IN
DEGREE PROJECT MEDICAL ENGINEERING, SECOND CYCLE, 30 CREDITS
STOCKHOLM SWEDEN 2020,
Reduce Stress among
Nurses through Gamification
- A Study of Finding Stress Factors among
Nurses and Suggesting Gamification to Reduce Stress
ADAM SMITH
KTH ROYAL INSTITUTE OF TECHNOLOGY
Reduce Stress among Nurses through Gamification
- A Study of Finding Stress Factors among Nurses and Suggesting Gamification to Reduce Stress
ADAM SMITH
Master’s in Medical Engineering Date: December 18, 2020
Supervisor: Maksims Kornevs Examiner: Sebastiaan Meijer TRITA-CBH-GRU-2020:297
School of Engineering Sciences in Chemistry, Biotechnology and Health Swedish title: Minsker Stress bland Sjuksköterskor genome Gamification
Acknowledgement
I would likely show my gratitude to my supervisor, examiner, and groupmate for helping me to complete the research project.
Abstract
This study shows that stress is one of the important issues which may have a negative impact both in physical and mental effects on a nurse's working life. Poor ergonomics of the hospital and a poor behavior approach of nurses can cause stress. To reduce these stress factors, this study suggests solutions based on gamification that imply activities to create a good working environment and to reduce the stress to ensure the good health and well-being of the nurses who work different shifts especially in night shifts. To achieve the purpose, qualitative research is used as a method. For this study, nurses who work in hospitals were interviewed in different shifts especially in night shifts with some open-ended questions related to stress and gamification. Based on their answers, trying to evaluate and analyze the problem and findings.
Based on the findings, a gamification concept was developed to provide recommendations to handle the stress and to be motivated and engaged to develop the well-being of life.
Key words: stress, factors, stress management (SM), nurse, shifts, behavior change, gamification
Sammanfattning
Denna studie visar att stress är en av de viktigaste frågorna som kan ha en negativ inverkan både på fysiska och mentala effekter på sjuksköterskans arbetsliv. Dålig ergonomi på sjukhuset och sjuksköterskors dåliga beteende kan orsaka stress. För att minska dessa stressfaktorer föreslår denna studie lösningar baserade på gamification som innebär aktiviteter för att skapa en bra arbetsmiljö och för att minska stressen för att säkerställa god hälsa och välbefinnande hos sjuksköterskor som arbetar olika skift, särskilt på nattskift. För att uppnå syftet används kvalitativ forskning som metod. För denna studie intervjuades sjuksköterskor som arbetar på sjukhus i olika skift, särskilt på nattskift med några öppna frågor relaterade till stress och gamification. Baserat på deras svar, försöker utvärdera och analysera problemet och resultaten.
Baserat på resultaten utvecklades ett spelkoncept för att ge rekommendationer för att hantera stress och för att vara motiverad och engagerad för att utveckla livets välbefinnande.
Nyckelord: stress, faktorer, stresshantering (SM), sjuksköterska, skift, gamification
Table of Contents
Chapter one ... 1
Introduction ... 1
1.1 Overview ... 1
1.2 Purpose ... 4
1.3 Research question ... 4
1.4 Thesis structure ... 4
Chapter two ... 5
Background ... 5
2.1 Stress factors among nurses in workplace ... 5
2.2 Gamification ... 8
2.2.1 Gamification in health-care system ... 8
2.2.2 Gamification as a general stress management tool ... 9
Chapter three ... 14
Methodology ... 14
3.1 Research design ... 14
3.2 Sampling procedures ... 15
3.3 Interview and Data collection instruments ... 15
3.4 Data analysis ... 16
3.5 Generating gamification concepts ... 16
3.5.1 Brainstorming ... 16
3.5.2 Interview ... 17
3.5.3 Clustering ... 17
3.5.4 Filtering, selecting, and combining concepts for designing gamification ... 18
Chapter four ... 19
Results ... 19
4.1 Findings ... 19
4.2 The process of gamification design (brainstorming, clustering, filtering, selecting, combining and design) ... 23
Cluster Drawing ... 23
Chapter 5 ... 27
Discussion ... 27
5.1 Results and Recommendations ... 27
5.2 Limitation of the method ... 29
5.3 Analysis of the designing gamification ... 29
Chapter six ... 32
Conclusion ... 32
References ... 34
Appendixes ... 38
A list of Tables
Table 1. The summary of the findings about stress factors………..22 Table 2. The glimpse of the discussed actions during the interviews………..23
Table 3. The feedbacks about this game design from nurses are given below………..23
Chapter one
Introduction
1.1 Overview
Human-environment interfaces related to healthcare include noise, temperature, humidity, airflow and vibration, and sound of equipment (Amalberti, R.A. & Hourlier, S. 2012). The environment of hospitals is always a crowded place. The patient room to the workstation nurses are always not well-organised. The workstation is always noisy, and stress is a common outcome of this environment. There is always a rush of the patients, nurses, doctors. The random alarms and the sounds of other equipment cause nurses stressed to stop the device. The anaesthesiologist also did the same for concentration due to noise of the alarm.
Stress is one of the important issues which may have a negative impact both in physical and mental effects on nurses’ working life. It happens usually more with nurses who work in shift- work basically at night. Poor ergonomics of the hospital and a poor behaviour approach of nurses can cause stress. There are different factors which can increase a level of different stress.
The working environment, time-schedule, sounds, noises, and improper sleep are the sources of stress. Sleeping problems can lead to the nurses who especially work in shifts such as night shifts. Rotating shift works can change the pattern of sleep of the nurses.Doing night shifts and rotating shifts can increase the mental problem for nurses. They can easily fall into depression.
Many papers show that the stress rates of night workers are quite more than normal day workers.
Human-organization interface or macro ergonomics is a combination of teamwork, organizational culture and learning, work-system and HROs (Amalberti, R.A. & Hourlier, S.
