explanatory case study yin

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Continuing to enhance the quality of case study methodology in health services research

Shannon l. sibbald.

1 Faculty of Health Sciences, Western University, London, Ontario, Canada.

2 Department of Family Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.

3 The Schulich Interfaculty Program in Public Health, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.

Stefan Paciocco

Meghan fournie, rachelle van asseldonk, tiffany scurr.

Case study methodology has grown in popularity within Health Services Research (HSR). However, its use and merit as a methodology are frequently criticized due to its flexible approach and inconsistent application. Nevertheless, case study methodology is well suited to HSR because it can track and examine complex relationships, contexts, and systems as they evolve. Applied appropriately, it can help generate information on how multiple forms of knowledge come together to inform decision-making within healthcare contexts. In this article, we aim to demystify case study methodology by outlining its philosophical underpinnings and three foundational approaches. We provide literature-based guidance to decision-makers, policy-makers, and health leaders on how to engage in and critically appraise case study design. We advocate that researchers work in collaboration with health leaders to detail their research process with an aim of strengthening the validity and integrity of case study for its continued and advanced use in HSR.

Introduction

The popularity of case study research methodology in Health Services Research (HSR) has grown over the past 40 years. 1 This may be attributed to a shift towards the use of implementation research and a newfound appreciation of contextual factors affecting the uptake of evidence-based interventions within diverse settings. 2 Incorporating context-specific information on the delivery and implementation of programs can increase the likelihood of success. 3 , 4 Case study methodology is particularly well suited for implementation research in health services because it can provide insight into the nuances of diverse contexts. 5 , 6 In 1999, Yin 7 published a paper on how to enhance the quality of case study in HSR, which was foundational for the emergence of case study in this field. Yin 7 maintains case study is an appropriate methodology in HSR because health systems are constantly evolving, and the multiple affiliations and diverse motivations are difficult to track and understand with traditional linear methodologies.

Despite its increased popularity, there is debate whether a case study is a methodology (ie, a principle or process that guides research) or a method (ie, a tool to answer research questions). Some criticize case study for its high level of flexibility, perceiving it as less rigorous, and maintain that it generates inadequate results. 8 Others have noted issues with quality and consistency in how case studies are conducted and reported. 9 Reporting is often varied and inconsistent, using a mix of approaches such as case reports, case findings, and/or case study. Authors sometimes use incongruent methods of data collection and analysis or use the case study as a default when other methodologies do not fit. 9 , 10 Despite these criticisms, case study methodology is becoming more common as a viable approach for HSR. 11 An abundance of articles and textbooks are available to guide researchers through case study research, including field-specific resources for business, 12 , 13 nursing, 14 and family medicine. 15 However, there remains confusion and a lack of clarity on the key tenets of case study methodology.

Several common philosophical underpinnings have contributed to the development of case study research 1 which has led to different approaches to planning, data collection, and analysis. This presents challenges in assessing quality and rigour for researchers conducting case studies and stakeholders reading results.

This article discusses the various approaches and philosophical underpinnings to case study methodology. Our goal is to explain it in a way that provides guidance for decision-makers, policy-makers, and health leaders on how to understand, critically appraise, and engage in case study research and design, as such guidance is largely absent in the literature. This article is by no means exhaustive or authoritative. Instead, we aim to provide guidance and encourage dialogue around case study methodology, facilitating critical thinking around the variety of approaches and ways quality and rigour can be bolstered for its use within HSR.

Purpose of case study methodology

Case study methodology is often used to develop an in-depth, holistic understanding of a specific phenomenon within a specified context. 11 It focuses on studying one or multiple cases over time and uses an in-depth analysis of multiple information sources. 16 , 17 It is ideal for situations including, but not limited to, exploring under-researched and real-life phenomena, 18 especially when the contexts are complex and the researcher has little control over the phenomena. 19 , 20 Case studies can be useful when researchers want to understand how interventions are implemented in different contexts, and how context shapes the phenomenon of interest.

In addition to demonstrating coherency with the type of questions case study is suited to answer, there are four key tenets to case study methodologies: (1) be transparent in the paradigmatic and theoretical perspectives influencing study design; (2) clearly define the case and phenomenon of interest; (3) clearly define and justify the type of case study design; and (4) use multiple data collection sources and analysis methods to present the findings in ways that are consistent with the methodology and the study’s paradigmatic base. 9 , 16 The goal is to appropriately match the methods to empirical questions and issues and not to universally advocate any single approach for all problems. 21

Approaches to case study methodology

Three authors propose distinct foundational approaches to case study methodology positioned within different paradigms: Yin, 19 , 22 Stake, 5 , 23 and Merriam 24 , 25 ( Table 1 ). Yin is strongly post-positivist whereas Stake and Merriam are grounded in a constructivist paradigm. Researchers should locate their research within a paradigm that explains the philosophies guiding their research 26 and adhere to the underlying paradigmatic assumptions and key tenets of the appropriate author’s methodology. This will enhance the consistency and coherency of the methods and findings. However, researchers often do not report their paradigmatic position, nor do they adhere to one approach. 9 Although deliberately blending methodologies may be defensible and methodologically appropriate, more often it is done in an ad hoc and haphazard way, without consideration for limitations.

Cross-analysis of three case study approaches, adapted from Yazan 2015

The post-positive paradigm postulates there is one reality that can be objectively described and understood by “bracketing” oneself from the research to remove prejudice or bias. 27 Yin focuses on general explanation and prediction, emphasizing the formulation of propositions, akin to hypothesis testing. This approach is best suited for structured and objective data collection 9 , 11 and is often used for mixed-method studies.

Constructivism assumes that the phenomenon of interest is constructed and influenced by local contexts, including the interaction between researchers, individuals, and their environment. 27 It acknowledges multiple interpretations of reality 24 constructed within the context by the researcher and participants which are unlikely to be replicated, should either change. 5 , 20 Stake and Merriam’s constructivist approaches emphasize a story-like rendering of a problem and an iterative process of constructing the case study. 7 This stance values researcher reflexivity and transparency, 28 acknowledging how researchers’ experiences and disciplinary lenses influence their assumptions and beliefs about the nature of the phenomenon and development of the findings.

