1. Weaver, Susan H. PhD, RN, CRNI, NEA-BC
  2. Paliwal, Mani MBA, MS
  3. Phillips, Maryjo MSN, RN-BC, CMSRN
  4. Androski, Ellen MSN, RN-BC
  5. Wurmser, Theresa A. PhD, MPH, RN, NEA-BC

Article Content

Nurse leaders continuously search for ways to improve patient satisfaction on their units and throughout their organization. A gamified digital platform that provides staff with real-time patient feedback may be a solution. A Magnet(R)-recognized acute care hospital in the Mid-Atlantic region of the US sought to explore if a gamified patient feedback system would improve nurse engagement and, ultimately, patient satisfaction by implementing it on a 43-bed medical-surgical unit.

Figure. No caption a... - Click to enlarge in new windowFigure. No caption available.


Today's employees have smartphones and frequently use social media and video games in their personal lives.1 Gamification-using the common and enjoyable gaming principles of video games in nonvideo game contexts-is intended to enhance engagement and motivate employee productivity.2-4 Badges, leaderboards, and points are all components of gamification.4 A gamified patient feedback system produces real-time data, with the aim of enhancing and transforming the patient's hospital experience.


For patients and families, the gamified system allows for anonymous reviews of individual team members who can view their daily performance and comment or like reviews on their newsfeed. Additionally, staff earn pecks (points) to trade in for rewards, ranging from gift cards to a preferential parking space. Administrators can view employee performance, send employees awards for positive patient comments, and recognize employees individually or as a group for exceptional performance. By leveraging immediate insight from patients, the gamified digital platform empowers staff members by providing feedback from patients for whom they've cared directly. This patient feedback is then used to inspire behavioral change.


Research has shown that there's a vital and interdependent connection between patient satisfaction and nurse engagement and satisfaction.5-7 It's also known that hospitals with highly engaged employees have better Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores.8 The gamified patient feedback system can improve care provider engagement, employee retention, and the overall patient experience.9 In fact, a case study report revealed that 6 months after implementation of the gamified system at an acute care hospital in California, HCAHPS scores significantly improved.10


Literature review

Research is just beginning to evaluate how gamification applications motivate and engage the end user.11 Subjective experiences of gamification applications were collected in a study performed in Italy to identify end users' motivation, loyalty, and engagement with gamified systems.11 The study found that initially users were motivated to participate but as time went on and they became more familiar with the gamified features, they viewed the applications as repetitive, static, and scarcely rewarding.11


A prospective nonrandomized-controlled study investigated whether implementation of a central line-associated bloodstream infection (CLABSI) app, which had a self-assessment checklist of the CLABSI prevention best-practice bundle and just-in-time microlearning with on-demand videos, would reduce the CLABSI rate on the intervention units.12 There was a 48% decrease (P = .03) in the CLABSI rate on the units that implemented the app.12 Competitions with prizes were also held, with shift- and unit-based teams earning points for each self-assessment; increased engagement was found during the competition months.12


Focus groups were held with ICU nurses in Portugal before implementation of gamification for hand hygiene compliance, which included a dashboard providing real-time feedback.13 The nurses who participated in the focus groups stated that it was good to receive feedback about their hand hygiene; however, they weren't interested in obtaining badges and virtual goods because that took extra time.13


Additional research is needed to discern the effects of gamification on employee satisfaction, engagement, and productivity. Whether a gamified platform improves patient and staff satisfaction, along with staff work engagement, has yet to be explored. Therefore, the aim of this study was to explore the use and implementation of a gamified patient feedback system, the perception of users, and the relationship of the product's use to patient and staff outcomes.



A pilot longitudinal mixed-methods study was conducted to explore staff members' and patients' perspectives of a system providing real-time patient feedback and investigate whether implementation of this system on the intervention unit would increase patient and staff satisfaction as compared with a similar 38-bed medical-surgical unit that hadn't implemented the gamified system.


Before implementing the gamified system on the intervention unit, representatives from the product vendor educated staff, leaders, and patient ambassadors. The patient ambassadors and leaders were instructed on the procedure for collecting patient feedback, which was to visit patients in their rooms and assist them and their families with filling out anonymous reviews of their caregivers on a tablet. Staff members gained access to their patient feedback on their personal dashboard after the gamified system had been implemented for 30 days.


On the intervention unit, patients were interviewed to obtain their perspective of the gamified system and staff members participated in focus groups to provide their feedback on this system. Staff members on the intervention and comparison units responded to a staff satisfaction and work engagement survey at four time periods: baseline, before implementation of the gamified system; after 3 months of use; after 6 months of use; and after 9 months of use. On both units, patient satisfaction was measured by HCAHPS surveys at baseline and 6 months after implementation of the gamified system. Before the study commencement, approval was obtained from the hospital system's Institutional Review Board to ensure that the rights of participants were protected.



