The Boardgame Design Project, Part 2: Brainstorming Mechanics

This is the second article in my series following the design of what will hopefully be my first game.  As I mentioned in the first post, the game is called Acute Care and is a cooperative game about nurses managing a busy acute care unit in a hospital.  This time around, I’m going to lay out some of my ideas about how the game might actually play and what sorts of mechanics it might include.

As I’ve started trying to figure out how Acute Care was going to play, I’ve tried to keep my design goals in mind all the time.  The main “educational” point I wanted to get across was that cooperation and teamwork are absolutely vital, so I started by identifying the main resource that must be shared by the nurses on this unit.  That resource is, of course, time.

Time = Actions

So while it’s not terribly original in coop games, I’ve decided that time will be represented in the game by action points.  Since each turn is supposed to be one hour of the 12-hour shift, I’ve broken it down into each nurse having 6 actions each hour (obviously representing 10 minutes each).  Since some level of realism is another design goal, I wanted it to be tied to “real life” as closely as I could, and I think that this number of actions will be a good balance between that and still being reasonable and manageable for players.


Obviously, a game about nursing must deal with patients.  In real hospitals, nurses on medical/surgical units tend to care for roughly 4-6 patients at a time.  So I plan on players starting with 4 patients, but then getting new admissions and having the possibility of discharges and transfers throughout the game to have this number fluctuate.  The max will probably be 6 patients each, however (even though in real life it sometimes may be pushed further than that).

Patients will be represented by cards that are placed into spots (“beds”) on the board.  They will have some sort of keywords (Surgical, Medical, Isolation, etc.) and an Acuity Level

Acuity is a measure of how sick someone is (and often, how much work they are to take care of), which I’m going to rate on a scale of 1 (ready to go home) to 5 (critical condition).  Players will be able to spend actions to improve acuity and even discharge patients once their acuity drops to level 1.  Event cards and maybe some other effects will also potentially worsen acuity.  My plan right now is to track Acuity using a d6 on the card itself, which can be dialed up or down as their condition changes.

One key to patients is that they will also require the players to spend actions just to care for them.  Right now, I think that I’m going to have each patient present at the beginning of a turn require players to spend one action point.  I’ve considered having this change based on acuity, but I’m worried about that being a little too complicated or cumbersome.  I also have some ideas about how I could still use higher acuity to make their lives a little harder with the Event Cards I’ll talk about in a minute. 

I’m still trying to work out exactly how I’m going to assign starting patients.  Just to ensure balance, I’ll probably build a patient pool with a defined range of acuity levels that will be either randomly dealt out to the players or assigned by the Charge Nurse.      

Charge Nurse

The thing I’ve probably waffled about most in this conceptual stage of design is the role of the Charge Nurse.  In real life, the Charge Nurse makes assignments, schedules lunches and breaks for staff, communicates with other units and administration, and generally helps out and oversees what’s happening on the unit.  In some areas, they also take a smaller patient assignment, while in others they do not.  

I really want to have this role in the game, but don’t know exactly how to do it.  In 4- or 5-player games, it would probably be interesting enough to have a person filling the role.  But with 2 or 3, I think it’d be sort of boring, so I’d probably just make it a pool of extra actions that the players could spend as they needed them.  The number of actions given to the Charge Nurse would probably need to scale as well, maybe something like 2 per player, or 2+1 per player, but that can be ironed out in playtesting.  But regardless, I really like having someone who will make decisions about assignments and admissions, and hope that it can be worked out.

Event Cards

As with all cooperative games, something has to happen to make things worse in the game.  Each round, players will have to draw a card from this deck, but I’m not sure right now whether all the cards will be drawn at one time or if players will draw them on their turn.  I’ll get into that at another time, but for now, I think I’m pretty clear about there being 3 types of cards:

1) New Admissions – New patients that pretty much function as other patients do, but would require spending 2-3 actions to admit them.  

