what is a qualitative single case study

The Ultimate Guide to Qualitative Research - Part 1: The Basics

• Introduction and overview
• What is qualitative research?
• What is qualitative data?
• Examples of qualitative data
• Qualitative vs. quantitative research
• Mixed methods
• Qualitative research preparation
• Theoretical perspective
• Theoretical framework
• Literature reviews

Research question

• Conceptual framework
• Conceptual vs. theoretical framework

Data collection

• Qualitative research methods
• Focus groups
• Observational research

What is a case study?

Applications for case study research, what is a good case study, process of case study design, benefits and limitations of case studies.

• Ethnographical research
• Ethical considerations
• Confidentiality and privacy
• Power dynamics
• Reflexivity

Case studies

Case studies are essential to qualitative research , offering a lens through which researchers can investigate complex phenomena within their real-life contexts. This chapter explores the concept, purpose, applications, examples, and types of case studies and provides guidance on how to conduct case study research effectively.

Whereas quantitative methods look at phenomena at scale, case study research looks at a concept or phenomenon in considerable detail. While analyzing a single case can help understand one perspective regarding the object of research inquiry, analyzing multiple cases can help obtain a more holistic sense of the topic or issue. Let's provide a basic definition of a case study, then explore its characteristics and role in the qualitative research process.

Definition of a case study

A case study in qualitative research is a strategy of inquiry that involves an in-depth investigation of a phenomenon within its real-world context. It provides researchers with the opportunity to acquire an in-depth understanding of intricate details that might not be as apparent or accessible through other methods of research. The specific case or cases being studied can be a single person, group, or organization – demarcating what constitutes a relevant case worth studying depends on the researcher and their research question .

Among qualitative research methods , a case study relies on multiple sources of evidence, such as documents, artifacts, interviews , or observations , to present a complete and nuanced understanding of the phenomenon under investigation. The objective is to illuminate the readers' understanding of the phenomenon beyond its abstract statistical or theoretical explanations.

Characteristics of case studies

Case studies typically possess a number of distinct characteristics that set them apart from other research methods. These characteristics include a focus on holistic description and explanation, flexibility in the design and data collection methods, reliance on multiple sources of evidence, and emphasis on the context in which the phenomenon occurs.

Furthermore, case studies can often involve a longitudinal examination of the case, meaning they study the case over a period of time. These characteristics allow case studies to yield comprehensive, in-depth, and richly contextualized insights about the phenomenon of interest.

The role of case studies in research

Case studies hold a unique position in the broader landscape of research methods aimed at theory development. They are instrumental when the primary research interest is to gain an intensive, detailed understanding of a phenomenon in its real-life context.

In addition, case studies can serve different purposes within research - they can be used for exploratory, descriptive, or explanatory purposes, depending on the research question and objectives. This flexibility and depth make case studies a valuable tool in the toolkit of qualitative researchers.

Remember, a well-conducted case study can offer a rich, insightful contribution to both academic and practical knowledge through theory development or theory verification, thus enhancing our understanding of complex phenomena in their real-world contexts.

What is the purpose of a case study?

Case study research aims for a more comprehensive understanding of phenomena, requiring various research methods to gather information for qualitative analysis . Ultimately, a case study can allow the researcher to gain insight into a particular object of inquiry and develop a theoretical framework relevant to the research inquiry.

Why use case studies in qualitative research?

Using case studies as a research strategy depends mainly on the nature of the research question and the researcher's access to the data.

Conducting case study research provides a level of detail and contextual richness that other research methods might not offer. They are beneficial when there's a need to understand complex social phenomena within their natural contexts.

The explanatory, exploratory, and descriptive roles of case studies

Case studies can take on various roles depending on the research objectives. They can be exploratory when the research aims to discover new phenomena or define new research questions; they are descriptive when the objective is to depict a phenomenon within its context in a detailed manner; and they can be explanatory if the goal is to understand specific relationships within the studied context. Thus, the versatility of case studies allows researchers to approach their topic from different angles, offering multiple ways to uncover and interpret the data .

The impact of case studies on knowledge development

Case studies play a significant role in knowledge development across various disciplines. Analysis of cases provides an avenue for researchers to explore phenomena within their context based on the collected data.

This can result in the production of rich, practical insights that can be instrumental in both theory-building and practice. Case studies allow researchers to delve into the intricacies and complexities of real-life situations, uncovering insights that might otherwise remain hidden.

Types of case studies

In qualitative research , a case study is not a one-size-fits-all approach. Depending on the nature of the research question and the specific objectives of the study, researchers might choose to use different types of case studies. These types differ in their focus, methodology, and the level of detail they provide about the phenomenon under investigation.

Understanding these types is crucial for selecting the most appropriate approach for your research project and effectively achieving your research goals. Let's briefly look at the main types of case studies.

Exploratory case studies

Exploratory case studies are typically conducted to develop a theory or framework around an understudied phenomenon. They can also serve as a precursor to a larger-scale research project. Exploratory case studies are useful when a researcher wants to identify the key issues or questions which can spur more extensive study or be used to develop propositions for further research. These case studies are characterized by flexibility, allowing researchers to explore various aspects of a phenomenon as they emerge, which can also form the foundation for subsequent studies.

Descriptive case studies

Descriptive case studies aim to provide a complete and accurate representation of a phenomenon or event within its context. These case studies are often based on an established theoretical framework, which guides how data is collected and analyzed. The researcher is concerned with describing the phenomenon in detail, as it occurs naturally, without trying to influence or manipulate it.

Explanatory case studies

Explanatory case studies are focused on explanation - they seek to clarify how or why certain phenomena occur. Often used in complex, real-life situations, they can be particularly valuable in clarifying causal relationships among concepts and understanding the interplay between different factors within a specific context.

Intrinsic, instrumental, and collective case studies

These three categories of case studies focus on the nature and purpose of the study. An intrinsic case study is conducted when a researcher has an inherent interest in the case itself. Instrumental case studies are employed when the case is used to provide insight into a particular issue or phenomenon. A collective case study, on the other hand, involves studying multiple cases simultaneously to investigate some general phenomena.

Each type of case study serves a different purpose and has its own strengths and challenges. The selection of the type should be guided by the research question and objectives, as well as the context and constraints of the research.

The flexibility, depth, and contextual richness offered by case studies make this approach an excellent research method for various fields of study. They enable researchers to investigate real-world phenomena within their specific contexts, capturing nuances that other research methods might miss. Across numerous fields, case studies provide valuable insights into complex issues.

Critical information systems research

Case studies provide a detailed understanding of the role and impact of information systems in different contexts. They offer a platform to explore how information systems are designed, implemented, and used and how they interact with various social, economic, and political factors. Case studies in this field often focus on examining the intricate relationship between technology, organizational processes, and user behavior, helping to uncover insights that can inform better system design and implementation.

Health research

Health research is another field where case studies are highly valuable. They offer a way to explore patient experiences, healthcare delivery processes, and the impact of various interventions in a real-world context.

Case studies can provide a deep understanding of a patient's journey, giving insights into the intricacies of disease progression, treatment effects, and the psychosocial aspects of health and illness.

Asthma research studies

Specifically within medical research, studies on asthma often employ case studies to explore the individual and environmental factors that influence asthma development, management, and outcomes. A case study can provide rich, detailed data about individual patients' experiences, from the triggers and symptoms they experience to the effectiveness of various management strategies. This can be crucial for developing patient-centered asthma care approaches.

Other fields

Apart from the fields mentioned, case studies are also extensively used in business and management research, education research, and political sciences, among many others. They provide an opportunity to delve into the intricacies of real-world situations, allowing for a comprehensive understanding of various phenomena.

Case studies, with their depth and contextual focus, offer unique insights across these varied fields. They allow researchers to illuminate the complexities of real-life situations, contributing to both theory and practice.

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Understanding the key elements of case study design is crucial for conducting rigorous and impactful case study research. A well-structured design guides the researcher through the process, ensuring that the study is methodologically sound and its findings are reliable and valid. The main elements of case study design include the research question , propositions, units of analysis, and the logic linking the data to the propositions.

The research question is the foundation of any research study. A good research question guides the direction of the study and informs the selection of the case, the methods of collecting data, and the analysis techniques. A well-formulated research question in case study research is typically clear, focused, and complex enough to merit further detailed examination of the relevant case(s).

Propositions

Propositions, though not necessary in every case study, provide a direction by stating what we might expect to find in the data collected. They guide how data is collected and analyzed by helping researchers focus on specific aspects of the case. They are particularly important in explanatory case studies, which seek to understand the relationships among concepts within the studied phenomenon.

Units of analysis

The unit of analysis refers to the case, or the main entity or entities that are being analyzed in the study. In case study research, the unit of analysis can be an individual, a group, an organization, a decision, an event, or even a time period. It's crucial to clearly define the unit of analysis, as it shapes the qualitative data analysis process by allowing the researcher to analyze a particular case and synthesize analysis across multiple case studies to draw conclusions.

Argumentation

This refers to the inferential model that allows researchers to draw conclusions from the data. The researcher needs to ensure that there is a clear link between the data, the propositions (if any), and the conclusions drawn. This argumentation is what enables the researcher to make valid and credible inferences about the phenomenon under study.

Understanding and carefully considering these elements in the design phase of a case study can significantly enhance the quality of the research. It can help ensure that the study is methodologically sound and its findings contribute meaningful insights about the case.

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Conducting a case study involves several steps, from defining the research question and selecting the case to collecting and analyzing data . This section outlines these key stages, providing a practical guide on how to conduct case study research.

Defining the research question

The first step in case study research is defining a clear, focused research question. This question should guide the entire research process, from case selection to analysis. It's crucial to ensure that the research question is suitable for a case study approach. Typically, such questions are exploratory or descriptive in nature and focus on understanding a phenomenon within its real-life context.

Selecting and defining the case

The selection of the case should be based on the research question and the objectives of the study. It involves choosing a unique example or a set of examples that provide rich, in-depth data about the phenomenon under investigation. After selecting the case, it's crucial to define it clearly, setting the boundaries of the case, including the time period and the specific context.

Previous research can help guide the case study design. When considering a case study, an example of a case could be taken from previous case study research and used to define cases in a new research inquiry. Considering recently published examples can help understand how to select and define cases effectively.

Developing a detailed case study protocol

A case study protocol outlines the procedures and general rules to be followed during the case study. This includes the data collection methods to be used, the sources of data, and the procedures for analysis. Having a detailed case study protocol ensures consistency and reliability in the study.

The protocol should also consider how to work with the people involved in the research context to grant the research team access to collecting data. As mentioned in previous sections of this guide, establishing rapport is an essential component of qualitative research as it shapes the overall potential for collecting and analyzing data.

Collecting data

Gathering data in case study research often involves multiple sources of evidence, including documents, archival records, interviews, observations, and physical artifacts. This allows for a comprehensive understanding of the case. The process for gathering data should be systematic and carefully documented to ensure the reliability and validity of the study.

Analyzing and interpreting data

The next step is analyzing the data. This involves organizing the data , categorizing it into themes or patterns , and interpreting these patterns to answer the research question. The analysis might also involve comparing the findings with prior research or theoretical propositions.

Writing the case study report

The final step is writing the case study report . This should provide a detailed description of the case, the data, the analysis process, and the findings. The report should be clear, organized, and carefully written to ensure that the reader can understand the case and the conclusions drawn from it.

Each of these steps is crucial in ensuring that the case study research is rigorous, reliable, and provides valuable insights about the case.

The type, depth, and quality of data in your study can significantly influence the validity and utility of the study. In case study research, data is usually collected from multiple sources to provide a comprehensive and nuanced understanding of the case. This section will outline the various methods of collecting data used in case study research and discuss considerations for ensuring the quality of the data.

Interviews are a common method of gathering data in case study research. They can provide rich, in-depth data about the perspectives, experiences, and interpretations of the individuals involved in the case. Interviews can be structured , semi-structured , or unstructured , depending on the research question and the degree of flexibility needed.

Observations

Observations involve the researcher observing the case in its natural setting, providing first-hand information about the case and its context. Observations can provide data that might not be revealed in interviews or documents, such as non-verbal cues or contextual information.

Documents and artifacts

Documents and archival records provide a valuable source of data in case study research. They can include reports, letters, memos, meeting minutes, email correspondence, and various public and private documents related to the case.

These records can provide historical context, corroborate evidence from other sources, and offer insights into the case that might not be apparent from interviews or observations.

Physical artifacts refer to any physical evidence related to the case, such as tools, products, or physical environments. These artifacts can provide tangible insights into the case, complementing the data gathered from other sources.

Ensuring the quality of data collection

Determining the quality of data in case study research requires careful planning and execution. It's crucial to ensure that the data is reliable, accurate, and relevant to the research question. This involves selecting appropriate methods of collecting data, properly training interviewers or observers, and systematically recording and storing the data. It also includes considering ethical issues related to collecting and handling data, such as obtaining informed consent and ensuring the privacy and confidentiality of the participants.

Data analysis

Analyzing case study research involves making sense of the rich, detailed data to answer the research question. This process can be challenging due to the volume and complexity of case study data. However, a systematic and rigorous approach to analysis can ensure that the findings are credible and meaningful. This section outlines the main steps and considerations in analyzing data in case study research.

Organizing the data

The first step in the analysis is organizing the data. This involves sorting the data into manageable sections, often according to the data source or the theme. This step can also involve transcribing interviews, digitizing physical artifacts, or organizing observational data.

Categorizing and coding the data

Once the data is organized, the next step is to categorize or code the data. This involves identifying common themes, patterns, or concepts in the data and assigning codes to relevant data segments. Coding can be done manually or with the help of software tools, and in either case, qualitative analysis software can greatly facilitate the entire coding process. Coding helps to reduce the data to a set of themes or categories that can be more easily analyzed.

Identifying patterns and themes

After coding the data, the researcher looks for patterns or themes in the coded data. This involves comparing and contrasting the codes and looking for relationships or patterns among them. The identified patterns and themes should help answer the research question.

Interpreting the data

Once patterns and themes have been identified, the next step is to interpret these findings. This involves explaining what the patterns or themes mean in the context of the research question and the case. This interpretation should be grounded in the data, but it can also involve drawing on theoretical concepts or prior research.

Verification of the data

The last step in the analysis is verification. This involves checking the accuracy and consistency of the analysis process and confirming that the findings are supported by the data. This can involve re-checking the original data, checking the consistency of codes, or seeking feedback from research participants or peers.

Like any research method , case study research has its strengths and limitations. Researchers must be aware of these, as they can influence the design, conduct, and interpretation of the study.

Understanding the strengths and limitations of case study research can also guide researchers in deciding whether this approach is suitable for their research question . This section outlines some of the key strengths and limitations of case study research.

Benefits include the following:

• Rich, detailed data: One of the main strengths of case study research is that it can generate rich, detailed data about the case. This can provide a deep understanding of the case and its context, which can be valuable in exploring complex phenomena.
• Flexibility: Case study research is flexible in terms of design , data collection , and analysis . A sufficient degree of flexibility allows the researcher to adapt the study according to the case and the emerging findings.
• Real-world context: Case study research involves studying the case in its real-world context, which can provide valuable insights into the interplay between the case and its context.
• Multiple sources of evidence: Case study research often involves collecting data from multiple sources , which can enhance the robustness and validity of the findings.

On the other hand, researchers should consider the following limitations:

• Generalizability: A common criticism of case study research is that its findings might not be generalizable to other cases due to the specificity and uniqueness of each case.
• Time and resource intensive: Case study research can be time and resource intensive due to the depth of the investigation and the amount of collected data.
• Complexity of analysis: The rich, detailed data generated in case study research can make analyzing the data challenging.
• Subjectivity: Given the nature of case study research, there may be a higher degree of subjectivity in interpreting the data , so researchers need to reflect on this and transparently convey to audiences how the research was conducted.

Being aware of these strengths and limitations can help researchers design and conduct case study research effectively and interpret and report the findings appropriately.

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• Perspective
• Published: 22 November 2022

Single case studies are a powerful tool for developing, testing and extending theories

• Lyndsey Nickels   ORCID: orcid.org/0000-0002-0311-3524 1 , 2 ,
• Simon Fischer-Baum   ORCID: orcid.org/0000-0002-6067-0538 3 &
• Wendy Best   ORCID: orcid.org/0000-0001-8375-5916 4  

Nature Reviews Psychology volume  1 ,  pages 733–747 ( 2022 ) Cite this article

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Psychology embraces a diverse range of methodologies. However, most rely on averaging group data to draw conclusions. In this Perspective, we argue that single case methodology is a valuable tool for developing and extending psychological theories. We stress the importance of single case and case series research, drawing on classic and contemporary cases in which cognitive and perceptual deficits provide insights into typical cognitive processes in domains such as memory, delusions, reading and face perception. We unpack the key features of single case methodology, describe its strengths, its value in adjudicating between theories, and outline its benefits for a better understanding of deficits and hence more appropriate interventions. The unique insights that single case studies have provided illustrate the value of in-depth investigation within an individual. Single case methodology has an important place in the psychologist’s toolkit and it should be valued as a primary research tool.

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The authors thank all of those pioneers of and advocates for single case study research who have mentored, inspired and encouraged us over the years, and the many other colleagues with whom we have discussed these issues.

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Nickels, L., Fischer-Baum, S. & Best, W. Single case studies are a powerful tool for developing, testing and extending theories. Nat Rev Psychol 1 , 733–747 (2022). https://doi.org/10.1038/s44159-022-00127-y

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The Advantages and Limitations of Single Case Study Analysis

As Andrew Bennett and Colin Elman have recently noted, qualitative research methods presently enjoy “an almost unprecedented popularity and vitality… in the international relations sub-field”, such that they are now “indisputably prominent, if not pre-eminent” (2010: 499). This is, they suggest, due in no small part to the considerable advantages that case study methods in particular have to offer in studying the “complex and relatively unstructured and infrequent phenomena that lie at the heart of the subfield” (Bennett and Elman, 2007: 171). Using selected examples from within the International Relations literature[1], this paper aims to provide a brief overview of the main principles and distinctive advantages and limitations of single case study analysis. Divided into three inter-related sections, the paper therefore begins by first identifying the underlying principles that serve to constitute the case study as a particular research strategy, noting the somewhat contested nature of the approach in ontological, epistemological, and methodological terms. The second part then looks to the principal single case study types and their associated advantages, including those from within the recent ‘third generation’ of qualitative International Relations (IR) research. The final section of the paper then discusses the most commonly articulated limitations of single case studies; while accepting their susceptibility to criticism, it is however suggested that such weaknesses are somewhat exaggerated. The paper concludes that single case study analysis has a great deal to offer as a means of both understanding and explaining contemporary international relations.

The term ‘case study’, John Gerring has suggested, is “a definitional morass… Evidently, researchers have many different things in mind when they talk about case study research” (2006a: 17). It is possible, however, to distil some of the more commonly-agreed principles. One of the most prominent advocates of case study research, Robert Yin (2009: 14) defines it as “an empirical enquiry that investigates a contemporary phenomenon in depth and within its real-life context, especially when the boundaries between phenomenon and context are not clearly evident”. What this definition usefully captures is that case studies are intended – unlike more superficial and generalising methods – to provide a level of detail and understanding, similar to the ethnographer Clifford Geertz’s (1973) notion of ‘thick description’, that allows for the thorough analysis of the complex and particularistic nature of distinct phenomena. Another frequently cited proponent of the approach, Robert Stake, notes that as a form of research the case study “is defined by interest in an individual case, not by the methods of inquiry used”, and that “the object of study is a specific, unique, bounded system” (2008: 443, 445). As such, three key points can be derived from this – respectively concerning issues of ontology, epistemology, and methodology – that are central to the principles of single case study research.

First, the vital notion of ‘boundedness’ when it comes to the particular unit of analysis means that defining principles should incorporate both the synchronic (spatial) and diachronic (temporal) elements of any so-called ‘case’. As Gerring puts it, a case study should be “an intensive study of a single unit… a spatially bounded phenomenon – e.g. a nation-state, revolution, political party, election, or person – observed at a single point in time or over some delimited period of time” (2004: 342). It is important to note, however, that – whereas Gerring refers to a single unit of analysis – it may be that attention also necessarily be given to particular sub-units. This points to the important difference between what Yin refers to as an ‘holistic’ case design, with a single unit of analysis, and an ’embedded’ case design with multiple units of analysis (Yin, 2009: 50-52). The former, for example, would examine only the overall nature of an international organization, whereas the latter would also look to specific departments, programmes, or policies etc.

Secondly, as Tim May notes of the case study approach, “even the most fervent advocates acknowledge that the term has entered into understandings with little specification or discussion of purpose and process” (2011: 220). One of the principal reasons for this, he argues, is the relationship between the use of case studies in social research and the differing epistemological traditions – positivist, interpretivist, and others – within which it has been utilised. Philosophy of science concerns are obviously a complex issue, and beyond the scope of much of this paper. That said, the issue of how it is that we know what we know – of whether or not a single independent reality exists of which we as researchers can seek to provide explanation – does lead us to an important distinction to be made between so-called idiographic and nomothetic case studies (Gerring, 2006b). The former refers to those which purport to explain only a single case, are concerned with particularisation, and hence are typically (although not exclusively) associated with more interpretivist approaches. The latter are those focused studies that reflect upon a larger population and are more concerned with generalisation, as is often so with more positivist approaches[2]. The importance of this distinction, and its relation to the advantages and limitations of single case study analysis, is returned to below.

Thirdly, in methodological terms, given that the case study has often been seen as more of an interpretivist and idiographic tool, it has also been associated with a distinctly qualitative approach (Bryman, 2009: 67-68). However, as Yin notes, case studies can – like all forms of social science research – be exploratory, descriptive, and/or explanatory in nature. It is “a common misconception”, he notes, “that the various research methods should be arrayed hierarchically… many social scientists still deeply believe that case studies are only appropriate for the exploratory phase of an investigation” (Yin, 2009: 6). If case studies can reliably perform any or all three of these roles – and given that their in-depth approach may also require multiple sources of data and the within-case triangulation of methods – then it becomes readily apparent that they should not be limited to only one research paradigm. Exploratory and descriptive studies usually tend toward the qualitative and inductive, whereas explanatory studies are more often quantitative and deductive (David and Sutton, 2011: 165-166). As such, the association of case study analysis with a qualitative approach is a “methodological affinity, not a definitional requirement” (Gerring, 2006a: 36). It is perhaps better to think of case studies as transparadigmatic; it is mistaken to assume single case study analysis to adhere exclusively to a qualitative methodology (or an interpretivist epistemology) even if it – or rather, practitioners of it – may be so inclined. By extension, this also implies that single case study analysis therefore remains an option for a multitude of IR theories and issue areas; it is how this can be put to researchers’ advantage that is the subject of the next section.

