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Alma: designing compassion for healthcare workers through interactive play

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Alma: designing compassion for healthcare workers through interactive play

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Content Alma: Designing Compassion for Healthcare Workers through Interactive Play
by
Francesca Isabella Palamara
______________________________________
A Thesis Presented to the
FACULTY OF THE USC SCHOOL OF CINEMA TIC ARTS
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
MASTER OF FINE ARTS
(Interactive Media)
May 2021
Copyright 2021 Francesca Isabella Palamara
Dedication
To Carlin. For believing in me and standing up for me when it mattered most. And most
importantly, for doing this right the second time around.
ii
Acknowledgments
I would like to thank my thesis chair, Laird Malamed, and faculty advisor, Marientina
Gotsis, for their invaluable teachings and wisdom. Without it, it would have been very difficult
for this project to come to fruition. Whether it was the countless hours of pouring over various
design concepts or citing useful resources, I have deeply valued all of the support and attention
to detail you have both brought to this vision. It has not gone unnoticed. I would also like to
thank Shawn Kittelsen at Skybound, my industry advisor, for challenging me to interact with
narrative differently and to always focus on the emotional realism of front-line healthcare
workers. It has been a meaningful journey sharing this project with the three of you, through both
the tribulations and successes and the various stages of creative development. I am deeply
indebted for the time, patience, and guidance you all have given to this pursuit and for always
encouraging me to follow my ideas.
I would like to thank my fearless team and MFA friends. For the time, commitment, and
energy in exploring this project together. There is no one else I would trust more to problem
solve difficult concepts with. I have thoroughly enjoyed working together with each and every
one of you. I have the utmost gratitude for the skillset, vision, and overall professionalism you all
brought to this entire creative process. Thank you.
Thirdly, I would like to extend my sincerest gratitude to the rest of the faculty and staff of
the Interactive Media and Games Department at the USC School of Cinematic Arts for their
endless love and support. For the past three years, USC Games has truly felt like home. It has
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been an honor studying here. I look forward to taking what I learned, both in knowledge and
friendship, and applying it to the road ahead.
Finally, I would like to thank pediatric nurses. For who without their stories, this project
would be incomplete.
iv.
Table Of Contents
Dedication ii
Acknowledgements iii
List of Figures vi
Abstract vii
Chapter 1: Introduction 1
1.1 Burnout Among Pediatric Care………………………………………………………… 1
1.2 Self-Care Games……………………………………….………………………………. 4
Chapter 2: The Narrative Design of Alma 7
2.1 Developing the Storylines……………………………………………………………… 7
Chapter 3: The Mechanics of Alma 10
3.1 How to Achieve a Work-Life Balance ………………………………………………… 10
3.2 The Solutions and Challenges a Tablet Brought ………………………………………. 14
Chapter 4: Evaluating the Gameplay Experience 17
4.1 Why Compassion as an Exploration for Resource Management………………………. 17
4.2 What It Means to Have a Compassion Bar ……………………………………………. 20
Chapter 5: Player vs. System: Designing Games for Change 22
5.1 Player vs. System: The Overlooked Challenges Moving Forward…………………….. 22
Chapter 6: Conclusions 24
6.1 Looking Back: The Takeaways from Alma …………………………………………… 24
Bibliography 25
v
List Of Figures
1.1 (Left): Stepstone Island is a fitness mobile game designed by Katie Pustolski. It
was developed at USC Games for her MFA thesis. (Right): Wayward Strand is an
interactive narrative developed by Ghost Pattern exploring choice-based systems.
……………………………………………………………………………………. 4
2.1 Various notes and mockups for early-stages of narrative design. Concepts are
Sketched and illustrated in notebooks and whiteboards……………………….…. 8
3.1 In this screenshot, Alma is seen in the hallway having access to both her patient
reports and personal messages. She is currently receiving a text from her mother,
Gloria………..……………………………………………………………………. 10
3.2 In this screenshot from Papers, Please, players are sifting through immigration
Documents (Left) while receiving a status report of their day’s earnings (Right).
……………………………………………………………………………………. 11
3.3 (Left) Early designs of tablet mockup. (Right) players can access the main
navigation screen and select either the work mode or home mode………………. 14
3.4 Examples of the tablet’s interfaces for both the work mode and home mode.
……………………………………………………………………………………. 15
4.1 An illustration of the Four Habits Model by RM Frankel designed by myself.
……………………………………………………………………………………. 17
4.2 A paper prototype exploring gameplay for compassion and energy. The yellow
box represents Alma’s home life. The blue box represents Alma’s work life. This
scene currently takes place in the hospital. On the top right, the yellow and blue
coded bar represents the amount of compassion Alma can use for either her
home or work life (represented by hearts). The bar slides up or down depending
on Alma’s choices, leaving her with a fixed amount of compassion to store or use.
……………………………………………………………………………………. 18
4.3 (Left) An example of in-game choices requiring Alma’s compassion. (Right) An
example of a choice that Alma cannot afford to give compassion to. This is
represented as a “grayed out” choice.
……………………………………………………………………………………. 20
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Abstract
Alma is an interactive narrative in development for PC in partial fulfillment of the
requirements for the degree of Master of Fine Arts in Interactive Media & Game Design at the
University of Southern California School of Cinematic Arts.
Alma is a case study that examines the unseen emotional burden of healthcare workers in
our modern-day care system, culturally, politically, and psychologically. Players take on the role
of Alma, a caring mother and pediatric nurse, who must tend to both aspects of her life. While
