qualitative instrumental case study

Case Study Research

• First Online: 29 September 2022

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• Robert E. White   ORCID: orcid.org/0000-0002-8045-164X 3 &
• Karyn Cooper 4  

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As a footnote to the previous chapter, there is such a beast known as the ethnographic case study. Ethnographic case study has found its way into this chapter rather than into the previous one because of grammatical considerations. Simply put, the “case study” part of the phrase is the noun (with “case” as an adjective defining what kind of study it is), while the “ethnographic” part of the phrase is an adjective defining the type of case study that is being conducted. As such, the case study becomes the methodology, while the ethnography part refers to a method, mode or approach relating to the development of the study.

The experiential account that we get from a case study or qualitative research of a similar vein is just so necessary. How things happen over time and the degree to which they are subject to personality and how they are only gradually perceived as tolerable or intolerable by the communities and the groups that are involved is so important. Robert Stake, University of Illinois, Urbana-Champaign

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A Case in Case Study Methodology

Christine Benedichte Meyer

Norwegian School of Economics and Business Administration

Meyer, C. B. (2001). A Case in Case Study Methodology. Field Methods 13 (4), 329-352.

The purpose of this article is to provide a comprehensive view of the case study process from the researcher’s perspective, emphasizing methodological considerations. As opposed to other qualitative or quantitative research strategies, such as grounded theory or surveys, there are virtually no specific requirements guiding case research. This is both the strength and the weakness of this approach. It is a strength because it allows tailoring the design and data collection procedures to the research questions. On the other hand, this approach has resulted in many poor case studies, leaving it open to criticism, especially from the quantitative field of research. This article argues that there is a particular need in case studies to be explicit about the methodological choices one makes. This implies discussing the wide range of decisions concerned with design requirements, data collection procedures, data analysis, and validity and reliability. The approach here is to illustrate these decisions through a particular case study of two mergers in the financial industry in Norway.

In the past few years, a number of books have been published that give useful guidance in conducting qualitative studies (Gummesson 1988; Cassell & Symon 1994; Miles & Huberman 1994; Creswell 1998; Flick 1998; Rossman & Rallis 1998; Bryman & Burgess 1999; Marshall & Rossman 1999; Denzin & Lincoln 2000). One approach often mentioned is the case study (Yin 1989). Case studies are widely used in organizational studies in the social science disciplines of sociology, industrial relations, and anthropology (Hartley 1994). Such a study consists of detailed investigation of one or more organizations, or groups within organizations, with a view to providing an analysis of the context and processes involved in the phenomenon under study.

As opposed to other qualitative or quantitative research strategies, such as grounded theory (Glaser and Strauss 1967) or surveys (Nachmias & Nachmias 1981), there are virtually no specific requirements guiding case research. Yin (1989) and Eisenhardt (1989) give useful insights into the case study as a research strategy, but leave most of the design decisions on the table. This is both the strength and the weakness of this approach. It is a strength because it allows tailoring the design and data collection procedures to the research questions. On the other hand, this approach has resulted in many poor case studies, leaving it open to criticism, especially from the quantitative field of research (Cook and Campbell 1979). The fact that the case study is a rather loose design implies that there are a number of choices that need to be addressed in a principled way.

Although case studies have become a common research strategy, the scope of methodology sections in articles published in journals is far too limited to give the readers a detailed and comprehensive view of the decisions taken in the particular studies, and, given the format of methodology sections, will remain so. The few books (Yin 1989, 1993; Hamel, Dufour, & Fortin 1993; Stake 1995) and book chapters on case studies (Hartley 1994; Silverman 2000) are, on the other hand, mainly normative and span a broad range of different kinds of case studies. One exception is Pettigrew (1990, 1992), who places the case study in the context of a research tradition (the Warwick process research).

Given the contextual nature of the case study and its strength in addressing contemporary phenomena in real-life contexts, I believe that there is a need for articles that provide a comprehensive overview of the case study process from the researcher’s perspective, emphasizing methodological considerations. This implies addressing the whole range of choices concerning specific design requirements, data collection procedures, data analysis, and validity and reliability.

WHY A CASE STUDY?

Case studies are tailor-made for exploring new processes or behaviors or ones that are little understood (Hartley 1994). Hence, the approach is particularly useful for responding to how and why questions about a contemporary set of events (Leonard-Barton 1990). Moreover, researchers have argued that certain kinds of information can be difficult or even impossible to tackle by means other than qualitative approaches such as the case study (Sykes 1990). Gummesson (1988:76) argues that an important advantage of case study research is the opportunity for a holistic view of the process: “The detailed observations entailed in the case study method enable us to study many different aspects, examine them in relation to each other, view the process within its total environment and also use the researchers’ capacity for ‘verstehen.’ ”

The contextual nature of the case study is illustrated in Yin’s (1993:59) definition of a case study as an empirical inquiry that “investigates a contemporary phenomenon within its real-life context and addresses a situation in which the boundaries between phenomenon and context are not clearly evident.”

The key difference between the case study and other qualitative designs such as grounded theory and ethnography (Glaser & Strauss 1967; Strauss & Corbin 1990; Gioia & Chittipeddi 1991) is that the case study is open to the use of theory or conceptual categories that guide the research and analysis of data. In contrast, grounded theory or ethnography presupposes that theoretical perspectives are grounded in and emerge from firsthand data. Hartley (1994) argues that without a theoretical framework, the researcher is in severe danger of providing description without meaning. Gummesson (1988) says that a lack of preunderstanding will cause the researcher to spend considerable time gathering basic information. This preunderstanding may arise from general knowledge such as theories, models, and concepts or from specific knowledge of institutional conditions and social patterns. According to Gummesson, the key is not to require researchers to have split but dual personalities: “Those who are able to balance on a razor’s edge using their pre-understanding without being its slave” (p. 58).

DESCRIPTION OF THE ILLUSTRATIVE STUDY

The study that will be used for illustrative purposes is a comparative and longitudinal case study of organizational integration in mergers and acquisitions taking place in Norway. The study had two purposes: (1) to identify contextual factors and features of integration that facilitated or impeded organizational integration, and (2) to study how the three dimensions of organizational integration (integration of tasks, unification of power, and integration of cultures and identities) interrelated and evolved over time. Examples of contextual factors were relative power, degree of friendliness, and economic climate. Integration features included factors such as participation, communication, and allocation of positions and functions.

Mergers and acquisitions are inherently complex. Researchers in the field have suggested that managers continuously underestimate the task of integrating the merging organizations in the postintegration process (Haspeslaph & Jemison 1991). The process of organizational integration can lead to sharp interorganizational conflict as the different top management styles, organizational and work unit cultures, systems, and other aspects of organizational life come into contact (Blake & Mounton 1985; Schweiger & Walsh 1990; Cartwright & Cooper 1993). Furthermore, cultural change in mergers and acquisitions is compounded by additional uncertainties, ambiguities, and stress inherent in the combination process (Buono & Bowditch 1989).

I focused on two combinations: one merger and one acquisition. The first case was a merger between two major Norwegian banks, Bergen Bank and DnC (to be named DnB), that started in the late 1980s. The second case was a study of a major acquisition in the insurance industry (i.e., Gjensidige’s acquisition of Forenede), that started in the early 1990s. Both combinations aimed to realize operational synergies though merging the two organizations into one entity. This implied disruption of organizational boundaries and threat to the existing power distribution and organizational cultures.

The study of integration processes in mergers and acquisitions illustrates the need to find a design that opens for exploration of sensitive issues such as power struggles between the two merging organizations. Furthermore, the inherent complexity in the integration process, involving integration of tasks, unification of power, and cultural integration stressed the need for in-depth study of the phenomenon over time. To understand the cultural integration process, the design also had to be linked to the past history of the two organizations.

DESIGN DECISIONS

In the introduction, I stressed that a case is a rather loose design that requires that a number of design choices be made. In this section, I go through the most important choices I faced in the study of organizational integration in mergers and acquisitions. These include: (1) selection of cases; (2) sampling time; (3) choosing business areas, divisions, and sites; and (4) selection of and choices regarding data collection procedures, interviews, documents, and observation.

Selection of Cases

There are several choices involved in selecting cases. First, there is the question of how many cases to include. Second, one must sample cases and decide on a unit of analysis. I will explore these issues subsequently.

Single or Multiple Cases

Case studies can involve single or multiple cases. The problem of single cases is limitations in generalizability and several information-processing biases (Eisenhardt 1989).

One way to respond to these biases is by applying a multi-case approach (Leonard-Barton 1990). Multiple cases augment external validity and help guard against observer biases. Moreover, multi-case sampling adds confidence to findings. By looking at a range of similar and contrasting cases, we can understand a single-case finding, grounding it by specifying how and where and, if possible, why it behaves as it does. (Miles & Huberman 1994)

Given these limitations of the single case study, it is desirable to include more than one case study in the study. However, the desire for depth and a pluralist perspective and tracking the cases over time implies that the number of cases must be fairly few. I chose two cases, which clearly does not support generalizability any more than does one case, but allows for comparison and contrast between the cases as well as a deeper and richer look at each case.

Originally, I planned to include a third case in the study. Due to changes in management during the initial integration process, my access to the case was limited and I left this case entirely. However, a positive side effect was that it allowed a deeper investigation of the two original cases and in hindsight turned out to be a good decision.

Sampling Cases

The logic of sampling cases is fundamentally different from statistical sampling. The logic in case studies involves theoretical sampling, in which the goal is to choose cases that are likely to replicate or extend the emergent theory or to fill theoretical categories and provide examples for polar types (Eisenhardt 1989). Hence, whereas quantitative sampling concerns itself with representativeness, qualitative sampling seeks information richness and selects the cases purposefully rather than randomly (Crabtree and Miller 1992).

The choice of cases was guided by George (1979) and Pettigrew’s (1990) recommendations. The aim was to find cases that matched the three dimensions in the dependent variable and provided variation in the contextual factors, thus representing polar cases.

To match the choice of outcome variable, organizational integration, I chose cases in which the purpose was to fully consolidate the merging parties’ operations. A full consolidation would imply considerable disruption in the organizational boundaries and would be expected to affect the task-related, political, and cultural features of the organizations. As for the contextual factors, the two cases varied in contextual factors such as relative power, friendliness, and economic climate. The DnB merger was a friendly combination between two equal partners in an unfriendly economic climate. Gjensidige’s acquisition of Forenede was, in contrast, an unfriendly and unbalanced acquisition in a friendly economic climate.

Unit of Analysis

Another way to respond to researchers’ and respondents’ biases is to have more than one unit of analysis in each case (Yin 1993). This implies that, in addition to developing contrasts between the cases, researchers can focus on contrasts within the cases (Hartley 1994). In case studies, there is a choice of a holistic or embedded design (Yin 1989). A holistic design examines the global nature of the phenomenon, whereas an embedded design also pays attention to subunit(s).

I used an embedded design to analyze the cases (i.e., within each case, I also gave attention to subunits and subprocesses). In both cases, I compared the combination processes in the various divisions and local networks. Moreover, I compared three distinct change processes in DnB: before the merger, during the initial combination, and two years after the merger. The overall and most important unit of analysis in the two cases was, however, the integration process.

Sampling Time

According to Pettigrew (1990), time sets a reference for what changes can be seen and how those changes are explained. When conducting a case study, there are several important issues to decide when sampling time. The first regards how many times data should be collected, while the second concerns when to enter the organizations. There is also a need to decide whether to collect data on a continuous basis or in distinct periods.

Number of data collections. I studied the process by collecting real time and retrospective data at two points in time, with one-and-a-half- and two-year intervals in the two cases. Collecting data twice had some interesting implications for the interpretations of the data. During the first data collection in the DnB study, for example, I collected retrospective data about the premerger and initial combination phase and real-time data about the second step in the combination process.

Although I gained a picture of how the employees experienced the second stage of the combination process, it was too early to assess the effects of this process at that stage. I entered the organization two years later and found interesting effects that I had not anticipated the first time. Moreover, it was interesting to observe how people’s attitudes toward the merger processes changed over time to be more positive and less emotional.

When to enter the organizations. It would be desirable to have had the opportunity to collect data in the precombination processes. However, researchers are rarely given access in this period due to secrecy. The emphasis in this study was to focus on the postcombination process. As such, the precombination events were classified as contextual factors. This implied that it was most important to collect real-time data after the parties had been given government approval to merge or acquire. What would have been desirable was to gain access earlier in the postcombination process. This was not possible because access had to be negotiated. Due to the change of CEO in the middle of the merger process and the need for renegotiating access, this took longer than expected.

Regarding the second case, I was restricted by the time frame of the study. In essence, I had to choose between entering the combination process as soon as governmental approval was given, or entering the organization at a later stage. In light of the previous studies in the field that have failed to go beyond the initial two years, and given the need to collect data about the cultural integration process, I chose the latter strategy. And I decided to enter the organizations at two distinct periods of time rather than on a continuous basis.

There were several reasons for this approach, some methodological and some practical. First, data collection on a continuous basis would have required use of extensive observation that I didn’t have access to, and getting access to two data collections in DnB was difficult in itself. Second, I had a stay abroad between the first and second data collection in Gjensidige. Collecting data on a continuous basis would probably have allowed for better mapping of the ongoing integration process, but the contrasts between the two different stages in the integration process that I wanted to elaborate would probably be more difficult to detect. In Table 1 I have listed the periods of time in which I collected data in the two combinations.

Sampling Business Areas, Divisions, and Sites

Even when the cases for a study have been chosen, it is often necessary to make further choices within each case to make the cases researchable. The most important criteria that set the boundaries for the study are importance or criticality, relevance, and representativeness. At the time of the data collection, my criteria for making these decisions were not as conscious as they may appear here. Rather, being restricted by time and my own capacity as a researcher, I had to limit the sites and act instinctively. In both cases, I decided to concentrate on the core businesses (criticality criterion) and left out the business units that were only mildly affected by the integration process (relevance criterion). In the choice of regional offices, I used the representativeness criterion as the number of offices widely exceeded the number of sites possible to study. In making these choices, I relied on key informants in the organizations.

SELECTION OF DATA COLLECTION PROCEDURES

The choice of data collection procedures should be guided by the research question and the choice of design. The case study approach typically combines data collection methods such as archives, interviews, questionnaires, and observations (Yin 1989). This triangulated methodology provides stronger substantiation of constructs and hypotheses. However, the choice of data collection methods is also subject to constraints in time, financial resources, and access.

I chose a combination of interviews, archives, and observation, with main emphasis on the first two. Conducting a survey was inappropriate due to the lack of established concepts and indicators. The reason for limited observation, on the other hand, was due to problems in obtaining access early in the study and time and resource constraints. In addition to choosing among several different data collection methods, there are a number of choices to be made for each individual method.

When relying on interviews as the primary data collection method, the issue of building trust between the researcher and the interviewees becomes very important. I addressed this issue by several means. First, I established a procedure of how to approach the interviewees. In most cases, I called them first, then sent out a letter explaining the key features of the project and outlining the broad issues to be addressed in the interview. In this letter, the support from the institution’s top management was also communicated. In most cases, the top management’s support of the project was an important prerequisite for the respondent’s input. Some interviewees did, however, fear that their input would be open to the top management without disguising the information source. Hence, it became important to communicate how I intended to use and store the information.

To establish trust, I also actively used my preunderstanding of the context in the first case and the phenomenon in the second case. As I built up an understanding of the cases, I used this information to gain confidence. The active use of my preunderstanding did, however, pose important challenges in not revealing too much of the research hypotheses and in balancing between asking open-ended questions and appearing knowledgeable.

There are two choices involved in conducting interviews. The first concerns the sampling of interviewees. The second is that you must decide on issues such as the structure of the interviews, use of tape recorder, and involvement of other researchers.

Sampling Interviewees

Following the desire for detailed knowledge of each case and for grasping different participant’s views the aim was, in line with Pettigrew (1990), to apply a pluralist view by describing and analyzing competing versions of reality as seen by actors in the combination processes.

I used four criteria for sampling informants. First, I drew informants from populations representing multiple perspectives. The first data collection in DnB was primarily focused on the top management level. Moreover, most middle managers in the first data collection were employed at the head offices, either in Bergen or Oslo. In the second data collection, I compensated for this skew by including eight local middle managers in the sample. The difference between the number of employees interviewed in DnB and Gjensidige was primarily due to the fact that Gjensidige has three unions, whereas DnB only has one. The distribution of interviewees is outlined in Table 2 .

The second criterion was to use multiple informants. According to Glick et al. (1990), an important advantage of using multiple informants is that the validity of information provided by one informant can be checked against that provided by other informants. Moreover, the validity of the data used by the researcher can be enhanced by resolving the discrepancies among different informants’ reports. Hence, I selected multiple respondents from each perspective.

Third, I focused on key informants who were expected to be knowledgeable about the combination process. These people included top management members, managers, and employees involved in the integration project. To validate the information from these informants, I also used a fourth criterion by selecting managers and employees who had been affected by the process but who were not involved in the project groups.

