Improving Health Care Training: A Serious Game Approach to Malnutrition Screening

Introduction

This article explores the use of a serious game, “Kamferhjemmet” (Camphorhome), to train health care professionals in Norway on monitoring malnutrition among patients in nursing and treatment homes. Serious games can be used to educate and train health care professionals to avoid medical errors, develop better work routines, use medical tools, and acquire new knowledge.^1–3 Developed by Kapoow AS for the Centre for Development of Institutional and Home Care Services Vestfold and Telemark (USHT-V), “Kamferhjemmet” aims to address systemic malnutrition issues in the Norwegian health care system. The goal was to help health care professionals in Tønsberg and Sandefjord develop better routines and knowledge using the Malnutrition Universal Screening Tool (MUST). ⁴ The MUST tool assesses nutritional status by combining weight, BMI, food intake, symptoms, degree of illness, and age. ⁵ It helps health care workers understand and act on nutritional risks. It is essential that health care workers understand the values it produces and use the tool routinely, either weekly or monthly, depending on the patient’s location. ⁵

Malnutrition is a significant challenge in the Norwegian health sector, with every third of hospital patients at risk, leading to increased morbidity, longer hospital stays, and higher mortality.^6–8 The elderly and those with serious or long-term illnesses are often at risk. ⁹ To prevent and treat malnutrition, the Norwegian Directorate of Health recommends assessing all patients for nutritional risk at admission and following up weekly.^8,10 But many health care personnel lack the routines and knowledge to ensure basic nutritional needs are met. ⁹ Good nutrition practice involves mapping, assessment, and documentation of nutritional status, assessing food intake in relation to needs, initiating targeted nutritional measures, and conducting evaluations. ¹⁰ Malnutrition in health care settings is a pressing issue not only in Norway but across many high-income countries with similar health care systems. In the United Kingdom, studies have shown that malnutrition affects around 45% of hospital admissions, leading to longer stays, higher treatment costs, and increased mortality rates. ¹¹ In Canada, malnutrition is present in up to 45% of hospitalized patients, contributing to delayed recovery and a higher risk of complications. ¹² The United States faces comparable challenges, with malnutrition impacting approximately 20%–50% of hospitalized adults, particularly among the elderly and those with chronic illnesses. ¹³ Therefore, malnutrition remains an underdiagnosed and undertreated condition in many high-income countries, especially in long-term care facilities and hospitals. These statistics underscore the need for effective screening tools like the MUST, and the potential for digital solutions such as serious games to enhance the training of health care professionals and improve routine malnutrition screening practices globally.

This pilot study aims to explore the potential of serious games as educational tools in health care, with a specific focus on user reception and potential areas for improvement. While the findings offer valuable insights, they are limited by the scope and context of this initial exploratory research.

The research statement of this article is to explore how the design and use of Kamferhjemmet meets these goals. If it was successful or not what kind of factors can explain its failure or success? Are there elements with the case that other serious games in the health care industry other designers and researchers need to be mindful off?

The case study uses quantitative and qualitative methods, involving 29 health care personnel from two institutions, pre- and postgame surveys, observations, and semistructured interviews. The two institutions also gathered data over MUST registrations a month before, during, and after the personnel had used the game to see if there was any immediate effect.

The case: Kamferhjemmet (camphorhome)

The term “serious game” has gained popularity over the last decade, particularly in health care. ¹⁴ Serious games are used across various fields, including military, health, education, and medicine, to educate, motivate, and change user behavior and are designed to be educational, impactful, and meaningful, addressing real-life skills and purposes beyond mere entertainment.^1,15

“Kamferhjemmet” is a serious game utilizing its game mechanics to train and familiarize health care professionals with the benefits of the MUST methodology.^4,16 “Kamferhjemmet” was developed by Kapoow AS in collaboration with the Centre for Development of Institutional and Home Care Services in Vestfold (USHT-V). The idea originated from USHT-V, which saw the potential for digital games as educational tools, especially for younger generations of health care professionals who are accustomed to digital platforms. The project received innovation funding from the Norwegian Directorate of Health in 2019, and development has been a continuous process with several rounds of testing and iteration. The game is currently not widely available but has been used in pilot studies to assess its effectiveness in training health care personnel. The game is played in a web browser where players act as health care professionals solving various cases, involving nursing home residents.

