=Paper=
{{Paper
|id=Vol-1547/paper3
|storemode=property
|title=Using Gamification for Improving Nurses Productivity in a Hospital Ward
|pdfUrl=https://ceur-ws.org/Vol-1547/paper3.pdf
|volume=Vol-1547
|authors=Rita Marques,João Gregório,Miguel Mira da Silva,Luís Velez Lapão
}}
==Using Gamification for Improving Nurses Productivity in a Hospital Ward==
https://ceur-ws.org/Vol-1547/paper3.pdf
II International Workshop on Gamification in Health: gHealth 2015
USING GAMIFICATION FOR IMPROVING NURSES’
PRODUCTIVITY IN A HOSPITAL WARD
Marques, Rita1,2, Gregório, João1, Mira da Silva, Miguel 2, Lapão, Luís Velez1
1: International Public Health and Biostatistics
Instituto de Higiene e Medicina Tropical
Universidade Nova de Lisboa
Rua Da Junqueira 100, 1300 Lisboa, Portugal
e-mail: [luis.lapao, jpgregorio]@ihmt.unl.pt., web: http://www.ihmt.unl.pt/
2: Informatics Engineering Department
Instituto Superior Técnico
Universidade de Lisboa
Avenida Rovisco Pais 628, 1049-001 Lisboa, Portugal
e-mail: [rita.marques, mms]@tecnico.ulisboa.pt, web: http://tecnico.ulisboa.pt/
Abstract. Healthcare acquired infections are one of the biggest problems healthcare
field is facing, which can end up in an increasing quantity of deaths, extra-days of
hospital stay and costs for both the hospital and the patient. Performing hand hygiene is
a simple and inexpensive prevention measure, but healthcare workers compliance with
it is still far from desired. Recognized hurdles are lack of time, forgetfulness, wrong
technique and motivation. Besides, nurses’ perception about their compliance is disturb
by a busy schedule. This study aims at exploring the use of gamification to promote
nurses’ HH compliance self-awareness and action. Real-time collected from an
indoor location system will provide feedback information to a group of nurses
working in an ICU ward. In this paper we present our research’s motivation and
methods, along with the collected results and its discussion.
Keywords: Healthcare-Acquired Infections, Hand hygiene compliance, Healthcare
workers, Gamification, Behavior changing
1. INTRODUCTION
Healthcare acquired infections (HAI) are infections that are neither present nor
incubating when a patient is admitted to hospital (Garner, Jarvis, Emori, Horan, &
Hughes, 1996). HAI are a risk that hospitals must control to manage healthcare
economically and safely for patients, whom can became disabled at long-term or even
die. Although preventable, by means of hand hygiene (HH) compliance, these infections
are the most adverse event a patient can experience during care delivery, and cause
more deaths than AIDS, breast cancer and auto accidents together (Carboneau, Benge,
Jaco, & Robinson, 2010).
Nonetheless, leading busy healthcare workers (HCW) to comply with HH remains
puzzling. Recognized hurdles are lack of time, forgetfulness, wrong technique and
motivation. Besides, nurses’ perception about their compliance is disturb by a busy
schedule.
Having this, it becomes crucial to monitor nurses’ compliance with existing guidelines
and provide them with feedback regarding their performance. Direct observation, the
observation of HCW’s HH practice by professional observers, is the standard approach
to fulfil this task, but it is costly and time-consuming.
II International Workshop on Gamification in Health: gHealth 2015
Automated monitoring systems have emerged during the last few years, and can
electronically identify when an HCW uses a sink or a handrub dispenser. It provides
exact quantitative results, which can be used to examine trends regarding the value of
HH compliance over time.
Gamification is a recent but popular approach which can be defined as “the use of game
elements and game-design in non-game contexts” (Werbach & Hunter, 2012) to
“engage and motivate people to achieve their goals” (Burke, 2014), providing a whole
different user experience. It aims at stimulating people’s intrinsic motivation in doing an
activity by trying to make it rewarding for itself.
Game elements are the “toolkit” for building a game (Werbach & Hunter, 2012) and
they must be chosen in the end of the process of designing a game, after some variables
are analyzed and defined (goals, behaviors we want to stimulate, our target players,
etc.). Werbach and Hunter (2012) provide a list of game elements divided into three
categories with different levels of abstraction.