she’s tending to other people’s children at work, she must also tend to her own child at home.
The game illustrates the precarious balance between work-life responsibilities and the difficulty
of compartmentalizing emotion from the two. It asks players to try to not please every character
in the world or “out-game” the narrative, but to act selflessly and treat Alma’s desires as a
criterion worth succeeding in. In the end, the game does what industry-standard games currently
do not: it asks players to spend their energy and compassion on what the player perceives to be
correct; not what the game deems correct. The game rewards players for increasing their
compassion by putting Alma’s wellbeing first; and not because the player wants to win. It’s a
system that balances the enticement of how a player wants to play versus the needs of the
character in their (in-game) journey of self-care.
This project aims to shed light, build meaningful engagement and propose solutions for
how contemporary audiences can significantly improve the work-life balance of healthcare
employees. It is a game that draws from disciplines of experimental design, narrative medicine,
and compassionate care to explore the pre-pandemic question: why do we take for granted the
wellbeing of our healthcare workers? How can we, as a society, be more mindful of the health
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and circumstances of people that are overlooked? How can media and games bring this issue
forward in an interactive and memorable way? Are games the best medium for this? If so, how
can they support systems of empathy and compassion while balancing player’s inherently selfish
whims?
As players help steer Alma clear of decisions that may jeopardize her work and home
life, they grasp the importance of evaluating how their own life may be caught at a similar
crossroads. In the end, Alma is an interactive story that asks users to look inward and to critique
their own relation with self-care, and challenge others to practice compassion selflessly.
viii
“Real courage is when you’re licked before you begin, but you begin anyway and see it
through no matter what.” - Harper Lee, To Kill a Mockingbird
Chapter 1
Introduction
“Professional burnout is a widespread phenomenon in healthcare. Burnout is a
psychological state that results from a persistent negative reaction to work-related stress.” For
1
individuals who experience professional burnout, they often describe feeling overwhelmed by
their work, experiencing a deep sense of depersonalization, and, in general, feeling unproductive.
In recent years, research has been conducted to highlight the culture surrounding professional
burnout and mental fatigue in healthcare spaces. Specifically, in pediatric critical care. How can
pediatric systems and organizations provide effective self-care strategies that protect nurses and
physicians from experiencing burnout? As Wei, Kifner, Dawes, Wei, and Boyd note:
In a recent study of 6586 actively practicing physicians, more than half (54.3%) of participants
reported symptoms of burnout, one-third (32.8%) experienced excessive fatigue, and 6.5%
indicated recent suicidal ideation. In a 2018 national survey of physicians representing 29
specialties, those working in critical care reported the highest rate of burnout. About half of
pediatric critical care physicians demonstrate symptoms of burnout. Nurses also experience high
burnout rates. About 60% of nurses working in pediatric and adult critical care units report
symptoms of burnout. (Wei, Kifner, Dawes, Wei and Boyd, 2020, 45)
Professional burnout is a serious phenomenon that is sweeping the infrastructure and
lives of those who work in pediatric care. Not only is it deteriorating the mental health of nurses
and physicians, but it is also putting an economic strain on hospitals. High staff turnover rates are
jeopardizing patient care quality and therefore, the stability of the workforce. The precarious
relation between staff and patient is built on meaningful care and when interventions are not put
1
Wei, Holly, Hadley Kifner, Melanie E. Dawes, Trent L. Wei, and Jenny M. Boyd, "Self-Care Strategies To Combat
Burnout Among Pediatric Critical Care Nurses And Physicians," in Critical Care Nurse (AACN Publishing, 2020),
44.
1
in place by organizations to protect those who work for them; professional burnout becomes the
norm.
Why does this matter? Unless you are actively working in healthcare, conducting
research, or have familial ties to the industry, this phenomenon is widely unknown. It is easier to
be aware of a system when you are in the thick of it; experiencing it, versus looking at it from
afar with no guidance or preview to the culture.
After listening to the oral accounts of pediatric care and culture, I became immensely
interested in finding ways to digitize and share these stories. How can people learn about this
phenomenon while not directly experiencing it? How can I, as an artist, humanize the triumphs
and plights of pediatric nurses and clinicians on any given day through an interactive experience?
Regardless if it’s a pandemic or if it’s a Tuesday. What type of stories will stay with audiences
and what type of stories will motivate behavioral change? This project is a call to action.
The ways we interact with healthcare professionals need to be intentional. It is no longer
enough to take compassionate care for granted and to not empathize with workers who
rejuvenate us. Our visits play a huge role, for better or for worse, in the cyclical fatigue that
clinicians and nurses face every day. How can we intervene and support strategies for self-care
from afar?
In pursuing interactive media, I hope to close the experiential divide between healthcare
professionals and non-healthcare. I hope to use play as an expressive medium that questions our
understanding of compassion and our inclination to neglect work-life balance in pediatric
systems.
2
I am doing this because this is what our healthcare workers need and these are the stories
that our games need. In addressing themes of work-life balance, I hope to combat tropes of
in-game task efficiency and instead place value on the well-being of in-game characters. Alma is