2012). Every organization wants to maintain their reputation and give the best services and works together in a team for achieving the goal. So, the organizational members, higher authorities make all the decisions, and the workers follow the workflow. Organizational
pressure makes nurses sometimes stressed and they are taking wrong actions towards the patients.
Nurses have faced different difficulties for stress. They cannot concentrate on their work, as well as they cannot perform well. It can impact their health. Nurses assist individuals suffering from various diseases, including those who are suffering from chronic diseases by managing symptoms of the disease and administering the prescriptions provided by doctors. The nurses independently assess their patients and identify the needs of such patients, before putting in place proper interventions to address such needs. In most cases, nurses concentrate so much on performing their duties and carrying through their routines, without giving thought to their own health. Studies have shown that stress is one of the most common disorders that nurses are at risk of. The mental and psychological health of nurses is an aspect of great importance as it affects their efficiency in providing care to the ill persons.
Stress is becoming both a physical and mental problem among nurses day by day because of lightning, bending, different shifts, roaster shifts, noisy work environments, long hours etc.
Nurses working in night shift may also suffer from disruption to their natural circadian rhythms, which in turn, can predispose them to illness (Patricia, B. 2015). Finally, with the current median age of a nurse being 45, many are simply not as physically resilient as they were in their younger years (Patricia, B. 2015). It is essential that nurses have to lead a healthy life both in working time as well as personal life. It is sometimes difficult for them to balance their both lives because of the impacts of different stresses. Stress can have a negative impact on their daily behaviour and it can
lead to unhealthy lifestyles. This can be a cause of their poor performance in work, lack of self- confidence, disturbance of providing care services to the patients, personal problems etc. A person’s well-being, however, does not solely depend on his or her exposure to stress, but also on the way he or she copes with stress (Hoffmann, A, 2017).
To reduce these stress factors, this paper suggests some solutions based on gamification to imply some activities to create a good working environment and to reduce the stress to ensure a good health and well-being of the nurses who work in night shifts. Gamification uses game elements to affect the behaviour. It is used in many areas to promote wellbeing and a better
work environment. Gamification has also been shown as an effective tool for stress management.
In today's society, stress is more and more often a cause of disease (Hoffmann, A, 2017). This makes stress management an important target of behaviour change programs. Gamification has been suggested as one way to support health behaviour change (Hoffmann, A, 2017). Coping techniques aim at the reduction, tolerance, or elimination of stress and stress triggers. Mobile health (mhealth) is already being applied to support mental health programs and has met broad acceptance(Hoffmann, A, 2017).
Nurse satisfaction levels are important for informing the quality of services that they offer to patients. In consideration of such, it is important for healthcare organizations to put in place all the necessary measures to reduce stress and improve nurse experiences. Ranging from motivation approaches to staffing and leadership practices, the working conditions to which nurses are exposed are important in promoting patient outcomes. Recent research has noted gamification as an important approach towards managing stress among users (Martsolf, et al., 2014).
In this case, gamification in the health care environment involves the establishment of processes and activities to facilitate the application of game element characteristics to solve problems. Hoffmann et. al. (2017) conducted a study to determine the perception of users concerning gamified stress management apps. According to their findings, the authors noted that a combination of stress management techniques with gamification was considered to be highly effective in achieving positive results among users (Hoffmann et al. 2017). These findings demonstrate the effectiveness of gamification in stress management, supporting the use of this technique in managing stress among nurses within the hospital settings.
Gamification, that is, use of game elements in nongame contexts, is aimed at making interventions (including mobile apps for behaviour change) more enjoyable, motivating and engaging (Hoffmann, A, 2017).
Hence, this degree proposal suggests investigating how gamification can be applied for stress reduction for nurses. The scope of the work will include understanding what stress factors
nursing are facing in Swedish Healthcare settings, identifying good and best practices to address these stress factors, and developing gamification to incorporate these practices into routine works of nurses.
1.2 Purpose
The purpose of this study is to find the stress factors of nurses during their working time and try to help the nurses to reduce their working stress by applying gamification.
1.3 Research question
· What are the stress factors causing nurses in the workplace?
· How is it possible to reduce or help them to keep them active and fresh in working times through gamification?
· What are the potential benefits of gamification for nurses?
1.4 Thesis structure
There are different chapters in this study and each chapter is showing different contents which are the chronological patterns of work doing for this study. Chapter 1is introduction, Chapter 2 stands for literature findings, Chapter 3 stands for methodology, Chapter 4 stands for results, chapter 5 stands for discussions and Chapter 6 stands for conclusion.
Chapter two
Background
This section highlights the occupational stress among nurses, gamification, gamification in nursing, and how it can be used as a stress management strategy among nurses. The information presents information in this section from scholarly secondary sources.
2.1 Stress factors among nurses in workplace
Stress can be referred to as a change or condition that results in emotional, psychological, and physical pressure (Bratianu,2015). Thus, stress is not an illness but a state that occurs as a body’s response to internal or external factors that affect one’s emotional, physical, or psychological state (Morstaka & Constantinidis n.d). All humans experience stress but what determines their well-being is the level of management. Individuals experience stress even in their workplaces. Several professionals state that workplace stress is an occupational hazard.
The nursing occupation exposes nurses to several stressors that affect their well-being and reduce work productivity. According to Briatianu (2015), the American Holistic Nurses’
Association states that nurses experience higher levels of stress than other professionals.
During practice, nurses experience a lot of challenges which have an impact on their psychological health. Such individuals are subjected to both physical stresses, which result from the numerous activities that they engage in while taking care of the patients, and emotional stress, which results from the response of the patients to their efforts, among other factors. Such stresses are manifested by the nurses in different forms, including depression, anger, frustration, fatigue, guilt, and loneliness. Stress is prevalent among those nurses who have a need to successfully deal with a high number of responsibilities simultaneously, while they have limited resources including energy and
time. Stress management techniques are important in helping these individuals to overcome their psychological conditions, and to be able to effectively help the patients to manage their health conditions.