Structured versus unstructured. In line with the explorative nature of the study, the goal of the interviews was to see the research topic from the perspective of the interviewee, and to understand why he or she came to have this particular perspective. To meet this goal, King (1994:15) recommends that one have “a low degree of structure imposed on the interviewer, a preponderance of open questions, a focus on specific situations and action sequences in the world of the interviewee rather than abstractions and general opinions.” In line with these recommendations, the collection of primary data in this study consists of unstructured interviews.

Using tape recorders and involving other researchers. The majority of the interviews were tape-recorded, and I could thus concentrate fully on asking questions and responding to the interviewees’ answers. In the few interviews that were not tape-recorded, most of which were conducted in the first phase of the DnB-study, two researchers were present. This was useful as we were both able to discuss the interviews later and had feedback on the role of an interviewer.

In hindsight, however, I wish that these interviews had been tape-recorded to maintain the level of accuracy and richness of data. Hence, in the next phases of data collection, I tape-recorded all interviews, with two exceptions (people who strongly opposed the use of this device). All interviews that were tape-recorded were transcribed by me in full, which gave me closeness and a good grasp of the data.

When organizations merge or make acquisitions, there are often a vast number of documents to choose from to build up an understanding of what has happened and to use in the analyses. Furthermore, when firms make acquisitions or merge, they often hire external consultants, each of whom produces more documents. Due to time constraints, it is seldom possible to collect and analyze all these documents, and thus the researcher has to make a selection.

The choice of documentation was guided by my previous experience with merger and acquisition processes and the research question. Hence, obtaining information on the postintegration process was more important than gaining access to the due-diligence analysis. As I learned about the process, I obtained more documents on specific issues. I did not, however, gain access to all the documents I asked for, and, in some cases, documents had been lost or shredded.

The documents were helpful in a number of ways. First, and most important, they were used as inputs to the interview guide and saved me time, because I did not have to ask for facts in the interviews. They were also useful for tracing the history of the organizations and statements made by key people in the organizations. Third, the documents were helpful in counteracting the biases of the interviews. A list of the documents used in writing the cases is shown in Table 3 .

Observation

The major strength of direct observation is that it is unobtrusive and does not require direct interaction with participants (Adler and Adler 1994). Observation produces rigor when it is combined with other methods. When the researcher has access to group processes, direct observation can illuminate the discrepancies between what people said in the interviews and casual conversations and what they actually do (Pettigrew 1990).

As with interviews, there are a number of choices involved in conducting observations. Although I did some observations in the study, I used interviews as the key data collection source. Discussion in this article about observations will thus be somewhat limited. Nevertheless, I faced a number of choices in conducting observations, including type of observation, when to enter, how much observation to conduct, and which groups to observe.

The are four ways in which an observer may gather data: (1) the complete participant who operates covertly, concealing any intention to observe the setting; (2) the participant-as-observer, who forms relationships and participates in activities, but makes no secret of his or her intentions to observe events; (3) the observer-as-participant, who maintains only superficial contact with the people being studied; and (4) the complete observer, who merely stands back and eavesdrops on the proceedings (Waddington 1994).

In this study, I used the second and third ways of observing. The use of the participant-as-observer mode, on which much ethnographic research is based, was rather limited in the study. There were two reasons for this. First, I had limited time available for collecting data, and in my view interviews made more effective use of this limited time than extensive participant observation. Second, people were rather reluctant to let me observe these political and sensitive processes until they knew me better and felt I could be trusted. Indeed, I was dependent on starting the data collection before having built sufficient trust to observe key groups in the integration process. Nevertheless, Gjensidige allowed me to study two employee seminars to acquaint me with the organization. Here I admitted my role as an observer but participated fully in the activities. To achieve variation, I chose two seminars representing polar groups of employees.

As observer-as-participant, I attended a top management meeting at the end of the first data collection in Gjensidige and observed the respondents during interviews and in more informal meetings, such as lunches. All these observations gave me an opportunity to validate the data from the interviews. Observing the top management group was by far the most interesting and rewarding in terms of input.

Both DnB and Gjensidige started to open up for more extensive observation when I was about to finish the data collection. By then, I had built up the trust needed to undertake this approach. Unfortunately, this came a little late for me to take advantage of it.

DATA ANALYSIS

Published studies generally describe research sites and data-collection methods, but give little space to discuss the analysis (Eisenhardt 1989). Thus, one cannot follow how a researcher arrives at the final conclusions from a large volume of field notes (Miles and Huberman 1994).

In this study, I went through the stages by which the data were reduced and analyzed. This involved establishing the chronology, coding, writing up the data according to phases and themes, introducing organizational integration into the analysis, comparing the cases, and applying the theory. I will discuss these phases accordingly.

The first step in the analysis was to establish the chronology of the cases. To do this, I used internal and external documents. I wrote the chronologies up and included appendices in the final report.

The next step was to code the data into phases and themes reflecting the contextual factors and features of integration. For the interviews, this implied marking the text with a specific phase and a theme, and grouping the paragraphs on the same theme and phase together. I followed the same procedure in organizing the documents.

I then wrote up the cases using phases and themes to structure them. Before starting to write up the cases, I scanned the information on each theme, built up the facts and filled in with perceptions and reactions that were illustrative and representative of the data.

The documents were primarily useful in establishing the facts, but they also provided me with some perceptions and reactions that were validated in the interviews. The documents used included internal letters and newsletters as well as articles from the press. The interviews were less factual, as intended, and gave me input to assess perceptions and reactions. The limited observation was useful to validate the data from the interviews. The result of this step was two descriptive cases.

To make each case more analytical, I introduced the three dimensions of organizational integration—integration of tasks, unification of power, and cultural integration—into the analysis. This helped to focus the case and to develop a framework that could be used to compare the cases. The cases were thus structured according to phases, organizational integration, and themes reflecting the factors and features in the study.

I took all these steps to become more familiar with each case as an individual entity. According to Eisenhardt (1989:540), this is a process that “allows the unique patterns of each case to emerge before the investigators push to generalise patterns across cases. In addition it gives investigators a rich familiarity with each case which, in turn, accelerates cross-case comparison.”

The comparison between the cases constituted the next step in the analysis. Here, I used the categories from the case chapters, filled in the features and factors, and compared and contrasted the findings. The idea behind cross-case searching tactics is to force investigators to go beyond initial impressions, especially through the use of structural and diverse lenses on the data. These tactics improve the likelihood of accurate and reliable theory, that is, theory with a close fit to the data (Eisenhardt 1989).

As a result, I had a number of overall themes, concepts, and relationships that had emerged from the within-case analysis and cross-case comparisons. The next step was to compare these emergent findings with theory from the organizational field of mergers and acquisitions, as well as other relevant perspectives.

This method of generalization is known as analytical generalization. In this approach, a previously developed theory is used as a template with which to compare the empirical results of the case study (Yin 1989). This comparison of emergent concepts, theory, or hypotheses with the extant literature involves asking what it is similar to, what it contradicts, and why. The key to this process is to consider a broad range of theory (Eisenhardt 1989). On the whole, linking emergent theory to existent literature enhances the internal validity, generalizability, and theoretical level of theory-building from case research.

According to Eisenhardt (1989), examining literature that conflicts with the emergent literature is important for two reasons. First, the chance of neglecting conflicting findings is reduced. Second, “conflicting results forces researchers into a more creative, frame-breaking mode of thinking than they might otherwise be able to achieve” (p. 544). Similarly, Eisenhardt (1989) claims that literature discussing similar findings is important because it ties together underlying similarities in phenomena not normally associated with each other. The result is often a theory with a stronger internal validity, wider generalizability, and a higher conceptual level.

The analytical generalization in the study included exploring and developing the concepts and examining the relationships between the constructs. In carrying out this analytical generalization, I acted on Eisenhardt’s (1989) recommendation to use a broad range of theory. First, I compared and contrasted the findings with the organizational stream on mergers and acquisition literature. Then I discussed other relevant literatures, including strategic change, power and politics, social justice, and social identity theory to explore how these perspectives could contribute to the understanding of the findings. Finally, I discussed the findings that could not be explained either by the merger and acquisition literature or the four theoretical perspectives.

In every scientific study, questions are raised about whether the study is valid and reliable. The issues of validity and reliability in case studies are just as important as for more deductive designs, but the application is fundamentally different.

VALIDITY AND RELIABILITY

The problems of validity in qualitative studies are related to the fact that most qualitative researchers work alone in the field, they focus on the findings rather than describe how the results were reached, and they are limited in processing information (Miles and Huberman 1994).

Researchers writing about qualitative methods have questioned whether the same criteria can be used for qualitative and quantitative studies (Kirk & Miller 1986; Sykes 1990; Maxwell 1992). The problem with the validity criteria suggested in qualitative research is that there is little consistency across the articles as each author suggests a new set of criteria.

One approach in examining validity and reliability is to apply the criteria used in quantitative research. Hence, the criteria to be examined here are objectivity/intersubjectivity, construct validity, internal validity, external validity, and reliability.

Objectivity/Intersubjectivity

The basic issue of objectivity can be framed as one of relative neutrality and reasonable freedom from unacknowledged research biases (Miles & Huberman 1994). In a real-time longitudinal study, the researcher is in danger of losing objectivity and of becoming too involved with the organization, the people, and the process. Hence, Leonard-Barton (1990) claims that one may be perceived as, and may even become, an advocate rather than an observer.

According to King (1994), however, qualitative research, in seeking to describe and make sense of the world, does not require researchers to strive for objectivity and distance themselves from research participants. Indeed, to do so would make good qualitative research impossible, as the interviewer’s sensitivity to subjective aspects of his or her relationship with the interviewee is an essential part of the research process (King 1994:31).

This does not imply, however, that the issue of possible research bias can be ignored. It is just as important as in a structured quantitative interview that the findings are not simply the product of the researcher’s prejudices and prior experience. One way to guard against this bias is for the researcher to explicitly recognize his or her presuppositions and to make a conscious effort to set these aside in the analysis (Gummesson 1988). Furthermore, rival conclusions should be considered (Miles & Huberman 1994).

My experience from the first phase of the DnB study was that it was difficult to focus the questions and the analysis of the data when the research questions were too vague and broad. As such, developing a framework before collecting the data for the study was useful in guiding the collection and analysis of data. Nevertheless, it was important to be open-minded and receptive to new and surprising data. In the DnB study, for example, the positive effect of the reorganization process on the integration of cultures came as a complete surprise to me and thus needed further elaboration.

I also consciously searched for negative evidence and problems by interviewing outliers (Miles & Huberman 1994) and asking problem-oriented questions. In Gjensidige, the first interviews with the top management revealed a much more positive perception of the cultural integration process than I had expected. To explore whether this was a result of overreliance on elite informants, I continued posing problem-oriented questions to outliers and people at lower levels in the organization. Moreover, I told them about the DnB study to be explicit about my presuppositions.

Another important issue when assessing objectivity is whether other researchers can trace the interpretations made in the case studies, or what is called intersubjectivity. To deal with this issue, Miles & Huberman (1994) suggest that: (1) the study’s general methods and procedures should be described in detail, (2) one should be able to follow the process of analysis, (3) conclusions should be explicitly linked with exhibits of displayed data, and (4) the data from the study should be made available for reanalysis by others.

In response to these requirements, I described the study’s data collection procedures and processing in detail. Then, the primary data were displayed in the written report in the form of quotations and extracts from documents to support and illustrate the interpretations of the data. Because the study was written up in English, I included the Norwegian text in a separate appendix. Finally, all the primary data from the study were accessible for a small group of distinguished researchers.

Construct Validity

Construct validity refers to whether there is substantial evidence that the theoretical paradigm correctly corresponds to observation (Kirk & Miller 1986). In this form of validity, the issue is the legitimacy of the application of a given concept or theory to established facts.

The strength of qualitative research lies in the flexible and responsive interaction between the interviewer and the respondents (Sykes 1990). Thus, meaning can be probed, topics covered easily from a number of angles, and questions made clear for respondents. This is an advantage for exploring the concepts (construct or theoretical validity) and the relationships between them (internal validity). Similarly, Hakim (1987) says the great strength of qualitative research is the validity of data obtained because individuals are interviewed in sufficient detail for the results to be taken as true, correct, and believable reports of their views and experiences.

Construct validity can be strengthened by applying a longitudinal multicase approach, triangulation, and use of feedback loops. The advantage of applying a longitudinal approach is that one gets the opportunity to test sensitivity of construct measures to the passage of time. Leonard-Barton (1990), for example, found that one of her main constructs, communicability, varied across time and relative to different groups of users. Thus, the longitudinal study aided in defining the construct more precisely. By using more than one case study, one can validate stability of construct across situations (Leonard-Barton 1990). Since my study only consists of two case studies, the opportunity to test stability of constructs across cases is somewhat limited. However, the use of more than one unit of analysis helps to overcome this limitation.

Construct validity is strengthened by the use of multiple sources of evidence to build construct measures, which define the construct and distinguish it from other constructs. These multiple sources of evidence can include multiple viewpoints within and across the data sources. My study responds to these requirements in its sampling of interviewees and uses of multiple data sources.

Use of feedback loops implies returning to interviewees with interpretations and developing theory and actively seeking contradictions in data (Crabtree & Miller 1992; King 1994). In DnB, the written report had to be approved by the bank’s top management after the first data collection. Apart from one minor correction, the bank had no objections to the established facts. In their comments on my analysis, some of the top managers expressed the view that the political process had been overemphasized, and that the CEO’s role in initiating a strategic process was undervalued. Hence, an important objective in the second data collection was to explore these comments further. Moreover, the report was not as positive as the management had hoped for, and negotiations had to be conducted to publish the report. The result of these negotiations was that publication of the report was postponed one-and-a-half years.

The experiences from the first data collection in the DnB had some consequences. I was more cautious and brought up the problems of confidentiality and the need to publish at the outset of the Gjensidige study. Also, I had to struggle to get access to the DnB case for the second data collection and some of the information I asked for was not released. At Gjensidige, I sent a preliminary draft of the case chapter to the corporation’s top management for comments, in addition to having second interviews with a small number of people. Beside testing out the factual description, these sessions gave me the opportunity to test out the theoretical categories established as a result of the within-case analysis.

Internal Validity

Internal validity concerns the validity of the postulated relationships among the concepts. The main problem of internal validity as a criterion in qualitative research is that it is often not open to scrutiny. According to Sykes (1990), the researcher can always provide a plausible account and, with careful editing, may ensure its coherence. Recognition of this problem has led to calls for better documentation of the processes of data collection, the data itself, and the interpretative contribution of the researcher. The discussion of how I met these requirements was outlined in the section on objectivity/subjectivity above.

However, there are some advantages in using qualitative methods, too. First, the flexible and responsive methods of data collection allow cross-checking and amplification of information from individual units as it is generated. Respondents’ opinions and understandings can be thoroughly explored. The internal validity results from strategies that eliminate ambiguity and contradiction, filling in detail and establishing strong connections in data.

Second, the longitudinal study enables one to track cause and effect. Moreover, it can make one aware of intervening variables (Leonard-Barton 1990). Eisenhardt (1989:542) states, “Just as hypothesis testing research an apparent relationship may simply be a spurious correlation or may reflect the impact of some third variable on each of the other two. Therefore, it is important to discover the underlying reasons for why the relationship exists.”

Generalizability

According to Mitchell (1983), case studies are not based on statistical inference. Quite the contrary, the inferring process turns exclusively on the theoretically necessary links among the features in the case study. The validity of the extrapolation depends not on the typicality or representativeness of the case but on the cogency of the theoretical reasoning. Hartley (1994:225) claims, “The detailed knowledge of the organization and especially the knowledge about the processes underlying the behaviour and its context can help to specify the conditions under which behaviour can be expected to occur. In other words, the generalisation is about theoretical propositions not about populations.”

Generalizability is normally based on the assumption that this theory may be useful in making sense of similar persons or situations (Maxwell 1992). One way to increase the generalizability is to apply a multicase approach (Leonard-Barton 1990). The advantage of this approach is that one can replicate the findings from one case study to another. This replication logic is similar to that used on multiple experiments (Yin 1993).

Given the choice of two case studies, the generalizability criterion is not supported in this study. Through the discussion of my choices, I have tried to show that I had to strike a balance between the need for depth and mapping changes over time and the number of cases. In doing so, I deliberately chose to provide a deeper and richer look at each case, allowing the reader to make judgments about the applicability rather than making a case for generalizability.

Reliability

Reliability focuses on whether the process of the study is consistent and reasonably stable over time and across researchers and methods (Miles & Huberman 1994). In the context of qualitative research, reliability is concerned with two questions (Sykes 1990): Could the same study carried out by two researchers produce the same findings? and Could a study be repeated using the same researcher and respondents to yield the same findings?