The game features simple 2D graphics, sound, interface, and control options using a computer mouse (Fig. 1). Players navigate each level using the MUST tool to solve cases, receiving help from a doctor or nurse for patient health information. The game involves three patients—Olga, Gerd, and Ragna—each presenting different scenarios requiring the use of the MUST tool. These scenarios help players develop routines for using the tool, as each patient’s weight and health status change over time. The first patient serves as a tutorial for both game mechanics and the MUST tool.

OPEN IN VIEWER

FIG. 1.

Screenshot of the game. All text in Norwegian.

The game’s start screen clearly outlines its learning goals: How to use the MUST survey tool, make appropriate measures based on the survey, and evaluate nutrition measures over time. Players have access to tools such as weight and height measurement devices and the health journal. Correct actions are rewarded with gold stars, indicating by animations and sound effects. The game does not penalize players with negative health outcomes for mistakes; instead, incorrect actions result in feedback and a lower star count, requiring players to retry until correct. Each patient’s case can be completed in approximately 15–20 minutes, with the option to replay for better scores.

Materials and Methods

To evaluate the game’s effectiveness, we employed a multimethods approach, incorporating surveys, semistructured interviews, and observations. The game was tested during the winter of 2021 at two health care institutions in Vestfold and Telemark County: Tønsberg Nes Sykehjem (Nursing Home) and Sandefjord Soletunet Bo-og Behandlingssenter (Residential and Treatment Center). These institutions provide long-term residential care and short-term treatment services for elderly patients and individuals with chronic conditions. Each facility has over 70 beds across short-term and long-term units in rural settings, providing residents access to nature, sensory gardens, and outdoor activities as part of their care philosophy.

Fourteen personnel at Tønsberg and 15 at Sandefjord participated, totaling 29 health care workers. Each institution had a contact person responsible for reminding personnel to play the game regularly, complete surveys, and identify individuals for interviews and observations. Ideally, each person should play the game 2–4 times over one month. The Centre for Development of Institutional and Home Care Services Vestfold and Telemark also held information meetings, explaining the project and the game to the participants before the project started. Participants also received an information pamphlet and details about the required surveys they had to fill out.

Two online surveys were developed using Nettskjema, a GDPR-compliant tool by the University of Oslo. The first survey, that 24 persons answered, was administered before the game and collected data on age, gender, Norwegian language skills, digital literacy, video game experience, and familiarity with the MUST tool. This was essential as some health care personnel in Norway speak Norwegian as a second language, which could affect their learning from the text-heavy game. The second survey, that only 16 persons answered, was administered after a month of using the game and focused on participants’ experiences, learning outcomes, and opinions on using a game as a learning method. Low participation in last survey can probably be explained due to both high sickness absence linked to the COVID-19 outbreak and the municipal strike in the time period.

Seven health care workers were observed during the game testing, with five participants from Tønsberg Nes Sykehjem and two from Sandefjord Soletunet Bo-og Behandlingssenter. The participants at Tønsberg included both male and female health care workers, while the group from Sandefjord consisted of three women and two men. All observations were conducted while the participants were at work, performing their regular duties. Due to COVID-19 restrictions, the gameplay sessions were conducted via Teams, with participants sharing their game screens, faces, and voices during the process.

In addition to quantitative data, we conducted four semistructured interviews—two from each institution, with three female participants and one male participant. Of these, three were educated nurses, and one was a health care worker, all of whom were native Norwegian speakers. The interviews were recorded and transcribed for analysis. An interview guide consisting of 39 open-ended questions was developed, focusing on themes such as familiarity with the MUST tool, digital literacy, and experiences using the “Kamferhjemmet” game. This structure facilitated the comparison of responses between the two institutions, revealing both similarities and differences in their digital competencies and attitudes toward the game.