Patient feedback. After the gamified system was implemented for 3 months, interviews were conducted with patients age 65 and older. Despite multiple attempts, only four patients consented to be interviewed. The conversations with patients and their families elicited feedback regarding the ease of use with the gamified system. One patient's granddaughter stated, "Very easy, straight forward, very quick to use...pretty easy to use especially on the [tablet]." Another patient's daughter explained that her mother had trouble seeing the photos of the staff members and further explained, "For somebody like my mom who's older, I think it's a little difficult."


This gamified platform allows patients to enter free-text comments of appreciation for their caregivers. The number of comments entered by patients is displayed in Figure 1, with the most comments received during the second and third months of gamified system use. The comments entered by patients about RNs ranged from three comments in the final month to 105 in the second month; comments about patient care technicians (PCTs) ranged from two comments in the final month to 48 in the second month. Patient comments were primarily positive, thanking the nurses and PCTs for their excellent care.

Figure 1:. Trend in ... - Click to enlarge in new windowFigure 1:. Trend in number of patient comments entered into the gamified system

The comments provided details on specific interactions that patients had with staff, such as: "I listened as he [the PCT] talked to my roommate who's very confused. He calmed her down and treated her as if she were his own mother. Truly a fine young man who does a great job." Another patient commented, "She [the nurse] went out of her way to explain things to me and my wife. When they were placing a PICC line in my wife, she explained why and how it was going to be placed. She's very understanding. When my wife didn't get breakfast this morning, she worked very hard to make sure that [my wife] was able to get her meal. She makes sure that everyone feels part of a team and that everyone was in the loop. She was training a nurse and kept her included in my wife's care as well."


Staff focus groups. Focus groups were held with staff members working on the intervention unit where the gamified system was implemented. All staff members who work on the intervention unit were invited to participate in the focus groups. Two focus groups were held with participation of 11 RNs and seven PCTs after the gamified system had been in use for 5 months. (See Table 1.)

Table 1 - Click to enlarge in new windowTable 1. Focus group demographic data

"Receive recognition," "boosts confidence," and "process of recognition" were the themes identified from the focus group discussions. When patients enter feedback into the gamified system, staff members receive recognition and feel appreciated as explained: "[The system] boosts our morale because patients appreciate us" and "It makes us feel really good and it puts some pep in our step." The real-time feedback received from patients also boosts staff confidence and even motivates them to "put out extra effort." A PCT stated, "I had a little lack of confidence in myself...the more positive comments I received, the more my confidence got boosted up more and more and the more comfortable [I was] in my job, [it] made me appreciate this job more."


Some staff members perceived the patient feedback received from the system as easy and positive, "I think it makes me feel hear a buzz on your phone, or you see something in your text message." Whereas other staff members worried about receiving negative comments, felt it was difficult for the night staff to be recognized, and stated "it takes a long time to accumulate pecks."


Staff satisfaction and engagement. All staff members who work on the intervention and comparison units were invited to participate in a survey about their job satisfaction and work engagement at four time periods: time 1, baseline before implementation of the gamified system; time 2, after 3 months of use; time 3, after 6 months of use; and time 4, after 9 months of use. The survey response rate from staff on the intervention unit ranged from 19% to 32%, whereas on the comparison unit, the survey response rate ranged from 21% to 65%. There was no statistically significant difference in the age or years in position for the staff members who responded to the satisfaction and engagement survey on the intervention and comparison units.


Measured by the Job Enjoyment Scale, job satisfaction for the staff on the intervention unit ranged from 3.18 to 4.17 over the four time periods, and from 3.69 to 3.48 for the staff on the comparison unit.14,15 As shown in Table 2, there was a statistically significant difference in the overall satisfaction (t(48) = (-)2.06, P = .045) in the final time period (time 4), with the comparison unit having higher satisfaction scores.

Table 2: Job Enjoyme... - Click to enlarge in new windowTable 2: Job Enjoyment Scale scores

To measure employee engagement, staff members responded to the 12 Gallup employee engagement questions. There was no statistically significant difference between the two units and between the four time periods. (See Table 3.) However, when analyzing the results from the question "In the last 7 days, have you received recognition or praise for doing good work?," there was a statistically significant difference (t(48) = (-)2.05, P = .046), with the comparison unit having higher scores in the last time period.

