The qualitative findings indicate that patients equate personal contact with physical face-to-face contact, which could be reduced by implementing telemedicine, thus negatively influencing the patient–doctor relationship. Correspondingly “no personal contact with the doctor” is the main reason (64%) why 38% of the surveyed patients refuse to try telemedicine. Professional stakeholders expect telemedicine to contribute to the effective allocation of scarce resources in rheumatology care. The main barriers reported by stakeholders were the scarcity of time resources in RMD care, the absence of physical examinations, and organizational challenges associated with the implementation of telemedicine in RMD care. While the exact integration of telemedicine into routine care has yet to be found, the consequences on the patient-physician relationship must be permanently considered.Despite all its promises, telemedicine is still not widely implemented in the care of rheumatic and musculoskeletal diseases (RMDs). The aim of this study is to investigate opportunities, barriers, acceptance, and preferences concerning telemedicine among RMD patients and professional stakeholders. From November 2017 to December 2019, a participatory, mixed-methods study was conducted, consisting of (1) expert interviews ( The global burden of rheumatic and musculoskeletal diseases (RMDs) is rising . While i“[T]he practice of medicine over a distance, in which interventions, diagnoses, therapeutic decisions, and subsequent treatment recommendations are based on patient data, documents and other information transmitted through telecommunication systems”  and the whole thing- Who of the old people up there in Mecklenburg [dense populated region in Germany] or so has the technical equipment? I always ask myself.” “As I said, I see the issue that you can no longer control who gets hold of certain data and what they do with it. (...) Suddenly people find out things, who should not have access to this information. And that’s really just the tip of it, because you can’t imagine what could be done with such data there.” Professional stakeholders also underlined the importance of physical, face-to-face contact between physicians and patients, emphasizing that the role of telemedicine must be to support, not replace, existing health care services.“Well, at the end of the day, I consider it as something supportive. It cannot replace the direct contact, the complete direct contact between doctor and patient, it neither can nor should. Because I think I also have to touch, I also have to see personally in front of me, without that it doesn’t work.” Under this premise, various opportunities of telemedicine in rheumatology, but also digital health in general, were mentioned by stakeholders. Yet, interview partners described obstacles that prevent the deployment of telemedicine use cases. One of these is access to adequate internet capacity.“It is a paradox, that patients who would be most affected by it [telemedicine], patients who live far away from the city, (...) still have white spots in their surroundings, for example areas, residential areas where ISDN is available. They don’t even have DSL 2000, they don’t have anything. And it doesn’t matter whether they want to or not, they simply can’t hold a video conference.” Another obstacle to the use of telemedicine reported by the interviewees was the reimbursement system for medical services in Germany, which does not yet adequately cover the use of telemedicine.“And I can’t bill that at all in the S[ocial] H[ealth] I[nsurance] system, so it’s a hobby that I do. But I do have hobbies. Most of my colleagues have hobbies, they know what they can do in their free time. You can’t. You can’t do hobby activities at work. That is not possible. And that’s just telemedicine, unfortunately, that falls into it.” n = 50); (2) outpatient rheumatology practices (n = 17); (3) inpatient rheumatology wards (n = 2). A total of 5000 questionnaires were distributed. Of those, 766 (15%) were returned. Of the 766 responses, 32 were excluded from further analysis because fewer than half the questions were answered.The questionnaires were handed out in different settings of rheumatology care: (1) working groups of the patient organization German League against Rheumatism (Most respondents (72%) were female. The mean age of the participants was 57 years. Most respondents reported that they were diagnosed with rheumatoid arthritis (46%), followed by osteoarthritis (24%), psoriasis arthritis (14%), or other conditions . Most respondents rated their own state of health as bad (40%) or very bad (7%) and 45% rated their own health as “okay”. Most of the respondents located their place of residence in rural areas (34%) and provincial towns (25%), followed by towns (21%) and cities (20%). Participants indicated that they have to travel a median of 10–20 km to their rheumatology practice. The median reported distance to a general practitioner’s office was up to 5 km. Most participants responded that they possess a telephone (86%), a personal computer (63%), a smartphone (57%), and a mobile phone (56%). Overall, 84% of the surveyed patients indicated that they have internet access at home. Further characteristics of the sample are illustrated in Most survey participants have previously used their phone to contact their physician (79%); followed by e-mail (23%) or fax machine 7%, . Two resAlmost two-thirds of the participants (66%) indicated that they had previously searched for information about their rheumatic disease on the internet. Most respondents 79%,  indicateA quarter of the respondents (25%) stated that they have previously visited the website of their rheumatology practice.Slightly more than half of the respondents (51%) reported that they had heard the term “telemedicine” previously before the survey. Further, 38% of the respondents indicated that they did not wish to try telemedicine .The item “no personal contact with the doctor” was most frequently quoted as a reason (64%), followed by “data security” 28%, .Less than one-third of the survey participants 30%,  indicateOverall, 4% of the participants responded that they would be willing to pay privately for telemedicine , and 21%Two focus groups were held with 10 patient representatives of the German League against Rheumatism and 4 rheumatologists of Working Group Young Rheumatology of the German Society for Rheumatology (DGRh). Both focus groups revealed a homogeneous spectrum of opinions with participants confirming the survey results.Patient representatives underlined the high relevance of personal contact reported in the survey, which was equated by the discussants with physical–personal contact with the doctor.“Discussant: Well, personal contact with the doctor is important. And not taking a picture and sending it somewhere. For me, personal contact is most important. Interviewer: And personal contact means you want to be in the same room with the doctor? Discussant: Yes.” Patient representatives discussed the potentials and risks of telemedicine in their personal health care. Participants were particularly averse to the use of telemedicine services if they were not applied by their own doctor, on the basis of an existing patient–doctor relationship.“Then I also imagine an overload for the doctor. Because he now also has patients who he doesn’t know. That would be irresponsible, because he doesn’t see the whole person and so on. I don’t want to imagine that at all. So at the very most, if you are under a doctor’s care and he knows you, you may then also ask a question by phone or by video or by telemedicine. For a doctor who has never seen me or so, I would not actually agree with that. A discussion point that complements the survey results is the organizational integration of telemedicine into medical routines in the context of scarce time resources.“I’m interested in the organizational side of things. When I make a phone call now, where do I actually end up? Is it a doctor who has office hours there, who only does telemedicine? Because when I arrive at my doctor’s office, he doesn’t have any time, he has to see his patients. He can’t focus on me. I do not see it.” Rheumatologists expressed a positive attitude toward telemedicine in the focus group, highlighting the potential of telemedicine as a support of existing care structures.“Perhaps telemedicine can then be seen more or less as a digital safety or support network, so to speak. We as physicians are more or less automatically notified of potential problems thus we can react as promptly as possible in the consultation.” Scarce time resources and practical integration of telemedicine into medical routines were also discussed in the focus group with the rheumatologists. As resources are already limited, telemedicine should not simply be appended to the existing medical tasks.“We are all open-minded, but nevertheless the doctors have no time for it... to practice telemedicine in addition to their normal office hours. It only works if retired doctors are brought on board again. So from there, the topic of time savings, I think you have to carefully consider for whom this is a time saving.” Overall, the results of the different methodological study parts coincide and complement each other, with qualitative findings allowing deeper interpretation of the quantitative data. This mixed-methods study combines findings from expert interviews, a patient survey, and focus groups on telemedicine acceptance, barriers, and opportunities in rheumatology care, conducted shortly before the COVID-19 outbreak. The results of our survey indicate patients’ heterogeneous opinions on telemedicine in RMD care—namely, the loss of personal contact with the doctor was the main reason for rejection, and telephone consultations were the most preferred telemedicine by patients. Furthermore, the results point to information needs regarding telemedicine implementation in RMD care. Qualitative findings substantiate these results, as interviewed patient representatives were generally amenable to the use of telemedicine and associate, for example, time savings or the reduction in travel distances to RMD care with telemedicine. However, according to the survey data, patient representatives identified major barriers as missing technical infrastructure, potential data insecurity, and, again, the loss of personal contact with the doctor, which, in the focus groups, was underlined