2) Events – Things that happen to throw a curveball to the unit.  The “big one” would be a Code Blue!, which is a medical emergency that would end up eliminating a patient (either through death or transder to the ICU), but would require some crazy amount of actions to complete (4-8, maybe depending on the number of players).  Other events would be things that would require actions to prevent a patient’s Acuity from worsening, losing points from their Quality score (which I’ll get to next), or other bad things.

3) Attachments/Conditions –  Generally, these would be things that modified patient cards, such as being confused, having a difficult dressing change, or other stuff that would usually require more time/actions.  They would be placed based on Acuity and keywords, so players would have some choice about where to put them within certain guidelines.

The Goal of the Game

One of the hardest things I’ve had to define about Acute Care so far is how to win or lose.  In a real hospital, there are a lot of things to consider when it comes to evaluating success, such as patient outcomes, patient satisfaction, staff morale, financial solvency, and reputation in the community.  I toyed with all sorts of ways to represent these things, and in the end decided to sort of clump them all together into the idea of Quality.

Quality will be the overall “score” that you’ll be working towards in the game.  Points can be gained or lost based on events that happen through play, and then there would be some threshold at the end of the game that would be considered “winning”.  There would probably also be some lower level that would cause the game to be lost immediately if it ever got that low (’cause all coop games need auto-loss conditions!).  

At this point, though, I really don’t have any sort of idea how big this scale might be or what kind of levels would be considered success or failure, and I figure that it’ll take some considerable playtesting and tweaking to figure it out.

Enough for now…

I’ve got more, but I think this is probably enough for right now.  In my next article, I’ll cover some of the other ideas I’ve had for mechanics, as well as some of the problems that I foresee already.  Until then, feel free to comment and even make suggestions, as well as giving me more feedback about whether or not this whole shebang is interesting or not.     


  1. Keep it up! I’m enjoying seeing your thought process as the game concept comes more into focus. I think this is a fascinating case of what veteran writers always say: “Write what you know.” It seems to hold true for game design, as well!

  2. Nice, original idea for a game. I’m always excited to see originality in the hobby gaming industry, whether it be from Fantasy Flight or a new designer on Kickstarter – and I wish you success!

    I like your concept of scoring using the idea of “Quality.” I think that can best be represented in your game by patient outcome, patient satisfaction, and community reputation – all measured by the success rate of how quickly patients are treated. Maybe base points on a per patient basis on a ratio of acuity level versus treatment time? In other words, not only higher points for treatment of higher acuity levels, but also higher points for faster treatment of all levels to model the themes of success rate, satisfaction, and community rep?

    Also, not sure what role doctors play in the acute care units – you mention the role of the charge nurse – but perhaps the docs can be worked in, too – maybe event cards, or something? Just added theme, perhaps?

  3. Chris Norwood

    Doctors will actually be pretty much completely “off screen” in the game.  Especially at a community hospital (like where I work), they aren’t really with an individual patient on a nursing unit more than a few minutes each day, so most of the interaction with them is from them admitting patients, giving orders, phone calls for things that come up, and sending patients to them for surgeries or procedures. 

    So more than anything, the role of physicians is tied up with the new admissions (since they would be admitting the patient to the hospital), from some of the events (since part of the time needed to complete them would be communication with the doctor), and from actions like discharging or transferring a patient (which would also involve communication and obtaining orders from the MD). 

  4. Chris Norwood


  5. Very interesting. I hope that you’re able to get it all worked out, because I think I’d like to try your game!

    A couple thoughts:

    If each player has 6 actions per round and each patient requires an action, a player would be unable to perform actions if he had 6 patients. That seems bad (possibly I misread, though).

    Secondly – all people have to take breaks or they will break. I noticed that you mentioned something with this in the Charge Nurse role. The other thing I thought of was for it to be an action that you could take that improved your stats in some way. (Or, you could have it be a coffee break and pretend that coffee cures all ails…)

  6. Chris Norwood

    Yeah, it’s going to be an interesting project.  And as long as I get a relatively playable game to use with my new grads, I’ll be happy.  Anything else (like actual publication) would be indredibly awesome.

