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• Published: 02 October 2023

Mapping crisis communication in the communication research: what we know and what we don’t know

• Shalini Upadhyay 1 &
• Nitin Upadhyay 2  

Humanities and Social Sciences Communications volume  10 , Article number:  632 ( 2023 ) Cite this article

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This paper presents a comprehensive analysis of crisis communication research from 1968 to 2022, utilizing bibliometric methods to illuminate its trajectories, thematic shifts, and future possibilities. Additionally, it presents foundational themes such as crisis communication and social media, health communication, crisis and leadership, and reputation and advertising. This analysis offers not only historical insights but also serves as a roadmap for future research endeavors. Furthermore, this study critically evaluates over five decades of scholarship by unveiling the intellectual, social, and conceptual contours of the field while highlighting thematic evolutions. Employing diverse bibliometric indices, this research quantifies authors’ and nations’ productivity and impact. Through co-word analysis, four thematic clusters emerge, capturing the dynamic nature of crisis communication research. However, the study also reveals limited collaboration among authors, primarily localized, indicating room for enhanced cross-border cooperation and exploration of emerging themes. The study’s social network analysis sheds light on key actors and entities within the crisis communication realm, underscoring opportunities to fortify global networks for a robust crisis communication spectrum. Beyond academic curiosity, these insights hold practical implications for policymakers, scholars, and practitioners, offering a blueprint to enhance crisis communication’s effectiveness. This study’s findings can be considered as a reference point for future studies in crisis communication.

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Introduction

Although crisis communication as such is not a new phenomenon (Coombs, 2021 ), it’s role has become more prominent in recent times because of the events such as 9/11, SARS, COVID-19 pandemic (Avraham and Beirman, 2022 ; Watkins and Walker, 2021 ). Such events have posed unprecedented challenges to crisis management teams and necessitated effective communication and appropriate response strategies. At the same time, these events have revived scholarly interest in the topic (Coombs, 2021 ). As a result, it becomes essential for the scholars to perform timely review of the literature, to explore and understand the diversity of the specific field (Tranfield et al., 2003 ). Not only such reviews help to consolidate the research but also establish connections between disparate bodies of research and understand the diversity of the field (Crossan and Apaydin, 2010 ; Tranfield et al., 2003 ).

Coombs ( 1998 ) defines crisis as “an event that is an unpredictable, a major threat that can have a negative effect on the organization, industry, or stakeholders if handled improperly.” Since a crisis can cause financial and reputational damage to the company, a considerable attention has been given to the research on crisis, crisis management and crisis communication (Coombs and Holladay, 2002 ) and also on appropriate crisis response strategies so as to enable the organizations to manage crisis and reduce harm (Coombs, 2007a ). Our results depict that crisis communication received recognition during late 1960s, and the first studies on “crisis communication” were published only in 1968. The field had limited contribution until late 1990s. However, the double digit annual publication began in the early 2000s and in the recent years the contribution has grown with over 150 publications annually. Between 1991 and 2009, the image restoration theory (Benoit, 1995 ; Benoit, 1997 ) and the situational crisis communication theory (Avery et al., 2010 ; Coombs, 1995 ; Coombs 2007b ) dominated crisis communication research. The image restoration theory was applied to analyze and study several case-based situations while the situational crisis communication theory was extensively utilized for experimental research. Both the theories have been adopted for qualitative and quantitative analyses with an aim to prevent reputational harm and thus these theories became organization centric. The current trend is more towards understanding stakeholders’ perspectives with a multivocal approach (Frandsen and Johansen, 2017 ). Additionally the dominance of social media increases the complexity of crisis communication (Bukar et al., 2020 ; Eriksson, 2018 ).

In the extensive literature on crisis communication, scholars have approached the study of crisis communication from various perspectives and have examined it through multiple lenses. Several recent literature (For e.g., Seeger et al., 2016 ; Zhao, 2020 ) have shed light on these perspectives. The research encompasses different stakeholders involved in crisis communication, including the supply side (such as destinations, cruise lines, hotels, and airlines), the demand side (including tourists, prospective visitors, and general public), as well as other relevant stakeholders like government entities, local residents, and employees. Moreover, the research has explored crisis issues across a wide spectrum, ranging from natural disasters like hurricanes, tsunamis, earthquakes, and wildfires, to human-made crises such as terrorist attacks and service failures (Avraham and Beirman, 2022 ; Watkins and Walker, 2021 ). Furthermore, the literature has also addressed the unprecedented crisis brought about by the COVID-19 pandemic, which has had far-reaching implications for crisis communication. Importantly, the body of research takes a global perspective, encompassing various regions and countries. For instance, studies have examined crisis communication practices in diverse regions, including Asia, the Middle East, coastal destinations, as well as Western countries like Australia, the United States, and the United Kingdom. This global lens provides valuable insights into the different cultural, social, and contextual factors that shape crisis communication strategies and outcomes across different regions. However, the recent trends related to crisis communication scholarly research have gained traction, particularly in the past decade, especially in the US region (For e.g., Barbe and Pennington-Gray, 2018 ; Beck et al., 2016 ; Briones et al., 2011 ; Kwak et al., 2021 ; Liu et al., 2015a , 2015b ; Seeger et al., 2016 ; Sellnow and Seeger, 2013 ; Zhao, 2020 ).

Moreover, crisis communication research has been fragmented over the past two decades due to the emergence of several new sub-fields (Coombs, 2010 ; Coombs, 2021 ). This poses challenges to the researchers to cope up with the pace and volume of corpora (Yuan et al., 2015 ). Scholars (e.g., Lim et al., 2022 ; Mukherjee et al., 2022 ) recommend capturing scientific progress of a field by means of a systematic and comprehensive review. There are several review techniques that may be used to trace the scientific growth and potential research domains of a field. Various such review techniques have been employed in the crisis communication field to integrate and synthesize the existing knowledge. However, these studies have limited coverage and context of crisis communication. For example, previous studies have focused on organizational crisis communication (Fischer et al., 2016 ) and crisis communication in public relations (Avery et al., 2010 ). Few papers have intensively reviewed crisis communication during the pandemic and infectious disease outbreaks (MacKay et al., 2022 ; Malecki et al., 2021 ; Sadri et al., 2021 ) or captured risk and disaster communication (Bradley et al., 2014 ; Goerlandt et al., 2020 ). Lately, the focus has shifted toward using virtual channels and space (Eriksson, 2018 ; Liu-Lastres, 2022 ; Tornero et al., 2021 ; Wang and Dong, 2017 ; Yang, 2016 ).

However, these studies have dealt with the development of the field either through the qualitative approach in structured literature review (e.g., Valackiene and Virbickaite, 2011 ) or through the quantitative content analysis method (e.g., Li, 2017 ). Zupic and Čater ( 2015 ) claim that though structured literature review analysis deals with an in-depth examination, it insinuates subjective biases thereby constraining the scope of works. Additionally, despite its broader coverage in exploring key authors, topics, theories and methodologies, the content analysis is unable to capture the socio-cognitive structure. Suffice it to say that a comprehensive literature review which may capture intellectual, social and conceptual structures along with the thematic evolution of the crisis communication field has not been attempted (Ha and Boynton, 2014 ; Sarmiento and Poblete, 2021 ).

To overcome this gap bibliometric analysis is recommended which comprehensively captures the literature and traces its thematic evolution (An and Cheng, 2010 ; Moreno-Fernández and Fuentes-Lara, 2019 ; Zurro-Antón et al., 2021 ). Moreover, it facilitates the exploration of various performance metrics and mapping of the intellectual, social, and conceptual structures (Harker and Saffer, 2018 ; Lazzarotti et al., 2011 ). Wamba and Queiroz ( 2020 ) argue that bibliometric analysis examines large corpora of literature in an objective and evidence-based outcomes and it is more effective than the traditional methods (e.g., systematic literature review, meta-analysis, narrative analysis, etc.), which are labor-intensive and subjective. Additionally, bibliometric methods and visualization examinations are scalable and can be easily applied to a large corpora of literature covering authors and articles (Ki et al., 2019 ; Morgan and Wilk, 2021 ).

There are two approaches in bibliometric techniques—evaluative and relational. The evaluative review uses qualitative and quantitative methods covering aspects of the field’s ranking and contribution of different elements (e.g., sources, documents, institutions, and authors) (Benckendorff, 2009 ). The evaluative review focuses on productivity and impact (McKercher, 2012 ; Park et al., 2011 ). In contrast, relational review investigates relationships within the structures of the research field. It explores thematic evolution, co-authorship patterns, and co-citation (Benckendorff and Zehrer, 2013 ). Cobo et al. ( 2012 ) propose four different relational techniques for different contexts that answer who, when, where, what, and with whom questions by performing suitable analyses such as profiling, temporal, geospatial, topical, and network. It also facilitates a three-level analysis- micro (individual researchers), meso (regional-groups- journals), and macro (entire field). Overall, the relational analysis provides an in-depth coverage of the field, however, in the crisis communication area, it has not been utilized to explore and understand crisis communication research activity. Thus there is an inadequate synthetization of numerous aspects of the field in a single paper.

This paper utilizes relational analysis to explore and investigate the broad structure of crisis communication research. It aims at mapping crisis communication field by exploring its social, intellectual and conceptual structures over the past 50 years. Subsequently, the paper’s specific objectives are- determining the influential authors, countries and sources; and identifying major thematic areas affecting thematic evolution. Therefore, the process and outcomes of this paper are different from the studies that have either used or use traditional methods, as discussed above. However, the study’s outcomes complement those review articles that focus on specific contexts and aspects of crisis communication.

Methodology

In this study, we aim to map crisis communication in the communication research. The study also seeks to find the field’s social, intellectual and conceptual structures over the past 50 years. Additionally the future directions need to be explored.

Research questions

We defined the following research questions to map crisis communication in the following way:

RQ1: Who are the prominent contributors to the literature on crisis communication discipline?

RQ2: What is the social structure (or collaboration patterns) in crisis communication literature?

RQ3: What is the conceptual structure (or main research themes) in crisis communication literature?

RQ4: What is the intellectual structure in crisis communication literature?

RQ5: What are the future research directions in crisis communication scholarship?

The first research question was aimed at identifying the core contributors (author, document, source, institution and country) to the literature on crisis communication discipline, while the second question was designed to examine the collaboration pattern across levels—individual, institution, and country-level. The purpose of the third question was to gain more in-depth insights into the themes that have received attention in the literature. While the fourth research questions was aimed at identifying the intellectual patterns across levels—individual, document, and source. Finally, the fifth question was to identify the future directions in the crisis communication field.

We prepared the data considering two steps. First, we selected the source of data and then extracted the relevant articles based on the search query. We selected Scopus database to extract the relevant articles. The Scopus database includes all authors in cited references. This gives accuracy to the author-based citation and co-citation analysis. Further, we searched for the term “crisis communication” to extract relevant articles, and subsequently gathered 2487 documents. However, to explore the growth, contributions, and thematic areas we limited our search only to the journal articles in the English language. The search fields focus on covering abstracts, titles and keywords. Moreover, the search also had a criteria of limiting extraction of only articles (research and review) from peer-reviewed journals and excluding documents such as opinion pieces, book reviews, and commentaries. Finally, a sample of 1850 papers were included for further analyses.

Bibliometric methods for addressing RQs

We addressed RQ1 by performing descriptive analysis to identify core sources, authors, countries, publications, affiliations and prominent contributors to the literature on crisis communication. Measurements such as source impact (h-index and m-index), total citations (TC), and annual net publications (NP) were used to determine core sources and core authors. We used Bradford’s law to identify the core sources which are categorized into three zones. Zone 1 (the nuclear zone) is considered highly productive, while zones 2 and 3 represent moderate and low productions respectively (Zupic and Čater, 2015 ). Further, publication frequency and total citations were used to determine the top countries and affiliations.

We addressed RQ2 by using co-author analysis as it provides evidence of co-authorship when the authors jointly contribute to papers. Social structures are created when authors collaborate to develop and create articles. Moreover, when two authors co-publish a paper, they establish social ties or relationships (Lu and Wolfram, 2012 ). Co-authorship analysis can examine social structure at the level of the institute and the country. Co-authorship networks play a significant role in analyzing scientific collaboration and assessing the status of individual researchers. While they bear some resemblance to extensively studied citation networks, co-authorship networks signify a more robust social connection than mere citations. Unlike citations, which can occur between authors who are unfamiliar with each other and extend over time, co-authorship signifies a collegial and time-bound relationship, making it a focal point of Social Network Analysis (SNA) (Acedo et al., 2006 ; Fischbach and Schoder, 2011 ). To build the collaboration network, Louvain method was used as a clustering algorithm (Lu and Wolfram, 2012 ). The threshold of 50 as the number of nodes and 2 as the minimum edges were considered to avoid isolated and “one-time” collaboration. The nodes depicting isolation due to a lack of ties or relationships were removed.

Furthermore, in the field of social network analysis, centrality measures are crucial when examining the status of actors within a network. While various methods and measures are employed in SNA, centrality provides valuable insights into an actor’s position. One commonly used measure is degree centrality, which captures the basic essence of centrality by quantifying the number of connections an actor has with its immediate neighbors in the network. It reflects the total number of edges adjacent to a node and represents the incoming and outgoing links of an actor. Another significant measure is closeness centrality, which focuses on an actor’s proximity to all other actors in the network. While authors may be well-connected within their immediate neighborhood, they could still be part of partially isolated groups. Despite having strong local connections, their overall centrality might be limited. Closeness centrality extends the concept of degree centrality by emphasizing an author’s closeness to all other authors. Calculating closeness centrality requires determining the shortest distances between a node and all other authors, and then converting these values into a metric of closeness. A central author in the network is identified by having multiple short links to other authors. In addition, betweenness centrality offers a distinct perspective on centrality. It measures how often a particular node lies on the shortest path between pairs of nodes in the network. Nodes that frequently appear on these paths are considered highly central as they regulate the flow of information within the network. Although betweenness centrality can be applied to disconnected networks, it may result in numerous nodes with zero centrality since many nodes may not act as bridges within the network. This measure is based on the number of shortest routes passing through an actor. Actors with high betweenness centrality act as “middlemen,” linking different groups together.

Network analysis software enables the computation of centrality measures such as degree, betweenness, and closeness. These measures hold varying significance based on the specific network under examination. For instance, within a co-authorship network, an author’s degree centrality reflects the number of co-authored papers with other authors (Fischbach and Schoder, 2011 ). High betweenness centrality suggests that an author serves as a crucial link between distinct research streams. Furthermore, authors with high closeness centrality can establish connections with other authors in the network through shorter paths. UCINET (Borgatti et al., 2002 ) and Pajek (Batagelj and Mrvar, 1998 ) are the predominant software packages employed for network visualization purposes. For the present study, Pajek was employed to examine the social network and conduct centrality analyses.

We addressed RQ3 by using co-word analysis to gather concept space knowledge by utilizing the co-occurrence frequency of keywords. A co-word network is prepared based on the co-occurrence of words to examine specific areas of interest in crisis communication. We performed co-occurrence network analysis and hierarchical clustering to identify clusters that represent common concepts. The results were then described on the thematic map and theme evolution space. We considered 50 nodes as a threshold and a minimum of two edges for each node. Further, we chose the Louvain method for the clustering algorithm and the association as the normalization parameter for the analysis. Thematic mapping, built upon the keyword co-occurrence network and clusters, was performed to study the conceptual structure. We divided the evolution of thematic areas into four distinct periods (1968–1999, 2000–2007, 2008–2014, 2015–2022). These thematic areas represent a group of evolved themes across different subperiods. The evolution of key themes helps to understand variations in the research stream as well as provide necessary directions for future research., while interconnections link one theme with another thematic area. We also developed a thematic map representing four different themes based on their placement in the quadrant (Cobo et al., 2012 ), for example,

Themes placed in the upper-right quadrant are based on strong centrality and high density. These are the motor themes which are well developed and are important for shaping the research field.

Themes placed in the upper-left quadrant refer to the niche themes that are specialized and that depict peripheral characteristics.

Themes placed in the lower-left quadrant refer to the emerging or disappearing themes. They depict weak centrality and low density. Such themes are weakly developed.

Themes placed in the lower-right quadrant refer to the basic themes. These themes are important to the research field but are underdeveloped.

For addressing the RQ4, we performed co-citation analysis to develop clusters depicting the intellectual base of the field. Co-citation refers to the citation of two (or more than two) articles in the third article, which is the counterpart of bibliographic coupling. The Louvain method was used as a clustering algorithm to develop the co-citation network considering articles, authors, and sources. A threshold of 50 for a number of nodes, and 20 as the minimum edge strength (representing approximately 5% of the corpora in crisis communication) was considered. This as a whole aided in performing cluster level analysis.

Finally, the synthesis of the results of RQ1, RQ2, RQ3, and RQ4 helped to address the RQ5.

Scientific output (RQ1)

This section elaborates on the research landscape of crisis communication from 1968 to 2022. We gathered a total of 1850 articles by 3277 authors from 1222 institutions published in 646 journals as per the set criteria.

Publication output

The contribution to the field is highest through journal articles with over 95%, followed by review articles (4.7%). Moreover, around 28% of the articles are single-authored publications, while 72% are published in collaboration. The overall annual production of articles in crisis communication shows an exponential growth (Supplementary Fig. S1 ). The growth of the articles is stagnant between 1968 and 2000, with a few publications until 2000. However, growth is evident from the early 2000s, crossing double-digit publications annually. From 2015 onwards, annual publication growth improves by over 100 publications. Between 2020 and 2022, the annual publication count increases by over 200. Since 2015, the number of annual publications has been larger than the cumulative number of articles published before 2015. Overall, the annual growth rate of the research articles is 15% (the calculation does not include the period 1968–2000 and 2022 due to sensitivity).

Source output

A total of 1850 articles have appeared in 646 journals. The leading journals are the Public Relations Review which has hosted 249 publications, followed by the Journal of Contingencies and Crisis Management with 65 publications. Subsequently, the Journal of Communication Management has hosted 51 publications, followed by Corporate Communications with 48 publications, and then the Journal of Public Relations Research with 37 publications, respectively (Supplementary Table S2 ). The subject of crisis communication also belongs to the broader area of public relations and communication, which matches with the aims and scope of these journals. Additionally, the most cited sources, showcasing that the Public Relations Review has fetched the highest citations of 8284, followed by Journal of Contingencies and Crisis Management with 1539 citations. Subsequently, the Journal of Applied Communications Research has fetched 1522 citations, followed by the Journal of Public Relations Research with 1333 citations, and Corporate Reputation Review with 1158 citations, respectively. The Public Relations Review is identified as the top outlet for publication having the highest impact in the crisis communication field.

Most productive authors

Considering our dataset, 3277 authors from 1222 organizations have published articles on crisis communication. Sellnow has published the maximum number of articles with 35 publications on crisis communication, followed by Jin with 34 articles (Supplementary Table S3 ). Subsequently, Liu has published 33 articles followed by Spence with 28 articles, and then Lachlan has published 27 articles.

The author’s productivity and impact are measured considering the number of published articles and citations per year. It can be noted that Sellnow, Jin, Liu, Spence, and Lachlan are the most productive authors. While Coombs, Jin, Holladay, Liu, and Sellnow have received the highest citations (Supplementary Fig. S4 ). Scholars argue that the total citations received is not the only metric that determines the author’s production (Forliano et al., 2021 ; Huang and Hsu, 2005 ). Thus, we used three indicators—m-index, h-index, and the total citations (Supplementary Table S5 ). The most cited authors having more than 1000 citations in the database are Coombs (with 3418 citations), Jin (with 1914 citations), Holladay (1833 with citations), Liu (with 1655 citations), Sellnow (with 1299 citations), Spence (with 1200 citations), and Seeger (with 1095 citations). However, Coombs (TC = 3418 and h index = 18), Jin (TC = 1914 and h-index = 20) and Liu (TC = 1299 and h-index = 18) and Sellnow (TC = 1299 and h-index = 20) have the best combination of productivity and impact (Hirsch, 2005 ). For example, Coombs with h-index 18 has published 18 articles that have received at least 18 citations. Out of the top 20 contributors, 11 authors have h-index of at least 10. Hirsch ( 2007 ) suggests considering the contribution of young authors by the metric m-index, which determines the h-index weighted for the activity period of an author. Hence, young authors such as Claeys, Cauberghie, Kim, and Liu who started publishing from 2009 can be counted amongst the most influential authors.

Most productive institution

The most active organizations in this field are the University of Maryland (with 79 publications), the University of Kentucky (with 75 publications), the University of Florida (with 51 publications), the University of Georgia (with 50 publications), and Nanyang Technological University (with 49 publications) (Supplementary Table S6 ).

Most productive countries

Scholars argue that multi-authored publications might not represent the open collaborations dimensions of the most prolific countries publishing the articles. Thus, three different metrics are considered: SCP (single-country publication; intra-country publications), MCP (multiple-country publications; inter-country publications) and MCP ratio (ratio between MCPs and the total number of publications in the database TC; Supplementary Table S7 ). The MCP ratio determines the level of openness of the country to collaborate. It is noted that the intra-country publications are highest in the USA (SCP = 589), Germany (SCP = 51), China (SCP = 42), Sweden (SCP = 42), and the United Kingdom (SCP = 41) while inter-country publications are highest in the USA (MCP = 41), Korea (MCP = 23), the United Kingdom (MCP = 20), China (MCP = 17), and Hong Kong (MCP = 15). However, considering the MCP ratio, Hong Kong (MCP ratio = 0.555), Korea (MCP ratio = 0.54), Finland (MCP ratio = 0.33), the United Kingdom (MCP ratio = 0.32), and China (MCP ratio = 0.28) showcase openness in collaborations. It is surprising to note that the top 2 countries (USA and Germany) despite publishing the highest number of articles have limited openness in international collaborations as per the MCP ratio.

Additionally, considering total citations and production, the US emerges as the leader in production and impact; however, Korea, Netherlands, and Australia show a rising trend in terms of the impact, while China and Sweden, a declining trend (Supplementary Table S8 ).

Social structure (RQ2)

In this section, we performed analysis of collaborations patterns across three levels: author, institution, and country. Crisis communication has received contributions from 75 countries and 1222 different institutions publishing 1850 articles that depict global attention given to the field. In the database, multiple-authored articles (72% of the total published articles) are higher than single-authored articles.

Authors’ social structure

Figure 1 shows 11 clusters (in different colors) of the 36 most influential authors. Out of these 11 clusters, 6 are dominated by double authors while rest have more than two authors. Among the double author collaborations clusters, the one including Coombs and Holladay leads in terms of contribution and impact.

The network depicts 11 clusters.

Institutions’ social structure

Figure 2 shows the collaborations among the institutions. The institutional social structure is dominated by two clusters—cluster 1 (red color) and cluster 2 (blue color)—are led by University of Maryland and University of Kentucky, respectively.

The network depicts five clusters.

Countries’ social structure

Figure 3 depicts country-wise social collaborations. The USA leads in terms of contribution and collaboration while countries like Malaysia and Nigeria show minimal collaborations. This indicates that there is a dearth of contributions from developing economies. Thus, investigating crisis communication in this context may be considered for further research.

Social network perspective

We gathered a total of 1850 articles by 3277 authors from 1222 institutions published in 646 journals as per the set criteria. For a deeper insights, we examined the social network measures at two levels. Firstly, at the cluster level network for authors (Fig. 1 ), institutes (Fig. 2 ), and countries (Fig. 3 ). Secondly, for the complete social network for authors, institutes and countries, See Fig. S10 .

Betweenness centrality is a measure that quantifies the number of shortest routes passing through an actor in a network. Actors with high betweenness centrality play a crucial role in linking different groups together, acting as “middlemen”. In Table S9 , we observed that Liu for cluster 1, has the highest betweenness centrality (140), followed by Jin (89.7), Besides, Herovic for cluster 8, has the highest betweenness centrality (114), followed by Sellnow (104) in the studied network. This indicates that they serves as a central figure, connecting authors within the network in the field of crisis communication in Scopus from 1968 to 2022.

Furthermore, authors with a high closeness centrality are connected to all other authors through a small number of routes or paths, indicating their strong proximity to the entire network. A central author is distinguished by having numerous short connections to other authors within the network. According to the closeness centrality values presented in Table S9 where each clusters has more than 5 nodes, Liu in cluster 1, Claeys in cluster 2 and Herovic in cluster 8 exhibits the highest closeness centrality in their cluster network.

In Table S10 , we observed that University of Georgia for cluster 2, has the highest betweenness centrality (144.90), followed by University of Maryland (122.32). Besides, University of Tennessee takes the third place (112.32) in the studied network. This indicates that they serve as a central figure/point, connecting institutions within the network in the field of crisis communication in Scopus from 1968 to 2022. Furthermore, considering cluster nodes greater than 5, University of Maryland in cluster 2, and University of Kentucky in cluster 4 exhibit the highest closeness centrality in the their cluster network.

In Table S11 , we observed that USA for cluster 2, has the highest betweenness centrality (377.40), followed by United Kingdom (180.57), Besides, Italy takes the third place (68) in the studied network. This indicates that they act as a central figure, connecting country’s within the network in the field of crisis communication in Scopus from 1968 to 2022. Furthermore, considering cluster nodes greater than 5, USA in cluster 2, and “Italy” in cluster 1 exhibit the highest closeness centrality in the their cluster network.

Furthermore, when we examined the complete social network (Fig. S10 ) of authors, institutes and country based on the degree centrality, closeness and betweenness metrics, we identified significant insights and patterns. For example, as per Table S12 , among the authors listed, Lachlan has the highest author centrality score of 37, indicating a significant level of influence or importance within the field. Sellnow closely follows with a centrality score of 31, while Spence, Jin, and Claeys have scores of 34, 29, and 24, respectively. In terms of university centrality, the University of Kentucky has the highest score of 24, suggesting it holds a prominent position within the academic network. The University of Maryland and the University of Georgia share the second-highest centrality score of 20, followed by Virginia Commonwealth University with 15 and the University of Central Florida with 14. The country with the highest centrality score is the USA, with a score of 159. It is followed by the UK with a score of 91, China with 49, Australia with 41, and Spain with 37.

