Throughout the years, care ethicists have raised concerns that prevalent definitions of empathy fail to adequately address the problem of otherness. They have proposed alternative conceptualizations of empathy that aim to acknowledge individual differences, help to extend care beyond one’s inner circle, and develop a critical awareness of biases and prejudices. We explore three such alternatives: Noddings’ concept of engrossment, Meyers’ account of broad empathy, and Baart’s concept of perspective-shifting. Based on these accounts, we explain that care ethics promotes a conceptualization of empathy that is radical in its commitment to engage otherness and that is characterized by being: (1) receptive and open, (2) broad and deep in scope, (3) relational and interactive, (4) mature and multifaceted, (5) critical and reflective, (6) disruptive and transformative. This type of empathy is both demanding and rewarding, as it may inspire health professionals to rethink empathy, its challenges, and its contribution to good care and as it may enrich empathy education and professional empathy practices in health care. This paper explores care ethics empathy, a distinctive form of empathy that is radical in its commitment to engage otherness and acknowledge individual differences between people. While empathy has traditionally been understood as a multidimensional concept that can have affective and cognitive aspects  attribute that involves an understanding (rather than feeling) of experiences, concerns, and perspectives of the patient, combined with a capacity to communicate this understanding, and an intention to help (p. 74).In health care, affective or emotional empathy is considered analogous to sympathy Hojat  and invoThe significance of empathy in health care is widely acknowledged throughout the field including but not limited to oncology, palliative care, general practitioner care, geriatrics, mental health care, and emergency care. In the emergency room, for example, empathy helps to establish so-called “emergency rapport”, a working alliance between the emergency physician and the patient  A relational anthropology as opposed to an anthropology based on autonomy; (2) A multidimensional, practice-based epistemology that values emotions and a variety of alternative knowledge sources, rather than being limited to reason; (3) A form of moral deliberation that values insights from multiple perspectives and that is primarily based on particularism and contextuality as opposed to being founded on universal, abstract, and general principles; (4) A sensitivity to power relations and the aim to include and give a voice to people who are dependent and socially excluded , an American mathematician, educationalist, and feminist philosopher, has been mentioned alongside Carol Gilligan as one of the “founding mothers” of care ethics . Noddings  illustraEventually, Noddings discarded the term engrossment as it was frequently confused with infatuation, and as more hybrid types of empathy were gaining ground in empathy theory Noddings , b. In rNoddings’ theory has been criticized for being “romantic” and politically naïve Koehn . In contWomen and Moral Theory (1987), which remains a classic in the field of care ethics (Sander-Staudt The American feminist philosopher Diana Meyers (*1947) co-edited the anthology best respond to you?” (p. 134). Empathic thought is the moral deliberation process that leads from empathic insight to moral decision-making. This type of moral thought or deliberation does not start from universal moral principles but rather springs from one’s moral identity. Moral subjects have their own moral ideals and sets of values, which they develop in relationships with others, based on mutual recognition and empathy. The fundamental question moral subjects ask themselves is: “Do you want to be the sort of person who would do such-and-such?” . Thus, it is grounded in a more complex relationship with others than incident-specific empathy. In Meyers’ theory of empathic thought, the paradigmatic moral relationship is that between acquaintances since “this personalized model explains the subtlety and complexity we ordinarily associate with moral choice and action” (p. 136). While more intimate relationships, such as friendships, may provide more opportunities for interaction, being acquainted is a solid foundation for broad empathy since acquaintances typically know each other, interact with each other, and matter to each other to at least some degree (p. 136).Broad empathy can help people reconsider their own values and moral identity, or even embrace new or different values and viewpoints, as “through empathy new constellations of needs, desires, beliefs, and values can be forged” Meyers , p. 38. Meyers  contendsThe importance of Meyers’ perspective on empathy lies in her distinction between incident-specific and broad empathy, her empathy-centered moral theory, and her focus on the problem of difference and prejudices in relation to empathy. Rather than drawing on self-focused perspective-taking, broad empathy is primarily other-focused. It aims to comprehend the other’s perspective through, ideally, extensive interactions with the other and thoughtful attention to the other’s life as a whole.Baart shares Meyers’ concern for vulnerable and socially excluded people, and for the harmful effects of biases and prejudices. While Meyers provides a primarily intellectual account, Baart takes an empirical approach that is grounded in everyday care practices. His concept of perspective-shifting provides a direct, primarily perception-based approach for engaging with others’ experiences.A theory of presence, which resulted from a seven-year grounded-theory study into the practices of pastoral ministers working in disadvantaged urban neighborhoods. Baart considers the presence theory to be a care ethics theory (Baart Andries Baart (*1952) is a Dutch empirical philosopher and care ethicist. In 2001 he published his foundational study, ry Baart . Among iry Baart .The presence theory was developed amidst a changing care and welfare sector in the Netherlands, where the language, mentality, and market system quickly became more dominant . Presence practitioners focus on making themselves available rather than problem-solving. One of the main goals of the exposure is to cultivate a lasting attitude and motivation to continuously practice perspective-shifting and to radically start from the client’s perspective  otherness and being prepared to be emotionally affected and changed by this encounter. This form of empathy may “shake up” one’s views and bring awareness to prejudices and biases. Being affected by the other’s experiences may generate concern and strengthen one’s commitment to care Noddings . EmpathyCare ethicists agree that empathy can have important moral caring functions. For example, they argue that empathy can motivate people to provide care, help to establish, maintain, and enrich caring relationships, and provide insight into what is morally at stake and needs to be addressed  theory, as such theories help explain how empathy or closely related phenomena can be guided and, if necessary, corrected Oxley . In thisSecond, moral theories clarify the process that leads from the empathic experience to good care or morally good behavior. In care ethics, empathy is not primarily guided by abstract principles or rules Koehn . The thrThird, additional practices and professional capacities further clarify the process of moving from empathy to moral actions or good care. For example, in Baart’s theory of presence, practical wisdom serves as a moral compass. To determine what “needs to be done”, caregivers try to understand what values are at stake for their client and reflect on what constitutes good care within the context of the larger good of the care practice of which they are a part . In the Netherlands, for example, the Presence Foundation has developed an exposure exercise that is part of an extensive teaching program in presence Baart . During Care ethics empathy can be defined as a multidimensional and relational form of empathy that is firmly grounded in open and receptive attention and that is radical in its commitment to engage otherness. It is an advanced or mature type of empathy that, preferably, focuses on the other’s life as a whole and strives to be physically present in the other’s lifeworld. The empathic engagement may disrupt caregivers’ reality, provoke critical reflection, and inspire them to reconsider their values and views, biases, and prejudices. Care ethics empathy may help discern clients’ unique needs and engage with their experiences on a deeper level. This radical form of empathy is both demanding and rewarding. It is our hope that care ethics empathy can help to enrich empathy education and inspire health professionals to rethink empathy, its challenges, and its significance to good care, and find encouragement and inspiration to engage otherness.


