“Accentus” - Experiencing the consequences of a lack of staff in Swedish healthcare through a serious game

(1)

“Accentus” - Experiencing the consequences of a

lack of staff in Swedish healthcare through a serious

game

Betty Brändström

Andreas Undfors

(2)

Abstract

The Swedish healthcare industry has been in a crisis and suffered from a lack of staff and high burnout rate for many years. In this thesis we explore the possibility of bringing this to everyones’ attention by developing a serious game, where the player can experience and learn about the issues from within a hospital. Our goal is to provide a way for the player to increase their knowledge on the issues and inspire a desire to participate in the ongoing healthcare debate. Although the ability to promote engagement appears bleak, the results suggest that serious games do have the potential to educate, both on this matter and in general.

(3)

9.5 Appendix E - Pre-test questionnaire questions 67 9.6 Appendix F - Post-test questionnaire questions 69 9.7 Appendix G - Post-test interview questions 70 9.8 Appendix H - Questionnaire answers summary 71 9.9 Appendix I - Questionnaire individual answers summary 75 9.10 Appendix J - Post-test interview answers summary 82

Response Letter to reviewers 88

Response to Reviewer 1: 88

Response to Reviewer 2: 88

Response Letter to opposition 89

Response to Opponent 1: 89 Response to Opponent 2: 90 Response to Opponent 3: 91 Response to Supervisor: 93 Response to Examiner: 93 Final Build 94

(6)

1. Introduction

For a number of years Swedish healthcare has been ranked among the top healthcare systems in comparisons performed by different organizations, such as WHO and EHCI 1 [1], [2]. This primarily due to its high quality of outcome in healthcare services and the 2

overall high life expectancy of the Swedish people. The system is also recognised for being universal for all of its citizens, publicly funded, and decentralized from the central government. On the other hand, important issues that have kept it from being an exemplary system is its longstanding poor accessibility and difficulties in staff recruitment _[3].

As statistics show, Sweden is in the group of OECD countries with more than the 3 average amount of nurses (10.9 versus an average at 8.8) and doctors (4.1 versus an average at 3.5) per 1000 population _{[4]. Still, Swedish government agencies report a} shortage of staff including both professions, with nurses and specialist nurses in particularly high demand _{[5]. Across its 21 regions, that are responsible for financing} and providing healthcare services, the majority reports an acute need of several medical professions _[6].

Over the years, the issue and its consequences has been actively reported on by the Swedish media, and is commonly referred to as the _{healthcare crisis}. With serious consequences such as increasing waiting times, overcrowding, outlying patients, increased workload for staff, and risking patient safety _{[7], the lack of qualified} healthcare personnel might certainly be described as a crisis.

Despite being continuously given attention in the media and even becoming a central topic in political discussions, the crisis continues, and in some areas, for example accessibility, the situation is getting worse _{[3]. Hence, it remains highly important to} keep the healthcare debate alive and relevant for as long as it is still an issue. There is also a need to add an argument to the debate in which the consequences are conveyed in a way that they are experienced. Evidence points to when an issue is experienced rather than just shown and/or talked about, humans are more inclined to become empathetic and willing to help and take action _{[8], [9]. In addition, people tend to learn} more efficiently about different topics through active learning (for example via a video game _{[10]) than passive learning [11].}

As the dynamic, responsive and visualised nature of video games generally produce a high motivational factor, immersive experience and strong user involvement _{[12], the}

1_{The World Health Organization} 2_{Euro Health Consumer Index}

(7)

medium through which we aim to bridge the previously stated concerns is a digital game. More specifically, a serious game.

Today, serious games have become a popular tool in various applicable areas for purposes such as raising awareness, educating and informing the end-user_{[13]. The} concept itself has over the years had many proposed definitions. With the most commonly agreed upon being ‘_{games that do not have entertainment, enjoyment, or}

fun as their primary purpose’_{[14, p. 3]. In essence, this means that serious games are}

games designed for purposes other than mere entertainment. They provide an advantage of offering the player to experience situations that are otherwise impossible and/or difficult to reproduce in the real world due to reasons of safety, time, cost, etc. [15]_.

This is why a serious game offers a great opportunity to put the player front and center in the stressful environment of a hospital. With this tool a working situation can be simulated where the player, on little resources, is expected to manage the high-pressure and difficult choices of everyday healthcare workers. The player is exposed to the consequences of a lack of staff similar to those that have been identified in real-life for this paper. The game is designed to be immersive and engaging, vivifying the experience in having to face the consequences of how the player has chosen to spend their resources, i.e. the staff. Also, the game showcases the other side of the healthcare business which is a point of view that can be hard to visualize for a person outside of it.

This paper implements a design research methodology which is well suited for designing and developing a serious game. More specifically, the suggested six-step process provided in Peffers et al. _{[16], has been followed for the creation of the artifact.} Furthermore, a design framework for serious games described by Annetta in “The “I’s” Have It” _{[17], is used for designing purposes. Expert opinions and feedback from four} professional healthcare workers has also been utilized to support and validate the design of the artifact.

1.1 Target audience

The main audience for this study is anyone in the general public who lacks or seeks a deeper and experiential understanding of the consequences of the so called _healthcare crisis in Sweden.

Because the artifact developed is a serious game, the target audience primarily includes people with some form of previous digital gaming experience. Ranging from the ages of younger to older adults. It is also primarily aimed at those who are not too well acquainted or familiar with the healthcare environment. I.e. non medical professionals. This is due to the fact that healthcare workers most likely already have a profound and first-hand experience of what the consequences of a limited staff are.

(8)

1.2 Purpose

There are two main purposes for this study. The first one is to create a serious game designed to immerse the player into a stressful hospital environment, to make them face and experience the issues in Swedish healthcare. It is a contribution to the healthcare debate, hopefully reaching more and/or a different range of people than traditional media. This contribution also aims to convey the message as more of an experience rather than just hard facts and information, to deepen and impact the players' understanding of the issues in Swedish healthcare.

The second purpose is to provide data on whether or not a serious game can be used to engage the player in the ongoing healthcare debate. I.e. can the game motivate the player to become more mindful of and/or inclined to take action in the debate.