Defining a case

A key tenet of case study methodology often underemphasized in literature is the importance of defining the case and phenomenon. Researches should clearly describe the case with sufficient detail to allow readers to fully understand the setting and context and determine applicability. Trying to answer a question that is too broad often leads to an unclear definition of the case and phenomenon. 20 Cases should therefore be bound by time and place to ensure rigor and feasibility. 6

Yin 22 defines a case as “a contemporary phenomenon within its real-life context,” (p13) which may contain a single unit of analysis, including individuals, programs, corporations, or clinics 29 (holistic), or be broken into sub-units of analysis, such as projects, meetings, roles, or locations within the case (embedded). 30 Merriam 24 and Stake 5 similarly define a case as a single unit studied within a bounded system. Stake 5 , 23 suggests bounding cases by contexts and experiences where the phenomenon of interest can be a program, process, or experience. However, the line between the case and phenomenon can become muddy. For guidance, Stake 5 , 23 describes the case as the noun or entity and the phenomenon of interest as the verb, functioning, or activity of the case.

Designing the case study approach

Yin’s approach to a case study is rooted in a formal proposition or theory which guides the case and is used to test the outcome. 1 Stake 5 advocates for a flexible design and explicitly states that data collection and analysis may commence at any point. Merriam’s 24 approach blends both Yin and Stake’s, allowing the necessary flexibility in data collection and analysis to meet the needs.

Yin 30 proposed three types of case study approaches—descriptive, explanatory, and exploratory. Each can be designed around single or multiple cases, creating six basic case study methodologies. Descriptive studies provide a rich description of the phenomenon within its context, which can be helpful in developing theories. To test a theory or determine cause and effect relationships, researchers can use an explanatory design. An exploratory model is typically used in the pilot-test phase to develop propositions (eg, Sibbald et al. 31 used this approach to explore interprofessional network complexity). Despite having distinct characteristics, the boundaries between case study types are flexible with significant overlap. 30 Each has five key components: (1) research question; (2) proposition; (3) unit of analysis; (4) logical linking that connects the theory with proposition; and (5) criteria for analyzing findings.

Contrary to Yin, Stake 5 believes the research process cannot be planned in its entirety because research evolves as it is performed. Consequently, researchers can adjust the design of their methods even after data collection has begun. Stake 5 classifies case studies into three categories: intrinsic, instrumental, and collective/multiple. Intrinsic case studies focus on gaining a better understanding of the case. These are often undertaken when the researcher has an interest in a specific case. Instrumental case study is used when the case itself is not of the utmost importance, and the issue or phenomenon (ie, the research question) being explored becomes the focus instead (eg, Paciocco 32 used an instrumental case study to evaluate the implementation of a chronic disease management program). 5 Collective designs are rooted in an instrumental case study and include multiple cases to gain an in-depth understanding of the complexity and particularity of a phenomenon across diverse contexts. 5 , 23 In collective designs, studying similarities and differences between the cases allows the phenomenon to be understood more intimately (for examples of this in the field, see van Zelm et al. 33 and Burrows et al. 34 In addition, Sibbald et al. 35 present an example where a cross-case analysis method is used to compare instrumental cases).

Merriam’s approach is flexible (similar to Stake) as well as stepwise and linear (similar to Yin). She advocates for conducting a literature review before designing the study to better understand the theoretical underpinnings. 24 , 25 Unlike Stake or Yin, Merriam proposes a step-by-step guide for researchers to design a case study. These steps include performing a literature review, creating a theoretical framework, identifying the problem, creating and refining the research question(s), and selecting a study sample that fits the question(s). 24 , 25 , 36

Data collection and analysis

Using multiple data collection methods is a key characteristic of all case study methodology; it enhances the credibility of the findings by allowing different facets and views of the phenomenon to be explored. 23 Common methods include interviews, focus groups, observation, and document analysis. 5 , 37 By seeking patterns within and across data sources, a thick description of the case can be generated to support a greater understanding and interpretation of the whole phenomenon. 5 , 17 , 20 , 23 This technique is called triangulation and is used to explore cases with greater accuracy. 5 Although Stake 5 maintains case study is most often used in qualitative research, Yin 17 supports a mix of both quantitative and qualitative methods to triangulate data. This deliberate convergence of data sources (or mixed methods) allows researchers to find greater depth in their analysis and develop converging lines of inquiry. For example, case studies evaluating interventions commonly use qualitative interviews to describe the implementation process, barriers, and facilitators paired with a quantitative survey of comparative outcomes and effectiveness. 33 , 38 , 39

Yin 30 describes analysis as dependent on the chosen approach, whether it be (1) deductive and rely on theoretical propositions; (2) inductive and analyze data from the “ground up”; (3) organized to create a case description; or (4) used to examine plausible rival explanations. According to Yin’s 40 approach to descriptive case studies, carefully considering theory development is an important part of study design. “Theory” refers to field-relevant propositions, commonly agreed upon assumptions, or fully developed theories. 40 Stake 5 advocates for using the researcher’s intuition and impression to guide analysis through a categorical aggregation and direct interpretation. Merriam 24 uses six different methods to guide the “process of making meaning” (p178) : (1) ethnographic analysis; (2) narrative analysis; (3) phenomenological analysis; (4) constant comparative method; (5) content analysis; and (6) analytic induction.

Drawing upon a theoretical or conceptual framework to inform analysis improves the quality of case study and avoids the risk of description without meaning. 18 Using Stake’s 5 approach, researchers rely on protocols and previous knowledge to help make sense of new ideas; theory can guide the research and assist researchers in understanding how new information fits into existing knowledge.

Practical applications of case study research

Columbia University has recently demonstrated how case studies can help train future health leaders. 41 Case studies encompass components of systems thinking—considering connections and interactions between components of a system, alongside the implications and consequences of those relationships—to equip health leaders with tools to tackle global health issues. 41 Greenwood 42 evaluated Indigenous peoples’ relationship with the healthcare system in British Columbia and used a case study to challenge and educate health leaders across the country to enhance culturally sensitive health service environments.

