive emotions in the hospital. This survey needs to be repeated with different types ofpaintings if we want to know the effect of art in the waiting area. In my study, visual art as a part ofenvironment was examined. After knowing about the environmental effect on patient feeling and therelation between satisfaction and Physical attraction in my case study.. We learned how to decrease theanxiety and stress by Choosing warm colors and materials and different type of furniture layout.

According to the importance of waiting time, I reframe my attempt to waiting time. I proposed aconceptual method of user experience in hospital to record patient from the first steps to the last andrecord their physical and emotional acts. Output will be user experience in hospital. I create anexperience stage model in whole patient journey, in Flow time, Wait time and Face time to be able torecord user experience in every step .

Obviously, most patient have an experience of long wait time, this requiresanalysis long wait time tofind the causes . Not being on time for patient and unpredictable patients are two main reasons of longwait time with a potential to affect on it by design.

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6. APPLY IMPLIMENTATION

Reframe the attempt to waiting time instead of waiting areas. Perception of time studied as a factor ofoverall experience. Diagnose factors of time usage and factor on process. I found the main reasons oflong waiting time is not being on time and unpredictable patient. I proposed redesign the process,redesign of experience and redesign of infrastructure.

Redesign Patient behavior: Reminding patient to be on time during their registration and before beingin the hospital has been happened in different ways from past till now. Different ways to persuadepeople to be on time can be Behavioral Design. B.g Fogg presented a Model for behavior change. Hismodel is based on three factors: Motivation, ability and triggers (BJFogg, 2009). Understanding patientbehavior and know about their ability of being on time. Use Chaldini’s six influences to convincepatient to be on time. His six influences are: Reciprocation, Commitment and consistency, Social proof,Liking, Authority and Scarcity. For instance commitment and consistency can be the reminder aboutthe time and date of the appointment and confirmation from the patient (Chaldini,2009). Connectingestablished patient with new patient to share experience can have an effect on patient expectation togive patient satisfaction. Unpredictable patient as a reason of long waiting time in hospitals is a goodinformation but not much can be done. On the other hand bad experience in wait time can be changedby a good Face time. Face time is a valuable time for patient and it is usually the main reason for being

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in hospital. Keep the distance between appointments, although it means visit less patient, can help todecrease the effect of long face time on the other patient time.

Redesign the Experience of Waiting Time: Decreasing patient expectation when they are late andshow them the result of coming late and effect on others’ time and the whole process visually. Theprinciple of reduction can be used in process to help patient in having a shorter journey. Divide thelong wait time to small waits in different places can help patient to decline perceived time. Keep theirmovement and keep patient active helps them to be occupied in waiting time and be more satisfied.Changing the shape of each wait will change the process and the way of passing every waits. Creatingsome activity in waiting time can change the passive patient to active patient. In the last study wetalked about Flow (Csikszentmihalyi, 2014) in waiting time and Flow can be passive or active , passiveflow such as listening to Music and active flow such as some activities like playing a game, watchingpainting or reading some information ( Shafieyoun, 2014). Flow time is an active time in patientjourney with more satisfaction, we can use the character of Flow time inWait time. Informing about thetime of waiting is noticeable in patient satisfaction. Informing helps them to feel control on their time.

Redesign of the Experience of Waiting Area : In one of our studies in a hospital in Milan ( INT),Comparing 4 waiting areas showed us people feel friendlier and more active in waiting areas withwarm colors. Circle furniture layout gives nice, funny, active and dynamic feeling. Warm material hasmore positive emotion than metal for seats (Shafieyoun, 2014). It shows that we can make people moreactive with physical attraction in environment.

Figure54 - Waits in Hospitals.

Figure 55 - Reducing Waits (Redesign the Experience of Waiting Time).

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Figure 56- Divideing Waits ( Redesigning the Experience of Waiting Time).

Figure 57 - Reshaping Waits ( Redesigning the Experience of Waiting Area)

All proposed redesigning depend on the character of waiting areas and user experience should bechosen and then the effect of the model should be measured. The result will help to improve the way ofapplying them. This can be a future work to implement redesign the process, redesign of experienceand redesign of infrastructure and evaluate, then improve them.

