Learner Involvement in The Co-Creation of Teaching and Learning: AMEE Guide No. 138
Learner Involvement in The Co-Creation of Teaching and Learning: AMEE Guide No. 138
Learner Involvement in The Co-Creation of Teaching and Learning: AMEE Guide No. 138
To cite this article: Karen D. Könings , Serge Mordang , Frank Smeenk , Laurents Stassen &
Subha Ramani (2020): Learner involvement in the co-creation of teaching and learning: AMEE
Guide No. 138, Medical Teacher, DOI: 10.1080/0142159X.2020.1838464
AMEE GUIDE
ABSTRACT KEYWORDS
This AMEE guide aims to emphasize the value of active learner involvement in the design and Teaching & learning; roles
development of education, referred to as co-creation, and provides practical tips for medical edu- of teacher; instructional
cators interested in implementing co-created educational initiatives at their own institutions. design; co-creation;
student support
Starting with definitions of co-creation and related terms, we then describe its benefits and sum-
marize the literature in medical and higher education to provide an appropriate context and a
shared mental model for health professions educators across the world. Potential challenges and
barriers to implementation of co-creation in practice are described in detail from the perspective
of learners, teachers, and institutions. Challenges are linked to relevant principles of Self-
Determination Theory, Positioning Theory and theory on Psychological Safety, to provide direction
and fundamental reasons for implementation of co-creation. Finally, solutions to listed challenges
and practical approaches to education design and implementation using co-creation are described
in detail. These tips include strategies for supporting learners and teachers in the process, enhanc-
ing the collaboration between them, and ensuring appropriate support at the organizational level.
Introduction and purpose of this guide education is to engage learners in the education program
and consider them as equal partners rather than consum-
Co-creation and active learner involvement in the design
ers of education. Taylor and Hamdy (2013) argue that
and development of education is garnering growing atten-
learning is about making sense and making use of know-
tion in educational practice and educational research.
ledge gained, so that it can be applied appropriately to
Involving learners in the design of teaching and learning
relevant practice. For this to occur, both teachers and
contributes to improvement in the quality of education, by learners need to challenge their assumptions as well as
addressing perspectives of different stakeholders and stim- perceptions of their respective roles in education (Taylor
ulating teachers’ growth. It also motivates learners by and Hamdy 2013). Despite the increasing calls and convinc-
enhancing their feelings of engagement, ownership, and ing arguments for learner involvement in educational
empowerment (Cook-Sather et al. 2014). Improvement in design, teachers and learners are not used to implementing
educational practice also requires meaningful feedback to this approach, and implementation is challenging for insti-
educators. However, at many higher education institutions, tutions. This AMEE guide aims to delve into key practical
it is still common practice for learners to provide feedback challenges of implementing co-creation in educational
to teachers through anonymous written surveys. The feed- practice as well as possible approaches for successful
back is primarily used by teachers to improve student implementation.
learning, but its impact on improving teachers’ educational The guide starts with a definition and description of co-
practice has not been demonstrated (Blair and Valdez Noel creation and related terms like participatory design and
2014; Golding and Adam 2016). Active engagement of learner-teacher partnership in the context of improving
learners in educational design, teaching formats and feed- teaching and learning. The impact of co-creation can be
back conversations can support formulation of plans for expected on three levels including the psychosocial learn-
change and professional development of teachers and ing environment, motivation and metacognition, and qual-
€nings et al. 2014).
learners alike (Cook-Sather et al. 2014; Ko ity of the educational design. We have developed the
The importance of active learner involvement in educa- Framework of Stakeholder Involvement in Co-Creation, to
tional design is increasingly recognized, for example in the visualize that co-creation not only has a direct impact on
recent ASPIRE-to-Excellence initiative on learner engage- the different stakeholders involved in the re/design of edu-
ment (Peters et al. 2019). Harden and Lilley (2018) cation, but also ultimately aims to affect a larger group of
described that one of the teachers’ future roles in medical learners, teachers and other stakeholders. Next, we discuss
CONTACT Karen D. K€onings kd.konings@maastrichtuniversity.nl Department of Educational Development and Research, Faculty of Health, Medicine
and Life Sciences, Maastricht University, Maastricht 6229, The Netherlands
ß 2020 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group.
This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives License (http://creativecommons.org/licenses/by-nc-
nd/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited, and is not altered, transformed, or
built upon in any way.