1.3 Research questions

The research questions this study aim to answer are:

RQ1: How did the players' understanding, about the consequences of a shortage of staff in Swedish healthcare, change after playing the game?

RQ2: How did the players’ opinion and everyday engagement in the ongoing healthcare debate change after playing the game?

2. Related research

In this section three main categories of related research are presented. The first contains the framework of related research in the field of serious gaming, on which this study is based. The second presents a few selected digital games that were analyzed and used as inspiration for design and development of the artifact. Lastly, the third category contains research supporting the consequences of a lack of qualified staff in Swedish healthcare.

2.1 Serious games

Because the field of serious gaming is wide and diverse, so are the results of its present research _{[9]. Different application areas include educational games, healthcare games,} advertising games, public policy and political games, etc., with purposes to provide an experience, inform, educate, train, market, influence and/or change behaviours _[15], [18]_{. As established by Boyle et al. [9], the diversity is reflected in the research, which} varies depending on the aim of the studies, outcomes reported on, underlying theoretical frameworks and methodologies implemented. Furthermore, while many classification systems have been proposed over the years _{[14], the lack of a general}

(9)

and accepted taxonomy persists and contributes to the diverse results seen in the field [19]_{, [20].}

Despite this difficulty, previous research shows promising results for knowledge acquisition through serious games across various disciplines _{[9]. Simultaneously, the} amount of scientific evidence pointing to the benefit of their persuasive effects is starting to increase _{[8]. In some literature serious games that are designed with a} purpose to convey a serious message of some kind are referred to as persuasive games (sometimes also called news games)_{[10], [21]. This subcategory seems to be} generally accepted by the community and is gaining attention by researchers and developers alike. These games generally aim to change, influence and/or reinforce the players attitude or thoughts through experiential and meaningful gameplay _{[8], [21].} Since the first aim of the artifact is that it gives the player a deeper understanding about issues in Swedish healthcare through experience, and the second is that it conveys a message of the seriousness of the consequences to promote action. It can be argued that it falls under the category of a serious game with both educational and persuasive qualities. When compared to traditional informative and educational methods, various studies in educational and persuasive serious games indicate that they both have a bigger potential of providing a more lasting impact and knowledge retention _{[9], [8].} Additionally, a study showed that a group that played one of the most recognized serious games of today, _{Darfur is Dying [22], had a significantly higher motivation to} help with the difficulties in Darfur, than the control group that was provided the same message and information via text or a video clip _{[23]. While the authors did not draw} any definitive conclusions, they suggest that the interactive and experiential nature of video games may have promoted more empathy in the player, contributing to the participants willingness to help and take action.

However, the theory of serious games having either a longer lasting effect and/or bigger impact compared to other learning or informative methods is considered out of scope for this paper and is not further investigated. Nevertheless, these previous studies are important to mention as they corroborate the potential effectiveness and benefits of serious games.

In a study by Neys and Jansz _{[21], four serious games that were developed to inform,} stimulate debate, promote action and engage people about a social and/or political issue through gameplay, were analyzed and tested on a total of 80 participants. The results showed that on average, participants expressed an increase in knowledge of the issue with about 33.75%, and that they had changed their attitude or opinion of the issue with 24.63%. The total number of participants expressing this gain in knowledge was 75%, and 25% expressing the change in attitude. Also, more than half reported that after having played the game they were more inclined to share their learnt experience as well as discuss the topic of the game with their friends. This points to the

(10)

ability of serious games to cause and stimulate debate about serious topics, while simultaneously being of educational and attitude changing value.

Based on the above research evidence suggests that a serious game with both educational and persuasive properties, is the tool through which the defined purposes of this study is achieved. As expressed by Protopsaltis et al. _{[18], digital games are} immersive media through which learners can directly experience real-world issues, along with the practical and emotional consequences of their choices. Which appropriately sums up the final intent of the artifact.

2.2 Other games

In this section two video games are presented. The games were analyzed and used as inspiration for how hospital environments and related concepts can be designed in a digital environment. While these games may have been developed with a totally different purpose than the ones for this study, there was still valuable information to be gained with regards to how different healthcare and hospital aspects can be implemented and portrayed.

Code Yellow

Made by BreakAway games, a leading serious game developer, _{Code Yellow is a} serious hospital management game specifically targeting healthcare personnel. The game allows a single or several players to take on different roles such as upper management, doctor, nurse, triage and/or security, to practise and develop skills for4 how to prepare and handle certain stressing situations at a hospital. Such as a mass casualty incident _{[24], [25].}

The game provided a look into how the real work-flow of a hospital can be portrayed, as well as how staff and patient related information can be presented to the player.

Project Hospital

A detailed hospital simulation and management game developed by the indie game studio Oxymoron games _{[26]. While not declared a serious game, Project Hospital} provides an realistic and in-depth experience into the environment and work-flow at a hospital _{[27]. Except for the tutorials, the player can choose to play in either sandbox} mode, where they can build a hospital or small clinic from scratch, or campaign mode, where they start with a pre-built building. They then have to manage their hospital, which they can do on a very detailed level by stepping into the shoes of the healthcare personnel, diagnosing and treating each individual patient, or leave this type of in-depth medical management to the AI.

4_{The process in which medical personnel determines a patients’ priority based on their}

(11)

The information and inspiration gained from the game ranged from basic hospital work-flow, to work tasks performed by different healthcare professionals at certain care units.

2.3 Consequences in healthcare

The issues described below were selected as the consequences to be portrayed in the artifact. They were selected based on data collected during the literature research as well as input from the healthcare professionals consulted for this study. Furthermore, it should be acknowledged that there most likely exist additional real life outcomes to the issue of a lack of staff in hospitals.

High workload, stress and burnout

The lack of qualified staff in Swedish healthcare results in a vicious cycle of consequences, where each feeds into the next. A regular and occurring issue is stress and burnout, which is causing every fifth nurse to leave the profession within the first five years after graduating _{[28]. This issue becomes present when an understaffed} workplace has to be driven at a level that produces a high workload for its staff and ends up being the majority reason for an employee quitting _{[29]. The staff turnover then} feeds right back into the issues of increased stress and a higher workload for the personnel that remains. Being persistently exposed to this stressful environment also contributes to the risk of professional mistakes being made by the staff, and thereby risking patient-safety _[7].