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7. CONCLUSION

Interaction in hospital includes a series of events and actions. Waits is a part of the journey with somespecific activities. Recording patient activities started by observation and shadowing people in wholejourney.Observation was a good way to record activities but it was not enough. Interviews helped to have alook on waiting time from the patient point of view and know about their activities and their feelings. Ithink, leaving patient to record their activities by themselves and reporting it to us can be anotheroption to consider. I needed to choose a method to understand patient and their feeling in waiting area. On the other hand,knowing patient interaction with environment. I used Kansei Engineering as a method to translatepatient emotion and know about their feeling in waiting area and what is environmental effect onpatient. I used this method in product design previously. I used the same type of Kansei Engineeringfor environment. Using Kansei in environment has some difficulties, I could not have the same patientin four waiting areas. These different patient were all cancer patient in different levels of treatment.Using the same questionnaire to know patient feeling about the color, material and furniture layout forsome patient as non designers was associated with confusion. Then based on the result and difficulties of last experiment, I proposed the Flow Kansei EngineeringMethod to measure patient emotion during their flow mode. Entering people to active and passive flowwill give us new information about patient satisfaction and besides that we could know how patientprefer to distract in waiting areas by some useful distraction or some health education. Entering peoplein their flow mode needs to know patient well and at least know about their interest and their individualin flow modecould be possible if patients wanted to talk about it and have collaboration. Different type of visual art uss in hospital, permanently or temporary. . Knowing the difference ofwaiting area with some paintings and without was possible during a small exhibition in waiting area intwo hospitals in Rome and Milan. These two surveys showed us even the character of painting andinstallation are important to influence on patient's emotion but this is no guarantee to create special

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emotion. Diversity in interpretation of art is one of the main reasons of creating different types ofemotion. I did not continue with other types of paintings but it is a huge domain to explore. In most of the literature reviews perception of time has a straight affect in patient satisfaction which Italked about in background and history. Knowing about user experience and all parts of the patientjourney based on the time is a conceptual framework in my research. I made a user experience model inpatient journey. User experience needs recording activities, feeling and emotion besides perception oftime and actual time in every step. Knowing about different types of user experiences would give us alot of useful data such as the part of journey with more difficulty or the easiest part and the place ofmore satisfaction and the reason of them all.Complaining about long wait and waiting time get along together for many years. changing theexperience of wait needs to know about the causes of long wait. Bonefish analysis helped me to findsome causes of long wait depending to the character of hospital and location. In my observation, notbeing on time and unpredictable patient are the main reasons of long wait. I proposed some solutions toinfluence on long wait by redesigning in behavior, experience of wait and experience of waiting area.They are all some ideas with the potential of work for future.

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8. DISCUSSION

This study focused on both waiting time, waiting areas in healthcare centers. Interactions in waitingareas was studied by knowing patients feeling in different waiting areas with different color, materialand furniture layout and effect of visual arts on their emotion. Waiting time was examined by userexperience and causes of long wait based on observation and literature reviews.According to Karapnos, user experience change over the time and we can describe temporality ofexperience in three phases: Orientation, Incorporation to identification (Karapnos, 2009). ErikStoleman proposed an alternative ways to study and describe temporal pattern of interaction(Stolterman, 2011). Record patient activities can happen, with an application, questionnaire, Observation, videography andinterviews. Knowing about their age, sex, life style and their perception of time and real duration oftime will be helpful. All results should be coding to build the verbal and visual vocabularies based onfollowing groups: focus, attention, actions, intention of being in hospital and element of time. Then,every group will be divide to orientation, Incorporation to identification. Then after analysis theobtained data to implementation in design then we can verify it to better design. Finding interaction in waiting time in hospitals needs record activities in every short moments of userexperience in whole patient journey. Events, activities, actions, perception of time and emotions arehappen in the same time and they will be change in time sequence. Focusing on specific moment ofpatient journey will provide better result. Dividing patient journey to several short journeys make thesurvey easier. Elements of time such as duration, session and frequently of every acts should be discover in threelevel of paying attention, getting involve and interact with environment. Finding relation betweenpatient emotion, action and the the difference between perception of time and actual time will show theamount of patient's satisfaction. Beside all above age, gender and life style of users has a role on theirinteraction with environment and even in perception of time. Figuring out the attention, focus, element of time, intention of act and notification based on the time inwhole journey will be helpful to know user experience better.