The final data point was the number of MUST registrations at the institutions a month before, under, and after the personnel had played the game. The institutions recorded their MUST survey numbers in a system called CosDoc. The contact person at each institution collected statistics from their database, ensuring compliance with strict privacy laws. The statistics included only the frequency of MUST surveys conducted, without any personal or health information.

The project received ethical approval from the Norwegian Centre for Research Data (NSD). All participants gave written informed consent after receiving detailed information about the study. Personal data collection followed Norwegian privacy regulations, with all data fully anonymized according to the project’s management plan. Participants were also informed of their right to withdraw from the study at any time without repercussions.

Results

Before engaging with the serious game “Kamferhjemmet,” a survey was conducted to assess health care professionals’ digital competence and familiarity with the MUST (see Table 1).

The participants, predominantly female, ranged in age, showcasing a diverse group with the majority in the 20–40 age range. The majority rated their digital skills highly, indicating strong confidence in using digital tools both at home and at work. Most felt they managed the digital systems used in their workplace and at home effectively, pointing to a high level of digital literacy.

There was a general positivity toward employing digital systems in professional tasks. About half of the participants regularly engaged with video games in their leisure time, suggesting a familiarity with gaming interfaces that could be beneficial for using a serious game as a learning tool. Knowledge and use of the MUST tool varied significantly, underscoring the necessity for comprehensive training and consistent implementation of the tool.

Postgame surveys reflected a nuanced reception of the game (see Table 2). While most participants were positive, the responses were varied, with some participants found the learning outcome of the game to be good, while others rated it as average or below average. Similarly, opinions on the game’s ease of use, enjoyment, and the effectiveness of the training it provided were spread across the spectrum from good to somewhat poor.

For example, although the majority of participants believed that “Kamferhjemmet” could improve proficiency with the MUST tool, and almost half expressed a desire to have the game available for future training, some were less convinced. The game was credited with helping participants systematically train on using MUST and implementing necessary measures based on its assessments, yet some participants felt the training on evaluating nutritional measures could be improved.

There were also three open-ended survey questions about what the users liked or didn’t like about “Kamferhjemmet,” and any suggestions for improvement. Many praised the game’s realistic case scenarios, simple interface, and easy visual style. The automatic BMI calculation was appreciated, and some found it helpful as a refresher on the MUST tool.

However, participants noted areas for improvement, such as repetitiveness, excessive clicking, and limited case variation. Interface issues, including login difficulties and unclear scoring, were also mentioned, along with delays between actions and feedback. Participants suggested that multiple treatment options, more varied scenarios, and alignment with real-life systems like “Costdoc” would improve the game.

Interviews with health care professionals from both institutions echoed the survey responses, offering deeper insights into their comfort with digital tools and their generally positive perceptions of “Kamferhjemmet.” Three interviewees were nurses, and one was a health care worker, all of whom had experience with digital systems in their daily work.

The game was viewed as beneficial for training in nutritional screening with MUST, though participants compared it to other digital systems, such as electronic health records, which also require time and effort to master. Concerns were raised about the practicality of using the game during work hours due to the priority of patient care.

While three out of four participants were enthusiastic about using digital games for training, they were skeptical about whether colleagues with varying levels of digital literacy would benefit equally. However, they acknowledged the game’s potential to encourage reflection on nutritional screening practices in health care. One participant from Tønsberg reported that the game improved their understanding of MUST, while another from Sandefjord found the interface challenging. Participants emphasized the need for dedicated time to use the game during busy work hours, noting that its use outside of work was unlikely. This reflects a broader challenge in health care: balancing patient care with continuous professional development.

Participants noted the value of digital learning tools, particularly for younger health care workers, but expressed concerns about the digital proficiency of older staff members, suggesting that resistance could hinder broader adoption. One participant recommended allowing independent MUST score calculations, while others suggested that the documentation system should resemble real-life systems, such as “Costdoc,” to better align the game with daily practice. These insights underscore the importance of user feedback in developing serious games.