Having elucidated the defining principles of the single case study approach, the paper now turns to an overview of its main benefits. As noted above, a lack of consensus still exists within the wider social science literature on the principles and purposes – and by extension the advantages and limitations – of case study research. Given that this paper is directed towards the particular sub-field of International Relations, it suggests Bennett and Elman’s (2010) more discipline-specific understanding of contemporary case study methods as an analytical framework. It begins however, by discussing Harry Eckstein’s seminal (1975) contribution to the potential advantages of the case study approach within the wider social sciences.

Eckstein proposed a taxonomy which usefully identified what he considered to be the five most relevant types of case study. Firstly were so-called configurative-idiographic studies, distinctly interpretivist in orientation and predicated on the assumption that “one cannot attain prediction and control in the natural science sense, but only understanding ( verstehen )… subjective values and modes of cognition are crucial” (1975: 132). Eckstein’s own sceptical view was that any interpreter ‘simply’ considers a body of observations that are not self-explanatory and “without hard rules of interpretation, may discern in them any number of patterns that are more or less equally plausible” (1975: 134). Those of a more post-modernist bent, of course – sharing an “incredulity towards meta-narratives”, in Lyotard’s (1994: xxiv) evocative phrase – would instead suggest that this more free-form approach actually be advantageous in delving into the subtleties and particularities of individual cases.

Eckstein’s four other types of case study, meanwhile, promote a more nomothetic (and positivist) usage. As described, disciplined-configurative studies were essentially about the use of pre-existing general theories, with a case acting “passively, in the main, as a receptacle for putting theories to work” (Eckstein, 1975: 136). As opposed to the opportunity this presented primarily for theory application, Eckstein identified heuristic case studies as explicit theoretical stimulants – thus having instead the intended advantage of theory-building. So-called p lausibility probes entailed preliminary attempts to determine whether initial hypotheses should be considered sound enough to warrant more rigorous and extensive testing. Finally, and perhaps most notably, Eckstein then outlined the idea of crucial case studies , within which he also included the idea of ‘most-likely’ and ‘least-likely’ cases; the essential characteristic of crucial cases being their specific theory-testing function.

Whilst Eckstein’s was an early contribution to refining the case study approach, Yin’s (2009: 47-52) more recent delineation of possible single case designs similarly assigns them roles in the applying, testing, or building of theory, as well as in the study of unique cases[3]. As a subset of the latter, however, Jack Levy (2008) notes that the advantages of idiographic cases are actually twofold. Firstly, as inductive/descriptive cases – akin to Eckstein’s configurative-idiographic cases – whereby they are highly descriptive, lacking in an explicit theoretical framework and therefore taking the form of “total history”. Secondly, they can operate as theory-guided case studies, but ones that seek only to explain or interpret a single historical episode rather than generalise beyond the case. Not only does this therefore incorporate ‘single-outcome’ studies concerned with establishing causal inference (Gerring, 2006b), it also provides room for the more postmodern approaches within IR theory, such as discourse analysis, that may have developed a distinct methodology but do not seek traditional social scientific forms of explanation.

Applying specifically to the state of the field in contemporary IR, Bennett and Elman identify a ‘third generation’ of mainstream qualitative scholars – rooted in a pragmatic scientific realist epistemology and advocating a pluralistic approach to methodology – that have, over the last fifteen years, “revised or added to essentially every aspect of traditional case study research methods” (2010: 502). They identify ‘process tracing’ as having emerged from this as a central method of within-case analysis. As Bennett and Checkel observe, this carries the advantage of offering a methodologically rigorous “analysis of evidence on processes, sequences, and conjunctures of events within a case, for the purposes of either developing or testing hypotheses about causal mechanisms that might causally explain the case” (2012: 10).

Harnessing various methods, process tracing may entail the inductive use of evidence from within a case to develop explanatory hypotheses, and deductive examination of the observable implications of hypothesised causal mechanisms to test their explanatory capability[4]. It involves providing not only a coherent explanation of the key sequential steps in a hypothesised process, but also sensitivity to alternative explanations as well as potential biases in the available evidence (Bennett and Elman 2010: 503-504). John Owen (1994), for example, demonstrates the advantages of process tracing in analysing whether the causal factors underpinning democratic peace theory are – as liberalism suggests – not epiphenomenal, but variously normative, institutional, or some given combination of the two or other unexplained mechanism inherent to liberal states. Within-case process tracing has also been identified as advantageous in addressing the complexity of path-dependent explanations and critical junctures – as for example with the development of political regime types – and their constituent elements of causal possibility, contingency, closure, and constraint (Bennett and Elman, 2006b).

Bennett and Elman (2010: 505-506) also identify the advantages of single case studies that are implicitly comparative: deviant, most-likely, least-likely, and crucial cases. Of these, so-called deviant cases are those whose outcome does not fit with prior theoretical expectations or wider empirical patterns – again, the use of inductive process tracing has the advantage of potentially generating new hypotheses from these, either particular to that individual case or potentially generalisable to a broader population. A classic example here is that of post-independence India as an outlier to the standard modernisation theory of democratisation, which holds that higher levels of socio-economic development are typically required for the transition to, and consolidation of, democratic rule (Lipset, 1959; Diamond, 1992). Absent these factors, MacMillan’s single case study analysis (2008) suggests the particularistic importance of the British colonial heritage, the ideology and leadership of the Indian National Congress, and the size and heterogeneity of the federal state.

Most-likely cases, as per Eckstein above, are those in which a theory is to be considered likely to provide a good explanation if it is to have any application at all, whereas least-likely cases are ‘tough test’ ones in which the posited theory is unlikely to provide good explanation (Bennett and Elman, 2010: 505). Levy (2008) neatly refers to the inferential logic of the least-likely case as the ‘Sinatra inference’ – if a theory can make it here, it can make it anywhere. Conversely, if a theory cannot pass a most-likely case, it is seriously impugned. Single case analysis can therefore be valuable for the testing of theoretical propositions, provided that predictions are relatively precise and measurement error is low (Levy, 2008: 12-13). As Gerring rightly observes of this potential for falsification:

“a positivist orientation toward the work of social science militates toward a greater appreciation of the case study format, not a denigration of that format, as is usually supposed” (Gerring, 2007: 247, emphasis added).

In summary, the various forms of single case study analysis can – through the application of multiple qualitative and/or quantitative research methods – provide a nuanced, empirically-rich, holistic account of specific phenomena. This may be particularly appropriate for those phenomena that are simply less amenable to more superficial measures and tests (or indeed any substantive form of quantification) as well as those for which our reasons for understanding and/or explaining them are irreducibly subjective – as, for example, with many of the normative and ethical issues associated with the practice of international relations. From various epistemological and analytical standpoints, single case study analysis can incorporate both idiographic sui generis cases and, where the potential for generalisation may exist, nomothetic case studies suitable for the testing and building of causal hypotheses. Finally, it should not be ignored that a signal advantage of the case study – with particular relevance to international relations – also exists at a more practical rather than theoretical level. This is, as Eckstein noted, “that it is economical for all resources: money, manpower, time, effort… especially important, of course, if studies are inherently costly, as they are if units are complex collective individuals ” (1975: 149-150, emphasis added).

Limitations

Single case study analysis has, however, been subject to a number of criticisms, the most common of which concern the inter-related issues of methodological rigour, researcher subjectivity, and external validity. With regard to the first point, the prototypical view here is that of Zeev Maoz (2002: 164-165), who suggests that “the use of the case study absolves the author from any kind of methodological considerations. Case studies have become in many cases a synonym for freeform research where anything goes”. The absence of systematic procedures for case study research is something that Yin (2009: 14-15) sees as traditionally the greatest concern due to a relative absence of methodological guidelines. As the previous section suggests, this critique seems somewhat unfair; many contemporary case study practitioners – and representing various strands of IR theory – have increasingly sought to clarify and develop their methodological techniques and epistemological grounding (Bennett and Elman, 2010: 499-500).

A second issue, again also incorporating issues of construct validity, concerns that of the reliability and replicability of various forms of single case study analysis. This is usually tied to a broader critique of qualitative research methods as a whole. However, whereas the latter obviously tend toward an explicitly-acknowledged interpretive basis for meanings, reasons, and understandings:

“quantitative measures appear objective, but only so long as we don’t ask questions about where and how the data were produced… pure objectivity is not a meaningful concept if the goal is to measure intangibles [as] these concepts only exist because we can interpret them” (Berg and Lune, 2010: 340).

The question of researcher subjectivity is a valid one, and it may be intended only as a methodological critique of what are obviously less formalised and researcher-independent methods (Verschuren, 2003). Owen (1994) and Layne’s (1994) contradictory process tracing results of interdemocratic war-avoidance during the Anglo-American crisis of 1861 to 1863 – from liberal and realist standpoints respectively – are a useful example. However, it does also rest on certain assumptions that can raise deeper and potentially irreconcilable ontological and epistemological issues. There are, regardless, plenty such as Bent Flyvbjerg (2006: 237) who suggest that the case study contains no greater bias toward verification than other methods of inquiry, and that “on the contrary, experience indicates that the case study contains a greater bias toward falsification of preconceived notions than toward verification”.

The third and arguably most prominent critique of single case study analysis is the issue of external validity or generalisability. How is it that one case can reliably offer anything beyond the particular? “We always do better (or, in the extreme, no worse) with more observation as the basis of our generalization”, as King et al write; “in all social science research and all prediction, it is important that we be as explicit as possible about the degree of uncertainty that accompanies out prediction” (1994: 212). This is an unavoidably valid criticism. It may be that theories which pass a single crucial case study test, for example, require rare antecedent conditions and therefore actually have little explanatory range. These conditions may emerge more clearly, as Van Evera (1997: 51-54) notes, from large-N studies in which cases that lack them present themselves as outliers exhibiting a theory’s cause but without its predicted outcome. As with the case of Indian democratisation above, it would logically be preferable to conduct large-N analysis beforehand to identify that state’s non-representative nature in relation to the broader population.

There are, however, three important qualifiers to the argument about generalisation that deserve particular mention here. The first is that with regard to an idiographic single-outcome case study, as Eckstein notes, the criticism is “mitigated by the fact that its capability to do so [is] never claimed by its exponents; in fact it is often explicitly repudiated” (1975: 134). Criticism of generalisability is of little relevance when the intention is one of particularisation. A second qualifier relates to the difference between statistical and analytical generalisation; single case studies are clearly less appropriate for the former but arguably retain significant utility for the latter – the difference also between explanatory and exploratory, or theory-testing and theory-building, as discussed above. As Gerring puts it, “theory confirmation/disconfirmation is not the case study’s strong suit” (2004: 350). A third qualification relates to the issue of case selection. As Seawright and Gerring (2008) note, the generalisability of case studies can be increased by the strategic selection of cases. Representative or random samples may not be the most appropriate, given that they may not provide the richest insight (or indeed, that a random and unknown deviant case may appear). Instead, and properly used , atypical or extreme cases “often reveal more information because they activate more actors… and more basic mechanisms in the situation studied” (Flyvbjerg, 2006). Of course, this also points to the very serious limitation, as hinted at with the case of India above, that poor case selection may alternatively lead to overgeneralisation and/or grievous misunderstandings of the relationship between variables or processes (Bennett and Elman, 2006a: 460-463).

As Tim May (2011: 226) notes, “the goal for many proponents of case studies […] is to overcome dichotomies between generalizing and particularizing, quantitative and qualitative, deductive and inductive techniques”. Research aims should drive methodological choices, rather than narrow and dogmatic preconceived approaches. As demonstrated above, there are various advantages to both idiographic and nomothetic single case study analyses – notably the empirically-rich, context-specific, holistic accounts that they have to offer, and their contribution to theory-building and, to a lesser extent, that of theory-testing. Furthermore, while they do possess clear limitations, any research method involves necessary trade-offs; the inherent weaknesses of any one method, however, can potentially be offset by situating them within a broader, pluralistic mixed-method research strategy. Whether or not single case studies are used in this fashion, they clearly have a great deal to offer.

References 

Bennett, A. and Checkel, J. T. (2012) ‘Process Tracing: From Philosophical Roots to Best Practice’, Simons Papers in Security and Development, No. 21/2012, School for International Studies, Simon Fraser University: Vancouver.

Bennett, A. and Elman, C. (2006a) ‘Qualitative Research: Recent Developments in Case Study Methods’, Annual Review of Political Science , 9, 455-476.

Bennett, A. and Elman, C. (2006b) ‘Complex Causal Relations and Case Study Methods: The Example of Path Dependence’, Political Analysis , 14, 3, 250-267.

Bennett, A. and Elman, C. (2007) ‘Case Study Methods in the International Relations Subfield’, Comparative Political Studies , 40, 2, 170-195.

Bennett, A. and Elman, C. (2010) Case Study Methods. In C. Reus-Smit and D. Snidal (eds) The Oxford Handbook of International Relations . Oxford University Press: Oxford. Ch. 29.

Berg, B. and Lune, H. (2012) Qualitative Research Methods for the Social Sciences . Pearson: London.

Bryman, A. (2012) Social Research Methods . Oxford University Press: Oxford.

David, M. and Sutton, C. D. (2011) Social Research: An Introduction . SAGE Publications Ltd: London.

Diamond, J. (1992) ‘Economic development and democracy reconsidered’, American Behavioral Scientist , 35, 4/5, 450-499.

Eckstein, H. (1975) Case Study and Theory in Political Science. In R. Gomm, M. Hammersley, and P. Foster (eds) Case Study Method . SAGE Publications Ltd: London.

Flyvbjerg, B. (2006) ‘Five Misunderstandings About Case-Study Research’, Qualitative Inquiry , 12, 2, 219-245.

Geertz, C. (1973) The Interpretation of Cultures: Selected Essays by Clifford Geertz . Basic Books Inc: New York.

Gerring, J. (2004) ‘What is a Case Study and What Is It Good for?’, American Political Science Review , 98, 2, 341-354.

Gerring, J. (2006a) Case Study Research: Principles and Practices . Cambridge University Press: Cambridge.

Gerring, J. (2006b) ‘Single-Outcome Studies: A Methodological Primer’, International Sociology , 21, 5, 707-734.

Gerring, J. (2007) ‘Is There a (Viable) Crucial-Case Method?’, Comparative Political Studies , 40, 3, 231-253.

King, G., Keohane, R. O. and Verba, S. (1994) Designing Social Inquiry: Scientific Inference in Qualitative Research . Princeton University Press: Chichester.

Layne, C. (1994) ‘Kant or Cant: The Myth of the Democratic Peace’, International Security , 19, 2, 5-49.

Levy, J. S. (2008) ‘Case Studies: Types, Designs, and Logics of Inference’, Conflict Management and Peace Science , 25, 1-18.

Lipset, S. M. (1959) ‘Some Social Requisites of Democracy: Economic Development and Political Legitimacy’, The American Political Science Review , 53, 1, 69-105.

Lyotard, J-F. (1984) The Postmodern Condition: A Report on Knowledge . University of Minnesota Press: Minneapolis.

MacMillan, A. (2008) ‘Deviant Democratization in India’, Democratization , 15, 4, 733-749.

Maoz, Z. (2002) Case study methodology in international studies: from storytelling to hypothesis testing. In F. P. Harvey and M. Brecher (eds) Evaluating Methodology in International Studies . University of Michigan Press: Ann Arbor.

May, T. (2011) Social Research: Issues, Methods and Process . Open University Press: Maidenhead.

Owen, J. M. (1994) ‘How Liberalism Produces Democratic Peace’, International Security , 19, 2, 87-125.

Seawright, J. and Gerring, J. (2008) ‘Case Selection Techniques in Case Study Research: A Menu of Qualitative and Quantitative Options’, Political Research Quarterly , 61, 2, 294-308.

Stake, R. E. (2008) Qualitative Case Studies. In N. K. Denzin and Y. S. Lincoln (eds) Strategies of Qualitative Inquiry . Sage Publications: Los Angeles. Ch. 17.

Van Evera, S. (1997) Guide to Methods for Students of Political Science . Cornell University Press: Ithaca.

Verschuren, P. J. M. (2003) ‘Case study as a research strategy: some ambiguities and opportunities’, International Journal of Social Research Methodology , 6, 2, 121-139.

Yin, R. K. (2009) Case Study Research: Design and Methods . SAGE Publications Ltd: London.

[1] The paper follows convention by differentiating between ‘International Relations’ as the academic discipline and ‘international relations’ as the subject of study.

[2] There is some similarity here with Stake’s (2008: 445-447) notion of intrinsic cases, those undertaken for a better understanding of the particular case, and instrumental ones that provide insight for the purposes of a wider external interest.

[3] These may be unique in the idiographic sense, or in nomothetic terms as an exception to the generalising suppositions of either probabilistic or deterministic theories (as per deviant cases, below).

[4] Although there are “philosophical hurdles to mount”, according to Bennett and Checkel, there exists no a priori reason as to why process tracing (as typically grounded in scientific realism) is fundamentally incompatible with various strands of positivism or interpretivism (2012: 18-19). By extension, it can therefore be incorporated by a range of contemporary mainstream IR theories.

— Written by: Ben Willis Written at: University of Plymouth Written for: David Brockington Date written: January 2013

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22 Case Study Research: In-Depth Understanding in Context

Helen Simons, School of Education, University of Southampton

• Published: 01 July 2014
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This chapter explores case study as a major approach to research and evaluation. After first noting various contexts in which case studies are commonly used, the chapter focuses on case study research directly Strengths and potential problematic issues are outlined and then key phases of the process. The chapter emphasizes how important it is to design the case, to collect and interpret data in ways that highlight the qualitative, to have an ethical practice that values multiple perspectives and political interests, and to report creatively to facilitate use in policy making and practice. Finally, it explores how to generalize from the single case. Concluding questions center on the need to think more imaginatively about design and the range of methods and forms of reporting requiredto persuade audiences to value qualitative ways of knowing in case study research.

Introduction

This chapter explores case study as a major approach to research and evaluation using primarily qualitative methods, as well as documentary sources, contemporaneous or historical. However, this is not the only way in which case study can be conceived. No one has a monopoly on the term. While sharing a focus on the singular in a particular context, case study has a wide variety of uses, not all associated with research. A case study, in common parlance, documents a particular situation or event in detail in a specific sociopolitical context. The particular can be a person, a classroom, an institution, a program, or a policy. Below I identify different ways in which case study is used before focusing on qualitative case study research in particular. However, first I wish to indicate how I came to advocate and practice this form of research. Origins, context, and opportunity often shape the research processes we endorse. It is helpful for the reader, I think, to know how I came to the perspective I hold.

The Beginnings

I first came to appreciate and enjoy the virtues of case study research when I entered the field of curriculum evaluation and research in the 1970s. The dominant research paradigm for educational research at that time was experimental or quasi- experimental, cost-benefit, or systems analysis, and the dominant curriculum model was aims and objectives ( House, 1993 ). The field was dominated, in effect, by a psychometric view of research in which quantitative methods were preeminent. But the innovative projects we were asked to evaluate (predominantly, but not exclusively, in the humanities) were not amenable to such methodologies. The projects were challenging to the status quo of institutions, involved people interpreting the policy and programs, were implemented differently in different contexts and regions, and had many unexpected effects.

We had no choice but to seek other ways to evaluate these complex programs, and case study was the methodology we found ourselves exploring, in order to understand how the projects were being implemented, why they had positive effects in some regions of the country and not others, and what the outcomes meant in different sociopolitical and cultural contexts. What better way to do this than to talk with people to see how they interpreted the “new” curriculum; to watch how teachers and students put it into practice; to document transactions, outcomes, and unexpected consequences; and to interpret all in the specific context of the case ( Simons, 1971 , 1987 , pp. 55–89). From this point on and in further studies, case study in educational research and evaluation came to be a major methodology for understanding complex educational and social programs. It also extended to other practice professions, such as nursing, health, and social care ( Zucker, 2001 ; Greenhalgh & Worrall, 1997 ; Shaw & Gould, 2001 ). For further details of the evolution of the case study approach and qualitative methodologies in evaluation, see House, 1993 , pp. 2–3; Greene, 2000 ; Simons, 2009 , pp. 14–18; Simons & McCormack, 2007 , pp. 292–311).

This was not exactly the beginning of case study, of course. It has a long history in many disciplines ( Simons, 1980; Ragin, 1992; Gomm, Hammersley, & Foster, 2004 ; Platt, 2007 ), many aspects of which form part of case study practice to this day. But its evolution in the context just described was a major move in the contemporary evolution of the logic of evaluative inquiry ( House, 1980 ). It also coincided with movement toward the qualitative in other disciplines, such as sociology and psychology. This was all part of what Denzin & Lincoln (1994) termed “a quiet methodological revolution” (p. ix) in qualitative inquiry that had been evolving over the course of forty years.

There is a further reason why I continue to advocate and practice case study research and evaluation to this day and that is my personal predilection for trying to understand and represent complexity, for puzzling through the ambiguities that exist in many contexts and programs and for presenting and negotiating different values and interests in fair and just ways.

Put more simply, I like interacting with people, listening to their stories, trials and tribulations—giving them a voice in understanding the contexts and projects with which they are involved, and finding ways to share these with a range of audiences. In other words, the move toward case study methodology described here suited my preference for how I learn.

Concepts and Purposes of Case Study

Before exploring case study as it has come to be established in educational research and evaluation over the past forty years, I wish to acknowledge other uses of case study. More often than not, these relate to purpose, and appropriately so in their different contexts, but many do not have a research intention. For a study to count as research, it would need to be a systematic investigation generating evidence that leads to “new” knowledge that is made public and open to scrutiny. There are many ways to conduct research stemming from different traditions and disciplines, but they all, in different ways, involve these characteristics.

Everyday Usage: Stories We Tell

The most common of these uses of case study is the everyday reference to a person, an anecdote or story illustrative of a particular incident, event, or experience of that person. It is often a short, reported account commonly seen in journalism but also in books exploring a phenomenon, such as recovery from serious accidents or tragedies, where the author chooses to illustrate the story or argument with a “lived” example. This is sometimes written by the author and sometimes by the person whose tale it is. “Let me share with you a story,” is a phrase frequently heard

The spirit behind this common usage and its power to connect can be seen in a report by Tim Adams of the London Olympics opening ceremony’s dramatization by Danny Boyle.