Overcrowding and outliers

In Swedish healthcare, overcrowding is a term used when inpatients are treated in care units which cannot guarantee that all necessary medical equipment and resources needed for proper treatment is available _{[30]. Outlying patients, or outliers, refers to} patients that are moved to different care units which do not offer the specialist care needed to properly treat the patient _{[30]. Overcrowding wards and outlying patients both} result in a working environment which poses a greater threat in causing patient injuries [31]_{. As described in a report by Socialstyrelsen [30], issues with overcrowding and} outliers have steadily been increasing in 2014-2018 and remains a relevant consequence of the lack of qualified staff today.

Poor accessibility

Poor accessibility with long waiting times has been a longstanding issue in Swedish healthcare _{[3]. The so called health guarantee act}, stipulates the maximum amount of time a patient has to wait before getting access to a specific healthcare service, and was implemented to address the accessibility issues _{[32]. While some regions are more} successful at keeping to the guarantee than others, accessibility is still a big issue for most_{[33]. One of the problems is that there is simply a lack of qualified personnel, and}

(12)

care providers are having difficulties in manning the available beds in their care units. For a bed to be considered disposable (i.e. available for use), it has to be ‘ _{designed for}

inpatient care and have access to equipment and qualified staff which will ensure

patient-safety and the working environment of the personnel ’ _{[30, p. 49]. Therefore,}

there are usually a lot less beds at the healthcare providers disposal than there are actual physical beds available in a unit _[7].

The poor accessibility poses multiple serious risks to patient-safety, including delayed diagnoses and treatments, which risks that a patients' condition escalates in the meantime _[5].

3. Method

The methodology that is used for this paper is the design research approach as explained by Peffers et al. _{[16]. This methodology consists of six iterative steps that are} well suited for the development of an artifact. The six steps are described in detail below and can also be seen in Figure 3.1.

1. Problem identification and motivation: In the first step, define the specific research problem and justify the value of the solution.

2. Define the objective for a solution: In the second step, infer the objectives of a solution from the problem definition and knowledge of what is possible and feasible. The objectives of a solution can be either qualitative or quantitative. 3. Design & development: In the third step, create the artifact. This includes

determining the artifact’s desired functionality and architecture, and then also creating the actual artifact.

4. Demonstration: In the fourth step, demonstrate the use of the artifact to solve one or more instances of the problem. Examples of demonstrations are its use in experimentation, simulation, case study, proof or other appropriate activity. 5. Evaluation: In the fifth step, observe and measure how well the artifact

supports a solution to the problem. This involves comparing the objectives of a solution to the actual observed results from use of the artifact in demonstration. From this step it is also possible to reiterate back to the third step to try to improve the effectiveness of the artifact or to continue to the last step.

6. Communication: In the sixth and last step, communicate the problem and its importance, the artifact, its utility and novelty, the rigor of its design, and its effectiveness to the relevant audiences.

(13)

Figure 3.1 - visually showcasing the steps of the design research methodology

3.1 How the method has been used

In the following section, a more detailed description of the previous steps and what they mean when it comes to the work of this paper is presented.

Problem identification and motivation

Swedish healthcare has been ranked among the top healthcare systems for a number of years _{[1], [2], but the staff is rapidly burning themselves out due to the stress and} lack of personnel. Patients are experiencing long wait times while the hospital is lacking in experience within certain fields and at the same time are having trouble with recruiting_{[3], [7]. In this area and because of these issues, there is room to expand on} the way information is provided and gathered in order to engage, motivate and spark debate. The medium to accomplish this in, is a serious game. Through a serious game the player is put front and center in the environment which allows the opportunity to experience these issues first hand, which research shows promote a deepened sense of responsibility and empathy in the subject _{[9], [23]. As there currently exists no serious} game matching these requirements, one is specifically designed, developed and utilized for this study.

Define the objectives for a solution

The solution is a serious game with the main objective to showcase and portray the struggles and issues in the Swedish healthcare system, in order to impact and deepen the players understanding of these issues. The secondary objective is that the solution can be used as a tool to persuade and motivate the player to become more engaged and inclined to take action in the Swedish healthcare debate. These objectives are closely connected with the research questions of this paper.

(14)

Design & Development

To achieve the objectives described above, the game is designed following a framework which specifies the fundamentals for optimal learning in serious games. A second aspect is also incorporated into the design process, which is the inclusion of subject matter experts. Implementation and description of both are presented in detail below. Furthermore, the game is developed for PCs using the cross-platform game engine Unity _[34].

Design framework

The model chosen for the design of the artifact is one established by Annetta in 2010 [17]_{. The framework defines six elements necessary for the development of a} successful serious educational game. The elements include the following;

Identity

Important to serious and entertaining games alike, is the element of player identity. Studies show that a sense of identity enables the player to feel that they are unique within the digital environment and are more likely to become invested in the game _[17]. By identifying with a mediated character, players are sensitive to outcomes that are perceptual, cognitive, emotional and motivational _{[35]. Meaning that the player is} absorbed into the characters environment, puts themselves in the mind of the character, develops empathy for the character, and shares the goals of the character. Thus, promoting immersion and engagement.

With these studies in mind, the artifact has a customization feature implemented that allows the player to choose how the character will look or appear in the game. Examples of the different choices that are available to be made are hair color, skin tone, gender and hairstyle.

Immersion

As expressed by Annetta _{[17], immersion in a video game can be compared to totally} losing oneself in a book, reading for several hours straight. Players are able to reach a state of immersion when they identify with the mediated character while also being thoroughly engaged and intrinsically motivated to succeed with the goals of the game [17]_{. When these criteria are achieved, the player enters a state of flow, which is the} ultimate goal of good game design. Annetta refers to eight characteristics, defined by Csikszentmihalyi_{[36], that become recognizable when a person is in a state of flow. For} example, the player gets fast feedback, is deeply involved, loses sense of self-awareness and feels that the goal is attainable and clear.

With these studies in mind, the artifact has a focus on providing good visual feedback, from choices that can be made as well as different options or areas that can be

(15)

selected. The artifact also has controls and movement that are easy to understand, and with the previous focus on identity, provide an experience that makes the transition into a state of flow easier.

