Author information Article notes Copyright and License information Disclaimer. Corresponding author. Sarah Crowe: ku. mahgnitton eworc. haras ; Kathrin Cresswell: ku. de reyeb. nirhtak ; Ann Robertson: ku. de nostrebor. a ; Guro Huby: ku. de ybuh. orug ; Anthony Avery: ku. mahgnitton yreva. ynot ; Aziz Sheikh: ku. de hkiehs. Received Nov 29; Accepted Jun Copyright © Crowe et al; licensee BioMed Central Ltd. Abstract The case study approach allows in-depth, multi-faceted explorations of complex issues in their real-life settings. 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. Table 1 Example of a case study investigating the reasons for differences in recruitment rates of minority ethnic people in asthma research[ 3 ].

Context: Minority ethnic people experience considerably greater morbidity from asthma than the White majority population. Research has shown however that these minority ethnic populations are likely to be under-represented in research undertaken in the UK; there is comparatively less marginalisation in the US. Objective: To investigate approaches to bolster recruitment of South Asians into UK asthma studies through qualitative research with US and UK researchers, and UK community leaders. Study design: Single intrinsic case study The case: Centred on the issue of recruitment of South Asian people with asthma. Data collection: In-depth interviews were conducted with asthma researchers from the UK and US. A supplementary questionnaire was also provided to researchers. Analysis: Framework approach.

The attitudes of the researchers' towards inclusion: The majority of UK researchers interviewed were generally supportive of the idea of recruiting ethnically diverse participants but expressed major concerns about the practicalities of achieving this; in contrast, the US researchers appeared much more committed to the policy of inclusion. Stereotypes and prejudices: We found that some of the UK researchers' perceptions of ethnic minorities may have influenced their decisions on whether to approach individuals from particular ethnic groups. These stereotypes centred on issues to do with, amongst others, language barriers and lack of altruism. Demographic, political and socioeconomic contexts of the two countries: Researchers suggested that the demographic profile of ethnic minorities, their political engagement and the different configuration of the health services in the UK and the US may have contributed to differential rates.

Open in a separate window. Table 2 Example of a case study investigating the process of planning and implementing a service in Primary Care Organisations[ 4 ]. Context: Health work forces globally are needing to reorganise and reconfigure in order to meet the challenges posed by the increased numbers of people living with long-term conditions in an efficient and sustainable manner. Through studying the introduction of General Practitioners with a Special Interest in respiratory disorders, this study aimed to provide insights into this important issue by focusing on community respiratory service development.

Objective: To understand and compare the process of workforce change in respiratory services and the impact on patient experience specifically in relation to the role of general practitioners with special interests in a theoretically selected sample of Primary Care Organisations PCOs , in order to derive models of good practice in planning and the implementation of a broad range of workforce issues. Study design: Multiple-case design of respiratory services in health regions in England and Wales. The cases: Four PCOs. Data collection: Face-to-face and telephone interviews, e-mail discussions, local documents, patient diaries, news items identified from local and national websites, national workshop. Analysis: Reading, coding and comparison progressed iteratively.

In the screening phase of this study which involved semi-structured telephone interviews with the person responsible for driving the reconfiguration of respiratory services in 30 PCOs , the barriers of financial deficit, organisational uncertainty, disengaged clinicians and contradictory policies proved insurmountable for many PCOs to developing sustainable services. A key rationale for PCO re-organisation in was to strengthen their commissioning function and those of clinicians through Practice-Based Commissioning. However, the turbulence, which surrounded reorganisation was found to have the opposite desired effect. Implementing workforce reconfiguration was strongly influenced by the negotiation and contest among local clinicians and managers about "ownership" of work and income.

Despite the intention to make the commissioning system more transparent, personal relationships based on common professional interests, past work history, friendships and collegiality, remained as key drivers for sustainable innovation in service development. This work was conducted in the early stages of a major NHS reorganisation in England and Wales and thus, events are likely to have continued to evolve beyond the study period; we therefore cannot claim to have seen any of the stories through to their conclusion. Table 3 Example of a case study investigating the introduction of the electronic health records[ 5 ]. Context: Healthcare systems globally are moving from paper-based record systems to electronic health record systems.

