group thinking case study

Groupthink: Definition, Signs, Examples, and How to Avoid It

Derek Schaedig

Outreach Specialist

B.A., Psychology, Harvard University

Derek Schaedig, who holds a B.A. in Psychology from Harvard University, is a mental health advocate. His lived experience with mental illness has been showcased in various podcasts and articles. He currently serves as a part-time outreach specialist for the Mental Health Foundation of West Michigan.

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Saul Mcleod, PhD

Editor-in-Chief for Simply Psychology

BSc (Hons) Psychology, MRes, PhD, University of Manchester

Saul Mcleod, PhD., is a qualified psychology teacher with over 18 years of experience in further and higher education. He has been published in peer-reviewed journals, including the Journal of Clinical Psychology.

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Groupthink refers to the tendency for certain types of groups to reach decisions that are extreme and which tend to be unwise or unrealistic

Groupthink occurs when individuals in cohesive groups fail to consider alternative perspectives because they are motivated to reach a consensus which typically results in making less-than-desirable decisions.

For example, group members may ignore or discount information that is inconsistent with their chosen decision and express strong disapproval against any group member who might disagree.

Janis (1971, 1982) popularized the term groupthink; however, he did not originate the concept. That is generally accredited to George Orwell as he describes the psychological phenomenon as “crimethink” or “doublethink” in his famous dystopian novel titled 1984 (Orwell, 1949).

Janis described groupthink early on as “the mode of thinking that persons engage in when concurrence seeking becomes so dominant in a cohesive ingroup that it tends to override realistic appraisal of alternative courses of action” (1972, p. 9).

Groupthink typically connotes a negative effect. In fact, Janis described it originally in his book published in 1972 titled Victims of Groupthink: A psychological study of foreign-policy decisions and fiascoes as “a deterioration of mental efficiency, reality testing, and moral judgment that results from in-group pressures” (Janis, 1972, p. 9).

Lack of diversity in groups : Groups that have members who are very similar to one another can be a cause of groupthink. With a lack of diverse perspectives, the group fails to consider outside perspectives.

Furthermore, these group embers may engage in more negative attitudes towards outgroup members, which can exacerbate groupthink.

Lack of impartial leadership : Groups with particularly powerful leaders who fail to seriously consider perspectives other than their own are prone to groupthink as well.

These leaders can overpower group members’ opinions that oppose their own ideas.

Stress : Placing a decision-making group under stress in scenarios such as one where there are moral dilemmas can increase the chances of groupthink occurring.

These groups may try to reach a consensus irrationally.

Time constraints : Related to stress, placing time constraints on a decision being made can increase the amount of anxiety, also leading to groupthink.

Highly cohesive groups : Groups that are particularly close-knit typically display more groupthink symptoms than groups that are not.

Lack of outside perspectives : Only considering the perspectives of in-group members can lead to groupthink as well.

Motivation to maintain group members’ self-esteem : If group members are motivated to maintain each other’s self-esteem, they may not raise their voices against the group consensus.

In Janis’s first book, he cited eight symptoms of groupthink to look out for in order to avoid the phenomena from occurring (Janis, 1972).

Invulnerability : When groups begin to believe their decisions and actions are untouchable or that the group is invincible, they ignore warnings or signs of danger that run contrary to their consensus.

Rationale : Groups that engage in groupthink rationalize their decisions even in the face of obvious warning signs or negative feedback that they receive.

This is typically thought to be the case because if the group took into further consideration these pushbacks, the group members’ egos, as well as the time needed to make the decision, may be harmed.

Morality : Groups may also believe that their group is inherently morally correct, and they may therefore ignore potential moral or ethical consequences of their decision.

Stereotypes : People or groups that oppose the group engaging in groupthink may be rendered enemies as well. This results in mislabeling the enemy group as “stupid” or “weak” when they may not be.

Pressure : Groups may directly pressure members of the group who contradict the policy advocated by the group.

This forces them to not be able to push back against any arguments being made. This can leave groups prone to making irrational decisions.

Self-censorship : Members of groups can sometimes censor themselves too.

These individuals may hold off on raising an opinion contrary to the group consensus or convince themselves their opposing viewpoint is unimportant for fear of judgment from the group.

Unanimity : Sometimes, the false assumption can be made that if everyone in the group is silent, then everyone must agree with what is being put forth.

Mindguards : This term refers to when members of the group appoint themselves as protectors of the leader or other important group members.

Mindguards dismiss information that contradicts popular opinion or about past decisions to maintain group self-esteem.

Consequences

Poor decisions : Potentially, the largest overall impact groupthink can have on decision-making groups is that they are more prone to making poor decisions.

The effects of groupthink can be especially harmful in the military, medical, and political courses of action.

Self-censorship :  Individuals within the group affected by groupthink may not be as effective as possible when helping make decisions because they may hold back their potentially helpful opinions if they run contrary to the group’s popular opinion.

Inefficient problem solving : Because groups who experience the effects of groupthink fail to consider alternative perspectives, they can sometimes fail to consider ways to solve problems that deviate from their original plan of action.

This can lead to inefficiencies in the group’s problem-solving capabilities.

Harmful stereotypes can develop : Groups may begin to believe that their group is inherently morally right.

They, therefore, consider themselves the “in-group” and label others as outsiders or the “out-group,” which can become harmful to those on the outside as irrational thoughts about them begin to develop.

Lack of creativity : Because members of these groups may self-censor themselves or have pressure put on them by the group to conform, a lack of creativity may result due to the group not encouraging different ideas than the norm.

Blindness to negative outcomes : Since groups affected by groupthink can sometimes believe they are inherently correct, they may be unable to see the potentially negative outcomes of their decisions.

They, therefore, will not be able to plan accordingly if a negative outcome occurs.

Lack of preparation to manage negative outcomes : Because these groups can be overconfident in their decisions, they are more likely to be ill-prepared if their plan does not succeed.

Inability to see other solutions : Groupthink can lead to the group failing to consider other opinions or ideas. This leads to the group viewing only the group consensus as the correct solution.

Obedience to authority without question : Members of the group are more likely to follow their leaders blindly, never raising their opinion against whether the actions the group agrees on are moral or the correct course of action.

Can Groupthink Ever be a Good Thing?

Groupthink is generally considered a negative phenomenon.

Groups generally can benefit from hearing a diverse set of perspectives and information, and failing to do so can result in suboptimal decisions being made.

However, it is true that groups who engage in groupthink can make decisions quickly (although they may not be the best decision possible).

Also, anxiety can be reduced in the group because the group believes their decisions cannot be flawed. Groups who suffer from groupthink view themselves as untouchable (Janis, 1972).

Furthermore, groups rationalize the decision they made, whether it was the best option or not, and therefore convince themselves that the risks they are assuming are not as great as they truly are.

Lastly, the group may also believe that they are inherently morally right, which helps the members of the group cease to feel shame or guilt.

Overall though, groups should take precautions to avoid groupthink as much as possible.

Real-Life Scenarios

The social and political consequences of groupthink may be far-reaching, and history has many examples of major blunders that have been the result of decisions reached in this way.

Many case scenarios have been analyzed, such as the Invasion of Iraq (Badie, 2010), the attempt to rescue the American prisoners in the Vietnam War in the Son Tay raid (Amidon, 2005), and fraudulent behavior at WorldCom (Scharff, 2005) among many other flawed decisions cited for failing due to groupthink.

However, the original real-life scenarios of groupthink discussed by Janis were the escalation of the Vietnam War, the Bay of Bigs Scandal, and the bombing of Pearl Harbor.

The Vietnam War

Elected United States (U.S.) government officials during Vietnam showed signs of invulnerability (Janis, 1972).

The U.S. suffered multiple failures and setbacks, but they continued with their war efforts ignoring the danger and warning signs because they believed they would win no matter what.

Furthermore, the U.S. leaders rationalized their escalated bombing campaigns ignoring the negative feedback that they continuously received.

The U.S. also viewed their decisions as inherently morally right. President Johnson considered the same four factors every Tuesday: the military advantage of the U.S., the risk to American aircraft and pilots, the danger of forcing other countries into the fighting, and the danger of heavy civilian causalities. By engaging in this ritualization, they failed to effectively consider the morality of their decisions.

President Lyndon B. Johnson’s domino theory was an example of stereotyping as well. By viewing the enemy and its surrounding countries as too incompetent to make their own correct decisions, the U.S. administration made decisions that escalated the war.

Reportedly, Johnson once pressured former White House Press Secretary Bill Moyers to stop pushing back against the U.S. bombing campaign. Once, when Moyers entered a meeting, Johnson said of Moyers, “Well, here comes Mr. Stop-the-bombings.”

Bay of Pigs

President John F. Kennedy’s administration suffered from the illusion of invulnerability as well. Despite the plans to invade the Bay of Pigs leaking out, Kennedy’s administration proceeded with the plans ignoring the negative warning signs (Janis, 1972).

Historian Arthur J. Schlesinger expressed his strong objections against the war to both President Kennedy and Secretary of State Dean Rusk individually, but when it came to the group discussions on the decision to invade or not, Schlesinger stayed quiet.

He fell prey to believing that the ingroup was inherently moral, so Janis argued and kept his qualms quiet.

Another symptom of groupthink that Kennedy and his group experienced was stereotyping (Janis, 1972). Kennedy and his team made three assumptions about the capabilities of Fidel Castro’s administration that proved to be incorrect.

Kennedy’s administration assumed that Castro’s forces were so weak that a small group of U.S. troops could establish a beachhead at the Bay of Pigs. Secondly, the U.S. administration thought that just a fleet of B-26s could knock out Castro’s entire air force. The third assumption was that Castro was not smart enough to stop any internal uprisings.

Kennedy and his team were wrong in all three assumptions because they negatively stereotyped the enemy and made faulty assumptions.

Many members of the group self-censored as well. It seemed as if there was a unanimous decision within the ingroup to continue with the Bay of Pigs invasion, but Rusk failed to voice his contrary opinion even when three government officials outside of the group expressed their concerns.

Pearl Harbor

Despite warning signs, the U.S. government failed to prepare for the attack on Pearl Harbor because they were subject to the illusion of invulnerability (Janis, 1972). They believed they were invincible against any attacks from the Japanese.

The U.S. leaders also rationalized that the Japanese would never dare to attack the U.S. because that would be an act of war, and the U.S. believed they would win and that their opponent viewed this the same.

This stereotype and failure to view the situation from the enemy’s point of view led to the poor decision to not adequately prepare for the bombing of Pearl Harbor.

Opposition to the Theory

Despite a lot of support for the theory over the years, it has received some pushback as well. Sally Fuller and Ramon Aldag argue that being in a cohesive group has been proven to be effective (Aldag & Fuller, 1993; Fuller S.R. & Aldag R.J., 1998).

They also argue that Janis’s theory is not empirically supported and can be inconsistent.  Robert Baron reflects on the many years of research conducted on groupthink and concludes that the body of evidence has largely failed to support the theory (Baron, 2005).

There has been a large body of experimental research conducted on groupthink, especially in the years directly following the introduction of the theory. Notably, one study found mixed support for the theory (Flowers, 1977).

Aligning with the groupthink theory, the groups in the study with directive leaders came up with fewer solutions, shared less information, and utilized fewer facts about the case before making a decision.

On the other hand, the more surprising finding was that the more cohesive groups did not perform worse than the less cohesive ones.

Opposing the group cohesion aspect of the groupthink theory as well, John Courtright found that group cohesion had no effect on a number of factors, including creativity, feasibility, significance, competence, and a number of possible solutions (Courtright, 1978).

Another set of researchers found similar results when it comes to group cohesion (Fodor & Smith, 1982).

Furthermore, both Callaway and Esser reported that both group cohesion and whether or not groups were told to consider all of the possible alternatives or given no instruction had no effect on task performance (Callaway & Esser, 1984).

However, despite the opposition, many researchers have advocated for the theory in their work as well, and groupthink is widely cited today (Hensley & Griffin, 1986; Tetlock, 1979).

Also, many scholars have adjusted the theory to address the opposition’s findings, including the ubiquity model (Baron, 2005), the general group problem-solving model (GGPS) (Aldag & Fuller, 1993), and the sociocognitive theory (Tsoukalas, 2007) to name a few.

How to Avoid Groupthink

To avoid groupthink, leaders and group members alike can take a variety of steps to help prevent the phenomenon from occurring. Some potential solutions are below.

Leaders or impactful group members should create a safe space for discussion. They should be open to opposition to the group consensus, accept criticism, and encourage new ideas regardless of a person’s status within the organization (Janis, 1972, 1982).

Key members of the group and leaders should hold back their opinions initially to reduce their influence over the group consensus.

Outside groups could be set up to work on the same problem to compare potential solutions.

If setting up an entire outside group is not feasible, the ingroup should discuss its ideas with experts outside of the group.

Another way to reduce groupthink is by having a “devil’s advocate” or someone who raises ideas contrary to the ones presented despite their own opinion to help produce debates, create new ideas, or help determine the strength of an existing idea.

Considering the opposing groups’ points of view is key as well.

Groups can be split up into smaller subgroups and asked to create their own possible solutions. These groups can then be reconvened to discuss the various options collectively.

After the group has reached a preliminary decision, the group could hold another meeting which gives group members one more chance to raise opposition to the consensus.

When possible, allow as much time as possible to make a decision.

Educating groups about the groupthink phenomenon can be helpful as well.

Lastly, it’s important to have a diverse set of group members in order to have different perspectives, which can help reach a more balanced, optimal conclusion.

Learning check

Which statement about groupthink is correct?

• Groupthink always occurs in small groups.
• Groupthink helps to maintain peace and avoid conflict within the group.
• Groupthink is a phenomenon where the desire for group consensus leads to the suppression of dissenting viewpoints.
• Groupthink tends to maximize the effectiveness of a team’s performance.

Answer : The correct statement is 3. Groupthink is a phenomenon where the desire for group consensus leads to the suppression of dissenting viewpoints.

Derek’s team is struggling to come to a consensus because several people are unwilling to share their thoughts. What would be the best question for the group to ask themselves to avoid groupthink?

Answer : “Are we creating an environment where everyone feels safe to express their honest opinions and concerns without fear of judgment or backlash?” This encourages open dialogue and reduces the risk of groupthink.

What is groupthink in psychology?

Groupthink in psychology is a phenomenon where the desire for group consensus and harmony leads to poor decision-making.

Members suppress dissenting viewpoints, ignore external views, and may take irrational actions that devalue independent critical thinking.

What causes groupthink?

Groupthink is often caused by group pressure, strong directive leadership, high group cohesion, and isolation from outside opinions.

It is also more likely in stressful situations where decision-making becomes rushed and critical evaluation is minimized.

What are the common results of groupthink?

Common groupthink results include poor decision-making, lack of creativity, ignored alternatives, suppressed dissent, and potentially irrational actions.

It may also lead to overlooking risks, not considering all possible outcomes, and failing to re-evaluate initially rejected options.

Further Information

Lunenburg FC. Group decision making: The potential for groupthink. International Journal of Management, Business, and Administration. 2010;13(1).

Bang, D., & Frith, C. D. (2017). Making better decisions in groups. Royal Society open science, 4(8), 170193.

Rose, J. D. (2011). Diverse perspectives on the groupthink theory–a literary review. Emerging Leadership Journeys, 4(1), 37-57.

Aldag, R. J., & Fuller, S. R. (1993). Beyond Fiasco: A Reappraisal of the Groupthink Phenomenon and a New Model of Group Decision Processes. Psychological Bulletin, 113 (3), 533–552. https://doi.org/10.1037/0033-2909.113.3.533

Amidon, M. (2005). Groupthink, politics, and the decision to attempt the Son Tay rescue. Parameters (Carlisle, Pa.), 35(3), 119.

Badie, D. (2010). Groupthink, Iraq, and the War on Terror: Explaining US Policy Shift toward Iraq: Groupthink, Iraq, and the War on Terror. Foreign Policy Analysis, 6 (4), 277–296. https://doi.org/10.1111/j.1743-8594.2010.00113.x

Baron, R. S. (2005). So Right It’s Wrong: Groupthink and the Ubiquitous Nature of Polarized Group Decision Making. In Advances in Experimental Social Psychology (Vol. 37, pp. 219–253). Academic Press. https://doi.org/10.1016/S0065-2601(05)37004-3

Callaway, M. R., & Esser, J. K. (1984). Groupthink: Effects of Cohesiveness and Problem-Solving Procedures on Group Decision Making. Social Behavior & Personality: An International Journal, 12 (2), 157–164. https://doi.org/10.2224/sbp.1984.12.2.157

Courtright, J. A. (1978). A laboratory investigation of groupthink. Communication Monographs, 45 (3), 229–246. https://doi.org/10.1080/03637757809375968

Flowers, M. L. (1977). A laboratory test of some implications of Janis’s groupthink hypothesis. Journal of Personality and Social Psychology, 35(12), 888–896. https://doi.org/10.1037//0022-3514.35.12.888

Fodor, E. M., & Smith, T. (1982). The power motive as an influence on group decision making. Journal of Personality and Social Psychology, 42 (1), 178–185. https://doi.org/10.1037/0022-3514.42.1.178

Fuller S.R. & Aldag R.J. (1998). Organizational Tonypandy: Lessons from a Quarter Century of the Groupthink Phenomenon. Organizational Behavior and Human Decision Processes, 73 (23), 163–184.

Hensley, T. R., & Griffin, G. W. (1986). Victims of Groupthink: The Kent State University Board of Trustees and the 1977 Gymnasium Controversy. Journal of Conflict Resolution, 30 (3), 497–531. https://doi.org/10.1177/0022002786030003006

Janis, I. (1971, November). Groupthink. Psychology Today, 84–89.

Janis, I. (1972). Victims of groupthink: A psychological study of foreign-policy decisions and fiascoes (pp. viii, 277). Houghton Mifflin.

Janis, I. (1982). Groupthink: Psychological studies of policy decisions and fiascoes (2nd ed.). Houghton Mifflin. https://espace.library.uq.edu.au/view/UQ:734003

Orwell, G. (1949). 1984. Signet Classic.

Raven, B. H. (1998). Groupthink, Bay of Pigs, and Watergate reconsidered: Theoretical perspectives on groupthink: a twenty-fifth anniversary appraisal. Organizational Behavior and Human Decision Processes, 73 (2–3), 352–361.

Scharff, M. M. (2005). WorldCom: A Failure of Moral and Ethical Values. The Journal of Applied Management and Entrepreneurship, 10(3), 35-.

Tetlock, P. E. (1979). Identifying victims of groupthink from public statements of decision makers. Journal of Personality and Social Psychology, 37 (8), 1314–1324. https://doi.org/10.1037/0022-3514.37.8.1314

Tsoukalas, I. (2007). Exploring the Microfoundations of Group Consciousness. Culture & Psychology, 13 (1), 39–81. https://doi.org/10.1177/1354067X07073650

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Groupthink among health professional teams in patient care: A scoping review

Affiliations.

• 1 Cornell University, Ithaca, NY, USA.
• 2 Department of Medicine, Weill Cornell Medicine, NY, USA.
• 3 Samuel J. Wood Library & C.V. Starr Biomedical Information Center, Weill Cornell Medicine, NY, USA.
• 4 Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA.
• PMID: 34641741
• PMCID: PMC9972224
• DOI: 10.1080/0142159X.2021.1987404

There is emerging interest in understanding group decision making among a team of health professionals. Groupthink , a term coined by Irving Janis to depict premature consensus seeking in highly cohesive groups, is a theory that has been widely discussed in disciplines outside health care. However, it remains unclear how it has been conceptualized, studied, and mitigated in the context of health professionals conducting patient care. This scoping review aimed to examine the conceptualization of groupthink in health care, empirical research conducted in healthcare teams, and recommendations to avoid groupthink. Eight databases were systematically searched for articles focusing on groupthink among health professional teams using a scoping review methodology. A total of 22 articles were included-most were commentaries or narrative reviews with only four empirical research studies. This review found that focus on groupthink and group decision making in medicine is relatively new and growing in interest. Few empirical studies on groupthink in health professional teams have been performed and there is conceptual disagreement on how to interpret groupthink in the context of clinical practice. Future research should develop a theoretical framework that applies groupthink theory to clinical decision making and medical education, validate the groupthink framework in clinical settings, develop measures of groupthink, evaluate interventions that mitigate groupthink in clinical practice, and examine how groupthink may be situated amidst other emerging social cognitive theories of collaborative clinical decision making.

Keywords: Groupthink; errors; group decision making; healthcare team; scoping review.

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7 Strategies for Better Group Decision-Making

• Torben Emmerling
• Duncan Rooders

What we’ve learned from behavioral science.

