Design

We applied the Interpretative Descriptive (ID) approach [26]. Using the ID approach to study the feasibility and acceptability of a cycling game exercise in LTC is appropriate because ID allows for a deep exploration of experiences and behaviors in real-world clinical settings. Qualitative data in the ID applied approach provides us with rich information explaining the reasons (the “why”) and the approaches (the “how”). ID is particularly useful for generating practical implementation knowledge that can directly inform clinical practice for wider adoption in LTC settings. We used focus groups with staff and practice leaders in the LTC home. We also conducted observations and conversational interviews with residents and families to gather diverse perspectives on the program’s acceptability and feasibility. Focus groups fostered group synergy and reflective collaboration [27], while conversational interviews provided a more intimate setting for vulnerable populations to share nuanced insights, complementing the broader perspectives gathered in the group discussions [28]. Over a four-week period, 14 residents from an LTC in Western Canada participated in a structured program involving gamified cycling exercises conducted twice a week. Our paper follows the Consolidated Criteria for Reporting Qualitative Research (COREQ) by Tong et al. [29], with detailed reporting provided in Supporting Information S1 Table.

Study settings and the cycling game

This study was conducted in a non-profit LTC, housing around 170 multicultural residents, 70% of whom have dementia and other comorbidities, with a staff-to-resident ratio of 1:10. The cycling program was implemented in the care home’s recreation center using an Active Passive Trainer (APT) connected to a TV that displayed a gamified program with high-definition animations, vibrant colors, and music to engage residents. A sensor on the APT tracked residents’ pedalling, which controlled the pace of an animated fox chasing rabbits on screen. Researchers briefed participants, explaining that the cycling helped the fox catch rabbits. During the intervention, we monitored residents’ performance and safety, using field notes to track heart rate with an oximeter, signs of sweating, fatigue, ability to talk, and asking if they felt tired. See Fig. 1.

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Fig 1. The Gamified Exercise Equipment and Programme.

https://doi.org/10.1371/journal.pone.0335679.g001

Sampling and recruitment

We utilized a convenience sampling method [30] to recruit participants through posters in the care home. Emails were sent to staff and leaders as well as families to invite participation. The inclusion criteria for participants included: (1) aged over 60; (2) residing in LTC homes; (3) currently participating in routine exercise without a gamified program; and (4) able to communicate in simple English and willing to participate. The exclusion criteria for participants included (1) severe cardiovascular conditions, (2) advanced respiratory diseases, (3) actively undergoing treatment and regularly visiting the hospital, and (4) not meeting the above inclusion criteria. For family members, the inclusion criterion was the ability to understand English. Staff and leadership participants had to be full-time or part-time employees at the LTC home in Vancouver, British Columbia, Canada. The recruitment period of this study spanned from June 12, 2024, to August 15, 2024. To respect the diverse composition of frontline staff and families from racialized communities, we did not require proficiency in English for participation and placed no additional exclusion criteria as long as the inclusion criteria were met. A demonstration video summarizing the project was shared with staff and family participants prior to the focus groups and interviews (https://youtu.be/be4WBJwC4gM).

Focus group and interview questions

The questions for the interview for residents were:

1. What do you like or dislike about the game?
2. What are the good and bad of this game?

These two questions focused on acceptability, reflecting residents’ emotional and cognitive responses to the intervention.

The questions for the semi-structured focus group for LTC staff and interviews with families were:

1. What are the benefits and concerns of this cycling game?
2. What suggestions do you have for making improvements to this game?
3. What are the barriers and facilitators in implementing gamified exercise across LTC homes? (only for leadership participants)

The first two questions addressed both acceptability and feasibility, depending on participants’ perspectives and emphasis in their responses. The last question was designed to explore feasibility, particularly organizational and operational factors, to scale the intervention.