a case study that tries to evaluate compassionate care within play and ultimately, poses the
potential for a new type of self-care game.
3
1.2 Self-Care Games
Self-care games are a continuously emerging field. There are very few parameters to
properly define them, but genres are shifting. Currently, there’s a huge range of mixed media
ranging from meditative spaces to behavioral diaries, to self-help apps, to gamified mobile health
applications. The list goes on. Each has its pros and its cons. For some audiences, these forms of
interaction are sufficient examples of self-care and for others, it’s not.
Figure 1.1: Different approaches to health-inspired games. (Left): Stepstone Island. (Right): Wayward
Strand.
The two games I looked to for reference are Katie Pustolski’s Stepstone Island and Ghost
Patterns’ Wayward Strand. Both of these games are different in content and in medium (one is
for mobile; the other for PC). They each deal with the balance of care and play differently.
Stepstone Island is a fitness mobile game about improving the livelihood of an island
through exercise. Players play as Olly the Osper and for each step they take a day, they gain
currency that can be used in-game and exchanged for island decorations. The game uses health
data collected by an iPhone's Health App and step count to determine the overall fitness
improvement in a player. The motivation behind Stepstone Island is to encourage players to be
4
active and to feel good about moving outside by being incentivized with currency and art
decorations within the game. Overall, the game has received positive reviews. Players noted that
they felt incentivized to be outside and to be active. One of the issues that the game poses,
however, is that its transactional design does not allow for other forms of well-being and
self-improvement.
Stepstone Island is built on gamification. Gamification is the means to achieve user
engagement. It is the process in which transforming an interaction or activity into a game can
motivate users to remain engaged with an application based on finite resources. In this case,
2
Stepstone Island has gamified the notion of exercising by creating a transactional reward system.
Each time a player walks, they are rewarded with currency. This design does not encourage users
to think or connect with their self-care but instead physically commodifies it. A routine is
presented to the player in an enjoyable and recognizable way, but it does not inspire behavioral
change past in-game currency.
Wayward Strand deals with care from a thematic point of view. The game is an
interactive narrative about exploring an airborne hospital off the shores of Australia. Aboard the
ship, elder citizens roam, revealing stories about themselves. Players play as Casey; the daughter
of the head nurse. Her objective: to secretly write an article for her school newspaper about life
on the ship. As the game progresses, Casey gets to explore the hospital, talk to patients, and take
notes on anything she finds interesting. The game uses intertwining narratives to create multiple
branches about patients. Although the game is set in a clinical space, the mechanics do very little
to reinforce this. Other than its melodic and empathetic tone, the game does not incorporate any
2
Wanderley de Oliveira, L. and S. Teixeira de Carvalho, "A Gamification-Based Framework for mHealth
Developers in the Context of Self-Care," in 2020 IEEE 33rd International Symposium on Computer-Based Medical
Systems (CBMS), (IEEE 2020).
5
action of care. Players are responsible for listening and engaging with on-screen characters, but
they are situated solely as an observer; not a caretaker. Had the game made more of an effort to
establish a clinical practice or initiate care in some capacity - the experience would have been
more impactful. Since it did not, we are left to wonder what the impact could have been for the
underlying stories and compassion within the game.
Both Stepstone Island and Wayward Strand are examples of our current infrastructure of
self-care games. Each game is missing actions of care or “self-care” rooted in their core designs.
For each experience, self-care is seen as an after-thought. A means to an end. In Stepstone
Island, it is the gamification of exercising. In Wayward Strand, it is the ambiance of care and
health without any in-game follow-through. The same observation can be made about a lot of
games in the various application stores. The majority of self-help apps or behavioral diaries
require the user to do an action in which the game’s feedback conveys themes of self-care. There
are no direct actions of users taking self-care for themselves; just the essence of it. If we want to
move forward in the field of self-care games, it’s important to establish a design that prioritizes
care first.
This is what I am trying to do with my game. Instead of urging users to spend attention
on micro-transactions (like Stepstone Island does), it encourages users to spend time and effort
on themselves. Self-care is rooted in the player’s action. Players connect with Alma in order to
connect with themselves. The game asks players to live introspectively through Alma’s decisions
in order to learn about themselves in the process.
6
Chapter 2
The Narrative Design of Alma
2.1 Developing the Storylines
The narrative design of Alma is complex because it requires interpersonal conflict to arise
between the player’s needs and the character's needs. The story takes place in 2003. Alma is a
young Cuban nurse working at South Florida’s Pediatric Care (a fictional facility). Players are
guided through one day of Alma’s life as a mother, practicing healthcare professional, and
compassionate human being. During the day, Alma is struggling to balance the needs of her
family - her mother’s adamant request that she and the family return back to Cuba - and the
emotional needs of her patients. All the while, these responsibilities require a substantive amount
of Alma’s own personal energy to dispense and maintain. As the story progresses, Alma relies
heavily on the players for guidance. Her hope, in the end, is that the player will prioritize Alma’s
self-care first, above all else, and not jeopardize the needs of those around her.
