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Collective Case Study: Making Qualitative Data More Impactful

To begin, the researcher must first understand case study design. Case study is defined as an examination of a confined or bounded system or unit, in context, involving both an in-depth examination and analysis in order to examine, reveal, or better understand a phenomenon, or a social or cultural issue (Creswell, 2013; Merriam & Tisdell, 2016; Putney, 2010; Stake, 1995; Yin, 2006). A case typically consists of an examination of one individual, organization, process, event, role, (sub)culture, encounter, period of time, or program (Miles, et al., 2020; Yin, 2006). Case studies can be either instrumental or intrinsic, and determining which type the researcher intends to use is an important step early on in the study design process. Instrumental cases are referred to when the case being examined is considered instrumental to comprehending not only that specific case, but something larger than itself (Putney, 2010; Stake, 1995). Intrinsic cases, in comparison, are used when there is an intrinsic interest in a particular case, not to learn about something that allows for generalization, but rather because of what the particular case has to offer in and of itself (Putney, 2010; Stake, 1995). Regardless of whether the case study is instrumental or intrinsic, the examination of a single case, bound in time and context, is the focus for this particular study design. There are significantly more elements to consider, in terms of design, when considering case study. For more information about case study design, the researcher may consult both Putney (2010) and Yin (2018).

Key Terms in this Chapter

Multiple Case Study : Explores a multiple bounded system involving multiple sources of information or relies on several instrumental, bounded cases to provide more extensive descriptions and explanations of a phenomenon or issue using varied data collection strategies to understand case similarities and differences to generalize conclusions over several units of analyses.

Case : A single bounded system or unit that is the investigational focus for a case study.

Data Management : The systematic organization of data into sets to assist meaning-making and prepare for analysis.

Data Collection : The process of gathering information in a systematic, organized, unbiased way.

Collective Case Study : Explores individual cases to provide detail and explanation regarding a situation, phenomenon, or experience where individual studies provides information into the “why” or “how,” and provides elaborative data through comparing cases cross-wise that allows for a more expansive understanding of the issue.

Case Study : An examination of a confined or bounded system or unit, in context, involving both an in-depth examination and analysis to examine, reveal, or better understand a phenomenon, or a social or cultural issue.

Results : The researcher’s systematic interpretation of the data in relation to the research question(s), making sense of the findings and providing contextual answers to the posited questions.

Findings : The identification of patterns and systematic recording of what the data sets display, prior to the researcher interpreting to determine results.

Data Analysis : The process of breaking down units into individual pieces for comparative and contrasting analysis, seeking intersection between pieces to identify patterns, and examining outliers to best understand how the pieces work in aggregate to explain the whole.

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The Collective Case Study Design: Comparing Six Research to Practice Case Studies

• First Online: 08 September 2016

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• Christine Grima-Farrell 2 , 3  

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Methodological terminology can sometimes be seen as a foreign language to those who are expected to be informed consumers of researchers. This chapter describes the methodological structure used in this research in detail with the aim of providing clarity around research decisions and protocols. It refutes any notions of teachers being perceived as objects of research or reform to teachers being change agents who are pivotal to inclusive education and the successful outcomes of students.

The fundamentals and critical features of empirical case study research design are featured through this chapter. The three distinct phases that comprise this study and are used as the operational pathway are also defined and described. The first phase of the research, the exploration phase, sought reports from teachers’ on the factors that contributed to the success or failure of the research projects they were implemting in their classrooms. This data was collected prior to teachers being introduced to the information derived from the literature.

The second phase of this study was the explanation phase. During this phase teacher participants were introduced to a 75 factor research to practice survey and a semi structured interview, based on the RTP knowledge gained from the analysis of five bodies of literature. Teachers responded to whether these factors were identified in their cases using a numerical (1–5) Likert scale. They also presented written responses to open-ended questions about other RTP factors that significantly contributed to the status of their projects at various stages of implementation.

The final data collection stage, the expansion phase, consisted of an opportunity for all teachers to contribute to a focus group discussion. Three Figures and Tables are presented to provide a visual overview of the phased research questions and the knowledge, experiences and trajectories reported by teachers as they progressed through the stages of implementing, monitoring and evaluating a range of validated research projects.