Low motor competence (MC) and inhibited psychosocial development are associated with mental health difficulties. Improving children’s MC through school-based physical activity interventions emphasising psychosocial development may therefore be a mechanism for promoting positive mental health. This study describes and provides reflective insights into the co-creation of ‘Move Well Feel Good’, a primary school physical activity intervention to improve children’s MC and mental health. Class teachers, school leaders, physical activity specialists, and children (aged 8–9 years) participated in a series of co-creation workshops. Stakeholders’ knowledge and experiences were integrated with existing research evidence using creative methods  to facilitate discussion. The co-creation process culminated in stakeholder consensus voting for one of three proposed intervention ideas. Children cited physical and mental health benefits, enjoyment with friends, and high perceived competence as motives for being physically active. Opportunities to develop MC across the different segments of the school day were identified by adult stakeholders, who perceived children’s lack of resilience, an overloaded curriculum, and poor parental support for physical activity as barriers to intervention implementation. The chosen intervention idea received six out of a possible twelve votes. Co-creation projects are specific to the contexts in which they are implemented. This study reinforces the complex nature of school-based intervention development and highlights the value of engaging with stakeholders in co-creation processes. Mental health difficulties amongst children are a leading cause of health-related issues worldwide . GloballThe COVID-19 lockdown restrictions also resulted in increases in children’s digital screen use and decreases in physical activity (PA), particularly for structured activities such as school PE lessons and sport participation ,16, whicThese inter-relationships between children’s MC, mental health, and their mediators are described in the Elaborated Environmental Stress Hypothesis (EESH), which posits that poor MC predisposes children to internalising mental health difficulties via interactions with environmental stressors such as low self-esteem, low social support, physical inactivity, and being overweight. These stressors can in turn be ‘buffered’ by social and personal resources such as peer and parental support and perceived competence . Butler School-based programmes can reach many children irrespective of family backgrounds, and thus may be a strong influence on children’s health and development . It is fThe MWFG primary school programme was co-created with school stakeholders in the West Lancashire region of northwest England between March and July 2022. The study received ethical approval from the Edge Hill University Science Research Ethics Committee (ETH2122-0062). Eligibility criteria for participating primary schools were (1) being situated in school postcode-linked English Indices of Multiple Deprivation deciles 1–3  , and (2)The co-creation research involved children, class teachers, school leaders, and PE specialists. Intervention co-creation was conducted through a 6-stage process facilitated by the research team. The stages aligned with the Double Diamond Design Approach (DDDA) by employing divergent and convergent thinking processes. These reflected how stakeholders discovered, defined, developed, and delivered solutions to the ‘problem’ of how to improve children’s MC and mental health, and how best to facilitate real-world implementation in school contexts . The DDDThe co-creation process was planned into four time-efficient workshops (between 60–180 min) to reduce the participation burden on stakeholders . Adult sSemi-structured interviews were conducted with selected teacher workshop participants to provide insight into the stakeholders’ perspectives of the co-creation process. Teachers were recruited based on their availability and interest to participate. A semi-structured interview guide was developed to ensure key topic areas were covered, while allowing for unanticipated responses. The interview questions were developed by the research team following their observations of the workshops. These questions were reflective of the stakeholders’ feedback, engagement, and enjoyment of the workshops  children across the five schools. Twelve adult stakeholders received the online presentation, and six completed the knowledge quiz prior to attending workshop 2.The children’s responses to the questions that they were asked regarding their PA preferences for inclusion in a new programme are presented in n = 17), running (n = 13), biking (n = 13), swimming (n = 11), basketball (n = 10), and tag (n = 8). The children’s motives for being physically active were physical and mental health benefits (“…because it (running) gets rid of energy. It helps you get to sleep easier” (Boy—School 5)), fun and enjoyment ” (Girl—School 3)), learning new skills (“To learn new skills” (Girl—School 1]), high perceived competence ), and social elements such as being with friends (“I enjoy ‘stuck in the mud’ because people work together” (Girl—School 3)). Elements of competition and winning were highlighted by a minority of children as a motive for being physically active ), although this was not common across all groups, whereby having fun was usually deemed more important ).Across the five schools, the children reported a variety of physical activities that they enjoyed participating in, including team sports, leisure activities, and active play. The most prevalent activities that the children reported enjoying were football (n = 10), ballet (n = 9), gymnastics (n = 7), football (n = 6), basketball (n = 6), and dancing (n = 3). Low perceived competence was the most prominent reason why children reported not enjoying an activity (“I don’t like swimming because I sink like a rock” (Boy—School 4)), alongside having a lack of understanding of the activity (“I do not enjoy rugby because I don’t know how to play it” (Girl—School 3)). An overview of the children’s PA preferences, reasons why, and examples of the completed worksheets is presented in The activities that children most frequently reported disliking were rugby It was apparent that these psychosocial challenges upon returning to school after the COVID-19 pandemic were central to the barriers that the adult stakeholder groups reported . These b“… they either see themselves as not being able to achieve as well as the known superstar which puts them off, or just an inability to be proud of somebody else and want to strive for that themselves”.School leaders believed a lack of parent/carer support and understanding of the importance of PE and PA was the most prominent barrier ). The PE specialists reported the most important barrier to be social influences of parents/carers and others ). This was manifested in children not having PE uniform for lessons, being self-conscious about their bodies, and not being interested in being active.The main task in workshop 3 was for the adult stakeholders to work together in their groups to create and develop their ideas for the MWFG programme, incorporating FMS and psychosocial skills. Prior to developing intervention ideas, feasibility and acceptability factors deemed essential for a prospective intervention programme were discussed. These are summarised in Two MSG were formed to draft and develop ideas for the MWFG programme. An example of one of the worksheets produced for this task is illustrated in Of the twelve stakeholders involved in the co-creation process, eleven engaged with the pre-recorded online presentation and the consensus vote. Group one’s idea received 1 vote, group two’s idea received 4 votes, and the hybrid idea 3, which had some researcher input, received 6 votes. Therefore, idea 3 was confirmed for feasibility implementation in participating schools in the following Autumn term. The components of the consensus MWFG programme are displayed in This study aimed to describe and provide reflective insights into the co-creation process used to create the MWFG programme, and to discuss the issues that this process generated. Several key learnings emerged relating to (1) stakeholders’ engagement and attendance, (2) stakeholders’ knowledge and competence, (3) time constraints, and (4) conflicting visions and motives. These are discussed below and, based on the lessons learned from our experiences, suggested recommendations for researchers planning to follow a similar process are presented at the end of each section.A lack of available time and the competing demands for teachers’ time accounted for observed engagement and attendance issues . Of the “I don’t think it’s ever going to be easy and you’re never going to nail the perfect way of working with primary schools in times like the summer term, because you’re always going to run into those pressure points where primary schools are being pulled in different directions to do different things at that point in the year”.Stakeholder discussions highlighted how the timing of the co-creation process presented its own challenges for teachers’ engagement and attendance. Due to inflexible project timelines and the time restrictions surrounding the research process , the co-“It’s hard because if you want anything to roll out successfully from the autumn term you have to do it in the summer term but trying to get people to engage in the summer term…there’s never a good time, there’s never a good time”.It is clear that there is never an optimal time to collaborate with primary schools, and every school term will bring about its own challenges, particularly in participatory research which can be time-consuming for teachers. The competing priorities for teachers’ time, coupled with the lack of available time that teachers have due to pressures of the ever-expanding curriculum, added adversity to the engagement and attendance issues that we observed ,48. ReseIt was clear that the stakeholder groups had differing capabilities regarding their knowledge and understanding of FMS. It is well documented that generalist teachers have a lack of knowledge and understanding of PE principles, particularly in primary schools where PE is commonly delivered by generalist teachers without a PE specialism ,55. ThisIt is widely recognised that co-creation is demanding of time, resources, and commitment for researchers and stakeholders involved in the process ,63. DespDiscussions with stakeholders highlighted how the time constraints in workshop 3 and the subsequent input from the research team led to feelings of nonaccomplishment and a lack of ownership over the process. The stakeholders would have preferred to have more time to collaborate with the other stakeholders to develop a combined programme idea, rather than the research team generating the combined hybrid version. Optimising the integration between the stakeholder groups within the three-hour workshop would have been beneficial to not risk de-valuing the co-creation ethos. However, given the time constraints experienced in workshop 3, it was not possible to do this, especially as the teachers needed to return to school afterwards. Further, extending the co-creation process was not feasible, as it was essential that the MWFG programme was designed and consensus was received before the end of the school year, to ensure that programme resources could be developed in time for delivery. The challenges of this type of research have been echoed by others. For example, O’Brien and Dadswell  highlighConflicting priorities in participatory research are common, particularly amongst multidisciplinary groups where there are contrasting views and expertise involved in the research process ,64. Thro“Every school will have their own difficulties, accommodations that need to be made… it was more us, me thinking how can we make this work for us?”.Ponsford et al.  highlighThese difficulties were associated with an imbalance of power in decision making between the stakeholders and the research team ,62. Tens“There seemed to be on that day two different trains of thoughts that I know that ended up with you producing was it three models, three proposals that we all voted on. And I don’t know whether that was an intention at the time, or just a product of that day at Edge Hill, that this was the only kind of way we could find to map our way forward”.During the initial headteacher meetings, the research team clearly outlined the process of co-creation and its aims, including the consensus voting and that the ‘winning’ idea would be implemented in each school. However, it cannot be assumed that the communications were accurately cascaded to the school leaders and class teachers participating in the co-creation process, particularly when only one headteacher engaged in the whole process. Had there not been time constraints surrounding co-creation in the current study, engaging with the participating stakeholders prior to the workshops would have been beneficial to clarify the co-creation process and its aims, overcome any early conflicts, and manage stakeholder expectations . This apThe MWFG programme was developed following a co-creation process involving children, school leaders, class teachers, and PE specialists. We have described and reflected on each stage of the process and the complexities that were raised whilst reporting honestly, offering perspectives from the research as it happened, proposing alternatives and creating key considerations for researchers which related to stakeholders’ engagement, attendance, knowledge and competence, time constraints, and conflicting visions and motives for taking part. Clearly, co-creation projects such as this are specific to the contexts in which they are implemented and the perspectives of the participants. For this reason, a ‘one size fits all’ approach is not applicable or appropriate. However, there may be certain characteristics of school-based co-creation projects that share some commonalities, which we reflect in our recommendations for other researchers. These relate to investing sufficient time at the start of the process to engage with stakeholders to clarify the co-creation process and its aims, gaining context-specific understanding of the time and resources needed, understanding and managing stakeholders’ roles, commitments, and expectations (including those of the research team), and overcoming any early conflicts. Engaging with stakeholders at all stages of co-creation projects in an open and clear way is crucial to shared success.