There are upsides and downsides to making decisions in a group. The main risks include falling into groupthink or other biases that will distort the process and the ultimate outcome. But bringing more minds together to solve a problem has its advantages. To make use of those upsides and increase the chances your team will land on a successful solution, the authors recommend using seven strategies, which have been backed by behavioral science research: Keep the group small, especially when you need to make an important decision. Bring a diverse group together. Appoint a devil’s advocate. Collect opinions independently. Provide a safe space to speak up. Don’t over-rely on experts. And share collective responsibility for the outcome.

When you have a tough business problem to solve, you likely bring it to a group. After all, more minds are better than one, right? Not necessarily. Larger pools of knowledge are by no means a guarantee of better outcomes. Because of an over-reliance on hierarchy, an instinct to prevent dissent, and a desire to preserve harmony, many groups fall into groupthink .

• Torben Emmerling is the founder and managing partner of Affective Advisory and the author of the D.R.I.V.E.® framework for behavioral insights in strategy and public policy. He is a founding member and nonexecutive director on the board of the Global Association of Applied Behavioural Scientists ( GAABS ) and a seasoned lecturer, keynote speaker, and author in behavioral science and applied consumer psychology.
• DR Duncan Rooders is the CEO of a Single Family Office and a strategic advisor to Affective Advisory . He is a former B747 pilot, a graduate of Harvard Business School’s Owner/President Management program. He is the founder of  Behavioural Science for Business (BSB)  and  an advisor  to several international organizations in  strategic and team  decision-making.”, and a consultant to several international organizations in strategic and financial decision making.

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Reviewed by Psychology Today Staff

Groupthink is a phenomenon that occurs when a group of well-intentioned people makes irrational or non-optimal decisions spurred by the urge to conform or the belief that dissent is impossible. The problematic or premature consensus that is characteristic of groupthink may be fueled by a particular agenda—or it may be due to group members valuing harmony and coherence above critical thought.

• Why Groupthink Happens
• Avoiding Groupthink

The term “groupthink” was first introduced in the November 1971 issue of Psychology Today by psychologist Irving Janis. Janis had conducted extensive research on group decision-making under conditions of stress .

Since then, Janis and other researchers have found that in a situation that can be characterized as groupthink, individuals tend to refrain from expressing doubts and judgments or disagreeing with the consensus. In the interest of making a decision that furthers their group cause, members may also ignore ethical or moral consequences. While it is often invoked at the level of geopolitics or within business organizations, groupthink can also refer to subtler processes of social or ideological conformity , such as participating in bullying or rationalizing a poor decision being made by one's friends.

Groups that prioritize their group identity and behave coldly toward “outsiders” may be more likely to fall victim to groupthink. Organizations in which dissent is discouraged or openly punished are similarly likely to engage in groupthink when making decisions. High stress is another root cause, as is time pressure that demands a fast decision. 

Even in minor cases, groupthink triggers decisions that aren’t ideal or that ignore critical information. In highly consequential domains—like politics or the military—groupthink can have much worse consequences, leading groups to ignore ethics or morals, prioritize one specific goal while ignoring countless collateral consequences, or, at worst, instigate death and destruction.

Groupthink, by definition, results in a decision that is irrational or dangerous. It is possible, however, for teams to make decisions harmoniously and with little disagreement, in ways that are not necessarily indicative of groupthink. While well-functioning teams can (and should) have some conflict , debate (as long as it's respectful) is antithetical to groupthink.

Groupthink and conformity are related but distinct concepts. Groupthink specifically refers to a process of decision-making; it can be motivated by a desire to conform, but isn’t always. Conformity , on the other hand, pertains to individuals who (intentionally or unintentionally) shift their behaviors, appearances, or beliefs to sync up to those of the group.

Risky or disastrous military maneuvers, such as the escalation of the Vietnam War or the invasion of Iraq, are commonly cited as instances of groupthink. In Janis’ original article, he highlighted groupthink during the 1961 Bay of Pigs invasion .

To recognize groupthink, it's useful to identify the situations in which it's most likely to occur. When groups feel threatened—either physically or through threats to their identity —they may develop a strong “us versus them” mentality. This can prompt members to accept group perspectives, even when those perspectives don’t necessarily align with their personal views. Groupthink may also occur in situations in which decision-making is rushed—in some cases, with destructive outcomes.

To minimize the risk, it's critical to allow enough time for issues to be fully discussed, and for as many group members as possible to share their thoughts. When dissent is encouraged, groupthink is less likely to occur. Learning about common cognitive biases, as well as how to identify them, may also reduce the likelihood of groupthink.

Individual members of the group self-censoring —especially if they fear being shunned or derided for speaking their mind—is one potential sign that the group may engage in groupthink. If those who do dissent are pressured to recant or conform to the majority view, it may similarly signal groupthink. Groups that actively deride “outsiders” may be more likely to fall prey.

Since groupthink often occurs because group members fear disagreeing with the leader , it can be beneficial for the leader to temporarily step back and allow members to debate the issue themselves. One member of the team can be appointed as “devil’s advocate,” who will argue against the consensus to highlight potential flaws.

Healthy dissent has been linked to more creative thinking and ultimately greater innovation within organizations . Asking one person to deliberately play devil’s advocate and argue with the solutions proposed by the majority is one strategy that has been shown to be effective against groupthink.

Diversity—both demographic diversity and diversity of thought— has been shown to reduce the possibility of groupthink . Group members’ different backgrounds, beliefs, or personality traits can all spawn unique ideas that can inspire innovation. It’s critical, though, that all group members—regardless of their position or demographics—be allowed to contribute to group decision-making.

Organizations that want to support critical thinking, creativity , and innovation should first foster a culture where dissent is allowed and encouraged. They should reward risk-taking , be open to ideas from all group members—regardless of their experience or position—and create regular opportunities for individuals to share their ideas , big and small.

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How Groupthink Impacts Our Behavior

Kendra Cherry, MS, is a psychosocial rehabilitation specialist, psychology educator, and author of the "Everything Psychology Book."

Emily is a board-certified science editor who has worked with top digital publishing brands like Voices for Biodiversity, Study.com, GoodTherapy, Vox, and Verywell.

Yuri Arcurs / Getty Images

How Groupthink Works

Examples of groupthink, impact of groupthink, potential pitfalls, tips for avoiding groupthink.

Groupthink is a psychological phenomenon in which people strive for consensus within a group. In many cases, people will set aside their own personal beliefs or adopt the opinion of the rest of the group. The term was first used in 1972 by social psychologist Irving L. Janis.

People opposed to the decisions or overriding opinions of the group frequently remain quiet, preferring to keep the peace rather than disrupt the uniformity of the crowd. The phenomenon can be problematic, but even well-intentioned people are prone to making irrational decisions in the face of overwhelming pressure from the group.

Signs of Groupthink

Groupthink may not always be easy to discern, but there are some signs that it is present. There are also some situations where it may be more likely to occur. Janis identified a number of different "symptoms" that indicate groupthink.  

• Illusions of unanimity lead members to believe that everyone is in agreement and feels the same way. It is often much more difficult to speak out when it seems that everyone else in the group is on the same page.
• Unquestioned beliefs lead members to ignore possible moral problems and not consider the consequences of individual and group actions.
• Rationalizing prevents members from reconsidering their beliefs and causes them to ignore warning signs.
• Stereotyping leads members of the in-group to ignore or even demonize out-group members who may oppose or challenge the group's ideas. This causes members of the group to ignore important ideas or information.
• Self-censorship causes people who might have doubts to hide their fears or misgivings. Rather than sharing what they know, people remain quiet and assume that the group must know best.
• "Mindguards" act as self-appointed censors to hide problematic information from the group. Rather than sharing important information, they keep quiet or actively prevent sharing.
• Illusions of invulnerability lead members of the group to be overly optimistic and engage in risk-taking. When no one speaks out or voices an alternative opinion, it causes people to believe that the group must be right.
• Direct pressure to conform is often placed on members who pose questions, and those who question the group are often seen as disloyal or traitorous.

Four of the main characteristics of groupthink include pressure to conform, the illusion of invulnerability, self-censorship, and unquestioned beliefs.

Why does groupthink occur? Think about the last time you were part of a group, perhaps during a school project. Imagine that someone proposes an idea that you think is quite poor.

However, everyone else in the group agrees with the person who suggested the idea, and the group seems set on pursuing that course of action. Do you voice your dissent or do you just go along with the majority opinion?

In many cases, people end up engaging in groupthink when they fear that their objections might disrupt the harmony of the group or suspect that their ideas might cause other members to reject them .

A number of factors can influence this psychological phenomenon. Some causes:

• Group identity : It tends to occur more in situations where group members are very similar to one another. When there is strong group identity, members of the group tend to perceive their group as correct or superior while expressing disdain or disapproval toward people outside of the group.
• Leader influences : Groupthink is also more likely to take place when a powerful and charismatic leader commands the group.
• Low knowledge : When people lack personal knowledge of something or feel that other members of the group are more qualified, they are more likely to engage in groupthink.  
• Stress : Situations where the group is placed under extreme stress or where moral dilemmas exist also increase the occurrence of groupthink.  

Contributing Factors

Janis suggested that groupthink tends to be the most prevalent in conditions:

• When there is a high degree of cohesiveness.
• When there are situational factors that contribute to deferring to the group (such as external threats, moral problems, difficult decisions).
• When there are structural issues (such as group isolation and a lack of impartial leadership ).  

Groupthink has been attributed to many real-world political decisions that have had consequential effects. In his original descriptions of groupthink, Janis suggested that the escalation of the Vietnam War, the Bay of Pigs invasion, and the failure of the U.S. to heed warnings about a potential attack on Pearl Harbor were all influenced by groupthink.

Other examples where decision-making is believed to be heavily influenced by groupthink include:

• The Watergate scandal
• The Challenger space shuttle disaster
• The 2003 invasion of Iraq
• The 2008 economic crisis
• Internet cancel culture

In more everyday settings, researchers suggest that groupthink might play a part in decisions made by professionals in healthcare settings.

In each instance, factors such as pressure to conform, closed-mindedness, feelings of invulnerability, and the illusion of group unanimity contribute to poor decisions and often devastating outcomes.

Groupthink can cause people to ignore important information and can ultimately lead to poor decisions . This can be damaging even in minor situations but can have much more dire consequences in certain settings. Medical, military, or political decisions, for example, can lead to unfortunate outcomes when they are impaired by the effects of groupthink.

The phenomenon can have high costs. These include:

• The suppression of individual opinions and creative thought can lead to inefficient problem-solving .
• It can contribute to group members engaging in self-censorship. This tendency to seek consensus above all else also means that group members may not adequately assess the potential risks and benefits of a decision. 
• Groupthink also tends to lead group members to perceive the group as inherently moral or right. Stereotyped beliefs about other groups can contribute to this biased sense of rightness.

Groupthink vs. Conformity

It is important to note that while groupthink and conformity are similar and related concepts, there are important distinctions between the two. Groupthink involves the decision-making process.

On the other hand, conformity is a process in which people change their own actions so they can fit in with a specific group. Conformity can sometimes cause groupthink, but it isn't always the motivating factor.

While groupthink can generate consensus, it is by definition a negative phenomenon that results in faulty or uninformed thinking and decision-making. Some of the problems it can cause include:

• Blindness to potentially negative outcomes
• Failure to listen to people with dissenting opinions
• Lack of creativity
• Lack of preparation to deal with negative outcomes
• Ignoring important information
• Inability to see other solutions
• Not looking for things that might not yet be known to the group
• Obedience to authority without question
• Overconfidence in decisions
• Resistance to new information or ideas

Group consensus can allow groups to make decisions, complete tasks, and finish projects quickly and efficiently—but even the most harmonious groups can benefit from some challenges.   Finding ways to reduce groupthink can improve decision-making and assure amicable relationships within the group.

There are steps that groups can take to minimize this problem. First, leaders can give group members the opportunity to express their own ideas or argue against ideas that have already been proposed.

Breaking up members into smaller independent teams can also be helpful. Here are some more ideas that might help prevent groupthink.

• Initially, the leader of the group should avoid stating their opinions or preferences when assigning tasks. Give people time to come up with their own ideas first.
• Assign at least one individual to take the role of the "devil's advocate."
• Discuss the group's ideas with an outside member in order to get impartial opinions.
• Encourage group members to remain critical. Don't discourage dissent or challenges to the prevailing opinion.
• Before big decisions, leaders should hold a "second-chance" meeting where members have the opportunity to express any remaining doubts.
• Reward creativity and give group members regular opportunities to share their ideas and thoughts.
• Assign specific roles to certain members of the group.
• Establish metrics or definitions to make sure that everyone is basing decisions or judgments on the same information.
• Consider allowing people to submit anonymous comments, suggestions, or opinions.

Diversity among group members has also been shown to enhance decision-making and reduce groupthink.  

When people in groups have diverse backgrounds and experiences, they are better able to bring different perspectives, information, and ideas to the table. This enhances decisions and makes it less likely that groups will fall into groupthink patterns.

Lunenburg FC. Group decision making: The potential for groupthink . International Journal of Management, Business, and Administration. 2010;13(1).

Bang D, Frith CD. Making better decisions in groups .  R Soc Open Sci . 2017;4(8):170193. doi:10.1098/rsos.170193

Rose JD. Diverse perspectives on the groupthink theory - A literary review . Emerging Leadership Journeys . 2011;4(1):37-57.

DiPierro K, Lee H, Pain KJ, Durning SJ, Choi JJ. Groupthink among health professional teams in patient care: A scoping review .  Med Teach . 2022;44(3):309-318. doi:10.1080/0142159X.2021.1987404

Gokar H. Groupthink principles and fundamentals in organizations . Interdisciplinary Journal of Contemporary Research in Business. 2013;5(8):225-240.

Janis IL. Victims of Groupthink: A Psychological Study of Foreign-Policy Decisions and Fiascoes. Boston: Houghton Mifflin; 1972.

By Kendra Cherry, MSEd Kendra Cherry, MS, is a psychosocial rehabilitation specialist, psychology educator, and author of the "Everything Psychology Book."

10 Groupthink Examples (Plus Definition & Critique)

Groupthink is a type of thinking when members of a group accept the group consensus uncritically. It can lead to disastrous conclusions because moral and logical thinking is suspended.

Group members often take the group’s competence and unity for granted, thereby failing to use their own individual thought. Alternatively, they might not want to avoid punishments associated with expressing dissent.

Groupthink might lead groups to reach more extreme or wrong decisions that only some members genuinely support.

Groupthink Definition and Theoretical Origins

The term “groupthink” was coined in 1952 by William Whyte to describe the perils of “rationalized conformity”.

However, American psychologist Irving Janis introduced the comprehensive theory of groupthink in 1972.

It emerged from his effort to understand why knowledgeable political groups often made disastrous decisions (especially in foreign policy). Janis defined groupthink as:

“…the mode of thinking that persons engage in when concurrence seeking becomes so dominant in a cohesive ingroup that it tends to override realistic appraisal of alternative courses of action.” (1972, p. 9)

Essentially, a lack of conflict or opposing viewpoints leads to poor decisions. The group doesn’t fully analyse possible alternatives, gather external information, or seek external advice to make an informed decision.

Groupthink then has negative effects. It marks “a deterioration of mental efficiency, reality testing, and moral judgment that results from ingroup pressures” (Janis, 1972, p. 9).

Key Characteristics of Groupthink

According to Janis, the key characteristics of groupthink are:

• The illusion that a group is invulnerable, fully competent, and coherent
• The rationalization of collective decisions
• An unquestioned belief in the group’s integrity,
• Stereotyping group adversaries or outsiders,
• The existence of “mindguards” blocking alternative information and options which leads to belief perseverance ,
• Self-censorship

10 Groupthink Examples

Real-world examples.

• American officials did not anticipate or adequately prepare for the Pearl Harbor bombing in 1941. They ignored external information that the Japanese were planning an attack, thinking they would never dare to fight the American “superpower”.
• The escalation of the Vietnam War in the 1960s resulted from the U.S. government’s feelings of invincibility, underestimating the opponent’s abilities, and ignoring opposing viewpoints.
• The Challenger disaster. In 1986, miscalculations regarding the launch of the Challenger shuttle claimed the lives of 7 people. Space shuttle engineers knew about the shuttle’s faulty parts but they did not block the launch because of public pressure.
• The Bay of Pigs invasion . Suffering from the illusion of invulnerability and based on faulty assumptions the Kennedy administration launched an unsuccessful attack against Cuba.  
• A homogenous (yet experienced) team of American decisionmakers decided to go to war in Iraq . Their illusion of invulnerability and moral righteousness led them to disregard intelligence information about weapons of mass destruction.

Fictional examples

• Employees not speaking up in a work meeting because they don’t want to seem unsupportive of their team’s efforts.
• Students not opposing to a strict professor’s views or behavior because they’re concerned about how this might affect their grades.
• A political organization has a firm ideological agenda. Their sources of information are limited to those aligned with their ideology. This group might come to distrust and even inflict violence on outgroup members with different political views.
• Members of a close-knit group might ignore or underestimate information that challenges their decisions. They might try to shut down any group member who brings a different perspective.
• Launching an offensive advertising campaign for a consumer product because employees don’t articulate their dissent. They were worried about how this could impact their career. However, their view could save the company/organization from making a mistake.

Case Studies

1. the challenger disaster.

In the 1980s, NASA earlier debuted a space shuttle program that would be accessible to the public. They have even planned for more than 50 affordable flights a year.

The first shuttle, name Challenger was planned to take off in January 1986. Space shuttle engineers knew about certain faulty parts before the take-off.

And yet, they did not block the launch because of public pressure to proceed. In its effort to avoid negative press, NASA’s Challenger mission claimed seven lives—while the nation was watching.

2. The Bay of Pigs invasion

A famous example of Groupthink is the ultimately unsuccessful attack against Cuba in 1961.

The J. F. Kennedy administration launched the attack by accepting negative stereotypes about the Cubans and Fidel Castro’s incompetence (Janis, 1972). They did not question whether the Central Intelligence Agency information was accurate.

Beyond stereotyping, Kennedy’s administration thought itself untouchable. Although the plans to invade the Bay of Pigs had leaked out, they carried on ignoring the adverse warning signs (Janis, 1972).

Also, individual members, like Secretary of State Dean Rusk, did not voice their contrary opinion in group discussions.

The Bay of Pigs Invasion showcases three characteristics of groupthink: (i) the illusion of invulnerability , (ii) stereotyping of the opponent and (iii) self-censorship .

3. The bombing of Pearl Harbour

Another real-life scenario of groupthink discussed by Janis is the bombing of Pearl Harbour in 1941.

Japanese messages had been intercepted. And yet, many senior officials at Pearl Harbor did not pay attention to the warnings from Washington DC about a potential Japanese attack.

They didn’t act or prepare because they rationalised that the Japanese wouldn’t never attempt such an invasion. They were sure that the Japanese would see the “obvious” futility of entering a war with the US.

Thus, they failed to prepare for the bombing of Pearl Harbour, which claimed many lives.

The symptoms of groupthink are: (i) stereotyping the adversary’s ineptitude, (ii) illusions of invincibility leading to excessive risk taking (Janis, 1972),.

4. The escalation of the Vietnam War

The escalation of the Vietnam War was also studied by Janis as a manifestation of dysfunctional group dynamics .

First, U.S. government officials during the war considered themselves untouchable despite having suffered multiple failures and financial/human losses. They ignored the dangers and negative feedback, blindly trusting the military advantage of the U.S.

They also stereotyped their enemies, deeming them unable to make correct decisions.

President Johnson felt that the U.S. was leading a “just war”, defending its ally, South Vietnam, from the Soviet threat. They saw the escalation of war as morally correct.

The ultimate purpose was to show to the rest of the world the unanimity of the Americans in fighting again Communist expansionism.

5. An offensive marketing campaign

A modern example of Groupthink is a politically incorrect marketing campaign, imagine a company seeking to launch a new marketing campaign for a consumer product. Other team members appear excited about and pleased with the campaign, but you have some concerns. You feel it might be offensive to some demographic groups.

You don’t speak up because you like your colleagues and want to avoid putting them in an awkward position by challenging their idea. You also want your team to succeed. Anyway no one seems to consider other possible marketing plans, while the dynamic team leader firmly pushes for this campaign.

At that point, you choose to go along with the group and start doubting that your idea is correct. This fictional example illustrates key symptoms of groupthink: (i) group cohesion , (ii) self – censorship , (ii) the “ mindguard ” (team leader) banning alternative opinions .