Based on the closeness centrality values presented in Table S13 , notable patterns emerged in the author, institutes, and country networks. In the author network, Jiu takes the lead with the highest closeness centrality score of 0.206531, closely followed by Herovic with 0.194615, Jin with 0.180714, and Sellnow and Kim with 0.171525. Shifting focus to the institutes network, the University of Maryland claims the top position with a score of 0.340000 in closeness centrality. Following closely behind is the University of Kentucky with 0.330000, the University of Tennessee with 0.325217, the University of Georgia with 0.320571, and the University of Central Florida with 0.295263. These institutions exhibit high closeness centrality, indicating their efficient access to information and strong connectivity within their respective networks. In the country network, the USA secures the highest closeness score of 0.660000, showcasing its exceptional accessibility and connectivity within the network. The United Kingdom follows closely with a score of 0.628571, demonstrating its strong network presence. Spain exhibits a score of 0.557746, Italy with 0.542466, and Australia and Sweden share a closeness score of 0.535135, all highlighting their significant connectivity and influence within the country network.

In Table S14 , a comprehensive view of betweenness centrality scores revealed significant insights into the network of authors and universities, along with their respective countries. Liu emerges as the most influential figure with the highest betweenness centrality score of 0.119048, followed closely by Sellnow with a score of 0.088435, and then Jin with 0.076288. These authors hold crucial positions, acting as central connectors within the field of crisis communication. Examining the betweenness centrality scores for universities, the University of Kentucky stands out with the highest score of 0.176513, occupying a prominent central position within the institution network. Following closely, the University of Georgia secures a score of 0.123216, and the University of Maryland follows suit with a score of 0.104022. Additionally, the University of Central Florida and the Nanyang Technological University both showcase their relevance, claiming positions in the top 5 among university betweenness centrality scores. Analyzing country betweenness centrality, the USA leads with the highest score of 0.320927, indicating its pivotal role in connecting various entities within the global network. The UK follows with a score of 0.153552, showcasing its significant influence as well. Australia, Italy, and Spain also demonstrate their bridging capacities, garnering respective scores of 0.082574, 0.058308, and 0.045895.

Conceptual structures (RQ3)

Scholars have argued the utility of keywords and co-occurrence analysis to develop prevalent themes in the underlying research field. The year wise cumulative occurrences of keywords depict dominance of “crisis communication” (Supplementary Fig. S9 ). The outcome of co-occurrence analysis is theme clusters. To explore the scientific knowledge structure of the field, in this study, a threshold of 500 author keywords was deployed. To explore the thematic evolution of crisis communication, four “time-slicing” periods were examined considering the publications growth, (Supplementary Fig. 1 ). These time periods are considered for the overall time distribution of publications: 1968–1999, 2000–2007, 2008–2014, 2015–2022. The time based thematic coverage analysis is based on four different quadrants (Cobo et al., 2012 ): motor themes, basic themes, niche themes, and emerging or disappearing themes.

First period (1968–1999)

During the period between 1968 and 1999, there is a limited development of the intellectual base depicting the emergence of only a few major themes. Crisis communication in the basic theme, plays a foundational role in defining the structure of the field during the first period. The basic theme indicates that “crisis communication” provided the foundation for exploring crisis management and issue management, which are important basic terms during this period. Advertising is identified as an emerging theme, with the focus on branding, e-communication, effective communication, image building, positioning, and reputation. The motor theme that emerges in this period is crisis focusing on crisis management and image restoration. However, this period does not identify niche themes.

During this period, several scholars have discussed the purpose and importance of reputation and advertising during crisis communication. Williams and Treadaway ( 1992 ) attribute the failure of Exxon’s crisis communication to the delay in the initial response and ineffective use of burden-sharing and scapegoating strategies. Argenti ( 1997 ), while exploring the “Dow Corning’s Breast Implant Controversy” case, identifies that the corporate (Dow Corning) failed to consider the reputation as a strategic tool during the crisis and poorly communicated with the stakeholders. Versailles ( 1999 ) argues the role of effective communication in shaping and building a reputation for Hydro-Québec’s crisis communication. Likewise, U.S. airlines gained public support and confidence after the 9/11 crisis by using timely and honest communication, and by utilizing appropriate crisis response strategies such as suffering (Coombs, 1995 ; Massey, 2005 ). Saliou ( 1994 ) advocates using an adaptive crisis communication strategy to defuse panic, avoid rumors and vulnerability, manage local and global stakeholders, and disseminate information to target groups. Advertising, on the other hand, plays a critical role in building reputation during crises (Versailles, 1999 ).

Second period (2000–2007)

The thematic focus during 2000 and 2007 indicates an expansion of the intellectual base with a diverse set of concepts.This suggests a slight paradigm shift toward recognizing crisis communication as a multi-dimensional theme. Motor themes in this period are: risk assessment, leadership, attribution, and public health. In the motor theme, public health and attribution dominate the theme. For the public health theme the focus is on the exploration of disaster communication, flu pandemic communication and terrorism management, while the attribution theme focuses on responsibility and accountability. Surprisingly, the basic themes have a large coverage focusing on corporate image, public relations, crisis communication and crisis. Crisis communication dominates the basic theme by having a larger coverage on risk communication, media relations, image repair, political communication, crisis management, and response strategies. The theme public relations focuses on crisis planning, conflict management, corporate image, and corporate communication. The presence of niche theme - attribution and emerging theme - communication strategies is also evident.

During this period, the focus is majorly on the developments of appropriate theoretical frameworks. Hearit’s ( 2001 ) theory of corporate apologia proposes the rhetorical concept of self-defense, wherein organizations are seen as possessing public characters, and this provides momentum to the term reputation. Kauffman ( 2001 ) argues that NASA’s timely, honest, and open communication regarding the Apollo 13 crisis with the public and stakeholders, bolstered its image and attracted public and congress support for further manned space explorations. Coombs ( 2007a , 2007b ) attribution theory and Situational Crisis Communication Theory (SCCT) suggest embracing the field’s evolution and the influx of empirical methods in the context of crisis communication (Arpan and Roskos-Ewoldsen, 2005 ). More emphasis is given to prescriptive, rather than descriptive methods of investigation and analysis. Attribution is directly linked to people’s need to search for causes of the event (Weiner, 1986 ), making it logical to connect crisis with attribution theory (Coombs, 2007a ). Cowden and Sellnow ( 2002 ) explores the role of attribution as part of the image restoration strategies for Northwest Airlines (NWA) in proactively reducing the culpability of the strike. Gallagher et al. ( 2007 ) argue that an organization’s decision to acknowledge its role in the crisis is vital for crisis communication and for establishing public relations. It is important to be in sync with health systems to share relevant and appropriate information. For example, Mebane et al. ( 2003 ) find that a deviation of media and information shared by the Centers for Disease Control and Prevention (CDC) related to Anthrax caused panic. Various empirical studies have attempted a prescriptive approach to analyzing the crisis. Additionally, public segmentation in communicating (Rawlins and Bowen, 2005 ) enhances the organization’s public relations. By doing so, organizations become aware of customers’ perceptions of the crisis response, thereby offering appropriate public relations communication.

Third period (2008–2014)

In this period, the number of annually published articles increases remarkably. Seven major themes emerge and their spread is evident in the four quadrants. There is a presence of a niche theme in terms of risk and crisis communication, focusing on health communication, pandemic, flu, H1N1, influenza, and risk perception. However, strong linkages are witnessed between health communication, and response strategy. The theme risk and crisis communication focuses on organizational communication, political communication, internal communication, and corporate communication. In addition, response strategy is closely linked to organizational communication, and crisis response. The emerging theme identifies situational crisis communication as a collective theme that focuses on leadership, contingency, crisis response strategy, ethos, crisis responsibility, image repair, and threats. The basic theme is dominated by crisis communication and communication. The motor themes include corporate communication, corporate social responsibility, communications and emotions.

Avery et al. ( 2009 ) attribute crisis communication to multiple contexts (e.g., delay, use of scapegoating strategies). Crisis communication, built around the concept of corporate apologia, aims to develop rhetorical strategies to reduce reputational harm and help organizations build images and restore order (Coombs et al., 2010 ). Gallagher et al. ( 2007 ) argue that an organization’s decision to acknowledge its role in the crisis is vital for crisis communication and for establishing public relations. However, when an organization responds in a timely manner and follows transparency in communication, it attracts the trust and support of stakeholders. Identifying the type of response and understanding its consequences also plays a critical role in managing crisis communication. For example, an organization in crisis struggles to choose the correct answer as the choices vary— defensive vs. offensive, reactive vs. proactive, vague vs. transparent, etc. However, to effectively manage crisis communication, an organization must consider reputational, legal and financial outcomes (Avery et al., 2009 ). Internal communication in health organizations is critical for health practices. For example, Schmidt et al. ( 2013 ) identify a lack of correct perception of influenza by healthcare workers, thereby limiting the execution of timely vaccination. Kim and Atkinson ( 2014 ) identify critical factors such as brand ownership, exposure to media, and involvement with the crisis and consider advertising as a tool to communicate with consumers during the crisis to shape reputation.

Fourth period (2015–2022)

In this period, the field grows multidimensionally, including all the four themes. The motor theme includes COVID-19, and crisis management. The emerging theme focuses on crisis. The basic theme represents crisis communication and the emerging theme depicts the importance of public relations, and crisis. The niche theme focuses on risk communication. An interesting insight is the inclusion of the pandemic COVID-19 under the motor theme, which is strongly related to the niche theme in the earlier period. This shows that this period witnessed a dramatic shift in the themes and focal interest.

During this period, both scholars and practitioners consider the use of social media as a new-age communication tool, as it helps to offer direct and personalized communication to social media consumers. Such communication helps to shape and build reputation during a crisis. For example, Wang ( 2016 ) argues that social media is an effective crisis communication tool for turning crises into opportunities. Ho et al. ( 2017 ) propose a corporate crisis advertising framework and validate its applicability in managing and restoring an organization’s reputation. The authors also focus on the role of omni-channel (e.g., social media, print media, TV, radio) and short-, medium-, and long-term crisis communication plans to manage and shape their reputations. Additionally, Claeys and Opgenhaffen ( 2021 ) argue that to manage crisis communication effectively impact of reputational consequences and legal and financial outcomes needs to be considered. Hyland-Wood et al. ( 2021 ) argue on deploying crisis communication responses by including clear messages shared through appropriate channels and trusted sources. Such messages are customized to attract diverse audience members. Additionally, public segmentation in communicating (Rawlins and Bowen, 2005 ) enhances the organization’s public relations (Wen et al., 2021 ). By doing so, organizations become aware of customers’ perceptions of the crisis response and thereby offer appropriate public relations communication. Santosa et al. ( 2021 ) argue using varied public relations professionals’ communication strategies based on gender. Moreover, Malik et al. ( 2021 ) highlight the role of health organizations in countering misinformation on social media. They suggest that few elements such as timely and accurate information, and inclusion of credible sources help to streamline the facts.

Overall themes

Figure 4 shows the development of the four major clusters. The number of times the term is used is proportional to the size of the node. The nodes that are closely linked are the proximate nodes, while the thickness of the links connecting the nodes is proportional to the strength of the connection.

The network depicts four clusters.

Cluster 1: crisis communication and social media

The largest cluster (in red) includes 23 items and is mainly related to crisis response strategies, strategic communication, situational crisis communication, and communication on social media. The linkages to terms such as image repair, internal communication, and corporate communication may indicate that crisis communication concerns related to organizations can provide multiple co-benefits and strengthen public relations (Coombs, 2021 ; Tornero et al., 2021 ).

Cluster 2: health communication

Cluster 2 (in blue) consists of ten items and mainly covers issues related to public health and health communication. This cluster has strong links to infectious disease outbreaks, pandemics, and associated risk communication. Moreover, the inclusion of political communication to deal with the level of severity of the threat or risk is found to be critical.

Cluster 3: crisis and leadership

Cluster 3 (in green) includes ten items and focuses on two major areas: crisis and leadership. Other terms, such as disaster, risk, apology, resilience, and reputation are closely related to crisis and leadership.

Cluster 4: reputation and advertising

Cluster 4 (in purple) includes seven items and focuses on two major aspects: reputation and advertising for brand building. This cluster has strong links to corporate reputation, media, trust, advertising, and leadership. Related terms are closely linked to reputation that may indicate strategic alignment of leadership to communicate effectively (Coombs and Holladay, 2002 ).

Intellectual structure (RQ4)

In this section, we examined the intellectual collaborations patterns across three levels: author, sources, and documents. We performed the co-citation network analyses to explore the intellectual structure. Figure 5 presents two clusters that dominate the intellectual structure based on the authors. Cluster 1 (in blue color) is driven by Kim, Jin, Liu, Lee, Veil Smith, and Schultz, while cluster 2 (in red color) is driven by the contributions of Coombs, Benoit, Seeger, Heath, and Ullmer. Cluster segmentation depicts diverse dominant areas of research interests among the authors.

The network depicts two clusters.

Figure 6 presents the development of three major clusters showcasing the intellectual structure of the research in crisis communication based on sources. Cluster 1 (in red color) is dominated by Public Relations Review, Journal of Public Relations Research , and Journal of Applied Communication Research . Cluster 2 (in green) is driven by Corporate Reputation review, Journal of Personality and Psychology, Journal of Business Research and Business Horizons . However, Cluster 3 (in blue), is driven by Management Communication Quarterly, Corporate Communications: An International Journal, and Journal of Business Communication .

The network depicts three clusters.

Figure 7 presents the development of three major clusters showcasing the intellectual structure of the research in crisis communication based on contributed papers. Cluster 1 (in red color) is dominated by Coombs ( 2007b ), Coombs and Holladay ( 2002 ), and Coombs ( 1998 ). Cluster 2 (in blue color) is driven by Benoit ( 1995 ), Benoit ( 1997 ), Seeger ( 2006 ) and Schultz et al. ( 2011 ). Cluster 3 (in green color) is driven by Schultz et al. ( 2011 ), Coombs ( 2009 ), and Jin ( 2010 ). The cluster segmentation depicts the diverse dominant areas of research interests among the authors.

Crisis communication is one of the most important critical elements of the communication research. The availability of large corpora of literature on crisis communication necessitated a bibliometric approach to study its evolution and growth in the communication field. We adopted bibliometric visualization techniques to understand the trajectory of crisis communication scholarship. First, we used descriptive analysis to study the prominent contributors to the field with respect to the authors, sources, institutions, and countries. We portrayed the growth trajectory and presented the trend analysis including the most productive and impactful authors, sources, countries and institutions. Second, the co-authorship analysis was done to project the social structures of the crisis communication research. This enabled us to present the social collaboration relationship of different, authors institutions and countries. Besides, we performed the analysis of social network measures to explore valuable insights into the dynamics of collaboration within the crisis communication domain. To delve deeper into the networks, we examined the cluster-level networks for authors, institutes, and countries, as well as the complete social network. The network measures (degree centrality, closeness and betweenness) shed light on the pivotal actors, institutes, and countries within the crisis communication domain, illustrating their roles as central connectors and influential figures. The findings have provided valuable insights into the collaborative landscape, facilitating a deeper understanding of the dynamics and relationships that shape the field of crisis communication in Scopus from 1968 to 2022.

Third, we performed the co-word analysis to gather concept space knowledge by utilizing the co-occurrence frequency of keywords. Subsequently, co-occurrence network analysis and clustering were used to identify clusters that represent common concepts. The keywords co-occurrence network and clusters developed the thematic mapping and thus presented the conceptual structure. Fourth, we performed the co-citation analysis of author, reference and sources to develop the intellectual structure of the field. This projected the network relationship among the authors.

Theoretical implications and roadmap for future research

This paper is one of its own kind, in which co-occurrence, co-authorship and co-citation analyses were performed to understand the growth and development of crisis communication research in the communication field. This paper presents the advantages of bibliometric analysis over the traditional methods in the study of crisis communication literature. For example, bibliometric analysis not only covers the full spectrum of the available literature, but it also objectively navigates the development of the field by exploring the social, conceptual and intellectual structures of the crisis communication research, while, traditional methods are unable to capture and synthesize large datasets of authors and articles (García-Lillo et al., 2016 ).

By utilizing bibliometric visualization, this study examines the patterns of interactions among key authors and articles; and develops clusters of research themes. The interaction patterns and relationships provide insights into the knowledge domain (Hu and Racherla, 2008 ), while clustering technique depicts key papers with similarities in topics (Chen, 2006 ). Bibliometric visualizations facilitate a display of temporal data in different colors. Additionally, a longitudinal view in the form of four quadrants provides the thematic evolution of crisis communication research and presents the evolution and growth of major themes. These projections aid researchers in identifying research boundaries and display recent themes (Chen, 2006 ).

This paper presents insights into the intellectual, social and conceptual structures of the crisis communication field. The other major contribution of the study is the formulation of the research questions which are mentioned in the methodology section. RQ1 findings identified core sources, authors, countries, publications, and affiliations to examine prominent contributors to the literature on crisis communication. We observed that 3277 authors from 1222 institutions published 1850 articles in 646 journals addressing crisis communication within more than 50 years (with the first publication being released in 1968). Though Sellnow appeared to be contributing the highest number of articles with the most extended unbroken series of publications from 1993 to 2022, Coombs received the best combination of productivity and impact (TC = 3418 and h-index = 18). Our results also corroborate with other bibliometric studies where the author’s production and impact are measured considering the number of articles published, total citations, and h-index (for example, Forliano et al., 2021 ). Moreover, among the young and influential authors the works of Claeys, Cauberghie, Kim and Lin are noteworthy. Further the annual scientific publication growth was stagnant in Period 1 and increased in Period 2. However, rapid growth was evident after 2015, in Period 4. This may be attributed to the wide availability of information channels and global events (Maal and Wilson-North, 2019 ). Public Relations Review outranks all other journals by publishing the highest number of articles (249) on crisis communication. This journal published thrice more than the number of articles published by the Journal of Contingencies and Crisis Management which stood second in the list. These results are in concurrence with the earlier studies that found Public Relations Review published the highest number of articles (e.g., An and Cheng, 2010 ; Avery et al., 2010 ).

RQ2 examined the social structure of the crisis communication research domain. Borgatti et al. ( 2013 ) and Grace et al. ( 2020 ) suggest that social collaborations are majorly driven by geographic and institutional proximity. This is corroborated in the current study as well. Country collaboration depicts network of authors and we observed that the concentration of the publication corpora was within a few countries, out of which the USA depicted a huge presence. We also observed that the most productive countries do not always have high openness in collaborations. This observation should encourage more scholars to consider contributing to the present debate and enhance cross country collaborations (Massaro et al., 2016 ). We noticed that the contributions in crisis communication were fragmented despite receiving increased attention in the recent years. Hence a proper synthesis and systemization of work is potent to expand the crisis communication production and impact. We identified 11 co-author clusters depicting the most influential scholars with confined collaborations. Out of these, 6 clusters had collaborations of only two influential scholars. We observed that 28% of contributions were from single-authored publications. We suggest that more scholars should contribute to the crisis communication space. The results from the co-authorship network present the current state of collaboration and the most influential authors on crisis communication. Our evidence suggests that there is relatively little collaboration among authors, and much of this is localized. We noticed that the social structure at the level of institutions is dominated by the universities in the USA (e.g., University of Maryland and University of Kentucky). According to the social collaboration structure, the contribution of developing countries is minimal in the crisis communication space. Thus, more collaborations and empirical evidence may be solicited from the developing countries.

RQ3 explored popular themes in the crisis communication literature with the help of keywords and co-occurrence (or co-word) analysis. Overall, four major themes emerged: (a) crisis communication and social media (b) health communication, (c) crisis and leadership, and (d) reputation and advertising. The keywords related to the themes were a part of the crisis communication evolution during the study period (1968–2022). The results of our citation analysis suggest that a limited number of articles have shaped the field. We observed a clear shift in crisis communication and response strategies with the onset of omni-channels, such as social media platforms.

RQ4 examined the emergence of two main groups in the intellectual structure (co-citation analysis). Despite having a relatively low number of relational ties, they act as knowledge brokers among the groups. This may be due to closed group collaborations, and thus, better collaborative efforts among scholars are needed. Coombs ( 2007b , 2002 , 1998 ) dominate the intellectual space in terms of the document-based intellectual structure. The thematic development and its evolution are helpful for scholars, sources (journals), institutions and countries to acquire knowledge on specialized and highly relevant topics. More specifically, niche and emerging themes may address the immediate call for research and collaborations. Journals are encouraged to announce special issues on these themes. Additionally, journals may increase the number of publications as they are ranked among the most impactful ones but have relatively low number of publications.

The findings of the paper has implications for crisis communication research in terms of examining the social, conceptual and intellectual structures of the field. Given the large corpora and growth of crisis communication research over the last 50 years, Biblioshiny, serves as a useful tool to objectively capture the social and intellectual collaborations, growth and evolution of concept and knowledge space of this field (Denyer and Tranfield, 2006 ). These insights, therefore, may be extremely useful to the early scholars or researchers from outside the field (Benckendorff and Zehrer, 2013 ).

The overall findings and analysis of this paper present several opportunities for future research in the field of crisis communication. A list of potential research questions is prepared as the outcome of RQ5 which was accomplished by collating the results of RQ1, RQ2, RQ3, and RQ4.

While research opportunities are immense in crisis communication, the following research questions can be considered for further understanding, see Table 1 :

The findings from our study on social network measures at two levels, namely, cluster-level networks for authors, institutes, and countries, as well as the complete social network for authors, institutes, and countries, have provided valuable insights into the field of crisis communication from 1968 to 2022. The application of network metrics, such as degree centrality, betweenness centrality and closeness centrality, has enabled us to identify key actors, institutions, and countries that play pivotal roles in linking different entities within the crisis communication domain. Figure 8 represents the framework enhancing social collaboration based on the social network analyses.

Identifying Key Connectors: The analysis of betweenness centrality in Tables S9 , S10 , and S11 has revealed central figures, such as Liu and Herovic in the author network, University of Georgia and University of Maryland in the institute network, and USA in the country network. These individuals and entities act as “middlemen,” connecting various clusters and facilitating efficient information flow between different groups. Researchers and policymakers can leverage this insight to foster collaboration and knowledge exchange among the identified central figures, thereby enhancing crisis communication efforts globally.

Enhancing Network Proximity: Authors with high closeness centrality scores, like Liu in cluster 1, Claeys in cluster 2, and Herovic in cluster 8, have strong proximity to the entire network. Similarly, institutes with high closeness centrality scores, such as University of Maryland, University of Kentucky, and University of Tennessee, exhibit efficient access to information within their respective clusters. Policymakers and practitioners can focus on strengthening ties and communication channels among these authors and institutions to foster a more cohesive and well-connected crisis communication community.

Promoting Global Collaboration: The country network analysis based on betweenness centrality in Table S11 has highlighted the significant role of countries like the USA, United Kingdom, and Italy in connecting various nations in the crisis communication research domain. This implies that these countries have the potential to facilitate global collaboration and knowledge dissemination. Encouraging international conferences, joint research initiatives, and exchange programs can further strengthen ties between these influential countries and foster a more inclusive and comprehensive approach to crisis communication worldwide.

Identifying Influential Authors and Universities: Table S12 has provided a comprehensive view of the author and university centrality scores. Researchers can collaborate with authors like Lachlan and Sellnow who hold substantial influence and importance within their field. Additionally, universities like University of Kentucky and University of Maryland stand out as prominent knowledge hubs, making them potential partners for collaborative research and academic exchanges.

Leveraging Network Insights for Crisis Management: The identification of influential actors, institutes, and countries through betweenness centrality can be instrumental in strategic crisis management. By collaborating with central figures, crisis communication efforts can be streamlined, and rapid response systems can be developed, ensuring effective handling of crises and their aftermath.

Framework for enhancing social collaboration based on the social network analyses.

Limitations

This study is not devoid of limitations. First, the Scopus database is used to gather a quality dataset for the study. This limits the analysis of publications as other databases such as Google Scholar, WOS, PubMed, etc., might include more publications. Additionally, some conditions were applied to improve the performance analysis (e.g., year of publication, type of document, language). Therefore, future research can address this gap by retrieving datasets from all popular databases for further analysis. Second, the inherent complexity of certain metrics, such as the usage of h-index or comparable metrics, might induce some inconsistencies. As such, future research can provide comparisons of metrics while performing an analysis. Third, a mixed approach (quantitative and qualitative) may be considered in future work to provide more specific analysis in terms of theory, context, and implications. Fourth, currently the social network analyses was limited to two levels—cluster and a complete network considering three measures degree centrality, betweenness, and closeness—to explain social collaborations. However, future research can perform an extensive and detailed social network analyses.

Lastly, Biblioshiny software presents some limitations in terms of database selection, division of periods, threshold selection and adjustment of suitable nodes and links for analysis. These parameters are generally selected by researchers on the basis of past papers, which may yield slightly different networks on account of different settings. However, Biblioshiny with its high stability in running the data provides consistent results for the same data and parameters. This enhances the reliability of the results. Though Biblioshiny offers visualization of data and networks at different depths by zooming-in and zooming-out, such dynamic visualizations are not present in the paper. We recommend inclusion of three-dimensional visualizations for improving visibility and exploring relationships as a separate supplementary material.

Conclusions

This paper presents the first bibliometric study of crisis communication between 1968 and 2022. We critically appraised more than 50 years of crisis communication scholarship, described its intellectual, social, and conceptual structure and its thematic evolution over time, and identified many opportunities and directions for future research. With the publications in the highly reputable journals, the research in crisis communication field has grown exponentially since 1968. Various bibliometric indicators were used to capture the productivity (e.g. total publications) and impact (total citations received, h-index, m-index, citations per year) of authors, sources and countries. We identified four thematic clusters under the conceptual structure by using co-word analysis, such as, crisis communication and social media, health communication, crisis and leadership, and reputation and advertising . The presence of crisis communication as a basic theme in all the four periods demonstrate that though the theme is important to the research field but it is underdeveloped. Collaboration analysis showed that the most productive countries do not always have high openness in collaborations. Further, the findings depicted relatively little collaboration among authors, and much of it was localized. More openness in country-wise collaborations along with examination of niche and emerging themes may provide immense opportunities for future research. Our study on social network measures has shed light on key actors, institutes, and countries in the field of crisis communication. The implications of this research extend beyond academic curiosity, as the identified central figures and well-connected entities offer potential avenues for strengthening global crisis communication networks and enhancing collaborative efforts in times of need. Policymakers, researchers, and practitioners should capitalize on these insights to create a more resilient and responsive crisis communication landscape for the future.Thus, this paper attempts to make a prominent contribution by presenting the growth of the field along with future research opportunities.This paper will help both the scholars and the practitioners with a comprehensive review of the scholarly literature on crisis communication to address the future needs and to explore proposed avenues for further research.

Data availability

The data analyzed in this study is subject to the licenses/restrictions: original data were sourced where indicated from the Scopus. Requests to access these datasets should be directed to https://www.scopus.com/home.uri .