to be meant as the physical–personal contact. Professional stakeholders who participated in the qualitative study modules considered telemedicine as a potential safety measure in RMD care delivery and a resource for achieving higher continuity of care. However, organizational challenges and the lack of digital equipment and infrastructure in Germany impede telemedicine implementation, according to the stakeholders. Plus, time resources to implement and use telemedicine in the first step are missing, which, combined with poor reimbursement modalities, leaves telemedical care unprofitable or, as one interviewed physician referred to it, “a hobby”. Recommendations to overcome barriers to telemedicine implementation in rheumatology are illustrated in Compared with German rheumatologists and general practitioners, our survey results illustrate that patients tend to be reluctant to use telemedicine . OverallThe lack of face-to-face contact with physicians, often equated with physical contact, remains a key issue regarding telemedicine implementation for patients and professionals alike. Patients fear a deterioration of the patient–doctor relationship due to telemedicine. Physicians mentioned missing physical exams while using telemedicine. This raises the fundamental concern of poorer rheumatology care via telemedicine—despite existing evidence that telerheumatology can achieve similar outcomes as conventional care  and highn = 193), conducted at an outpatient clinic of a major German university hospital in 2018/2019 [Our survey data revealed that patients were mainly using the telephone for physician communication, and interestingly, only 2/714 indicated that they had a video consultation with their physician. More patients preferred the telephone to video consultation, consistent with previous studies that identified the telephone as the preferred means of contact with rheumatologists. ,44. In c018/2019 , signifi018/2019 . These aSimilar to previous work ,43, we iAll data reported in this study were collected shortly before the COVID-19 outbreak. The pandemic, infection control measures, and changes in traditional health care delivery, however, have impacted patient and professional stakeholder perspectives on telemedicine globally , locallyThere are limitations to our study. Following an exploratory, participatory, mixed-methods approach, we deliberately defined telemedicine broadly in order to explore telemedicine concepts in rheumatology from the user perspectives. However, this also may have led to reduced comparability of the qualitative results. In consultation with the patient organization, we aimed to provide a questionnaire that was understandable for all potential participants—digitally skilled or not. In consequence, the general acceptance of patients toward telemedicine in rheumatology is well covered in the survey results. However, developmental and treatment-related issues of telemedicine use, such as mode (asynchronous vs. synchronous) or specific telemedicine approaches, were only outlined in the qualitative data and need to be examined in subsequent studies. In addition, the study information sent with the questionnaire could be a source of learning bias . It inclInterviews were conducted over a 21-month period (November 2017–July 2019). The response rate to the patient survey was comparatively low, at 15% , with a To the best of our knowledge, we performed the first participatory, multi-perspective, mixed-methods study on telemedicine in adult rheumatology. To ensure a representative sample, patient representatives were also involved at all stages and patient inclusion was extensive . The mixed-methods approach provides comprehensive insights into the perspective of RMD patients and key stakeholders in rheumatology care. The results of our study demonstrate the great importance of trustful patient–physician relationships in rheumatology, based on physical–personal contacts, which might be complemented but not replaced by telemedicine. Our findings also revealed RMD patient demands for further information and knowledge on digital health that rheumatologists must meet as their discipline faces ongoing digital transformation.Based on pre-COVID data, we identified barriers and opportunities to further support the design and implementation of telemedicine in rheumatology care. RMD patients value the physical–personal contact with their rheumatologists and fear a negative impact on the patient–doctor relationship with the introduction of telemedicine to their personal health care. Thus, many RMD patients reject the use of telemedicine. On the other hand, participants perceive immediacy of care, overcoming distances, and efficient allocation of scarce resources as opportunities for telemedicine. Both the qualitative and the survey data revealed that organizational and infrastructural barriers have to be overcome, and information needs have to be met in order to implement telemedicine effectively and sustainably in rheumatology care.


Indirect reciprocity is a mechanism for the evolution of cooperation based on social norms. This mechanism requires that individuals in a population observe and judge each other’s behaviors. Individuals with a good reputation are more likely to receive help from others. Previous work suggests that indirect reciprocity is only effective when all relevant information is reliable and publicly available. Otherwise, individuals may disagree on how to assess others, even if they all apply the same social norm. Such disagreements can lead to a breakdown of cooperation. Here we explore whether the predominantly studied ‘leading eight’ social norms of indirect reciprocity can be made more robust by equipping them with an element of generosity. To this end, we distinguish between two kinds of generosity. According to assessment generosity, individuals occasionally assign a good reputation to group members who would usually be regarded as bad. According to action generosity, individuals occasionally cooperate with group members with whom they would usually defect. Using individual-based simulations, we show that the two kinds of generosity have a very different effect on the resulting reputation dynamics. Assessment generosity tends to add to the overall noise and allows defectors to invade. In contrast, a limited amount of action generosity can be beneficial in a few cases. However, even when action generosity is beneficial, the respective simulations do not result in full cooperation. Our results suggest that while generosity can favor cooperation when individuals use the most simple strategies of reciprocity, it is disadvantageous when individuals use more complex social norms. This human concern for a good reputation can be an important motivation to engage in cooperative behavior: Once somebody’s reputation is at stake, people have more of an incentive to engage in costly acts of helping others10. This reputation-based mechanism for the evolution of cooperation is referred to as indirect reciprocity14. In contrast to direct reciprocity18, which is based on repeated interactions between the same players, indirect reciprocity does not require any two individuals to interact with one another more than once. Instead it only requires population members to continually assess each others’ actions, and to act based on these reputations. Whereas direct reciprocity is based on individual memories of interactions with a given group member, indirect reciprocity builds upon a group’s collective memories.People tend to put in time and effort to achieve and maintain a good standing with those that surround them14. In the simplest case, each dilemma situation involves only two population members, who are referred to as ‘donor’ and ‘recipient’, respectively. The donor is asked whether or not to pay a personal cost to provide help to the recipient. The two possible actions of either offering help or refusing help are interpreted as cooperation and defection, respectively. While the recipient does not make any decisions, the donor’s action is observed by other population members. These observers then decide how the donor’s reputation should be updated in light of their behavior.In order to analyze the process by which reputations evolve, the literature on indirect reciprocity considers certain social dilemma situations21. According to the assessment rule of image scoring, a donor’s reputation should improve every time the donor cooperates, and it should deteriorate every time the donor defects. According to its action rule, a donor should only cooperate with those recipients who are sufficiently well-reputed. Importantly, the social norm of Image Scoring has the property that assessments only depend on whether or not the donor cooperated. Social norms with this property are sometimes referred to as ‘first-order’ norms. While this basic principle of first-order norms may appear intuitive, Image Scoring has been shown to be unstable24. The reason for this instability is that individuals are required to defect against an ill-reputed group member; yet by doing so, they harm their own reputation. To overcome this inconsistency, it has been argued that stable norms of indirect reciprocity need to be sufficiently complex to differentiate between justified and unjustified acts of defection23.How observers update reputations, and how donors decide whom to help, depends on the social norm applied in the population. These social norms consist of two components. First, the social norm’s assessment rule specifies which behaviors of the donor should improve the donor’s reputation, and which behaviors should be condemned. Second, the social norm’s action rule tells the donor whether or not to help the recipient; this decision may in turn depend on the recipient’s and the donor’s current reputation. A well-known example of a social norm is ‘Image Scoring’26 consider an even simpler decision situation. In their setup, reputations are required to be binary, such that individuals can either be ‘good’ or ‘bad’. For this binary model of reputations, they allow for up to all ‘third-order’ assessment rules. In addition to the donor’s action, third-order assessments may also depend on the current reputation of the donor and the recipient. For example, while helping a good recipient may be assessed as good, the very same action towards a bad recipient may be assessed as bad. With an exhaustive search on the space of all third-order norms, Ohtsuki