The Experts:

Shari McKeown

Shari McKeown is the director of clinical improvement at the BC Patient Safety & Quality Council in Vancouver, Canada. She tests, teaches and publishes on the use of game science in a health improvement context and has a range of interests and expertise in mobile technology, simulation, social movement theory, large-scale change, and improvement science. Ms McKeown received a fellowship designation from the Canadian Society of Respiratory Therapists for her significant contribution to her profession. She holds a master’s degree in learning and technology from Royal Roads University and an adjunct faculty health science appointment at Thompson Rivers University.

Christina Krause

Christina Krause brings a variety of healthcare experience to her role as executive director with the BC Patient Safety & Quality Council. Her passion and interests include the use of social change models and network theory to engage and mobilise stakeholders to improve quality of care. More recently, this has expanded to include social media to create enhanced connections and shared learning. Ms Krause was an author on the Canadian Disclosure Guidelines and serves as master faculty with the Institute for Healthcare Communication’s Disclosing Unanticipated Medical Outcomes. She holds a Master of Science in community health and epidemiology from the University of Saskatchewan and a Bachelor of Home Economics in family science and nutrition from the University of British Columbia. She is also an EXTRA fellow with the Canadian Health Services Research Foundation.

Their View:

The term gamification means using elements from games (such as Monopoly and Minecraft), and applying it in a non-gaming context (such as healthcare). Gamification is seen as a way to motivate and engage people in positive change. Technology can make the process easier but it is not a crucial aspect of gamification.

There are many examples demonstrating how gamification has been used to improve heath behaviour, including Fitbit. Fitbit is a movement tracking device which incorporates several elements of game design, such as awarding badges for climbing a certain number of floors. However, incorporating game design into a health improvement system involves much more than adding points or giving out prizes.

A gamification pyramid can be used as a guide to developing gamified initiatives. The pyramid comprises: dynamics at the top, mechanics in the middle and components at the base. Dynamics include ‘big picture’ aspects, such as narrative, objective and how players improve their skills. Mechanics focuses on what happens as a player moves through the game, such as challenges, rewards and feedback loops. Components are specific, tangible manifestations of the mechanics and dynamics, such as avatars, badges, levels and leader boards.

The British Colombia (BC) Patient Safety & Quality Council’s 150 Lives in 150 Days campaign is an example of the successful use of gamification in a health improvement context. The campaign used literature to determine that for every five times a health professional uses a protocol for severe sepsis or septic shock, one life can be saved. Health professionals in BC that had joined the BC Sepsis Network were engaged with the aim of reducing sepsis mortality and morbidity. Teams from 32 emergency departments across the province voluntarily tracked every sepsis patient they screened and the protocols they used. The campaign used the gaming elements of time urgency, narrative, challenges, social networking, positive feedback, teamwork, competition and rewards.

Extrinisic motivators such as positive feedback and rewards can be incorporated into gamification, but rewards should be used with caution lest they lead to abuse or replace intrinsic motivation.

There are four primary intrinsic motivators that, when incorporated into a gamified system, will be more likely to lead to positive behaviour change:
• Autonomy – control over one’s own behaviour.
• Mastery – developing competence in a task.
• Relatedness – connection to other individuals or a community.
• Purpose – an end goal to give meaning to actions.

It can be helpful when gamifying for health behaviour to identify who the users are and what motivates them. Most people will display many of these traits in varying degrees but, generally, they can be divided into six user types: ‘disruptors’ – motivated by change; ‘philanthropist’ – motivated by purpose; ‘socialiser’ – motivated by relatedness; ‘free spirit’ – motivated by autonomy; ‘achiever’ – motivated by mastery; and ‘player’ – motivated by rewards. Gamification components will vary depending on which type is being targeted. For example, an achiever will likely enjoy different levels and progression within a game, while a socialiser will appreciate gamification components that use social networks.

When applying gamification into a health improvement context, there are 10 steps to incorporate:
• Define your objectives.
• Define the behaviour change.
• Create a meaningful narrative.
• Identify your players.
• Incorporate ‘feedback loops’ (feedback on progress and clear choices).
• Add rules and ‘onboarding’ (process for learning the ‘rules’).
• Design pathways to mastery (neither be too easy nor too challenging).
• Add gaming components (to motivate different user types).
• Find the fun (include aspects that add enjoyment).
• User testing.

Any techniques used to modify someone’s behaviour need to be scrutinised through an ethical lens, and should include patients and end-users in the development. Principles to be considered include ensuring the gamified initiative is not dangerous to others, does not discriminate, is effective and easy to understand, and is of benefit to the majority of users.

This article is adapted from Shari McKeown and Christina Krause’s intensive workshop at the APAC Forum 2016. Ms Krause will facilitate two sessions at this year’s APAC Forum: a full-day intensive workshop, I 02: Striking the Balance: Approaches to Accountability and Quality Improvement to Achieve Results, and concurrent session D5: Leading Change Through Optimising Organisational and Individual Energy. Click here to register for the APAC Forum 2017.

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