=Paper=
{{Paper
|id=Vol-1857/gamifin17_p20
|storemode=property
|title=Possible Benefits of Gamification for Improving Surgical Patients’ Quality of Care
|pdfUrl=https://ceur-ws.org/Vol-1857/gamifin17_p20.pdf
|volume=Vol-1857
|authors=Jaana-Maija Koivisto,Jari Multisilta,Elina Haavisto
|dblpUrl=https://dblp.org/rec/conf/gamifin/KoivistoMH17
}}
==Possible Benefits of Gamification for Improving Surgical Patients’ Quality of Care==
https://ceur-ws.org/Vol-1857/gamifin17_p20.pdf
Possible Benefits of Gamification for Improving Surgical Patients’
Quality of Care
Jaana-Maija Koivisto
University of Helsinki
Finland
jaana-maija.koivisto@helsinki.fi
Jari Multisilta
Tampere University of Technology
Finland
jari.multisilta@tut.fi
Elina Haavisto
University of Turku
Finland
elina.haavisto@utu.fi
Abstract: This paper considers the potential benefits of gamification from the perspective of surgical patients’
quality of care. There is little published data on gamifying the work of healthcare professionals even though the
use of serious games in healthcare has been growing. Literature on the quality of care shows that patients are often
satisfied with the care they have received. However, research indicates that deficiencies exist in patient education,
in patients’ opportunities to participate in and have impact on decision making regarding their care, and in preven-
tion and management of complications. Workplace culture is significantly connected with the incidence of patient
complications. Gamification of healthcare workers’ daily work routines could have positive effects on nurses’
ownership and the meaningfulness of their work, and on the prevention and management of complications, which
would in turn improve the quality of care for surgical patients. In this paper, a hypothetical gamification case is
presented and directions for future research are discussed.
Keywords: Quality of Care, Gamifying Healthcare, Nurses’ Work Processes
1. Introduction
This article discusses the potential benefits of gamification from the perspective of surgical patients’
quality of care. This approach was chosen because earlier research has shown that workplace culture is
significantly connected with the incidence of patient complications (Hahtela, 2015). Further, evidence
has shown that even though patients are satisfied in general with the care that they have received, defi-
ciencies exist in patient education and in patients’ opportunities to participate in and have an impact on
decision making with regard to their care (Gröndahl & Leino-Kilpi, 2013). Additionally, this paper
goes beyond an ongoing research project investigating the quality of care received by surgical patients
and looks to the future by considering possibilities to embed gamelike features into the daily work rou-
tines of nurses.
Recently, a considerable amount of literature has emerged around the theme of gamification (Hamari et
al., 2014) but there is little published data on gamifying the work of healthcare professionals. In the
healthcare sector, serious games have been used in professional education (Graafland et al., 2012; Koi-
visto et al., 2016b) and in patients’ health promotion and rehabilitation (e.g. Burke 2009). However,
gamification has not been embedded in the daily work routines of healthcare workers even though it
might have positive effects on commitment to and ownership of the work, feelings of belonging to a
workplace community, and feelings of achievement. In addition to these, gamification might increase
intrinsic motivation (see Huotari & Hamari, 2011) to provide high-quality patient care. Furthermore,
from the patients’ point of view, patient engagement has been insufficiently instilled into nursing prac-
tice even though it could improve the quality and safety of healthcare (Steelman, 2014). According to
Steelman (2014), patient engagement is not only about individual patients participating in decisions
about their care, but also involving them in designing new facilities, remodelling existing facilities,
developing new programs, and carrying out quality improvement projects.
GamiFIN Conference 2017, Pori, Finland, May 9-10, 2017 150
In this paper, the challenges for quality of care are discussed. Further, the benefits of gamification for
quality of care are considered, and a hypothetical gamification case is presented. Finally, directions for
future research are summarised.