Interactivity

Social communications in a game support the overall effectiveness of the learning process as it promotes further engagement _[17].

With this description of interactivity in mind, the artifact has a scoreboard feature to promote social engagement. It shows the overall success of the game session, including for example the overall patient happiness and health. The scoreboard offers some minor player to player interaction through comparison of game session stats.

Increasing complexity

In order to keep the player in a state of flow, it is important that as the player progresses, the complexity of the game increases. As explained by Annetta _{[17], the} learning process is at its most effective when a student is challenged to the extent of their abilities. If the task at hand is made either too easy or too difficult, the subject may become disengaged, frustrated or bored.

The difficulty and complexity of the artifact naturally increases with time and progress, as the player is starting out treating a number of patients and is continuously being given more to handle.

Informed teaching

Defined by Annetta as ‘_{the feedback and embedded assessments within the serious}

educational game’ _{[17, p. 5], informed teaching describes the process of recording the}

players data and actions in order to further enhance learning.

The artifact displays feedback to the player in the form of a scoreboard, at the end of the game. The player will be able to see the results of their actions, including how many times staff members got burnt out, if any healthcare mistakes were made, how many patients were treated or outlied, and their overall health and happiness.

Instructional

When a video game successfully incorporates all the above components, they are considered instructional tools for learning _{[17]. However, Annetta also points out that} educational games are at their best when the active learning is done “stealthy”. Meaning that when the player is thoroughly immersed in a game, they become unaware of the fact that they are actually learning and picking up lessons from embedded content.

(16)

The consequences of a lack of staff in healthcare are the main stealthy learning points in the artifact. Such as the staff getting stressed, patients having to wait, and wards getting overcrowded. As the game progresses, this becomes more and more evident to the player.

Domain expertise

While the focus of the game is not to educate the player in medical or clinical knowledge, it is important to design the game in a sufficiently realistic way to provide an immersive experience for the player _{[18]. This may include everything from the digital} environment and characters, to interactivity, general game-flow and mechanics. In order to achieve this level of simulated realism, professional medical workers, as well as people in regular contact with the Swedish healthcare system (hereafter referred to as patients), are consulted and interviewed.

The input opinion of domain professionals has many benefits in serious gaming, as emphasized by many researchers in the field _{[10], [37], [38], [39]. Generally referred to} as ‘_{subject matter experts}’ _{[10, p. 2], these people can provide in-depth understanding} of a problem domain, and may range from a single individual to an entire company or organization. Typically, the experts are integrated as a part of the development team and are involved from the get-go in design, initial development and testing _[39].

The group of subject matter experts consulted for this paper consist of one nurse assistant, one doctor, two nurses and two patients. Their role is that of consultants for the main design of the game, as well as playtesters and testers for the initial pilot tests.

Demonstration

In order to demonstrate and test if the artifact is capable of solving one or more instances of the problem, test-sessions are held with about 8-10 people in the target audience. The testers are allowed to play through the game under supervision, but there is no intervening unless there is a problem with the artifact. There are two different questionnaires for the testers to fill out, one before they play the game and one after. Pre- and post-questionnaires are an effective and common method of determining if a game had an impact on the tester. They are used as a measuring tool to see how well the artifact has performed in solving the problems such as explained in the _problem

identification and motivation section. In addition to the questionnaires, an interview is

held. The purpose of the interview is to allow the tester to express themselves more freely and in-depth.

All test-sessions are held through an online communications tool such as Discord or Skype, depending on the testers preference. The only requirement is that the tool should allow for clear voice-on-voice communications as well as screen sharing.

(17)

To minimize the chance of encountering a problem during the test-sessions, two pilot tests are held before the test-sessions begin. This to make sure that the questionnaires are correct and understandable, while also providing an opportunity to take note on how well the game is understood and if there is any flaw in game design.

As explained before, there are two types of questionnaires for the tester to fill out. The first is a pre-test questionnaire and the second a post-test questionnaire. Except for two initial questions acquiring basic knowledge about the tester, the content of the questionnaires are identical. This way a comparison of the answers can show whether or not the artifact has had an impact and effect on the tester. The questions consist of linear-scale, ‘Yes’ and ’No’, as well as checkbox answers. This effectively measures and controls the testers knowledge and engagement of the topic, prior and after the game session.

After the post-test questionnaire has been answered by the tester, a short interview is held. This interview consists of five questions which will allow the tester to go into more detail and freely express their experience of the session. The questions control whether or not the tester has fully understood the underlying purpose of the artifact as well as determine if current events, i.e. the corona pandemic, has had any influence on their answers.

Evaluation

For this step, a deeper look and comparison of the data on the two different questionnaires is performed, along with an analysis of the interview answers. This is brought into the purpose of reviewing if the player has had an increase in knowledge, engagement and motivation for the ongoing healthcare debate and the consequences of a shortage of staff in this industry.

The overall success of the artifact will be based on a set combination of questions from both questionnaire and interview, which all are designed to measure some form of increase, improvement or change in the participants. Evaluating the increase in understanding takes question 1 and 2 of the questionnaire (see Appendix E), plus question 3 of the interview (see Appendix G) into account. Evaluating the increase in engagement takes question 4 and 5 of the questionnaire (see Appendix E), plus question 4 of the interview (see Appendix G) into account.

This, in relation with the research questions, is the main point of evaluation for the artifact.

(18)

Communication

In this last step, results are presented from the questionnaires and the_{evaluation step.} A discussion is also introduced, revolving around how the results compare to the research questions.

3.2 Method Discussion

As explained in the previous sections, the adopted method for this paper is the design science research method established by Peffers et al. _{[16]. It is typically used in studies} and research aiming to iteratively design, develop and test an artifact as a solution to their specified problem _{[40]. Created specifically for such purposes, the methodology} stands out as a suitable and clear choice.

With the help of subject matter experts, the artifact developed for this study is iteratively designed and tested. Said experts do not only contribute with the overall design of the game, but help validate the issues dealt with in this paper with their real life experiences.