2 K. D. KÖNINGS ET AL.
researchers, software developers, or architects (Cober et al. learners’ dependent position in the educational hierarchy
2015; Harrison et al. 2017; Ko €nings and McKenney 2017; (Enright et al. 2017). Power issues are particularly disturbing
Ruskin and Bilous 2020). The outer circle of the if the learner teacher ratio is too low (e.g. 1 learner: 6
Figure suggests that effects of co-creation could, in prin- teachers, as opposed to a more equal ratio) and learners
ciple, be transferred to a larger population of learners and feel underrepresented (Carey 2013).
teachers. Arrows indicate that not only are all learners
ultimately expected to benefit from the co-created educa-
Voice fatigue, perception that their concerns
tion, but also that a wider population of teachers benefits
go unheard
from educational designs that better fit the context and
Learner willingness to be involved cannot be assumed.
are more implementation ready.
They dislike situations where their influence appears to be
limited to giving advice without actual involvement in the
Challenges of implementing co-creation implementation process (Martens et al. 2019b; Meeuwissen
in practice et al. 2019). Learners’ cynicism and frustration increase if
they perceive lack of action or non-resolution of challenges
Bringing ideas of co-creation to practice can be challeng- previously discussed with teachers (Carey 2013). The phe-
ing. Being aware of potential pitfalls and challenges helps nomenon of ‘voice fatigue’ has been reported to indicate
to prevent and/or mitigate them. Below, we describe the learners’ reluctance to involvement in co-creation because
challenges at the level of the learners, the teachers, and it is not important enough to them (self-interest instead of
the institution. Learners and teachers are the main stake- a more altruistic motivation to let future learners benefit),
holders most frequently mentioned in the literature; chal- because they prefer a more comfortable, passive role or
lenges for teachers might also apply to other stakeholders feel a lack of ownership over the curriculum or course,
in education (left corner of Figure 2; i.e. educationalists, because involvement is accompanied by a high workload
researchers, software developers). and time constraints, or because they are primarily con-
cerned with own tests and study progress (Bovill et al.
Challenges for learners 2011; Carey 2013; Seale et al. 2015; Blau and Shamir-Inbal
2018; Martens et al. 2020).
Lack of process and content expertise
Learners are often unfamiliar with the process of co-cre-
ation, which may hinder their understanding of roles and Challenges for teachers
provoke uncertainty (Bovill 2013a; Bergmark and Westman Giving up control and feelings of insecurity
2016). Being a partner in co-creation is different from the Co-creation requires teachers to redefine long-held
traditional learner role; changing roles, responsibilities and assumptions about roles and responsibilities, and power
sense of self can be perceived as uncomfortable, threaten- relations, which can lead to insecurity (Cook-Sather and
ing and confusing (Cook-Sather and Luz 2015; Deeley and Luz 2015; Bergmark and Westman 2016; Marquis et al.
Bovill 2017). Learners need to move beyond evaluating 2017). Teachers generally prefer to be in control of teach-
education, and contribute to problem-solving (Carey 2013). ing and this can be undermined by fears that co-creation
Learners can also feel insecure about their knowledge and may focus on complaints, blame and critique, and the pos-
skills, especially when co-creation requires them to think sibility that outcomes of the re/design process can be
‘outside the box,’ the content is unfamiliar, and they lack unpredictable (Kadi-Hanifi et al. 2014; Bergmark and
content and pedagogical expertise (Bovill et al. 2016; Westman 2016; Bovill 2019). They can feel threatened by
Brown 2019). Memories of their personal experiences of the idea of giving up control of elements in the curriculum,
schooling and educational design limit their imagination of partly because they feel responsible for the teaching and
alternative design options for education (Burke and partly because they assume that their content expertise
Ko€nings 2016). Learners might need to develop communi- confers them authority over it (Bovill et al. 2011; Bovill
cation and collaboration skills to a level necessary to con- 2013a; Bovill 2019). Giving up some power might also raise
structively communicate with teachers, provide input that feelings of vulnerability within the institution and uncer-
is clear and understandable to teachers and ensure that tainty about job security (Matthews et al. 2018). It is diffi-
their input does not offend teachers (Martens et al. 2020). cult for individual teachers to change the existing
hierarchical climate in universities, especially if deconstruct-
ing of such hierarchies is not done collectively with col-
Power relations
leagues (Marquis et al. 2017).