The problem of reliability in qualitative research is that differences between replicated studies using different researchers are to be expected. However, while it may not be surprising that different researchers generate different findings and reach different conclusions, controlling for reliability may still be relevant. Kirk and Miller’s (1986:311) definition takes into account the particular relationship between the researcher’s orientation, the generation of data, and its interpretation:

For reliability to be calculated, it is incumbent on the scientific investigator to document his or her procedure. This must be accomplished at such a level of abstraction that the loci of decisions internal to the project are made apparent. The curious public deserves to know how the qualitative researcher prepares him or herself for the endeavour, and how the data is collected and analysed.

The study addresses these requirements by discussing my point of departure regarding experience and framework, the sampling and data collection procedures, and data analysis.

Case studies often lack academic rigor and are, as such, regarded as inferior to more rigorous methods where there are more specific guidelines for collecting and analyzing data. These criticisms stress that there is a need to be very explicit about the choices one makes and the need to justify them.

One reason why case studies are criticized may be that researchers disagree about the definition and the purpose of carrying out case studies. Case studies have been regarded as a design (Cook and Campbell 1979), as a qualitative methodology (Cassell and Symon 1994), as a particular data collection procedure (Andersen 1997), and as a research strategy (Yin 1989). Furthermore, the purpose for carrying out case studies is unclear. Some regard case studies as supplements to more rigorous qualitative studies to be carried out in the early stage of the research process; others claim that it can be used for multiple purposes and as a research strategy in its own right (Gummesson 1988; Yin 1989). Given this unclear status, researchers need to be very clear about their interpretation of the case study and the purpose of carrying out the study.

This article has taken Yin’s (1989) definition of the case study as a research strategy as a starting point and argued that the choice of the case study should be guided by the research question(s). In the illustrative study, I used a case study strategy because of a need to explore sensitive, ill-defined concepts in depth, over time, taking into account the context and history of the mergers and the existing knowledge about the phenomenon. However, the choice of a case study strategy extended rather than limited the number of decisions to be made. In Schramm’s (1971, cited in Yin 1989:22–23) words, “The essence of a case study, the central tendency among all types of case study, is that it tries to illuminate a decision or set of decisions, why they were taken, how they were implemented, and with what result.”

Hence, the purpose of this article has been to illustrate the wide range of decisions that need to be made in the context of a particular case study and to discuss the methodological considerations linked to these decisions. I argue that there is a particular need in case studies to be explicit about the methodological choices one makes and that these choices can be best illustrated through a case study of the case study strategy.

As in all case studies, however, there are limitations to the generalizability of using one particular case study for illustrative purposes. As such, the strength of linking the methodological considerations to a specific context and phenomenon also becomes a weakness. However, I would argue that the questions raised in this article are applicable to many case studies, but that the answers are very likely to vary. The design choices are shown in Table 4 . Hence, researchers choosing a longitudinal, comparative case study need to address the same set of questions with regard to design, data collection procedures, and analysis, but they are likely to come up with other conclusions, given their different research questions.

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Christine Benedichte Meyer is an associate professor in the Department of Strategy and Management in the Norwegian School of Economics and Business Administration, Bergen-Sandviken, Norway. Her research interests are mergers and acquisitions, strategic change, and qualitative research. Recent publications include: “Allocation Processes in Mergers and Acquisitions: An Organisational Justice Perspective” (British Journal of Management 2001) and “Motives for Acquisitions in the Norwegian Financial Industry” (CEMS Business Review 1997).

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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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The case study approach

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The case study approach allows in-depth, multi-faceted explorations of complex issues in their real-life settings. The value of the case study approach is well recognised in the fields of business, law and policy, but somewhat less so in health services research. Based on our experiences of conducting several health-related case studies, we reflect on the different types of case study design, the specific research questions this approach can help answer, the data sources that tend to be used, and the particular advantages and disadvantages of employing this methodological approach. The paper concludes with key pointers to aid those designing and appraising proposals for conducting case study research, and a checklist to help readers assess the quality of case study reports.

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Introduction

The case study approach is particularly useful to employ when there is a need to obtain an in-depth appreciation of an issue, event or phenomenon of interest, in its natural real-life context. Our aim in writing this piece is to provide insights into when to consider employing this approach and an overview of key methodological considerations in relation to the design, planning, analysis, interpretation and reporting of case studies.

The illustrative 'grand round', 'case report' and 'case series' have a long tradition in clinical practice and research. Presenting detailed critiques, typically of one or more patients, aims to provide insights into aspects of the clinical case and, in doing so, illustrate broader lessons that may be learnt. In research, the conceptually-related case study approach can be used, for example, to describe in detail a patient's episode of care, explore professional attitudes to and experiences of a new policy initiative or service development or more generally to 'investigate contemporary phenomena within its real-life context' [ 1 ]. Based on our experiences of conducting a range of case studies, we reflect on when to consider using this approach, discuss the key steps involved and illustrate, with examples, some of the practical challenges of attaining an in-depth understanding of a 'case' as an integrated whole. In keeping with previously published work, we acknowledge the importance of theory to underpin the design, selection, conduct and interpretation of case studies[ 2 ]. In so doing, we make passing reference to the different epistemological approaches used in case study research by key theoreticians and methodologists in this field of enquiry.

This paper is structured around the following main questions: What is a case study? What are case studies used for? How are case studies conducted? What are the potential pitfalls and how can these be avoided? We draw in particular on four of our own recently published examples of case studies (see Tables 1 , 2 , 3 and 4 ) and those of others to illustrate our discussion[ 3 – 7 ].

What is a case study?

A case study is a research approach that is used to generate an in-depth, multi-faceted understanding of a complex issue in its real-life context. It is an established research design that is used extensively in a wide variety of disciplines, particularly in the social sciences. A case study can be defined in a variety of ways (Table 5 ), the central tenet being the need to explore an event or phenomenon in depth and in its natural context. It is for this reason sometimes referred to as a "naturalistic" design; this is in contrast to an "experimental" design (such as a randomised controlled trial) in which the investigator seeks to exert control over and manipulate the variable(s) of interest.

Stake's work has been particularly influential in defining the case study approach to scientific enquiry. He has helpfully characterised three main types of case study: intrinsic , instrumental and collective [ 8 ]. An intrinsic case study is typically undertaken to learn about a unique phenomenon. The researcher should define the uniqueness of the phenomenon, which distinguishes it from all others. In contrast, the instrumental case study uses a particular case (some of which may be better than others) to gain a broader appreciation of an issue or phenomenon. The collective case study involves studying multiple cases simultaneously or sequentially in an attempt to generate a still broader appreciation of a particular issue.

These are however not necessarily mutually exclusive categories. In the first of our examples (Table 1 ), we undertook an intrinsic case study to investigate the issue of recruitment of minority ethnic people into the specific context of asthma research studies, but it developed into a instrumental case study through seeking to understand the issue of recruitment of these marginalised populations more generally, generating a number of the findings that are potentially transferable to other disease contexts[ 3 ]. In contrast, the other three examples (see Tables 2 , 3 and 4 ) employed collective case study designs to study the introduction of workforce reconfiguration in primary care, the implementation of electronic health records into hospitals, and to understand the ways in which healthcare students learn about patient safety considerations[ 4 – 6 ]. Although our study focusing on the introduction of General Practitioners with Specialist Interests (Table 2 ) was explicitly collective in design (four contrasting primary care organisations were studied), is was also instrumental in that this particular professional group was studied as an exemplar of the more general phenomenon of workforce redesign[ 4 ].

What are case studies used for?

According to Yin, case studies can be used to explain, describe or explore events or phenomena in the everyday contexts in which they occur[ 1 ]. These can, for example, help to understand and explain causal links and pathways resulting from a new policy initiative or service development (see Tables 2 and 3 , for example)[ 1 ]. In contrast to experimental designs, which seek to test a specific hypothesis through deliberately manipulating the environment (like, for example, in a randomised controlled trial giving a new drug to randomly selected individuals and then comparing outcomes with controls),[ 9 ] the case study approach lends itself well to capturing information on more explanatory ' how ', 'what' and ' why ' questions, such as ' how is the intervention being implemented and received on the ground?'. The case study approach can offer additional insights into what gaps exist in its delivery or why one implementation strategy might be chosen over another. This in turn can help develop or refine theory, as shown in our study of the teaching of patient safety in undergraduate curricula (Table 4 )[ 6 , 10 ]. Key questions to consider when selecting the most appropriate study design are whether it is desirable or indeed possible to undertake a formal experimental investigation in which individuals and/or organisations are allocated to an intervention or control arm? Or whether the wish is to obtain a more naturalistic understanding of an issue? The former is ideally studied using a controlled experimental design, whereas the latter is more appropriately studied using a case study design.

Case studies may be approached in different ways depending on the epistemological standpoint of the researcher, that is, whether they take a critical (questioning one's own and others' assumptions), interpretivist (trying to understand individual and shared social meanings) or positivist approach (orientating towards the criteria of natural sciences, such as focusing on generalisability considerations) (Table 6 ). Whilst such a schema can be conceptually helpful, it may be appropriate to draw on more than one approach in any case study, particularly in the context of conducting health services research. Doolin has, for example, noted that in the context of undertaking interpretative case studies, researchers can usefully draw on a critical, reflective perspective which seeks to take into account the wider social and political environment that has shaped the case[ 11 ].

How are case studies conducted?

Here, we focus on the main stages of research activity when planning and undertaking a case study; the crucial stages are: defining the case; selecting the case(s); collecting and analysing the data; interpreting data; and reporting the findings.

Defining the case

Carefully formulated research question(s), informed by the existing literature and a prior appreciation of the theoretical issues and setting(s), are all important in appropriately and succinctly defining the case[ 8 , 12 ]. Crucially, each case should have a pre-defined boundary which clarifies the nature and time period covered by the case study (i.e. its scope, beginning and end), the relevant social group, organisation or geographical area of interest to the investigator, the types of evidence to be collected, and the priorities for data collection and analysis (see Table 7 )[ 1 ]. A theory driven approach to defining the case may help generate knowledge that is potentially transferable to a range of clinical contexts and behaviours; using theory is also likely to result in a more informed appreciation of, for example, how and why interventions have succeeded or failed[ 13 ].

For example, in our evaluation of the introduction of electronic health records in English hospitals (Table 3 ), we defined our cases as the NHS Trusts that were receiving the new technology[ 5 ]. Our focus was on how the technology was being implemented. However, if the primary research interest had been on the social and organisational dimensions of implementation, we might have defined our case differently as a grouping of healthcare professionals (e.g. doctors and/or nurses). The precise beginning and end of the case may however prove difficult to define. Pursuing this same example, when does the process of implementation and adoption of an electronic health record system really begin or end? Such judgements will inevitably be influenced by a range of factors, including the research question, theory of interest, the scope and richness of the gathered data and the resources available to the research team.

Selecting the case(s)

The decision on how to select the case(s) to study is a very important one that merits some reflection. In an intrinsic case study, the case is selected on its own merits[ 8 ]. The case is selected not because it is representative of other cases, but because of its uniqueness, which is of genuine interest to the researchers. This was, for example, the case in our study of the recruitment of minority ethnic participants into asthma research (Table 1 ) as our earlier work had demonstrated the marginalisation of minority ethnic people with asthma, despite evidence of disproportionate asthma morbidity[ 14 , 15 ]. In another example of an intrinsic case study, Hellstrom et al.[ 16 ] studied an elderly married couple living with dementia to explore how dementia had impacted on their understanding of home, their everyday life and their relationships.

For an instrumental case study, selecting a "typical" case can work well[ 8 ]. In contrast to the intrinsic case study, the particular case which is chosen is of less importance than selecting a case that allows the researcher to investigate an issue or phenomenon. For example, in order to gain an understanding of doctors' responses to health policy initiatives, Som undertook an instrumental case study interviewing clinicians who had a range of responsibilities for clinical governance in one NHS acute hospital trust[ 17 ]. Sampling a "deviant" or "atypical" case may however prove even more informative, potentially enabling the researcher to identify causal processes, generate hypotheses and develop theory.

In collective or multiple case studies, a number of cases are carefully selected. This offers the advantage of allowing comparisons to be made across several cases and/or replication. Choosing a "typical" case may enable the findings to be generalised to theory (i.e. analytical generalisation) or to test theory by replicating the findings in a second or even a third case (i.e. replication logic)[ 1 ]. Yin suggests two or three literal replications (i.e. predicting similar results) if the theory is straightforward and five or more if the theory is more subtle. However, critics might argue that selecting 'cases' in this way is insufficiently reflexive and ill-suited to the complexities of contemporary healthcare organisations.

The selected case study site(s) should allow the research team access to the group of individuals, the organisation, the processes or whatever else constitutes the chosen unit of analysis for the study. Access is therefore a central consideration; the researcher needs to come to know the case study site(s) well and to work cooperatively with them. Selected cases need to be not only interesting but also hospitable to the inquiry [ 8 ] if they are to be informative and answer the research question(s). Case study sites may also be pre-selected for the researcher, with decisions being influenced by key stakeholders. For example, our selection of case study sites in the evaluation of the implementation and adoption of electronic health record systems (see Table 3 ) was heavily influenced by NHS Connecting for Health, the government agency that was responsible for overseeing the National Programme for Information Technology (NPfIT)[ 5 ]. This prominent stakeholder had already selected the NHS sites (through a competitive bidding process) to be early adopters of the electronic health record systems and had negotiated contracts that detailed the deployment timelines.

It is also important to consider in advance the likely burden and risks associated with participation for those who (or the site(s) which) comprise the case study. Of particular importance is the obligation for the researcher to think through the ethical implications of the study (e.g. the risk of inadvertently breaching anonymity or confidentiality) and to ensure that potential participants/participating sites are provided with sufficient information to make an informed choice about joining the study. The outcome of providing this information might be that the emotive burden associated with participation, or the organisational disruption associated with supporting the fieldwork, is considered so high that the individuals or sites decide against participation.

In our example of evaluating implementations of electronic health record systems, given the restricted number of early adopter sites available to us, we sought purposively to select a diverse range of implementation cases among those that were available[ 5 ]. We chose a mixture of teaching, non-teaching and Foundation Trust hospitals, and examples of each of the three electronic health record systems procured centrally by the NPfIT. At one recruited site, it quickly became apparent that access was problematic because of competing demands on that organisation. Recognising the importance of full access and co-operative working for generating rich data, the research team decided not to pursue work at that site and instead to focus on other recruited sites.

Collecting the data

In order to develop a thorough understanding of the case, the case study approach usually involves the collection of multiple sources of evidence, using a range of quantitative (e.g. questionnaires, audits and analysis of routinely collected healthcare data) and more commonly qualitative techniques (e.g. interviews, focus groups and observations). The use of multiple sources of data (data triangulation) has been advocated as a way of increasing the internal validity of a study (i.e. the extent to which the method is appropriate to answer the research question)[ 8 , 18 – 21 ]. An underlying assumption is that data collected in different ways should lead to similar conclusions, and approaching the same issue from different angles can help develop a holistic picture of the phenomenon (Table 2 )[ 4 ].

Brazier and colleagues used a mixed-methods case study approach to investigate the impact of a cancer care programme[ 22 ]. Here, quantitative measures were collected with questionnaires before, and five months after, the start of the intervention which did not yield any statistically significant results. Qualitative interviews with patients however helped provide an insight into potentially beneficial process-related aspects of the programme, such as greater, perceived patient involvement in care. The authors reported how this case study approach provided a number of contextual factors likely to influence the effectiveness of the intervention and which were not likely to have been obtained from quantitative methods alone.

In collective or multiple case studies, data collection needs to be flexible enough to allow a detailed description of each individual case to be developed (e.g. the nature of different cancer care programmes), before considering the emerging similarities and differences in cross-case comparisons (e.g. to explore why one programme is more effective than another). It is important that data sources from different cases are, where possible, broadly comparable for this purpose even though they may vary in nature and depth.

Analysing, interpreting and reporting case studies

Making sense and offering a coherent interpretation of the typically disparate sources of data (whether qualitative alone or together with quantitative) is far from straightforward. Repeated reviewing and sorting of the voluminous and detail-rich data are integral to the process of analysis. In collective case studies, it is helpful to analyse data relating to the individual component cases first, before making comparisons across cases. Attention needs to be paid to variations within each case and, where relevant, the relationship between different causes, effects and outcomes[ 23 ]. Data will need to be organised and coded to allow the key issues, both derived from the literature and emerging from the dataset, to be easily retrieved at a later stage. An initial coding frame can help capture these issues and can be applied systematically to the whole dataset with the aid of a qualitative data analysis software package.

The Framework approach is a practical approach, comprising of five stages (familiarisation; identifying a thematic framework; indexing; charting; mapping and interpretation) , to managing and analysing large datasets particularly if time is limited, as was the case in our study of recruitment of South Asians into asthma research (Table 1 )[ 3 , 24 ]. Theoretical frameworks may also play an important role in integrating different sources of data and examining emerging themes. For example, we drew on a socio-technical framework to help explain the connections between different elements - technology; people; and the organisational settings within which they worked - in our study of the introduction of electronic health record systems (Table 3 )[ 5 ]. Our study of patient safety in undergraduate curricula drew on an evaluation-based approach to design and analysis, which emphasised the importance of the academic, organisational and practice contexts through which students learn (Table 4 )[ 6 ].