As primary drivers of global growth, China and India as Asian giants are on the path to reforming their higher education systems to drive innovation. This paper based on both primary and secondary data sources investigates how India’s democratic political leadership has facilitated higher education reform for fostering innovation while underlining key differences in the policy approach of the Chinese leadership. Findings identify the areas of reform for India and also reveal that epistemic boundaries between India and China are beginning to blur so far as right-wing ideological regimentation is concerned, with possible implications for innovation. As primary drivers of global growth, though rebounding from the pandemic to varying degrees, China and India as Asian giants are building themselves into knowledge economies for sustainable economic growth, socio-economic development, and success in the competitive global market. Both are beset with common development challenges such as poverty, income inequality, urban–rural inequality, and health hazards while operating in a global economic environment marked by the primacy of knowledge and the ascendancy of “innovation economics” . Given tknowledge creation and knowledge impact  but not knowledge diffusion or transformational innovation . As such, they place both China and India among Cluster 3 countries that are ahead of low-income countries in innovation performance but trail behind Cluster 4 countries  in knowledge diffusion or global influence of their innovations.Innovation, defined in terms of output, may be classified into “knowledge creation, knowledge impact, knowledge diffusion, intangible assets, creative goods and services, and online creativity” : 370. In (GER) of 26.3, while China’s GER is 51.6. As for the reengineered focus of higher learning institutions, China’s 13th five-year plan (FYP) (2016–2020) gave a green light to “innovation-driven development” and entrusted its universities and research institutions with creating “national technological innovation centers.” And India’s National Education Policy , a grouping of emerging economies in the global economic architecture, India and China are commonly sized up in innovation race regardless of their current asymmetry. In fact, China’s Science Technology Exchange Center in its BRICS Innovation Competitiveness Report 2017 predicted a rise in India’s innovation competitiveness with the possibility to outpace China in 2025–2030 owing to the massive promotion of science and technology and entrepreneurship. Indian policymakers are striving to bridge the gap to actualize this potential. This endeavor extends to the domain of universities, in the context of which Reuters’s ranking of the World’s 100 Most Innovative Universities considers advancement of science, technology inventions, and powering of new markets and industries as markers of innovativeness. While it may not be the yardstick of innovativeness, it captures the dynamism of research universities contributing to novel technological solutions and original findings. The United States, Germany, France, and the United Kingdom are the top four hotspots, followed by South Korea, Japan, and China . China’sNo Indian university clinched the spot because of the low level of patent filing by and commercial impact of Indian institutions. It is hardly surprising since in world university rankings as well, Indian universities are at the lower end of the ladder. Nevertheless, the laggardness of Indian universities is a reminder to Indian policymakers that China, India’s strategic competitor and a country with the nearly similar demographic size and socio-economic challenges, has swiftly and strenuously shaped its trajectory upward in the competitive arena of knowledge economy. This is especially noteworthy because just a little over the past decade, both countries shared the tag of “emerging technological powers” . UndeniaNotably, on the Global Knowledge Index, China clinched the 29th spot and India 45th in university–industry collaboration in R&D. Furthermore, China is addressing the gap in Chinese universities’ share in R&D which is 7%, compared to the industry’s and the government’s contribution of 77% and 16%, respectively. For example, in 2019, R&D spending by Chinese HEIs increased by 23.2% compared to 2018 . As suchTechnology transfer is considered yet another indicator of university-driven innovation. Although the rate of such transfer in India is not known, its level is known to be low, except for premium institutions such as Indian Institutes of Technology (IITs) at Delhi, Bombay, and Kharagpur. As for China, university technology transfer organizations in China were established as early as the 1980s to facilitate technology transfer (TT) between university and industry . The impEconomic Times, China with its topmost position had 5,28,263 publications in the same year, partly because of vigorous international collaborations in authorship. Nevertheless, between 2008 and 2018, India had the fastest average annual growth rate of scientific publications with 10.73%, while that of China’s was 7.81%  growth rate averaged 10.5%. Its impressive economic performance earned the epithet of the “Beijing Consensus,” though controversial, denoting vindication of the Chinese model of “authoritarian capitalism” in contrast to the Washington Consensus based on the “primacy of the market.” Over time, it became clear that the conventional growth model was unsustainable in the face of persisting poverty, “sagging exports,” regional inequality, environmental degradation, and growing social protests . Also, CIn India’s case, the political economy perspective posits that the post-independent, socialist democratic India’s “import substitution industrialization (ISI)”  policy dDrEducation, Economic Times, Moreover, India’s 11th FYP (2007–2012) provided for establishing 14 world-class innovation universities in India  investment that is mere 0.69% of GDP in comparison with 2.1% in China or 2.8% in the United States. It proposes for more investments in research to support India’s rise in “global knowledge production” (pp. 45). To address the missing focus of Indian universities on research and innovation, the policy provides for the National Research Foundation (NRF) with an “overarching goal” to infuse research culture in Indian universities and competitively fund research in multiple disciplines: science, technology, social sciences, and arts and humanities (pp. 45). The government announced in its 2021 budget allocation of Rupees 500 billion to the NRF for a period of 5 years.In the words of K. Vijay Raghavan, Principal Scientific Adviser to the Indian government, the NRF will “seed, grow, and facilitate research at academic institutions, particularly at universities and colleges where research capacity is currently in a nascent stage.” Notably, teaching receives a disproportionate focus in most Indian universities, with less than 1% of the country’s nearly 40,000 HEIs engaged in research  and R&D Furthermore, India’s National Intellectual Property Rights Policy  lent impcolleges and universities will become the main force behind building the world’s main AI innovation centers and will lead the development of a new generation AI talent pool to provide China with the scientific and technological support and guaranteed talent to put it at the forefront of innovation-oriented countries.Development of talent in artificial intelligence is yet another policy priority in both India and China. India’s NEP 2020 provides that universities offer doctorate and masters programs in machine learning and in multidisciplinary fields (“AI” + “X”). And China’s 2017 AI development plan establishes a distinct connection between AI talent and the country’s education system, outlining the following steps: building the “high-end talent team as the most important development of artificial intelligence”; and strengthening “the talent pool and echelon construction, especially to accelerate the introduction of the world’s top talent and young talent, and form China’s talent highland of artificial intelligence” . In ApriHence, China’s proactive action reflects in moving from a generic AI plan to a detailed action plan focused on postsecondary education .In this context, it is noteworthy that tests and memorization are virtually embedded in Indian and Chinese learning processes. Such entrenched practice detracts from innovation culture, leading policy makers to make assessment reforms. Thus, China has reoriented its national exam to incorporate “complex analytical skills”  with a vApart from policy launch, the Indian government has undertaken a plethora of innovation-specific measures. As a “flagship” initiative, the Atal Innovation Mission (AIM) has established “world-class” incubators at universities. Not losing sight of China’s phenomenal technological advancement, further manifest from its massive deep technology investment , India’s AIM Prime Program aims to promote “science based, knowledge intensive, deep technology entrepreneurship” through training and mentoring of researchers. And the National Innovation and Startup Policy for Students and Faculties, 2019, provides an extensive 10-point guiding framework for HEIs: setting up an “Innovation Fund” through allocation of at least 1% of the institution’s total budget; academic break to work on startups; and 2%–9.5% equity in startup by the institution’s incubator, apart from IP ownership mechanisms. Furthermore, the education ministry’s Innovation Cell is mandated to work with HEIs to promote startups and entrepreneurship. Its initiatives include Smart India Hackathon (SIH)—a platform for students to devise “world-class solutions” for the world’s top industrial organizations—and Institution’s Innovation Councils (IICs), established in HEIs in 28 states and 6 union territories, to create a “vibrant local innovation ecosystem.” IICs, set up without substantial capital investment, cover multiple fields such as pharmacy, management, medical sciences, art, science, and commerce, with a total of 483 incubation centers ..As for the specific focus on building a US$100 billion bioeconomy by 2024, the government’s Innovate in India program fosters industry–academia collaborative research . NotablyIn fact, government intervention is integral to national innovation systems in both India and China in contrast to the US model of the predominance of industrial clusters in shaping the innovation system . Li et aAt the same time, the following key differences are found in policy approaches and determinants of Indian higher education reform in comparison with China’s under Xi Jinping’s leadership.China Daily, the government guidelines in this context include the following:First, the Chinese government is steering the focus of Chinese universities away from patent volume to patent quality such as commercial viability. It has emphasized the strategic role of universities in the chain “from ideas to development and commercialization” through knowledge creation. With this, China is moving past the phase that India is currently in. Taking a cue from world-class universities, it is rather pushing for “invention evaluation.” According to the The government will assist in establishing IP management offices at “better-resourced” universities and in launching courses in IP management and technology transfer.Technology transfer, rather than the number of patent applications and patent grants, will carry more significance in performance appraisal.Universities have been asked to slash financial incentives for patent grants, with inventors to be rewarded with a bigger share of revenue resulting from commercialization .Governmental involvement in setting priorities for universities has intensified during the Xi regime to spur innovation. In positive terms, it is a