In late 2011, the Special Committee on Aging provided testimony before the United States Senate. The Office of Inspector General OIG) revealed 2 reports about the overuse and misuse of antipsychotics in patients with dementia residing in nursing homes. OIG determined that over 80% of the Medicare claims for the antipsychotics in long-term care were off-label use (unapproved indication)!  An unprecedented effort has been put forth to reduce these medications in long-term care. 

 What this also means is that the C.N.A (Certified Nursing Assistant) will become the most vital role in deploying multiple non-pharmacologic interventions in nursing homes. In other words, the C.N.A role just got 100X more complex and challenging. The C.N.A will need tremendous support and ongoing education to meet the needs of this new era in long-term care.  

 Two important questions:

 1) How does one motivate and retain excellent C.N.A's within long-term care facilities (nursing homes and assisted livings) during this initiaive on a limited budget?  

 2) How does one reward the use of creative non-pharmacologic interventions within long-term care?  Gamification!

gamification jpeg  Gamification is the concept that the fundamental elements of a video game possess the potential to foster motivation in non-game based situations. Researchers have proved that gamification improves a desired outcome by initiating a rewards system.  This concept would allow healthcare managers to motivate nurse assistants with a visual based solution and encourage specific tasks. Essentially, the concept transposes everyday life concepts into a visible reward of achievement. The purpose of gamification in essence is to break down a goal or task into achievable milestones.  Gamification is an option that turns the chore of achieving the goal or task into a fun and visual game of sorts. 

 Imagine the break room within a long-term care facility. You will see a few dated policies, on faded paper tacked to a corkboard.  Now imagine a small (cheap) flat screen with individual avatars representing each nursing staff member. Each staff would have their own personal avatar, which would accrue points and badges. The points can be rewarded (via the nursing director) for outstanding patient care or after achieving x amount of days without taking a sick day.  Bonus points would be given to a staff member who developed a model non-pharmacologic solution.  The facility administration would determine whether or not the points could also be exchanged for real goods (such as a gift card at the local coffee shop) or virtual goods, such as a distinguished avatar, or a combination of both. Through this process, the nursing assistant would view the necessary steps as fun tasks in which they receive awards, points, and badges. The concept turns work into a game in some sense of the word and at the same time, the individual takes steps without apprehension and fulfills the designated goal(s). 


 Avatars are graphical images that represent a person or player within a game or other graphical interface. Users have the option to select physical attributes of the avatar such as hair color, clothing, and overall appearance.  


 Badges are prizes which characters unlock after achieving tasks within a given level. In gamification, these badges could represent the accomplishment of tasks assigned within a project. Users receive several badges per level within a given game. In gamification, badges could represent goals listed within a milestone and the user earns them by completing a special project task. 


 Participants earn points by accomplishing tasks. The tasks each represent a predetermined amount of points. The points represent rewards such as gift cards and other incentives. The participant with the most points appears at the top the leader board. 

 Leader Board

 The leader board is a list of all participants. The participants with the most points top the list. The use of leader boards motivates participants to perform tasks quickly to advance on the board. The concept is similar to top score lists within video games. Through gamification, participants who appear at the top of the leader board receive the most prizes and incentives. 

 Managers utilize levels, points, and badges to influence desired behaviors within the nursing team. When utilizing these tools, a leader board brandishes the nurse assistants or nurses who earn the highest points. The nursing director then selects methods to reward these behaviors based on the top positions found on the leader board. With this concept, the creative output and revitalized critical thinking of the nursing staff may improve patient care significantly. 

 Gamification Concepts Used Today

 Throughout offices within America, employers utilize the concept of the Biggest Loser TV show to encourage employees to lose weight. Employers ask that all participants add small increments of money into a pool each week. All participants weigh in, and someone records the weight of each employee. The employee who loses the most weight wins the money pool after a predetermined amount of time. The concept feeds, into the intrinsic desire to lose weight. 

 The same is true of programs such as Weight Watchers. In gaming, players earn points by performing tasks. Weight Watchers and similar programs allow participants to earn points for performing exercises and by eating the right foods. Most video games present challenges and milestones. Weight Watchers present challenges based on the weight loss goals of the participant and counselors set milestones according to weight loss goals. 

 Platforms such as Four Square and Zynga utilize the same gamification concepts to motivate players to achieve milestones, receive badges, and reach higher levels. Players who achieve these goals receive awards by advancing within the game. The same concepts utilized through gamification in everyday life motivate employees in healthcare and other industries to reach goals. USA network gamified the popular "Club Psych" site website (after the TV show "Psych") using Bunchball's nitro gamification platform. This increased fan loyalty.  Imagine what this platform could do for nursing retention?


  The Future of Gamification

In terms of healthcare, gamification may help some forms of health promotion. In fact, healthcare providers may now require that the insured person utilize systems such as Humana Vitality, a Humana Healthcare based game. This game of sorts requires the user to enter information based on their health, which assesses their health risks. The programmed healthcare professionals take the player on a journey to educate them on ways to become healthier and decrease health risks. 

 Take for instance the app known as Plum; the concept instructs individuals to track locations in which they visit while performing tasks such as to quit smoking. The app allows the user to mark locations easily where they often smoke. The user receives diverted paths to take instead, to remove them from places in which they often smoke cigarettes without getting caught. The player receives virtual rewards for following the diverted path and successfully returning to the starting point without smoking. 

 Gamification concepts will become widespread throughout the business world. With additional documental projects based on gaming interfaces, businesses will possess more efficient methods of documentation of tasks entered into computer systems. 

 In conclusion, gamification is beneficial in a vast number of industries including healthcare. These concepts correctly applied to the field of nursing and long-term care are needed now more than ever.  Nurses are faced with a massive shift away from the utilization of antipsychotic medications and towards the non-pharmacologic strategies for dementia behavior.  Gamification is the perfect solution for encouraging and motivating the nursing staff in long-term care. Future studies should attempt to measure nursing retention, non-pharmacologic innovation and morale within facilities that utilize gamification to the fullest extent possible.