A total of 4807 SMS messages were sent to recent callers, of which 1680 (35%) responded. The vast majority (88%, rating 5 or 6) were very satisfied with the 113-call (Fig. 1).

Fig. 1

Distribution of the 1639 received responses (of 4807) SMS on the experience of the conversation with the emergency communication centre EMCC). Ratings between 1 (not satisfied), and 6 (very satisfied)

Based on the solid responses to the SMS survey, it was evident that people needed or wanted to provide feedback on their experiences with the 113 services. The specific numbers were also the first measure of the callers’ general level of satisfaction prior to further in-depth research into this concept.

A total of 823 (49%) respondents volunteered for the interviews, making informant recruitment accessible. Of these, 50 callers were randomly, and equally selected for all values (1 to 6). We were unable to perform 19 interviews because of either unavailability or lack of answers when calling the selected numbers. The 31 callers interviewed (14 (45%) men and 17 (55%) women) had surprisingly miscellaneous background. Seven patients had a relevant medical history. Some called 113 for the first time, whereas 21 (68%) had previous experience (Table 1).

Table 1 Distribution of ratings by those interviewed

By interviewing the 31 informants, including both satisfied and dissatisfied individuals, several factors were identified. Table 2 summarizes the main results from the interview. In addition, we found that some topics were unexpectedly mentioned as important to callers. In Additional file 3 more quotes are given with their corresponding codes and main themes.

Table 2 Main findings from the interviews with main themes and comments

Callers expressed a high threshold for calling the EMCC. None of the informants stated that calling 113 was their first choice; many other options were considered first. Several informants stated that they wanted to stay in the comfort of their own homes rather than in a hospital or emergency room. They preferred to take care of themselves, and most importantly, they did not want to become sick. Several participants also expressed concerns about being anticipated as hysterical when calling an EMCC.

Participant 24 (rating 4) described the fear of being perceived as a hysterical parent. Participant 13 (rated 2) said that although his doctor advised him immediately to call 113 when needed, he wanted to wait as long as possible before calling. Several informants said that they needed to be certain before calling for help, as they did not want to unnecessarily disturb the EMCC or exploit public resources. They did not want to place a financial burden on the healthcare system or their families and communities. Participant 28 (rated 3) described calling 113 as a difficult choice, as it could have consequences for other people in more urgent need, meaning that if they were to be helped, someone else who possibly needs an ambulance more than they would not receive a timely dispatch.

Hence, the choice of calling 113 seemed to be difficult. The informants said they would only make the call if they had no other options. Participant 3 (rated 6) described calling 113 as their ‘biggest cry for help.’ Several participants explained that bad experiences while calling the EMCC increased the threshold for future calls.

Nearly all informants with positive experiences stated that the EMCC reassured them that they had made the right decision when calling for help, even when an ambulance dispatch was not the final solution. This is particularly important if the caller has had previous negative experiences.

Even medically trained participants expressed hesitation in challenging the operator’s decisions. For example, informant 5, a nurse (rated 1), perceived that they could not ask for an ambulance. The result was a higher threshold because they dreaded calling back or did not expect to obtain sufficient help. Another instance was a call made by Informant 15 (rated 2), who wondered, after several rejections, whether it was worth calling 113.

The caller’s expectations

All participants were expected to receive help soon after the call. Most informants had the impression that calling 113 equaled getting an ambulance and/or being admitted to the hospital. Only a few callers, most of whom had a medical background, called 113 for advice.

Several informants expected the dispatcher to know or even be able to see the location from which they were calling and that the EMCC had full access to their previous medical records. Most callers did not distinguish between the various organizational units within the healthcare system, as they considered their uniform.

Considering the callers’ high threshold for calling 113 and their deep wish to take care of themselves, many described a feeling of relief when the operator said that there was no need for an ambulance. The callers also understood that the EMCC had to prioritize resources, especially when their situation was not urgent.

The context and acknowledging the caller’s perspective

Several informants performed well beyond expectations during their conversations with the dispatcher. Participant 26 (rated 3) described an incident in which he was talking to the EMCC while providing CPR, using a defibrillator, and simultaneously assisting the air ambulance in landing safely.

Participant 27 (rated 3) sat with the patient, a stranger that she had found on the street for almost an hour, even after he had threatened and waved her with a knife. He had collapsed on his way ‘to kill someone’ as he explicitly explained. The informant never considered leaving him because he needed help, and she did not want him to be a danger to anyone else, staying put until the police and paramedics arrived.