Case study findings can have implications both for theory development and theory testing. They may establish, strengthen or weaken historical explanations of a case and, in certain circumstances, allow theoretical (as opposed to statistical) generalisation beyond the particular cases studied[ 12 ]. These theoretical lenses should not, however, constitute a strait-jacket and the cases should not be "forced to fit" the particular theoretical framework that is being employed.

When reporting findings, it is important to provide the reader with enough contextual information to understand the processes that were followed and how the conclusions were reached. In a collective case study, researchers may choose to present the findings from individual cases separately before amalgamating across cases. Care must be taken to ensure the anonymity of both case sites and individual participants (if agreed in advance) by allocating appropriate codes or withholding descriptors. In the example given in Table 3 , we decided against providing detailed information on the NHS sites and individual participants in order to avoid the risk of inadvertent disclosure of identities[ 5 , 25 ].

What are the potential pitfalls and how can these be avoided?

The case study approach is, as with all research, not without its limitations. When investigating the formal and informal ways undergraduate students learn about patient safety (Table 4 ), for example, we rapidly accumulated a large quantity of data. The volume of data, together with the time restrictions in place, impacted on the depth of analysis that was possible within the available resources. This highlights a more general point of the importance of avoiding the temptation to collect as much data as possible; adequate time also needs to be set aside for data analysis and interpretation of what are often highly complex datasets.

Case study research has sometimes been criticised for lacking scientific rigour and providing little basis for generalisation (i.e. producing findings that may be transferable to other settings)[ 1 ]. There are several ways to address these concerns, including: the use of theoretical sampling (i.e. drawing on a particular conceptual framework); respondent validation (i.e. participants checking emerging findings and the researcher's interpretation, and providing an opinion as to whether they feel these are accurate); and transparency throughout the research process (see Table 8 )[ 8 , 18 – 21 , 23 , 26 ]. Transparency can be achieved by describing in detail the steps involved in case selection, data collection, the reasons for the particular methods chosen, and the researcher's background and level of involvement (i.e. being explicit about how the researcher has influenced data collection and interpretation). Seeking potential, alternative explanations, and being explicit about how interpretations and conclusions were reached, help readers to judge the trustworthiness of the case study report. Stake provides a critique checklist for a case study report (Table 9 )[ 8 ].

Conclusions

The case study approach allows, amongst other things, critical events, interventions, policy developments and programme-based service reforms to be studied in detail in a real-life context. It should therefore be considered when an experimental design is either inappropriate to answer the research questions posed or impossible to undertake. Considering the frequency with which implementations of innovations are now taking place in healthcare settings and how well the case study approach lends itself to in-depth, complex health service research, we believe this approach should be more widely considered by researchers. Though inherently challenging, the research case study can, if carefully conceptualised and thoughtfully undertaken and reported, yield powerful insights into many important aspects of health and healthcare delivery.

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We are grateful to the participants and colleagues who contributed to the individual case studies that we have drawn on. This work received no direct funding, but it has been informed by projects funded by Asthma UK, the NHS Service Delivery Organisation, NHS Connecting for Health Evaluation Programme, and Patient Safety Research Portfolio. We would also like to thank the expert reviewers for their insightful and constructive feedback. Our thanks are also due to Dr. Allison Worth who commented on an earlier draft of this manuscript.

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Home » Case Study – Methods, Examples and Guide

Case Study – Methods, Examples and Guide

Table of Contents

A case study is a research method that involves an in-depth examination and analysis of a particular phenomenon or case, such as an individual, organization, community, event, or situation.

It is a qualitative research approach that aims to provide a detailed and comprehensive understanding of the case being studied. Case studies typically involve multiple sources of data, including interviews, observations, documents, and artifacts, which are analyzed using various techniques, such as content analysis, thematic analysis, and grounded theory. The findings of a case study are often used to develop theories, inform policy or practice, or generate new research questions.

Types of Case Study

Types and Methods of Case Study are as follows:

Single-Case Study

A single-case study is an in-depth analysis of a single case. This type of case study is useful when the researcher wants to understand a specific phenomenon in detail.

For Example , A researcher might conduct a single-case study on a particular individual to understand their experiences with a particular health condition or a specific organization to explore their management practices. The researcher collects data from multiple sources, such as interviews, observations, and documents, and uses various techniques to analyze the data, such as content analysis or thematic analysis. The findings of a single-case study are often used to generate new research questions, develop theories, or inform policy or practice.

Multiple-Case Study

A multiple-case study involves the analysis of several cases that are similar in nature. This type of case study is useful when the researcher wants to identify similarities and differences between the cases.

For Example, a researcher might conduct a multiple-case study on several companies to explore the factors that contribute to their success or failure. The researcher collects data from each case, compares and contrasts the findings, and uses various techniques to analyze the data, such as comparative analysis or pattern-matching. The findings of a multiple-case study can be used to develop theories, inform policy or practice, or generate new research questions.

Exploratory Case Study

An exploratory case study is used to explore a new or understudied phenomenon. This type of case study is useful when the researcher wants to generate hypotheses or theories about the phenomenon.

For Example, a researcher might conduct an exploratory case study on a new technology to understand its potential impact on society. The researcher collects data from multiple sources, such as interviews, observations, and documents, and uses various techniques to analyze the data, such as grounded theory or content analysis. The findings of an exploratory case study can be used to generate new research questions, develop theories, or inform policy or practice.

Descriptive Case Study

A descriptive case study is used to describe a particular phenomenon in detail. This type of case study is useful when the researcher wants to provide a comprehensive account of the phenomenon.

For Example, a researcher might conduct a descriptive case study on a particular community to understand its social and economic characteristics. The researcher collects data from multiple sources, such as interviews, observations, and documents, and uses various techniques to analyze the data, such as content analysis or thematic analysis. The findings of a descriptive case study can be used to inform policy or practice or generate new research questions.

Instrumental Case Study

An instrumental case study is used to understand a particular phenomenon that is instrumental in achieving a particular goal. This type of case study is useful when the researcher wants to understand the role of the phenomenon in achieving the goal.

For Example, a researcher might conduct an instrumental case study on a particular policy to understand its impact on achieving a particular goal, such as reducing poverty. The researcher collects data from multiple sources, such as interviews, observations, and documents, and uses various techniques to analyze the data, such as content analysis or thematic analysis. The findings of an instrumental case study can be used to inform policy or practice or generate new research questions.

Case Study Data Collection Methods

Here are some common data collection methods for case studies:

Interviews involve asking questions to individuals who have knowledge or experience relevant to the case study. Interviews can be structured (where the same questions are asked to all participants) or unstructured (where the interviewer follows up on the responses with further questions). Interviews can be conducted in person, over the phone, or through video conferencing.

Observations

Observations involve watching and recording the behavior and activities of individuals or groups relevant to the case study. Observations can be participant (where the researcher actively participates in the activities) or non-participant (where the researcher observes from a distance). Observations can be recorded using notes, audio or video recordings, or photographs.

Documents can be used as a source of information for case studies. Documents can include reports, memos, emails, letters, and other written materials related to the case study. Documents can be collected from the case study participants or from public sources.

Surveys involve asking a set of questions to a sample of individuals relevant to the case study. Surveys can be administered in person, over the phone, through mail or email, or online. Surveys can be used to gather information on attitudes, opinions, or behaviors related to the case study.

Artifacts are physical objects relevant to the case study. Artifacts can include tools, equipment, products, or other objects that provide insights into the case study phenomenon.

How to conduct Case Study Research

Conducting a case study research involves several steps that need to be followed to ensure the quality and rigor of the study. Here are the steps to conduct case study research:

• Define the research questions: The first step in conducting a case study research is to define the research questions. The research questions should be specific, measurable, and relevant to the case study phenomenon under investigation.
• Select the case: The next step is to select the case or cases to be studied. The case should be relevant to the research questions and should provide rich and diverse data that can be used to answer the research questions.
• Collect data: Data can be collected using various methods, such as interviews, observations, documents, surveys, and artifacts. The data collection method should be selected based on the research questions and the nature of the case study phenomenon.
• Analyze the data: The data collected from the case study should be analyzed using various techniques, such as content analysis, thematic analysis, or grounded theory. The analysis should be guided by the research questions and should aim to provide insights and conclusions relevant to the research questions.
• Draw conclusions: The conclusions drawn from the case study should be based on the data analysis and should be relevant to the research questions. The conclusions should be supported by evidence and should be clearly stated.
• Validate the findings: The findings of the case study should be validated by reviewing the data and the analysis with participants or other experts in the field. This helps to ensure the validity and reliability of the findings.
• Write the report: The final step is to write the report of the case study research. The report should provide a clear description of the case study phenomenon, the research questions, the data collection methods, the data analysis, the findings, and the conclusions. The report should be written in a clear and concise manner and should follow the guidelines for academic writing.

Examples of Case Study

Here are some examples of case study research:

• The Hawthorne Studies : Conducted between 1924 and 1932, the Hawthorne Studies were a series of case studies conducted by Elton Mayo and his colleagues to examine the impact of work environment on employee productivity. The studies were conducted at the Hawthorne Works plant of the Western Electric Company in Chicago and included interviews, observations, and experiments.
• The Stanford Prison Experiment: Conducted in 1971, the Stanford Prison Experiment was a case study conducted by Philip Zimbardo to examine the psychological effects of power and authority. The study involved simulating a prison environment and assigning participants to the role of guards or prisoners. The study was controversial due to the ethical issues it raised.
• The Challenger Disaster: The Challenger Disaster was a case study conducted to examine the causes of the Space Shuttle Challenger explosion in 1986. The study included interviews, observations, and analysis of data to identify the technical, organizational, and cultural factors that contributed to the disaster.
• The Enron Scandal: The Enron Scandal was a case study conducted to examine the causes of the Enron Corporation’s bankruptcy in 2001. The study included interviews, analysis of financial data, and review of documents to identify the accounting practices, corporate culture, and ethical issues that led to the company’s downfall.
• The Fukushima Nuclear Disaster : The Fukushima Nuclear Disaster was a case study conducted to examine the causes of the nuclear accident that occurred at the Fukushima Daiichi Nuclear Power Plant in Japan in 2011. The study included interviews, analysis of data, and review of documents to identify the technical, organizational, and cultural factors that contributed to the disaster.

Application of Case Study

Case studies have a wide range of applications across various fields and industries. Here are some examples:

Business and Management

Case studies are widely used in business and management to examine real-life situations and develop problem-solving skills. Case studies can help students and professionals to develop a deep understanding of business concepts, theories, and best practices.

Case studies are used in healthcare to examine patient care, treatment options, and outcomes. Case studies can help healthcare professionals to develop critical thinking skills, diagnose complex medical conditions, and develop effective treatment plans.

Case studies are used in education to examine teaching and learning practices. Case studies can help educators to develop effective teaching strategies, evaluate student progress, and identify areas for improvement.

Social Sciences

Case studies are widely used in social sciences to examine human behavior, social phenomena, and cultural practices. Case studies can help researchers to develop theories, test hypotheses, and gain insights into complex social issues.

Law and Ethics

Case studies are used in law and ethics to examine legal and ethical dilemmas. Case studies can help lawyers, policymakers, and ethical professionals to develop critical thinking skills, analyze complex cases, and make informed decisions.

Purpose of Case Study

The purpose of a case study is to provide a detailed analysis of a specific phenomenon, issue, or problem in its real-life context. A case study is a qualitative research method that involves the in-depth exploration and analysis of a particular case, which can be an individual, group, organization, event, or community.

The primary purpose of a case study is to generate a comprehensive and nuanced understanding of the case, including its history, context, and dynamics. Case studies can help researchers to identify and examine the underlying factors, processes, and mechanisms that contribute to the case and its outcomes. This can help to develop a more accurate and detailed understanding of the case, which can inform future research, practice, or policy.

Case studies can also serve other purposes, including:

• Illustrating a theory or concept: Case studies can be used to illustrate and explain theoretical concepts and frameworks, providing concrete examples of how they can be applied in real-life situations.
• Developing hypotheses: Case studies can help to generate hypotheses about the causal relationships between different factors and outcomes, which can be tested through further research.
• Providing insight into complex issues: Case studies can provide insights into complex and multifaceted issues, which may be difficult to understand through other research methods.
• Informing practice or policy: Case studies can be used to inform practice or policy by identifying best practices, lessons learned, or areas for improvement.

Advantages of Case Study Research

There are several advantages of case study research, including:

• In-depth exploration: Case study research allows for a detailed exploration and analysis of a specific phenomenon, issue, or problem in its real-life context. This can provide a comprehensive understanding of the case and its dynamics, which may not be possible through other research methods.
• Rich data: Case study research can generate rich and detailed data, including qualitative data such as interviews, observations, and documents. This can provide a nuanced understanding of the case and its complexity.
• Holistic perspective: Case study research allows for a holistic perspective of the case, taking into account the various factors, processes, and mechanisms that contribute to the case and its outcomes. This can help to develop a more accurate and comprehensive understanding of the case.
• Theory development: Case study research can help to develop and refine theories and concepts by providing empirical evidence and concrete examples of how they can be applied in real-life situations.
• Practical application: Case study research can inform practice or policy by identifying best practices, lessons learned, or areas for improvement.
• Contextualization: Case study research takes into account the specific context in which the case is situated, which can help to understand how the case is influenced by the social, cultural, and historical factors of its environment.

Limitations of Case Study Research

There are several limitations of case study research, including:

• Limited generalizability : Case studies are typically focused on a single case or a small number of cases, which limits the generalizability of the findings. The unique characteristics of the case may not be applicable to other contexts or populations, which may limit the external validity of the research.
• Biased sampling: Case studies may rely on purposive or convenience sampling, which can introduce bias into the sample selection process. This may limit the representativeness of the sample and the generalizability of the findings.
• Subjectivity: Case studies rely on the interpretation of the researcher, which can introduce subjectivity into the analysis. The researcher’s own biases, assumptions, and perspectives may influence the findings, which may limit the objectivity of the research.
• Limited control: Case studies are typically conducted in naturalistic settings, which limits the control that the researcher has over the environment and the variables being studied. This may limit the ability to establish causal relationships between variables.
• Time-consuming: Case studies can be time-consuming to conduct, as they typically involve a detailed exploration and analysis of a specific case. This may limit the feasibility of conducting multiple case studies or conducting case studies in a timely manner.
• Resource-intensive: Case studies may require significant resources, including time, funding, and expertise. This may limit the ability of researchers to conduct case studies in resource-constrained settings.

About the author

Muhammad Hassan

Researcher, Academic Writer, Web developer

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• Ann Geriatr Med Res
• v.25(2); 2021 Jun

Older Adults’ Experiences and Adaptation Strategies during the Midst of COVID-19 Crisis: A Qualitative Instrumental Case Study

Jonaid m. sadang.

1 College of Health Sciences, Mindanao State University, Marawi City, Philippines

2 College of Nursing, Cebu Normal University, Cebu City, Philippines

Daisy R. Palompon

Wanich suksatan.

3 Faculty of Nursing, HRH Princess Chulabhorn College of Medical Science, Chulabhorn Royal Academy, Bangkok, Thailand

This study aimed to validate one of the propositions of the Need-Threat Internal Resiliency Theory.

This study used an instrumental case study of five participants to qualitatively explore older adults’ experiences and adapting strategies during the coronavirus disease 2019 (COVID-19) crisis. We selected participants based on parameters and conducted in-depth interviews of 15–30 minutes. The transcribed responses were then analyzed using a phenomenological holistic description.

Five major themes emerged to explain and describe the various experiences of coping with COVID-19, known as internal resiliency, developed by the older adult participants in response to the perceived threat from this crisis.

These findings showed that older adult participants had established internal resiliency in response to changes caused by the COVID-19 crisis, resulting in adaptation and coping with the situation, consistent with one proposition of the Need-Threat Internal Resiliency Theory.