and Iwasa identified eight successful norms that can maintain cooperation, which they coined the “leading eight”. All leading eight norms agree that a cooperative action towards a good recipient should yield a good reputation, whereas a defecting action towards a good recipient should yield a bad reputation. The norms differ, however, in how they evaluate interactions with a bad recipient. While some norms find it acceptable if help is provided to a bad recipient, other norms like ‘Stern Judging’27 condemn such behaviors completely.To identify such stable cooperative norms, the landmark papers by Ohtsuki and Iwasa32, yet they are based on a number of important assumptions. One of their key assumptions is that reputations are assigned publicly. This means that after any interaction between a donor and recipient, it is a central authority that assigns an updated reputation to the donor; this publicly assigned reputation is then adopted by the entire population. As a consequence, the views of different individuals are always perfectly correlated: if a given group member is considered to be good by one individual, they are also considered to be good by anyone else. The assumption of public information greatly facilitates the mathematical analysis of indirect reciprocity. However, it cannot capture scenarios in which individuals make their own judgments, based on their own private information. When individuals make their own judgments, they may start to disagree about which reputation they assign to a given group member. Such disagreements can arise, for example, when individuals differ in which interactions they observe, or when they occasionally misinterpret a given interaction. Once such disagreements arise, they can further proliferate, because individuals now also perceive all future interactions of that group member differently35. For private, scarce, and incomplete information, individual-based simulations thus suggest that the leading-eight social norms no longer effectively promote the evolution of cooperation36.The findings of Ohtsuki and Iwasa have been hugely influential for the further development of the field38. Here we explore the effect of a particular mechanism, generosity. The value of generosity has previously been stressed in the literature on direct reciprocity43. For example, by occasionally cooperating against defectors, the strategy ‘Generous Tit-for-Tat’ can stabilize full cooperation40, even though the classical Tit-for-Tat strategy cannot. Similarly, the analogous first-order social norm ‘Generous Scoring’ has been shown to be stable in the context of indirect reciprocity44, even though classical Image Scoring is not. In both cases, there is the same intuition for why a certain degree of generosity is favorable. By becoming more generous, populations of reciprocators are more likely to sustain cooperation among themselves even in noisy environments. This in turn makes them more robust against invasion by unconditional cooperators. At the same time, however, reciprocators must not be too forgiving, for otherwise they can be invaded by unconditional defectors. The optimal degree of generosity thus needs to strike a balance between being sufficiently forgiving to correct errors, and being sufficiently strict to avoid exploitation.This finding naturally calls for mechanisms to mitigate the effect of noisy environments and private information on indirect reciprocityIn the following, we propose a framework to incorporate an element of generosity into the leading eight social norms. To this end, we distinguish between two kinds of generosity. The first, assessment generosity, makes individuals more generous when assigning reputations to other group members. In situations in which they would usually assign a bad reputation to a given group member, they may occasionally assign a good reputation instead. The second, action generosity, makes individuals more generous in their decisions whom to help as a donor. In situations in which they would usually defect, they may occasionally cooperate instead. Although these two kinds of generosity may seem similar, our results suggest that their effect on the resulting reputation dynamics is very different. In particular, while action generosity can sometimes enhance cooperation, assessment generosity is always detrimental. Moreover, even under action generosity, we do not observe the evolution of high cooperation rates when environments are noisy. Our results suggest that complex social norms of indirect reciprocity are not compatible with individual acts of generosity. Unless generosity is the result of a coordinated effort among all population members, generosity merely acts as another seed of disagreement.N. In every round, two players are randomly chosen to engage in an interaction. One of the players is randomly assigned to be the donor, whereas the other player is assigned to be the recipient. The donor chooses whether to confer a benefit b to the recipient, at an own cost of c, with q. We assume that information is private: every observer keeps track of others’ reputations by updating their personal reputation repository, and there is no shared judgment of observed actions (see “Methods”). Players thus individually update and keep track of their opinion about others based on their observations. These observations are subject to noise: observers can misperceive an action with a probability To incorporate generosity into higher-order social norms of indirect reciprocity, we consider a well-mixed population of fixed size 14. The assessment rule prescribes how reputations are updated, based on the observed actions and the possible context of an interaction. The action rule governs a player’s behavior when it is their turn to decide whether to confer a benefit to a co-player. Following Ohtsuki and Iwasa26, we assume that reputations are binary (good or bad), and social norms are at most third order. To allow for generosity, we consider modified versions of the deterministic leading eight social norms L1–L8  makes no distinction between a player who cooperates with a bad recipient and a player who defects with a good recipient. In both cases, the observer generously assigns a good reputation with probability We note that our framework makes two assumptions about the stochasticity we introduce. For one, players are only forgiving, but not spiteful: players never defect when the original leading eight rule prescribes cooperation, and they never assign a bad reputation to a player they are supposed to regard as good. This means that only when the original norm prescribes a negative assessment or defection, there is a probability to positively assess  is updated. The updated image matrix depends on which players are chosen to be the donor and the recipient, on the donor’s action, on who observes the interaction, and on the social norms applied by the observers. For example, if an individual j is regarded as good by all players, but j defects against some other good individual, then some of the entries of the image matrix may change from In the following, we first explore each kind of generosity in isolation. We start by considering the effects of assessment generosity. To this end, we first take the players’ norms as given. Different players may adopt different norms, but each player’s social norm is fixed in time. We can then describe how the players’ reputations change over time with a so-called image matrixALLC, ALLD. Here, ALLC is the  social norm that assigns a good reputation to all behaviors, and that prescribes to cooperate with everyone. Similarly, ALLD is the norm that uniformly assigns bad reputations and that always prescribes to defect. We consider four scenarios, depending on whether or not information is noisy, and depending on whether or not ALLD opponent as good despite their constant defection. Similarly, 36. It is exactly this excess in bad assessments that generosity might help to reduce.Let us illustrate the concept of image matrices with an example. To this end, we consider a population that in equal proportions applies one of the social norms entclass1pt{minimaentclass1pt{minimaALLD opponents (i) With and without errors, generosity reduces the likelihood that members of the ii) With and without errors, generosity increases the likelihood that Surprisingly, we find that assessment generosity rather has the opposite effect. It further increases the mismatch between the players’ social norms and their reputations  Generous players provide help to the defector  They assign bad reputations to fellow To gain some intuition for these results, Fig. ALLC, and ALLD, and we compare the outcomes with and without errors, and with and without action generosity .In a similar way, we can also explore the isolated effects of action generosity. To this end, we again consider populations that consist in equal proportions of ity Fig. a. In conALLD player . For all details, see “Methods”.To describe how successful social norms spread in a population, we consider a simple imitation dynamics based on pairwise comparison36. Overall, ALLC, and 65.8% for ALLD. While ALLC. Overall, the dynamics is similar to a rock-paper-scissors cycle: ALLC mutants are favored to invade into ALLD is favored to invade into ALLC, and ALLD in turn. However, due to the relative robustness of ALLD, players only cooperate in a minority of cases. Adding a moderate amount of either assessment generosity , and substantially negative in the case of assessment generosity (where the share of defectors increases to 78.6%). For the given parameter values, we thus conclude that neither form of generosity favors the evolution of the social norm Figure ALLC and ALLD compete with the alternative norm ALLC to ALLD and back to ALLC; but on the other hand, it also reduces ALLD. However, for This conclusion, however, can change for other leading eight social norms. To illustrate this point, Fig. i) In the presence of noise, almost all of the leading eight norms have problems to evolve, irrespective of how generous they are. The only social norm that is able to reach an abundance of more than 50% is 36). However, this social norm is most successful without generosity, when ii) In those cases in which the leading eight norm is played by a sizable fraction of the population , which is updated in every step of the dynamics. An entry i regards player j as good (bad), respectively. In the following, we always start with all