The narrative behind Alma is very unique because it forces players to try and establish an
equilibrium that does not exist. Players can influence Alma’s relationships based on the amount
of compassion she has to give. With each choice, Alma’s compassion is drained or boosted for
different onscreen characters. If a player decides to prioritize Alma’s home storyline instead of
her work storyline, Alma will notice and communicate it to the player. If the opposite is done and
the player decides to prioritize the work storyline instead of the home storyline, Alma will
intervene and notify the player of their actions. In either case, the narrative is set up to be
7
imbalanced. Only the input and agency of the player will tip the scales and ultimately, favor one
aspect of Alma’s life over the other.
Figure 2.1: Various notes and mockups for early-stages of narrative design. Concepts are sketched and
illustrated in notebooks and whiteboards.
In the game, Alma has to work hard and efficiently to please her boss, colleagues, and
patients. Simultaneously, her daughter and ex-partner are spending the day at the zoo making
memories without her. In addition, Alma’s mother is pestering her about returning to Cuba. The
main storyline revolves around Alma’s pediatric care (the “A” storyline). The “B” storyline is the
events that are happening off-screen with her family. Players are exposed to a variety of daily
events and tasks in both arcs. The game sets up a realistic framework of how work-boundaries
and home-boundaries can blur on any given day. By the end of the shift, all storylines collide -
one way or another - leaving the player to decide how they feel about Alma’s work-life relations.
In designing Alma’ s narrative, it was important to me that the project be set in the past
rather than contemporary covid- times. In doing so, I wanted to argue for the importance of
covering professional burnout and mental health issues that pediatric nurses and physicians face
all the time; not just during a global pandemic. With the prolific media coverage of the on-going
pandemic, trauma, and overall lack of infrastructure - I felt it was not my responsibility to relive
8
the historical event in interactive media. Audiences would not internalize any new lessons apart
from the ones that are already being experienced. Instead, I wanted to emphasize the challenges
that pediatric care faces all the time. Not just when the world is watching. Who is going to record
the stories of caregivers post-pandemic? Five years from now? Ten years from now? How are
pediatric nurses going to be remembered when resources aren’t constantly being devoted to
them? This project aims to raise a bigger question. In playing a narrative about compassionate
care, do we, as players, gain value in humanizing intimate connection? Or are we better off
playing games that don’t humanize workers?
9
Chapter 3
The Mechanics of Alma
3.1 How to Achieve a Work-Life Balance
The premise of Alma - a nurse trying to balance both her familial and professional life as
pressures rise - is a system waiting for conflict to happen. Alma is designed inside a world where
balance permeates everything; the player must balance Alma’s decisions, her actions, her
compassion, and the reactions of those around her. It’s a world that says; Alma, you can’t tackle
every task at one hundred miles per hour. There’s a bigger goal ahead: your own well-being in
the long-run. At some point, you are going to need to stop and take a breath.
This is the world that Alma is founded on. It’s a system that gives players sole
responsibility of ensuring Alma’s livelihood and choices. When players are first introduced to
Alma’s dynamics and schedule; her world is going to tip one way or another. It will either lean
towards prioritizing her work or her family. In either case, it’s up to the player to decide which
way her life tips and if it’s possible to prioritize Alma’s well-being in the process.
Figure 3.1: In this screenshot, Alma is seen in the hallway having access to both her patient report and
personal messages. She is currently receiving a text from her mother, Gloria.
10
Keeping this in mind, it was extremely important that the mechanics propel this vision
forward. How were they going to be a driving force for Alma’s actions? How were they going to
utilize a choice-based system while still having meaningful and substantive interactivity? These
were the types of questions that ran through my head as I prototyped and mapped out my player
experience goals. It became clear that in order to accurately capture our player experience goals
and maintain the credibility of this system - the mechanics would need to evoke a sense of
tension and relief. A way to traverse in and out of every potential worldly imbalance and arc.
The first approach I took to this proposed system was the following: could our world be
divided into two parts? One that represented both the home and the work side of Alma’s life.
Each interface and interaction would have to mirror the other. A parallel system in which the
player’s decisions directly balanced or counter-balanced Alma’s overall well-being. Alma, after
all, was a pediatric nurse who would have to go home after her shifts. Would players witness
both locations - the hospital and her home - or just the aftermath of certain on-screen
interactions? Was there a way to experience both at the same time?
Figure 3.2: In this screenshot from Papers, Please, players are sifting through immigration documents
(Left) while receiving a status report of their day’ s earnings (Right).
11
For reference, I looked to indie developer Lucas Pope and his simulation game, Papers,
Please. Papers, Please is an interactive puzzle and work simulator that places the player as an
immigration officer in the fictional land of Arstotzka. In the game, players must either admit or
deny entry to incoming refugees based on the arrangement and legality of their documents.
Players have the power to bend the rules or act as dutiful agents as the day progresses. At the end
of each day, players are given a progress report on how they did at work and a status update on
their home life. In many cases, players would not meet their work quota and therefore, not have
