Medical Teacher

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Learner involvement in the co-creation of teaching

and learning: AMEE Guide No. 138

Karen D. Könings , Serge Mordang , Frank Smeenk , Laurents Stassen &

Subha Ramani

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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

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MEDICAL TEACHER
https://doi.org/10.1080/0142159X.2020.1838464

AMEE GUIDE

Learner involvement in the co-creation of teaching and learning: AMEE Guide

No. 138
€ningsa
Karen D. Ko , Serge Mordanga, Frank Smeenka,b , Laurents Stassena,c and Subha Ramanid,e
a
Educational Development and Research and School of Health Professions Education, Faculty of Health, Medicine and Life Sciences,
Maastricht University, Maastricht, The Netherlands; bDepartment of Pulmonary Medicine, Catharina Hospital, Eindhoven, The
Netherlands; cDepartment of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands; dDepartment of Medicine,
Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA; eResearch and Scholarship, Harvard Macy Institute, Boston,
MA, USA

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
Co-creation and active learner involvement in the design
and development of education is garnering growing atten-
tion 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 stim-
ulating 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 feed-
back 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 feed-
back conversations can support formulation of plans for
change and professional development of teachers and
€nings et al. 2014).
learners alike (Cook-Sather et al. 2014; Ko
The importance of active learner involvement in educa-
tional design is increasingly recognized, for example in the
recent ASPIRE-to-Excellence initiative on learner engage-
ment (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 consum-
ers of education. Taylor and Hamdy (2013) argue that
learning is about making sense and making use of know-
ledge 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 convinc-
ing arguments for learner involvement in educational
design, teachers and learners are not used to implementing
this approach, and implementation is challenging for insti-
tutions. 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 learn-
ing environment, motivation and metacognition, and qual-
ity 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 edu-
cation, but also ultimately aims to affect a larger group of
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.
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 dif-
ferences 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 learn-
ers to contribute positively to problem solving in
educational design and collaboratively develop of
solutions to challenges.
 Training in feedback-providing skills among learn-
ers 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 engage-
ment can build confidence of participants in co-
creation initiatives.
 Connecting and sharing experiences with col-
leagues and peers who are also involved in co-
creation can foster mutual learning, and support
from faculty developers can facilitate the co-cre-
ation process.
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 strat-
egies 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 provid-
ing learners with choices, to giving learners control of
some areas, to partnerships or even learners being in con-
trol (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 cur-
ricular 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 educa-
tion, 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 educa-
tional design.
 The first cluster consists of effects on the psychosocial
learning environment: enhanced learner-teacher rela-
tionships, 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 communica-
tion, collaboration, and how to deal with conflicts
(Cook-Sather et al. 2014). Empowering learners contrib-
utes to the development of positive feelings and atti-
tudes 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 under-
standing of the teacher’s perspective and the aims of
education, while teachers obtain clearer insights regard-
ing learners’ perspectives on education (Bovill 2013a;
Cook-Sather et al. 2014). Reflection on personal behav-
ior 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 (Ko €nings et al. 2010b; Dollinger et al. 2018)
 MEDICAL TEACHER 3

