Co-Design in Electrical Medical Beds with Caregivers

Davide Bacchin, Conceptualization , Data curation , Funding acquisition , Methodology , Writing – original draft , Writing – review & editing , 1, * Gabriella Francesca Amalia Pernice, Data curation , Investigation , 1 Leonardo Pierobon, Formal analysis , Writing – original draft , 2 Elena Zanella, Formal analysis , Writing – original draft , 2 Marcello Sardena, Funding acquisition , Project administration , Resources , 3 Marino Malvestio, Funding acquisition , Resources , 3 and Luciano Gamberini, Conceptualization , Supervision , Writing – review & editing 2

Davide Bacchin

1 Department of General Psychology, University of Padova, 35131 Padova, Italy

Gabriella Francesca Amalia Pernice

1 Department of General Psychology, University of Padova, 35131 Padova, Italy

Leonardo Pierobon

2 Human Inspired Technology (HIT) Research Centre, University of Padova, 35121 Padova, Italy

Elena Zanella

2 Human Inspired Technology (HIT) Research Centre, University of Padova, 35121 Padova, Italy

Marcello Sardena

3 Malvestio Spa, Villanova di Camposampiero, 35010 Padova, Italy

Marino Malvestio

3 Malvestio Spa, Villanova di Camposampiero, 35010 Padova, Italy

Luciano Gamberini

2 Human Inspired Technology (HIT) Research Centre, University of Padova, 35121 Padova, Italy

Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https://creativecommons.org/licenses/by/4.0/).

Associated Data

The data presented in this study are available on request from the corresponding author. The data are not publicly available due to privacy issues.

Abstract

Among the plethora of instruments present in healthcare environments, the hospital bed is undoubtedly one of the most important for patients and caregivers. However, their design usually follows a top-down approach without considering end-users opinions and desires. Exploiting Human-centered design (HCD) permits these users to have a substantial role in the final product outcome. This study aims to empower caregivers to express their opinion about the hospital bed using a qualitative approach. For a holistic vision, we conducted six focus groups and six semi-structured interviews with nurses, nursing students, social-health operators and physiotherapists belonging to many healthcare situations. We then used thematic analysis to extract the themes that participants faced during the procedures, providing a comprehensive guide to designing the future electrical medical bed. These work results could also help overcome many issues that caregivers face during their everyday working life. Moreover, we identified the User Experience features that could represent the essential elements to consider.

1. Introduction

There are many instruments and devices present in hospitals. Many have become obsolete over time, but one will never go into disuse: the medical bed. The development of the modern hospital bed started between 1815 and 1825, introducing adjustable rails. At the beginning of 1900, the beds began to present three sections to allow both head and feet to be elevated [1]. In 1956, the bed’s equipment started to include electrical functions. Nowadays, almost all medical beds present side rails with control pads, three electrically movable sections, adjustable height and other features. The guiding concept behind this evolution was the creation of a tool to provide comfort to patients and reduce caregivers’ workload.

Most of the time, research in this field has approached new feature development starting from designers’ ideas. Many examples in literature follow this path, testing new features such as integrated toilets [2], systems to prevent bedsores [3], bedside angle measuring devices [4], and bed movers [5], to name just a few. Nowadays, human-centred design (HCD) is replacing this approach. In this new technology development vision, the innovation process actively involves stakeholders, empowering them by exploiting participatory methods from ideation to testing a new product. The human-centred design approach offers many advantages. One of the most important is the possibility of addressing real user problems and permitting people to have a substantial role in the design process outcomes [6]. Human–Computer Interaction (HCI) and Design Thinking (DT) are two slightly different design approaches that share this vision of understanding and observing users.