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Observation is the first choice to people and record them and obviously It can not be accurate. Storytelling, flow chart, sketches, graphic scenario, speaking, diagram, writing, videography andphotography are other helpful ways to reviews event and activities and the result usually is summarizedevent and some special minor activities will be ignored. Thanks Erik Stolterman to introduce Visualand verbal component in his survey in 2011(Huang, Chung-Ching, and Erik Stolterman, 2011). Basedon his work below I will propose a preliminary method for this study.Create a form filling questionnaire to know the time sequence of patient's act, emotion and theirperception of time during their journey in the hospital. The ask patient to fill it help us to know moredetails in patient journey by keeping continuity. Use the model of patient experience in chapter 4 canenrich the study.Author intent can be clear by having open structure interview. Patient can explain their filling formby their language. Coding verbal components in interviewing and then categorized them to emotion,intention of act, action, elements of time, focus, others. Obviously, After apply this method can figureout more sufficient categories. Acts can be categories to pay attention, get involved and interact or orientation, incorporation,identification groups based on duration session and frequency of time. I prefer to use seven basicemotions to classify emotions.

t1: E1 , Act 1 , Event1 , t2: E2,Act 2, Event 2, …, tn: En,Act n, Event n

n

Σ (E,Act, Event)x.txX=1

n

Σ (E,Act, Event)x= UXX=1

n

Σ UXx.tx X=1

Table 11- Sample of form filling questionnaire

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BIBLIOGRAPHY

Anderson, Roger T., Fabian T. Camacho, and Rajesh Balkrishnan. "Willing to wait?: the influence ofpatient wait time on satisfaction with primary care." BMC Health Services Research 7.1 (2007): 31.Ancarani, Di Mauro, & Giammanco, 2009

Arneill, A. B. and A. S. Devlin. "Perceived quality of care: The influence of the waiting roomenvironment." Journal of Environmental Psychology 22.4 (2002): 345-360.Arnold, 1960

Averill, J. R. (2010). “Ten questions about anger that you may never have thought to ask”. In F.Pahlavan (Ed.), “Multiple facets of anger: Getting mad or restoring justice?” (pp. 1– 25). New York,NY: Nova Science.

Ayas, Ebru, Jörgen Eklund, and Shigekazu Ishihara. "Affective design of waiting areas in primaryhealthcare." The TQM Journal 20.4 (2008): 389-408.Barrington, 1984

Berk, Ronald A. "The active ingredients in humor: Psychophysiological benefits and risks for olderadults."Educational Gerontology 27.3-4 (2001): 323-339.

Becker, Franklin, and Stephanie Douglass. "The ecology of the patient visit: physical attractiveness,waiting times, and perceived quality of care."The Journal of ambulatory care management 31.2 (2008):128-141

Berker, E. M., Vernez-Moudon, A., and Kang, B. "Built environment change: a framework to supporthealthenhancing behaviour through environmental policy and health research." Journal of

\81

Epidemiology and Community Health (2014): jech-2012.

Becker, Franklin, and Stephanie Douglass. "The ecology of the patient visit: physical attractiveness,waiting times, and perceived quality of care." The Journal of ambulatory care management 31.2(2008): 128-141.

Bitner, M. J. "Servicescapes: the impact of physical surroundings on customers and employees." TheJournal of Marketing (1992): 57-71.

Brownson, R. C., et al. "Measuring the built environment for physical activity: state of the science."American journal of preventive medicine 36.4 (2009): S99-S123.

Camacho, Fabian, et al. "The relationship between patient’s perceived waiting time and office-basedpractice satisfaction." NC Med J 67.6 (2006): 409-413.

Cialdini, Robert B.Influence: Science and practice. Vol. 4. Boston: Pearson Education, 2009.

Csikszentmihalyi, Mihaly, and Isabella Selega Csikszentmihalyi.Optimal experience: Psychologicalstudies of flow in consciousness. Cambridge university press, 1992.

Csikszentmihalyi, Mihaly. Flow: The classic work on how to achieve happiness. Random House, 2002.

Csikszentmihalyi, Mihaly.Flow: The psychology of happiness. Random House, 2013.

Csikszentmihalyi, Mihaly. "Flow." Flow and the Foundations of Positive Psychology. SpringerNetherlands, 2014. 227-238.

Delle Fave, Antonella, and Faust Massimini. "Parenthood and the quality of experience in daily life: Alongitudinal study."Social Indicators Research 67.1-2 (2004): 75-106.