It was the point when we suddenly collectively wised up to the idea that what we are about to receive over the next two weeks was not only about “legacy collateral” and “targeted deliverables,” not about G4S failings and traffic lanes and branding opportunities, but about the second-by-second possibilities of human endeavour and spirit and communality, enacted in multiple places and all at the same time. Stories in other words. ( Adams, 2012 )

This was a collective story, of course, not an individual one, but it does convey some of the major characteristics of case study—that richness of detail, time, place, multiple happenings and experiences—that are also manifest in case study research, although carefully evidenced in the latter instance. We can see from this common usage how people have come to associate case study with story. I return to this thread in the reporting section.

Professions Individual Cases

In professional settings, in health and social care, case studies, often called case histories , are used to accurately record a person’s health or social care history and his or her current symptoms, experience, and treatment. These case histories include facts but also judgments and observations about the person’s reaction to situations or medication. Usually these are confidential. Not dissimilar is the detailed documentation of a case in law, often termed a case precedent when referred to in a court case to support an argument being made. However in law there is a difference in that such case precedents are publicly documented.

Case Studies in Teaching

Exemplars of practice.

In education, but also in health and social care training contexts, case studies have long been used as exemplars of practice. These are brief descriptions with some detail of a person or project’s experience in an area of practice. Though frequently reported accounts, they are based on a person’s experience and sometimes on previous research.

Case scenarios

Management studies are a further context in which case studies are often used. Here, the case is more like a scenario outlining a particular problem situation for the management student to resolve. These scenarios may be based on research but frequently are hypothetical situations used to raise issues for discussion and resolution. What distinguishes these case scenarios and the case exemplars in education from case study research is the intention to use them for teaching purposes.

Country Case Studies

Then there are case studies of programs, projects, and even countries, as in international development, where a whole-country study might be termed a case study or, in the context of the Organization for Economic Co-operation and Development (OECD), where an exploration is conducted of the state of the art of a subject, such as education or environmental science in one or several countries. This may be a contemporaneous study and/or what transpired in a program over a period of time. Such studies often do have a research base but frequently are reported accounts that do not detail the design, methodology, and analysis of the case, as a research case study would do, or report in ways that give readers a vicarious experience of what it was like to be there. Such case studies tend to be more knowledge and information-focused than experiential.

Case Study as History

Closer to a research context is case study as history—what transpired at a certain time in a certain place. This is likely to be supported by documentary evidence but not primary data gathering unless it is an oral history. In education, in the late 1970s, Stenhouse (1978) experimented with a case study archive. Using contemporaneous data gathering, primarily through interviewing, he envisaged this database, which he termed a “case record,” forming an archive from which different individuals,, at some later date, could write a “case study.” This approach uses case study as a documentary source to begin to generate a history of education, as the subtitle of Stenhouse’s 1978 paper indicates “Towards a contemporary history of education.”

Case Study Research

From here on, my focus is on case study research per se, adopting for this purpose the following definition:

Case study is an in-depth exploration from multiple perspectives of the complexity and uniqueness of a particular project, policy, institution or system in a “real-life” context. It is research based, inclusive of different methods and is evidence-led. ( Simons, 2009 , p. 21).

For further related definitions of case study, see Stake (1995) , Merriam (1998), and Chadderton & Torrance (2011) . And for definitions from a slightly different perspective, see Yin (2004) and Thomas (2011a) .

Not Defined by Method or Perspective

The inclusion of different methods in the definition quoted above definition signals that case study research is not defined by methodology or method. What defines case study is its singularity and the concept and boundary of the case. It is theoretically possible to conduct a case study using primarily quantitative data if this is the best way of providing evidence to inform the issues the case is exploring. It is equally possible to conduct case study that is mainly qualitative, to engage people with the experience of the case or to provide a rich portrayal of an event, project, or program.

Or one can design the case using mixed methods. This increases the options for learning from different ways of knowing and is sometimes preferred by stakeholders who believe it provides a firmer basis for informing policy. This is not necessarily the case but is beyond the scope of this chapter to explore. For further discussion of the complexities of mixing methods and the virtue of using qualitative methods and case study in a mixed method design, see Greene (2007) .

Case study research may also be conducted from different standpoints—realist, interpretivist, or constructivist, for example. My perspective falls within a constructivist, interpretivist framework. What interests me is how I and those in the case perceive and interpret what we find and how we construct or co-construct understandings of the case. This not only suits my predilection for how I see the world, but also my preferred phenomenological approach to interviewing and curiosity about people and how they act in social and professional life.

Qualitative Case Study Research

Qualitative case study research shares many characteristics with other forms of qualitative research, such as narrative, oral history, life history, ethnography, in-depth interview, and observational studies that utilize qualitative methods. However, its focus, purpose, and origins, in educational research at least, are a little different.

The focus is clearly the study of the singular. The purpose is to portray an in-depth view of the quality and complexity of social/educational programs or policies as they are implemented in specific sociopolitical contexts. What makes it qualitative is its emphasis on subjective ways of knowing, particularly the experiential, practical, and presentational rather than the propositional ( Heron, 1992 , 1999 ) to comprehend and communicate what transpired in the case.

Characteristic Features and Advantages

Case study research is not method dependent, as noted earlier, nor is it constrained by resources or time. Although it can be conducted over several years, which provides an opportunity to explore the process of change and explain how and why things happened, it can equally be carried out contemporaneously in a few days, weeks, or months. This flexibility is extremely useful in many contexts, particularly when a change in policy or unforeseen issues in the field require modifying the design.

Flexibility extends to reporting. The case can be written up in different lengths and forms to meet different audience needs and to maximize use (see the section on Reporting). Using the natural language of participants and familiar methods (like interview, observation, oral history) also enables participants to engage in the research process, thereby contributing significantly to the generation of knowledge of the case. As I have indicated elsewhere ( Simons, 2009 ), “This is both a political and epistemological point. It signals a potential shift in the power base of who controls knowledge and recognizes the importance of co-constructing perceived reality through the relationships and joint understandings we create in the field” (p. 23).

Possible Disadvantages

If one is an advocate, identifying advantages of a research approach is easier than pointing out its disadvantages, something detractors are quite keen to do anyway! But no approach is perfect, and here are some of the issues that often trouble people about case study research. The “sample of one” is an obvious issue that worries those convinced that only large samples can constitute valid research and especially if this is to inform policy. Understanding complexity in depth may not be a sufficient counterargument, and I suspect there is little point in trying to persuade otherwise For frequently, this perception is one of epistemological and methodological, if not ideological, preference.

However, there are some genuine concerns that many case researchers face: the difficulty of processing a mass of data; of “telling the truth” in contexts where people may be identifiable; personal involvement, when the researcher is the main instrument of data gathering; and writing reports that are data-based, yet readable in style and length. But one issue that concerns advocates and nonadvocates alike is how inferences are drawn from the single case.

Answers to some of these issues are covered in the sections that follow. Whether they convince may again be a question of preference. However, it is worth noting here that I do not think we should seek to justify these concerns in terms identified by other methodologies. Many of them are intrinsic to the nature and strength of qualitative case study research.

Subjectivity, for instance, both of participants and researcher is inevitable, as it is in many other qualitative methodologies. This is often the basis on which we act. Rather than see this as bias or something to counter, it is an intelligence that is essential to understanding and interpreting the experience of participants and stakeholders. Such subjectivity needs to be disciplined, of course, through procedures that examine both the validity of individuals’ representations of “their truth”, and demonstrate how the researcher took a reflexive approach to monitoring how his or her own values and predilections may have unduly influenced the data.

Types of Case Study

There are numerous types of case study, too many to categorize, I think, as there are overlaps between them. However, attempts have been made to do this and, for those who value typologies, I refer them to Bassey (1999) and, for a more extended typology, to Thomas (2011b) . A slightly different approach is taken by Gomm, Hammersley, and Foster (2004) in annotating the different emphases in major texts on case study. What I prefer to do here is to highlight a few familiar types to focus the discussion that follows on the practice of case study research.

Stake (1995) offers a threefold distinction that is helpful when it comes to practice, he says, because it influences the methods we choose to gather data (p. 4). He distinguishes between an intrinsic case study , one that is studied to learn about the particular case itself and an instrumental case study , in which we choose a case to gain insight into a particular issue (i.e., the case is instrumental to understanding something else; p. 3). The collective case study is what its name suggests: an extension of the instrumental to several cases.

Theory-led or theory-generated case study is similarly self-explanatory, the first starting from a specific theory that is tested through the case; the second constructing a theory through interpretation of data generated in the case. In other words, one ends rather than begins with a theory. In qualitative case study research, this is the more familiar route. The theory of the case becomes the argument or story you will tell.

Evaluation case study requires a slightly longer description as this is my context of practice, one which has influenced the way I conduct case study and what I choose to emphasize in this chapter. An evaluation case study has three essential features: to determine the value of the case, to include and balance different interests and values, and to report findings to a range of stakeholders in ways that they can use. The reasons for this may be found in the interlude that follows, which offers a brief characterization of the social and ethical practice of evaluation and why qualitative methods are so important in this practice.

Interlude: Social and Ethical Practice of Evaluation

Evaluation is a social practice that documents, portrays, and seeks to understand the value of a particular project, program, or policy. This can be determined by different evaluation methodologies, of course. But the value of qualitative case study is that it is possible to discern this value without decontextualizing the data. While the focus of the case is usually a project, program, policy, or some unit within, studies of key individuals, what I term case profiles , may be embedded within the overall case. In some instances, these profiles, or even shorter cameos of individuals, may be quite prominent. For it is through the perceptions, interpretations, and interactions of people that we learn how policies and programs are enacted ( Kushner, 2000 , p. 12). The program is still the main focus of analysis, but, in exploring how individuals play out their different roles in the program, we get closer to the actual experience and meaning of the program in practice.

Case study evaluation is often commissioned from an external source (government department or other agency) keen to know the worth of publicly funded programs and policies to inform future decision making. It needs to be responsive to issues or questions identified by stakeholders, who often have different values and interests in the expected outcomes and appreciate different perspectives of the program in action. The context also is often highly politicized, and interests can conflict. The task of the evaluator in such situations becomes one of including and balancing all interests and values in the program fairly and justly.

This is an inherently political process and requires an ethical practice that offers participants some protection over the personal data they give as part of the research and agreed audiences access to the findings, presented in ways they can understand. Negotiating what information becomes public can be quite difficult in singular settings where people are identifiable and intricate or problematic transactions have been documented. The consequences that ensue from making knowledge public that hitherto was private may be considerable for those in the case. It may also be difficult to portray some of the contextual detail that would enhance understanding for readers.

The ethical stance that underpins the case study research and evaluation I conduct stems from a theory of ethics that emphasizes the centrality of relationships in the specific context and the consequences for individuals, while remaining aware of the research imperative to publicly report. It is essentially an independent democratic process based on the concepts of fairness and justice, in which confidentiality, negotiation, and accessibility are key principles ( MacDonald, 1976 ; Simons, 2009 , pp. 96–111; and Simons 2010 ). The principles are translated into specific procedures to guide the collection, validation, and dissemination of data in the field. These include:

engaging participants and stakeholders in identifying issues to explore and sometimes also in interpreting the data;

documenting how different people interpret and value the program;

negotiating what data becomes public respecting both the individual’s “right to privacy” and the public’s “right to know”;

offering participants opportunities to check how their data are used in the context of reporting;

reporting in language and forms accessible to a wide range of audiences;

disseminating to audiences within and beyond the case.

For further discussion of the ethics of democratic case study evaluation and examples of their use in practice, see Simons (2000 , 2006 , 2009 , chapter 6, 2010 ).

Designing Case Study Research

Design issues in case study sometimes take second place to those of data gathering, the more exciting task perhaps in starting research. However, it is critical to consider the design at the outset, even if changes are required in practice due to the reality of what is encountered in the field. In this sense, the design of case study is emergent, rather than preordinate, shaped and reshaped as understanding of the significance of foreshadowed issues emerges and more are discovered.

Before entering the field, there are a myriad of planning issues to think about related to stakeholders, participants, and audiences. These include whose values matter, whether to engage them in data gathering and interpretation, the style of reporting appropriate for each, and the ethical guidelines that will underpin data collection and reporting. However, here I emphasize only three: the broad focus of the study, what the case is a case of, and framing questions/issues. These are steps often ignored in an enthusiasm to gather data, resulting in a case study that claims to be research but lacks the basic principles required for generation of valid, public knowledge.

Conceptualize the Topic

First, it is important that the topic of the research is conceptualized in a way that it can be researched (i.e., it is not too wide). This seems an obvious point to make, but failure to think through precisely what it is about your research topic you wish to investigate will have a knock-on effect on the framing of the case, data gathering, and interpretation and may lead, in some instances, to not gathering or analyzing data that actually informs the topic. Further conceptualization or reconceptualization may be necessary as the study proceeds, but it is critical to have a clear focus at the outset.

What Constitutes the Case

Second, I think it is important to decide what would constitute the case (i.e., what it is a case of) and where the boundaries of this lie. This often proves more difficult than first appears. And sometimes, partly because of the semifluid nature of the way the case evolves, it is only possible to finally establish what the case is a case of at the end. Nevertheless, it is useful to identify what the case and its boundaries are at the outset to help focus data collection while maintaining an awareness that these may shift. This is emergent design in action.

In deciding the boundary of the case, there are several factors to bear in mind. Is it bounded by an institution or a unit within an institution, by people within an institution, by region, or by project, program or policy,? If we take a school as an example, the case could be comprised of the principal, teachers, and students, or the boundary could be extended to the cleaners, the caretaker, the receptionist, people who often know a great deal about the subnorms and culture of the institution.

If the case is a policy or particular parameter of a policy, the considerations may be slightly different. People will still be paramount—those who generated the policy and those who implemented it—but there is likely also to be a political culture surrounding the policy that had an influence on the way the policy evolved. Would this be part of the case?

Whatever boundary is chosen, this may change in the course of conducting the study when issues arise that can only be understood by going to another level. What transpires in a classroom, for example, if this is the case, is often partly dependent on the support of the school leadership and culture of the institution and this, in turn, to some extent is dependent on what resources are allocated from the local education administration. Much like a series of Russian dolls, one context inside the other.

Unit of analysis

Thinking about what would constitute the unit of analysis— a classroom, an institution, a program, a region—may help in setting the boundaries of the case, and it will certainly help when it comes to analysis. But this is a slightly different issue from deciding what the case is a case of. Taking a health example, the case may be palliative care support, but the unit of analysis the palliative care ward or wards. If you took the palliative care ward as the unit of analysis this would be as much about how palliative care was exercised in this or that ward than issues about palliative care support in general. In other words, you would need to have specific information and context about how this ward was structured and managed to understand how palliative care was conducted in this particular ward. Here, as in the school example above, you would need to consider which of the many people who populate the ward form part of the case—nurses, interns, or doctors only, or does it extend to patients, cleaners, nurse aides, and medical students?

Framing Questions and Issues

The third most important consideration is how to frame the study, and you are likely to do this once you have selected the site or sites for study. There are at least four approaches. You could start with precise questions, foreshadowed issues ( Smith & Pohland, 1974 ), theories, or a program logic. To some extent, your choice will be dictated by the type of case you have chosen, but also by your personal preference for how to conduct it—in either a structured or open way.

Initial questions give structure; foreshadowed issues more freedom to explore. In qualitative case study, foreshadowed issues are more common, allowing scope for issues to change as the study evolves, guided by participants’ perspectives and events in the field. With this perspective, it is more likely that you will generate a theory of the case toward the end, through your interpretation and analysis.

If you are conducting an instrumental case study, staying close to the questions or foreshadowed issues is necessary to be sure you gain data that will illuminate the central focus of the study. This is critical if you are exploring issues across several cases, although it is possible to do a cross-case analysis from cases that have each followed a different route to discovering significant issues.

Opting to start with a theoretical framework provides a basis for formulating questions and issues, but it can also constrain the study to only those questions/issues that fit the framework. The same is true with using program logic to frame the case. This is an approach frequently adopted in evaluation case study where the evaluator, individually or with stakeholders, examines how the aims and objectives of the program relate to the activities designed to promote it and the outcomes and impacts expected. It provides direction, although it can lead to simply confirming what was anticipated, rather than documenting what transpired in the case.

Whichever approach you choose to frame the case, it is useful to think about the rationale or theory for each question and what methods would best enable you to gain an understanding of them. This will not only start a reflexive process of examining your choices—an important aspect of the process of data gathering and interpretation—it will also aid analysis and interpretation further down the track.

Methodology and Methods

Qualitative case study research, as already noted, appeals to subjective ways of knowing and to a primarily qualitative methodology, that captures experiential understanding ( Stake, 2010 , pp. 56–70). It follows that the main methods of data gathering to access this way of knowing will be qualitative. Interviewing, observation, and document analysis are the primary three, often supported by critical incidents, focus groups, cameos, vignettes, diaries/journals, and photographs. Before gathering any primary data, however, it is useful to search relevant existing sources (written or visual) to learn about the antecedents and context of a project, program, or policy as a backdrop to the case. This can sharpen framing questions, avoid unnecessary data gathering, and shorten the time needed in the field.

Given that there are excellent texts on qualitative methods (see, for example, Denzin & Lincoln, 1994 ; Seale, 1999 ; Silverman, 2000 , 2004 ), I will not discuss all potential relevant methods here, but simply focus on the qualities of the primary methods that are particularly appropriate for case study research.

Primary Qualitative Data Gathering Methods

Interviewing.

The most effective style of interviewing in qualitative case study research to gain in-depth data, document multiple perspectives and experiences and explore contested issues is the unstructured interview, active listening and open questioning are paramount, whatever prequestions or foreshadowed issues have been identified. This can include photographs—a useful starting point with certain cultural groups and the less articulate, to encourage them to tell their story through connecting or identifying with something in the image.

The flexibility of unstructured interviewing has three further advantages for understanding participants’ experiences. First, through questioning, probing, listening, and, above all, paying attention to the silences and what they mean, you can get closer to the meaning of participants’ experiences. It is not always what they say.

Second, unstructured interviewing is useful for engaging participants in the process of research. Instead of starting with questions and issues, invite participants to tell their stories or reflect on specific issues, to conduct their own self-evaluative interview, in fact. Not only will they contribute their particular perspective to the case, they will also learn about themselves, thereby making the process of research educative for them as well as for the audiences of the research.

Third, the open-endedness of this style of interviewing has the potential for creating a dialogue between participants and the researcher and between the researcher and the public, if enough of the dialogue is retained in the publication ( Bellah, Madsen, Sullivan, Swidler, & Tipton, 1985 ).

Observations

Observations in case study research are likely to be close-up descriptions of events, activities, and incidents that detail what happens in a particular context. They will record time, place, specific incidents, transactions, and dialogue, and note characteristics of the setting and of people in it without preconceived categories or judgment. No description is devoid of some judgment in selection, of course, but, on the whole, the intent is to describe the scene or event “as it is,” providing a rich, textured description to give readers a sense of what it was like to be there or provide a basis for later interpretation.

Take the following excerpt from a study of the West Bromwich Operatic Society. It is the first night of a new production, The Producers , by this amateur operatic society. This brief excerpt is from a much longer observation of the overture to the first evening’s performance, detailing exactly what the production is, where it is, and why there is such a tremendous sense of atmosphere and expectation surrounding the event. Space prevents including the whole observation, but I hope you can get a glimmer of the passion and excitement that precedes the performance:

Birmingham, late November, 2011, early evening.... Bars and restaurants spruce up for the evening’s trade. There is a chill in the air but the party season is just starting....

A few hundred yards away, past streaming traffic on Suffolk Street, Queensway, an audience is gathering at the New Alexandra Theatre. The foyer windows shine in the orange sodium night. Above each one is the rubric: WORLD CLASS THEATRE.

Inside the preparatory rituals are being observed; sweets chosen, interval drinks ordered and programmes bought. People swap news and titbits about the production.... The bubble of anticipation grows as the 5-minute warning sounds. People make their way to the auditorium. There have been so many nights like this in the past 110 years since a man named William Coutts invested £10,000 to build this palace of dreams.... So many fantasies have been played under this arch: melodramas and pantomimes, musicals and variety.... So many audiences, settling down in their tip-up seats, wanting to be transported away from work, from ordinariness and private troubles.... The dimming lights act like a mother’s hush. You could touch the silence. Boinnng! A spongy thump on a bass drum, and the horns pipe up that catchy, irrepressible, tasteless tune and already you’re singing under your breath, ‘Springtime for Hitler and Germany....’ The orchestra is out of sight in the pit. There’s just the velvet curtain to watch as your fingers tap along. What’s waiting behind? Then it starts it to move. Opening night.... It’s opening night! ( Matarasso, 2012 , pp. 1–2)

For another and different example—a narrative observation of an everyday but unique incident that details date, time, place, and experience—see Simons (2009 , p. 60).

Such naturalistic observations are also useful in contexts where we cannot understand what is going on through interviewing alone—in cultures with which we are less familiar or where key actors may not share our language or have difficulty expressing it. Careful description in these situations can help identify key issues, discover the norms and values that exist in the culture, and, if sufficiently detailed, allow others to cross corroborate what significance we draw from these observations. This last point is very important to avoid the danger in observation of ascribing motivations to people and meanings to transactions.

Finally, naturalistic observations are very important in highly politicized environments, often the case in commissioned evaluation case study, where individuals in interview may try to elude the “truth” or press on you that their view is the “right” view of the situation. In these contexts, naturalistic observations not only enable you to document interactions as you perceive them, but they also provide a cross-check on the veracity of information obtained in interviews.

Document analysis

Analysis of documents, as already intimated, is useful for establishing what historical antecedents might exist to provide a springboard for contemporaneous data gathering. In most cases, existing documents are also extremely pertinent for understanding the policy context.

In a national policy case study I conducted on a major curriculum change, the importance of preexisting documentation was brought home to me sharply when certain documentation initially proved elusive to obtain. It was difficult to believe that it did not exist, as the evolution of the innovation involved several parties who had not worked together before. There was bound, I thought, to be minuted meetings sharing progress and documentation of the “new” curriculum. In the absence of some crucial documents, I began to piece together the story through interviewing. Only there were gaps, and certain issues did not make sense.

It was only when I presented two versions of what I discerned had transpired in the development of this initiative in an interim report eighteen months into the study that things started to change. Subsequent to the meeting at which the report was presented, the “missing” documents started to appear. Suddenly found. What lay behind the “missing documents,” something I suspected from what certain individuals did and did not say in interview, was a major difference of view about how the innovation evolved, who was key in the process, and whose voice was more important in the context. Political differences, in other words, that some stakeholders were trying to keep from me. The emergence of the documents enabled me to finally produce an accurate and fair account.