Existing power relations between learners and teachers can
hamper effective learner contributions to the co-creation
process. The hierarchical structure in education places the Skepticism that learners may not add value
learner in a situation of power imbalance, which can lead Teachers can be skeptical about learners’ capabilities to
to perceived personal risks of redefining learner-teacher engage effectively in co-creation (Cook-Sather and Luz
roles and relationships (Bovill et al. 2016). Learners might 2015). Teachers sometimes either do not recognize, or
avoid negative comments to, and disagreements with, underestimate, the value of learners’ contributions, which is
teachers (Seale et al. 2015), to prevent upsetting teachers a barrier to taking them seriously and involving them in
or even fearing punishment (Carey 2013; Seale et al. 2015). co-creation (Bovill 2013a; Bovill et al. 2016; Matthews et al.
This especially holds true if the teachers involved are also 2018). Teachersˊ underestimation of learner contributions
responsible for learner assessment, further cementing the contrasts with the reality where learners often contribute
MEDICAL TEACHER 5
beyond teacher expectations (Bovill 2013a). For such illumi- Lack of recognition
nating experiences, teachers, however, first have to really Institutions might demotivate learners to engage if they do
listen to learners and take their views seriously (Bovill not carefully report back to learners how their input has
2013a; Meeuwissen et al. 2019). been used and implemented (Carey 2013; Meeuwissen
et al. 2019). Lack of teacher recognition for the effort is
potentially a problem (Martens et al. 2020), as is a lack of a
Perceived threats in opening up for change
safe culture to allow some risk taking for teachers, without
Teachers need to be willing to reflect and continue to
causing perceived threats to job security (Matthews et al.
develop their own skills. ‘Since the typical reaction to differ-
2018). Traditional institutional structures, practices and
ence is to see it as strange and threatening and to seek to
norms may not recognize or value co-creation, which ham-
band together with people who seem the same, what is
pers its implementation (Bergmark and Westman 2016;
needed is for those of us in higher education to rethink our
Bovill et al. 2016; Matthews et al. 2018). Lack of clarity of
positions, perspectives, and identities in ways that move us
the roles of stakeholders can be a barrier as learner and
toward greater empathy and from there to deeper under-
teacher roles in co-creation not being clearly defined or
standing of one another’ (Cook-Sather 2015, pp. 21). Many
communicated can cause misunderstanding and misalign-
teachers tend to stick to pedagogic habits and familiar
ment of expectations between those involved in the pro-
ways of teaching, especially if time is limited (Bovill 2013a).
cess (Martens et al. 2019).
Changing ideas and opinions, based on learner feedback
Table 1 summarizes the main challenges in the co-
and suggestions, can seem threatening (Seale et al. 2015).
creation process in education, at the level of learners,
teachers and institutions.
Usual way of communicating with learners no lon-
ger fits
Theoretical principles in co-creation
Facilitating the conversation process during the co-creation
process can be a challenge as well. Teachers need an open Three key educational theories can be used to deepen our
attitude and need to be approachable for learners understanding of challenges and approaches to implementa-
(Meeuwissen et al. 2019; Martens et al. 2020). In co-creation tion of co-creation: Self-Determination Theory, Positioning
the aim is to bring different perspectives of stakeholders Theory and theory on Psychological Safety.
together, but this implies that it can be difficult to find
common ground (Marquis et al. 2017). Involving larger
groups of learners can make it extra challenging, especially
Self-Determination Theory
if the tone of the conversation is not automatically in good Theoretical principles of the Self-Determination Theory
harmony; learner groups can be problematic or resistant to (SDT) describe three key psychological needs that enhance
engage and take co-responsibility for the process (Bovill individual’s intrinsic motivation: autonomy, relatedness and
2019). Generally, if the conversation is too much about competence (Ryan and Deci 2000, 2017). Autonomy can be
negative issues and complaints only, this can hamper the fostered when teachers offer choices, and when learners’
constructive progress of the conversation, which also opinions and inputs are welcomed (Ryan and Deci 2000).
requires focus on positive aspects (Carey 2013). Teachers Relatedness concerns the desire of social connectedness,
need to develop strong communication skills to have this belonging to a group and feeling significant among others
new kind of conversations with learners (Enright et al. (Ryan and Deci 2017). Co-creation requires collaboration
2017; Marquis et al. 2017). and interdependency with teachers; literature reports indi-
cate that learners feel more connected to teachers and
peers resulting in improved learner-teacher relationships
Challenges at the institutional level
(Bovill 2013a, 2019). Finally, competence refers to a feeling
Lack of support of mastery and being effective in one’s actions (Ryan and
Institutions that do not to overtly support co-creation ini- Deci 2017).