2. Challenges for Quality of Care
Previous research has established that poor workplace culture (Hahtela et al., 2015), nurses’ decreased
commitment to work (Flinkman et al., 2008), poor clinical reasoning skills (Ludikhuize et al., 2012;
Soar et al., 2015), deficiencies in patient education, as well as patients’ participation in decision mak-
ing impair the quality of patient care (Gröndahl & Leino-Kilpi, 2013). There is increasing concern that
poor opportunities for professional advancement and development, lack of affective professional com-
mitment, low job satisfaction, and higher quantitative work demands may lead to nurses (especially
young qualified nurses) leaving nursing to start a new career in some other profession (Flinkman et al.,
2008). Another concern especially related to surgical patients is the fact that workplace culture is sig-
nificantly connected with the incidence of patient complications (Hahtela et al., 2015). Moreover, van
Oostveen et al. (2015) found that one of the most important patient-related factors that influence the
care intensity of hospitalised surgical patients is the occurrence of complications. Surgical nurses are
focused on direct patient care, such as checking patients’ vital signs, guiding patients towards self-care,
and providing wound care (van Oostveen et al., 2015). These are all factors that relate to preventing
and monitoring complications, which in turn relate to nurses’ clinical reasoning skills. Workplaces
should invest in the creation of a supportive practice environment (Hahtela et al., 2014), where nurses
can use their professional competence to provide the best possible patient care. Hahtela et al. (2015)
found that a positive workplace culture is one of the key factors in retaining and recruiting nurses.
Thus, workplace culture also affects job satisfaction and quality of care.
Poor or insufficient clinical reasoning can have serious consequences. Previous research has estab-
lished that nursing staff lack knowledge and skills in the ability to detect signs of deterioration in hos-
pitalised patients, and this may lead to severe adverse events (Ludikhuize et al., 2012; Soar et al.,
2015). The quality of surgical patients’ care can be improved by recognising and managing complica-
tions at an early stage (Friese & Aiken, 2008), since signs of deterioration are clear and can be detected
24–48 hours before a life-threatening event (Ludikhuize et al., 2012). Friese and Aiken (2008) argue
that post-operative complications, such as gastrointestinal bleeding and respiratory compromise, are
easily detectable by nurses, and those clinical conditions can be managed successfully with timely in-
terventions. The implementation of a simple physiological risk-management tool, Modified Early
Warning Score (MEWS), for all surgical in-patients enables improvement in the quality and safety
provided to surgical ward patients (Gardner-Thorpe et al., 2015). MEWS includes the measurement of
vital signs (see Table 1).
Table 1. Modified Early Warning Score (MEWS) (Ludikhuize et al., 2012).
MEWS score 3 2 1 0 1 2 3
Heart rate <40 40–50 51–100 101–110 111–130 >130
Systolic blood <70 70–80 81–100 101–200 >200
pressure
Respiratory rate <9 9–14 15–20 21–30 >30
Temperature <35.1 35.1–36.5 36.6–37.5 >37.5
AVPU score A (Alert) V (re- P (react- U (Unre-
sponse to ing to spon-
Voice) Pain) siveness)
Worried about patient’s condition: 1 point
Urine production below 75 ml during previous 4 hours: 1 point
Saturation below 90% despite adequate oxygen therapy: 3 points
The use of MEWS in daily work requires nurses to learn the MEWS parameters, which could be
learned, for example, by using simulation games as a part of regular staff education for recognising,
monitoring, and managing critically ill patients (Graafland et al., 2012; Koivisto et al., 2016a, 2016b).
Such games replicate reality and allow healthcare professionals to practise patient care in an immersive
virtual environment without compromising patient safety (e.g. Dev et al., 2011). This increases staff
competence in preventing post-operative complications, and thus improves the quality of care for sur-
GamiFIN Conference 2017, Pori, Finland, May 9-10, 2017 151
gical patients. However, learning the MEWS tool in theory does not guarantee that it is applied in prac-
tice.
3. Benefits of Gamification for Quality of Care
To improve the quality of care, one possibility could involve the use of gamification to increase nurses’
ownership and the meaningfulness of their work. According to Hamari et al. (2014) gamification has
three main parts: 1) the implemented motivational affordances, 2) the resulting psychological out-
comes, and 3) the further behavioural outcomes. The motivational affordance categories can include
points, leader boards, achievements/badges, levels, story/theme, clear goals, feedback, rewards, pro-
gress, and/or challenges. Psychological outcomes often relate to motivation, attitude, and enjoyment
(Hamari et al., 2014). The motivational affordances could be implemented in healthcare workplace
culture, thus increasing nurses’ ownership of their own work and job satisfaction. This in turn would
have an impact on the quality of patient care.