Causes of Groupthink

It should be clear from the above that the main causes of groupthink are:

• Highly cohesive and/or non-diverse groups
• An influential leader who feels “infallible” and suppresses dissenting information
• Decision-making under stress or time constraints
• Non-consideration of outside perspectives
• Efforts to maintain/boost group members’ self-confidence

Criticisms of Groupthink Theory

Despite the significant uptake of Janis’ Groupthink model in the social sciences, many scholars have criticized its validity (Kramer, 1998). Scholars have found that decision-making processes only sometimes define ultimate outcomes.

Not all poor group decisions result from groupthink. Similarly, not all cases of groupthink result in failures or ‘fiascoes’ to use Janis’ wording. In some cases, scholars have found that being in a cohesive group can be effective; it can boost members’ self-esteem and speed up decision-making (Fuller & Aldag, 1998).

Indeed, previous research has challenged Janis’ model. However, groupthink has been very influential in understanding group dynamics and poor decision-making processes in a much broader range of settings than initially imagined (Forsyth, 1990).

Groupthink is a process in which the motivation for consensus in a group causes poor decisions—made by knowledgeable people.

Instead of expressing dissent and risking losing a sense of group unity, members stay silent. They subscribe to views/decisions they disagree with. Therefore, groupthink prioritizes group harmony over independent judgment and might rationalize immoral actions.

Although groupthink often leads to bad (even unethical) decisions, group leaders should try avoid groupthink by creating diverse and inclusive groups, enabling members to voice their views without fear, and considering opposing views seriously.

Forsyth, D. (1990). Group dynamics (2nd ed.). Pacific Grove, Calif: Brooks/Cole.

Fuller S.R, & Aldag R.J. (1998). Organizational Tonypandy: Lessons from a Quarter Century of the Groupthink Phenomenon. Organizational Behavior and Human Decision Processes , 73(23), 163-184.

Janis, I. (1982). Groupthink: Psychological studies of policy decisions and fiascoes (2nd ed.). Boston, Mass.: Houghton Mifflin.

Kramer, R. M. (1998). Revisiting the Bay of Pigs and Vietnam Decisions 25 Years Later: How Well Has the Groupthink Hypothesis Stood the Test of Time?. Organizational Behavior and Human Decision Processes , 73(2-3), pp. 236-271.

Chris Drew (PhD)

Dr. Chris Drew is the founder of the Helpful Professor. He holds a PhD in education and has published over 20 articles in scholarly journals. He is the former editor of the Journal of Learning Development in Higher Education. [Image Descriptor: Photo of Chris]

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Do Your Students Know How to Analyze a Case—Really?

Explore more.

• Case Teaching
• Student Engagement

J ust as actors, athletes, and musicians spend thousands of hours practicing their craft, business students benefit from practicing their critical-thinking and decision-making skills. Students, however, often have limited exposure to real-world problem-solving scenarios; they need more opportunities to practice tackling tough business problems and deciding on—and executing—the best solutions.

To ensure students have ample opportunity to develop these critical-thinking and decision-making skills, we believe business faculty should shift from teaching mostly principles and ideas to mostly applications and practices. And in doing so, they should emphasize the case method, which simulates real-world management challenges and opportunities for students.

To help educators facilitate this shift and help students get the most out of case-based learning, we have developed a framework for analyzing cases. We call it PACADI (Problem, Alternatives, Criteria, Analysis, Decision, Implementation); it can improve learning outcomes by helping students better solve and analyze business problems, make decisions, and develop and implement strategy. Here, we’ll explain why we developed this framework, how it works, and what makes it an effective learning tool.

The Case for Cases: Helping Students Think Critically

Business students must develop critical-thinking and analytical skills, which are essential to their ability to make good decisions in functional areas such as marketing, finance, operations, and information technology, as well as to understand the relationships among these functions. For example, the decisions a marketing manager must make include strategic planning (segments, products, and channels); execution (digital messaging, media, branding, budgets, and pricing); and operations (integrated communications and technologies), as well as how to implement decisions across functional areas.

Faculty can use many types of cases to help students develop these skills. These include the prototypical “paper cases”; live cases , which feature guest lecturers such as entrepreneurs or corporate leaders and on-site visits; and multimedia cases , which immerse students into real situations. Most cases feature an explicit or implicit decision that a protagonist—whether it is an individual, a group, or an organization—must make.

For students new to learning by the case method—and even for those with case experience—some common issues can emerge; these issues can sometimes be a barrier for educators looking to ensure the best possible outcomes in their case classrooms. Unsure of how to dig into case analysis on their own, students may turn to the internet or rely on former students for “answers” to assigned cases. Or, when assigned to provide answers to assignment questions in teams, students might take a divide-and-conquer approach but not take the time to regroup and provide answers that are consistent with one other.

To help address these issues, which we commonly experienced in our classes, we wanted to provide our students with a more structured approach for how they analyze cases—and to really think about making decisions from the protagonists’ point of view. We developed the PACADI framework to address this need.

PACADI: A Six-Step Decision-Making Approach

The PACADI framework is a six-step decision-making approach that can be used in lieu of traditional end-of-case questions. It offers a structured, integrated, and iterative process that requires students to analyze case information, apply business concepts to derive valuable insights, and develop recommendations based on these insights.

Prior to beginning a PACADI assessment, which we’ll outline here, students should first prepare a two-paragraph summary—a situation analysis—that highlights the key case facts. Then, we task students with providing a five-page PACADI case analysis (excluding appendices) based on the following six steps.

Step 1: Problem definition. What is the major challenge, problem, opportunity, or decision that has to be made? If there is more than one problem, choose the most important one. Often when solving the key problem, other issues will surface and be addressed. The problem statement may be framed as a question; for example, How can brand X improve market share among millennials in Canada? Usually the problem statement has to be re-written several times during the analysis of a case as students peel back the layers of symptoms or causation.

Step 2: Alternatives. Identify in detail the strategic alternatives to address the problem; three to five options generally work best. Alternatives should be mutually exclusive, realistic, creative, and feasible given the constraints of the situation. Doing nothing or delaying the decision to a later date are not considered acceptable alternatives.

Step 3: Criteria. What are the key decision criteria that will guide decision-making? In a marketing course, for example, these may include relevant marketing criteria such as segmentation, positioning, advertising and sales, distribution, and pricing. Financial criteria useful in evaluating the alternatives should be included—for example, income statement variables, customer lifetime value, payback, etc. Students must discuss their rationale for selecting the decision criteria and the weights and importance for each factor.

Step 4: Analysis. Provide an in-depth analysis of each alternative based on the criteria chosen in step three. Decision tables using criteria as columns and alternatives as rows can be helpful. The pros and cons of the various choices as well as the short- and long-term implications of each may be evaluated. Best, worst, and most likely scenarios can also be insightful.

Step 5: Decision. Students propose their solution to the problem. This decision is justified based on an in-depth analysis. Explain why the recommendation made is the best fit for the criteria.

Step 6: Implementation plan. Sound business decisions may fail due to poor execution. To enhance the likeliness of a successful project outcome, students describe the key steps (activities) to implement the recommendation, timetable, projected costs, expected competitive reaction, success metrics, and risks in the plan.

“Students note that using the PACADI framework yields ‘aha moments’—they learned something surprising in the case that led them to think differently about the problem and their proposed solution.”

PACADI’s Benefits: Meaningfully and Thoughtfully Applying Business Concepts

The PACADI framework covers all of the major elements of business decision-making, including implementation, which is often overlooked. By stepping through the whole framework, students apply relevant business concepts and solve management problems via a systematic, comprehensive approach; they’re far less likely to surface piecemeal responses.

As students explore each part of the framework, they may realize that they need to make changes to a previous step. For instance, when working on implementation, students may realize that the alternative they selected cannot be executed or will not be profitable, and thus need to rethink their decision. Or, they may discover that the criteria need to be revised since the list of decision factors they identified is incomplete (for example, the factors may explain key marketing concerns but fail to address relevant financial considerations) or is unrealistic (for example, they suggest a 25 percent increase in revenues without proposing an increased promotional budget).

In addition, the PACADI framework can be used alongside quantitative assignments, in-class exercises, and business and management simulations. The structured, multi-step decision framework encourages careful and sequential analysis to solve business problems. Incorporating PACADI as an overarching decision-making method across different projects will ultimately help students achieve desired learning outcomes. As a practical “beyond-the-classroom” tool, the PACADI framework is not a contrived course assignment; it reflects the decision-making approach that managers, executives, and entrepreneurs exercise daily. Case analysis introduces students to the real-world process of making business decisions quickly and correctly, often with limited information. This framework supplies an organized and disciplined process that students can readily defend in writing and in class discussions.

PACADI in Action: An Example

Here’s an example of how students used the PACADI framework for a recent case analysis on CVS, a large North American drugstore chain.

The CVS Prescription for Customer Value*

PACADI Stage

Summary Response

How should CVS Health evolve from the “drugstore of your neighborhood” to the “drugstore of your future”?

Alternatives

A1. Kaizen (continuous improvement)

A2. Product development

A3. Market development

A4. Personalization (micro-targeting)

Criteria (include weights)

C1. Customer value: service, quality, image, and price (40%)

C2. Customer obsession (20%)

C3. Growth through related businesses (20%)

C4. Customer retention and customer lifetime value (20%)

Each alternative was analyzed by each criterion using a Customer Value Assessment Tool

Alternative 4 (A4): Personalization was selected. This is operationalized via: segmentation—move toward segment-of-1 marketing; geodemographics and lifestyle emphasis; predictive data analysis; relationship marketing; people, principles, and supply chain management; and exceptional customer service.

Implementation

Partner with leading medical school

Curbside pick-up

Pet pharmacy

E-newsletter for customers and employees

Employee incentive program

CVS beauty days

Expand to Latin America and Caribbean

Healthier/happier corner

Holiday toy drives/community outreach

*Source: A. Weinstein, Y. Rodriguez, K. Sims, R. Vergara, “The CVS Prescription for Superior Customer Value—A Case Study,” Back to the Future: Revisiting the Foundations of Marketing from Society for Marketing Advances, West Palm Beach, FL (November 2, 2018).

Results of Using the PACADI Framework

When faculty members at our respective institutions at Nova Southeastern University (NSU) and the University of North Carolina Wilmington have used the PACADI framework, our classes have been more structured and engaging. Students vigorously debate each element of their decision and note that this framework yields an “aha moment”—they learned something surprising in the case that led them to think differently about the problem and their proposed solution.

These lively discussions enhance individual and collective learning. As one external metric of this improvement, we have observed a 2.5 percent increase in student case grade performance at NSU since this framework was introduced.

Tips to Get Started

The PACADI approach works well in in-person, online, and hybrid courses. This is particularly important as more universities have moved to remote learning options. Because students have varied educational and cultural backgrounds, work experience, and familiarity with case analysis, we recommend that faculty members have students work on their first case using this new framework in small teams (two or three students). Additional analyses should then be solo efforts.

To use PACADI effectively in your classroom, we suggest the following:

Advise your students that your course will stress critical thinking and decision-making skills, not just course concepts and theory.

Use a varied mix of case studies. As marketing professors, we often address consumer and business markets; goods, services, and digital commerce; domestic and global business; and small and large companies in a single MBA course.

As a starting point, provide a short explanation (about 20 to 30 minutes) of the PACADI framework with a focus on the conceptual elements. You can deliver this face to face or through videoconferencing.

Give students an opportunity to practice the case analysis methodology via an ungraded sample case study. Designate groups of five to seven students to discuss the case and the six steps in breakout sessions (in class or via Zoom).

Ensure case analyses are weighted heavily as a grading component. We suggest 30–50 percent of the overall course grade.

Once cases are graded, debrief with the class on what they did right and areas needing improvement (30- to 40-minute in-person or Zoom session).

Encourage faculty teams that teach common courses to build appropriate instructional materials, grading rubrics, videos, sample cases, and teaching notes.

When selecting case studies, we have found that the best ones for PACADI analyses are about 15 pages long and revolve around a focal management decision. This length provides adequate depth yet is not protracted. Some of our tested and favorite marketing cases include Brand W , Hubspot , Kraft Foods Canada , TRSB(A) , and Whiskey & Cheddar .

Art Weinstein , Ph.D., is a professor of marketing at Nova Southeastern University, Fort Lauderdale, Florida. He has published more than 80 scholarly articles and papers and eight books on customer-focused marketing strategy. His latest book is Superior Customer Value—Finding and Keeping Customers in the Now Economy . Dr. Weinstein has consulted for many leading technology and service companies.

Herbert V. Brotspies , D.B.A., is an adjunct professor of marketing at Nova Southeastern University. He has over 30 years’ experience as a vice president in marketing, strategic planning, and acquisitions for Fortune 50 consumer products companies working in the United States and internationally. His research interests include return on marketing investment, consumer behavior, business-to-business strategy, and strategic planning.

John T. Gironda , Ph.D., is an assistant professor of marketing at the University of North Carolina Wilmington. His research has been published in Industrial Marketing Management, Psychology & Marketing , and Journal of Marketing Management . He has also presented at major marketing conferences including the American Marketing Association, Academy of Marketing Science, and Society for Marketing Advances.

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Home » Business » 25 Most Famous Groupthink Examples in History and Pop Culture

25 Most Famous Groupthink Examples in History and Pop Culture

What is groupthink? This concept was first spoken about by social psychologist Irving Janis and journalist William H. Whyte. According to them, it’s a phenomenon where members of a group begin to think erroneously.

This happens because group members want to keep a feeling of overall unity and/or harmony within the group, and this leads to dissenting voices being silenced. Unfortunately, it also leads to a situation where team members end up making poor decisions. To make this easier to understand, here is a deeper explanation and some real-world examples of groupthink.

Top Characteristics of Groupthink

• An illusion of invulnerability
• An illusion of unanimity
• Pressure to conform
• Closed mindedness
• Isolation of the group
• Pressure to self-censor

Best Known Examples of Groupthink

1. the bay of pigs invasion.

As mentioned, the theory of groupthink was first spoken about by Yale psychologist Irving Janis. He wrote about this phenomenon in the 1972 publication titled Victims of Groupthink a Psychological Study of Foreign-policy Decisions and Fiascoes. In this book, he provides the reader with several examples of poor group decision-making.

One of these examples is the Bay of Pigs Invasion. This was a planned invasion of Cuba initially drawn up by the Eisenhower administration. Once President Kennedy came into power, the plan was immediately put into action.

The government did this without questioning the basic assumptions of this plan and without undertaking any further investigation. The invasion ended up being an enormous failure, and people directly blamed the Kennedy administration. What’s also interesting to note is that this event paved the way for the Cuban Missile Crisis.

2. The Pearl Harbor Attack

This is an excellent example of groupthink theory. Weeks before the attack, hundreds of communications were intercepted from Japan. These communications confirmed that an attack was imminent. Despite this, the Pearl Harbor command didn’t actually believe that the Japanese would attack. Why would they risk war with a much stronger enemy?

The command was also more concerned with Japanese citizens living in Hawaii – who they believed were a far bigger threat to Pearl Harbor. As we now know, the United States’ decision to ignore this critical information proved was an immense disaster.

3. The Challenger Space Shuttle Disaster

Here’s another famous example of groupthink. Engineers of the space shuttle repeatedly voiced concerns about the safety of the Challenger. Despite this, group leaders within NASA choose to ignore these warnings.

This was mostly because they wanted to launch the shuttle on schedule. More specifically, it was because members of the team who designed the shuttle felt that the testing efforts were adequate.

4. Kony 2012 Viral Video

Kony 2012 was a documentary that focused on Ugandan war criminal and militia leader Joseph Kony. The purpose of this film was supposedly to start an international movement that would bring him to justice. The movie was highly successful and quickly went viral. It spread like wildfire over social media and had millions of views within days. In fact, it was actually the first video in the history of YouTube to break one million views.

In spite of this success, it was later discovered that most of the information in the film was incorrect. When this news hit the headlines, it proved to have dire consequences for the people behind the film (some were even arrested.) Not only was Kony 2012 a stunning example of the theory of groupthink in action, but it also shows how easily social networks can manipulate the public.

5. Insolvency of Swissair

The Swiss national carrier was once renowned for its financial stability. Due to high levels of liquidity, it was even known as the “flying bank.” During the 1990s, things started to change. Overconfidence and hubris led to a series of bad decisions, which eventually caused the airline to collapse.

Foremost of these was the ill-advised “hunter strategy” in which the airline attempted to expand by buying up smaller airlines. While this did give the airline easier access to the European market, things didn’t last. The airliner soon found itself overwhelmed by debt and was quickly insolvent.

What this example really teaches us is how groupthink impacts your problem-solving abilities. Even though incredibly intelligent people ran this airline, they couldn’t find a way out of the situation.

6. Kodak Cameras

At one point, Kodak was the world leader in camera technology. It seemed unbeatable, and this gave the company leaders a feeling of invulnerability. All of this changed once digital cameras arrived. Kodak succumbed to the symptoms of groupthink and flatly refused to adopt this new technology. This, along with a failure to make other important decisions, eventually led to the downfall of the company.

The strangest part of this story is that Kodak actually developed the world’s first digital camera. Instead of bringing this product to market, they dropped it to protect their lucrative film processing business. This is one of the more extreme cases of groupthink and proved disastrous. What was once the world’s No. 1 camera company now trails behind competitors like Canon, Sony, Nikon, and Samsung.

7. Escalation of the Vietnam War

One of the most significant moments of the Vietnam War was The Gulf of Tonkin incident. In case you don’t know, this was an event where North Vietnamese ships attacked the U.S.S. Maddox and U.S.S.C. Turner Joy. This was seen as an act of aggression which led to the Gulf of Tonkin resolution, which in turn escalated the Vietnam War. This escalation resulted in a bombing campaign known as Operation Rolling Thunder and the eventual deployment of American troops in Vietnam.

What makes this an example of groupthink and acting without enough information was the fact that North Vietnam did not actually attack the U.S. unprovoked. Later reports showed that America was the aggressor and provoked North Vietnam by supporting South Vietnamese forces, as well as supplying them with reconnaissance information.

8. Kendall Jenner Pepsi Ad

In 2017, Kendall Jenner appeared in a highly controversial ad for Pepsi. This ad shows Jenner attending a protest march and climaxes with her handing a can of Pepsi to a police officer. Upon release, this ad sparked a huge outcry, resulting in it being pulled from television within a day. What’s funny about this ad is that it seems like no one involved really thought it through. They simply went ahead and ran the ad.

This shows an incredible failure of critical thinking and decision-making. It also demonstrates that the makers paid little attention to the feelings of diverse groups. Ultimately, this advert probably happened due to ideological conformity created by political correctness.

9. The Switch to “New Coke”

By the mid-80s, Coke was in big trouble. The company was rapidly losing market share to Pepsi and other drinks. For example, the root cause of their problems was the growing popularity of fruit juices and diet sodas. To counter this, the company devised an audacious marketing plan. It would reformulate its product and release it as “New Coke.”

As far as wrong decisions go, this was a major blunder. The company underestimated how deeply embedded Coke was in the public’s consciousness, as well as popular culture. Within days of release, customers bombarded the company with angry complaints. The company hotline received more than 1,500 calls per day. In addition to this, the Coca-Cola company also received large amounts of negative press and attention. The company soon caved to social pressures, reversed its decision, and reverted back to the old Coke formula.

10. The 2003 Invasion of Iraq

In 2003, a multi-country coalition chose to invade Iraq and topple Saddam Hussein. The reason given for this war was supposedly that Hussein was stockpiling WMDs. New evidence later showed that Hussein did not actually have any WMDs.

According to experts, this happened because intelligence agents needed to please their superiors. The people in charge wanted Saddam to have these weapons, so agents only supplied information confirming their biases. Regardless of this, the public and news media went along with the lie, and this helped to create support for the invasion. Another aspect was the idea that Saddam was planning to launch attacks with these weapons. This added the feeling of time pressure to the groupthink.

11. The Salem Witch Trials

This historical event provides an excellent groupthink definition and explanation. The Salem Witch Trials are also a fantastic example of mass hysteria. From February 1692 to May 1693, the town charged more than 200 people with witchcraft. Of these people, 20 were later executed. It’s interesting to note how the community reached a consensus, based on almost no evidence.

This more than likely happened because the community wanted to keep group cohesiveness and harmony in the town. It’s also a great example of how small groups of people can have an outsized influence when it comes to groupthink. According to historical sources, a small group of teenage girls (led by a 17-year-old called Elizabeth Hubbard) instigated the trials when they began accusing others of witchcraft.

12. Enron Collapse

On December 2, 2001, energy giant Enron filed for bankruptcy. How did this happen to a company with revenues of more than $100 billion? There were dozens of reasons why (the biggest being accounting irregularities), but another answer was groupthink. This is according to a book by former Enron employee Sherron Watkins. She claims that a small group of individuals controlled Enron and had complete control over the companies decision-making processes. This group believed that it was possible to increase profits quarter after quarter.