    As far as the 6 actions go, you’re completely right.  But the Charge Nurse will have actions to help out the staff nurses, and there’s another mechanic that I’ll talk about next time to get extra actions as well.  Plus, there will be some card effects that may grant extra actions (either temporarily or long-term).

    As for breaks and the like, they may things that I abstract away in the design.  I’ve considered things like having built in challenges depending on the hour (like having to spend extra actions to feed patients at meal times, devote extra actions to getting lunch yourself, and stuff like that), but as for now, I doubt that I’ll include them just for gameplay sake.

    Thanks for the comments!

  7. sarebear

    This sounds interesting! I’ve read both posts.

    You may want to think about some things from the patient’s perspective; like, I dunno, lots ofnegative for taking an HOUR fishing an iv line starter in and out before calling the head nurse . . . lol (OUCH). Not that you need to take any of my ideas, specifically, generally, or conceptually. Just throwing out a few patient perspective ideas@! For example, last year I had two knee replacement surgeries (though 38 yo, rather young). The first one I left the hospital a day early as I didn’t want to be in hospital on Christmas; so if you have any positive event cards, perhaps factoring in early leaving for whatever reason could be one. Second knee I stayed the three days lol, course it was only a couple months after the other. Another event might be, you discover new patient is your cousin’s wife (my husband’s cousin was male nurse) and freaks you might see her butt. Well not that graphic but you know (no pun intended).

  8. Chris Norwood

    I’m definitely going to have some “Opportunity” cards in the game, where players will be able to spend time to get some good reward as well as the “Crisis” cards that require them to spend time or take some negative effect.  One of them could certainly be something along the lines of, “If this patient is discharged before the end of the shift, gain +2 Quality” or something like that, where they would have to first reduce their Acuity level to 1 and then invest the time to discharge them…

    Thanks for the comment!

  9. Keith

    I jotted down some notes as I reread your brainstorming. So what follows is in post order. Hopefully they are not too cryptic.

    1) Six actions. It fits the hour per turn time frame. Six is more actions than the other action point based cooperative games that I have played. Could bring up the issue of down time if in a four player game each player has to wait for 18 actions to be taken before getting to take another turn. If 1/3 to 1/2 are fairly static/easy decisions or player turns are interactive then I doubt a down time issue would arise, might not anyway.

    2) Number of patients. Four to six sounds like a good difficulty level mechanism. If new admissions and discharges were set to mathematically equal out on average a level six would mean usually six, sometimes five and sometimes seven.

    3) Acuity scale of one to five fits nicely with a d6 roll range. If a patient is at acuity level five and an event or health check roll pushes them up does the patient then go to level six and what does level six mean, Code Blue, ICU?

    4)If I understand correctly the scope of a game is a single twelve hour shift. How much acuity change is there normally over the course of twelve hours?

    5) Charge nurse. Seems like an important aspect. Would one player in the role of Charge Nurse raise an alpha player issue? I think it depends a lot on the group of players, however, most cooperative games I have played factor something into the play procedure relating to reducing alpha impact.

    6) Quality score. Instead of a bianary win or lose there could be levels of success or failure.

  10. Chris Norwood

    1) My assumption prior to playtesting is that 4 or 5 of the actions will be locked down every turn just caring for patients, so it’s really more about spending the 1 or 2 extra action and then deciding if you need to Shift Priorities (mentioned in part 3) to get another 1 or 2.  Plus, I think that the turns are going to be integrated, so everyone will draw their cards at the same time, and then they will spend their actions at the same time as well.  As the group discusses their plan, they can literally place the action cubes right then, so there really shouldn’t be any downtime at all.

    2) I hadn’t really thought about this being a difficulty-level thing.  It’s more just that they will start with 4 patients and 2 empty beds, but then will get new admissions through the shift and maybe be able to discharge or transfer a patient or two to make more room.

    3) My initial thought was that acuity 6 would mean that the patient Coded/died, but I need to really think more about that and what the Quality implications would be.