Both start with discovering users’ problems. The difference between the two is that HCI aims to understand users’ requirements, and DT instead stresses the concept of building empathy with them. The HCI process generally emphasizes the solutions’ analysis, evaluation and testing, while DT focuses on profound observation and inquiries [7]. However, HCI has a more systematic vision of the design process due to its exploitation of golden rules and guidelines (i.e., Nielsen’s 10 Heuristics [8]). The first step in the HCI process is the “what is wanted” phase. In this phase, researchers investigate users to provide information about their needs using tools such as interviews (e.g., Focus Groups), user behaviour recording, document analysis and direct observation. Then the “analysis” step collects and organizes the results to provide valuable insights for the “design” phase and generate solutions. The designers often exploit early prototypes to test the users’ interaction efficacy with the product and enhance its usability. This evaluation phase permits the study of issues with the prototype in the early stage of development and can be performed many times, creating an iterative process. The subsequent correction of the problems and assessing the prototype’s efficacy and functionality bring the product to its implementation and deployment in the market [9].

1.1. Human-Centred Design in Healthcare Environments

The literature presents many examples of the exploitation of HCD. Indeed, many fields of activity experience the benefits of this approach, such as industry [7,10], education [11], Internet of Things technologies [12], transport and automotive [13,14], websites [15], applications for people with disabilities [16] and many others. Among these, one field that is receiving colossal attention is healthcare. For example, Harte and colleagues [17] proposed a structured methodology that could help designers follow HCD principles to consider user needs while maintaining a short development time. Their method was composed of three phases: construction of a use case document, expert usability inspection and end-user testing. They applied the method to a fall detection and prevention system, indicating that this methodology could be a good support for designing connected health devices. Moreover, public health projects are applying the HCD approach. In their interesting review, Bazzano and colleagues [18] indicated four global health contexts that exploited participatory design:

Disease management, serious and chronic health conditions (e.g., dementia, cancer), health system and care management (e.g., HIV patients, vaccine safety), infectious disease prevention/care (e.g., hand hygiene, health care workers), primary intervention and health behaviour/education (e.g., contraception, infant mortality)

In our study, we were interested in applying HCD in specific healthcare locations: hospitals and elderly retirement homes. These environments represent a challenge for HCD studies because of their complexity. Indeed, the literature presents some examples of studies that try to simplify and re-design them [19,20]. The employees that have to manage and face this complexity are mainly caregivers, often involved in HCD processes (e.g., discovering needs, end-user testing) for research technologies. In some cases, they participate in the early phases of a device’s development, giving information about user requirements for specific technologies [21,22,23,24,25], while in other cases, they test the developed devices [25,26,27,28]. For a scoping review of health and medical device development, the work by Matinolli and colleagues can provide valuable insights [29].

1.2. Medical Beds

The research subject of this study is the electrical medical bed and its design, whose modern history and related innovations have been explored in recent reviews by Ghersi [30,31]. He identified the electrical beds’ origins with the invention of adjustable sides around 1815 and 1825 [32]. Following technological development, beds gradually transformed themselves into what he defines as Intelligent Mechatronic Beds. In modern electric hospital beds, software and hardware work together, allowing the bed and its components to move concertedly, thus integrating mechanics with electronics and computer science. Nowadays, the advanced versions of these tools usually present an electrical engine moving four different sections. The bed presents three articulated parts (back, thighs or upper leg, calves or lower leg) and a fixed central part. The latter prevents the mattress from deforming and guarantees an equal pressure distribution even if the movement of each section reaches its limit. Moreover, the leg portion of the bed is subdivided into thighs (upper leg) and calves (lower leg) sections. This subdivision allows a slight elevation at the knees level, permitting patients to reach a position similar to an armchair (chair position). Furthermore, modern beds present split side rails, four moving wheels with a brake, control panels for patients and caregivers, removable footboard/headboard and many other features depending on the production company.

A scheme of this structure is shown in Figure 1 .

Scheme presenting the structure of a modern electrical medical bed.