Dansky, Kathryn H., and Jeffrey Miles. "Patient satisfaction with ambulatory healthcare services:waiting time and filling time." Journal of Healthcare Management 42.2 (1997): 165.

Dellaert, Frank, Thomas Polzin, and Alex Waibel. "Recognizing emotion in speech." SpokenLanguage, 1996. ICSLP 96. Proceedings., Fourth International Conference on. Vol. 3. IEEE, 1996.

De Man, Stefanie, et al. "Impact of waiting on the perception of service quality in nuclearmedicine."Nuclear medicine communications 26.6 (2005): 541-547.

Dalke, Hilary, et al. "Colour and lighting in hospital design." Optics & Laser Technology 38.4 (2006):343-365.

Damasio, A. R. "Emotions and feelings. Self Comes to Mind: Constructing the Conscious Brain." (2010): 108-29.

Darwin, Charles. "The origin of species by means of natural selection." (1872).

\82

Davidson, James. Stochastic Limit Theory: An Introduction for Econometricians: An Introduction forEconometricians. Oxford University Press, UK, 1994.

Desmet, Pieter. "Measuring emotion: Development and application of an instrument to measureemotional responses to products." Funology. Springer Netherlands, 2005. 111-123.

Devlin, Ann Sloan. "Psychiatric Ward Renovation Staff Perception and PatientBehavior." Environment and Behavior 24.1 (1992): 66-84.

Devlin, A. S. (1995). Sta¡, patients, and visitors: Re- sponsestohospitalunitenhancements.InJ.Nasar, P.Grannis & K. Hanyu (Eds), Proceedings of the 26th Annual Conference of the Environmental DesignRe- search Association (pp. 75^80). Oklahoma City, OK: EDRA.

Devlin, A. S. and Arneill, A. B. "Health Care Environments and Patient Outcomes A Review of theLiterature." Environment and behavior 35.5 (2003): 665-694.

Decker, Christine. "Take a time-out from stress." Nursing made Incredibly Easy13.3 (2015): 1-3.

Dormann, Claire. "Laughter as the Best Medicine: Exploring Humour-Mediated HealthApplications."Distributed, Ambient, and Pervasive Interactions. Springer International Publishing,2015. 639-650.

Dube, L., Schmitt, B. H. and Leclerc, F. (1991). “Consumers’ Affective Response to Delays atDifferent Phases of a Service Delivery,” Journal of Applied Social Psychology, 21 (10): 8 10-820.

Dube-Rioux, Laurette, Bernd H. Schmitt, and France Leclerc. "Consumers’ reactions to waiting: whendelays affect the perception of service quality." Advances in consumer research 16.1 (1989): 59-63.

de Boulogne, Guillaume-Benjamin Duchenne. Mécanisme de la physionomie humaine: Texte.Renouard, 1862.de Boulogne, G-B. Duchenne. The mechanism of human facial expression. Ed. R. AndrewCuthbertson. Cambridge university press, 1990.

Dugdale, David C., Ronald Epstein, and Steven Z. Pantilat. "Time and the patient–physicianrelationship."Journal of General Internal Medicine14.S1 (1999): 34-40.

Durrande-Moreau, Agnes, and Jean-Claude Usunier. "Time Styles and the Waiting Experience AnExploratory Study."Journal of Service Research 2.2 (1999): 173-186.

Ekman, Paul. "Facial expressions."Handbook of cognition and emotion 16 (1999): 301-320.

Feddock, Christopher A., et al. "Can physicians improve patient satisfaction with long waitingtimes?." Evaluation & the health professions 28.1 (2005): 40-52.

Ferrell, Betty R., et al. "Pain management at home Struggle, comfort, and mission." CancerNursing 16.3 (1993): 169-178.

\83

Fogg, Brian J. "A behavior model for persuasive design." Proceedings of the 4th internationalConference on Persuasive Technology. ACM, 2009.

Gomez, Rafael E., Vesna Popovic, and Sam Bucolo. "Emotional driving experiences: an opportunityfor future technology." (2006).

Goleman, Daniel.Emotional intelligence. Bantam, 2006.

Gilbert, Daniel.Stumbling on happiness. Vintage Canada, 2009.

Gross, David A., et al. "Patient satisfaction with time spent with their physician. "The Journal of familypractice (1998).