Data collection

This project was led by the first author, LH, who is an experienced gerontological nurse in LTC. Interviews were conducted with both residents and family members; however, these were conducted separately due to differing schedules in this study setting. Each family member was interviewed individually at their preferred time points, while residents were interviewed directly after their final exercise session. The aim was to gather in-depth reflections on their overall experience with the intervention rather than session-specific feedback. We conducted 11 focus groups with LTC staff and leadership between June and August 2024. Each focus group consisted of two to seven participants, based on the participants’ availability and workload. There was no repetition in focus group participation; each staff member attended only one discussion session. Focus groups were organized by role type for scheduling and comfort reasons. Specifically, allied health professionals participated in one group, managers in another, and nurses and care aides were grouped together in several sessions due to their different working sites. This structure also helped avoid the potential influence of hierarchical dynamics in the focus group discussions. Researcher trainees YZ, ML, TW, and JL conducted these focus groups at the nursing stations of the care home. Each session was audio-recorded and transcribed verbatim. Observation field notes were also recorded during the group sessions to document non-verbal cues and contextual factors that might impact the conversation. Our team included diverse trainees: JL, RS, ML, MX, TW, YZ and AF. YZ is an Asian male health leadership and policy graduate. JL is a female undergraduate student in Cognitive Science. AF is an Asian female undergraduate student in Integrated Sciences. ML, MX, and TW are Asian female bachelor’s students in nursing. RS is an Asian female undergraduate student in Speech Sciences. All data collection activities by trainees were under the supervision of LH, the principal investigator of the study, who is a female Asian professor in nursing.

Data analysis and theoretical framework

Our iterative data analysis was guided by the consolidated framework for implementation research (CFIR) [31]. CFIR informed us in analyzing how individual and contextual factors impacted the effectiveness of gamified exercise programs in LTC settings. Our study utilized Braun and Clarke’s [32] six-step reflexive thematic analysis approach. Step 1: Trainees transcribed the data, and all research team members read independently. With this, the team oriented itself to the data. Step 2: YZ and JL performed initial analysis and generated the initial codes with the transcribed data. This study used the NVivo version 14.0 program to store all the transcripts, quotations, and codes. Based on the CFIR framework and research questions, the team developed a system for deductive and inductive coding. To enhance methodological rigor, a subset of transcripts was independently coded by two researchers (YZ and JL) to establish inter-coder reliability. Discrepancies were resolved through discussion and consensus. Step 3: Based on the codes developed, YZ, ML, TW, and JL searched for common themes. Step 4: YZ presented and discussed the preliminary themes with the research team. Step 5: Based on the team discussion, we refined the themes. Step 6: The trainees wrote the initial draft and revised it through several iterations. The supervisor LH provided guidance to the student authors during the data analysis and writing process. Descriptive statistics, including frequencies and percentages, were used to analyze demographic variables such as age range, gender distribution, ethnicity, dementia status, and staff roles.

Patient and public involvement

One family partner, LW, was involved in organizing focus groups and interviews, as well as in data analysis. She had previously worked with the first author on several research projects (e.g., [33,34]). LW brought valuable insights from her lived experience as a caregiver for LTC residents, helping to ensure that the research addressed the real-world needs of residents and caregivers. Additionally, she led staff huddles and informal meetings to share research progress in the LTC home.

Ethical considerations

This research study was approved by the Office of Research Ethics at the University of British Columbia (H24-00010). Written consent was gathered from all participants through a consent form discussing the details of the research, outlining its purpose, potential benefits, risks involved, and the right to withdraw from the study. Documentation of consent forms is securely maintained as part of the study records. To maintain confidentiality, pseudonyms were employed to protect the anonymity of participants’ identities. The resident in Fig 1 and their family have given written informed consent (as outlined in PLOS consent form) to publish these case details. To protect participant privacy, full transcripts and anonymized data are not available in a public repository. However, coding frameworks and selected de-identified excerpts are included in this manuscript to support transparency.

