vodafone in japan case study

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Vodafone in Japan (A)

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Juan Alcacer

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• September 2012
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Vodafone Japan (A), (B) and (C) (TN)

• December 2010 (Revised January 2012)

Vodafone in Japan (B)

• Vodafone Japan (A), (B) and (C) (TN)  By: Juan Alcacer
• Vodafone in Japan (B)  By: Juan Alcacer, Mary Furey and Mayuka Yamazaki
• Vodafone in Japan (A)  By: Juan Alcacer, Mary Furey and Mayuka Yamazaki

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Home » Management Case Studies » Case Study: Failure of Vodafone in Japan

Case Study: Failure of Vodafone in Japan

Vodafone Group plc is a British multinational mobile network operator, its main headquarter is in Newbury, England. It is the world’s largest mobile telecommunication network company, based on revenue, its market value on the UK stock exchange is about £80.2 billion as of August 2010, making it Britain’s third largest company. It is currently operating in 31 countries and has partner networks in a further 40 countries.

In 2001 Vodafone announced to get into Japanese market with acquiring AT&T’s 10% economic interest in Japan Telecom Co., Ltd. (“Japan Telecom”) for a cash consideration of US$1.35 billion ( £0.93 billion). Japan Telecom was one of Japan’s leading telecommunications companies and parent of the fast growing mobile network, J-Phone Communications Co., Ltd., and its regional wireless operating companies (collectively known as “the J-Phone Group”). After this deal, Vodafone held 25% of Japan Telecom’s equity.

The reason for Vodafone going into Japanese market was the way this market was increasing. In 2001, the mobile market was worth 5789 billion Yen and it was growing with 3-4% every year. Japan Telecom in which Vodafone bought shares was in second place in Telecom market and was having 18.6% of market share. Although, the nature of Japanese government was not very open for the foreign industries, but the market was worth getting into the risk.

But the failure of Vodafone had nothing to do with the closed nature of Japan or any Government intervention. It was because of lack of market understanding and not changing its strategies aggressively. Consumers in Japan use high technology and Vodafone was lacking in this thing. Vodafone was working with traditional handsets from Nokia and Motorola, so it was unable to offer 3G services successfully there. Vodafone captured only 2.2 million 3G subscribers there which were just 6.3% of the total 3G market. Whereas, NEC and Panasonic were working with NTT DoCoMo and KDDI for years.

Japanese customers are more advanced and unique, along with Vodafone, Nokia and Motorola also admitted this thing. They were making those handsets which were doing well in other countries, but they didn’t realize that Japanese are more choosy and they are very forward in technology. Technology keeps changing in Japan and you need to cope up with that change.

Japan failure was not a marketing failure, because people were coming to Vodafone stores, but they were not satisfied with the range of handsets Vodafone was offering. Even those who bought those sets, found that Vodafone’s services are not up-to the mark. Vodafone attracted the customers initially but was unable to sustain them because it was not spending enough on the 3G infrastructure. Although Vodafone finally moved with speed to rectify the problem, users, even in major metropolitan areas, were often left with frustratingly unusable handsets.

On 17 March 2006, Vodafone announced an agreement to sell all its interest in Vodafone Japan to SoftBank for £8.9 billion, of which £6.8 billion will be received in cash on closing of deal. Vodafone Japan later changed its name to SoftBank Mobile.

After acquiring Vodafone-Japan, SoftBank succeeded to turn around the company within about 6 months by giving customers the handset and the tariffs they wanted, and by investing at the levels required in Japan for network coverage etc.

After selling its stake in Japan, Vodafone learnt a lesson that choices of consumers are increasing and came up with a new strategy, they call it 2006 five point strategy .

• Revenue stimulation and cost reduction in Europe.
• Deliver strong growth in emerging markets .
• Innovate and deliver on our customers’ total communications needs.
• Actively manage our portfolio to maximize returns.
• Align capital structure and shareholder returns policy to strategy.

In Europe they focused on cost reduction and revenue stimulation. For that they did outsourcing and shared their services . They also realized that emerging markets will deliver strong growth. Emerging markets would be of 60% of total growth expected in 5 years.

Vodafone bought 67% stake in HutchisonEssar in India for $19 billion in 2006. Here they understood market well and did not repeat the mistake they did in Japan. They knew that consumers in India are not tech savvy, so they came up with economic deals there, kept their business simple and today they are one of the top market leaders in Telecommunication market in India.

Related posts:

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Vodafone in japan (a) description.

Despite a rough start in the Japanese telecom market, by late 2003, Vodafone seemed to have weathered the storm, largely based on the strength of their mobile phone unit. But was it simply the calm before the storm?

Case Description Vodafone in Japan (A)

Strategic managment tools used in case study analysis of vodafone in japan (a), step 1. problem identification in vodafone in japan (a) case study, step 2. external environment analysis - pestel / pest / step analysis of vodafone in japan (a) case study, step 3. industry specific / porter five forces analysis of vodafone in japan (a) case study, step 4. evaluating alternatives / swot analysis of vodafone in japan (a) case study, step 5. porter value chain analysis / vrio / vrin analysis vodafone in japan (a) case study, step 6. recommendations vodafone in japan (a) case study, step 7. basis of recommendations for vodafone in japan (a) case study, quality & on time delivery.

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Case Analysis of Vodafone in Japan (A)

Vodafone in Japan (A) is a Harvard Business (HBR) Case Study on Strategy & Execution , Texas Business School provides HBR case study assignment help for just $9. Texas Business School(TBS) case study solution is based on HBR Case Study Method framework, TBS expertise & global insights. Vodafone in Japan (A) is designed and drafted in a manner to allow the HBR case study reader to analyze a real-world problem by putting reader into the position of the decision maker. Vodafone in Japan (A) case study will help professionals, MBA, EMBA, and leaders to develop a broad and clear understanding of casecategory challenges. Vodafone in Japan (A) will also provide insight into areas such as – wordlist , strategy, leadership, sales and marketing, and negotiations.

Case Study Solutions Background Work

Vodafone in Japan (A) case study solution is focused on solving the strategic and operational challenges the protagonist of the case is facing. The challenges involve – evaluation of strategic options, key role of Strategy & Execution, leadership qualities of the protagonist, and dynamics of the external environment. The challenge in front of the protagonist, of Vodafone in Japan (A), is to not only build a competitive position of the organization but also to sustain it over a period of time.

Strategic Management Tools Used in Case Study Solution

The Vodafone in Japan (A) case study solution requires the MBA, EMBA, executive, professional to have a deep understanding of various strategic management tools such as SWOT Analysis, PESTEL Analysis / PEST Analysis / STEP Analysis, Porter Five Forces Analysis, Go To Market Strategy, BCG Matrix Analysis, Porter Value Chain Analysis, Ansoff Matrix Analysis, VRIO / VRIN and Marketing Mix Analysis.

Texas Business School Approach to Strategy & Execution Solutions

In the Texas Business School, Vodafone in Japan (A) case study solution – following strategic tools are used - SWOT Analysis, PESTEL Analysis / PEST Analysis / STEP Analysis, Porter Five Forces Analysis, Go To Market Strategy, BCG Matrix Analysis, Porter Value Chain Analysis, Ansoff Matrix Analysis, VRIO / VRIN and Marketing Mix Analysis. We have additionally used the concept of supply chain management and leadership framework to build a comprehensive case study solution for the case – Vodafone in Japan (A)

Step 1 – Problem Identification of Vodafone in Japan (A) - Harvard Business School Case Study

The first step to solve HBR Vodafone in Japan (A) case study solution is to identify the problem present in the case. The problem statement of the case is provided in the beginning of the case where the protagonist is contemplating various options in the face of numerous challenges that Vodafone Storm is facing right now. Even though the problem statement is essentially – “Strategy & Execution” challenge but it has impacted by others factors such as communication in the organization, uncertainty in the external environment, leadership in Vodafone Storm, style of leadership and organization structure, marketing and sales, organizational behavior, strategy, internal politics, stakeholders priorities and more.