This is an example of the importance of having access to all relevant documents relating to a program or policy in order to study it fairly. The other major way in which document analysis is useful in case study is for understanding the values, explicit and hidden, in policy and program documents and in the organization where the program or policy is implemented. Not to be ignored as documents are photographs, and these, too, can form the basis of a cultural and value analysis of an organization ( Prosser, 2000 ).

Creative artistic approaches

Increasingly, some case study researchers are employing creative approaches associated with the arts as a means of data gathering and analysis. Artistic approaches have often been used in representing findings, but less frequently in data gathering and interpretation ( Simons & McCormack, 2007 ). A major exception is the work of Richardson (1994) , who sees the very process of writing as an interpretative act, and of Cancienne and Snowber (2003) , who argue for movement as method.

The most familiar of these creative and artistic forms are written—narratives and short stories ( Clandinin & Connelly, 2000 ; Richardson, 1994 ; Sparkes, 2002 ), poems or poetic form ( Butler-Kisber, 2010 ; Duke, 2007 ; Richardson, 1997 ; Sparkes & Douglas, 2007 ), cameos of people, or vignettes of situations. These can be written by participants or by the researcher or developed in partnership. They can also be shared with participants to further interpret the data. But photographs also have a long history in qualitative research for presenting and constructing understanding ( Butler-Kisber, 2010 ; Collier, 1967 ; Prosser, 2000 ; Rugang, 2006 ; Walker, 1993 ).

Less common are other visual forms of gathering data, such as “draw and write” ( Sewell, 2011 ), artefacts, drawings, sketches, paintings, and collages, although all forms are now on the increase. For examples of the use of collage in data gathering, see Duke (2007) and Butler-Kisber (2010) , and for charcoal drawing, Elliott (2008) .

In qualitative inquiry broadly, these creative approaches are now quite common. And in the context of arts and health in particular (see, for example, Frank, 1997 ; Liamputtong & Rumbold, 2008 ; Spouse, 2000 ), we can see how artistic approaches illuminate in-depth understanding. However, in case study research to date, I think narrative forms have tended to be most prominent.

Finally, for capturing the quality and essence of peoples’ experience, nothing could be more revealing than a recording of their voices. Video diaries—self-evaluative portrayals by individuals of their perspectives, feelings, or experience of an event or situation—are a most potent way both of gaining understanding and communicating that to others. It is rather more difficult to gain access for observational videos, but they are useful for documentation and have the potential to engage participants and stakeholders in the interpretation.

Getting It All Together

Case study is so often associated with story or with a report of some event or program that it is easy to forget that much analysis and interpretation has gone on before we reach this point. In many case study reports, this process is hidden, leaving the reader with little evidence on which to assess the validity of the findings and having to trust the one who wrote the tale.

This section briefly outlines possibilities, first, for analyzing and interpreting data, and second, for how to communicate the findings to others. However it is useful to think of these together and indeed, at the start, because decisions about how you report may influence how you choose to make sense of the data. Your choice may also vary according to the context of the study—what is expected or acceptable—and your personal predilections, whether you prefer a more rational than intuitive mode of analysis, for example, or a formal or informal style of writing up that includes images, metaphor, narratives, or poetic forms.

Analyzing and Interpreting Data

When it comes to making sense of data, I make a distinction between analysis—a formal inductive process that seeks to explain—and interpretation, a more intuitive process that gains understanding and insight from a holistic grasp of data, although these may interact and overlap at different stages.

The process, whichever emphasis you choose, is one of reducing or transforming a large amount of data to themes that can encapsulate the overarching meaning in the data. This involves sorting, refining, and refocusing data until they make sense. It starts at the beginning with preliminary hunches, sometimes called “interpretative asides” or “working hypotheses,” later moving to themes, analytic propositions, or a theory of the case.

There are many ways to conduct this process. Two strategies often employed are concept mapping —a means of representing data visually to explore links between related concepts—and progressive focusing ( Parlett & Hamilton, 1976 ), the gradual reframing of initially identified issues into themes that are then further interpreted to generate findings. Each of these strategies tends to have three stages: initial sense making, identification of themes, and examination of patterns and relationships between them.

If taking a formal analytic approach to the task, the data would likely be broken down into segments or datasets (coded and categorized) and then reordered and explored for themes, patterns, and possible propositions. If adopting a more intuitive process, you might focus on identifying insights through metaphors and images, lateral thinking, or puzzling over paradoxes and ambiguities in the data, after first immersing yourself in the total dataset, reading and re-reading interview scripts, observations and field notes to get a sense of the whole. Trying out different forms of making sense through poetry, vignettes, cameos, narratives, collages, and drawing are further creative ways to interpret data, as are photographs taken in the case arranged to explain or tell the story of the case.

Reporting Case Study Research

Narrative structure and story.

As indicated in the introduction, telling a story is often associated with case study and some think this is what a case study is. In one sense, it is and, given that story is the natural way in which we learn ( Okri, 1997 ), it is a useful framework both for gathering data and for communicating case study findings. Not any story will do however. To count as research, it must be authentic, grounded in data, interpreted and analyzed to convey the meaning of the case.

There are several senses in which story is appropriate in qualitative case study: in capturing stories participants tell, in generating a narrative structure that makes sense of the case (i.e., the story you will tell), and in deciding how you communicate this narrative (i.e., in story form). If you choose a written story form (and advice here can be sought from Harrington (2003) and Caulley (2008) ), it needs to be clearly structured, well written, and contain only the detail that is necessary to give readers the vicarious experience of what it was like in the case. If the story is to be communicated in other ways, through, for example, audio or videotape, or computer or personal interaction, the same applies, substituting visual and interpersonal skill for written.

Matching forms of reporting to audience

The art of reporting is strongly connected to usability, so forms of reporting need to connect to the audiences we hope to inform: how they learn, what kind of evidence they value, and what kind of reporting maximizes the chances they will use the findings to promote policies and programs in the interests of beneficiaries. As Okri (1997) further reminds us, the writer only does half the work; the reader does the other (p. 41).

There may be other considerations as well: how open are commissioners to receiving stories of difficulties, as well as success stories? What might they need to hear beyond what is sought in the technical brief? And through what style of reporting would you try and persuade them? If conducting noncommissioned case study research, the scope for different forms of reporting is wider. In academia, for instance, many institutions these days accept creative and artistic forms of reporting when supported by supervisors and appreciated by examiners.

Styles of Reporting

The most obvious form of reporting is linear, often starting with a short executive summary and a brief description of focus and context, followed by methodology, the case study or thematic analysis, findings, and conclusions or implications. Conclusion-led reporting is similar in terms of its formality, but simply starts the other way around. From the conclusions drawn from the analyzed data, it works backward to tell the story through narrative, verbatim, and observational data of how these conclusions were reached. Both have a strong story line. The intent is analytic and explanatory.

Quite a different approach is to engage the reader in the experience and veracity of the case. Rather like constructing a portrait or editing a documentary film, this involves the sifting, constructing, re-ordering of frames, events and episodes to tell a coherent story primarily through interview excerpts, observations, vignettes, and critical incidents that depict what transpired in the case. Interpretation is indirect through the weaving of the data. The story can start at any point provided the underlying narrative structure is maintained to establish coherence ( House, 1980 , p. 116).

Different again, and from the other end of a continuum, is a highly interpretative account that may use similar ways of presenting data but weaves a story from the outset that is highly interpretative. Engaging metaphor, images, short stories, contradictions, paradoxes, and puzzles, it is invariably interesting to read and can be most persuasive. However, the evidence is less visible and therefore less open to alternative interpretations.

Even more persuasive is a case study that uses artistic forms to communicate the story of the case. Paintings, poetic form, drawings, photography, collage, and movement can all be adopted to report findings, whether the data was acquired using these forms or by other means. The arts-based inquiry movement ( Mullen & Finley, 2003 ) has contributed hugely to the validation and legitimation of artistic and creative ways of representing qualitative research findings. The journal Qualitative Inquiry contains many good examples, but see also Liamputtong & Rumbold (2008) . Such artistic forms of representation may not be for everyone or appropriate in some contexts, but they do have the power to engage an audience and the potential to facilitate use.

Generalization in Case Study Research

One of the potential limitations of case study often proposed is that it is impossible to generalize. This is not so. However, the way in which one generalizes from a case is different from that adopted in traditional forms of social science research that utilize large samples (randomly selected) and statistical procedures and which assume regularities in the social world that allow cause and effect to be determined. In this form of research inferences from data are stated as formal propositions that apply to all in the target population. See Donmoyer (1990) for an argument on the restricted nature of this form of generalization when considering single-case studies.

Making inferences from cases with a qualitative data set arises more from a process of interpretation in context, appealing to tacit and situated understanding for acceptance of their validity. Such inferences are possible where the context and experience of the case is richly described so the reader can recognize and connect with the events and experiences portrayed. There are two ways to examine how to reach these generalized understandings. One is to generalize from the case to other cases of a similar or dissimilar nature. The other is to see what we learn in-depth from the uniqueness of the single case itself.

Generalizing from the Single Case

A common approach to generalization and one most akin to a propositional form is cross-case generalization. In a collective or multi-site case study, each case is explored to see if issues that arise in one case also exist in other cases and what interconnecting themes there are between them. This kind of generalization has a degree of abstraction and potential for theorizing and is often welcomed by commissioners of research concerned that findings from the single case do not provide an adequate or “safe” basis for policy determination.

However, there are four additional ways to generalize from the single case, all of which draw more on tacit knowledge and recognition of context, although in different ways. In naturalistic generalization , first proposed by Stake (1978) , generalization is reached on the basis of recognition of similarities and differences to cases with which we are familiar. To enable such recognition, the case needs to feature rich description; people’s voices; and enough detail of time, place, and context to provide a vicarious experience to help readers discern what is similar and dissimilar to their own context ( Stake, 1978 ).

Situated generalization ( Simons, Kushner, Jones, & James, 2003 ) is close to the concept of naturalistic generalization in relying for its generality on retaining a connectedness with the context in which it first evolved. However, it has an extra dimension in a practice context. This notion of generalization was identified in an evaluation of a research project that engaged teachers in and with research. Here, in addition to the usual validity criteria to establish the warrant for the findings, the generalization was seen as dependable if trust existed between those who conducted the research (teachers, in this example) and those thinking about using it (other teachers). In other words, beyond the technical validity of the research, teachers considered using the findings in their own practice because they had confidence in those who generated them. This is a useful way to think about generalization if we wish research findings to improve professional practice.

The next two concepts of generalization— concept and process generalization —relate more to what you discover in making sense of the case. As you interpret and analyze, you begin to generate a theory of the case that makes sense of the whole. Concepts may be identified that make sense in the one case but have equal significance in other cases of a similar kind, even if the contexts are different.

It is the concept that generalizes, not the specific content or context. This may be similar to the process Donmoyer (2008) identifies of “intellectual generalization” (quoted by Butler-Kisber, 2010 , p. 15) to indicate the cognitive understanding one can gain from qualitative accounts even if settings are quite different.

The same is true for generalization of a process. It is possible to identify a significant process in one case (or several cases) that is transferable to other contexts, irrespective of the precise content and contexts of those other cases. An example here is the collaborative model for sustainable school self-evaluation I identified in researching school self-evaluation in a number of schools and countries ( Simons, 2002 ). Schools that successfully sustained school self-evaluation had an infrastructure that was collaborative at all stages of the evaluation process from design to conduct of the study, to analyzing the results and to reporting the findings. This ensured that the whole school was involved and that results were discussed and built into the ongoing development of school policies and practice. In other cases, different processes may be discovered that have applicability in a range of contexts. As with concept generalization, it is the process that generalizes not the substantive content or specific context.

Particularization

The forms of generalization discussed above are useful when we have to justify case study in a research or policy context. But the overarching justification for how we learn from case study is particularization —a rich portrayal of insights and understandings interpreted in the particular context. Several authors have made this point ( Stake, 1995 ; Flyvberg, 2006 ; Simons 2009 ). Stake puts it most sharply when he observes that “The real business of case study is particularization, not generalization” (p. 8), referring here to the main reason for studying the singular, which is to understand the uniqueness of the case itself.

My perspective (explored further in Simons, 1996 ; Simons, 2009 , p. 239; Simons & McCormack, 2007 ) is similar in that I believe the “real” strength of case study lies in the insights we gain from in-depth study of the particular. But I also argue for the universality of such insights—if we get it “right.” By which I mean that if we are able to capture and report the uniqueness, the essence, of the case in all its particularity and present this in a way we can all recognize, we will discover something of universal significance. This is something of a paradox. The more you learn in depth about the particularity of one person, situation, or context, the more likely you are to discover something universal. This process of reaching understanding has support both from the way in which many discoveries are made in science and in how we learn from artists, poets, and novelists, who reach us by communicating a recognizable truth about individuals, human relationships, and/or social contexts.

This concept of particularization is far from new, as the quotation from a preface to a book written in 1908 attests. Stephen Reynolds, the author of A Poor Man’s House , notes that the substance of the book was first recorded in a journal, kept for purposes of fiction, and in letters to one of his friends, but fiction proved an inappropriate medium. He felt that the life and the people were so much better than anything he could invent. The book therefore consists of the journal and letters drawn together to present a picture of a typical poor man’s house and life, much as we might draw together a range of data to present a case study. It is not the substance of the book that concerns us here but the methodological relevance to case study research. Reynolds notes that the conclusions expressed are tentative and possibly go beyond this man’s life, so he thought some explanation of the way he arrived at them was needed:

Educated people usually deal with the poor man’s life deductively; they reason from the general to the particular; and, starting with a theory, religious, philanthropic, political, or what not, they seek, and too easily find, among the millions of poor, specimens—very frequently abnormal—to illustrate their theories. With anything but human beings, that is an excellent method. Human beings, unfortunately, have individualities. They do what, theoretically, they ought not to do, and leave undone those things they ought to do. They are even said to possess souls—untrustworthy things beyond the reach of sociologists. The inductive method—reasoning from the particular to the general... should at least help to counterbalance the psychological superficiality of the deductive method. ( Reynolds, 1908 : preface) 1

Slightly overstated perhaps, but the point is well made. In our search for general laws, we not only lose sight of the uniqueness and humanity of individuals, but reduce them in the process, failing to present their experience in any “real” sense. What is astonishing about the quotation is that it was written over a century ago and yet many still argue today that you cannot generalize from the particular.

Going even further back, in 1798, Blake proclaimed that “To Generalize is to be an Idiot. To Particularize is the Alone Distinction of Merit.” In research, we may not wish to make such a strong distinction: these processes both have their uses in different kinds of research. But there is a major point here for the study of the particular that Wilson (2008) notes in commenting on Blake’s perception when he says: “Favouring the abstract over the concrete, one ‘sees all things only thro’ the narrow chinks of his cavern”’ (referring here to Blake’s The Marriage of Heaven and Hell [1793]; in Wilson, 2008 , p. 62). The danger Wilson is pointing to here is that abstraction relies heavily on what we know from our past understanding of things, and this may prevent us experiencing a concrete event directly or “apprehend[ing] a particular moment” ( Wilson, 2008 , p. 63).

Blake had a different mission, of course, than case researchers, and he was not himself free from abstractions, as Wilson points out, although he fought hard “to break through mental barriers to something unique and living” ( Wilson, 2008 , p. 65). It is this search for the “unique and living” and experiencing the “isness” of the particular that we should take from the Blake example to remind ourselves of the possibility of discovering something “new,” beyond our current understanding of the way things are.

Focusing on particularization does not diminish the usefulness of case study research for policy makers or practitioners. Grounded in recognizable experience, the potential is there to reach a range of audiences and to facilitate use of the findings. It may be more difficult for those who seek formal generalizations that seem to offer a safe basis for policy making to accept case study reports. However, particular stories often hold the key to why policies have or have not worked well in the past. It is not necessary to present long cases—a criticism frequently levelled—to demonstrate the story of the case. Such case stories can be most insightful for policy makers who, like many of us in everyday life, often draw inferences from a single instance or case, whatever the formal evidence presented. “I am reminded of the story of....”

The case for studying the particular to inform practice in professional contexts needs less persuasion because practitioners can recognize the content and context quite readily and make the inference to their own particular context ( Simons et al., 2003 ). In both sets of circumstances—policy and practice—it is more a question of whether the readers of our case research accept the validity of findings determined in this way, how they choose to learn, and our skill in telling the case study story.

Conclusion and Future Directions

In this chapter, I have presented an argument for case study research, making the case, in particular, for using qualitative methods to highlight what it is that qualitative case study research can bring to the study of social and educational programs. I outlined the various ways in which case study is commonly used before focusing directly on case study as a major mode of research inquiry, noting characteristics it shares with other qualitative methodologies, as well as itsdifference and the difficulties it is sometimes perceived to have. The chapter emphasizes the importance of thinking through what the case is, to be sure that the issues explored and the data generated do illuminate this case and not any other.

But there is still more to be done. In particular, I think we need to be more adventurous in how we craft and report the case. I suspect we may have been too cautious in the past in how we justified case study research, borrowing concepts from other disciplines and forms of educational research. More than 40 years on, it is time to take a greater risk—in demonstrating the intrinsic nature of case study and what it can offer to our understanding of human and social situations.

I have already drawn attention to the need to design the case, although this could be developed further to accentuate the uniqueness of the particular case. One way to do this is to feature individuals more in the design itself, not only to explore programs and policies through perspectives of key actors or groups and transactions between them, which to some extent happens already, but also to get them to characterize what makes the context unique. This is the reversal of many a design framework that starts with the logic of a program and takes forward the argument for personal evaluation ( Kushner, 2000 ), noted in the interlude on evaluation. Apart from this attention to design, there are three other issues I think we need to explore further: the warrant for creative methods in case study, more imaginative reporting; and how we learn from a study of the singular.

Warrant for More Creative Methods in Case Study Research

The promise that creative methods have for eliciting in-depth understanding and capturing the unusual, the idiosyncratic, the uniqueness of the case, was mentioned in the methods section. Yet, in case study research, particularly in program and policy contexts, we have few good examples of the use of artistic approaches for eliciting and interpreting data, although more, as acknowledged later, for presenting it. This may be because case study research is often conducted in academic or policy environments, where propositional ways of knowing are more valued.

Using creative and artistic forms in generating and interpreting case study data offers a form of evidence that acknowledges experiential understanding in illuminating the uniqueness of the case. The question is how to establish the warrant for this way of knowing and persuade others of its virtue. The answer is simple. By demonstrating the use of these methods in action, by arguing for a different form of validity that matches the intrinsic nature of the method, and, above all, by good examples.

Representing Findings to Engage Audiences in Learning

In evaluative and research policy contexts, where case study is often the main mode of inquiry or part of a broader study, case study reports often take a formal structure or sometimes, where the context is receptive, a portrayal or interpretative form. But, too often, the qualitative is an add-on to a story told by other means or reduced to issues in which the people who gave rise to the data are no longer seen. However, there are many ways to put them center stage.

Tell good stories and tell them well. Or, let key actors tell their own stories. Explore the different ways technology can help. Make video clips that demonstrate events in context, illustrate interactions between people, give voice to participants—show the reality of the program, in other words. Use graphics to summarize key issues and interactive, cartoon technology, as seen on some TED presentations, to summarize and visually show the complexity of the case. Video diaries were mentioned in the methods section: seeing individuals tell their tales directly is a powerful way of communicating, unhindered by “our” sense making. Tell photo stories. Let the photos convey the narrative, but make sure the structure of the narrative is evident to ensure coherence. These are just the beginnings. Those skilled in information technology could no doubt stretch our imagination further.

One problem and a further question concerns our audiences. Will they accept these modes of communication? Maybe not, in some contexts. However, there are three points I wish to leave you with. First, do not presume that they won’t. If people are fully present in the story and the complexity is not diminished, those reading, watching, or hearing about the case will get the message. If you are worried about how commissioners might respond, remember that they are no different from any other stakeholder or participant when it comes to how they learn from human experience. Witness the reference to Okri (1997) earlier about how we learn.

Second, when you detect that the context requires a more formal presentation of findings, respond according to expectation but also include elements of other forms of presentation. Nudge a little in the direction of creativity. Third, simply take a chance, that risk I spoke about earlier. Challenge the status quo. Find situations and contexts where you can fully represent the qualitative nature of the experience in the cases you study with creative forms of interpretation and representation. And let the audience decide.

Learning from a Study of the Singular

Finally, to return to the issue of “generalization” in case study that worries some audiences. I pointed out in the generalization section several ways in which it is possible to generalize from case study research, not in a formal propositional sense or from a case to a population, but by retaining a connection with the context in which the generalization first arose—that is, to realize in-depth understanding in context in different circumstances and situations. However, I also emphasized that, in many instances, it is particularization from which we learn. That is the point of the singular case study, and it is an art to perceive and craft the case in ways that we can.

Acknowledgments

Parts of this chapter build on ideas first explored in Simons, 2009 .

I am grateful to Bob Williams for pointing out the relevance of this quotation from Reynolds to remind us that “there is nothing new under the sun” and that we sometimes continue to engage endlessly in debates that have been well rehearsed before.

Adams, T. ( 2012 ) ‘ Olympics 2012: Team GB falters but London shines bright on opening day ’, Observer, 29.07.12.

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Methodology or method? A critical review of qualitative case study reports

Despite on-going debate about credibility, and reported limitations in comparison to other approaches, case study is an increasingly popular approach among qualitative researchers. We critically analysed the methodological descriptions of published case studies. Three high-impact qualitative methods journals were searched to locate case studies published in the past 5 years; 34 were selected for analysis. Articles were categorized as health and health services ( n= 12), social sciences and anthropology ( n= 7), or methods ( n= 15) case studies. The articles were reviewed using an adapted version of established criteria to determine whether adequate methodological justification was present, and if study aims, methods, and reported findings were consistent with a qualitative case study approach. Findings were grouped into five themes outlining key methodological issues: case study methodology or method, case of something particular and case selection, contextually bound case study, researcher and case interactions and triangulation, and study design inconsistent with methodology reported. Improved reporting of case studies by qualitative researchers will advance the methodology for the benefit of researchers and practitioners.

Case study research is an increasingly popular approach among qualitative researchers (Thomas, 2011 ). Several prominent authors have contributed to methodological developments, which has increased the popularity of case study approaches across disciplines (Creswell, 2013b ; Denzin & Lincoln, 2011b ; Merriam, 2009 ; Ragin & Becker, 1992 ; Stake, 1995 ; Yin, 2009 ). Current qualitative case study approaches are shaped by paradigm, study design, and selection of methods, and, as a result, case studies in the published literature vary. Differences between published case studies can make it difficult for researchers to define and understand case study as a methodology.