Despite its central role in caregivers’ and patients’ hospital life, the hospital bed has received little attention in HCD research for innovative features. Indeed, it is rare to find examples of complete design processes in the literature. One example is the extensive work conducted by Wiggerman and colleagues [33], where they described the design process starting from an observational study conducted in 29 hospital units in North America. After creating the prototype, they conducted multiple usability tests and concluded their work by listing the selected design features. More common are studies which describe performance tests of new innovative features and their use. For example, some studies tried to detect unchecked patients’ bed exits and fall, since these are severe causes of injuries [34]. Hilbe and colleagues [35] developed a bed-exit alarm system, starting the design process by reviewing the literature and conducting open interviews with 12 nurses. They subsequently built a prototype that has gone through laboratory testing, in which they confirmed its usefulness in preventing falls. Another work by Wolf and colleagues [36] used the same methodology to test another similar system for fall prevention. An important theme is the maneuverability of the beds. A work by Zhou and Wiggerman [37] evaluated the brake pedal location with nine healthcare workers, establishing its design implications and the preferred height for the push handle. Another study by the same authors analysed the effect of two bed features (e.g., Trendelenburg position and maximum mattress inflation) on the caregivers’ physical stress during typical patient repositioning tasks [38]. Some studies have explored the medical bed with subjective methods, for example, by investigating the caregivers’ satisfaction with the hospital bed, highlighting how often the difficulty in maneuvering operations, transportation of patients and bed cleaning are the most physically demanding and troublesome tasks [39]. Another study pointed out the importance of technical support and user-friendliness to influence nurses in using the functions of the bed [40]. Another example is a semi-structured interview study that described bed comfort criteria to create an evaluation checklist [40]. Other examples in the literature describe similar features, but they look at laboratory testing without considering end-users [41,42] or involving novice participants [43,44,45].

1.3. Research Objective

As addressed previously, the bed plays a central role in many healthcare environments. It represents the object with which caregivers and patients often interact. In our opinion, it is fundamental that its design encounters end-users needs in order to release part of the work-related stress from people who spend their working time in such stressful environments [46,47]. To the best of our knowledge, the literature lacks comprehensive work describing caregivers’ opinions and needs regarding the medical bed. Therefore, this work aims to provide researchers and companies with a qualitative study that deeply explores this theme. The results will list modern electrical bed features’ advantages and limitations, creating a valuable tool for analyzing bed-related caregivers’ problems and providing guidelines for the future design of medical beds.

2. Materials and Methods

2.1. Focus Group

This study utilized the Focus Group (FG) technique. This consists of forming a selected group of participants, usually homogeneous (e.g., sharing similar professions, backgrounds and experiences), to enhance their comfort during the discussion of a topic. A moderator is present to propose the questions, manage any problems among the participants, control the time of their interventions and maintain the discussion on the desired topics. Finally, an observer is instructed to pay attention to the non-verbal language of the participants to assist in moderating the debate. Health researchers have extensively used Focus Groups because of their capacity to generate ideas and identify issues [48].

The FG was divided into two distinct parts. The first part of the FG start consisted of a rapid phase of acquaintance with a round of participants’ names, followed by some easy and immediate questions (i.e., When was the last time you used an electrical medical bed? What are the actions that you often perform with the electrical medical bed?). This initial part was useful in breaking the ice among the participants and introducing them to the subject matter. Next, four questions explored the participants’ wishes regarding the hospital bed and its impact on their work. We elaborated four questions starting from the work of Güzelbey Esengün [41] and colleagues, where they subdivided the bed-related arguments into five categories. We excluded economic-related questions because in Italy this is not a caregiver’s responsibility. The four questions were concerned with the impact of the physical characteristics (e.g., height, weight, etc.), the materials used, the electrical functions (e.g., electric inclination of the backrest, lifting of the bed base, etc.), and any psychological feature able to give serenity to the operator. The birth of new ideas on the beds currently in use was stimulated during the discussion to find new proposals and possible adjustments.

Each focus group lasted on average 2.5 h, and was audio and video recorded to permit consequential transcription of the contents. The data analysis was carried out with thematic analysis [49]. The interviews were transcribed starting from the audio recordings. Afterwards, three researchers independently read all the transcriptions, defining and then discussing the emerging themes into which participants ‘answers could be subdivided.