corrective measure to curb “junk patents” that had spawned following the Ministry of Education (MOE’s) previous evaluation criteria for university researchers, namely, the number of patents, and the resulting pressure to meet performance targets . In IndiTo provide fillip to university–industry collaboration, Innovation and Science @Bharat, division of the Office of Principal Scientific Adviser (PSA) to the Government of India, is working toward forming partnerships between academia and industry in the form of joint R&D, establishment of Centers of Excellence (CoEs) by industry in academia, and innovative solutions for social benefit. Interestingly, analysis of the PSA-released list of outcomes shows (1) the Indian government’s predominant presence in these collaborations (other than that of foreign companies) with a minuscule share of domestic private companies, and (2) the major role of IITs, which indicates a need for diversification supported by research capacity across non-IITs. For example, National Buildings Construction Corporation (NBCC) Limited, a government company, will set up a lab space as a CoE at IIT Madras campus, and IITs’ R&D proposals have been shortlisted by Bharat Electronics Limited, an Indian state-owned company. Interestingly, the PSA list includes the Election Commission of India’s acceptance of an IIT proposal as an example of industry–academia partnership ..Global Times, Second, while India has attempted to catch up with China, the latter has been driven by tech-nationalism to replace the United States as the foremost superpower in science and technology. President Third, while China has an official blueprint dedicated to AI for postsecondary institutions, India does not have an exclusive action plan to revamp HEIs for AI readiness. Also, the Indian policy document (2018) provides a broad-brush direction for course upgrades and training in AI, whereas China’s 2018 action plan carries AI training-specific targets for 2020, including the development of 100 “AI + X” majors for interdisciplinary growth, the publication of 50 world-class undergraduate and graduate textbooks, the establishment of 50 AI schools, and the launch of 50 national-level 20 quality open online AI courses . ImpliedFourth, China has been more proactive in reversing brain drain and in attracting foreign talent to support and trigger innovation. Following the strong government endorsement, in October 2017, Shanghai-based universities such as Fudan University, Shanghai Jiao Tong University, and Shanghai University dispatched a 12-university delegation to American universities such as Harvard University, the University of Pennsylvania, and Columbia University in hunt for skilled graduates and professors . PremierImportantly, China launched the “Double First-Class University Strategy” in 2015 as it strives to advance an “innovation excellence culture” in science. This ambitious initiative sets out to optimize the disciplinary structures of major research universities, and intensify their efforts to bring in top scientists and talented researchers from within China and abroad. The authorities identified 42 out of 2000 Chinese universities as part of “world-class” universities, and another 95 institutions to develop “world-class” disciplines. Because most of the designated schools are in well-developed metropolises and provinces, this policy appears to have perpetuated structural imbalances in the state’s allocation and distribution of public resources . Impliedthe talent pool of scientists and entrepreneurs, internationally to encourage their engagement with the institutes of Higher Education in India so as to augment the country’s existing academic resources, accelerate the pace of quality reform, and elevate India’s scientific and technological capacity to global excellence. As for India, the government’s Institutions of Eminence promotion scheme provides for hiring foreign faculty to address the deficit in talent attraction. Furthermore, the Global Initiative of Academic Networks in Higher Education, 2015, seeks to harnessIndian salaries in the IITs, according to the latest Pay Commission recommendations, start at US$17,622 for assistant professors, rising to around US$38,165 for full professors. Higher ranks earn somewhat more. China, which is also actively luring top international faculty to its research universities, offers salaries of US$100,000 or more, along with additional research funding. But India’s prime challenge is to attract top faculty especially given the disincentive of low academic salaries. Drawing a comparison with China on this front, Of late, institutions like IITs have been offering a higher salary package plus benefits to recruit faculty of Indian origin, but it may not still be enticing for those who have better opportunities overseas.The previous sections illuminated differences in policies and operation of Indian and Chinese political regimes in terms of impacting HEI-induced innovations. With this, the areas of improvement for India were brought to light. However, while policy directives, funding, and schemes may be considered tangible measures to promote innovation, the intangible aspect of state support manifests in the government’s grant of autonomy and its policy practices. And this is why, given the paper’s focus on India, this section highlights practical challenges for India. Based on news stories and semi-structured interviews with university vice chancellors and academics, it presents themes on politics-based implications for innovation in India.Times Now, Authors of the new education policy borrowed from the mainstream terminology to direct higher education reforms, and cabinet ministers’ language smacks of non-rational advocacy of the rightist agenda. The policy document refers to ancient Indian practices without providing solid connections between “what to achieve” and “how to achieve.” For example, it speaks of restoration of India’s role as Vishwa Guru and in this context mentions building India as a “global study destination.” This is an egregious simplification of what “Vishwa Guru” [world leader in learning] means. Innovation demands not just funding or infrastructure but also mindset; even if the government channels funds into research projects, it is at the same time promoting one line of thinking which if it becomes entrenched will stifle unconventional approach to problem solving. The implications may not be felt immediately but the seed of passivity and obedience to authority is being sown. There is a mismatch between policy and practice which is unfavorable to fostering innovation culture in Indian HEIs. NEP 2020 provides for a shift in student assessment to test “higher-order skills, such as analysis, critical thinking, and conceptual clarity” (p.17). But Indian policymakers’ statements detract from the purported national drive for a “scientific spirit.” For example, Indian Environmental Minister Prakash Javedkar’s refutation of a link between lifespan and air pollution drew flak from the World Health Organization Actually, the government is serving old wine in a new bottle. It did away with the National Innovation Council that envisioned creation of the India Inclusive Innovation Fund to generate social impact of innovative projects. The current IMPRINT is a rehash of those ideas. To citizens it won’t matter of course insofar as the promised outcomes are realized. Some interviewees found fault with the implicit rhetoric in the Indian government’s policy postures. It was argued that schemes and measures to boost innovation are a glitter that conceal the tightening state control over information dissemination: to foster socially relevant innovation has triggered “backlash” among a section of scientists who advocate neutrality and objectivity in conducting research that allows for refutation of hypotheses sanctifying traditional knowledge. Jayant Murthy, a professor at the Indian Institute of Astrophysics, comments, “While the Chinese are on the far side of the moon, Indians are busy treating cancer with cow urine and looking to the past for modern fighter jets”  chairman, triggering a 139-day protest by students, questioning Chauhan’s qualifications.It further points out that as a result, “the culture of questioning and reasoning cannot be inculcated as a part of higher education in most institutions.” Even though the HRD minister called for filling vacancies on a “war footing” level, the solution appears even more intricate than the problem owing to politicization of selection procedures . Gill anIndia has had a culture of debate since ancient times. And the people of Indian origin are heading MNCs as CEOs which testifies to their strategic entrepreneurial acumen. But in terms of quantity, we are not generating enough mass of analytical human capital base, thanks to the faulty teaching methods and outdated curricula. There is not much debate, discourse, and practical activities that could train young minds along problem-solving lines. Apparently this is beginning to change because there is a realization among policy makers and education providers that 21stcentury skills are indispensable. The question is: where to get such faculty for non-IIT institutions . . . and another question is: how to cultivate critical thinking when dissent is curbed in the current right-wing regime. When you [the central government] can’t tolerate student activism, how can you tell them to think critically? There is a steady decline of whatever autonomy we had because of increasing political interference. The new policy is a sham. The so-called emphasis on critical thinking is that anti-minority thinking is critical thinking and any thought of inquiry challenging the current regime is considered anti-nationalist. If, as you [X] mentioned, India is taking the China road of ideological control, it’s possible that innovations would at most be incremental, not radical. It’s very common these days to speak of China’s success in the e-commerce and digital world as evidence of their capacity for innovation but they aren’t known for technological breakthroughs with global effect. Furthermore, a common theme emerging from interviews with vice chancellors (VCs) and scholars is the diminishing academic freedom and autonomy:Has China been encumbered by ideology? No. It’s innovating on a consistently improved scale, whether it is patents, business models, or high-speed rail. Whatever controls exist they mostly impact humanities, and innovation, which China is aiming at, derives from STEM. Similar is the case with India: cultural resurgence might be the government’s agenda but that won’t impede innovation. The government is withdrawing from most sectors of governance . . . The whole atmosphere is tipped in favor of privatization, and this is liberating for a knowledge economy because with the government interference gone, individual initiative for innovation will receive encouragement. This government is taking the job of catching up with and even surpassing China very seriously. The Made in India campaign extends to manufacturing and virtually everything. So, we see the focus of innovation on indigenous knowledge, and this is how the government has provided much-needed thrust to relevant innovations that match with our local conditions. The [ National Intellectual Property] NIP policy is in place; artificial intelligence in education has received lots of attention; and the prime minister’s speeches are laden with the word “innovation” in his address to the youth. Results will take time to show but the beginning has been made. By giving China’s example, VC 4 noted the implications of ideological control for the prospect of breakthrough innovations in India. However, a different perspective was offered by another stream of academics:These excerpts suggest that some academics are positive about