When the company began to fail, they refused to listen to differing viewpoints or consider alternative courses of action. The negative effects of these faulty decisions eventually began to accumulate and eventually led to the collapse of the company.

13. David Letterman Joins CBS

In 1992, talk show Johnny Carson decided to retire from The Tonight Show. At this point, the board of broadcaster NBC had a critical decision to make. They could either replace the host with Jay Leno or David Letterman. Company president Bob Wright’s personal views ultimately overrode majority opinion he decided to hire comedian Jay Leno.

This was a catastrophic choice. Letterman accepted a contract from rival CBS, launched The Late Show with David Letterman, and went into direct competition with NBC – eventually winning the war for ratings and advertising money. Examples like these are why many boards now select a person who plays devil’s advocate. This is essentially a member who argues against the group’s accepted opinion. Doing this helps these types of groups make better decisions.

14. 12 Angry Men

Juries can also fall victim to groupthink. Members may alter their own opinions for the sake of group cohesion. Some members may also do this because they want to seem like a team players.

According to studies, this also happens due to the status of some members. It’s been found that members with better jobs and education have a great amount of influence over lesser members and can persuade them to change their verdict. A great example of this is the movie 12 Angry Men.

15. The American Auto Industry

Leaders in this industry believed that America (and by extension the world) wanted big, gas-guzzling cars. In reality, it was the exact opposite. Consumers wanted a new look. They preferred smaller and more fuel-efficient cars. This need was soon fulfilled by Japanese automakers.

Despite all evidence to the contrary, the American auto industry stubbornly clung to this belief, only changing their views after losing significant market share to Japanese car manufacturers.

16. Doctors Recommending Smoking

Believe it or not, there was actually a time when smoking was seen as good for you or even healthy. Not only that, doctors advertised these cigarettes and recommended smoking for people with sore throats. These doctors were obviously a victim of groupthink and refused to alter their claims despite growing evidence that cigarettes caused health issues. It was only when the evidence became undeniable that these doctors reversed their claims.

What this example also shows us is how the use of experts can influence people.

17. The 2008 Financial Crises

There are dozens of reasons why the market crashed. One of these reasons was groupthink in the financial industry. The people involved in this industry refused to believe that anything could go wrong. House prices would continue to rise no matter what.

What actually happened was that an economic bubble steadily grew and eventually popped. This caused widespread devastation and financial ruin for many people.

18. The Lord of the Flies

Lord of the Flies is a 1954 novel by British author William Golding. It tells the story of a group of boys stranded on an island during a fictional World War 3. A social group in this type of group setting can quickly develop conformity for the sake of cohesion. Unsurprisingly, this quickly happens, and the boys soon descend into anarchy and chaos. An example of this is when a larger group of boys begins to victimize an overweight boy, culminating in his murder.

This book also demonstrates that the likelihood of groupthink greatly increases when you remove outside influences.

19. The Watergate Scandal

When the Washington Post broke Watergate, it caused a national scandal and led to Richard Nixon resigning. Some people have classified this event as an example of groupthink. This is because Nixon had an inner group of people who were fiercely loyal to him.

This group soon turned toxic and was no longer qualified to make good decisions. Isolated from dissenting opinions, they thought of themselves as invincible. The group also believed they were morally right and pressured other people to agree with them.

20. Nazi Germany

One symptom of groupthink is a fanatical need to carry out decisions made by the team leader, project manager, or person in charge (no matter how horrific these decisions are.) In the case of Nazi Germany, this is what clearly happened. Hitler used his understanding of group dynamics and above-average ability for public speaking to hold an entire nation in sway. This eventually led to the outbreak of World War 2, the deaths of millions of people, and different groups being oppressed.

21. Mean Girls

Mean Girls is a 2004 teenage comedy film that has since become a cult-classic. The film centers on a group of girls who come together to bully and ostracize another girl. This group of girls (known as The Plastics) routinely engage in groupthink. They follow their leader fanatically and blindly go along with anything she tells them to do.

The girls also believe that everything they do is right and discard their personal opinions. What’s more, they also believe that their actions are morally justified and are actually a good thing.

22. The Wave

The Wave is a 2008 film that explores the phenomena of groupthink and how it creates highly cohesive groups. Based on an in-class social experiment by the American teacher and author Ron Jones, this exercise helped to show students why Germans accepted the Nazi Party and fell beneath Hitler’s spell. In this experiment, Jones told students he was starting a fictional movement known as “The Third Wave.” He then took various beliefs held by the Nazi Party and passed these off as the aims of his movement.

For example, he explained to students that the eventual aim of the movement was to “eliminate democracy.” Accompanying this was a series of exercises and rules which students had to follow. One of these rules required that students stand up when answering questions and begin their answer by saying “Mr. Jones.” The experiment took place over five days, and each day added more rules and beliefs. On the fifth day, Ron told students that they were going to watch a video. This video then explained that they were part of a social experiment.

23. The Ice Bucket Challenge

What started out as a challenge to bring awareness to the motor neuron disease ALS soon spiraled into a terrifying example of groupthink. In this challenge, participants dumped a bucket of ice water over their heads and uploaded the video to social media.

This challenge quickly went viral, and millions of people took part, without really knowing what the purpose of the stunt was. And although groups like the ALS Association received millions in extra funding, most people had no idea that there were positive intentions behind this challenge. In the end, it became nothing more than a way to seek attention on social media.

24. Cancel Culture

“Cancel culture” is another blatantly obvious example of groupthink. This phenomenon embodies the worst aspects of this concept, including the total belief that the group is in the right. All it takes is one accusation, and an unthinking lynch mob will descend on you. Victims of cancel culture are convicted without trial and may have their careers, lives, and families destroyed. Worst of all, there’s almost nothing they can do about it. And yes, there are people who genuinely deserve cancellation, but many people are innocent victims.

One of the features of groupthink is that such groups often have exaggerated beliefs in their abilities. A good example of this is Mensa. Members of this group believe they are geniuses when in fact, many have only average intelligence. Their higher intelligence also makes them believe that whatever they think is right.

Some people actually believe that this organization is a scam. Considering that Mensa charges hefty membership fees, this could actually be true.

Groupthink can occur any time you involve a group of people in decision-making. This can have disastrous consequences for the group. The best way to avoid this phenomenon is to make yourself aware of it (studying the above examples will help.) It’s also important that you practice open-mindedness in your thinking and base your decisions on a variety of viewpoints. Also, avoid spending too much time with the group and seek outside advice.

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Teaching Online Pedagogical Repository

Create a Case Method Group Activity to Engage Students in Critical Thinking

Tags: Adult Learning , Assessment , Assignments , Blog , Case method , Cognitive Theory , Collaborative Learning , Community of Inquiry , Critical Thinking , Discussions , Experiential Learning , Google , Learning Activities , LMS , Problem-Based Learning , Scaffolding , Social Media , Video , Wiki

Description

The case method group activity is an instructional design strategy that involves faculty members providing one or more case studies to which groups of students respond. The case(s) could be a real-life case or simulation. It could be description of key concept(s) applied, a story or scenario, an actual case study, a problem or mystery, a performance, a visual, or an example.

The case method in online learning as an intervention presents students with ill-structured, real-world derived problems with multiple solutions (Choi & Lee, 2009). In a group activity this case method has the potential to harnesses the effectiveness of collaborative learning (Kolb, 1984) and group activities provide a space for collaborative problem solving, fostering a constructivist learning environment with potential to build a community of learning (Jonassen, 1997). The teaching facilitator can influence learners’ engagement in and adoption of the activity by communicating the relative advantage of key features of the online environment (Karamanos & Gibbs, 2012), as well as mapping and intervening in the group interactions to keep students focused on the problem (Etmer & Koehler, 2014). This mapping creates a plan for instructors to scaffold (or build in techniques to progressively support students to greater levels of learning independence and effective group interactions). Introduction of scaffolds and learning resources, perhaps additional readings and activities, presented at later stages of problem solving were associated with deep meaningful learning and critical thinking (Choi & Lee, 2009).

Because the case reflects a real-life situation, as the group members interact with each other, they should uncover multiple solutions, perspectives, or methods of analyzing the situation, with no single right answer. This divergence is important to encourage for fostering deeper levels of learning and critical thinking (Choi & Lee, 2009). A guiding question for the lesson can offer some parameters for faculty to map and scaffold activities, guiding students’ interactions as they engage with others in their groups about the case. This guiding question should depend on the purpose of the instruction (University of Illinois, 2015). The process of a faculty member scaffolding activities should result in more than one individual or group deliverable associated with it and a corresponding timeline for each. Consider, too, whether each component will have a group or individual grade (Carnegie Mellon University, 2015).

Link to example artifact(s)

As an example of the case method group activity, a faculty member teaching an industrial/organizational psychology course divided the students into groups based on time zones and created a discussion forum for each group. They completed a learning team charter to establish their group covenant. The parameters for the group activity were well-defined: students completed a group charter to agree on expectations for each member’s contribution to the group, the faculty provided an explanation of the purpose of the group activity for learning the material and succeeding in the course. The faculty explicitly stated how the quality of interactions and ideas derived from the group conversation and supported with evidence could contribute to the success of individual assignments.

The faculty provided the same case scenario across each group discussion forum. The case described in writing a company whose strict hierarchy and “us” (management) versus “them” (workers) mentality had led to a dysfunctional workplace environment with punitive acts from management and passive aggressive behaviors from employees. The faculty prompted students to analyze the situation using management and leadership approaches and theories from the course as a group by midway through the course, brainstorm as a group solutions to remedy the situation by applying key course concepts from middle to the end of the course, and submit an individual solution to the problem the case presented as the final assignment.

The faculty member interacted with each group several times throughout the course in their discussion forums, guiding them to consider important motivational and management theories (like Maslow’s hierarchy of needs and McGregor’s theory x and y) to analyze the behavioral dynamics of management and the employees in the case. Additionally, a rubric was associated with each component presented prior to the assignment to set expectations and utilized by the faculty member for grading. To assess critical thinking, elements from the AASU Value rubric were incorporated into the individual solution activity rubric (2017). Students were graded individually even though they were interacting as a group for their mid-course analysis of the scenario, as a group on the solution brainstorming activity for a group grade, and individually on their submissions of their individual solution to the case.

Students’ critical thinking improvements and favorable reaction provided good evidence for the success of the case scenario activities in this course. During the discussion, students often related the scenario to their own real-life experiences in workplace settings. As the discussions progressed, students began identifying these experiences with key concepts, referring and citing course content, and this habit transferred to their individual solutions to the case presented in their papers. Some students developed a clear thesis for their perspectives, recounting nuances of the situation in the scenario (such as the organizational structure and emerging management styles) to substantiate their position. Even fewer students gave multiple solutions and explained why one is better than another. Students generally responded positively to the course and case scenario format. They indicated that they appreciated the real-life examples from other students and expressed that the group discussion contributed development of their individual submissions. Satisfaction with the course, as indicated on students’ end-of-course reviews, was high to very high.

Applying this case method group activity strategy to other disciplines should result in similar success, strengthening students’ critical thinking skills. This strategy is definitely generalizable, as the aim is for students’ collaboration for achieving the course or module objective(s) associated with the activity/assignment (University of Illinois, 2015), guiding students to:

• Identify key concepts reflected by a case, • Situate a case within a given system, • Summarize or recapitulate a case, • Generalize patterns or symbolic representations within a case, • Generate plausible causes that result in a case, • Analyze the components of a case, • Assess or judge the appropriate application presented in a case scenario, • Solve a problem that the case presents or that the faculty presents about the case Any discipline where students would benefit cognitively from collaboration to achieve one of the above objectives could apply this strategy: create a case method group activity to engage students in critical thinking.

Individual Paper Case Study Rubric

Case Study Rubric for Group Collaboration Discussion

Instructor: Revathi Viswanathan Course: Biotechnology

Students were asked to discuss case studies relating to their subject, and Edmodo was used as a learning platform for handling them. The purpose of integrating the technological tool was to encourage students to actively participate in the teaching and learning process even beyond their classroom. Besides this, Edmodo, as an application could be accessed both in a computer and a mobile, which in turn helps teachers to post resources, initiate discussions, create small groups, and enroll students to do collaborative tasks.

As part of the classroom based research, the students were put in small groups, and inputs for case study was posted as video files and reading texts to each group in the Edmodo page. Each group was given guidance on holding case study discussions. The preliminary discussion was initiated through brainstorming questions, which encouraged students to get to the important issue or aspect of the case study. For example, the following questions were posted related to the case study on ‘ Regenerative medicine- Current therapies and future directions’:

• What do you know about regenerative medicine?
• How does it help common man?

Similarly, one of the groups discussed ‘Genetic Engineering of Animals: ethical issues, including welfare concerns’ and the following questions were asked:

• Discuss how ‘deletion of genes, or the manipulation of genes already present’ affects the animals.
• What do you think about this as a biotechnology student?

After a few dialogues online, it was felt that most of the students could not identify the main aspect of the case study and the teacher researcher had to intervene by posting guidelines for discussing a case study (Source: https://plato.acadiau.ca/courses/Busi/IntroBus/CASEMETHOD.html#CASEMETHOD ). They were told about the process by which a case study has to be analysed. They were asked to look for issues that are stated in the case study, critically read and see how the issue is handled in depth. Then, they had to look for opening paragraph, background information, specific area of interest covered, specific problem stated, alternatives given and the conclusion drawn from the discussion, in the case study.

Besides posting these tips for handling case studies, the teacher explained the components of a case study (stated above) in the class. It was felt that this online collaborative activity had to be handled by following the online collaborative theory advocated by Harasim (2012). According to her, a teacher plays an important role (in an online collaborative learning scenario) in the process of knowledge construction among students, by providing inputs and integrating the core concept along with the subject domain. In this context, it must be stated that the teacher researcher had already brought in the integration of biotechnology related case studies for discussion. However, considering the extent to which they could use the subject knowledge for discussing the given case study, it was evident that the students expected teacher’s intervention. In other words, the teacher had to draw their attention to the main issue of the case study by posting a few specific (case study related) questions.

For example, the group which was working on the case study, ‘Genetic engineering of animals’, were asked to focus on the specific concepts. The following question was posted in Edmodo group page:

• How does it affect an animal when it is genetically modified or genetically altered or genetically manipulated or transgenic, and biotechnology-derived
• How will the animal cope with when it is modified?

The extent to which the students of respective groups (group A & B) could discuss the case study by using their subject knowledge was evaluated by comparing two groups (both before-the-intervention and after-the-intervention of the teacher) using Causal-Comparative method. The analysis of performance of the group members was done with the help of the rubrics, ‘Undergraduate Case Analysis Rubrics’ (Source https://www.onlineethics.org/File.aspx?id=31203&v=859a7ffb ). The frequency polygon drawn for both groups (Figures 1 and 2) and the ANOVA test scores evaluated showed variation, particularly in group A’s performance (ie before and after teacher’s intervention).

It was evident that students’ application of subject knowledge in their discussion had promoted communicative ability. Further, it proved the application of online collaborative theory in encouraging students to contribute to online discussions.

Link to scholarly references

Association of American Colleges & Universities (2017). Critical thinking VALUE rubric. Retrieved from  https://www.aacu.org/value/rubrics/critical-thinking

Carnegie Mellon University Eberly Center (2015). How can I assess group work? Retrieved from  https://www.cmu.edu/teaching/designteach/design/instructionalstrategies/groupprojects/assess.html

Choi, I., & Lee, K. (2009). Designing and implementing a case-based learning environment for enhancing ill-structured problem solving: Classroom management problems for prospective teachers. Educational Technology Research and Development , 57( 1 ), 99-129.  https://doi.org/10.1007/s11423-008-9089-2

David, H. J. (1997). Instructional design models for well-structured and ill-structured problem-solving learning outcomes. Educational Technology Research and Development , 45( 1 ). Retrieved from  http://www.webkelley.com/HBS/ID%20Models%20for%20Well-Structured.pdf

Ertmer, P. A., & Koehler, A. A. (2014). Online case-based discussions: Examining coverage of the afforded problem space. Educational Technology Research and Development , 62( 5 ), 617-636.  https://doi.org/10.1007/s11423-014-9350-9

Jonassen, D. H. (1999). Designing constructivist learning environments. In C. M. Reigeluth I nstructional-design theories and models: Volume II (pp. 215-239). Mahwah, N.J: Lawrence Erlbaum Associates. Retrieved from  https://www.savoiabenincasa.gov.it/wp-content/uploads/2016/04/1999-Jonassen.pdf

Karamanos, N., & Gibbs, P. (2012). A model for student adoption of online interactivity. Research in Post-Compulsory Education , 17( 3 ), 321-334.  https://doi.org/10.1080/13596748.2012.700108

Kolb, D. (1984). Experiential learning: Experience as the source of learning and development . Englewood Cliffs, NJ: Prentice Hall. Retrieved from  https://www.pearson.com/us/higher-education/program/Kolb-Experiential-Learning-Experience-as-the-Source-of-Learning-and-Development-2nd-Edition/PGM183903.html

University of Illinois. (2015). Online teaching activity index: Case study or case based index. Retrieved from  www.ion.uillinois.edu%2Fresources%2Fotai%2Fcasestudies.asp&token=yz%2BG1QALcwhrBLaVIIOV1qkwVJCS27mZAH624RoGdAc%3D

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An Individual’s Thoughts on Group Thinking

Fast and Furious As I rode to my hockey game that night, I feared pressing submit. My banner – a video involving the whole grade – needed to be released.

Dierks Bentley came on the radio as my aggressive father veered in and out through traffic. We were late. Start of Something New When Dwayne Michael Carter Jr. wanted better representation in his accomplished musical career, he took it upon himself to create a company putting the interests of the artists first. In 2003, Carter, better known by his stage name Lil Wayne, while working alongside business associate Cortez Bryant, created the Young Money label.

We Will Write a Custom Case Study Specifically For You For Only $13.90/page!

Part of Cash Money Productions, owned by Universal, Wayne used his connections in the rap industry to sign budding new artists Curren$y and Boo in early 2004. Lost in Thought Having a thought is a journey in itself. Action potentiation veers through the neurons in the brain, trying to reach its final destination: the hippocampus. A tired mind means traffic on the expressway. This thought struggles to find shortcuts, meandering through foreign neighborhoods and traveling in all directions. Left and right turns, forward and backwards progression, even the occasional U-turn are all part of the voyage.

There are no posted signs giving directions, no hitchhikers on the side of the road with their thumb aimed skyward, no traffic cameras. Don’t get lost. Too Soon to Quit In 2011, Don Firke, head of the Latin School of Chicago, issued a statement that after the end of the season, the Latin Hockey program would be cut from Latin Athletics. Decreased participation, poor results and a spike in costs were the main reasons why the headmaster decided to end the program. A Facebook page, “Support Latin Hockey” was created by Pete Matias (’05) to provide a voice to the current students, parents, and alums in order to save the program.

In two months, over 70 responses were posted. These responses were each read in front of the board of trustees, the athletic director, and Mr. Firke himself in an effort to save the program. Blue Button I worked diligently on the lyrics for the banner, spending late nights listening to “BedRock”, trying to understand the tempo, the down beats and rhymes. Incorporating the class of 2017 into a song about drugs, sex and alcohol was risky; however, if it was executed well, I could go down as a legend.

The other grade rep had tasked me with the banner while she tended to more nit-picky activities like early morning meetings and constitution revisions. My task involved using the bland Google doc template to create the freshman banner for that years spring carnival. Never a creative one, I relied on RhymeZone for rhymes and RapGenius for lyrical interpretations as I molded our grade into four and a half minutes of previously explicit lyrics. So that night, as I began to be flustered with questions on what the banner would be, with a deadline looming so near that I calculated there was no chance we finish this in time, I stared blankly at my screen.

The navy blue ‘submit’ button shone effervescently at the bottom right corner of the screen, urging me to press it. I had all the lyrics in the textbox, evidence of the sleepless nights I had put into the process. Release Date After being leaked in September 2009 to Lil Wayne fan sites, “BedRock” was finally released on November 14, 2009. Approval Rating Just as my finger inched toward the screen, horns blared, and my father swerved out the way of a stalled truck pulled on the shoulder of the highway. I feared the reaction and critique of my classmates, but also yearned for their approval. My baggy hockey warm-ups coupled with my flaming hot seat warmer caused sweat to glaze over my body as I wondered if this was the right time.

I decided to press submit just before I got on the ice. Fast Lane The thought process is different if you are with others. Suddenly the thought has a police escort. Maps and GPS are now at its disposal. It travels forward at high speeds.