Rigor

This study implements several measures to ensure rigor in the output research, including the active involvement of family partners for credibility. Our team incorporated regular reflective discussions into weekly research meetings and kept reflexivity notes to critically evaluate our assumptions. Team members with different disciplinary backgrounds brought diverse perspectives to data interpretation, supporting triangulation of analytic insights. Our team consists of multiple researchers collaborating on coding, analysis, and interpretations. A subset of transcripts was double-coded to enhance dependability, and discrepancies were reconciled through consensus-building discussions. Detailed research documentation, description of data collection, and analysis processes were documented in an audit trail. These practices, including triangulation, inter-coder checks, and transparent documentation, were established to continually promote accountability and transparency in our research.

Participants

The study included 59 participants, including 14 residents, 11 family members, and 34 staff, whose ethnicity is all Asian (see Table 1; demographic data are available in the Supporting Information, S2 Dataset). Staff are from various professional backgrounds, with nurses (29.4%) and care aides (29.4%) representing the largest groups. Recreational team (20.6%) and rehabilitation team (5.9%) also participated. Notably, the leadership group comprised two nurses, one rehabilitation therapist, one recreational therapist, and one manager. The gender distribution was predominantly female (82.4%). Staff’s ages ranged from 20 to 60 years, with the largest age group being 50–60 years (35.3%), followed by 30–40 years (29.4%), 40–50 years (23.5%), and 20–30 years (11.8%). This diverse demographic provided a comprehensive perspective on the implementation of the gamified cycling program.

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Table 1. Demographic Characteristics of Participants (n = 59).

https://doi.org/10.1371/journal.pone.0335679.t001

The gender distribution of residents was predominantly female (78.6%). Participants’ ages ranged from 68 to 96 years, with the largest age group being older than 90 (64.3%), followed by 80–89 years (21.4%). The majority of residents are living with moderate dementia (57.1%).

All participants reported positive impact brought by this cycling game and expressed their anticipation on the next phase of this program. One family member Leilani mentioned, “It seems like my dad really enjoyed it, and I’m excited to see what’s next. Will he be involved in the next phase as well?” This research created three themes: ease of use and accessibility, physical and mental health benefits, fun engagement and community building. See Table 2.

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Table 2. Codes and Themes.

https://doi.org/10.1371/journal.pone.0335679.t002

Theme 1: Ease of use and accessibility

Accessibility

Staff and family members identified several facilitators for the accessibility of the cycling game, such as its integration into current exercise routines, available monitoring and supervision, and its suitability for residents in wheelchairs. Ruby, a family member, commented, “They don’t have to use as much strength since they’re just seated and cycling. Walking is more tiring because it requires weight-bearing. So, I think this is a great intervention.”

Leilani, another family member, shared, “I know that in the past, he did this type of cycling during physio, so I was confident he could do it again. It’s great to see him back at it! Plus, since he likes video games, combining the two has been very beneficial for him.”

However, some staff highlighted a few barriers to the game’s feasibility, such as exclusion criteria for residents with cognitive impairments, concerns about safety, staffing shortages, leadership approval, and accountability in case of accidents.

Zoey, a care aide, explained, “Some residents aren’t very interested or have more complicated conditions, so it might not be suitable for their floor.”

Oliver, a recreation staff member, remarked, “I think the project coordinator or the department head will try to integrate it into their program, and that will be their responsibility. In the future, a couple of months down the line, they can start spreading it out to suitable residents. However, I believe it should start with the rehab team of professionals to lead the initial efforts.”

Lily, in leadership, noted, “The goal of exercise can differ depending on whether it’s part of an activity program or a rehab program. By incorporating it into an activity program, I think more residents can have access to it.”

Families and staff also expressed initial hesitation about involving certain residents due to health concerns, such as the risk of heart attacks. However, after observing the heart rate monitoring and supervision during the exercise, they felt reassured about the project’s sustainability and scalability. One family member remarked, “Wow, so you’re measuring them, that’s awesome! I’m curious though, how do you know if they’re tired or not? Then I found there was something (oximeter) hooked up to them. That’s great!”