the government’s innovation practices and perceive a direct connection between the government’s privatization drive and a liberating environment for innovation.The foregoing discussion revealed that China is ahead of India in quantitative metrics of university-driven innovation because of massive reforms in higher education. In fact, China has unseated the United States, the world’s “leading powerhouse,” from its foremost position in patent applications. As such, the gap between India and China in innovation should not spring any surprises. However, India is catching up with several significant policies, action plans, and initiatives, with the National Research Foundation being among prime examples. Basically, while China’s proactive pursuit of innovation is encompassed in its Chinese Dream of national rejuvenation, India’s initiatives have been presented in the government’s stated goal of building a “self-reliant India.” What is, however, significant is that epistemic boundaries between India and China are beginning to blur so far as right-wing ideological regimentation is concerned.This paper addressed the research question as to how the divergent political regimes have facilitated their countries’ innovation drive. Parallels between current regimes in India and China may be drawn as the former is exhibiting ideological controls, threatening the culture of dissent in the democratic India. While China’s technology giant Tencent is considered a world-class innovative company, the government’s crackdown on Alibaba is perceived as being prompted by its CEO Jack Ma’s criticism of financial regulators. Not surprisingly, the fact that he had to step down as president of the Hupan Innovation Center reinforces the upper hand of the communist state. As such, critics apprehend the repercussions of authoritarianism in the democratic India if it goes unchecked.Arguably, Chinese universities’ achievements in innovation are largely driven by “top-down” initiatives and the financial succor of the communist regime. And innovation has had thrived in other non-democratic regimes as well such as the former Soviet Union. The crux of this analysis is not as to which political system is favorable to reforming higher education systems for innovation. What is significant to note is that while the liberal democratic environment has not yielded any distinctive advantage in favor of innovation in India, as evident from the leading position of Chinese universities, the growing political controls in India are sounding the death knell of creative potential. The political regime in India appears to be sanctioning the innovation-frame-of-mind selectively, which is applicable to encouraging socially relevant products and solutions rather than to the education system that produces a generation of critical thinkers. This trend has implications for nurturing innovativeness and scientific temper regardless of the new education policy or IP regime being in place. Hence, the acid test of the newly created National Research Foundation will lie in funding projects of promise without politicization of the research mandate.It is pertinent to mention the trend for research-intensive universities to enter into R&D partnerships with international enterprises with the onset of globalization of R&D . For ins


There are many cognitive, physical, and social–emotional benefits for youths from participating in outdoor adventure activities. However, youths with visual impairments are not given the same opportunities to participate in outdoor adventure activities as their peers without disabilities. The purpose of this study was to examine the outdoor adventure experiences of youths with visual impairments participating in a week-long sports camp. Thirty-seven youths with visual impairment (ages 9–19 years) attending a one-week sports camp participated in this study. Participants engaged in a variety of outdoor adventure activities throughout the week of camp . Participants provided written accounts about their outdoor adventure experiences and were observed throughout the week during each activity to examine instructional strategies and task modifications. Additionally, 10 randomly chosen athletes, their one-on-one coaches, and five outdoor recreation specialists participated in focus group interviews. The data analysis revealed three major themes: (1) Benefits, (2) Support, and (3) Barriers. The subthemes of benefits were enjoyment, independence, and relationships; the subthemes of support were instructional strategies and task modifications; and subthemes for barriers were fear and anxiety, exclusion and low expectations, and lack of equipment. These findings support the inclusion of youths with visual impairments in all outdoor adventure programming with appropriate instruction and modification. Outdoor adventure experiences benefit individuals’ cognitive, physical, and social–emotional well-being. In particular, outdoor adventure experiences can improve not only an individual’s physical health, but also self-concept, self-determination, social skills, and mental health ,2,3. WooThe benefits of outdoor adventure programs extend to individuals with disabilities, particularly individuals with visual impairments ,3. SucceMany benefits of outdoor adventure experiences align with components of the Expanded Core Curriculum (ECC). The ECC includes nine skill areas that most youths acquire through incidental learning but must be explicitly taught to students with visual impairments . These nDespite these potential benefits, individuals with visual impairments participate in outdoor adventure activities at lower rates than their peers without disabilities . Lower pAlthough many youths and young adults with visual impairments experience barriers to outdoor adventure activities, participation can be beneficial to students and facilitate instruction in the ECC. Considering the potential benefits of outdoor adventure activities for youths with visual impairments, the purpose of this study was to explore camp athletes’ experiences with such activities at a sports camp for youths with visual impairments using a qualitative approach. Within this paper, we consider outdoor adventure experiences such as hiking, biking, stand-up paddleboarding, kayaking, rock climbing and sailing. In addition, we seek to determine how the Camp experiences compared to their previous experiences in outdoor adventure.What are the experiences of youths with visual impairments related to outdoor adventure during a one-week sports camp?What accommodations or supports help youths with visual impairments access outdoor adventure activities?How did these experiences compare or inform their previous and future experiences in outdoor adventure programming?The research questions were:Participants were recruited from 37 campers attending a one-week overnight educational sports camp for youths with visual impairments. Participants included 10 athletes with visual impairment aged 9–19 years, with an average age of 13.2. There were 4 females and 6 males. Their visual impairment ranged from B1–B4 as recognized by the USABA sport classifications: “B1 has no light perception in either eye up to light perception, and an inability to recognize the shape of a hand at any distance or in any direction, B2 has the ability to recognize the shape of a hand up to visual acuity of 20/600 and/or a visual field of less than 5 degrees in the best eye with the best practical eye correction, B3 has visual acuity above 20/600 and up to visual acuity of 20/200 and/or a visual field of less than 20 degrees and more than 5 degrees in the best eye with the best practical eye correction, and B4 has visual acuity above 20/200 and up to visual acuity of 20/70 and a visual field larger than 20 degrees in the best eye with the best practical eye correction”. See Participants experienced a variety of outdoor adventure activities throughout the week at camp including sailing, hiking, rock climbing, kayaking, stand-up paddleboarding, biking, and high ropes elements. During the week, three main sources of data were collected to understand how participants experienced the various outdoor adventure activities. These sources of data included written accounts, observations, and focus groups.Throughout camp, posters were available in the main common area of the camp dorms for participants to record their thoughts about the different activities as well as adaptations and modifications they experienced. Each poster had the name of one of the outdoor adventure activities and blank post-it notes as well as cards to add braille that athletes could post. Participants recorded their responses using black markers on the post-it notes and stuck them on the corresponding activity. In addition to the posters, a clipboard with paper and pens was set up at each outdoor activity, and researchers encouraged participants to write down their feelings, adaptations used, as well as instructional strategies that worked or did not work. All participants were invited to share their feelings about the outdoor adventure as well as the modifications and instructional strategies that worked or did not. Most of the campers shared their feelings about at least one activity according to anecdotal feedback from their coaches. The true number is not known, as this step was anonymous.Four of the researchers collected field notes during all of adventure activities and recorded interactions with the coaches and their peers, instructional strategies, feedback, and adaptations used for each activity. These four researchers documented adaptations , comments heard related to involvement in the activity, and any socialization aspects. One to two researchers attended each activity on a daily basis throughout the week.Ten of the athletes and their one-on-one coaches were randomly chosen to participate in focus groups  on activity modifications and how the participants felt during each outdoor adventure activity. These three methods of data collection support triangulation of the data ,13In addition, at the beginning of each focus group interview, the researchers exposed their positionality. This explanation of their lens gave the participants insight related to their professional and personal perspective on the topic of outdoor adventure . MoreoveThis study revealed three major themes of outdoor adventure experience for youths with visual impairments during a one-week camp: (1) Benefits, (2) Support, and (3) Barriers. Benefits included three subthemes: enjoyment, independence, and relationships. The subthemes emerging from support included instructional strategies and task modifications. Three subthemes emerged from barriers: fear and anxiety, exclusion and low expectations, and lack of equipment. Most participants, according to the focus group interviews, had previous experience with outdoor adventure activities and actively participated in these activities during camp. Similar to previous research, many benefits were found to be derived from outdoor activities ,10. BothMost athletes described their enjoyment of outdoor adventure activities, which is in line with previous research wherein increased enjoyment, satisfaction, and well-being was derived from participating in outdoor activities in comparison to indoor activities ,17. EvenOther participants noted the sense of freedom and independence they felt. One of the tandem biking specialists shared that “tandem gives the kids freedom”, and she observed that there seemed to be more independent bikers this year than in the past. Alexander stated that nighttime activities, which were “free choice”, allowed athletes to be successful because “you could go out and do what you wanted to do with you and your coach and friends”. When asked what his favorite activity was, Alexander elaborated, “Fishing because you are by