However, Hamari et al. (2014) highlight that the role of the context being gamified, and the qualities of
the users are essential antecedents for engaging gamification. This is especially true in the healthcare
sector, where workers deal with serious issues: they are responsible for patients and their well-being. It
might be challenging to implement gamification into healthcare workplace culture; already the terms
gamification and gamifying might be understood narrowly as referring to ‘having fun at patients’ ex-
pense’ or ‘playing with patients’ lives’. Maybe, when referring to the gamification of healthcare pro-
fessionals’ work, some other term could be more convenient and suitable. Nevertheless, gamification
that includes social aspects could be beneficial for healthcare workplaces since, as Koivisto and Hama-
ri (2014) found, women in particular value the social aspects of gamification (most nurses are women).
A second advantage of gamification with regard to the quality of care relates to the positive effects and
benefits, such as engagement and enjoyment (Hamari et al., 2014). Marques et al. (2015) studied the
use of gamification to promote nurses’ hand hygiene compliance self-awareness and action. They used
an automated monitoring system to collect data in real time and provide feedback information to nurses
working in an intensive care unit. They found that nurses liked the concept of leader boards but showed
little interest in components such as badges, virtual goods, and content unlocking. The opportunity to
obtain feedback and improve performance was rated positively. Similarly, the importance of feedback
for improving performance has been found to be important in nursing educational games (Koivisto et
al., 2016b). Gamification has a positive influence on learning outcomes, for example, increased moti-
vation, engagement, and enjoyment in the learning tasks (Hamari et al., 2014).
Huotari’s and Hamari’s (2011) definition of gamification can be applied to improving patients’ quality
of care. They define gamification as ‘a form of service packaging where a core service is enhanced by
a rules-based service system that provides feedback and interaction mechanisms to the user with an aim
to facilitate and support the users’ overall value creation’. When applying gamification to improve pa-
tients’ quality of care, the core service in a nursing context could be nursing tasks related to high-
quality care, for example, preventing and managing complications (see Figure 1 and the hypothetical
case). The service could be enhanced by augmenting the prevention and management of complications
through the implementation of gamelike features that appeal to nurses’ intrinsic motivations. The nurs-
es’ intrinsic motivation could be engaged by using motivational affordances, such as clear goals, feed-
back, rewards, progress, and competition (see Hamari et al. 2014). However, it would be important to
investigate what appeals to nurses’ or patients’ intrinsic motivation, what are the motivational af-
fordances that influence nurses’ or patients’ intrinsic motivation, and what would be the best reward
regarding patient care. After that, the nurses’ work could be gamified by using motivational affordanc-
es that generate intrinsic motivation (psychological outcome) for implementing high-quality care (be-
havioural outcome) (see Hamari et al., 2014). Furthermore, changing the behaviour of professionals (an
undesired behaviour is abandoned in favour of a new one) requires that a person performs a target be-
haviour, and to do so, three factors needs to be present at the same time: sufficient motivation, suffi-
cient ability, and an effective trigger (AlMarshedi et al., 2017; Fogg, 2009).
3.1 Hypothetical Case
In this hypothetical case, gamification is used to improve the identification of patients at risk for cardi-
ac arrest, which is a common complication for surgical patients. Hamari et al.’s (2014) definition of
gamification is applied (see Figure 1). Signs of deterioration are clear and can be detected 24–48 hours
GamiFIN Conference 2017, Pori, Finland, May 9-10, 2017 152
before a life-threatening event (Ludikhuize et al., 2012). Due to this, it is important to regularly observe
critically ill patients and document vital signs in real time in order to prevent cardiac arrests (Resuscita-
tion: Current Care Guidelines Abstract, 2016; Soar et al., 2015). In this case, the use of a mobile docu-
mentation device (mobile phone) is thought to promote identification of patients at risk for cardiac ar-
rest. Identification is one of the most important factors in preventing and managing complications. Mo-
bile documentation allows nurses to document information near the patient. With mobile documenta-
tion, nurses have up-to-date information about a patient’s clinical condition, since it enables nurses to
manage measurements and statistics in real time. In addition, the data can be transferred directly to the
patient information system. The core work process in this case could be the identification of patients at
risk for cardiac arrest. The implemented motivational affordances include the use of gamelike features
to engage intrinsic motivation to change behaviour related to the identification of patients at risk for
cardiac arrest.