In , the NHS in England embarked on the most ambitious and expensive IT-based transformation in healthcare in history seeking to introduce electronic health records into all hospitals in England by Objectives: To describe and evaluate the implementation and adoption of detailed electronic health records in secondary care in England and thereby provide formative feedback for local and national rollout of the NHS Care Records Service. Study design: A mixed methods, longitudinal, multi-site, socio-technical collective case study. The cases: Five NHS acute hospital and mental health Trusts that have been the focus of early implementation efforts. Data collection: Semi-structured interviews, documentary data and field notes, observations and quantitative data. Analysis: Qualitative data were analysed thematically using a socio-technical coding matrix, combined with additional themes that emerged from the data.

Hospital electronic health record systems have developed and been implemented far more slowly than was originally envisioned. The top-down, government-led standardised approach needed to evolve to admit more variation and greater local choice for hospitals in order to support local service delivery. A range of adverse consequences were associated with the centrally negotiated contracts, which excluded the hospitals in question. The unrealistic, politically driven, timeline implementation over 10 years was found to be a major source of frustration for developers, implementers and healthcare managers and professionals alike.

Main limitations: We were unable to access details of the contracts between government departments and the Local Service Providers responsible for delivering and implementing the software systems. This, in turn, made it difficult to develop a holistic understanding of some key issues impacting on the overall slow roll-out of the NHS Care Record Service. Early adopters may also have differed in important ways from NHS hospitals that planned to join the National Programme for Information Technology and implement the NHS Care Records Service at a later point in time. Table 4 Example of a case study investigating the formal and informal ways students learn about patient safety[ 6 ]. Context: There is a need to reduce the disease burden associated with iatrogenic harm and considering that healthcare education represents perhaps the most sustained patient safety initiative ever undertaken, it is important to develop a better appreciation of the ways in which undergraduate and newly qualified professionals receive and make sense of the education they receive.

Objectives: To investigate the formal and informal ways pre-registration students from a range of healthcare professions medicine, nursing, physiotherapy and pharmacy learn about patient safety in order to become safe practitioners. Study design: Multi-site, mixed method collective case study. The cases : Eight case studies two for each professional group were carried out in educational provider sites considering different programmes, practice environments and models of teaching and learning. Data collection and analysis: Structured in phases relevant to the three knowledge contexts: Phase 1: Academic context Documentary evidence including undergraduate curricula, handbooks and module outlines , complemented with a range of views from course leads, tutors and students and observations in a range of academic settings.

Phase 2a: Organisational context Policy and management views of patient safety and influences on patient safety education and practice. NHS policies included, for example, implementation of the National Patient Safety Agency's Seven Steps to Patient Safety , which encourages organisations to develop an organisational safety culture in which staff members feel comfortable identifying dangers and reporting hazards. Phase 2b: Practice context The cultures to which students are exposed i. patient safety in relation to day-to-day working.

NHS initiatives included, for example, a hand washing initiative or introduction of infection control measures. Practical, informal, learning opportunities were valued by students. On the whole, however, students were not exposed to nor engaged with important NHS initiatives such as risk management activities and incident reporting schemes. NHS policy appeared to have been taken seriously by course leaders. Patient safety materials were incorporated into both formal and informal curricula, albeit largely implicit rather than explicit. Resource issues and peer pressure were found to influence safe practice.

Variations were also found to exist in students' experiences and the quality of the supervision available. Main limitations: The curriculum and organisational documents collected differed between sites, which possibly reflected gatekeeper influences at each site. The recruitment of participants for focus group discussions proved difficult, so interviews or paired discussions were used as a substitute. Discussion What is a case study? Table 5 Definitions of a case study. Author Definition Stake[ 8 ] "A case study is both the process of learning about the case and the product of our learning" p.

a phenomenon of some sort occurring in a bounded context" p. an instance of a class of events [where] the term class of events refers to a phenomenon of scientific interest that the investigator chooses to study with the aim of developing theory regarding causes of similarities or differences among instances cases of that class of events" p. Table 6 Example of epistemological approaches that may be used in case study research. Approach Characteristics Criticisms Key references Critical Involves questioning one's own assumptions taking into account the wider political and social environment. It can possibly neglect other factors by focussing only on power relationships and may give the researcher a position that is too privileged. Howcroft and Trauth[ 30 ] Blakie[ 31 ] Doolin[ 11 , 32 ] Interprets the limiting conditions in relation to power and control that are thought to influence behaviour.