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Upadhyay, S., Upadhyay, N. Mapping crisis communication in the communication research: what we know and what we don’t know. Humanit Soc Sci Commun 10 , 632 (2023). https://doi.org/10.1057/s41599-023-02069-z

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“The person who can combine frames of reference and draw connections between ostensibly unrelated points of view is likely to be the one who makes the creative breakthrough.” —Denise Shekerjian

In the previous section, our framework describing the interaction of multiple competing messages provided a useful way to describe how risk communicators should create convergence and understanding with their audiences in pre-crisis, crisis, and post-crisis situations. In addition, the identification of best practices offers a way to identify why particular risk messages may have more influence than others on how audiences respond. Adding to the complexity of the situation for risk communicators are multiple publics who may not share the same understanding or willingness to respond to the messages due to how the risk or potential crisis may affect them in what we described as spheres of ethnocentricity.

In the complex communication context of risk communication, one research methodology is particularly appropriate, due to its capacity to explore, describe, or explain the dynamics of the situation. The case study approach to research in the social sciences is a fitting method for identifying the interaction between individuals, messages, and context. Yin ) summarizes, “The case study method allows investigators to retain the holistic and meaningful characteristics of real-life events” (p. 2). The case study approach works well to identify best practices for risk communication because individual situations are defined or isolated, relevant data are collected about the situation, and the findings are presented in such a way that a more complete understanding is reached regarding how messages shape perceptions and serve to prompt particular responses from those hearing the messages.

We consider the case study method as both an approach to research and a choice of what to study (Patton, 2002 ). Therefore, in the construction of the case studies presented in this book, a consistent methodological approach was followed. In order to establish common areas of analysis within the research design, we focused on risk situations involving the unintentional or intentional contamination or compromise of the food system. A conceptual framework based upon the best practices explained in Chapter 2 and a chronological exposition of the pre-crisis, crisis, and post-crisis messages created consistency as we drew implications about what happened, how it happened, and why. Collectively, the cases allowed us to generalize about the best practices as a whole.

Individually, the choice of cases provided opportunities to demonstrate various aspects of the best practices. Each of the forthcoming cases includes particular situations and context-sensitive information whereby the best practices for risk communication could be identified and studied. In some cases, preemptive communication strategies designed to promote compliant behavior are found. In others, the exposition of the crisis revealed how risks were not anticipated or communicated effectively to the public. In fact, as demonstrated by how a crisis actually unfolded, the evidence suggests that those managing the crisis were not always mindfully considering the competing arguments. Rather than seeking congruence, reliance on economic or social models enabled decision-makers to simplify the risk situation at a time when complexity should have been acknowledged. In such situations, the value of the best practices may not have been recognized until after the crisis had passed.

Justification for the Case Study Approach

We selected the case study approach as a way to illustrate the interactive process involved in the convergence of ris(2003k messages for several reasons. Case studies have been used frequently by scholars and practitioners in public health, agriculture, education, psychology, and the social sciences as a legitimate methodological approach to research (Rogers, 2003 ; Tuschman & Anderson, 1997 ). In addition, they provide a method to investigate a contemporary event involving risk within a real life context; and they contribute to enhanced knowledge of complex social phenomena.

Legitimacy as a Methodological Approach

The case study approach has been used to study many different situations involving individual, group, organizational, social, political, and related phenomena (Yin, 2003). Throughout his treatise on diffusion theory, Rogers ( 2003 ) offers cases to illustrate the following: social systems (Iowa hybrid corn case), pro-innovation bias (Egyptian villages pure drinking water case), socioeconomic status (California hard tomatoes case), the reinvention process (horse culture among the Plains Indians case), attributions of innovations (photovoltaics, cellular telephones case), adopter types (Old Order Amish case), opinion leadership (Alpha Pups in the viral marketing of an electronics game case), diffusion networks (London Cholera epidemic case), change agents (Baltimore needle-exchange project case), stages in the innovation process (Santa Monica freeway diamond lane experiment case), and the consequences of innovations (steel axes for stone-age Aborigines case), to name but a few.

In their collection of readings on managing strategic innovation and change, Tuschman and Anderson ( 1997 ) offer numerous case studies involving technology cycles, design changes, power dynamics in organizations, managing research and development, product development, cross-functional linkages, and leadership styles. Similarly, risk and crisis scholars have used case studies to illustrate best practices and organizational learning.

Sellnow and Littlefield ( 2005 ) use case studies describing both accidental and intentional contamination to demonstrate lessons learned about protecting America's food supply. Three cases focused on particular companies and their experiences managing a crisis: Schwan's demonstration of social responsibility in response to a Salmonella contamination crisis, Chi-Chi's inability to survive a Hepatitis A outbreak despite apologia, and Jack in the Box restaurants' organizational learning following an E. coli outbreak in Seattle, Washington. A case involving interagency coordination and the tainted strawberries in the National School Lunch Program revealed how various stakeholders affect crisis planning efforts. Two cases of potentially intentional contamination—one by Monsanto, a major producer of genetically engineered wheat and the other by the Boghwan Shree Rajneesh cult in an Oregon community—explored the effect of public opinion and outrage.

In their work, Ulmer et al. ( 2007 ) provide case studies revealing lessons learned about managing uncertainty, effective communication, and demonstrating leadership. They focused on four areas: industrial disasters (Exxon and the Valdez oil tanker, and the fires at Malden Mills and Cole Hardwoods), food borne illness (Jack in the Box's E. coli O157:H7, Hepatitis A at a Chi-Chi's restaurant, and the Schwan's Salmonella crisis), terrorism (the case of 9/11, the Oklahoma City bombing, and the CDC's handling of the SARS outbreak), and natural disasters (the 1997 Red River Valley floods, the Tsunami and the Red Cross, and the 2003 San Diego County fires).

Exploring risk and crisis situations in public health, Seeger et al. ( 2008 ) categorize case studies focusing on bioterrorism, food borne illness, infectious disease outbreaks, and crisis prevention and responses. Cases of bioterrorism focused on lessons learned from the 2001 Anthrax crisis through the U.S. Postal System; the threat of agro-terrorism in high reliability organizations and organizational responses to the Chi-Chi's Hepatitis A outbreak provided cases demonstrating the risk of food-borne illness and the need for crisis prevention; and the strategies used by communities, nations, and the world when dealing with the risk of West Nile Virus, SARS, Encephalitis, HIV and AIDS provided cases where infectious disease outbreaks required effective risk and crisis responses. These collections and others similarly have found value in studying particular examples of an identified phenomenon for the benefit of understanding more about what, how, and why something happened.

Multiple Sources of Information

One of the reasons supporting the legitimacy of the case study approach is its use of multiple sources of information to establish claims about a particular situation.

Multiple sources may include textual materials, on-line websites and resources, interviews, media accounts, and personal observations. Due to the nature of the case study approach, choices must be made about the kinds of information to be utilized. Accessibility often dictates the kinds of information to be included, in which case the researchers must continually cross reference to be sure that the most accurate depiction of the situation is conveyed.

For the case studies included within this volume, text-based materials provided the majority of the information consulted (Fig. 4.1 ). Information drawn from national newspapers (e.g., New York Times and The Wall Street Journal ), regional newspapers (e.g., The Boston Globe) or—as in the New Zealand foot and mouth hoax case—international outlets (e.g., Financial Times and The Dominion Post ) provided contextual material enabling the researcher to establish the time frame and variables at work in each case. Websites and on-line materials, such as those offered by governmental and industrial groups provided insight from the perspective of those in positions to respond to the risk or crisis situation. A number of groups were accessed through such websites, including the U.S. Department of Health and Human Services, the Department for the Environment, Food, and Rural Affairs, Odwalla, Inc., KidSource Online, and ConAgra Foods. Interviews were conducted with individuals holding positions of responsibility, enhancing the researcher's understanding of the dynamics of the situation in New Zealand.

Multiple sources of information used in case studies

When interviewing was impossible, official comments from key decision-makers were drawn from the available textual sources. Together, these multiple sources enabled the observer to engage in triangulation, a process where more than one source of information is used when drawing inferences or conclusions about a given situation. Stake ( 2000 ) argues that triangulation was valuable not only to clarify meaning, but also to identify “different ways the phenomenon is being seen” (p. 444).

Need for Theoretical Framework

In addition to the need for multiple sources of data to understand the complexity of a risk or crisis situation, another reason researchers use the case study approach stems from the way theoretical propositions may be used to guide data collection and analysis. Case study researchers can set the parameters for what will be included within the analysis. As such, the introduction of a theoretical framework provides an overlay for the data that the researcher may use as a way to explore, describe, or explain what happened. In the selected cases included in this volume, the researchers utilized existing theoretical perspectives about risk and crisis drawn from the professional journals of the field, including Journal of Applied Communication Research, Management Communication Quarterly, Journal of Epidemiol Community Health , and The New England Journal of Medicine . The existing theoretical framework provided a backdrop for considering each case.

Specifically for this volume, best practices for risk communication were used as a theoretical framework (Fig. 4.2 ). As already explained in Chapter 2 , these best practices are theory driven and stem from the work previously done through a collaboration of risk and crisis communicators who introduced the ten best practices for crisis communication through the National Center for Food Protection and Defense (Seeger, 2006 ). Each of the case studies used these best practices to help to reveal problems faced by risk and crisis communicators, as well as to identify the strategies used as individuals, organizations, and communities worked to move through the crisis to recovery and in some cases, renewal.

Best practices of risk communication

Utility for Investigation into Contemporary Events

In addition to the case study method being multidimensional, researchers value the approach because it provides an empirical way to investigate a contemporary phenomenon within a real life context. There are differences between the case study approach and studies utilizing a more structured research methodology. For example, in an experimental setting, variables may be controlled or accounted for as particular actions are taken to affect the outcome. In this closed environment, researchers can make generalizations based upon the sophistication of their design.

However, situations where risk messages are communicated through the media and events are reported and presented as they unfold, researchers have less control over how competing risk message are transmitted and received by diverse groups within the public. The range of variables that cannot be controlled or manipulated further complicates the coverage of contemporary events outside of the laboratory. For example, Chapter 8 examines the case of in the tainted Odwalla juice, the Cryp-tosporidium outbreak case, or in the case of finding Salmonella in ConAgra Foods pot pies, human error could not have been predicted with certainty. In disasters like Hurricane Katrina, elements of nature could not be controlled. They happened. In the New Zealand hoax case, the potential threat of a terrorist's intentional foot and mouth disease could not have been precluded. The realization that a host of variables are interacting in a real-world setting affords the scholar a unique opportunity to explore, describe, and explain events as they occur.

The opportunity to examine what transpired in a particular crisis situation is unique to the case study approach. Due to the dynamic, chaotic nature of crisis events that are not always represented in cause-to-effect relationships, the case study approach enabled us to examine and understand situations in ways that might not have been foreseen prior to the start of our investigation. While not statistically generalizable, after examining several cases, the identification of the presence or absence of the best practices provides researchers with the arguments needed to find consistency about the situation that may have applicability to other similar risk situations. By using the case study framework to separate the pre-crisis from the crisis, observers may note events leading up to the crisis, factors that may have contributed to the way the risks were presented, and what happened (or should have happened) as a result of the way these messages were processed and acted upon.

Enhancement of Knowledge About Complex Phenomena

Within any given situation involving risk, there are many variables of interest, including the processes at work within the dynamic of the situation; the changes that occur due to the introduction of particular risk messages; relations between various stakeholders during the pre-crisis, crisis, or post-crisis situations; and the learning that results following the response to a crisis situation. These variables involving individuals, groups, organizations, or social entities represent the multidimensionality of the phenomena involved in risk communication.

In addition, the varied nature of questions posed by researchers and practitioners pertaining to risk situations further demonstrates how the complexity of a case can be studied using this approach. Case studies seeking to know what happened in a particular context rely on “what” questions. What happened in a particular situation causing a response? When researchers seek answers to “how” questions, they want descriptions. How did an entity communicate risk messages? Researchers seeking explanations regarding the particular motivations of communicators in a situation rely on “why” questions. Why were company spokespeople compelled to communicate particular messages to the public about a risk situation? In contrast to quantitative and qualitative methodologies where researchers tend to focus on one dimension or variable, the case study approach enables the researcher to use all of these questions. Questions like these are used throughout the cases to reveal the multidimensionality of the risk and crisis events.

Establishing a Framework for Case Studies

Identifying a framework for case studies is essential if comparisons are to be made. Stake ( 2000 ) suggests the following items as essential in the creation of a case study:

The nature of the case; the case's historical background; the physical setting; other contexts (e.g., economic, political, legal, and aesthetic); other cases through which this case is recognized; and those informants through whom the case can be known. (pp. 438– 439)

Thus, to provide clarity, we determined that each case study should be written to include common elements providing comparable information for the reader to consider. In the following case studies, we provide:

An introduction and overview of the case.

Evidence and application of the best practices for risk communication within the case.

Lessons learned and implications drawn from the use of best practices for risk communication.

From a research perspective, with these elements as constants, individual authors were able to gather data appropriate to each case and uniformly present their findings. In addition, similar textual materials were used in each of the studies, providing the reader with comparable information to consider.

Five Cases of Risk Communication

Stake ( 2000 ) argues that, “perhaps the most unique aspect of the case study is the selection of cases to study” (p. 446). With this in mind, we selected crisis situations where the presence or absence of best practices for risk communication could be identified, providing the readers with insight into how risk communication may or could have been used to affect the behavior of various stakeholders prior to the onset of a crisis situation. Each case study is unique in the risks posed, as well as how the communication agent sought to affect compliant behavior from the various stakeholders receiving the risk messages.

In the case of the Cryptosporidium crisis, the risks associated with water quality in a major metropolitan area and a community's response to a water quality crisis are examined. The risks associated with inadequate planning and the events related to the Hurricane Katrina disaster reveal how different levels of the government responded to a natural disaster. A government's use of interacting arguments revealed a paradox between appearing to accept the risk of foot and mouth disease and dismissing its likelihood on a New Zealand island. The Odwalla case study focuses on the risks associated with their trademark apple juice and how it struggled to renew itself within the health food industry. Finally, the ConAgra Foods Salmonella case study features the complexities of addressing multiple audiences during a major recall event involving pot pies.

“ Cryptosporidium: Unanticipated Risk Factors ,” provides the example of a community organization that experienced a crisis because it did not respond in time to government warnings calling for stronger guidelines for guarding municipal water against Cryptosporidium invasions. At the time of the crisis, Milwaukee had no water monitoring systems in place and the outbreak served as a wake-up call by exposing weaknesses in the public health system and pointing out the bioterrorism risks. Throughout the crisis, community leaders failed to be open, honest, and timely with the information they provided to the public. They failed to be mindful of public concerns expressed prior to the cryptosporidium outbreak. In addition, they did not collaborate or coordinate across agencies, exacerbating the crisis. Milwaukee was unprepared but learned from the event, established a plan should such a crisis occur in the future, and now has one of the safest water treatment systems in the country.

“Hurricane Katrina: Risk Communication in Response to a Natural Disaster,” examines how local leaders failed to create an adequate crisis plan, despite having knowledge of the damage that would occur if a hurricane of Katrina's magnitude struck New Orleans. While local crisis managers had a plan, its usefulness was mitigated by the length and format of the document. Once the hurricane struck, New Orleans crisis managers faced the difficult challenge of collaborating and coordinating resource distribution to affected residents. Another difficulty was getting information to the stakeholders. In the pre-crisis and crisis stages, the media were often ahead of local officials in presenting information to residents. This compromised the local officials' credibility and accountability. Clearly, lack of pre-event planning, the absence of collaboration and coordination, and the need for honest, candid, open, and accountable communication are key reasons why local crisis managers were unable to plan for, manage, and move past what was a devastating event for New Orleans and the surrounding region.

“New Zealand Beef Industry: Risk Communication in Response to a Terrorist Hoax” expands knowledge of risk communication by introducing how hoaxes and terrorist threats complicate our understanding of risk situations. In New Zealand, after receiving a threat claiming a deliberate release of the foot and mouth disease virus on Waiheke Island, the government had to provide intersecting messages demonstrating their capacity to manage the crisis situation. In essence, they claimed to be treating the situation as a potential crisis, while at the same time indicating their belief that the threat was a hoax. Managing crisis uncertainty became the focus for local leaders as they presented messages minimizing the risk as a hoax while acknowledging their treatment of the message as a viable threat to the security of the cattle and the New Zealand economy. The pre-crisis partnerships established between crisis managers and the various stakeholders proved valuable as the agencies worked together to disseminate information and communicate with the local citizens, as well as New Zealand's international partners. While a crisis plan was in place, and had been tested, there were some initial concerns raised by the local public that were ultimately mitigated due to open communication, as well as an attitude of compassion and empathy demonstrated by crisis spokespeople. While the hoax never developed into a crisis, providing messages of self-efficacy about checking for symptoms became an effective way to garner public confidence.

How a company managed to survive the challenge of an E. coli outbreak associated with one of its juice products is the subject of the chapter, “Odwalla: The Long Term Implications of Risk Communication.” Despite the potential risks associated with the continued consumption product, the public stood by Odwalla and its actions during and after the crisis. Odwalla met the needs of the media and remained accessible by holding press conferences, continually updating a website, instituting a hotline, and maintaining open communication with consumers and the press. The company delivered messages of self-efficacy and offered multiple ways for consumers to remain safe. In addition, company leaders apologized publicly, acknowledged the tragedy of the situation, paid medical bills for victims, and acknowledged the impact of the crisis on the image of the company. Following the crisis, Odwalla created an advisory council that ultimately recommended a new pasteurization process, breaking new ground in the industry. The use of some of the best practices enabled Odwalla to embrace a crisis, use it as an opportunity to become an industry leader, initiate industry wide change, and to encourage organizational renewal.

“ConAgra: Audience Complexity in Risk Communication” focuses on the need for organizations to consider multiple audiences when issuing risk messages. In the process of what appeared to be a demonstration of more concerned about their bottom line than with the safety of their customers, ConAgra initially shifted the blame for the outbreak to consumers for not cooking the pot pies properly. In addition, ConAgra made overly-assuring statements to the public about which products were affected by Salmonella (chicken and turkey), and which were not (beef). The assumptions made by ConAgra Foods about the literacy levels, economic status, access to media, proximity to outbreak, and cultural group identities of those receiving the risk messages also complicated their communication with stakeholders. In this case, once Salmonella was linked to ConAgra Foods' pot pies, the company issued a recall of all brands associated with their product. While additional information about the ConAgra Foods recall has yet to emerge, the case points to the need for greater attention by company spokespeople to the best practices of risk communication in order to preserve a positive reputation with the public.

This chapter introduced the case study method as a viable way to study risk communication in crisis situations. Our reasons for choosing the case study approach include its utility for exploring situations from multiple points of view, its usefulness when investigating contemporary events, and its ability to provide enhanced knowledge about complex phenomena. The best practices of risk communication, based on the best practices of crisis communication (Seeger, 2006 ), provide the theoretical framework for the case studies included in this book.

The framework we used for the case studies includes an introduction and overview to the case, a timeline of events, evidence and application of the best practices, and lessons learned. Five cases were introduced: the Milwaukee Cryp-tosporidium crisis, the Hurricane Katrina crisis, the New Zealand foot and mouth disease hoax crisis, the Odwalla juice crisis, and the ConAgra Foods Salmonella crisis. In each case, the best practices of risk communication provide insight into what occurred, or failed to occur, and the implications that followed in each crisis situation.

The five case studies provide insight into the best practices of risk communication. In all of the cases, risk communicators should have acknowledged competing arguments in the construction of risk messages. For example, the Cryptosporid-ium case demonstrates the need to infuse risk communication into policy making. By accepting that current practices would take care of the problem, local leaders allowed the crisis to develop. In the Hurricane Katrina case, the dynamic state of affairs required communicators to continuously review the situation and be proactive in communicating strategies of self-efficacy. Regarding the New Zealand potential foot and mouth disease case, a clear argument exists for why risk communicators must acknowledge and reinforce the unknown when framing messages for the public. Similarly, the collaboration and coordination among agencies with credible information sources helped the New Zealand crisis leaders build support among the various stakeholders affected by the potential contamination. As for Odwalla, the company was forced to acknowledge diverse levels of risk tolerance as the complexity of the situation unfolded. Similarly, a recognition of the need for a culture-centered approach would have enhanced the communication of ConAgra Foods with consumers and demonstrated a commitment to safety over profit. The following five chapters serve as examples of case studies involving risk communication.

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To cite this article Young, C. L., & Flowers, A. (2012). Fight viral with viral: A case study of Domino’s Pizza’s crisis communication strategies. Case Studies in Strategic Communication, 1 , article 6. Available online: http://cssc.uscannenberg.org/cases/v1/v1art6

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Fight Viral with Viral: A Case Study of Domino’s Pizza’s Crisis Communication Strategies

Cory L. Young Arhlene Flowers Ithaca College

Domino’s Pizza was embroiled in a viral crisis situation when two rogue employees posted videos of adulterated food on YouTube in April 2009. Tim McIntyre, Vice President of Communications, was part of the internal team that delivered the company’s crisis communication plan through Twitter and YouTube. What makes this story so compelling is the social media aspect of both the crisis itself and the strategy for managing the crisis. Using a case study approach, this paper assesses Domino’s decision to integrate the same medium that sparked the crisis into the strategies to manage the situation, and it questions the efficacy of best practices and principles of crisis management in the age of social media.

Keywords : Domino’s Pizza; crisis communication; social media; YouTube; Twitter; case study; public relations

Overview and Background

The way in which companies communicate with stakeholders during a crisis event is rapidly changing with the 24-hour access provided by the Internet, Facebook, Twitter, and YouTube. Public relations practitioners and other communication executives are struggling to craft messages and maintain control of the flow of messages within this dynamic landscape. As Schiller (2007) explains, in “times of crisis, while corporate communication executives are preparing manicured statements, customers are [simultaneously] blogging, e-mailing and posting photos out of rage and desperation because the very people who should be listening to them aren’t” (p. 16). Bell (2010) asserts that stakeholders become “interpretive communities in organizational crisis contexts,” capable of cultivating an organization’s reputation through information they receive in cyberspace (p. 148). Social media allow stakeholders to control when, where, and how “reputational meanings are born and disseminated” as “an organization’s reputation is built on the stories formed by stakeholders and spread within networks” (Aula, 2011, p. 28, 30). Nowhere is this dynamic between organizations and their publics more apparent than on video sharing sites, such as YouTube, that encourage citizens and bloggers to be the co-producers of messages.

Burgess and Green (2009) explain that YouTube users engage with this medium “as if it is a space specifically designed for them and that should therefore serve their own particular interests” (p. vii). This can have enormous positive or negative impacts for organizations involved in crisis management, including but not limited to the inability of boundary spanners to monitor the vastness of this space; malicious users who might create a crisis; and the leveraging capabilities of this platform to enhance a brand during a crisis. Just as consumers can use this social medium to create a crisis for a company and interpret an organization’s reputation throughout, so too can an organization use this medium to manage a crisis and improve its reputation. Patrick Doyle, President of Domino’s Pizza, would come to understand this dynamic as his brand suffered a devastating blow when two employees uploaded a vulgar video demonstrating their grotesque adulteration of food.

Bob Garfield (2010), a writer for Ad Age Blogs , recounts in an online article how this incident began. On Easter Sunday in April 2009, two Domino’s employees who were bored “working in a North Carolina store figured it would be just hilarious to post a video of themselves, defiling sandwich ingredients” (para. 2). The duo created five videos in total, one of which showed an individual sticking mozzarella cheese up his nose and then blowing the cheese on a sandwich, among other unsanitary and stomach-turning activities. An estimated 1 million people viewed these videos before they were pulled two days later.

During the first 24 hours, Tim McIntyre, Vice President of Corporate Communications, surveyed the situation and determined that the videos were not a hoax. He then began to communicate internally and externally with “relevant audiences at that time [including] our social media people, our head of security, senior management team,” according to Amy Jacques (2009) in an article published in The Public Relations Strategist (para. 4, 7). McIntyre collaborated with the consumer watchdog organization GoodAsYou.org , which first alerted Domino’s of the employee video, to identify the rogue employees as Kristy Hammond and Michael Setzer. By Tuesday, according to McIntyre, the company was responding to customers’ queries on Twitter about whether the company knew about the situation, what the company was doing, and why the company had not issued an official statement (Jacques, 2009). By Wednesday, Patrick Doyle, President of Domino’s Pizza, recorded an apology that was then uploaded onto YouTube.

During this event, bloggers and journalists alike captured this crisis in articles and case studies, offering step-by-step timelines [1] (Jacques, 2009; Peeples & Vaughn, 2010) and criticisms of Domino’s responses (Beaubien, 2009; Esterline, 2009; Gregory, 2009; Vogt, 2009; Weiss, 2009; York, 2009). What follows in this case study is an analysis of Domino’s crisis communication strategies, using a blend of best practices for crisis management from the principles of public relations management crafted by Arthur W. Page and from an academic perspective as the framework for analysis. From a communication perspective, according to Jaques (2008), case studies “are generally a narrative of events which are critically examined in relation to recognized public relations theories and models in order to fully appreciate what happened and to consider alternative strategies and outcomes” (p. 194), and are written to provide practical value to managers and practitioners alike who are struggling to manage and control the flow of messages in the viral/digital landscape (Coombs, 2008; “How Social Media,” 2009; Oneupweb, 2007).

The Arthur W. Page Society is a professional organization for executives in the public relations and communication industries. Named after one of the first public relations executives to work for a Fortune 500 corporation (AT&T), this organization is charged with the goal of “embracing the highest professional standards; advancing the way communications is understood, practiced and taught; and providing a collegial and dynamic learning environment” (“Vision, Mission & Goals,” n.d., para. 2). According to the Society’s website, the following principles are designed to guide public relations practitioners’ actions and behaviors and exemplify Page’s philosophy of public relations management: (1) Tell the truth ; (2) Prove it with action ; (3) Listen to the customer ; (4) Manage for tomorrow ; (5) Conduct public relations as if the whole company depends on it ; (6) Realize a company’s true character is expressed by its people ; and lastly, (7) Remain calm, patient and good-humored (“The Page Principles,” n.d.).

These principles are similar to the 10 best crisis communication practices Seeger (2006) generated, based on the work of communication scholars and expert practitioners:

• Process approaches and policy development ;
• Pre-event planning ;
• Partnership with the public ;
• Listen to the public’s concerns and understand the audience ;
• Honesty, candor, and openness ;
• Collaborate and coordinate with credible sources ;
• Meet the needs of the media and remain accessible ;
• Communicate with compassion, concern and empathy ;
• Accept uncertainty and ambiguity ; and
• Messages of self-efficacy .