Experienced qualitative researchers have identified case study research as a stand-alone qualitative approach (Denzin & Lincoln, 2011b ). Case study research has a level of flexibility that is not readily offered by other qualitative approaches such as grounded theory or phenomenology. Case studies are designed to suit the case and research question and published case studies demonstrate wide diversity in study design. There are two popular case study approaches in qualitative research. The first, proposed by Stake ( 1995 ) and Merriam ( 2009 ), is situated in a social constructivist paradigm, whereas the second, by Yin ( 2012 ), Flyvbjerg ( 2011 ), and Eisenhardt ( 1989 ), approaches case study from a post-positivist viewpoint. Scholarship from both schools of inquiry has contributed to the popularity of case study and development of theoretical frameworks and principles that characterize the methodology.

The diversity of case studies reported in the published literature, and on-going debates about credibility and the use of case study in qualitative research practice, suggests that differences in perspectives on case study methodology may prevent researchers from developing a mutual understanding of practice and rigour. In addition, discussion about case study limitations has led some authors to query whether case study is indeed a methodology (Luck, Jackson, & Usher, 2006 ; Meyer, 2001 ; Thomas, 2010 ; Tight, 2010 ). Methodological discussion of qualitative case study research is timely, and a review is required to analyse and understand how this methodology is applied in the qualitative research literature. The aims of this study were to review methodological descriptions of published qualitative case studies, to review how the case study methodological approach was applied, and to identify issues that need to be addressed by researchers, editors, and reviewers. An outline of the current definitions of case study and an overview of the issues proposed in the qualitative methodological literature are provided to set the scene for the review.

Definitions of qualitative case study research

Case study research is an investigation and analysis of a single or collective case, intended to capture the complexity of the object of study (Stake, 1995 ). Qualitative case study research, as described by Stake ( 1995 ), draws together “naturalistic, holistic, ethnographic, phenomenological, and biographic research methods” in a bricoleur design, or in his words, “a palette of methods” (Stake, 1995 , pp. xi–xii). Case study methodology maintains deep connections to core values and intentions and is “particularistic, descriptive and heuristic” (Merriam, 2009 , p. 46).

As a study design, case study is defined by interest in individual cases rather than the methods of inquiry used. The selection of methods is informed by researcher and case intuition and makes use of naturally occurring sources of knowledge, such as people or observations of interactions that occur in the physical space (Stake, 1998 ). Thomas ( 2011 ) suggested that “analytical eclecticism” is a defining factor (p. 512). Multiple data collection and analysis methods are adopted to further develop and understand the case, shaped by context and emergent data (Stake, 1995 ). This qualitative approach “explores a real-life, contemporary bounded system (a case ) or multiple bounded systems (cases) over time, through detailed, in-depth data collection involving multiple sources of information … and reports a case description and case themes ” (Creswell, 2013b , p. 97). Case study research has been defined by the unit of analysis, the process of study, and the outcome or end product, all essentially the case (Merriam, 2009 ).

The case is an object to be studied for an identified reason that is peculiar or particular. Classification of the case and case selection procedures informs development of the study design and clarifies the research question. Stake ( 1995 ) proposed three types of cases and study design frameworks. These include the intrinsic case, the instrumental case, and the collective instrumental case. The intrinsic case is used to understand the particulars of a single case, rather than what it represents. An instrumental case study provides insight on an issue or is used to refine theory. The case is selected to advance understanding of the object of interest. A collective refers to an instrumental case which is studied as multiple, nested cases, observed in unison, parallel, or sequential order. More than one case can be simultaneously studied; however, each case study is a concentrated, single inquiry, studied holistically in its own entirety (Stake, 1995 , 1998 ).

Researchers who use case study are urged to seek out what is common and what is particular about the case. This involves careful and in-depth consideration of the nature of the case, historical background, physical setting, and other institutional and political contextual factors (Stake, 1998 ). An interpretive or social constructivist approach to qualitative case study research supports a transactional method of inquiry, where the researcher has a personal interaction with the case. The case is developed in a relationship between the researcher and informants, and presented to engage the reader, inviting them to join in this interaction and in case discovery (Stake, 1995 ). A postpositivist approach to case study involves developing a clear case study protocol with careful consideration of validity and potential bias, which might involve an exploratory or pilot phase, and ensures that all elements of the case are measured and adequately described (Yin, 2009 , 2012 ).

Current methodological issues in qualitative case study research

The future of qualitative research will be influenced and constructed by the way research is conducted, and by what is reviewed and published in academic journals (Morse, 2011 ). If case study research is to further develop as a principal qualitative methodological approach, and make a valued contribution to the field of qualitative inquiry, issues related to methodological credibility must be considered. Researchers are required to demonstrate rigour through adequate descriptions of methodological foundations. Case studies published without sufficient detail for the reader to understand the study design, and without rationale for key methodological decisions, may lead to research being interpreted as lacking in quality or credibility (Hallberg, 2013 ; Morse, 2011 ).

There is a level of artistic license that is embraced by qualitative researchers and distinguishes practice, which nurtures creativity, innovation, and reflexivity (Denzin & Lincoln, 2011b ; Morse, 2009 ). Qualitative research is “inherently multimethod” (Denzin & Lincoln, 2011a , p. 5); however, with this creative freedom, it is important for researchers to provide adequate description for methodological justification (Meyer, 2001 ). This includes paradigm and theoretical perspectives that have influenced study design. Without adequate description, study design might not be understood by the reader, and can appear to be dishonest or inaccurate. Reviewers and readers might be confused by the inconsistent or inappropriate terms used to describe case study research approach and methods, and be distracted from important study findings (Sandelowski, 2000 ). This issue extends beyond case study research, and others have noted inconsistencies in reporting of methodology and method by qualitative researchers. Sandelowski ( 2000 , 2010 ) argued for accurate identification of qualitative description as a research approach. She recommended that the selected methodology should be harmonious with the study design, and be reflected in methods and analysis techniques. Similarly, Webb and Kevern ( 2000 ) uncovered inconsistencies in qualitative nursing research with focus group methods, recommending that methodological procedures must cite seminal authors and be applied with respect to the selected theoretical framework. Incorrect labelling using case study might stem from the flexibility in case study design and non-directional character relative to other approaches (Rosenberg & Yates, 2007 ). Methodological integrity is required in design of qualitative studies, including case study, to ensure study rigour and to enhance credibility of the field (Morse, 2011 ).

Case study has been unnecessarily devalued by comparisons with statistical methods (Eisenhardt, 1989 ; Flyvbjerg, 2006 , 2011 ; Jensen & Rodgers, 2001 ; Piekkari, Welch, & Paavilainen, 2009 ; Tight, 2010 ; Yin, 1999 ). It is reputed to be the “the weak sibling” in comparison to other, more rigorous, approaches (Yin, 2009 , p. xiii). Case study is not an inherently comparative approach to research. The objective is not statistical research, and the aim is not to produce outcomes that are generalizable to all populations (Thomas, 2011 ). Comparisons between case study and statistical research do little to advance this qualitative approach, and fail to recognize its inherent value, which can be better understood from the interpretive or social constructionist viewpoint of other authors (Merriam, 2009 ; Stake, 1995 ). Building on discussions relating to “fuzzy” (Bassey, 2001 ), or naturalistic generalizations (Stake, 1978 ), or transference of concepts and theories (Ayres, Kavanaugh, & Knafl, 2003 ; Morse et al., 2011 ) would have more relevance.

Case study research has been used as a catch-all design to justify or add weight to fundamental qualitative descriptive studies that do not fit with other traditional frameworks (Merriam, 2009 ). A case study has been a “convenient label for our research—when we ‘can't think of anything ‘better”—in an attempt to give it [qualitative methodology] some added respectability” (Tight, 2010 , p. 337). Qualitative case study research is a pliable approach (Merriam, 2009 ; Meyer, 2001 ; Stake, 1995 ), and has been likened to a “curious methodological limbo” (Gerring, 2004 , p. 341) or “paradigmatic bridge” (Luck et al., 2006 , p. 104), that is on the borderline between postpositivist and constructionist interpretations. This has resulted in inconsistency in application, which indicates that flexibility comes with limitations (Meyer, 2001 ), and the open nature of case study research might be off-putting to novice researchers (Thomas, 2011 ). The development of a well-(in)formed theoretical framework to guide a case study should improve consistency, rigour, and trust in studies published in qualitative research journals (Meyer, 2001 ).

Assessment of rigour

The purpose of this study was to analyse the methodological descriptions of case studies published in qualitative methods journals. To do this we needed to develop a suitable framework, which used existing, established criteria for appraising qualitative case study research rigour (Creswell, 2013b ; Merriam, 2009 ; Stake, 1995 ). A number of qualitative authors have developed concepts and criteria that are used to determine whether a study is rigorous (Denzin & Lincoln, 2011b ; Lincoln, 1995 ; Sandelowski & Barroso, 2002 ). The criteria proposed by Stake ( 1995 ) provide a framework for readers and reviewers to make judgements regarding case study quality, and identify key characteristics essential for good methodological rigour. Although each of the factors listed in Stake's criteria could enhance the quality of a qualitative research report, in Table I we present an adapted criteria used in this study, which integrates more recent work by Merriam ( 2009 ) and Creswell ( 2013b ). Stake's ( 1995 ) original criteria were separated into two categories. The first list of general criteria is “relevant for all qualitative research.” The second list, “high relevance to qualitative case study research,” was the criteria that we decided had higher relevance to case study research. This second list was the main criteria used to assess the methodological descriptions of the case studies reviewed. The complete table has been preserved so that the reader can determine how the original criteria were adapted.

Framework for assessing quality in qualitative case study research.

Adapted from Stake ( 1995 , p. 131).

Study design

The critical review method described by Grant and Booth ( 2009 ) was used, which is appropriate for the assessment of research quality, and is used for literature analysis to inform research and practice. This type of review goes beyond the mapping and description of scoping or rapid reviews, to include “analysis and conceptual innovation” (Grant & Booth, 2009 , p. 93). A critical review is used to develop existing, or produce new, hypotheses or models. This is different to systematic reviews that answer clinical questions. It is used to evaluate existing research and competing ideas, to provide a “launch pad” for conceptual development and “subsequent testing” (Grant & Booth, 2009 , p. 93).

Qualitative methods journals were located by a search of the 2011 ISI Journal Citation Reports in Social Science, via the database Web of Knowledge (see m.webofknowledge.com). No “qualitative research methods” category existed in the citation reports; therefore, a search of all categories was performed using the term “qualitative.” In Table II , we present the qualitative methods journals located, ranked by impact factor. The highest ranked journals were selected for searching. We acknowledge that the impact factor ranking system might not be the best measure of journal quality (Cheek, Garnham, & Quan, 2006 ); however, this was the most appropriate and accessible method available.

International Journal of Qualitative Studies on Health and Well-being.

Search strategy

In March 2013, searches of the journals, Qualitative Health Research , Qualitative Research , and Qualitative Inquiry were completed to retrieve studies with “case study” in the abstract field. The search was limited to the past 5 years (1 January 2008 to 1 March 2013). The objective was to locate published qualitative case studies suitable for assessment using the adapted criterion. Viewpoints, commentaries, and other article types were excluded from review. Title and abstracts of the 45 retrieved articles were read by the first author, who identified 34 empirical case studies for review. All authors reviewed the 34 studies to confirm selection and categorization. In Table III , we present the 34 case studies grouped by journal, and categorized by research topic, including health sciences, social sciences and anthropology, and methods research. There was a discrepancy in categorization of one article on pedagogy and a new teaching method published in Qualitative Inquiry (Jorrín-Abellán, Rubia-Avi, Anguita-Martínez, Gómez-Sánchez, & Martínez-Mones, 2008 ). Consensus was to allocate to the methods category.

Outcomes of search of qualitative methods journals.

In Table III , the number of studies located, and final numbers selected for review have been reported. Qualitative Health Research published the most empirical case studies ( n= 16). In the health category, there were 12 case studies of health conditions, health services, and health policy issues, all published in Qualitative Health Research . Seven case studies were categorized as social sciences and anthropology research, which combined case study with biography and ethnography methodologies. All three journals published case studies on methods research to illustrate a data collection or analysis technique, methodological procedure, or related issue.

The methodological descriptions of 34 case studies were critically reviewed using the adapted criteria. All articles reviewed contained a description of study methods; however, the length, amount of detail, and position of the description in the article varied. Few studies provided an accurate description and rationale for using a qualitative case study approach. In the 34 case studies reviewed, three described a theoretical framework informed by Stake ( 1995 ), two by Yin ( 2009 ), and three provided a mixed framework informed by various authors, which might have included both Yin and Stake. Few studies described their case study design, or included a rationale that explained why they excluded or added further procedures, and whether this was to enhance the study design, or to better suit the research question. In 26 of the studies no reference was provided to principal case study authors. From reviewing the description of methods, few authors provided a description or justification of case study methodology that demonstrated how their study was informed by the methodological literature that exists on this approach.

The methodological descriptions of each study were reviewed using the adapted criteria, and the following issues were identified: case study methodology or method; case of something particular and case selection; contextually bound case study; researcher and case interactions and triangulation; and, study design inconsistent with methodology. An outline of how the issues were developed from the critical review is provided, followed by a discussion of how these relate to the current methodological literature.

Case study methodology or method

A third of the case studies reviewed appeared to use a case report method, not case study methodology as described by principal authors (Creswell, 2013b ; Merriam, 2009 ; Stake, 1995 ; Yin, 2009 ). Case studies were identified as a case report because of missing methodological detail and by review of the study aims and purpose. These reports presented data for small samples of no more than three people, places or phenomenon. Four studies, or “case reports” were single cases selected retrospectively from larger studies (Bronken, Kirkevold, Martinsen, & Kvigne, 2012 ; Coltart & Henwood, 2012 ; Hooghe, Neimeyer, & Rober, 2012 ; Roscigno et al., 2012 ). Case reports were not a case of something, instead were a case demonstration or an example presented in a report. These reports presented outcomes, and reported on how the case could be generalized. Descriptions focussed on the phenomena, rather than the case itself, and did not appear to study the case in its entirety.

Case reports had minimal in-text references to case study methodology, and were informed by other qualitative traditions or secondary sources (Adamson & Holloway, 2012 ; Buzzanell & D'Enbeau, 2009 ; Nagar-Ron & Motzafi-Haller, 2011 ). This does not suggest that case study methodology cannot be multimethod, however, methodology should be consistent in design, be clearly described (Meyer, 2001 ; Stake, 1995 ), and maintain focus on the case (Creswell, 2013b ).

To demonstrate how case reports were identified, three examples are provided. The first, Yeh ( 2013 ) described their study as, “the examination of the emergence of vegetarianism in Victorian England serves as a case study to reveal the relationships between boundaries and entities” (p. 306). The findings were a historical case report, which resulted from an ethnographic study of vegetarianism. Cunsolo Willox, Harper, Edge, ‘My Word’: Storytelling and Digital Media Lab, and Rigolet Inuit Community Government (2013) used “a case study that illustrates the usage of digital storytelling within an Inuit community” (p. 130). This case study reported how digital storytelling can be used with indigenous communities as a participatory method to illuminate the benefits of this method for other studies. This “case study was conducted in the Inuit community” but did not include the Inuit community in case analysis (Cunsolo Willox et al., 2013 , p. 130). Bronken et al. ( 2012 ) provided a single case report to demonstrate issues observed in a larger clinical study of aphasia and stroke, without adequate case description or analysis.

Case study of something particular and case selection

Case selection is a precursor to case analysis, which needs to be presented as a convincing argument (Merriam, 2009 ). Descriptions of the case were often not adequate to ascertain why the case was selected, or whether it was a particular exemplar or outlier (Thomas, 2011 ). In a number of case studies in the health and social science categories, it was not explicit whether the case was of something particular, or peculiar to their discipline or field (Adamson & Holloway, 2012 ; Bronken et al., 2012 ; Colón-Emeric et al., 2010 ; Jackson, Botelho, Welch, Joseph, & Tennstedt, 2012 ; Mawn et al., 2010 ; Snyder-Young, 2011 ). There were exceptions in the methods category ( Table III ), where cases were selected by researchers to report on a new or innovative method. The cases emerged through heuristic study, and were reported to be particular, relative to the existing methods literature (Ajodhia-Andrews & Berman, 2009 ; Buckley & Waring, 2013 ; Cunsolo Willox et al., 2013 ; De Haene, Grietens, & Verschueren, 2010 ; Gratton & O'Donnell, 2011 ; Sumsion, 2013 ; Wimpenny & Savin-Baden, 2012 ).

Case selection processes were sometimes insufficient to understand why the case was selected from the global population of cases, or what study of this case would contribute to knowledge as compared with other possible cases (Adamson & Holloway, 2012 ; Bronken et al., 2012 ; Colón-Emeric et al., 2010 ; Jackson et al., 2012 ; Mawn et al., 2010 ). In two studies, local cases were selected (Barone, 2010 ; Fourie & Theron, 2012 ) because the researcher was familiar with and had access to the case. Possible limitations of a convenience sample were not acknowledged. Purposeful sampling was used to recruit participants within the case of one study, but not of the case itself (Gallagher et al., 2013 ). Random sampling was completed for case selection in two studies (Colón-Emeric et al., 2010 ; Jackson et al., 2012 ), which has limited meaning in interpretive qualitative research.

To demonstrate how researchers provided a good justification for the selection of case study approaches, four examples are provided. The first, cases of residential care homes, were selected because of reported occurrences of mistreatment, which included residents being locked in rooms at night (Rytterström, Unosson, & Arman, 2013 ). Roscigno et al. ( 2012 ) selected cases of parents who were admitted for early hospitalization in neonatal intensive care with a threatened preterm delivery before 26 weeks. Hooghe et al. ( 2012 ) used random sampling to select 20 couples that had experienced the death of a child; however, the case study was of one couple and a particular metaphor described only by them. The final example, Coltart and Henwood ( 2012 ), provided a detailed account of how they selected two cases from a sample of 46 fathers based on personal characteristics and beliefs. They described how the analysis of the two cases would contribute to their larger study on first time fathers and parenting.

Contextually bound case study

The limits or boundaries of the case are a defining factor of case study methodology (Merriam, 2009 ; Ragin & Becker, 1992 ; Stake, 1995 ; Yin, 2009 ). Adequate contextual description is required to understand the setting or context in which the case is revealed. In the health category, case studies were used to illustrate a clinical phenomenon or issue such as compliance and health behaviour (Colón-Emeric et al., 2010 ; D'Enbeau, Buzzanell, & Duckworth, 2010 ; Gallagher et al., 2013 ; Hooghe et al., 2012 ; Jackson et al., 2012 ; Roscigno et al., 2012 ). In these case studies, contextual boundaries, such as physical and institutional descriptions, were not sufficient to understand the case as a holistic system, for example, the general practitioner (GP) clinic in Gallagher et al. ( 2013 ), or the nursing home in Colón-Emeric et al. ( 2010 ). Similarly, in the social science and methods categories, attention was paid to some components of the case context, but not others, missing important information required to understand the case as a holistic system (Alexander, Moreira, & Kumar, 2012 ; Buzzanell & D'Enbeau, 2009 ; Nairn & Panelli, 2009 ; Wimpenny & Savin-Baden, 2012 ).

In two studies, vicarious experience or vignettes (Nairn & Panelli, 2009 ) and images (Jorrín-Abellán et al., 2008 ) were effective to support description of context, and might have been a useful addition for other case studies. Missing contextual boundaries suggests that the case might not be adequately defined. Additional information, such as the physical, institutional, political, and community context, would improve understanding of the case (Stake, 1998 ). In Boxes 1 and 2 , we present brief synopses of two studies that were reviewed, which demonstrated a well bounded case. In Box 1 , Ledderer ( 2011 ) used a qualitative case study design informed by Stake's tradition. In Box 2 , Gillard, Witt, and Watts ( 2011 ) were informed by Yin's tradition. By providing a brief outline of the case studies in Boxes 1 and 2 , we demonstrate how effective case boundaries can be constructed and reported, which may be of particular interest to prospective case study researchers.

Article synopsis of case study research using Stake's tradition

Ledderer ( 2011 ) used a qualitative case study research design, informed by modern ethnography. The study is bounded to 10 general practice clinics in Denmark, who had received federal funding to implement preventative care services based on a Motivational Interviewing intervention. The researcher question focussed on “why is it so difficult to create change in medical practice?” (Ledderer, 2011 , p. 27). The study context was adequately described, providing detail on the general practitioner (GP) clinics and relevant political and economic influences. Methodological decisions are described in first person narrative, providing insight on researcher perspectives and interaction with the case. Forty-four interviews were conducted, which focussed on how GPs conducted consultations, and the form, nature and content, rather than asking their opinion or experience (Ledderer, 2011 , p. 30). The duration and intensity of researcher immersion in the case enhanced depth of description and trustworthiness of study findings. Analysis was consistent with Stake's tradition, and the researcher provided examples of inquiry techniques used to challenge assumptions about emerging themes. Several other seminal qualitative works were cited. The themes and typology constructed are rich in narrative data and storytelling by clinic staff, demonstrating individual clinic experiences as well as shared meanings and understandings about changing from a biomedical to psychological approach to preventative health intervention. Conclusions make note of social and cultural meanings and lessons learned, which might not have been uncovered using a different methodology.

Article synopsis of case study research using Yin's tradition

Gillard et al. ( 2011 ) study of camps for adolescents living with HIV/AIDs provided a good example of Yin's interpretive case study approach. The context of the case is bounded by the three summer camps of which the researchers had prior professional involvement. A case study protocol was developed that used multiple methods to gather information at three data collection points coinciding with three youth camps (Teen Forum, Discover Camp, and Camp Strong). Gillard and colleagues followed Yin's ( 2009 ) principles, using a consistent data protocol that enhanced cross-case analysis. Data described the young people, the camp physical environment, camp schedule, objectives and outcomes, and the staff of three youth camps. The findings provided a detailed description of the context, with less detail of individual participants, including insight into researcher's interpretations and methodological decisions throughout the data collection and analysis process. Findings provided the reader with a sense of “being there,” and are discovered through constant comparison of the case with the research issues; the case is the unit of analysis. There is evidence of researcher immersion in the case, and Gillard reports spending significant time in the field in a naturalistic and integrated youth mentor role.

This case study is not intended to have a significant impact on broader health policy, although does have implications for health professionals working with adolescents. Study conclusions will inform future camps for young people with chronic disease, and practitioners are able to compare similarities between this case and their own practice (for knowledge translation). No limitations of this article were reported. Limitations related to publication of this case study were that it was 20 pages long and used three tables to provide sufficient description of the camp and program components, and relationships with the research issue.