Participant 5 (rated 1), a registered nurse, described feeling pressured to drive her severely ill husband to the emergency room. She was certain that the patient was about to lose consciousness as his condition worsened. She was alone, driving through the city center during rush hour and combining the roles of driver and nurse. When asked if she ever considered stopping the car or calling 113 again, she replied, ‘How could I? I had already talked to them, and they had made their decision clear. Furthermore, it was not possible as I was both driving and taking care of my husband.’ Participant 11 (rated 2) also felt pressured to drive her severely ill husband to the emergency room. In retrospect, she described this as a bad idea, as she was emotionally imbalanced, scared, and driving too fast, ‘I drove him myself, but I shouldn’t have [done so] because I was so scared, and drove so fast…’.

In addition, the informants expressed great respect for the authority of the EMCCs. Participant 21 (rated 6) followed the EMCC operator’s advice to take a drug he knew could be potentially dangerous to him. He did not question this advice or inform the operator of his condition because he trusted his expertise. This information was an accidental finding because the informant was very satisfied with the call.

In addition to the workload of having someone in immediate distress (sometimes themselves), some callers felt stressed by EMCC operators’ numerous questions. Participant 31 (rated 3) said he became frustrated with answering several questions when he wanted to comfort the patient. Other informants, being alone at the time of the call, as it was for their sake, described finding the situation challenging and that, at the moment, even answering simple questions was a strain. Participant 21 (rated 6) said, ‘All those questions when you’re very ill shouldn’t be necessary. (…) It’s not so easy when you’re feeling that ill.

Some patients were less available for excessive questioning than others. They may have been in the middle of an incredibly stressful situation or calling because of an emergency concerning themselves. What is even worse was that some questions were perceived as irrelevant. Understandably, the EMCC operators wanted to talk directly to the patients; however, several informants highlighted the importance of the dispatcher listening to them as the person’s next of kin. They felt pressured to hand the phone over to patients who were not in a state of taking care of or explaining themselves to them.

The informants also described the importance of explaining why the questions were asked, especially those that might have been perceived as irrelevant or unnecessary. Participants with negative experiences often described feelings of not being listened to. For instance, a dispatcher followed a prescribed list of questions rather than listening to or asking more relevant questions. Participant 31 (rated 3), ‘When I asked, and requested a confirmation, that the ambulance was on its way, she said that it was not. Then she asked some questions that were, to me, meaningless.’

Positive and negative experiences with the EMCC operator

A majority of the informants expressed that the feeling of being taken seriously and listened to by the operator was the main reason for their satisfaction with the call; an operator who genuinely listened to their story made them feel supported and taken care of. Several participants answered the EMCC follow-up questions to confirm that the incident had been taken seriously.

Participants with positive experiences described feelings of cooperation and alliance with the dispatcher. For example, holding the line until an ambulance arrives, offering to transfer the call directly to the doctor´s office, or having the doctor call the patient back are all perceived as positive elements of the 113 call. It is also important to give callers the feeling that they can change their minds and call back at any time if, for example, they regret agreeing to drive the patient to the emergency room instead of getting an ambulance.

Several informants explicitly confirmed the importance of the EMCC, confirming that it was the correct decision to call 113.

Participant 18 (rated 6) described the operator as a ‘very nice lady,’ ‘She did great and asked all the right questions. I called, and we agreed on what I should do. So that was not a problem.’ She explained that the operator seemed to understand the situation and that the two of them, the operator and caller, cooperated to find a solution. When asked whether she felt she had the possibility to choose and decide, she answered ‘Yes, absolutely. She told me that if I wanted an ambulance, she would send it right away. It was my choice to be transported by my husband.’ The respondent further described that she genuinely felt that she could change her mind if she wanted to, as the operator had asked whether she was acceptable with that solution and that she had to feel safe about it. She described the operator’s calmness as a key factor in the success of this call.

We found that callers accept many solutions if they obtain proper explanations and information. When asked whether there was something, in particular, the informant remembered from the call and how the operator was interpreted, informant 20 (rated 5) answered that the operator was ‘pretty professional and comfortable.’ When asked about the meaning of ‘professional,’ the informant meant that ‘She listened to what I said, took it seriously, acted upon it, and asked questions that were, in my opinion, relevant.’

In contrast, some callers did not think they had taken this seriously. Participant 13 (rated 2) explained, ‘It seemed like I was seen as someone who was just joking.’ Furthermore, she described the dreadful feeling of the operator not believing in her and that she felt she had to argue for the help she needed.

Some informants experienced delayed assistance because of prejudice. For example, informant 27 (rated 3) sat with the patient for almost an hour, even after he had almost stabbed her with a knife, and did not consider leaving him. This also demonstrates the callers’ strong feelings of responsibility. Given this and being often emotionally affected, callers will do nearly anything that the EMCC would ask them to do. Several informants described the EMCC as the authority that they were reluctant to question. It is important to note that operators and their words have a significant impact on callers.