Veil, Buehner, and Palenchar (2011) extend Seeger’s best practices, incorporating social media tools by making social media engagement a part of risk and crisis management policies and procedures; incorporating social media when scanning the environment; being a part of rumor management to determine appropriate channels; and using social media to communicate updates in an interpersonal manner (pp. 119-120).

Compiling and synthesizing these practices is not an easy task as “crises and disasters are relatively unique in nature, inherently dynamic, and unpredictable” (Bell, 2010, p. 151). These practices, according the Seeger (2006) “do not constitute a plan, but are the principles or processes that underlie an effective crisis communication plan and effective crisis response” (p. 242). Given the nature of crises, these practices will unfold and evolve differently within each situation.

Taking a situational approach to crisis communication, Coombs (2004) offers the Situational Crisis Communication Theory as an explanation for how organizations select a crisis response strategy. Essentially, a crisis triggers attributions of responsibility to the organization from stakeholders, along three dimensions: 1) whether the crisis has happened before or will likely happen again; 2) whether the event was controllable or uncontrollable by an individual or the organization; and 3) whether the crisis occurs within the organization or external to it. In this case, Domino’s as an organization was not directly responsible for this crisis, as the event occurred internally at the hands of employees, and this type of crisis had never happened before.

Based on stakeholder attributions, an organization will respond communicatively by cycling through a four step process: 1) observe events; 2) interpret information for accuracy and relevance; 3) choose a strategy among alternatives; and 4) implement the solution (Hale, Dulek, & Hale, 2005). Ideally, the strategy chosen will be aligned with the best practices and principles articulated above and will follow the four step process. Did Domino’s follow the best practices outlined by Seeger and the Page principles? What were the brand’s overall actions, decisions, and strategies for managing the crisis? In the case of Domino’s, it was not the consumers’ attributions of responsibility to Domino’s that triggered the strategy. Rather, what triggered Patrick Doyle’s decision to deliver a video apology on YouTube was the medium itself, which begs the questions, How did social media impact or influence the decision making process?, and What crisis communication lessons were learned in the process?

Strategies and Execution

This first Page principle—Tell the truth—begs a series of questions about whose truth needs to be told and about what in particular. In crisis situations, multiple truths or social constructions of the event(s) are vying for attention simultaneously: in general, customers, the company, its employees, and the media. In the case of Domino’s, particular watchdog organizations like GoodAsYou.org and Consumerist.com were also constructing versions of the event. The truth that Tim McIntyre, VP of Communications, wanted to convey was that this incident was “a rogue act of two individuals who thought they were being funny. That they do not represent this brand. That they do not represent the 100,000 people who work every day at Domino’s Pizza all over the world” (Flandez, 2009, para. 6). The truth that Patrick Doyle wanted to articulate was that “We didn’t do this. We’re sorry. And we want to earn your trust back” (Peeples & Vaughn, 2010, p. 3).

However, in wanting to be honest, open and candid (Seeger, 2006) about the situation, Domino’s needed to take responsibility. However, taking responsibility had the potential of exposing the organization to lawsuits and other legal vulnerabilities (Claeys & Cauberghe, 2012), including freedom of speech and copyright claims. In order to mitigate the consequences of being truthful and minimize the damage to the organization’s reputation, the company collaborated and coordinated with credible sources (the watch dog organizations and local authorities) and partnered with the public to observe and interpret the events , so as to not “act too hastily and alert more consumers to the situation it was attempting to contain” (York, 2009, para. 5), and to not “add fuel to the online fire” (Levick, 2009, para. 5). Unfortunately, a consequence of following the principles and best practices was that a 24 hour lag occurred. Because Domino’s hesitated, customers began tweeting about whether the company actually knew what was happening and questioning what it was going to do about the videos. Veil, Buehner, and Palenchar (2011) point to the fact that “The power to communicate remains with the communicating organization and their behaviors and narrative content, not in the technology” (p. 120).

A second challenge in telling the truth in the digital age hinges on additional questions (Roberts, 2010): Where in cyber and virtual spaces does an organization tell the truth and with what social medium or platform? York (2009) brought this to our attention in her online article, asking “why Domino’s has been lambasted for a lack of social media presence. After all . . . the brand is on MySpace, Twitter, YouTube and most visibly on Facebook with nearly 300,000 fans” (para. 18). There is a big difference, however,

between how emerging social media are used for marketing and how they work in a serious crisis situation . . . Companies that fail to integrate their marketing efforts with their online crisis response plans before a crisis hits are letting their antagonists have free reign. (Levick, 2009, para. 2-4)

The first message acknowledging the crisis was uploaded onto the corporate website on the day after the offending videos had been posted, but the message hardly yielded any hits. Domino’s did not reach its most popular audience through this social medium.

According to McIntyre, prior to this event ,

[the crisis team had a social media plan] already in place. We didn’t want to just jump in without a strategy. We wanted to do it right. So the irony for us was that we have a plan and we were going to implement it only a week later, so we ended up having to jump in [during] a crisis, which was the opposite of how we wanted to do it. (quoted in Jacques, 2009, para. 10)

However, after listening to the customers/publics’ tweets , the company was compelled to speed up the implementation of the social media plan. A decision was made to

[change] course and [respond] with a viral video . . . [that] featured all the elements of effective crisis communication. The company president apologized. He thanked the online community for bringing the issue to his attention. He separated the company from wrongdoers and announced their prosecution. And he outlined steps that Domino’s was taking to deal with the issue to make sure it never happens again (Levick, 2009, para. 6).

This strategy and decision to fight the crisis’ viral nature using YouTube was the tipping point that allowed the company “to cull user-generated content from social networking sites and use the platform for distributing information back to users” in order to prove itself with action and to communicate with passion, concern and empathy (Veil et al., 2011, p. 114). Levick (2009), in an online article for Bloomberg Businessweek , stipulated that “Domino’s not only demonstrated concern for its customers, but also an understanding of the critical importance of reaching out to a target audience on its own terms and in its own preferred space” (para. 7). This strategy and decision also suggests that Domino’s has the ability to manage the crisis for tomorrow : “This crisis happened online. It had to be dealt with online. By learning that lesson under fire Domino’s broke new ground and opened a new chapter in the ongoing evolution of crisis communications” (Levick, 2009, para. 7).

Evaluation & Discussion

Arthur W. Page advocated for public relations practitioners to tell the truth, a laudable goal to aspire to, but nonetheless one that is increasingly challenging in today’s digital era. Initially, Domino’s relied on its traditional technology (the Internet) to upload a video response on its corporate website to tell the public the truth about the situation. However, the number of people who viewed this video paled in comparison to the number of YouTube viewers who watched the employee prank videos—over one million within 24 hours. This realization accelerated and expedited the implementation of Domino’s social media plan that was still in development.

The crucial lesson to be learned about crisis communication comes in the form of extending and aligning the Situational Crisis Communication Theory with best practices for the integrating of social media (Veil et al, 2011). Coombs (2004) stipulated that a crisis triggers stakeholders’ attributions regarding the organization’s level of responsibility. These attributions, in turn, influence the strategy that an organization will use to lessen the damaging effects. In this case, however, it was not stakeholder attributions that dictated Domino’s strategy, but rather it was the social medium in which the crisis occurred that shaped the company’s decision to respond on YouTube as well as its overall strategy.

The only way to combat and lessen the impact of a social media generated crises like what Domino’s experienced is to integrate social media into crisis communication strategies and to create strategies for monitoring social media dialogue (Tinker, Fouse, & Currie, 2009). Schiller (2007) agrees that “Brands that get it right will be the ones that will use the same online tools as their customers” (p. 16). Further, Peeples and Vaughn (2010) concluded that Domino’s “effectively leveraged social media – the same channel used by the pranksters – to transparently communicate the company’s efforts to address the situation” (p. 1).The end result was that Domino’s emerged from this vulnerability criticized, yet knowledgeable about the reality of crisis communication in the age of social media.

The reality of crisis communication today is complex and contradictory. The speed at which consumers generate information about organizations is surpassing the speed by which public relations practitioners can monitor and verify the validity of such content, in order to respond before, during, and after a crisis incident. Because social media users can instantaneously create visual and textual dialogue with an organization, there is a corresponding expectation that organizations should respond just as quickly throughout all phases of a crisis incident. But taking the time to verify information and craft appropriate and effective responses is necessary to avoid legal issues and other complications. This dynamic has several implications for:

• How often organizations need to communicate with stakeholders: Regular updates across multiple social media should occur, using such platforms as HootSuite or Bottlenose to ensure consistency.
• How far and wide organizations need to span the boundaries of cyberspace and social media for potential crises and for potential stakeholder groups that can be impacted and affected: Johnson, Bazaa, and Chen (2011) conducted a study on boundary spanning, concluding that “organizations should focus on recruiting, attracting, and nurturing those online users with high levels of enduring involvement and social identity,” i.e., highly engaged social media users (p. 15).
• How organizations can manage their online reputations through search engine optimization (SEO).
• How new principles and best practices need to be developed to determine what messages or images from which stakeholder groups will tip towards a crisis.

As organizations grapple with these new directions, employees and consumers will need to learn how to accept uncertainty and ambiguity , and remain calm, patient and good humored.

Discussion Questions

• What impact does social media have on public relations practices, particularly crisis communications and reputation management? How significant is it for organizations today to monitor content on social media sites, including hash tags and other signs of internal and external dialogue?
• How should crisis communications preparedness plans address the proliferation of social media outlets?
• From the perspective of crisis communicators concerned with social media, what else could Domino’s have done or said to prove with action that its key messages are sincere? What other messages could Domino’s have delivered?
• What other types of traditional media and social media could Domino’s have used to reach its stakeholders?
• What other challenges do you think that PR practitioners, marketers, or corporate communicators could have in telling the truth in the digital age?
• How important is speed of response rate in a digital world, particularly when an organization is facing a crisis situation?
• Are there any other conclusions that you can draw from this incident?

Learning Activities

• According to its website, Media Curves “is the leader in public perception of topical issues.” This communications research company uses its patent pending technology to evaluate the “believability” of a particular video, such as the apology posted on YouTube by Domino Pizza’s President Patrick Doyle. To see how Media Curves’ technology captured people’s perceptions of Doyle’s apology video, watch Doyle’s apology video here: http://www.youtube.com/watch?v=uFiXWboPD5A . Discuss the specific moments in the video that people found most believable and least believable and what public relations practitioners can learn from studies like this. Visit the Media Curves website to watch other assessments of video apologies.
• Using the framework presented in this article, apply the Arthur W. Page Society’s principles (“Vision, Mission & Goals,” n.d.), Seeger’s (2006) best practices, and Veil, Buehner, and Palenchar’s (2011) suggestions for integrating social media to United Airlines and its handling of Dave Carroll’s “United Breaks Guitar Video” or to Providence Renaissance and its handling of “Joey Quits” video . What lessons can be learned about social media and crisis communication from analyzing these organizations’ strategies?
• To see how Domino’s has dealt with this crisis, consider some background information about its Pizza Turnaround campaign . How does this compare with the best practices? How did tweets like #newpizza help?

[1] A visual timeline of the first four days is available on the Arthur W. Page’s website: http://www.awpagesociety.com/insights/winning-case-studies/2010/

Aula, P. (2011). Meshworked reputation: Publicists’ views on the reputational impacts of online communication. Public Relations Review, 37 , 28-36.

Beaubien, G. (2009, April 21). Domino’s YouTube flap: ‘A landmark event in crisis management.’ Public Relations Tactics . Retrieved December 31, 2012, from http://www.prsa.org/SearchResults/view/7978/105/Domino_s_YouTube_flap_a_landmark_event_in_crisis_m

Bell, L. M. (2010). Crisis communication: The praxis of response. The Review of Communication, 10 (2), 142-155.

Burgess, J., & Green, J. (2009). YouTube: Online video and participatory culture . Malden, MA: Polity Press.

Claeys, A., & Cauberghe, V. (2012). Crisis response and crisis timing strategies, two sides of the same coin. Public Relations Review, 38 , 83-88.

Coombs, W. T. (2004). Impact of past crises on current crisis communication: Insights from Situational Crisis Communication Theory. Journal of Business Communication, 41 (3), 265-289.

Coombs, W. T. (2008, April 2). Crisis communication and social media. Institute for Public Relations . Retrieved December 31, 2012, from http://www.instituteforpr.org/topics/crisis-communication-and-social-media/

Esterline, R. M. (2009, April 25). Case study: Domino’s YouTube video . Retrieved December 31, 2012, from http://crisiscomm.wordpress.com/2009/04/25/case-study-dominos

Flandez, R. (2009, April 20). Domino’s response offers lessons in crisis management. The Wall Street Journal . Retrieved December 31, 2012, from http://blogs.wsj.com/independentstreet/2009/04/20/dominos-response-offers-lessons-in-crisis-management

Garfield, B. (2010, January 11). Domino’s does itself a disservice by coming clean about its pizza: We like apologies and honesty, but there are limits. Just ask Ford. Ad Age Blogs . Retrieved December 31, 2012, from http://adage.com/article/ad-review/advertising-domino-s-a-disservice-ads/141393

Gregory, S. (2009, April 18). Domino’s YouTube crisis: Five ways to fight back. Time Magazine . Retrieved December 31, 2012, from http://www.time.com/time/nation/article/0,8599,1892389,00.html

Hale, J. E., Dulek, R. E., & Hale, D. P. (2005). Crisis response communication challenges: Building theory from qualitative data. Journal of Business Communication, 42 (2), 112-134.

How social media are changing crisis communications—for better and worse. (2009, November 1). Security Director’s Report, 9 (11), 2-5.

Jacques, A. (2009, August 17). Domino’s delivers during crisis: The company’s step-by-step response after a vulgar video goes viral. The Public Relations Strategist . Retrieved December 31, 2012, from http://www.prsa.org/Intelligence/TheStrategist/Articles/view/8226/102/Domino_s_delivers_during_crisis_The_company_s_step

Jaques, T. (2008). A case study approach to issue and crisis management: Schadenfreude or an opportunity to learn? Journal of Communication Management, 12 (3), 192-203.

Johnson, P. R., Bazaa, U., & Chen, L. (2011, May). The new boundary spanners: Social media users, engagement, and public relations outcomes . Paper presented at the annual meeting of the International Communication Association, Boston, MA. Retrieved December 31, 2012, from http://www.icavirtual.com/wp-content/uploads/2011/05/FULL-PAPER-SUBMISSION-TEMPLATE-EK1.pdf

Levick, R. S. (2009, April 21). Domino’s discovers social media. Bloomberg Businessweek . Retrieved December 31, 2012, from http://www.businessweek.com/print/managing/content/apr2009/ca20090421_555468.htm

Oneupweb. (2007). Principles of crisis management in a viral age: Integrating the tools and lessons of search 2.0 into a comprehensive crisis response [White paper]. Traverse City, MI: Oneupweb. Retrieved December 31, 2012, from http://internetetopinion.files.wordpress.com/2008/01/crisis_management.pdf

The Page principles. (n.d.). Arthur W. Page Society . Retrieved December 31, 2012, from http://www.awpagesociety.com/about/the-page-principles/

Peeples, A. & Vaughn, C. (2010). Domino’s “special” delivery: Going viral through social media (Parts A & B). Arthur W. Page Society case study competition in corporate communications . Retrieved December 31, 2012, from http://www.awpagesociety.com/insights/winning-case-studies/2010

Roberts, J. (2010, March 18). Bringing your brand back from the brink. Marketing Week . Retrieved December 31, 2012, from http://www.marketingweek.co.uk/bringing-your-brand-back-from-the-brink/3011206.article

Schiller, M. (2007, March 5). Crisis and the web: How to leverage the Internet when a brand takes a hit. Adweek, 48 (10), 16.

Seeger, M. W. (2006). Best practices in crisis communication: An expert panel process. Journal of Applied Communication Research, 34 (3), 232-244.

Tinker, T., Fouse, D. (Eds.), & Currie, D. (Writer). (2009). Expert round table on social media and risk communication during times of crisis: Strategic challenges and opportunities [Report]. Washington, DC: American Public Health Association. Retrieved December 31, 2012, from http://www.apha.org/NR/rdonlyres/47910BED-3371-46B3-85C2-67EFB80D88F8/0/socialmedreport.pdf

Veil, S. R., Buehner, T., & Palenchar, M. J. (2011). A work-in-progress literature review: Incorporating social media in risk and crisis communication. Journal of Contingencies and Crisis Management, 19 (2), 110-122.

Vision, mission & goals. (n.d.). Arthur W. Page Society . Retrieved December 31, 2012, from http://www.awpagesociety.com/about/vision-misson-goals/

Vogt, P. (2009, April 24). Brands under attack: Marketers can learn from Domino’s video disaster. Forbes . Retrieved December 31, 2012, from http://www.forbes.com/2009/04/24/dominos-youtube-twitter-leadership-cmo-network-marketing.html

Weiss, T. (2009, April 22). Crisis management—Domino’s case study research. Trendsspotting Blog . Retrieved December 31, 2012, from http://www.trendsspotting.com/blog/?p=1061

York, E. B. (2009, April 20). What Domino’s did right–and wrong–in squelching hubbub over YouTube video. Advertising Age [Online]. Retrieved December 31, 2012, from http://adage.com/article/news/crisis-pr-assessing-domino-s-reaction-youtube-hubub/136086/

CORY L. YOUNG, Ph.D. , is an associate professor of communication management and design in the Department of Strategic Communication, Roy H. Park School of Communications, at Ithaca College in Ithaca, New York, where she teaches courses in corporate communication. Email: youngc[at]ithaca.edu.

ARHLENE FLOWERS is an associate professor of integrated marketing communications in the Department of Strategic Communication, Roy H. Park School of Communications, at Ithaca College in Ithaca, New York, where she teaches courses in public relations. Email: aflowers[at]ithaca.edu.

Acknowledgments

This manuscript was made possible in part by a James B. Pendleton grant from the Roy H. Park School of Communications at Ithaca College. A version of this paper was presented at the International Communication Association’s pre-conference hosted in Tokyo, Japan, June 2010. Additionally, the following graduate assistants need to be acknowledged for their research contributions: Rui Liu, Savitha Ranga, Nate (Zheli) Ren, and Danielle Clarke.

Editorial history Received November 4, 2011 Revised April 9, 2012 Accepted June 12, 2012 Published December 31, 2012 Handled by editor; no conflicts of interest

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• What Is a Case Study? | Definition, Examples & Methods

What Is a Case Study? | Definition, Examples & Methods

Published on May 8, 2019 by Shona McCombes . Revised on November 20, 2023.

A case study is a detailed study of a specific subject, such as a person, group, place, event, organization, or phenomenon. Case studies are commonly used in social, educational, clinical, and business research.

A case study research design usually involves qualitative methods , but quantitative methods are sometimes also used. Case studies are good for describing , comparing, evaluating and understanding different aspects of a research problem .

Table of contents

When to do a case study, step 1: select a case, step 2: build a theoretical framework, step 3: collect your data, step 4: describe and analyze the case, other interesting articles.

A case study is an appropriate research design when you want to gain concrete, contextual, in-depth knowledge about a specific real-world subject. It allows you to explore the key characteristics, meanings, and implications of the case.

Case studies are often a good choice in a thesis or dissertation . They keep your project focused and manageable when you don’t have the time or resources to do large-scale research.

You might use just one complex case study where you explore a single subject in depth, or conduct multiple case studies to compare and illuminate different aspects of your research problem.

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Once you have developed your problem statement and research questions , you should be ready to choose the specific case that you want to focus on. A good case study should have the potential to:

• Provide new or unexpected insights into the subject
• Challenge or complicate existing assumptions and theories
• Propose practical courses of action to resolve a problem
• Open up new directions for future research

TipIf your research is more practical in nature and aims to simultaneously investigate an issue as you solve it, consider conducting action research instead.

Unlike quantitative or experimental research , a strong case study does not require a random or representative sample. In fact, case studies often deliberately focus on unusual, neglected, or outlying cases which may shed new light on the research problem.

Example of an outlying case studyIn the 1960s the town of Roseto, Pennsylvania was discovered to have extremely low rates of heart disease compared to the US average. It became an important case study for understanding previously neglected causes of heart disease.

However, you can also choose a more common or representative case to exemplify a particular category, experience or phenomenon.

Example of a representative case studyIn the 1920s, two sociologists used Muncie, Indiana as a case study of a typical American city that supposedly exemplified the changing culture of the US at the time.

While case studies focus more on concrete details than general theories, they should usually have some connection with theory in the field. This way the case study is not just an isolated description, but is integrated into existing knowledge about the topic. It might aim to:

• Exemplify a theory by showing how it explains the case under investigation
• Expand on a theory by uncovering new concepts and ideas that need to be incorporated
• Challenge a theory by exploring an outlier case that doesn’t fit with established assumptions

To ensure that your analysis of the case has a solid academic grounding, you should conduct a literature review of sources related to the topic and develop a theoretical framework . This means identifying key concepts and theories to guide your analysis and interpretation.

There are many different research methods you can use to collect data on your subject. Case studies tend to focus on qualitative data using methods such as interviews , observations , and analysis of primary and secondary sources (e.g., newspaper articles, photographs, official records). Sometimes a case study will also collect quantitative data.

Example of a mixed methods case studyFor a case study of a wind farm development in a rural area, you could collect quantitative data on employment rates and business revenue, collect qualitative data on local people’s perceptions and experiences, and analyze local and national media coverage of the development.

The aim is to gain as thorough an understanding as possible of the case and its context.

In writing up the case study, you need to bring together all the relevant aspects to give as complete a picture as possible of the subject.

How you report your findings depends on the type of research you are doing. Some case studies are structured like a standard scientific paper or thesis , with separate sections or chapters for the methods , results and discussion .

Others are written in a more narrative style, aiming to explore the case from various angles and analyze its meanings and implications (for example, by using textual analysis or discourse analysis ).

In all cases, though, make sure to give contextual details about the case, connect it back to the literature and theory, and discuss how it fits into wider patterns or debates.

If you want to know more about statistics , methodology , or research bias , make sure to check out some of our other articles with explanations and examples.

• Normal distribution
• Degrees of freedom
• Null hypothesis
• Discourse analysis
• Control groups
• Mixed methods research
• Non-probability sampling
• Quantitative research
• Ecological validity

Research bias

• Rosenthal effect
• Implicit bias
• Cognitive bias
• Selection bias
• Negativity bias
• Status quo bias

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The course including ethical decision-making has to be reshuffled for now, but in the future I will definitely use the book as a source for supporting material.

Excellent supplement to text I'm using. Offers in depth case studies and addresses evaluation using critical thinking.

Is there any instructor material available?

This book provides an effective way to engage students into theory. The cases presented can also be further analysed using a plethora of approaches, which makes it a useful teaching tool.

This book will be particularly helpful for students who have an interest in communication. I will also use it to supplement my lectures with examples in class. The book is very well laid out, engaging in its detail with signposting to further material for those students who wish to read more.

Matched with course design- practical and applied pedagogy for studying ethical issues and communication in everyday life.

NEW TO THIS EDITION

• The Second Edition includes expanded coverage of the recent economic meltdown, globalization, new technologies, and corporate social responsibility.
• Eighteen new case studies on current workplace issues include companies such as BP, Google, Toyota, Gap, Wyeth, and Enron.

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• Emerging issues in the workplace, explored in several case studies, include work/family balance, sexual harassment, outsourcing, personal privacy, bribery, new technologies, social networking, corporate social responsibility, and other issues.
• International case studies examine the ethical behavior of non-American organizations, providing a more thorough understanding of ethics in a global business environment.
• The consistent case study structure allows instructors and students greater opportunity to compare and contrast cases on comparable terms.

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Home » Case Study – Methods, Examples and Guide

Case Study – Methods, Examples and Guide

Table of Contents

A case study is a research method that involves an in-depth examination and analysis of a particular phenomenon or case, such as an individual, organization, community, event, or situation.

It is a qualitative research approach that aims to provide a detailed and comprehensive understanding of the case being studied. Case studies typically involve multiple sources of data, including interviews, observations, documents, and artifacts, which are analyzed using various techniques, such as content analysis, thematic analysis, and grounded theory. The findings of a case study are often used to develop theories, inform policy or practice, or generate new research questions.

Types of Case Study

Types and Methods of Case Study are as follows:

Single-Case Study

A single-case study is an in-depth analysis of a single case. This type of case study is useful when the researcher wants to understand a specific phenomenon in detail.

For Example , A researcher might conduct a single-case study on a particular individual to understand their experiences with a particular health condition or a specific organization to explore their management practices. The researcher collects data from multiple sources, such as interviews, observations, and documents, and uses various techniques to analyze the data, such as content analysis or thematic analysis. The findings of a single-case study are often used to generate new research questions, develop theories, or inform policy or practice.

Multiple-Case Study

A multiple-case study involves the analysis of several cases that are similar in nature. This type of case study is useful when the researcher wants to identify similarities and differences between the cases.

For Example, a researcher might conduct a multiple-case study on several companies to explore the factors that contribute to their success or failure. The researcher collects data from each case, compares and contrasts the findings, and uses various techniques to analyze the data, such as comparative analysis or pattern-matching. The findings of a multiple-case study can be used to develop theories, inform policy or practice, or generate new research questions.

Exploratory Case Study

An exploratory case study is used to explore a new or understudied phenomenon. This type of case study is useful when the researcher wants to generate hypotheses or theories about the phenomenon.

For Example, a researcher might conduct an exploratory case study on a new technology to understand its potential impact on society. The researcher collects data from multiple sources, such as interviews, observations, and documents, and uses various techniques to analyze the data, such as grounded theory or content analysis. The findings of an exploratory case study can be used to generate new research questions, develop theories, or inform policy or practice.

Descriptive Case Study

A descriptive case study is used to describe a particular phenomenon in detail. This type of case study is useful when the researcher wants to provide a comprehensive account of the phenomenon.

For Example, a researcher might conduct a descriptive case study on a particular community to understand its social and economic characteristics. The researcher collects data from multiple sources, such as interviews, observations, and documents, and uses various techniques to analyze the data, such as content analysis or thematic analysis. The findings of a descriptive case study can be used to inform policy or practice or generate new research questions.

Instrumental Case Study

An instrumental case study is used to understand a particular phenomenon that is instrumental in achieving a particular goal. This type of case study is useful when the researcher wants to understand the role of the phenomenon in achieving the goal.

