Learner involvement in the co-creation of teaching and learning: AMEE Guide No. 138

Abstract

This AMEE guide aims to emphasize the value of active learner involvement in the design and development of education, referred to as co-creation, and provides practical tips for medical educators interested in implementing co-created educational initiatives at their own institutions. Starting with definitions of co-creation and related terms, we then describe its benefits and summarize 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, enhancing the collaboration between them, and ensuring appropriate support at the organizational level.

Keywords:

• Teaching & learning
• roles of teacher
• instructional design
• co-creation
• student support

Introduction and purpose of this guide

Co-creation and active learner involvement in the design and development of education is garnering growing attention in educational practice and educational research. Involving learners in the design of teaching and learning contributes to improvement in the quality of education, by addressing perspectives of different stakeholders and stimulating teachers’ growth. It also motivates learners by enhancing their feelings of engagement, ownership, and empowerment (Cook-Sather et al. 2014). Improvement in educational practice also requires meaningful feedback to educators. However, at many higher education institutions, it is still common practice for learners to provide feedback to teachers through anonymous written surveys. The feedback is primarily used by teachers to improve student learning, but its impact on improving teachers’ educational practice has not been demonstrated (Blair and Valdez Noel 2014; Golding and Adam 2016). Active engagement of learners in educational design, teaching formats and feedback conversations can support formulation of plans for change and professional development of teachers and learners alike (Cook-Sather et al. 2014; Könings et al. 2014).

Practice points

• Through co-creation, teachers and learners get a better understanding of each other’s perspectives on education. This can facilitate a more positive, inclusive and democratic learning environment, increased internal motivation, and higher quality of the educational design.

• To enable an open exchange of thoughts and ideas among learners and teachers, it is important to ensure psychological safety, where power differences between teachers and learners are diminished and trust is established.

• Teachers should genuinely listen to learners and be open to implementing educational change through shared responsibility with learners. Institutions and teachers should encourage learners to contribute positively to problem solving in educational design and collaboratively develop of solutions to challenges.

• Training in feedback-providing skills among learners and feedback-receiving skills among teachers can help to improve the quality and effectiveness of bidirectional conversations.

• The degree of learner involvement must be aligned with their skills, willingness to learn and engage, and earlier experience in co-creation. Starting small and gradually increase in engagement can build confidence of participants in co-creation initiatives.

• Connecting and sharing experiences with colleagues and peers who are also involved in co-creation can foster mutual learning, and support from faculty developers can facilitate the co-creation process.

The importance of active learner involvement in educational design is increasingly recognized, for example in the recent ASPIRE-to-Excellence initiative on learner engagement (Peters et al. 2019). Harden and Lilley (2018) described that one of the teachers’ future roles in medical education is to engage learners in the education program and consider them as equal partners rather than consumers of education. Taylor and Hamdy (2013) argue that learning is about making sense and making use of knowledge gained, so that it can be applied appropriately to relevant practice. For this to occur, both teachers and learners need to challenge their assumptions as well as perceptions of their respective roles in education (Taylor and Hamdy 2013). Despite the increasing calls and convincing arguments for learner involvement in educational design, teachers and learners are not used to implementing this approach, and implementation is challenging for institutions. This AMEE guide aims to delve into key practical challenges of implementing co-creation in educational practice as well as possible approaches for successful implementation.

The guide starts with a definition and description of co-creation and related terms like participatory design and learner-teacher partnership in the context of improving teaching and learning. The impact of co-creation can be expected on three levels including the psychosocial learning environment, motivation and metacognition, and quality of the educational design. We have developed the Framework of Stakeholder Involvement in Co-Creation, to visualize that co-creation not only has a direct impact on the different stakeholders involved in the re/design of education, but also ultimately aims to affect a larger group of learners, teachers and other stakeholders. Next, we discuss an overview of potential challenges for learners, teachers and institutions when implementing co-creation in practice. We apply principles from the Self-Determination Theory, the Positioning Theory and theory on Psychological Safety to give fundamental meaning to these challenges. The guide will conclude with a description of potential strategies that can help teachers and educational leaders to implement co-creation of teaching and learning in health professions education.

Co-creation: Definitions and benefits

Definition

Co-creation is defined as a close collaboration between learners and teachers, aiming to improve teaching and learning by welcoming learners’ perspectives and actively involving them in the educational (design) process (Bovill et al. 2016). A closely related term is participatory design, which also refers to a collaboration with all stakeholders in designing education. While co-creation mainly aims for positive effects of engagement for those learners directly involved in co-creation, participatory design mainly focuses on improving the quality of educational innovations by ensuring use, usability and utility of educational design for both teachers and learners (Martens et al. 2019a). The role of learners in educational design can be considered as a ladder with each rung representing an increasing level of engagement and responsibility: from a dictated curriculum that does not interact with learners in its design, to providing learners with choices, to giving learners control of some areas, to partnerships or even learners being in control (Bovill and Bulley 2011). A learner-teacher partnership is defined as ‘a collaborative, reciprocal process through which all participants have the opportunity to contribute equally, although not necessarily in the same way, to curricular or pedagogical conceptualization, decision-making, implementation, investigation, or analysis’ (Cook-Sather et al. 2014, pp. 6–7). The level of learner involvement should be aligned with the purpose of the chosen approach (Martens et al. 2019a). In this AMEE guide, we do not aim to be prescriptive about the level of learner involvement to be pursued or be selective based on the terminology used, but to elaborate on its potential impact, challenges to implementation, and approaches to open an honest dialogue with learners on how to improve education, which we will refer to as ‘co-creation’ throughout the paper.