No stop signs to the right; no red lights above; nothing can stop it. An Unattended Phone I exited the rink after a great win. My line combined for 4 goals in a 5-3 win over Highland Park. I was momentarily cheerful before peering down at my phone. Two hours away from it resulted in over 75 notifications about my work.

While some of my classmates loved the work I had produced for the banner, I received a lot more negative feedback as my inbox was flooded with demeaning messages. I had no idea how to respond to all of these personal attacks, but at the same time I struggled to share my emotions with my family. I was afraid they would agree that the work I had produced was not ok, that my peers were making valid points. Teamwork Makes the Dream Work In December of 2009, Young Money, produced their freshman album, “We are Young Money” which included #1 song “BedRock.” The group’s work was very popular as it reached gold just five months after being released. Enemies to Teammates The Latin hockey team was saved after months of battles with the school.

Many have said that remarks made by players were the most powerful statements at the trial. Many were relieved to know that their voice The saved program opted to become a consortium for city hockey players. Now students from schools throughout the city were involved. Latin and Parker, Walter Peyton and Whitney Young, Northside and Lab: bitter rivals became teammates. Latin Hockey was the city’s team. Acting Like Everything is not OK What caught me by surprise the most was the collective hatred of my piece from the theatre department.

Many of the messages I received came from that group as if they were all conspiring against me. “As a theater homie I can speak for the group and say we are offended by a few of the lines.” New Friends The signing of both Drake and Nicki Minaj to Young Money’s label in 2008 was a major breakthrough for Young Money Entertainment. In the next five years, both produced No. 1 Billboard albums, Take Care and Pink Friday respectively. Additionally, both were important contributors to Lil Wayne’s first version of “BedRock.

” What’s on Your Back? Saving the program for some was a chance to show their attachment to the game. “When I step into an ice rink a chill runs up my spine because I am so excited to get on the ice. If hockey is taken away from Latin many people will lose the opportunity to play the game they love, and get a chance to wear that jersey that represents our school” • Matt Lucas Job Change I was forced to reconsider my banner. Due to the complaints, I reached out to the rest of the grade, asking for help from anyone interested. I was stripped of my role as chief lyricist and assigned to supervisor. I now had no say.

Putting Our Heads Together Social psychologist Irving Janis was the first to diagnose group thinking in 1972. He discovered that it most often occurs when a group is very tight-knit and under considerable pressure. Moreover, groups affected tend to ignore alternative solutions and often times act irrationally. Fifth Time’s the Charm There are five versions of “BedRock”. The artists that have been involved are Lil Wayne, Drake, Nicki Minaj, Lloyd, Gudda Gudda, Jae Millz, Tyga, Rasheeda, Omarion, Kandi, Diamond, Lola Monroe and Toya Wright.

Plebiscite A grade wide vote was held: “BedRock” was ousted by “Royals.” All my work and collaboration with classmates was for nothing as the final tally suggested the grade favored change. We were never able to come to a unanimous decision. Unity Saving the program for others was less for personal reasons. Latin Hockey was inclusive, taking in a wide breadth of talent levels.

Not everyone played because they loved the game, but they loved the team mentality: one for all, and all for one. “When commitment is coupled with students sacrificing their time for the respect of a team, an incredible sense of unity manifests itself. It would be a travesty to deny Latin students a rare opportunity to demonstrate their commitment to their school.” • Arielle Saporta Playing the Odds “Decisions shaped by groupthink have low probability of achieving successful outcomes.”

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• Open access
• Published: 10 May 2024

Community-based participatory-research through co-design: supporting collaboration from all sides of disability

• Cloe Benz   ORCID: orcid.org/0000-0001-6950-8855 1 ,
• Will Scott-Jeffs 2 ,
• K. A. McKercher   ORCID: orcid.org/0000-0003-4417-585X 3 ,
• Mai Welsh   ORCID: orcid.org/0000-0002-7818-0115 2 , 4 ,
• Richard Norman   ORCID: orcid.org/0000-0002-3112-3893 1 ,
• Delia Hendrie   ORCID: orcid.org/0000-0001-5022-5281 1 ,
• Matthew Locantro 2 &
• Suzanne Robinson   ORCID: orcid.org/0000-0001-5703-6475 1 , 5  

Research Involvement and Engagement volume  10 , Article number:  47 ( 2024 ) Cite this article

820 Accesses

Metrics details

As co-design and community-based participatory research gain traction in health and disability, the challenges and benefits of collaboratively conducting research need to be considered. Current literature supports using co-design to improve service quality and create more satisfactory services. However, while the ‘why’ of using co-design is well understood, there is limited literature on ‘ how ’ to co-design. We aimed to describe the application of co-design from start to finish within a specific case study and to reflect on the challenges and benefits created by specific process design choices.

A telepractice re-design project has been a case study example of co-design. The co-design was co-facilitated by an embedded researcher and a peer researcher with lived experience of disability. Embedded in a Western Australian disability organisation, the co-design process included five workshops and a reflection session with a team of 10 lived experience and staff participants (referred to as co-designers) to produce a prototype telepractice model for testing.

The findings are divided into two components. The first describes the process design choices made throughout the co-design implementation case study. This is followed by a reflection on the benefits and challenges resulting from specific process design choices. The reflective process describes the co-designers’ perspective and the researcher’s and organisational experiences. Reflections of the co-designers include balancing idealism and realism, the value of small groups, ensuring accessibility and choice, and learning new skills and gaining new insights. The organisational and research-focused reflections included challenges between time for building relationships and the schedules of academic and organisational decision-making, the messiness of co-design juxtaposed with the processes of ethics applications, and the need for inclusive dissemination of findings.

Conclusions

The authors advocate that co-design is a useful and outcome-generating methodology that proactively enables the inclusion of people with disability and service providers through community-based participatory research and action. Through our experiences, we recommend community-based participatory research, specifically co-design, to generate creative thinking and service design.

Plain language summary

Making better services with communities (called co-design) and doing research with communities (e.g. community-based participatory research) are ways to include people with lived experience in developing and improving the services they use. Academic evidence shows why co-design is valuable, and co-design is increasing in popularity. However, there needs to be more information on how to do co-design. This article describes the process of doing co-design to make telepractice better with a group of lived experience experts and staff at a disability organisation. The co-design process was co-facilitated by two researchers – one with a health background and one with lived experience of disability. Telepractice provides clinical services (such as physiotherapy or nursing) using video calls and other digital technology. The co-design team did five workshops and then reflected on the success of those workshops. Based on the groups’ feedback, the article describes what worked and what was hard according to the co-designers and from the perspective of the researchers and the disability organisation. Topics discussed include the challenge of balancing ideas with realistic expectations, the value of small groups, accessibility and choice opportunities and learning new skills and insights. The research and organisational topics include the need to take time and how that doesn’t fit neatly with academic and business schedules, how the messiness of co-design can clash with approval processes, and different ways of telling people about the project that are more inclusive than traditional research. The authors conclude that co-design and community-based participatory research go well together in including people with lived experience in re-designing services they use.

Peer Review reports

Introduction

Co-design has the potential to positively impact co-designers and their community, researchers, and organisations. Co-design is defined as designing with, not for, people [ 1 ] and can reinvigorate business-as-usual processes, leading to new ideas in industry, community and academia. As co-design and community-based participatory research gain traction, the challenges and benefits of collaborative research between people with lived experience and organisations must be considered [ 2 ].

Disability and healthcare providers previously made decisions for individuals as passive targets of an intervention [ 3 ]. By contrast, the involvement of consumers in their care [ 4 ] has been included as part of accreditation processes [ 4 ] and shown to improve outcomes and satisfaction. For research to sufficiently translate into practice, consumers and providers should be involved actively, not passively [ 4 , 5 ].

Approaches such as community-based participatory research promote “a collaborative approach that equitably involves community members, organisational representatives and researchers in all aspects of the research process” [ 6 ] (page 1). This approach originated in public health research and claims to empower all participants to have a stake in project success, facilitating a more active integration of research into practice and decreasing the knowledge to practice gap 6 . Patient and public involvement (PPI) increases the probability that research focus, community priorities and clinical problems align, which is increasingly demanded by research funders and health systems [ 7 ].

As community-based participatory research is an overarching approach to conducting research, it requires a complementary method, such as co-production, to achieve its aims. Co-production has been attributed to the work of Ostrom et al. [ 8 ], with the term co-design falling under the co-production umbrella. However, co-design can be traced back to the participatory design movement [ 9 ]. The term co-production in the context of this article includes co-planning, co-discovery, co-design, co-delivery, and co-evaluation [ 10 ]. Within this framework, the concept of co-design delineates the collaborative process of discovery, creating, ideating and prototyping to design or redesign an output [ 11 ]. The four principles of co-design, as per McKercher [ 1 ], are sharing power, prioritising relationships, using participatory means and building capacity [ 1 ]. This specific method of co-design [ 1 ] has been used across multiple social and healthcare publications [ 10 , 12 , 13 , 14 ].

A systematic review by Ramos et al. [ 15 ] describes the benefits of co-design in a community-based participatory-research approach, including improved quality and more satisfactory services. However, as identified by Rahman et al. [ 16 ], the ‘ why ’ is well known, but there is limited knowledge of ‘ how ’ to co-design. Multiple articles provide high-level descriptions of workshops or briefly mention the co-design process [ 13 , 17 , 18 , 19 ]. Pearce et al. [ 5 ] include an in-depth table of activities across an entire co-creation process, however within each part i.e., co-design, limited descriptions were included. A recent publication by Marwaa et al. [ 20 ] provides an in-depth description of two workshops focused on product development, and Tariq et al. [ 21 ] provides details of the process of co-designing a research agenda. Davis et al. [ 11 ] discuss co-design workshop delivery strategies summarised across multiple studies without articulating the process from start to finish. Finally, Abimbola et al. [ 22 ] provided the most comprehensive description of a co-design process, including a timeline of events and activities; however, this project only involved clinical staff and did not include community-based participation.

As “We know the why, but we need to know the how-to” [ 16 ] (page 2), of co-design, our primary aim was to describe the application of co-design from start to finish within a specific case study. Our secondary aim was to reflect on the challenges and benefits created by specific process design choices and to provide recommendations for future applications of co-design.

Overview of telepractice project

The case study, a telepractice redesign project, was based at Rocky Bay, a disability support service provider in Perth, Australia [ 23 ]. The project aimed to understand the strengths and pain points of telepractice within Rocky Bay. We expanded this to include telepractice in the wider Australian disability sector. The project also aimed to establish potential improvements to increase the uptake and sustainability of Rocky Bay’s telepractice service into the future. Rocky Bay predominantly serves people under the Australian National Disability Insurance Scheme (NDIS) [ 24 ] by providing a variety of services, including allied health (e.g. physiotherapy, dietetics, speech pathology, etc.), nursing care (including continence and wound care), behaviour support and support coordination [ 23 ]—Rocky Bay services metropolitan Perth and regional Western Australia [ 23 ].

The first author, CB, predominantly conducted this research through an embedded researcher model [ 25 ] between Curtin University and Rocky Bay. An embedded researcher has been defined as “those who work inside host organisations as members of staff while also maintaining an affiliation with an academic institution” [ 25 ] (page 1). They had some prior contextual understanding which stemmed from being a physiotherapist who had previously delivered telehealth in an acute health setting. A peer researcher, WSJ, with lived experience of disability, worked alongside CB. They had no previous experience in research or co-design, this was their first paid employment and they had an interest in digital technology. Peer Researcher is a broad term describing the inclusion of a priority group or social network member as part of the research team to enhance the depth of understanding of the communities to which they belong [ 26 ]. Including a peer researcher in the team promoted equity, collective ownership, and better framing of the research findings to assist with connecting with people with lived experience. These outcomes align with key components of community-based participatory research and co-design [ 27 , 28 , 29 , 30 ].

Person-first language was used as the preference of experts with lived experience who contributed to this research to respect and affirm their identity. However, we respect the right to choose and the potential for others to prefer identity-first language [ 31 ].

A summary of the structure of the phases completed before co-design workshops are represented in Fig.  1 below. Ethical approval for the project was received iteratively before each phase on the timeline (Fig.  1 ) from the Curtin Human Research Ethics Committee (HRE2021-0731). The reporting of this article has been completed in line with the Guidance for Reporting Involvement of Patients and the Public (GRIPP2) checklist [ 7 ].

Summary of telepractice co-design project structure [ 1 ]

Here, we present an outline of the chosen research methods with descriptions of each process design choice and supporting reasons and examples specific to the study. The format is in chronological order, with further details of each step provided in Appendix 1 (Supplementary Material 1).

Methods and results

Process of co-production and preparation for co-design.

Co-production was chosen as the planning method for the study, as the inclusion of community members (Rocky Bay Lived experience experts and Staff) in each step of the research process would increase buy-in and make the research more likely to meet their needs [ 5 ]. An example of co-planning (part of co-production) includes the study steering committee, with a lived experience expert, clinician and project sponsor representatives collaborating on the selection of study aim, methods and recruitment processes. Another example of co-planning, co-design, and co-delivery was recruiting a peer researcher with disability, who worked with the embedded researcher throughout the study design and delivery.

The second process design choice was to attempt to build safe enough conditions for community participation, as people who feel unsafe or unwelcome are less likely to be able to participate fully in the research [ 1 ]. Building conditions for safety was applied by repeatedly acknowledging power imbalances, holding space for community input, and anticipating and offering accessibility adjustments without judgment.

Getting started

Understanding and synthesising what is already known about telepractice experiences and learning from lived experience was prioritised as the first step in the process. We paired a scoping review of the literature with scoping the lived experiences of the community [ 32 ]. Our reasoning was to understand whether the findings aligned and, secondly, to learn what had already been done and to ask what was next, rather than starting from the beginning [ 1 ]. Examples of strategies used in this step included interviewing clinicians and service provider Managers across Australia to establish how they implemented telepractice during the pandemic and understand their views of what worked and what did not. The second learning process occurred onsite at Rocky Bay, with people with lived experience, clinicians and other support staff, whom the embedded researcher and peer researcher interviewed to understand experiences of telepractice at Rocky Bay.

The authors presented the interview findings during focus groups with Rocky Bay participants to share the learnings and confirm we had understood them correctly. The groups were divided into staff and lived experience cohorts, allowing for peer discussions and sharing of common experiences. This helped build relationships and a sense of familiarity moving into the workshop series.

Co-design workshops

This section outlines specific components of the co-design workshop preparation before describing each of the five workshops and the final reflection session.

Staff and community co-designers

Two process design choices were implemented to form the co-design group. The first was to prioritise lived experience input as there are generally fewer opportunities for lived experience leadership in service design [ 16 ], and because the disability community have demanded they be included where the focus impacts them [ 33 ]. To acknowledge the asymmetry of power between community members, people with lived experience of disability and professionals, we ensured the co-design group had at least the same number of lived experience experts as staff.

The second priority for the co-design group was to include people for whom involvement can be difficult to access (e.g. people who are isolated for health reasons and cannot attend in-person sessions, people who live in supported accommodation, part-time staff, and people navigating the dual-role of staff member while disclosing lived experience). It was important to learn from perspectives not commonly heard from and support equity of access for participants [ 4 ].

Workshop series structure

When structuring the workshop series, lived experience co-designers nominated meeting times outside standard work hours to reduce the impact of co-design on work commitments and loss of income while participating. The workshops were designed to be delivered as a hybrid of in-person and online to give co-designers a choice on how they wanted to interact. The workshops were designed as a series of five sequential 90-minute workshops, where co-designers voted for the first workshop to be predominantly in-person and the remainder of the workshops online. Some co-designers chose to attend the initial session in person to build rapport. However, the virtual option remained available. The subsequent online sessions reduced the travel burden on co-designers, which the co-designers prioritised over further face-to-face meetings.

Workshop facilitators

To maintain familiarity and ensure predictability for co-designers, the workshops were co-facilitated by the embedded researcher and peer researcher. The co-facilitators built on relationships formed through previous interactions (interviews and focus groups), and each facilitator represented part of the co-designer group as a clinician or a person with disability. An extra support person was tasked with supporting the co-designers with disability to break down tasks and increase the accessibility of activities. The reason for selecting the support person was that they could contribute their skills as a school teacher to support the communication and completion of activities, and they had no previous experience with disability services to influence the co-designers opinions. This role was adapted from the provocateur role described by McKercher [ 1 ].

Pre-workshop preparations

To prepare for the workshops, each co-designer was asked to complete a brief survey to ensure the co-facilitators understood co-designers collect preferences and needs ahead of the session to enable preparation and make accommodations. The survey included pronouns, accessibility needs and refreshment preferences. Following the survey, the co-facilitators distributed a welcome video; the peer researcher, a familiar person, was videoed explaining what to expect, what not to expect and expected behaviours for the group to support a safe environment [ 1 ]. This process design choice was made to allow co-designers to alleviate any potential anxieties due to not having enough information and to increase predictability.

Workshop resources and supports

As the first workshop was in-person, specific process choices were made to ensure co-designers felt welcome and to uphold the dignity of co-designers with lived experience [ 34 ]. Examples of process design choices include facilitating transport and parking requests, providing easy access to the building and room, making a sensory breakout room available and having the peer researcher waiting at the entrance to welcome and guide people to the workshop room.

After reaching the workshop room, all co-designers received an individualised resource pack to equalise access to workshop materials, aiming again to balance power in a non-discriminatory way [ 11 ]. The resource pack included name tags with pronouns, individualised refreshments, a fidget toy [ 35 ] whiteboard markers and a human bingo activity described in a later section. An easy-to-apply name tag design was selected after consulting a co-designer with an upper limb difference. Further details on the resource packs are included in Appendix 1 (Supplementary Material 1).

Enabling different kinds of participation

We provided non-verbal response cards to each co-designer as communication preferences vary significantly within the disability community. The cards were intended to benefit any co-designer who struggled to use the response buttons on MS teams. The co-facilitators co-created the Yes, No, and In-the-middle response cards (Fig.  2 ) and were guided by recommendations by Schwartz and Kramer [ 29 ]. They found that people with intellectual disability were more likely to respond “yes” if the negative option included a frowning face or red-coloured images, as choosing these types of alternatives was perceived as being negative or would cause offence [ 29 ].

Non-verbal response cards

A summary of the structure and purpose of each of the five workshops is shown in Fig.  3 , followed by a more in-depth discussion of the strategies employed in each workshop.

Outline of workshop and group structures

Workshop 1: the beginning

Human Bingo was the first workshop activity, as it aimed to support relationship building in an inclusive way for both in-person and online attendees. The activity asked each co-designer to place a name in each worksheet box of someone who fit the described characteristic of that square(for example, someone who likes cooking). To include the two online attendees, laptops were set up with individual videocall streams and noise cancelling headphones enabling the online co-designers to interact one-on-one with others during the activities.

The second activity used The Real Deal cards by Peak Learning [ 36 ] to ask the co-designers to sort cards to prioritise the top five experiences and feelings they would want in a future version of telepractice. This activity aimed to set initial priorities for the redesign of telepractice [ 1 ]. Small groups with a mix of lived experience experts and staff were tasked with negotiating and collaborating to produce their top five desired experiences and feelings for future service success.

A follow-up email was sent after the session to thank co-designers, provide closure, invite feedback and let co-designers know what to expect from the next session.

Workshop 2: mapping the journey

In the second workshop, held online, the co-facilitators explained the journey mapping process and showed a draft of how the visual representation would likely look (Fig.  4 ). As the first step, co-designers were tasked with completing a series of activities to analyse lived experience interview data on the current experience of telepractice for lived experience experts. Small mixed groups were created, prioritising the needs of the lived experience experts to have staff who would be the best fit in supporting them to work through the task [ 1 ]. The small groups were allocated interview quotes corresponding to the steps of a customer journey through telepractice and asked to identify strengths, challenges and emotions associated with the current Telepractice service journey at Rocky Bay [ 1 ]. Further details on the journey map analysis are described in Appendix 1 (Supplementary Material 1) and in a published article co-authored by the co-designers (Benz et al. [ 37 ]).

Draft journey map visualisation

After workshop two, the embedded researcher drafted a journey map by compiling the co-designer group responses to the analysis activity, which was then circulated for feedback and confirmation. The completed journey map is published with further details on the process in an article co-authored with the co-designers, Benz et al. [ 37 ].

Workshop 3: ideas for addressing pain points

For the third workshop, the co-facilitators selected activities to be completed separately by lived experience and staff co-designers. The lived experience expert activity involved exploring preferences for improving pain points identified through the journey map. The lived experience expert activity was facilitated by the peer researcher and support person and included questions such as, how would it be best to learn how to use telepractice? Visual prompt cards were shared to support idea creation, where lived experience expert co-designers could choose any option or suggest an alternative (Fig.  5 ).