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

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 teach-
ers 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 incorpo-
rating the expertise and perspectives of relevant stake-
holders, 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 percep-
tions 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 (Ko €nings et al.
2010b; Brown 2018). However, an important intended Figure 2. Framework of Stakeholder Involvement in Co-Creation.
benefit of co-creation is that broader groups of learners
and teachers profit from the improved quality of educa- for any professional having a teaching or supervisory role
tional innovations and use, usability and utility of the (staff, clinical supervisor etc.) and ‘learner’ for any level of
educational design. student or learner (undergraduate and postgraduate learn-
ers and professional learners in continuing education) in a
setting that promotes learning (university or clin-
Literature on co-creation of education ical workplace).
Scientific literature on co-creation of learning in medical
education is scarce. Reports from recent innovative initia- A framework for co-creation
tives describe successful learner-teacher partnership for cur-
ricular improvement in undergraduate medical education Based on the literature review of co-creation, we developed
(Scott et al. 2019), learner involvement in the development the Framework of Stakeholder Involvement in Co-Creation
of interprofessional education courses (Behrend et al. (Figure 2), which depicts the effects of active involvement
2019), innovative curricular changes through learner-driven of different stakeholders in the educational design process.
initiatives (Zdravkovic et al. 2018), and assignment of mod- The inner triangle emphasizes that learners’ involvement
ule co-director roles to medical learners in curriculum leads to improved learning processes (due to psychosocial
development (Milles et al. 2019). While these initiatives are and/or motivational and metacognitive effects) (Ko €nings
encouraging, they do not provide a good overview of et al. 2010b; Bovill 2013a; Cook-Sather et al. 2014).
potential challenges or facilitators in the co-creation pro- Teachers benefit from co-creation, as dialogues with learn-
cess. In higher education literature, co-creation has been ers improve teaching practices and foster their own profes-
described more extensively and for a longer time, as evi- sional development through the same mechanisms
denced by a growing number of citations over the last few described above (Bovill 2013a; Cook-Sather et al. 2014;
years (Figure 1). We reviewed publications focusing on bar- Cook-Sather and Luz 2015). The left corner of the triangle
riers, struggles, and challenges as well as facilitators and visualizes other relevant stakeholders who can also engage
approaches for co-creation in higher education, included in in the co-creation process, for example workplace partners,
the Web of Science. In this paper we use the term ‘teacher’ nurses, patients, educational designers/educationalists,
4 K. D. KÖNINGS ET AL.
researchers, software developers, or architects (Cober et al.
2015; Harrison et al. 2017; Ko €nings and McKenney 2017;
Ruskin and Bilous 2020). The outer circle of the
Figure suggests that effects of co-creation could, in prin-
ciple, 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 educa-
tion, but also that a wider population of teachers benefits
from educational designs that better fit the context and
are more implementation ready.
Challenges of implementing co-creation
in practice
Bringing ideas of co-creation to practice can be challeng-
ing. 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 stake-
holders most frequently mentioned in the literature; chal-
lenges 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-cre-
ation, 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, threaten-
ing 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
Ko€nings 2016). Learners might need to develop communi-
cation and collaboration skills to a level necessary to con-
structively 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 phe-
nomenon 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 con-
cerned 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 teach-
ing and this can be undermined by fears that co-creation
may focus on complaints, blame and critique, and the pos-
sibility 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 uncer-
tainty about job security (Matthews et al. 2018). It is diffi-
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-
leagues (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 illumi-
nating 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 differ-
ence 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 under-
standing 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 lon-
ger 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 ini-
tiatives, set aside dedicated time, and enable and empower
teachers and learners to work on these initiatives, limit the
implementation of co-creation (Bjo €rklund 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
€rklund et al. 2019). Time issues are related to difficulties
(Bjo
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 commit-
ments and dialogue over time, which are needed to create
a context of trust for open exchange of ideas (Seale et al.
2015; Gros and Lo pez 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).
MEDICAL TEACHER 5
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 ham-
pers 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 misalign-
ment of expectations between those involved in the pro-
cess (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.
Theoretical principles in co-creation
Three key educational theories can be used to deepen our
understanding of challenges and approaches to implementa-
tion 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 indi-
cate 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 conversa-
tions. 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 feed-
back 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
6 K. D. KÖNINGS ET AL.

Table 1. Challenges in the co-creation process.

Learner level
Lack of process and content expertise:
 Unfamiliairity with new role and
responsibility
 Insecure about own knowledge and skills
 Insufficient communication and
collaboration skills
Power relationships:
 Perceived risks of speaking up
 Power imbalance through assessment
Voice fatigue and feeling unheard:
 Learners not involved in implementation
 Perceived lack of action
 Lack of sense of ownership
Teacher level Institutional level
Giving up control: Lack of support:
 Redefine roles and responsibilities  Lack of time for meetings, revision of
 Threatened to give up control education and long-lasting commitments
 Feeling vulnerable within institution  Lack of funding
Skepticims that learners add value: Lack of recognition:
 Not recognize value in learners’ input  Lack of recognition and safety for teachers
 Not really listen to learners  Lack of clarity about roles
 Not underlining the value of co-creation
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

educational initiatives can stimulate feelings of competence
on all sides. In summary, effective co-creation approaches
should focus on respecting teachers’ and learners’ auton-
omy 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 Harre 1999). Each individual assigns a pos-
ition 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 stake-
holders 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 col-
lective objectives, rather than on own interests such as
self-protection (Edmondson and Lei 2014). Lack of psycho-
logical 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 communi-
cation 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 improve-
ment (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-cre-
ation as a mutual learning process in which making mis-
takes is a learning experience and by responding
respectfully and appreciatively to learners’ input and feed-
back (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.
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
 MEDICAL TEACHER 7

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

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

will be given to institutions interested in co-creation in Ensure safety to speak up