3.3 Pilot-tests

Prior to the official test-sessions, two pilot-tests are conducted. One of these is with a tester that has previous insight or experience within the healthcare industry, i.e. a healthcare professional, while the other is with one without. While the target audience of the artifact is the general public with no medical expertise, a healthcare professional may provide valuable feedback on the artifact and the way that data is collected during this stage.

The testers are both informed that they are only part of the pilot-testing and that they are free to give any kind of feedback during the test-session. Also, the data collected in these pilot-tests are not taken into account in the final results.

The first pilot-test

The first of the pilot-tests was held over Skype with a healthcare professional. They were informed that they were only part of a pilot-test session and were encouraged to give feedback at any time. The tester filled out the pre-questionnaire before the session began, and the post-questionnaire after playing the game. When they had completed the post-questionnaire, the interview was held.

The following is a summary of open feedback given by the tester during and after the test-session;

1. The different colors of the active character marker in the game are confusing. For example, the marker above the doctor character is red, which makes one think that there was something wrong with the character.

(19)

2. The general speed and flow of the game gets slowed down by not being able to change the active characters action before they have completed a task or reached the selected room. This proves very annoying when one accidentally clicks the wrong action or sends the wrong staff member to perform a task. 3. The first and second question of the post-interview felt very similar.

The following actions were taken after the pilot-test to address the feedback;

1. The active character marker was changed so that it looked the same for each character, instead of having different colors for each different staff type in the game. The dark blue marker was chosen to not confuse the player with a green or red marker, which can be interpreted as the character being in a “healthy” vs “unhealthy” state.

2. Actions not limited by a timer can now be interrupted in the game. If a player for example orders their staff to a specific room or task, this action may now be changed/interrupted before they reach their destination in order to make the gameplay more fluent.

3. No changes were made to question 1 and 2 of the post-interview. The authors argue that one could not assume that all testers will have a similarity in their answers regarding question 1 and 2.

The second pilot-test

The second pilot-test was held over Discord with the same procedure as the first. The person was informed that this was a pilot-test and that open feedback was encouraged. The pre-questionnaire was filled out, followed by the game-session and concluded with the post-questionnaire and interview.

The following points were raised in the open feedback by the tester, during and after the session;

1. The speed of the side-scrolling function felt too slow. The tester desired to be able to faster move their view of one side of the hospital to the other.

2. The meaning of the color surrounding the portraits of the personnel on the UI was not clear on its own merit.

3. You should be able to stack tasks with the personnel so that you do not have to micro-manage them all simultaneously. For example clicking on every room to prepare them and have the nurse assistant prepare each room sequentially without stopping.

The following are actions taken after the pilot-test to address the feedback;

1. The speed of the side-scrolling function was increased. This will allow to quicker traverse the hospital view and control the environment in it. In addition, the ability to zoom out to get a greater view of the hospital was increased.

(20)

2. No changes were made to the color or function of the personnel portraits as they provide a fast and clear feedback of the state of each staff member.

3. No changes were made to the action system. The authors believe that the current version offers a more honest view of the real-life hospital environment and forces the person playing the game to micro-manage and be in control as much as possible.

4. The Artifact

The artifact produced for this paper is a serious game that aims to let the player experience the consequences that a shortage of staff have on the Swedish healthcare industry. Staff being overworked, patients having to wait longer, overcrowded wards and risking patient safety are some of the issues that have been focused on, among others mentioned throughout this paper. The goal is that through this artifact, the player gains a deeper and experiential understanding of the issues. Hopefully giving them a new level of meaning, promoting the players engagement in the healthcare debate. To ensure proper engagement and learning for the player, the artifact is designed following the serious game design framework established by Annetta (2010) _{[17], as} explained in greater detail in section 3.1 _{Design framework}.

The game is developed only for PC and in the Unity game engine, which was chosen due to prior developing experience. Figure 4.0 shows game components of the main game screen of the artifact.

(21)

Figure 4.0 - Picture of the main game screen. Includes counters for treated patients and

outlied patients (1), countdown-timer of current work shift (2), counter for current patients in

need of treatment (3), staff avatar/selection icons (4), selected staff profession and action

info (5), selected staff energy and morale bars (6), nurse with default appearance (7), nurse assistant with default appearance (8), doctor with default appearance (9),

selected/active staff marker (10), patients (11), patient info window 1 - before admission to

hospital (12), patient info window 2 - after admission to hospital (13).

4.1 Design & Inspiration

The planning phase for the initial game design of the artifact was spent going through various games to find something that could fit the style of what the artifact would look like, or play like. Some recognizable titles have been The Sims 4 and Fallout Shelter, which both inspired the gameplay along with level and visual design of the artifact.The Sims 4 puts the player in control of a house of people and can choose what chore or activity they should perform or what other person they should interact with. Fallout Shelter puts the player in control of a bunker of people during an apocalypse and it is up to the player to choose what activity they should engage in or what chore they should contribute with. There is an undeniable similarity between these two titles that was in line with the vision of the artifact and brought into the final design, the player being put in control of a hospital of people and is tasked with choosing what assignment they should be performing. Other examples of lesser known games that have been analyzed was Project Hospital, Code Yellow and Mini Hospital, where the first two served as inspiration for how to portray a hospital environment (as explained in section 2.2), and the last example served as a strong inspiration for the final art style.

(22)

Figure 4.1.1 - The Sims 4 (Maxis) presented on the left side and Fallout Shelter (Bethesda) presented on the right side.

Art design

The art had been discussed early in the development of the artifact and was chosen to be in the style of pixel, as it is also based out of previous experience and ease of use. Presented below in Figure 4.1.2, is an image of the game Mini Hospital which featured a pixel-styled hospital environment similar to what was envisioned for the artifact and was therefore used as the main inspiration for the art design.

(23)

An example of the artifact is shown in Figure 4.1.3. The image shows two staff members manning the triage room where the patients are seen and prioritized. To the right is the inner waiting room of the hospital, where a patient is waiting to get called by the staff. The image also shows that the currently active/controlled staff is marked by the white/blue diamond image floating above their head.

Figure 4.1.3 - The triage process. Shows the patient flow into the hospital.

For both staff and patients, two animations were designed, one for idle and one for active states. The first consists of a simple blinking animation, while the latter is shown as walking. Both were developed and implemented as frame animations.