Resource constraints

Resource constraints have been identified as a significant barrier to the successful implementation of this project in LTC homes. While most of the care team did not feel that the program increased their workload, both leadership and other teams highlighted staffing and equipment shortages as major challenges.

Lily, from the leadership team, explained, “The main barrier is still staffing. Not many residents are in a PT program because the goals of exercise differ. However, if it’s part of an activity program instead of rehab, more residents could participate. But since this is a one-on-one game, it requires more dedicated staff because only one resident can play at a time, even though others can watch – they still have to line up.”

She also pointed out the issue of accessibility: “Accessibility is the second challenge – how can we get more residents involved at the same time? We’ve tried other games where three or four can play together, but this one is just one at a time. I remember some residents asking, ‘When is it my turn?’ So, improving accessibility and creating smoother arrangements will definitely be a challenge.”

Suggestions to address these constraints were provided by families, staff, and leadership. These included increasing residents’ independence, enhancing the game design, and introducing group exercise options.

Gianna, another member of leadership, remarked, “If only one or two residents participate, it won’t be cost-effective. For example, under the management’s funding criteria, one recreation team covers 32 to 36 residents. One recreational staff member is responsible for residents on two floors, so we expect at least 5 to 8 residents to participate at the same time.”

Theme 2: Physical and mental health benefits

Mental health benefits

The cycling game offered varying cognitive benefits depending on the residents’ cognitive levels. While some residents could not recall the game, others remembered it fondly, reporting that recalling the experience made them laugh. Staff noted that the cycling game provided residents with opportunities to learn new things, helping to maintain their attention and cognitive functions. Everly, a family member, shared, “It can help her learn to focus since she’s completely lost track of things. This can help her regain that focus.”

Many family members and staff also noted that the cycling game increased social interaction opportunities, positively impacting residents’ mental health. Luna, a nurse, commented, “Most people here feel quite lonely and are seeking attention. If someone sits beside them and offers encouragement, it makes them really happy.” Similarly, Joshua, a family member, observed, “Right now, no one really interacts with each other. I’m hesitant to talk to the neighboring resident because I don’t know them or their family. But an activity like this could increase interactions between families and residents, improving the social aspect. It would bring people together instead of everyone living on the same floor without ever speaking.”

Lainey, a recreation staff member, highlighted the combined benefits of exercise and other activities, stating, “The body and mind are connected, so doing exercise is definitely good for other parts of the body too. When I do art with them, I start with some warm-up exercises or body movements. This helps them feel more energetic, uplifts their mood, and makes them feel warmer. Then they’re ready to create art.” This insight suggests the potential for integrating exercise with other recreational activities.

Physical and mental health benefits make the game more acceptable because it delivers meaningful outcomes, such as improved mobility, cognitive focus, and social interaction. From a feasibility perspective, the cognitive stimulation provided by the game, alongside its potential to enhance social interaction, meant that it could serve multiple purposes—physical exercise and mental health improvement. This dual purpose makes the intervention more efficient and easier to justify within a resource-constrained environment. Additionally, the social aspect increased residents’ willingness to participate, reducing the need for one-on-one supervision and making it more feasible to integrate into group activities.

Theme 3: Fun engagement and community building

Community building

The game not only sparked social interaction and excitement among residents, who eagerly anticipated each session, but it also fostered a fun atmosphere that encouraged collaboration between staff and families. This collaboration strengthened support for the residents and contributed to building a sense of community. Residents expressed a need for staff to be beside them, providing encouragement and support through auditory cues and assistance with setting up the APT equipment. While some staff noted that a few residents preferred solitude in their rooms, many more expressed a desire to cycle together with friends. Both staff and family members recognized the happiness derived from group exercise and offered suggestions for improving the program.

For example, one family member, Joshua, suggested, “Competing with their neighbour to see who can score the most points will also boost their motivation.” Recreational staff member Oliver added, “You add the player into the game, and then they start interacting, trying different things. The game is divided into different sections and windows, where they can track each other. You can keep everything in the same setting but make it more interesting to engage them.”