Step 2 – External Environment Analysis

Texas Business School approach of case study analysis – Conclusion, Reasons, Evidences - provides a framework to analyze every HBR case study. It requires conducting robust external environmental analysis to decipher evidences for the reasons presented in the Vodafone in Japan (A). The external environment analysis of Vodafone in Japan (A) will ensure that we are keeping a tab on the macro-environment factors that are directly and indirectly impacting the business of the firm.

What is PESTEL Analysis? Briefly Explained

PESTEL stands for political, economic, social, technological, environmental and legal factors that impact the external environment of firm in Vodafone in Japan (A) case study. PESTEL analysis of " Vodafone in Japan (A)" can help us understand why the organization is performing badly, what are the factors in the external environment that are impacting the performance of the organization, and how the organization can either manage or mitigate the impact of these external factors.

How to do PESTEL / PEST / STEP Analysis? What are the components of PESTEL Analysis?

As mentioned above PESTEL Analysis has six elements – political, economic, social, technological, environmental, and legal. All the six elements are explained in context with Vodafone in Japan (A) macro-environment and how it impacts the businesses of the firm.

How to do PESTEL Analysis for Vodafone in Japan (A)

To do comprehensive PESTEL analysis of case study – Vodafone in Japan (A) , we have researched numerous components under the six factors of PESTEL analysis.

Political Factors that Impact Vodafone in Japan (A)

Political factors impact seven key decision making areas – economic environment, socio-cultural environment, rate of innovation & investment in research & development, environmental laws, legal requirements, and acceptance of new technologies.

Government policies have significant impact on the business environment of any country. The firm in “ Vodafone in Japan (A) ” needs to navigate these policy decisions to create either an edge for itself or reduce the negative impact of the policy as far as possible.

Data safety laws – The countries in which Vodafone Storm is operating, firms are required to store customer data within the premises of the country. Vodafone Storm needs to restructure its IT policies to accommodate these changes. In the EU countries, firms are required to make special provision for privacy issues and other laws.

Competition Regulations – Numerous countries have strong competition laws both regarding the monopoly conditions and day to day fair business practices. Vodafone in Japan (A) has numerous instances where the competition regulations aspects can be scrutinized.

Import restrictions on products – Before entering the new market, Vodafone Storm in case study Vodafone in Japan (A)" should look into the import restrictions that may be present in the prospective market.

Export restrictions on products – Apart from direct product export restrictions in field of technology and agriculture, a number of countries also have capital controls. Vodafone Storm in case study “ Vodafone in Japan (A) ” should look into these export restrictions policies.

Foreign Direct Investment Policies – Government policies favors local companies over international policies, Vodafone Storm in case study “ Vodafone in Japan (A) ” should understand in minute details regarding the Foreign Direct Investment policies of the prospective market.

Corporate Taxes – The rate of taxes is often used by governments to lure foreign direct investments or increase domestic investment in a certain sector. Corporate taxation can be divided into two categories – taxes on profits and taxes on operations. Taxes on profits number is important for companies that already have a sustainable business model, while taxes on operations is far more significant for companies that are looking to set up new plants or operations.

Tariffs – Chekout how much tariffs the firm needs to pay in the “ Vodafone in Japan (A) ” case study. The level of tariffs will determine the viability of the business model that the firm is contemplating. If the tariffs are high then it will be extremely difficult to compete with the local competitors. But if the tariffs are between 5-10% then Vodafone Storm can compete against other competitors.

Research and Development Subsidies and Policies – Governments often provide tax breaks and other incentives for companies to innovate in various sectors of priority. Managers at Vodafone in Japan (A) case study have to assess whether their business can benefit from such government assistance and subsidies.

Consumer protection – Different countries have different consumer protection laws. Managers need to clarify not only the consumer protection laws in advance but also legal implications if the firm fails to meet any of them.

Political System and Its Implications – Different political systems have different approach to free market and entrepreneurship. Managers need to assess these factors even before entering the market.

Freedom of Press is critical for fair trade and transparency. Countries where freedom of press is not prevalent there are high chances of both political and commercial corruption.

Corruption level – Vodafone Storm needs to assess the level of corruptions both at the official level and at the market level, even before entering a new market. To tackle the menace of corruption – a firm should have a clear SOP that provides managers at each level what to do when they encounter instances of either systematic corruption or bureaucrats looking to take bribes from the firm.

Independence of judiciary – It is critical for fair business practices. If a country doesn’t have independent judiciary then there is no point entry into such a country for business.

Government attitude towards trade unions – Different political systems and government have different attitude towards trade unions and collective bargaining. The firm needs to assess – its comfort dealing with the unions and regulations regarding unions in a given market or industry. If both are on the same page then it makes sense to enter, otherwise it doesn’t.

Economic Factors that Impact Vodafone in Japan (A)

Social factors that impact vodafone in japan (a), technological factors that impact vodafone in japan (a), environmental factors that impact vodafone in japan (a), legal factors that impact vodafone in japan (a), step 3 – industry specific analysis, what is porter five forces analysis, step 4 – swot analysis / internal environment analysis, step 5 – porter value chain / vrio / vrin analysis, step 6 – evaluating alternatives & recommendations, step 7 – basis for recommendations, references :: vodafone in japan (a) case study solution.

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Vodafone in Japan (C)

By: Juan Alcacer, Mary Furey, Mayuka Yamazaki

An update to Vodafone cases A and B, describing Softbank's acquisition of Vodafone and its performance in Japan.

• Length: 6 page(s)
• Publication Date: Jan 31, 2011
• Discipline: Strategy
• Product #: 711470-PDF-ENG

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Learning Objectives

To highlight knowledge-seeking as a motivation for international expansion; to explore the trade-offs between adaptation and standardization for international subsidiaries; to illustrate the extent to which related horizontal diversification works; and to illustrate how operations in one country are impacted by operations in another.

Jan 31, 2011

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eurotechnology.com

M&A and growth in Japan – founded 1997 in Tokyo

Vodafone Japan fail: Why did Vodafone lose the opportunity of US$ 83 billion value, and help jumpstart the growth of SoftBank

Vodafone’s opportunity cost of us$ 83 billion, asset write-down by £28bn (= approx. us$ 50 billion) in 2006, and kicking off softbank’s meteoric rise.

by Gerhard Fasol

Vodafone Japan fail: learn from the missed US$ 83 billion opportunity in Japan

Vodafone japan fail: a painful lesson for the vodafone group, and the jumpstart for softbank’s meteoric rise.

Japan telecommunications industry (66th edition) – Market analysis & tutorial

When Vodafone acquired Japan Telecom in a series of transactions, Japan Telecom was a full service fixed and mobile (= J-phone) telecom operator servicing private and corporate customers, competing neck-to-neck with KDDI Corporation (TYO:9433) for the second place in Japan’s telecom sector.

KDDI Corporation (TYO:9433) today (10 August 2016) has a market cap of YEN 8450 billion (= US$ 83 billion), and at the time when Vodafone acquired Japan Telecom, was very similar to KDDI.

It can therefore easily be argued that if Japan Telecom had been managed equally well as KDDI, then there is no reason to believe that Japan Telecom today would not have a market cap of at least US$ 83 billion as well.

Instead, Vodafone sold off Japan Telecom bit-by-bit to the SoftBank Group in a large number of transactions, the biggest one the sale of Vodafone KK (= Vodafone Japan) to Softbank on 17 March 2006 for about US$ 15 billion.

And according to the BBC , Vodafone announced in February/March 2006, that Vodafone would write off (write down the value of Vodafone assets) £28bn (= approx. US$ 50 billion).

