In the years after COVID-19, workplace pressures made it difficult for nurses to stay connected to the joy and purpose of caregiving, pushing the estimated rates of nurse burnout to above 40%.1 Burnout has caused nurses to quit at every stage of professional development. Newly licensed RNs (NLRNs) are among the most challenging and important to retain in the profession. Already burnt-out NLRNs quit at rates of up to 25% in the 1st year and nearly 51% in the 1st 4 years.2

Perceived social support is critical in coping with nurse burnout because what is even more important than actual social support for a caregiver's emotional well-being is the caregiver's perception of receiving support, respect, and consideration from others.3 To respond to the crisis of nurse retention, hospitals and health systems need to create work environments where nurses feel engaged, supported, and valued for their caregiving.

With the objective to build a workplace culture of positivity and belonging, this performance improvement project introduced a mobile social gaming app as an innovative way of providing support and recognition for the day-to-day practice of nursing.

Connecting to the Joy of Being a Nurse

Half of nurses in US healthcare have considered leaving the profession in some part, because they feel a lack of appreciation.4 A study among 273 hospitals in 35 states on RN turnover and retention found that 50% of nurses plan to change positions within a year and most at risk are nurses younger than 35 years.5 The same study showed that a 13.5% increase from 2021 to 2022 raised the average cost of turnover for 1 staff RN to $52 350, and each percent change in overall RN turnover will cost or save the average hospital $380 600 per year. This financial burden also threatens care quality, including the patient experience of care.6,7 Feeling unappreciated, nurses face compassion fatigue and burnout if they choose to stay in the profession. This negatively impacts the safe and reliable delivery of care, because compassionate care is essential for better clinical and patient outcomes.7-9

Peer support and recognition connect nurses to the joy and purpose of being a nurse and are instrumental coping strategies against compassion fatigue and burnout. A study conducted on 862 professionally active nurses found that when nurses perceive they have higher levels of peer support, they suffer less from compassion fatigue; they have higher job satisfaction and a lower risk of burnout.10 A meta-analysis of 18 quantitative, 2 mixed-methods, and 4 qualitative studies showed that a third of the variability in nurse burnout depended on whether nurses felt supported by their peers, underlining the critical role of peer support in coping with work stressors behind burnout.1 Another study showed that perceived support from peers as well as from the employing organization decreased the moderate to high levels of burnout among a sample of 73 nurses, who were identified as bedside caregivers in palliative care.11

Studies on caregiver burnout call for interventions to help caregivers remain empathetic and compassionate professionals,12 such as building a culture of peer support through multidisciplinary support teams.13 Sharing positive feedback with nurses about their caregiving excellence is a simple yet effective intervention toward building a culture of support, and it improves nurses' job satisfaction and job enjoyment. When nurses enjoy their work, they experience less burnout, because they feel more compassion, which improves resilience against secondary traumatic stress.14

Research also shows the importance of building workplace cultures on supportive structures that enable the recognition of accomplishments by caregivers.15 These supportive structures include opening communication channels and hosting interactive forums that showcase the organization's intentionality to support and recognize the work done by caregivers. When these structures are in place, caregivers perceive support, they have visible pride in their work, they feel motivated by and committed to their work, and they report greater satisfaction and well-being.

Faced with alarming rates of nurse burnout, nurse leaders and innovators need to design and implement solutions that enable such supportive structures. To maximize effectiveness, these structures need to make it frictionless to connect nurses to the joy of their work.

Digital Gaming

Digital gaming can help build supportive structures for nurses to easily share positive feedback. Thangavelu et al16 provide an extensive review of “serious digital games,” which are interactive computer apps with engaging designs and scoring systems used to facilitate motivation and goal achievement in simulated learning environments. Although digital games are used in developing clinical competence to prepare new nurses for clinical decision making,17 these apps have not been fully leveraged to engage nurses in the actual practice of nursing. This project explored the effectiveness of a digital app for mobile social gaming to provide support and recognition for the day-to-day life of being a nurse.

Building a Workplace Culture of Positivity and Belonging Through a Mobile Social Gaming App

The project took place at 2 hospitals of a not-for-profit healthcare system with medical centers, critical access hospitals, and medical clinics located in the states of Washington, Oregon, and Alaska. The same launch protocol was used across different care settings at both hospitals—site 1 in Alaska and site 2 in Oregon.

For this project, the mobile social gaming app was introduced on a voluntary basis at nurse huddles on 2 consecutive days at each project site for a convenience sampling of participants. Those who opted in to participate were briefed on how the app worked and were asked for their feedback on the app.

A total number of 18 nurses initially downloaded the app at both hospitals (10 nurses at site 1 and 8 nurses at site 2). The recruitment was limited to introducing the mobile social game to the nurses at the beginning of huddles and then directing those who agreed to participate in the project to the iOS and Android app stores. The participants downloaded the app on their personal phones, following the procedures and security protocols for downloading a social app from the iOS and Android app stores. The 2nd author was on-site at both hospitals to answer questions while the initial sets of participants downloaded the app and joined the game. Fliers with a QR code to download the app were left behind at the nursing stations at both hospitals. No additional presentation or solicitation was done to encourage the participants to keep playing or to invite their coworkers to join the game.