entries b to the recipient at own cost c. Her action is dependent on her norm as well as the reputation she assigns to herself and the recipient. This action is observed by her co-players with individual probability q. This observation is subject to misperception with probability T rounds in total, the average image that player i’s assigns to player j is defined as We first describe how the reputations of players change over time. To this end, we assume social norms to be fixed for each individual. We record the reputations that players assign to one another in one image matrix entclass1pt{minima25. In their definition, the terms “good” and “bad” already have some intrinsic meaning. Here, “good” is considered to mean the reputation label that, according to the leading eight’s action rule, makes it more likely for the respective player to receive cooperation. In our model, players thus unambiguously prefer to be labeled as “good”. In that case, assessment generosity is straightforward to define. It means that players are more likely to assign good reputation to their peers.We want to point out that in general, “good” and “bad” are merely labels with no inherent meanings. In particular, for each of the leading eight strategies, one could also define “mirror strategies”. According to these mirror strategies, acceptable behavior would be rewarded with a “bad” reputation, and players would be more likely to cooperate with “bad” individuals. If we are also to allow for such mirror strategies, it might be less clear how “assessment generosity” should be defined. After all, for the mirrors, assessment generosity should imply that forgiveness makes it more likely that players now assign a “bad” reputation to the respective player. However, in this study, we are only concerned with the leading eight strategies as defined by Ohtsuki and IwasaAs one of our results, we show that action generosity may be more conducive to the evolution of cooperation than assessment generosity. This may appear unsurprising, because action generosity immediately affects cooperation. In case of action generosity, each instance of generosity directly translates into an act of cooperation. In contrast, in the case of assessment generosity, each instance of generosity only affects the respective player’s reputation. Whether this improved reputation translates into more received cooperation depends on the player’s further interactions. However, for many of the presented results, we actually do not explore the impact of generosity on the eventual cooperation rate. Rather, we explore how easily generosity can induce disagreements between leading eight players Figs.  and 3, oWe also emphasize that our analysis technique is not limited to the restricted setup where only three social norms compete. The approach can be naturally extended by allowing population members to choose among additional norms. However, computational complexity increases rapidly in the number of considered social norms. Also, our results show that already when competing with only these two very simple other strategies, the leading eight norms are unstable. Thus, adding further social norms is unlikely to increase the stability of the leading eight norms and similarly unlikely to affect our conclusions.45. According to this process, in every evolutionary time step, one player is randomly chosen from the population. With probability ALLC, and ALLD. Meanwhile, with s is called the strength of selection. When s is small, imitation occurs largely at random. For larger s, however, players are most likely to imitate those role models with a higher payoff.In a next step, we explore which social norms the individuals themselves choose to adopt when their norms are no longer fixed. To describe this process formally, we assume players change their norms over a separate, longer time scale. On this longer time scale, we assume individuals adopt new social norms based on a pairwise comparison processmentclass2pt{minim46. Thus, the results would not change.We note that in evolutionary game theory, imitation processes are often used as a standard model to describe the spread of strategies in a population. For this model to be sensible, it is necessary to assume however that players are able to infer their co-players’ strategies from their observed behaviors. This is straightforward for simple games, where strategies correspond to the action that a player chooses. It is less straightforward in games of indirect reciprocity. Here, individuals use more complex norms that are more difficult to learn by imitation. However, it may still be argued that players may be able to learn each other’s norms. For example, it is not unusual to assume that people discuss their world views and moral guidelines with others. This is what we implicitly assume for this study. Instead of imitation, one could also consider an alternative model by assuming that social norms spread through a birth-death process, i.e. that parents pass on their own social norms to their children. However, for the function we use to model imitation, the imitation process is equivalent to a birth-death process with exponential fitness mappingM into a resident population with social norm R explicitly as64M) and residents (R) when k individuals in the population employ the mutant norm. This means that we can describe the evolution of the social norms between three available norms in the rare mutation limit as a Markov chain with three states. These three states correspond to the respective homogeneous populations, i.e. all players using ALLC, all using ALLD or all players using a leading eight norm. Given the pairwise fixation probabilities according to Eq. 50. Given this equilibrium, we can compute how often players cooperate on average by taking the average cooperation rate of each homogeneous population, and multiplying it by how often we are to observe the respective homogeneous population in equilibrium.This evolutionary process based on mutations and imitation is ergodic. Hence, it gives rise to a unique stationary distribution, which we refer to as the selection-mutation equilibrium. This equilibrium reflects how often each of the available social norms is adopted over time. In this work, we use the limit of rare mutations, which assumes that populations are homogeneous most of the time. When a mutation arises, it either fixes in the population or goes extinct before the next mutant appears. We can calculate this fixation probability of a mutant with social norm ALLC, and ALLD players. Payoffs are computed with Eq. We use this approach in Fig. mentclass2pt{minimALLD, 1/3 uses ALLC, and 1/3 uses a leading eight norm. We consider the cases of a,b) and c,d). We additionally differentiate between four parameter setups. For these setups we first distinguish whether information is perfect or noisy  and action (x-axis) generosity in steps of 0.05 between 0 and 0.5. To visualize the impact of action generosity on the three norms a, b, g.In Fig. b , noise q. We again compare a, the baseline without generosity (b), assessment generosity only (c), action generosity only (d), both kinds of generosity , action generosity only with b), and symmetric generosity, with c). Methods employed are as in the previous evolutionary figures Fig. Figure For Fig. Supplementary Information 1.


Researchers often stress the necessity and challenge of integrating the positionings of residents, family members and nurses in order to realize each actor's involvement in long‐term dementia care. Yet most studies approach user and family involvement separately.To explain how productive involvement in care provision is accomplished in triadic relationships between residents, family members and nurses.An ethnographic study of identity work, conducted between 2014 and 2016 in a Dutch nursing home.We identify four ideal‐typical identity positionings performed by nurses through daily activities. The findings reveal how their identity positionings were inseparable from those of the residents and family members as they formed triads. Congruent, or ‘matching’, identity positionings set the stage for productive involvement. Our systematic analysis of participants' identity work shows how—through embedded rights and responsibilities—their positionings inherently shaped and formed the triadic types and degrees of involvement observed within these relationships.This study both unravels and juxtaposes the interrelatedness of, and differences between, the concepts of user and family involvement. Accordingly, our findings display how residents, family members and nurses—while continuously entangled in triadic relationships—can use their identity positionings to accomplish a variety of involvement activities. To mirror and optimize the implementation of user and family involvement, we propose a rights‐based and relational framework based on our findings.Conversations with and observations of residents; feedback session with the Clients' Council. When the users' identity, as reflected in their life history and preferences, is taken as a starting point for good care,(p.1305) have recently called attention to ‘a gap [in scholarship] concerning how the care relationship between older patients, their relatives and nurses in triad encounters is established’.Previous research has analysed the meaning and experiences of actors' involvement,To understand the dynamics of their different positionings, we must understand what occurs when residents, family members and nurses meet and form a triadic relationship. Because their interactions—as manifested in care routines—shape involvement,2(p.21)Given a large body of work on rights‐based involvement that stresses the importance of roles and relationships in everyday encounters, we deemed a theoretical framework of situated interactional identity work to be particularly valuable. Indeed, people identify and enact their rights and responsibilities in care routines through their corresponding identities. In organizational settings, identity work implies that people do not passively undergo influences from others—for example, from management, their peers, competitors or clients—but rather they actively ‘work on’ their identities(p. 18) In other words, individuals not only position themselves, they are also positioned by others. In response, individuals may, for example, reaffirm their own positioning of the self,and competitive identities,In this paper, the term ‘identity