An important but often omitted step in case study research is an assessment of quality and rigour. We recommend using a framework or set of criteria to assess the rigour of the qualitative research. Suitable resources include Caelli et al., 43 Houghten et al., 44 Ravenek and Rudman, 45 and Tracy. 46

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Explanatory Case Study Design—A Clarification

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Megan Anne Simons, Jenny Ziviani, Explanatory Case Study Design—A Clarification, Journal of Burn Care & Research , Volume 32, Issue 1, January-February 2011, Page e14, https://doi.org/10.1097/BCR.0b013e3182033569

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For the purpose of clarity for the readership, we wish to address the description of the explanatory case study design (ECSD) as a qualitative research method in the invited critique to our original article. 1 Yin, 2 the primary source for ECSD, described case study as suitable when the number of variables of interest exceeds the number of data points (i.e., participants). He has positioned the case study as a stand-alone method, in which the collection of both quantitative and qualitative data is appropriate. 3 We agree that within a qualitative research paradigm, the sample size of seven participants 1 would likely be insufficient to satisfy the sampling strategy. However, ECSD is “driven to theory.” 3 , p. 1212 The use of multiple case studies (as in the original study) is deemed the equivalent of multiple experiments. 2 Generalization from the case studies is accomplished using replication logic derived from theoretical propositions (hypotheses) or theories about the case. Results are considered even more potent when two or more cases support the same theory but not an equally plausible, rival theory. 2 The problem of generalizing from case studies is the same as generalizing from experiments—where hypotheses and theory are the vehicles for generalization. 3 With this point of clarification, we acknowledge that the findings from the original study are limited to children with lower injury severity (when measured as %TBSA) within a shortened timeframe postburn injury (6 months).

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• R. M. Channaveer 4 &
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This chapter reviews the strengths and limitations of case study as a research method in social sciences. It provides an account of an evidence base to justify why a case study is best suitable for some research questions and why not for some other research questions. Case study designing around the research context, defining the structure and modality, conducting the study, collecting the data through triangulation mode, analysing the data, and interpreting the data and theory building at the end give a holistic view of it. In addition, the chapter also focuses on the types of case study and when and where to use case study as a research method in social science research.

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Case Study Research and Applications Design and Methods

• Robert K. Yin - COSMOS Corporation
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Password-protected Instructor Resources include the following:

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“The book is filled with tips to the researcher on how to master the craft of doing research overall and specifically how to account for multi-layered cases.”

“Yin covers all of the basic and advanced knowledge for conducting case study and why they are useful for specific research studies without getting lost in the weeds.”

“The applications enhance the original material because it gives the reader concrete examples.”

“Yin is much more in-depth on case study methods both within a general qualitative text and any other case study text I have seen.”

On demand used as recommendation for basic literature for case study research

An essential reading for people doing case studies.

very thoruogh introduction

Very good introduction to Case Study design. I have used case study approach for my PhD study. I would recommend this book for an indepth understanding of case study design for research projects.

Dr Siew Lee School of Nursing, Midwifery and Paramedic Practice Robert Gordon University, Aberdeen.

The book is a really good introduction to case study research and is full of useful examples. I will recommend as the definitive source for students interested in pursuing this further in their projects.

In our Doctor of Ministerial Leadership (DML), Case Study is the Methodology that is required in this program. Robert Yin's book provides the foundational knowledge needed to conduct research using his Case Study design.

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The Case Study Anthology

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"This anthology is very useful. It speaks directly to students. The writing is extraordinarily strong throughout the samples—clear and concise, interesting and insightful, authoritative and accessible. This is a book I will order with enthusiasm as required reading in my course on research design." —Dr. Larissa A. Grunig, Department of Communication, University of Maryland

The Case Study Anthology , the latest from bestselling author Robert Yin, introduces readers to the world of case study research. It contains 19 carefully chosen and well-edited works, some of which represent excerpts from all-time classic case studies in sociology, political science, and related disciplines. This anthology will help readers to understand how case study research has been conducted—including the current state of the art—and how they might conduct their own case studies. With this in mind, the cases are arranged according to the process of doing case study research:

* Theoretical perspectives and case selection * The strength of multiple cases * Quantitative evidence and "embedded" units of analysis * More illustrations of case study evidence * Analysis and conclusions

Authors of the cases include many eminent social scientists, including

Graham Allison Anthony S. Bryk James S. Coleman Seymour Martin Lipset Helen Merrell Lynd Robert S. Lynd Ira Magaziner Richard Neustadt Everett M. Rogers Martin Trow W. Lloyd Warner Aaron Wildavsky

The Case Study Anthology will be a perfect supplemental text or reference for any research course in the social sciences, including sociology, anthropology, and political science, as well as related practice fields such as education, planning, health, and management.

See what’s new to this edition by selecting the Features tab on this page. Should you need additional information or have questions regarding the HEOA information provided for this title, including what is new to this edition, please email [email protected] . Please include your name, contact information, and the name of the title for which you would like more information. For information on the HEOA, please go to http://ed.gov/policy/highered/leg/hea08/index.html .

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“This anthology is very useful. It speaks directly to students. The writing is extraordinarily strong throughout the samples—clear and concise, interesting and insightful, authoritative and accessible. This is a book I will order with enthusiasm as required reading in my course on research design.”

Every case in the Anthology is worth reading.

This book is like an “anthology” overarching subject of case studies. It is a must have or must read book if you are embarking on a research adopting a case study approach. The book will certainly appeal to the students in that it speaks directly to them and in plain English. Additionally, the book has extensive description of what a case study is with examples drawn from various disciplines with easy to follow explanations on cast study techniques such as descriptive, explanatory, cross-case and methodological. It is an interesting and insightful book with authoritative and accessible nature. Everything a research student has to ask on cast studies, is answered in this book!

This book is suited for someone who is interested in examples of case studies. The book does not contain instructions on HOW to do a case study as such, but more on case studies that have already been done.

Not all of my students carry out case study research, so it would be wrong of me to recommend the book as essential. However those that do use case studies will be recommended the book. Thanks

Another excellent book by Yin - clear, concise and very easy to understand. Comprehensive examples of the approaches are especially useful.

clearly demonstrates how the other works by Yin are used in real world research, with clarity and diverse case studies to bring to life the method of case study research

• Four distinct sections, each focusing on specific issues/perspectives of case study research: Theoretical Perspectives, Multiple Cases, Quantitative Evidence and "Embedded" Units of Analysis, and More Illustrations of Case Study Evidence.
• Case Studies from a wide range of settings, including health, politics, business/management, sociology, education, and technology.
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• Research article
• Open access
• Published: 08 April 2013

Using case study within a sequential explanatory design to evaluate the impact of specialist and advanced practice roles on clinical outcomes: the SCAPE study

• Joan G Lalor 1 ,
• Dympna Casey 2 ,
• Naomi Elliott 1 ,
• Imelda Coyne 1 ,
• Catherine Comiskey 1 ,
• Agnes Higgins 1 ,
• Kathy Murphy 2 ,
• Declan Devane 2 &
• Cecily Begley 1  

BMC Medical Research Methodology volume  13 , Article number:  55 ( 2013 ) Cite this article

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The role of the clinical nurse/midwife specialist and advanced nurse/midwife practitioner is complex not least because of the diversity in how the roles are operationalised across health settings and within multidisciplinary teams.