The acquisition of Vodafone KK (=Vodafone Japan) by SoftBank laid the foundation for SoftBank ‘s meteoric rise to a major global player.

Vodafone Japan fail: Learn from Vodafone’s experience in Japan for your own business

Vodafone Japan failed not for one single reason but for hundreds of reasons, which can be grouped into soft factors (mainly lack of understanding Japan and Japan’s telecom markets and it’s true size) and hard factors (mainly far too low investment) – read more details in our SoftBank-report :

• Japan knowledge at HQ, and knowledge at HQ about the specifics of Japan’s telecom sector (or lack thereof).
• choice of management structure (there were attempts to correct the management structure, however too little and too late).
• attitude displayed both privately e.g. within the Japanese industry sector and publicly via marketing messages and advertising
• choice of executives and lower ranking managers and their knowledge and experience in Japan’s telecom sector (or lack thereof)
• lack of sufficient know-how and experience to manage a large Japanese company, and particular the chain of retail stores
• lack of management and execution know-how in Japan: tried three (3!!) times to introduce / roll-out 3G services in Japan, and failed every time to attract sufficient subscribers. As a result Vodafone Japan was far behind in 3G introduction. Only after sale to SoftBank, did SoftBank succeed in implementing the transition to 3G
• too high expectations for profitability and margins from HQ, which were out of line with profitability and returns usual in Japan, and out of line of competitor’s margins at that time. Note that SoftBank turned round the failed Vodafone-Japan company within a few months, and today Japan’s mobile operators Docomo, KDDI and SoftBank enjoy some of the highest profit margins on planet earth .
• and many more
• far too low budgets for infrastructure investment resulting in much lower coverage and network quality compared to competitors NTT-DoCoMo and KDDI/au and TuKa, Willcom and others. As a consequence of far too low investment budgets, Vodafone failed three times to introduce 3G services in Japan. (3G services were not successfully introduced until after the acquisition by Softbank, and after conversion of Vodafone KK to Softbank-Mobile).
• mobile phone handsets were inferior to the handsets offered by competitors NTT-DoCoMo and KDDI , and TuKa

Vodafone Japan? Why did it fail and sell to SoftBank? – Detailed answer

Find a long answer in this blog post below, in our other blog posts, and in some detail including statistics and financial data in our Softbank Report .

On Friday March 17, 2006, Vodafone and Softbank announced that Vodafone sells Vodafone KK (the totality of all Vodafone operations in Japan) to Softbank.

It has been reported that on Monday March 20, 2006, Softbank started to move all Vodafone KK staff, furniture and equipment from Vodafone KK’s former headquarters in the top floors of the Atago-Greenhills-Mori-Tower to Softbank headquarters in Shiodome (near Shinbashi). Also Softbank arranged very quickly that essentially all foreign expatriate managers left Vodafone KK – some stayed in Japan working for other IT companies, some returned to European Vodafone divisions, and some pursued telecom careers in USA, India, Bangladesh, or elsewhere.

By total coincidence, I had dinner with a high-level manager of Vodafone KK, of European nationality, at the indian restaurant Moti’s in Tokyo-Roppongi on exactly the same day, the Friday March 17, 2006 a few hours after the sale of Vodafone KK to Softbank was announced. I asked him: “Which of the following is true:”

• Vodafone never did any market research in Japan?
• Vodafone did market research in Japan, but the quality was low?
• Vodafone did market research in Japan, but nobody read it?

This Vodafone KK (Vodafone Japan) manager’s answer at the indian dinner was (3): market research was done about Japan’s mobile phone market, but the market research was not sufficiently taken into account in the business and strategy planning.

Fact is, that Vodafone KK (Vodafone Japan) took many major strategy and market decisions in Japan, which were not related to the realities of Japan’s market. Here one example. When “rebranding” (=changing the company / product / services names) from J-Phone to Vodafone, this “rebranding” campaign was centered on global roaming, i.e. Vodafone enabled Japanese customers to use Japanese J-Phone/Vodafone mobile phones in a very large number of countries outside Japan as well as inside Japan. This was at a time, when Japan’s mainstream mobile 2G phone system which both DoCoMo and J-Phone used was PDC, while much of the rest of the world, especially Europe used GSM. However, what Vodafone overlooked was, that at that time DoCoMo had about 30,000 roaming customers, out of approx. 50 million subscribers, i.e. only about 0.1% of Japanese mobile phone users used international roaming at that time. Thus Vodafone KK in Japan focused their main nation-wide poster and TV and other media campaign on about 0.1% of the Japanese market (and about 0.02% of Vodafone KK’s accessible market, given Vodafone KK’s approx. 20% market share) – less than a niche. (The reason we know how many roaming customers DoCoMo had at that time, is because one of Vodafone KK’s competitors in Japan engaged our company Eurotechnology Japan KK to analyze Japan’s roaming market, and help our client to develop strategy to better compete with Vodafone KK’s roaming products, which were aggressively marketed, and the core of Vodafone KK’s marketing focus).

Another example was Vodafone KK’s strategic focus on Japan’s prepaid market (find detailed statistics and market shares and analysis of Japan’s prepaid market in our JCOMM report ). In 2006 there were about 2.6 million prepaid mobile phone customers in Japan, i.e. about 2.7% of the market, while DoCoMo had about 45,200 prepaid subscribers, i.e. about 0.09% of DoCoMo’s subscribers were prepaid customers. Since the prepaid market in Europe (especially Italy where about 1/2 of the market is prepaid) is extremely important and highly profitable, Vodafone decided on the strategy to focus strongly on the development and growth of Japan’s prepaid market. Almost at the same time however, a national campaign started in Japan linking unregistered and illegally traded prepaid mobile phones to crime, and a law was proposed in Japan’s parliament to outlaw any type of prepaid mobile phones. Thus Vodafone KK found itself on the one hand promoting and investing to develop prepaid mobile phone services in Japan, developing, purchasing (as was the business model in Japan at that time) and bringing to market special prepaid handsets, and organizing national media campaigns promoting Vodafone prepaid mobile phones, while at the same time on the other hand facing the possibility that Japan’s parliament would outlaw these same prepaid mobile phones, and a broad press and TV national discussion on how prepaid mobile phones are linked to crime. The end result was, that instead of outlawing prepaid mobile phones, it was decided to introduce far stricter registration requirements and ID requirements for mobile phones and especially for prepaid mobile phones, and the unauthorized/unregistered sale or transfer of prepaid mobile phones in Japan was made a crime. The end effect for Vodafone of course was a commercial failure of Vodafone’s prepaid mobile phone campaign, in addition to a general decrease of ARPU (average revenue per user).

Instead of focusing on its core business in Japan, Vodafone KK focused management resources, and other resources to try to influence political decisions concerning 2.7% of the market: Japan’s minute and decreasing prepaid market.

Vodafone had many other management issues in Japan, which included recruitment and personality and retain issues of top executives, many kinds of HR issues, management issues at the retail stores, handset planning issues, branding and brand management issues, localization issues and much more.

As a consequence of these and other factors, Vodafone KK’s market share continuously decreased, subscribers moved from Vodafone KK to DoCoMo and KDDI/au, and the financial performance of Vodafone KK deteriorated, in the end convincing Vodafone that the best option was to sell Vodafone’s Japan operations and terminate business activities in Japan.

Vodafone-Japan’s leadership was also chaotic. While normally sending a stream of European Vodafone executives without knowledge of Japan or Japanese language on very expensive expatriate packages for limited periods to Japan, at some stage Vodafone decided to headhunt one of Japan’s top mobile industry veterans, who had just lost a battle for Docomo’s CEO position. This Japanese mobile phone industry veteran after a few weeks asked to be transferred from his executive CEO of Vodafone-Japan position to the non-executive Chairman position and soon after left Vodafone-Japan – clearly it took him only a few weeks to understand the hopelessness of the situation.