The quality of patient care has become an important part of healthcare services, even as patients prefer healthcare organizations that are cognizant of their individual needs. Nurses play a significant role in the recovery of the patients as they offer the baseline services to patients.
The performance of nurses is highly dependent on their level of satisfaction with their working conditions. As such, motivation and stress management inform the achievement of quality care.
Various researchers have examined the factors that inform nurse stress and the quality of care of care offered to patients.
Van Bogaert et al. (2017) conducted a study to determine the relationship between nurse engagement and nurse burnout, and the implications that such had on the quality of care and job outcomes as reported by nurses. Using an explanatory sequential study design, in which they employed a mixed method approach in examining the study question. To start with, they engaged in a cross-sectional survey of large acute care hospitals, after which they carried out semi- structured interviews with individual nurse managers and nurses (Van Bogaert, et al., 2017).
According to the findings of the study, burnout and increased workload were considered to contribute to increased stress, reduced nurse performance and the quality of care offered to patients (Van Bogaert, et al., 2017). These findings suggest the importance of addressing the problem of nursing stress in efforts to improve nurse performance and the quality of care received by patients.
Deficits in inpatient quality have important implications for the well-being and health of patients. Furthermore, they pose critical cost implications for both the payers of healthcare services and the healthcare facilities offering the services as they contribute
to increased intensity of treatment and prolonged hospital stays. In most cases, the deficits in care quality are informed by nursing care. Martsolf et al. (2014) conducted a study to examine
the impact that nurse staffing has on nurse fatigue and stress and the quality of care offered to patients and the costs of care. The authors employed a longitudinal analysis to explore hospital nurse staffing data and healthcare utilization and cost data from the Healthcare Cost and Utilization Project State Inpatient Databases (Martsolf, et al., 2014).
According to the findings of the study, an increase in the number of nurses employed within a healthcare organization was associated with reduced length of patient stay and nursing- sensitive adverse outcomes, including burnout and stress (Martsolf, et al., 2014). This is because a reduction in the nurse-to-patient ratio contributes to a reduction in the workload of nurses and the related stressors. The findings of the study support the importance of nurse staffing in facilitating inpatient care improvements, including reductions in the length of stay of patents and improved quality of care.
In a different study, Kieft et al. (2014) examined the perceptions of Duct nurses concerning the influence that their working environment and their work had on patient experiences. Using a descriptive qualitative research design, the authors engaged four focus groups with a total of 26 nurses, in interviews (Kieft, de Brouwer, Francke, & Delnoij, 2014). The nurses involved in the study noted various factors that would facilitate improvements in nurse performance and, subsequently, patient experiences of quality care offered by nurses. Some of the elements identified by the nurses include patient-centered culture, managerial support, nurse autonomy, adequate staffing, collaborative working relationships, and clinical competence among nurses.
Moreover, the nurses also mentioned some of the factors that are likely to inhibit the achievement of increased performance and quality of patient care (Kieft, de Brouwer, Francke,
& Delnoij, 2014). These factors include external accountability transparency
goals and policies for cost-effectiveness. The nurses noted that pressure from the administration to increase their productivity through taking up a high workload was not likely to facilitate achievement of improvements in the quality of care offered (Kieft, de Brouwer, Francke, &
Delnoij, 2014). Instead, this is a major source of stress, which results in reduced productivity and poor patient outcomes.
Various factors affect nurse stress levels and inform the commitment of nurses to the healthcare organization and the implications that such has on job performance. An increase in nurse burnout contributes to an increase in stress and a reduction in affective commitment among the nurses (Sharma & Dhar, 2016). Additionally, an increase in affective commitment among nurses is also associated with perceived procedural justice and organizational support. On the other hand, effective commitment among nurses is associated with increased job performance and an increase in patient satisfaction (Sharma & Dhar, 2016).
Toode and colleagues also investigated whether the level of satisfaction among nurses with their working conditions had an impact on job performance and quality of patient care (Martsolf, et al., 2014). The authors examined nurse perceptions concerning workplace conditions and characteristics, including stress management, work motivation, learning opportunities and skill exploitation, teamwork, work climate, decision authority, and the level of autonomy (Toode, Routasalo, Helminen, & Suominen, 2015). They then drew an association between these conditions and characteristics and nursing practice outputs include the quality of care and patient safety (Toode, Routasalo, Helminen, & Suominen, 2015). The findings of the study revealed that perceived control over one’s work and elimination of stressors significantly motivated nurses.
2.2 Gamification
Gamification is the addition of game-design elements to a task to increase productivity, participation, and people's wellness (Gentry et al., 2019). The primary purpose of gamification is to create fun in non-game activities and enhance participants' motivation and cognitive skills.
Studies indicate that many people regard games as an effective entertainment strategy (Litvin, Saunders, Maier &Luttke, 2020). Gamification helps an organization to shift from traditional approaches to modern strategies of providing services.
2.2.1 Gamification in health-care system
Nursing and health care institutions must utilize gamification as a stress management tool for nurses. Gamification provides nurses an opportunity to relieve their occupational stress by
engaging in problem-solving activities and active learning (Gentry et al., 2019). Occupational stress among nurses can lead them to develop severe mental and emotional disorders such as depression (Briatianu, 2015).
There are many ways to play games in the workplace. Most common ways are playing games on mobile phones. There are also other ways to help the nurses to reduce their stress. The introduction of designing a new game based on the nurse’s behavior and movements can be helpful and be time efficient. They do not need to play games on mobile phones if they do not want to. Based on their daily activity-based performance, they can adopt a strategy to play games. Stress management strategy can be done by doing physical exercises in the working place, walking, taking a break, walking in nature, meditation, etc. These daily behaviors can help to make activity-based games which help them in the stressful working environment.