For Example, a researcher might conduct an instrumental case study on a particular policy to understand its impact on achieving a particular goal, such as reducing poverty. The researcher collects data from multiple sources, such as interviews, observations, and documents, and uses various techniques to analyze the data, such as content analysis or thematic analysis. The findings of an instrumental case study can be used to inform policy or practice or generate new research questions.

Case Study Data Collection Methods

Here are some common data collection methods for case studies:

Interviews involve asking questions to individuals who have knowledge or experience relevant to the case study. Interviews can be structured (where the same questions are asked to all participants) or unstructured (where the interviewer follows up on the responses with further questions). Interviews can be conducted in person, over the phone, or through video conferencing.

Observations

Observations involve watching and recording the behavior and activities of individuals or groups relevant to the case study. Observations can be participant (where the researcher actively participates in the activities) or non-participant (where the researcher observes from a distance). Observations can be recorded using notes, audio or video recordings, or photographs.

Documents can be used as a source of information for case studies. Documents can include reports, memos, emails, letters, and other written materials related to the case study. Documents can be collected from the case study participants or from public sources.

Surveys involve asking a set of questions to a sample of individuals relevant to the case study. Surveys can be administered in person, over the phone, through mail or email, or online. Surveys can be used to gather information on attitudes, opinions, or behaviors related to the case study.

Artifacts are physical objects relevant to the case study. Artifacts can include tools, equipment, products, or other objects that provide insights into the case study phenomenon.

How to conduct Case Study Research

Conducting a case study research involves several steps that need to be followed to ensure the quality and rigor of the study. Here are the steps to conduct case study research:

• Define the research questions: The first step in conducting a case study research is to define the research questions. The research questions should be specific, measurable, and relevant to the case study phenomenon under investigation.
• Select the case: The next step is to select the case or cases to be studied. The case should be relevant to the research questions and should provide rich and diverse data that can be used to answer the research questions.
• Collect data: Data can be collected using various methods, such as interviews, observations, documents, surveys, and artifacts. The data collection method should be selected based on the research questions and the nature of the case study phenomenon.
• Analyze the data: The data collected from the case study should be analyzed using various techniques, such as content analysis, thematic analysis, or grounded theory. The analysis should be guided by the research questions and should aim to provide insights and conclusions relevant to the research questions.
• Draw conclusions: The conclusions drawn from the case study should be based on the data analysis and should be relevant to the research questions. The conclusions should be supported by evidence and should be clearly stated.
• Validate the findings: The findings of the case study should be validated by reviewing the data and the analysis with participants or other experts in the field. This helps to ensure the validity and reliability of the findings.
• Write the report: The final step is to write the report of the case study research. The report should provide a clear description of the case study phenomenon, the research questions, the data collection methods, the data analysis, the findings, and the conclusions. The report should be written in a clear and concise manner and should follow the guidelines for academic writing.

Examples of Case Study

Here are some examples of case study research:

• The Hawthorne Studies : Conducted between 1924 and 1932, the Hawthorne Studies were a series of case studies conducted by Elton Mayo and his colleagues to examine the impact of work environment on employee productivity. The studies were conducted at the Hawthorne Works plant of the Western Electric Company in Chicago and included interviews, observations, and experiments.
• The Stanford Prison Experiment: Conducted in 1971, the Stanford Prison Experiment was a case study conducted by Philip Zimbardo to examine the psychological effects of power and authority. The study involved simulating a prison environment and assigning participants to the role of guards or prisoners. The study was controversial due to the ethical issues it raised.
• The Challenger Disaster: The Challenger Disaster was a case study conducted to examine the causes of the Space Shuttle Challenger explosion in 1986. The study included interviews, observations, and analysis of data to identify the technical, organizational, and cultural factors that contributed to the disaster.
• The Enron Scandal: The Enron Scandal was a case study conducted to examine the causes of the Enron Corporation’s bankruptcy in 2001. The study included interviews, analysis of financial data, and review of documents to identify the accounting practices, corporate culture, and ethical issues that led to the company’s downfall.
• The Fukushima Nuclear Disaster : The Fukushima Nuclear Disaster was a case study conducted to examine the causes of the nuclear accident that occurred at the Fukushima Daiichi Nuclear Power Plant in Japan in 2011. The study included interviews, analysis of data, and review of documents to identify the technical, organizational, and cultural factors that contributed to the disaster.

Application of Case Study

Case studies have a wide range of applications across various fields and industries. Here are some examples:

Business and Management

Case studies are widely used in business and management to examine real-life situations and develop problem-solving skills. Case studies can help students and professionals to develop a deep understanding of business concepts, theories, and best practices.

Case studies are used in healthcare to examine patient care, treatment options, and outcomes. Case studies can help healthcare professionals to develop critical thinking skills, diagnose complex medical conditions, and develop effective treatment plans.

Case studies are used in education to examine teaching and learning practices. Case studies can help educators to develop effective teaching strategies, evaluate student progress, and identify areas for improvement.

Social Sciences

Case studies are widely used in social sciences to examine human behavior, social phenomena, and cultural practices. Case studies can help researchers to develop theories, test hypotheses, and gain insights into complex social issues.

Law and Ethics

Case studies are used in law and ethics to examine legal and ethical dilemmas. Case studies can help lawyers, policymakers, and ethical professionals to develop critical thinking skills, analyze complex cases, and make informed decisions.

Purpose of Case Study

The purpose of a case study is to provide a detailed analysis of a specific phenomenon, issue, or problem in its real-life context. A case study is a qualitative research method that involves the in-depth exploration and analysis of a particular case, which can be an individual, group, organization, event, or community.

The primary purpose of a case study is to generate a comprehensive and nuanced understanding of the case, including its history, context, and dynamics. Case studies can help researchers to identify and examine the underlying factors, processes, and mechanisms that contribute to the case and its outcomes. This can help to develop a more accurate and detailed understanding of the case, which can inform future research, practice, or policy.

Case studies can also serve other purposes, including:

• Illustrating a theory or concept: Case studies can be used to illustrate and explain theoretical concepts and frameworks, providing concrete examples of how they can be applied in real-life situations.
• Developing hypotheses: Case studies can help to generate hypotheses about the causal relationships between different factors and outcomes, which can be tested through further research.
• Providing insight into complex issues: Case studies can provide insights into complex and multifaceted issues, which may be difficult to understand through other research methods.
• Informing practice or policy: Case studies can be used to inform practice or policy by identifying best practices, lessons learned, or areas for improvement.

Advantages of Case Study Research

There are several advantages of case study research, including:

• In-depth exploration: Case study research allows for a detailed exploration and analysis of a specific phenomenon, issue, or problem in its real-life context. This can provide a comprehensive understanding of the case and its dynamics, which may not be possible through other research methods.
• Rich data: Case study research can generate rich and detailed data, including qualitative data such as interviews, observations, and documents. This can provide a nuanced understanding of the case and its complexity.
• Holistic perspective: Case study research allows for a holistic perspective of the case, taking into account the various factors, processes, and mechanisms that contribute to the case and its outcomes. This can help to develop a more accurate and comprehensive understanding of the case.
• Theory development: Case study research can help to develop and refine theories and concepts by providing empirical evidence and concrete examples of how they can be applied in real-life situations.
• Practical application: Case study research can inform practice or policy by identifying best practices, lessons learned, or areas for improvement.
• Contextualization: Case study research takes into account the specific context in which the case is situated, which can help to understand how the case is influenced by the social, cultural, and historical factors of its environment.

Limitations of Case Study Research

There are several limitations of case study research, including:

• Limited generalizability : Case studies are typically focused on a single case or a small number of cases, which limits the generalizability of the findings. The unique characteristics of the case may not be applicable to other contexts or populations, which may limit the external validity of the research.
• Biased sampling: Case studies may rely on purposive or convenience sampling, which can introduce bias into the sample selection process. This may limit the representativeness of the sample and the generalizability of the findings.
• Subjectivity: Case studies rely on the interpretation of the researcher, which can introduce subjectivity into the analysis. The researcher’s own biases, assumptions, and perspectives may influence the findings, which may limit the objectivity of the research.
• Limited control: Case studies are typically conducted in naturalistic settings, which limits the control that the researcher has over the environment and the variables being studied. This may limit the ability to establish causal relationships between variables.
• Time-consuming: Case studies can be time-consuming to conduct, as they typically involve a detailed exploration and analysis of a specific case. This may limit the feasibility of conducting multiple case studies or conducting case studies in a timely manner.
• Resource-intensive: Case studies may require significant resources, including time, funding, and expertise. This may limit the ability of researchers to conduct case studies in resource-constrained settings.

About the author

Muhammad Hassan

Researcher, Academic Writer, Web developer

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• Open access
• Published: 03 April 2024

Co-development of a training programme on disability for healthcare workers in Uganda

• Tracey Smythe 1 , 2 ,
• Andrew Sentoogo Ssemata 3 , 4 ,
• Sande Slivesteri 3 ,
• Femke Bannink Mbazzi 1 , 3 &
• Hannah Kuper 1  

BMC Health Services Research volume  24 , Article number:  418 ( 2024 ) Cite this article

Metrics details

Approximately 1.3 billion people worldwide face barriers in accessing inclusive healthcare due to disabilities, leading to worse health outcomes, particularly in low and middle-income countries (LMIC). However, there is a lack of training of healthcare workers about disability, both globally and in Uganda.

To use mixed research methods to develop a comprehensive training program with standardisedelements for healthcare workers in Uganda, focusing on improving their knowledge, attitudes, and skills inproviding care for people with disabilities.

The Medical Research Council (MRC) approach was employed to guide the development of the training intervention. We conducted an umbrella review to gather relevant literature on disability training for healthcare workers. Interviews were conducted with international experts to gain insights and perspectives on the topic. Additionally, interviews were undertaken with people with disabilities and healthcare workers in Uganda to understand their experiences and needs. A participatory workshop was organised involving key stakeholders, to collaboratively design the training material based on the findings from these data sources.

Eight review articles examined training programs for healthcare workers on disability. Training settings ranged from specialised clinical settings to non-clinical settings, and the duration and evaluation methods of the training varied widely. Lectures and didactic methods were commonly used, often combined with other approaches such as case studies and simulations. The impact of the training was assessed through healthcare worker reports on attitudes, knowledge, and self-efficacy. Interviews emphasised the importance of involving people with disabilities in the training and improving communication and understanding between healthcare providers and people with disabilities. Five themes for a training on disability for healthcare workers were generated through the workshop, including responsibilities and rights, communication, informed consent, accommodation, and referral and connection, which were used to guide the development of the curriculum, training materials and training approach.

This study presents a novel approach to develop a training program that aims to enhance healthcare services for people with disabilities in Uganda. The findings offer practical insights for the development of similar programs in LMICs. The effectiveness of the training program will be evaluated through a pilot test, and policy support is crucial for its successful implementation at scale.

Key messages

1. Healthcare workers require training to effectively address the health concerns of people with disabilities, yet this is rarely included in curricula worldwide.

2. Uganda recognises the importance of addressing this issue and is taking steps to improve training programs about disability for healthcare workers.

3. We used multiple research methods (umbrella review, semi-structured interviews, participatory research and collaborative design) to co-develop a comprehensive training program with standardised elements for healthcare workers in Uganda, focusing on improving their knowledge, attitudes, and skills in providing care for people with disabilities.

4. The developed training material could be adapted for healthcare workers in other resource-limited settings, and policy support is needed to ensure its implementation at scale.

Peer Review reports

Introduction

Approximately 16% of the world’s population, or 1.3 billion people, live with a disability, and the majority live in low and middle income countries (LMIC) [ 1 ]. Access to inclusive healthcare services is vital for promoting health equity and social inclusion for all [ 2 , 3 ]. However, healthcare workers’ lack of knowledge, skills, and attitudes towards disability remains a significant barrier to achieving this goal [ 4 ]. Efforts to integrate disability-related education and training into healthcare curricula and continuing education programs, as emphasized by the WHO report [ 1 ], are crucial in addressing this issue. Equipping healthcare workers with the necessary tools and resources to provide effective, respectful, and culturally sensitive care to people with disabilities is essential in meeting their needs and promoting positive health outcomes. People with disabilities want to be “expected, accepted and connected” by the health system [ 2 ]. This requires training to ensure that healthcare staff are aware of disabilities, possess relevant skills, and maintain positive attitudes, enabling them to make appropriate linkages to other necessary care. Efforts to integrate disability-related education and training into healthcare curricula and continuing education programs are crucial in addressing this issue [ 1 , 2 , 3 , 5 ].

Training on disability can lead to improvements in the knowledge and attitudes of healthcare workers towards people with disabilities throughout all stages of their careers. For example, two medical colleges in the US integrated disability across medical student training curricula, and medical students improved their knowledge, attitudes, and core competencies in treating patients with disabilities [ 6 ]. In Rwanda, continuing professional development training about childhood disability used case studies and clinic visits, and instructors gave participants’ immediate feedback on their practice. As a result, participants demonstrated improved clinical decision making skills in paediatric rehabilitation [ 7 ]. Similarly, programmes that invited people with disabilities as teachers found that participants believed the nonclinical interaction enhanced their comfort and attitudes towards people with disabilities [ 8 , 9 ].

Despite the global recognition that well-trained, fairly distributed and motivated healthcare workers are critical to improving population health and achieving universal health coverage (UHC) and Sustainable Development Goals (SDGs) [ 10 ], there are limited standardised training programs focusing on disability [ 11 ], especially in LMICs. Existing programs cover diverse content areas such as general disability awareness, condition-specific knowledge, rehabilitation skills, assistive technology, inclusive design, universal design for learning, mental health, and primary healthcare (Table  1 ). There has been little consideration to date on what is optimal in terms of content of disability training for healthcare workers.

There are various potential approaches to training, including face-to-face or remote, involvement of people with disabilities or not, and emphasis on knowledge, skills, or attitudes, as well as different underlying models, such as medical or rights-based [ 11 , 12 ]. Despite this range of possibility, there is limited collation or scrutiny of information, including input from people with disabilities and healthcare workers, to identify the most effective approach. Additionally, LMICs face unique challenges in healthcare provision, including resource constraints and limited access to education and training [ 13 ], which may contribute to the acute lack of training opportunities for healthcare workers. For instance, Uganda encounters significant challenges in training healthcare workers on disability due to limited resources, infrastructure, and cultural barriers that may stigmatise or exclude people with disabilities [ 14 , 15 , 16 ].

The objective of this study was therefore to use multiple research methods to develop a comprehensive training program with standardised elements for healthcare workers in Uganda, focusing on improving their knowledge, attitudes, and skills in providing care for people with disabilities. This paper describes the development of the disability training and presents the framework of the training material developed. We provide an in-depth examination of the training needs of healthcare workers in the area of disability and offer a practical solution in the form of the developed training material that can be used to improve the knowledge and skills of healthcare workers on disability. A future study will pilot test and evaluate the training material.

We used the Medical Research Council (MRC) approach, which involves a systematic and evidence-based framework to development of a programme [ 17 ]. It emphasises the importance of involving stakeholders throughout the process and ensures that interventions are evidence-based, feasible, and acceptable to those involved in their implementation. This approach aims to create effective and sustainable interventions that improve health outcomes and services.

Overview of methods

This study utilised data from an umbrella review, interviews with international experts on disability training for healthcare workers, and interviews with people with disabilities and healthcare workers in Uganda. The data informed the design of a workshop that involved key stakeholders, including healthcare workers and people with disabilities, in co-creating the training material. The training material was developed based on information gathered from the umbrella review, interviews, and design workshop.

Umbrella review

The umbrella review was conducted to identify systematic reviews and meta-analyses of studies that examined associations between training of healthcare workers on any disability and change in healthcare worker behaviour, attitude or treatment delivered. The protocol for this study was registered in the International Prospective Register of Systematic Reviews (PROSPERO), reference number #CRD42023390881. We used the Preferred Reporting Items for Overviews of Reviews (PRIOR) statement for conducting umbrella reviews. We searched PubMed for studies published in English between 1st January 2015 and 11th January 2023, using the terms (“train*” OR “educat*”) AND (“healthcare worker” OR “health professional” OR “medical professional”) AND (“disability” OR “impairment”) filtered for systematic reviews and meta-analyses for this rapid umbrella review. Inclusion criteria were established as: systematic reviews or meta-analyses that evaluated training on disability (intervention) for any health professional (population). Studies were excluded if published prior to 2015 to ensure the currency and relevance of information, and if in any other language than English. We searched reference lists of included studies for additional eligible papers.

Two reviewers (TS, ASS) independently assessed study eligibility and extracted the data. The risk of bias of the included studies was assessed using AMSTAR 2 (A MeaSurement Tool to Assess systematic Reviews) [ 18 ], designed to appraise systematic reviews that include randomised controlled trials. The instrument provides a broad assessment of quality, including flaws that may have arisen through poor conduct of the review with uncertain impact on findings. We developed and pilot-tested an extraction tool in Excel, to systematically record information from included studies. Extracted information included: (1) Publication characteristics: author, title, year of publication, setting/country; (2) Study design: study design, sample size; (3) Participant characteristics: cadre, and any other relevant descriptive data; (4) Outcomes: effect size of training. Data were extracted by TS and checked for accuracy by ASS. Where studies included information on training other professionals (e.g. police officers, teachers) only data on healthcare workers were extracted. Data were also only extracted on training when reviews included additional information (e.g. use of disability measurement tools). We narratively synthesised the results.

Semi-structured interviews

Interviews were conducted with international experts with experience of delivering training on disability in January 2022, in order to explore current practices and to identify gaps in practice and policy. Six experts were purposively sampled to represent people with and without disabilities, in low and high income settings. They were interviewed by TS, a physiotherapist and epidemiologist from Zimbabwe with mixed-methods expertise. Interviews were held online using Zoom. Verbal informed consent was given. A set of open-ended questions (Supplementary file 1) elicited detailed responses on the experiences, perspectives and practices of experts in the field of healthcare worker training on disability. The interviews were recorded and transcribed for analysis. Transcripts were coded and thematically analysed using NVIVO.

Interviews were then conducted in Uganda with people with disabilities and healthcare workers. Written consent was given. People with disabilities were asked what they wished healthcare workers would know about disability, and interviews with a range of healthcare workers were used to gather more detailed information on their specific training needs and to understand their perceptions of the current training available. Semi-structured interviews were conducted in-person with 17 healthcare workers and 27 people with disabilities in Luuka District, Uganda. ASS and SS, Ugandan social scientists with expertise in qualitative methodology undertook the interviews. Participants were recruited through existing networks, non-government organisations and health facilities. The healthcare workers were selected from the eight sub-counties that make up Luuka district based on cadre (clinical officers, midwives, nurses, village health trainers, laboratory technicians, health officers), and level of health facility (health centre, II, III or IV). The people with disabilities were purposively selected to ensure representation of age, gender and impairment. Interviews were undertaken with persons with visual impairment ( n  = 5), physical impairment ( n  = 5), multiple impairment ( n  = 5), cognitive/ intellectual impairment ( n  = 5) and albinism ( n  = 1). Interviews with people with hearing impairment ( n  = 6) were conducted by a member of the research team who is deaf (Supplementary file 2: Participant demographics). The semi-structured interviews explored experiences and perspectives of delivering and receiving health services (Supplementary file 3: Healthcare worker, Supplementary file 4: People with disability). The interviews were conducted in a private and comfortable setting and lasted 50–80 min. They were audio recorded and transcribed. Those conducted in Lusoga and Luganda were translated to English. The transcripts were coded and manually analysed using a deductive thematic analysis approach.

Design workshop

A design workshop was held to develop a framework for the disability training intervention in Entebbe Uganda in September 2022. The workshop brought together a group of people with diverse disabilities ( n  = 7) and healthcare workers and medical educationalist ( n  = 5) to actively participate in the design process over 2 days. The workshop was facilitated by TS and ASS. The workshop consisted of a series of participatory activities, including group discussions, brainstorming sessions, and small group exercises. These activities were designed to elicit the perspectives, experiences, and recommendations of participants. The workshop concluded with a consensus-building activity, where participants discussed and agreed on the key components of the training framework.

Development of training material

A theory of change was used to inform the content design and implementation of the training framework. The research team created the first theory of change model, led by TS, drawing on information gathered from the international experts. The theory of change approach involved identifying the desired outcomes of the training and the necessary steps and activities to be put in place to achieve those outcomes. The training material was then developed by the study team drawing on evidence from the umbrella review, interviews and design workshop on the most effective training strategies for healthcare workers on disability, and was refined based on feedback from five people with disabilities.

The literature search for the umbrella review yielded 377 studies, with 24 full-text articles selected for further review. Eight review articles were eligible for inclusion in the final analysis (Fig.  1 ). A total of 227 studies were included in the reviews, but only 4 studies were conducted in LMICs. The reviews related to training in intellectual and developmental disabilities, mental health, and all disabilities. Three systematic reviews were rated with high confidence on the AMSTAR2 tool, two rated with medium and three rated with low confidence (Supplementary file 5 ). The systematic reviews receiving a low confidence rating in their findings were evaluated as such because they failed to pre-register the review and did not include an appropriate evaluation of bias, including publication bias of the included studies.

PRISMA for umbrella review of systematic reviews and meta-analyses on training of healthcare workers on disability

The training settings included specialised clinical settings, non-specialised clinical settings (inpatient and outpatient), continuity-clinic based, non-clinical settings, medical schools, GP practices, primary care clinics, and various other settings such as clinics, camps, schools, residential settings, and universities. The timeline of training and training evaluation methods varied across the articles; Some articles reported single-session training, short-term training (< 1 month), and longer-term training (1–3 months or > 3 months).

Lectures and didactic (instructional) methods were the most commonly reported teaching methods in disability education, often combined with other approaches, such as case studies, simulations, and placements. Some training programmes leverage multimedia tools, such as video recording or simulations, to enhance the learning experience. The content of the education typically includes disability from a rights-based perspective, as well as particular skills, such as sign language for medical and pharmacology terms (Table  2 ). Many programmes involved people with disabilities as active participants in the education, such as simulating patients or serving as teachers to help run activities. Through these interactions, contact with people with disabilities was transformative, leading to significant changes in attitudes and perceptions of participants.

A broad variety of evaluation methods were used, such as pre- and post-test knowledge assessments, questionnaires at baseline up to 18 months, and immediate post-training evaluations. The impact of the education was typically measured by healthcare worker reports of comfort and attitudes towards people with disabilities, as well as communication skills, knowledge, and self-efficacy. Target outcomes for the training interventions varied, with some focusing on perspective/awareness/comfort, medical and clinical knowledge. Several had unclear outcomes. However, only a few studies considered the longer-term impact, specifically three months post-intervention. The training effect estimates are almost exclusively for high income countries.

Interviews with international experts

International experts reported that people with disabilities play an important role in improving the quality of care for themselves and others. Interviewees identified several ways that this role would occur, as people with disabilities can: offer unique insights into their experiences and perspectives, identify areas for improvement in their care, serve as advocates and role models, and help to promote a culture of inclusion and understanding in the healthcare system. They can also help to ensure that training programs are relevant, effective, and responsive to the needs of people with disabilities.

Experts reported that good practice examples of training methods included contextualized story-telling and activities adapted by the trainer to the local context. Participants believed that these methods were most effective in engaging learners and improving their knowledge, attitudes, and skills related to disability. However, the success of these methods depended on the quality of the training materials, the experience and skills of the trainers, and the level of buy-in and engagement from learners.

Interviewees identified challenges in providing disability education within healthcare training, citing issues such as lack of standardization in curricula and limited time and resources. They expressed concern that these factors may contribute to inadequate understanding of disability issues among healthcare providers, resulting in disparities in care and outcomes for people with disabilities. Additionally, participants discussed emerging trends in healthcare, such as the use of telemedicine and wearable devices, which they believed would require healthcare workers to develop an even deeper understanding of the needs of people with disabilities. They identified opportunities for scaling training, including integrating disability education into undergraduate degrees, continuing education programs, mentoring, and coaching. Overall, participants viewed the future of disability education for healthcare workers as an exciting opportunity for growth and advancement in the healthcare industry.

Interviews in Uganda

Overall, the importance of improving communication, understanding, and collaboration between healthcare providers and people with disabilities to promote equitable and high-quality healthcare services was emphasised in interviews with both people with disabilities and healthcare workers.

People with disabilities highlighted that they expected healthcare workers to recognise and be made aware of the challenges they face when trying to access healthcare services. Additionally, they emphasised that they desired to be treated with the same respect and dignity as any other patient, and they value a positive attitude from healthcare providers towards their care.

“We want healthcare workers to know that all people are equal, including those of us with disabilities, and they should treat each person with dignity.” (Male, visual impairment). “The doctors in the hospital should know that we too are humans, and have blood like them. The difference maybe is that one of my parts is weak, but it doesn’t stop us from getting sick like them.” (Female, physical impairment).

Many of the participants with disabilities acknowledged that better communication skills from healthcare providers, such as clear and concise explanations, are essential to building trust and rapport with people with disabilities.

“What I know is that for my life to continue being good, it is important for me to be able to visit a healthcare worker who understands my situation and I am not insulted…The care and respect you give me when you see me, and how you speak, is helpful.” (Male, Albinism).

Similarly, the healthcare workers expressed a need for more training and education on disability to provide high-quality care. The reported training needs ranged from basic training orientation on disability, including communication skills and knowledge on how to navigate the time needed for disability-inclusive care, to how to examine and treat people with disabilities during routine health visits.

“First of all, we need training because people with disabilities cannot be managed like other individuals. We need training on the forms of disabilities because the different types of disabilities call for different management. So, we can be empowered…and we can manage the expected and non-expected challenges.”(Male, Medical officer) . “We need to know, how do you assess, and how do you support and counsel them. If you do not have those skills sometimes you can mishandle them. For example, you may just look at the cough they have but behind the cough there could be other things.” (Female, Senior nursing officer).

Furthermore, healthcare providers pointed out the need for adequate information about specialised service needs, how to make referrals and contextual considerations (e.g. cultural, social, economic) to ensure that people with disabilities received appropriate care and were referred for further management.