In addition, a series of semi-structured interviews were conducted (6) to deepen the discussion of the topics. The researcher prepared the same list of questions above for FG. The interviews lasted an average of 50 min and were recorded in audio and video. The researchers followed the same analysis procedure as for FG.

2.2. Procedure

The FGs started by receiving the participants in a welcoming environment, where they could comfortably sit in a circle ( Figure 2 a,b). The objective was to create a place where participants felt equal and could freely express their ideas. They first completed the informed consent and a demographic questionnaire. Then discussion behaviour rules were listed. Food and water were at the participants’ disposal for the entire duration of the discussion. Once the preparations were finished, the FGs took place.

(a) Focus Group with nurses employed in a hospital. (b) Focus group conducted with a mixed group of nurses, SHO and physiotherapists at a retirement home.

2.3. Participants

All the participants involved in the study were healthcare professionals from different working situations, namely healthcare institutions and hospitals. Daily, these professionals deal with a wide range of patients with different needs and problems. In our opinion, to encourage discussion, it was important that participants in each FGs belonged to the same structured healthcare facility (e.g., institution for the elderly, home care service). Their common experiences could be crucial in underlining their work limitations and criticalities regarding the electronic bed, providing solutions that can be adopted in a wide range of healthcare settings. Consequently, meeting professionals’ different needs could lead to better care for their patients.

To this aim, participants were assigned to six FGs. Specifically, 3FGs collected nurses’ experience (FG1-2) and that of healthcare assistants (FG5) who worked in different hospital wards. Two FGs involved professionals employed in institutions caring for fragile patients (i.e., an institution for the elderly in FG3 and an institution for disabled people in FG4). Finally, in the last FG6, we reported the experience of a group of nurses who provided home care assistance. The whole sample was composed of 29 people (Female = 19, Male = 39, SD = 9). Professionals had an average of 13 years of experience in healthcare (SD = 5.17), and they generally worked with electronic beds daily. However, only three participants reported that they had been properly trained to use the electronic bed during these years.

A brief socio-demographic description of the different cohorts is represented in Table 1 .

Table 1

Table describing the characteristics of the participants participating in the study.

To further explore the object of the study, we conducted six semi-structured interviews (INT) with bachelor students of nursing science (Female = 3, Mage = 27, SDage = 9.3). They represent the next generations of healthcare professionals, and their opinion could be an opportunity to provide new insight. However, despite already having at least three years of experience with the electronic bed, they were not part of a structured work organization, which was one of the criteria used in designing the FGs. For this reason, their experience was reported separately trough semi-structured interviews.

3. Results

During the discussion of the results, we will list every theme that describes a specific element or characteristic of the bed, providing valuable citations. We identify the number of occurrences in which the features appear across the different interviews/focus groups. For each theme presenting comments with more than three occurrences, we provide a graphical representation of the three most common comments and suggestions.

3.1. Side Rails

Regarding the physical characteristics of the side rails, the analysis highlights the first element of discussion in their composition (i.e., subdivided into two parts or as a single long side rail).

The participants indicated the multiple side rails as a positive element in 10 occurrences; among the advantages, they can facilitate hygiene procedures for the patient (FG1-P04: “The split ones are comfortable for hygiene”), allow the creation of escape routes for tubes and drains, make restraint less evident (FG-P02: “you can only pull up the side rails of the feet, keeping the head part raised and the patient still feels safer”) and follow the movement of the backrest. However, a negative found for this type of side rail concerns the creation of spaces in which the patient could get stuck. The single side rail was considered as a positive element in six occurrences. Among the advantages of this type emerged the possibility of being lowered with a single gesture (INT-P06: “Just one move to lower it”), preventing any cables from getting stuck or being cut (FG1-P02: “Then in those no wires or drips got stuck”) and removing the risk for the patient of getting stuck between spaces created by multiple side rails (FG1-P03: “With those divided, halfway the space is a danger, they get stuck, it is an escape route”). However, there remains the possibility of the patient getting stuck between the boards that compose the side rail (FG3-P05: “They get stuck in the space between the boards that make up the side wall”).