This aim of this paper is to use The SCAPE Study: Specialist Clinical and Advanced Practitioner Evaluation in Ireland to illustrate how case study was used to strengthen a Sequential Explanatory Design.

In Phase 1, clinicians identified indicators of specialist and advanced practice which were then used to guide the instrumental case study design which formed the second phase of the larger study. Phase 2 used matched case studies to evaluate the effectiveness of specialist and advanced practitioners on clinical outcomes for service users. Data were collected through observation, documentary analysis, and interviews. Observations were made of 23 Clinical Specialists or Advanced Practitioners, and 23 matched clinicians in similar matched non-postholding sites, while they delivered care. Forty-one service users, 41 clinicians, and 23 Directors of Nursing or Midwifery were interviewed, and 279 service users completed a survey based on the components of CS and AP practice identified in Phase 1. A coding framework, and the generation of cross tabulation matrices in NVivo, was used to make explicit how the outcome measures were confirmed and validated from multiple sources. This strengthened the potential to examine single cases that seemed ‘different’, and allowed for cases to be redefined. Phase 3 involved interviews with policy-makers to set the findings in context.

Case study is a powerful research strategy to use within sequential explanatory mixed method designs, and adds completeness to the exploration of complex issues in clinical practice. The design is flexible, allowing the use of multiple data collection methods from both qualitative and quantitative paradigms.

Conclusions

Multiple approaches to data collection are needed to evaluate the impact of complex roles and interventions in health care outcomes and service delivery. Case study design is an appropriate methodology to use when study outcomes relate to clinical practice.

Peer Review reports

Case study design has been used frequently in health and social sciences to answer complex research questions due to its flexible and pragmatic approach [ 1 ]. Case study has been described as a ‘study of the particular’ (p XI) [ 2 ] as it is allows for the study of highly context-bound phenomena with a multiplicity of variables not amenable to control. More often than not, case study is undertaken in ‘real life situations’ (p 104) [ 3 ]. It is particularly useful in organisational research [ 4 , 5 ] as the methods of data collection and analysis used are selected on a pragmatic basis [ 6 ] conducive to undertaking research in clinical settings. Although much has been written about case study in terms of the difference in the epistemological bases of seminal authors such as Stake and Yin, Merriam contends that “there is little consensus on what constitutes a case study or how this type of research is done”(p26) [ 6 ]. Although it is differentiated from other qualitative approaches as the focus of the research bounded by the case, this lack of certainty in definition of case study has led to some confusion, as although there is some overlap on what a case is or is not, there are significant philosophical differences between key authors. For the purpose of illustration only, let us consider three key authors in the area of case study; Merriam, Stake and Yin, in terms of where they might theoretically position case study within a qualitative-quantitative continuum. Merriam [ 6 ] contends that the single defining characteristic of case study research lies in the bounding of ‘the case’, that is giving consideration to the case as “a thing, a single entity, a unit around which there are boundaries” (p27). Case study typically utilises qualitative and quantitative data sources, selected to encapsulate the complexity of the phenomenon. Merriam [ 6 ] offers precise direction for the researcher employing a case study design in terms of using a theoretical framework to define the problem, and suggests sampling of the case (and within the case) from typical or unique examples or a range of examples to achieve maximum variation. Data are typically collected from multiple sources and can be subjected to a range of analytical strategies such as those used in, but not limited to, grounded theory, ethnography or other approaches that involve developing systems to categorise data. Although firmly grounded in a qualitative paradigm, she offered an intensely pragmatic approach to using case study in the field, and therefore (metaphorically speaking) could be located in the middle of the continuum. Stake [ 7 ] contends that the most critical role of the researcher is that of interpreter, one who constructs a view of the phenomenon through explanation and description “providing readers with good raw material for their own generalizing” (p102). Consequently, as Stake is firmly rooted in an interpretative paradigm, he could be considered to be located on the far left of the continuum. Given Stake’s position that the researcher must be “ever-reflective” (p 927) to find meanings in the data, his creative approach may have contributed to a perception that case study design is somewhat ‘elusive’ [ 8 ], as authors in nursing journals, in particular, fail to define their interpretations or offer a rationale for the approach taken [ 9 ]. Alternatively, Yin contends that a systematic approach to data collection and analysis is crucial to ensuring the methodological integrity of case study, and to demonstrate rigour, the procedural steps undertaken must be made explicit [ 2 , 8 , 10 ]. Using our continuum, Yin could be positioned on the far right, as his view also allows for the inclusion of quantitatively generated data, requires data to be collected through clearly articulated steps, integrating multiple sources of evidence to create a database of evidence in the form of narratives, documents, fieldnotes, observations etc. to increase the reliability of the case study. For this study, we consider case study as a research strategy, aligned with the position held by Yin [ 5 , 11 ], as given the nature of this nationwide evaluation, the large membership of the research team and multiple case sites, a structured rather than a reflective approach to data collection and analysis was required. However, the study was also influenced by the need to take a pragmatic approach [ 6 ], as data were being collected within the context of healthcare delivery.

This aim of this paper is to use The SCAPE Study: Specialist Clinical and Advanced Practitioner Evaluation in Ireland (present authors 2010) to illustrate how case study was used to strengthen a Sequential Explanatory Mixed Methods Design [ 12 ]. The SCAPE study evaluated the role of Clinical Nurse and Midwife Specialists (CNS/CMS) and Advanced Nurse and Midwife Practitioners (ANP/AMP), in a 3-phase study focusing on the clinical, professional and economic impact of the roles within the Irish publically funded health service. The paper will make particular reference to how case study ‘fit’ within a multiphase design, was bounded by data from phase 1 and relevant theoretical frameworks, and discuss how case study assisted in uncovering the complexity of specialist and advanced practice roles. The case study approach was deemed most appropriate for the proposed study as it examined a contemporary topic, (clinical nurse specialist and advanced nurse practitioner roles, skills, and impact), in a real life situation, (ward/unit setting), where it was difficult to extract practices from the influence of the social environment. It was important therefore, that the influence of contextual conditions on nurses’ and midwives’ practice was examined.