positionings’ refers to the sayings and doings used by individuals as they mutually and reiteratively position themselves and others in order to enact who they are within situated interactions.Altogether, by focusing on situated and interactional dynamics, our conceptual framework helps further research on how involvement activities are accomplished through the triadic relationships of residents, family members and nurses as they interact during care practices and enact their setting‐specific identity positionings.3The implementation of a Dutch nursing home's ‘family participation policy’ prompted our ethnographic study on how identities and involvement are shaped in daily practice. We chose an ethnographic approach because it is commonly used to observe and trace the meanings and (inter)actions experienced by various actors in real time3.1Discussed in advance via written communication with the Ethical Review Commission of the university's faculty, all data have been processed according to the guidelines of the Dutch Central Commission on Research Involving Human Subjects for non‐medical research. The residence facility's management and ethical commission also gave their consent for this research and, on various occasions and through several channels, communicated the purpose of the research on an organizational level—for example, in their monthly newsletters for residents and family, in nurses' team meetings and in the Clients' Council. Moreover, before engaging in conversations with the fieldworker, both nurses and family members verbally consented to observation of themselves and the residents. The fieldworker also respected residents' expressions of welcoming or opposing her presence. To anonymize the data, all names in this article are pseudonyms.3.2Seen as a frontrunner in the implementation of their family participation policy, the gated, long‐term care facility was selected as an ‘atypical case’ of involvement, which amplified the processes of analytical interest.3.3Most data were collected between August 2014 and August 2016, encompassing 325 hours spent in the residence and almost 700 pages of fieldnotes. In the first 3 months, the fieldworker shadowedAs she collected data, the fieldworker questioned participants to avoid misinterpreting their sayings and doings3.4Our analytical procedure comprised an inductive, iterative process.Next, by ‘zooming in and out’ to compare the observed involvement activities to theoretical conceptualizations,4In this section, we describe the predominantly performed identity positionings of residents, family members and nurses. Our findings elaborate on these actors' productive triadic formations—each of which concerned a different type and degree of triadic involvement—and on how these actors divided their corresponding rights and responsibilities.4.1Because the positioning of one's self inherently implies the positioning of others, residents, family members and nurses inevitably came to form specific constellations or ‘triads’. In harmonious situations and interactions, the triads comprised matching identity positionings, which we define as the sayings and doings through which these parties mirrored, confirmed or reinforced each other's identity positionings. In this section, we describe the four triads we observed in relation to residents' and family members' most frequently occurring positionings vis‐à‐vis nurses.care recipients by screaming, crying, moaning or grimacing in pain, for example: ‘It's so cold in here!’ (Mrs Biddle); and, ‘Nurse! Where are my pills?’ (Mrs David). Such interactions forced nurses to take on their role of care expert. At times, we heard residents invoke their family members as experts of experience on their behalf: ‘I don't know which medicines I take, ask my son’. Second, many residents expressed feeling like vulnerable persons: ‘It's better that I'm here, you know. I'm better than most here, but sometimes I get confused. Then I do funny stuff. [My daughter] didn't know what to do. She cried’ (Mrs Logan). This quote illustrates residents' recognition of their family as care recipients who need nurses' shoulders for socio‐emotional support and to take over caretaking tasks. Third, residents positioned themselves as homeowners, for example: ‘This is my home now, I'm grateful. I have a roof over my head, a nice bedroom, I eat until I'm full. My family comes to visit me here’ . Likewise, residents searched for social companionship from their nurses and family members, for example, by chatting, winking or adopting a social role: ‘I'm the joker of the house!’ (Mrs Little). Fourth, residents also sometimes acted like relinquishers when they did not mind waiting or adjusting to the rhythm of nurses (and sometimes their helping family) as they organized things, for example: ‘Dinner will be ready soon – first [the nurse] has other things to do”; and, “My daughter is cleaning my room, I'll wait for her here’.First, residents acted like experts of experience, were able to augment nurses' care expertise thanks to their knowledge of residents' character traits, preferences, habits, and prior life and care experiences. ‘She used to get locked up in the broom closet as a kid. The nurses didn't understand why she was screaming every night, so I told them. Now they leave her bedroom door open!’ (Julie). Second, family members would position themselves as extended care recipients, leaving the nurses to look after the vulnerable older persons, and seeking nurses' compassion; hence our identification of nurses' positioning as shoulders. As one granddaughter explained: ‘My mom took care of my grandma when she still lived at home, but she doesn't come here. She can't bear to see her mother this way! She's relieved that the nurses are taking care of her now’. Third, family members also often related to the residents as companions while viewing the nurses as socializers, for example: ‘Mom and I just watch TV or have coffee. Today I baked a cake. There's a piece for everyone. [Nurse] Alice, will you grab some plates? Let's make it nice in here!’ (Holly). Fourth, family members also behaved as the busy nurses' helpers who felt impelled to organize housekeeping: ‘I always do the laundry, that's one less thing for the nurses to do’!Family members, who—first—also considered themselves to be care recipients, nurses—first and foremost—positioned themselves as care experts who fostered intimate relationships and provided personal attention in order to both get to know each resident and to handle disruptive or delicate situations, for example, bathroom needs or public undressing. As such, and by gathering information from family, nurses conceived family as experts by experience, for example: ‘Mrs Costa's son told me she's not a morning person so, before bringing her into the living room, I always gently open the curtains and give her breakfast in bed or sit down with her and chat a little’ (nurse Chloe). Second, nurses would serve as compassionate shoulders to lean and cry on for the family of vulnerable persons, who were viewed as extended care recipients: ‘You know, most of them just went through a heavy process of losing their loved one as they knew them, who they already gave as much care as they could’ (nurse Jaimè). Third, nurses also acted like socializers by greeting, making conversation, joking and focusing on social activities: ‘Sometimes I put on some music or the TV, or paint their nails; they enjoy that’ (nurse Abigail). Likewise, nurses often included family members, for example, by playing a game or dining together: ‘You're all part of the family, because this is [the residents'] home now and you're all together so much’ (nurse Bob). In this manner, nurses positioned the residents as homeowners and their visiting family as their companions. Finally, nurses often positioned themselves as organizers, which meant formulating and sharing information about residents with colleagues, as well as organizing the household : ‘It's my job to provide a safe and clean environment’ (nurse Olivia). For this purpose, nurses expected family to act as helpers and residents as relinquishers to their work routines.By framing residents as In short, by positioning themselves, each party also positioned the others, either explicitly or implicitly. Consequently, the residents, family members and nurses formed triads. Figure 4.2A rights‐based approach, on which our analysis is based, grounds the involvement activities we observed in the rights and responsibilities of all actors. By identifying whose and which rights and responsibilities were embedded in each of the four observed triads of identity positionings, this section places the underlying types and degrees of triadic involvement on a continuum from mostly cooperative (ie contributions resulting from either non‐action or others' initiatives) to mostly operational (ie contributions resulting from self‐initiation).4.2.1perceived user involvement—a term we suggest to mean the hearing and voicing of residents' care perspectives based on the caregiver's own sensory observations and inquiries regarding the residents' preferences, needs and intentions . In order to accomplish perceived user involvement, nurses also invoked the support of family. Because nurses did not expect the residents and their families to take responsibility for acting or speaking up, their degree of involvement is described as cooperative.The right of residents to receive professional, tailored care: this focus motivated nurses to learn and execute the residents' care preferences and needs—for example, by preparing their favourite foods, bringing them to bed at the time of their preference or helping them get dressed in a specific way. Nurses felt responsible, explaining: ‘You have to really understand the person. They often can't just tell you. You have to put yourself in their shoes and think: what do they want? Why do they do what they do?’ (nurse Graciela). Nurses also welcomed insights from family members, who were seen as experts of residents' past preferences, habits and care needs: ‘When family members join for dinner, we learn more about the residents and their past. That really helps us understand them better’. The families echoed this sentiment: ‘We create “life‐story books” so the nurses can learn who they are and what they want’. In other words, nurses aimed to enact 4.2.2perceived family involvement—that is, the hearing and voicing of family's views on both their own willingness to be involved and the residents' personal circumstances and care experiences—was a central focus that cooperatively involved residents and family alike.The right of family members to be supported in dealing with the disabling condition of their loved ones: this imperative was underlined by both the nurses and the residents. Residents often considered their family's best interest more important than their own vulnerabilities. They effaced themselves to enable support for their family, for example: ‘I wanted to stay home, I really did. But my daughter cried. I don't want her to cry anymore. It's better this way' (Mrs Logan). Nurses took responsibility for care tasks, claiming it was too much for the family: ‘[Family members] don't bring their loved ones here for no reason. Now it's our turn’ (nurse Phil). Family members also emphasized the responsibility of ‘paid professionals’: ‘Because of you, we can breathe. I used to cry and cry all day long, but now I see my dad's okay. For the first time just now, he said he was home. He meant this is his home. That really helps me’ (Heather). As these quotes illustrate, 4.2.3social user and family involvement of residents can be seen as cooperative, and that of family and nurses as operational.The right of residents and their family members to feel socially valuable and included in the home: this, nurses expressed, was also their responsibility. This was made evident by their continuous efforts to socially engage: ‘Mrs Alden [a resident] always helps me set the table. I like to sit down and eat with the residents (…). It's like back in the day in my dormitory, friends are always walking in and out’ (nurse Henry). Likewise, family members often volunteered to share the responsibility of encouraging residents and each other to participate in social activities: ‘[Nurse] Otto is always so good at making things fun, he's just great! For example, he started organizing theme dinners. Then others took his lead and we [as relatives] are now arranging dinners ourselves’ (Lilli). Residents also made themselves useful, but were not seen as responsible: ‘After dinner I always clear the table. But first I'll sit down. This is my seat, next to Mrs Penny, because it's my job to help her eat’ (Mrs Draper). This right implicates the entwinement of user and family involvement as nurses aimed to engage both residents and their family members, and family members sought to engage residents and other family. Because nurses and family members shared in this responsibility, but residents' efforts were seen as optional, the 4.2.4instrumental family involvement—which, accordingly, implied family's operational and, again, residents' cooperative involvement.The right of nurses to be recognized for and supported in their workload. Residents often confirmed that nurses were busy: ‘I think the nurse is with Mrs Patrick, in the bathroom. I don't want to bother her, she has enough to worry about. I'm doing just fine, enjoying my tea’ (Mrs Steven). Similarly, nurses claimed that family members were also partly responsible for providing instrumental care, viewing them as a source of hands‐on assistance: ‘When [a family member] is here and I know everything is getting done, then I can use my time to tuck [residents] in after dinner. It's the only one‐on‐one time we have!’ (nurse Marijke). Family members also displayed a feeling of responsibility, especially regarding housekeeping: ‘Just tell me what needs to be done, I'm here to help. I can cook, but last time you preferred me to change the bed sheets’ (Kaitlyn). This type of involvement entails the instrumental assistance of nurses by family members. To unburden family and nursing staff, residents would sometimes refrain from asking for help, which enabled In sum, each party's triadic identity positioning determined the applicable rights and responsibilities of residents, family and nurses, which then shaped their types and degrees of involvement  involvement of each party.First, since partnership‐building efforts with residents and family simultaneously develop and affect all parties, our findings demonstrate that separately approaching user and family involvement is insufficient. Indeed, to ensure perceived and social user involvement, nurses involve family through advocacy, social inclusion and validation. Reflecting the reciprocal nature of family involvement, we also observed—in cases of perceived and social family involvement—residents' effacement of their own needs in favour of their family's interests. Similarly, by supporting and welcoming their presence, family felt encouraged to accomplish both user and family involvement: family members' efforts helped nurses create more opportunities to better support residents, for example, by freeing up time for them to give each resident more personal attention. In this sense, user and family involvement formed two sides of the same coin—a finding supported by similar studies.Second, our framework helps unravel the differences between user and family involvement in a triadic context. Johnsson et al(p. 267‐277) distinction between the indirect involvement of service users, for example, by informing caregivers of their preferences, and their direct involvement, for example, by taking part in actual decision‐making. In the context of this paper, we considered ‘actual decision‐making’ as it applied to everyday issues, such as breakfast, schedules or music preferences. Indeed, our findings indicate that the nature of involvement in long‐term dementia care concerns small, direct and personal gestures rather than big, overarching activities.These findings respond to calls for research on the scope, extent and nature of user and family involvementOften citing Arnstein's6Our study has aimed to explain productive user and family involvement by developing a framework that captures actors' identity positionings in triads. Consequently, our study does not contain an exhaustive overview, but rather an in‐depth look at the prototypical identities enacted within a residential care facility. According to our field observations, participants in this study did not necessarily engage in each triad . Also, within each category of actors, different persons preferred different identity positionings . These positionings sometimes overlapped (eg when family offered help by assisting residents during family dinners). Instead of comprehensively elaborating on the characteristics and preferences of each identity positioning as researchers have already done extensively, we focused on the consequences of each positioning in terms of its types and degrees of involvement in a triadic context.Moreover, not all situated interactions proved harmonious. While we have elsewhere analysed how tensions arise as a result of incongruent triadic identity positionings, such interactions were beyond the scope of this paper. Given the complex power inequalities that emerge in the identity work of residents versus family and nurses, we hope that future research will further explore both the implications of identity work and power in the context of people with dementia, and how the involved actors negotiate and achieve shared solutions. Indeed, we acknowledge that there is a fine line to walk—between over‐estimation and under‐stimulation—when it comes to safeguarding the ability of people with dementia to meaningfully partake in involvement.Furthermore, and in contrast to most care settings, nursing homes for people with dementia require relatively long‐standing and interdependent relationships. Actors' identity positionings may therefore evolve over time and as the conditions of the residents, family, nurses and/or the care organization change. Whereas we primarily shadowed nurses, future research may want to focus more on the changing networks around such residents and their family members.7Our framework contributes to a better understanding of triadic and interdependent relationships, which may also be applicable to other long‐term care services, for example, those for people with chronic physical disabilities, psychiatric conditions or child care. More specifically, our framework may help both researchers and practitioners examine which identity positionings influence the legitimacy and acceptance of triadic involvement and through which embedded rights and responsibilities. As was done in the residence facility we studied, training and counselling programmes for nurses and family may then be developed to address specific complex situated interactions. To compile a diversified team, managers may choose to profile and recruit nurses according to their competencies vis‐à‐vis different types and degrees of involvement.In order to facilitate destigmatized, equal and inclusive involvement in the context of long‐term dementia care, our findings suggest that researchers and practitioners must reframe the concept and practice of triadic involvement as a dynamic, relational micro‐endeavour: through a lens of identity work and with a focus on amplified opportunities for, and contributions from, people with dementia together with family and nurses. Involvement in dementia care, in sum, is a large concept practised through small, subtle and situated (inter)actions.The authors declare that there is no conflict of interest.All data were collected by the first author. Both authors have made substantial contributions to the present study's conception, data analysis and interpretation. The first author drafted the manuscript and both authors revised it critically for important intellectual content. Both authors have approved the final version to be published and agreed to be accountable for all aspects of the work.All data have been processed according to the guidelines of the Dutch national Central Commission on Research Involving Human Subjects (CCMO) for non‐medical research (WMO) and based on written communication with the Ethical Review Commission of the university's faculty. The residence facility's management and ethical commission gave their consent for this research and, various times and through several channels, communicated the purpose of the research on an organizational level for example, in their monthly newsletters for residents and family, in nurses' team meetings and in the Clients' Council. Moreover, before engaging in conversations with the fieldworker, participants gave their oral consent. To anonymize the data, all names used in this article are pseudonyms.