enough money left over to cover basic family needs such as rent and food.
This game does two things really beautifully. First, it provides a very comprehensive
player experience system that directly simulates a work environment. There is no
misunderstanding that players are doing manual work in the game. It is not a “gamified”
experience where players get to skip the brunt of the work and blissfully engage with the
narrative. It’s a work simulator. Players have to manually skim through documents, find the
correct information, and then make informed decisions about how they would like to address the
refugee in front of them; all while following orders and not getting caught before their shift ends.
It’s stressful and there are high stakes. This is a player experience goal I want to replicate in
Alma. I want players to feel that they are doing work; to feel spread-thin seeing patients back to
back. It was important that players feel the emotional work necessary to perform their job and
not take for granted an engaging narrative about healthcare. That was not the type of game I
wanted to build. Alma needed to be a game about work-life balance so that players could
sympathize with the mental and physical energy required to perform compassionate care through
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a demanding work simulator. Papers, Please became a wonderful reference for keeping the
project on track.
Secondly, the game is effective at reminding players about their character’s home
responsibilities without spending costly resources to visually prove that it exists. At the end of
every shift, players learn new information about a family member falling ill or children going
hungry on a black summary screen (Figure 3.2). When this appears there are no characters or
audio changes to signify that it is of importance. It’s stated as a matter of fact. Naturally, we
know this information is linked to the player’s in-game performance as an immigration officer.
Yet, it feels that the player’s character is unable to tend to their family needs. This is extremely
powerful because it shows a level of immersion captured through simple mechanics. It is
possible to preoccupy the player’s mind with the family’s arc without requiring to build a scene
to show it. To have players engage and immerse themselves with activities at the hospital while
being preoccupied with their family’s well-being. In Alma, I wanted to balance the two arcs -
both the home and the work-life - without jumping back and forth between various different
scenes. Papers, Please prove that it is possible to not use costly resources. However, I wanted to
push it a step further. Could the game, Alma, present a work simulator that invokes the sensation
of balancing - in both its mechanics, narrative, and system - and yet host less gameplay time in
one of the character’s storylines?
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3.2 The Solutions and Challenges a Tablet brought
Lucas Pope proved it was possible to preoccupy a player’s mind without devoting a lot of
art resources to the home storyline. There are ways of establishing a narrative without visuals. So
how can the design for Alma incorporate this idea?
Figure 3.3: (Left) Early designs of tablet mockup. (Right) players can access the main navigation screen
and select either the work mode or home mode.
Alma’s attention needs to be at odds with the demands of her patients and family
members. Players need to be convinced that a storyline is taking place at home even if they never
physically visit Alma’s home. After interviewing various healthcare employees about their
experiences on the floor and their ups and downs, it was obvious that there was an unstated
agreement about technology in the workplace:
“While I’m at work, patients come first. I need to always be on my toes. Something can
happen and if I’m not wired in - it’ s a risk for the whole team. I know this. But that
doesn’t mean that the world outside stops. I’ll still get bombarded by messages from my
personal life and it’ s up to me to make the cost decision analysis. Do I look at this now
knowing that it can wait? Or do I look at it on my break, risking the possibility of
potentially pissing off the person on the other line?” - E.R. Pediatric Nurse
With the introduction of new technology, comes new responsibility. Technology has
vastly improved work-productivity in a myriad of ways but in the process, people have also
become more susceptible to distractions and stress. Whether a phone or tablet is pinging with
14
notifications all day long, people’s attention is often divided between the task they are doing and
the task that is being pinged to them virtually. The same can be said about work-life
responsibilities. There’s a constant push and pull between the demands of individuals from one's
personal life and one’s professional life. This can get increasingly more apparent with every new
addition to life. Whether it’s the introduction of kids or the type of careers that are being pursued
(odd hours, remote work, etc.). People often find themselves spread-thin in trying to establish a
work-life balance because there are so many factors to manage.
Alma experiences a similar challenge. In the game, she is being pulled in different
directions by the needs and wants of people in both avenues of her life: work and home. It was
important to me that this sensation come across to the player not only in the narrative but also in
the mechanics and interface. They needed to go hand in hand. The game would have a blurred
line in its interface and mechanics in “managing” Alma’s home responsibilities and work
responsibilities. The player's screen could be “bombarded” with demands from both worlds.
How would players decide which one to react to and how would they prioritize mid-play?
Figure 3.4: Examples of the tablet’ s interfaces for both the work mode and home mode.
To illustrate this feeling, I decided to incorporate a tablet. The tablet would function as a
feature where Alma could get patient assignments from work and receive text messages from
15
home. She would have to manage both. There are three apps to each side: six in total. A contact,
work, and calendar app. Both sides of the tablet represent the character’s world: Alma’s
