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As many countries fear and even experience the emergence of a second wave of COVID-19, reminding health care workers (HCWs) and other hospital employees of the critical role they play in preventing SARS-CoV-2 transmission is more important than ever. Building and strengthening the intrinsic motivation of HCWs to apply infection prevention and control (IPC) guidelines to avoid contaminating their colleagues, patients, friends, and relatives is a goal that must be energetically pursued. A high rate of nosocomial infections during the first COVID-19 wave was detected by IPC specialists and further cemented their belief in the need for an engaging intervention that could improve compliance with COVID-19 safe behaviors.
Our aim was to develop a serious game that would promote IPC practices with a specific focus on COVID-19 among HCWs and other hospital employees.
The first 3 stages of the SERES framework were used to develop this serious game. A brainswarming session between developers and IPC specialists was used to identify the target audience and acquisition objectives. Nicholson’s RECIPE mnemonic (reflection, engagement, choice, information, play, exposition) for meaningful gamification was used to guide the general design. A common and simple terminology was used to suit the broad target audience. The game was tested on various platforms (smartphones, tablets, laptops, desktop computers) by different users during each development loop and before its final release.
The game was designed to target all hospital staff who could be in direct contact with patients within the Geneva University Hospitals. In total, 10 acquisition objectives were defined by IPC specialists and implemented into the game according to the principles of meaningful gamification. A simple storyboard was first created using Microsoft PowerPoint and was progressively refined through multiple iteration loops. Articulate Storyline was then used to create two successive versions of the actual game. In the final version, a unique graphic atmosphere was created with help from a professional graphic designer. Feedback mechanisms were used extensively throughout the game to strengthen key IPC messages.
The SERES framework was successfully used to create “Escape COVID-19,” a serious game designed to promote safe IPC practices among HCWs and other hospital employees during the COVID-19 pandemic. This game can be obtained free of charge for research and educational purposes. A SCORM (shareable content object reference model) package is available to facilitate results and completion tracking on most current learning management systems.
As the COVID-19 death toll continues to rise [
As the pandemic draws out, lassitude and conspiracy theories can lead to a slackening of safety measures [
Nevertheless, building and strengthening the intrinsic motivation of HCWs to rigorously apply IPC guidelines and to do their very best to avoid contaminating their patients, colleagues, friends, and relatives is a goal that must be energetically pursued [
The high rate of nosocomial infections detected during the first COVID-19 wave and the need to train a large number of people while respecting the need for physical distance require the creation of original and inspirational material to promote IPC guidelines. Serious games possess motivational properties that can enhance learner engagement and satisfaction while still delivering important messages [
Our aim was to develop a serious game to promote the dissemination of COVID-19 IPC practices among HCWs and other hospital employees. By raising awareness about situations that could potentially lead to COVID-19 contamination in this key population, such a game could help decrease SARS-CoV-2 transmission between HCWs and from HCWs to patients.
The first 3 stages of the SERES framework were used to develop this serious game [
The target audience was identified through a brainswarming session [
Field observations by specialists from the Geneva University Hospitals infection control program were used to identify the acquisition objectives. We decided to use the term “acquisition objectives” rather than “learning objectives” as the main purpose of this serious game was to promote and stimulate desirable behaviors in HCWs rather than to teach them new procedures.
The theoretical bases relevant to the creation of gamified content in the context of the COVID-19 pandemic were already identified in the course of a previously published project [
We also performed a search for articles reporting information related to SARS-CoV-2 transmission. The MeSH keywords “covid-19,” “sars-cov-2,” and “transmission” were used in combination with the Boolean operators “AND” and “OR” to retrieve potentially relevant references from MEDLINE using the PubMed engine. To avoid inducing doubts or even mistrust in HCWs [
The scientific grounds on which this serious game relies were decided during brainswarming sessions between the developers and IPC specialists from the Geneva University Hospitals. Each iteration of the serious game was reviewed by at least 2 such specialists to ensure that the intended message was correctly and adequately conveyed by the serious game.
The scientific foundations reviewed or established during the previous stage were used to create the general design of the serious game. We used Nicholson’s RECIPE mnemonic (reflection, engagement, choice, information, play, and exposition) for meaningful gamification to guide the development of the game mechanics [
Arnab et al’s [
Design decisions were tailored to the target population and the COVID-19 context. Ease of access to the serious game was considered to be of paramount importance, as was the ability to rapidly capture the player’s attention and interest. True to the SERES framework, we decided to use an iterative approach to build the game. We therefore sought regular feedback from the IPC specialists as well as from potential end users and implemented the required adaptations accordingly.
All the data gathered through the scientific foundation and design foundation stages were used to choose a development platform and to proceed with the development of the serious game. Acquisition objectives were reassessed, and theoretical bases were used to decide upon acquisition mechanics and game mechanics.