INTRODUCTION

Because of their social vulnerabilities, older persons are among the most affected special population during the coronavirus disease 2019 (COVID-19) pandemic. 1 ) Moreover, this population has higher risks of acquiring such illnesses owing to their advanced age and the presence of chronic comorbidities. 2 ) In the Philippines, there were 1,276,004 confirmed cases of COVID-19, with 21,969 deaths, with a high mortality rate disproportionately affecting older Filipinos. 3 ) This health crisis has a notable disproportionate impact on most marginalized and vulnerable individuals, including older adults. 4 ) The incidence of diseases, such as hypertension, diabetes mellitus, heart failure, and some respiratory problems, in most older people has greatly affected the prognosis of most patients with COVID-19, especially those aged 60 years and above. 5 ) Moreover, compared to younger adults, older people affected by this illness have higher numbers of documented cases and risk of developing complications related to COVID-19 owing to the abovementioned factors. 6 )

Filipinos in their later years are often strongly religious and hold strong beliefs about God’s influence on their health and well-being. Their deep spirituality and faith serve as a source of strength and protection against stress and sorrow. 7 ) For older adult Filipinos, regularly attending church (masjid for Muslims) services and participating in church events are normal routines in their everyday lives. 7 , 8 ) However, the social restriction measures that the society was forced to implement have created imbalances and disrupted the social interaction of older persons within their respective communities. 1 ) These policy decisions and actions have aggravated the conditions of these older individuals, in turn resulting in poor healthcare access and limited sources for their individual basic needs. 9 ) Social isolation and disconnection itself poses a serious health concern in this special group considering both psychosocial and physiological aftereffect it may create during such crisis which includes mental health issues and other at-risk health problems. 10 ) In fact, multiple studies have shown that this COVID-19 crisis has led to psychological morbidities in older people including but not limited to depression, anxiety, increased level of stress and fear, sleep disturbance resulting to poor sleep quality, accelerated cognitive decline and some physiological problems such as poor cardiovascular and impaired immunity functions while on home or quarantined at healthcare facilities. 2 , 11 )

Social engagement which includes meaningful interactions and connectedness with others is an essential stimulus necessary for older person to improve their physical and mental health as individuals. 1 , 6 ) Positive social connections and relationships are considered to be an integral factor for older person’s well-being as social beings. 4 ) Hence, in the presence of this social disequilibrium, older adults are triggered to develop strategies in order to cope with such situation. 1 , 2 ) These coping strategies are natural adaptive capacities known as internal resiliency 12 ) developed by older person in respond to the process of ageing and stressful life experiences such COVID-19 crisis. 1 ) Coping strategies are essential factors that determine one’s well-being in old age. 13 ) It compensates or alleviates stressful circumstance through reformulation and adjustment to a new and positively assessed environment. 12 , 13 )

The theory on need-threat internal resiliency proposed that in times of crisis, health needs develop into a health threat that compels older persons to develop internal resiliency in order to preserve their integrity, well-being and quality of life as individuals. 12 ) Internal resiliency refers to the ability to adapt well in the face of adversity, dangers, trauma, or significant sources of stress, collectively known as crisis (e.g., COVID-19 pandemic), to sustain a sense of purpose and vigor, as well as to emerge stronger from such stressful situations. 1 , 12 ) In connection, this study aimed to validate one of the assumptions of this theory which states that in times of crisis when threat is perceived, older persons developed a sense of internal control and adaptation to the changes it creates known as internal resiliency, 12 ) through a qualitative exploration of older person’s experiences and coping strategies in the midst of COVID-19 pandemic crisis. Instrumental case studies allow the researchers to utilize the case as a comparison point in different circumstances where the phenomenon may be present while testing established theories. 14 )

To produce novel insights and a more detailed understanding of complex realities, diverse lived experiences, and how older people are making sense of and coping with what is happening around them during this crisis, qualitative insights are needed, influencing their resiliency and adaptation to such difficult situations as the COVID-19 pandemic. 15 ) Moreover, understanding these factors and mechanism that drives older adult’s internal resilience during such situations could guide healthcare practitioners including nurses in providing an effective and efficient intervention approaches to such special population who have been greatly affected by this pandemic illness. 6 , 16 )

MATERIALS AND METHODS

A qualitative instrumental case study was adopted to conduct this research. This approach refers to the inquiry of a case (e.g., an individual or specific group) to provide insights regarding a particular issue (such as COVID-19) and the development of internal resiliency in older people owing to the threat it creates among this population. 17 ) This design allows researchers to use the case as a comparison point in other situations where the phenomenon might be present while developing and testing an established theory. 14 )

Participants and Setting

The target population in this study was (1) older adults aged at least 65 years; (2) currently living within the transitory shelters of Barangay Sagonsongan in Marawi City, Philippines during the peak months of the crisis between March and December 2020; and (3) showing any qualities or characteristics of adaptation during the COVID-19 crisis (e.g., calmness or an absence of fear and anxiety owing to the ongoing health crisis). This group of people has been greatly affected by the pandemic crisis in terms of economic and health resources, considering their societal status and as victims of the previous Marawi siege crisis. The Marawi siege, a violent conflict between government forces and pro-ISIS (Islamic State) militants in the city of Marawi, forcibly displaced 98% of the city’s inhabitants, including older adults, who were forced to flee owing to severe food shortages and economic constraints. 18 ) As such, the present study selected these older residents of transitory shelters as target participants based on their experiences in both past and present crises.

We applied non-probability sampling using the purposive and snowball approach to identify five participants included in the final analysis. The sample size was determined by data saturation, which occurred when no new themes emerged from the participants’ responses following data processing. 17 ) Purposive sampling uses the judgment of an expert or researcher to identify information-rich cases related to the phenomenon of interest 17 ) and is widely used in qualitative research such as instrumental case studies. 19 )

Instrument & Data Collection

An open-ended guide questionnaire tool was used to collect data during individual in-depth interviews of 15–30 minutes. Some of the questions were as follows: (1) “What is it like to live during the COVID-19 pandemic crisis?” and (2) “What are the challenges you have encountered during the COVID-19 pandemic crisis and what did you do to cope with such circumstances?” A probing question was asked to encourage the participants to provide more details about their experiences. Three qualitative research experts evaluated the guide questionnaire for appropriateness based on the research objectives. We performed a qualitative simulation before actual data collection to identify possible behaviors during the interview process. Rigor in qualitative trustworthiness, including credibility, transferability, dependability, and conformability, was strictly observed. 17 ) This included confirming with each participant that the detailed description accurately reflected their experiences of coping with the COVID-19 crisis, as well as noting any unclear or misinterpreted themes or discussions, prompting the researchers to amend the relevant descriptions.

Ethical Considerations

We obtained informed consent from all participants and strictly observed health measures regarding COVID-19. The College of Health Sciences of Mindanao State University Ethics Review Committee provided ethics clearance (Approval code: CHS-16-2021) as part of the research protocol included humans. Participants were anonymized by using code names (e.g., P1) during the transcription and analysis of their respective responses. The participants were free to withdraw from the study at any time even after signing the informed consent without any consequences on their part. Participation was voluntary, and no compensation was provided to the participants after the interview.

Phenomenological analysis using a holistic description of the bounded phenomenon was adopted to identify themes supporting the study objective. 20 ) This thematic analysis goes from the original data to the identification of meanings of the participant’s verbatim responses, which are then organized into patterns and combined into themes related to the research aim and actual context. 17 , 21 )

Characteristics of the Key Participants

The key informants for this qualitative instrumental case study included five older adult participants comprising four women and one man aged 65–75 years ( Table 1 ). Most participants were widowed and were living in transitory shelters of the Sagonsongan area in Marawi City since COVID-19 began in 2020.

Participant profile

Thematic Analysis

Sixty-two significant statements from the five older adult participants were extracted from the interview transcripts to generate meanings from their verbatim responses. Careful analysis of these statements revealed five main themes and 13 subthemes that explained the experiences and coping strategies of older adults during the COVID-19 crisis. These themes and their corresponding subthemes are summarized in Table 2 and discussed further in the following sections.

Derived themes and subthemes

COVID-19, coronavirus disease 2019.

Theme 1: Everyday Struggles

This theme included three subthemes, as described below. During a crisis, older adults’ constant challenges with their daily lives forced them to adapt and deal with the situation, a process referred to as internal resiliency.

Sub-theme 1: Prohibition of going outside and limitation of activities

Most participants reported that the restriction of their normal activities, namely the prohibition of leaving their respective residences, caused them more difficulties than the threat that this virus posed to their health as older adults. These movement restrictions forced the participants to individually adapt and cope with their everyday lives, as indicated by one of the participants’ statements:

• “When we talk of the way I live right now, I am not having a hard time because of this COVID-19 crisis but because of the protocols in which we are being prohibited to go outside.” (P1)

Sub-theme 2: Insufficient government support

The participants indicated that the government provided very little support since the crisis began. Moreover, some of the participants had not received any government assistance during the pandemic crisis. Thus, they were forced to seek alternative sources of living, such as financial help from relatives or neighbors, to survive and cope with the challenges that this crisis imposed on them as older adults. This was supported by the following statement from one of the participants:

• “Since they had initiated this strict lockdown policy every Sunday’s, we are having a hard time to find ways where we can get our source of living considering that there was no any constant reliefs or aids from the local government.” (P2)

Sub-theme 3: Lack of sources of income or livelihood

The participants also described the difficulties they had experienced in surviving this pandemic crisis, not because of the health threats posed by the illness but rather due to the challenges associated with a lack of financial resources. Some participants were still living with their grandchildren who were also responsible for them. Despite these difficulties, the participants were forced to find ways to adapt and cope with the crisis by looking for possible sources of income. This was supported by the following statement from one of the participants:

• “What makes it difficult for us now is that no one wants to buy what we sell and we can’t also look for another source of living due to this pandemic.” (P5)

Theme 2: Embracing Reality

This theme included two subthemes, as described below. When a crisis arises, an older adult embraces reality to adapt to the situation, which is referred to as internal resiliency.

Sub-theme 1: Acceptance

According to older adult participants, such crises have happened before, and the only thing that they can do is recognize their existence in our society. They indicated that they must accept this situation to adapt and continue what they have become used to in life. This was supported by the following statement from one of the participants:

• “What is happening now is the same as what happened before which they called measles but all we can do is have patience and to accept the reality because it already happened and came to us.” (P4)

Sub-theme 2: Left with no other choices

COVID-19 left most of the participants feeling that they had no choice but to recognize its presence and accept that they must leave it to God and adapt to certain circumstances to live as they had become accustomed. This was supported by the following statement from one of the participants:

• “I don’t have a choice but to leave this with God, that’s the reason I am saying that we are not having a hard time because of this COVID-19 crisis.” (P1)

Theme 3: Cultivating a Strong Spirituality

This theme included four subthemes, as described below. To respond to this situation, older adults typically cultivated a deep spirituality during times of hardship (crises), which is referred to as internal resiliency.

Sub-theme 1: Belief in one’s fate

Most participants expressed the value and critical need to believe in one’s destiny to adapt and deal with the pandemic crisis. Accordingly, they also felt that if God allowed you to become infected, even if you planned to hide, you would become infected and would be unable to avoid the virus. This view was supported by the following participant statement:

• “One of the blessings of God for me is that I haven’t been to doctor since this pandemic happened because I believe that man was resurrected in this world with fate. This mean that what a person does or is doing is what God will give him. A person can work to get sick if he or she does not avoid them.” (P3)

Sub-theme 2: Surrendering self to God and being left with no fear

Most older adults in this study said that they had surrendered themselves to God’s will and that what matters was that they were following and practicing the prescribed preventive measures to avoid being infected with this virus. They said that they felt unafraid, knowing that God would be there to support and help them no matter what challenges the crisis brought to them as individuals. This belief was illustrated by the following participant statement:

• “I always come to God when I have a problem and I’m having a hard time. Like the previous days where we had difficulties and problems with livelihood and what I did was I trusted him and reported all these problems during my prayers and a few days later, his help came to my family.” (P4)

Sub-theme 3: Strong belief and trust to God

Older adult participants claimed that they worshiped and strengthened their relationship with God while also placing their complete confidence in God during this crisis as they believed that faith and prayers were the only factors to help them forget problems brought about by the current pandemic crisis. Therefore, the participants reported feeling at ease and experiencing a lack of anxiety when going about their daily lives during the crisis. This feeling was supported by the following participant statement:

• “God knows that the only thing I am doing is to worship him and I always ask for help from him to exclude me from getting infected from this virus.” (P1)

Sub-theme 4: Considering the situation as a blessing from God

The participants reported that trials and crises such as COVID-19 are blessings from God since they teach us to appreciate the little things in life. This was also his way of making them feel and understand that all powers belong to God and that God is the only one who can turn negative situations into positive ones. This view was supported by the following participant statement:

• “This is one of the blessings of God (ALLAH swt) for us to know our current standing as of today.” (P3)

Theme 4: Finding Things to Enjoy

This theme included two subthemes, as described below. To adjust to unforeseen circumstances, such as crises, older adults are triggered to cope by having something enjoyable to do, which is known as internal resiliency.

Sub-theme 1: Practice of religious rituals and prayers

According to the participants, one of the main coping mechanisms during the pandemic crisis was reading the Qur’an (the holy book for Muslims) and conducting their routine prayers daily. They indicated that these actions provided them strength and protection to prevent COVID-19. Accordingly, they helped the participants to adjust and appreciate things the way they did before the crisis by observing religious rituals and prayers at home. This is supported by the following participant statement:

• “What I usually do to cope from this situation is I keep on performing daily prayers and ask God to end this pandemic so that we can go out.” (P4)

Sub-theme 2: Alternative diversional activities to alleviate boredom

To address this situation, most of the participants sought alternative diversionary activities, which also made them appreciate the simple activities in which they had participated before the pandemic, resulting in adaptation to the ongoing crisis, such as gardening in their small backyards, watching television with their loved ones, and having a brief talk with their neighbors. This was supported by the following participant statement:

• “These little flowers we’ve planted on the sides of our house are the only thing that helps me to get rid of my boredom.” (P2)

Theme 5: Health Consciousness

This theme included two subthemes, as described below. During a crisis, older adults tend to be more health-conscious, particularly when a threat is perceived, which motivates them to cope with the situation, a tendency referred to as internal resiliency.

Sub-theme 1: Observing and taking precautions regarding one’s health

As a result of the danger that this illness posed to their health, most older adults admitted to being more health-conscious. They also described having been extremely vigilant in following and putting into practice the recommended health precautions to avoid contracting COVID-19. These shifts in health-seeking attitudes compelled them to respond to the pandemic’s continuing crisis. This change was supported by the following participant statement:

• “What I did was I continued to avoid the prohibitions in my illness so I was also kept away from the need for a doctor’s help. I continued to avoid do and don’ts in my illness. I have been very careful.” (P3)

Sub-theme 2: Misconceptions regarding COVID-19

Most study participants acknowledged having certain misconceptions about the current health crisis. These misunderstandings resulted from a variety of factors, including hearsay and a lack of information about the disease. Owing to their uncertainty regarding the virus, the participants become more health-conscious, especially in terms of following health precautions to avoid being infected, which required them to adapt or cope with the current pandemic crisis. This change was supported by the following participant statement:

• “I am still undecided whether I will give my consent to be vaccinated in case there’s this vaccine to be allotted for the whole community due to the different issues and hearsays existing about this vaccine.” (P2)

This study tested one of the assumptions of Need-Threat Internal Resiliency Theory, which states that when a threat is perceived in times of crisis, older persons develop a sense of internal control and adapt to changes caused by the crisis, known as internal resiliency. We identified five key themes, each of which illustrated and described the different internal regulations and adaptations that evolved to adapt or cope with the ongoing pandemic crisis, as proposed by the Need-Threat Internal Resiliency Theory.

The first theme, everyday struggles, explains how, during the COVID-19 crisis, challenges with their daily lives forced older adults to adapt and deal with their situations, a response referred to as internal resiliency. As we face the COVID-19 crisis, older adults are among the most vulnerable populations because the pandemic has severely tested their resources and capacities for adaptation and resilience. 22 ) The individual coping strategies in this population are significantly affected by financial problems. 23 ) These events may be attributed to the imposition of community quarantines and lockdowns in most areas, in which public and private establishments, including businesses, public transit, workplaces, and other essential operations, were halted for months, causing vulnerable communities (e.g., older adults and people living in poverty) to struggle in terms of day-to-day survival. 23 , 24 ) These preventive community strategies have made it impossible for older persons to leave their homes, even to obtain basic necessities, without making other arrangements for food and social security. Furthermore, in most cases, as was the case for the participants in this study, community outreach programs were disrupted, adding to the structural alienation of older adults during the pandemic. The findings of this study, in which most of the older adult participants expressed financial insecurity and a lack of income, were consistent with Li and Mutchler 24 ) prediction that the financial resources of the older population would be severely impacted due to the COVID-19 crisis.