Table 3: Gallup empl... - Click to enlarge in new windowTable 3: Gallup employee engagement scores

Patient satisfaction. The HCAHPS patient satisfaction questions of communication with nurses and responsiveness of staff showed an increase in the top box scores from the 2018 baseline to the end of the first quarter 2019 for both the intervention and comparison units. (See Table 4.)

Table 4: HCAHPS pati... - Click to enlarge in new windowTable 4: HCAHPS patient satisfaction scores


The need to improve the work environment for nurses and other healthcare workers is undeniable. Technology with real-time patient feedback may be the mechanism to achieve meaningful recognition of staff-one of the healthy work environment standards.16


Staff members felt recognized and appreciated with the feedback they received from their patients. In the focus groups, the overall feedback about the gamified system was positive. The recognition from patients had a positive impact on the staff. Recognition of his efforts motivated one staff member to do more for his patients, and the positive feedback helped improve the confidence of another staff member.


Patients entered comments into the gamified system thanking staff members for their care. Of the few patients who agreed to be interviewed, their comments were limited and focused primarily on use of the system. Regarding the process and procedure for use of the gamified system, there were mixed reviews from patients and staff. Some patients and their families found the system easy to use, whereas others had difficulty identifying healthcare workers due to functional limitations. For staff, some liked receiving the text message notification of patient feedback, whereas night-shift staff didn't feel that their patients had the opportunity to provide feedback about their care. Staff members also felt that it took a long time to accumulate the rewards, or pecks, so the incentives need to be timely, consistent, and meaningful.


For the first 6 months with the gamified system, the research team had a presence on the intervention unit interviewing patients and conducting focus groups. Tablets weren't available in the patient rooms for patients and their families to enter feedback into the gamified system on their own; patient ambassadors and leaders needed to elicit their responses. The number of comments entered by patients was highest in the second and third months of use and then gradually decreased. This is similar to the findings of Rapp, in which users were initially motivated to participate but use decreased as time went on.11


Job enjoyment and employee engagement on the intervention unit increased from baseline in time 2 and time 3. After 9 months of use (time 4), job enjoyment and employee engagement for the intervention unit decreased from baseline and there was a statistically significant difference of the comparison unit having higher job enjoyment scores. Staff and leadership on the intervention unit may have become less enthusiastic about the gamified system in the final 3 months. Also, in the last 3 months a decision was made to implement the gamified system on all hospital units throughout the healthcare system. The higher job enjoyment and engagement recognition scores on the comparison unit may reflect staff members' enthusiasm with the gamified system starting on their unit during this final time period.


Although HCAHPS results for communication with nurses and responsiveness of staff showed an increase in scores, there may be other confounding variables that affected the scores.



A limitation of this study is that the participants were a voluntary convenience sample of staff working on two medical-surgical units at one acute care hospital in the Mid-Atlantic region of the US.


In addition, patients could only enter information into the gamified system when a nurse leader, such as an assistant nurse manager or a representative from the patient experience team, invited them to respond to questions on a tablet. Lastly, during the final research time period, the decision was made by the organization to implement the gamified system on all hospital units, including the comparison unit. This may account for the difference in staff enjoyment and engagement scores.


Recognition for a healthy work environment

Cost-benefit analysis needs to be conducted weighing the cost of the system, incentives, and required personnel to obtain the feedback versus the benefits of having real-time patient feedback for staff. More research needs to be conducted on the use of gamified digital platforms, evaluating the impact on the work environment, patient and staff satisfaction, staff engagement, and employee retention. Because meaningful recognition is an important element of a healthy work environment, nurse leaders need to consider ways to provide staff with positive feedback from patients, including mechanisms that use gamification.


Research overview

Purpose: The purpose of this pilot longitudinal mixed-methods study was to explore patients' and staff members' perspectives of a gamified system that provided real-time patient feedback and investigate whether implementation of this system on a 43-bed medical-surgical unit at an acute care hospital would increase patient and staff satisfaction and work engagement as compared with a similar 38-bed medical-surgical unit.


Location: A Magnet(R)-recognized hospital in the Mid-Atlantic region of the US


Time frame: July 2018 to June 2019


Population: Patients on one medical-surgical unit and staff who work on two medical-surgical units


Collection tools: Interview guides were used for the semistructured patient interviews and the staff focus group sessions. A demographic data form was used to collect descriptive data on the characteristics of the focus group participants. The seven-item Job Enjoyment Scale and 12 Gallup employee engagement questions were used to measure job satisfaction and engagement. Patient satisfaction, as measured by HCAHPS surveys, was also reviewed.


Sample size: Four patients were interviewed; 18 staff members from the intervention unit participated in one of two focus group sessions.


INSTRUCTIONS The impact of real-time patient feedback using a gamified system



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