Regarding their shape, according to the caregivers, they should be curved/rounded (FG6-P05: “They don’t have to be straight, which gives a sense of containment and suffocation, more dynamic”), and lower to reduce the height of a possible fall (INT-P01: “If they are too tall some patients can climb over them and the higher it is, the higher the fall height”). In addition, they should physically support the patient (three occurrences). The participants showed the need to create support points for the movement of patients (FG5-P02: “Good grip helps us to lift them”; INT-P03: “It would be a support for the patient to hang on or sit down, they shouldn’t hang on to the operator”).

Regarding possible functions related to the side rails, some comments (four occurrences) that emerged during the FGs show the need to create an electric height adjustment mechanism (FG3-P03: “Often with anti-decubitus mattresses, they are too low”) or a manual one in case of need (FG4-P03: “I would need a manual mechanism in case of need”). For their release/movement mechanism, it should allow lowering under the bed surface (eight occurrences; FG-P02: “Closing under the support surface”) to avoid accidents (two occurrences; FG1-P04: “When they get off, they cut your feet, giving you a hit”; FG2-P01: “Tall operators bang to maneuver in the center”) and the creation of gaps between the bed and other supports (FG-P01: “Even when they are transported by stretcher/bed or bed/bed, there is a big void”). Furthermore, the mechanism should be easy to use and manageable (three occurrences; FG5-P02: “They should be easy to lift down, even for making the bed”), and equipped with an electric self-locking mechanism (three occurrences) and braked (FG-P03: “Often it can pinch you”). Raising and lowering the side rails should require a fast single action (four occurrences; FG3-P02: “That closes with a single action, which does not become difficult to raise and lower them”), operated with one hand (three occurrences; FG2-P02: “The closure should be one-handed”). Finally, they highlight the need for an alarm for lowered sides (INT-P05: “Maybe you pull up the banks, but you also pull down the sides, in which case you would be notified”).

Caregivers have highlighted how the material that composed the side rails should be light (two occurrences) but resistant (five occurrences). The reasons are safety (FG6-P06: “Often we are alone we have to put a lot of pillows between the person and the edge and they often hit knees etc. creating new injuries”) and comfort (INT-P01: “Patients put hands on them and feel a sensation that is not comfortable, icy or too hot or hard. It could also be therapeutic from a certain point of view, evoking good sensations”). Materials should be soft on the inside and padded (seven occurrences). Furthermore, they should be plastic, fireproof and possibly smooth (two occurrences; FG5-P03: “Smooth would be practical to sanitize”). Furthermore, it was indicated not to use wood as a material due to matters of deterioration and hygiene (three occurrences, FG4-P02: “The wooden sides with a single band, sometimes broke, maybe hitting the lifter. Here we talk more about materials, and some are poor“; INT-P02: “I have seen some with wooden sides, but this is much less hygienic compared to plastic”).

Regarding the psychological impact of the side rails, they have been seen as elements that give safety to the patient and the operator (four occurrences; P05-INT: “Sometimes they give a sense of safety, even for operators”). On the contrary, other participants indicated that these were a limitation to the patient’s freedom since they give a sense of being in a cage (seven occurrences; FG3-P02: “Sometimes they represent a limitation of freedom”). For this last problem, the use of sides without holes (two occurrences; P01-INT: “Very beautiful modern sides, perhaps if they could be full and not angular”) or transparent was proposed. Finally, they proposed avoiding the use of straight bars (FG6-P05: “they don’t have to be straight, which give a sense of containment and suffocate”).

To summarize, based on comments’ frequency we can say that professionals recruited prefer to work with split side rails, with a soft part inside to avoid patients’ injuries. It seems also important that the release mechanism of the side rails should be hidden. The suggestions with more occurrences are described in Figure 3 .

Graphical representation desires with more occurrences for the Side Rails theme.

