The Introduction of SteriDefi^TM: a Serious Game for Continuous Training of Sterilization Staff in French Hospitals

Sterilization is a little-known discipline but continues to be in a state of constant development from both a scientific and a technical viewpoint. The emergence of new diseases and improvements in surgical instruments have indeed strengthened its corpus of knowledge, but they have also made the management of operating room instruments more complex [1, 2]. This has, in turn, led to an increased requirement for the training and specialization of sterilization staff, who are becoming ever more highly-qualified. In this context, initial training is essential to habilitate staff to perform their duties, and regulatory texts on the discipline specify areas of mandatory training [3]. However, the knowledge acquired must be maintained and updated regularly. Despite this, in France there are very few obligations in terms of continuous professional training. Indeed only qualifications concerning the use of autoclaves must be renewed and those only to the extent that staff judged by their managers as capable of operating this equipment must be “periodically reconfirmed in this role” [3]. The French Society for Sterilization Sciences (SF2S) wanted to develop a tool to facilitate the implementation of this continuous training. This tool, called “SteriDefi^TM”, is a serious game accessible via the SF2S website [4]. This article aims to present the different steps followed to develop the serious game, as well as the interest of this type of learning.

The decision to develop this tool was taken following the publication of 2 studies conducted in sterilization departments in French hospitals [5, 6]. The first study concerned 60 institutions and indicated that only 59 % of sterilization services have implemented continuous training [5]. The second survey gathered feedback from sterilization manager of 113 institutions [6]. In this second study, only 11 % of respondents considered their continuous training to be very appropriate, while 74 % felt that learning through playing a game would be a good way to take their ongoing training forward. Given the highlighted need, the SF2S decided to develop the game. In order to establish specifications, a literature review was conducted to identify key points to respect. The aim was to study game development designed for healthcare professionals’ education and to avoid possible pitfalls. In addition, it was also to validate the choice of the game as a learning method through the benefits described in the scientific literature.

In carrying out the literature review we have adhered to the majority of the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) recommendations [7]. Indeed, all the items in the checklist were followed except for the risk of bias across studies, because the objective was not to discuss the results obtained by these studies. The research was conducted on Pubmed using the terms “serious game” and “health”. The following definition of serious game proposed by Bergeron was used: “interactive computer applications, with or without significant material components, created for the purpose of transmitting knowledge or skills, and which incorporate an element of evaluation as well as ambitious objectives and an engaging design” [8]. The search was limited to dates ranging between 2000/01/01 and 2017/01/01. Only articles written in English, for which abstracts were available, were selected.

A total of 146 articles were analyzed, of which only 15 dealt with serious games developed for the training of healthcare professionals. All other articles were related to games without computer components or serious games designed for patients or students in non-medical or paramedical disciplines. What was learned from published studies was the heterogeneity of their designs (quiz, training simulation, management simulation, adventure …) and the use of non-validated methodology. The areas studied were also very different (medications, securing patient care, surgical instruments). However, most of the time, they lead to the evaluation of knowledge acquired through pre/post intervention studies. And in most cases, the difference in knowledge measured before and after several sessions of game is significant. For example the game Riskdom geriatrics^TM helped medical students to increase the score to an MCQ from 42 % to 90 % [9]. In another student group, the Pediatric jeopardy^TM increased the correct answer score from 54 % to 90 % [10]. But correlation between knowledge and know-how is difficult to establish because having knowledge does not mean that we are necessarily going to apply it. And even if this is done, no reliable indicators seem to have been found yet. This is the reason why, with a few exceptions [11], real-life impact of implementing this type of training is not realized. Concerning the studies, it should be noted that there are currently very few instances of negative feedback on the use of games and no accounts of problems that may be encountered during their design. So what information should be take from the literature? The first point is that competition increases the learner’s motivation [12]. Playing against one or more teams is certainly a stimulating factor, since the more you learn, the better your chances of winning are. Multiplayer games also appear to encourage interaction between players and thus enhance cooperation, communication and human relations [13]. In terms of how performance information is relayed, immediate feedback is popular and is in widespread use [14]. This allows users to learn from their mistakes, which in turn allows for a better integration of knowledge [15]. The correct balance between challenges and rewards is also very important, as it determines the desire to remain immersed in the game [16]. In addition, the idea of reward reinforces self-esteem [17]. We therefore decided to incorporate all of these elements during the design phase. In light of the lack of methodology described in the literature for the design of serious games, it was decided that a theoretical framework on which there was a consensus would also be researched. Criteria used for the evaluation of serious games developed in the health field were used as a starting point [18]. From these criteria, it was possible to methodically construct the game. Thus, the functionality and validity of our game had been particularly well studied before being incorporated into our specification sent to the computer company (Table 1). A graphic charter was also given to a graphic designer for the development of the visual and gameplay.