tiatives, set aside dedicated time, and enable and empower Implementation of co-creation requires that these three
teachers and learners to work on these initiatives, limit the needs are met. The way teachers and learners feel related,
implementation of co-creation (Bjo €rklund et al. 2019). communicate, and collaborate in co-creation differs from
Enthusiastic teachers and learners are usually willing to put typical teaching situations in terms of changing roles and
in the extra effort and accept the extra workload, but responsibilities, power relations, and bidirectional conversa-
implementing best practices on a broader scale needs tions. The learning culture should actively promote
changes in traditional structures and additional resources teacher-learner relationships and address the power gap to
€rklund et al. 2019). Time issues are related to difficulties
(Bjo promote relatedness. To enhance autonomy, teachers
in finding time for planning joined meetings, lack of time should be open to questioning their teaching and lesson/
for the extra work for revising earlier education methods course design by learners, viewing it as constructive feed-
and materials, and limited time for long-lasting commit- back that targets improvement, while learners should be
ments and dialogue over time, which are needed to create convinced that their input is incorporated and concerns are
a context of trust for open exchange of ideas (Seale et al. being addressed. Learners who feel really heard and taken
2015; Gros and Lo pez 2016; Marquis et al. 2017; Bovill seriously regarding their experiences in education perceive
2019). Time issues are particularly challenging if no funding recognition of their expertise on education (Cook-Sather
or dedicated time is available and activities are planned et al. 2014). Training teachers and learners in the process
alongside to the formal curriculum (Marquis et al. 2017). of co-creation and explicitly using all opinions in designing
6 K. D. KÖNINGS ET AL.
educational initiatives can stimulate feelings of competence limited teacher motivation to listen to learners and open
on all sides. In summary, effective co-creation approaches up for feedback and reflection.
should focus on respecting teachers’ and learners’ auton- Psychological safety has been connected to speaking-up
omy and competence, while facilitating strong, respectful or voice behavior, defined as constructive verbal communi-
relationships between teachers and learners. cation that is directed upwards, for example a superior.
Speaking-up challenges usual communication patterns
(Edmondson and Lei 2014), reflected as reluctance to
Positioning Theory meaningfully change power relations and hierarchy.
The Positioning Theory states that people assume certain Speaking up can stimulate a dialogue on quality improve-
positions during interactions; these positions are associated ment (Edmondson and Lei 2014), however, perceptions of
with rights and duties and guide their actions (Van psychological safety are often insufficient for learners to
Langenhove and Harre 1999). Each individual assigns a pos- risk sharing their thoughts (Detert and Edmondson 2011).
ition to him/herself as well as to others in conversations Teachers can promote psychological safety by being
and interactions. Positions are also dynamic, depending on accessible, acknowledging their own imperfections, and by
the context and culture and guide not only what to do but proactively asking learners’ input. They can frame co-cre-
ation as a mutual learning process in which making mis-
also what not to do. Positioning Theory has been used to
takes is a learning experience and by responding
analyze social practices in classrooms and interactions
respectfully and appreciatively to learners’ input and feed-
between clinical supervisors and learners (McVee et al.
back (Nembhard and Edmondson 2006; Edmondson 2018).
2011; Georgakopoulou 2013; Sargeant et al. 2017).
Finally, institutions and their traditional structures might
Teachers and learners have developed a deeply rooted
not provide teachers with the necessary psychological
understanding of their mutual positions in the process of
safety to engage in co-creation, to experiment with giving
teaching and learning, based on experiences in education
up some control and open up for feedback or reflection.
over many years. Therefore, co-creation can cause struggles
For implementation of co-creation, thus, stimulating a safe
with changing roles and responsibilities, adapting power
climate to openly share thoughts and ideas among all
relations, and taking the learner voice seriously. Tenets of is crucial.
this theory are relevant and applicable to co-creation of Table 2 summarizes the implications of the principles of
education, where teachers and learners and other stake- these three theories on the implementation of co-creation
holders need to collaborate in construction of their roles of educational practice. It shows that in different ways they
(positions), and need to reach a shared understanding of all point to the need to reframe relationships between
roles, tasks and educational outcomes. learners and teachers as respectful, open and safe
partnerships.