The second theme, embracing reality, described how, during the COVID-19 pandemic, older adults created a sense of internal resiliency by embracing reality to adapt or cope with the current crisis. Religion, spirituality, and belief systems have always played a variety of roles in the daily lives of older adults, including providing strength, hope, and comfort in challenging situations, such as the COVID-19 crisis. 25 ) With age, these beliefs become even more important as they serve as a foundational source of strength for achieving positive health outcomes and fostering coping mechanisms, particularly in times of adversity owing to various life crises. 26 ) These aspects are critical and unique features of resilience in the older population as they are effective coping mechanisms that allow them to adjust to their evolving needs. 27 ) The participants’ descriptions of how they have recognized the COVID-19 crisis as having been planned by God and that the only way for them to adapt or cope with it is to embrace its reality is consistent with the findings reported by Manning, 26 ) wherein the participants stated that religion, spirituality, and belief systems helped them adapt and develop resiliency in challenging times, including the COVID-19 crisis. 27 )

The third theme, cultivating a strong spirituality, explains how, during the COVID-19 crisis, older adults usually cultivate a deep spirituality to respond to such situations, which is referred to as internal resiliency developed by such population groups to adapt or cope with these circumstances. Spirituality is a collection of values that adds vitality and value to people’s lives by guiding them to find meaning and intent of their lives, as well as providing hope, compassion, inner peace, comfort, and support. 28 ) Accordingly, high spirituality levels during times of hardship owing to a crisis can lead to peace of mind and calmness, which can influence an individual’s quality of life and resilience, particularly in older adults. 29 ) Spirituality has the greatest impact on older adults’ everyday lives because it offers a structure that guides them through life struggles, allowing them to separate the positive from the negative. 26 ) This result is reinforced by the findings of a Brazilian study, which concluded that religiosity and spirituality among long-living older adults were important mechanisms of resilience that helped them cope with pathologies, depression, and other significant demands, such as pandemic crises, which reduce their individual well-being and quality of life. 30 )

The fourth theme, finding things to enjoy, describes how, during the COVID-19 crisis, the older adult participants in this study were prompted to engage in enjoyable activities, referred to as internal resiliency, to better adapt and cope with their situations. The vulnerability to the COVID-19 crisis, which has resulted in social isolation, has greatly increased the likelihood of certain psychosocial health problems in this group. 16 ) Religious and spiritual activities during times of crisis are important for assisting individuals, especially older persons, to adapt and cope with such situations. 31 ) The results of this study are consistent with those of Lucchetti et al. 27 ) who found that three out of four older adults recognized how religious and spiritual activities (e.g., prayers, reading holy books) have improved the ability of these individuals to cope with the current crisis, especially in terms of their mental and social well-being. Moreover, the participants in this study engaged in recreational activities such as gardening in their small backyards and watching television with their family members to distract themselves. These activities provided them time to do things they would not normally do and taught them to appreciate small things, which has helped ease their concerns and feelings of uncertainty, as well as adjust to their circumstances. This may also explain why the older adults in this study built a sense of internal control and adaptation in response to the perceived threat of this crisis as physical activity in older age is closely linked to higher resilience and the absence or fewer psychosocial issues in times of crisis. 32 ) The final theme, health consciousness, describes how older adults became more health-conscious during the COVID-19 crisis, particularly when danger was perceived, which motivated them to cope with the situation. This internal resiliency in response to the circumstances allowed them to maintain their individual well-being, integrity, and quality of life. During the COVID-19 pandemic, public activities were suspended in many locations, including recreational facilities, senior daycare centers, and places of worship, to minimize the risk of virus transmission within the population. 33 ) This proactive strategy negatively affected the everyday lives of older people, making it difficult for them to adapt to new situations, 33 , 34 ) as demonstrated by the study participants. The participants in our study strictly followed preventive measures to minimize COVID-19 exposure, such as proper handwashing, social distancing, and wearing a mask and face shield. They used these behaviors as coping mechanisms to protect themselves, their family members, and others. As expressed by the participants, such practices helped them manage stress, limit their fears of infection, and keep busy during the pandemic, allowing them to adapt and live normally throughout the crisis. This finding is consistent with that reported by Finlay et al. 15 ) who found that older adults often used and identified coping strategies to be resilient amidst the COVID-19 crisis, including changing habits, following public health recommendations, and avoiding health-restricting behaviors (e.g., overeating), all of which encouraged them to have positive adjustments as individuals. Furthermore, Igarashi et al. 34 ) reported increased self-awareness as a coping mechanism that was unique to older adults.

Resiliency is a common concept that is underestimated among older populations due to a variety of factors, including aging, sexism, vulnerability, and discrimination. The results of this study provide valuable lessons on coping and resilience strategies among older adults during crises; these strategies included (1) everyday struggles, (2) embracing reality, (3) cultivating a strong spirituality, (4) finding things to enjoy, and (5) health consciousness to adapt or cope in their daily battles against difficult and demanding circumstances. The sources of internal resilience identified in this study may have practical implications for promoting the well-being, integrity, and quality of life of older people during the current pandemic and future societal crises. Moreover, health professionals, particularly nurses on the front lines, must recognize and understand the complex needs of older people and tailor their care to support their patients’ ability to adapt and cope well in these circumstances. By being aware of their coping strengths as a population group, nurses may be able to identify older adults at risk of being unable to respond to a crisis. This knowledge is essential for bolstering coping strategies that foster internal control and adaptation, also known as internal resiliency, while also considering the personal interests, autonomy, and capabilities of older adults during any crisis. In addition, policymakers, healthcare providers, communities, gerontology experts, and advocates should work together to help this marginalized group by developing and strengthening infrastructures and programs that assist them in connecting to critical resources and services when they are in need, such as in the case of a pandemic crisis, to easily adapt and cope with these situations. In summary, the older adult participants in this study established certain internal resiliency in response to the changes caused by the COVID-19 crisis, resulting in adaptation and coping with the situation, as proposed by the Need-Threat Internal Resiliency Theory.

Limitations

To date, no other studies have assessed older persons’ experiences, coping strategies, and resilience in the context of Filipino culture during the COVID-19 pandemic. Thus, this study contributes to the advancement of literature on the Filipino older population during this crisis. However, this study included only five participants and was undertaken in a specific setting (transitory shelters) with identified pre-criteria parameters; therefore, older adults in other areas or communities may have had different experiences and used different coping strategies during the COVID-19 crisis. Future research should apply both qualitative and quantitative approaches to investigate the presence of internal resilience within this population during a crisis (e.g., COVID-19) in a more representative sample.

Implications for Practice

• Resilience, as experienced by the older adult participants in this study, does not imply that a person will not face difficulty or distress during a crisis; indeed, the path to resilience will almost certainly include significant challenges in most aspects of their lives, including their physiological, sociocultural, psychological, developmental, and spiritual well-being.

• Spiritual well-being is important for crisis adaptation and coping in older persons as it can lead to a better quality of life at such times.

• In times of crisis (e.g., the COVID-19 pandemic), providers of direct care to older people, such as nurses, doctors, and other allied healthcare professionals, must always consider the individual’s overall well-being when providing care and assistance as it can promote resilience.

• Understanding and recognizing the holistic requirements of older people in times of crisis could help nurses and other healthcare providers to tailor their care to support the ability of their patients to adapt and cope with difficult circumstances.

• The sources of internal resilience and coping strategies of older adult participants in this study could have practical implications in promoting the well-being, integrity, and quality of life of this population, particularly during pandemics and community crises. This further suggests that legislators, community members, healthcare professionals, and advocates involved in the care of the older population should devise and implement community initiatives that support older people’s positive coping methods to increase their individual resiliency.

Acknowledgments

The authors acknowledge the support of their respective universities to increase research awareness among their faculty members. Further, we thank the participants of this study for sharing their rich experiences during the COVID-19 pandemic.

CONFLICT OF INTEREST

The researchers claim no conflicts of interest.

AUTHOR CONTRIBUTIONS

Conceptualization, JMS; Data curation, JMS, DRP, WS; Investigation, JMS; Methodology, JMS, DRP; Project administration, JMS; Supervision, JMS; Writing-original draft, JMS; Writing-review & editing, JMS, DRP, WS.

Science-Education-Research

Prof. Keith S. Taber's site

Instrumental case studies

A topic in research methodology

A case study is an enquiry into one specific instance among many . Sometimes the case is selected because it is the specific case we wish to know about. There is something special about that case that makes it worth investigating. Such cases are described as intrinsic cases. However, often a case is selected for study because it is considered to represent the wider class of possible cases. The case is an extrinsic case study , as we study it less for its own value, but for its value in telling us something about the wider class of such cases. This is potentially problematic, as case study recognises the idiosyncratic nature of cases and so a case study is not readily generalisable.

“The use of case study is to understand something else…instrumental to accomplishing something other than understanding this particular teacher [or…]” Stake, 1995: p.3

“Sometimes (instrumental) cases are chosen because they are considered reasonably typical of a class of instances, where the complexity of what is being studied suggests more can be learnt by detailed exploration of an instant than surveying a representative sample..” Taber, 2014

Sources cited:

• Stake, R. E. (1995). The Art of Case Study Research . Thousand Oaks, California: Sage.
• Taber, K. S. (2014). Methodological issues in science education research: a perspective from the philosophy of science. In M. R. Matthews (Ed.), International Handbook of Research in History, Philosophy and Science Teaching (Vol. 3, pp. 1839-1893). Dordrecht: Springer Netherlands.

My introduction to educational research:

Taber, K. S. (2013).  Classroom-based Research and Evidence-based Practice: An introduction (2nd ed.).  London: Sage.

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A Single-Case Instrumental Case Study

2. methodology: a qualitative case study of accountability practice, 2.6 a single-case instrumental case study.

The mode of enquiry selected for my study of NGO accountability is the qualitative case study and this section illustrates why. Yin (2009, p. 16) defines a case study as:

an empirical inquiry 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. Three features of this definition illustrate why I selected the case study as appropriate to my research question. Firstly, the emphasis on an empirical study of practice, which gaps in the literature demonstrate is required in the area of NGO accountability. Secondly, the focus on depth is important for my study. Depth is also mentioned by Casley and Lury (1981, p. 62) as the key strength of a case study. Given my contention, which I expand on in the next chapter, that most literature has not delved deeply into either the concepts or the practice of NGO accountability, an in-depth study is required, which allows room for the complexity of the issues to be explored. Finally, Yin’s emphasis on the importance of the context surrounding a case, a characteristic of case studies also raised by Stake (2005, p. 444), is highly relevant to my research question. For instance, considerations of power and authority of NGOs with respect to donors and beneficiaries are significant as is further discussed in the literature review chapter. The case study mode of enquiry allows me to delve into such issues which comprise part of the ‘context’ of a case. In his description of the actor-oriented approach, Long (2001, p. 155) provides a good summary of these points as he describes the importance of case studies for the study of complex social issues in practice: “Only detailed case studies can adequately identify and analyse the ways in which differences of value and interest are negotiated in the everyday practices of sustaining or transforming social networks.”

The main criticism of case study research that it is not generalisable, in that one case is not necessarily representative of a larger set of cases. Much of the literature

acknowledges this and cautions that this is an inherent feature of case studies (Flyvbjerg, 2006; Gerring, 2004; Stake, 2005). However, Burawoy (1991, p. 271) looks at the issue of broader learning from a single case from a different angle. He contrasts “generic” and “genetic” explanations: generic explanations are abstract “invariant laws”, whereas genetic explanations are “explanations of particular outcomes” which are grounded in a specific history and context. Burawoy notes:

In the generic mode, we seek out what different social situations have in common, and generalization is based on the likelihood that all similar situations have similar attributes. Here significance refers to statistical significance , generalization from a sample to a population. In the genetic mode the significance of a case relates to what it tells us about the world in which it is embedded. What must be true about the social context or historical past for our case to have assumed the character we have observed? Here significance refers to societal significance . The importance of a single case lies in the importance of what it tells us about society as a whole rather than about the population of similar cases. (pp. 280-281, emphasis in original)

Burawoy’s view resonates with my use of the actor-oriented sociology approach which stresses the importance of understanding historical and contextual particularities. In line with this perspective, while I aim to draw out wider implications and learning from my specific case findings that have implications for NGOs, the aid sector and accountability theory more broadly, I do not claim that my case study is representative of NGO accountability initiatives.

My aim to draw broader learning from one particular case led me to conduct an ‘instrumental’ case study. Stake (1995, p. 3) introduces the concept of an instrumental case study to be used in a situation in which the researcher has “a research question, a puzzlement, a need for general understanding, and feel that [they] may get insight into the question by studying a particular case.” Hence the case here is ‘instrumental’ in understanding something.

As the next section demonstrates, I studied an extreme or atypical case. Whyte (1984, p. 285) recommends searching for an atypical case: “At best, further research on ‘standard organizations’ would yield only theoretical and practical implications regarding how marginal improvements in performance might be achieved”. Similarly, Stake (2005, p. 451) makes the point that using ‘typical’ cases can be over-rated, as far

more can be learnt from an atypical case. As is illustrated in the next section, a key criterion for my case selection is that an organisation should have made significant efforts to transform its accountability systems. Since most organisations do not seem to have done this, as evidenced by the dearth of empirical studies in the literature, there would simply be a lack of data if a typical organisation were selected. Thus my selected case, while by no means the only organisation to have made efforts, has made more efforts than any other organisation that I know of, in this sense I view it as extreme.

• A Single-Case Instrumental Case Study (You are here)
• Embedded Case Study Design
• My Role as Researcher
• Relationship with Host Organisation
• Semi-Structured Interviews
• Theoretical Perspectives on Accountability
• How Is Accountability Being Practiced? Empirical Studies
• Why Does Disjuncture Persist?
• What Enables Disjuncture to Function?
• ActionAid International: Major Shifts in the Late-1990s
• External Authors
• Accountability in Crisis?
• What Happened with ALPS?
• Transparency Boards in Kenya
• Quality of Staff and Partners
• Prioritisation of Donor Requirements

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Open Access

Peer-reviewed

Research Article

The use and application of intensive care unit diaries: An instrumental multiple case study

Roles Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Writing – original draft

Affiliations Intensive Care Department, County Hospital, Region Kalmar County, Kalmar, Sweden, Department of Health and Caring Sciences, Linnaeus University, Kalmar, Sweden

Roles Conceptualization, Formal analysis, Funding acquisition, Investigation, Methodology, Resources, Supervision, Validation, Writing – review & editing

Affiliations Intensive Care Department, County Hospital, Region Kalmar County, Kalmar, Sweden, Department of Health and Caring Sciences, Linnaeus University, Kalmar, Sweden, Research Section, Region Kalmar County, Kalmar, Sweden

Roles Conceptualization, Formal analysis, Methodology, Supervision, Validation, Visualization, Writing – review & editing

Affiliations Department of Health and Caring Sciences, Linnaeus University, Kalmar, Sweden, Swedish Family Care Competence Centre, Kalmar, Sweden

Roles Conceptualization, Formal analysis, Methodology, Supervision, Validation, Writing – review & editing

* E-mail: [email protected]

• Maria Johansson, 
• Ingrid Wåhlin, 
• Lennart Magnusson, 
• Elizabeth Hanson

• Published: February 29, 2024
• https://doi.org/10.1371/journal.pone.0298538
• Reader Comments

Aims and objectives

The study aim was to explore the use of an Intensive Care Unit (ICU) diary within four different ICUs units in Sweden and thereby contribute to practice guidelines regarding the structure, content and use of an ICU diary.

ICU diaries are used to aid psychological recovery among critical care patients, but differences remain in diary writing both within and across countries. Few studies have focused on the combined views and experiences of ICU patients, family members and nursing staff about the use of ICU diaries.

An instrumental multiple case study design was employed.

Three focus groups interviews were carried out with 8 former patients and their family members (n = 5) from the research settings. Individual interviews were carried out with 2 patients, a family member and a nurse respectively. Observations, field notes, documentary analysis and conversations with nursing staff were also conducted. Consolidated criteria for reporting qualitative research (COREQ) was followed.

The qualitative findings firstly consisted of a matrix and descriptive text of the four ICU contexts and current practices. This highlighted that there were similarities regarding the aims and objectives of the diaries. However, differences existed across the case study sites about how the ICU diary was developed and implemented. Namely, the use of photographs and when to commence a diary. Second, a thematic analysis of the qualitative data regarding patients’ and family members’ use of the ICU diary, resulted in four themes: i) the diary was used to take in and fully understand the situation; ii) the diary was an opportunity to assimilate warm, personalised and human care; iii) the diary was used to manage existential issues; and iv) the diary was a tool in daily activities.

Conclusions

Analysis of the instrumental case study data led to the identification of core areas for inclusion in ICU diary practice guidelines.

Citation: Johansson M, Wåhlin I, Magnusson L, Hanson E (2024) The use and application of intensive care unit diaries: An instrumental multiple case study. PLoS ONE 19(2): e0298538. https://doi.org/10.1371/journal.pone.0298538

Editor: Sascha Köpke, University Hospital Cologne: Uniklinik Koln, GERMANY

Received: April 20, 2023; Accepted: January 25, 2024; Published: February 29, 2024

Copyright: © 2024 Johansson et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: Data cannot be shared publicly because of the risk of identifying individual study participants. Data requests may be sent to the head of research at Region Kalmar County, Professor Cecilia Fagerström: [email protected] .

Funding: The first author was partly financed for her PhD education of which this study forms a part by the Health Research Council of South East Sweden and Kalmar County Council. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript".

Competing interests: The authors have declared that no competing interests exist.

Introduction

Intensive Care Unit (ICU) diaries are increasingly being used in intensive and critical care nursing practice as an intervention that may facilitate the patient’s psychological recovery. Namely, by describing what happened to them in the ICU and about their health condition [ 1 – 3 ] with the aim of helping to put possible unpleasant memories into context [ 4 ]. The authoring of diaries may help both patients and family members process the critical illness experience during and after the time in the ICU [ 1 , 5 – 7 ] as well as support family members’ bereavement process when the patient does not survive [ 6 – 8 ]. Due to the COVID 19 pandemic, some ICUs opened up fewer diaries because of worries about infection control and due to excessive workload. In addition, visiting restrictions limited the use of diaries written by family members [ 9 ]. However, web-based solutions are under development and may in the future become a replacement for or supplement to hard copy diaries [ 10 ]. A hard copy diary is described as a handwritten booklet written in collaboration with nurses/staff members and family to the unconscious patient based on a chronology of clinical and social events that occurred during the ICU stay [ 6 ]).