You can find further details and statistics, financial performance and market share data during this period in our reports:

SoftBank today and 300 year vision (20th edition)

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Vodafone in Japan (A) Harvard Case Solution & Analysis

Home >> Business Case Studies >> Vodafone in Japan (A)

Despite a rough start in the Japanese telecom market , by late 2003, Vodafone seemed to have weathered the storm, largely based on the power of their mobile telephone unit. But was it merely the calm before the storm?

Vodafone in Japan (A) Case Study Solution

PUBLICATION DATE: December 15, 2010 PRODUCT #: 711464-HCB-ENG

This is just an excerpt. This case is about STRATEGY & EXECUTION

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Rare kidney cancer mutation found in 70% of Japan patients, study shows

A unique genetic mutation has been found in more than 70% of certain kidney cancer patients in Japan, a higher percentage than in other countries, an international team of researchers said Tuesday.

The team conducted whole-genome analyses of cancer cells from 962 patients with clear cell renal cell carcinoma, the most common type of kidney cancer, in 11 countries, including Japan, the United States and European countries. It extracted mutational signatures from genetic sequences to analyze the causes of cancer and regional differences.

It found that the SBS12 mutational signature was detected in 26 of the 36 Japanese patients in the study, while it was found in only about 2% of patients from other countries. The characteristics of the signature differed from those linked to aging, obesity and high blood pressure.

The mutation was detected frequently in a previous genetic analysis of hepatocellular carcinoma, a type of liver cancer, in Japanese people.

According to the National Cancer Center Japan, about 80% of kidney cancer patients suffer from renal cell carcinoma, of which 60% to 75% are the clear cell type.

That type of kidney cancer is highly prevalent in central and northern Europe and has been on the rise in Japan in recent years.

The center plans to cooperate with the World Health Organization to identify the carcinogenic factor causing the mutation and investigate its distribution.

Tatsuhiro Shibata, director of cancer genomics research at the Japanese cancer center, called the latest study "a step toward developing new prevention and treatment methods."

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"Considering Microsoft Advertising’s rich data and knowing that the quality of trivago users in Japan is very high, we thought it was a great opportunity.”

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Strategy & Execution Case Study | Authors :: Juan Alcacer, Mary Furey, Mayuka Yamazaki

Case study description.

Despite a rough start in the Japanese telecom market, by late 2003, Vodafone seemed to have weathered the storm, largely based on the strength of their mobile phone unit. But was it simply the calm before the storm?

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• HBR case studies provide anecdotal instances from managers and employees in the organization to give a feel of real situation on the ground. Use these instances and opinions to mark out the organization's culture, its people priorities & inhibitions.
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In our live classes we often come across business managers who pinpoint one problem in the case and build a case study analysis and solution around that singular point. Business environments are often complex and require holistic solutions. You should try to understand not only the organization but also the industry which the business operates in. Porter Five Forces is a strategic analysis tool that will help you in understanding the relative powers of the key players in the business case study and what sort of pragmatic and actionable case study solution is viable in the light of given facts.

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• Business Unit Level Solution - The case study may put you in a position of a marketing manager of a small brand. So instead of providing recommendations for overall company you need to specify the marketing objectives of that particular brand. You have to recommend business unit level recommendations. The scope of the recommendations will be limited to the particular unit but you have to take care of the fact that your recommendations are don't directly contradict the company's overall strategy. For example you can recommend a low cost strategy but the company core competency is design differentiation.
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Step 8 -Implementation Framework

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Step 9 - Take a Break

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Step 10 - Critically Examine Vodafone in Japan (A) case study solution

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• Vodafone in Japan (B)
• Strategy & Execution / MBA Resources

Introduction to case study solution

EMBA Pro case study solution for Vodafone in Japan (B) case study

At EMBA PRO , we provide corporate level professional case study solution. Vodafone in Japan (B) case study is a Harvard Business School (HBR) case study written by Juan Alcacer, Mary Furey, Mayuka Yamazaki. The Vodafone in Japan (B) (referred as “Vodafone Japan” from here on) case study provides evaluation & decision scenario in field of Strategy & Execution. It also touches upon business topics such as - Value proposition, Diversity, Entrepreneurship, Growth strategy, International business, IT, Marketing, Mergers & acquisitions, Operations management, Reorganization, Risk management. Our immersive learning methodology from – case study discussions to simulations tools help MBA and EMBA professionals to - gain new insight, deepen their knowledge of the Strategy & Execution field, and broaden their skill set.

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Case Description of Vodafone in Japan (B) Case Study

By 2005, Vodafone Group was losing its footing in the sophisticated Japanese telecom market. What were they doing wrong? Should they cut their losses and leave Japan, or could they learn from mistakes and turn things around?

Case Authors : Juan Alcacer, Mary Furey, Mayuka Yamazaki

Topic : strategy & execution, related areas : diversity, entrepreneurship, growth strategy, international business, it, marketing, mergers & acquisitions, operations management, reorganization, risk management, what is the case study method how can you use it to write case solution for vodafone in japan (b) case study.

Almost all of the case studies contain well defined situations. MBA and EMBA professional can take advantage of these situations to - apply theoretical framework, recommend new processes, and use quantitative methods to suggest course of action. Awareness of the common situations can help MBA & EMBA professionals read the case study more efficiently, discuss it more effectively among the team members, narrow down the options, and write cogently.

Case Study Solution Approaches

Three Step Approach to Vodafone in Japan (B) Case Study Solution

The three step case study solution approach comprises – Conclusions – MBA & EMBA professionals should state their conclusions at the very start. It helps in communicating the points directly and the direction one took. Reasons – At the second stage provide the reasons for the conclusions. Why you choose one course of action over the other. For example why the change effort failed in the case and what can be done to rectify it. Or how the marketing budget can be better spent using social media rather than traditional media. Evidences – Finally you should provide evidences to support your reasons. It has to come from the data provided within the case study rather than data from outside world. Evidences should be both compelling and consistent. In case study method there is ‘no right’ answer, just how effectively you analyzed the situation based on incomplete information and multiple scenarios.

Case Study Solution of Vodafone in Japan (B)

We write Vodafone in Japan (B) case study solution using Harvard Business Review case writing framework & HBR Strategy & Execution learning notes. We try to cover all the bases in the field of Strategy & Execution, Diversity, Entrepreneurship, Growth strategy, International business, IT, Marketing, Mergers & acquisitions, Operations management, Reorganization, Risk management and other related areas.

Objectives of using various frameworks in Vodafone in Japan (B) case study solution

By using the above frameworks for Vodafone in Japan (B) case study solutions, you can clearly draw conclusions on the following areas – What are the strength and weaknesses of Vodafone Japan (SWOT Analysis) What are external factors that are impacting the business environment (PESTEL Analysis) Should Vodafone Japan enter new market or launch new product (Opportunities & Threats from SWOT Analysis) What will be the expected profitability of the new products or services (Porter Five Forces Analysis) How it can improve the profitability in a given industry (Porter Value Chain Analysis) What are the resources needed to increase profitability (VRIO Analysis) Finally which business to continue, where to invest further and from which to get out (BCG Growth Share Analysis)

SWOT Analysis of Vodafone in Japan (B)

SWOT analysis stands for – Strengths, Weaknesses, Opportunities and Threats. Strengths and Weaknesses are result of Vodafone Japan internal factors, while opportunities and threats arise from developments in external environment in which Vodafone Japan operates. SWOT analysis will help us in not only getting a better insight into Vodafone Japan present competitive advantage but also help us in how things have to evolve to maintain and consolidate the competitive advantage.

- Experienced and successful leadership team – Vodafone Japan management team has been a success over last decade by successfully predicting trends in the industry.