Researcher and case interactions and triangulation

Researcher and case interactions and transactions are a defining feature of case study methodology (Stake, 1995 ). Narrative stories, vignettes, and thick description are used to provoke vicarious experience and a sense of being there with the researcher in their interaction with the case. Few of the case studies reviewed provided details of the researcher's relationship with the case, researcher–case interactions, and how these influenced the development of the case study (Buzzanell & D'Enbeau, 2009 ; D'Enbeau et al., 2010 ; Gallagher et al., 2013 ; Gillard et al., 2011 ; Ledderer, 2011 ; Nagar-Ron & Motzafi-Haller, 2011 ). The role and position of the researcher needed to be self-examined and understood by readers, to understand how this influenced interactions with participants, and to determine what triangulation is needed (Merriam, 2009 ; Stake, 1995 ).

Gillard et al. ( 2011 ) provided a good example of triangulation, comparing data sources in a table (p. 1513). Triangulation of sources was used to reveal as much depth as possible in the study by Nagar-Ron and Motzafi-Haller ( 2011 ), while also enhancing confirmation validity. There were several case studies that would have benefited from improved range and use of data sources, and descriptions of researcher–case interactions (Ajodhia-Andrews & Berman, 2009 ; Bronken et al., 2012 ; Fincham, Scourfield, & Langer, 2008 ; Fourie & Theron, 2012 ; Hooghe et al., 2012 ; Snyder-Young, 2011 ; Yeh, 2013 ).

Study design inconsistent with methodology

Good, rigorous case studies require a strong methodological justification (Meyer, 2001 ) and a logical and coherent argument that defines paradigm, methodological position, and selection of study methods (Denzin & Lincoln, 2011b ). Methodological justification was insufficient in several of the studies reviewed (Barone, 2010 ; Bronken et al., 2012 ; Hooghe et al., 2012 ; Mawn et al., 2010 ; Roscigno et al., 2012 ; Yeh, 2013 ). This was judged by the absence, or inadequate or inconsistent reference to case study methodology in-text.

In six studies, the methodological justification provided did not relate to case study. There were common issues identified. Secondary sources were used as primary methodological references indicating that study design might not have been theoretically sound (Colón-Emeric et al., 2010 ; Coltart & Henwood, 2012 ; Roscigno et al., 2012 ; Snyder-Young, 2011 ). Authors and sources cited in methodological descriptions were inconsistent with the actual study design and practices used (Fourie & Theron, 2012 ; Hooghe et al., 2012 ; Jorrín-Abellán et al., 2008 ; Mawn et al., 2010 ; Rytterström et al., 2013 ; Wimpenny & Savin-Baden, 2012 ). This occurred when researchers cited Stake or Yin, or both (Mawn et al., 2010 ; Rytterström et al., 2013 ), although did not follow their paradigmatic or methodological approach. In 26 studies there were no citations for a case study methodological approach.

The findings of this study have highlighted a number of issues for researchers. A considerable number of case studies reviewed were missing key elements that define qualitative case study methodology and the tradition cited. A significant number of studies did not provide a clear methodological description or justification relevant to case study. Case studies in health and social sciences did not provide sufficient information for the reader to understand case selection, and why this case was chosen above others. The context of the cases were not described in adequate detail to understand all relevant elements of the case context, which indicated that cases may have not been contextually bounded. There were inconsistencies between reported methodology, study design, and paradigmatic approach in case studies reviewed, which made it difficult to understand the study methodology and theoretical foundations. These issues have implications for methodological integrity and honesty when reporting study design, which are values of the qualitative research tradition and are ethical requirements (Wager & Kleinert, 2010a ). Poorly described methodological descriptions may lead the reader to misinterpret or discredit study findings, which limits the impact of the study, and, as a collective, hinders advancements in the broader qualitative research field.

The issues highlighted in our review build on current debates in the case study literature, and queries about the value of this methodology. Case study research can be situated within different paradigms or designed with an array of methods. In order to maintain the creativity and flexibility that is valued in this methodology, clearer descriptions of paradigm and theoretical position and methods should be provided so that study findings are not undervalued or discredited. Case study research is an interdisciplinary practice, which means that clear methodological descriptions might be more important for this approach than other methodologies that are predominantly driven by fewer disciplines (Creswell, 2013b ).

Authors frequently omit elements of methodologies and include others to strengthen study design, and we do not propose a rigid or purist ideology in this paper. On the contrary, we encourage new ideas about using case study, together with adequate reporting, which will advance the value and practice of case study. The implications of unclear methodological descriptions in the studies reviewed were that study design appeared to be inconsistent with reported methodology, and key elements required for making judgements of rigour were missing. It was not clear whether the deviations from methodological tradition were made by researchers to strengthen the study design, or because of misinterpretations. Morse ( 2011 ) recommended that innovations and deviations from practice are best made by experienced researchers, and that a novice might be unaware of the issues involved with making these changes. To perpetuate the tradition of case study research, applications in the published literature should have consistencies with traditional methodological constructions, and deviations should be described with a rationale that is inherent in study conduct and findings. Providing methodological descriptions that demonstrate a strong theoretical foundation and coherent study design will add credibility to the study, while ensuring the intrinsic meaning of case study is maintained.

The value of this review is that it contributes to discussion of whether case study is a methodology or method. We propose possible reasons why researchers might make this misinterpretation. Researchers may interchange the terms methods and methodology, and conduct research without adequate attention to epistemology and historical tradition (Carter & Little, 2007 ; Sandelowski, 2010 ). If the rich meaning that naming a qualitative methodology brings to the study is not recognized, a case study might appear to be inconsistent with the traditional approaches described by principal authors (Creswell, 2013a ; Merriam, 2009 ; Stake, 1995 ; Yin, 2009 ). If case studies are not methodologically and theoretically situated, then they might appear to be a case report.

Case reports are promoted by university and medical journals as a method of reporting on medical or scientific cases; guidelines for case reports are publicly available on websites ( http://www.hopkinsmedicine.org/institutional_review_board/guidelines_policies/guidelines/case_report.html ). The various case report guidelines provide a general criteria for case reports, which describes that this form of report does not meet the criteria of research, is used for retrospective analysis of up to three clinical cases, and is primarily illustrative and for educational purposes. Case reports can be published in academic journals, but do not require approval from a human research ethics committee. Traditionally, case reports describe a single case, to explain how and what occurred in a selected setting, for example, to illustrate a new phenomenon that has emerged from a larger study. A case report is not necessarily particular or the study of a case in its entirety, and the larger study would usually be guided by a different research methodology.

This description of a case report is similar to what was provided in some studies reviewed. This form of report lacks methodological grounding and qualities of research rigour. The case report has publication value in demonstrating an example and for dissemination of knowledge (Flanagan, 1999 ). However, case reports have different meaning and purpose to case study, which needs to be distinguished. Findings of our review suggest that the medical understanding of a case report has been confused with qualitative case study approaches.

In this review, a number of case studies did not have methodological descriptions that included key characteristics of case study listed in the adapted criteria, and several issues have been discussed. There have been calls for improvements in publication quality of qualitative research (Morse, 2011 ), and for improvements in peer review of submitted manuscripts (Carter & Little, 2007 ; Jasper, Vaismoradi, Bondas, & Turunen, 2013 ). The challenging nature of editor and reviewers responsibilities are acknowledged in the literature (Hames, 2013 ; Wager & Kleinert, 2010b ); however, review of case study methodology should be prioritized because of disputes on methodological value.

Authors using case study approaches are recommended to describe their theoretical framework and methods clearly, and to seek and follow specialist methodological advice when needed (Wager & Kleinert, 2010a ). Adequate page space for case study description would contribute to better publications (Gillard et al., 2011 ). Capitalizing on the ability to publish complementary resources should be considered.

Limitations of the review

There is a level of subjectivity involved in this type of review and this should be considered when interpreting study findings. Qualitative methods journals were selected because the aims and scope of these journals are to publish studies that contribute to methodological discussion and development of qualitative research. Generalist health and social science journals were excluded that might have contained good quality case studies. Journals in business or education were also excluded, although a review of case studies in international business journals has been published elsewhere (Piekkari et al., 2009 ).

The criteria used to assess the quality of the case studies were a set of qualitative indicators. A numerical or ranking system might have resulted in different results. Stake's ( 1995 ) criteria have been referenced elsewhere, and was deemed the best available (Creswell, 2013b ; Crowe et al., 2011 ). Not all qualitative studies are reported in a consistent way and some authors choose to report findings in a narrative form in comparison to a typical biomedical report style (Sandelowski & Barroso, 2002 ), if misinterpretations were made this may have affected the review.

Case study research is an increasingly popular approach among qualitative researchers, which provides methodological flexibility through the incorporation of different paradigmatic positions, study designs, and methods. However, whereas flexibility can be an advantage, a myriad of different interpretations has resulted in critics questioning the use of case study as a methodology. Using an adaptation of established criteria, we aimed to identify and assess the methodological descriptions of case studies in high impact, qualitative methods journals. Few articles were identified that applied qualitative case study approaches as described by experts in case study design. There were inconsistencies in methodology and study design, which indicated that researchers were confused whether case study was a methodology or a method. Commonly, there appeared to be confusion between case studies and case reports. Without clear understanding and application of the principles and key elements of case study methodology, there is a risk that the flexibility of the approach will result in haphazard reporting, and will limit its global application as a valuable, theoretically supported methodology that can be rigorously applied across disciplines and fields.

Conflict of interest and funding

The authors have not received any funding or benefits from industry or elsewhere to conduct this study.

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Chapter 8: Case study

Darshini Ayton

Learning outcomes

Upon completion of this chapter, you should be able to:

• Identify the key terms and concepts used in qualitative case study research.
• Discuss the advantages and disadvantages of qualitative case study research.

What is a case study?

The key concept in a case study is context .

In qualitative research, case studies provide in-depth accounts of events, relationships, experiences or processes. Stemming from the fields of evaluation, political science and law, the aim of a qualitative case study is to explore a phenomenon within the context of the case 1 and to answer how and why research questions. 2 The contextual conditions are relevant to the phenomenon under study and the contextual factors tend to lie with the case. 1 From the outset it is important (a) to determine who or what is your case – this can be a person, program, organisation or group, or a process – and (b) to articulate the phenomenon of interest.

An example of why context is important in understanding the phenomenon of interest is a study of health promotion action by local churches in Victoria, Australia. 3 The phenomenon under study was health promotion action, with 10 churches comprising the cases, which were mapped across the framework of health promotion approaches. 4 The contextual factors included church denomination (Baptist, Church of Christ, Uniting, Anglican, Catholic and Salvation Army), size (small, medium and large), location (rural and metropolitan), partnerships with external organisations (government, local schools and social welfare organisations) and theological orientation (traditional, modern or postmodern), to understand the phenomenon of health promotion action. Data collection took 12 months and involved interviews with 37 church leaders, 10 focus groups with volunteers, 17 instances of participant observation of church activities, including church services, youth events, food banks and community meals, and 12 documentary analyses of church websites, newsletters and annual reports. The case studies identified and illustrated how and why three different expressions of church – traditional, new modern and emerging – led to different levels and types of health promotion activities.

Three prominent qualitative case study methodologists, Robert Stake, Robert Yin and Sharan Merriams, have articulated different approaches to case studies and their underpinning philosophical and paradigmatic assumptions. Table 8 outlines these approaches, based on work by Yazan, 5 whose expanded table covers characteristics of case studies, data collection and analysis.

Table 8.1. Comparison of case study terms used by three key methodologists

Table 8.1 is derived from ‘Three Approaches to Case Study Methods in Education: Yin, Merriam, and Stake ‘  by Bedrettin Yazan,  licensed under CC BY-NC-SA 4.0. 5

There are several forms of qualitative case studies. 1,2

Discovery-led case studies, which:

• describe what is happening in the setting
• explore the key issues affecting people within the setting
• compare settings, to learn from the similarities and differences between them.

Theory-led case studies, which:

• explain the causes of events, processes or relationships within a setting
• illustrate how a particular theory applies to a real-life setting
• experiment with changes in the setting to test specific factors or variables.

Single and collective case studies, where: 2, 9

• the researcher wants to understand a unique phenomenon in detail– known as an intrinsic case study
• the researcher is seeking insight and understanding of a particular situation or phenomenon, known as an illustrative case study or instrumental case study.

In both intrinsic, instrumental and illustrative case studies, the exploration might take place within a single case. In contrast, a collective case study includes multiple individual cases, and the exploration occurs both within and between cases. Collective case studies may include comparative cases, whereby cases are sampled to provide points of comparison for either context or the phenomenon. Embedded case studies are increasingly common within multi-site, randomised controlled trials, where each of the study sites is considered a case.

Multiple forms of data collection and methods of analysis (e.g. thematic, content, framework and constant comparative analyses) can be employed, since case studies are characterised by the depth of knowledge they provide and their nuanced approaches to understanding phenomena within context. 2,5 This approach enables triangulation between data sources (interviews, focus groups, participant observations), researchers and theory. Refer to Chapter 19 for information about triangulation.

Advantages and disadvantages of qualitative case studies

Advantages of using a case study approach include the ability to explore the subtleties and intricacies of complex social situations, and the use of multiple data collection methods and data from multiple sources within the case, which enables rigour through triangulation. Collective case studies enable comparison and contrasting within and across cases.

However, it can be challenging to define the boundaries of the case and to gain appropriate access to the case for the ‘deep dive’ form of analysis. Participant observation, which is a common form of data collection, can lead to observer bias. Data collection can take a long time and may require lengthy times, resources and funding to conduct the study. 9

Table 8.2 provides an example of a single case study and of a collective case study.

Table 8.2. Examples of qualitative case studies

Qualitative case studies provide a study design with diverse methods to examine the contextual factors relevant to understanding the why and how of a phenomenon within a case. The design incorporates single case studies and collective cases, which can also be embedded within randomised controlled trials as a form of process evaluation.

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Qualitative Research – a practical guide for health and social care researchers and practitioners Copyright © 2023 by Darshini Ayton is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License , except where otherwise noted.

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Qualitative study design: Case Studies

• Qualitative study design
• Phenomenology
• Grounded theory
• Ethnography
• Narrative inquiry
• Action research

Case Studies

• Field research
• Focus groups
• Observation
• Surveys & questionnaires
• Study Designs Home

In depth description of the experience of a single person, a family, a group, a community or an organisation.

An example of a qualitative case study is a life history which is the story of one specific person.  A case study may be done to highlight a specific issue by telling a story of one person or one group. 

• Oral recording

Ability to explore and describe, in depth, an issue or event. 

Develop an understanding of health, illness and health care in context. 

Single case can be used to develop or disprove a theory. 

Can be used as a model or prototype .  

Limitations

Labour intensive and generates large diverse data sets which can be hard to manage. 

Case studies are seen by many as a weak methodology because they only look at one person or one specific group and aren’t as broad in their participant selection as other methodologies. 

Example questions

This methodology can be used to ask questions about a specific drug or treatment and its effects on an individual.

• Does thalidomide cause birth defects?
• Does exposure to a pesticide lead to cancer?

Example studies

• Choi, T. S. T., Walker, K. Z., & Palermo, C. (2018). Diabetes management in a foreign land: A case study on Chinese Australians. Health & Social Care in the Community, 26(2), e225-e232. 
• Reade, I., Rodgers, W., & Spriggs, K. (2008). New Ideas for High Performance Coaches: A Case Study of Knowledge Transfer in Sport Science.  International Journal of Sports Science & Coaching , 3(3), 335-354. 
• Wingrove, K., Barbour, L., & Palermo, C. (2017). Exploring nutrition capacity in Australia's charitable food sector.  Nutrition & Dietetics , 74(5), 495-501. 
• Green, J., & Thorogood, N. (2018). Qualitative methods for health research (4th ed.). London: SAGE. 
• University of Missouri-St. Louis. Qualitative Research Designs. Retrieved from http://www.umsl.edu/~lindquists/qualdsgn.html   
• << Previous: Action research
• Next: Field research >>
• Last Updated: Apr 8, 2024 11:12 AM
• URL: https://deakin.libguides.com/qualitative-study-designs

• Open access
• Published: 26 April 2024

Clinician and staff experiences with frustrated patients during an electronic health record transition: a qualitative case study

• Sherry L. Ball 1 ,
• Bo Kim 2 , 3 ,
• Sarah L. Cutrona 4 , 5 ,
• Brianne K. Molloy-Paolillo 4 ,
• Ellen Ahlness 6 ,
• Megan Moldestad 6 ,
• George Sayre 6 , 7 &
• Seppo T. Rinne 2 , 8  

BMC Health Services Research volume  24 , Article number:  535 ( 2024 ) Cite this article

Metrics details

Electronic health record (EHR) transitions are known to be highly disruptive, can drastically impact clinician and staff experiences, and may influence patients’ experiences using the electronic patient portal. Clinicians and staff can gain insights into patient experiences and be influenced by what they see and hear from patients. Through the lens of an emergency preparedness framework, we examined clinician and staff reactions to and perceptions of their patients’ experiences with the portal during an EHR transition at the Department of Veterans Affairs (VA).

This qualitative case study was situated within a larger multi-methods evaluation of the EHR transition. We conducted a total of 122 interviews with 30 clinicians and staff across disciplines at the initial VA EHR transition site before, immediately after, and up to 12 months after go-live (September 2020-November 2021). Interview transcripts were coded using a priori and emergent codes. The coded text segments relevant to patient experience and clinician interactions with patients were extracted and analyzed to identify themes. For each theme, recommendations were defined based on each stage of an emergency preparedness framework (mitigate, prepare, respond, recover).

In post-go-live interviews participants expressed concerns about the reliability of communicating with their patients via secure messaging within the new EHR portal. Participants felt ill-equipped to field patients’ questions and frustrations navigating the new portal. Participants learned that patients experienced difficulties learning to use and accessing the portal; when unsuccessful, some had difficulties obtaining medication refills via the portal and used the call center as an alternative. However, long telephone wait times provoked patients to walk into the clinic for care, often frustrated and without an appointment. Patients needing increased in-person attention heightened participants’ daily workload and their concern for patients’ well-being. Recommendations for each theme fit within a stage of the emergency preparedness framework.

Conclusions

Application of an emergency preparedness framework to EHR transitions could help address the concerns raised by the participants, (1) mitigating disruptions by identifying at-risk patients before the transition, (2) preparing end-users by disseminating patient-centered informational resources, (3) responding by building capacity for disrupted services, and (4) recovering by monitoring integrity of the new portal function.

Peer Review reports

Electronic health record (EHR) transitions present significant challenges for healthcare clinicians and staff. These transitions require adjustments in care delivery and may threaten care quality and value. It is critical that healthcare organizations undergoing these changes learn from others who have undergone similar transitions [ 1 , 2 ]. However, the current literature lacks adequate guidance on navigating EHR transitions, especially as they relate to how clinicians and staff interact with patients [ 3 ].

Embedded within EHRs, patient portals facilitate complete, accurate, timely, and unambiguous exchange of information between patients and healthcare workers [ 4 , 5 ]. These portals have become indispensable for completing routine out-of-office-visit tasks, such as medication refills, communicating laboratory results, and addressing patient questions [ 6 ]. In 2003, the VA launched their version of a patient portal, myHealtheVet [ 7 ] and by 2017 69% of Veterans enrolled in healthcare at the VA had registered to access the patient portal [ 8 ]. Similar to other electronic portals, this system allows Veterans to review test results, see upcoming appointments, and communicate privately and securely with their healthcare providers.

EHR transitions can introduce disruptions to patient portal communication that may compromise portal reliability, impacting patient and clinician satisfaction, patients’ active involvement in self-management, and ultimately health outcomes [ 9 ]. During an EHR transition, patients can expect reductions in access to care even when clinician capacity and IT support are increased. Patients will likely need for more assistance navigating the patient portal including and using the portal to communicate with their providers [ 10 ]. Staff must be prepared and understand how the changes in the EHR will affect patients and safeguards must be in place to monitor systems for potential risks to patient safety. Building the capacity to respond to emerging system glitches and identified changes must be included in any transition plan. Although portal disruptions are likely to occur when a new EHR is implemented, we know little about how these disruptions impact healthcare workers’ interactions and care delivery to patients [ 11 , 12 ].

Due to an urgency to raise awareness and promote resolution of these patient portal issues,, we utilized existing data from the first EHR transition site for the Department of Veterans Affairs (VA)’s enterprise-wide transition. We focused on end users’ responses to the question “How Veterans were affected by the transition?”. We used qualitative methods to begin to understand how provider and patient interactions were affected during and by the EHR transition. We explored the impact of the EHR transition on patients through healthcare workers’ vicarious and direct experiences with patients. Due to the high level of disruption in care delivery we draw on insights from an emergency preparedness framework [ 13 ] to generate a set of recommendations to improve healthcare workers’ experiences during EHR transitions. The emergency preparedness framework includes 4 phases of an iterative cycle that include: (1) building capacity to mitigate issues, (2) preparing for the inevitable onset of issues, (3) responding to issues as they emerge, and (4) strategies to recover from any damage incurred.

In early 2020, the VA embarked on an EHR transition from a homegrown, legacy EHR system, developed by VA clinicians and used since the 1990s, to a new commercial system by the Oracle-Cerner Corporation. The primary objectives of this transition were to standardize care and improve interoperability between VA Medical Centers nationwide and the Department of Defense (DoD). Spanning over a decade, this transition plan is scheduled to roll out to all VA medical centers and outpatient clinics.

In this manuscript, we present data from the Mann-Grandstaff VA Medical Center in Spokane, WA, VA’s first EHR transition site. The study uses qualitative methods with clinician and staff interviews as part of a larger multi-method evaluation of the EHR transition. Our overarching goal is to identify and share recommendations to improve VA’s EHR transition efforts; rather than be guided by a theoretical framework our study design including the interview guides [ 14 , 15 ] were based primarily on what was being experienced. An experienced team of ten qualitative methodologists and analysts conducted the study.

This evaluation was designated as non-research/quality improvement work by the VA Bedford Healthcare System Institutional Review Board deeming it exempt from needing an informed consent. Study materials, including interview guides with verbal consent procedures, were reviewed and approved by labor unions and by the VA Bedford Healthcare System Institutional Review Board; all methods were carried out in accordance with local and national VA guidelines and regulations.

Interview guides and an outline of the data collection plans were reviewed and approved by relevant national unions before beginning recruitment.