This chapter:

Describes the methodology implemented thoughout this investigation and highlights the importance of comprehending and analysing the specific detail critical to research rigour.

Defines case study research, the different types of case study and related approaches that were used to inform the well considered design decisions.

Presents a definition of comparative case studies with related strengths and limitations.

Introduces Yin’s (1994) complex case study design and Fraenkel and Wallen’s (2006) description of the features of comparative case study.

Explains how replication logic is utilised as an approach that ensures consistency in implementation.

Describes data collection methods, analysis and validity techniques employed to address the research questions.

Presents the specific procedures used in the context of the study describing, participant researcher bias, participant details, setting, research design, data collection and analysis processes.

Highlights the importance of reading and comprehending the methodological decisions as well as focussing on the elements essential to practical applications.

Outlines how important the methodological decisions are to the validity of the research and how they are at the core of this chapter.

Presents key components of comparative case study analysis for future use in national and international RTP investigations.

Specifics related to the methods and research instruments are presented in detail to provide a scaffold for professionals who may wish to use this methodological approach (or elements from it) to embark upon their own case study research journey.

• Focus Group
• Data Collection Method
• Expansion Phase
• Case Study Research
• Data Collection Tool

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Grima-Farrell, C. (2017). The Collective Case Study Design: Comparing Six Research to Practice Case Studies. In: What Matters in a Research to Practice Cycle?. Springer, Singapore. https://doi.org/10.1007/978-981-10-2087-2_3

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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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• Keleher H, Murphy C. Understanding Health: A Determinants Approach . Oxford University Press; 2004.
• Yazan B. Three approaches to case study methods in education: Yin, Merriam, and Stake. The Qualitative Report . 2015;20(2):134-152. doi:10.46743/2160-3715/2015.2102
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• Nayback-Beebe AM, Yoder LH. The lived experiences of a male survivor of intimate partner violence: a qualitative case study. Medsurg Nurs . 2012;21(2):89-95; quiz 96.
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Qualitative Research – a practical guide for health and social care researchers and practitioners Copyright © 2023 by Darshini Ayton is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License , except where otherwise noted.

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Encyclopedia of Case Study Research

• Edited by: Albert J. Mills , Gabrielle Durepos & Elden Wiebe
• Publisher: SAGE Publications, Inc.
• Publication year: 2010
• Online pub date: December 27, 2012
• Discipline: Anthropology
• Methods: Case study research
• DOI: https:// doi. org/10.4135/9781412957397
• Print ISBN: 9781412956703
• Online ISBN: 9781412957397
• Buy the book icon link

Reader's guide

Entries a-z, subject index.

Case study research has a long history within the natural sciences, social sciences, and humanities, dating back to the early 1920's. At first it was a useful way for researchers to make valid inferences from events outside the laboratory in ways consistent with the rigorous practices of investigation inside the lab. Over time, case study approaches garnered interest in multiple disciplines as scholars studied phenomena in context. Despite widespread use, case study research has received little attention among the literature on research strategies.

The Encyclopedia of Case Study Research provides a compendium on the important methodological issues in conducting case study research and explores both the strengths and weaknesses of different paradigmatic approaches. These two volumes focus on the distinctive characteristics of case study research and its place within and alongside other research methodologies.

Key Features

Presents a definition of case study research that can be used in different fields of study; Describes case study as a research strategy rather than as a single tool for decision making and inquiry; Guides rather than dictates, readers understanding and applications of case study research; Includes a critical summary in each entry, which raises additional matters for reflection; Makes case study relevant to researchers at various stages of their careers, across philosophic divides, and throughout diverse disciplines

Academic Disciplines; Case Study Research Design; Conceptual Issues; Data Analysis; Data Collection; Methodological Approaches; Theoretical Traditions; Theory Development and Contributions

From Case Study Research

Types of Case Study Research

Front Matter

• Editorial Board
• List of Entries
• Reader's Guide
• About the Editors
• Contributors
• Introduction

Reader’s Guide

Back matter.