Focus is on theory building. Often difficult to explain unintended consequences and for neglecting surrounding historical contexts Stake[ 8 ] Doolin[ 11 ] Positivist Involves establishing which variables one wishes to study in advance and seeing whether they fit in with the findings. Focus is often on testing and refining theory on the basis of case study findings. It does not take into account the role of the researcher in influencing findings. Yin[ 1 , 27 , 28 ] Shanks and Parr[ 34 ]. 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 ].

Table 7 Example of a checklist for rating a case study proposal[ 8 ]. Communication Clarity: Does the proposal read well? Integrity: Do its pieces fit together? Attractiveness: Does it pique the reader's interest? Content The case: Is the case adequately defined? The issues: Are major research questions identified? Data Resource: Are sufficient data sources identified? Method Case Selection: Is the selection plan reasonable? Data Gathering: Are data-gathering activities outlined? Validation: Is the need and opportunity for triangulation indicated? Practicality Access: Are arrangements for start-up anticipated?

Confidentiality: Is there sensitivity to the protection of people? Cost: Are time and resource estimates reasonable? Selecting the case s The decision on how to select the case s to study is a very important one that merits some reflection. 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. 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.

Table 8 Potential pitfalls and mitigating actions when undertaking case study research. Table 9 Stake's checklist for assessing the quality of a case study report[ 8 ]. Is this report easy to read? Does it fit together, each sentence contributing to the whole? Does this report have a conceptual structure i. themes or issues? Are its issues developed in a series and scholarly way? Is the case adequately defined? Is there a sense of story to the presentation? Is the reader provided some vicarious experience? In some cases, case studies are also used to evaluate programs or interventions.

Exploratory case studies are conducted when little is known about a phenomenon. They are used to generate hypotheses and gather preliminary data. Descriptive case studies describe a phenomenon in detail. They are used to develop an understanding of a complex issue. Explanatory case studies explain why or how something happens. They are used to test theories and identify cause-and-effect relationships. Interviews are perhaps the most common type of data collection in case studies. Observations can also be useful in case studies, particularly if the researcher is interested in studying how people interact with their environment.

Calculate Price. Case study methodology. Advantages and Disadvantages of Case Study Methodology in Research for Your Dissertation Are you a student of social science with a dissertation due and are searching for a research methodology for the investigative process? Then why not use the case study methodology. The research methodology case study may be somewhat controversial as far as data collection methods are concerned but are widely used if your research concerns an in-depth explanation of social behavior which makes case studies methodology a perfect technique for social science students. Type the above number:.

The new PMC design is here! Learn more about navigating our updated article layout. The PMC legacy view will also be available for a limited time. Federal government websites often end in. gov or. The site is secure. 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. 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? Example of a case study investigating the reasons for differences in recruitment rates of minority ethnic people in asthma research[ 3 ]. Example of a case study investigating the process of planning and implementing a service in Primary Care Organisations[ 4 ]. Example of a case study investigating the introduction of the electronic health records[ 5 ]. Example of a case study investigating the formal and informal ways students learn about patient safety[ 6 ]. 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.

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. 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 ]. 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. 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. 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 ]. 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. 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. 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 ]. Example of a checklist for rating a case study proposal[ 8 ]. 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.

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. 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.

In another example of an intrinsic case study, Hellstrom et al. 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. Choosing a "typical" case may enable the findings to be generalised to theory i. analytical generalisation or to test theory by replicating the findings in a second or even a third case i. replication logic [ 1 ]. Yin suggests two or three literal replications i. 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. 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. 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. 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. questionnaires, audits and analysis of routinely collected healthcare data and more commonly qualitative techniques e.

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. the extent to which the method is appropriate to answer the research question [ 8 , 18 - 21 ]. 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. the nature of different cancer care programmes , before considering the emerging similarities and differences in cross-case comparisons e. 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. 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.

Example of a case study investigating the reasons for differences in recruitment rates of minority ethnic people in asthma research[ 3 ]. Info Systems J. Data collection is used to evaluate propositions or hypotheses related to an existing theory. 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. Masters vs PhD — Differences Explained.

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