- Streamlined processes and efficient operation management – Vodafone Japan is one of the most efficient firms in its segment. The credit for the performance goes to successful execution and efficient operations management.

- Little experience of international market – Even though it is a major player in local market, Vodafone Japan has little experience in international market. According to Juan Alcacer, Mary Furey, Mayuka Yamazaki , Vodafone Japan needs international talent to penetrate into developing markets.

- Vodafone Japan business model can be easily replicated by competitors – According to Juan Alcacer, Mary Furey, Mayuka Yamazaki , the business model of Vodafone Japan can be easily replicated by players in the industry.

Opportunities

- Developments in Artificial Intelligence – Vodafone Japan can use developments in artificial intelligence to better predict consumer demand, cater to niche segments, and make better recommendation engines.

- Increase in Consumer Disposable Income – Vodafone Japan can use the increasing disposable income to build a new business model where customers start paying progressively for using its products. According to Juan Alcacer, Mary Furey, Mayuka Yamazaki of Vodafone in Japan (B) case study, Vodafone Japan can use this trend to expand in adjacent areas Diversity, Entrepreneurship, Growth strategy, International business, IT, Marketing, Mergers & acquisitions, Operations management, Reorganization, Risk management.

- Age and life-cycle segmentation of Vodafone Japan shows that the company still hasn’t able to penetrate the millennial market.

- Customers are moving toward mobile first environment which can hamper the growth as Vodafone Japan still hasn’t got a comprehensive mobile strategy.

Once all the factors mentioned in the Vodafone in Japan (B) case study are organized based on SWOT analysis, just remove the non essential factors. This will help you in building a weighted SWOT analysis which reflects the real importance of factors rather than just tabulation of all the factors mentioned in the case.

What is PESTEL Analysis

PESTEL /PEST / STEP Analysis of Vodafone in Japan (B) Case Study

PESTEL stands for – Political, Economic, Social, Technological, Environmental, and Legal factors that impact the macro environment in which Vodafone Japan operates in. Juan Alcacer, Mary Furey, Mayuka Yamazaki provides extensive information about PESTEL factors in Vodafone in Japan (B) case study.

Political Factors

- Little dangers of armed conflict – Based on the research done by international foreign policy institutions, it is safe to conclude that there is very little probability of country entering into an armed conflict with another state.

- Political consensus among various parties regarding taxation rate and investment policies. Over the years the country has progressively worked to lower the entry of barrier and streamline the tax structure.

Economic Factors

- According to Juan Alcacer, Mary Furey, Mayuka Yamazaki . Vodafone Japan should closely monitor consumer disposable income level, household debt level, and level of efficiency of local financial markets.

- Foreign Exchange movement is also an indicator of economic stability. Vodafone Japan should closely consider the forex inflow and outflow. A number of Vodafone Japan competitors have lost money in countries such as Brazil, Argentina, and Venezuela due to volatile forex market.

Social Factors

- Leisure activities, social attitudes & power structures in society - are needed to be analyzed by Vodafone Japan before launching any new products as they will impact the demand of the products.

- Demographic shifts in the economy are also a good social indicator for Vodafone Japan to predict not only overall trend in market but also demand for Vodafone Japan product among its core customer segments.

Technological Factors

- 5G has potential to transform the business environment especially in terms of marketing and promotion for Vodafone Japan.

- Proliferation of mobile phones has created a generation whose primary tool of entertainment and information consumption is mobile phone. Vodafone Japan needs to adjust its marketing strategy accordingly.

Environmental Factors

- Environmental regulations can impact the cost structure of Vodafone Japan. It can further impact the cost of doing business in certain markets.

- Consumer activism is significantly impacting Vodafone Japan branding, marketing and corporate social responsibility (CSR) initiatives.

Legal Factors

- Intellectual property rights are one area where Vodafone Japan can face legal threats in some of the markets it is operating in.

- Property rights are also an area of concern for Vodafone Japan as it needs to make significant Diversity, Entrepreneurship, Growth strategy, International business, IT, Marketing, Mergers & acquisitions, Operations management, Reorganization, Risk management infrastructure investment just to enter new market.

What are Porter Five Forces

Porter Five Forces Analysis of Vodafone in Japan (B)

Competition among existing players, bargaining power of suppliers, bargaining power of buyers, threat of new entrants, and threat of substitutes.

What is VRIO Analysis

VRIO Analysis of Vodafone in Japan (B)

VRIO stands for – Value of the resource that Vodafone Japan possess, Rareness of those resource, Imitation Risk that competitors pose, and Organizational Competence of Vodafone Japan. VRIO and VRIN analysis can help the firm.

What is Porter Value Chain

Porter Value Chain Analysis of Vodafone in Japan (B)

As the name suggests Value Chain framework is developed by Michael Porter in 1980’s and it is primarily used for analyzing Vodafone Japan relative cost and value structure. Managers can use Porter Value Chain framework to disaggregate various processes and their relative costs in the Vodafone Japan. This will help in answering – the related costs and various sources of competitive advantages of Vodafone Japan in the markets it operates in. The process can also be done to competitors to understand their competitive advantages and competitive strategies. According to Michael Porter – Competitive Advantage is a relative term and has to be understood in the context of rivalry within an industry. So Value Chain competitive benchmarking should be done based on industry structure and bottlenecks.

What is BCG Growth Share Matrix

BCG Growth Share Matrix of Vodafone in Japan (B)

BCG Growth Share Matrix is very valuable tool to analyze Vodafone Japan strategic positioning in various sectors that it operates in and strategic options that are available to it. Product Market segmentation in BCG Growth Share matrix should be done with great care as there can be a scenario where Vodafone Japan can be market leader in the industry without being a dominant player or segment leader in any of the segment. BCG analysis should comprise not only growth share of industry & Vodafone Japan business unit but also Vodafone Japan - overall profitability, level of debt, debt paying capacity, growth potential, expansion expertise, dividend requirements from shareholders, and overall competitive strength. Two key considerations while using BCG Growth Share Matrix for Vodafone in Japan (B) case study solution - How to calculate Weighted Average Market Share using BCG Growth Share Matrix Relative Weighted Average Market Share Vs Largest Competitor

5C Marketing Analysis of Vodafone in Japan (B)

4p marketing analysis of vodafone in japan (b), porter five forces analysis and solution of vodafone in japan (b), porter value chain analysis and solution of vodafone in japan (b), case memo & recommendation memo of vodafone in japan (b), blue ocean analysis and solution of vodafone in japan (b), marketing strategy and analysis vodafone in japan (b), vrio /vrin analysis & solution of vodafone in japan (b), pestel / step / pest analysis of vodafone in japan (b), swot analysis and solution of vodafone in japan (b), references & further readings.

Juan Alcacer, Mary Furey, Mayuka Yamazaki (2018) , "Vodafone in Japan (B) Harvard Business Review Case Study. Published by HBR Publications.

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Case volume and specialization in critically ill emergency patients: a nationwide cohort study in Japanese ICUs

• Jun Fujinaga   ORCID: orcid.org/0000-0001-6222-7292 1 ,
• Takanao Otake 1 ,
• Takehide Umeda 1 , 2 &
• Toshio Fukuoka 1  

Journal of Intensive Care volume  12 , Article number:  20 ( 2024 ) Cite this article

Metrics details

Previous studies have explored the association between the number of cases and patient outcomes for critical illnesses such as sepsis and trauma, as well as various surgeries, with the expectation that a higher number of cases would have a more favorable effect on patient outcomes. The aim of this study was to elucidate the association among intensive care unit (ICU) case volume, specialization, and patient outcomes in critically ill emergency patients and to determine how ICU case volumes and specializations impact the outcomes of these patients in Japanese ICUs.