Impact of co-creation

The impact of co-creation can be categorized under three clusters: it effects on psychosocial learning environment, motivation and metacognition, and quality of the educational design.

• The first cluster consists of effects on the psychosocial learning environment: enhanced learner-teacher relationships, a stronger sense of identity, and an increased sense of belongingness and cohesion (Bovill 2013a, 2020). Additionally, learners and teachers continuously develop their skills and attitudes regarding communication, collaboration, and how to deal with conflicts (Cook-Sather et al. 2014). Empowering learners contributes to the development of positive feelings and attitudes and to the establishment of safe environments, where learners are respected and where emotions can be safely addressed (Hill et al. 2019). All these benefits contribute to a more positive, inclusive and democratic learning climate for learners and teachers (Cook-Sather and Luz 2015).

• The second cluster comprises effects on motivation and metacognition. Learners develop a better understanding of the teacher’s perspective and the aims of education, while teachers obtain clearer insights regarding learners’ perspectives on education (Bovill 2013a; Cook-Sather et al. 2014). Reflection on personal behavior is stimulated among both learners and teachers, strengthening metacognitive awareness and developing metacognitive skills (Seale 2009). Additionally, both develop a sense of ownership, responsibility and increased engagement with education, resulting in increased motivation and confidence (Bovill 2013a; Cook-Sather and Luz 2015); as well as increased lifelong learning skills and problem-solving skills (Dollinger et al. 2018). Co-creation positively impacts satisfaction with education (Könings et al. 2010b; Dollinger et al. 2018) and, because of a deeper engagement with concepts and subject matter by learners and teachers involved in the co-creation, teaching and learning can be improved (Bovill 2013a; Brown 2018). These motivational and metacognitive effects of co-creation improve quality of teaching and learning among those learners and teachers involved in the co-creation process.

• The third cluster refers to effects on the quality of the educational design, which goes beyond the effects caused by direct involvement in co-creation. By incorporating the expertise and perspectives of relevant stakeholders, co-creation can result in a more effective or appealing design of a course or curriculum. Brooman Darwent, and Pimor (2014) have shown that, in contrast to teacher-led redesign, seriously listening to learners’ voices increased learner performance, learner perceptions and attendance of the whole cohort. It can be challenging to prove positive learning effects or increased satisfaction in those learners involved in co-creation compared to non-involved peers (Könings et al. 2010b; Brown 2018). However, an important intended benefit of co-creation is that broader groups of learners and teachers profit from the improved quality of educational innovations and use, usability and utility of the educational design.

Literature on co-creation of education

Scientific literature on co-creation of learning in medical education is scarce. Reports from recent innovative initiatives describe successful learner-teacher partnership for curricular improvement in undergraduate medical education (Scott et al. 2019), learner involvement in the development of interprofessional education courses (Behrend et al. 2019), innovative curricular changes through learner-driven initiatives (Zdravkovic et al. 2018), and assignment of module co-director roles to medical learners in curriculum development (Milles et al. 2019). While these initiatives are encouraging, they do not provide a good overview of potential challenges or facilitators in the co-creation process. In higher education literature, co-creation has been described more extensively and for a longer time, as evidenced by a growing number of citations over the last few years (Figure 1). We reviewed publications focusing on barriers, struggles, and challenges as well as facilitators and approaches for co-creation in higher education, included in the Web of Science. In this paper we use the term ‘teacher’ for any professional having a teaching or supervisory role (staff, clinical supervisor etc.) and ‘learner’ for any level of student or learner (undergraduate and postgraduate learners and professional learners in continuing education) in a setting that promotes learning (university or clinical workplace).

Figure 1. Numbers of citations on co-creation (or synonyms) in higher education.

A framework for co-creation

Based on the literature review of co-creation, we developed the Framework of Stakeholder Involvement in Co-Creation (Figure 2), which depicts the effects of active involvement of different stakeholders in the educational design process. The inner triangle emphasizes that learners’ involvement leads to improved learning processes (due to psychosocial and/or motivational and metacognitive effects) (Könings et al. 2010b; Bovill 2013a; Cook-Sather et al. 2014). Teachers benefit from co-creation, as dialogues with learners improve teaching practices and foster their own professional development through the same mechanisms described above (Bovill 2013a; Cook-Sather et al. 2014; Cook-Sather and Luz 2015). The left corner of the triangle visualizes other relevant stakeholders who can also engage in the co-creation process, for example workplace partners, nurses, patients, educational designers/educationalists, researchers, software developers, or architects (Cober et al. 2015; Harrison et al. 2017; Könings and McKenney 2017; Ruskin and Bilous 2020). The outer circle of the Figure suggests that effects of co-creation could, in principle, be transferred to a larger population of learners and teachers. Arrows indicate that not only are all learners ultimately expected to benefit from the co-created education, but also that a wider population of teachers benefits from educational designs that better fit the context and are more implementation ready.

Figure 2. Framework of Stakeholder Involvement in Co-Creation.

Challenges of implementing co-creation in practice

Bringing ideas of co-creation to practice can be challenging. Being aware of potential pitfalls and challenges helps to prevent and/or mitigate them. Below, we describe the challenges at the level of the learners, the teachers, and the institution. Learners and teachers are the main stakeholders most frequently mentioned in the literature; challenges for teachers might also apply to other stakeholders in education (left corner of Figure 2; i.e. educationalists, researchers, software developers).