3.2. Headboard/Footboard

Regarding the physical features of these components, they should be a low bulky component of the bed (two occurrences; FG1-P06: “It is still a nice piece, heavy, and then cluttered, you no longer know where to put it”). They should also be able to accommodate accessories and shelves of various types (two occurrences; INT-P02: “Headboard/footboard with elements for hanging devices to be used concurrently”).

The footboard and headboard should be removable (four occurrences) for caregivers’ comfort and safety (FG1-P03: “It becomes safer for me too, it’s a convenience”). One comment further proposed that these bed elements could become interchangeable (FG2-P02).

The material of these elements should be light (three occurrences; FG2-P03: “They should be detachable light pieces”) and softer to avoid injury (two occurrences, FG4-P05: “Maybe even a softer material, because they hit their heads”).

From a psychological point of view, these elements of the bed should be quick to detach for the operator (three occurrences; FG6-P03: “I should be able to lift it and quickly access the lower and upper limbs”) and comfortable for hygiene (two comments; INT-P01: “For various needs, orthopedics and machine encumbrance, cleaning even under the mattress”; FG5-P02: “They are easily washable due to removal, they are practical for hygiene”) and for various therapies (FG1 -P03: “We often work from there, it becomes safer for me too, it’s a convenience”).

Therefore, looking at the frequency of comments regarding the headboard/footboard, we can say that the most desired qualities of the bed are removability and quick release, but also lightness of material.

The suggestions with more occurrences are described in Figure 4 .

Graphical representation of desires with more occurrences for the Headboard/Footboard theme.

3.3. Bed Base Surface

The bed surface, the plan that supports the mattress, has also been mentioned (three occurrences) because it is an element particularly prone to getting dirty (FG6-P03: “It takes liquids of all kinds”). Therefore, the participants would like solid bed surfaces without holes (two occurrences; INT-P01: “All grooves should be covered to facilitate cleaning”; FG4-P02: “Large holes, like normal bed bases, do not allow to put anti-decubitus mattresses”).This has to be waterproof (FG6-P03).

As for the materials, the composition of the bed surface’s cover should be smooth plastic (FG3-P01), resistant (FG6-P02) and fixed (FG6-P05: “Not that it wobbles as soon as you move it”).

3.4. Electrical System

Participants indicated that integrating electric sockets to the bed could be helpful for attaching various instruments (five occurrences) and overcoming issues with cables (five occurrences, FG1-P02: “Often by moving the sides or other, the plugs disconnect”; FG4-P05: “No more cables can be added”).

Regarding the patient, the participants indicated as useful a socket in the internal part of the bed, reachable by the patient, because if placed externally it could be uncomfortable (INT-P04). Moreover, they indicated placing it on the head part of the side rails (two occurrences, FG3-P02: “Then the socket should always be on the head side; instead, they are all on the foot side”). In addition, participants proposed magnetic loading (FG2-P02). The participants suggest integrating more plugs to connect the anti-decubitus mattress (FG2-P02: “when I did orthopedics, if there was an electric bed, you did not have the anti-decubitus mattress because the bed was connected to the plug and then it happened that in the operating room came the ward bed with a different socket and you had to go in search of the adapter, which cannot be used because it is not standard. Then, you have to contact the mattress manufacturer to change the plug”) to attach various electrical tools while moving the bed (three occurrences; INT-P04: “Possibility to use tools even while on the move”) and for USB devices of patients (two comments; INT-P04: “Increased comfort for the patient”).

Regarding the electric cables, the participants expressed the need (two occurrences) to hide them to reduce wear and improve aesthetics (FG4-P02: “The cables have to be hidden, often they are exposed and wear, could be cut”; FG5-P01: “When you move beds they often go under the wheels”; FG4-P02: “Cables should be hidden for aesthetics and patient safety”).

From a functional point of view, the participants highlighted as a practical function the alarm that occurs when the bed electrical plug is disconnected (INT-P03: “Excellent functions, not in all beds but most cases it is the fact that they sound when they are disconnected from the current”).