Utilizing data from the Japanese Intensive Care PAtient Database (JIPAD) from April 2015 to March 2021, this retrospective cohort study was conducted in 80 ICUs across Japan and included 72,214 emergency patients aged ≥ 16 years. The primary outcome measure was in-hospital mortality, and the secondary outcomes encompassed ICU mortality, 28-day mortality, ventilator-free days, and the lengths of ICU and hospital stays. Bayesian hierarchical generalized linear mixed models were used to adjust for patient- and ICU-level variables.

This study revealed a significant association between a higher ICU case volume and decreased in-hospital mortality. In particular, ICUs with a higher percentage (> 75%) of emergency patients showed more pronounced effects, with the odds ratios for in-hospital mortality in the higher case volume quartiles (Q2, Q3, and Q4) being 0.92 (95% credible interval [CI]: 0.88–0.96), 0.70 (95% CI: 0.67–0.73), and 0.78 (95% CI: 0.73–0.83), respectively, compared with the lowest quartile (Q1). Similar trends were observed for various secondary outcomes.

Conclusions

Higher ICU case volumes were significantly associated with lower in-hospital mortality rates in Japanese ICUs predominantly treating critically ill emergency patients. These findings emphasize the importance of ICU specialization and highlight the potential benefits of centralized care for critically ill emergency patients. These findings are potential insights for improving health care policy in Japan and may be valuable in emergency care settings in other countries with similar healthcare systems, after careful consideration of contextual differences.

Previous studies have explored the association between the number of cases and patient outcomes for critical illnesses such as sepsis and trauma and various surgeries, with the expectation that a higher number of cases would have a more favorable effect on patient outcomes [ 1 , 2 , 3 , 4 , 5 , 6 , 7 , 8 ]. Therefore, a positive relationship between case volume and outcome in a broader emergency patient population is expected. However, no such studies have been conducted.

In Japan’s emergency medical care system, critically ill emergency patients are admitted to intensive care units (ICUs) dedicated to emergency patients or to ICUs that also admit critically ill patients whose condition deteriorated while being treated on the general ward and patients after major surgery. These two types of ICUs in Japan exist in roughly equal numbers [ 9 ]. In addition to the different nature of each type, the number and proportion of emergency patients admitted to ICUs is expected to vary widely, depending on the individual hospital and the nature of the local healthcare system. Despite the potentially important role these differences could have on patient outcome, no comprehensive study has examined the effect of ICU specialization and case volume on patient outcomes within the Japanese emergency medical care framework. Therefore, the aim of this study was to examine the association between critically ill emergency patient case volumes, specialization, and outcomes by using a nationwide database to provide valuable insights into the optimization of emergency care.

Study design and data

This retrospective cohort study used data from the Japanese Intensive Care PAtient Database (JIPAD), a national registry established by the Japanese Society of Intensive Care Medicine (JSICM) to create a high-quality ICU database. The details of this registry have been previously described [ 10 ]. The JIPAD was initiated in 2014, and data have been available since fiscal year (FY) 2015.

Patients aged ≥ 16 years who were registered in the JIPAD between April 1, 2015 and March 31, 2021 included emergency patients admitted directly from the emergency department (ED), emergency patients admitted after surgery, emergency patients transferred from other hospitals, and patients transferred from non-ICU wards or care units within 2 days of emergency admission.

Patients were excluded who were transferred from non-ICU care units or wards after 2 days of emergency admission, had planned admissions, and were admitted to the ICU only for procedures. Facilities with missing information on the ICU staff (e.g., dedicated intensivists and dedicated ICU nurses) and on patients admitted to these facilities, and patients with missing Japan Risk of Death (JROD) scores [ 11 ] were excluded because they lacked essential information. Facilities having < 10 eligible patients per year and patients admitted to these facilities were excluded to address heterogeneity in patient care. The JROD score is a prognostic score calibrated for Japanese ICU patients, based on the Acute Physiology and Chronic Health Evaluation III-j scoring system [ 11 , 12 ].

Ethics statement

This study was approved by the Institutional Ethics Committee of Kurashiki Central Hospital (approval number: 4266; approval date: November 5, 2023). The committee confirmed that this study adheres to national ethical guidelines and the Declaration of Helsinki. All patients were de-identified, and the need for informed consent was waived.

Patient-level variables collected at admission included the JROD score, Sequential Organ Failure Assessment score, age, sex, underlying disease, body mass index (BMI), emergency surgery, cardiac resuscitation before admission, route of admission (i.e., ED, operating room, transfer from another hospital, non-ICU care unit, or ward), and disease group diagnosed at admission. We collected data on various invasive procedures performed in the ICU such as extracorporeal membrane oxygenation (venovenous or venoarterial), invasive mechanical ventilation, and the administration of continuous renal replacement therapy. Additionally, the fiscal years of admission and length of hospitalization were recorded. Facility-level data such as the type of hospital (university hospital or nonuniversity hospital), the proportion of emergency admissions, the number of intensivists and nurses, and the quantity of ICU and hospital beds were also collected.

Study outcomes

The primary outcome assessed was in-hospital mortality. Secondary outcomes included ICU mortality, 28-day mortality, ventilator-free days (VFDs) 28 days after admission, total length of ICU stay, and length of hospital stay. We defined VFDs as the number of days alive and free of invasive mechanical ventilation during the first 28 days after admission (i.e., 0 days if the patient died within 28 days or received invasive mechanical ventilation for > 28 days) [ 13 ].

Statistical analysis

We divided each ICU by the quartile of the average number of eligible patients admitted per year and described the patient and facility characteristics for each quartile. Categorical data are presented as the number and percentage, and continuous variables are presented as the median and interquartile range (IQR). We calculated the risk-standardized mortality ratio (RSMR) [ 14 ] for each ICU by using the number of deaths in each ICU and the JROD score for each patient. We compared each ICU by using a funnel plot of the RSMR.

To account for our two-level hierarchy data structure, we used Bayesian hierarchical generalized linear mixed models with ICU-specific random effects, while adjusting for patient- and ICU-level variables as the fixed effects, and allowing for heterogeneity between ICUs. A random intercept was calculated for each ICU. We estimated an ‘‘empty’’ model (Model 1), which only included each ICU as a random intercept and allowed the detection of in-hospital mortality in various ICUs. The ICU-level random effect of the intercept was assumed to be normally distributed, with a mean value of zero. Thereafter, we estimated the full model (Model 2) to assess the association between case volume and in-hospital mortality by using patient- and ICU-level variables. Logistic regression was applied to in-hospital mortality, ICU mortality, and 28-day mortality. Linear regression models were applied to VFDs at 28 days, total length of ICU stay, and length of hospital stay. Patient-level variables were adjusted for age, sex, JROD score, BMI, cardiac resuscitation before admission, emergency surgery, admission diagnosis, and hospitalization period (FY 2015–2019 or FY 2020–2021). We classified the patients’ BMI into categories appropriate for Asian populations [ 15 ]. We adjusted for the type of hospital (university hospital or nonuniversity hospital), number of beds, number of intensivists per ICU bed, number of nurses per ICU bed, and percentage of emergency patients among all admitted patients. The number of beds in each hospital was classified into quartiles. The proportion of emergency patients to all admitted patients was divided into four quadrants, separated by 25%. Each quartile group was stratified, based on the percentage of emergency patients among all patients admitted to each ICU (Model 3), to assess the effects of case volume and specialization on critical emergency patients. We defined the 75% threshold as the “emergency patient-dominant group.” The threshold of 50% or 90% was used for the sensitivity analysis. Markov chain Monte Carlo (MCMC) methods were used to calculate the odds ratios (ORs) or regression coefficients and their corresponding 95% credible intervals (CIs). In the MCMC process, the first 2500 simulations were discarded as the burn-in and the remaining 10,000 simulations were obtained. Normal priors were used for the fixed effects, and noninformative uniform priors were used for the variance of each ICU in the mixed-effects model. The median ORs (MORs) were computed for ICU-level variance [ 16 , 17 ]. All analyses were performed using the Stata version 16.1 software (Stata, College Station, TX, USA).