Character design

The design of the staff members was made in close collaboration with the subject matter experts of this paper. The sleeves of a uniform should always be short, as to avoid contamination and spreading of bacteria, as well as having roomy pockets for carrying medical instruments. Each region in Sweden typically implements different colored uniforms, but the all-white work uniforms used in the artifact are typical for healthcare personnel employed in “Region Skåne”.

(24)

In real life it is usually difficult to know one medical profession from another just by looking at them, other than by observing the little color coded name tags on their chest. In the game, the staff not only have the colored name tags to separate their role from each other, but also typical movie/tv-show elements such as the stethoscope around the neck, and a doctor's coat. While this may not usually be worn by real healthcare professionals today, it is something that is familiar to almost anyone in the general public and helps the player to differentiate between the staff's medical roles. In addition to this, the staff members role will be shown in text, in the center of the player UI.

The staff's professional roles in the artifact not only differ in appearance, but also in their abilities. A triage room, or triage process, is usually manned and overseen by either nurses and nurses assistants, or a doctor and nurses assistants. So therefore, to get the patient flow starting in the game, the player has to send at least one nurse or a doctor to man the room. Another example is that the doctor is the one with the authority to discharge patients, or that the nurse assistants are the ones in charge of keeping the hospital up to standards in order to give proper healthcare.

An example of what the staff may look like is given in Figure 4.1.4 below (default appearance).

(25)

4.2 Game mechanics

In this section the main game mechanics of the artifact are described more in-depth.

Game loop

The main game loop puts the player in charge of a hospital with five employees and is tasked with admitting and treating several waves of ill patients. The procedure for treating a patient is to first bring them into the Triage where their health is examined and determined. Next step is to bring them to their room where they will be treated by all the different professional roles and when fully cured, they can be sent home. The personnel can also send away a patient to a different ward of the hospital if they feel that they cannot properly treat them or if they do not have the manpower to do so. The process that the patient goes through was created by reviewing the real-life procedure in a hospital.

The player must also maintain the energy and moral levels of the personnel and make sure that they take a moment to rest to keep up their energy and high-spirits, as to not risk an employee becoming burned out.

The game loop plays out over 15 minutes, simulating a single workshift for the staff, and the main goal is to treat as many patients as possible while retaining as;

● many patients treated, ● few mistakes,

● few sent away patients, ● low wait-time for the patients, ● high satisfaction for the patients, ● few overcrowding,

● few burned out personnel,

as possible. All of this data is shown at the end of the game loop for the player to review and reflect upon.

The amount of patients arriving at the hospital with each wave increases over the 15 minute game loop, constantly raising the difficulty level of the game and putting pressure on the player.

Character customization

The player is taken to a character customization screen when they start the game from the main menu. In the customization menu, they are able to select between four different options of hair styles and hair colors, as well as three different skin tones and

(26)

two genders. This is done for each of the five members in the hospital staff that the player controls.

The customization feature allows the player to form a sense of identity with the unique characters. This supports the first element in the framework established by Annetta [17]_{, described in greater detail in section Design & Development, Design Framework} . In Figure 4.2.1 below, the player has customized the appearance of their staff, and is ready to play.

Figure 4.2.1 Customization screen

Game statistics/score

During and at the end of the game, the player is valued based on the following game statistics;

● Amount of treated patients.

● Amount of patients sent away to a different ward, i.e. outliers.

● Amount of satisfaction the patients feel regarding their care and treatment during their stay.

● Amount of time the patients have to wait before getting assigned to a bed. ● Amount of mistakes made by the personnel due to fatigue.

● Amount of burned out staff members.

(27)

These statistics are shown to the player as their 15 minutes expire and the game comes to an end. The player is also able to view the statistics of other players in the main menu of the game. This enables some minor player to player interaction through the comparison of player “scores”, supporting the _{‘Interactivity’} element of the framework established by Annetta _[17].

In Figure 4.2.2 below, data from a single game session is shown. The session is uniquely identified by date and time and shows the overall success of the player, based on the statistics described above. A player can scroll through the saved game sessions to view each one.

4.2.2 - Statistics screen showing data from the latest game session

Learning elements

The artifact is designed to convey its core learning elements in a “stealthy” way. Annetta describes this as learning whilst being unaware that you are actually picking up lessons from embedded content _{[17]. The main message (shortage of staff in swedish} healthcare) as well as the learning elements (related consequences) are all implemented as such, and lets the player experience said issues via gameplay and embedded content.

The player experiences the shortage of staff as the game progresses, spawning larger waves of patients, making it more and more difficult for them to keep up with the staff at hand. It also makes the message more evident as the player constantly has to balance between keeping the staff happy and healthy, versus keeping the patients happy and healthy. Typically resulting in either one suffering from the negative consequences. Such consequences may for instance be that the staff gets exhausted and burnt out, or

(28)

that the patient's health decreases. These learning elements are further reinforced by the scoreboard, shown at the end of the game, where the player sees the overall outcome of their actions.

High workload, stress and burnout

The learning elements are made evident to the player over time, by not being able to manage and tend to all patients adequately enough for them to exit the hospital in full health and happiness. If the workload is too high and the player keeps the staff working without taking breaks, the overall speed and performance of the staff will decrease. If the player pushes his staff to the limit, i.e. when their energy and moral bars are at 0, the stress becomes overwhelming and the staff becomes burnt out. This paralyzes the overwhelmed staff member for 20 seconds while also making them start flashing red. Overcrowding and outliers

As the amount of patients waiting for help gets higher, the hospital runs out of available beds in which to treat the patients. The player may then choose to overcrowd the ward, i.e. put in extra beds in either the hallway or the patient rooms, to be able to admit more patients. They may also choose to send a currently admitted patient away to be treated at another ward, i.e. outlying, to make space for a new patient. However, both of these options come at a cost. The first decreases the overall morale of the staff as they will now have more than the normal amount of patients to treat at the same time, as well as their work-environment becoming clustered. The second option also decreases the morale of the staff, as a patient that is not completely treated is passed on to a different ward due to a lack of beds. Additionally, the happiness of that patient decreases. The consequences of choosing either of these options are made evident to the player by the related staff and/or patient morale and happiness bar decreasing. By choosing to forgo these actions, patients not already admitted will have to wait longer for treatment and thereby become more and more unhappy.

