“I imagine people call [911] all the time for minor things… or just call and ask stupid questions.” A typical civilian response on a recent THF project. Our team was exploring the Emergency Medical Services system in the US, digging into the increased dependence on 911 to fill ‘non-emergency’ needs, and our research was hitting a wall. From another civilian, “I don’t personally know anyone who does this, but I imagine it happens.”
As we mapped the complex EMS system, a critical (and nuanced) slice of the challenge emerged: the public’s reliance on emergency response teams to fulfill unmet needs in healthcare and home assistance puts significant pressure on EMS. Our team engaged over 700 civilian stakeholders – members of the public who have interacted with EMS – to better understand the civilian point of view; but, their responses lacked depth. We had significant data from EMS providers (EMTs, ambulance paramedics, flight paramedics) on the high rate at which civilians rely on EMS for non-emergencies, and the implications on the EMS system were clear, but we could not find a single civilian who viewed their own EMS use as ‘bending the rules’; rather, civilians were quick to identify other civilians as the guilty party. We came at the problem from multiple angles over dozens of rounds of surveying; we posed hypothetical questions about EMS, asked for accounts of real EMS interactions, solicited general opinions, and more. We used multiple choice, ranked choice, and open-ended questions, but the civilian perspective remained inconclusive.
As qualitative researchers, we’re no stranger to the disconnect between stakeholders’ thoughts, actions, and words. We know that humans are complex and we expect stakeholder responses to be just as complex. In this case, the heightened emotions and vulnerability surrounding EMS interactions influenced civilian’s memories and perceptions of their own experiences. Civilians struggled to articulate their stories. Perhaps they lacked medical language, perhaps they had a narrow view of their role in the EMS system, perhaps their answers were clouded by their opinion of the healthcare system. So how might qualitative researchers understand the stakeholder experience when certain stakeholders groups are not the most reliable sources? One approach we use at The Human Factor: stakeholder proxies.
Stakeholder Proxies
On our projects, a proxy is someone who engages closely with the stakeholder group being studied who can share their observations about that group through recounting stories and interactions. They have seen a lot— across a variety of cases—and are willing to reflect honestly on what they’ve experienced. They have to be good storytellers when recounting their own personal experiences and the experiences of the other stakeholder, as stories are so powerful in qualitative data; and they have to go broad – parsing personal challenges from systematic challenges to help our team identify large-scale trends and leverage points in a system for solutioning.
An example to bring it to life: a social worker could be a proxy for children in an exploration of the foster care system. Social workers have a detailed and nuanced bank of stories that represent children, parents, and themselves. They also have broad observational data across many cases. Social workers could serve as a proxy to fill gaps in our understanding of systemic trends in foster care and childcare in America. Critically, including a social worker as a proxy would elevate the perspective of children and families through stories; because of a social workers’ training and experience, they are able to articulate stories in the context of a nuanced system – something that children themselves may not be able to do.
In our EMS system mapping work, EMS providers were excellent proxies for civilian stakeholders because of their abundance of observational data, their ability to identify high-level trends in civilians’ use of EMS, and their deep empathy for the civilians they serve. Whereas most civilians have minimal interaction with EMS and thus their reflections are based on a few, intense situations over a lifetime, EMS providers have thousands of hours of experience interacting with civilians. They have done everything: from transporting civilians who have had a stroke, to fixing a civilian’s medical bed, to transporting civilians to routine appointments. Because of their work’s breadth and depth, EMS providers could zoom into a civilian’s story, and zoom out to an important trend.
Further, the most effective proxies are empathetic to other stakeholders in the system. EMS providers were excellent proxies for civilians because empathy is embedded into their professional experience. Assessing scenes and actively listening to civilian’s needs are critical EMS skills, which primes them to be empathetic to civilians. Rather than judge civilian behaviors at face value, paramedics and EMTs see the root causes that drive over-reliance on EMS like poverty, lack of transportation options, isolation, misaligned incentives in the broader healthcare system, and more.
Right time, right proxies, right questions
This system mapping project was just one example of a situation in which engaging proxies was a more accurate, nuanced, and efficient way to triangulate stakeholder perspectives – to “hold our data accountable”, as we like to say in our work. If your team is thinking of trying on this method, we have some tips to consider:
First, make sure yours is the right type of problem space to rely on proxies. Are you exploring a problem area where emotions run high? A challenge for which stakeholders may not have the right language or exposure to the problem space to describe their perspective? Do social structures disincentivize certain perspectives? Are there significant barriers to engaging stakeholders directly?
If you have identified the right opportunity to use stakeholder proxies, the next step is finding the right proxies. Just like the EMS providers, the right proxies will have a high quantity of observational data on the stakeholder group, but will have a degree of separation (and thus, objectivity). We screen carefully for proxies who demonstrate empathy for the stakeholders they are representing, who are articulate storytellers and communicators, and who have a high-level view of the system they operate within.
The final step in effectively using stakeholder proxies is asking the right questions to get strong and reliable insights. Prime proxies by explaining their role and letting them know your desire to understand a specific stakeholder group. Ask questions that help them articulate stakeholder needs, help them differentiate between their perspective on the issue and that of the stakeholders, and probe them for root causes that may explain stakeholder behavior. Our favorite question for engaging with EMS providers was, “Okay, if civilians are using the system in this way, what’s missing? What do they need that they don’t have?” And, it’s important to recognize and validate that proxies have important needs of their own.
At The Human Factor, involving stakeholders is our bread and butter. When researching a complex system, stakeholder stories, motivations, and memories are the data that drive our insights and discovery. We trust, empathize with, and value the humans whose lives are impacted by the systems we study. That said, we also know that these humans are… humans. And we know that humans are not always the most reliable sources of information when they are reporting on themselves. Using stakeholder proxies to research and validate the stakeholder experience in a complex system has proven to be a great tool for us, enabling us to identify root causes and generate solutions that make a difference for the stakeholders involved.