Patients and ICU characteristics

We identified 248,908 ICU admission records from 89 ICUs. After applying the exclusion criteria, a total of 80 centers and 72,214 participants were included in the analysis (Fig.  1 ). Table 1 and Supplementary Table 1 show the patients’ characteristics for each quartile of the number of eligible patients in each ICU. The characteristics of the ICUs for each quartile of the number of patients are described in Table  2 . The annual number of eligible admissions was 352 (215.8–469.5) with 152 (118.6–192.3) in the first quartile (Q1), 294 (266.7–318.3) in the second quartile (Q2), 396.6 (391–459.8) in the third quartile (Q3), and 682.5 (541.8–699.3) for the fourth quartile (Q4). A total of 10,704 (14.8%) patients died during hospitalization with a VFD of 23 days.

Study flow diagram. The included patients are 16 years or older. They were enrolled in the JIPAD between April 2015 and March 2021 and were admitted immediately to the ICU or the next day after hospital admission. The exclusion criteria applied to facilities missing ICU staff data, patients lacking JROD scores, and facilities with fewer than 10 qualifying patients annually among their patients. JIPAD Japanese Intensive Care PAtient Database, ICU intensive care unit, JROD Japan Risk of Death

Risk-standardized mortality ratio

The RSMR for each ICU are shown in Fig.  2 . The variation in the RSMR was higher in ICUs with fewer emergency admissions, especially those with less than 200 admissions.

Funnel plots showing risk-standardized mortality rates among ICUs. The overall distribution is presented using the mean mortality ratio (solid line) and the control limits of 95% (dashed line) and 99.8% (dotted line). Each circle represents a single ICU

• In-hospital mortality

The ORs for the in-hospital mortality rates are shown in Table  3 and Supplementary Table 2. In Model 2, higher ICU volumes were associated with decreased in-hospital mortality. We evaluated the association between case volume and in-hospital mortality, adjusted for patient-level and ICU-level variables, and found that the ORs for Q3 and Q4 were 0.92 (95% CI: 0.88–0.95) and 0.93 (95% CI: 0.88–0.99), respectively, indicating decreased in-hospital mortality, compared with Q1. In Model 1, the MOR is 1.40 (95% CI: 1.32–1.49), indicating a significant variation in in-hospital mortality at the ICU level. In Model 2, adjusted for patient-level and ICU-level variables, we found a smaller MOR of 1.07 (95% CI: 1.02–1.12).

Secondary outcomes

Results for the secondary outcomes are shown in Supplementary Table 3. Q4 had ORs of 1.32 (95% CI: 1.24–1.41) and 1.12 (95% CI: 1.09–1.15) for ICU deaths and 28-day deaths, respectively. These values remained large after adjusting for patient-level and ICU-level variables in Model 2, but were inconsistent with the results for in-hospital mortality. We found that the case volume did not affect VFDs, ICU length of stay, or the reduced hospital length of stay in Q3 and Q4.

Stratified analyses

In Model 3, the quartiles were further stratified and examined, based on the percentage of emergency patients (i.e., > 75%). In Q1, no ICUs were included in the “emergency patient-dominant group” stratum. The findings of the study suggests that case volume had a larger effect on ICUs with an “emergency patient-dominant group” strata, as indicated by the lack of overlap in their respective 95% CI ranges (Fig.  3 ). The ORs for Q2, Q3, and Q4 in this stratum were 0.92 (95% CI: 0.88–0.96), 0.70 (95% CI: 0.67–0.73), and 0.78 (95% CI: 0.73–0.83), respectively. In-hospital mortality rates were lower in Q2, Q3, and Q4 than in Q1, even in ICUs with emergency patient ratios of < 75%. Sensitivity analyses were similar when the thresholds were set at 90% and 50% (Supplementary Table 4).

In-hospital mortality, stratified by the number of ICU admissions and percentage of emergency patients. Odds ratios were calculated using a multilevel logistic regression model, thereby allowing for a random effect (i.e., random intercept) model for each ICU. We adjusted ICU-level and patient-level variables, as follows: age, sex, BMI (< 18.5, 18.5–23, 23–27.5, and ≥ 27.5), JROD score, diagnosis at admission and after cardiac resuscitation, emergency surgery, hospitalization period (from FY 2015 through FY 2019 and from FY 2020 through FY 2021), number of nurses per ICU beds, number of intensivists per ICU beds, quartile of hospital beds, and type of hospital (university hospital or nonuniversity hospital). ICU intensive care unit, JROD Japan Risk of Death, BMI body mass index, FY fiscal year, Ref. reference

The stratified analysis of secondary outcomes is shown in Supplementary Table 5. For the “emergency patient-dominant group,” Q4 showed a reduction in ICU mortality with an OR of 0.77 (95% CI; 0.73–0.82), indicating heterogeneity in the association between case volume and outcome, depending on the frequency of emergency patients.

This study assessed the effects of case volume and specialization on the outcomes of critically ill emergency patients by using a comprehensive ICU patient database. The results revealed that higher ICU case volumes were associated with lower in-hospital mortality rates, particularly in ICUs with higher proportions of emergency patients.

This association is consistent with the findings of previous studies [ 2 , 3 , 7 , 8 , 18 ] conducted on other certain emergencies, supporting the learning curve hypothesis [ 18 ]. Another possible mechanism is that the ICUs in the lowest quartile (Q1) had fewer ICU beds relative to total hospital beds (Table  2 ), suggesting limited resources. Although these ICUs may treat more severely ill patients, the impact of bed count is minimal because adjustments were made for illness severity and staff number. Our analysis also revealed a nonlinear association between case volume and patient outcomes. This U-shaped association was more evident for ICU mortality and 28-day mortality, suggesting that a similar mechanism may exist as that described in a previous studies [ 19 , 20 ] in which an excess case volume was negatively associated with mortality. However, as shown in Supplementary Table 5, we observed differences in short-term mortality rates and hospital mortality rates in Q4, depending on the proportion of emergency patients. This indicates that the effect of case volume on short-term mortality is heterogeneous across the proportion of emergency patients in the ICU.

Furthermore, the stratified analysis by proportion of emergency patients showed a more obvious reduction in in-hospital mortality in ICUs with a predominantly emergency patient population, which may be because of the positive impact of ICU specialization. These ICUs may be well resourced and experienced in the treatment of emergency conditions, which may lead to better patient outcomes.

In this study, the MOR for in-hospital mortality was low (MOR 1.07; 95% CI: 1.02–1.12), indicating little variation in in-hospital mortality among ICUs. However, the MOR for short-term mortality, especially ICU mortality, was significantly higher (MOR 1.36; 95% CI: 1.27–1.46), suggesting a notable disparity in short-term outcomes, which were potentially influenced by ICU-level and patient-level variables. The MOR is defined as the median value of the OR between the highest and lowest risk clusters; if two clusters are chosen at random, the MOR indicates the increased risk (in median) of moving to another higher-risk cluster [ 16 ].

The MOR for ICU mortality increased substantially, suggesting a significant variation in short-term mortality risk across ICUs, which cannot be fully explained by ICU- or patient-level variables. These MOR results may have been derived from differences between the ICUs that were not captured in this dataset. Factors that may have created variations include ICU practices and protocols (e.g., differences in treatment protocols, staffing, and available resources), admission criteria (e.g., variation in patient admission criteria that may affect the risk profile of ICU patients), discharge criteria (affecting the length of ICU stay), facility characteristics (e.g., lack of high-dependency care units, which may affect admission and discharge criteria), and regional differences in the provision and use of critical care beds [ 21 ]. These findings indicate that further investigation of the factors affecting patient outcomes in the ICUs is required.