An Innovative Method to Share Positive Feedback

The technology deployed in this project, Charge Health (a mobile social gaming app),18 allows users to invite other caregivers to show support and recognition for each other by answering polls about the positive attributes, behaviors, and actions of caregiving. After downloading, the app prompts the users to enter their phone numbers and identify their roles in the care setting (such as RN, nurse executive, etc) to receive polls.

Figure 1 shows screen images of sample polls. The polls either reflect professional kudos valued among nurses (“Most likely to win a DAISY Award”) or show patients' comments about excellent nursing (“The night nurse was so understanding. I will never forget her empathy”). Above the unstructured text on each poll is an emoji that represents the text's content; for example, a “daisy (✿)” emoji for “Most likely to win a DAISY Award.” Below the text are a set of 4 names as choices for the coworkers to be recognized. Emojis used in the polls are inclusive of different demographic groups.

Figure 1:

Screen images of sample polls from the mobile social gaming app.

For each poll, the user can click on: 1) one of the 4 names that appear below the unstructured text to send “Sparks (✦✧✧),” that is, a phrase describing a positive attribute, behavior, or action to recognize a coworker; 2) “Shuffle Names” to get a different set of 4 names as options; or 3) “Skip Poll” to not answer a particular poll and move on to the next.

Displayed on the top left corner of each screen is the number of polls per 1 round of the game. For this project, each round of the game included 8 polls. On the top right corner, the user can see the number of “Charges (⚡)” (points) earned in the game. Answering each poll earns the user 5 points. On the bottom of the screen, there is an inbox icon, which the user can click to see the list of Sparks received from coworkers with different roles in the care setting. Every 100 points earned allows the user to choose 1 among the list of Sparks received and reveal the name of the coworker who sent the user a Spark.

In the middle of the final screen of a full round of the game, under a “shut lock (?)” emoji, the user sees the countdown of the time (in hours, minutes, and seconds) when new polls will be available. The user can “Skip the Wait” and immediately get the next set of polls by clicking on the button below the countdown to “Invite Co-workers.”

Project Goals

The project focused on signing up initial sets of users at site 1 and site 2 and then tracking post launch the metrics of: 1) user growth; 2) number of daily active users (DAU); 3) number of weekly active users (WAU); and 4) the likelihood to recommend (LTR) the workplace.

For this project, all the polls except the 1 on LTR (for the workplace) were based on unstructured text. Patients' comments used in the polls were reviewed to ensure they contained no protected health information. Executive sponsors of the project at both hospitals wanted to see whether playing the game had any impact on the nurses' choices for LTR, because LTR scores from nurses have important implications for organizational initiatives, such as Magnet® designation, in addition to nurse recruitment and retention. To provide this observation, a poll asking “Would you recommend this workplace to a friend or colleague?” was included among the polls in the 1st and 4th weeks of the project. The users could skip this poll or respond by choosing between a “thumbs up ()” and a “thumbs down ()” emoji.

Findings

Within the 1st 4 weeks of the project, the number of the app's users grew by 489% to be played by 20% of the total nursing workforce (n = 106 RNs, LPNs, and certified nursing assistants) at site 1 and site 2. This growth rate was achieved organically, that is, through the adoption and use by nurses from all age groups inviting coworkers to join the game and by coworkers joining the game without any further solicitation.

Daily active users (DAU) and WAU are important indicators of user activation and engagement for apps. For this project, DAU was 50.5% and WAU was 86%. These metrics indicated strong engagement with the app. For reference, DAU of 20% is considered good engagement for a social gaming app. These authors believe the indicators of activation and engagement were strong because of the convenience that the app provided for nurses to support and recognize their peers, which are deeply embedded practices in caregiving settings.

These metrics were achieved with the average use time of less than 3 minutes per user per day. No disruption to the workflow processes or alert fatigue issues occurred from using the app.

The project created an environment where 5678 Sparks (messages of recognition) were sent among the nurses and 206 unique individuals were recognized by 106 users who downloaded the app. Table 1 summarizes these findings that indicate the rapid adoption of the mobile social gaming app for the messaging and distribution of peer support and recognition across the nursing workforce.

Table 1 - Adoption and Use of the Mobile Social Gaming App With Examples of Sparks (Messages of Recognition) Sent Among Nurses at Site 1 and Site 2 Convenience Sample of Initial Users (Introduced to the App at Nurse Huddles) No. Organically Acquired Users No. Sparks Sent Among Nurses No. Nurses Recognized 18 88 5678 206 Examples of Sparks:
Destined for leadership
Always energized, no matter the hour
Patient whisperer
Ensures highest hygiene standards
Nightshift ninja
Most likely to inspire others to become nurses

Table 2 shows the results from the poll on LTR for both project sites. The LTR results were measured at the 1st and 4th weeks of the project for comparison. Although site 2 had a higher starting point of LTR than site 1, the overall LTR across the 2 project sites increased by 8.80%. At site 1, with the lower starting point, positive (thumbs up) responses to the LTR poll increased by 12.5%. At site 2, with the significantly better starting point for LTR, the positive responses showed a meaningful increase (5.10%). In addition, 84% of users responded to the LTR poll, which is very high compared with response rates for traditional engagement surveys. These findings indicate that a digital game for sharing positive feedback can contribute to building cultures of positivity and belonging at caregiving organizations, regardless of whether they already have satisfactory LTR scores (for the workplace).