The research study: evaluation of CS and AP roles- ‘the SCAPE study’

For the past ten years, Ireland, like other countries, has seen the promulgation of specialist and advanced practice roles in nursing and midwifery. The development of this clinical career pathway has taken place against a backdrop of unparalleled health service reform. The reform measures aimed to ensure the efficient management of the health system and to consolidate health service delivery ensuring quality and value for money whilst promoting and protecting the health and welfare of the public. Changes in care delivery signalled a service requirement for clinical specialists and advanced practitioners within the multidisciplinary team, and the changing epidemiological profile of the population indicated a need for CS and AP posts to develop and proliferate into the future. Although considerable research has been undertaken both nationally and internationally evaluating the effectiveness of advanced nursing practice in many specialities, the challenges of distinguishing between tangible clinical outcomes and capturing the art of expert practice have been documented previously [ 13 – 15 ]. International comparisons between roles have been fraught with methodological difficulty, due to wide variations in the location of services, the organisational frameworks that dictate how practitioners work within multidisciplinary teams and the extent to which health service reform influences how the role and care pathways are operationalised. Hence, a national evaluation of these posts within the Irish health service was required if they were to continue to proliferate in line with planned reforms for service configuration and delivery [ 16 ].

Defining case study research

Case study is a flexible research design that allows for the capture of holistic and meaningful characteristics of real life events [ 17 – 19 ]. Consequently it has been chosen as a favoured research approach by practitioners and policymakers [ 7 , 20 ]. One of the advantages of case study research is that it places emphasis on the use of multiple sources of evidence, and multiple realities, offering an opportunity to bridge paradigms [ 3 ]. Although case study can rarely be generalised, it can provide a unique understanding of the individual, organisational, social and political processes in context [ 11 ], allowing for the constraints experienced by participants in daily work to be taken into account [ 21 ]. Case study is most apt when examining complex factors that require answers [ 2 , 22 , 23 ] and when investigating nursing practice, given the multifaceted components that influence care delivery [ 24 ]. In particular, case study research is most appropriate when a: “‘how’ or ‘why’ question is being asked about a contemporary set of events over which the investigator has little or no control” (p9) [ 19 ]. Furthermore, it is an approach characterised by the use of multiple data collection methods, which provide a more “convincing and accurate” (p93) case study [ 17 ]. Although a popular methodology, case study is not without its critics, not least because of issues related to disentangling the ‘definitional morass’ (p17) [ 25 , 26 ]. Debates exist about the validity and generalisability of case study findings [ 27 , 28 ], and the fact that the two proponents of this approach, Yin and Stake, employ different terminology and epistemological positions [ 29 ]. Nevertheless, its pragmatic approach is a key strength along with its ability to facilitate ‘intensive study of one or more cases for an explicit purpose’ (p154) [ 28 ].

In this study, a sequential explanatory design (three phases) (Figure  1 ) was used to evaluate advanced (AP) and specialist (CS) roles across the health service seeking to determine if these roles had an impact on the clinical outcomes of patients accessing services with a post holder. Phase one involved establishing the activities and outcomes clinicians viewed to be associated with these posts through a three round Delphi method. Once established, Phase two was designed to gather data on the activities of APs and CSs and the context in which they practised. In order to undertake this evaluation, it was deemed necessary to compare the outcomes of services users receiving care from CSs and APs to those accessing a comparable service without an AP or CS working in the team. In phase two the focus was the existing state of specialist and advanced practice in Ireland; practitioners were observed and data were collected within a real-life context using multiple sources of evidence, and theoretical propositions from the literature and phase one of the study were used to guide data collection and analysis. Therefore a Yin approach to case study was deemed appropriate for several reasons:

Outline of ‘The SCAPE study’: phase 2- the case study.

The case study was ‘bounded’ by the data from phase one in relation to what clinicians deemed were the activities of postholders and clinical outcomes of these posts.

The sampling frame for Phase two available to the team to make comparisons was a national database of accredited post holders and the services within which they worked, held by the NCNM.

Cases were selected from the NCNM database of postholders to achieve maximum learning during the period of time available for the study [ 30 ]. Although we opted for a maximum variability sample in terms of location of postholder (geographical spread, urban/regional, based in acute services or community practice), case selection was ultimately limited to the availability of a matched service without a postholder for comparison. This meant that unique cases could not be sampled.

As it was a national study evaluating 23 (paired) services, with a large research team from two universities and four research assistants in the field, a pre-agreed theoretical/coding framework and rigorous procedures in terms of data collection and analysis (including database management) were required to ensure consistency.

A theoretical model of the processes and activities of advanced practice (the Logic Model) [ 31 ] was utilised as a coding framework for the analysis and integration of datasets. Practitioners’ activities were compared against a nationally agreed set of competencies for CSs and APs [ 32 ] to measure if the activities related to specialist or advanced practice.

Procedures to ensure internal validity included using four research assistants trained in using the tools to identify activities that represent specialist or advanced practice, regular research team meetings to ensure a shared interpretation of the data as they were being collected and analysed, analysts worked in pairs on data analysis and comparison within one of the core categories, and all findings were reviewed by one principal investigator for consistency.

Procedures to ensure external validity included: using independent research assistants not linked with the clinical case sites or data analysis, selection of cases to ensure generalisability of the findings within the publically funded health service in Ireland, ensuring data were categorised using a framework that would allow for international comparison (the Logic Model), extending data collection and analysis beyond the activities of the postholders to include contextual detail relevant to how the posts were operationalised.

The primary purpose of the larger research study was to understand and evaluate specialist and advanced practice in terms of the future of these posts within the health service rather than to describe the variation in how these roles were operationalised at an individual or local level. The case was deemed to be the organisation or institution where nurses or midwives worked, for example a ward or community clinic. Within this study, although 23 postholders and 23 non-postholders took part, they were at times located across a range of services provided by the same health provider. The flexibility of the case study approach ensured that the research team had access to a range of data collection strategies in order to undertake a comprehensive evaluation of what are complex, multi-faceted and intrinsically difficult to measure interventions, such as those delivered by CSs and APs [ 13 , 14 , 33 ]. The advantage to using a case study design over other triangulation methods was the continued focus on the case. As the purpose of The SCAPE Study [ 34 ] was to evaluate advanced and specialist practice roles, using case study within a sequential explanatory design allowed the research team to search for observable patterns across cases [ 35 ] at specialist and advanced practice levels, and to compare and contrast the outcomes of these roles with services without a specialist or advanced practitioner in post. This ensured that both the research assistants in the field and the research team handling the data during each phase of the study did not become distracted by the context and individuality of particular services or participants but rather allowed some degree of familiarity with the competencies demonstrated by specialist and advanced practitioners in comparison to the framework established by the NCNM for these roles.