Theory on Psychological Safety
Theory on Psychological Safety can contribute to the Practical approaches
understanding of effective co-creation efforts. Psychological In providing solutions to the described challenges, we will
safety concerns individual perceptions of taking social risk give an overview of possible approaches to effectively
in a context that could trigger change and uncertainty. It is implement co-creation. First, approaches are described that
an important aspect to consider in how individuals work specifically address the challenges respectively for learners
together toward a shared result. When one perceives an and teachers. It should be emphasized that approaches for
environment of psychological safety, one can focus on col- teachers are likely to be relevant for other stakeholders
lective objectives, rather than on own interests such as such as workplace partners, educational designers,
self-protection (Edmondson and Lei 2014). Lack of psycho- researchers or software developers. Then, approaches are
logical safety in the learner-teacher relationship can cause described that contribute to effective collaboration among
lack of motivation among learners to engage, as well as learners and teachers as a team. Finally, recommendations
MEDICAL TEACHER 7
Approaches on how to involve learners Start involving learners already early in the curriculum,
For overcoming challenges at the learner level, teachers so they get used to the way of working and develop
and institutions could use the following four strategies: self-confidence (Moore-Cherry et al. 2016; Peters
motivate learner engagement, ensure safety to speak up, et al. 2019).
support learners in developing necessary skills, and stimu- Avoid the involvement of learners and teachers in a co-
late fulfilment in their role of co-creator. creation process if they are also involved in a formal
assessment relation (Enright et al. 2017) or change the
focus of such assessments from summative to formative
feedback (Englander et al. 2019).
Motivate learner engagement in co-creation Consider involving learners that have no (past,
To raise learners’ motivation and interest, it is current or future) connection to the teachers involved
important to assess their areas of interest, passion, prior in co-creation (Cook-Sather and Luz 2015; Jensen and
experience and skills. In addition, it is essential to famil- Bennett 2016).
iarize learner roles in the co-creation process as well as Think about creative alternatives to face-to-face conver-
the process itself. We suggest the following poten- sations, like inviting learners to write a letter to an
tial strategies: imaginary friend regarding the course at hand, so learn-
ers have more choice and control about how they share
Learners must be invited to participate in projects that their thoughts with teachers (Seale 2009).
are close to learners’ hearts (Brown 2019). In case of resistance, have an open discussion with
Learner involvement must fit their level of experience learners about their concerns (with or without teachers
and skills in co-creation. For learners with limited experi- being present) (Deeley and Bovill 2017).
ence in co-creation, start small by first focusing on the
design/redesign of a course or module, instead of co-
creating a whole curriculum (Cook-Sather et al. 2014;
Support learners in developing necessary skills
Providing learners some training at the start of the co-cre-
Moore-Cherry et al. 2016).
ation process is beneficial. Training sessions can focus on
Consider gradually increasing levels of learner involve-
leaderships skills, on providing constructive and quality
ment to ease them into the process, for example by first
feedback to teachers, and on feeling empowered and con-
providing learners with choices or limited control of
fident to engage and bring in their perspective in discus-
areas that resonate with them (Bovill and Bulley 2011).
sions with teachers (Jensen and Bennett 2016; Stalmeijer
Ensure that learners are not required to work far
et al. 2016), as well as on conflict resolution, program
beyond their expertise (Bovill et al. 2016).
evaluation and curriculum design (Geraghty et al. 2020).
It is best when learners voluntarily engage in co-cre-
Skills for giving useful feedback to teachers can potentially
ation. It has been suggested to let learners apply for
be trained in a joint session with teachers (Dudek et al.
involvement in co-creation by submitting a letter on
2016; Myers and Chou 2016). Extra support can be pro-
why they want to participate and what they think they
vided during the process by a coordinator/mentor, provid-
are able to contribute (Cook-Sather and Luz 2015;
ing ad hoc individual support and organizing regular
Jensen and Bennett 2016).
meetings with other learners involved in co-creation to dis-
Ideally, learners selected to engage in co-creation are
cuss experiences and best practices in contributing to the
motivated to contribute to the improvement of educa-
co-creation (Cook-Sather and Luz 2015; Scott et al. 2019).
tion (Geraghty et al. 2020; Martens et al. 2020), hold a
proactive and critical attitude (Meeuwissen et al. 2019;
Geraghty et al. 2020), are open minded, and show self- Stimulate fulfilment in the role of co-creator
confidence and diplomacy (Marquis et al. 2019; Seeing involvement in co-creation as a constructive and
Meeuwissen et al. 2019). rewarding experience is important for learners, for staying
8 K. D. KÖNINGS ET AL.
motivated to contribute to a co-creation project. Strategies ideas, and collectively reflect on challenges and issues
that increase fulfillment could be: during the process (Bovill 2013a; Bergmark and
Westman 2016; Marquis et al. 2017).