Poor accessibility

This learning element becomes most evident to the player when the hospital is full and there are patients waiting for help in either the reception or the inner waiting room. If the patients are kept waiting for too long, their happiness and health will start to decrease over time, which is reflected in the respective bars of the patient.

Figure 4.2.3 shows the described consequences and related scenarios. The first is a staff member that has become burnt out. The second shows an outlier (patient) leaving for another ward through the elevator. The third shows what an overcrowded ward may look like. The last displays the happiness and health bars of a patient waiting for help in the inner waiting room.

(29)

Figure 4.2.3 - Learning elements and related scenarios

5. Results

In this section the results of the questionnaires and interview will be presented and analyzed. It is composed of two main sections, where the first consists of data generated in purpose to answer RQ1 (defined in section 1.3) followed by an analysis. The latter similarly consist of data and analysis generated in purpose to answer RQ2 (defined in section 1.3).

The results are composed out of answers given by a total of 10 participants, as 2 were excluded due to being gathered from pilot testing. All participants had some form of

(30)

previous PC-gaming experience and all 10 were considered ‘non-medical experts’. I.e. no one was currently, or have ever been, working as a healthcare professional.

5.1 RQ1 Results

Data presentation - Questionnaire

As can be seen in table 5.1.1 below, 6 out of the 10 participants expressed that their understanding about the consequences of staff shortages in Swedish healthcare improved after playing the game. 2 participants showed a decreased understanding, while 2 others felt that they remained unchanged. On average, this amounts to the testers expressing an increased understanding by a total of +22%.

Table 5.1.1 - Summary of all testers self-quantified level of understanding from questionnaire question 1

Question 1: How comprehensive* would you say your understanding of the consequences of staff-shortages in Swedish healthcare is?

*Measured on scale 1-10, where 1 equals to minimum and 10 equals to maximum.

Tester Pre test answer Post test answer Change

1 3 5 +2 (+67%) 2 1 10 +9 (+900%) 3 8 9 +1 (+13%) 4 7 8 +1 (+14%) 5 5 6 +1 (+20%) 6 7 7 ±0 (±0%) 7 8 8 ±0 (±0%) 8 9 8 -1 (-11%)

(31)

9 8 7 -1 (-13%)

10 8 10 +2 (+25%)

Average 6.4 7.8 +1.4 (+22%)

In table 5.1.2 below, results of knowledge gain in the testers can be seen. 4 out of 10 showed an increase, while 6 out of 10 remained as knowledgeable as before. The average increase was +24%, which was a gain of +0.8 from 3.3 to 4.1, with a max score of 6. It should also be noted that tester 8 changed one of their chosen consequences to another.

Table 5.1.2 - Summary of all testers change in knowledge from questionnaire question 2

Question 2: Which of the alternatives* below do you recognize as consequences of

staff-shortages in Swedish healthcare?

*Alternative 1: Daily outlying of patients *Alternative 2: Increased risk of patient-safety *Alternative 3: Staff stress and burnout

*Alternative 4: Longer queues to get healthcare

*Alternative 5: Increased risk of healthcare-related mistakes *Alternative 6: Daily overcrowding

Tester Pre test answer*

*Number of checked

alternatives

Post test answer*

*Number of checked alternatives Change 1 3 4 +1 (+33%) 2 1 1 ±0 (±0%) 3 1 4 +3 (+300%) 4 5 5 ±0 (±0%) 5 3 5 +2 (+67%) 6 4 4 ±0 (±0%)

(32)

7 3 3 ±0 (±0%)

8 3 3 ±0 (±0%)

9 4 6 +2 (+50%)

10 6 6 ±0 (±0%)

Average 3.3 4.1 +0.8 (+24%)

Data presentation - Interview

4 participants (tester 2, 5, 6, 8) answered that the game had somewhat affected their understanding of the consequences of staff shortages in healthcare. 2 testers felt that the game did not affect their understanding about the issues at all (tester 1, 4), while 4 felt their understanding about consequences had increased significantly (tester 3, 7, 9, 10).

Table 5.1.3 - Summary of all testers translated answers from interview question 3

Question 3: Has the game deepened or in any way affected your understanding of

the consequences of staff shortages in healthcare? If yes, how has your

understanding changed?

Tester Answer

1 No, nothing special for the consequences of staff shortages. But an insight into how patients need to be treated by different healthcare professionals, and that it includes several roles, not just doctors etc.

2 Well, it has always been there, but you get a pretty clear picture.

3 Yes, I knew about it before, but if you look at it in the game, it became more obvious actually.

(33)

4 No, not in any way.

5 Well, maybe it made it all a little more “tangible”

6 Can see some of the problems.

7 It has affected me in such a way that you suffer with those who work in healthcare who have to work hard and may not have time to take out their entire lunch or break but have to work all the time.

8 I myself am strongly affected by the healthcare crisis and my mother works in a hospital, so I already have an understanding of how it is, but what I learned with the game is that it is not only in specialist care but also in general care, in health centers and so on.

9 Very much so, to see how staff get burned out so quickly is something that one has not really thought about before.

10 More understanding of burnout.

Data analysis

The results of the data generated from the pre and post-questionnaire, along with the post-interview, points to the fact that the testers gained some form of increased understanding about the consequences of a lack of staff in Swedish healthcare. Question 1 of the questionnaire, where the testers quantify their self-proclaimed understanding about the issue, show that 6 out of 10 feel that theirs improved after playing the game. It also showed that 2 testers did not change their level of understanding at all, and that 2 actually experienced a slight decrease. Despite this, the total average increase in understanding amounted to +22%. This increase in personal understanding of the issue is somewhat reflected in the overall outcome of question 3 of the post-interview (see question in table 5.1.3), where 4 testers said that they had gained a slight and/or general increase, 4 testers expressed a significant increase, and 2 said that it had not affected them at all.