Case study within a sequential explanatory design

The research was based on a multiphase design (Figure  1 ), further details of which may be found elsewhere [ 36 ]. Ethical approval was granted by a University ethics Committee, and by all clinical sites. The case studies of postholding and matched non-postholding services comprised the second phase, and aimed to provide an in-depth exploration of the CS and AP roles with reference to the parameters identified in the literature review, focus groups with clinicians and a Delphi survey of CSs and APs undertaken in phase one (further detail is provided below).

Case selection and context

In order to meet the objectives of the evaluation (did CS and AP roles have an impact on clinical outcomes), the cases were selected on the basis that a matched service similar to that being delivered by a CS or an AP in a non- postholding site was available for comparison. Primarily typical cases such as diabetes maternity care, anticoagulant therapy, and infectious diseases were chosen as these posts were common in the Irish health service and were also described in the literature. However, some posts were either so common as to lead to a situation whereby a service no longer existed without having a CS or AP in post, such as lactation specialists in midwifery and diabetic nurse specialist posts in general nursing. Alternatively posts were excluded as they were deemed to be so unique as to be ‘like no other’ (p 175) [ 37 ] such as fetal cardiac screening and spinal cord injury liaison. In these cases a matched non-postholding service could not be found for comparison. In keeping with an instrumental case design (the assumption being that studying CSs and APs in context is instrumental to understanding the impact of these roles on service user outcomes), the cases were purposively selected for the informational representativeness they could yield. This was determined by reviewing the national database of posts held by the National Council of Nursing and Midwifery, applying the theoretical propositions regarding specialist and advanced practice in the literature and locating a matched non-postholding service for comparison. Twenty-three postholders across nursing (general, mental health, intellectual disability, community health and children’s) and midwifery, located within acute and community settings were matched with 23 non postholding services for the case study.

Developing a framework for case-focused analysis

In order to undertake a rigourous evaluation of specialist and advanced practice roles in Ireland, consideration was given to the need for an analytical framework to interpret and integrate the data from multiple data sources across the three phases of the study. Consideration was given to Ritchie and Spencer’s [ 38 ] framework analysis approach as it has been recognised as a valuable tool within applied policy research where, not unlike The SCAPE Study, the research question is designed to gather specific information, the sample is pre-defined (accredited practitioners registered with the NCNM), and the primary concern is to describe and interpret what is happening in context (impact of the roles). Within a framework analysis approach, a thematic framework (the second stage) is identified after the researcher has become familiarised with the transcripts/fieldnotes etc., and although themes may have been identified a priori, it is modified based on the themes emerging in the data. Given the nature and complexity of the SCAPE study (i.e. multiple phases, large research team, four research assistants in the field, 23 matched pairs of cases and a wide and varied range of data sources and types), a robust framework to guide data collection and analysis was essential. To achieve consistency, this framework had to be identified a priori. Phase one of the study aimed to identify indicators of specialist and advanced practice activities or interventions deemed to have clinical/professional impact by participants working as, or working with, CSs and APs in clinical practice. Theoretical propositions regarding the key indicators of specialist and advanced practice guided the topics for exploration in seven focus group interviews (FGIs) with five health professional groups made up of CSs, APs, Directors of Nursing/Midwifery, Medical Consultants, Staff nurses/midwives and Assistant DON/Ms, and clinical managers. Emergent data from the groups then formed the basis of an instrument that was developed and refined in a three-round Delphi study. The instrument generated in round two of the Delphi study formed the basis of the variable-orientated analysis of cases of specialist and advanced practice. Core outcomes included (but were not limited to) communication, therapeutic relationship, shared decision-making, access to care, quality of life, symptom management, use of clinical guidelines, integration of research in practice, clinical leadership, clinical and educational interventions, multidisciplinary work, continuity of care, attitudes of others to the work of the postholder and best practice in service delivery (locally (within the service), nationally (within that patient/client group in Ireland) or internationally (contribution to the field)). In addition, a theoretical framework that would allow for international comparison with the specialist and advanced practice roles as operationalised in Ireland when compared with other countries where posts have been established for longer, was required.

Developing a framework to collect data from multiple sources in the field

It has been acknowledged in previous work on specialist, advanced practice and nurse consultant roles that these posts were developed with the intention of having a positive impact on patient/client outcomes. The underpinning assumptions to support the potential positive impact of these roles on clinical outcomes such as the clinical competencies of the individual practitioner and education of practitioners to master’s level and beyond, should be associated with the delivery of evidence based care leading to improved quality and efficiency in health care delivery. However, the actual clinical impact of these roles has been notoriously difficult to measure statistically [ 33 ]. Therefore, as an alternative to focussing on clinical outcome measures alone, Schultz et al. [ 39 ] suggested that the clinical significance of the outcome attributed to the postholder requires consideration. Guest et al. [ 14 ] contend that the impact of postholders is not limited to clinical outcomes, but rather that their activities in terms of the development of new services and the provision of clinical leadership for their colleagues may have an indirect impact on care. Consequently, if the focus were to remain on measuring clinical outcomes exclusively, the perceived professional outcomes associated with the role would fail to be captured. Gerrish et al. [ 13 ] proposed a framework of indicators of impact to take account of those with both clinical and professional significance such as symptomatology, quality of life, social significance and social validity.

Phase one of the study (literature review, focus groups and Delphi study) allowed for the identification of indicators and activities to populate these constructs and guide data collection during the observation periods within the case study. For example, core outcomes included but are not limited to: therapeutic relationship, shared decision-making, access to care, appropriateness of referral, patient/client satisfaction with information given, use of clinical guidelines by postholder, development of a new intervention, multidisciplinary teamwork, and other professionals’ knowledge level (e.g. improved understanding of clinical and social issues, patient needs/family experience). Given the size and complexity of the study, six members of the research team were involved in managing the case study, and training and supporting the four research assistants who were immersed across 23 postholding and 23 matched non postholding areas to collect data (Table  1 ).