Option cards for Lived experience expert co-designer workshop activity

Simultaneously, the staff co-designers completed a parallel activity to address pain points from a service delivery point of view. These pain points were identified in the clinical and non-clinical staff interviews and from the journey map summary of lived experience expert interviews (analysed in Workshop 2). Staff co-designers completed a mind map based on service blueprinting guidelines by Flowers and Miller [ 38 ]. The activity used service blueprinting to identify a list of opportunities for improvement, with four prompts for co-designers to commence planning the actions required to implement these improvements. The foci of the four prompts were roles, policies, technology and value proposition [ 38 ] (described further in Appendix 1 (Supplementary Material 1)). Each of the four prompts were completed for the ten proposed opportunities for improvement to draft plans for future telepractice service delivery.

Workshop 4: story telling and generation of future state solutions

In the fourth workshop, we introduced the concept of prototyping [ 39 ] as a designerly way to test co-designers’ ideas for improving telepractice according to desirability, feasibility and viability with a wider audience of lived experience experts and staff. The co-designers helped to plan the prototyping, and accessibility was a key consideration in selecting a prototype, as the group were conscious of the target audience.

Creating the prototype was collaborative, allowing co-designers to produce an output representing their ideas. They selected a video storyboard prototype with a staff and customer version formatted similarly to a children’s book. It included cartoon animations completed on PowerPoint, voiceover narration, closed captioning and an introductory explanation from two co-designers.

After workshop four, the co-designers collaborated on the customer and staff prototypes during the two weeks between workshops four and five, with support and input from the facilitators. The prototype files were co-produced, with different co-designers working on the visual aspects, the script for the main audio narration and the introductory explanation.

Workshop 5: finishing the story

The co-design group reviewed the draft prototypes in the final workshop, with specific attention paid to the story’s cohesiveness.

The feedback questionnaire was then created to be completed by viewers outside of the co-design group after engaging with either the staff or the customer prototype. The survey allowed Rocky Bay customers and staff to contribute ideas. Following thoughtful discussions, consensus was reached by all co-designers on the final survey questions (Appendix 2 (Supplementary Material 1)).

A reflection activity concluded the final workshop, allowing co-designers to provide feedback on the co-design process, elements for improvement and aspects they valued in participating in the project. Their reflections on the benefits and challenges of co-design in this study are included in the section Co-designer’s perspectives of the workshop series , with the reflection questions included in Appendix 3 (Supplementary Material 1).

Post prototype reflection session

The prototype feedback responses were reviewed with co-designers in a final reflection session. The group then discussed adaptations to the implementation plan for proposal to Rocky Bay. Following the survey discussion, co-designers reviewed proposed service principles for the new telepractice implementation recommendations. These principles aim to align any future decisions in the implementation and service provision stages of the telepractice project with the intentions of the co-designers. An additional reflection activity was completed, specific to the telepractice proposal they had produced and the prototyping process. Feedback relevant to subsequent discussions of the challenges and benefits of co-design is included in the following section: Co-designer’s perspectives of the workshop series , with the reflection prompts in Appendix 3 (Supplementary Material 1).

Benefits and challenges

Learnings derived from completing a study of this kind are complex. However, it is necessary to reflect on which strategies used in the project were beneficial and which strategies created challenges - anticipated and unexpected. These reflections are discussed in two sections, the first being the challenges and benefits reflected upon by co-designers. The second set of reflections relates to organisational and research project-level benefits and challenges from the perspective of clinical department managers and researchers involved in the project.

Co-designer’s perspectives of the workshop series

Co-designers were positive overall about the workshop series. Responses to a prompt for one-word descriptors of their experience included “captivating, innovative, fulfilling, exciting, insightful, helpful, eye-opening and informative ” .

Co-designing as a team

A foundational strategy implemented in this project was the intentional collaboration of lived experience experts with staff; this linked to the co-design principle of prioritising relationships and sharing power. Multiple reflections commented on feeling like a team and that having diverse perspectives across the group was beneficial.

It was especially interesting to hear the perspective of clinicians (for us, the other side of Telepractice). [Lived experience expert Co-designer]

Additionally, the combination of facilitators, including an embedded researcher with an allied health clinical background, a peer researcher with lived experience and a support person with strengths in breaking down tasks, provided different facets of support and task modelling to the co-designers throughout the process.

Balancing idealism and realism

There is an inherent challenge in collaboration between lived experience experts and service providers, whereby co-designers formulate ideas for service improvement and then, in good faith, propose required changes to be implemented. Strategies to support imagination and idealism while being honest about the constraints of what can be delivered were implemented in the context of this project. This was essential to reinforce to co-designers that their contributions and ideas are valid while tempering their hopes with the truth that organisational change is challenging and funding for change is limited. Co-designers were encouraged to be cognisant of ideas that would require high investment (cost and time) and which ideas faced fewer barriers to implementation. This strategy did not prevent the ideation of changes and prioritising what mattered most to them, and co-designers felt it was beneficial in adding a level of consideration regarding what investments they deemed necessary versus those that would be nice to have. For example, having a person to call for help was viewed as necessary, while a nice to have was more advanced technological features.

I feel that the prototype is useful; however, I worry that nothing will be carried over to the Rocky Bay Service. I feel like more customers will want to access telepractice, and Rocky Bay now needs to start the implementation process to ensure that telepractice is utilised, including processes, education and training. [Clinician Co-designer]

The value of small groups

Working in small groups was another beneficial strategy, aiming to create a more hospitable environment for co-designers to voice their thoughts. The small groups varied across activities and workshops, with facilitators intentionally pairing groups that would best support the lived experience of expert co-designers completing activities. As described in the workshop sections, some activities suited mixed groups, whereas others suited lived experience expert and staff-specific groups. Two reflective comments demonstrated the benefit of the small groups, one from a clinician who reflected on supporting a fellow co-designer:

I found that in our group, all of us had a say; however, [Lived Experience Co-designer name] was a bit overwhelmed at times, so I tried to support her with that. [Clinician Co-designer]

And a lived experience expert co-designer additionally reflected:

The breakout rooms were a very good idea. It can be quite intimidating speaking in front of the main group. I found it much easier to participate in the smaller groups . [Lived experience expert Co-designer]

The second session included an unplanned whole group activity, which challenged co-designers. Co-designers reflections of this experience demonstrate the benefits of smaller groups:

I did feel that at the end when the whole group did the task, there wasn’t as much collaboration as there were quite a few more assertive participants, so the quieter ones just sat back. [Clinician Co-designer]

Accessibility and choice

A challenge navigated throughout the workshop series with a diverse group of co-designers was meeting their varying individual health and other needs. This required responding in sensitive, non-judgemental, and supportive ways to encourage co-designers to engage fully. Examples of support include the presence of a support person and adaption of resource packs for co-designers who have difficulty swallowing (re: refreshments), as well as the previously mentioned non-verbal response cards and accessible name tags.

Accessibility supports were also provided for the peer researcher during facilitation activities, including pre-written scripts to provide clarity when explaining tasks to the co-design group, written reminders and regular check-ins. A lived experience expert co-designer reflected that it was beneficial that they could tell the peer researcher was nervous but appreciated that he was brave and made them feel like they did not need to be perfect if the peer researcher was willing to give it a go.

When facilitating the sessions, the embedded researcher and peer researcher identified that the workshops were long and, at times, mentally strenuous. One co-designer requested “more breaks during each session” . Breaks were offered frequently; however, upon reflection, we would schedule regular breaks to remove the need for co-designers to accept the need for a break in front of the group. The instructions for each activity were visual, verbal and written and given at the start of a task. However, once the co-designers were allocated to breakout rooms, they could no longer review the instructions. Many co-designers suggested that having the instructions in each breakout room’s chat window would have been a valuable visual reminder.

One thing I think might of helped a little is having the instructions in the chat as I know I that I listened but couldn’t recall some of the instructions for the group task. [Lived experience expert Co-designer]

Learning new skills and gaining new insight

The co-designers considered that the benefits of working together included learning new skills and widening their understanding of research, the services they provide or use, and the differences between the priorities of lived experience experts and staff. Two lived experience experts commented that the opportunity to learn collaboration skills and create cartoons using PowerPoint were valuable skills for them to utilise in the future. One clinician reflected that the process of co-design had improved their clinical practice and increased their use of telepractice:

My practice is 100% better. I am more confident in using telepractice and more confident that, as a process, it doesn’t reduce the impact of the service- in some ways, it has enhanced it when customers are more relaxed in their own environments. I have not seen my stats, but my use of telepractice has increased significantly, too. [Clinician Co-designer]

The management co-designer acknowledged that although ideas across the group may be similar, prioritisation of their importance can vary dramatically:

Whilst all the feedback and potential improvements were very similar, some things that I viewed as not an issue, was very different to a customer’s perspective. [Management Co-designer]

Overall, the workshop series challenged co-designers. However, the provision of a supportive and accessible environment resulted in mutual benefits for the research, organisation, and co-designers themselves. The strategy for facilitating the workshops was to pose challenges, support the co-designers in rising to meet them, and take into account their capabilities if provided with the right opportunity. A lived experience expert co-designer summarised the effectiveness of this strategy:

I found the activities to be challenging without being too difficult. Each activity provided enough guidance and structure to encourage interesting group discussions and make collaboration easy. [Lived experience expert Co-designer]

Research and organisational reflections of benefits and challenges of co-design

A significant challenge in completing this project was that building foundational relationships and trust takes time. While the authors view this trust as the foundation on which community-based participatory research and co-design are built, they note the direct tension of the time needed to develop these foundational relationships with the timeline expectations of academic and organisational decision-making. The flexibility required to deliver a person-centred research experience for the co-designers resulted in regular instances when timeline extensions were required to prioritise co-designer needs over efficiency. The result of prioritising co-designer needs over research timeline efficiency was an extended timeline that was significantly longer than expected, which sometimes created a disconnect between the flexibility of co-design and the rigidity in traditional academic and organisational processes.

The impacts of a longer-than-expected timeline for completion of the co-design process included financial, project scope, and sponsorship challenges. The project’s initial scope included a co-implementation and co-evaluation phase; however, due to the three-year time constraint, this was modified to conclude following the prototyping process. Whilst the three-year period set expectations for project sponsors and other collaborators from Rocky Bay, the wider context for the project varied significantly and rapidly over this period. This included two changes in Rocky Bay supervisor and one change in Rocky Bay project sponsor. Additionally, one of the academic supervisors left Curtin. This challenge indicates that the project would benefit from key role succession planning.

The peer researcher role was beneficial in providing an opportunity for a person with lived experience to join the study in a strength-based role and experience academic and business processes. However, challenges arose with the timeline extensions, which required this part-time, casual role to be extended by seven months. While the contract extension posed budgetary challenges, the role was viewed as vital to the completion of the project.

While an essential component of research, particularly involving vulnerable populations, ethical approvals proved challenging due to the non-traditional research methods involved in co-design. It was evident to the authors that while the ethics committee staff adhered to their processes, they were bound by a system that did not have adequate flexibility to work with newer research methods, such as co-design. Multiple methods in this study were heavily integrated into the community, including embedded research, peer research and co-design.

The present ethics process provided a comprehensive review focusing on planned interactions within research sessions (e.g. interviews and workshops). Unfortunately, this failed to account for a wider view, including the initial co-production prior to ethical application and anecdotal interactions that occurred regularly in the organic co-design process. In addition to the repeated submissions required to approve the sequential study format, these interactions created a significant workload for the research team and ethics office. These challenges were compounded by the need to navigate Rocky Bay’s organisational processes and changing business needs within ethical approval commitments.

In the authors’ opinion, prioritising the inclusion of lived experience experts in co-creating outputs to disseminate findings was beneficial. The co-creation enabled an authentic representation of the study to audiences regarding community-based participatory research and co-design method implementation. For example, the presentation of a panel discussion at a conference in which the peer researcher could prerecord his responses to questions as his preferred method of participation. All posters presented by the project were formatted to be accessible to lay consumers and were collaboratively produced, with the additional benefit of the posters being displayed across Rocky Bay hubs for customers and staff to gain study insights.

Due to the co-design method’s dynamic nature, some budgetary uncertainty was challenging to navigate. However, financial and non-financial remuneration for all non-staff participants in the project was prioritised. As previously discussed, the position of peer researcher was a paid role; additionally, all lived experience expert participants were remunerated at a rate of AUD 30/hour in the form of gift cards. The carer representative on the steering committee recommended using gift cards to avoid income declaration requirements from government benefits people may receive. Non-financial remuneration for the valuable time and contribution of the co-designer group included co-authorship on an article written regarding the Journey Map they produced (Benz et al. [ 37 ]) and acknowledgement in any other appropriate outputs. The implementation proposal provided to Rocky Bay included recommendations for continued inclusion and remuneration of co-designers.

Setting a new bar for inclusion

Another benefit to reflect upon, which may be the most significant legacy of the project, was setting the precedence for the inclusion of people with disability in decision-making roles in future projects and research conducted by the University and Rocky Bay. After this project commenced, other Rocky Bay clinical projects have similarly elevated the voices of lived experience in planning and conducting subsequent quality improvement initiatives.

I’m lucky enough to have been part of a lot of projects. But I guess I probably haven’t been a part of continuous workshops, pulling in all perspectives of the organisation perfectly… So, collaboration and getting insight from others I haven’t usually was a very unique experience, and I definitely found value if this were to continue in other projects. [Manager Co-designer]

In summary, the findings from using a co-design method for the telepractice research study produced a series of benefits and presented the researchers with multiple challenges. The findings also addressed a literature gap, presenting in-depth descriptive methods to demonstrate how co-design can be applied to a specific case.

Drawn from these findings, the authors identified six main points which form the basis of this discussion. These include (1) the fact that the necessary time and resources required to commit to co-design process completion adequately were underestimated at the outset, (2) there is a need to support the health, well-being and dignity of lived experience expert participants, (3) academic ethical processes have yet to adapt to address more participatory and integrated research methods, (4) strategies used to foster strong collaborative relationships across a diverse group were valued by all participants, (5) better delineation between terminologies such as co-design and community-based participatory research or patient and public involvement would improve the clarity of research methods and author intent and, (6) broader non-traditional impacts that participatory research can create should be better quantified and valued in the context of research impact. Each point will now be discussed in further detail.

In underestimating the time and resources required to complete the telepractice study, a scope reduction was required. This scope reduction removed the study’s originally planned co-implementation and co-evaluation phases. While Harrison et al. [ 40 ] and Bodden and Elliott [ 41 ] advocate for more frequent and comprehensive evaluation of co-designed initiatives, the authors acknowledge that this became no longer feasible within the study constraints. A growing body of literature indicates expected timelines for completed co-production projects from co-planning to co-evaluation. An example by Pearce et al. [ 5 ] indicated that a timeline of five years was reasonable. In contrast, a more limited co-design process was completed with a shorter timeline by Tindall et al. [ 13 ]. Although neither of these articles were published when this study commenced, they are complementary in building an evidence base for future research to anticipate an adequate timeline.

While co-design and other co-production processes are resource and time-intensive, the investment is essential to prioritise the health and other needs of potentially vulnerable population groups in the context of an imbalance of power [ 42 ]. In exploring the concept of dignity for people with disability, Chapman et al. [ 34 ] indicated that recognising the right to make decisions and proactively eliminating or minimising barriers to inclusion are key to protecting dignity. Community participation in decision-making processes such as this study can result in messy and unpredictable outcomes. However, the onus must be placed on policymakers, organisations, and academia to acknowledge this sufficiently rather than demand conformity [ 15 ].

The authors posit that the study would have benefited from an alternative ethics pathway, which may provide additional required flexibility while upholding the rigour of the ethical review process. The increasing frequency of participatory research studies indicates that challenges experienced by the authors of this study are unlikely to be isolated. Lloyd [ 43 ] described challenges regarding information gathered in-between, before and after structured research sessions, reflecting that they relied on personal judgement of the intent to consent for research use. Similarly, Rowley [ 44 ] reflected on the ethical complexities of interacting with families and respecting their confidentiality within the context of being integrated within an organisation. While these studies were co-production in child protection and education, the ethical challenges of their reflections parallel those experienced in the telepractice study. The risks posed by inadequate ethical support in these contexts are that increased poor ethical outcomes will occur, especially in the in-between times of co-design. Therefore, an ethics pathway that involves more frequent brief liaisons with a designated ethics representative to update project progress and troubleshoot ethical considerations may better support researchers to safeguard study participants.

We believe the decision to complete a sequential workshop series with a consistent group of diverse co-designers, led by co-facilitators, was a strength of the co-design process implemented in the telepractice re-design project. The group worked together across a series of workshops, which enabled them to build solid working relationships. Pearce et al. [ 5 ], Rahman et al. [ 16 ] and Tindall et al. [ 13 ] also demonstrated a collaborative whole-team approach to co-design. By contrast, studies that involved separate workshops with different cohorts or multiple of the same workshop did not demonstrate strong collaboration between co-designers [ 18 , 19 , 20 ]. Nesbitt et al. [ 19 ] explicitly highlighted that they would improve their method by completing sequential workshops with a continuous cohort. Stephens et al. [ 45 ] found that small mixed groups were not sufficient to support the participation of people with disability, indicating that the choice to intentionally balance groups to meet the lived experience expert co-designer’s needs may have been an impacting factor on our success.

A lack of clarity in the terminology used in co-design and community-based participatory practice was identified during the completion of this study. We found that co-design frequently meant either a collaborative design process or good participatory practices [ 46 ]. When viewing the structure of the telepractice re-design project, the overarching research approach was community-based participatory-research, and the method was co-design [ 9 ]. The delineation between the overarching approach and methods clarifies the misappropriation of the term co-design with the intent of meaning public participation [ 46 ] rather than the joint process of creative thinking and doing to design an output [ 11 ]. The use of the two-level structure appears more prominent in the United Kingdom, whereas Fox et al. [ 47 ] systematic review assessing public or patient participants identified that 60% of studies originated from the United Kingdom, compared to the next highest 16% for Canada or 4% from Australia and the United States. To improve clarity and reduce confusion about the terminology used, the authors advocate for greater awareness and implementation of the delineation between the concepts of a community-based-participatory-research/patient or public involvement approach versus the co-design method.

An example of co-design being used where alternate terms such as community-based participatory processes (or research) may be more relevant was the most recent amendment to the act governing the NDIS under which this project resided [ 48 ]. The term co-design could be interpreted as an intent to collaborate with people with disability for equitable involvement in all aspects of the NDIS [ 48 ]. It is proposed that the differentiation of these terms would assist in clarifying the intent of the study and dissuade inaccurate expectations of community involvement or design processes.

Implementing community-based participatory research has demonstrated the potential to create an impact that expands further than the original aim of the study. The skills learned by co-designers, the learning of the research team in collaboration with people with disability, the engagement and skill-building of a peer researcher with lived experience, the organisations who engaged in the co-design process and the academic and lay people who engaged with research outputs, all carry a piece of the impact of the co-design process. Rahman et al. [ 16 ] contend that co-design processes positively impact communities. In the context of this study, the peer researcher was included in the National Disability Insurance Agency’s quarterly report as an example of strength-based employment opportunities, which significantly positively impacted his career prospects [ 49 ]. This project provided skills for people with disability that they value and improved the clinical practice of clinician co-designers, which echoes the conclusions of Ramos et al. [ 15 ], who described that participants felt valued and experienced improved self-esteem. There is additional intent from the authors to positively impact disability providers and academia, to advocate for greater collaboration, and to provide open-access publications to provide a stronger evidence base for co-design in clinical practice and service delivery.

Strengths and limitations

The study provides reflective evidence to support the challenges and benefits experienced during the implementation of the study. However, a limitation in the project’s design was the exclusion of outcome measures to assess the impact of process design choices directly. Stephens et al. [ 45 ] completed targeted outcome measures correlating to accessibility adaptations in co-design and conceded that the variability of findings and individual needs reduced the usefulness of these measures.

The reduction of project scope enabled the completion of the study within the limitations of budgeting and timeline restrictions. Although the scope of the project had some flexibility, there were limitations to how far this could be extended as resources were not infinite, and staffing changes meant that organisational priorities changed. Including implementation and evaluation would have improved the study’s rigour. However, Rocky Bay now has the opportunity to implement internally without potential research delays and restrictions.

The blended and flexible approach to the co-design process was a strength of the study as it met the co-designers needs and maximised the project’s potential inclusivity. This strength has the potential to positively impact other studies that can modify some of the process design choices to suit their context and increase inclusivity [ 11 ]. It is believed that the messiness of co-design is important in meeting the needs and context of each individual study; therefore, no two co-design processes should look the same.