Challenges for learners

Lack of process and content expertise

Learners are often unfamiliar with the process of co-creation, which may hinder their understanding of roles and provoke uncertainty (Bovill 2013a; Bergmark and Westman 2016). Being a partner in co-creation is different from the traditional learner role; changing roles, responsibilities and sense of self can be perceived as uncomfortable, threatening and confusing (Cook-Sather and Luz 2015; Deeley and Bovill 2017). Learners need to move beyond evaluating education, and contribute to problem-solving (Carey 2013). Learners can also feel insecure about their knowledge and skills, especially when co-creation requires them to think ‘outside the box,’ the content is unfamiliar, and they lack content and pedagogical expertise (Bovill et al. 2016; Brown 2019). Memories of their personal experiences of schooling and educational design limit their imagination of alternative design options for education (Burke and Könings 2016). Learners might need to develop communication and collaboration skills to a level necessary to constructively communicate with teachers, provide input that is clear and understandable to teachers and ensure that their input does not offend teachers (Martens et al. 2020).

Power relations

Existing power relations between learners and teachers can hamper effective learner contributions to the co-creation process. The hierarchical structure in education places the learner in a situation of power imbalance, which can lead to perceived personal risks of redefining learner-teacher roles and relationships (Bovill et al. 2016). Learners might avoid negative comments to, and disagreements with, teachers (Seale et al. 2015), to prevent upsetting teachers or even fearing punishment (Carey 2013; Seale et al. 2015). This especially holds true if the teachers involved are also responsible for learner assessment, further cementing the learners’ dependent position in the educational hierarchy (Enright et al. 2017). Power issues are particularly disturbing if the learner teacher ratio is too low (e.g. 1 learner: 6 teachers, as opposed to a more equal ratio) and learners feel underrepresented (Carey 2013).

Voice fatigue, perception that their concerns go unheard

Learner willingness to be involved cannot be assumed. They dislike situations where their influence appears to be limited to giving advice without actual involvement in the implementation process (Martens et al. 2019b; Meeuwissen et al. 2019). Learners’ cynicism and frustration increase if they perceive lack of action or non-resolution of challenges previously discussed with teachers (Carey 2013). The phenomenon of ‘voice fatigue’ has been reported to indicate learners’ reluctance to involvement in co-creation because it is not important enough to them (self-interest instead of a more altruistic motivation to let future learners benefit), because they prefer a more comfortable, passive role or feel a lack of ownership over the curriculum or course, because involvement is accompanied by a high workload and time constraints, or because they are primarily concerned with own tests and study progress (Bovill et al. 2011; Carey 2013; Seale et al. 2015; Blau and Shamir-Inbal 2018; Martens et al. 2020).

Challenges for teachers

Giving up control and feelings of insecurity

Co-creation requires teachers to redefine long-held assumptions about roles and responsibilities, and power relations, which can lead to insecurity (Cook-Sather and Luz 2015; Bergmark and Westman 2016; Marquis et al. 2017). Teachers generally prefer to be in control of teaching and this can be undermined by fears that co-creation may focus on complaints, blame and critique, and the possibility that outcomes of the re/design process can be unpredictable (Kadi-Hanifi et al. 2014; Bergmark and Westman 2016; Bovill 2019). They can feel threatened by the idea of giving up control of elements in the curriculum, partly because they feel responsible for the teaching and partly because they assume that their content expertise confers them authority over it (Bovill et al. 2011; Bovill 2013a; Bovill 2019). Giving up some power might also raise feelings of vulnerability within the institution and uncertainty about job security (Matthews et al. 2018). It is difficult for individual teachers to change the existing hierarchical climate in universities, especially if deconstructing of such hierarchies is not done collectively with colleagues (Marquis et al. 2017).

Skepticism that learners may not add value

Teachers can be skeptical about learners’ capabilities to engage effectively in co-creation (Cook-Sather and Luz 2015). Teachers sometimes either do not recognize, or underestimate, the value of learners’ contributions, which is a barrier to taking them seriously and involving them in co-creation (Bovill 2013a; Bovill et al. 2016; Matthews et al. 2018). Teachersˊ underestimation of learner contributions contrasts with the reality where learners often contribute beyond teacher expectations (Bovill 2013a). For such illuminating experiences, teachers, however, first have to really listen to learners and take their views seriously (Bovill 2013a; Meeuwissen et al. 2019).

Perceived threats in opening up for change

Teachers need to be willing to reflect and continue to develop their own skills. ‘Since the typical reaction to difference is to see it as strange and threatening and to seek to band together with people who seem the same, what is needed is for those of us in higher education to rethink our positions, perspectives, and identities in ways that move us toward greater empathy and from there to deeper understanding of one another’ (Cook-Sather 2015, pp. 21). Many teachers tend to stick to pedagogic habits and familiar ways of teaching, especially if time is limited (Bovill 2013a). Changing ideas and opinions, based on learner feedback and suggestions, can seem threatening (Seale et al. 2015).

Usual way of communicating with learners no longer fits

Facilitating the conversation process during the co-creation process can be a challenge as well. Teachers need an open attitude and need to be approachable for learners (Meeuwissen et al. 2019; Martens et al. 2020). In co-creation the aim is to bring different perspectives of stakeholders 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 if the tone of the conversation is not automatically in good harmony; learner groups can be problematic or resistant to engage and take co-responsibility for the process (Bovill 2019). Generally, if the conversation is too much about negative issues and complaints only, this can hamper the constructive progress of the conversation, which also requires focus on positive aspects (Carey 2013). Teachers need to develop strong communication skills to have this new kind of conversations with learners (Enright et al. 2017; Marquis et al. 2017).