Four hours of observations were conducted with each of 23 Clinical Specialists or Advanced Practitioners and 23 clinicians providing a service in similar matched non-postholding sites. Forty-one service users, 41 clinicians, and 23 Directors of Nursing or Midwifery were interviewed about their experiences of receiving care from, or working with, CS/APs or matched clinicians. Service users (n = 279) also completed a survey based on the components of CS and AP practice identified in Phase 1. Given the variation that was likely to be found in the roles, the context in which practitioners were working and the location of the service, a framework that could be applied in practice to ensure consistency in data collection and analysis was required. Bryant-Lukosius and DiCenso [ 40 ] developed ‘The PEPPA Framework’ to guide the implementation of advanced practice roles. The process involves identification of the service user group, the goal of the post, the need for a new model of care and key outcomes of the role. As the role is developed and implemented, policies and guidelines are developed and the education, support and resources that are required to support the role are determined. Each postholder in this study would have developed a job description along the lines of the PEPPA Framework in order for the post to be approved and accredited; therefore data relating to the goal of the post, expected outcomes etc. would be available to the team. Bryant-Lukosius developed the PEPPA Framework further, now known as ‘The Logic Model’ [ 41 ], in order that newly developed roles could be evaluated subsequently, taking account of both short and long-term outcomes.

Using the logic model, the postholder’s practice was thus evaluated under four main core categories: clinical practice, clinical leadership, professional leadership, and research. In this study, the indicators that represented the activities undertaken by the postholder in each of the core categories were based on the Round 2 instrument from the Delphi study. For example, in the category of clinical practice, examples of autonomous practice were sought and described; for research, examples of leading nursing and midwifery research were recorded, and so forth. The team also used the Logic Model to take account of the situation in which the postholder was working and the input (resources) required for them to carry out their role to maximum effect. An example in terms of clinical practice relating to the development of a therapeutic relationship might be that a private space/office would be required for that particular encounter, the absence of which might have a negative influence on the outcome. If the activity related to research and implementation of evidence-based practice, then access to guidelines, information databases and protected time to undertake research should form part of the structures required to support the role. Although data from Phase One generated the indicators of activities/outputs related to the role, the team took additional steps to ensure the quality of the case study within the overall sequential explanatory design. Given the volume of data, computer assisted qualitative data analysis software (CAQDAS) was required for data management and analysis. NVivo Version 8 (QSR International 2009) was selected as the package of choice, and the Logic Model [ 31 ] was used to set up the project database. Data were classified based on the following criteria: postholder/non-postholder, specialist or advanced practice, community/hospital location (each case site had a unique study identifier), discipline, service, data type (interview, observation etc.) and data source (service user, member of the multidisciplinary team etc.). Four level one codes were assigned based on the four categories from the Logic model- clinical practice, clinical leadership, professional leadership and research and audit. The use of the framework focussed data collection and analysis without limiting the richness of the data as the research assistants were asked to look for examples of specialist and advanced practice as compared with the NCNM competencies, and were not asked to look for examples of specific practices. Within each category, data were further analysed to identify evidence of activities of the postholder that demonstrated achievement (at the level of specialist or advanced practice) of the competencies defined by the NCNM. For example, within the category of research and audit, clinical specialists are required to audit their service, whereas advanced practitioners, in addition to audit, are required to lead and support research within their specialist area. From a pragmatic perspective, the case study approach also allowed for data to be gathered on facilitators and barriers to implementing the role; for example, it was noted during the periods of observation of postholders in practice that undertaking audit is more difficult for specialists (or other clinicians) working in a community as opposed to a hospital setting as data are collected manually rather than electronically.

Steps to enhance data quality and consistency of coding decisions within the team

In order to ensure validity, robustness and comprehensiveness of the framework for data collection, data analysis and coding levels used, four external experts were requested to test it based on the initial data collected. Each expert took a sample of data and analysed it using the framework to verify if the coding matrix generated using the Logic Model [ 41 ] based on data from Phase One was appropriate, and to evaluate if the attributes in the matrix were identified in the data. This was found to be the case. In addition, the experts added to the attributes within the four first level codes, based on their sample analysis. This process of expert review, with minor additions to the activities identified in Phase One, confirmed the suitability of the framework for analysis. All narrative data (interview transcripts, field notes taken by the research assistants and synopsis of documentary evidence) from the case study were managed and analysed using the computer assisted, qualitative data analysis software NVivo Version 8 (QSR International 2009). Once all data were coded within the framework, queries were run within NVivo to contrast the findings for each of the four first level codes between postholding and non-postholding sites, in order to explore the impact of postholders on practice and service delivery. All data were analysed taking cognisance of the context in which care was delivered, and the factors that facilitate or impede practitioners in the field. The number and source of all documentary evidence collected from the sites was collated and synopsised.

Steps to managing case study data analysis

One of the key challenges in case study design is how to manage data analyses especially as the data come from multiple and diverse sources. In this case study, NVivo was used so that the case study data from the observations in clinical practice, interviews with key stakeholders such as service users, family members/carers, healthcare professionals and Directors of Nursing/ Midwifery, could be analysed and also enable researchers to compare outcomes across the case study sites with and without CSs/APs. A coding framework was constructed using the outcomes previously identified in phase 1 and within NVivo all the interview and observation data were analysed and the evidence for each outcome was extracted. In order to evaluate the outcomes of specialist and advanced practitioners, the evidence from case study sites with and without CSs/APs was cross tabulated (Figure  2 ). This example demonstrates how using cross tabulation matrices provided a means of managing data analysis whereby ALL the evidence relating to case management outcomes from case study data sources were presented clearly, which allowed researchers to carry out detailed comparisons for each outcome. Using a coding framework and generating cross tabulation matrices enabled the researchers to carry out a focused evaluation of the impact of the CS and AP roles on healthcare outcomes and make explicit how the outcome measures were confirmed and validated from multiple sources in clinical practice.

Comparison of cases in matched sites within Nvivo.