During playtesting observations, seven health care workers were observed. Gameplay duration varied from 10 to 25 minutes, with an average of 18.6 minutes. No complaints were made about the graphics, suggesting that low-fidelity design did not impede gameplay or learning goals. Players navigated the game’s levels and performed tasks competently, though interface issues like data entry and how to close informational screens detracted from the experience. This implied that the user interface could have been better at communicating player actions and goals.

A critical observation point was the engagement with the game’s educational objectives. While most tasks were completed promptly, tasks involving MUST score calculations and patient weight changes were more challenging. The game lacked immediate feedback on incorrect answers, forcing trial-and-error learning without much understanding of why they finally succeeded in a task. Players missed essential information displayed briefly in dialogue bubbles, suggesting pacing issues that could hinder knowledge retention. One player’s repeated sighs indicated potential monotony and areas for improving engagement.

To assess the game’s impact on MUST registration, data were collected from two nursing homes a month before, during, and after using the game. In Sandefjord, there was an increase in MUST registrations for 9 out of 13 patients, which may suggest a positive impact of the game. However, in Tønsberg, practices and registrations remained largely unchanged. The increased registration in Sandefjord can also be explained by the institution’s focus on raising awareness on a systemic and institutional level regarding MUST as a part of using the game. What the data did show over its timeline was that the practice of MUST registration varied among departments, highlighting systemic challenges in regular malnutrition assessment. But the data and changes were too small to show any direct causality between using the game and increased MUST usage.

Overall, the findings suggest that while “Kamferhjemmet” shows promise as an educational tool, further refinements, and supportive measures are needed to fully leverage its potential in health care training.

Discussion

The findings from the testing of “Kamferhjemmet” underscore the potential of serious games as powerful tools in the health care sector, making tools like MUST more accessible and ingrained in clinical practice. The multimethods approach revealed several key points regarding efficacy, reception, and areas for improvement of the game.

Conclusion

While this study demonstrates the possible potential of serious games as educational tools in health care, it is essential to recognize its exploratory nature. The game did show potential in making the complex process of using the MUST tool more accessible through game mechanics, showing promise in enhancing health care professionals’ proficiency in identifying and addressing malnutrition. However, the game remains in a pilot stage, and further refinements in its design are necessary to optimize user engagement and learning outcomes.

Participants’ generally high digital competence was crucial for the successful reception of “Kamferhjemmet,” which aligns with research highlighting the role of digital literacy in adopting new health care technologies.^17–19

However, areas for improvement in the gamedesign, such as the game’s repetitiveness, lack of scenario variety, and confusing scoring systems, were identified. Addressing these through iterative testing and more user involvement in development could enhance its effectiveness.^24,25 The need for a user-friendly interface and immediate feedback mechanisms is critical for maintaining engagement and ensuring effective learning outcomes.

Participants’ positive attitude toward serious games for learning supports previous findings that games are motivating and engaging due to their different and interactive nature. ²⁸ However, practical integration into daily work schedules remains a challenge. Structured training programs with dedicated time for the game are essential to balance training with patient care responsibilities (Farokhzadian et al., 2020).

To be truly effective, “Kamferhjemmet” must be part of a broader educational strategy, including instructor-led sessions and practical applications. Aligning the game with health care professionals’ work routines and professional identity is critical to its acceptance (Lluch, 2011).

In summary, a serious game like “Kamferhjemmet” shows promise as an educational tool in health care, but further refinements and supportive measures are needed to fully leverage its potential.

Limitations

This study has several limitations. The small sample size (29 participants) limits generalizability, and the focus on Norwegian institutions may restrict the applicability of findings in other health care contexts. Additionally, the lack of a control group trained with traditional methods hinders a direct comparison of the game’s effectiveness. Since the game was a pilot, some design elements were not fully optimized, which may have impacted participants’ engagement and learning. Finally, the study took place during the COVID-19 pandemic, which may have affected participation and survey responses due to increased stress and workload pressure on health care workers.