Challenges at the institutional level

Lack of support

Institutions that do not to overtly support co-creation initiatives, set aside dedicated time, and enable and empower teachers and learners to work on these initiatives, limit the implementation of co-creation (Björklund et al. 2019). Enthusiastic teachers and learners are usually willing to put in the extra effort and accept the extra workload, but implementing best practices on a broader scale needs changes in traditional structures and additional resources (Björklund et al. 2019). Time issues are related to difficulties in finding time for planning joined meetings, lack of time for the extra work for revising earlier education methods and materials, and limited time for long-lasting commitments and dialogue over time, which are needed to create a context of trust for open exchange of ideas (Seale et al. 2015; Gros and López 2016; Marquis et al. 2017; Bovill 2019). Time issues are particularly challenging if no funding or dedicated time is available and activities are planned alongside to the formal curriculum (Marquis et al. 2017).

Lack of recognition

Institutions might demotivate learners to engage if they do not carefully report back to learners how their input has 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 safe culture to allow some risk taking for teachers, without causing perceived threats to job security (Matthews et al. 2018). Traditional institutional structures, practices and norms may not recognize or value co-creation, which hampers its implementation (Bergmark and Westman 2016; Bovill et al. 2016; Matthews et al. 2018). Lack of clarity of the roles of stakeholders can be a barrier as learner and teacher roles in co-creation not being clearly defined or communicated can cause misunderstanding and misalignment of expectations between those involved in the process (Martens et al. 2019).

Table 1 summarizes the main challenges in the co-creation process in education, at the level of learners, teachers and institutions.

Table 1. Challenges in the co-creation process.

Learner level	Teacher level	Institutional level
Lack of process and content expertise: Unfamiliairity with new role and responsibility Insecure about own knowledge and skills Insufficient communication and collaboration skills	Giving up control: Redefine roles and responsibilities Threatened to give up control Feeling vulnerable within institution	Lack of support: Lack of time for meetings, revision of education and long-lasting commitments Lack of funding
Power relationships: Perceived risks of speaking up Power imbalance through assessment	Skepticims that learners add value: Not recognize value in learners’ input Not really listen to learners	Lack of recognition: Lack of recognition and safety for teachers Lack of clarity about roles Not underlining the value of co-creation
Voice fatigue and feeling unheard: Learners not involved in implementation Perceived lack of action Lack of sense of ownership	Perceived threats in opening up for change: Not be open for reflection and personal growth Difficulties with receiving feedback Stick to pedagogical habits
	Usual way of communication no longer fits: Challenge to find common ground Learners might be resistant to contribute Too much focus on negative issues

Theoretical principles in co-creation

Three key educational theories can be used to deepen our understanding of challenges and approaches to implementation of co-creation: Self-Determination Theory, Positioning Theory and theory on Psychological Safety.

Self-Determination Theory

Theoretical principles of the Self-Determination Theory (SDT) describe three key psychological needs that enhance individual’s intrinsic motivation: autonomy, relatedness and competence (Ryan and Deci 2000, 2017). Autonomy can be fostered when teachers offer choices, and when learners’ opinions and inputs are welcomed (Ryan and Deci 2000). Relatedness concerns the desire of social connectedness, belonging to a group and feeling significant among others (Ryan and Deci 2017). Co-creation requires collaboration and interdependency with teachers; literature reports indicate that learners feel more connected to teachers and peers resulting in improved learner-teacher relationships (Bovill 2013a, 2019). Finally, competence refers to a feeling of mastery and being effective in one’s actions (Ryan and Deci 2017).

Implementation of co-creation requires that these three needs are met. The way teachers and learners feel related, communicate, and collaborate in co-creation differs from typical teaching situations in terms of changing roles and responsibilities, power relations, and bidirectional conversations. The learning culture should actively promote teacher-learner relationships and address the power gap to promote relatedness. To enhance autonomy, teachers should be open to questioning their teaching and lesson/course design by learners, viewing it as constructive feedback that targets improvement, while learners should be convinced that their input is incorporated and concerns are being addressed. Learners who feel really heard and taken seriously regarding their experiences in education perceive recognition of their expertise on education (Cook-Sather et al. 2014). Training teachers and learners in the process of co-creation and explicitly using all opinions in designing educational initiatives can stimulate feelings of competence on all sides. In summary, effective co-creation approaches should focus on respecting teachers’ and learners’ autonomy and competence, while facilitating strong, respectful relationships between teachers and learners.

Positioning Theory

The Positioning Theory states that people assume certain positions during interactions; these positions are associated with rights and duties and guide their actions (Van Langenhove and Harré 1999). Each individual assigns a position to him/herself as well as to others in conversations and interactions. Positions are also dynamic, depending on the context and culture and guide not only what to do but also what not to do. Positioning Theory has been used to analyze social practices in classrooms and interactions between clinical supervisors and learners (McVee et al. 2011; Georgakopoulou 2013; Sargeant et al. 2017). Teachers and learners have developed a deeply rooted understanding of their mutual positions in the process of teaching and learning, based on experiences in education over many years. Therefore, co-creation can cause struggles with changing roles and responsibilities, adapting power relations, and taking the learner voice seriously. Tenets of this theory are relevant and applicable to co-creation of education, where teachers and learners and other stakeholders need to collaborate in construction of their roles (positions), and need to reach a shared understanding of roles, tasks and educational outcomes.