Grimsaeth, K. "Kansei Engineering, Linking emotions and product feelings." (2005).

Haig, Robin Andrew.The anatomy of humor: Biopsychosocial and therapeutic perspectives. No. 1079.Charles C. Thomas Publisher, 1988.

Harada, Akira. "On the definition of Kansei."Modeling the Evaluation Structure of Kansei 1998Conference. Vol. 2. 1998.

Harris, Paul B., et al. "A place to heal: environmental sources of satisfaction among hospital Patients1."Journal of Applied Social Psychology 32.6 (2002): 1276-1299.

Heinrichs, Markus, and Gregor Domes. "Neuropeptides and social behaviour: effects of oxytocin andvasopressin in humans." Progress in brain research 170 (2008): 337-350.

Hojat, Mohammadreza, et al. "Empathy and health care quality." American journal of medical quality:the official journal of the American College of Medical Quality 28.1 (2013)

Hojat, Mohammadreza, et al. "Empathic and sympathetic orientations toward patient care:conceptualization, measurement, and psychometrics." Academic Medicine 86.8 (2011): 989-995.

Hosking, Sarah, and Liz Haggard. "Healing the hospital environment." Design, Management andMaintenance of Healthcare Premises (1999).

\84

Hsu, Shang H., Ming C. Chuang, and Chien C. Chang. "A semantic differential study of designers’ andusers’ product form perception." International Journal of Industrial Ergonomics 25.4 (2000): 375-391.

Huang, Chung-Ching, and Erik Stolterman. "Temporality in interaction design."Proceedings of the2011 Conference on Designing Pleasurable Products and Interfaces. ACM, 2011.

Irurita, Vera. "Factors affecting the quality of nursing care: the patient’s perspective." Internationaljournal of nursing practice 5.2 (1999): 86-94.

Ishihara, I., et al. "Kansei And Product Development (In Japanese), Ed. M." (2005).

Jackson, Susan A., and Herbert W. Marsh. "Development and validation of a scale to measure optimalexperience: The Flow State Scale."Journal of sport and exercise psychology 18 (1996): 17-35.

Jackson, Jeffrey L., Judith Chamberlin, and Kurt Kroenke. "Predictors of patient satisfaction." Socialscience & medicine 52.4 (2001): 609-620.

Kaplan, Stephen, Rachel Kaplan, and John S. Wendt. "Rated preference and complexity for natural andurban visual material." Perception & Psychophysics12.4 (1972): 354-356.

Karapanos, Evangelos. "User experience over time." Modeling Users' Experiences with InteractiveSystems. Springer Berlin Heidelberg, 2013. 57-83.

Katz, Karen L., Blaire M. Larson, and Richard C. Larson. "Prescription for the waiting-in-line blues:Entertain, enlighten, and engage." MIT Sloan Management Review 32.2 (1991): 44.

Katz, K., Larson, B. and Larson, R. (1991), “Perception for the waiting in the line blues: entertain,enlighten, and engage”, Sloan Management Review, VoL. 32, No. 2, pp. 44-53.

Kleinsmith, A., Bianchi-Berthouze, N. (2013). Affective Body Expression Perception andRecognition: A Survey. IEEE Transactions on Affective Computing 4(1), 15-33.

Kravitz, Richard L. "Measuring patients' expectations and requests."Annals of InternalMedicine 134.9_Part_2 (2001): 881-888.

Krznaric, Roman. Empathy: A handbook for revolution. Random House, 2014.

Lokman, Anitawati Mohd, and Mitsuo Nagamachi. Kansei Engineering: A Beginners Perspective.University Pub. Centre (UPENA), 2010.

Lakoff, George. The All New Don't Think of an Elephant!: Know Your Values and Frame the Debate.Chelsea Green Publishing, 2014.

Leske, J. S. "Needs of adult family members after critical illness: prescriptions forinterventions."Critical care nursing clinics of North America 4.4 (1992): 587-596.

\85

Leddy, Kelly M., Dennis O. Kaldenberg, and Boris W. Becker. "Timeliness in ambulatory caretreatment: an examination of patient satisfaction and wait times in medical practices and outpatient testand treatment facilities."The Journal of ambulatory care management 26.2 (2003): 138-149

Lin, Yen-Ko, and Chia-Ju Lin. "Factors predicting patients' perception of privacy and satisfaction for emergency care."Emergency Medicine Journal (2010): emj-2010.