Figure 1. Gamifying complication prevention and management in surgical wards
(adopted from Hamari et al., 2014).
The gamelike features could be:
• Goal: identification of patients at risk by monitoring vital signs in real time by using mobile
documentation with a mobile phone.
• Feedback: feedback regarding patient’s MEWS is provided by using colour effects as triggers
to identify patients at risk.
• Reward: patients at risk are identified and cardiac arrests are prevented; satisfaction with own
work is increased by being able to prevent complications.
• Progress: data from patient’s MEWS is collected and analysed every hour, which makes
nurse’s documentation visible.
Suppose all nurses have mobile devices and they are instructed to document a patient’s vital signs by
using mobile documentation every hour. The Fogg Behavior Model (FBM) is applied (Fogg, 2009) to
understand the behaviour change related to performing new a task. The expected behaviour change is
using a mobile device for documenting vital signs in real time. In this hypothetical case, this task is
GamiFIN Conference 2017, Pori, Finland, May 9-10, 2017 153
new for nurses. The target behaviour is to use mobile documentation to monitor vital signs at regular
intervals (i.e. every hour) to identify patients at risk for cardiac arrest. In the mobile documentation, the
MEWS is applied to identify deteriorating patients (see Table 1) (Ludikhuize et al., 2012). Using the
device means that a nurse documents a patient’s vital signs once in every hour by using the mobile
device. The device analyses the data by using MEWS as a framework. Motivation to perform the target
behaviour refers here to the nurse’s motivation to use mobile documentation to monitor vital signs at
regular intervals. Low motivation means that the nurse does not use the mobile documentation device
to document vital signs because, for example, he or she might think that it is one more new task in a
busy work shift. High motivation means that the nurse documents the vitals sign at regular intervals by
using the device. Ability to perform a target behaviour refers here to the ability to use the mobile doc-
umentation device to monitor vital signs at regular intervals. The nurse might have a low ability to use
the mobile documentation device because, for example, of a non-intuitive user interface, lack of mobile
devices, or lack of time. The trigger in this case is the visual representation of MEWS in the mobile
phone display: Colour effects demonstrate the points in the MEWS to help the nurses notice changes in
a patient’s vital signs and to identify patients at risk for cardiac arrest (see Table 2). Green refers to
zero (0) points, yellow refers to one (1) point, and red refers to two and three (2–3) points in MEWS
(see Tables 1 and 2). In this way, the trigger is associated with the behaviour: the nurse uses the mobile
documentation device at regular intervals (is motivated and has the ability) and is able to see the
changes in patient’s clinical condition in real time. This in turn supports the behaviour change, which
in this hypothetical case is using mobile documentation with a mobile device as part of the nurse’s dai-
ly routine. This enables the management of complications and further improves the quality of patient
care.
Table 2. Patient’s MEWS at 1:00, 2.00 and 3:00 p.m. in the mobile device display.
This table is a hypothetical example (i.e. not real patient data).
MEWS MEWS MEWS
1:00 p.m. 2:00 p.m. 3:00 p.m.
Heart rate Heart rate Heart rate
Systolic blood pressure Systolic blood pressure Systolic blood pressure
Respiratory rate Respiratory rate Respiratory rate
Temperature Temperature Temperature
AVPU score AVPU score AVPU score
Worried about patient’s condi- Worried about patient’s condi- Worried about patient’s condi-
tion: 1 tion tion
Urine production below 75 ml Urine production below 75 ml Urine production below 75 ml
during previous 4 hours during previous 4 hours during previous 4 hours
Saturation below 90% despite Saturation below 90% despite Saturation below 90% despite
adequate oxygen therapy adequate oxygen therapy adequate oxygen therapy
4. Directions for Future Research
This paper has considered the potential benefits of gamification to improve the quality of care of surgi-
cal patients. Further research should be undertaken to establish whether quality of care can be im-
proved by gamifying, for example, prevention, recognition, and management of post-operative compli-
cations. New knowledge on motivational affordances that produce psychological outcomes and further
behavioural outcomes (see Hamari et al., 2014) in surgical patients’ care is needed from nurses’ and
patients’ points of view.