• Selected Bibliography: Case Study Publications by Contributing Authors
• Case Study Research in Anthropology
• Before-and-After Case Study Design
• Action-Based Data Collection
• Activity Theory
• Case Study and Theoretical Science
• Analytic Generalization
• ANTi-History
• Case Study Research in Business and Management
• Blended Research Design
• Bayesian Inference and Boolean Logic
• Analysis of Visual Data
• Actor-Network Theory
• Chicago School
• Case Study as a Teaching Tool
• Case Study Research in Business Ethics
• Bounding the Case
• Authenticity and Bad Faith
• Anonymity and Confidentiality
• Colonialism
• Authenticity
• Case Study in Creativity Research
• Case Study Research in Education
• Case Selection
• Author Intentionality
• Case-to-Case Synthesis
• Anonymizing Data for Secondary Use
• Autoethnography
• Constructivism
• Concatenated Theory
• Case Study Research in Tourism
• Case Study Research in Feminism
• Causal Case Study: Explanatory Theories
• Archival Records as Evidence
• Base and Superstructure
• Critical Realism
• Conceptual Argument
• Case Study With the Elderly
• Case Study Research in Medicine
• Case Within a Case
• Contentious Issues in Case Study Research
• Chronological Order
• Audiovisual Recording
• Case Study as a Methodological Approach
• Critical Theory
• Conceptual Model: Causal Model
• Collective Case Study
• Case Study Research in Political Science
• Comparative Case Study
• Cultural Sensitivity and Case Study
• Coding: Axial Coding
• Autobiography
• Dialectical Materialism
• Conceptual Model: Operationalization
• Configurative-Ideographic Case Study
• Case Study Research in Psychology
• Critical Incident Case Study
• Dissertation Proposal
• Coding: Open Coding
• Case Study Database
• Class Analysis
• Epistemology
• Conceptual Model in a Qualitative Research Project
• Critical Pedagogy and Digital Technology
• Case Study Research in Public Policy
• Cross-Sectional Design
• Ecological Perspectives
• Coding: Selective Coding
• Case Study Protocol
• Existentialism
• Conceptual Model in a Quantitative Research Project
• Diagnostic Case Study Research
• Decision Making Under Uncertainty
• Cognitive Biases
• Case Study Surveys
• Codifying Social Practices
• Contribution, Theoretical
• Explanatory Case Study
• Deductive-Nomological Model of Explanation
• Masculinity and Femininity
• Cognitive Mapping
• Consent, Obtaining Participant
• Communicative Action
• Formative Context
• Credibility
• Exploratory Case Study
• Deviant Case Analysis
• Objectivism
• Communicative Framing Analysis
• Contextualization
• Community of Practice
• Frame Analysis
• Docile Bodies
• Inductivism
• Discursive Frame
• Comparing the Case Study With Other Methodologies
• Historical Materialism
• Equifinality
• Institutional Ethnography
• Healthcare Practice Guidelines
• Computer-Based Analysis of Qualitative Data: ATLAS.ti
• Consciousness Raising
• Interpretivism
• Instrumental Case Study
• Pedagogy and Case Study
• Pluralism and Case Study
• Computer-Based Analysis of Qualitative Data: CAITA (Computer-Assisted Interpretive Textual Analysis)
• Data Resources
• Contradiction
• Liberal Feminism
• Explanation Building
• Intercultural Performance
• Event-Driven Research
• Computer-Based Analysis of Qualitative Data: Kwalitan
• Depth of Data
• Critical Discourse Analysis
• Managerialism
• Extension of Theory
• Intrinsic Case Study
• Exemplary Case Design
• Power/Knowledge
• Computer-Based Analysis of Qualitative Data: MAXQDA 2007
• Diaries and Journals
• Critical Sensemaking
• Falsification
• Limited-Depth Case Study
• Extended Case Method
• Computer-Based Analysis of Qualitative Data: NVIVO
• Direct Observation as Evidence
• North American Case Research Association
• Functionalism
• Multimedia Case Studies
• Extreme Cases
• Researcher as Research Tool
• Concept Mapping
• Discourse Analysis
• Decentering Texts
• Generalizability
• Participatory Action Research
• Congruence Analysis
• Documentation as Evidence
• Deconstruction