Internationally, mental health service developments are increasingly informed by the principles of recovery, and the availability of arts and creative activities are becoming more common as part of provision. Mental health service users’ experiences, reflecting on the complex nature of using music participation in recovery are, however, limited. This essay considers literature that explores how music can support mental health service users in a recovery process. We have selected studies that include a broad spectrum of music activities, as well as literature considering various concepts about recovery. The conceptual recovery framework CHIME, that includes five important components in the recovery process, is used as the backdrop for exploring music activities as a contribution to recovery-oriented practice and services in mental health care. Eleven key components are identified in which music can support the recovery process: Feelings of equality; Social and emotional wellbeing; Tolerance; Hope and social agency; Triggering encounters; Redefining and reframing; A social practice; Moments of flow and peak experiences; Moments of meaning; Continuity; and Potentials instead of limitations. This essay concludes that the experiential knowledge of music activities from service users’ perspectives is essential knowledge when developing and using music activities in mental health recovery services. While this essay acknowledges that music activities can also produce unintended negative outcomes, the focus is on the positive contributions of music to mental health recovery processes. There is an increase in research that explores the potential benefits of music, participation in music activities, and music therapy ,2,3 in mWe all experience music in unique ways , which mThe scope of different approaches to music activities is broad; however, within this essay we do not distinguish between these approaches but focus on the service users’ experiences with music activities. We consider music activities to include active music making , music medicine  , as wellWithin the field of music therapy, we see an increasing amount of research about clinical effects, different client populations ,10,11,12This is important in documenting the use of music therapy as an effective clinical treatment in mental health service provision. However, according to McCaffrey and Solli ,16, a onWe understand that there are also negative effects of music, including unhealthy psychological habits such as ‘rumination’ or overindulgence in ‘nostalgia’ or attraction to “(sad) music as manifestations of maladaptive mood regulation strategies”  (p. 147)This essay aims to provide an insight into research, based on experiential knowledge of music activities and service users’ perspectives and relating to a variety of mental health disorders—we are not considering details of how the various activities are most appropriate for individual diagnosis. Furthermore, the essay will consider how the findings can strengthen or support existing understanding of practices in mental health services. We will introduce “personal and social recovery” as a user-oriented perspective on mental illness and mental health care. To emphasize the focus on personal and social recovery processes, the CHIME framework developed by Leamy and colleagues will be applied . The fraWHO defines mental health as “A state of well-being in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community” . AccordiIn the context of civil rights and independent living movements, the concept of recovery was developed in the 1960s and the 1970s. This was a response to a history of expert-led treatment of mental illness that had led to stigmatization and deindividuation . From th“A deeply personal, unique process of changing one’s attitudes, values, feelings, goals, skills and/or roles. It is a way of living a satisfying, hopeful, and contributing life even with limitations caused by the illness. Recovery involves the development of new meaning and purpose in one’s life as one grows beyond the catastrophic effects of mental illness. Recovery from mental illness involves much more than recovery from the illness itself.”  (p. 15).The definition by Anthony describes properties of personal recovery and is focused on the personal and distinctive process of learning to live with continuing challenges and to be able to control difficulties as they surface . In EnglPersonal and social understanding of how people with mental health problems experience processes of recovery is vital in developing recovery-oriented mental health practices ,37,38. AWhile the mental health recovery approach has gained momentum over the past decade and is providing standard models of mental health care in some parts of the world and while governments support recovery as a principle, implementation processes are still ongoing. A review of mental health recovery programs in various countries concluded that, although there seemed to be an acceptance of recovery being an important domain in health care, it is still a work in progress that requires sustained resources and commitment .An underlying context for the development of the recovery perspective is that “general expectations of clinical recovery from severe mental illnesses have traditionally been pessimistic and progressive deterioration has mostly been the expected outcome”   project in Norfolk, UK, . A commuHope and optimism—see An evaluating study by McCaffrey and colleagues showed some personal challenges posed in music activities . ParticiIn a meta-synthesis of service users’ experience, a combination of hope, joy, and social participation appears in numerous studies about music and mental health recovery . As an eThe concept of ‘musical recovery’ represents a process of regaining healthy relationships based on music promotion ,16. HoweThe relationship between music activities and recovery has also been identified in McFerran’s study , suggestIdentity—see The use of music to intensify or ruminate about existing thoughts and feelings has been explored by Garrido and Schubert  arguing Meaning—see “Understanding, redefining and accepting self; incorporating illness; and overcoming stigma are some of the essential building blocks of recovery”  (p. 113)Over a period of many years, mental health recovery has been understood as a unique and personal process , meaningIn a qualitative study, participants described moments of sharpened focus, and experiences of the outside world that “seemed to fade away and nothing other than being in a creative process seemed to matter”  (p. 10).“Participating in music and theatre workshops made lives of service users’ with long-term mental illness more meaningful”  (p. 7). “Yeah, especially for the first few years, the music and theater workshop held me up. It was the only thing I could do except from lying in bed unable to do anything […] I remember it lifting me up, lifting me up from Wednesday to Wednesday, and then to more and more practices. Then I remember how I finally got out of the mud. It lifted me out of my depression through the hours I spent practicing every week”.Empowerment—see Participating in the music and theatre workshop offered the participants a central point in their everyday lives. This is coherent with findings from Borg and Davidson’s study , where pHaving control over one’s life, focusing on strengths, and employing personal responsibility are three crucial aspects of personal recovery. According to Davidson and colleagues, it is important to be included in activities that are experienced as empowering and meaningful , even ifA study  focusingA qualitative study found that completing and managing challenging tasks created a possibility for creative growth. The participants were considered to be musicians and actors, rather than people living with mental health illnesses—even if the material in the workshops  was based on narratives from living with mental health problems.According to Ørjasæter and colleagues , interacSlade  characteWithin the structure of the conceptual framework CHIME, we have identified important aspects and key components of music activities in recovery processes based on perspectives of mental health service users—see We now discuss the findings, inspired by McCaffrey and colleagues’ four central ways of empowering the contribution to recovery-oriented practice and services in mental health care . The fouexpertise by experience. It is all-important to regard service users as experts because of their experience. An important understanding in mental health recovery is that service users gain expertise by living with mental illness [First, it is crucial to recognize and respect  illness . This pe illness . This fupersonally defined recovery, where “individuals are supported to define their own needs, goals, dreams, and plans for the future to shape the content of care” [Second, recovery-oriented practice acknowledges of care”  .ipation” . From thipation” ,114. We ipation” ,83.There are, however, and according to Slade, structural challenging conditions for promoting personal and social recovery . StandarThis essay has presented literature exploring how music activities can support mental health and recovery processes, seen from service users’ perspectives. Engagement in music activities has the potential to promote interpersonal communication. Music can initiate a spiral of positive processes such as feelings of hope and being connected that can promote personal and social agency, wellbeing, and mental health recovery. We propose that to maximize support for recovery, a focus on social participation, inclusion, and participation in music activities can help develop positive relationships with others, expand social networks, support personal recovery, and strengthen social participation as well as create positive, joyful experiences.