Staff emphasized that familiarity is essential for building close relationships with residents. Oliver explained, “When you first start working with a senior, you’re not really familiar with them yet – you don’t know their limitations or strengths. But after a few times, as you build a relationship, you get to know them better. Everyone has different backgrounds and needs, and once you understand that, it becomes easier to keep things moving smoothly, right?”

Many family members expressed their anticipation of exercise engagement and their passion for motivating residents to seize more exercise opportunities and leverage this meaningful program. Joshua remarked, “Often, when family members visit residents, they’re unsure how to spend the time. A cycling game that helps residents exercise for 10-20 minutes would be a great way to make their visit more meaningful.” He also recalled the challenges of collaboration during the COVID-19 pandemic, suggesting, “The staff didn’t want families to start nitpicking, so there was resistance to the idea (of collaboration). But if everyone shares the same goal, there’s no need to officially name a family representative – they’ll naturally take on that role and help nearby residents exercise.”

Both families and staff acknowledged the necessity of supervision during exercise for safety concerns. Penelope, a leadership staff member, noted, “When it’s in passive mode, it just keeps spinning non-stop, which is a concern. So, when residents use it, we always have close supervision. All it takes is one slip, and they could seriously fracture something. That’s why I find that part a bit worrisome.” Sophie, a family member, added, “I feel like if it wasn’t supervised, my grandma might get a little too competitive.” Another family member, Natalie, felt reassured knowing that safety can be guaranteed: “I don’t really see a downside (to this program) as long as they’re being supervised. It’s just the physical limitations we have to watch out for.”

To scale this program effectively, family and staff emphasized the importance of training and orientation. Oliver suggested, “To make it more successful, I think creating a short video or an online course would help. Everyone could then meet in a room for a brief training session.”

The collaboration among all partners is crucial for the success of community building, which in turn enhances the program’s feasibility. The focus on staff familiarity with residents facilitates smoother operations and creates a more supportive environment for both staff and participants. Additionally, the emphasis on training and orientation highlights the practicality of scaling the program, as clear guidance can lead to its effective implementation across various care settings. The attention to supervision and safety protocols further ensures that the program remains viable and safe, particularly in LTC settings. All these factors contribute to the program’s sustainability and scalability, making it a promising intervention for enhancing the well-being of residents.

The following summary integrates the key themes in relation to the study’s two research questions, demonstrating how the data supports our conclusions on acceptability and feasibility. Together, the three key themes—ease of use and accessibility, physical and mental health benefits, and fun engagement and community building—offer a comprehensive understanding of the acceptability and feasibility of implementing a gamified cycling game in LTC. Feasibility and acceptability are not mutually exclusive in this study; rather, they are interconnected aspects that together inform the successful implementation of a gamified cycling program in LTC settings. Each theme includes two to three subthemes that address both the user experience and practical realities of the LTC context. Themes related to ease of use, fun engagement, and perceived physical and mental health benefits address acceptability from the perspective of residents, aligning with the first research question on older adults’ experiences. However, acceptability also emerged in the perspectives of staff and family, particularly regarding ease of use and perceived health improvement. In contrast, subthemes related to accessibility, resource constraints, and community building reflect broader systematic and contextual factors influencing feasibility, speaking to the second research question regarding staff, family, and leadership perceptions. Notably, some themes, like ease of use and perceived health benefits, reflect an overlap between acceptability and feasibility; the positive responses from participants suggest that greater willingness to adopt the intervention can reduce resistance, increase engagement, and support long-term sustainability. Although we began with conceptually distinct definitions—acceptability as perceptions of value and engagement, and feasibility as practical implementation within LTC contexts—our analysis revealed that these constructs frequently intersect in practice. To maintain analytical clarity, we interpreted overlapping themes through the lens of stakeholder role and context, allowing us to capture how acceptability and feasibility manifest differently yet complementarily across levels of care. These themes offer a comprehensive view across individual, interpersonal, and organizational levels, guiding future implementation strategies for the successful adoption of gamified intervention in LTC environments.