Table 2 - Poll Results on the LTR the Workplace for Both Project Sites Starting LTR Ending LTR Change in LTR Site 1 0.75 0.875 12.5% Site 2 0.929 0.98 5.10% Average change in LTR 8.80%

Next, this new approach to providing support and recognition among nurses will be discussed regarding nurse engagement, resilience, and retention.

Discussion

Digital gaming technology has not been applied to enhance the day-to-day life of being a nurse, even though the positive social impact of gaming has long been established.19 This project explored using mobile social gaming to boost the engagement of nurses and connect them to the joy of their work. As the findings show, nurses did not need any further encouragement than an introduction to an app to co-participate in a workplace culture of positivity and belonging, where coworkers were supported and recognized.

The mobile social gaming app provided an innovative and convenient way for nurses to engage and support each other. The polls in the digital game reflected a positive attribute, behavior, or action that is either valued among peers (eg, “Quick on their feet during emergencies” or “is the glue that keeps the unit together”) or significant from the perspective of patients (eg, “They knew exactly how I should sit so I would feel most comfortable” or “They were the shining star in a tough time, their empathy and compassion were invaluable”). These polls captured in a few words a wide variety of moments of joy for nursing practice. Nurses were excited to invite peers to the digital game and used the polls as a catalyst (with a “Spark”) to engage their fellow caregivers.

The app's users were protected from potential negative impacts of social networks or social media platforms, such as disseminating misinformation or cyberbullying, because: 1) the prewritten content of the polls focused on positivity; and 2) there was no capability to generate content by the users.

During the introduction of the game, the initial sets of users were observed laughing with and talking to each other about the polls. This observation became evident in the data with the extraordinarily high numbers for the organic growth rate and for the app's DAU and WAU in addition to the increase in positive responses to the poll on LTR. These results indicated that nurses enjoyed seeing in words the moments that bring joy to their work and sharing their recognition of how their peers embody these moments of joy. These findings were best captured in a quote by the chief nursing officer (CNO) of one of the project sites. In the evaluation of the project, the CNO commented, “I know it seems like a simple game, but its power is in how it re-programs our culture to be focused on the positive.”

Bringing Positivity From Patients and Coworkers in an App

A database of more than 1 million artificial intelligence–enabled insights from patients shows that: 1) patients mention care from nurses more than any other aspect of their inpatient care experiences; and 2) the number of positive insights about nurses is twice more than the number of negative insights.9 In other words, nursing care is what matters the most to patients about their inpatient care, and their feedback about nurses is significantly positive. The mobile social gaming app used in this project was designed to make visible to nurses this overwhelming evidence of positivity and appreciation from patients and from the day-to-day observations of coworkers.

The app was quickly adopted as a simple and effective way for nurses to share positive feedback and nurture a workplace culture of positivity and belonging. The limitations of the existing recognition programs are overcome by the engagement mechanism of a digital game. For example, existing programs enable peer recognition for rare events where coworkers go above and beyond their roles and responsibilities. Although it is necessary and important to recognize rare events, the impact of these recognition efforts might be limited, because they include few and exclude many caregivers, whereas a digital game encourages more frequent recognition.

It is also time-consuming for nurses to log into a computer and write several paragraphs to provide thoughtful recognition. When barriers are removed, nurses send recognition to larger numbers of their coworkers on a more frequent basis, which supports caregiver engagement and excellence and nurtures caregivers' sense of belonging.

Industry insights are clear about the importance of workplace culture in caregiver retention. Pride in the work and loyalty to coworkers are what makes caregivers stay with their organization.20 Acting on these insights, hospitals and health systems focus on creating work environments that nurture relationship building among caregivers to retain and reinspire their workforces.6 This project was undertaken because of the industry-wide need for innovative solutions to improve nurse retention. On the basis of these findings, the authors have the following recommendations:

Connecting nurses to the joy and purpose of their work matters for nurse engagement, resilience, and retention. It is important for nurse leaders to adopt solutions that intentionally build workplace cultures of positivity and belonging. Recognition from patients and peers builds workplace cultures of positivity and belonging. Digital gaming provides an effective method of creating opportunities for recognition from patients and peers (as a type of supportive structure) to improve nurse engagement, resilience, and retention.

Organizations that are faced with the urgency to retain nurses would benefit from new methods of showing their support and recognition for the work that all their nurses do every day. Leaders should use every opportunity to recognize their nursing workforce, especially when the opportunity is as simple as a game.

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