“If I recognise the need for specialised care, I would simply write a referral note. However, many times I am unsure of where to refer them, so I am unable to follow up on whether they received the necessary assistance. Writing a referral is the best I can do.” (Male, Senior medical officer). “We can train healthcare workers within the facility on the best practices for interacting with people with disabilities. Even those of us who support them in the community can be trained on how to connect them with specialised services .” (Male, VHT coordinator). “It may be beneficial to collaborate with others who work with individuals with disabilities and provide holistic care. Since we operate at different levels and some hospitals have specialised clinics for individuals with disabilities, working together can help ensure they receive proper services”. (Female, Midwife)

Involving people with disabilities in training was regarded as a way of facilitating mutual understanding and enabling healthcare workers to better address the specific needs of persons with disabilities, while establishing a designated person for follow-up could enhance continuity of care.

“Sometimes we are left behind, but if we are invited to health workshops, we can share our experiences with healthcare workers, including how we feel and how we should be treated. We can discuss the specific disabilities we face and the challenges we encounter. This would provide an opportunity for healthcare workers to better understand and appreciate what individuals with disabilities go through. ” (Male, Person with disability councillor, Visual impairment).

The findings suggest that healthcare workers often feel uncertain about referring people with disabilities for specialised care, leading to challenges in ensuring necessary and appropriate healthcare. Training healthcare workers on best practices for interacting with people with disabilities, both within the facility and in the community was recommended to help improve their ability to connect patients with specialised services and provide holistic care.

Themes and recommendations from the participatory workshop

Five themes for healthcare worker training on disability were generated by consensus from discussions during the participatory workshop. These themes included the need for a focus on:

Responsibilities and rights: emphasising understanding of the rights of people with disabilities;

Communication: highlighting effective communication for building rapport;

Informed consent: focusing on respecting privacy during examinations;

Accommodation: advocating for disability-inclusive practices; and

Referral and connection: ensuring appropriate referrals and connections to other healthcare services.

The workshop also emphasised the importance of active participation, clear communication, and inclusivity in the design process.

It was recommended that the disability training program should adopt a modular approach, focusing on different aspects of providing healthcare to people with disabilities. It should also focus on increasing knowledge and understanding of disabilities, and improving the attitudes and practices of healthcare workers towards people with disabilities. Emphasis should be placed on adopting a disability-inclusive approach, training healthcare workers on the social model of disability, recognising the impact of societal barriers on the lives of people with disabilities, and addressing these barriers to promote greater inclusion and participation in society. Cultural sensitivity and the use of appropriate terminology are essential help to ensure that the training is inclusive and relevant to the diverse population of people with disabilities that healthcare workers may encounter.

Interaction with people with disabilities was recommended as a key component. This will involve inviting people with disabilities to participate in the training sessions to share their experiences and perspectives. The training should also adopt a learner-centred and participatory approach, based on the values of the healthcare worker, promoting reflection on their own values and beliefs and applying them in their practice, which may be effective in promoting a sense of ownership and commitment to working with people with disabilities.

Ongoing mentorship and peer learning should support the training, pairing healthcare workers with experienced mentors to provide guidance and support as they apply their new knowledge and skills in practice. Practical skills should be included in the training, such as techniques for measuring the weight of a person with a physical impairment, to ensure comprehensive and considerate examination and treatment of people with disabilities.

Training material structure

The theory of change provided a clear and logical structure for the development of the training framework and helped to ensure that the framework was comprehensive, evidence-based and responsive to the specific needs and experiences of people with disabilities in Uganda. The desired outcomes of the training included increasing the knowledge, skills and attitudes of healthcare workers on disability, to ensure that people with disabilities are expected, accepted and connected within health systems. The ceiling of responsibility is the distal outcome that healthcare workers provide disability inclusive care that is considerate and comprehensive. Key components and activities that would be necessary to achieve the proximal outcomes included interaction with people with disabilities, a learner centred participatory approach based on the values of healthcare workers, ongoing mentorship and peer learning (Fig.  2 ).

Theory of change *HCW = healthcare worker, PWD = people with disabilities

The developed training programme included a range of activities such as pre-training self-assessments, interactive workshops, case studies and mentoring. The training framework also included specific provisions for accessibility and inclusion, recognising the importance of addressing the specific needs and experiences of people with disabilities.

The training will be delivered by a healthcare worker and a person with a disability. They will facilitate the training in person over one day for various healthcare workers (nurses, technicians, community health workers, allied health professionals, doctors). The programme will focus on key areas such understanding disability, good practices in work, and personal motivations for providing disability-inclusive healthcare. Participants will learn about routine health needs, communication skills, assessing and treating persons with disabilities, appropriate referrals, and ensuring accessibility in healthcare settings.

The training program aims to achieve its goals through several strategies. It promotes a disability-inclusive approach by engaging people with disabilities and encouraging active participation and reflection. Ongoing mentorship and peer learning opportunities are provided for continuous support. Practical tools are shared to equip healthcare workers with necessary skills. Cultural sensitivity is fostered to ensure healthcare workers can provide care that is respectful and responsive to diverse cultural backgrounds and language preferences. By incorporating these strategies, the training program aims to empower healthcare workers with the expertise needed to provide inclusive and effective healthcare services for persons with disabilities.

Developing a comprehensive training programme for healthcare workers on disability is an important step in addressing barriers to healthcare access for people with disabilities [ 3 ]. We used the Medical Research Council approach to develop the training material [ 17 ], considering practical solutions to improve the knowledge and skills of healthcare workers on disability. Our umbrella literature search revealed that lectures and didactic methods were commonly used in disability education, often combined with other approaches such as case studies and simulations. The review also highlighted the importance of using various teaching methods and including people with disabilities in disability education. The impact of education was measured in various ways, including through healthcare worker reports on comfort, attitudes, communication skills, knowledge, and self-efficacy. There is need for a standardised approach to allow comparison between contexts and countries. Standardisation in curricula and limited time and resources were identified as challenges in providing disability education within healthcare training.

People with disabilities and healthcare workers in Uganda expressed the need for better communication skills from healthcare providers, training on disability, and recognition of challenges faced by people with disabilities. These findings are echoed in other studies globally [ 19 , 20 , 21 , 22 ]. The participatory workshop successfully generated a comprehensive and inclusive framework for a disability training programme, incorporating the diverse perspectives of people with disabilities and healthcare workers. Our findings are consistent with other studies that highlight the importance of disability education in healthcare training, utilising various teaching methods and incorporating the perspectives of people with disabilities [ 23 , 24 ]. The next step is to pilot-test the training programme with healthcare workers in Luuka District, Uganda. During pilot testing, the training program will also consider the cultural context in which it will be delivered, as previous research has shown that cultural competence is essential for providing effective and appropriate care to people with disabilities [ 25 , 26 ].

One of the strengths of our study was the use of the MRC approach to develop the training material, which enabled us to systematically examine training needs and develop practical solutions to improve the knowledge and skills of healthcare workers on disability. In addition, the study encompasses a diverse range of health worker cadres and people with varying types of disabilities, ensuring a comprehensive exploration of perspectives and experiences. Our study also has limitations to consider when interpreting the results. A systematic umbrella review was undertaken rather than a systematic review. Recruitment through existing networks, NGOs, and health facilities may not capture the perspectives of people with disabilities who are not affiliated with these organisations. We included the perspectives of people with disabilities and healthcare workers in Uganda, and thus the generalisability of the disability training to other contexts may be limited. While we did include the opinions of international experts and a global umbrella review, further research is needed to confirm the effectiveness and applicability of the training program in different settings, as the umbrella review noted important gaps in the literature.

Our findings have important implications for policy, programmes and research. Specifically, our study suggests that a disability training programme should be inclusive of diverse cultural backgrounds and adaptable to specific needs, and should incorporate the perspectives of both people with disabilities and healthcare workers. These findings could be used to inform the adaptation of future training programs for healthcare workers in Uganda and other resource-limited settings. Nevertheless, people with disabilities are a diverse group with varying needs and this has implications for training. While advocating for overall disability training, it is essential to also focus on different types of impairment. Additionally, the needs of different healthcare workers will vary due to their diverse roles, raising questions about the feasibility of a generic training programme. Policy support is vital to ensure implementation and support of disability training for healthcare workers (e.g. mandating inclusion in medical and nursing curricula). Future studies could use more objective measures of impact, such as patient outcomes or changes in healthcare service provision.

The proposed development of a disability training for healthcare workers aims to address the barriers and challenges faced by people with disabilities in accessing health care services in Africa. The training will adopt a modular approach. Components of the training include interaction with people with disabilities, a learner-centred and participatory approach, ongoing mentorship and peer learning, practical tools to deliver a comprehensive and considerate examination and treatment, and cultural sensitivity.

Data availability

The majority of the datasets supporting the conclusions of this article are included within the article and its additional files. However, underlying interview data associated with this study will not be made freely available, as the small number of healthcare worker and people with disabilities makes data potentially identifying. Applications for access to the raw qualitative data for this study should be made via email to the corresponding author [email protected], outlining the purpose of the proposed analyses and the data requested. These applications will be reviewed by the LSHTM’s data access committee, and if accepted, the requested data will be shared.

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TS and HK designed the work: TS, HK, TS, ASS and SS collected the data, TS, ASS and SS analysed and interpreted the data. TS drafted the article, TS, ASS, SS, FBM and HK provided critical revision of the article and all authors gave final approval of the version to be submitted.

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Smythe, T., Ssemata, A.S., Slivesteri, S. et al. Co-development of a training programme on disability for healthcare workers in Uganda. BMC Health Serv Res 24 , 418 (2024). https://doi.org/10.1186/s12913-024-10918-z

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Power imbalances and equity in the day-to-day functioning of a north plus multi-south higher education institutions partnership: a case study

• Silondile Luthuli 1 , 2 ,
• Marguerite Daniel 1 &
• J. Hope Corbin 1 , 3  

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Partnerships between Higher Education Institutions (HEIs) in the global north and south have commonly been used as a vehicle to drive global health research and initiatives. Among these initiatives, include health system strengthening, research capacity building, and human resource training in developing countries. However, the partnership functioning of many global north-south partnerships still carry legacies of colonialism through unrecognized behavior patterns, attitudes, and belief systems in how they function. Even with research literature calling for a shift from equality to equity in the functioning of these partnerships, many still struggle with issues of complex and unspoken power dynamics. To understand the successes and challenges of north-south partnerships, this paper explored partnership development and functioning of a northern and multi-southern HEIs partnership focused on nutrition education and research.

A qualitative research approach was used; data were collected through in-depth interviews (IDIs) with questions developed from the Bergen Model of Collective Functioning (BMCF). Thirteen IDIs were conducted with partners from all institutions including stakeholders.

The partnership was built on the foundation of experiences and lessons of a previous partnership. Partners used these experiences and lessons to devise strategies to improve partnership inputs, communication, leadership, roles and structures, and maintenance and communication tasks. However, these strategies had an impact on partnership functioning giving rise to issues of inequitable power dynamics. The northern partner had two roles: one as an equal partner and another as distributor of project funds; this caused a conflict in roles for this partner. The partners distinguished themselves according to partner resources – two partners were named implementing partners and two named supportive partners. Roles and partner resources were the greatest contributors to power imbalances and caused delays in project activities.

Using the BMCF to examine partnership dynamics illuminated that power imbalances caused a hierarchical stance in the partnership with northern partners having overall control and power of decision-making in the partnership. This could impact the effectiveness and sustainability of project in the southern institutions going forward.

Partnerships between countries in the global north and global south have been recognized as crucial and beneficial to southern countries in addressing health-related challenges and promoting global health for all [ 1 , 2 , 3 ]. Countries in the global south often face health-related challenges such as high rates of infectious diseases, non-communicable diseases, inadequate healthcare infrastructure, and limited access to healthcare services [ 4 , 5 , 6 , 7 ], leading to poor health indicators and outcomes. Many of these health challenges can be argued to be products of systematic deprivation through colonialism and unfavorable economic policies and programs at the country level [ 8 ].

Partnerships with governments and health and education institutions in High-Income Countries (HICs) have assisted low-middle-income countries (LMICs) in combating health-related challenges and developing relevant interventions and policies for health [ 9 , 10 , 11 , 12 ]. Moreover, partnerships between Higher Education Institutions (HEIs) in the global north and global south have commonly been used as a vehicle to drive global health initiatives and research between HICs and LMICs. These partnerships are often focused on health systems strengthening, research capacity building, and human resource training to improve health through human resources [ 9 , 13 , 14 , 15 , 16 , 17 , 18 ]. However, Khan et al. [ 19 ] and Whitehead et al. [ 20 ] argue that many of the north-south partnerships still carry legacies of colonialism through unrecognized behavior patterns, attitudes, and belief systems that are adopted by these partnerships.

The success of north-south partnerships between HEIs for Global health and health research in achieving their outcomes has been documented [ 21 , 22 , 23 , 24 ] but literature reports on the operation and functioning of these partnerships are scarce [ 25 ]. Key characteristics of the success of global health partnerships include a common understanding of vision and mission, mutual respect and benefits, trust, good communication, and clear partner role distribution and expectations [ 21 , 26 ]. Even with these key characteristics in place, many global health partnerships still face challenges with power dynamics and these are often rooted in colonial legacies that perpetuate the paternalistic approach of HICs on LMICs [ 1 , 27 , 28 , 29 ].

Crane [ 1 ] and Geissler [ 27 ] further mention that the conceptualization of global health exacerbates power dynamics because it often pairs countries that are unequal to improve or promote health. Over the years there has been a shift toward equity in global health research between HICs and LMICs [ 30 , 31 , 32 , 33 ], with researchers recognizing that inequalities do exist in global health partnerships but strategies need to be implemented to mitigate power dynamics. Key areas of improvement to flatten power dynamics include recognizing ethical issues within partnership functioning [ 32 ], research should focus on local health priorities [ 34 , 35 , 36 ], acknowledge capacities and limitations to contribution in partnership [ 32 ], recognize different skill sets, training background, resources, and funding [ 32 , 37 ], recognize local expertise [ 38 ], build trust between funders and southern partners [ 32 , 36 ], and transparent communication from beginning of partnership [ 39 ]. Even with these key strategies to flatten power dynamics in partnerships, and characteristics of successful partnerships mentioned above, many global health partnerships between HICs and LMICs still experience challenging power dynamics, therefore, more research is needed to understand the functioning of north-south partnerships between HEIs, perhaps from the standpoint of day-to-day operation of these partnerships.

Having identified issues raised in the literature, a case study using categories from the Bergen Model of Collaborative Functioning (BMCF) will be helpful to trace the pathway to understand partnership successes and negative processes that impact partnership functioning. The BMCF framework has been used in some global health partnerships with power dynamics rising as key issues [ 39 , 40 , 41 ]. However, literature that focuses on the day-to-day functioning of these partnerships is scarce. This paper describes a study investigating the partnership development and functioning of a northern and multi-southern partnership focused on nutrition education and research by exploring how different partners understood and contributed to: (1) mission, partner resources, and financial resources (2) Leadership and roles and structures (3) input interaction and communication (4) production and maintenance tasks.

PROJECT-2 is a North-multi-South partnership between Higher Education Institutions (HEIs) focused on nutrition education, research, and capacity building. Four institutions are collaborating on PROJECT-2. The partners comprise ‘supporting’ partners – Northern partner (N1) Footnote 1 and one Southern partner (S1) – and ‘implementing’ partners – the remaining Southern partners (S2 & S3). The terms ‘supporting’ and ‘implementing’ were informally developed by the partners based on how they perceived their roles in the partnership. PROJECT-2 is an extension of a former project, PROJECT-1, with a new partner (S3) joining the partnership. The project is funded by a Northern government funding agency referred to as FUNDER in the paper. The aim of FUNDER agency is to support projects that promote global development, green living, and ending world poverty. Much like the project, the funding agency has funding programs – FUNDING-1 refers to funding for previous partnership, and FUNDING-2 funding for the new project, PROJECT-2. The FUNDING program aims to strengthen the capacity of higher education institution in developing countries to produce higher-quality graduates, higher-quality research, and inclusive higher education. According to FUNDING, the projects must be based on partner institutions’ identified needs and contextual needs.

PROJECT-2 is built upon learnings and experiences from PROJECT-1. The main aim of the partnership is to address the shortage of research capacity to inform the development of locally relevant evidence-based policies in two low-income countries (where S2 and S3 are based), using nutrition as the vehicle for capacity building. The objectives of the partnership are (1) to develop and implement a master’s and PhD Nutrition program (2) to establish research capacity building (3) to inform the development of locally relevant nutrition policies. The countries S2 and S3 were chosen as research sites because they were among countries on the FUNDING-2 list as potential collaborating countries according to FUNDER country’s development policy and they presented poor nutrition health indicators. At the core of PROJECT-2 was to build a partnership that was mutually beneficial to all partners and founded upon the health and nutrition needs of S2 and S3 at the forefront of the partnership.

Conceptual framework

The study used the Bergen Model of Collaborative Functioning (BMCF). Most details about the model were drawn from Corbin and Mittlemark [ 42 ] and used as a reference in this section. The systems model provides an input-throughput-output analytical frame to examine partnerships. The inputs and throughputs interact and function together to produce outputs that feedback to the partnership positively or negatively, all of this happens within a context (Fig.  1 ). The inputs to the partnership are the mission, partner resources, and financial resources. The mission is the vision and objectives of the partnership in how the project will function. Partner resources refer to the skills, knowledge, commitment, connections, and other attributes that humans contribute to the partnership. Financial resources are all the monetary and material investments in the partnership.

The bergen model of collaborative functioning [ 44 ]

The throughput is the collaborative context, the inputs enter the context and interact positively or negatively with elements in the collaborative context as they work on the production tasks (related to the mission) and the maintenance tasks (related to administrative duties). There are four elements within the collaborative context – input interaction, leadership, roles/structure, and communication. These elements create dynamics and reinforce cycles within the collaborative context through their interactions.

The outputs of the collaborative context may be additive, synergy or antagony. Synergy is the intended product of partnership, all the partners bring resources, skills, etc. to bring forth a product bigger than their individual effort. Antagony is not only the failure to reach synergy in the partnership but also the wasting of partner and financial resources so that more is consumed in the partnership process than produced in the partnership. Antagony is any tension in the interaction between collaborative partners that causes interferences, tension, and counter-productivity [ 43 ].

The model was appropriate for the current study because it allowed the researchers to explore various aspects and characteristics of the PROJECT-2 partnership. The model has also been successfully used in many health research partnerships with countries in the global north and south [ 39 , 40 , 41 , 43 , 44 ]. In this paper, only the input and throughput sections of the model were used during the analysis of the data.

A qualitative research approach using in-depth interviews (IDIs) was used in the study to explore the partners’ understanding of the mission and the functioning of the PROJECT-2 partnership. Interviews were conducted with partners and stakeholders involved in the project.

Participants and recruitment

The study population included participants from all the partner institutions and stakeholders from the relevant Government Departments in the research site countries. Participants included Principal Investigators (PIs), administrators, professors, researchers, PhD candidates, and representatives at country level in research site. A purposive sampling strategy was employed in which participants were selected based on their expertise on the subject matter [ 45 ]. Using purposive sampling enabled the researcher to select participants who had extensive knowledge and experience of the project – this was determined by the participants’ involvement in the following project activities: (1) involvement in proposal development (2) engaged in daily activities of the project at individual institution (3) Attending monthly and annual partner meetings, and (4) administrative duties of the project. Recruitment began with the first author attending all the partner virtual monthly meetings to take note of key members from each institution and their involvement in the project. The first author was part of the list of people attending project activities, this included the first annual in-person workshop with the partners. In the annual meeting, the first author introduced the study and invited all participants to participate. Partner representatives who did not attend any monthly meetings or the physical annual meetings were excluded from the study.

Data collection

Semi-structured IDIs were conducted with participants over a period of five months, between February and June 2022. A total of 13 interviews were conducted by the first author. These were three IDIs with members from N1 institution, three IDIs with members from S1, three IDIs with members from S2 and three IDIs with members from S3, and one stakeholder representing country level department in S3. One partner representative was unavailable for an interview and was therefore excluded from the study. An interview guide was developed using the BMCF model to structure topics to be included in the interviews. Topics included in the guide were the partners’ understanding of the mission, contribution of each institution to the partnership, project funding, distribution of roles, views on project leadership, and expected outcomes from the project. Seven interviews were conducted in-person, of these five were done during the partner’s annual meeting. Five interviews were conducted virtually using ZOOM, and one participant requested to provide written answers to interview questions due to the language barrier. All interviews were done in English language.

Data analysis

All interviews were either audio or digitally recorded, using audio recording device for in-person interviews and digital recording through Zoom during virtual interviews. The interviews were 13 to 64 min long. Interviews were transcribed verbatim using a transcribing software Amberscript and Zoom transcribing. All interviews were quality checked by the first author to ensure that everything was accurately captured during transcribing process. The first author listened to audios and read transcripts and made necessary corrections. Analysis was conducted by the first and second authors. The steps of thematic network analysis were followed to analyze the data [ 46 ] and NVIVO v12 was used to manage the data. A hybrid approach, using both inductive and deductive approaches, was employed to guide the analysis process. The inductive approach was used in the initial stages of coding and analysis, followed by deductive approach during the process of developing organizing and global themes (see Table  1 ). The authors (SL, MD) read all the transcripts to familiarize themselves with the data and met frequently virtually and physically to discuss coding process, develop codebook, and themes coming from the data. The final global themes that emerged are structured according to the BMCF model: context, input, and throughput.

Ethical considerations

This study’s data management plan was approved by the [name of institution] for Research Data. Signed informed consent was obtained from all participants before each interview and all identifying information was removed to ensure confidentiality.

The findings are presented according to the structure of BMCF. Elements of the model used are context, inputs, and throughputs which became the global themes of the findings with basic and organizing themes reflecting the initial experiences of participants in developing and establishing the partnership.

Partnership background

Building from project-1:.

coming to the new partnership, the participants expressed that PROJECT-2 is founded on experiences and relationships, achievements, and challenges learned from PROJECT-1. This had an influence on changes that were planned for this second round of the project. Participants presented mixed views about their experiences of being involved in PROJECT-1. Some participants commented on the functioning of the first project and how that might impact the new partnership. Mentioning that “ what is good, is that most of the partners are the ones that were involved in PROJECT-1. So we already know each other and I know how we work, I know we had no problem like collaborating” (Participant 7, IP Footnote 2 ). Another participant mentioned the operation of the first project being poorly managed, commenting specifically that:

a lot of things in PROJECT-1 were done on a fairly ad hoc basis… we had meetings here and there quite often, but people didn’t always turn up… It was… sort of normalized that if you have something else to do, then you would not go to the PROJECT meeting (Participant 8, SP).

In some cases, the outcomes of the first project were perceived to have benefited one partner more than others in the whole project.

… S2 received an extension budget to develop a e-Learning system. And we did just before Covid pandemic and the system helped the school to continue with delivering teaching and courses remotely (Participant 10, IP).

PROJECT-1 achieved several other positive outcomes, for example “… they managed to kind of get out with 40 out of the 41 students that got their masters in the partnership… there will be four PhD candidates also” (Participant 3, SP). The participant also commented on the good relationships between the partners on which the second project was built. However, the participants also expressed that there were numerous challenges that affected the functioning of PROJECT-1. These included issues with security in Country S2 “ … where it was not possible to travel because of conflict” (Participant 3, SP) , language barriers which had an impact on communication between partners and students, communication with the funders, and relationships with institutional boards.

Language as barrier to communication:

PROJECT-1 was operated in English, which meant all communication between partners, and students was done in English. However, there were misunderstandings between partners, students, and institutional boards about the requirements of the project and that of the institution for academic programs. As a requirement of the project, the students had to write and defend their theses in English to pass the program. However, S2 institution only accepted work done in French. “ We learnt that in PROJECT-1, we forced the students to write their thesis in English, and just yesterday we learnt that many of those theses were back translated into French and defended in French” (Participant 3, SP). The participant went on to explain that had the country steering committee told them at that time, they could have come up with alternative solutions. Communication between funders and institution in Country S2 was another challenge expressed by one of the participants. The institution in Country S2 experienced issues with reports to funders that were embedded in language barrier between the partners.

“ … since our accountant, is not that strong in the English, it was a bit complicated and we had to write rewrites [of reports]… we had some troubles like spending some of the money that we requested” (Participant 7, IP).

Going into PROJECT-2 partnership, there were changes implemented by the funders and by partners . The funders made the northern partners in charge of distribution of funds to the other partners and the coordination of the overall project.

Before in PROJECT-1, they gave the responsibility to each south partner, but now they have given it to the N1 partner to coordinate everything that happens in the project when it comes to administration, like the money transfer and all of these things (Participant 1, SP).

Some of the participants found the change implemented by the funders frustrating because they introduced uncertainties and delays with project activities “ … instead of us as project, me as project manager relating to FUNDER directly, we have to now go through the N1 Secretariat. And they have a quite unclear role… but we know we have to wait” (Participant 3, SP).

Another change implemented in the project is the exchange of students from the northern partners to the southern partner institutions; whereas previously only southern partner students had opportunity of attending courses in northern institution. Participant 3, SP explained the introduction of a new practice:

“ … a set of N1 students will come and join students in Country S3 and Country S2 to see what learning opportunities are there from that process, it will be quite interesting” .

Expanding structure:

the partnership brought changes in the form of a new partner joining the project. The participants mentioned that “ … bringing in [a] new partner has strengthened the program…” (Participant 3, SP). The participant went on to say “ … the new partner has shown to be, I think, very strong and fitted extremely well into the program and taking responsibility and has been a very positive addition to the program”. Bringing in a new partner has also brought a sense of commitment from the old partners.

“ And as I see the old participants who have been working, they are committed. Each site wants to make sure that they attain their goals” (Participant 4, IP).

Involving stakeholders in the partnership activities was an important aspect of expanding the structure and developing context-relevant research agenda, focused on the health priorities of the southern partners. The partners were in communication with representatives from various departments at country level to get support and a list of research priorities in the research site countries.

The stakeholder in one of the sites went on to say that they will be working closely with the institution as research hub to provide access to data that students can use in their studies.

I have research ongoing, I have platforms that can give access to data via other government sources and… they can access the information they need for their research projects (Participant 12, IP).

Going into PROJECT-2, the context (background of PROJECT-1) became the foundation of the collaborative context for PROJECT-2. The partners made changes and developed strategies to mitigate the challenges that were previously experienced. The program was set to continue to operate in English with planned strategies to enhance communication and engagements between students and partners.

Inputs emerged as a global theme that was pivotal in the development and functioning of PROJECT-2 partnership.

Understanding the mission of the project:

the participants had different understandings about the mission of the project. For the majority of the participants, the mission of the project was related to developing human resources and building strong collaborations between countries. As highlighted by one participant who mentioned that PROJECT-2 mission is similar to PROJECT-1 mission, and stated that the mission is.