The introduction of gamification in nurses’ workplaces will involve the installation of mobile apps on their phones. The mobile apps contain fun games that nurses can play during their free time to raise their motivation and engagement as a preparation for any strenuous task.
Gamification is a form of mobile health (mHealth) that utilizes wireless technologies to improve nurses' mental wellness (Gentry et al., 2019). Data from the Global Digital Statshot indicate that more than five billion people have a mobile phone across the globe (Coelhoso et al., 2019). Based on these statistics, nurses have adequate access to mobile devices that creates a chance for them to install mHealth gamification apps to improve their mental wellness in the workplace.
2.2.2 Gamification as a general stress management tool
Although everybody has the capacity to adapt to stress, not everyone responds to similar stress or the same (Marjan Laala). Managing stress may assist persons in maintaining psychological adaptation during stressful events as a stabilizing factor, hence the actual reaction to an environmental event may be as important as the event itself (Marjan Laala). Stress has a great number of impacts on worker behaviour including adaptive and maladaptive responses resulting in short -and long-term health implications, including substance abuse, depression, anxiety, sleeping problems and other complications. (Marjan Laala).
Stress management (SM) has been described as positive or negative and as active or reactive which can be positive or negative, depending on the situation and the content of the response (Marjan Laala). In workplace employees from different organizations apply or follow different types of stress management techniques strategies to reduce or control their stress in the workplace. These stress management techniques can be therapeutic, non-therapeutic, self- management stress techniques, gamification for stress management techniques etc.
Nurses are encouraged to practise different stress management techniques in the workplace.
They are doing yoga, physical exercising, meditation to avoid stress. Different organizations are following some stress management strategies to motivate their workers to reduce stress by applying some fun activity like gamification.
Now-a-days gamification is used as a stress management tool. Gamification has now been suggested as one way to support behaviour change. Gamification which is the use of game elements in nongame contexts, is aimed at making interventions (including mobile apps for behaviour change) more enjoyable, motivating and engaging (Hoffmann, A, 2017). This approach could be a possible solution to the lack of motivation to follow self-management procedures and to care for oneself which can be helpful for health-related problems (Hoffmann, A, 2017). For the possibilities gamification can be applied to influence user behaviour and lifestyle (Hoffmann, A, 2017).
Gamification has already been suggested to positively influence user self-management (Hoffmann, A, 2017). Different mobile apps based on stress management in the form of gamification have been used for different purposes. However, it proved to have positive impacts on health and behaviour outcomes (Marjan Laala).
Studies indicate that incorporating gamification in a workplace is an ideal method of improving the workers’ mental health. Thus, one of the main importance of using gamification to manage stress among nurses is that it acts as a meditation tool (Sort, 2020). When nurses play games, they will invoke their inner peace as they try to prepare their minds to solve the task in the
games. The relaxation and meditation through online or fun games improve cognitive flexibility and raise the attention of a person (Gentry et al., 2019). Gamification can help nurses focus on solving the present task rather than worrying about past or future scenarios. Playing games is a form of physical therapy to help nurses relax their mind and body. Effective use of gamification strategies among nurses helps them to have high levels of mindfulness, which they can replicate in the real work environment to avoid errors that can lead to stress.
Gamification is a great stress and anxiety reduction strategy among nurses as it provides a chance for them to have a break from strenuous and challenging tasks (Sort, 2020). Nurses adhere to a strict schedule of heavy workload. The working environment has stressor factors such as frequent noises, long working hours, and providing services to critically injured.
Playing online games plays a significant role in helping nurses to engage in fun activities that improve their motivation and social interaction abilities (Litvin et al., 2020). However, gamification should be designed in a way that when nurses play games, it does not affect the ability of patients to receive treatment. Nurses can play games during break times to avoid affecting normal working schedules.
The incorporation of playing games in non-gaming contexts in workplaces invokes creativity, freedom of expression, and productivity; the nurses tend to invent new ways to fulfill the game's objectives. In most instances, a significant number of nurses can replicate the creativity from the gamification into their work environment. Many nurses will try to create new strategies for providing healthcare, new strategies for improving communication with patients, and innovative technologies to improve the nursing sector (Sort, 2020). Thus, innovating new work practices and activities is a result of freedom of expression that allows one to showcase their ability and ideologies to their peers. Gamification also improves work productivity among nurses as they invent new work strategies and a relaxed mind to meet their daily tasks.
Indeed, gamification has already been suggested to positively influence user self-management (Hoffmann, A, 2017). It proved to have positive effects on health and behavioral outcomes and the retention of desired user behaviors (Hoffmann, A, 2017). These positive effects are most likely the result of comprehensive motivational support and invoking flow experiences
(Hoffmann, A, 2017). Gamification also helps to make the user feel represented and in control by adjusting techniques to the user’s motives and abilities (Hoffmann, A, 2017). Invoking user motivation through this manner is an
important way to keep the user’s interest and thus, to increase his or her exposure to the evidence-based content (Hoffmann, A, 2017).
In fact, it could already be shown that the implementation of gamification in the form of rewards for diabetes patients and combinations of gamification techniques for weight management in children can be effective in promoting behavior change through apps (Hoffmann, A, 2017). This is further supported by Hamari, who showed that the use of gamification techniques can, indeed, increase the use of a service (Hoffmann, A, 2017).
Gamification is an approach which seeks to positively impact diverse wellness and health- related contexts, not only because it can get more people engaged and make them more responsible for their health-related decisions, but also because it can enhance the performance of healthcare workers (Pedro, P. 2014). It, therefore, affects both the costs of personal wellness and healthcare (Pedro, P. 2014).