In line with the theoretical bases, the game was tested on various platforms (smartphones, tablets, laptops, desktop computers) by different users at the end of each development loop and before its final release.
Early on in the development process, developers and IPC specialists agreed that the target audience should be composed of all the professionals who could be in direct contact with patients within the Geneva University Hospitals. The game was therefore designed to target many different kinds of health care professionals including physicians, nurses, physiotherapists, assistants, technicians, and therapists but also non–health care professionals. Indeed, some of these employees have close and regular contact with patients (stretcher-bearers, housekeepers, etc) and might therefore be exposed to patients or play a role in SARS-CoV-2 transmission.
We used previously identified resources to establish the theoretical background [
The “reflection” element seeks to connect the game to events that happen or might happen to the player in real life. This element was therefore quite straightforward to embed into the game as it was linked to its core concept. We decided to make the player virtually experience scenes that could occur on a normal day to let them make choices that could influence SARS-CoV-2 transmission. We decided to split the game into 4 levels, each related to a specific part of the day (
There are two components to the “engagement” element. Social engagement such as that found in multiplayer games is the component that has gained the most popularity in recent history. While such games have shown many positive features, they are also controversial and have been accused of drawing some players away from reality [
The “choice” element relates to the autonomy the player has within the game. Giving the player the ability to make meaningful choices reinforces the player’s autonomy and the feeling of being responsible for their actions. We therefore decided to let players make choices that IPC specialists would disapprove, and to experience (at least virtually) the consequences such potentially harmful choices might have.
“Information” means providing the player with key concepts to help them understand the reasons behind the serious game, rather than just providing them with points or rewards, which could prove ineffective or even harmful in the long run [
The “play” element is perhaps the hardest to define, and there are many and sometimes conflicting definitions of this element. We have elected to use Nicholson’s approach [
Exposition means creating a meaningful narrative in the serious game. Engaging the player into the serious game requires capturing their interest and curiosity while still permitting them to make their own choices. To create such a narrative, we decided that the player would virtually go through the steps they usually undertake on a daily basis, and to make choices that may lead to the contamination of patients or of fellow HCWs.
Audio elements were not considered necessary as many hospital employees will play the serious game on institutional computers and will not be able to activate the sound. Attractive graphics adapted to the target population were however deemed essential to increase engagement [
First version of the welcome screen.
Final version of the welcome screen.
First version of a simple-choice interaction.
Final version of a simple-choice interaction.
Simple-choice interaction.
Rebuilding the donning sequence. The player must drag and drop the elements of personal protective equipment in the right order.
Multiple-choice interaction. The player must choose in which situations N95 masks should be worn. Illustrations change as the cursor hovers over the buttons on the left.
The IPC specialists defined 10 acquisition objectives according to their field observations.
Acquisition objectives, RECIPE (R=reflection, EN=engagement, C=choice, I=information, P=play, and EX=exposition) elements, and implementation examples.
Acquisition objective | RECIPE elements | Implementation |
Avoid going to work when potentially infectious | R, EN, C, P, EX | |
Recognize COVID-19 symptoms | I |
|
Recognize that HCWsa have a higher probability of being contaminated by a colleague than by a patient | R, EN, I, EX |
|
Recognize that even asymptomatic carriers can be contagious | EN, I, EX |
|
Recall safety measures in the working environment | R, I, EX | |
Recall the correct way of using a face mask | R, I, EX |
|
Recall the correct donning sequence | R, EN, I, EX |
|
Identify when an N95 mask should be worn | R, C, I, EX |
|
Identify when eye protection should be worn | R, C, I, EX |
|
Identify when gloves should be worn and changed | R, C, I, EX |
|
aHCW: health care worker.
Feedback. The player has chosen to go to work despite the symptoms and is now told they should have undergone a test to screen for SARS-CoV-2 infection. The virus count (top right) has increased accordingly.
Feedback. The player has chosen not to go to work, and this choice is encouraged by a positive message and by a "thumbs-up" image. The "thumbs-up" count (top right) has increased accordingly.
Multiple-choice interaction. The player has to identify the symptoms that should prompt a COVID-19 screening test.
Simple-choice interaction. The player has not selected any option and cannot click on “Validate my answer” for the moment.
Simple-choice interaction. The player has already clicked on “Yes” and the “Validate my answer” button can now be clicked.
Multiple-choice interaction. The player has to identify the safety precautions that must be taken at work, including at the cafeteria.
Feedback. The player has failed to choose the expected answers at the first try and can click on “Retry” (retry) to have a second (and last) chance. The number of wrong answers is provided along with the number of correct answers missing from the original attempt.