The second step was to launch IT (Information Technology) development. In parallel, the game database was designed by a panel of 8 experts in the field of sterilization. It included 180 questions and answers divided into 6 categories covering the key points of the sterilization process: pre-disinfection and washing; recomposition and conditioning; sterilization; traceability and management of non-compliance; transport, storage, security; hygiene and environment. These questions include key points in relation to guidelines, recommendations and good practice. For each of them, the source of the answer is cited in order to alow the learners to find the reference material such as “good hospital pharmacy practices” [19]. Within the question database, each question was rated either 1, 2 or 3 stars depending on its difficulty. These ratings allowed user to choose the level of difficulty by automatically selecting an easy, intermediate or difficult level. The game animator could also disable any questions at their own discretion and generate as many questions as required.

At last, the version initially produced by the computer company was tested over a two-month period. The accessibility, its settings and gameplay were tested and improved, leading to version 2.0, which is currently online. SteriDefi^TM takes the form of a virtual board game on which 2 pawns in the form of trolleys move around. According to the roll of the dice, players choose a square, whose color refers to a category of questions. The goal of the game is to answer the questions correctly and to land on special squares which give them a chance to win a set by answering the next question correctly (Figure 1). The team that wins the most colored set wins the game.

Figure 1:

Presentation of SF2S serious game: Steridefi^TM.

SteriDefi^TM is provided alongside a number of recommendations. These come from 2 University Hospital Centre, who have more than 3 years of experience in hosting educational games. Before launching the game, the following elements should be clearly defined: the organization, the objectives, database management, and the choice of animator. In fact, as far as organization is concerned, it is necessary to know beforehand what the target audience is, the frequency, day and duration of the sessions and, in some cases, the way in which players will be selected to play the game. This integrates the game into hospital life and forces to maintain game sessions despite recurring staff worries or activity overload. The objectives must also be considered in advance (number of sessions per player and per year, indicators for monitoring the effectiveness of the sessions). The management of the database and its personalization by each institution wishing to play are essential aspects, because the questions will be even more relevant if they cover the instructions and procedures players face every day. This is what should make it possible to correlate the increase in knowledge with real-life benefits for the sterilization unit. Database must also be maintained so that each new quality document or non-conformity return can be considered. Renewing the database allows the game to follow developments in practice and renews players’ curiosity. Finally, the last point concerns the choice of the game animator. It is important to choose a person who can ensure a positive atmosphere during the game, a certain level of expertise in the comments made on each question, and especially a person who wants to host the game. Staff members’ motivation to play depends largely on the desire of the person supervising the game to host it, and this is probably the most important point for sustaining the game and maintaining an educational atmosphere.

Since the game was made available online, 24 establishments have played a total of 120 games. On average, 18 questions were asked to each game.

The development of SteriDefi^TM lasted 16 months and was presented at the first National Congress of the French Society of Sterilization Sciences, which took place in September 2017. Contrary to external training courses, which are often costly and involve people for whole days, SteriDefi^TM can easily be integrated into the life of sterilization unit and remains free of charge. Data have been collected to determine the number of user establishments and games played since the game has been online. In addition, a multi-centre study is planned to measure evolution of knowledge on theoretical and practical questions as well as satisfaction of players and animators with the game.