professional and personal. The tablet would act as a work simulator in which each skill set that is
picked up in one mode directly transfers to the other. Each side of the tablet mirrors one another
in both form and function.
In presenting a feature in which players can manage and control both aspects of Alma’s
life; the intent was that players would be motivated to guide it. Instead, they found themselves
too overwhelmed to interact with it. The tablet presented too many options. With so many
features available, players did not have enough constraints to center their focus. There was a
general understanding that Alma had responsibilities both at home and at work that needed
assistance but players felt too overwhelmed to engage. The tablet was not the solution to
replicating a work simulator and in the end, brought more challenges than victories.
16
Chapter 4
Evaluating the Gameplay Experience
4.1 Why Compassion as an Exploration for Resource Management
The Four Habits Model (RM Frankel 1999) is a research article that uses medical
interviewing to foster connections between physicians and patients. It outlines four categories of
skills and techniques that can be employed to establish interpersonal acts of care. The article
examines various forms of thinking and acting to establish the best mode of clinical
communication. After reading it, I became extremely invested in finding ways to systemize the
form of communication for my game.
Figure 4.1: The Four Habits are as follows: (1) Invest in the Beginning, (2) Elicit the Patient’ s
Perspective, (3) Demonstrate Empathy, and lastly, (4) Invest in the End.
This model for patient interaction introduces empathetic rapport and compassionate care
on a systemic level. It’s a wonderful foundation that shows how to guide patients who are in
distress and ultimately, are in need of sympathy and care from their physician. Frankel’s
17
simplicity in breaking down the process of a professional skill motivated me to try and explore
the ways I could recreate communication in Alma.
As an experiment, I took the four habits and broke them into four tiers of questioning that
Alma could engage patients with. Players could communicate with patients and unlock their trust
by posing questions of empathy and care that directly correlated with the model. Players could
choose to give attention, practice pediatric care, or listen to any part of the conversation. After a
few playtests, it was apparent that some constraints were missing. There was no limitation to the
conversation and players were unclear about the end-goal. Players struggled to understand how
fostering trust with patients would make their character’s life easier. How is Alma going to
benefit from this interaction? There needed to be more feedback from the game about the
correlation between communication skills and the personal amount of energy that Alma has to
spend in a day.
Figure 4.2: A paper prototype exploring compassionate gameplay for Alma’ s work mode. The sidebar
illustrates the potential for limited compassion per choice.
To do this, I focused on the concept of using compassion as a limited resource. Each
question and conversation that Alma has with patients and colleagues at work detracts from her
own personal compassion. She would have the choice to nurture others or nurture herself. This
18
worked relatively well and I coined the term “compassion bar” to represent the amount of energy
Alma can give.
Research shows that healthcare workers bring a high level of compassion and empathy to
their jobs in order to better connect with patients. Over time, this compassion can deteriorate or
fluctuate depending on encounters that occur on shift. At the end of the day, physicians and
nurses are human. Some days are good. Some days are bad. This game uses interactivity to
bridge the experiential divide between healthcare professionals and non-healthcare professionals.
It does so by giving players the opportunity to feel their character’s vulnerability through
decision-making. Decisions become offline or “gray” when Alma’s well-being is insufficient.
“Sorry, Alma can’t make this choice right now she doesn’t have enough compassion to give.”
Compassion encourages users to be more mindful of the energy and well-being that their
character has to dispense. It also provides an opportunity for players to see the flaws and
strengths of the character’s they play.
19
4.2 What It Means to Have a Compassion Bar
What is a compassion bar and why do we need it? In Alma, the compassion bar is the
emotional and energy payoff to making certain binary choices. It allows players to visually see
their character’s mental status while making decisions for them. Players cannot control the
fluctuation of this meter but they can be aware of which binary choices will have a direct impact
on it. For instance, at the beginning of the game during the tutorial sequence players will notice
an icon next to their choices.
Figure 4.3: (Left) An example of in-game choices requiring Alma’ s compassion. (Right) An example of a choice
that Alma cannot afford to give compassion to. This is represented as a “grayed out” choice.
The heart icon located in the dialogue choices of Figure 4.3 represents how much
compassion is needed in order for Alma to make that choice. After making this choice, the player
will notice a boost or depletion in Alma’s compassion bar located in the upper right corner.
During gameplay, the compassion bar is subject to fluctuate and change. This system provides
players with the opportunity to manage Alma’s compassion through both on-screen interactions
and choices.
The intended user experience of this design is that players will feel that Alma has a
limited amount of compassion to give. As a result, it will encourage players to prioritize certain
20
social decisions within the game. In Figure 4.3, we see an example of this. Based on Alma’s
current compassion bar she does not have enough energy to make the decision with three hearts.
As a result, it is grayed out and the player is required to choose the first option. Had the player
been more mindful of Alma’s emotional needs and not spent the majority of her compassion on
others; the player could have selected that dialogue choice. Players are encouraged to save