… to establish a strong collaboration for improving nutritional epidemiology, research and education in nutritional epidemiology in Country S2 and Country S3… so improving nutritional epidemiology research and education in both countries (Participant 10, IP).

For another participant, the mission of the project was to establish a master’s and PhD program in nutrition research in Country S2 and Country S3.

And I think, looking back to the kind of call from the donors, it’s that building, that the higher education, which is the main objective of, of FUNDING. And by that I think we have succeeded in PROJECT-1, and the hope that we can succeed in PROJECT-2 in kind of building this master, and PhD capacity (Participant 3, SP).

The participant continued, highlighting the importance of research, “ where the big challenges is on the research,… because you can’t have research-based master’s program and PhD programs without having a good research project”.

In contrast, some participants had uncertainties about what is the mission of the project. Participant 8 (SP), mentioned she could not remember what the mission was about “ … participatory research and education to develop to develop skills, something like that was what we wrote… but I think it’s empowering”. Whereas, participant 5 (IP), was convinced that the project “ … does not have the mission yet. We have objectives… to address the human resource shortages… creating evidence that can also support the challenges of nutrition related conditions”.

Vision of the project:

the participants also expressed different views about the vision of the project. One of the participants explained the vision of the project is working together towards a common goal and working well together based on relationships built in the previous project.

… we all want the project to do well, and that we all do have a fairly common vision into as to where we’re going and that we’ve worked together for all this time, not Country S3, but the other people without any conflict, really (Participant 8, SP).

Another participant, expressed that like the mission, the vision is not yet set (Participant 5, IP).

Institution gains from the project:

when asked about the gains of each institution in the project, the participants found it easy to articulate the gains of the two southern partners where the project will be implemented but difficult to describe the institution gains of the northern partner and the other southern partner. By the end of the project the partners in institution S2 and institution S3 would have gained master’s and PhD graduates in the field of nutrition, an opportunity for staff and students to develop careers and broaden horizons, facilitation and teaching skills, distance learning skills and materials, and sound research. The stakeholder in one institution made it clear that the government department at the country level will also benefit from the project in different ways.

… my gains are two-fold… I do have a lot of data, some are redundant, that are sitting here, then that would benefit a lot from having somebody manipulate, model, and give us more information on it, so that’s one. I will have hands on local information on what is happening on the ground in terms of nutrition (Participant 12, IP).

The participant went on to say that once the project starts producing graduates there will be “… a bigger pool of employees who are competent in manipulating and analyzing and even collecting data but more importantly, conceptualizing the design of different research projects”.

For partners in Country N1 and Country S1, the institution gains were unclear. One participant mentioned that there is nothing that the N1 partners are expecting to gain in the project, he explained that working in north-south partnerships “… is our mission. So, if we are able to complete our mission to train staff members in lower-middle-income countries, we are just happy” (Participant 2, SP). The participant expanded to say that the institution gains of the Country S1 partner “ … will be expanding the horizons of the Centre, knowing more about Africa outside Country S1”.

Expected outputs:

the participants were asked about their expectations in working on the project to understand the outputs. Much like institution gains, some partners were expecting to get graduates and researchers in nutrition research by the end of the project. Other outputs mentioned by the participants are divided into short-term and long-term outputs. For short-term outputs, participants mentioned getting started with the program in Country S3, the partners being focused, structured, and output orientated, large research studies for students, and getting students’ research proposals in good English and through N1 ethics processes. The students in S2 and S3 institutions had to submit their research proposals for ethical approval to northern institution as part of their PROJECT-2 requirement.

The participants in institution S2 also mentioned that there were changes in the curriculum due to a new teaching strategy that was implemented by the institution. As an outcome, the participants, are anticipating a smooth transition that will honor expectations from both project partners and institution. Long-term, the participants mentioned that they expect to see research publications coming from the project, more partnerships and other funding opportunities, and improvement in nutrition and food indicators in both research site countries.

Personal learning and goals:

the participants were asked what they would hope to have personally gained by the end of the project. These included improving language communication, new skills in financial management and administration, writing skills, communication skills, use of technology for blended learning, online teaching and assessment skills, development of online/distance learning courses skills, research skills, teaching skills, staff development, and opportunities to exploring other cultures. A common skill mentioned by the partners was the management skill in relation to leading organisations and multinational projects.

Partner resources

The participants distinguished themselves according to implementing partners and supporting partners in the project. These labels are according to the role distribution and resources that each institution is bringing into the partnership. The supporting partners, Country N1, they are “… the one who like funds the project… they also have this rich contribution on the management of the whole project” (Participant 10, IP) and also provide support in supervision, teaching, and research. The institution in Country S1 team brings skills related to training and research to the partnership.

I think the Country S1 team brings with it, strength in the development of training materials and development of research proposals, development of tools, and those kind of aspects within the research (Participant 11, SP).

With the implementing partners, the resources they bring to the partnership were related to skills in teaching and curriculum development of the program. “ I understand that the [role] of S3 and S2 will be more into the teaching of the curriculum that we have developed” (Participant 6, IP).

Financial resources

Funders and funding:.

with the changes introduced by the funders in PROJECT-2, this presented mixed views from the participants. For the northern partners, this was an added administrative duty that caused frustration and delays in the progress of project activities for all the institutions.

… because FUNDER… have changed the way they organize the structure… there was more than half a year delay because of the contractor issues… and think it will maybe take even maybe half a year or a year to have a full circle in (Participant 1, SP).

The collaborative context (throughput)

Input interaction.

In the study, this was understood as the participants’ understanding of their own personal contribution and the different institutions’ contribution in fulfilling the mission . Many of the participants made a link between the roles they play in the partnership as a key contribution they are making in fulfilling the mission of partnership. One participant felt his role in the partnership was not clear and was not sure how he will individually contribute to fulfil the partnership mission.

When describing the contributions of each partner institution to the mission of the partnership, the participants had clear understandings of what the supporting partners were contributing. For example, this particular participant explained that N1 institution’s contribution to the partnership was “… to improve the opportunities for training and pushing the knowledge agenda forward in Country S3 and… Country S2” (Participant 2, SP). Other participants had a clear understanding that S1 was contributing through providing research skills, training, teaching, and supervision; as highlighted in the resources sub-theme.

The participants were not so clear in describing the role of the implementing institutions in fulfilling the partnership mission. The implementing partners themselves and some other partners kept referring to the roles of teaching and supervision as key contributions to the fulfilment of mission.

The supporting partners often had comparative and competitive descriptions of the individual contributions of the implementing institutions, as seen in the leadership theme. Participant two in particular, felt that one specific partner was not contributing much resources into the partnership but needed the most support to fulfil mission in institution, see below.

… with Country S2, I think it will be like the small brother in the group, who is contributing the least, and needs the most guidance, and the local issues I talked about earlier is, adding to this… (Participant 2, SP).

Production and maintenance tasks

Even though the main focus of the paper/data collection was to understand the initial stages of partnership development and implementation, however, the partners did have plans and activities for production and maintenance tasks. In this section, we present findings of how different activities had a positive and negative interaction with each other during the early stages of partnership development and implementation.

Production tasks

Production tasks include activities that are undertaken for the purpose of achieving the mission in a partnership. Two characteristics (roles and leadership) are important in understanding how production tasks are conducted to produce the intended outcomes in the partnership.

Roles and responsibilities:

All the partners were aware of the various roles that they individually play in the partnership and there was an awareness of the various roles and responsibilities that institutions play in fulfilling the mission of the project. One of the partners highlighted that there was a fair distribution of responsibilities with regard to project activities, this helped “… everyone know what is expected of them” (Participant 7, IP). The roles mentioned by participants include administrative and financial management roles, project manager/coordinator, principal investigators in each site responsible for overseeing the implementation of objectives and research activities in institutions, being a teacher and co-supervisor in the project, coordinating the development of curriculum in the institution, being a stakeholder and research hub, and being PhD candidates in the project. One of the participants expressed that coming from a northern partner, their role was conflicting because the partnership is structured to be equal “ … where we are on the very egalitarian basis, but in the same time, the N1 plays a role as a controller of the others, because we are the ones that are report to the donors” (Participant 3, SP) , they felt that they have more power to control roles and responsibilities in the partnership.

Leadership:

the partnership has leaders in each institution but there is also an overall leader/manager in the project, the PI from Country N1. The project manager’s role in the partnership is to organize partner meetings (virtual and physical), facilitate the meetings, take notes during meetings, and liaise with the funders. When asked about leadership style in the partnership, some of the partners expressed that leadership is good, encourages shared decision-making among partners, there is openness to share the leadership role, and the project manager does “ … not try to control the way things are going and gives everybody the floor and let everybody speak…” (Participant 8, SP) , and this was perceived as a good model of leadership and an improved leadership style from the previous, PROJECT-1 partnership, leaning towards a more collaborative orientated project.

However, some of the N1 partners were concerned about the power dynamics in the partnership. They felt the northern side of the partnership was “… imposing a lot of things on the partners…” (Participant 1, SP) because of their dual role and multiple responsibilities in the partnership. The northern partners felt that some of these responsibilities needed to be shared among partners in order to flatten out the power dynamics. One of the participants explained that a platform to share some of the project administrative duties with the project manager was opened in the first partner meeting but none of the other partners took up the offer.

When describing the leadership in the implementing institutions , the partners often compared the leadership styles of these two leaders in implementing institutions. The participants spoke of one leader as driven, clearly understanding the mission, committed, wanting to build a future and career, and bringing wealth of knowledge and experience to the partnership. Whereas, when speaking about leadership in the other institution, some participants alluded to underlying issues in leadership that affect the functioning of project in that institution.

Teaching and supervision tasks:

one of the main production tasks in PROJECT-2 was the development and implementation of the nutrition research program (curriculum) in S3 institution and continued support at S2 institution. Other teaching and supervision tasks in the partnership included finding strategies for blended learning in the implementation institutions.

In PROJECT-1 we had made the recommendation that we move to mixed methods teaching platform, where one would not teach only face-to-face… but rather use multiple methodologies for teaching and I think that from the workshop its very clear that that’s the way they want to go (Participant 11, SP).

Research tasks:

building a research agenda that addresses nutrition priorities and policy at country level was important for the project. Research studies that would be conducted by the students in the project had to link to country priorities, and this was done through working in collaboration with government departments in each implementing country and they provided a list of research priorities in nutrition for the country. Ensuring that research studies conducted in the project address policy change and the need for evidence for interventions or publication in the implementing countries was important for the partners. As highlighted by participant 5 who explained that project would be.

… generating evidence that can address the dearth of evidence, in these countries for policymaking processes to address the nutrition challenges, and together we can also address issues with regard to health and welfare of the society (Participant 5, IP).

However, in developing plans and strategies about the research agenda, the partners had agreed that having “ … bigger research projects that involve both master’s students and PhD students around a few projects… instead of… very small studies” (Participant 3, SP) would work best for the project. This would allow the partners and project at large to get an in-depth understanding of the topic under investigation.

Maintenance tasks

Maintenance tasks are activities that keep the partnership functioning, these include administration duties, meetings, grant writing, and writing reports. Communication is an important characteristic of maintenance tasks. Maintenance tasks do not affect the mission of the project directly but play a significant supportive role in its achievement.

Team meetings:

the partners had regular virtual meetings to discuss project progress in each site and updates on project activities. As highlighted by Participant 4, who mentioned that the meetings were important in getting an understanding of activities they have to do as an institution and “… reporting what we have been doing and what has been done and what needs to be done”. The partners had their first in-person meeting/workshop and this provided partners an opportunity to engage with one another better. The workshop also provided partners “… clarity in terms of what are the expectations from the project” (Participant 5, IP). During discussions in the workshop, a decision was made that principal investigators (PIs) from all the institutions should have their own meetings to discuss “ … issues that need to be really interrogated that not everybody is agreeing with or if there is issues where one partner is lagging a bit behind…” (Participant 11, SP).

Admin tasks:

the partners had to prepare budgets and reports for the funders about the first period of the project. One of the partners had delayed submitting the budget because they were unaware of the procedures. This particular partner explained that being part of the monthly meetings assisted in getting clarity about what is expected of them during reporting.

I had some delays in submitting reports… but from being a member of those meetings, then I was becoming aware that I was supposed to do this and this… there is a budget, but we were required to prepare some six-month budgets for supporting some of the activities that are being done (Participant 4, SP).

The same participant continued to express dissatisfaction about how administrators in the partnership have limited chance to interact amongst each other and learn from one another. The participant suggested that administrators should have their own workshops or maybe zoom meetings where they can learn from each other.

New administrative role in northern institution:

the overall administrative role and management of the project were operated by the northern partner and this caused frustration in the N1 partners because there was a lack of clarity of what is expected of them from the funders and there was concern that the role adds another dimension in the power dynamics. There was also concern that the shift in financial management duties may limit opportunities for capacity building for the south partners. Participant 3 (SP) explained that FUNDING-1 experienced numerous admin challenges in the previous project which led to moving all project management duties to northern partners. However, the shift in administrative duties was welcomed with gladness for one of the south partners because this meant they do not have to interact directly with the funders. This made their work easy as they were often unfamiliar with funder’s procedures of reporting.

We were like directly responsible over all the things are related to financing, with FUNDER. But now we have to pass through the N1 [institution] which is a very good like way of doing things because actually, they are more accustomed to working with FUNDER agency and it makes things very easy for us (Participant 7, IP).

Practical and contextual challenges in communication:

in the first year of PROJECT-2, the partners communicated mostly virtually through emails and Zoom meetings due to travel restrictions caused by COVID-19 pandemic. During that time, the partners were writing a funding proposal virtually and a lot of challenges related to communication were experience; some of these issues transferred to physical communication when the partners eventually met. There were concerns about misunderstandings when everything was done via text or zoom in a partnership and also there was often confusion on who was to be invited into zoom meetings. Some partners felt that communication was clear and structured with everyone knowing what is expected of them in the partnership. Other partners expressed a view that more physical meetings would strengthen relationships in the partnership and perhaps smaller groups within the partnership would be beneficial for better communication and shared experiences among different roles in the partnership. Participant 1 (SP) highlighted that perhaps it would be better “ … to arrange in these workshops to get more in smaller groups that is maybe easier to talk and to communicate and share experiences when you’re in that small group” and separate these groups according to different roles in the partnership.

Culture and language were also an added layer of dynamics in the partnership that had an impact on communication. The partners come from diverse cultural backgrounds and speak different languages, an incident that happened during the first partner meeting brought awareness to the partners on the need to be considerate and respectful of different cultural contexts in the partnership. In this incident, one partner spoke harshly to another partner during a team meeting sending waves of shock among partners.

I think it… speaks to a lack of understanding of culture and norms. And I think that working in a diverse cultural background, diversity of cultural backgrounds, we need to be mindful (Participant 11, SP).

Using the Bergen Model of Collaborative Functioning (BMCF), this paper explored partnership development and functioning of PROJECT-2 as well as partners’ understanding and experiences of partnership. In this study, we found that PROJECT-2 was built on an existing partnership among the majority of the participants plus one new partner. Many of the participants alluded to the previous partnership experiences, PROJECT-1, having a significant impact on the establishment and overall functioning of the current partnership. These experiences were both positive and negative during PROJECT-1. Negative experiences in PROJECT-1 included poor management of the project, skewed benefit ratio between the partners, and poor communication between partners, funders, and institutions. These became the backbone of key changes intended in PROJECT-2, including the expansion of the nutrition program by introducing a new partner and involving stakeholders to influence the development of a context-relevant research agenda. The positive experiences included good working relationships, successfully developing and implementing master’s and PhD programs, and producing graduates from the program.

As a way to increase the chances of success in north-south partnerships, many authors have suggested that partnerships should be anchored on a shared understanding of vision or mission, shared resources and skills, mutual benefits, and good management practices [ 47 ]. In their study, Dean et al. [ 25 ] found good working relationships from previous partnerships as a contributor to effectiveness and sustainability in north-south partnerships. Going into PROJECT-2, the participants incorporated many of the experiences and lessons learned from PROJECT-1 into establishing PROJECT-2, including some of the characteristics highlighted by Buse and Tanaka [ 47 ] and Dean et al. [ 25 ], it seemed the partners understood and recognized their strengths and weaknesses going into PROJECT-2 and planned strategies to improve the functioning of the partnership.

Mission for sustainability – a house divided cannot stand

The establishment of a clear mission and vision for partnership is important not only for role and resource distribution but also has an impact on the sustainability of projects even long after funding has ceased. An understanding of the purpose of coming together into partnership with end goals clearly understood by all partners involved is key. This includes the alignment of project mission to that of institution for sustainability. John, Ayodo, and Musoke [ 21 ] also included the same moral values as an important characteristic to effective global partnerships, this promotes trust among the partners. Even though the partners understood the importance of establishing a vision and mission for the effectiveness of the partnership prior to establishing PROJECT-2, during the interviews the participants struggled to articulate a collective understanding of the vision and mission of the partnership. The participants were pulling apart different aspects of the project objectives without a clear understanding of the overall partnership aim. However, what was interesting in their definitions of partnership mission was how the partners were linking the mission to the outputs of the project, but what was missing was the partners’ understanding of project outcomes and linking those to the institution needs and mission. Using the Theory of Change (ToC) concepts to distinguish outputs and outcomes, mission connects to overall goals linked to context and is future-orientated, whereas outputs connect to shorter term goals that contribute to fulfilment of outcomes in partnership [ 48 , 49 ]. In the interviews, only one participant (Participant 10, IP) gave a definition of the mission that focused outcomes rather than outputs, moving beyond institution and partnership but also national level objectives. A clear understanding of project outcomes has an impact on sustainability which in turn influences mission and functioning of partnerships. In PROJECT-2 the partners stated that they were intentional about developing a partnership that is driven by the needs of southern partners. Working closely with stakeholders at the country level in developing a research agenda focused on nutrition priorities was a strategy implemented by the partners in ensuring sustainability of project. This also increases the chances of project impact and sustainability in the country; and long-standing challenges of global north and south partnerships [ 50 , 51 ].

Communication breakdown impacts transparency

Effective communication among the partners not only has an impact on partnership functioning but can also promote transparency in the partnership. Good work relationships established from the PROJECT-1 project were perceived as a strength to establish PROJECT-2. However, it is interesting that these good work relationships were mentioned only by the supporting partners. These perceived good work relationships should be questioned for their genuineness and relevance in PROJECT-2. The communication and working together between the partners in PROJECT-1 are seen as not transparent. When the partners in S2 institution experienced language barriers and translation issues within the institution, they did not communicate with the partners about changes implemented at the institutional level. This then undermined the view of good work relationships and brings to question what could have led S2 to implement changes in the partnership without informing the rest of the partners and funders. During the in-person meeting, an explanation was asked for and given for the changes that were implemented in S2 but the issue was not followed up post the in-person meeting to make relevant changes in the functioning of the program in S2 institution. Transparency as highlighted by Monetta et al. [ 26 ] and Nakanjako et al. [ 18 ] goes beyond financial transparency but also to challenges experienced at an institution level and the openness of partners to welcome contextual knowledge to improve partnership functioning. This means going to the root of issues at the institute level and finding contextually appropriate solutions without following stringent partnership legacies that are not beneficial to all partners.

The power of language in communication between partners is equally important in promoting respect, knowledge value, fairness, and transparency in north-south partnerships. In the interviews, one participant referred to one of the southern institutions as a “little brother” in the partnership, alluding to the partner’s contribution and distribution of resources. Using such language in north-south partnerships is paternalistic and continues the legacy of colonialism [ 52 ] and diminishes the value and knowledge value of southern partners. This could be argued to explain the reasons the southern partners did not tell the partners about changes at institution level, tied to value of partners in the partnership and knowledge value.

Unclear role distribution and resource contributions give rise to power dynamics

Role distributions and resource contributions in partnerships can be a birthplace for inequitable power dynamics if partners do not understand the inequalities that exist within them in the partnership. These can often lead to frustrations and unmet expectations – antagony in partnerships. The changes in administrative duties and communication with funders implemented in PROJECT-2 raised issues of power dynamics within the partnership functioning. This is nothing new to global health partnerships. Historically, issues of power dynamics and equality have been and continue to be an ongoing challenge of partnerships with countries in the global north and south [ 32 , 36 , 53 ]; with updates in literature calling for a shift from equality (sameness) to equity (fairness) in global north-south partnerships [ 33 ]. Although many partners in PROJECT-2 believed that there was equality in the partnership, there were concerns expressed by some participants about control and power. These were implied in control and the overall decision-making power of PROJECT-2 held by the northern partners. Even then, with these concerns of power dynamics expressed by some participants, the partners did not have any effective strategies to flatten the power dynamics. Such dynamics further raises questions on collaborations with local expertise in these partnerships, the people who have better understanding of context and who are able to make decisions aligning with true needs of southern partners.

Even though there has been a shift over the years, with developments of approaches and models for engagements in north-south partnerships, issues of inequitable power dynamics and control persist in these partnerships. These are often rooted in who has control over decision-making. In as much as the PROJECT-2 partnership approached the development of the partnership from the model that puts Southern partners at the forefront of decisions about the research agenda, the partnership was at risk of falling victim to many pitfalls of global health partnerships due to overall decision-making power held by Northern partner. There have been many approaches and models developed to improve global health partnerships over the years [ 54 , 55 ], in practice, many of these partnerships still struggle with challenges of power dynamics and these are often rooted in the mismatch in research priorities and research context, unclear role distributions, resources, communication, funding, and a lack of clear understanding of the research agenda [ 15 , 54 , 56 , 57 ]. All of these could be summed up as ‘control’ and can be attributed to the power of decision-making in many of these partnerships.

Control is further highlighted in the partnership by how the partners understand each other’s resource contributions and benefits in the project. In defining contributions and benefits, the partners created a divide in the partnership by calling themselves implementing and supporting partners. Using these labels created hierarchy in the partnership with the supporting seen as experts and the implementing seen as beneficiaries of the partnership; potentially exacerbating ‘the little brother effect’ attached to global north-south partnerships [ 33 , 52 ]. However, the focus should be shifted to understanding what are the hidden or unacknowledged benefits of the partners who are considered experts in partnerships between countries in the global north and south. In their study, Syed et al. [ 58 ] found that benefits for HICs in these partnerships included deeper contextual understanding of working in LMICs for future research and transferring research learnings and innovations to their countries. Dean et al. [ 25 ] further state that having a clear understanding of benefits for all partners is important, this has an impact on the effectiveness and sustainability of partnerships.

In PROJECT-2, the supporting partners see their main role as providing support in the partnership with minimal benefits directly linked to the partnership. This is an interesting perspective from the supporting partners whereas they view the partnership as an equal partnership. By definition, an equal partnership connotes that all partners contribute and benefit equally [ 59 ]. According to Crane [ 1 ] and Geissler [ 27 ] partnerships steered towards ‘global health’ should not be considered ‘partnerships’ or ‘collaborations’ because of their intrinsic nature of inequality. As stated above, literature has seen a shift in global health partnerships towards equity (fairness) instead of equality (sameness) emphasizing differences in contributions and benefits of partners [ 33 , 60 , 61 ]; these are fixed according to the needs of the partners.

Study limitations

Firstly, the PROJECT-2 partnership has a small membership, so maintaining anonymity and confidentiality in the data was difficult as participants knew each other very well. Anonymity also made it difficult in presenting the research findings in this paper, we could not contextualize the quotes and certain quotes had to be removed from presentation of findings to preserve anonymity and confidentiality of participants. Secondly, the researcher (SL) was well acquainted with the research participants as she worked on the PROJECT-1 and works on PROJECT-2 as a researcher. This could have caused response bias from the participants. Thirdly, language was a barrier to communicating with one participant. For this particular participant, an interview guide was sent to answer the questions. Lastly, the use of digital platforms to conduct interviews was a challenge, the internet connection was a problem at times, and getting participants available was a challenge at times.

Using the Bergen Model of Collaborative Functioning (BMCF), the study explored the development and functioning of a northern and multi-south partnership in global health. Even though the study was conducted during the initial stages of partnership development, the partners seemed to be aware of some of the underlying issues in the partnership and their potential to influence functioning. Roles and structures were experienced by the partners as possibly the main contributor to complex power dynamics. Tied to roles and structure are financial resources, partner resources, and leadership which also had an impact on distribution of roles. Lessons from the previous partnership included lack of agreement on mission and vision for the partnership, and poor communication with students, among partners, and with institutions. Even though the partners had an intention of developing vision and mission and communication strategies, these seemed to be ineffective as participants did not have a common mission and vision and the partners still maintained functioning of partnership and teaching and learning to be in English without effective solutions to mitigate those issues. A key feature usually missing in global north-south health partnerships is positioning projects based on southern needs, not only on paper but actually finding research priorities that are rooted in context and allowing southern partners to lead projects as members with the most contextual understanding. Such changes in the functioning of global health partnerships would mitigate and solidify the shift from equality to equity, therefore promoting sustainability of these projects even after funding ceases.

Data availability

No datasets were generated or analysed during the current study.

All country names and institutions have been concealed in the paper to maintain anonymity and confidentiality of the partnership.

IP = Implementing Partner.

SP = Supporting Partner.

Abbreviations

Bergen Model of Collaborative Functioning

Higher Education Institutions

High Income Countries

In–depth Interviews

Low–and–middle income countries

Principal Investigator

Theory of Change

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Acknowledgements

The authors would like to thank all the participants of this research who made the production of this paper possible.

Open access funding provided by University of Bergen. The study received funding from the PROJECT-2 partnership. However, the partnership had no role in the study design, data analysis, and preparation of the manuscript or the decision to publish.

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S.L. designed and carried out the research, analyzed and interpreted the findings, and drafted the manuscript. M.D. advised in the design of the research and guided in the analysis and interpretation of the findings, recommended literature, and edited the manuscript up to the final version. J.H.C. advised on the theoretical background of the study, and the interpretation findings, and provided editing of the final paper. All authors read and approved the final manuscript.