yourself, it takes a while, it is calming, relaxing, and quiet”. Similarly, Dennis reported stand-up paddle board was his favorite outdoor activity because he liked “moving fast and piloting my own ‘ship’”. The researchers also observed that many of the participants became independent in rowing, rock climbing, and in biking.Independence (one facet of self-determination) is one of the components of the ECC , and LieSimilar to the results from Lieberman and colleagues’  researchAll athletes must have a visual impairment to participate in camp, and this shared identity creates a unique sense of community not often experienced in other settings. For example, Robert’s coach observed, “… the other thing is they are most likely the only kid with a visual impairment in their school and they come here, and they do not stick out. Accommodations no one thinks twice about it, and it so cool when they walk around and talk about the similarities/differences of their vision.”Andrei’s coach agreed, reporting, “Andrei found it so cool that one of the Paralympians had his exact same disability”. Dennis’ coach shared, “Dennis had his braille reader and he let Alexander play with it. Alexander stated, ‘omg, I want a friend like you’. It was great to see the joy in his face with someone else who had complete blindness”. The observations also revealed that the participants felt fine with physical and verbal assistance because many of their peers “needed the same instructional strategies”.All athletes required some type of support to successfully participate in outdoor adventure activities. The theme of support highlights the modifications and instructional strategies that facilitate youths with visual impairments to be able to engage in outdoor recreation experiences . EngaginWhen asked, most athletes remarked that the supports they most appreciated were emotional; they thrived on their coaches’ words of encouragement. As Elena noted, “Motivation helped me as well; everything here is so positive … but here it felt like a community, and it was supportive”. The specialists agreed, emphasizing the importance of positive encouragement.Coaches, specialists, and the researcher’s observations also reported adaptations or modifications used to help their athletes succeed. These fell into two categories: instructional strategies and task modifications. General Teaching StrategiesInstructional strategies include techniques used to help athletes perform successfully and independently . InstrucVerbal instructions and tactile accommodations were commonly used by both coaches and specialists as instructional strategies as noted on the posters in the dorms. Coaches and specialists agreed that communication was vital before, during, and after outdoor adventure activities. Coach Paula observed, “There are never enough words or guidance, especially with blind soccer, and just like Coach Ella said, ‘if you are not speaking the entire time, you are not speaking enough’”. Coach Maryna agreed, saying, “…we have to say what is going on and what we expect them to do. I think communication is the key and what I learned the most”. Robert’s coach added, “Being very specific. You cannot just say, ‘oh, it’s over there’”. Similarly, Steven’s coach reported that “Steven is very independent, but the verbal cues helped”. The importance of communication was emphasized not only in the focus groups, but also on the clipboards and during observations. Coaches and specialists also provided tactile accommodations. One specialist described how a coach mapped out the course for an athlete on their back . Michael’s coach reported that “he [Michael] gets very often distracted so he needs reminders and physical guidance”. Similarly, Dennis benefited from more tactile cues and guidance. He shared, “I had a struggle with physical movements that you should know when you were a toddler”. His coach supported him with both verbal and physical cues. “I guided him to make him try and make him more successful”.Athletes also utilized task adaptations and modifications to successfully access outdoor adventure activities. It was noted in the researcher’s observations that there was a variety of equipment  that made access to each activity possible. Coaches and specialists designed these adaptations and modifications to build on athlete strengths while also addressing their needs. For athletes with some vision, coaches and specialists provided high contrast materials as noted on the clipboards. For example, specialists at stand-up paddleboarding marked the paddles with high-contrast duct tape to indicate proper hand placement and paddle alignment. The fishing specialist provided brightly colored bobbers for athletes to use, and athletes wore brightly colored vests when tandem biking around campus. As Elena’s coach observed, “the tactile boards were really good because she always wanted to feel first. Elena likes to be independent, and the braille instructions really helped”. Other athletes benefited from tactile representations as well. Alexander’s coach shared, “The tactile boards really helped Alexander. He is completely blind and having a physical representation of everything he was doing helped a ton”.These accommodations were often supplemented with auditory cues and equipment. For example, the fishing specialist placed bells on the bobbers for an auditory cue, and the stand-up paddleboard specialists placed a sound source at the dock to assist athletes in navigation as noted in observations and written on the clipboards. Coaches agreed that the combination of verbal/auditory and tactile cues often benefited their athletes. Robert’s coach observed, “Robert was really into feeling out the boards and all the auditory equipment really helped”. While most athletes discussed the benefits of outdoor adventure activities, some expressed barriers associated with accessing these activities. Subthemes of barriers included fear and anxiety, exclusion and low expectations, and lack of equipment.Many athletes reported feeling fearful or anxious, especially when starting outdoor adventure activities. Julia stated, “I was very nervous to stand on the paddleboard because I did not want to fall into the water. I was even scared with my life jacket”. However, most athletes felt more confident when participating in activities. Michael’s coach shared, “Michael was a bit hesitant to do a lot of things, but when he was participating, he was really happy with each and every sport”.The specialists agreed that some athletes expressed fear to go on their own, and according to one specialist, “the hardest part was getting them to go out there”. Some athletes were anxious about being on a bike, while others were afraid of the heights associated with the ropes course. The specialists felt, though, that “by talking them through it, the specialists and coaches were able to help the athletes to feel more comfortable...enough to not be scared anymore”. Another specialist shared that it was important to “take it slow and easy”. Coaches and specialists often faded supports as athletes became more confident and comfortable in the activity. Lieberman and colleagues  similarlAthletes are encouraged to actively and fully participate in all camp activities; however, their experiences outside of camp may differ. Elena shared, “Sometimes at school things can be negative and you think to yourself that you do not want to do it. They will pull you apart to make you feel like you are nothing, but here it felt like a community, and it was supportive.”Several coaches echoed these feelings. Elena’s coach reported, “I talked a lot to Elena about physical activity and her gym classes and it hurts a lot because she loves physical activity but sometimes, she gets excluded from her classes mostly because she has a visual impairment and got bullied from her friends and the teachers did not help so much.” Similarly, Dennis’ coach shared, “With Dennis, he was just placed in Adapted PE  without being told, and I feel like a lot of people put these kids in bubbles when they can do anything”. Although physical education does not always encompass outdoor adventure these feelings are pervasive in outdoor adventure pursuits and physical education outside of camp for many of the participants.Participating in a wide variety of outdoor activities can encourage youths to feel a part of something and increase self-determination. Rather than excluding youths with visual impairments from participating in new and challenging outdoor activities, modifications should be made when appropriate to enable the child to participate safely and with a reasonable amount of risk . By encoThe need for specialized equipment can limit athletes’ participation in outdoor adventure activities outside of camp. Specialists noted that many of the activities that were new to athletes, such as sailing or stand-up paddleboarding, required specialized equipment that many could not access. For example, Steven shared that he had enjoyed the rock-climbing wall, so he was excited to receive a day pass from a local rock-climbing gym. However, camp provides a unique opportunity for athletes to experience these outdoor adventure activities. As one specialist observed, “Kids are more likely to ask for more opportunities and equipment when they go home now that they realize they can do these activities with their friends”. Several coaches agreed, and in particular, Elena’s coach stated, “She loved sailing mostly and SUP [stand-up paddleboarding] because she, well, is very good at it, she got one from her parents last year, so she has been practicing ever since”. In fact, one athlete focus group concluded with the athletes brainstorming with one another on how to acquire the equipment needed to participate in outdoor activities, such as fishing.It should be noted here that although this was a heterogeneous camp with all athletes with a visual impairment the authors are not taking a stance on one setting over another. The fact is that this setting promoted the involvement in outdoor adventure activities with necessary accommodations. These youths now know what they need and what to ask for then they go into any school or community program.Lack of appropriate equipment is consistent with the literature ,22. To an = 37 in the Camp program, and n = 10 athletes in the focus groups and n = 12 coaches and specialists in the focus groups) convenience sample of athletes and coaches in attendance at camp, and athletes participating in the focus groups were purposively chosen. Furthermore, athletes and coaches chose to participate in camp, which focuses on sport and recreational activities, rather than academics or other ECC skills. These factors, along with the fact that data were collected over a period of one week, limit the full generalizability of the findings. The current study relied upon a relatively small (Outdoor adventure activities can provide youths with visual impairments opportunities to be physically active while engaging with their peers or independently. From the present study three themes emerged: benefits, support, and barriers. While many benefits emerged from the findings, the importance of appropriate instructional strategies and task modifications was also very apparent in the findings. In addition, parents and practitioners should be aware of their own safety concerns as well as those of the youths with visual impairments as these fears may be barriers to providing and participating in outdoor adventure opportunities. It is important for all practitioners to be aware that youths with visual impairments have the right to participate in the same activities as their sighted peers and every effort should be made to provide safe opportunities for all children to participate. All children deserve the opportunity to enjoy the many benefits of outdoor adventure activities.