Alma’s compassion for meaningful decisions in the long-run. When they chose not to, players
can see how Alma’s lack of compassion will impact both her home and work relations.
21
Chapter 5
5.1 Player vs. System: The Overlooked Challenges Moving Forward
For the past year and a half, this project has consumed my thoughts and the way I view
games. In particular, I am extremely vigilant and aware of the time and effort that goes into
designing meaningful games. Whether it’s a mobile game, an interactive installation, or a PC
game, there are a plethora of ways to make social commentary through any given medium. One
of the most valuable lessons I have learned from working on Alma is that being intentional and
setting a player experience goal early on helps specialize the game and provides a more
comprehensive experience.
Games are memorable when there is a defined player experience. It’s very difficult for a
designer to develop a game without having identified the player experience goal first. How can
games be made for others if there is no target goal on how they should be feeling when playing?
A player cannot react to a designer’s work if they have not already designed the backend
objective of what that reaction should be. There is a design challenge in creating games for
others in which the player’s real-time gameplay dramatically differs from the intended
experience. When the intent of the designer is inconsistent with what players are actually
experiencing; it leaves players with a disjointed feeling or sense of absence. The closer these two
aspects are to one another; the more cohesive the experience is for players. The same rule applies
to games for change.
“Games for change” are games that are designed with the intent of making a real-world
impact or behavioral change. It is a very popular pursuit in game-design and can be challenging
to execute. The risk in designing a game for change is that creatives tend to prioritize the system
22
(the social issue that is being critiqued) over the memorable experience the player is supposed to
have. If we don’t identify and prioritize the emotion and tension of the player experience first;
then it's impossible to create a system that explores the emotion in a meaningful and impactful
way. It does not matter if the system under scrutiny is cultural, political, economic, or historical -
if the experience loses the player in the process they will overlook the game’s message and
therefore, any potential for behavioral change.
I found this to be particularly true with Alma. Every challenge I faced had to do with how
the player goals were set up and how far off the system was from executing them. Users would
report feeling that they had different objectives than the game’s. For every player system, there is
a player experience. If game developers do not take the time to prioritize player-experience goals
before system goals, then we will be unable to make meaningful games moving forward.
23
Chapter 6
Conclusions
6.1 Looking Back: The Takeaways from Alma
Alma is a game founded on the principle of compassionate design and putting the
character’s well-being first. It utilizes a system of limited “compassion” or energy source to
make cost-benefit decisions. Players are exposed to the varying difficulty and challenges of
Alma’s interpersonal relations. The game illustrates the precarious balance between work-life
responsibilities and the difficulty of compartmentalizing emotion from the two. It asks players to
try to not please every character in the world or “out-game” the narrative, but to act selflessly
and treat Alma’s desires as a criterion worth succeeding in. It’s a system that balances the
enticements of how a player wants to play versus the needs of the character in their (in-game)
journey of self-care.
When I first set out to make this game, I thought I was creating a game about healthcare
workers. I thought I was exploring themes of mental health in pediatric care. By the end, I
realized I was making a game about compassion. Compassion has the potential to create
introspective gameplay. It emotionally connects people and allows them to think about
themselves in ways they have not. This project aims to reveal the potential that compassionate
gameplay has in games for change and challenges others to think introspectively about the types
of human-connection that exist within games today. Alma is a game that asks you to look
inwards at your own values and wonder have you been prioritizing your own well-being today?
Or have you been taking it for granted as Alma has?
24
Bibliography
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The Patient–Clinician Encounter: A Contemplative Approach". Journal Of Palliative Medicine 12, no. 12
(2009): 1113-1117. doi:10.1089/jpm.2009.0175.
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"SPIKES—A Six ‐Step Protocol For Delivering Bad News: Application To The Patient With Cancer".
The Oncologist 5, no. 4 (2000): 302-311. doi:10.1634/theoncologist.5-4-302.
Burridge, Letitia Helen, Sarah Winch, Margaret Kay, and Amanda Henderson. "Building Compassion
Literacy: Enabling Care In Primary Health Care Nursing". Collegian 24, no. 1 (2017): 85-91.
doi:10.1016/j.colegn.2015.09.004.
Charon, Rita. "Narrative Medicine: A Model For Empathy, Reflection, Profession, And Trust". JAMA
286, no. 15 (2001): 1897. doi:10.1001/jama.286.15.1897.
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Pubmed, 2001. Jan-Feb;16(4);184-91. https://pubmed.ncbi.nlm.nih.gov/11317576/.
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(2004): 961.1. doi:10.1136/bmj.328.7445.961.
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Shea, Sue, Wynyard, Robin, and Lionis, Christos. “Providing Compassionate Healthcare: Challenges in
Policy and Practice”. Routledge 1, (2014). doi:10.4324/9781315890180
Wanderley de Oliveira, L. and S. Teixeira de Carvalho. "A Gamification-Based Framework for mHealth
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10.1109/CBMS49503.2020.00033.
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Wei, Holly, Hadley Kifner, Melanie E. Dawes, Trent L. Wei, and Jenny M. Boyd. "Self-Care Strategies To
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(2020): 44-53. doi:10.4037/ccn2020621.
26