What is now needed is a study involving researchers, practising nurses, and doctors in collaboration to
explore how gamification could be implemented in patient care. By involving nurses and doctors in the
process, their ownership regarding the new approaches can be strengthened, which increases the likeli-
hood of promoting the intended outcomes (Marques et al., 2015; de Vito Dabbs et al., 2009). One pos-
sible methodological approach could be design-based research, which leads to the development of
knowledge that advances pragmatic and theoretical aims (Design-Based Research Collective, 2003;
Wang & Hannafin, 2005). Design-based research is well suited to gamifying work processes since it is
conducted over a long period within a single real-life setting, which increases the likelihood that gami-
fication can be embedded in the daily routines of nurses’ work and patient care. Another possible re-
search design could be a randomised controlled trial that investigates the effectiveness of a gamified
GamiFIN Conference 2017, Pori, Finland, May 9-10, 2017 154
intervention to prevent surgical patients’ cardiac arrests by using an intervention group and a control
group. Nevertheless, in order to implement gamification in the healthcare sector on a larger scale, more
research is needed to better understand the benefits of gamification for the ownership and the meaning-
fulness of nurses’ work.
References
AlMarshedi, A., Wanick, V., Wills, G.B. & Ranchhod, A. (2017). Gamification and Behaviour. In S.
Stieglitz et al. (eds.), Gamification. (pp. 19-29) Progress in IS, doi:10.1007/978-3-319-45557-0_2
Burke JW, McNeil, MDJ, Charles DK, Morrow P., Crosbie JH & McDonough SM. (2009). Optimising
engagement for stroke rehabilitation using serious games. Visual Computer, 25, 1085–1099. DOI
10.1007/s00371-009-0387-4.
de Vito Dabbs, A., Myers, B. A., McCurry, K. R., Dunbar-Jacob, J., Hawkins, R. P., Begey, A., & Dev,
M. A. (2009). User-centered design and interactive health technologies for patients. CIN: Computers,
Informatics, Nursing, 27(3), 175–183. doi:10.1097/NCN.0b013e31819f7c7c
Design-Based Research Collective. (2003). Design-based research: An emerging paradigm for educa-
tional enquiry. Educational Researcher, 32(1), 5–8.
Dev, P., Heinrichs, L. R., & Youngblood, P. Y. (2011). CliniSpace: A multiperson 3D online immer-
sive training environment accessible through a browser. Stud Health Technol Inform, 163, 173–179.
Flinkman M., Laine M., Leino-Kilpi H., Hasselhorn H-M. & Salanterä S. (2008). Explaining young
registered Finnish nurses’ intention to leave the profession: A questionnaire survey. International
Journal of Nursing Studies, 45(5), 727–739.
Fogg, B.J. (2009). A Behavior Model for Persuasive Design. Persuasive '09 Proceedings of the 4th
International Conference on Persuasive Technology. Article No. 40 Claremont, California, USA —
April 26 - 29, 2009. doi>10.1145/1541948.1541999
Friese, C.R., & Aiken, L.H. (2008). Failure to Rescue in the Surgical Oncology Population: Implica-
tions for Nursing and Quality Improvement. Oncology Nursing Forum, 35(5).
doi:10.1188/08.ONF.779-785
Gardner-Thorpe, J., Love, N., Wrightson, J., Walsh, S. & Keeling, N. (2012). The Value of Modified
Early Warning Score (MEWS) in Surgical In-Patients: A Prospective Observational Study. Annals of
The Royal College of Surgeons of England, 88(6), 571-575
doi:http://dx.doi.org/10.1308/003588406X130615
Gröndahl, W. Leino-Kilpi, H. (2013). HYVÄ HOITO -mittarin kehittäminen ja käyttö 1987-2013. In
W. Gröndahl, H. Leino-Kilpi (edit.) Potilaslähtöinen hoidon laatu - näkökulmia arviointiin. University
of Turku. Department of Nursing Science. A:67/2013.