• Paradigm Plurality in Case Study Research
• Genericization
• Participatory Case Study
• Holistic Designs
• Utilitarianism
• Constant Causal Effects Assumption
• Ethnostatistics
• Dialogic Inquiry
• Philosophy of Science
• Indeterminacy
• Content Analysis
• Fiction Analysis
• Discourse Ethics
• Indexicality
• Pracademics
• Integrating Independent Case Studies
• Conversation Analysis
• Field Notes
• Double Hermeneutic
• Postcolonialism
• Processual Case Research
• Cross-Case Synthesis and Analysis
• Postmodernism
• Macrolevel Social Mechanisms
• Program Evaluation and Case Study
• Longitudinal Research
• Going Native
• Ethnographic Memoir
• Postpositivism
• Middle-Range Theory
• Program-Logic Model
• Mental Framework
• Document Analysis
• Informant Bias
• Ethnography
• Poststructuralism
• Naturalistic Generalization
• Prospective Case Study
• Mixed Methods in Case Study Research
• Factor Analysis
• Ethnomethodology
• Poststructuralist Feminism
• Overdetermination
• Real-Time Cases
• Most Different Systems Design
• Eurocentrism
• Radical Empiricism
• Plausibility
• Retrospective Case Study
• High-Quality Analysis
• Iterative Nodes
• Radical Feminism
• Probabilistic Explanation
• Re-Use of Qualitative Data
• Multiple-Case Designs
• Language and Cultural Barriers
• Process Tracing
• Single-Case Designs
• Multi-Site Case Study
• Interactive Methodology, Feminist
• Multiple Sources of Evidence
• Scientific Method
• Spiral Case Study
• Naturalistic Inquiry
• Interpreting Results
• Narrative Analysis
• Front Stage and Back Stage
• Scientific Realism
• Reporting Case Study Research
• Storyselling
• Natural Science Model
• Socialist Feminism
• Rhetoric in Research Reporting
• Number of Cases
• Naturalistic Context
• Symbolic Interactionism
• Statistical Generalization
• Outcome-Driven Research
• Knowledge Production
• Nonparticipant Observation
• Governmentality
• Substantive Theory
• Paradigmatic Cases
• Method of Agreement
• Objectivity
• Grounded Theory
• Theory-Building With Cases
• Method of Difference
• Over-Rapport
• Hermeneutics
• Theory-Testing With Cases
• Multicollinearity
• Participant Observation
• Underdetermination
• Multidimensional Scaling
• Imperialism
• Polar Types
• Institutional Theory, Old and New
• Problem Formulation
• Pattern Matching
• Personality Tests
• Intertextuality
• Quantitative Single-Case Research Design
• Re-Analysis of Previous Data
• Isomorphism
• Quasi-Experimental Design
• Regulating Group Mind
• Questionnaires
• Langue and Parôle
• Quick Start to Case Study Research
• Relational Analysis
• Reflexivity
• Layered Nature of Texts
• Random Assignment
• Replication
• Life History
• Research Framework
• Reliability
• Logocentrism
• Research Objectives
• Rival Explanations
• Repeated Observations
• Management of Impressions
• Research Proposals
• Secondary Data as Primary
• Researcher-Participant Relationship
• Means of Production
• Research Questions, Types of Retrospective Case Study
• Serendipity Pattern
• Situational Analysis
• Sensitizing Concepts
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• Subjectivism
• Multimethod Research Program
• Socially Distributed Knowledge
• Statistical Analysis
• Subject Rights
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• Statistics, Use of in Case Study
• Temporal Bracketing
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• Negotiated Order
• Textual Analysis
• Use of Digital Data
• Network Analysis
• Thematic Analysis
• Utilization
• One-Dimensional Culture
• Visual Research Methods
• Ordinary Troubles
• Theory, Role of
• Organizational Culture
• Webs of Significance
• Within-Case Analysis
• Performativity
• Phenomenology
• Practice-Oriented Research
• Primitivism
• Qualitative Analysis in Case Study
• Qualitative Comparative Analysis
• Self-Confrontation Method
• Self-Presentation
• Sensemaking
• Signifier and Signified
• Sign System
• Social-Interaction Theory
• Storytelling
• Structuration
• Symbolic Value
• Symbolic Violence
• Thick Description
• Writing and Difference