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

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 stimu-
late 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 famil-
iarize learner roles in the co-creation process as well as
the process itself. We suggest the following poten-
tial 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 experi-
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;
Moore-Cherry et al. 2016).
 Consider gradually increasing levels of learner involve-
ment 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-cre-
ation. 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 educa-
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-
confidence and diplomacy (Marquis et al. 2019;
Meeuwissen et al. 2019).
 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 conver-
sations, like inviting learners to write a letter to an
imaginary friend regarding the course at hand, so learn-
ers 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-cre-
ation process is beneficial. Training sessions can focus on
leaderships skills, on providing constructive and quality
feedback to teachers, and on feeling empowered and con-
fident to engage and bring in their perspective in discus-
sions 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 pro-
vided during the process by a coordinator/mentor, provid-
ing ad hoc individual support and organizing regular
meetings with other learners involved in co-creation to dis-
cuss 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
8 K. D. KÖNINGS ET AL.
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 (Ko€nings 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 (Ko€nings 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 fol-
lowing 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 ser-
iously 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 vol-
untary 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 dedi-
cated 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 neces-
sary 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 collabor-
ation (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 stu-
dents’ 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 teach-
ers 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 initia-
tive, 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 import-
ant. 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 Lo pez 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 collab-
orate towards improving teaching and learning (Dudek
et al. 2016; Myers and Chou 2016). Start such conversa-
tion with some self-reflection and showing personal vul-
nerability 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 communi-
cation and feedback. They need skills in facilitating co-cre-
ation 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-cre-
ation (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 teach-
ers 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 identi-
ties 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 strat-
egies 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-cre-
ation 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; Ko €nings
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 Lo pez 2016). Autonomy of the co-creating team
encourages shared ownership of the project (Freeman
et al. 2014). Level of responsibilities of different stakehold-
ers can vary in different phases of the co-creation process
€nings et al. 2017). Experiencing a shared responsibility
(Ko
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 through-
out the process (Martens et al. 2019b).
 Develop a shared understanding of the aims of the co-
creation process, by having open communication about
MEDICAL TEACHER 9
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 opportuni-
ties help developing a shared passion (Ko €nings 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 under-
standing 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 cul-
ture 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 recog-
nize the value of the process itself (Bovill et al. 2011;
Freeman et al. 2014) while being flexible in unantici-
pated 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 (Ko€nings et al. 2017).
 Using visualization tools, like post-its or drawings, facili-
tate discussion and imagination during co-creation
€nings et al. 2017; Ko
(Ko €nings et al. 2010a; Koutamanis,
Heuer, & Ko €nings et al. 2017).
Approaches at the institutional level
Provide support
Co-creating teams need support from their schools, depart-
ments 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 ini-
tiatives in co-creation initiatives (Freeman et al. 2014).
 Institutionalizing a structure for frequent and efficient
bidirectional feedback and collaboration on revising
10 K. D. KÖNINGS ET AL.
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 learn-
ers 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 posi-
tions 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 initia-
tives, including supporting equal conversations and
stimulating collaboration and taking responsibilities
(Bovill et al. 2011; Little 2016).
 They offer training sessions for developing the neces-
sary 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 implementa-
tion 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 involve-
ment 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’ contribu-
tions are appreciated and rewarded (Cook-Sather et al.
2014; Freeman et al. 2014; Meeuwissen et al. 2019;
Geraghty et al. 2020).
Figure 3. Overview of approaches for implementation of co-creation, at the
level of learners, teachers, teams of learners and teachers, and institutions.
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.
How to get started
Before setting up a co-creation initiative, it is important
clarify the most important goals pursued with the involve-
ment 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 bene-
fits for the co-creating participants (within the inner tri-
angle) 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, tim-
ing of co-creation during the curriculum or afterwards, and
duration of co-creation (Bovill 2013a; Bovill et al. 2016;
Ko€nings et al. 2017; Bovill and Woolmer 2019).
Text box 1 provides an overview of recommendations
we suggest when using co-creation for its proximate bene-
fits for the participating learners and teachers, or for its dis-
tal 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.
Conclusions
In this guide, we have discussed the importance of co-cre-
ation 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
 MEDICAL TEACHER 11

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)
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)
 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.
 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.

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 practi-
ces. It is the intentional collaboration between learners,
teachers and potential other stakeholders for improving edu-
cation 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.
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, 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, 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.

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.

Serge Mordang, MSc is psychologist and PhD student in the References

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