Furthermore, the autonomy of the bed battery received opposite evaluations. On the one hand, it is perfectly adequate (two occurrences; INT-P01: “Exceptional autonomy”; FG5-P03: “Never been a problem”), and on the other hand, it needs improvements (FG2-P03: “We need more autonomy in travel”). In any case, the autonomy of the battery must be adequate to exploit the bed’s functions also when it is unplugged from the current (INT-P02: “It must have a certain autonomy even when disconnected from the current as its functions are very useful also for example when entering the elevator”). A possible solution to overcome the problem is an external battery to activate when moving the bed (FG2-P01: “It would be nice to have a small auxiliary battery that allows you to be a support to move”).

So, based on the frequency of participants’ comments the electrical system should be integrated to the bed and should have multiple plugs. The suggestions with more occurrences are described in Figure 5 .

Graphical representation of desires with more occurrences for the Electrical System theme.

3.5. Accessories

Although not strictly part of the bed structure, participants often cited accessories as practical elements for their work. In general, the bed should be flexible in supporting the operators and able to accommodate a great variety of accessories to use in various situations (two occurrences; INT-P02: “It must allow the installation of other devices”; INT-P02: “Maybe also that allows you to install applications, devices, such as drip poles, very useful things not so much when the patient is in the ward but during transport, which is a very useful thing”; FG2-P02: “It should be adaptable to many accessories, to reduce the effort of adapting it to different instruments”; FG2-P03: “I also thought that many patients stay in orthopedist ward, and have external instruments. Sometimes using these and making them sit comfortably is difficult. You find yourself in difficulty with back and foot positioning, and sometimes you can’t because the mattress doesn’t allow it. So, personalizing the final part of the bed is important. Because then you need to re-adapt a series of non-functional conditions. Maybe support for accessories on the footboard is missing”).

One of the accessories taken into consideration by the operators is the IV pole, which is considered convenient and useful (four occurrences; INT-P04: “The pole can be a reason for peace of mind because it removes problems with needles and movements with wires attached to the patient”; INT-P05: “Also keeps instruments out of reach of the patient”). For the participants, the bed should integrate the pole, which has to be adaptable (five occurrences, INT-P02: “The IV pole should be foldable, integrated into the bed. Attached to the bed, it would allow it to be used while moving it, and if it were integrated, I would not have to go looking for it”; INT-P04: “Very useful, they must be flexible for different uses or heights. they are not always standard, they should always be present, even in the nursing home bed”; FG2-P02: “The IV pole should be telescopic”; FG5-P02: “It should be easier, more flexible the exchange between IV poles and poles for the triangle”), and resistant (two occurrences; FG5-P01: “They are often fragile, maybe you put the nutrition bags and the stakes because those are heavy”; INT-P04: “Put the nutrition bags, the poles break easily”).

The participants negatively mentioned the hooks for the diuresis bag several times (six occurrences). Their positions are often too low, causing the bag to touch the ground (six occurrences; FG6-P05: “The holder is too low”; FG5-P02: “The attachment of the diuresis bag is not practical, we need a hook to hold it up. Because when you lower the bed, it goes too low for those bags, and they touch the ground”; INT-P04: “It is difficult to find a position where it does not touch the ground and is low enough to operate”). Precisely for this reason, they expressed the desire for a higher or adjustable attack (FG6-P05: “Even the pole they put on beds is sometimes too low, it is so low that you must always remember to pull it up. It has to be adjustable so that I don’t have to pull it up or put the bag on the patient”) and to make it standard equipment (INT-P02).

Furthermore, participants suggested the integration of shelves and various types of storage compartments (four occurrences, INT-P03: “The objects should be inside the figure of the bed, perhaps underneath, so as not to collide with external elements during the transport”; FG4-P05: “It would take a space for the compressor of the anti-decubitus mattress, to store it safely and hidden”, INT-P04: “There could be a basket for patients, for their comfort”; FG5-P02 “Parrot carrier”).