Qualitative studies have highlighted how the written content in the diaries helped patients to realize what they had undergone, provided a sense of coherence and understanding after a critical illness [ 11 – 13 ] and acted as a support in the process of setting up realistic goals for recovery [ 7 , 11 , 14 ]. According to Backman & Walther [ 6 ] if photos are added, they might augment the information and help to make sense of the information provided, akin to a reality check. The diaries could also convey a feeling of humanised care despite being immersed in a technological environment [ 15 ].

Earlier quantitative studies have revealed how the diaries reduced the occurrence of patient post-traumatic stress, depression, and anxiety related to critical illness and critical care [ 16 , 17 ] as well as aid the wellbeing of their relatives [ 18 , 19 ] and improved patient health-related quality of life after a critical illness [ 20 ].Overall, the quantitative studies have been criticised due to small sample sizes and differences in the diary’s application [ 21 , 22 ]. Thus, it remains unclear as to the efficacy of ICU diaries in reducing PTSD, anxiety and depresession in patients and family members [ 9 ]. The majority of previous studies consist of mainly qualitative studies, which highlight that the diary helped to fill in the memory gap of the patients [ 6 , 7 , 23 ]. Also, the diaries assisted the patient when working through their ICU experiences [ 14 , 24 ] and at the same time provided individual or improved quality care [ 14 , 24 ]. Taken together, considerable diversities remain in diary writing both within and between countries which make it difficult to draw comparisons among the existing empirical studies. A major identified barrier regarding the use of ICU diaries for health care professionals is lack of dedicated time, which was further exacerbated during the COVID-19 pandemic [ 9 ]. A consensus exists on the need for guidelines to support diary writing for use in current critical care nursing practice [ 25 – 27 ]. In this regard, the international ICU diary network (established in 2012 by a group of ICU nurses as a non-profit organisation) acts as a vehicle to help with the implementation of ICU diaries via coordinating information, projects and new empirical studies for interested health care staff [ 28 ].

The overall aim is to explore the use of the ICU diary within four different ICU units in Sweden, and thereby contribute to practice guidelines regarding its structure, content and use.

The research questions were as follows:

• What are the current practices surrounding the use of a diary in the chosen ICU settings? What local guidelines exist (if any) and in what ways (if any) are they implemented in clinical practice?
• What strengths or positive aspects are identified by nursing staff, former patients, and family members of ICU patients with regards to current practices in the chosen research settings concerning the use of an ICU diary?
• Further, what are the challenges or drawbacks that are identified by nursing staff, former patients and family members of ICU patients with regards to current practices in the chosen research settings concerning the use of an ICU diary?
• What are the core areas for consideration arising from this multiple case study that can be taken up in future development work concerning national clinical practice guidelines on the use of the ICU diary?

An instrumental multiple case study design was adopted for the study. An instrumental case study enables a contemporary phenomenon to be investigated in-depth and in its real-world context–in this instance, the use of ICU diaries. Further, a multiple case study approach was chosen as it enabled the researchers to explore similarities and differences in the individuals’ experiences within cases and compare and contrast the experiences across cases [ 29 ]. A case study design provides opportunities to use multiple data sources to answer ‘how’ and ‘why’ questions- in this case, about ICU diary use, implementation and how to further develop the diary. The use of several data sources may also enhance data credibility to reach a holistic understanding of the phenomenon [ 29 , 30 ]. The use of evidence from multiple sources also means a kind of triangulation, where the findings have been supported by more than a single source of evidence [ 28 ]. This study followed Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups [ 31 ] (See S1 Table ).

Study setting

There are approximately 41070 admissions to 82 adult intensive care units in Sweden annually [ 32 ]. ICUs are situated in university, county and district hospitals. County and district hospitals have general ICUs. The ICUs in university hospitals may have a range of specialized ICUs, for example; burns ICU, neurosurgical ICU, medical ICU, surgery ICU and thoracic surgical ICU. The specialized ICUs serve other hospitals in their region when specialized care is required. The study took place in 2018 between March and October at four different Swedish ICUs (units A, B, C and D) in four ICU settings, equal to four cases where the ICU diary has been developed and implemented. Henceforth, ICU settings are called cases, which means everything associated with the settings, such as documents, observations, notes, routines, interviews, and study participants. One ICU setting was a university hospital, and three were county hospitals (See Table 1 ).

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https://doi.org/10.1371/journal.pone.0298538.t001

The included cases were purposively selected as they were representative of a diversity of care provision, context, and implementation practices of the ICU diary [ 29 ]. All participant hospitals were in the same geographical region of Sweden which covers an approximate radius of 170 km by 46954 km 2 , and they all formed part of a regional research collaborative initiative financed by the involved health care regions to stimulate closer cooperation concerning health care research. Nursing staff consisted of specialist critical care nurses with a bachelor level degree and assistant nurses. The staff-patient ratio at the time of the study was between 1.0 and 1.2. Medical staff consisted of 1–2 chief intensive care specialists and several junior physicians and at the units there were 1–2 head nurses of the department. There were no psychologists attached to the ICU units. Nurses, physicians, and nurse assistants provided psychological support to patients and their family members. ICU diaries have been used at the participating units for between 25–30 years.

Data collection

A protocol for conducting a multiple case study was established (See S2 Table ) in accordance with Yin’s (29). The protocol was a procedural guide for collecting data for a case, including a set of field questions to be addressed by the researcher (first author, MJ). The role of the protocol was also a standardised agenda for the researcher’s line of inquiry to increase reliability [ 29 ]. The data sources included observations, field notes, documents, informal, unstructured field interviews, a telephone interview, individual interviews, focus group interviews and a text message. A trusted external secretary with prior experience as a medical secretary transcribed the recordings.

Observations.

The first author (MJ) engaged in direct observations of selected cases for approximately 24–32 hours respectively in the ICUs (B, C, D). MJ was working clinically at that time in ICU A, and was subsequently familiar with the unit thus needed no assistance in collecting documents.

Field notes.

Field notes consisted of a continuous record of responses reported from the different units according to the study protocol. They were written by MJ both in the ICU but also directly after each observation period.

Collected documents included pamphlets related to the patient in critical care, documents about patient diary guidelines and informed consent forms about diary writing/photography.

Informal field interviews.

The field interviews took the form of spontaneous, informal conversations which described the nursing staff’s views and experiences of how the ICU diary was used within everyday nursing practice on their respective unit. These informal interviews were not audio-taped but rather written up in the form of field notes by the first author (MJ).

Individual interviews.

An interview was conducted with one patient and their family members recruited via telephone from the ICU follow-up programme at one of the ICU settings. The interview was based on the questions from the study protocol but reformulated into open-ended questions ( S2 Table ). Moreover, an interview with a nurse with experience of developing diary implementation in Sweden was carried out in the same way. The interviews were audio-taped with the participants’ permission, ranging from 60–70 minutes in duration and subsequently transcribed verbatim. These participants were originally invited to the focus group interviews but were prevented from attending for various reasons. Nevertheless, they wished to communicate their experience of using the diary. A telephone interview/conversation and a textual message from a former patient were also included in the data. Field notes were duly written directly after the telephone conversation had taken place.

Focus group interviews.

Three focus group interviews with a total of 8 patients and 5 family members at the participant hospitals were conducted to explore the use of an ICU diary in the respective care settings. The design of the ICU diary was developed in keeping with each unit’s guidelines and practices. The participants were only aware of the version they had received from their respective ICU. Nurses from the individual ICU follow-up programme recruited the participants via telephone. Information about the focus group sample is provided in S3 Table .

Patients had been discharged for a period of seven to fourteen months depending on their recovery process and were invited to bring family members with them to the focus group session. The inclusion criteria for patients and family members included; being a former ICU patient, having an ICU diary, being willing to share their experiences and aged 18 years or older.

In accordance with Krueger & Casey [ 33 ], open-ended questions were posed in order to allow for explanations, descriptions and illustrations relating to ICU diary writing and practices. Key questions included the following; how was it to read/write in the diary? When was the diary handed over? When were the photos handed over? What are your thoughts about the content in the diary? MJ moderated all focus group interviews. The second author (IW), a critical care nurse specialist with a PhD in caring sciences, operated as an assistant moderator and concluded the interview by briefly summarizing the main points and asked if the summary reflected what participants had experienced in the group [ 33 ]. Interviews were audiotaped, and were of 86–127 minutes in duration. The data were transcribed verbatim. Unstructured field notes were written by MJ directly after the interviews to document key remarks and reflections, such as something surprising and/or unexpected to MJ or how a group’s responses were similar to or different from earlier focus group sessions [ 33 ].

Data analysis

In keeping with Yin’s [ 29 ] recommendation with case study analysis work, the authors duly returned to the core research questions. To help answer the first research question, the extensive amount of practical information from the observational studies, documents and informal, and unstructured field interviews were systematised with the help of a matrix (see Table 2 below) developed from the study protocol (See S2 Table ) [ 29 ].

https://doi.org/10.1371/journal.pone.0298538.t002

Second, to answer the remaining research questions (2, 3 and 4), a thematic analysis, inspired by Braun and Clark [ 34 ], was conducted of the qualitative data from the focus group interviews, individual interviews, telephone interview, and textual message [ 34 ]. This approach was deemed suitable for identifying, reporting and interpreting patterns of meaning within the transcribed data. It was also chosen for being a flexible yet rigorous method for examining the perspectives of different research participants, highlighting similarities and differences and also generating unanticipated insights [ 34 ].

The analysis commenced with repeated reading to be familiar with all aspects of the data. Thereafter, a coding process began using highlighters and writing notes on the texts. Extracts that demonstrated each code were brought together in Word documents, one for each pattern. An extract might be uncoded, coded once, or coded many times as it was relevant. This way, all the codes with their extracts were organised in their document. The documents were organised into theme piles. In the final step of the analysis, core themes were developed that reflected patients’ and family members’ use of the ICU diary (See Fig 1 below).

https://doi.org/10.1371/journal.pone.0298538.g001

Ethical considerations

The study was conducted in compliance with the established ethical guidelines of the Declaration of Helsinki [ 35 ] and the Regional Ethical Committee in Linköping, Sweden provided formal ethical approval for the study (Dnr 2017/550-31). The clinical medical director at each of the respective units was informed about the study and approved the study. Potential focus group participants were recruited through the respective ICU’s follow-up services, and the hospital with the strategically optimal location was chosen for the interviews. Participants were financially compensated for their travel costs.

Information about the study was repeated verbally to participants prior to the start of the observation study and the interviews. Voluntary participation, informed consent, confidential treatment of all data and the right of participants to withdraw at any time without repercussion to their care or working situation (as appropriate) and appropriate storage of the qualitative data were all emphasised. Informed oral consent by the observation participants was witnessed by the first author and consisted of the participants verbally stating that they agreed to the first author observing activities and interactions involving the participant as part of her research study. Informed oral consent by the interview participants was also witnessed by the first author and consisted of the interview participants verbally agreeing to take part in an interview as part of the first author’s research study. Verbal consents were documented by the first author as part of her methodological field notes and as approved by the regional ethics committee. As the first author was working as a critical care nurse in ICU A, qualitative interviews were not carried out in this particular setting [ 36 ].

Table 2 below provides an overview matrix of the main similarities and differences regarding the structure, content, and ICU diary use within participating ICU settings arising from the systematized observational study, documentary and informal field interview data as outlined above. The matrix is supplemented with a written summary description of the four ICU contexts and main current practices drawn from the qualitative data. Core findings from a thematic analysis of the qualitative data are subsequently presented.

ICU contexts

It was self-evident by nursing staff in all ICUs to involve family members in writing/reading the diary without them feeling obliged to write. Family members might come and go around the clock at some units, but in others, staff agreed on their visiting times. ICU nursing staff had diverse experiences of diary writing from 10 to 23 years. Prepared diaries were readily available on the ICUs in a room intended for follow-up services.

Staff from the general ICUs’ follow-up services had regularly networked since 2012, together with another two ICUs in the region in order to exchange experiences about diary implementation and follow-up services. At that time, all participant ICUs had the same members in the follow-up services and in the diary group who prepared and were responsible for diary implementation.

Nursing staff at each ICU had established their own purpose statement in the absence of national guidelines on patient diaries. Diary writing had been realised as a spontaneous initiative by nursing staff, and the activity had advanced often through “learning by doing”. The assumption being that the patient needed to know and come to terms with what happened while they were in ICU. Also, family members needed help to also understand and process the patient’s stay.

Written guidelines were found in one ICU and comprised inclusion, exclusion criteria, writing style, informed consent, the process around photographing, and handover of the diaries. Another unit was developing written guidelines, but the other units had only oral guidelines about the structure, content, and use of the diary. Experienced nursing staff communicated informal guidelines to new employees and less experienced ICU nursing staff. The absence of clear, written guidelines meant that many patients did not receive a diary because of the hesitation in deciding which patients should get a diary and how to prioritise the process. The uncertainty was expressed as a cause of frustration among the participant nursing staff.

Diary structure.

The diary was an A5 notebook, lined, laminated cardboard folder, and spiral bounded or bound. Some ICU nursing staff had chosen a picture of a well-known sight from the town to act as the cover. Others had chosen colourful images such as flowers or trees. The ICU diaries’ format was open, only blank pages, handwritten, and without any editing (that is, there was no one responsible who approved the diary before it was handed over to the patient). On the initial page/s, the diary included dedication to the patient and the patient’s name.

Next, diaries usually contained a summary and a reason for the patient’s admission to ICU and daily entries. The summary and closing framed the diary’s story about the time in ICU. There was also a glossary, and in three of four ICUs, generic photos on the most common ICU medical equipment.

Diary content

All diaries contained a page called ‘Who am I? What is important for me?’ The page asked for the patient’s sleep habits, favourite sports, favourite food and drinks, music, and philosophy on life which family members were requested to complete. The diaries in some ICUs comprised the 24-hour circle in the ICU with an associated timeframe. This information highlighted that the activities varied around the clock and explained that somebody was always nearby the patient. Next followed the narratives of daily activities with and around the critically ill patient, which formed a central part of the diary. The narratives contained information about medical treatment, daily care of the patient, information about progression, such as mobilising out of bed, conversely how the patient’s condition had deteriorated, and that the patient was approaching death.

Other entries were psychosocial, which expressed and confirmed the presence of the family members at the bedside. Family members added information about what happened at home or greetings from other family members. Entries included reflections around the weather, seasons, Swedish festivals, sports events together with entries of a more personal nature. Staff members who wrote the entry included the whole team, dated, and signed the note. A unique contribution from staff at one ICU was a poem at the end of the diary intended to provide a respectful content if diary entries were sparse.

Use of the diary

All units kept the diaries at the patient’s bedside so that nursing staff and family members could write whenever they wanted to. The diary was seen as the patient’s property and was not deemed to be part of the patient’s medical records. Written or oral guidelines stated that a diary should be offered to the patient when they were expected to be cared for >72 hours or for those who ‘needed’ it. In one ICU, there was an ambition to open up a diary to all patients admitted to the ICU, especially patients cared for following a cardiac arrest, which meant a shorter care stay than three days. Care of patients with cardiac arrests denoted heavy sedation, ventilation and connection to a range of cannulas and tubes for about 24–36 hours and then awoken. In general, this group were deemed to benefit from a diary.

The nursing staff did not open an ICU diary for patients with severe brain injuries, and dementia, poor prognosis nor for patients who did not speak/understand Swedish. Often, some nursing staff commenced a diary immediately when a patient was admitted to ICU, but sometimes days elapsed, and the diary writing did not take place. Reason/s for the delay included lack of time or difficulties to start the diary as the summary was deemed to be the most essential and extensive aspect. In some units, assistant nurses frequently opened a diary as they had more time to initiate the process than the registered nurses.

Two ICUs kept registers about patients who had a diary. This included a checklist with the patient’s name and informed consent given by family members to photograph the patient. The checklist was stored in a diary file in the staff room and accessed by nursing staff who belonged to the diary group. Other ICUs asked family members for informed consent orally in conjunction with information about the diary without any written documentation. The consensus was that the photographing was a part of the treatment and therefore did not necessitate permission from the patient or family members, thereby facilitating the prompt starting of a diary and with photographs. However, the patient was required to give retrospective consent once they were sufficiently well enough to receive the diary.

Use of photographs

All staff from the four ICUs used photos to augment the written content. Nursing staff were aware of the photos’ supportive role and that the patients frequently requested more pictures. Usually, the first photographs were taken when the patient was fully sedated, ventilated, and linked to a range of tubes and cannulas. Subsequent photos were taken on significant events and progressions during the ICU stay. Typically, the patient was photographed at a distance so as not to expose the patient at an inappropriate angle.