Abstract (if available)

Abstract Alma is a case study that examines the unseen emotional burden of healthcare workers in our modern-day care system, culturally, politically, and psychologically. Players take on the role of Alma, a caring mother and pediatric nurse, who must tend to both aspects of her life. While she’s tending to other people’s children at work, she must also tend to her own child at home. The game illustrates the precarious balance between work-life responsibilities and the difficulty of compartmentalizing emotion from the two. It asks players to try to not please every character in the world or “out-game” the narrative, but to act selflessly and treat Alma’s desires as a criterion worth succeeding in. In the end, the game does what industry-standard games currently do not: it asks players to spend their energy and compassion on what the player perceives to be correct

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Asset Metadata

Creator Palamara, Francesca Isabella (author)

Core Title Alma: designing compassion for healthcare workers through interactive play

School School of Cinematic Arts

Degree Master of Fine Arts

Degree Program Interactive Media

Publication Date 03/29/2021

Defense Date 04/14/2021

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag compassion,game,game design,game development,healthcare,interactive,interactive fiction,OAI-PMH Harvest,pediatric,pediatric care,Unity

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Malamed, Laird (committee chair), Gotsis, Marientina (committee member), Kittelsen, Shawn (committee member)

Creator Email fipalamara@gmail.com,palamara@usc.edu

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c89-432892

Unique identifier UC11667445

Identifier etd-PalamaraFr-9365.pdf (filename),usctheses-c89-432892 (legacy record id)

Legacy Identifier etd-PalamaraFr-9365.pdf

Dmrecord 432892

Document Type Thesis

Rights Palamara, Francesca Isabella

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the a...

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus MC 2810, 3434 South Grand Avenue, 2nd Floor, Los Angeles, California 90089-2810, USA