Theory on Psychological Safety

Theory on Psychological Safety can contribute to the understanding of effective co-creation efforts. Psychological safety concerns individual perceptions of taking social risk in a context that could trigger change and uncertainty. It is an important aspect to consider in how individuals work together toward a shared result. When one perceives an environment of psychological safety, one can focus on collective objectives, rather than on own interests such as self-protection (Edmondson and Lei 2014). Lack of psychological safety in the learner-teacher relationship can cause lack of motivation among learners to engage, as well as limited teacher motivation to listen to learners and open up for feedback and reflection.

Psychological safety has been connected to speaking-up or voice behavior, defined as constructive verbal communication that is directed upwards, for example a superior. Speaking-up challenges usual communication patterns (Edmondson and Lei 2014), reflected as reluctance to meaningfully change power relations and hierarchy. Speaking up can stimulate a dialogue on quality improvement (Edmondson and Lei 2014), however, perceptions of psychological safety are often insufficient for learners to risk sharing their thoughts (Detert and Edmondson 2011). Teachers can promote psychological safety by being accessible, acknowledging their own imperfections, and by proactively asking learners’ input. They can frame co-creation as a mutual learning process in which making mistakes is a learning experience and by responding respectfully and appreciatively to learners’ input and feedback (Nembhard and Edmondson 2006; Edmondson 2018). Finally, institutions and their traditional structures might not provide teachers with the necessary psychological safety to engage in co-creation, to experiment with giving up some control and open up for feedback or reflection. For implementation of co-creation, thus, stimulating a safe climate to openly share thoughts and ideas among all is crucial.

Table 2 summarizes the implications of the principles of these three theories on the implementation of co-creation of educational practice. It shows that in different ways they all point to the need to reframe relationships between learners and teachers as respectful, open and safe partnerships.

Table 2. Theory-inspired directions to overcome challenges in co-creation.

	Self-Determination Theory	Positioning Theory	Psychological Safety
Learner level/teacher level	Ensure recognition of both leaners’ and teachers’ competence and autonomy	Change existing mutual positions of learners and teachers in education	Increase learner motivation to participate, increase teacher motivation to listen and open up for feedback
Team level	Build strong and respectful relationships between teachers and learners	Develop shared understanding of roles and responsibilities in co-creation	Develop a psychological safe environment where learners can speak up
Organizational level	Create learning opportunities to develop new competencies for co-creation	Allow and support redefining roles and responsibilities and reducing hierarchy	Provide support and stimulate a safe climate for teachers to give up some control and allow experimenting with co-creation

Practical approaches

In providing solutions to the described challenges, we will give an overview of possible approaches to effectively implement co-creation. First, approaches are described that specifically address the challenges respectively for learners and teachers. It should be emphasized that approaches for teachers are likely to be relevant for other stakeholders such as workplace partners, educational designers, researchers or software developers. Then, approaches are described that contribute to effective collaboration among learners and teachers as a team. Finally, recommendations will be given to institutions interested in co-creation in educational design.

Approaches on how to involve learners

For overcoming challenges at the learner level, teachers and institutions could use the following four strategies: motivate learner engagement, ensure safety to speak up, support learners in developing necessary skills, and stimulate fulfilment in their role of co-creator.

Motivate learner engagement in co-creation

To raise learners’ motivation and interest, it is important to assess their areas of interest, passion, prior experience and skills. In addition, it is essential to familiarize learner roles in the co-creation process as well as the process itself. We suggest the following potential strategies:

• Learners must be invited to participate in projects that are close to learners’ hearts (Brown 2019).

• Learner involvement must fit their level of experience and skills in co-creation. For learners with limited experience 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; Moore-Cherry et al. 2016).

• Consider gradually increasing levels of learner involvement to ease them into the process, for example by first providing learners with choices or limited control of areas that resonate with them (Bovill and Bulley 2011).

• Ensure that learners are not required to work far beyond their expertise (Bovill et al. 2016).

• It is best when learners voluntarily engage in co-creation. It has been suggested to let learners apply for involvement in co-creation by submitting a letter on why they want to participate and what they think they are able to contribute (Cook-Sather and Luz 2015; Jensen and Bennett 2016).

• Ideally, learners selected to engage in co-creation are motivated to contribute to the improvement of education (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-confidence and diplomacy (Marquis et al. 2019; Meeuwissen et al. 2019).

Ensure safety to speak up

Developing comfort and safety in learners to share their thoughts and ideas with teachers can be stimulated by the following strategies:

• Start involving learners already early in the curriculum, so they get used to the way of working and develop self-confidence (Moore-Cherry et al. 2016; Peters et al. 2019).

• Avoid the involvement of learners and teachers in a co-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).

• Consider involving learners that have no (past, current or future) connection to the teachers involved in co-creation (Cook-Sather and Luz 2015; Jensen and Bennett 2016).

• Think about creative alternatives to face-to-face conversations, like inviting learners to write a letter to an imaginary friend regarding the course at hand, so learners have more choice and control about how they share their thoughts with teachers (Seale 2009).

• In case of resistance, have an open discussion with learners about their concerns (with or without teachers being present) (Deeley and Bovill 2017).

Support learners in developing necessary skills

Providing learners some training at the start of the co-creation process is beneficial. Training sessions can focus on leaderships skills, on providing constructive and quality feedback to teachers, and on feeling empowered and confident to engage and bring in their perspective in discussions with teachers (Jensen and Bennett 2016; Stalmeijer et al. 2016), as well as on conflict resolution, program evaluation and curriculum design (Geraghty et al. 2020). Skills for giving useful feedback to teachers can potentially be trained in a joint session with teachers (Dudek et al. 2016; Myers and Chou 2016). Extra support can be provided during the process by a coordinator/mentor, providing ad hoc individual support and organizing regular meetings with other learners involved in co-creation to discuss experiences and best practices in contributing to the co-creation (Cook-Sather and Luz 2015; Scott et al. 2019).