As part of a multicenter evidence-based intervention for surgical site infection prevention, a qualitative study was conducted with infection control teams and surgical staff members at three Department of Veterans Affairs Healthcare Systems in the USA. This study aimed to identify strategies used by nurses and other facility champions for the implementation of a nasal decolonization intervention. Site visit observations and field notes provided contextual information. Interview data were analyzed with inductive and deductive content analysis. Interview data was mapped to the Expert Recommendations for Implementing Change (ERIC) compilation of implementation strategies. These strategies were then considered in the context of power and relationships as factors that influence implementation. We found that implementation of this evidence-based surgical site infection prevention intervention was successful when nurse champions drove the day-to-day implementation. Nurse champions sustained implementation strategies through all phases of implementation. Findings also suggest that nurse champions leveraged the influence of their role as champion along with their understanding of social networks and relationships to help achieve implementation success. Nurse champions consciously used multiple overlapping and iterative implementation strategies, adapting and tailoring strategies to stakeholders and settings. Commonly used implementation categories included: “train and educate stakeholders,” “use evaluative and iterative strategies,” “adapt and tailor to context,” and “develop stakeholder interrelationships.” Future research should examine the social networks for evidence-based interventions by asking specifically about relationships and power dynamics within healthcare organizations. Implementation of evidence-based interventions should consider if the tasks expected of a nurse champion fit the level of influence or power held by the champion.ClinicalTrials.gov, identifier: NCT02216227. Staphylococcus aureus bacteria is the most common cause of adult surgical site infections, and specifically the most common pathogen causing orthopedic (38.6%) and cardiac (27%) surgery infections  facilities. Healthcare facility data reported to the Center for Disease Control and Prevention's National Healthcare Safety Network shows that fections . S. aure cardiac 7% surgerthopedic 8.6% and ion site . Patient cardiac 7% surgernfection .S. aureus surgical site infections” supported implementing an evidence-based surgical site infection prevention bundle in the orthopedic and cardiac surgical programs of eleven geographically dispersed VA facilities  Collaborative Research to Enhance and Advance Transformation and Excellence (CREATE) program project “Checklist to Prevent Methicillin-resistant cilities , 12. Thierations , 9. Howeerations . We founerations –16. Reseerations . As wellerations .This paper presents results from a subset of three VA facilities that independently initiated implementing pre-operative intranasal decolonization with povidone-iodine instead of mupirocin. This alternate evidence-based surgical site infection prevention intervention aimed to reduce challenging patient-burden steps and overcome other barriers with using mupirocin. The purpose of this subset study was to identify barriers, facilitators, and strategies used for successful implementation or uptake of intranasal povidone-iodine decolonization. Specifically, we assessed the role of nurse champions, including their use of relationships and power as facilitators and strategies for implementation of this intervention. We define power as having the authority and ability to influence behavior, for example buy-in from the end users of the intervention. Power also includes authority to make decisions about intervention steps.Most implementation strategies are complex processes and are socially mediated, involving dynamic interactions among stakeholders , 18. Impn = 1) for nasal decolonization, or key leaders at the facility expressed a goal to switch to using povidone-iodine (n = 2). The facilities each independently initiated the intervention locally, not through external facilitation. Two of the three VA facilities (site A and site B) were able to implement the surgical site infection prevention evidence-based intervention and move into the sustainment phase. Sites A and B each had a primary nurse champion responsible for driving through the implementation, and also had secondary nurse champions who helped support implementation activities. The third site (site C) did not have a sustained champion and was unable to move beyond the pre-implementation phase for the povidone iodine intervention.Our qualitative study design included semi-structured, open-ended interviews and site visits . The thrThe principal investigator and the qualitative lead, from fields of epidemiology and anthropology, conducted semi-structured interviews in-person (11 interviews) and by telephone (2 interviews) during 2019–2021. Interviews were conducted with surgery and clinic staff , infection control staff, and administrative leadership. The qualitative lead and the principal investigator designed the interview guide based on their previous research with the surgical site infection prevention topic and based on previous interview experience with relevant stakeholders. The interview guide focused on learning about the povidone-iodine implementation process, including timeline, decision makers, barriers, facilitators and strategies see , 29. TheThe principal investigator and the qualitative lead conducted in-person site visits at two of the three VA facilities and telephone interviews with the third VA facility. We collected detailed field notes from observations of infection control practices, surgery-patient flow through the facility, and informal conversations with healthcare workers involved in the implementation . At one The study was approved by the VA Central Institutional Review Board and Research and Development Committee at the Iowa City VAHCS. Informed consent was reviewed with all interview participants.Interview transcripts were imported into MAXQDA, a qualitative data management and analysis software program . Data anData was analyzed in an iterative process. There were four main activities of data analysis. First analysis activity: We conducted thematic content analysis using a negotiated, or consensus, approach –35. Our Second analysis activity: For this paper, interview segments that were coded relating to roles, hospital units, barriers, facilitators, strategies, and recommendations were evaluated for relevancy as implementation factors. The lead qualitative analyst identified and categorized specific implementation strategies used by facilities. Interview segments were mapped retrospectively to the strategies and organizational categories of the Expert Recommendations for Implementing Change (ERIC) compilation , 37, 38.Third analysis activity: Following conceptual content analysis , 41, theFourth analysis activity: In keeping with Proctor et al.  we identA total of thirteen healthcare workers from the three VA facilities participated in semi-structured interviews. Interview length ranged from 15 to 64 min, with an average (mean) duration of 33 min. Participants included members of infection control teams and surgical nurses. Interview analysis identified multiple themes around implementation process and factors, including barriers, facilitators, strategies, actors, and hospital units. Two main themes emerged from interview thematic content analysis: (1) Implementation of this evidence-based surgical site infection prevention intervention was successful when nurse champions drove the implementation; and (2) Nurse champions leveraged their influence or power along with their understanding of social networks and relationships to help achieve implementation success. Champions used their understanding of decision makers' motivators to facilitate implementation in every phase of the process, by adapting strategies and messages variant on their audience and contextual setting.Identify and Prepare Champions is one strategy from the larger organizational category “Develop Stakeholder Interrelationships,” and was frequently identified when mapping interview data. Because the champions were also the drivers of most identified implementation strategies, Identify and Prepare Champions is the overarching implementation strategy strengthening successful implementation of this evidence-based intervention.Interview data from all three sites on the topic of how change happens locally, and discussion of the specific details of how the evidence-based intervention came to be implemented, indicated that having a nurse as the champion was a core component , 44 to tAt site A, the nurse champion and their colleagues described the importance of the sustained role and actions of the nurse champion throughout all phases of the implementation process:Primary Nurse Champion, site A “I've been instrumental, and in this evidence-based process, I was involved in an implementation level that was really granular … I did all the research. And then in little bits I did a lot of it [the implementation steps] and then it sort of culminated… I have continued the project and have been tweaking and working on compliance a lot.” -Infection Prevention nurse, site A “I look for [name of nurse champion]'s out there for the interventions and she just did a stunning job. I can't say enough about her project.” -Infectious Disease physician, site A “Oh yeah, [infection prevention] it's a process, but having someone just, keeping on, [name of nurse champion] she keeps on with it.” -At site B, the nurse champions described adjusting approaches and strategies to drive the process and work through barriers. A primary nurse champion initiated each step of implementing the evidence-based intervention:Primary Nurse Champion: “I'm positive about [the evidence-based intervention]. It's, I mean, it probably took [name of secondary nurse champion] and I–was it a year? Year and a half? Almost in that range to get moving forward, but that's because we had to start from ground zero.”Secondary Nurse Champion: “We didn't have anything to start. I mean, literally ground zero. Nothing, just—”Primary Nurse Champion: “Yeah, and we tried talking to all the outside facilities that had pieces of this or didn't, so we had [facility W]. We had . I mean—”Secondary Nurse Champion: “But nobody had the full package. And everybody's VA functions so differently.”Interviewer: “You are making this change happen. Who else would you put in a category like that...?Secondary Nurse Champion, site B: “…I feel like the majority of the work actually has been done by [name of primary nurse champion], and I've just assisted.”At site C, a member of infection control leadership described achieving some early buy-in during the pre-implementation phase, by utilizing evidence-based data and appealing to a common goal:-Hospital Epidemiologist, site C “Some of the things that I think were helpful were finding a common goal to organize around and say ‘yes, we all agree, we want lower surgical site infection rates.' This was I think a strong argument [to make] for the surgeons…‘I have data to show you this causes less surgical infections' and that really resonated with them.” However, the infection control member was a local leader facilitating buy-in, and was not the role intended to carry out the implementation steps. At site C when the nurse champion left the facility, the project stalled at pushback during this pre-implementation phase. In the absence of a nurse champion, the early buy-in gained from surgeons was not sufficient support to move past concerns about potentially increasing staff workload:-Hospital Epidemiologist, site C “…the biggest champion [left the hospital facility]– this was a person who was both in their position and their voice, a strong advocate for it, and that left the opposers…and they said ‘We're not going to implement that. That's not our thing, it's more work and you're not going to give us more staff so we're not going to implement it.”' Another core component to the