    4) There can be a lot, but this game will still certainly be a little more dynamic and take some liberties with things like that.  You can certainly have crazy shifts with lots of acuity shifts, tons of admissions and discharges, and a number of other wacky things going on, but if every shift was like that, no one could survive being a nurse for very long.  So, in order to have an exciting game experience, it will have to take some liberties with time, patient progress, numbers of admission and discharges and codes, and other stuff like that. 

    5) I’m waffling a lot about the Charge Nurse.  Practically crowning an Alpha Player is certainly one concern, but I’m also worried that there just won’t be enough for them to do.  They would have a pool of “extra” action cubes to help others with, and I assume that they would also draw an event card each turn (making it more difficult), but otherwise I don’t know whether it would be better to just have the extra actions available for anyone to use rather than have a person “play” that role.  I’ll test it both ways, though.

    6) Absolutely.  Right now, though, the whole Quality score economy is still completely cloudy to me, so I have no earthly idea what sorts of values, swings, or targets I should set.

    Thanks for the feedback! 

  11. Keith

    2) I figured I was thinking in a different direction than you. It is more of an idea than a strong suggestion. There are lots of ways to adjust difficulty like starting acuity or pace of event card draws.

  12. Hi Chris,

    I have just finished reading your 2nd article and I have not jumped ahead, so my comments will be in complete ignorance of what you have done since this post.

    I read some comments about break times coming into play. Here is my thought. You have 6 actions per turn as units of time 6 “ten minute” blocks of time in an hour, 12 hours in a shift. How about using some kind of “energy/alertness” mechanism? If a player works for six or seven hours straight, they are going to need a break. About adding something where if the person doesn’t take a “break” after a certain number of turns, then they lose 1 action per turn for the rest of the game until they take a break. In real world terms this would mean that this nurse would only be able to perform 5 actions per turn due to fatigue.

    As for a Quality score…Let’s say you have a scale from 0-6, and that the hospital starts with a score of 3 at the beginning of the game. As events happen and players deal with them, the marker on this track will move up and down based upon the success/failures of the players.

    Turn order: Since this is a cooperative game, I would imagine that a player can give up some of their actions to help “assist” another player on their turn. So if Player 1 needs assistance dealing with a certain event, then Player 2 can give then 2 of their actions to help with that task.

    Anyhoo, those are my thoughts so far.

    That Cowboy Guy

  13. Chris Norwood

    You’re right on with some of my ongoing thoughts with the game.  After the playtesting I did in November, one of the biggest things I’m definitely going to add are the “real life” events of the day, such as lunch, morning assessments, and prepping for the end-of-shift report.  Just as you said, my plan for lunch would be that if you haven’t taken lunch by the end of the 1300 hour, you’ll lose an action cube for the rest of the game!

    My Quality score ranges have been anywhere from -15 or so all the way up to +30, so I still have a lot of work to do with evening that out and making it more consistent.  But I also got some good ideas about other elements that will relate to win and loss conditions.

    Keep reading, and maybe I’ll be able to get my next article posted soon!

  14. Seth Jaffee

    Seems o me that a good “break” mechanism would be to say that you must spend actions to draw cards. So you have a handful of cards which represent stuff you can do. As you get tired, you are limited in what you can do (exactly what and also how much) to represent that you are drained. Take a 10 minute break, draw a couple of cards (maybe 2), now you can do more stuff. Maybe spend 2 AP (20 mins) and draw 5 (economy of scale)…

    Random idea: suppose the actions you can do in your game required some particular combination of maybe between 2-4 cards, and players start with say 6 cards face up in front of them (or I suppose in their hand). Upon performing an action (showing the appropriate combo of cards), one of those cards is discarded. In order to get more cards, a player would need to take a “break” action to draw more. Maybe you draw 2, and if you wish you can discard 1 to draw 1 more (to help get the right combos of cards in hand).

    Dunno if that fits your plans for the game, but if so, feel free to use it 🙂

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