Stimulate fulfilment in the role of co-creator

Seeing involvement in co-creation as a constructive and rewarding experience is important for learners, for staying motivated to contribute to a co-creation project. Strategies that increase fulfillment could be:

• Learners must be stimulated to start with a focus on what works well and on the strengths of the current educational design. Starting from a positive point of view helps to build a trusting relationship with teachers, which is needed to be able to also discuss more difficult issues (Könings et al. 2010a; Cook-Sather et al. 2018).

• Learners should move away from a complaints culture and think about solutions to educational challenges (Carey 2013).

• Learners could take responsibilities to act as consultants who are mainly in charge of collecting learner feedback and discussing this with the teachers (Cook‐Sather 2009; Milles et al. 2019; Scott et al. 2019; Geraghty et al. 2020).

• By positioning themselves as contact persons to other learners, who are not directly involved in the co-creation, they collect information about issues experienced by others (Könings et al. 2010b; Geraghty et al. 2020), which is an effective as well as personally rewarding role.

Approaches for teachers who want to get involved in co-creation

For overcoming teachers’ challenges in co-creation, the following strategies can be recommended to teachers as well as faculty developers who support the co-creation process: build confidence in co-creation with learners, listen seriously to learners, and invest in professionalization of teacher skills for co-creation.

Build confidence in co-creation with learners

Teachers (like learners) best engage in co-creation on a voluntary basis (Cook-Sather et al. 2014; Jensen and Bennett 2016). Ideally, teachers will feel a need for change or improvement of their educational practice or a wish to receive feedback on certain aspects of teaching (Bovill et al. 2016; Jensen and Bennett 2016), and will be dedicated to continuous quality improvement of education (Meeuwissen et al. 2019). For building (self-)confidence in co-creation the following strategies can be supportive:

• Start with small initiatives linked to the own practice, instead of a large innovation like a curriculum (Bovill et al., 2016; Healey and Healey 2019).

• Adjust the level of learner involvement to learners’ and teachers’ ability to fulfill their roles and take the necessary responsibilities (Bovill and Bulley 2011).

• Build on existing collaborations with learners as this facilitates implementation of co-creation and increases feeling safe to involve learners (Bovill et al. 2011).

• Identify on forehand on which aspects of education learners’ insights are welcomed. This helps to account for teachers’ and learners’ level of prior experience in co-creation and create a safe environment for collaboration (Bovill and Woolmer 2019; Ruskin and Bilous 2020).

• Connect to other teachers involved in co-creation, share experiences, learn from each other’s practice, gather ideas, and collectively reflect on challenges and issues during the process (Bovill 2013a; Bergmark and Westman 2016; Marquis et al. 2017).

• Teachers should be informed that co-creation does not imply giving away control of education as it ‘does not entail uninformed decision-making or following students’ wishes in an unquestioning manner’ (Deeley and Bovill 2017, p. 473). In the end teachers are accountable (Deeley and Bovill 2017; Martens et al. 2020).

• When taking a positive and constructive stance during co-creation, it is reassuring that co-creation gives teachers insight in what works well in their teaching and learning, stimulating continued professional growth among teachers (Cook-Sather et al. 2018).

Listen to learners seriously

For ensuring that co-creation develops as a shared initiative, really listening to learners’ voices and showing true interest are crucial (Cook-Sather 2015; Cook-Sather and Luz 2015; Meeuwissen et al. 2019). Already in early stages of the process, teachers have to make clear to learners that their insights and ideas are heard and considered important. Strategies to demonstrate willingness to listen and take learners seriously include:

• Give feedback-on-feedback and act on the outcomes of shared brainstorms or discussions (Carey 2013; Bovill 2013a, 2013b).

• Communicate expectations on roles and responsibilities with learners to ensure that learners perceive their involvement as real and meaningful (Bovill 2013b; Gros and López 2016; Bovill and Woolmer 2019; Martens et al. 2019b).

• Stimulate learners to speak up by directly inviting them for feedback and carefully express intentions to collaborate towards improving teaching and learning (Dudek et al. 2016; Myers and Chou 2016). Start such conversation with some self-reflection and showing personal vulnerability to emphasize a strong willingness to listen (Myers and Chou 2016).

Invest in professionalization of teacher skills for co-creation

Teachers must develop advanced skills regarding communication and feedback. They need skills in facilitating co-creation discussions with learners, including skills in feedback receiving, stimulating bidirectional feedback conversations, negotiating and sharing power, supporting learners, and also in facilitating difficult and risky conversations (Bovill 2013b; Dudek et al. 2016; Myers and Chou 2016; Enright et al. 2017). This can be achieved through:

• Training sessions provided by a faculty development unit (Bovill 2013b; Dudek et al. 2016; Myers and Chou 2016)

• Mentorship among teachers (Myers and Chou 2016)

• Role modelling by teachers more experienced in co-creation (Martens et al. 2020)

• Getting oneself involved in a co-creation project in the role of a learner (Enright et al. 2017).

Approaches on how to improve collaboration between teachers and learners

To overcome shared challenges that both learners and teachers face regarding new roles and responsibilities in a new kind of collaboration process, we suggest three strategies: decrease the power difference, develop shared responsibility, and value and improve the co-creation process.