Compared with other stress management approaches, gamification has some important advantages. For example, gamification can positively affect the participant’s emotional experiences as well as can help them persist through negative emotional experiences and even transform them into positive ones (Pedro, P. 2014). The participants’ sense of identity and their social positioning can also be enhanced by gamification (Pedro, P. 2014). Cognition can also be positively affected by providing complex systems of rules for players to explore through active experimentation and discovery (Pedro, P. 2014). Moreover, gamification is found to enhance communication judgement and high-level social skills such as leadership and collaboration (Pedro, P. 2014). The time spent playing some type of entertainment games which can be part of a gamification strategy can also enhance psychomotor skills (Pedro, P.
2014).
Building a gamification solution is a multidisciplinary effort which seeks to solve a set of problems pertaining to computer engineering, usability, interface design, marketing among others (Pedro, P. 2014). This wide range of fields poses challenging difficulties for design
teams, which need to have a broad knowledge about each of these disciplines, as well as to adopt a User-Centered Design approach (Pedro, P. 2014).
According to Zichermann and Cunningham, gamification is “the process of game-thinking and game mechanics to engage users and solve problems, a definition that “unite(s) concepts into a cohesive worldview that's informed by the latest research into behavioral psychology and the success of social games” (Pedro, P. 2014). Subsequently, gamification typically involves applying game design thinking to non-game applications in order to make them more fun and engaging. Several analysts have referred to gamification as one of the most important trends in technology (Pedro, P. 2014).
Through gaming principles, gamification has the ability to transform the obstacles that may lead to behavioral changes, such as failure, into engaging, positively reinforcing and perhaps fun experiences that encourage users to make sound decisions and activate the desired behaviour for the benefit of their health and wellness (Pedro, P. 2014). With gamification, health workers can engage and collaborate more effectively, as well as administrative professionals can increase performance and customer service levels, all resulting in a positive influence across the activity (Pedro, P. 2014).
As McGonigal suggests, games can involve hard (e.g., high-stakes work -it is fast and action oriented; busy work - some games tend to become predictable and monotonous; mental work - it can be rapid-fire and condensed, challenging or to drawn-out complex; physical work - increase energy expenditure, as well as heart and respiratory frequency) and, some of them, require teamwork. Since a pleasurable, informed and voluntary participation (with freedom to leave) is required for everyone who engaged in the game-like activities, two groups deserve a brief call of attention in this respect: children and older people (Pedro, P. 2014).
Chapter three
Methodology
This section describes the research design, sampling procedures, data collection instruments, pilot studies, and data analysis methods, creating action process and gamification.
3.1 Research design
For the research questions and other related information about the thesis topic the author applied a search strategy. The search strategy should be conducted thoroughly which helps to carry out the work forward with providing relevant information matched with the thesis topic.
The search for the papers was collected from ACM, IEEE, Springer, ScienceDirect, Google scholar. The papers which contain key-word such as healthcare, stress, stress-factors, nurses, stress management, gamification are the selecting criteria words for this thesis paper. After finding all the relevant papers, the author filtered out the desirable and appropriate papers.
There are some duplicates of similar papers which were filtered out. Some papers have published quite a long time ago and are not relevant which were also filtered out. Then finalize more than 60 papers for literature analysis to find out the research questions and the problems and last of all included 50 papers in this thesis. After all the research is carried out in the medium of interviewing nursing. Research questions that seek to assess an individual’s opinion, perceptions, and actions after experiencing a particular phenomenon are best answered using phenomenology research (Elkatawneh, 2016).
For this study, a qualitative approach was chosen as a research method for carrying out the purpose. Qualitative approach is used for collecting and analyzing nonnumerical data to understand concepts, opinions, or experiences. (Conroy, 2010-9). This approach is used in this study to gather in-depth insights of problems which are indicated in literature. It will help to give information based on real-life experiences in support of theoretical literature.
3.2 Sampling procedures
This study adopted a criterion sampling to determine the participants. Criterion sampling is a type of purposive sampling in which study respondents must meet a predetermined standard for them to take part in a study (Moser & Korstjens, 2018). The author set a standard that the participants are supposed to have worked for more than five years. The participants were drawn from both private and public hospitals. Participants were also drawn from all nursing disciplines from registered nurses, licensed practical nurses, advanced practice nurses, Intensive care unit registered nurses, and emergency room nurses, among others. After conducting the criterion sampling, ten nurses were selected for the study. The nurses were selected by personal author’s personal contact and the author also took help from other groupmate for this purpose .
3.3 Interview and Data collection instruments
Before starting the interview, the summary of the thesis project and the questions were sent to all the participants by email. There were five questions which were written in English. These five questions were asked in the interviews.
Interview Questions
1. What types of stress are you experiencing during work? To what extent are you facing this stress?
2. How does the stress as you mentioned earlier affect you physically and mentally?
3. Can you explain the causes of stress?
4. How do you handle or cope up with this stress?
5. Do you feel any stress related to this pandemic in your work, can you share your experiences and how does it affect you and how you handle this thing?
After that, interviews were taken according to the scheduled time by calling each of them one by one. They all gave their consent while starting the interview. Each interview lasted about 40-45 minutes. Data from the ten study participants were collected from interviews. The
interviews were administered to the participants through calling by phone. A mobile transcribe phone app was used to record each interview while the conversions.
3.4 Data analysis
This study adopted a thematic analysis method. Thematic analysis is a form of qualitative data analysis (Caufield, 2020). A close examination of the data is carried out to find out common themes, ideologies, and patterns that relate to the data. Thematic analysis is ideal for research that seeks to identify more content about a phenomenon using interpretation. According Caulfield (2020), thematic analysis steps include familiarization, coding, generation of themes, review of themes, definition, and naming themes, and then writing the findings.
After interviews, the author transcribed as part of familiarization. The next step was coding that was performed in word processor software, and after there was an in-depth review to identify any recurring themes using Transcribe software. It is an application that supports qualitative methods of data analysis. The software allows a author to organize, analyze, and determine conversations texts in qualitative data collection methods like interviews. The author also identified quotes and phrases from the interview schedules significant to the research.