A common scenario in which prejudice interrupted communication was calling due to intoxication. Nearly all of the informants who called for a specific emergency felt that they were not taken seriously. Participant 22 (rated 1) was explicitly told by the EMCC that they did not believe in her because of several recent non-serious calls from other young people. Informant 10 (rated 2), when he was calling due to non-alcohol related injuries, felt judged by the fact that the incident happened on a Saturday evening; ‘I felt that the attitude was “It is Saturday evening, and falling down some stairs…,” so there must be alcohol involved. I felt that they didn’t completely believe me.’

The informants who were dissatisfied with the call described the operator as uninterested, passive, oblivious, ignorant, arrogant, and even unprofessional or ‘tired of their job,’ as if the caller had disturbed the dispatcher by calling 113. Participant 16 (rated 2) said, ‘I felt like she was sitting there, rolling her eyes.

A considerable number of informants said that they felt belittled or sad after the conversation with the EMCC, describing feeling rejected even though they seemed reluctant to get an ambulance. In some cases, after having to argue for help, dissatisfied informants feared not getting help if they called for another time.

Consequences beyond the actual situation

Several informants stated that they blamed themselves for delayed or unfavorable medical assistance. They described that they might have been unclear about their communication or even made a bad impression. Participant 24 (rated 4) said, ‘I don’t know if I was unclear in my communication. I could have been sloppy and tired and not knowing exactly how to articulate myself, and that might have caused an inaccurate evaluation at the other end. But that shouldn’t be decisive for the outcome.’ The informants would replay the conversation in their minds, trying to find mistakes that they had made that caused medical assistance to be less optimal or delayed. Several participants expressed frustration and wondered what they needed to say the next time to get help.

Participant 31 (rated 3) said that he had decided if he were to call in the future. He would ask for an ambulance and then hang up, avoiding the risk of any delay if he was forced to answer many irrelevant questions. He actively planned for this alternative strategy, hoping to get more efficient help next time. Participant 24 (rated 4) described having intentionally “…learned medical terminology from his medical doctor sister to get the EMCC operator’s proper attention in the call.” and participant 15 (rated 2) stated that after several rejections, she wondered whether ‘…it was even worth calling 113 at all.”

The callers want to give feedback to the EMCC

All informants expressed that they would gladly receive an SMS requesting feedback after a 113 call, as they were used to receiving similar SMS questionnaires after having contacted nearly all the other services. Several informants wanted to complain about their insufficient EMCC experience, but had no idea where to start. Therefore, they gave up on that thought, and several informants let it go because nobody died because of this phenomenon in the experiences described by the informants.

Additional unanticipated findingsPandemic related issues

Several informants experienced delayed help due to COVID-19-related questions at the beginning of the conversation. For Informant 31 (rated 3), these questions were asked before more important questions concerning the patient’s vital signs. Informant 11 (rated 2) perceived being refused an ambulance due to the fear of COVID-19, similar to informant 30 (rated 4), who got the impression that “If the patient had COVID-19 symptoms, she would not get an ambulance.” An interesting finding was that neither of the informants expressed any concern regarding fearing contamination when having to meet medical personnel and environment. They experienced life-threatening situations, and desperately requested help. Their dissatisfaction was with the delayed help due to questions about Covid-19.

Paramedic’s behavior

Participant 10 (rated 2) was met by degrading comments from the paramedics, wanting to determine whether they were influenced by the unsympathetic EMCC operator. Participants 16 (rated 2) and 4 (rated 6) had heard paramedics explicitly say that there was no need for an ambulance during these incidents. In the case of Informant 16, this unpleasant comment from the professional paramedic became the last memory the patient had in her home before passing away a few days later.

Inter-agency coordination

Informants 17 (rated 2) and 26 (rated 3) both called 113 because of incidents that required the involvement of both the police and fire and rescue departments. After informing the EMCC about the situation, both perceived the conversation as unstructured and chaotic, especially considering that they had to repeat all the information when other emergency operators joined.

Video calls

Video has quite recently been introduced in the emergency medical services in Norway [13]. Participants 14 (rated 5) and 22 (rated 1) accepted the use of video options for the EMCC to better understand their situations. In these two incidents, the test project had a crucial impact, as the participants felt understood and believed in their despair. ‘But then they asked me to accept a video conference so I could film him and show them that this, in fact, was true. And how did it work? Well, they saw it, then said that they would come, and then came for him.’ (Participant 22).