This study aims at exploring the use of gamification to promote nurses’ HH compliance
self-awareness and action. An automated monitoring system will be used to collect data
in real time and provide feedback information to a group of nurses working in an ICU
ward, in a fun and engaging way.
We start this paper by defining the methods we used to conduct our research. The
already collected results will be presented, followed by their discussion. We end with
future work statements and a conclusion.
2. METHODS
In this section we present the methods used in our study. A design science research
approach is being used to iteratively design, test and evaluate our solution (Peffers,
Tuunanen, Rothenberger, & Chatterjee, 2007), which consists on an automated
monitoring system, composed by an indoor location system and a gamified system. The
solution was already presented to its target users (the nurses) and its usage was
simulated in both non-real environment (by non-real users) and real environment (by a
real user).
2.1. Design and implementation of the solution
The first component of our solution is an innovative indoor system built with smart
beacons and smart tags, which use both Bluetooth and a proprietary protocol (also
operating on the 2.4GHz frequency band) to communicate, and a proximity-based
technique.
More specifically, the smart tags (which are carried by the nurses) receive information
from smart beacons and send a message to the server (communicating the smart tag ID,
the detected beacon ID, the current time and the type of message – approaching or
leaving) whenever they are approaching a beacon or walking away from it. Analyzing
the messages stored in the server, we are able to detect nurses’ position over time.
The next step is for the system to detect and validate HH moments. To achieve this, we
use the World Health Organization (WHO)’s “My five moments for hand hygiene”
framework (World Health Organization, 2009), which links specific moments to HH
opportunities (Table 1). With this framework, we are able to create and implement
business rules in our system (for example, if a nurse is approaching a bed, it must have
approaching an alcohol handrub dispenser or a sink previously).
II International Workshop on Gamification in Health: gHealth 2015
Period where HH must take place
Moment
After… Before…
1 – Before touching …the last contact with a surface in …the first contact with a surface in the
a patient the health-care area patient zone
2 – Before …access to a critical site with infectious
clean/aseptic …the last exposure with a surface risk for the patient or critical site with
procedure combined infection for patient care.
…a care task associated with a
3 – After body fluid critical site with body fluid
…the first contact with any other surface
exposure risk exposure risk for the patient or
critical site with combined infection
… the last contact with a surface in
4 – After touching a …the first contact to any surface in the
the patient zone, with touching the
patient health-care area
patient
…the last contact with a surface in
5 - After touching …the first contact to any surface in the
the patient zone, without touching
patient surroundings health-care area
the patient
Table 1- WHO’s “My five moments for hand higiene” framework, adapted from (World Health
Organization, 2009)
After this processing, we have information regarding each nurse’s compliance, which is
displayed, in an anonymous way, in a screen in real-time (Figure 1).
Figure 1 – Part of the gamification solution presented in a screen in the nurses’ room
This, along with other components, including the player’s profile (Figure 2),composes
the gamification solution, which aims at solving the compliance problem by engaging
and motivating people to achieve specific goals (King, Greaves, Exeter, & Darzi,
2013), using several and distinct game elements (feedback, competition, points, levels,
badges, etc.). The technological architecture of this solution is presented in Figure 3.
2.2. Meeting with the nurses
There have been some meetings with the nurses from the ICU where the system is to be
implemented. We presented the Information System (IS) aiming at gathering feedback
regarding their feelings about it.
II International Workshop on Gamification in Health: gHealth 2015
Figure 1 – Page of one player’s profile
2.3. Simulation
A simulation was performed, in a non-real environment by non-real users (the
research members), in order to validate if the solution was technologically working
correctly. A protocol was written and executed, and after that we looked at the HH
compliance rate computed, which was compared with the expected rate.
To analyze the impact of the IS’s usage by a real user, we asked one nurse from the
ICU ward to carry a smart tag during a workday. This data was compared to a
previously established baseline (built with respect to an observational study) to
measure the changes in behavior.
3. RESULTS
From the already done work, we extracted some results, which are presented in this
section.
3.1. Installation of the solution
After being designed and implemented, the IS was installed in the ward. We placed one
screen in the nurses’ room and 26 beacons in specific positions: in the rooms’ doors, in
each alcohol-based hand rub container, in each sink and in each bed. This way, the
system would be able to trace a nurse’s position along time based on the proximity to
each beacon.