Learners must be stimulated to start with a focus on Teachers should be informed that co-creation does not
what works well and on the strengths of the current imply giving away control of education as it ‘does not
educational design. Starting from a positive point of entail uninformed decision-making or following stu-
view helps to build a trusting relationship with teachers, dents’ wishes in an unquestioning manner’ (Deeley and
which is needed to be able to also discuss more difficult Bovill 2017, p. 473). In the end teachers are accountable
issues (Ko€nings et al. 2010a; Cook-Sather et al. 2018). (Deeley and Bovill 2017; Martens et al. 2020).
Learners should move away from a complaints culture When taking a positive and constructive stance during
and think about solutions to educational challenges co-creation, it is reassuring that co-creation gives teach-
(Carey 2013). ers insight in what works well in their teaching and
Learners could take responsibilities to act as consultants learning, stimulating continued professional growth
who are mainly in charge of collecting learner feedback among teachers (Cook-Sather et al. 2018).
and discussing this with the teachers (Cook-Sather 2009;
Milles et al. 2019; Scott et al. 2019; Geraghty
et al. 2020). Listen to learners seriously
By positioning themselves as contact persons to other For ensuring that co-creation develops as a shared initia-
learners, who are not directly involved in the co-creation, tive, really listening to learners’ voices and showing true
they collect information about issues experienced by interest are crucial (Cook-Sather 2015; Cook-Sather and Luz
others (Ko€nings et al. 2010b; Geraghty et al. 2020), which 2015; Meeuwissen et al. 2019). Already in early stages of
is an effective as well as personally rewarding role. the process, teachers have to make clear to learners that
their insights and ideas are heard and considered import-
ant. Strategies to demonstrate willingness to listen and
Approaches for teachers who want to get involved in take learners seriously include:
co-creation
For overcoming teachers’ challenges in co-creation, the fol- Give feedback-on-feedback and act on the outcomes of
lowing strategies can be recommended to teachers as well shared brainstorms or discussions (Carey 2013; Bovill
as faculty developers who support the co-creation process: 2013a, 2013b).
build confidence in co-creation with learners, listen ser- Communicate expectations on roles and responsibilities
iously to learners, and invest in professionalization of with learners to ensure that learners perceive their
teacher skills for co-creation. involvement as real and meaningful (Bovill 2013b; Gros
and Lo pez 2016; Bovill and Woolmer 2019; Martens
et al. 2019b).
Build confidence in co-creation with learners Stimulate learners to speak up by directly inviting them
Teachers (like learners) best engage in co-creation on a vol- for feedback and carefully express intentions to collab-
untary basis (Cook-Sather et al. 2014; Jensen and Bennett orate towards improving teaching and learning (Dudek
2016). Ideally, teachers will feel a need for change or et al. 2016; Myers and Chou 2016). Start such conversa-
improvement of their educational practice or a wish to tion with some self-reflection and showing personal vul-
receive feedback on certain aspects of teaching (Bovill nerability to emphasize a strong willingness to listen
et al. 2016; Jensen and Bennett 2016), and will be dedi- (Myers and Chou 2016).
cated to continuous quality improvement of education
(Meeuwissen et al. 2019). For building (self-)confidence in
co-creation the following strategies can be supportive: Invest in professionalization of teacher skills for
co-creation
Start with small initiatives linked to the own practice, Teachers must develop advanced skills regarding communi-
instead of a large innovation like a curriculum (Bovill cation and feedback. They need skills in facilitating co-cre-
et al., 2016; Healey and Healey 2019). ation discussions with learners, including skills in feedback
Adjust the level of learner involvement to learners’ and receiving, stimulating bidirectional feedback conversations,
teachers’ ability to fulfill their roles and take the neces- negotiating and sharing power, supporting learners, and
sary responsibilities (Bovill and Bulley 2011). also in facilitating difficult and risky conversations (Bovill
Build on existing collaborations with learners as this 2013b; Dudek et al. 2016; Myers and Chou 2016; Enright
facilitates implementation of co-creation and increases et al. 2017). This can be achieved through:
feeling safe to involve learners (Bovill et al. 2011).