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Types of Case Studies

There are several different types of case studies, as well as several types of subjects of case studies. We will investigate each type in this article.

Different Types of Case Studies

There are several types of case studies, each differing from each other based on the hypothesis and/or thesis to be proved. It is also possible for types of case studies to overlap each other.

Each of the following types of cases can be used in any field or discipline. Whether it is psychology, business or the arts, the type of case study can apply to any field.

Explanatory

The explanatory case study focuses on an explanation for a question or a phenomenon. Basically put, an explanatory case study is 1 + 1 = 2. The results are not up for interpretation.

A case study with a person or group would not be explanatory, as with humans, there will always be variables. There are always small variances that cannot be explained.

However, event case studies can be explanatory. For example, let's say a certain automobile has a series of crashes that are caused by faulty brakes. All of the crashes are a result of brakes not being effective on icy roads.

What kind of case study is explanatory? Think of an example of an explanatory case study that could be done today

When developing the case study, the researcher will explain the crash, and the detailed causes of the brake failure. They will investigate what actions caused the brakes to fail, and what actions could have been taken to prevent the failure.

Other car companies could then use this case study to better understand what makes brakes fail. When designing safer products, looking to past failures is an excellent way to ensure similar mistakes are not made.

The same can be said for other safety issues in cars. There was a time when cars did not have seatbelts. The process to get seatbelts required in all cars started with a case study! The same can be said about airbags and collapsible steering columns. They all began with a case study that lead to larger research, and eventual change.

Exploratory

An exploratory case study is usually the precursor to a formal, large-scale research project. The case study's goal is to prove that further investigation is necessary.

For example, an exploratory case study could be done on veterans coming home from active combat. Researchers are aware that these vets have PTSD, and are aware that the actions of war are what cause PTSD. Beyond that, they do not know if certain wartime activities are more likely to contribute to PTSD than others.

For an exploratory case study, the researcher could develop a study that certain war events are more likely to cause PTSD. Once that is demonstrated, a large-scale research project could be done to determine which events are most likely to cause PTSD.

Exploratory case studies are very popular in psychology and the social sciences. Psychologists are always looking for better ways to treat their patients, and exploratory studies allow them to research new ideas or theories.

Multiple-Case Studies or Collective Studies

Multiple case or collective studies use information from different studies to formulate the case for a new study. The use of past studies allows additional information without needing to spend more time and money on additional studies.

Using the PTSD issue again is an excellent example of a collective study. When studying what contributes most to wartime PTSD, a researcher could use case studies from different war. For instance, studies about PTSD in WW2 vets, Persian Gulf War vets, and Vietnam vets could provide an excellent sampling of which wartime activities are most likely to cause PTSD.

If a multiple case study on vets was done with vets from the Vietnam War, the Persian Gulf War, and the Iraq War, and it was determined the vets from Vietnam had much less PTSD, what could be inferred?

Furthermore, this type of study could uncover differences as well. For example, a researcher might find that veterans who serve in the Middle East are more likely to suffer a certain type of ailment. Or perhaps, that veterans who served with large platoons were more likely to suffer from PTSD than veterans who served in smaller platoons.

An intrinsic case study is the study of a case wherein the subject itself is the primary interest. The "Genie" case is an example of this. The study wasn't so much about psychology, but about Genie herself, and how her experiences shaped who she was.

Genie is the topic. Genie is what the researchers are interested in, and what their readers will be most interested in. When the researchers started the study, they didn't know what they would find.

They asked the question…"If a child is never introduced to language during the crucial first years of life, can they acquire language skills when they are older?" When they met Genie, they didn't know the answer to that question.

Instrumental

An instrumental case study uses a case to gain insights into a phenomenon. For example, a researcher interested in child obesity rates might set up a study with middle school students and an exercise program. In this case, the children and the exercise program are not the focus. The focus is learning the relationship between children and exercise, and why certain children become obese.

What is an example of an instrumental case study?

Focus on the results, not the topic!