Instructors can deliberately design for equity, diversity, and inclusion, including for large first‐year classes, and now instructors have added challenges given COVID‐19. Our paper explores the question: How do we integrate equity, diversity, and inclusion and universal design for learning (UDL) into first‐year, undergraduate ecology and evolution introductory lessons given the COVID‐19 pandemic? Given the large field exploring equity, diversity, and inclusion, we chose to focus on developing reflective practice question rubrics for before, during, and after lessons to encourage UDL for instructors, teaching assistants, and learners. We conducted a focus group within our team and discussed ideas related to online learning, including related pitfalls and solutions. Lastly, we created a figure to illustrate ideas and end with a general discussion. Our reflective practice questions for UDL rubrics, figure, focus group, and discussion aim to increase positive action for equity, diversity, and inclusion in the classroom and beyond. The premise of this article, which is a response to a special issue call, “Taking learning online in ecology and evolution," is to promote equity, diversity, and inclusion for large first‐year ecology and evolution lessons. This article provides citations and ideas as well as before, during, and after reflective questions rubrics for universal design for learning, a conceptual figure, and focus group relevant for during the COVID‐19 pandemic. Many ideas provided, however, will be useful after the pandemic is over. This is an iterative process that fosters an environment where everyone involved in the class is impacted by internal and external situational factors, and in which reflective practice questions and UDL can help make the class more equitable, diverse, and inclusive Figure . The rubGiven STEM culture, which is still not fully inclusive, STEM education includes some learners while excluding other learners, reducing equity, diversity, and inclusion , a crucial thing to keep in mind before, during, and after lessons is to be flexible and creative, as there will be no one size fits all; it is key to foster a patient and kind culture, especially given all the COVID‐19 disruptions and changes. Some instructors for spring, summer, and fall 2020 have been forced to re‐write their lesson plans to make them deliverable online; and it is unclear what disruptions might arise due to COVID‐19 even into 2021. Field and laboratory components of ecology and evolution courses are being canceled, deferred, or greatly modified (as they are for research). Furthermore, there are often issues with time and space for instruction; international students, and instructors may be living in different time zones. Being aware and helpful for asynchronous learning is key to many post‐secondary classrooms to accommodate different time zones, which can be complicated.In spite of teaching and learning being complex and difficult at this time, it is still crucial to incorporate equity, diversity, and inclusion into lessons even with pandemic restrictions. At this time, some institutions will have instruction completely online and others might be blended (online and offline), which will impact how content is taught and learned. While it is difficult (and maybe even contradictory) to unilaterally decide, what an inclusive classroom will look like in first‐year science, biology, or more specifically in ecology and evolution lessons, being thoughtful and reflective and incorporating UDL can help alleviate issues that can arise.3.1for UDL action). To motivate and engage , learners can be encouraged to be proactive in written or other forms of feedback online. This is their learning journey! Before lesson planning and suggestions can be gathered in multiple ways, including an anonymous online survey or written prompt, to help inform instruction. Planning ahead and being flexible given uncertainty will be common ways to cope during COVID‐19. Instructors can create a culture that fosters learner constructive feedback about what students find helpful or would want to try. Check‐in questions can help with better integration of the types of lived experiences of learners regarding what they want to learn and how they prefer to learn it. Instructors can ask learners via online polls before the lesson preferred presentation methods (give options).Table For those instructors who enjoy being outside‐the‐box, they can be creative and think about ways to incorporate STEAM (STEM + the Arts) to foster creative, well‐rounded learners and budding scientists  can help the instructor(s) in monitoring and collecting pre‐quiz and pre‐survey data to gather important information on how learners feel about potential representations. For example, a pre‐reading quiz and pre‐class interest survey, both for participation marks, might show that learners are struggling to understand the importance and basic concepts around population dynamics of plants in an alpine meadow (from quiz) and may want to more, given interest (from survey), bridging to health, and environmental sustainability. In which case, the TAs could use their computer and data science skills to summarize that data from these learners to use for a brainstorming session in a TA meeting with the instructor; during that meeting, they could use concepts from the scientific literature to create a small exercise on population dynamics (using the same concepts as for the plants) of city‐dwelling rats to embed the difficult population dynamics material into health and sustainability in cities given overcrowding, the pandemic, and climate change.TAs can explore with the instructor(s) what is needed to support learners in active learning through a bridging discussion with learners; undergraduates are often more comfortable talking with other students, and TAs are often graduate students. If the before the lesson questions Table  are usedWhile ways to modify the before, during, and after lesson rubrics Tables , 2 and 33.2in UDL action). A more rewarding during lesson experience can use information from the before lesson check‐ins  and can benefit from extra scaffolding without COVID‐19, but given the pandemic and so much uncertainty could benefit from more. Earlier experiences suggest that the transition to university of first‐year learners from high school to university was bumpy in Australia early in the pandemic for example , and with the during rubric Table , it helpWith COVID‐19, even with planning, there will likely be much uncertainty during class, including unexpected issues such online platforms not working given an outage or learners, TAs, and/or instructors unexpectedly needing to take time to take care of loved ones. With the reflective questions, learners are given autonomy to provide feedback on their learning experience to the instructor(s) and TA(s) and also can self‐reflect on their learning process, including when unexpected events happen that derail learning in the lesson. Furthermore, mental health needs or other scenarios may need to be addressed unexpectedly, so it is important to support a flexible during the lesson learning environment. COVID‐19 has impacted the mental health of all ages, including university faculty, staff, and students (undergraduate and graduate) and is likely to have more impacts as the pandemic continues Sahu, .3.3of UDL action, Table After a lesson , and instructors should do reflection as part of a course in a helpful fashion, for example, as a main overall course learning objective, which can be modeled by the instructor in the beginning of term when discussing explicitly an equitable, diverse, and inclusive course environment. Learners and TAs can be engaged in creating a classroom community agreement in which learners, TAs, and instructors can explicitly discuss, agree, and write down explicitly ways to help people feel valued in the classroom and how to value others; learners are being assessed on course content, but it does help them to have explicit modeling by their TAs and instructor of equity, diversity, and inclusion practices. It also helps to have ways in a kind fashion to call in (privately discuss) and call out (publicly discuss) if equity, diversity, and inclusion are not being respected. Reflection is helpful for learners as it helps them become better at metacognition and other higher order problem solving; knowing what you know and do not know and also how to work well independently and with others are key skills inside and outside the classroom.Our focus group members thought that UDL with reflective practice online might be in some ways easier and some ways harder than in‐person delivery of large first‐year, ecology, and evolution lessons. For example, there are learners who prefer online learning, and even some learners who enjoy typing responses more than speaking, so they would have an easier time expressing their needs in response to reflective practice for UDL. However, different time zones (asynchronous classes) and lack of technology access for some learners could result in barriers. We think post‐secondary institutions should make it possible for learners to acquire the technological resources they need for free if they are in need. This is something above the course level, but will impact an ecology and evolution lesson online if not remedied. We also thought it important that learners, TAs, and instructors be positive and inclusive with respect to helping learners online who might need accommodations given disabilities or other specific learning needs. For example, it is important that websites and other online materials be accessible to screen readers for those with visual needs or learning disabilities. Some students with anxiety might find online assessment stressful and might need support advocating for what they need to best foster UDL. The key thing is to have an online classroom culture that promotes being reflective and includes everyone in that reflection, as if some people are not engaged it will be less effective, and to make sure people understand the three principles of UDL and have ways to properly integrate them, as things should be authentic! Also, check‐in with people as they should not be forced to reflect if they are not interested. Focus group members thought a way to acquire responses from people with limited effort would be to have quick poll questions that are acted upon right away by others. It is important that people see that their responses lead to action for people to feel that their engagement matters. Just as the principles of UDL promote multiple ways for engagement with course material and how it is presented and assessed, the check‐ins can use different types of methods . Our focus group with respect to online teaching in general had themes about what we thought works well and does not work well. The focus group members concluded the following given online learning: (a) Asynchronous instruction can help learners work with flexibility whenever they can wherever they are as long as they submit their quizzes, assignments, and examinations before the deadline. (b) Multiple representations that were effective have already been implemented (in spring 2020): lecture videos with text of the audio playing at the same time, smaller format audio‐only files, textbooks provided for download, and forums. (c) Forums can be helpful whereby instructors, TAs, and learners answer questions. For large courses, the instructor may not be able to answer all the questions, but for tutorials with a smaller group, for example, forums give a sense of community. (d) Online whiteboard instruction is more difficult because not everyone has a stylus.4Given equity, diversity, and inclusion are complex and big topics, we developed reflective practice questions in rubrics Tables , 2 and 3Authors had no conflicts of interest.Laura Super: Conceptualization (lead); Visualization (lead); Writing‐original draft (lead); Writing‐review & editing (lead). Analise Hofmann: Conceptualization (lead); Visualization ; Writing‐original draft (supporting); Writing‐review & editing . Connie Leung: Conceptualization ; Visualization (supporting); Writing‐original draft ; Writing‐review & editing . Mabel Ho: Conceptualization ; Visualization ; Writing‐original draft ; Writing‐review & editing (supporting). Emma Harrower: Conceptualization (supporting); Visualization ; Writing‐original draft (supporting); Writing‐review & editing (supporting). Najah Adreak: Conceptualization ; Writing‐original draft (supporting); Writing‐review & editing (supporting). Zohreh Rezaie Manesh: Conceptualization (supporting); Visualization (supporting); Writing‐original draft (supporting); Writing‐review & editing (supporting).