Lin, Chen-Tan, et al. "Is patients' perception of time spent with the physician a determinant ofambulatory patient satisfaction?."Archives of Internal Medicine161.11 (2001): 1437-1442.Lyubomirsky, Sonja, and Heidi S. Lepper. "A measure of subjective happiness: Preliminary reliabilityand construct validation." Social indicators research 46.2 (1999): 137-155.

Lynch, 2004

McDuff, D. J., el Kaliouby, R. and Picard, R. W., "Crowdsourcing Facial Responses to Online Videos",In the IEEE Transactions on Affective Computing, Volume 3 Issue 4, pp.456-468, 2012.

Mahony, Diana L., W. Jeffrey Burroughs, and Arron C. Hieatt. "The effects of laughter on discomfortthresholds: does expectation become reality?."The Journal of general psychology 128.2 (2001): 217-226.

Martin, Rod A., and James P. Dobbin. "Sense of humor, hassles, and immunoglobulin A: evidence fora stress-moderating effect of humor."The International Journal of Psychiatry in Medicine 18.2 (1989):93-105.

Melzack, Ronald, and Patrick D. Wall. "Pain mechanisms: a new theory."Survey of Anesthesiology11.2 (1967): 89-90.

Maslow, Abraham H., and Norbett L. Mintz. "Effects of esthetic surroundings: I. Initial effects of threeesthetic conditions upon perceiving “energy” and “well-being” in faces." The Journal of Psychology41.2 (1956): 247-254.

Miceli, P. J., and R. J. Wolosin. "You’re “running late”—now what?: Patient satisfaction, wait time andphysician behavior." (2004).

Pillan, M. Maiocchi and M. Radeta, "Teaching Constraints, Learning Creativity," in Prceedings of the2nd International Conference for Design Education Researchers, DRS// CUULUS Oslo, ISBN 978-82-93298-02-1, 2013, vol. 2, no. 1, 2013, pp. 607–620.

\86

Powers, Thomas L., and Dawn Bendall-Lyon. "The satisfaction score." Marketing health services 23.3(2002): 28-32.

Oermann, Marilyn H., et al. "Clinic visit and waiting: Patient education and satisfaction." NursingEconomics 20.6 (2002): 292.

Oermann, Marilyn H. "Effects of educational intervention in waiting room on patient satisfaction." TheJournal of ambulatory care management 26.2 (2003): 150-158.

Merriam-Webster Inc. Merriam-Webster's collegiate dictionary. Merriam-Webster, 2004.

Nagamachi, M. "The story of Kansei engineering."Japanese Standards Association 6 (1995).

Nagamachi, Mitsuo, and Anitawati Mohd Lokman. Innovations of Kansei engineering. CRC Press,2010.

Nagasawa, Shin’ya. "Customer experience management influencing on human Kansei toMOT." Knowledge-Based Intelligent Information and Engineering Systems. Springer BerlinHeidelberg, 2006.

Nakamura, Jeanne, and Mihaly Csikszentmihalyi. "The concept of flow."Handbook of positivepsychology (2002): 89-105.

Nuttman-Shwartz, Orit, Rachel Scheyer, and Herzl Tzioni. "Medical clowning: Even adults deserve adream." Social work in health care 49.6 (2010): 581-598.

Norman, Donald A. "The design of future things: Author of the design of everyday things." (2007).

Omachonu, Vincent K. "Quality of care and the patient: New criteria for evaluation." Health CareManagement Review 15.4 (1990): 43-50.

Oatley, Keith, Dacher Keltner, and Jennifer M. Jenkins. Understanding emotions . Blackwell publishing, 2006.

Olsen, Richard V. "The effect of the hospital environment: Patient reactions to traditional versus progressive care settings." Journal of Architectural and Planning Research (1984): 121-136..

Omachonu, Vincent K. "Quality of care and the patient: New criteria for evaluation." Health Care Management Review 15.4 (1990): 43-50.

\87

Snider, James G., and Charles Egerton Osgood, eds. Semantic differential technique: A sourcebook.Chicago: Aldine Publishing Company, 1969.

Panksepp, Jaak. Affective neuroscience: The foundations of human and animal emotions. Oxforduniversity press, 1998.