An interesting notion here is that while the overall results of question 1 of the questionnaire seem to match with the answers given in question 3 of the post-interview, a closer comparison of the individual answers show that they do not always align as one would think. The 2 testers (tester 1 and 2) with the highest increase of

(34)

self-proclaimed understanding, as calculated from the questionnaire result, were not among those who in the interview claimed to have had their understanding most affected by the game. While tester 1 showed a +64% increase of understanding in the questionnaire (an increase from 2 to 5 on a 1-10 scale), and tester 2 showed a massive +900% increase (an increase from 1 to 10 on a 1-10 scale), their answer to question 3 of the post-interview was:

“_{No, nothing special for the consequences of staff shortages. But an insight into how} patients need to be treated by different healthcare professionals, and that it includes

several roles, not just doctors etc.” (see table 5.1.3, tester 1)

“_{Well, it has always been there, but you get a pretty clear picture.}” (see table 5.1.3, tester 2)

Given that tester 1 and 2 showed that big of an improvement in the questionnaire, one would expect an answer more aligned to such an increase in the interview as well. Similarly on the other side of the spectrum, the 2 testers (tester 8 and 9) whose self-proclaimed understanding decreased after playing the game, did not express the same in question 3 of the post-interview. While tester 8 had a decreased understanding by -11% (a decrease from 9 to 8 on a 1-10 scale), and tester 9 by -13% (a decrease from 8 to 7 on a 1-10 scale), their answers to the post-interview question 3 was:

“_{I myself am strongly affected by the healthcare crisis and my mother works in a} hospital, so I already have an understanding of how it is, but what I learned with the game is that it is not only in specialist care but also in general care, in health centers

and so on” (see table 5.1.3, tester 8)

“_{Very much so, to see how staff get burned out so quickly is something that one has not}

really thought about before” (see table 5.1.3, tester 9)

Answers such as these may suggest that the testers interpret and value the two questions differently. While one asks them to quantify their change in level of understanding, and the other asks them to express it in words, this ends up yielding somewhat different data as a result. Both are however a tool in measuring the overall change and/or improvement in the testers personal understanding about the consequences of a lack of staff in Swedish healthcare, and one does not rule out the other.

Another variable in measuring the increase in understanding is the results of question 2 of the questionnaire, which reads: ‘_{Which of the alternatives* below do you recognize}

as consequences of staff-shortages in Swedish healthcare?’ (see table 5.1.2). This

question controlled if the testers had gained any factual knowledge, by the means of the tester selecting what issues they knew about. The majority of the testers, 6 out of 10, were left with the same level of knowledge, while 4 out of 10 improved their score.

(35)

These results are more in line with the results of the post-interview, where 40% expressed a significant increase in understanding. The average change in knowledge in question 2 was +24%. This measurement does not however take a change of answer into consideration, which was the case for tester 8, who in the pre-questionnaire selected alternatives 3, 4, and 5, then changed to 2, 3 and 4 in the post-questionnaire (see table 9.9.8) . A possible explanation might be the similarity of the two alternatives, which might have caused the tester to mix them up, or a flaw in game design, promoting the change.

When looking at the average of how many participants that the artifact had a successful impact on, the results of the analyzed questions above is combined. The outcome of the questionnaire, question 1 showed an increased level of understanding in 60% of the testers, and question 2 showed that 40% improved their factual knowledge. Lastly, in question 3 of the post-interview, 40% expressed a significant increase in understanding of the issue. Summing up the result of these three questions, 46% of the testers expressed some level of increased understanding after playing the game. The combined average change in understanding, not including the post-interview question since it is not measurable in percentage loss/gain, was +23%.

5.2 RQ2 Results

Data presentation - Questionnaire

As seen in table 5.2.1 below, there were little to no changes in the participants self-expressed engagement level for healthcare-debate issues. Only 3 out of the 10 participants showed a slight increase in engagement, and 1 expressed a slight decrease. While the majority, 6 participants, showed no changes in their answer, the total average was an increase of +7% in engagement regarding healthcare-debate issues.

Table 5.2.1 - Summary of all testers self-quantified level of engagement from questionnaire question 4

Question 4: How big* would you say that your engagement in issues around healthcare, the so-called ‘healthcare-debate’, is?

*Measured on scale 1-10, where 1 equals to minimum and 10 equals to maximum.

Tester Pre test answer Post test answer Change

(36)

2 1 1 ±0 (±0%) 3 5 5 ±0 (±0%) 4 1 1 ±0 (±0%) 5 2 2 ±0 (±0%) 6 3 3 ±0 (±0%) 7 5 6 +1 (+20%) 8 6 6 ±0 (±0%) 9 1 2 +1 (+100%) 10 2 1 -1 (-50%) Average 2.8 3 +0.2 (+7%)

In table 5.2.2 below are the results of the testers' increased willingness to take certain, everyday actions to show commitment to the ongoing healthcare debate. 4 out of 10 increased in ways they would be willing to show engagement, while the 6 out of 10 majority did not. Tester 2 did however change their answer to how they would show commitment (see table 9.9.2).

Table 5.2.2 - Summary of all testers change in everyday engagement from questionnaire question 5

Question 5: Which of the following alternatives* corresponds to how you personally

would like to participate in / show commitment to issues in healthcare debate?

*Alternative 1: Read up on and stay updated on the debate *Alternative 2: Discuss the issue with friends and family

*Alternative 3: Share or spread information regarding the issue on social media

*Alternative 4: Familiarize yourself with the opinions and mindset of individual political parties

on the issue

(37)

Tester Pre test answer*

*Number of checked

alternatives

Post test answer*

*Number of checked alternatives Change 1 0 1 N/A 2 1 1 ±0 (±0%) 3 1 2 +1 (+100%) 4 2 2 ±0 (±0%) 5 1 3 +2 (+200%) 6 2 2 ±0 (±0%) 7 1 1 ±0 (±0%) 8 2 2 ±0 (±0%) 9 1 3 +2 (+200%) 10 3 3 ±0 (±0%) Average 1.4 2 +0.6 (+43%)

Data presentation - Interview

In this question, 6 participants (tester 1, 2, 3, 4, 5, 10) denied that the game increased or affected their engagement, while the other 4 (tester 6, 7, 8, 9) acknowledged some of the problems in the Swedish healthcare debate, but still remained personally uninspired.

Table 5.2.3 - Summary of all testers translated answers from interview question 4