Accessories useful by healthcare personnel are also the anchors for restraint methods (four occurrences; FG1-P02: “It would take a safe and comfortable point to reach. You can’t do it on the edge because you risk breaking his arm”; FG5-P02: “Regarding the hooks for restraint, it would take something more external, more under the bed, something that can be extracted”; FG3-P02: “One thing that is missing is the possibility of putting a restraint belt, at least creating a mechanism to easily hook them. Now the process is very inconvenient”).

The participants also mentioned the mattress and its size, which is often not the same as the bed. Therefore, they reported the need to have mattresses of the right size or to create aids to remove spaces and stop the patient slipping (four occurrences; FG5-P01: “The beds are larger than the mattress, it always goes down. It always has a space where the mattress slides down”; FG3-P02: “The beds and the mattress are sold separately, and for the mattress, which is sometimes wider than the bed, you ruin it with the side rails. You pinch it, it deteriorates”; FG6-P05: “The mattress is small compared to the bed and voids are created”; FG6-P05: “The mattress should have hooks to the bed surface because it often slides down together with the patient”; FG1-P01: “We need a mattress already prepared for bed because changing it and ordering the right ones is a waste of energy, time and funds”);

The triangle pole (two occurrences) is an accessory that the staff rated as uncomfortable (FG5-P02: “The triangle is a bit uncomfortable at times”), heavy (FG1-P03: “Then there is the pole of the triangle which is very heavy. It indeed has to hold the patient, but it is dangerous”) and which needs to physically support the patient’s movement (FG5-P02: “Like the triangle, something to support them to cling to because you cannot leave the triangle there because it is dangerous”).

The headrest (two occurrences) has been cited as a support for the patients’ hair washing (FG-1P05: “Hair washing was not provided, it would take a headrest, like hairdressers. An accessory”) or to support comfort (FG3-P03: “A headrest to support the patient”).

The participants also proposed a bed-wall spacer (two occurrences; FG4-P02: “Something we need to distance the bed from the wall to prevent it from banging, perhaps vertical wheels to slide on the wall”).

Some comments emerged regarding the blanket’s lifter (three occurrences). The participants want it integrated into the bed (three occurrences; INT-P06: “The idea that I could put some kind of extractable structure from the bed that can be composed but that it is already integrated into the bed”) and electrically adjustable (two occurrences; FG6-P02: “The height of the blanket lifter, which is adjustable so that I don’t have to pull it up and put it on the patient”; FG4-P02: “The lift blankets, it’s not a quick thing to take off, you usually leave it there even if you don’t need it. Also, when you make the bed, it’s not nice to look at. So it would be convenient”).

The participants also proposed less bulky bumpers wheels (one occurrence; INT_P02: “They must not clutter up because the operators hit us in agitated moments. Then they must not let the patient feel the impact”).

The participants also find it useful to add an armrest for patients (one occurrence; FG6-P02: “When I have to take a venous route or similar, it would be useful to have a support for the patient’s arm”) and an attachment for the anti-decubitus mattress (one occurrence; FG5-P02: “We use MAD a lot, we have the motor to support. We put it where the large remote control of the bed rests, and it just sits there. Maybe a longer space because they don’t fit together, it’s not very practical”).

Finally, it was highlighted in five comments how the bed-to-bed or bed-to-stretchers spaces cause discomfort among the operators (five occurrences; FG3-P03: “Gaps are created between the bed and prams/stretchers”; INT-P04: “Systems for the interaction between the two are non-existent”). Participants expressed the desire for systems to facilitate this transition of the patient (INT-P04: “It would take a system to be able to move the patient easily”; FG2-P01: “It would take a support base for lateral movement”; FG3-P03: “We need an adjustment in the support surface change”). One of the causes is the space required for the vertical descent of the side rails (FG1-P01: “Even when transported by stretcher/bed or bed/bed, there is a large void”).

Finally, the participants reported that the base of the bed could represent a potential obstacle to the operator’s work (INT-P01: “Often it is an obstacle for patient lifting trolley”).

Therefore, the most desired accessories based on the frequency of participants’ comments are the integrated attack of the diuresis, the bed/stretcher transfer system and an integrated IV pole. Suggestions with more occurrences are described in Figure 6 .