However, nursing staff at one ICU meant that the pictures should be realistic, and nursing staff should go close to the patient when photographing because the patient needed to recognise themself. The photos should assist as a ‘reality check’ when setting goals for recovery.

Three ICUs used a digital camera with memory, where nursing staff might print out the photograph straightaway and then delete the original from the memory card. The fourth ICU moved and stored the pictures in image management on a desktop. At one ICU, the pictures were pasted in the diary immediately, close to the written text, so that text and image interacted. Sometimes, photos were collected in an envelope at the back of the diary.

Another ICU used mounted the photos directly in their context in the diary but left the other side empty. This made it possible for the patient to remove the picture but without destroying any existing text.

In contrast, two ICUs did not include the photos directly in the diaries. The rationale being that the patient needed a ‘face to face’ meeting with ICU nursing staff and an explanation of the photos to fully understand the pictures and be allowed to ask any questions. Otherwise, they feared that the patient might be frightened or re-traumatised if no explanations was given. Another reason for the personal meeting was to obtain retrospective consent for the pictures. If the patient refused the photos, they were destroyed.

Handover process

The diary followed the patient by the nursing staff placing the diary at the end of the bed or giving it to family members on transfer to the general ward. Diary group/follow-up service staff visited the patient at the ward when they were transferred from the ICU. During this visit, the photographs were discussed in those cases they were not included in the diary. If the patient wanted the photos at that time, they were handed over. Otherwise, the pictures were discussed at the follow-up service later and then handed over. Patients who did not attend any follow up service received their photos by mail at home, if they requested them.Family members where the patient did not survive, received a telephone call about 6–8 weeks after the patient’ death and were invited to the follow-up service to discuss the patient’s stay at the ICU.

Thematic analysis findings

Four interconnected themes were derived from the qualitative thematic analysis that reflected patients’ and family members’ use of the ICU diary. The themes are represented in the following sections and highlighted in Fig 1 below. Participants are cited using the number of the focus group and P (atient), S (pouse) number identifier.

The diary was used to take in and fully understand the situation.

The chronology in the diary and the everyday language were understood as valuable characteristics because family members expressed feeling unsure about specific dates and events during their family member’s ICU stay. Even in the diary, patients and family members sometimes had difficulty distinguishing specific dates. A positive aspect of the ICU diary highlighted by participants was the ability to read and re-read the information to assimilate it.

That you can go and look in the diary a little now and then and think about it ( I/S1)

Patients and family members requested ongoing summaries in the diary, as the information was sometimes perceived to be insufficient or irregularly provided, especially during more extended periods of stay. The diary was mainly experienced as a tool to help process the time in ICU by describing what daily life looked like, which was not included in the medical records.

Patients described dreams, nightmares and unreal experiences that caused long-standing problems post-ICU discharge despite a few other more positive memories. This meant that patients and family members had different experiences of events which sometimes led to misunderstandings among families. However, patients expressed missing entries with sufficient personal details which described confused thoughts they had expressed and what the thoughts were about, so they might orientate themselves. Patients expressed a need to know that these confused thoughts were often of a frequent occurrence.

The nursing staff explained to my wife and children–but nothing in the diary , about the confused thoughts . They said it calmly , and that he’s going to recognize you . ( II/P3) .

All patients and family members emphasized how important the summary was, which told the story prior to admission and why the ICU admission had taken place. Despite this, patients and their family members experienced that critical and life-threatening episodes were sometimes neglected, and they wanted more realistic adjectives to be used such as “deadly condition” and “hovering between life and death” to understand how critically ill the patient was. Another drawback relating to missing information was the setting’s description with its sounds, sights, machines and bed. In other words, former patients wanted to have events clarified, which were known to be the source of nightmares, distorted thoughts and hallucinations; as an example, the ICU bed was often experienced as a container, boat or a railway truck. The ICU diary became a way of summarizing and making countless details visible in a single concrete picture. It was considered as a reliable document against which to check their personal memories of their ICU stay.

The diary is fantastic; without it , I would not have known anything . The wife has a hard time reading the diary . The children also find it difficult . ( I/P2) .

The photographs were expressed by patients as being personal and they offered them a window into the past to fully understand their history. All insisted that it was important that photos were tightly connected to the written texts. Some had received photos in bulk (in envelopes) connected with the follow-up services, to insert them independently in the diary.

I had a need to get a whole of the ICU stay . I got loose pictures that I could not put into context ( telephone interview)

In general, patients wanted realistic photographs without embellishments because they wanted to know their actual health status in order to set realistic rehabilitation goals. They also requested close-ups to be able to recognize themselves, otherwise, they argued that it could be anyone in the photo. Patients with realistic pictures of themselves with all the equipment, expressed that it did not feel so scary anymore.

Yes , but then that’s not pleasant , you see it’s me , but further away , then it wouldn’t have been easy to see that it was me ( II/P2) .

The diary was an opportunity to assimilate the warmth, personalized and human care.

Patients and family members found the diary to be personally touching. They explained that naming the patient in each entry gave identity and a personal touch to the diary. They found an unexpected kindness in the staff’s diary writing which deeply moved them. The diary was thoughtful and often well-written with warmth that patients expressed that they would carry with them for life.

They (nursing staff) really showed from the bottom of their hearts that they liked me , that I’m important ( II/P2) .

The diary bore traces of the authors’ varying ability to express themselves, which participant patients and family members appreciated. Family members felt that the nursing staff was there for them all the time, even if it was for the patient’s sake. The diary testified that the patient was cared for with respect and not as an object. For family members, the diary was considered a symbol of human care and hope in situations where the outcome for the patient was uncertain during the ICU stay.

We can read in the diary . ‘We see a slight improvement’ . This little word is so important ( I/S2)

Some former patients proudly read descriptions such as “the ward’s trump card”, “the ward’s sunshine story”, which further underscored the personalized caring and how sick the patient had been and survived the trauma. Others read about how the nursing staff washed the hair of unconscious patients, helped with the first shower, provided offers of TV watching and fulfilled requests for particular drinks.

I think it’s nice to read . Today you have sat on the edge of the bed , and it’s the nursing staff who wrote . They (nursing staff) care so much about one . It warms . ( I P3) .

Patients emphasized the importance of the family members’ notes. However, many family members admitted that they could not write in the diary themselves. They expressed that they were too sad and worried, but they experienced it was good to read the nursing staff’s entries as they found it to be sign of hope among all the sorrow. Patients felt that family members had been well-taken care of. Patients and family members expressed that the support and empathy that they could make out in the diary acted as a long-standing form of support for them.

The diary was used to manage existential issues.

Spiritual issues about the meaning of life emerged for patients experiencing a life-threatening illness, especially when the trauma was lived through and vividly described in the diary. Some of the patients had experienced a near death experience on a visit related to cardiac arrest and asked themselves. Why did I get sick? Why did I survive? The patients might go back and look in the diary from time to time and tend to ask themselves the same existential questions. Patients admitted that it was often serious issues that were raised and that were difficult to share with “outsiders”. Patients and family members believed that one must have been there to fully understand. The pictures in the diary might explain the problematic situation and the ever-present threat of death. They explained that the diary “sharpened the mind”, to pay intention to how fragile life could be and how quickly it could change.

However , it was strange to me; why did I get this disease . I kept thinking , why did I have a cardiac arrest ? For twenty years I haven´t had anything , but suddenly I got it ( II/P2) .

Family members admitted that it caused a disturbance in the family, when a member was ill with a life-threatening illness but that the family was brought together by reading the diary. Some patients noted that they found it challenging yet exciting to read what they had been through in the diary and experienced gratitude that they were alive and believed that life was now too short to dwell on existential issues. Patients admitted that they were not afraid of the future and felt that the experience had empowered them in a way as they now appreciated life even more. Even for family members, existential issues could deeply touch them as illustrated by the following quotation.

Mum , where do you have the diary ? So , she can crawl away for herself , so she is 27 , and then I see how a few tears fall , and then she comes and holds me , says mother , I’m so glad you’re here ( II/P3) .

The diary was used as a tool in daily activities.

Family members described the diary as a tool for information and communication during the ICU stay. To access, understand and take in the medical information. They found the diary glossary to be useful as it often explained the use of medical terms, which eased conversations with nursing staff and provided a feeling of being included. Family members described the diary as available when needed and that they used the diary as a company, comfort and sometimes as an intimate friend at the ICU.

It was great to not just sit alone in the waiting room spending time and biting nails . It was great to have a diary available ( III/S1) .

The diary was viewed by family members as something to keep them occupied with instead of constantly following the monitoring screens and as a way of overcoming uncertainty. Family admitted that they wrote not only for the sick person but also for their own sake to unload their personal worries and thoughts.

On discharge home from hospital, participants explained that the diary became a basis for the patient to ask questions. The diary also became a support for family members to be able to account for the course of events. The diary was perceived as a reliable document about the time spent in ICU. Pictures of family members showed that they had been there during the critical illness.

All visits are listed here . I think it is vital that all the sons are in the pictures and not just S and I ( I/S2) .

However, the diary could evoke unpleasant memories for some patients, which caused the diary to be set aside.

I experienced the diary as a bit silly initially , but now I can get hurt by it when I look at it; the trauma remains and gets even more challenging . (I/P2)

A participant former patient had used the pictures in the diary as proof of how ill they had been in their effort to convince persons in authority. Others had let family members and friends read the diary themselves, as they had not been able to tell and re-tell their story.

The aim of the study was to explore the use of the ICU diary within four different ICUs units in Sweden and thereby contribute to practice guidelines regarding its structure, content and use. The practice recommendations arising from the study findings can be summarised into three areas, namely the need for guidelines, guidelines outlining the content of the diary, and how the diary making process reflected the approach of person-centred care. Each will be considered in turn. This is followed by a discussion of the study’s main methodological considerations.

The need for practical guidelines

The study revealed that it was left to the discretion of the nurse caring for the patient if a diary was opened up. The rather haphazard selection of patients for keeping a diary has previously been demonstrated in Scandinavian surveys 1 [ 4 , 24 ]. National guidelines could act as a support for priority setting and to provide guidance as to whom and when to open up an ICU diary. A common standard would make it possible to follow up on the diary as a caring intervention continuously and systematically. National guidelines may pay attention to the diary making process and so increase awareness among nursing staff that the diary can act as a useful debriefing tool and as a help in reorientation for the patients [ 1 , 2 , 17 , 23 ].

Based on the study findings, family members’ roles in the ICU setting are important to highlight in the national guidelines, including the promotion and support of their active participation in the writing, including the start-up of the diary. It is known from previous studies that family members benefit from the diary [ 5 – 7 ] and that the diary may also act as bereavement support if the patient should die [ 8 ].

In the current study, patients with severe critical illness, (little chance of survival), dementia, and people with learning disabilities were automatically excluded. Therefore, guidelines need to outline that the diary may also benefit family members and then the green light is given to commence a diary to broader groups of patients. Further, it is regarded as a human right to be provided equal treatment as a Swedish inhabitant, and this approach would also include patients with other languages [ 37 ]. The diary may be translated in some way and/or compiled with more pictures and generic pictures.

The study highlighted that guidelines need to be flexible, only stating certain main principles and being considered for every person admitted to the ICU. Further, it showed how practical knowledge sustained the writing as patient categories cared for shorter periods than three days were included. An example is patients having had a cardiac arrest, who were deemed to need follow-up support as this group of patients tended to develop both cognitive and emotional difficulties [ 38 ].

Guidelines outlining the content of the diary

The study revealed that patients and their families requested relevant, realistic content with close-up pictures in the diary because they wanted to know the main details to gain a better understanding of the patient’s illness and what happened to them during their ICU stay. The findings were contradictory to those of the nursing staff, in keeping with a previous study that demonstrated how the staff weighed every word to avoid harming the patient in any way [ 39 ]. It has been previously noted how nursing staff experienced diary writing as “complicated in its simplicity”, due to difficulties finding “the right words” in writing and at the same time providing comfort and confidence that patients and family members needed both during and post the ICU stay [ 40 ]. Further, it was noted that pictures were often taken at a distance and avoided being taken of a patient with a swollen face, which is in line with previous findings [ 14 , 26 ]. This poses the question of whether nursing staff are overly cautious with regards to diary content to avoid causing the patient any potential offence or distress. In addition to the diary content.

The process of photographing highlighted the main differences between the four cases and were related to local legal and ethical considerations. Previous research highlighted that photography caused additional considerations and units removed pictures in the diaries that were taken without prior consent and that could potentially impinge on patient privacy [ 12 , 14 ]. On the other hand, patients who were provided photographs appreciated them and wanted additional ones [ 41 ]. Previous studies have demonstrated the value of pictures noting that photographs added realism and neutralized frightening fantasies [ 42 ] and that the diary with its text and photos can be seen to be important to induce post-experience reflections [ 43 ].

How the diary making process reflected the approach of person-centred care

The participant family members in the study underscored how they were naturally offered to participate actively in care by reading/writing in the diary. In this way, they experienced themselves as valuable and equal partners. Writing the diaries was about doing an intervention with patients and their families in partnership rather than ‘to’ them. Family members highlighted the personality of the critically ill patient, and together with the nursing staff, they helped to meet the patient’s needs for information and support. Writing a personal diary is in line with current healthcare policy concerning people-centred care, which means putting patients and their families at the centre of decisions and working alongside them to secure the best possible outcome [ 44 ]. Establishing a partnership in the ICU was challenging because the patient was not awake and unable to tell their life story. However, the diary and the page with questions ‘Who am I? What is important to me? were created to understand the patient as a human being with physical, psychological, and existential needs. This information was often captured from family members and used to tailor conversation topics, activities and motivational features in daily nursing care. Likewise, the diary itself may be regarded as documentation of a piece of life that would otherwise have been unknown to the patient.

Patients expressed feeling cared for when they read a diary written primarily for them as the diaries were dedicated to the patient. The writing helped to maintain a feeling of togetherness among the family members and nursing staff, which has been expressed in previous studies [ 8 , 45 , 46 ]. The belief that diaries are a caring activity was coined by Roulin, Hurst & Spirig [ 47 ] as writers from different backgrounds took part in an everyday activity for the patient’s benefit. A personal diary with personal photographs also demonstrates that the nursing staff has been willing to go that extra mile for the patient [ 12 ]. Diary writing also created a caring relationship between the patient, family members and nursing staff [ 48 ].

Methodological considerations

The study was carried out by using a qualitative multiple case study methodology, where the study protocol acted as a guide helping the first author in carrying out the data collection from a single case as one of several in the multiple-case study approach [ 29 ]. It can also be seen as a way of increasing the reliability of the case study research and a possibility to replicate findings across cases. Multiple methods of data collection, for example, the combination of focus groups, the individual interviews and notes from observational studies were used to identify similar, different, or complementary views and experiences across the different participant groups. The approach allowed for methodological triangulation and increased the likelihood that findings were credible [ 29 , 30 ].

Limitations.

A study limitation is that the four ICU settings were located in one geographical area of Sweden so that the degree of transferability of the findings to other settings can be questioned. Nevertheless, the study likely reflects the different use of ICU diaries in Sweden. Further, it can be argued that the findings are applicable to other ICU settings with similar publicly financed health care systems. The study can be considered as a first step in a longer-term research and practice development work towards national guidelines regarding the use of the ICU diary.

The first author (MJ) was an ICU nurse at one of the participating clinics, so it could be argued that she potentially lacked objectivity and was biased in her data collection and analysis activities due to her insider knowledge of ICU A [ 36 ]. Nevertheless, MJ kept detailed field notes which included reflections of her researcher role in the settings which were duly discussed on a regular basis with her doctoral supervisors. Also, it can be argued that MJ’s insider knowledge was an advantage as she was familiar with the ICU context so that she was also able to ask relevant questions and was able to have an in-depth understanding of participants’ responses and actions.

Based on the findings it can be argued that clinical practice guidelines concerning ICU diaries would help to ensure their wider and more consistent use for all ICU patients, as opposed to a more selective groups of ICU patients. Second, they would help to make the role of family members more transparent and valued. Finally, they would provide concrete guidance to nursing staff about how best to write in the ICU diary to ensure relevant, real-world content bringing the human element and aiding with genuine person-centered care.

Relevance to clinical practice

The findings are intended to act as an impetus for future practice development work concerning ICU diary guidelines in ICU settings in other health care regions in Sweden and internationally in countries with a similar health care system to that of Sweden. The aim being to help facilitate and promote nursing staff’s everyday clinical practices concerning ICU diary writing in keeping with a person-centred approach.

Supporting information

S1 table. consolidated criteria for reporting qualitative research (coreq): a 32-item checklist for interviews and focus groups..

https://doi.org/10.1371/journal.pone.0298538.s001

S2 Table. Study protocol for instrumental multiple case study.

https://doi.org/10.1371/journal.pone.0298538.s002

S3 Table. Description of focus group interview participants.

https://doi.org/10.1371/journal.pone.0298538.s003

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