Types of Subjects of Case Studies

There are generally five different types of case studies, and the subjects that they address. Every case study, whether explanatory or exploratory, or intrinsic or instrumental, fits into one of these five groups. These are:

Person – This type of study focuses on one particular individual. This case study would use several types of research to determine an outcome.

The best example of a person case is the "Genie" case study. Again, "Genie" was a 13-year-old girl who was discovered by social services in Los Angeles in 1970. Her father believed her to be mentally retarded, and therefore locked her in a room without any kind of stimulation. She was never nourished or cared for in any way. If she made a noise, she was beaten.

When "Genie" was discovered, child development specialists wanted to learn as much as possible about how her experiences contributed to her physical, emotional and mental health. They also wanted to learn about her language skills. She had no form of language when she was found, she only grunted. The study would determine whether or not she could learn language skills at the age of 13.

Since Genie was placed in a children's hospital, many different clinicians could observe her. In addition, researchers were able to interview the few people who did have contact with Genie and would be able to gather whatever background information was available.

This case study is still one of the most valuable in all of child development. Since it would be impossible to conduct this type of research with a healthy child, the information garnered from Genie's case is invaluable.

Group – This type of study focuses on a group of people. This could be a family, a group or friends, or even coworkers.

An example of this type of case study would be the uncontacted tribes of Indians in the Peruvian and Brazilian rainforest. These tribes have never had any modern contact. Therefore, there is a great interest to study them.

Scientists would be interested in just about every facet of their lives. How do they cook, how do they make clothing, how do they make tools and weapons. Also, doing psychological and emotional research would be interesting. However, because so few of these tribes exist, no one is contacting them for research. For now, all research is done observationally.

If a researcher wanted to study uncontacted Indian tribes, and could only observe the subjects, what type of observations should be made?

Location – This type of study focuses on a place, and how and why people use the place.

For example, many case studies have been done about Siberia, and the people who live there. Siberia is a cold and barren place in northern Russia, and it is considered the most difficult place to live in the world. Studying the location, and it's weather and people can help other people learn how to live with extreme weather and isolation.

Location studies can also be done on locations that are facing some kind of change. For example, a case study could be done on Alaska, and whether the state is seeing the effects of climate change.

Another type of study that could be done in Alaska is how the environment changes as population increases. Geographers and those interested in population growth often do these case studies.

Organization/Company – This type of study focuses on a business or an organization. This could include the people who work for the company, or an event that occurred at the organization.

An excellent example of this type of case study is Enron. Enron was one of the largest energy company's in the United States, when it was discovered that executives at the company were fraudulently reporting the company's accounting numbers.

Once the fraud was uncovered, investigators discovered willful and systematic corruption that caused the collapse of Enron, as well as their financial auditors, Arthur Andersen. The fraud was so severe that the top executives of the company were sentenced to prison.

This type of case study is used by accountants, auditors, financiers, as well as business students, in order to learn how such a large company could get away with committing such a serious case of corporate fraud for as long as they did. It can also be looked at from a psychological standpoint, as it is interesting to learn why the executives took the large risks that they took.

Most company or organization case studies are done for business purposes. In fact, in many business schools, such as Harvard Business School, students learn by the case method, which is the study of case studies. They learn how to solve business problems by studying the cases of businesses that either survived the same problem, or one that didn't survive the problem.

Event – This type of study focuses on an event, whether cultural or societal, and how it affects those that are affected by it. An example would be the Tylenol cyanide scandal. This event affected Johnson & Johnson, the parent company, as well as the public at large.

The case study would detail the events of the scandal, and more specifically, what management at Johnson & Johnson did to correct the problem. To this day, when a company experiences a large public relations scandal, they look to the Tylenol case study to learn how they managed to survive the scandal.

A very popular topic for case studies was the events of September 11 th . There were studies in almost all of the different types of research studies.

Obviously the event itself was a very popular topic. It was important to learn what lead up to the event, and how best to proven it from happening in the future. These studies are not only important to the U.S. government, but to other governments hoping to prevent terrorism in their countries.

Planning A Case Study

You have decided that you want to research and write a case study. Now what? In this section you will learn how to plan and organize a research case study.