The authors concede that the inclusion of a cohort of people with disability and clinical staff does not represent the entirety of their communities, and their proposed changes may cause some parts of the disability community to experience increased barriers [ 50 ]. It is important to note that while the co-designers who participated in this project provided initial design developments, future opportunities remain to iterate the proposed telepractice service and continue to advocate for equitable access for all.

Recommendations for future studies

Recommendations from this study fall into two categories: recommendations for those intending to utilise the described methods and recommendations for future avenues of research inquiry. For those intending to implement the methods, the primary recommendations are to build ample time buffers into the project schedule, implement key role succession planning and set remuneration agreements at the outset, and work together as partners with the mindset that all contributors are creative [ 51 ] with important expertise and invaluable insights if supported appropriately.

Regarding avenues for future inquiry, we recommend investigating a more dynamic and flexible ethics process that may utilise more frequent short consultations to respond to ethical considerations during the emergent co-design and participatory research.

In the authors’ opinion, supported by co-designers experiences, co-design is a useful and outcome-generating methodology that can proactively enable the inclusion of people with disability and service providers in a community-based participatory research approach. The process is both time and resource-intensive; however, in our opinion, the investment is justified through the delivery of direct research benefits and indirect wider community benefits. We advocate for using community-based participatory-research/processes paired with co-design to generate creative thinking within service design processes. Through co-design processes, we recommend collaborating with a single diverse group of co-designers who have the time and space to build trusting working relationships that enable outputs representative of the group consensus.

Data availability

The dataset supporting the conclusions of this article is predominantly included within the article (and its additional files). However, due to the small number of co-designers reflecting upon the research, despite deidentification, there is a reasonable assumption of identification; therefore, the reflection activity response supporting data is not available.

Abbreviations

Australian Dollar

Guidance for Reporting Involvement of Patients and the Public 2 Checklist

Human Research Ethics Committee

Doctor of Philosophy

Patient and Public Involvement

Microsoft Teams

National Disability Insurance Scheme

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Acknowledgements

The authors acknowledge the contribution of Rocky Bay as the industry partner of this project and would like to thank the Co-designers of this project, without whom none of this was possible. The research team would also like to thank Katie Harris for her time and support throughout the workshop series, which were invaluable to the completion of the project and the formation of the published study.

The article forms part of a PhD project funded by the first author, CB’s Australian Government Research Training Program (RTP) scholarship.

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Contributions

CB and MW liaised with the steering committee and conceived the study and structure. SR, DH and RN guided the protocol development and ethics approval. KAM provided methodological support to the project and subject matter expertise. CB and WJS completed participant recruitment, facilitation of workshops and data collection. KAM and CB ideated the format and content of the article. CB completed data analysis and wrote the first draft of the manuscript. All authors reviewed and edited the manuscript and approved of the final version of the manuscript.

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Correspondence to Cloe Benz .

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Ethical approval and consent.

The study was approved by the Curtin University Human Research Ethics Committee (ID# HRE2021-0731), and all participants provided written informed consent before engaging in any research activity.

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Not applicable.

Competing interests

Cloe Benz, Richard Norman, Delia Hendrie & Suzanne Robinson do not have any competing interests to declare. Will Scott-Jeffs, Matthew Locantro and Mai Welsh, for all or part of the study period were employed by Rocky Bay a Not-For-Profit Disability Service provider who function as the industry partner for the project. K.A. McKercher is the author of a co-design method book referenced in the article. McKercher also runs a business that helps people co-design.

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Benz, C., Scott-Jeffs, W., McKercher, K.A. et al. Community-based participatory-research through co-design: supporting collaboration from all sides of disability. Res Involv Engagem 10 , 47 (2024). https://doi.org/10.1186/s40900-024-00573-3

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A Robot-assisted real case-handling approach to improving students’ learning performances in vocational training

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• Gwo-Jen Hwang   ORCID: orcid.org/0000-0001-5155-276X 2 , 3  

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In vocational education, cultivating students’ ability to deal with real cases is a crucial training objective. The BSFE (i.e., Brainstorming, Screening, Formation, Examination) model is a commonly adopted training procedure. Each stage is designed for guiding students to analyze and find solutions to handle real cases. However, as one teacher is generally responsible for several dozen students, it becomes challenging for the teacher to adequately address each student’s questions and individual needs. Therefore, this study proposed the robot teaching assistant-supported learning (RTAL) mode following the BSFE model to cope with this problem. This investigation assessed its efficacy through an experiment within an Acute Asthma Attack curriculum. The research involved 103 nursing students in their third year from two distinct classes at a vocational university. Fifty-three students from a class constituted the experimental group that implemented the RTAL approach, whereas the other class, comprising 50 students, was the control group utilizing the standard technology-supported learning (CTL) approach. Findings indicated that the experimental group surpassed the control group in various aspects, including learning outcomes, learning attitudes, problem-solving tedencies, critical thinking awareness, acceptance of technology, and satisfaction with the learning experience. The interview findings also revealed that the RTAL mode could cater to individualized learning needs, facilitate interaction, and serve as an auxiliary instructional tool.

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This study is supported in part by the National Science and Technology Council of Taiwan under contract numbers NSTC 112-2410-H-011-012-MY3 and MOST 111-2410-H-011 -007 -MY3. The study is also supported by the “Empower Vocational Education Research Center” of National Taiwan University of Science and Technology (NTUST) from the Featured Areas Research Center Program within the framework of the Higher Education Sprout Project by the Ministry of Education (MOE) in Taiwan.

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The authors contributed to the conceptualization and design of the study. Material preparation, data collection, analysis, project management and methodology were performed by Chun-Chun Chang. Methodology and supervision were performed Gwo-Jen Hwang.

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Chang, CC., Hwang, GJ. A Robot-assisted real case-handling approach to improving students’ learning performances in vocational training. Educ Inf Technol (2024). https://doi.org/10.1007/s10639-024-12778-w

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Developing a survey to measure nursing students’ knowledge, attitudes and beliefs, influences, and willingness to be involved in Medical Assistance in Dying (MAiD): a mixed method modified e-Delphi study

• Jocelyn Schroeder 1 ,
• Barbara Pesut 1 , 2 ,
• Lise Olsen 2 ,
• Nelly D. Oelke 2 &
• Helen Sharp 2  

BMC Nursing volume  23 , Article number:  326 ( 2024 ) Cite this article

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Medical Assistance in Dying (MAiD) was legalized in Canada in 2016. Canada’s legislation is the first to permit Nurse Practitioners (NP) to serve as independent MAiD assessors and providers. Registered Nurses’ (RN) also have important roles in MAiD that include MAiD care coordination; client and family teaching and support, MAiD procedural quality; healthcare provider and public education; and bereavement care for family. Nurses have a right under the law to conscientious objection to participating in MAiD. Therefore, it is essential to prepare nurses in their entry-level education for the practice implications and moral complexities inherent in this practice. Knowing what nursing students think about MAiD is a critical first step. Therefore, the purpose of this study was to develop a survey to measure nursing students’ knowledge, attitudes and beliefs, influences, and willingness to be involved in MAiD in the Canadian context.

The design was a mixed-method, modified e-Delphi method that entailed item generation from the literature, item refinement through a 2 round survey of an expert faculty panel, and item validation through a cognitive focus group interview with nursing students. The settings were a University located in an urban area and a College located in a rural area in Western Canada.

During phase 1, a 56-item survey was developed from existing literature that included demographic items and items designed to measure experience with death and dying (including MAiD), education and preparation, attitudes and beliefs, influences on those beliefs, and anticipated future involvement. During phase 2, an expert faculty panel reviewed, modified, and prioritized the items yielding 51 items. During phase 3, a sample of nursing students further evaluated and modified the language in the survey to aid readability and comprehension. The final survey consists of 45 items including 4 case studies.

Systematic evaluation of knowledge-to-date coupled with stakeholder perspectives supports robust survey design. This study yielded a survey to assess nursing students’ attitudes toward MAiD in a Canadian context.

The survey is appropriate for use in education and research to measure knowledge and attitudes about MAiD among nurse trainees and can be a helpful step in preparing nursing students for entry-level practice.

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Medical Assistance in Dying (MAiD) is permitted under an amendment to Canada’s Criminal Code which was passed in 2016 [ 1 ]. MAiD is defined in the legislation as both self-administered and clinician-administered medication for the purpose of causing death. In the 2016 Bill C-14 legislation one of the eligibility criteria was that an applicant for MAiD must have a reasonably foreseeable natural death although this term was not defined. It was left to the clinical judgement of MAiD assessors and providers to determine the time frame that constitutes reasonably foreseeable [ 2 ]. However, in 2021 under Bill C-7, the eligibility criteria for MAiD were changed to allow individuals with irreversible medical conditions, declining health, and suffering, but whose natural death was not reasonably foreseeable, to receive MAiD [ 3 ]. This population of MAiD applicants are referred to as Track 2 MAiD (those whose natural death is foreseeable are referred to as Track 1). Track 2 applicants are subject to additional safeguards under the 2021 C-7 legislation.

Three additional proposed changes to the legislation have been extensively studied by Canadian Expert Panels (Council of Canadian Academics [CCA]) [ 4 , 5 , 6 ] First, under the legislation that defines Track 2, individuals with mental disease as their sole underlying medical condition may apply for MAiD, but implementation of this practice is embargoed until March 2027 [ 4 ]. Second, there is consideration of allowing MAiD to be implemented through advanced consent. This would make it possible for persons living with dementia to receive MAID after they have lost the capacity to consent to the procedure [ 5 ]. Third, there is consideration of extending MAiD to mature minors. A mature minor is defined as “a person under the age of majority…and who has the capacity to understand and appreciate the nature and consequences of a decision” ([ 6 ] p. 5). In summary, since the legalization of MAiD in 2016 the eligibility criteria and safeguards have evolved significantly with consequent implications for nurses and nursing care. Further, the number of Canadians who access MAiD shows steady increases since 2016 [ 7 ] and it is expected that these increases will continue in the foreseeable future.

Nurses have been integral to MAiD care in the Canadian context. While other countries such as Belgium and the Netherlands also permit euthanasia, Canada is the first country to allow Nurse Practitioners (Registered Nurses with additional preparation typically achieved at the graduate level) to act independently as assessors and providers of MAiD [ 1 ]. Although the role of Registered Nurses (RNs) in MAiD is not defined in federal legislation, it has been addressed at the provincial/territorial-level with variability in scope of practice by region [ 8 , 9 ]. For example, there are differences with respect to the obligation of the nurse to provide information to patients about MAiD, and to the degree that nurses are expected to ensure that patient eligibility criteria and safeguards are met prior to their participation [ 10 ]. Studies conducted in the Canadian context indicate that RNs perform essential roles in MAiD care coordination; client and family teaching and support; MAiD procedural quality; healthcare provider and public education; and bereavement care for family [ 9 , 11 ]. Nurse practitioners and RNs are integral to a robust MAiD care system in Canada and hence need to be well-prepared for their role [ 12 ].

Previous studies have found that end of life care, and MAiD specifically, raise complex moral and ethical issues for nurses [ 13 , 14 , 15 , 16 ]. The knowledge, attitudes, and beliefs of nurses are important across practice settings because nurses have consistent, ongoing, and direct contact with patients who experience chronic or life-limiting health conditions. Canadian studies exploring nurses’ moral and ethical decision-making in relation to MAiD reveal that although some nurses are clear in their support for, or opposition to, MAiD, others are unclear on what they believe to be good and right [ 14 ]. Empirical findings suggest that nurses go through a period of moral sense-making that is often informed by their family, peers, and initial experiences with MAID [ 17 , 18 ]. Canadian legislation and policy specifies that nurses are not required to participate in MAiD and may recuse themselves as conscientious objectors with appropriate steps to ensure ongoing and safe care of patients [ 1 , 19 ]. However, with so many nurses having to reflect on and make sense of their moral position, it is essential that they are given adequate time and preparation to make an informed and thoughtful decision before they participate in a MAID death [ 20 , 21 ].

It is well established that nursing students receive inconsistent exposure to end of life care issues [ 22 ] and little or no training related to MAiD [ 23 ]. Without such education and reflection time in pre-entry nursing preparation, nurses are at significant risk for moral harm. An important first step in providing this preparation is to be able to assess the knowledge, values, and beliefs of nursing students regarding MAID and end of life care. As demand for MAiD increases along with the complexities of MAiD, it is critical to understand the knowledge, attitudes, and likelihood of engagement with MAiD among nursing students as a baseline upon which to build curriculum and as a means to track these variables over time.

Aim, design, and setting

The aim of this study was to develop a survey to measure nursing students’ knowledge, attitudes and beliefs, influences, and willingness to be involved in MAiD in the Canadian context. We sought to explore both their willingness to be involved in the registered nursing role and in the nurse practitioner role should they chose to prepare themselves to that level of education. The design was a mixed-method, modified e-Delphi method that entailed item generation, item refinement through an expert faculty panel [ 24 , 25 , 26 ], and initial item validation through a cognitive focus group interview with nursing students [ 27 ]. The settings were a University located in an urban area and a College located in a rural area in Western Canada.

Participants

A panel of 10 faculty from the two nursing education programs were recruited for Phase 2 of the e-Delphi. To be included, faculty were required to have a minimum of three years of experience in nurse education, be employed as nursing faculty, and self-identify as having experience with MAiD. A convenience sample of 5 fourth-year nursing students were recruited to participate in Phase 3. Students had to be in good standing in the nursing program and be willing to share their experiences of the survey in an online group interview format.

The modified e-Delphi was conducted in 3 phases: Phase 1 entailed item generation through literature and existing survey review. Phase 2 entailed item refinement through a faculty expert panel review with focus on content validity, prioritization, and revision of item wording [ 25 ]. Phase 3 entailed an assessment of face validity through focus group-based cognitive interview with nursing students.

Phase I. Item generation through literature review

The goal of phase 1 was to develop a bank of survey items that would represent the variables of interest and which could be provided to expert faculty in Phase 2. Initial survey items were generated through a literature review of similar surveys designed to assess knowledge and attitudes toward MAiD/euthanasia in healthcare providers; Canadian empirical studies on nurses’ roles and/or experiences with MAiD; and legislative and expert panel documents that outlined proposed changes to the legislative eligibility criteria and safeguards. The literature review was conducted in three online databases: CINAHL, PsycINFO, and Medline. Key words for the search included nurses , nursing students , medical students , NPs, MAiD , euthanasia , assisted death , and end-of-life care . Only articles written in English were reviewed. The legalization and legislation of MAiD is new in many countries; therefore, studies that were greater than twenty years old were excluded, no further exclusion criteria set for country.

Items from surveys designed to measure similar variables in other health care providers and geographic contexts were placed in a table and similar items were collated and revised into a single item. Then key variables were identified from the empirical literature on nurses and MAiD in Canada and checked against the items derived from the surveys to ensure that each of the key variables were represented. For example, conscientious objection has figured prominently in the Canadian literature, but there were few items that assessed knowledge of conscientious objection in other surveys and so items were added [ 15 , 21 , 28 , 29 ]. Finally, four case studies were added to the survey to address the anticipated changes to the Canadian legislation. The case studies were based upon the inclusion of mature minors, advanced consent, and mental disorder as the sole underlying medical condition. The intention was to assess nurses’ beliefs and comfort with these potential legislative changes.

Phase 2. Item refinement through expert panel review

The goal of phase 2 was to refine and prioritize the proposed survey items identified in phase 1 using a modified e-Delphi approach to achieve consensus among an expert panel [ 26 ]. Items from phase 1 were presented to an expert faculty panel using a Qualtrics (Provo, UT) online survey. Panel members were asked to review each item to determine if it should be: included, excluded or adapted for the survey. When adapted was selected faculty experts were asked to provide rationale and suggestions for adaptation through the use of an open text box. Items that reached a level of 75% consensus for either inclusion or adaptation were retained [ 25 , 26 ]. New items were categorized and added, and a revised survey was presented to the panel of experts in round 2. Panel members were again asked to review items, including new items, to determine if it should be: included, excluded, or adapted for the survey. Round 2 of the modified e-Delphi approach also included an item prioritization activity, where participants were then asked to rate the importance of each item, based on a 5-point Likert scale (low to high importance), which De Vaus [ 30 ] states is helpful for increasing the reliability of responses. Items that reached a 75% consensus on inclusion were then considered in relation to the importance it was given by the expert panel. Quantitative data were managed using SPSS (IBM Corp).

Phase 3. Face validity through cognitive interviews with nursing students

The goal of phase 3 was to obtain initial face validity of the proposed survey using a sample of nursing student informants. More specifically, student participants were asked to discuss how items were interpreted, to identify confusing wording or other problematic construction of items, and to provide feedback about the survey as a whole including readability and organization [ 31 , 32 , 33 ]. The focus group was held online and audio recorded. A semi-structured interview guide was developed for this study that focused on clarity, meaning, order and wording of questions; emotions evoked by the questions; and overall survey cohesion and length was used to obtain data (see Supplementary Material 2  for the interview guide). A prompt to “think aloud” was used to limit interviewer-imposed bias and encourage participants to describe their thoughts and response to a given item as they reviewed survey items [ 27 ]. Where needed, verbal probes such as “could you expand on that” were used to encourage participants to expand on their responses [ 27 ]. Student participants’ feedback was collated verbatim and presented to the research team where potential survey modifications were negotiated and finalized among team members. Conventional content analysis [ 34 ] of focus group data was conducted to identify key themes that emerged through discussion with students. Themes were derived from the data by grouping common responses and then using those common responses to modify survey items.

Ten nursing faculty participated in the expert panel. Eight of the 10 faculty self-identified as female. No faculty panel members reported conscientious objector status and ninety percent reported general agreement with MAiD with one respondent who indicated their view as “unsure.” Six of the 10 faculty experts had 16 years of experience or more working as a nurse educator.

Five nursing students participated in the cognitive interview focus group. The duration of the focus group was 2.5 h. All participants identified that they were born in Canada, self-identified as female (one preferred not to say) and reported having received some instruction about MAiD as part of their nursing curriculum. See Tables  1 and 2 for the demographic descriptors of the study sample. Study results will be reported in accordance with the study phases. See Fig.  1 for an overview of the results from each phase.

Fig. 1  Overview of survey development findings

Phase 1: survey item generation

Review of the literature identified that no existing survey was available for use with nursing students in the Canadian context. However, an analysis of themes across qualitative and quantitative studies of physicians, medical students, nurses, and nursing students provided sufficient data to develop a preliminary set of items suitable for adaptation to a population of nursing students.

Four major themes and factors that influence knowledge, attitudes, and beliefs about MAiD were evident from the literature: (i) endogenous or individual factors such as age, gender, personally held values, religion, religiosity, and/or spirituality [ 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 ], (ii) experience with death and dying in personal and/or professional life [ 35 , 40 , 41 , 43 , 44 , 45 ], (iii) training including curricular instruction about clinical role, scope of practice, or the law [ 23 , 36 , 39 ], and (iv) exogenous or social factors such as the influence of key leaders, colleagues, friends and/or family, professional and licensure organizations, support within professional settings, and/or engagement in MAiD in an interdisciplinary team context [ 9 , 35 , 46 ].

Studies of nursing students also suggest overlap across these categories. For example, value for patient autonomy [ 23 ] and the moral complexity of decision-making [ 37 ] are important factors that contribute to attitudes about MAiD and may stem from a blend of personally held values coupled with curricular content, professional training and norms, and clinical exposure. For example, students report that participation in end of life care allows for personal growth, shifts in perception, and opportunities to build therapeutic relationships with their clients [ 44 , 47 , 48 ].

Preliminary items generated from the literature resulted in 56 questions from 11 published sources (See Table  3 ). These items were constructed across four main categories: (i) socio-demographic questions; (ii) end of life care questions; (iii) knowledge about MAiD; or (iv) comfort and willingness to participate in MAiD. Knowledge questions were refined to reflect current MAiD legislation, policies, and regulatory frameworks. Falconer [ 39 ] and Freeman [ 45 ] studies were foundational sources for item selection. Additionally, four case studies were written to reflect the most recent anticipated changes to MAiD legislation and all used the same open-ended core questions to address respondents’ perspectives about the patient’s right to make the decision, comfort in assisting a physician or NP to administer MAiD in that scenario, and hypothesized comfort about serving as a primary provider if qualified as an NP in future. Response options for the survey were also constructed during this stage and included: open text, categorical, yes/no , and Likert scales.

Phase 2: faculty expert panel review

Of the 56 items presented to the faculty panel, 54 questions reached 75% consensus. However, based upon the qualitative responses 9 items were removed largely because they were felt to be repetitive. Items that generated the most controversy were related to measuring religion and spirituality in the Canadian context, defining end of life care when there is no agreed upon time frames (e.g., last days, months, or years), and predicting willingness to be involved in a future events – thus predicting their future selves. Phase 2, round 1 resulted in an initial set of 47 items which were then presented back to the faculty panel in round 2.