Simple-choice interaction. The player must drag the “thumbs-up” on the image of the only colleague correctly wearing a face mask.
Multiple-choice interaction. The player must choose the situations in which eye protection should be worn.
Multiple-choice interaction. The player must choose in which situations they should wear or change gloves. Illustrations change as the cursor hovers over the buttons on the left.
To keep track of the player’s choices and to strengthen IPC messages, a virus counter was created. Whenever the player selects an answer that can lead to a possible contamination, a red virus image appears, and the virus count rises incrementally. Conversely, every time the player selects an answer that matches a desirable behavior, a positive token in the form of a “thumbs-up” image is awarded. If the player reaches a total of 5 viruses, a “game over” screen (
Feedback mechanisms were used extensively and systematically in this serious game [
Game over screen. The player can choose to exchange their thumbs-up for viruses (1:1) or to restart the level and decrease the virus count by 2.
We first created a storyboard using PowerPoint 16 (Microsoft Corp). This storyboard, split into 4 game levels, was refined through multiple iterations until we deemed it advanced enough to begin the actual game development. A common and simple terminology was used to suit the broad target audience. We chose to develop the actual game under Articulate Storyline 3 (Articulate Global). This software is easy to use, embeds many elements that are essential for creating interactive content and serious games, and allows developers to export their creations to many different platforms using HTML5.
The first version of the game was developed using stick figures created by PresenterMedia (Eclipse Digital Imaging Inc).
Although developers and IPC specialists found this first version to be both adequate and usable after having been refined through multiple iterations, they felt that it resembled a gamified e-learning module rather than a serious game. We therefore hired a well-known Swiss graphic designer to help us enhance the graphical aspects of the game and create a unique atmosphere. First, sketches in line with the multiple iterations concept of the SERES framework were produced by the graphic designer. These sketches were revised, adapted, and finally validated. They were then transformed into actual images that were embedded in the serious game.
Each iteration of the game was tested by at least 3 authors whose feedback was systematically assessed and, when relevant and feasible, integrated into the next iteration of the game. The final version was validated by all the authors and by IPC specialists, some of whom act as consultants for the World Health Organization. Apart from the authors, all of whom are part of the medical or nursing staff, the game was tested by nonclinical staff from the Geneva University Hospitals training center before its release. These testing sessions showed that the game takes 15 minutes to complete on average.
The heuristic evaluation procedure described by Davids et al [
This serious game can be freely accessed on the internet [
The first 3 stages of the SERES framework were successfully used to create the “Escape COVID-19” serious game. The content created meets the definition given by Gentry et al [
Since HCWs perceive a higher likelihood of contracting COVID-19 than the general population [
Though we chose to use Nicholson’s RECIPE mnemonic for meaningful gamification [
The main limitation of this study is the current lack of evidence to support the use of this serious game. A longitudinal trial assessing the evolution of the rate of SARS-CoV-2 contamination in HCWs and in other hospital employees should be carried out to help assess the impact of this serious game. Assessing the added value of specific elements might however prove difficult, and multiple confounding factors (progressive dissemination of new guidelines, natural and unforeseeable evolution of the pandemic, etc) will make this more difficult.
Since knowledge regarding SARS-CoV-2 transmission mechanisms is evolving quickly, this serious game could be obsolete in a matter of months or less. This limitation is however relative as the platform used to develop this serious game is quite flexible and should allow us to rapidly update the game.
Finally, even though most screenshots are displayed in English, the original game was developed in French and the English translation has not been completed yet. It should however be completed by the end of 2020.
While the creation of this serious game was considered successful, we cannot be certain of its actual impact on IPC practices and behavior. The SCORM package is available to any researcher or institution willing to deploy it on a learning management system, whether for research purposes or simply to make it available as an additional educational tool.
Following the release of version 2.08, the Geneva University Hospitals have deployed Escape COVID-19 and made it available to their 13,000 employees, including medical, nursing, and administrative and support staff. In the wake of this deployment, the Geneva Directorate of Health requested us to make this serious game available to nursing home employees. Indeed, long-term care facilities have been severely hit by the COVID-19 pandemic [
The SERES framework was successfully used to create “Escape COVID-19,” a serious game designed to promote safe behaviors among HCWs and other hospital employees during the COVID-19 pandemic. The impact of this game should now be assessed through a longitudinal trial.
electronic learning
health care worker
infection prevention and control
Medical Subject Headings
personal protective equipment
reflection, engagement, choice, information, play, exposition
shareable content object reference model
The authors would like to warmly thank Eric Buche, who designed all the magnificent graphical elements used in this serious game. We also thank Alistair Dumps for his inputs at the initial stages of the project, and Paul Tairraz and Lolita Loureiro from the Geneva University Hospitals training center for their tests and inputs.
None declared.