Panksepp, Jaak, and Jules B. Panksepp. "Toward a cross-species understanding of empathy." Trends in neurosciences 36.8 (2013): 489-496.

Panksepp, Jaak, and Douglas Watt. "Why does depression hurt? Ancestral primary-process separation-distress (PANIC/GRIEF) and diminished brain reward (SEEKING) processes in the genesis ofdepressive affect." Psychiatry74.1 (2011): 5-13.

Pedersen, Cort A., et al. "Oxytocin activation of maternal behavior in the rata."Annals of the New York Academy of Sciences 652.1 (1992): 58-69.

Picard, Rosalind W. "Affective computing: challenges." International Journal of Human-Computer Studies 59.1 (2003): 55-64.

Plutchik, Robert. Emotion: A psychoevolutionary synthesis. Harpercollins College Division, 1980.

Powers, Thomas L., and Dawn Bendall-Lyon. "The satisfaction score."Marketing health services 23.3 (2002): 28-32.

Preston, Stephanie D., and Frans De Waal. "Empathy: Its ultimate and proximate bases."Behavioraland brain sciences 25.01 (2002): 1-20.

Martin, Rod A. "Humor, laughter, and physical health: methodological issues and researchfindings."Psychological bulletin 127.4 (2001): 504.

Radeta, Marko, and Marco Maiocchi. "Towards automatic and unobtrusive recognition of primary-process emotions in body postures." Affective Computing and Intelligent Interaction (ACII), 2013Humaine Association Conference on. IEEE, 2013.

Reimer, Anja, and Richard Kuehn. "The impact of service scape on quality perception."EuropeanJournal of Marketing 39.7/8 (2005): 785-808.

Raviv, Amnon. "The clown's carnival in the hospital: a semiotic analysis of the medical clown'sperformance." Social Semiotics 24.5 (2014): 599-607.

Rice, Gillian, Jenny Ingram, and Jacques Mizan. "Enhancing a primary care environment: a case studyof effects on patients and staff in a single general practice." British Journal of General Practice 58.552(2008): e1-e8.

\88

Rizzolatti, Giacomo, et al. "Premotor cortex and the recognition of motor actions."Cognitive brainresearch 3.2 (1996): 131-141.

Rondeau, Kent V. "Managing the clinic wait: an important quality of care challenge." Journal ofnursing care quality 13.2 (1998): 11-20.

Roter, Debra L., et al. "Communication patterns of primary care physicians."Jama 277.4 (1997): 350-356.

Ruch, Willibald. "Exhilaration and humor."Handbook of emotions 1 (1993): 605-616.

Sasser, W. E. (1976). “Match Supply and Demand in Service Industries,” Harvard Business Review,54 (November-December): 133-140.

Stahl, James E., Julie K. Holt, and Nancy J. Gagliano. "Understanding performance and behavior oftightly coupled outpatient systems using RFID: initial experience." Journal of Medical Systems 35.3(2011): 291-297.

Seligman, Martin EP, and Mihaly Csikszentmihalyi. Positive psychology: An introduction. Vol. 55. No.1. American Psychological Association, 2000.

Seligman, Martin EP. "Foreword: The past and future of positive psychology."Flourishing: Positivepsychology and the life well-lived (2003): 15-36.

Haidt, Jonathan, and Corey LM Keyes, eds. Flourishing: Positive psychology and the life well-lived.American Psychological Association, 2003.

Sherwin, Heather N., et al. "The waiting room “wait” From annoyance to opportunity." CanadianFamily Physician 59.5 (2013): 479-481.

Schutte, Simon. "Engineering emotional values in product design: kansei engineering in development."(2005).

Schutte*, Simon TW, et al. "Concepts, methods and tools in Kansei Engineering." Theoretical Issues inErgonomics Science 5.3 (2004): 214-231.

Shafieyoun, Zhabiz, Nasser Koleini Mamaghani, and Saeed Jahanbakhsh. "The Difficulties of UsingKansei Engineering Method in Iran." Proceedings of Kansei Engineering and Emotion Research,KEER (2010).

Shafieyoun, Zhabiz, and Marco Maiocchi. "Flow Kansei Engineering.”

Shafieyoun, Zhabiz, Marko Radeta, and Marco Maiocchi. "Environmental Effect on Emotion in

\89

Waiting Areas Based on Kansei Engineering and Affective Neuroscience."