(found in Appendix).
3.5 Generating gamification concepts
The author has followed some steps to generate gamification .
3.5.1 Brainstorming
For creating actions, the author looked and reviewed the findings from the above-mentioned interviews of the methodology. Then the author tried to find actions for the problems by brainstorming. In this part, the author combined his work with another groupmate. The combined work is to share the actions or ideas with the author as the groupmate working on the gamification part also with interviewing the same participants which were needed for the brainstorming process. For the brainstorming process, the author looked at different sources such as online, literature, own ideas. Then pointed out different actions which can be implemented for different problems. The author also discussed the positive sides of each idea
or actions as well as negative sides with the groupmate. Then the author did an interview again with the same selected nurses as before, then showed the actions of the findings for different problems based on the previous interviews. They gave their suggestions or opinions by looking at the actions by saying a specific word good/better/bad.
3.5.2 Interview
After generating different actions based on brainstorming, the author did an interview again with the same nurses for addressing them and needed their feedback or comments on those.
Seven nurses from the previous interview participated and the other three nurses were selected by the help of the groupmate who was mentioned on the above. So, the seven could easily relate the things and give their feedback. And the other three, the author explained all the things. In this step, the interview was done by phone call as before. This time the detailed actions or ideas also including the cluster- drawing of the actions were put together in a word file and sent to them before the schedule of interview time. The actions including the cluster were sent by the personal email of the participants.
The interview was done over phone and lasted about 30/40 minutes. The nurses chose the interview time according to their suitable times. The interview was about their suggestions based on the actions, clustering the actions and their feedback for generating gamification based on the actions. From the beginning of the interview, the nurses were discussing with the researcher about each action regarding the problems from seeing the word-file. Then the clustering part was also discussed for their feedback and they were being asked to rate as good/better/bad among the categories of concepts of the actions.
3.5.3 Clustering
The clustering was the summarized picture of the actions. There were a lot of actions mentioned in the brainstorming process, so the clustering was the picture of the actions categorized in different sections which helped the participants to give a quick comment easily after discussing all actions in the beginning of the interviews.
After brainstorming the author found some actions which will help nurses to be active in the workplace. Then the writer tried to cluster all the actions based on similar nature or pattern and divided them into four different concepts. Each concept presents similar actions which are different from each-other categories.
In the middle of the cluster drawing found the title of the thesis. Around the middle part, there were four concepts which categorized into different actions for designing gamification for nurses based on their comments. The clustering drawing can be found at chapter four. (found in Appendix).
3.5.4 Filtering, selecting, and combining concepts for designing gamification
After reviewing the interview regarding actions for the problems and clustering drawing, the writer filtered the actions and selected concepts based on the majority of nurses’ feedback on good/bad/better to design gamification among the four categories from the clustering drawing which have common pattern or similarities activities among them.Chapter four
Results
4.1 Findings
This First section presents the study findings from the ten participants. The data present here is drawn from the response of the participants in the ten interview schedules. Data are presented according to the research questions.
All ten participants stated that the types of stress they encountered in the workplace are burnout, fear-based stress, overwork stress, workplace-conflict, stress, and anticipatory stress. The ten participants stated that they face burnout due to constant criticism from their supervisors regardless of the level of their work productivity. Constant criticism made the participants develop a sense that their performance is always poor, which leads them to develop burnout.
Participants 2, 5, and 9 stated that they also feel burnout due to lack of adequate resources such as personal protective equipment (PPEs). The lack of work resources causes irritability among nurses and low social interaction skills.
All the participants stated that the workload is heavy in some instances, which leads them to perform several assignments that drain their energy levels. The participants stated that working with biohazard materials causes them to develop fear-based stress due to the likelihood of contracting diseases or experiencing hazards. The workplace-conflicts stress that the participants face occurs due to gossip and bullying from some of their peers. Anticipatory stress among the participants results from developing fear due to future aspects like life after the nursing career.
Participants 1, 2, 5, 8, and 10 stated that they experience insomnia. The participants stated that they lack sleep as they spend a long period trying to find a solution to a problem at the workplace. Restlessness due to stress makes one have tension, anxiety, and difficulty in achieving relaxation during sleep. Participants 3, 4, 6, and 7 stated they had an eating disorder due to occupational stress. Studies indicate that many people have low appetite due to high
cortisol levels that the body releases due to anxiety or stress. High secretion of cortisol leads to high levels of acid production abdomen that leads to quick digestion of food in readiness for action, but the process also leads to low appetite.
All the participants stated that they experience emotional discomfort such as frustrations, restlessness, sadness, and irritability to occupational stress. The participants stated that irritability and frustrations occur when they receive criticism from their supervisors despite their efforts to achieve the laid-down objectives. Irritability and frustrations led the nurses to display high anger levels towards their peers and supervisors, thus deteriorating communication in the workplace. The participants stated that restlessness and sadness showcase them as a result of irritability and anger.
All the participants stated that the causes of stress in their workplace resulted from a heavy workload, long working hours, especially in the weekends and night shifts, tight deadlines, inadequate work equipment, and over supervision. Further, participants 5, 6, 8, and 10 who were from a public hospital stated that limited promotional opportunities, management changes, and harassment are also major causes of stress in their workplaces. The above- identified causes of stress among the participants
Participants 1, 3, 4, 6, and 8 stated that they engage in regular exercises to cope with stress.
Regular physical exercises help the body release endorphins, which helps suppress the effects of depression and anxiety. The participants stated that they use physical exercises as a meditation tool to ease the work pressure. Participants 2, 5, 7, 8, 9, and 10 stated they use outdoor explorations to manage their stress through nature walks. Outdoor explorations help people to reduce their blood pressure, heart rate, and have effective muscle relaxation due to viewing scenery. All the participants highlighted that they schedule activities to create a balance between work and home responsibilities. Home and work responsibilities that do not require urgent timelines are conducted later to pave the way for tasks that have tight deadlines.