Decrease the power difference

Hierarchical positions between learners and teachers must be acknowledged and discussed from the start (Freeman et al. 2014). By elaborating on the usual roles and the expected different – more equal – relationship between learners and teachers in co-creation, changed relations must get clear to all (Freeman et al. 2014). Considering teachers and learners as co-learners ‘gives permission for both staff and students to consider and enact new identities as mutual learners.’ (Matthews et al. 2018, p. 966). In developing a good relationship, respect and mutual trust is crucial for enabling constructive and critical bidirectional feedback conversations (Freeman et al. 2014; Sargeant et al. 2018; Brown 2019; Ramani et al. 2019). Possible strategies for limiting the power differences include:

• An open feedback culture is needed in which learners are expected to provide feedback to teachers (Dudek et al. 2016; Ramani et al. 2017).

• Realization that both the risks and rewards of co-creation are shared by learners and teachers contributes to building confidence together (Moore-Cherry et al. 2016).

• Expertise of both learners and teachers has to be valued (Cook-Sather et al. 2014; Freeman et al. 2014; Könings et al. 2014; Peters et al. 2019) while both perspectives must be equally appreciated in conversations (Martens et al. 2020).

• Improve equality by inviting participants in an equal teacher to learner ratio (Carey 2013; Martens et al. 2020) and calling each other with first names (Englander et al. 2019).

• Co-creation in a digital environment can make it easier to ignore hierarchy and communicate on an equal level (Cook-Sather 2017; Blau and Shamir-Inbal 2018).

Develop shared responsibility

The distribution of responsibilities and redefinition of roles must be frequently negotiated (Enright et al. 2017; Gros and López 2016). Autonomy of the co-creating team encourages shared ownership of the project (Freeman et al. 2014). Level of responsibilities of different stakeholders can vary in different phases of the co-creation process (Könings et al. 2017). Experiencing a shared responsibility can be stimulated by the following strategies:

• Ensure learner involvement in the implementation phase and closing feedback loops for learners (Martens et al. 2019b; Peters et al. 2018).

• Clearly define roles and levels of involvement throughout the process (Martens et al. 2019b).

• Develop a shared understanding of the aims of the co-creation process, by having open communication about the conditions for co-creation, including which elements are open to change, and the expected outcomes (Bovill 2013a; Englander et al. 2019).

• Do not allow a complaints culture (Carey 2013). Appreciative inquiry and a positive focus on opportunities help developing a shared passion (Könings et al. 2010a; Kadi-Hanifi et al. 2014).

Value and improve the co-creation process

Collaborative reflection contributes to adjusting to new roles, developing relationships and building trust, and also helps learners to develop a better and more nuanced understanding of the teaching and learning process from the teacher perspective as well as giving the teacher insight in learners’ experiences and interpretation of it (Cook-Sather 2014; Freeman et al. 2014; Enright et al. 2017). Optimizing the co-creation process means to find ways that work best in the own team. Possible strategies are:

• Collaboratively reflect on questions about the values of co-creation, like: how do we show respect and fairness in our discussions? What unique experiences and talents can we bring in and how can we support and use these in the project? How do we distribute and share power? (Healey and Healey 2019).

• Get training in providing and receiving both positive and negative feedback to enabling safe communication among learners and teachers. Develop a feedback culture in which feedback is provided to both learners and teachers (Myers and Chou 2016; Ramani et al. 2017).

• Learners and teachers must not be focused too much on the outcomes of the collaboration, but also recognize the value of the process itself (Bovill et al. 2011; Freeman et al. 2014) while being flexible in unanticipated developments in the process and its outcomes (Cook-Sather et al. 2014; Moore-Cherry et al. 2016).

• For stimulating the process of developing new solutions to educational problems, experimentation and school visits can be helpful (Könings et al. 2017).

• Using visualization tools, like post-its or drawings, facilitate discussion and imagination during co-creation (Könings et al. 2017; Könings et al. 2010a; Koutamanis, Heuer, & Könings et al. 2017).

Approaches at the institutional level

Provide support

Co-creating teams need support from their schools, departments or educational institutions. Support can consist of:

• Availability of time, space, tools, and small-scale funding (Bovill et al., 2016; Marquis et al. 2017; Martens et al. 2020).

• The institution allowing some risk-taking, as hierarchical relations change and the process and outcomes of co-creation are uncertain (Bovill 2013a).

• Key individuals in the organization supporting new initiatives in co-creation initiatives (Freeman et al. 2014).

• Institutionalizing a structure for frequent and efficient bidirectional feedback and collaboration on revising course content and pedagogy (Meeuwissen et al. 2019; Milles et al. 2019; Scott et al. 2019; Geraghty et al. 2020).

• Different formats for formalizing learner involvement can be considered, like learner representatives or learners as module co-directors (Meeuwissen et al. 2019; Milles et al. 2019).

Invest in hands-on support by faculty developers

Faculty developers can support co-creating learners and teachers, as they act as ‘catalysts, advisors or supporters’ (Bovill 2013a, p. 7). The faculty developer has been described as vital to the success of co-creation (Little 2016). They contribute to the success of co-creation initiatives by taking on the following responsibilities:

• As intermediaries they help connecting teachers and learners, and create willingness to revise roles and positions and to manage mutual expectations (Bovill et al. 2011; Little 2016). They support the development of relationships, that build on trust, openness and respect by facilitating collective reflection (Bovill et al. 2011; Cook-Sather 2014; Healey and Healey 2019).

• They directly facilitate and support co-creation initiatives, including supporting equal conversations and stimulating collaboration and taking responsibilities (Bovill et al. 2011; Little 2016).

• They offer training sessions for developing the necessary skills (Bovill 2013b; Dudek et al. 2016; Myers and Chou 2016).