implementation process was that the nurse champion role needed to have power or authority to make decisions about the intervention details, and power to facilitate necessary approvals from facility leadership or committees. Power may be designated through assignment of status, as in site A where the project champion role was assigned to a motivated nurse:Infection Prevention nurse, site A “… she wanted a meaningful project. And I said well, I think we have one if you really, really REALLY want a meaningful project… I was going to need to mount the energy to do this somehow, so it was very fortuitous that, you know, a fabulous Masters student needed a project. And she had a relationship with all of those people. So it was, you know, I think the stars aligned that somehow it does–, -Or, power may come from specific role responsibilities within a facility, such as at site B when the primary nurse champion already had an established role tracking infection rate data. The champion was able to leverage the authority of their formal role to enforce the need for a new surgical site infection prevention intervention and achieve early buy-in:-Primary Nurse Champion, site B “We had noticed that our infection [rate data] stayed above the national level for the past year and a half, which is considerably high. I reviewed outside facilities within our [region] and we were noted to be the highest. So that really pushed us over the edge of implementing a new protocol.” Champions also identify situations where it is strategic to leverage the structural hierarchy of power within a facility, in response to resistance:Infection Prevention nurse, site A “…I just go up the chain…it's very strategic to say, ‘ok, Dr. [Hospital Epidemiologist]or [Infectious Disease physician], you know, they [detractors] need to hear this from you. Not me. I'm just a nurse, you know? So, I'm gonna use your voice and here's what we're gonna accomplish', and so they're incredibly supportive and you know, they're very, very busy so I use that judicially and I think that also helps. ‘Cause when I bring them, we really mean it.” - In order to document implementation strategies used for this evidence-based intervention, interview data from all stakeholders was mapped to the strategies and categories of the ERIC compilation see . Site A Facilitation from the implementation category Provide interactive assistance was synchronous with nearly all other strategies. We removed Facilitation from the measure of frequency table  setting:Additional categories and strategies utilized for this intervention intersect with building relationships and understanding of social networks. The category “Use evaluative and iterative strategies” was ranked 2-Primary Nurse Champion, site A “…what has been really helpful is that...the OR nurse does this audit and then she goes to her peers and she reminds them [to do the intervention]. ‘Cause, you know, I'm the…PACU [post-anesthesia care unit] nurse, I'm the CNL [clinical nurse leader], I'm someone who keeps telling them they did something wrong, but I don't really have a relationship with them as much…when they need education, I come, and I give the education. And my way may not be the OR way. I've never been an OR nurse. So, you know, they kinda… speak their own language, they have their own culture…” Stage Implementation Scale Up, also from the “Use Evaluative and Iterative Strategies” category. At site B, the champions purposely phased the povidone-iodine bundle implementation by launching with surgery services that they knew would be open to change rather than starting with the services where the surgical site infection reduction had greatest immediate need:At sites A and B, the nurse champions utilized the implementation strategy Secondary Nurse Champion, site B “And one of the reasons we picked these two services is just because they don't mind change. They were agreeable to it. So rather than jumping it right to general surgery… it wasn't that we had most infections in these populations at all. We just picked them because they were the easiest to work with at the time.” -OR Nurse Manager, site B “Ortho did it ‘cause we were hoping they could get away from having to use mupirocin,” -At both sites A and B, after rollout with targeted services, an understanding of comfort level and feedback from clinic staff allowed for quick scale up to additional surgery services:-Infection Prevention nurse, site A “And we quickly moved it to all of the surgeries because it simplified the intervention within that pre-op clinic.”-OR Nurse Manager, site B “I think it was good doing it with one or two services just because then you work through the issues and the questions people had…I felt like they [clinic staff] kinda– got their feet wet. They felt confident so when they were rolling it out needing to do it at a faster pace or because the volume was higher, they were more comfortable with it.” Implementation strategies were driven by different actors or stakeholders during different phases of the implementation cycle see .Nurse champions were actors or drivers of implementation strategies across all three phases, and in collaboration with leadership and clinic staff. Many of the strategies driven by nurse champions took place during the implementation phase. Facility leadership primarily used implementation strategies during pre-implementation. Clinic staff tended to be involved minimally during pre-implementation and were more involved with utilizing implementation strategies in the late-implementation and sustainment phases.Inform Local Opinion Leaders and Involve Executive Boards, both of which fall into the parent category “Develop Stakeholder Interrelationships.” Stakeholders from each of the three sites discussed the importance of gaining buy-in from facility opinion leaders who hold influence and power, which can facilitate moving forward in the face of pushback:Implementation strategies used by leadership largely focused on achieving buy-in for the intervention, and centered on utilizing the ERIC strategies -Hospital Epidemiologist, site A Interviewer: “Who are the key decision makers for saying we're…gonna make this change?” Respondent: “Probably [Infection Prevention nurse], [Infectious Disease physician], myself, Chief of Surgery, the pre-surgical clinic, the nurse manager…everybody plays probably some semi-major role. We had a couple of services within surgery that gave us some pushback, said ‘I don't know if we need to do this'…but I think the Chief of Surgery was fairly strongly behind it, so it doesn't make sense not to standardize this. And so, I think that he was helpful in getting it done for sure.” Several interviews highlighted the observation that just one or two influential people can derail or halt implementation, described by leadership at site A as being “bogged down by…organizational constipators”:Nurse care coordinator, site A “Change can be so hard. I have been a part of several changes here and it's amazing how one or two people can really be that barrier.” -At site B, the implementation process timeline was influenced by pushback from the OR nurse manager, who was protective about the workload and workflow for the staff they manage:-OR Nurse Manager, site B “I'll be very frank. I think when we first introduced this it was like, ‘oh God just here's another thing I've gotta do'… I know I kind of pushed back ‘cause I just—‘don't they know it's just another thing we gotta do?' It's busy work.” After the intervention was well-established with fidelity, the same nurse manager shared they had changed their mind about the burden of the evidence-based intervention and felt acceptance for using it within their unit:-OR Nurse Manager, site B “…I was probably one that was worried that it was gonna add a lot of time to preparation. And I'm delightfully surprised that it did not. They [nurses] found ways to work it into their normal assessment, pre-op process, that it hasn't added a lot of time. Much less than what I thought it might be. I tend to be kinda protective and try to think about- value their [nurses] time just like everybody else's– but I think overall it's gone really well.” Once the evidence-based intervention had buy-in from opinion leaders and approval from relevant executive boards or committees, the active use of implementation strategies by those in leadership tended to be reduced but continued at a lower level of engagement into the implementation phase.Nurse champions maintained steady involvement in all stages of implementation, including utilizing strategies to continue to achieve buy-in and motivation as the intervention moved through the implementation and sustainment phases:Primary Nurse Champion, site A “I think, you know, process improvement, which was what this really is, my part of it, it is a marathon. It is not a sprint. And some days it feels like you're running as fast as you can, but you're still in the marathon and you have continually–, you know when people, like, attack you and say verbally, ‘I don't know why we are doing this. This is stupid,'…so what really got people onboard is bringing back the data and results frequently around every three months for about the first year.” -At both sites A and B, the nurse champions along with some members of leadership iteratively educated staff at every position level affected by the intervention to achieve and sustain buy-in. During interviews, clinic staff shared that it was influential when they understood how the intervention helped patients. At each site, surgeons and infection prevention staff were shown infection rate data and research that demonstrated intervention effectiveness, in order to facilitate buy-in. While this data was also shared with the nurses who directly use the intervention with patients, one nurse champion described leveraging their comprehension that nurses may be motivated through education and awareness of the impact of surgical site infections on an individual patient level:Primary Nurse Champion, site A “… if you can do a vignette of a patient with a joint infection and their lifestyle, it's really–, that's really impactful.” -Infection Preventionist nurse, site A). Allowing the povidone-iodine to be available without a prescription overcame major barriers that occurred for the mupirocin decolonization product, which had delays and communication issues with the prescription ordering process. At site B, the nurse champions wrote a decolonization bundle policy and a yearly competency intended for inpatient nurses. The formalized materials were planned to simplify and streamline the decolonization process for patients coming to surgery from an inpatient unit, and allow patients to receive the evidence-based intervention bundle while in the inpatient unit. Developing these materials also illustrates the iterative nature of implementation, moving the process back into pre-implementation phase to plan for the expansion of the evidence-based intervention into a different setting within the facility.Nurse champions at both sites A and B initiated strategies to formalize and standardize the evidence-based intervention as expected practice, as the intervention moved into the sustainment phase of implementation. At site A, after a one-year pilot of using povidone-iodine, the nurse champion wrote a Standard Operating Procedure (SOP) that formally allowed the povidone-iodine to be a supply and not require a prescription. This SOP “…was signed off by a lot of entities…it's signed off by the chief of surgery, anesthesiology, ID. You know, it's quite a long list.”  service, the Centers for Disease Control & Prevention (CDC), and the Collaborative Research to Enhance and Advance Transformation and Excellence (CREATE) program (CRE 12-291 to primary investigator EP) from the VA HSR&D.Author MS reports grant and donated product from PDI Healthcare and 3M for a different study. He reports honoraria for creating educational module on surgical site infections and honoraria for presenting on surgical site infections. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.The views presented in this manuscript are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States Government.