A team of researchers at University of Alabama in Birmingham led by Dr. Nancy Wingo recently investigated this question among 94 nursing students, many of whom were Millennials (born between 1982 and 2001). This was a qualitative study to assess students’ perceptions of the game mechanics in a question-answer online game called ‘Kaizen’ (a Japanese word referring to continuous improvement). 
Students received multiple choice questions in a game format, with their performance ranked on individual and team leaderboards.  Badges were awarded based on specific achievements such as consecutive correct answers (hot streak badges) and initial participation (“urine the game”).  The content of the questions focused on core nursing content that would be tested on the nursing licensing exams.  The researchers recruited a subset of 13 students to participate in focus groups in which they were asked a uniform set of questions about the program: how did your individual score affect your motivation to play, how was your level of anxiety affected by playing in a team, etc. 

From the transcribed interview transcripts, the researcher identified several themes that emerged from the data.  The most interesting of these to me addressed ‘learning in teams’ and ‘motivators to play’.  Some representative quotes from their interviews:

Learning in teams

“It made it more exciting, being on a team, because you wanted to do well because it affected everyone’s average score [in the game] . . . It added another competitive aspect. You wanted your team to do well, and you wanted to do well for your team.”

“I think it was a good idea first semester to go ahead and put you with people. You don’t know who knows anybody. It’s another way to kind of pull your clinical group into another group to give you some ground work.”

 “I was stuck with people that didn’t even want to play. I wanted to win, but I can’t win by myself.”


Motivators to play

“We were playing for bragging rights.”

“It got really competitive, so we started texting our group . . . ‘Hey guys, come on. Do this.’”

“I would go on there, and I’m like oh, my goodness, I’m five, and I need to get to number one.”

The game mechanics clearly engaged and motivated most Millennial participants, consistent the findings from our randomized trial of game mechanics among 422 doctors-in-training at UCLA. Millennial students are not alone in this --- game mechanics were also whole-heartedly embraced by senior physicians in a randomized trial that I conducted across 63 countries.

Of note, a few students in Dr. Wingo’s study described their team members as “apathetic” and “lazy” and were disappointed that their teammates were not as driven to win as they were.  We too have found this in a small minority of Qstream participants.  Understandably, it can be demotivating for engaged learners to be on an under-performing team.  There is no easy fix for this because, by definition, 25% teams in the competition are going to be in the lowest quartile!  The best solution that I have found for this is regularly to mix up the teams.  Rather than run one long Qstream with consistent teams, we mix it up so that an engaged learner on an under-performing team can expect to be on a different (and hopefully more competitive team) in the near future.  In the business world and also in healthcare, this can be achieved by planning a new Qstream with new teams each quarter.  Let the games begin….especially with Millennials.

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