Shostack, G. Lynn. "Service positioning through structural change." The Journal of Marketing (1987):34-43.

Sobolev, Boris, and Lisa Kuramoto. Analysis of waiting-time data in health services research. SpringerScience & Business Media, 2008.

Stevens, John. "Stand up for dementia: Performance, improvisation and stand up comedy as therapy forpeople with dementia; a qualitative study." Dementia(2011): 1471301211418160

The Oxford english dictionary. Oxford: Clarendon Press, 1989.

Soremekun, Olanrewaju A., James K. Takayesu, and Stephen J. Bohan. "Framework for analyzing waittimes and other factors that impact patient satisfaction in the emergency department." The Journal ofemergency medicine41.6 (2011): 686-692.

Huang, Chung-Ching, and Erik Stolterman. "Temporality in interaction design."Proceedings of the 2011 Conference on Designing Pleasurable Products and Interfaces. ACM, 2011.

Szmigin, Isabelle, and Marylyn Carrigan. "Time, consumption, and the older consumer: An interpretivestudy of the cognitively young." Psychology & Marketing 18.10 (2001): 1091-1116.

Takagi, M., Watada, J., Naoyosi, Y. ”Realization of Comfortable Space Based on SensesInformation,” IEEE SMC 2004, Session 77, pp. 6363-6364, (2004).

Taylor, S. "Waiting for service: the relationship between delays and evaluations of service." TheJournal of Marketing (1994): 56-69

Tamblyn, Robyn, et al. "The feasibility and value of using patient satisfaction ratings to evaluateinternal medicine residents." Journal of general internal medicine 9.3 (1994): 146-152.

Tsai, Chun-Yen, et al. "Hospital outpatient perceptions of the physical environment of waiting areas:the role of patient characteristics on atmospherics in one academic medical center." BMC healthservices research 7.1 (2007): 198.

Ugur, Secil, et al. "Embodiment of emotions through wearable technology."ASME 2011 InternationalDesign Engineering Technical Conferences and Computers and Information in EngineeringConference. American Society of Mechanical Engineers, 2011.

Ulrich, Roger. "View through a window may influence recovery." Science224.4647 (1984): 224-225.

Ulrich, R. S. "How design impacts wellness." The Healthcare Forum Journal. Vol. 35. No. 5. 1992.

\90

Ulrich, R. S. et al. "A review of the research literature on evidence-based healthcare design." Healthenvironments research & design journal 1.3 (2008): 61-125.

Usunier, Jean-Claude, and Pierre Valette-Florence. "The Time Styles Scale A review of developmentsand replications over 15 years."Time & Society 16.2-3 (2007): 333-366.

Verderber, Stephen. "Dimensions Ofperson-Window Transact ionsin the HospitalEnvironment."Environment and behavior18.4 (1986): 450-466.

Wanzer, Melissa, Melanie Booth-Butterfield, and Steve Booth-Butterfield. "“If we didn't use humor,we'd cry”: Humorous coping communication in health care settings."Journal of healthcommunication10.2 (2005): 105-125.

Warren, Bernie, and Peter Spitzer. Smiles are everywhere: Integrating clown-play into healthcarepractice. Routledge, 2013.

Waters, Catherine M. "Professional nursing support for culturally diverse family members of critically ill adults." Research in nursing & health 22.2 (1999): 107-117.

Weiss, Gail Garfinkel. "How to cut patient wait time." Medical economics 80.19 (2003): 75-8.

Wilson, Larkin M. "Intensive care delirium: The effect of outside deprivation in a windowlessunit." Archives of Internal Medicine 130.2 (1972): 225-226.

Winkel, Gary H., and Charles J. Holahan. "The Environmental Psychology of the Hospital: is the cureworse than the illness?." Journal of Prevention & Intervention in the Community 4.1-2 (1985): 11-33.

Yoon, JungKyoon, and Marieke Sonneveld. "Anxiety of patients in the waiting room of the emergencydepartment." Proceedings of the fourth international conference on Tangible, embedded, and embodiedinteraction. ACM, 2010.

Yeddula, Vineeth R. "Healthcare Quality: Waiting Room Issues." (2012).

Zeisel, John. Inquiry by design: tools for environment-behaviour research. No. 5. CUP Archive, 1984.

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