• They serve as mentors for both learners and teachers (Myers and Chou 2016; Scott et al. 2019).

• Being contact person for both learners and teachers, faculty developers have built expertise in co-creation projects and background knowledge on history of other initiatives (Little 2016).

• They can also provide specific support, for example by observing teaching, followed by reflection (Bergmark and Westman 2016) or providing structured support and encouragement when workplace partners are involved (Ruskin and Bilous 2020).

• They can also promote and practice co-creation during faculty development courses (Bovill et al. 2011).

Establish a culture of empowerment

Change of culture is needed for sustainable implementation of co-creation in education. Strategies to develop a culture in which learners are empowered to be actively involved in improving teaching and learning include:

• Explicitly invite learners to speak-up and communicate the expectation that learners also provide feedback to teachers (Dudek et al. 2016; Myers and Chou 2016; Peters et al. 2019; Ramani et al. 2019).

• Develop ‘partnership learning communities’ among learners and teachers to contribute to increased involvement and success of co-creation (Healey et al. 2016).

• Ensure that co-creation efforts are recognized, results and improvements are disseminated and shared in the community, and that learners’ and teachers’ contributions are appreciated and rewarded (Cook-Sather et al. 2014; Freeman et al. 2014; Meeuwissen et al. 2019; Geraghty et al. 2020).

Figure 3 summarizes the practical approaches described at the level of learners, teachers, learners and teachers together, and the institution. Quadrants are visualized as pieces of a jigsaw, as for successful co-creation attention should be paid to facilitating and optimizing the co-creation process from all these angles.

Figure 3. Overview of approaches for implementation of co-creation, at the level of learners, teachers, teams of learners and teachers, and institutions.

How to get started

Before setting up a co-creation initiative, it is important clarify the most important goals pursued with the involvement of learners and potentially other stakeholders. As shown in the Framework of Stakeholder Involvement in Co-Creation (Figure 2), co-creation can be focused on benefits for the co-creating participants (within the inner triangle) and for the wider population of learners and teachers (outer circle). These two foci do not exclude each other, but one of them will be most important, which impacts the priorities set in the approaches described above. Decisions when starting the co-creation include whom to invite as participants, how many participants, in which phases participants have certain responsibilities, timing of co-creation during the curriculum or afterwards, and duration of co-creation (Bovill 2013a; Bovill et al. 2016; Könings et al. 2017; Bovill and Woolmer 2019).

Text box 1 provides an overview of recommendations we suggest when using co-creation for its proximate benefits for the participating learners and teachers, or for its distal effects on quality of education for a wider population. The distinction between the levels are less absolute than the table might suggest, but it enables to contrast the choices to be taken for planning the set-up of a co-creation initiative, fitting its main aims.

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: Benefits for co-creating participants, including an improved psychosocial learning environment (more positive, inclusive and democratic learning climate, because of better relationships, increased sense of belonging, safety) and increased motivation and metacognition (understanding each other’s perspectives, increased ownership and responsibility, deeper engagement with education, improved skills)	Strong selection of participants will not be appropriate. Learners who are not yet very motivated for learning and teachers whose professional development would benefit from more bidirectional feedback may also be invited to be involved. Co-creation can be performed during the educational program as participants can real-time contribute to its improvement and benefit from this improvement themselves. 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: Benefits for the wider population, regarding improved quality and usability of the educational design of a course/ curriculum or way of teaching (incorporating expertise and perspectives of all important stakeholders in the set-up of education)	Priority could be given to selecting a limited number of learners, teachers and other stakeholders who are highly motivated and already have relevant skills and attitudes to perform well in co-creation. Best invite learners who already followed the 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.

Conclusions

In this guide, we have discussed the importance of co-creation in education and provided an overview of potential challenges at the level of learners, teachers, and institutions, to be anticipated when implementing co-creation. These have been linked to the principles of three psychological theories, indicating that learners and teachers have to revise their existing roles and relationships, respect each other’s perspectives and competencies, and warrant a psychological safe environment for exchange, discussion and collaboration. The approaches described facilitate constructive co-creation processes being implemented in different educational practices. It is the intentional collaboration between learners, teachers and potential other stakeholders for improving education that creates synergy of co-creation.

Disclosure statement

The authors have no declarations of interest to report. The authors are responsible for the content and writing of the article.

Additional information

Notes on contributors

Karen D. Könings

Karen D. Könings, PhD is psychologist and Associate Professor in the Department of Educational Development and Research and the School of Health Professions Education, Faculty of Health, Medicine and Life Sciences at Maastricht University and Honorary Professor at the School of Health Sciences at University of East Anglia.

Serge Mordang

Serge Mordang, MSc is psychologist and PhD student in the Department of Educational Development and Research and the School of Health Professions Education, Faculty of Health, Medicine and Life Sciences at Maastricht University.

Frank Smeenk

Frank Smeenk, PhD, MD is pulmonologist and Dean at the Catharina Hospital Eindhoven and Professor at the School of Health Professions Education, Faculty of Health, Medicine and Life Sciences at Maastricht University.

Laurents Stassen

Laurents Stassen, PhD, MD is surgeon, chief of surgical training and Professor at the School of Health Professions Education, Faculty of Health, Medicine and Life Sciences at Maastricht University.

Subha Ramani

Subha Ramani, MBBS, PhD, FAMEE is general internist and Director, Program for Research, Innovation and Scholarship in Education, Department of Medicine & Director of Scholars in Medical Education Pathway, Internal Medicine Residency Program at the Brigham and Women’s Hospital; and Associate Professor of Medicine at Harvard Medical School, Boston, USA.