The RSMR for in-hospital mortality for each ICU (Fig.  2 ) could be appropriately compared with that of the entire population by using a funnel plot [ 14 ], showing the variation in the RSMR for ICUs with fewer emergency admissions. This finding suggests disparities in resources, quality of care, or patient population characteristics. This disparity was supported by the multilevel analysis (Model 2), which showed increased in-hospital mortality in ICUs with fewer than 200 emergency admissions per year (Q1), after adjusting for patient characteristics and ICU resources. Higher-case-volume ICUs may have lower RSMRs, possibly because of factors such as experienced staff, effective protocols, and resource availability.

The RSMR is a crucial indicator of quality of care but must be interpreted in conjunction with other indicators, such as the length of stay and readmission rates, for a comprehensive view of ICU performance. When calculating the RSMR, the method of risk adjustment must be considered to avoid misleading results—particularly if certain high-risk patient populations are inadequately accounted for. We improved the reliability of our results by using the JROD score [ 11 ], a newly developed index for intensive care patients in Japan. However, missing values or reporting bias when calculating the RSMR could affect the accuracy and reliability of the results.

One strength of this study was the use of the JIPAD, which registers various ICUs nationwide and regularly undertakes efforts to maintain data accuracy [ 22 ]. It is the most reliable database for ICUs in Japan in terms of size, reliability, and precision. Therefore, we believe that the participants and facilities in this study represent a highly representative population of emergency patients requiring intensive care in Japan.

This study has some limitations. Each facility in the JIPAD is anonymized; therefore, we classified the participating facilities, based on the ratio of emergencies to admitted patients. Second, a possibility of selection bias existed because five of nine centers were excluded because they had a small number of potentially eligible patients, they treated primarily pediatric patients, and were highly heterogeneous, whereas the other four centers lacked information on the number of intensivists and nurses. Although information on the number of intensivists and nurses was lacking, the small number of excluded patients had little impact on the results. Third, participation in the JIPAD was voluntary; therefore, the participating ICUs may have been more proactive in improving the quality of care. ICUs with larger case volumes or a higher proportion of emergency patients are more likely to participate in the JIPAD, which may cause further selection bias. Nevertheless, analyzing a homogeneous population increases the validity of comparisons and the reliability of statistical analysis. Furthermore, caution should be exercised when generalizing the results because these ICUs may not be fully representative of all ICUs in Japan. Fourth, we were unable to assess the proficiency or years of experience of the ICU staff. In Japan, intensivists typically have a background in emergency medicine or anesthesia [ 23 ]. We also could not assess differences in the background of intensivists. These differences could have influenced the patient outcomes, and therefore require further investigation into the effect of the expertise and training of ICU staff on patient outcomes. A fifth limitation is differences in healthcare systems. Extrapolating the results of this study to other countries may be limited by differences in healthcare systems, especially in ICU settings. However, extrapolation to other countries may be possible. Even after considering the effects of these differences, the results of this study may be relevant beyond the Japanese healthcare system. For instance, a comparable mechanism may be responsible for favorable patient outcomes in the emergency department intensive care unit (ED-ICU) system in the United States [ 24 ] or in ICUs where emergency physicians led operations in South Korea [ 25 ]. Specifically, this improvement in outcomes can be attributed to the shortened time to ICU admission for emergency patients, effective coordination between the ED and ICU, reduced length of stay in the ED, and a comprehensive understanding of the patients’ condition. Nevertheless, direct comparisons among different healthcare systems should be made with caution. Finally, the utilization of critical care and emergency medical systems in Japan was affected by the COVID-19 pandemic since April 2020 (FY 2020 and beyond) [ 26 , 27 , 28 ], which may have an impact on patient outcomes. Thus, we categorized data entry into two periods: FY 2015–2019 and FY 2020–2021. Future research could potentially focus on exploring the impact of different ICU characteristics and healthcare reimbursement classifications on critically ill patient outcomes. This research could involve examining factors, such as ICU size, patients’ demographics, and financial incentives within the reimbursement system, to better understand how these factors may influence care quality.

Higher case volumes and specialization of critically ill emergency patients are associated with a lower risk of in-hospital mortality. Based on these results, we recommend that critically ill emergency patients be centralized and admitted to specialized ICUs for emergency patients to optimize the emergency care system. Meanwhile, significant variability existed among ICUs in short-term mortality. Future studies focusing on regional differences and staff specialization are needed to determine the causes contributing to this variation.

Availability of data and materials

The author’s agreement with the JIPAD does not allow publishing the data used for this manuscript or sharing it with others. The JIPAD Working Group would cooperate in case any fraud or forgery is suspected in manuscripts in which JIPAD data are used.

Abbreviations

Body mass index

Credible interval

Emergency department

Fiscal year

Intensive care unit

Interquartile range

Japan Risk of Death

Japanese Intensive Care PAtient Database

Japanese Society of Intensive Care Medicine

Median odds ratio

Ventilator-free day

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Acknowledgements

We would like to thank the JIPAD Working Group in the Japanese Society of Intensive Care Medicine (Tokyo, Japan) for their help with this study.

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Emergency and Critical Care Center, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki City, Okayama, 710-8602, Japan

Jun Fujinaga, Takanao Otake, Takehide Umeda & Toshio Fukuoka

Department of Epidemiology, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, 2-5-1 Shikata-Cho, Kita-Ku, Okayama, 700-8558, Japan

Takehide Umeda

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JF conceived the fundamental idea and the study design, analyzed the data, and drafted the manuscript. TO and TU provided advice on study design, data analysis and interpretation, and critically revised the manuscript. TF supervised the conduct of the study and data collection and critically revised the manuscript. JF takes responsibility for the paper as a whole. All authors have read and approved the final manuscript.

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This study was approved by the Institutional Ethics Committee of Kurashiki Central Hospital (Kurashiki City, Japan; approval number: 4266; approval date: November 5, 2023). The committee confirmed that this study adheres to national ethical guidelines and the Declaration of Helsinki. All patients were de-identified, and the need for informed consent was waived.

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The authors declare no conflicts of interest associated with this manuscript. TF is supported by the Japan Agency for Medical Research and Development (AMED) (Grant number: 22lk0201085h0005). The funding sources had no role in the study design; in the collection, analysis and interpretation of data; in the writing of the manuscript; and in the decision to submit the manuscript for publication.

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Fujinaga, J., Otake, T., Umeda, T. et al. Case volume and specialization in critically ill emergency patients: a nationwide cohort study in Japanese ICUs. j intensive care 12 , 20 (2024). https://doi.org/10.1186/s40560-024-00733-3

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

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

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

31 Accesses

Metrics details

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

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

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

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

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

Peer Review reports

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

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

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

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

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

Aim, design, and setting

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

Participants

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

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

Phase I. Item generation through literature review

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

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

Phase 2. Item refinement through expert panel review

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

Phase 3. Face validity through cognitive interviews with nursing students

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

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

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

Fig. 1  Overview of survey development findings

Phase 1: survey item generation

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

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

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

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

Phase 2: faculty expert panel review

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

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

Ranking level of importance for survey items

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

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

Phase 3. Outcomes of cognitive interview focus group

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

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

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

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

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

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

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

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

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

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

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

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

Availability of data and materials

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

Abbreviations

British Columbia College of Nurses and Midwives

Medical assistance in dying

Nurse practitioner

Registered nurse

University of British Columbia Okanagan

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Acknowledgements

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

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

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

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JS conducted this study as part of their graduate requirements in the School of Nursing, University of British Columbia Okanagan.

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Correspondence to Barbara Pesut .

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All participants provided written and informed consent through approved consent processes. Research was conducted in accordance with the Declaration of Helsinki.

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

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Received : 24 October 2023

Accepted : 28 April 2024

Published : 14 May 2024

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

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