The contribution of a case orientated approach to studying complexity within a multiphase design

As the objective of the research was to evaluate the impact of both specialist and advanced practice roles in the Irish health service, it became necessary to understand the commonalities and differences within and between the levels of specialist and advanced practice. As mentioned previously, cases were selected for their informational representativeness and comparability with matched non-postholding services, therefore a case-orientated approach to analysis was undertaken. The team compared the configuration of variables within the four primary level codes of clinical practice, clinical leadership, professional leadership and research and subunit analysis was based on whether the data were obtained from a case of a CS or an AP, or a matched service. A combination of indicators gathered from questionnaires from service users, interviews with clinicians, service users and Directors of Nursing or Midwifery, field notes recorded by the research assistants on their observations and other documentary evidence were combined within NVivo so that the strength of evidence to support a particular finding could be collated. In order to take account of the variation in context when comparing cases within, across and between CSs and APs, other variables relating to clinical significance such as educational interventions, service developments, implementation of evidence-based care and the resources available to support the role were added to the analysis. Although any one case can be considered as a unique configuration of elements, our interest lay in the comparison of outcomes between postholder and matched services. By labelling data based on whether they were generated from a postholding site or a matched non-postholding site, cross case comparisons and queries could be run within the software. With 23 postholding and 23 matched cases in the study, the large volume of data obtained inevitably led to heterogeneity [ 42 ], both in how the posts were operationalised locally, and in the resources that were available to the practitioner to fulfil the role. In addition, levels of activity that equate with advanced practice were observed amongst some clinical specialists, and consequently outcomes relating to clinical interventions were also influenced by this finding. A case orientated approach to analysis based on the presence of indicators associated with specialist and advanced practice, which were determined prior to the immersion of the research assistants in the case study sites, allowed the team to identify, for example, a case of a CS practising at an advanced level, whereas other research approaches may have analysed the configuration of variables in such a way as to consider the case as ‘deviant’, ‘unique’ or as an ‘outlier’.

Using data from multiple sources within the case study and managing the data within a computer assisted qualitative data analysis software package allowed the team to synthesise and empirically evaluate strength of evidence from multiple sources to support a particular finding. For example, the analyst could run a query to search for evidence to support a core outcome such as the effect of the CS or AP on increasing knowledge and skill of other care providers. To do this, all sources could be searched i.e. Delphi outcomes, interviews (and the number and nature of the sources), field notes of observation, documentary evidence etc. and the strength of the evidence to support the outcome measured. The impact of a CS or AP on core clinical and professional outcomes could also be analysed taking account of the support structures available for the role. For example, when postholders had protected time for audit and research activities the output was more significant. Using similar techniques, differences in care between postholding and matched services could also be evaluated.

The use of a case study approach within a multiphase study strengthened the potential to examine a single case that seemed ‘different’ to other cases, but more importantly it allowed for the case to be redefined. This was evident in the data from the clinical midwife specialist in diabetes, as her activities across each of the four categories of the Logic Model when compared to the competencies defined by the NCNM were demonstrated to be at advanced practice levels. Given that the findings of The SCAPE Study [ 36 ] might have significant policy implications for the future support and development of these roles in the Irish health service, it was critical that a methodology sufficiently flexible to take account of complexity in terms of the nature and range of data sources required to take account of multiple phenomena i.e. specialist and advanced practice, the context of service delivery (micro and macro), service user, service provider and policy maker perspectives was chosen for this evaluation study. The case study approach, through the application of a theoretical model of advanced practice, and the use of multiple data collection strategies, allowed for the rigorous examination of individual cases, the redefinition of others based on relevant causal conditions and the comparison of postholding cases with those from matched services. Even though it has been recognised that not all phenomena are amenable to measurement, some research consumers continue to remain sceptical about the veracity of the evidence produced through qualitative inquiry. In an era where the pressure of quantification continues to exist, a significant advantage to using a case study approach within a sequential explanatory design is that it allowed the research team to quantify, across the range of data sources, the level of evidence generated within the study to support particular claims regarding the effectiveness of CS and AP roles on specific clinical outcomes. For example, across the 23 postholding sites it was possible to quantify the amount of evidence that was generated from a range of data sources (service users, policy-makers, members of the multidisciplinary team, Directors of Nursing/Midwifery) and data types (interviews, surveys, observations, documentary analysis) to support the outcome of reduction in waiting times.

Policy makers frequently pay particular attention to the weight of evidence given to support research claims. Consequently we would urge researchers to consider the suitability of this approach within multiphase designs to avoid losing focus on the critical question when searching for completeness in the exploration of complex phenomena, and to think about the potential to quantify the strength of evidence supporting particular outcomes especially if it is hoped the findings will influence future policy development.

Limitations

Although this study cannot generate statistical generalisations regarding the impact of specialist and advanced practice roles worldwide, the findings can be generalised for typical posts across the Irish health service. As this study focussed on using matched comparisons to evaluate the effectiveness of the CS and AP roles, unique posts could not be evaluated. However, through the rigorous application of the Delphi method to achieve consensus on important activities and outcomes in Phase one, and the a priori application of the Logic Model to data collection and analysis, following an acknowledgement of the context in which the roles are operationalised, the findings from the study can be compared with similar research internationally.

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School of Nursing and Midwifery, Trinity College Dublin, Dublin, Ireland

Joan G Lalor, Naomi Elliott, Imelda Coyne, Catherine Comiskey, Agnes Higgins & Cecily Begley

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Dympna Casey, Kathy Murphy & Declan Devane

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Competing interests.

The authors declare that they have no competing interests.

The SCAPE study was funded by the National Council for Nursing and Midwifery (NCNM) in Ireland. The NCNM has since been dissolved and its functions have been transferred to the Nursing and Midwifery Board. Consequently, there are no financial or non-financial competing interests to declare in relation to this manuscript. The authors are funding (either personally or through their host university) the processing charge for this manuscript.

Authors’ contributions

JL participated in the study design, data collection and analysis, project write up and drafted the manuscript. DC, NE, IC, CC, AH, and DD all participated in study design, data collection analysis and write up, CB and KM participated in study design, data collection, analysis, and were joint principal investigators with responsibility for coordinating the project and the write up. All authors read, contributed to and approved the final manuscript.

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Lalor, J.G., Casey, D., Elliott, N. et al. Using case study within a sequential explanatory design to evaluate the impact of specialist and advanced practice roles on clinical outcomes: the SCAPE study. BMC Med Res Methodol 13 , 55 (2013). https://doi.org/10.1186/1471-2288-13-55

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Received : 17 October 2012

Accepted : 27 March 2013

Published : 08 April 2013

DOI : https://doi.org/10.1186/1471-2288-13-55

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