3.2. Feedback from the nurses
The group of nurses to whom the IS was presented to enjoyed the concept and think it is
a unique and good opportunity to receive feedback regarding their performance
(although they are sometimes subject to audits, they said that this would give them a
totally different experience). Although worried with the accuracy of the location system,
they found the avatars experience funny. Regarding future improvements suggested,
they showed little interest in components like badges, virtual goods and content
unlocking because it would require them to use the system outside their labor hours.
They, however, liked the concept of leaderboards. To finish, we asked them if they
prefer to maintain their privacy (that is, information presented by sensor and not by
HCW) or if they wanted their name (or a chosen nickname) to appear on the screen.
They said that this was indifferent for them, since they had no problem in having their
identity exposed in the screen.
II International Workshop on Gamification in Health: gHealth 2015
Figure 2 – Technological architecture of the solution
3.3. Simulation
The simulation in a non-real environment presented good results. The system worked
accordingly to our expectations, returning a HH compliance rate of 100% regarding the
moments simulated. However, when testing it at the hospital, we noticed that these
results were a false positive and that the system needed some refinements.
Regarding the simulation performed by the nurse from the ICU ward during one 12-
hour shift, the feedback received was that she got happier as she progressed in the game,
and whenever she noticed that the rate had decreased (even if only a little), she felt the
urge for being more aware of the HH moments.
4. DISCUSSION
Based on the results presented in the previous section, we can conclude that the IS was
conceptually validated, since we were able to detect the nurse’s movements using
proximity and to quantify the compliance with good precision, which was only possible
due to the indoor system’s capability of providing nurses’ position with great accuracy
and in a real-time basis, despite using radio-frequency based technologies.
The participant nurse approved the measure as an opportunity to improve her
performance, which corresponds with the results from the initial meeting with the
nurses. Since nurses were a little skeptical in using some game elements that required
them to access the system outside their work time, we decided to include a functionality
in the system to send an e-mail to each nurse in the end of the day. This simple e-mail
provides feedback regarding their HH compliance rate and has a link to their profile for
further information. This nurse realized that she ended up consulting the webpage, even
though she said she wouldn’t in a first instance.
5. CONCLUSIONS AND FUTURE WORK
The impact of gamification on HH compliance is still under evaluation. Even though
we only performed small validation tests to check whether or not the concept would
II International Workshop on Gamification in Health: gHealth 2015
work, so far the results show that the IS is promising in improving nurses’ productivity.
A demonstration in the ICU ward is already planned. During a 5-day trial, 24 nurses
will be using the gamification solution and will be provided with feedback regarding
their HH compliance rate. Simultaneously, we will be observing their behaviors and
reactions, trying to understand if they are comfortable with it and if they trust the
presented results, and focused on spotting some technical issues that might be leading to
undesired side effects of the system. In the end, we will analyze the gathered results and
refine our tool, both in terms of improving our gamification solution and fixing some
problems that may emerge during the demonstration. After this, our goal is to
implement the solution in a unit of another hospital during a larger number of days.
To conclude, we believe that the IS is aligned with nurses’ needs and that it will have a
positive impact on their daily routine. Although we noted some resistance to some ideas
we discussed for future work with the nurses, the nurse who participated in our initial
test agreed that she ended up using the system, so we trust that after using the IS on a
daily basis nurses can be more interested in different options.
It must be highlighted that nurses participated in IS’s design since the beginning, which
enabled a higher sense of ownership in the process, recognized as to improve
performance.
6. ACKNOWLEDGEMENTS
OSYRISH project is funded by Fundação para a Ciência e Tecnologia (PTDC/IVC-
COM/5016/2012) and GTHM/FCT (UID/Multi/04413/2013). This support and the
individual grants to R. Marques and J. Gregório are gratefully acknowledged.
REFERENCES
Burke, B. (2014). Gamify: How Gamification motivates people to do extraordinary
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Carboneau, C., Benge, E., Jaco, M. T., & Robinson, M. (2010). A lean Six Sigma team
increases hand hygiene compliance and reduces hospital-acquired MRSA infections by
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Garner, J., Jarvis, W., Emori, T., Horan, T., & Hughes, J. (1996). CDC definitions for
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