Graafland, M., Schraagen, J. M., & Schijven, M. P. (2012). Systematic review of serious games for
medical education and surgical skills training. British Journal of Surgery, 99, 1322–1330.
Hahtela N, Paavilainen E, McCormack B, Helminen M, Slater P & Suominen T. (2015). Nurses’ per-
ceptions of workplace culture in primary health care in Finland. International Nursing Review. DOI:
10.1111/inr.12207
Hahtela N, Paavilainen E, McCormack B, Slater P, Helminen M & Suominen T. (2014). Influence of
workplace culture on nursing-sensitive nurse outcomes in municipal primary health care. Journal of
Nursing Management. doi: 10.1111/jonm.12237.
Hamari, J., Koivisto, J. & Sarsa, H. (2014). Does Gamification Work? — A Literature Review of Em-
pirical Studies on Gamification. 2014 47th Hawaii International Conference on System Science.
GamiFIN Conference 2017, Pori, Finland, May 9-10, 2017 155
Huotari, K. & Hamari, J. (2011). “Gamification” from the perspective of service marketing. CHI 2011,
May 7–12, 2011, Vancouver, BC, Canada. ACM 978-1-4503-0268-5/11/05.
Koivisto, J-M., Multisilta, J., Niemi, H., Katajisto, J., & Eriksson, E. (2016a). Learning by playing: A
cross-sectional descriptive study of nursing students’ experiences of learning clinical reasoning. Nurse
Education Today, 45, 22–28. doi:10.1016/j.nedt.2016.06.009.
Koivisto, J-M., Haavisto, E., Niemi, H., Katajisto, J., & Multisilta, J. (2016a). Elements explaining
learning clinical reasoning using simulation games. International Journal of Serious Games, 3(4), 29-
43. http://dx.doi.org/10.17083/ijsg.v1i4.47
Koivisto, J. & Hamari, J. (2014). Demographic differences in perceived benefits from gamification.
Computers in Human Behavior, 35, 179–188.
Ludikhuize, J., Smorenburg, S. M., de Rooij, S. E., & de Jonge, E. (2012). Identification of deteriorat-
ing patients on general wards: Measurement of vital parameters and potential effectiveness of the Mod-
ified Early Warning Score. Journal of Critical Care, 27(4), 424.e7–424.e13.
doi.org/10.1016/j.jcrc.2012.01.003
Marques, R., Gregório, J., Mira da Silva, M. Lapão, L.V. (2015). Using gamification for improving
nurses’ productivity in a hospital ward. II International Workshop on Gamification in Health: gHealth
2015.
Reeves, T. C., Herrington, J., & Oliver, R. (2005). Design research: A socially responsible approach to
instructional technology research in higher education. Journal of Computing in Higher Education,
16(2), 96–115.
Resuscitation (online). Current Care Guidelines. (2016). Working group appointed by the Finnish Med-
ical Society Duodecim, the Finnish Resuscitation Council, the Finnish Society of Anaesthesiologists
and the Finnish Red Cross. Helsinki: The Finnish Medical Society Duodecim, 2016 (referred March
20, 2017). Available online at: www.kaypahoito.fi
Soar, J., Nolan, J. P., Böttiger, B. W., Perkins, G. D., Lott, C., Carli, P., … Deakin, C. D. (2015). Euro-
pean Resuscitation Council guidelines for resuscitation 2015, section 3: Adult advanced life support.
Resuscitation, 95, 100–147. doi.org/10.1016/j.resuscitation.2015.07.016
Steelman, V.M. (2014). Pursuing Excellence Through Patient Engagement. AORN Journal 100(2),
119-122. http://dx.doi.org/10.1016/j.aorn.2014.06.001
van Oostveen, C.J., Vermeulen, H., Nieveen van Dijkum, E.J.M., Gouma, D.J. & Ubbink, D.T. (2015).
Factors determining the patients’ care intensity for surgeons and surgical nurses: a conjoint analysis.
BMC Health Services Research, 15, 395. doi:10.1186/s12913-015-1052-4
Wang, F., & Hannafin, M. J. (2005). Design-based research and technology-enhanced learning envi-
ronments. Educational Technology Research & Development, 53(4), 5–23.
GamiFIN Conference 2017, Pori, Finland, May 9-10, 2017 156