Recruitment

Recruitment began in July 2020, before the first site implemented the new EHR. Prior to collecting data, we met with site leadership to get buy-in and support for the study, understand local context, determine how the site was approaching the transition, and to obtain the names of clinicians and staff for potential interviews. All potential participants were invited by email to participate in a one-hour voluntary interview conducted on Microsoft Teams® about their experiences with this transition; we used snowball sampling during interviews to expand the pool of interviewees. Verbal permission for audio recording of interviews was obtained immediately prior to the interview. Interview participants were informed that they could skip any questions, pause or stop the recording, and stop the interview at any time and were invited to ask questions before beginning the interview.

Most participants were interviewed at multiple timepoints; these included pre-implementation interviews, brief check-ins, and post-implementation interviews (Table  1 ). At the end of the pre-implementation interview, participants were invited to participate in 3–4 additional, shorter (15–20 min), check-in interviews where information about any changes in the transition process, context, or experience could be discussed. Most initial interviewees, in addition to three new participants, participated in post-implementation interviews (35–60 min; approximately 2–3 months and 10–12 months after the implementation) to reflect on the entire transition process.

Data collection

Experienced qualitative interviewers included PhD trained qualitative methodologist and masters level qualitative analysts (JB, SB, AC, EK, MM, GS) conducted individual interviews with clinicians and staff, aligning to a semi-structured interview guide with follow-up probes using the participant’s words to elicit rich responses grounded in the data [ 16 ]. The guide was designed to inform ongoing efforts to improve the rollout of the new EHR. Six main categories were covered in our interview guides, including (1) attitudes toward the new software, (2) information communicated about the transition, (3) training and education, (4) resources, (5) prior experience with EHRs, and (6) prior experiences with EHR transitions. After piloting the interview guide with a clinician, initial interviews were completed between September and October 2020 and averaged  ∼  45 min in duration. Two-month and one-year post-implementation interview guides included an additional question, “Has the Cerner transition affected Vets?”; data presented here largely draw from responses to this question. Check-ins (October 2020– December 2020) took  ∼  15 min; two-month post-implementation interviews (December 2020– January 2021) and one-year post-implementation interviews (October 2020 - November 2021) took  ∼  45 min. Audio recordings of all interviews were professionally transcribed. To ensure consistency and relationship building, participants were scheduled with the same interviewer for the initial and subsequent interviews whenever feasible (i.e., check-ins and post-implementation interviews). Immediately following each interview, interviewers completed a debrief form where highlights and general reflections were noted.

Throughout the data collection process, interviewers met weekly with the entire qualitative team and the project principal investigators to discuss the recruitment process, interview guide development, and reflections on data collection. To provide timely feedback to leadership within the VA, a matrix analysis [ 17 ] was conducted concurrently with data collection using the following domains: training, roles, barriers, and facilitators. Based on these domains, the team developed categories and subcategories, which formed the foundation of an extensive codebook.

Data analysis

All interviewers also coded the data. We used inductive and deductive content analysis [ 18 ]. Interview transcripts were coded in ATLAS.ti qualitative data analysis software (version 9). A priori codes and categories (based on the overall larger project aims and interview guide questions) and emergent codes and categories were developed to capture concepts that did not fit existing codes or categories [ 18 ]. Codes related to patient experience and clinician interactions with patients were extracted and analyzed using qualitative content analysis to identify themes [ 18 ]. Themes were organized according to their fit within the discrete stages of an emergency preparedness framework to generate recommendations for future rollout. In total, we examined data from 111 interviews with 24 VA clinicians and staff (excluding the initial 11 stakeholder meetings (from the 122 total interviews) that were primarily for stakeholder engagement). We focused on participants’ responses related to their experiences interacting with patients during the EHR transition.

Exemplar quotes primarily came from participants’ responses to the question, “Has the Cerner transition affected Vets?” and addressed issues stemming from use of the patient portal. This included both clinicians’ direct experiences with the portal and indirect experiences when they heard from patients about disruptions when using the portal. We identified four themes related to clinicians’ and staff members’ reported experiences: (1) stress associated with the unreliability of routine portal functions and inaccurate migrated information; (2) concern about patients’ ability to learn to use a new portal (especially older patients and special populations); (3) frustration with apparent inadequate dissemination of patient informational materials along with their own lack of time and resources to educate patients on use of the new portal; and (4) burden of additional tasks on top of their daily workload when patients needed increased in-person attention due to issues with the portal.

Stress associated with the unreliability of routine portal functions and inaccurate migrated information

One participant described the portal changes as, “It’s our biggest stress, it’s the patients’ biggest stress… the vets are definitely frustrated; the clinicians are; so I would hope that would mean that behind the scenes somebody is working on it” (P5, check-in).

Participants expressed significant frustration when they encountered veterans who were suddenly unable to communicate with them using routine secure messaging. These experiences left them wondering whether messages sent to patients were received.

Those that use our secure messaging, which has now changed to My VA Health, or whatever it’s called, [have] difficulty navigating that. Some are able to get in and send the message. When we reply to them, they may or may not get the reply. Which I’ve actually asked one of our patients, ‘Did you get the reply that we took care of this?’ And he was like, ‘No, I did not (P11, 2-months post)

Participants learned that some patients were unable to send secure messages to their care team because the portal contained inaccurate or outdated appointment and primary site information.

I’ve heard people say that the appointments aren’t accurate in there… veterans who have said, ‘yeah, it shows I’m registered,’ and when they go into the new messaging system, it says they are part of a VA that they haven’t gone to in years, and that’s the only area they can message to, they can’t message to the [site] VA, even though that’s where they’ve actively being seen for a while now. (P20, 2-months post)

After the EHR transition, participants noted that obtaining medications through the portal, which was once a routine task, became unreliable. They expressed concern around patients’ ability to obtain their medications through the portal, primarily due to challenges with portal usability and incomplete migration of medication lists from the former to the new EHR.

I think it’s been negative, unfortunately. I try to stay optimistic when I talk to [patients], but they all seem to be all having continued difficulty with their medications, trying to properly reorder and get medications seems to still be a real hassle for them. (P17, one-year post) …the medications, their med list just didn’t transfer over into that list [preventing their ability to refill their medications]. (P13, 2-months post)

Concern about patients’ ability to learn to use a new portal

Clinicians and staff expressed concerns around veterans’ ability to access, learn, and navigate a new portal system. Clinicians noted that even veterans who were adept at using the prior electronic portal or other technologies also faced difficulties using the new portal.

They can’t figure out [the new portal], 99% of them that used to use our [old] portal, the electronic secure messaging or emailing between the team, they just can’t use [the new one]. It’s not functioning. (P13, one-year post) Apparently, there’s a link they have to click on to make the new format work for them, and that’s been confusing for them. But I still am having a lot of them tell me, I had somebody recently, who’s very tech savvy, and he couldn’t figure it out, just how to message us. I know they’re still really struggling with that. (P5, 2-months post) And it does seem like the My Vet [my VA Health, new portal], that used to be MyHealtheVet [prior portal], logging on and getting onto that still remains really challenging for a large number of veterans. Like they’re still just unable to do it. So, I do think that, I mean I want to say that there’s positive things, but really, I struggle (P17, one-year post)

Participants recognized difficulties with the new system and expressed empathy for the veterans struggling to access the portal.

I think that a lot of us, individually, that work here, I think we have more compassion for our veterans, because they’re coming in and they can’t even get onto their portal website. (P24, one-year post)

Participants acknowledged that learning a new system may be especially difficult for older veterans or those with less technology experience.

But, you know, veterans, the general population of them are older, in general. So, their technologic skills are limited, and they got used to a system and now they have to change to a new one. (P13, 2-months post) So, for our more elderly veterans who barely turn on the computer, they’re not getting to this new portal. (P8, check in) And you know, I do keep in mind that this is a group of people who aren’t always technologically advanced, so small things, when it’s not normal to them, stymie them.(P13, one-year post)

Concerns were heightened for veterans who were more dependent on the portal as a key element in their care due to specific challenges. One participant pointed out that there may be populations of patients with special circumstances who depend more heavily on the prior portal, MyHealtheVet.

I have veterans from [specific region], that’s the way they communicate. Hearing impaired people can’t hear on the phone, the robocall thing, it doesn’t work, so they use MyHealtheVet. Well, if that goes away, how is that being communicated to the veteran? Ok? (P18, Check-in)

Frustration with inadequate dissemination of information to veterans about EHR transition and use of new portal

Participants were concerned about poor information dissemination to patients about how to access the new portal. During medical encounters, participants often heard from patients about their frustrations accessing the new portal. Participants noted that they could only give their patients a phone number to call for help using the new system but otherwise lacked the knowledge and the time to help them resolve new portal issues. Some clinicians specifically mentioned feeling ill-equipped to handle their patients’ needs for assistance with the new portal. These experiences exacerbated clinician stress during the transition.

Our veterans were using the MyHealtheVet messaging portal, and when our new system went up, it transitioned to My VA Health, but that wasn’t really communicated to the veterans very well. So, what happened was they would go into their MyHealtheVet like they had been doing for all of these years, to go in and request their medications, and when they pulled it up it’d show that they were assigned to a clinician in [a different state], that they have no active medications. Everything was just messed up. And they didn’t know why because there was no alert or notification that things would be changing. (P8, check in) I field all-day frustration from the veterans. And I love my job, I’m not leaving here even as frustrated as I am, because I’m here for them, not to, I’m here to serve the veterans and I have to advocate for them, and I know it will get better, it can’t stay like this. But I constantly field their frustrations.… So, I give them the 1-800 number to a Cerner help desk that helps with that, and I’ve had multiple [instances of] feedback that it didn’t help. (P13, one-year post) And [the patients are] frequently asking me things about their medication [within the portal], when, you know, I can’t help them with that. So, I have to send them back up to the front desk to try to figure out their medications. (P17, one-year post)

Veteran frustration and the burden of additional tasks due to issues with the portal

Clinicians reported that veterans expressed frustration with alternatives to the portal, including long call center wait times. Some veterans chose to walk into the clinic without an appointment rather than wait on the phone. Clinicians noted an increase in walk-ins by frustrated veterans, which placed added workload on clinics that were not staffed to handle the increase in walk-ins.

It’s been kind of clunky also with trying to get that [new portal] transitioned. And then that’s created more walk-ins here, because one, the vets get frustrated with the phone part of it, and then MyHealtheVet (prior portal) not [working], so they end up walking [into the clinic without an appointment]. (P19, check-in) In terms of messages, they can’t necessarily find the clinician they want to message. We had a veteran who came in recently who wanted to talk to their Rheumatologist, and it’s like, yeah, I typed in their name, and nothing came up. So, they have to try calling or coming in. (P20, 2-months post)

In summary, participants described the new patient portal as a source of stress for both themselves and their patients.

In addition to their own direct experience using a new EHR to communicate with their patients, clinicians and staff can be affected by perceptions of their patients’ experiences during an EHR transition [ 19 ]. At this first VA site to transition to the new EHR, clinicians and staff shared their concerns about their patients’ experiences using the portal. They were particularly troubled by unreliability of the secure messaging system and challenges patients faced learning to use the new system without proper instruction. Moreover, clinicians were alarmed to hear about patients having to make in-person visits– especially unplanned (i.e., walk in) ones– due to challenges with the new portal. Each of these issues needs to be addressed to ensure veteran satisfaction. However, the only solution participants could offer to frustrated patients was the telephone number to the help desk, leaving them with no clear knowledge of a solution strategy or a timeline for resolution of the issues.

We propose applying emergency preparedness actions to future EHR rollouts: mitigate, prepare, respond, and recover (Fig.  1 ) [ 13 ]. By applying these actions, patient portal disruptions may be alleviated and patients’ communication with their clinicians and access to care can be maintained. For example, issues stemming from a disruption in the portal may be mitigated by first identifying and understanding which patients typically use the portal and how they use it. Sites can use this information to prepare for the transition by disseminating instructional materials to staff and patients on how to access the new portal, targeting the most common and critical portal uses. Sites can respond to any expected and emerging portal disruptions by increasing access to alternative mechanisms for tasks disrupted by and typically completed within the portal. After the transition, recovery can begin by testing and demonstrating the accuracy and reliability of functions in the new portal. These actions directly address reported clinician concerns and can help maintain patient-clinician communication, and access to care.

The emergency preparedness framework was applied. This framework includes 4 actions: (1) mitigate, (2) prepare, (3) respond, and (4) recover. These actions can be repeated. Recommendations for how each action (1–4) can be applied to a portal transition are included in each blue quadrant of the circle

Sites could mitigate issues by first understanding which patients will be most affected by the transition, such as those who rely heavily on secure messaging. Reliable use of secure messaging within the VA facilitates positive patient-clinician relationships by providing a mechanism for efficient between-visit communication [ 20 , 21 , 22 , 23 ]. During the EHR transition, clinicians and staff became concerned about the well-being of patients from whom they weren’t receiving messages and those who depended on the portal to complete certain tasks. Since secure messaging is often initiated by patients to clinicians [ 23 ], clinicians will likely be unaware that messages are being missed. Understanding how and which patients currently use the portal and anticipating potential portal needs is a first step toward mitigating potential issues.

Despite efforts to inform Veterans of the EHR transition and patient portal [ 24 ] including information sent to a Veteran by email, direct mail, postings on VA websites, and a town hall, our findings agree with those of Fix and colleagues [ 10 ] and suggest that many Veterans were unprepared for the transition. Our findings suggest that end users heard that more is needed to improve the dissemination of knowledge about the transition and how to navigate the new patient portal to both VA employees and the patients they serve.

Preparations for the transition should prioritize providing VA clinicians and staff with updated information and resources on how to access and use the new portal [ 25 ]. VA clinicians deliver quality care to veterans and many VA employees are proud to serve the nation’s veterans and willing to go the extra mile to support their patients’ needs [ 26 ]. In this study, participants expressed feeling unprepared to assist or even respond to their patients’ questions and concerns about using the new portal. This unpreparedness contributed to increased clinician and staff stress, as they felt ill-equipped to help their patients with portal issues. Such experiences can negatively affect the patient-clinician relationship. Preparing clinicians and patients about an upcoming transition, including technical support for clinicians and patients, may help minimize these potential issues [ 10 , 27 ]. Specialized training about an impending transition, along with detailed instructions on how to gain access to the new system, and a dedicated portal helpline may be necessary to help patients better navigate the transition [ 23 , 28 ].

In addition to a dedicated helpline, our recommendations include responding to potential changes in needed veteran services during the transition. In our study, participants observed more veteran walk-ins due to challenges with the patient portal. Health systems need to anticipate and address this demand by expanding access to in-person services and fortifying other communication channels. For example, sites could use nurses to staff a walk-in clinic to handle increases in walk-in traffic and increase call center capacity to handle increases in telephone calls [ 29 ]. Increased use of walk-in clinics have received heightened attention as a promising strategy for meeting healthcare demands during the COVID-19 pandemic [ 30 ] and can potentially be adapted for meeting care-related needs during an EHR transition. These strategies can fill a gap in communication between clinicians and their patients while patients are learning to access and navigate a new electronic portal.

Finally, there is a need for a recovery mechanism to restore confidence in the reliability of the EHR and the well-being of clinicians and staff. Healthcare workers are experiencing unprecedented levels of stress [ 31 ]. A plan must be in place to improve and monitor the accuracy of data migrated, populated, and processed within the new system [ 2 ]. Knowing that portal function is monitored could help ease clinician and staff concerns and mitigate stress related to the transition.

Limitations

This study has several limitations. First, data collection relied on voluntary participation, which may introduce self-selection response bias. Second, this work was completed at one VA medical center that was the first site in the larger enterprise-wide transition, and experiences at other VAs or healthcare systems might differ substantially. Third, we did not interview veterans and relied entirely on secondhand accounts of patient experiences with the patient portal. Future research should include interviews with veterans during the transition and compare veteran and VA employee experiences.

Despite a current delay in the deployment of the new EHR at additional VA medical centers, findings from this study offer timely lessons that can ensure clinicians and staff are equipped to navigate challenges during the transition. The strategies presented in this paper could help maintain patient-clinician communication and improve veteran experience. Guided by the emergency preparedness framework, recommended strategies to address issues presented here include alerting those patients most affected by the EHR transition, being prepared to address patients’ concerns, increasing staffing for the help desk and walk-in care clinics, and monitoring the accuracy and reliability of the portal to provide assurance to healthcare workers that patients’ needs are being met. These strategies can inform change management at other VA medical centers that will soon undergo EHR transition and may have implications for other healthcare systems undergoing patient portal changes. Further work is needed to directly examine the perspectives of veterans using the portals, as well as the perspectives of both staff and patients in the growing number of healthcare systems beyond VA that are preparing for an EHR-to-EHR transition.

Data availability

Deidentified data analyzed for this study are available from the corresponding author on reasonable request.

Abbreviations

Electronic health record

Department of Veterans Affairs

VA Medical Centers

Department of Defense

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Acknowledgments

We acknowledge and thank members of the EMPIRIC Evaluation qualitative and supporting team for their contributions to this work including Ellen Ahlness, PhD, Julian Brunner, PhD, Adena Cohen-Bearak, MPH, M.Ed, Leah Cubanski, BA, Christine Firestone, Bo Kim, PhD, Megan Moldestad, MS, and Rachel Smith. We greatly appreciate the staff at the Mann-Grandstaff VA Medical Center and associated community-based outpatient clinics for generously sharing of their time and experiences participating in this study during this challenging time.

The “EHRM Partnership Integrating Rapid Cycle Evaluation to Improve Cerner Implementation (EMPIRIC)” (PEC 20–168) work was supported by funding from the US Department of Veterans Affairs, Veterans Health Administration, Health Services Research & Development Quality Enhancement Research Initiative (QUERI) (PEC 20–168). The findings and conclusions in this article are those of the authors and do not necessarily reflect the views of the Veterans Health Administration, Veterans Affairs, or any participating health agency or funder.

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Contributions

S.R. designed the larger study. G.S. was the qualitative methodologist who led the qualitative team. S.B., E.A., and M.M. created the interview guides and completed the interviews; Data analysis, data interpretation, and the initial manuscript draft were completed by S.B. and B.K. S.C. and B.M. worked with the qualitative team to finalize the analysis and edit and finalize the manuscript. All authors read and approved the final manuscript.

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Correspondence to Sherry L. Ball .

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Ethics approval and consent to participate.

This evaluation was designated as non-research/quality improvement by the VA Bedford Healthcare System Institutional Review Board. All methods were carried out in accordance with local and national VA guidelines and regulations for quality improvement activities. This study included virtual interviews with participants via MS Teams. Employees volunteered to participate in interviews and verbal consent was obtained to record interviews. Study materials, including interview guides with verbal consent procedures, were reviewed and approved by labor unions and determined as non-research by the VA Bedford Healthcare System Institutional Review Board.

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Not applicable.

The findings and conclusions in this paper are those of the authors and do not necessarily represent the official position of the Department of Veterans Affairs.

Prior presentations

Ball S, Kim B, Moldestad M, Molloy-Paolillo B, Cubanski L, Cutrona S, Sayre G, and Rinne S. (2022, June). Electronic Health Record Transition: Providers’ Experiences with Frustrated Patients. Poster presentation at the 2022 AcademyHealth Annual Research Meeting. June 2022.

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Ball, S.L., Kim, B., Cutrona, S.L. et al. Clinician and staff experiences with frustrated patients during an electronic health record transition: a qualitative case study. BMC Health Serv Res 24 , 535 (2024). https://doi.org/10.1186/s12913-024-10974-5

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DOI : https://doi.org/10.1186/s12913-024-10974-5

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eMethods 1. Semi-Structured Interview Guide for Primary Care Team Members

eMethods 2. Discussion Questions for Patient Engagement Studio (PES) With Patient Stakeholders

eTable 1. Descriptive Statistics for Social Determinants of Health (SDOH) Screening Responses

eTable 2. Descriptive Statistics for Practices, Providers and Patients With Unrestricted Sample (N = 147 096)

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Rudisill AC , Eicken MG , Gupta D, et al. Patient and Care Team Perspectives on Social Determinants of Health Screening in Primary Care : A Qualitative Study . JAMA Netw Open. 2023;6(11):e2345444. doi:10.1001/jamanetworkopen.2023.45444

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Patient and Care Team Perspectives on Social Determinants of Health Screening in Primary Care : A Qualitative Study

• 1 Department of Health Promotion, Education, and Behavior, Arnold School of Public Health, University of South Carolina, Greenville
• 2 Department of Medicine, Prisma Health, Upstate, University of South Carolina School of Medicine Greenville, Greenville
• 3 Department of Epidemiology/Biostatistics, Arnold School of Public Health, University of South Carolina, Greenville
• 4 Department of Biomedical Sciences, University of South Carolina School of Medicine Greenville, Greenville
• 5 Addiction Medicine Center, Prisma Health, Greenville, South Carolina

Question   Are patient and clinician factors associated with early implementation of social determinants of health (SDOH) screening in primary care, and what strategies can improve these efforts?

Findings   In this qualitative study of 78 928 primary care visits from the inception of primary care–based SDOH screening, visits with a physician assistant, belonging to a racial minority group, and having noncommercial/nonprivate health insurance were associated with greater screening likelihood. Stakeholders suggest that patient-clinician rapport, practice champions, streamlined questions, and referral follow-up ability may improve screening implementation.

Meaning   Results of this study suggest that primary care SDOH screening is feasible but limited by barriers that can be overcome with consideration of stakeholder feedback.

Importance   Health systems in the US are increasingly screening for social determinants of health (SDOH). However, guidance incorporating stakeholder feedback is limited.

Objective   To examine patient and care team experiences in early implementation of SDOH screening in primary care.

Design, Setting, and Participants   This qualitative study included cross-sectional analysis of SDOH screenings during primary care visits from February 22 to May 10, 2022, primary care team member interviews from July 6, 2022, to March 8, 2023, and patient stakeholder engagement on June 30, 2022. The setting was a large southeastern US health care system. Eligible patients were aged 18 years or older with completed visits in primary care.

Exposure   Screening for SDOH in primary care.

Main outcomes and Measures   Multivariable logistic regression evaluated patient (eg, age, race and ethnicity) and care team characteristics (eg, practice type), and screening completeness. Interviews contextualized the quantitative analysis.