Identify on forehand on which aspects of education Training sessions provided by a faculty development
learners’ insights are welcomed. This helps to account unit (Bovill 2013b; Dudek et al. 2016; Myers and
for teachers’ and learners’ level of prior experience in Chou 2016)
co-creation and create a safe environment for collabor- Mentorship among teachers (Myers and Chou 2016)
ation (Bovill and Woolmer 2019; Ruskin and Role modelling by teachers more experienced in co-cre-
Bilous 2020). ation (Martens et al. 2020)
Connect to other teachers involved in co-creation, share Getting oneself involved in a co-creation project in the
experiences, learn from each other’s practice, gather role of a learner (Enright et al. 2017).
MEDICAL TEACHER 9
Approaches on how to improve collaboration between the conditions for co-creation, including which elements
teachers and learners are open to change, and the expected outcomes (Bovill
2013a; Englander et al. 2019).
To overcome shared challenges that both learners and teach-
Do not allow a complaints culture (Carey 2013).
ers face regarding new roles and responsibilities in a new
Appreciative inquiry and a positive focus on opportuni-
kind of collaboration process, we suggest three strategies:
ties help developing a shared passion (Ko €nings et al.
decrease the power difference, develop shared responsibility,
2010a; Kadi-Hanifi et al. 2014).
and value and improve the co-creation process.
Decrease the power difference Value and improve the co-creation process
Hierarchical positions between learners and teachers must Collaborative reflection contributes to adjusting to new
be acknowledged and discussed from the start (Freeman roles, developing relationships and building trust, and also
et al. 2014). By elaborating on the usual roles and the helps learners to develop a better and more nuanced under-
expected different – more equal – relationship between standing of the teaching and learning process from the
learners and teachers in co-creation, changed relations teacher perspective as well as giving the teacher insight in
must get clear to all (Freeman et al. 2014). Considering learners’ experiences and interpretation of it (Cook-Sather
teachers and learners as co-learners ‘gives permission for 2014; Freeman et al. 2014; Enright et al. 2017). Optimizing
both staff and students to consider and enact new identi- the co-creation process means to find ways that work best in
ties as mutual learners.’ (Matthews et al. 2018, p. 966). In the own team. Possible strategies are:
developing a good relationship, respect and mutual trust is
crucial for enabling constructive and critical bidirectional Collaboratively reflect on questions about the values of
feedback conversations (Freeman et al. 2014; Sargeant co-creation, like: how do we show respect and fairness
et al. 2018; Brown 2019; Ramani et al. 2019). Possible strat- in our discussions? What unique experiences and talents
egies for limiting the power differences include: can we bring in and how can we support and use these
in the project? How do we distribute and share power?
An open feedback culture is needed in which learners (Healey and Healey 2019).
are expected to provide feedback to teachers (Dudek Get training in providing and receiving both positive
et al. 2016; Ramani et al. 2017). and negative feedback to enabling safe communication
Realization that both the risks and rewards of co-cre- among learners and teachers. Develop a feedback cul-
ation are shared by learners and teachers contributes to ture in which feedback is provided to both learners and
building confidence together (Moore-Cherry et al. 2016). teachers (Myers and Chou 2016; Ramani et al. 2017).
Expertise of both learners and teachers has to be valued Learners and teachers must not be focused too much
(Cook-Sather et al. 2014; Freeman et al. 2014; Ko €nings on the outcomes of the collaboration, but also recog-
et al. 2014; Peters et al. 2019) while both perspectives nize the value of the process itself (Bovill et al. 2011;
must be equally appreciated in conversations (Martens Freeman et al. 2014) while being flexible in unantici-
et al. 2020). pated developments in the process and its outcomes
Improve equality by inviting participants in an equal (Cook-Sather et al. 2014; Moore-Cherry et al. 2016).
teacher to learner ratio (Carey 2013; Martens et al. 2020) For stimulating the process of developing new solutions
and calling each other with first names (Englander to educational problems, experimentation and school
et al. 2019). visits can be helpful (Ko€nings et al. 2017).