Of the 47 initial questions presented to the panel in round 2, 45 reached a level of consensus of 75% or greater, and 34 of these questions reached a level of 100% consensus [ 27 ] of which all participants chose to include without any adaptations) For each question, level of importance was determined based on a 5-point Likert scale (1 = very unimportant, 2 = somewhat unimportant, 3 = neutral, 4 = somewhat important, and 5 = very important). Figure  2 provides an overview of the level of importance assigned to each item.

Ranking level of importance for survey items

After round 2, a careful analysis of participant comments and level of importance was completed by the research team. While the main method of survey item development came from participants’ response to the first round of Delphi consensus ratings, level of importance was used to assist in the decision of whether to keep or modify questions that created controversy, or that rated lower in the include/exclude/adapt portion of the Delphi. Survey items that rated low in level of importance included questions about future roles, sex and gender, and religion/spirituality. After deliberation by the research committee, these questions were retained in the survey based upon the importance of these variables in the scientific literature.

Of the 47 questions remaining from Phase 2, round 2, four were revised. In addition, the two questions that did not meet the 75% cut off level for consensus were reviewed by the research team. The first question reviewed was What is your comfort level with providing a MAiD death in the future if you were a qualified NP ? Based on a review of participant comments, it was decided to retain this question for the cognitive interviews with students in the final phase of testing. The second question asked about impacts on respondents’ views of MAiD and was changed from one item with 4 subcategories into 4 separate items, resulting in a final total of 51 items for phase 3. The revised survey was then brought forward to the cognitive interviews with student participants in Phase 3. (see Supplementary Material 1 for a complete description of item modification during round 2).

Phase 3. Outcomes of cognitive interview focus group

Of the 51 items reviewed by student participants, 29 were identified as clear with little or no discussion. Participant comments for the remaining 22 questions were noted and verified against the audio recording. Following content analysis of the comments, four key themes emerged through the student discussion: unclear or ambiguous wording; difficult to answer questions; need for additional response options; and emotional response evoked by questions. An example of unclear or ambiguous wording was a request for clarity in the use of the word “sufficient” in the context of assessing an item that read “My nursing education has provided sufficient content about the nursing role in MAiD.” “Sufficient” was viewed as subjective and “laden with…complexity that distracted me from the question.” The group recommended rewording the item to read “My nursing education has provided enough content for me to care for a patient considering or requesting MAiD.”

An example of having difficulty answering questions related to limited knowledge related to terms used in the legislation such as such as safeguards , mature minor , eligibility criteria , and conscientious objection. Students were unclear about what these words meant relative to the legislation and indicated that this lack of clarity would hamper appropriate responses to the survey. To ensure that respondents are able to answer relevant questions, student participants recommended that the final survey include explanation of key terms such as mature minor and conscientious objection and an overview of current legislation.

Response options were also a point of discussion. Participants noted a lack of distinction between response options of unsure and unable to say . Additionally, scaling of attitudes was noted as important since perspectives about MAiD are dynamic and not dichotomous “agree or disagree” responses. Although the faculty expert panel recommended the integration of the demographic variables of religious and/or spiritual remain as a single item, the student group stated a preference to have religion and spirituality appear as separate items. The student focus group also took issue with separate items for the variables of sex and gender, specifically that non-binary respondents might feel othered or “outed” particularly when asked to identify their sex. These variables had been created based upon best practices in health research but students did not feel they were appropriate in this context [ 49 ]. Finally, students agreed with the faculty expert panel in terms of the complexity of projecting their future involvement as a Nurse Practitioner. One participant stated: “I certainly had to like, whoa, whoa, whoa. Now let me finish this degree first, please.” Another stated, “I'm still imagining myself, my future career as an RN.”

Finally, student participants acknowledged the array of emotions that some of the items produced for them. For example, one student described positive feelings when interacting with the survey. “Brought me a little bit of feeling of joy. Like it reminded me that this is the last piece of independence that people grab on to.” Another participant, described the freedom that the idea of an advance request gave her. “The advance request gives the most comfort for me, just with early onset Alzheimer’s and knowing what it can do.” But other participants described less positive feelings. For example, the mature minor case study yielded a comment: “This whole scenario just made my heart hurt with the idea of a child requesting that.”

Based on the data gathered from the cognitive interview focus group of nursing students, revisions were made to 11 closed-ended questions (see Table  4 ) and 3 items were excluded. In the four case studies, the open-ended question related to a respondents’ hypothesized actions in a future role as NP were removed. The final survey consists of 45 items including 4 case studies (see Supplementary Material 3 ).

The aim of this study was to develop and validate a survey that can be used to track the growth of knowledge about MAiD among nursing students over time, inform training programs about curricular needs, and evaluate attitudes and willingness to participate in MAiD at time-points during training or across nursing programs over time.

The faculty expert panel and student participants in the cognitive interview focus group identified a need to establish core knowledge of the terminology and legislative rules related to MAiD. For example, within the cognitive interview group of student participants, several acknowledged lack of clear understanding of specific terms such as “conscientious objector” and “safeguards.” Participants acknowledged discomfort with the uncertainty of not knowing and their inclination to look up these terms to assist with answering the questions. This survey can be administered to nursing or pre-nursing students at any phase of their training within a program or across training programs. However, in doing so it is important to acknowledge that their baseline knowledge of MAiD will vary. A response option of “not sure” is important and provides a means for respondents to convey uncertainty. If this survey is used to inform curricular needs, respondents should be given explicit instructions not to conduct online searches to inform their responses, but rather to provide an honest appraisal of their current knowledge and these instructions are included in the survey (see Supplementary Material 3 ).

Some provincial regulatory bodies have established core competencies for entry-level nurses that include MAiD. For example, the BC College of Nurses and Midwives (BCCNM) requires “knowledge about ethical, legal, and regulatory implications of medical assistance in dying (MAiD) when providing nursing care.” (10 p. 6) However, across Canada curricular content and coverage related to end of life care and MAiD is variable [ 23 ]. Given the dynamic nature of the legislation that includes portions of the law that are embargoed until 2024, it is important to ensure that respondents are guided by current and accurate information. As the law changes, nursing curricula, and public attitudes continue to evolve, inclusion of core knowledge and content is essential and relevant for investigators to be able to interpret the portions of the survey focused on attitudes and beliefs about MAiD. Content knowledge portions of the survey may need to be modified over time as legislation and training change and to meet the specific purposes of the investigator.

Given the sensitive nature of the topic, it is strongly recommended that surveys be conducted anonymously and that students be provided with an opportunity to discuss their responses to the survey. A majority of feedback from both the expert panel of faculty and from student participants related to the wording and inclusion of demographic variables, in particular religion, religiosity, gender identity, and sex assigned at birth. These and other demographic variables have the potential to be highly identifying in small samples. In any instance in which the survey could be expected to yield demographic group sizes less than 5, users should eliminate the demographic variables from the survey. For example, the profession of nursing is highly dominated by females with over 90% of nurses who identify as female [ 50 ]. Thus, a survey within a single class of students or even across classes in a single institution is likely to yield a small number of male respondents and/or respondents who report a difference between sex assigned at birth and gender identity. When variables that serve to identify respondents are included, respondents are less likely to complete or submit the survey, to obscure their responses so as not to be identifiable, or to be influenced by social desirability bias in their responses rather than to convey their attitudes accurately [ 51 ]. Further, small samples do not allow for conclusive analyses or interpretation of apparent group differences. Although these variables are often included in surveys, such demographics should be included only when anonymity can be sustained. In small and/or known samples, highly identifying variables should be omitted.

There are several limitations associated with the development of this survey. The expert panel was comprised of faculty who teach nursing students and are knowledgeable about MAiD and curricular content, however none identified as a conscientious objector to MAiD. Ideally, our expert panel would have included one or more conscientious objectors to MAiD to provide a broader perspective. Review by practitioners who participate in MAiD, those who are neutral or undecided, and practitioners who are conscientious objectors would ensure broad applicability of the survey. This study included one student cognitive interview focus group with 5 self-selected participants. All student participants had held discussions about end of life care with at least one patient, 4 of 5 participants had worked with a patient who requested MAiD, and one had been present for a MAiD death. It is not clear that these participants are representative of nursing students demographically or by experience with end of life care. It is possible that the students who elected to participate hold perspectives and reflections on patient care and MAiD that differ from students with little or no exposure to end of life care and/or MAiD. However, previous studies find that most nursing students have been involved with end of life care including meaningful discussions about patients’ preferences and care needs during their education [ 40 , 44 , 47 , 48 , 52 ]. Data collection with additional student focus groups with students early in their training and drawn from other training contexts would contribute to further validation of survey items.

Future studies should incorporate pilot testing with small sample of nursing students followed by a larger cross-program sample to allow evaluation of the psychometric properties of specific items and further refinement of the survey tool. Consistent with literature about the importance of leadership in the context of MAiD [ 12 , 53 , 54 ], a study of faculty knowledge, beliefs, and attitudes toward MAiD would provide context for understanding student perspectives within and across programs. Additional research is also needed to understand the timing and content coverage of MAiD across Canadian nurse training programs’ curricula.

The implementation of MAiD is complex and requires understanding of the perspectives of multiple stakeholders. Within the field of nursing this includes clinical providers, educators, and students who will deliver clinical care. A survey to assess nursing students’ attitudes toward and willingness to participate in MAiD in the Canadian context is timely, due to the legislation enacted in 2016 and subsequent modifications to the law in 2021 with portions of the law to be enacted in 2027. Further development of this survey could be undertaken to allow for use in settings with practicing nurses or to allow longitudinal follow up with students as they enter practice. As the Canadian landscape changes, ongoing assessment of the perspectives and needs of health professionals and students in the health professions is needed to inform policy makers, leaders in practice, curricular needs, and to monitor changes in attitudes and practice patterns over time.

Availability of data and materials

The datasets used and/or analysed during the current study are not publicly available due to small sample sizes, but are available from the corresponding author on reasonable request.

Abbreviations

British Columbia College of Nurses and Midwives

Medical assistance in dying

Nurse practitioner

Registered nurse

University of British Columbia Okanagan

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We would like to acknowledge the faculty and students who generously contributed their time to this work.

JS received a student traineeship through the Principal Research Chairs program at the University of British Columbia Okanagan.

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JS made substantial contributions to the conception of the work; data acquisition, analysis, and interpretation; and drafting and substantively revising the work. JS has approved the submitted version and agreed to be personally accountable for the author's own contributions and to ensure that questions related to the accuracy or integrity of any part of the work, even ones in which the author was not personally involved, are appropriately investigated, resolved, and the resolution documented in the literature. BP made substantial contributions to the conception of the work; data acquisition, analysis, and interpretation; and drafting and substantively revising the work. BP has approved the submitted version and agreed to be personally accountable for the author's own contributions and to ensure that questions related to the accuracy or integrity of any part of the work, even ones in which the author was not personally involved, are appropriately investigated, resolved, and the resolution documented in the literature. LO made substantial contributions to the conception of the work; data acquisition, analysis, and interpretation; and substantively revising the work. LO has approved the submitted version and agreed to be personally accountable for the author's own contributions and to ensure that questions related to the accuracy or integrity of any part of the work, even ones in which the author was not personally involved, are appropriately investigated, resolved, and the resolution documented in the literature. NDO made substantial contributions to the conception of the work; data acquisition, analysis, and interpretation; and substantively revising the work. NDO has approved the submitted version and agreed to be personally accountable for the author's own contributions and to ensure that questions related to the accuracy or integrity of any part of the work, even ones in which the author was not personally involved, are appropriately investigated, resolved, and the resolution documented in the literature. HS made substantial contributions to drafting and substantively revising the work. HS has approved the submitted version and agreed to be personally accountable for the author's own contributions and to ensure that questions related to the accuracy or integrity of any part of the work, even ones in which the author was not personally involved, are appropriately investigated, resolved, and the resolution documented in the literature.

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Schroeder, J., Pesut, B., Olsen, L. et al. Developing a survey to measure nursing students’ knowledge, attitudes and beliefs, influences, and willingness to be involved in Medical Assistance in Dying (MAiD): a mixed method modified e-Delphi study. BMC Nurs 23 , 326 (2024). https://doi.org/10.1186/s12912-024-01984-z

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Received : 24 October 2023

Accepted : 28 April 2024

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DOI : https://doi.org/10.1186/s12912-024-01984-z

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HEC Partners Harvard Business Publishing Education for Case Studies

HEC Paris and Harvard Business Publishing Education (HBP Education) have signed a new collaboration to increase the school’s visibility through its case studies. HEC joins an elite group of institutions distributing cases globally through the HBP Education catalog .

HEC Paris Partners with Harvard Business Publishing Education to distribute quality cases

HBP Education, which celebrates its 30th anniversary this year, serves as a bridge between academia and enterprises through its reach into academic, corporate, and consumer markets. " This is just the beginning of a most fruitful relationship ,” said HBP co-president Ellen Desmarais at the April 23 signing ceremony in the HEC Alumni Association headquarters. " Our partnership provides so many opportunities to work together, to innovate together, and to think about this future together ,” she continued. HEC Paris is one of the very few case partners providing both French and English cases, which is helping HBP Education better serve its global audience of students and educators. Other major business schools partnering HBP include Wharton and INSEAD.   HEC Dean of Research Andrea Masini declared: “ This partnership tells our professors that writing case studies is absolutely vital not only because it has an impact on the pedagogy but also on the international visibility of the school .”    Associate Dean for Pedagogy, Anne Michaut thanked HBP Education for their help in the past two years: “ Collaboration between the two has been instrumental in refining case methodologies and identifying relevant topics. The partnership continues to unveil new opportunities for collaboration and growth .”

The collaboration between HEC and Harvard will continue to be instrumental in helping academics in case methodologies and identifying topics deemed relevant for students on all continents. The Co-president of the American not-for-profit organization, Ellen Desmarais, cited the example of cases in citizenship: “ One of the things we are hearing more and more from deans around the world is that they believe it's important for students to learn how to be true citizens of the world and think about the global context and global environment. Case studies on this subject can have a huge impact ." Professor Michaut praised the quality of dialogue between her business school and HBP Education: “ I want to thank you for pushing us to put in place a process to support our faculty in case writing for publication . As Andrea Masini said, it increases our visibility tremendously and encourages quality exchange between faculty members .” Michaut went on to thank the work achieved in instigating the partnership by HEC’s Ioana Helou and Mala Banerjee . 

Also present at the ceremony were HBP Education’s senior director EMEA & Asia Pacific, Gabriela Allmi, and the publication editors Stefaan Van Waes and David Champion. HEC’s 50 case studies are scheduled to go online before the 2024 summer break.

Case Study: UTMB Group Improves Content Discovery and Collaboration With Moments Lab AI-Powered Cloud Media Hub

By SVG Staff Monday, May 13, 2024 - 10:20 am Print This Story | Subscribe

Story Highlights

Based in Chamonix-Mont-Blanc, France, UTMB Group is the organization behind the UTMB World Series, a premier global trail running circuit with 40+ events taking place across Asia, Oceania, Europe, Africa, and the Americas. It is also the only place where runners can begin their quest to the HOKA UTMB Mont-Blanc, where the prestigious UTMB World Series Finals are held in the OCC, CCC, and UTMB races. Inaugurated in 2003, the UTMB race stands as a beacon of trail running excellence with an awe-inspiring course around the iconic Mont-Blanc — traversing Italy, Switzerland, and France — covering a distance of 171 kilometers with a staggering 10,000 meters of positive elevation gain.

“The HOKA UTMB Mont-Blanc is the most incredible and competitive trail running event,” explains Coralie Batté, head of brand and communication at UTMB Group . “Each year, the best athletes meet in Chamonix, and more than 10,000 runners participate in one of our eight races, including the UTMB World Series Finals.”

Through the UTMB Live streaming service, and content shared on social media channels, people can follow their favorite athletes and share in the breathtaking beauty of the landscapes as runners cross the finish line in Chamonix.

The UTMB charts a stunning course around the iconic Mont-Blanc, traversing Italy, Switzerland, and France.

Simplifying the Allocation of Media Content

UTMB Group accumulates a large collection of media as it documents each race — as many as 2,000 photos from a single event. Many of the images and videos did not have adequate metadata, and the UTMB Group team spent significant time properly tagging new media files to ensure that content could be found by partners and stakeholders. Finding the correct image or video clip for a sponsor or partner was often a time-consuming process. Moreover, UTMB Group had to manually review the footage to ensure the presence of sponsor logos. This workflow was not sustainable nor scalable given the large volume of media across all 40+ events and its small content team.

UTMB Group needed an easy and efficient way to access, store, manage, and share its media content with sponsors and athletes.

“Our goal was to modernize our media management and create a media marketplace where partners, athletes and our content team could easily — and independently —  find the content they were searching for,” says Batté.

Aside from being user-friendly, the solution needed to be deployed quickly. With several upcoming races, UTMB Group wanted to move forward and bring its new media asset management solution online as soon as possible to enable simpler sharing of content for improved brand awareness and athlete and partner relations.

Swiftly Deploying a Media Asset Management Solution

Moments Lab’s Cloud Media Hub with Multimodal AI indexing, and Media Marketplace met UTMB Group’s requirements for an efficient and centralized space to store and work with their media assets.

The deployment was quick. During the implementation process, Moments Lab’s team set up five sponsor media collections per event.

“We had a lot to do in a short amount of time,” says Philippe Petitpont, co-founder and CEO of Moments Lab . “Within three days, we established about 15 events and 85 media collections with visuals for UTMB Group, which is an unprecedented speed, especially considering that none of the media content was properly tagged.”

Each media collection was created with specific AI detection parameters, including the year, event, race, and logo to ensure content is easy to find.

The Cloud Media Hub and Media Marketplace contain all original files and proxies. UTMB Group can use Moments Lab’s live photo media upload capability to provide partners and athletes with faster access to content.

Winning the Race for Faster Content Search Experiences

The Cloud Media Hub is powered by revolutionary multimodal AI indexing technology. Photographers and Videographers can automatically or manually upload shots of the trail runs to the Cloud Media Hub from anywhere. AI indexing then scans the media and detects athletes and sponsor logos. Utilizing AI, UTMB Group can instantly tag media with the names of athletes leveraging automatic facial recognition technology, optical character recognition (OCR) for sponsor logos, and speech-to-text transcription for video interviews. The result is infinitely more powerful search experiences.

AI indexing scans UTMB Group’s media and detects individual athletes and sponsor logos.

“Moments Lab’s Cloud Media Hub transforms our workflow, reducing our production times and improving collaboration,” adds Batté. “We can now find media assets in just a few seconds.”

Boosting Content Engagement With the Media Marketplace

The UTMB Group team manages the partner and sponsor collections folders in the Media Hub and the validation of content access via the Media Marketplace. Through the Media Marketplace, UTMB Group can efficiently manage access to photos and know when a particular partner has hit their quota. Sponsors and partners have the autonomy to log in to the Media Hub and access their designated collection.

UTMB Group sponsors and partners have autonomous access to designated media collections.

In addition, UTMB Group’s social media team uses the Media Hub to search for, select, and download images and video clips for use on its channels, including Instagram where it currently engages with more than 400,000 followers.

Batté explains, “The Media Marketplace enables us to easily publish relevant videos or photos on our channels and share content with partners and sponsors. They love how simple it is to view and download approved content.”

Increasing Workflow Efficiency, Sponsor Satisfaction, and ROI

Since deploying Moments Lab’s cloud and AI-based platform, UTMB Group has successfully stored, managed, and shared media content for its 2022 and 2023 races. The team uploaded close to 2,000 photos to the Cloud Media Hub from the 2023 UTMB Mont-Blanc event alone.

Adopting Moments Lab’s solution saves UTMB Group significant time while increasing their engagement with sponsors and partners. Prior to using Moments Lab, UTMB Group manually scanned about 1,000 photos per event to identify and tag sponsors. This process took the UTMB Group team eight hours at a minimum. Now, the same work is completed in about 15 minutes.

“A time saving of 97% on manual photo tagging is just incredible. We’re already seeing a huge return on investment from being able to store, manage, and share our race images much more efficiently. Enabling our partners and sponsors to independently download footage and shots from anywhere and rapidly activate their marketing and social media campaigns is a game-changer. Moments Lab’s solutions propel our business on a path toward future growth and collaboration,” says Batté.

In 2024, UTMB will oversee 42 incredible trail running events in Asia, Oceania, Europe, Africa and the Americas. Leveraging the Moments Lab solution, UTMB Group can share every captivating race moment with the world.

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