Results   There were 78 928 visits in practices conducting any SDOH screening. The population with visits had a mean (SD) age of 57.6 (18.1) years; 48 086 (60.9%) were female, 12 569 (15.9%) Black, 60 578 (76.8%) White, and 3088 (3.9%) Hispanic. A total of 54 611 visits (69.2%) were with a doctor of medicine and 13 035 (16.5%) with a nurse practitioner. Most had no SDOH questions answered (75 298 [95.4%]) followed by all questions (2976 [3.77%]). Logistic regression analysis found that clinician type, patient race, and primary payer were associated with screening likelihood: for clinician type, nurse practitioner (odds ratio [OR], 0.13; 95% CI, 0.03-0.62; P  = .01) and physician assistant (OR, 3.11; 95% CI, 1.19-8.10; P  = .02); for patient race, Asian (OR, 1.69; 95% CI, 1.25-2.28; P  = .001); Black (OR, 1.49; 95% CI, 1.10-2.01; P  = .009); or 2 or more races (OR, 1.48; 95% CI, 1.12-1.94; P  = .006); and for primary payer, Medicaid (OR, 0.62; 95% CI, 0.48-0.80; P  < .001); managed care (OR, 1.17; 95% CI, 1.07-1.29; P  = .001); uninsured or with Access Health (OR, 0.26; 95% CI, 0.10-0.67; P  = .005), and Tricare (OR, 0.71; 95% CI, 0.55-0.92; P  = .01). Interview themes included barriers (patient hesitancy, time and resources for screening and referrals, and number of questions/content overlap) and facilitators (communication, practice champions, and support for patient needs).

Conclusions and Relevance   This qualitative study presents potential guidance regarding factors that could improve SDOH screening within busy clinical workflows.

Health systems in the US recognize the importance of social determinants of health (SDOH) in patient outcomes and care. The SDOH are economic and social conditions affecting health outcomes, 1 health care use, 2 and health inequities. 3 Health systems are increasingly engaging in SDOH screening. 4 Although such screening can potentially improve health outcomes and reduce health care use, 5 , 6 there is limited peer-reviewed evidence incorporating patient and clinician or care team characteristics and perspectives when describing early screening initiatives.

Given the personal nature and limited evidence guiding SDOH screening adoption, 7 - 9 it is critical to understand stakeholder perspectives. Prior research indicates that health care professionals recognize the importance of addressing patient SDOH needs and strive to adopt patient-centered approaches 10 but face ethical and time-related challenges. 8 , 11 , 12 Existing work reports greater SDOH screening uptake in primary care vs specialist visits and lower completion among patients requiring interpreters and patients with racial and ethnic minority status. 7 Studies on patient and caregiver perspectives have documented SDOH screening acceptability and preferences. 13 The role of practice and care team characteristics in screening uptake has not been assessed within a multistakeholder analysis.

To address this research gap, we conducted a qualitative study of a large southeastern US health care system's experiences during the early stages of SDOH screening in primary care. Quantitative analysis examined practice, care team, and patient characteristics and SDOH screening uptake. Qualitative analysis engaged team member feedback. Patient experts informed interview protocols and finding interpretation. Our goal was to identify barriers and facilitators to SDOH screening within primary care to inform future screening.

This qualitative study was classified as exempt by the Prisma Health institutional review board in accordance with 45 CFR §46. In February 2022, Prisma Health, South Carolina’s largest nonprofit health system with approximately 1.5 million unique patients annually, began screening adults for SDOH needs in primary care practices with the goal of annual screening. Practices had implementation flexibility and determined how and when to screen during the clinical workflow. Patients were screened using a 16-question electronic health record (EHR)–embedded survey (eTable 1 in Supplement 1 ). Questions were chosen using validated questionnaires and clinical input on system priorities and resource availability. Answers triggered automated input of community-based service information curated to patient SDOH needs and location into patient after-visit summaries using an EHR-compatible platform connecting patients to community-based organizations (NowPow; Unite Us). Practices provided the after-visit summaries to patients at visit end. Reporting follows the 21-item Standards for Reporting Qualitative Research ( SRQR ) reporting guideline.

The study population included patients aged 18 years or older with a visit in a family or internal medicine practice in the northwestern region of South Carolina from February 22 to May 10, 2022. Visits classified as future, cancelled, no show, or left without being seen were excluded. The last screen on a day was the patient final value, and the same patient could have multiple visits over the study period. In 2021, the northwestern region (4 counties) had 813 069 inhabitants, with 14.2% in poverty (11.4% nationally) and 13.9% uninsured (10.2% nationally). The population is 75.8% White, 14.6% Black, 6.5% Hispanic, 0.4% American Indian or Alaska Native, 1.6% Asian, and 0.1% Native Hawaiian or Other Pacific Islander. 14

The primary outcome was SDOH screening completion status. Visits with a response to at least 1 question were deemed partial screening while complete screening included responses to all questions. Our primary outcome compared visits with complete or partial screening (any screening) with no screening. Secondary outcomes compared visits with complete vs partial or no screening and visits with complete screening vs partial screening.

Potential explanatory variables included practice type (family or internal medicine), clinician qualification (medical doctor, doctor of osteopathic medicine, nurse practitioner, and physician assistant), patient demographic characteristics (age, sex, race and ethnicity [treated as classified in the electronic medical records as separate fields], preferred language, primary payer), and SDOH risk (calculated as the ratio of screener questions with positive responses to the total number of questions answered by patients). Race and ethnicity came from the EHR and thus were primarily patient self-reported. Race is reported as Asian, Black, White, 2 or more races, other race, patient refused, or unknown. Other race comprises American Indian or Alaska Native, Native Hawaiian or Other Pacific Islander, and other as reported in the EHR. Ethnicity is reported as in the EHR. We included SDOH risk to test whether patients with a need might be more likely to be screened (ie, care team members suspect a need or patients are more likely to answer questions).

Binary logistic regression was used to determine the odds of screening completion. Standard errors were clustered by practice to account for practice-specific differences. A 95% CI not including 1 indicated statistical significance. We tested for multicollinearity using variance inflation factors and omitted variable bias using the Ramsey Regression Equation Specification Error Test (RESET). Analysis was conducted using Stata/MP, version 11 (StataCorp LLC).

Six practices were categorized as higher-adopting facilities as they performed SDOH screening during at least 4.0% of visits over the study period. Two of these practices were excluded because of involvement in other SDOH-related studies. Lower-adopting practices performed at least 10 screenings but in less than 2.0% of visits. Four practices met this criterion, but 1 practice was excluded because of involvement in SDOH pilot efforts. Higher- and lower-adopting was defined by quantitative analysis. We excluded practices performing no or minimal screening because we wanted to learn from those practices with some screening familiarity and those screening at both higher and lower levels. These 7 practices were approached for interviews of primary care team members (ie, physicians, administrative staff, nursing staff, and allied health professionals). Six practices participated in a total of 9 interviews (at least 1 interviewee from each of these 6 practices). Interview findings contextualized the quantitative analysis.

Two trained medical students (E.K. and M.J.) conducted and recorded 9 semistructured interviews online between July 6, 2022, and March 8, 2023. The students had not met the interviewees or worked in these clinics prior to the interviews. Interview questions focused on potential barriers and facilitators to screening (eMethods 1 in Supplement 1 ). Oral consent was obtained prior to interviews. Interviews were transcribed verbatim by a speech-to-text service (rev.com). Interview recordings were accessible only to interviewers and the team member uploading for transcription. Interviewers asked questions aimed to not yield identifying information. Additionally, transcripts were kept either on secure file-sharing systems or on password-protected computers. Using a web application (Dedoose), transcripts were coded by 2 research team members (D.G. and M.M.) and analyzed using an inductive grounded theory approach, in which important concepts and themes are derived from close reading of the text, and similar concepts are grouped into conceptual categories (codes). No further interviews were necessary as theme saturation was achieved.

To ensure the research was relevant and ethical for patients and the broader community, we included a meeting with patient experts from the University of South Carolina Patient Engagement Studio (PES) in our research strategy. 15 - 17 The PES is built on guidance from the Patient-Centered Outcomes Research Institute and provides structured opportunities for research teams to engage with community-recruited patient experts. Patient expert refers to individuals or caregivers with substantial health system interaction due to their health conditions who are trained in communication, research methods, and team building.

The research team met with patient experts on June 30, 2022, prior to interviews with primary care practices. In accordance with standard PES processes, 18 patient experts were provided the health system SDOH screening tool as presession reading material. Discussion topics at that meeting included screening and referral processes (eMethods 2 in Supplement 1 ). Patient expert feedback was incorporated into the research process through practice interview topics and by incorporating what we heard from patient experts when discussing study results.

Over the study period, there were 147 096 practice visits, with 3630 (2.5%) involving complete (2976 [3.8%]) or partial (654 [0.8%]) SDOH screening. In the restricted sample, 22 of 58 practices (37.9%) performed any screening during the study period ( Table 1 ). Of the 78 928 visits (mean [SD] age of 57.6 [18.1] years; 48 086 [60.9%] were female, 12 569 [15.9%] Black, 60 578 [76.8%] White and 3088 [3.9%] Hispanic) in the restricted sample, 41 574 (52.7%) were in family medicine and 37 354 (47.3%) in internal medicine practices. Most visits were with medical doctors (54 611[69.2%]), followed by nurse practitioners (13 035 [16.5%]), doctors of osteopathic medicine (5877 [7.4%]), and physician assistants (2958 [3.8%]). On average, patients had a mean (SD) of 0.08 (0.13) (95% CI, 0.08-0.09) positive responses per SDOH question answered.

The SDOH screener responses in order of question appearance are given in eTable 1 in Supplement 1 . Earlier questions were more likely to be asked and answered. Overall, patient response refusal was low (≤3.3%). Descriptive statistics for the unrestricted sample (visits to all practices) are given in eTable 2 in Supplement 1 .

Table 2 displays regression results examining factors associated with any SDOH screening (complete or partial screening vs no screening) in the restricted (model 1) and unrestricted (model 2) practice samples. In model 1 (restricted), compared with visits with a medical doctor, visits with a physician assistant had 3.11 (95% CI, 1.19-8.10; P  = .02) greater odds of any screening done, while visits with nurse practitioners had significantly lower odds (odds ratio [OR], 0.13; 95% 0.03-0.62; P  = .01) of any screening done. Visits with patients identifying as Asian (OR, 1.69; 95% CI, 1.25-2.28; P  = .001), Black (OR, 1.49; 95% CI, 1.10-2.01; P  = .009), or 2 or more races (OR, 1.48; 95% CI, 1.12-1.94; P  = .006) were more likely to have any screening compared with visits with patients identifying as White. With regard to primary payer, visits where patients had managed care had 1.17 (95% CI, 1.07-1.29; P  = .001) greater odds of any screening compared to visits where patients had private or commercial payers. Visits where patients had Medicaid (OR, 0.62; 95% CI, 0.48-0.80; P  < .001), were uninsured or had Access Health (OR, 0.26; 95% CI, 0.10-0.67; P  = .005) or had Tricare (OR, 0.71; 95% CI, 0.55-0.92; P  = .01) had lower odds of any screening. Practice type, patient age, sex, language, and ethnicity had no significant associations with screening likelihood. Results were consistent in model 2 (unrestricted) except for visits with physician assistants and uninsured patients, where the finding was not significant.

We also compared visits completing the entire screening questionnaire vs partial or no screening ( Table 3 ) for the restricted practice sample. In model 3, compared with visits with a medical doctor, visits with a physician assistant had 3.78 times (95% CI; 1.43-10.0; P  = .007) greater odds of screening completion while visits with a nurse practitioner had lower screening completion odds (OR, 0.15; 95% CI, 0.03-0.75; P  = .02). Visits where patients identified as Black had greater odds of screening completion (OR, 1.33; 95% CI, 1.01-1.74; P  = .04) than visits where patients identified as White. Visits where patients had managed care had 1.15 (95% CI, 1.05-1.26; P  = .002) times greater screening completion odds than visits where patients had private or commercial payers. However, screenings were less likely to be complete if patients had Medicaid (OR, 0.53; 95% CI, 0.40-0.72; P  < .001), Tricare (OR, 0.76; 95% CI, 0.58-0.98; P  = .04), or were uninsured or had Access Health (OR, 0.14; 95% CI, 0.05-0.40; P  < .001). Results were consistent in model 4 comparing the odds of complete vs partial screening.

Model 5 extended model 4 to include patient SDOH risk from screening responses. Patient SDOH risk was not associated with screening completion (OR, 1.03; 95% CI, 0.56-1.88; P  = .93). Results in model 5 are consistent with model 4.

All models had variance inflation factors of less than 10 indicating absence of multicollinearity. Models 4 and 5 had omitted variable bias.

We identified 7 themes regarding barriers and facilitators from health care team member interviews for implementing SDOH screening ( Table 4 ). Care team members reported patient reluctance in responding to screener questions. Hesitancy was attributed to perceptions about questions being intrusive or offensive. Interviewees reported patients reacting unfavorably to sensitive questions (eg, violence/abuse, financial strain). Time to administer the screener, interpret results, and address identified needs posed challenges with existing workloads.

Clinicians expressed concerns about potential patient response burden and overlap with routine care questions (eg, stress and Patient Health Questionnaire 2). Clinicians suggested streamlining the screener by combining multiple related questions and then tailoring subsequent questions based on patient initial responses.

Some clinicians felt inadequately trained in navigating the screening tool and expressed uncertainty about effective use of screening results. Many practices lacked social workers or resource navigators to connect patients with resources and follow up on referrals. Clinicians felt their attention diverted from the primary goal of medical care provision.

Care team members reported that screening facilitated patient care by uncovering socioeconomic issues not identified in routine care. Practices that informed patients about the screening purpose, assured them it would not affect care, and obtained verbal consent prior to screener administration perceived more successful uptake.

Some practices identified practice champions as being responsible for screening implementation and supporting patient needs. Some practices had a referral coordinator or social worker who connected patients to community-based resources and provided follow-up support. Clinicians reported they would benefit from training on how to best use screening.

Table 5 presents feedback from patient experts. Patient experts preferred that screening be done at annual appointments to allow for discussion time and in the examination room to ensure privacy. Patient experts emphasized rapport building between patients and care teams and providing information about the screening purpose. They expressed the importance of empathetic clinicians performing screening. Recommendations for rephrasing questions included expanding the partner violence or abuse questions (eTable 2 in Supplement 1 ) to include safety concerns related to family members, neighborhoods, and caretakers. Patient experts expressed concern about timely referral follow-up.

This qualitative study assessed factors associated with SDOH screening completion in primary care and explored patient and care team member perspectives on screening. We found that clinician type, patient race, and primary payer were linked to any screening but that practice type, patient age, sex, language, ethnicity and SDOH risk were not.

Completion rates differed in this study (3.8%) from previous research (58.7%) 7 also examining systemwide SDOH screening implementation. This may be related to study duration, timing (intra–COVID-19 pandemic vs pre–COVID-19 pandemic), or implementation (recommendation for all primary care patients vs preassigned screening). 7 Based on qualitative interviews, our study completion rates may be affected by the desire to receive more resources to support patient referrals.

Our findings suggest that primary care visits with nonphysician clinicians, such as physician assistants, may be favorable for SDOH screening. However, this result did not hold for nurse practitioners and deserves further research, as previous studies demonstrated nonphysician clinician confidence in addressing SDOH needs and greater community-based resource awareness. 19 Clinician type could be serving as a proxy for visit type as our data set did not include visit reason. Consistent with previous studies, 20 our interview-based findings suggest that clinicians faced an additional time burden from incorporating SDOH screening, which they perceived to affect care provision.

We found patients with managed care to be more likely to be screened, while those with Medicaid and those who were uninsured or had Access Health and Tricare were less likely. Medicare and Medicare Advantage had no effect relative to private or commercial payer status. Patients with Medicaid and uninsured or had Access Health may benefit most from screening; therefore this finding is critical for further implementation. Of note, these patients may have been screened via other programs at the health system thus, lack of screening in primary care is not necessarily reflective of screening otherwise.

A lack of association between screening and other patient characteristics (age, gender, language, ethnicity, SDOH risk) suggests that perhaps these characteristics are not associated with SDOH needs in the perceptions of those performing screening. These results differed from previous research that found members of racial and ethnic minority groups less likely to be screened, 7 thereby providing support for universal implementation across primary care practices as a potential mitigation against screening disparities. 7

In our quantitative analysis, questions appearing later in the screener were less likely to be completed. Interviews further explained this finding as questionnaire length and repetitive questions led to a greater perceived patient response burden by health care clinicians. Although there is no consensus on screener length, existing tools range from 6 to 23 questions. 21 Generally, short-form surveys are more acceptable to patients. 22 Notably, patients did not express the same concerns as clinicians about survey length or repetitiveness.

Interviews and patient expert feedback found that patient–care team communication is crucial for screener uptake. Sensitive questions about patient needs may lead to incomplete or untruthful responses if patients have privacy concerns, 10 , 23 feel embarrassed, or fear stigmatization. 24 Patient experts and health care team members emphasized rapport building and communicating the screening purpose to mitigate patient concerns and build trust. Future investigation should include assessment of standard phrasing to introduce the screener rationale and consideration of the best location and visit type for screening. Last, patient experts and care team members expressed concerns about referral follow-up, perceiving that care would benefit from an enhanced ability to follow up on referral outcomes.

Our study has a few limitations to be considered. First, findings are restricted to primary care practices within 1 health system in 1 region, limiting generalizability. However, this study is comprehensive by including all primary care practices in 1 region covered by a large health system that statewide serves approximately 25% of residents. 14 Second, we used a convenience sample of practice staff for our qualitative assessment. This restricted our examination of how qualitative themes differed based on practice characteristics. However, practice choice for interviews was based on screening implementation to intentionally capture those screening at higher and lower adoption rates. Third, our data set included whether a survey was taken on MyChart (Epic). No surveys were done on MyChart. Accordingly, we were unable to test screening modality association with screening completion. We also had no information on screening completion via telemedicine vs office visits and did not include this topic in our interview guide. In addition, we do not know at what rate patients refused to verbally consent to screener administration if a practice asked for such consent.

Although health systems face different challenges in implementing SDOH screening, identifying and addressing common barriers are critical for improved patient activation and care collaboration. Future research should focus on robust assessment of strategies to improve screening uptake.

Accepted for Publication: October 19, 2023.

Published: November 28, 2023. doi:10.1001/jamanetworkopen.2023.45444

Open Access: This is an open access article distributed under the terms of the CC-BY License . © 2023 Rudisill AC et al. JAMA Network Open .

Corresponding Author: A. Caroline Rudisill, PhD, MSc, Department of Health Promotion, Education, and Behavior, Arnold School of Public Health, University of South Carolina, 300 E McBee Ave, Ste 401, Greenville, SC 29601 ( [email protected] ).

Author Contributions: Dr Rudisill and Ms Gupta had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Rudisill, Eicken, Macauda, Self, Thomas, Hartley.

Acquisition, analysis, or interpretation of data: Rudisill, Eicken, Gupta, Macauda, Self, Kennedy, Kao, Jeanty.

Drafting of the manuscript: Gupta, Kao, Hartley.

Critical review of the manuscript for important intellectual content: Rudisill, Eicken, Macauda, Self, Kennedy, Thomas, Jeanty.

Statistical analysis: Rudisill, Gupta, Self.

Obtained funding: Rudisill, Eicken.

Administrative, technical, or material support: Rudisill, Kennedy, Thomas, Kao, Jeanty.

Supervision: Rudisill, Eicken, Macauda.

Conflict of Interest Disclosures: Dr Rudisill reported grants from the Prisma Health Transformative Seed Grant Program during the conduct of the study and The Duke Endowment, Centers for Disease Control and Prevention, Viiv Healthcare, University of Michigan/National Institute on Aging/National Institutes of Health, South Carolina(SC)/NIA/NIH, SC Research Foundation (SCRF)/BlueCross/BlueShield Foundation of SC and National Heart, Lung, and Blood Institute/NIH. Dr Eicken reported grants from Prisma Health Transformative Seed Grant Program during the conduct of the study; grants from the Duke Endowment and grants from the Prisma Health Transformative Seed Grant Program outside the submitted work; Dr Eicken sits on the board of the Piedmont Health Foundation. Ms Gupta reported grants from Prisma Health during the conduct of the study; and support from the Duke Endowment. Dr Self reported grants from Prisma Health during the conduct of the study; personal fees from Companion Animal Parasite Council and personal fees from Merck outside the submitted work. Dr Kennedy reported grants from Prisma Health The Patient Engagement Studio received a portion of the grant to provide feedback during the conduct of the study; and has received 2 Eugene Washington Engagement Awards for capacity building with patients from the Patient-Centered Outcomes Research Institute in 2020 and in 2021. Ms Kao reported grants from Prisma Health Seed Grant during the conduct of the study. Ms Jeanty reported grants from Prisma Health Seed Grant Program during the conduct of the study. Mr Hartley reported grants from Prisma Health Seed Grant Program during the conduct of the study. No other disclosures were reported.

Funding/Support: This research was funded by the Prisma Health Research Seed Grant program.

Role of the Funder/Sponsor: The funding organization had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Data Sharing Statement: See Supplement 2 .

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Advancing the entrepreneurship ecosystem of India: A qualitative study with Chevening Fellows

• Published: 26 December 2023

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• Kamal Gulati 1 ,
• Amrik Sohal 2 ,
• Tharaka de Vass 2 &
• Nrupal Das 3  

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Using social cognitive theory as a guide, this research seeks to explain the perceptions of current and aspiring Indian entrepreneurs. A multiple case study approach using 19 interviews with intellectuals provided qualitative data to conduct a cross-case analysis of the two groups with the qualitative analysis software NVivo. Rare insights from current and aspiring opportunity-motivated entrepreneurial Chevening Fellowships from a predominantly necessity-motivated context offer valuable insights into entrepreneurship in India. The findings reveal what entrepreneurship means to established entrepreneurs, their motivation for embarking on the entrepreneurial journey, the skills they require to be successful, the challenges they face and their strategies to sustain are mostly different to what aspiring entrepreneurs believe how it would be. Compiled recommendations may help strengthen the entrepreneurial ecosystem, particularly in developing economy contexts, to help improve the 10% startup success rate.

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Acknowledgements

Authors gratefully acknowledge the support of Chevening fellows who consented to participate in this study, Chevening Secretariat, Foreign Commonwealth & Development Office, Prof. Richard Briant, University of Oxford, Prof. John Hoffmaire, Chairman, Oxford Pharmaceuticals, Ms. Sarah Fallon, Regional Director, Science and Innovation, British High Commission New Delhi, Ms. Supriya Chawla, Head Chevening Scholarships India for their support.

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Gulati, K., Sohal, A., de Vass, T. et al. Advancing the entrepreneurship ecosystem of India: A qualitative study with Chevening Fellows. Asia Pac J Manag (2023). https://doi.org/10.1007/s10490-023-09940-2

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