Co-creation in a digital environment can make it easier Using visualization tools, like post-its or drawings, facili-
to ignore hierarchy and communicate on an equal level tate discussion and imagination during co-creation
(Cook-Sather 2017; Blau and Shamir-Inbal 2018). €nings et al. 2017; Ko
(Ko €nings et al. 2010a; Koutamanis,
Heuer, & Ko €nings et al. 2017).
Develop shared responsibility
The distribution of responsibilities and redefinition of roles Approaches at the institutional level
must be frequently negotiated (Enright et al. 2017; Gros
and Lo pez 2016). Autonomy of the co-creating team Provide support
encourages shared ownership of the project (Freeman Co-creating teams need support from their schools, depart-
et al. 2014). Level of responsibilities of different stakehold- ments or educational institutions. Support can consist of:
ers can vary in different phases of the co-creation process
€nings et al. 2017). Experiencing a shared responsibility
(Ko Availability of time, space, tools, and small-scale funding
can be stimulated by the following strategies: (Bovill et al., 2016; Marquis et al. 2017; Martens
et al. 2020).
Ensure learner involvement in the implementation The institution allowing some risk-taking, as hierarchical
phase and closing feedback loops for learners (Martens relations change and the process and outcomes of co-
et al. 2019b; Peters et al. 2018). creation are uncertain (Bovill 2013a).
Clearly define roles and levels of involvement through- Key individuals in the organization supporting new ini-
out the process (Martens et al. 2019b). tiatives in co-creation initiatives (Freeman et al. 2014).
Develop a shared understanding of the aims of the co- Institutionalizing a structure for frequent and efficient
creation process, by having open communication about bidirectional feedback and collaboration on revising
10 K. D. KÖNINGS ET AL.
Text box 1. Overview of our recommendations for implementing co-creation on each of the levels of the Framework of Stakeholder Involvement in
Co-Creation
Inner triangle Most important aims: Strong selection of participants will not be
Benefits for co-creating participants, including an appropriate. Learners who are not yet very
improved psychosocial learning environment motivated for learning and teachers whose
(more positive, inclusive and democratic professional development would benefit from more
learning climate, because of better bidirectional feedback may also be invited to
relationships, increased sense of belonging, be involved.
safety) and increased motivation and Co-creation can be performed during the
metacognition (understanding each other’s educational program as participants can real-time
perspectives, increased ownership and contribute to its improvement and benefit from this
responsibility, deeper engagement with improvement themselves.
education, improved skills) Co-creation might be done with all learners in a
class and performed by larger numbers of teachers.
Getting familiar with new roles and responsibilities
needs extra attention as well as developing
necessary skills for co-creation in learners
and teachers.
Working on a sense of shared responsibility and
limiting power differentials is important.
Optimizing the co-creation process by reflection
and keeping a positive stance contribute to the
effectiveness of the collaboration.
Support from faculty developers and the institution
is needed.
Co-creation can be a long-lasting initiative.
Outer circle Most important aim: Priority could be given to selecting a limited
Benefits for the wider population, regarding number of learners, teachers and other stakeholders
improved quality and usability of the who are highly motivated and already have
educational design of a course/ curriculum or relevant skills and attitudes to perform well in
way of teaching (incorporating expertise and co-creation.
perspectives of all important stakeholders in Best invite learners who already followed the
the set-up of education) educational program and are able to look back and
reflect for developing ideas to improve education.
Given a stricter selection of participants, less
emphasis might be needed on ensuring that the
conditions for co-creation (familiarization,
confidence, communication and feedback skills,
adjusting to new roles and shared responsibility)
are met. This, however, needs to be judged in the
own context.
Support by faculty developers and the institution is
important to optimally facilitate the process.
Co-creation can be a development project with a
clear endpoint, for example when an educational
design is delivered, or be a continuous process for
quality assurance and readjusting of education.
ORCID
Notes on contributors
€nings
Karen D. Ko http://orcid.org/0000-0003-0063-8218
Karen D. Ko€nings, PhD is psychologist and Associate Professor in the Frank Smeenk http://orcid.org/0000-0003-4963-2714
Department of Educational Development and Research and the School Laurents Stassen http://orcid.org/0000-0002-3383-9035
of Health Professions Education, Faculty of Health, Medicine and Life Subha Ramani http://orcid.org/0000-0002-8360-4031
Sciences at Maastricht University and Honorary Professor at the School
of Health Sciences at University of East Anglia.
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