Effective work schedules act as a stress management tool and help nurses improve their productivity, which increases their motivation and engagement.
Participants 6 and 7, who work in the intensive care unit and emergency room, respectively, state that the Covid-19 pandemic is presenting overwork stress to them. Participant 6 states that patients with novel coronavirus patients in the intensive care unit require constant care and supervision, which leads her to work even overtime due to a shortage of nurses. Participant 7 states that in the emergency room, the high infection rate of novel coronavirus leads to an increase of patients requiring emergency services due to preexisting conditions. The participant states that the emergency room is under constant standby to receive emergency cases due to community transmission of Covid-19. All the participants also state that they are afraid-based stress due to the risk of contracting the virus.
Table 1. The summary of the findings about stress factors
4.2 The process of gamification design (brainstorming, clustering, filtering, selecting, combining and design)
The full explanations of initial actions from the brainstorming process which were discussed in the interviews can be found in the Methodology and Appendix part.
Table 2. The glimpse of the discussed actions during the interviews
Cluster Drawing
This drawing process can be found in the method part. Here is given the summary of all the actions belonging four different categories for creating concepts for gamification in a drawing form of clustering. This drawing also showed in the interviews among the nurses for their suggestions.
Based on the nurse’s suggestions of commenting good/better/bad reviews by seeing the cluster drawings, the researcher filtered them according to their most common answers from the concept and gave an example for gamification for the nurses.
Designing gamification
Based on the suggestions from the nurses, there is an example of gamification.
The game is called “Change my mood’’.
This game has some certain features. When the user opens the app, some emojis will appear on the screen. The emojis can be happy face, sad face, angry face, confused face, and different types of facial expression. Each emojis expresses different types of expressions. If the user is very much stressed, she can select the specific emoji. Each emoji has some features to carry out the process in forward. The stress face has some simple questions regarding the issues. And there is also an option for writing one’s thoughts. Then the user must answer the simple answers and based on the answers the app suggests him or her some simple and quick solutions like playing soothing music to calm the body and mind, giving motivational quotes, giving compliment, giving simple tasks like taking a deep breath, witty messages for charring up the mood and so on. Each action has some rewards points which help him or her to reach the next level. Based on the specific points, the user can receive a new character. This character will get improved by their appearance day-by-day. The need for improving the character is to do some daily common activities which are mentioned by app. At the beginning of the app, the user can give some information about his hobby, likes-dislikes, to do lists. Based on these, the app will suggest doing some activities and will give the chance to make the character strong and look good. There will be a shop store where clothes, shoes, and other things to add on.
If the user does not want the character still, he or she can play the game. By playing the games, the user can get virtual gifts like flowers, virtual hugs, witty messages. The duration is not fixed. The user can play at any time, can pause the game at any time.
This game can be played alone or in groups. For playing in groups the user will get a common code to share the game platform. They can also have access to the participants. While playing in a group, there will be an additional feature. The feature is from the participants there will be an adviser. The app randomly selects the adviser. The adviser will get to know he or she is the adviser, but the others do not know. Then when they share their emojis and their answers to
each other, the adviser can advise them by messaging or giving virtual gifts like songs, poets, flowers, friendly stickers saying good things about life, friendship, healthy lifestyle etc.
Chapter 5
Discussion
5.1 Results and Recommendations
The study findings indicate that occupational stress is a prevalent problem among nurses. All the participants stated there were experiencing at least five types of stress. The prevalence of stress among the nurses may lead to chronic mental illnesses like depression if coping measures are not instituted. The nursing workplace setting is full of several stressor factors, which are internal or external forces. The external forces that cause stress among the nurses include noisy environments, heavy workloads, and lack of work equipment (Eslami, Elahi, Mohammadi &
Khoshknab, 2017). The internal force that causes stress among nurses is individual pressure to meet daily commitments.
Different kinds of stress among nurses leads to physical and mental illnesses. According to the study findings, stress can cause insomnia, loss of appetite, and emotional discomforts (Eslami et al., 2017). Occupational stress may cause disruptions of sleep activity as one spends several hours trying to solve a problem. In other instances, nurses with occupational stress tend to have eating disorders that can cause them to develop gastrointestinal illnesses such as ulcers (Ajibade, Olabisis, Fabiyi, Ajao, Ayeni, 2016). Nurses subjected to stress may also develop emotional discomfort such as irritability, sadness, restlessness, and frustrations. Emotional discomforts reduce the level of social interaction among nurses and cause conflicts.
In a nursing workplace environment, there are several causes of stress among nurses. The main factors that lead to occupational stress are heavy workload, long working hours, tight deadlines, inadequate work equipment, and over supervision (Eslami et al, 2017). In other scenarios, limited promotions, changes in management, and harassment of the nurses also result in occupational stress. Heavy workload, long working hours, and tight deadlines leads many nurses to work even past their schedule to meet the objectives. Overworking drains the energy levels of the nurses, which reduces their motivation and engagement (Ajibade et al., 2016).
Other factors like lack of job promotions and harassment lead nurses to develop fear about their job security and safety at work, respectively.
Covid-19 pandemic presents several challenges to the medical sector due to the heavy number of patients requiring medical care. Most healthcare institutions have a shortage of medical workers, especially nurses. The nurses who are already working in the hospitals face an increased workload that leads to overwork stress (Hu et al., 2020). Further, Covid-19 is causing fear-based stress among nurses due to its high infection rate. The nurses' constant stay at the hospitals that are screening and treating people with the novel coronavirus is exposing nurses to the virus despite them having the personal protective equipment (Hu et al., 2020). Despite the nurses' personal protective equipment, they can still contract the virus if they are not careful during removing the gloves and forget to wash their hands.