Strengths and limitations

This study highlights several strengths, including the novel approach of incorporating gamified exercise into LTC, which fosters both physical and cognitive engagement among residents. A key strength of this study is the inclusion of a significantly older population (64.3% over 90 years old) and a high proportion of residents with moderate to severe dementia (64.2%), addressing gaps in previous research that largely focused on younger, less cognitively impaired individuals. The inclusion of various partners – residents, families, and staff – allowed for a comprehensive understanding of the program’s acceptability and feasibility from multiple perspectives. The study also demonstrates how gamification can enhance motivation and engagement, as residents reported enjoying the interactive nature of the game. The collaborative nature of the study, with input from leadership and caregivers, further strengthens its practical applicability to real-world settings.

Despite its strengths, the study has some limitations. The relatively small sample size and the demographic composition, primarily of Chinese individuals from a single LTC facility, may restrict the generalizability of the findings. The demographic homogeneity of our sample was not intentional selection but a natural consequence of recruiting at the available site. While this reflects the local institutional and cultural context, it was not a deliberate choice to limit diversity. As such, the findings may not capture the perspectives or experiences of residents, families, and staff in other regions, cultural contexts, or care models. For instance, attitudes toward technology use, physical activity, or family involvement in care may vary across cultural or socioeconomic groups. In addition, organizational policies, staffing structures and recreational programming can differ across LTC facilities, which may influence how interventions like gamified cycling are received and implemented. To further examine the acceptability and feasibility of this cycling game, future research involving multiple long term care facilities, a broader diversity in ethnicities and cultures, and a larger number of individuals is needed. Additionally, this study primarily focused on qualitative data. Incorporating quantitative measures such as heart rate variability, loneliness and happiness scales, and quality of life assessments in future studies could provide a more holistic understanding of the program’s effectiveness. Future research could examine the cost-benefit analysis and long-term impacts of gamified cycling exercises in improving residents’ physical and mental health outcomes, helping LTC facilities make informed decisions about the program’s feasibility and suitability for boarder implementation.

Practice implications

Based on the insights shared by residents, family, and multidisciplinary staff working in LTC homes, there are some lessons learned/ practical tips - “PEDALING” for all partners when implementing gamified exercises in LTC:

• Personalized and Inclusive Design: Customize the game to accommodate residents with diverse cognitive and physical abilities (e.g., simplified controls, color sets, subtitles, culture-related content). This ensures inclusivity and ease of use for a broad range of participants.
• Engagement Through Group Play: Modify the game to support group activities and friendly competition. This fosters social interaction, community building, and encourages more residents to participate, boosting overall engagement.
• Digital Tools for Scalability: Create online tutorials and training modules to facilitate implementation across different care settings. This will help streamline staff onboarding and enable the game to scale more effectively to a wider and larger study population.
• Adaptability into Routine Care: Integrate the game into existing care routines by aligning it with both rehabilitation and recreational programs. This improves feasibility without significantly increasing staff workloads.
• Leadership and Family Involvement: Encourage family participation to motivate residents and empower family members to engage meaningfully with their loved ones. Leadership support is crucial in coordinating the program’s integration and expansion.
• Improving Motivation with Game Elements: Incorporate rewards, varying levels of difficulty, and visual/auditory cues to keep residents engaged. These elements prevent monotony and encourage sustained participation, making the game enjoyable and effective.
• Necessary Supervision and Safety Protocols: Ensure close supervision during gameplay, especially for residents with mobility challenges. Safety measures like heart rate monitoring and protocols to prevent overexertion are vital to maintaining program viability and acceptability.
• Goal-Oriented Physical and Cognitive Health Monitoring: Use the game to track residents’ physical and cognitive improvements (e.g., muscle strength, attention span). Regular feedback loops between staff, residents, and families will optimize individual care plans.