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Luthuli, S., Daniel, M. & Corbin, J. Power imbalances and equity in the day-to-day functioning of a north plus multi-south higher education institutions partnership: a case study. Int J Equity Health 23 , 59 (2024). https://doi.org/10.1186/s12939-024-02139-x

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Published on 4.4.2024 in Vol 26 (2024)

Impacts of an Acute Care Telenursing Program on Discharge, Patient Experience, and Nursing Experience: Retrospective Cohort Comparison Study

Authors of this article:

Original Paper

• Courtenay R Bruce, MA, JD   ; 
• Steve Klahn, RN, MBA   ; 
• Lindsay Randle, MBA   ; 
• Xin Li, BS   ; 
• Kelkar Sayali, BS   ; 
• Barbara Johnson, BSN, MBA, DNP   ; 
• Melissa Gomez, MBA   ; 
• Meagan Howard, MHA   ; 
• Roberta Schwartz, PhD   ; 
• Farzan Sasangohar, PhD  

Houston Methodist, Houston, TX, United States

Corresponding Author:

Courtenay R Bruce, MA, JD

Houston Methodist

8100 Greenbriar Drive

Houston, TX, 77030

United States

Phone: 1 281 620 9040

Email: [email protected]

Background: Despite widespread growth of televisits and telemedicine, it is unclear how telenursing could be applied to augment nurse labor and support nursing.

Objective: This study evaluated a large-scale acute care telenurse (ACTN) program to support web-based admission and discharge processes for hospitalized patients.

Methods: A retrospective, observational cohort comparison was performed in a large academic hospital system (approximately 2100 beds) in Houston, Texas, comparing patients in our pilot units for the ACTN program (telenursing cohort) between June 15, 2022, and December 31, 2022, with patients who did not participate (nontelenursing cohort) in the same units and timeframe. We used a case mix index analysis to confirm comparable patient cases between groups. The outcomes investigated were patient experience, measured using the Hospital Consumer Assessment of Health Care Providers and Systems (HCAHCPS) survey; nursing experience, measured by a web-based questionnaire with quantitative multiple-choice and qualitative open-ended questions; time of discharge during the day (from electronic health record data); and duration of discharge education processes.

Results: Case mix index analysis found no significant case differences between cohorts ( P =.75). For the first 4 units that rolled out in phase 1, all units experienced improvement in at least 4 and up to 7 HCAHCPS domains. Scores for “communication with doctors” and “would recommend hospital” were improved significantly ( P =.03 and P =.04, respectively) in 1 unit in phase 1. The impact of telenursing in phases 2 and 3 was mixed. However, “communication with doctors” was significantly improved in 2 units ( P =.049 and P =.002), and the overall rating of the hospital and the ”would recommend hospital” scores were significantly improved in 1 unit ( P =.02 and P =04, respectively). Of 289 nurses who were invited to participate in the survey, 106 completed the nursing experience survey (response rate 106/289, 36.7%). Of the 106 nurses, 101 (95.3%) indicated that the ACTN program was very helpful or somewhat helpful to them as bedside nurses. The only noticeable difference between the telenursing and nontelenursing cohorts for the time of day discharge was a shift in the volume of patients discharged before 2 PM compared to those discharged after 2 PM at a hospital-wide level. The ACTN admissions averaged 12 minutes and 6 seconds (SD 7 min and 29 s), and the discharges averaged 14 minutes and 51 seconds (SD 8 min and 10 s). The average duration for ACTN calls was 13 minutes and 17 seconds (SD 7 min and 52 s). Traditional cohort standard practice (nontelenursing cohort) of a bedside nurse engaging in discharge and admission processes was 45 minutes, consistent with our preimplementation time study.

Conclusions: This study shows that ACTN programs are feasible and associated with improved outcomes for patient and nursing experience and reducing time allocated to admission and discharge education.

Introduction

Telemedicine, particularly video televisits, has greatly expanded in the wake of the COVID-19 pandemic [ 1 , 2 ]. Televisits have shown promise as a robust, practical, efficacious, and scalable alternative to in-person office visits that could ameliorate labor supply shortages [ 3 , 4 ]. The published evidence suggests a generally positive attitude toward televisit appointments for chronic care, focused on addressing financial and transportation barriers and improving patients’ access to care [ 5 - 7 ]. Despite the promise shown by televisits, limited attention has been paid to applying this method in the acute care setting and, in particular, on how this promising technology can be leveraged to support nurses.

Estimates suggest that approximately 200,000 open nursing positions will become available each year between 2021 and 2031 [ 8 ]. Telenursing can augment nursing labor supply, decrease nursing workload, maintain patient and nurse safety, and positively impact nursing and patient experiences [ 9 ]. However, the impact of telenursing on outcomes in acute care settings remains a research gap.

To address this gap, this study aimed to evaluate the outcomes associated with a large-scale acute care telenurse (ACTN) program to support web-based admission and discharge processes for hospitalized patients compared to patients who did not undergo the ACTN program intervention. Admission and discharge are 2 substantive and time-consuming acute care nursing tasks that involve tedious documentation in the electronic health record (EHR) and extensive interaction with patients and families to gather history and provide patient education [ 10 , 11 ]. We aimed to develop an ACTN program to augment nursing care by conducting admission and discharge processes through telenursing in a large health system. Subsequently, we discuss the impacts on 4 end points: patient experience, nursing experience, time of discharge during the day, and length of time for discharge education processes. We hypothesized that the ACTN program would be associated with higher patient experience scores and improved nursing experience compared to standard admission and discharge practices.

This study was conducted in a large academic hospital system (approximately 2100 beds) in Houston, Texas. The preimplementation methods are reported more extensively in the studies by Hehman et al [ 12 ] and Schwartz et al [ 13 ]. Program implementation was first informed by nursing time and workload surveys and pilot implementation in 4 comparatively understaffed units. The chief innovation officer, along with nursing leaders and ACTN program administrators, met with the bedside nursing staff of these 4 understaffed units to solicit their input on where and how ACTN would add value to their workflow. Bedside nursing staff provided critical input on admission processes that could be delegated to individuals working remotely with no perceived negative impact on patient experience. We conducted participatory workflow design sessions with bedside nursing staff on the ACTN program to cocreate workflow integration points where the remote team could assist [ 13 ].

Pilot Implementation and Procedures

Before implementation, the ACTN administrators trained bedside nurses in pilot units by demonstrating the use of technology during shift huddles. Then, the trainers presented slides on contact information and available support and provided a role demarcation process map, showing what the remote telenurse staff would be doing compared to what the bedside nurses needed to do to launch and conduct discharge education. Furthermore, the trainers invited the nursing staff to observe several discharges to learn how to conduct them. A software with Health Insurance Portability and Accountability Act compliance was uploaded to iPads (Apple Inc) and stored on each unit. Handheld iPads were available, and roaming iPads were made available for patients who could not hold an iPad.

The pilot implementation was staggered in a phased rollout, consisting of 3 sequenced phases, as shown in Figure 1 . Upon admission, the acute care bedside nurse contextualized the ACTN program with patients and families by handing the patient an iPad with a preloaded remote program app (Caregility) and then pressing a soft key to allow the ACTN to enter the patient’s room via the iPad screen. The ACTN introduced themselves, completed the nursing admission profile in the EHR, placed a request for a consultation, and notified the bedside nurse that the admission was completed using secure SMS text messaging [ 13 ]. A similar process was followed for discharge workflow processes, where the ACTN completed patient education on discharge instructions, confirmed the patient’s pharmacy details, confirmed discharge transportation, and arranged for departure.

Bedside nurses used their discretion regarding which patients would be appropriate for the ACTN program. They based this determination principally on whether documentation was needed and whether the patient could benefit from the undivided attention the ACTN program could afford. Furthermore, they excluded patients from the ACTN program if the patients expressed discomfort using an iPad. After the initial rollout, patients’ input was sought on their experience with the ACTN program to identify where and how improvements could be made, and this feedback was incorporated into iterative revisions in subsequent rollouts.

Pilot Outcomes Monitoring

A retrospective, observational cohort comparison was performed, in which all patients in our pilot units for the ACTN program (telenursing cohort) between June 15, 2022, and December 31, 2022, were compared with all patients who did not participate (nontelenursing cohort) in the same units in the same timeframe.

Our primary outcomes were patient experience and nursing experience. Patient experience scope was any process observable by patients [ 14 ]. We compared patient experiences in the telenursing and nontelenursing cohorts by evaluating patients’ responses to the widely used Hospital Consumer Assessment of Health Care Providers and Systems (HCAHPS) survey [ 15 ], which represented 8 aspects (called dimensions) of patient satisfaction. Each dimension was measured using a continuous variable (0 to 100 points).

For the telenursing cohort, we analyzed bedside nurses’ collective responses using a Forms (Microsoft Corp) survey conducted in April 2023. The survey consisted of 5 questions, asking them to indicate whether the ACTN program was helpful using a Likert scale with 5 items (very helpful to very unhelpful). Nurses were asked to provide open-ended comments to explain the reasons for their evaluation. At the end of the survey, we included 2 open-ended fields for nurses to describe opportunities for improvement in future rollouts and provide any additional comments.

Furthermore, we explored the time at which discharge occurred using the EHR admission, discharge, and transfer date and time. We compared the hour of the day the patient was discharged in the telenursing cohort with the hour of the day the patient was discharged in the nontelenursing cohort, hypothesizing a priori that patients might be discharged earlier in the day in the telenursing cohort. Finally, we analyzed the duration of discharge education for both cohorts, measured in minutes.

Data Analysis

The patient demographic data were available for all patients. To confirm that the telenursing cohort had similar patient demographics as the nontelenursing cohort (and therefore to confirm that nurse biases in patient selection for the ACTN program were unlikely), we conducted a case mix index (CMI) evaluation. We first isolated the population of both cohorts into adults (aged ≥18 y). We compared only those patients who were discharged home and excluded those who were on extracorporeal membrane oxygenation or those who underwent a tracheostomy. The remaining population was evaluated to determine whether there was a difference in patient acuity and severity. After confirming that patient acuity and severity were of no significant difference, we included the inpatient and observation populations to evaluate the intervention results.

For the patient experience data, independent sample t tests (2-tailed) were used to compare the telenursing and nontelenursing cohorts across different HCAHPS dimensions and units. Analysis was conducted using R software (R Foundation for Statistical Computing). For the nursing experience survey data, we used Excel (Microsoft Corp) to analyze the responses to multiple-choice, discrete questions and thematic analysis to evaluate the open-text fields. Thematic analysis allows for eliciting key themes that emerge based on recurring statements [ 16 ]. The analysis followed an inductive approach. This approach uses open-ended questions, allowing themes to emerge with a few previously articulated assumptions on responses. Given the limited content, CRB served as the primary coder. Coding labels were used for data contextualizing, allowing for new themes to emerge throughout the coding process, using a codebook [ 16 , 17 ]. We stored emergent patterns and themes in an electronic format.

Ethical Considerations

The hospital’s review board determined that the ACTN pilot would not be considered regulated human subjects research. All data reported in this study were aggregated and deidentified.

The demographics of the telenursing and nontelenursing cohorts were relatively similar. Both cohorts had an average age of 60 years with an SD of 16.91; had a similar distribution in race and ethnicity (approximately 92/2319, 3.96% Asian; 525/2319, 22.64% Black; 425/2319, 18.33% Hispanic; 70/2319, 3.02% Native American, declined to identify, or other categories; and 1202/2319, 51.83% White); and had a similar distribution in female participants versus male participants (1249/2319, 53.86% vs 1070/2319, 46.14%). To further understand the population, the CMI analysis for acuity and severity showed that the CMI was slightly higher in the telenursing cohort than in the nontelenursing cohort, but the difference was not statistically significant ( P =.75).

Patient Experience

Among the first 4 units that rolled out in phase 1, all units experienced improvement in at least 4 and up to 7 HCAHPS domains (Table S1 in Multimedia Appendix 1 ). On average, 6 out of 8 HCAHPS domains were improved for patients in the telenursing cohort. All 4 units experienced improvements in the “overall rating” domain, and 3 of the 4 units experienced improvements in “likelihood to recommend” domain for patients in the telenursing cohort compared to those in the nontelenursing cohort within the same units. The improvement scores ranged from 1.4% for the neurosurgery unit (36 beds) to 11.6% for the medical unit (37 beds). Furthermore, all 4 units in the first phase of roll out experienced improved scores in the “responsiveness” domain by >4 points (ranging from 5% to 10.1%). A total of 2 out of the 4 units also experienced improvements in the “communication with nurses” (ranging from 1.7% to 3%) and “communication about medicines” (ranging from 3.3% to 11.7%) domains. The 2 units that did not experience improvement in the communication domains were the combined medical and surgery neurology and neurosurgical units (36 beds). Only the neurosurgical unit showed statistically significant improvements in 2 dimensions: “communication with doctors” ( P =.03) and “would recommend hospital” ( P =.04).

For the 7 units that rolled out during phase 2, only 1 orthopedic surgery unit (28 beds) experienced improvements in every domain (ranging from 0.9% to 12.5%). Medical observation unit 1 also improved in 5 areas. However, only improvements in “communication with doctors” ( P =.002), “overall rating of hospital” ( P =.02), and “would recommend hospital” ( P =.04) were statistically significant . The remaining units experienced improvements in some domains for the telenursing cohort compared to the nontelenursing cohort, with no improvement in other domains. However, the scores for “communication with nurses” and “communication with doctors” domains were improved for most of the units that rolled out in phase 2 (Table S2 in Multimedia Appendix 1 ).

For the 2 units that rolled out in phase 3, both of which were surgical cardiac units with 36 beds, 1 unit experienced improvement in every domain except “responsiveness” (ranging from 1% to 12%). The other unit only experienced improvement in the “communication with doctors” (4.9%) and “care transitions” domains (1.1%). However, none of these improvements were statistically significant (Table S3 in Multimedia Appendix 1 ).

Nursing Experience

Of the 289 nurses who were invited to participate in the survey, 106 completed the survey (36.7% response rate). Of the 106 nurses, 101 (95.3%) indicated that the ACTN program was “very helpful” or “somewhat helpful” to them as bedside nurses.

Quantitative Findings

The main reasons nurses gave for the program’s helpfulness included that it saved them time (94/106, 88.7%), allowed them to focus on more urgent clinical needs (90/106, 84.9%), allowed them to focus on activities they felt were more in line with their skill level (55/106, 51.9%), and allowed patients to have undivided attention for their discharge education (52/106, 49.1%). Among the 5 nurses who indicated that the ACTN program was somewhat unhelpful or very unhelpful, 3 (60%) indicated that workflows were not clear or needed further refinement or clarification. Furthermore, the nurse respondents shared several barriers and provided opportunities for improvement, with 91 (85.8%) out of 106 nurses offering suggestions.

Qualitative Findings

For the free-text explanation fields, all but 3 nurses (103/106, 97.2%) provided additional comments on the ACTN program helpfulness. Three themes emerged from the qualitative analysis of the free-text comments: (1) most of the nurses’ comments reflected that telenurses help bedside nurses save time, (2) respondents indicated that extra hands provided emotional and physical support in providing patient care, and (3) respondents perceived an improvement in patient safety by having a telenurse who could “catch missed” issues.

Time Saving

One of the perceived benefits of the telenursing program was saving time. One nurse said the following:

... Just putting in home medications alone takes up so much time. This new telenurse service helps [save time]

Several nurses highlighted that admission and discharge processes are so complex and time-consuming that shifting this work to the ACTN program freed nurses to perform other activities, as reflected by this nurse:

The tele RN is able to spend as much time possible sufficiently educating an admission or discharge while allowing me time to respond to the needs of my other patients saving me time on one patient especially charting.

Emotional and Physical Support

For the second theme, several responses focused less on time management and perceived efficiencies and instead centered more on the emotional appeal and support in having an extra hand, as one nurse mentioned:

Being in such a fast-paced unit, it can be a bit stressful with so many discharges and admissions. Having a helpful hand is beneficial.

Improved Patient Safety

Finally, the third theme was perceived improvement in patient safety by having a telenurse who could “catch missed” issues (eg, an incorrectly identified pharmacy details), simultaneously allowing the primary bedside nurse to focus more intensely on other needs, essentially creating a 2-fold safety promotion. Some nurses noted that they could begin carrying out orders while the telenurses began completing the admission, facilitating quicker treatment and resolution of care needs, thereby improving the safety and quality of care. One nurse mentioned the following:

Allows [telenurses] to take on thorough and accurate admissions, while also preventing any rushing the patient might experience from the primary RN.

When asked for areas of improvement, the most recurring theme was having 24 hours of support during the weekend and during the week. The second theme for improvement was the reduced time to connect to a telenurse. The third theme was the availability of iPads. Nurses mentioned that iPads could sometimes be unavailable in patients’ rooms or they may not be fully charged.

Time of Discharge

The time of day distribution is presented in Figure 2 . The only noticeable difference between the telenursing and nontelenursing cohorts was a shift in the volume of patients discharged before 2 PM compared with those discharged after 2 PM at a hospital-wide level ( Table 1 ). At an individual unit level, these results were not consistent and could be further explored by patient population and their needs to discharge. The variation was further illustrated when reviewing the length of stay of patients in the telenursing and nontelenursing cohorts. Only 5 out of the 12 units showed a decrease in the average inpatient length of stay.

Discharge Length

The ACTN admissions averaged 12 minutes and 6 seconds (SD 7 min and 29 s), and the discharges averaged 14 minutes and 51 seconds (SD 8 min and 10 s). The average duration for ACTN calls was 13 minutes and 17 seconds (SD 7 min and 52 s). Traditional cohort standard practice of a bedside nurse engaging in discharge and admission processes was 45 minutes, consistent with our preimplementation nursing time study.

Principal Findings

Our results suggest that the ACTN program was associated with positive nursing experiences because it saved time. Furthermore, the ACTN program was associated with higher HCAHPS scores in several domains but only in the first series of units that piloted the intervention. In phase 1, the improvement in “communication with doctors” and “would recommend hospital” scores in 1 unit was statistically significant. In phase 2, the improvement in “communication with doctors” score was significant in 2 units and that in “overall rating of hospital” and “would recommend hospital” scores were significant in 1 unit. The time of day discharge was nearly the same in both the telenursing and nontelenursing cohorts. The duration for discharge processes was less than half in the ACTN cohort compared to the nonintervention cohort.

At the time of writing this paper, the United States was experiencing a critical nursing shortage that will likely reach an epidemic level in the next few decades [ 8 ]. Despite the promise shown by telenursing, to our knowledge, only 1 existing paper documents the impact of ACTN programs on HCAHPS-measured patient satisfaction using a small cohort of patients in a single, time-limited pre- and posttelenursing analysis [ 18 ]. A study by Schuelke et al [ 18 ] revealed a 6.2% increase in “communication with meds” and 12.7% increase in “communication with nursing” domain scores; other HCAHPS domains were not evaluated. This research builds upon the promising work of Schuelke et al [ 18 ], evaluating the impact of an ACTN program on several units with a much larger cohort of patients using a staggered rollout and comparing all HCAHPS domains between telenursing and nontelenursing cohorts within the same time frame and in the same units.

By conducting granular HCAHPS analyses, we identified what we believed to be a time sequence variability in that units that rolled out in phase 1 performed considerably stronger in HCAHPS impacts than units that rolled out in later phases. An explanation for this sequence effect might be that some later adopters had less potential for high effect size, given that the first 4 units of the rollout were specifically chosen for their staffing problems compared to later units. ACTN support might have augmented the staffing support to such a degree that allowed the impacts of the program to be more salient. An alternative explanation is that the early adopters and promoters tend to have greater diffusion uptake, greater saturation and adoptability, and greater impacts compared to late adopters or those resistant to adoption [ 19 , 20 ]. Our anecdotal evidence suggests that early adopters might have wanted the telenursing program to succeed; therefore, they applied consistent implementation practices to ensure success. Adopters in later stages were more aware of barriers and potential downsides and might have been more ambivalent about telenursing and, therefore, less likely to modify their behaviors to promote the telenursing program’s success.

Another interesting finding was that the ACTN program seemed to be effective for both medical and surgical units of all specialties. Phase 1 was a mix of medical and surgical units; however, all units experienced increases in scores. Phases 2 and 3 experienced mixed results, without a clear lead for one specialty over the other. This may suggest that ACTN programs are broadly applicable across acute settings and that success depends most crucially on the need and desire of unit leaders.

Our time of day discharge findings showed only a few quantitative positive efficiencies. However, our discharge duration analysis and nursing experience survey results showed that ACTN has major time-saving benefits for nurses, suggesting a discrepancy between perceived and actual time savings versus time-of-day discharge savings. One explanation for this discrepancy may be that many factors beyond nursing impact the time of the day a patient is discharged; therefore, while the bedside nurses’ time is saved, the remaining discharge processes beyond nurses remain unaffected. Specifically, there are 3 segments of time during discharge processes: (1) the time for the discharge order and medication reconciliation [ 21 ] to the time the after-visit summary (AVS) is populated and printed [ 22 ]; (2) the time the AVS is completed and printed to the time the discharge instructions are provided; and (3) the time from providing the discharge instructions to the actual discharge ( Figure 3 ). Notably, telenurses’ involvement is currently limited to only the second segment of time. Specifically, telenurses’ involvement is not initiated until the AVS is printed by the nurse, which means that telenurses cannot positively impact any discharge activity that occurs between the time the discharge order is written and the time the AVS is printed. However, there are inefficiencies and bottlenecks in discharge processes that occur well before the AVS is printed [ 23 , 24 ]. For instance, the discharging physician may write a conditional discharge order early in the morning, listing conditions that cannot be fulfilled within a few hours or it may take bedside nursing longer than anticipated time to print the AVS.

To create a wider cascade effect for positively impacting the discharge processes for all segments of time, we are currently trying to obtain greater transparency through EHR reporting in what occurs for segments 1 and 3. For instance, at present, we know that at least 2 hospitals in our 8-hospital system have high incidence rates of conditional discharge orders that should be reduced. One hospital anecdotally reports that the discharging physician identifies incorrect pharmacies, which requires a nurse to send the scripts back to the discharging pharmacist to reconcile before discharge education can occur [ 25 ]; however, the prevalence and location of these issues remain speculative. Segment 3 is a black box of time [ 26 ]—the time it takes for hospital transport or an ambulance to arrive and move the patient to their destination and the time it takes for the family to pick up the patient. All these factors impact the discharge processes and need to be fully elucidated, explored, and streamlined. Furthermore, we hope to facilitate processes that enable telenurses to print the AVS, to remove the dependency on bedside nurses to begin the discharge education process.

Limitations

This study has several noteworthy limitations. First, the study was conducted in 1 health system and the results may not be generalizable to other settings with different patient populations, processes, and implementation strategies [ 27 ]. Second, in this study, we did not control for other factors that could impact patient and provider satisfaction as well as discharge times; telenursing can only improve upon one component in a complex set of factors limiting discharge efficiency and satisfaction outcomes. Finally, participating nurses were aware of the ongoing study, and this knowledge might have affected their behavior [ 28 ].

Future Directions

After the completion of this pilot study, the ACTN admission and discharge program has been rolled out to pilot medical units and all surgical and observation units. Our rationale for expansion rested on the premise that nursing experience is important to maintain and strengthen, particularly at a time when turnover is high in the health care industry in general. It is important to reduce staff inefficiencies in workload as a means of preserving or strengthening organizational morale and cost saving. Because our nursing experience findings for the ACTN program heavily supported the program, this served as the primary motivation for expansion. The nursing experience findings, coupled with the findings related to time-savings in discharge education and modest improvement, though not negative, in the HCAHPS findings for the ACTN program compared to the nontelenursing cohort, further supported expansion.

The initial scope for expansion included a complete system-wide implementation for all admissions and discharges. Furthermore, we are planning to expand the ACTN program beyond admissions and discharges. Responsive to qualitative feedback reported earlier, the next phase of the ACTN program will add safeguards on high-risk medications by having telenurses conduct double-checks, skin assessments, hourly rounding assistance, and auditing of safety functions and educational activities. These activities were chosen because they are time-intensive for nursing staff on the patient floors. Additional support in these areas would be a staff morale booster in addition to improved efficiencies for bedside nursing. Conducting hourly rounding using the ACTN program will require more time and resources; however, conducting high-quality, uninterrupted hourly rounds is known to be effective at improving patient safety and patient experience outcomes [ 29 ]. Therefore, we suspect that the ACTN program will have some positive impacts if rounds are consistently conducted, even if conducted virtually.

In addition, the ACTNs have been motivating other specialties to adopt or consider a similar program as the ACTN program to support stretched staffing. These specialties include respiratory care, in which virtual support can quickly identify patients in need of intensive on-site support; pharmacy, in which direct communication with staff on medications and patient training can happen through virtual means; infection control, in which room environments can be reviewed through virtual audits, moving quickly from floor to floor; and guest relations and spiritual care, in which patients can be visited virtually upon patient request. Furthermore, physicians who wish to either virtually enter inpatient rooms during their clinic days or from home can quickly drop in to see patients using the virtual program. For these groups to further develop advanced inpatient telemedicine programs, additional technology will be required, including cameras that can zoom into various portions of the room and advanced sound capabilities. Future work could expand programs similar to ACTN to specialties such as respiratory therapy, pharmacy, infection prevention, and spiritual care.

Conclusions

This study provides preliminary evidence suggesting that telenursing may effectively address nursing shortages in acute care settings and positively impact patient and provider satisfaction as well as admission and discharge times. More work is needed to validate the findings in other settings, use other satisfaction metrics, and investigate the impact of telenursing on the quality of care and cost.

Acknowledgments

The authors would like to thank Jacob M Kolman, MA, ISMPP CMPP, senior scientific writer, Houston Methodist Academic Institute, for the critical review and for providing formatting feedback on this manuscript. The authors would also like to thank Amir Hossein Javid for his help with statistical analysis.

Data Availability

Data sharing is not applicable as no data sets were generated during this study.

Authors' Contributions

All authors were involved in the conceptualization, review and approval, and writing of the manuscript. LR, BJ, MG, RS, SK, and MH were extensively involved in the implementation of the project. BJ, MH, SK, and MG conducted the training. SK and XL conducted the analyses. CRB wrote and edited the manuscript, inserted and refined the citations, and provided critical feedback during implementation and analyses. CRB and FS were involved in all stages of writing and publication. All authors meaningfully contributed to the drafting, writing, brainstorming, executing, finalizing, and approving of the manuscript.

Conflicts of Interest

None declared.

Additional outcome information for Hospital Consumer Assessment of Health Care Providers and Systems, time of day discharges, and discharge education processes.

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Abbreviations

Edited by T de Azevedo Cardoso, G Eysenbach; submitted 06.11.23; peer-reviewed by C Jensen; comments to author 08.12.23; revised version received 16.01.24; accepted 17.02.24; published 04.04.24.

©Courtenay R Bruce, Steve Klahn, Lindsay Randle, Xin Li, Kelkar Sayali, Barbara Johnson, Melissa Gomez, Meagan Howard, Roberta Schwartz, Farzan Sasangohar. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 04.04.2024.

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