One of the ways that nurses can handle stress is through regular physical exercises. Regular exercises help one to relax their mind and muscles and ease the tension or restlessness associated with stress (Marselle, Warber, Irvine, 2019). Further, regular physical exercises help a person's body to secrete endorphins, which plays a significant role in reducing emotional discomfort like stress and emotions. Engaging in nature walks to explore sceneries can also help nurses to cope with occupational stress. Outdoor explorations are a meditation tool that can help a person have a reduced heartbeat, blood pressure and relax muscles (Marselle et al., 2019). Nature walks create an opportunity for nurses to have a break from their workplace and normal schedules and explore other phenomena in life. The other stress coping strategy that nurses can adopt is effective work schedules. Work schedules will play a significant role in helping nurses to categorize activities that require urgent attention and those that can be undertaken later.
The suggested actions are good choices to cope-up the stress management. The actions are suggested in the second time’s interviews can be helpful for the nurses to reduce stress. The actions are simple and fun to perform. Nurses can easily change their regular activity by changing it in a fun way in the form of playing games. The game design in the result section can be helpful and nurses do not have to push themselves so hard to play it. They can play it according to their suitable time without disturbing others. Generally, they always do this thing
while working but not in a fun way. Their daily activities and behavior can be changed in a fun way by adopting this game.
The suggested actions are based on different stress factors during work. From the findings from the second time interviews, the nurses are talking about different advice and they are very interested in hearing the actions which can be used to design a fun game in the workplace. They liked certain actions which can be implemented without doing any hardships but some of the actions they are not sure about how to implement those. As the hospital is a busy place and there are also heavy workloads.
5.2 Limitation of the method
While undertaking the study some limitations were found. The method applied for this research gave the results based on personal thinking, expressions, and experiences. There was no numerical observation or data which helped the research to compare and present the data statistically in this study. Quantitative approach will be a good option to acquire numerical data.
On the other hand, for the interview, 10 participants were selected to perform the qualitative research. 10 participants were not enough to gather and perform good informative research.
5.3 Analysis of the designing gamification
The “change my mood” game can be helpful to the nurses as they will play it on their mobile phone. They can play it wherever they want, and it is not time-consuming. In the workplace they can play it in the break-time instead of gossiping or talking with other people. Then I can also play it outside of work. Instead of being stressed, they can play it by changing their behaviour in a fun way.
Merits are:
· Fun way to play
· Easy to access
· Not deeply involved
· Not time consuming
· Emojis are funny way to express one’s expression
· Motivating
· Engage oneself to an active talk without disturbing other
· Meet with friends in one platform
· Play and enjoy by group
Demerits are:
· Need smartphone
· Need internet
· Old people or other people who do not like playing mobile games, cannot like it
· Sometimes may be boring
· Can be difficult to play while rush hours
This is the designing gamification of a game which can help nurses to reduce stress. It is not applied in practical life. But the author wanted to gather some feedback about this designed game from the nurses. As it is not tested in the workplace, so the author did a short interview and told the nurses about this game in a descriptive way. The nurses were the same participants whom the author had the previous 2 interviews. This time there are six nurses whom the author discussed this design gamification. For the limitation of time, the restrictions of the working environments, the availability of nurses, the author could not arrange more than six nurses.
This was about just collecting feedback as saying good/better/not good by nurses about their thoughts to this game. The interview was done by phone and lasted for 15-17 minutes. The designed game was described in the interview time by the author and then collected the feedback. The author called them according to their suitable time and also had their permission for doing the interview with them. It will be better if the game is tested with them and observe how it will go.
Table 3. The feedbacks about this game design from nurses are given below.
Participants Feedback- good/better/ not good
Assistant nurse
Better idea , but not sure in what extent it will reduce stress
Head nurse Not good, as there are lot of works to do in the workplace
Intern nurse Good, can play whenever and like the character ideas
Assistant
nurse Good-better both as it will funny way to take a break
Nurse Not good as it is not so convincing how to imply this game in the workplace and how everyone looks after it
Nurse Good as one can play on mobile
Chapter six
Conclusion
The nursing working environment comprises busy schedules, noises, and heavy workload that exposes nurses to high levels of stress. The nursing sector should explore the use of gamification as a coping strategy to stress. Gamification involves the use of game design elements that invoke fun in a non-game contact. The suggested game design in the result section helps nurses increase their creativity, problem-solving skills and take a break from their daily roles.
The study participants identified burnout, fear-based stress, overwork, work conflict stress, and anticipatory as forms of stress they encountered in the workplace. Participants 1, 2, 5, 8, and 10 stated that they experience insomnia. Participants 3, 4, 6, and 7 stated they had an eating disorder due to occupational stress. The emotional discomforts that all the participants were experiencing were frustrations, restlessness, sadness, and irritability to occupational stress.
Heavy workload, long working hours, especially in the weekends and night shifts, tight deadlines, inadequate work equipment, and oversight were identified as the main causes of stress among the study participants.
Participants 1, 3, 4, 6, and 8 stated that they engage in regular exercises to cope with stress.
Participants 2, 5, 7, 8, 9, and 10 stated they use outdoor explorations to manage their stress through nature walks. All the participants highlighted that they schedule activities to create a balance between work and home responsibilities. Participants 6 and 7, who work in the intensive care unit and emergency room, respectively, state that the Covid-19 pandemic is presenting overwork stress to them. All the participants also state that they are afraid-based stress due to the risk of contracting the virus.
All the participants stated that the suggested actions are a good way to perform as a form of games to reduce stress in the workplace. All of them quietly give positive feedback about the
gamifications based on their daily activities and behaviors because they are generally doing these on a daily basis but not in a fun way. This game can be helpful for them to work safely in the stressful working environment to the betterment of themselves also for the welfare of others in the working place.
The designing game can be helpful to reduce stress. The game is not practically implemented but may be a good choice for the well-being of nurses in near future. It can motivate them to change their behavior by not freaking out or getting panic due to stress by playing and shifting their mood.
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