Selecting a Case

The first step is to choose the subject, topic or case. You will want to choose a topic that is interesting to you, and a topic that would be of interest to your potential audience. Ideally you have a passion for the topic, as then you will better understand the issues surrounding the topic, and which resources would be most successful in the study.

You also must choose a topic that would be of interest to a large number of people. You want your case study to reach as large an audience as possible, and a topic that is of interest to just a few people will not have a very large reach. One of the goals of a case study is to reach as many people as possible.

Who is your audience?

Are you trying to reach the layperson? Or are you trying to reach other professionals in your field? Your audience will help determine the topic you choose.

If you are writing a case study that is looking for ways to lower rates of child obesity, who is your audience?

If you are writing a psychology case study, you must consider whether your audience will have the intellectual skills to understand the information in the case. Does your audience know the vocabulary of psychology? Do they understand the processes and structure of the field?

You want your audience to have as much general knowledge as possible. When it comes time to write the case study, you may have to spend some time defining and explaining terms that might be unfamiliar to the audience.

Lastly, when selecting a topic you do not want to choose a topic that is very old. Current topics are always the most interesting, so if your topic is more than 5-10 years old, you might want to consider a newer topic. If you choose an older topic, you must ask yourself what new and valuable information do you bring to the older topic, and is it relevant and necessary.

Determine Research Goals

What type of case study do you plan to do?

An illustrative case study will examine an unfamiliar case in order to help others understand it. For example, a case study of a veteran with PTSD can be used to help new therapists better understand what veterans experience.

An exploratory case study is a preliminary project that will be the precursor to a larger study in the future. For example, a case study could be done challenging the efficacy of different therapy methods for vets with PTSD. Once the study is complete, a larger study could be done on whichever method was most effective.

A critical instance case focuses on a unique case that doesn't have a predetermined purpose. For example, a vet with an incredibly severe case of PTSD could be studied to find ways to treat his condition.

Ethics are a large part of the case study process, and most case studies require ethical approval. This approval usually comes from the institution or department the researcher works for. Many universities and research institutions have ethics oversight departments. They will require you to prove that you will not harm your study subjects or participants.

This should be done even if the case study is on an older subject. Sometimes publishing new studies can cause harm to the original participants. Regardless of your personal feelings, it is essential the project is brought to the ethics department to ensure your project can proceed safely.

Developing the Case Study

Once you have your topic, it is time to start planning and developing the study. This process will be different depending on what type of case study you are planning to do. For thissection, we will assume a psychological case study, as most case studies are based on the psychological model.

Once you have the topic, it is time to ask yourself some questions. What question do you want to answer with the study?

For example, a researcher is considering a case study about PTSD in veterans. The topic is PTSD in veterans. What questions could be asked?

Do veterans from Middle Eastern wars suffer greater instances of PTSD?

Do younger soldiers have higher instances of PTSD?

Does the length of the tour effect the severity of PTSD?

Each of these questions is a viable question, and finding the answers, or the possible answers, would be helpful for both psychologists and veterans who suffer from PTSD.

Research Notebook

1. What is the background of the case study? Who requested the study to be done and why? What industry is the study in, and where will the study take place?

2. What is the problem that needs a solution? What is the situation, and what are the risks?

3. What questions are required to analyze the problem? What questions might the reader of the study have? What questions might colleagues have?

4. What tools are required to analyze the problem? Is data analysis necessary?

5. What is your current knowledge about the problem or situation? How much background information do you need to procure? How will you obtain this background info?

6. What other information do you need to know to successfully complete the study?

7. How do you plan to present the report? Will it be a simple written report, or will you add PowerPoint presentations or images or videos? When is the report due? Are you giving yourself enough time to complete the project?

The research notebook is the heart of the study. Other organizational methods can be utilized, such as Microsoft Excel, but a physical notebook should always be kept as well.

Planning the Research

The most important parts of the case study are:

1. The case study's questions

2. The study's propositions

3. How information and data will be analyzed

4. The logic behind the propositions

5. How the findings will be interpreted

The study's questions should be either a "how" or "why" question, and their definition is the researchers first job. These questions will help determine the study's goals.

Not every case study has a proposition. If you are doing an exploratory study, you will not have propositions. Instead, you will have a stated purpose, which will determine whether your study is successful, or not.

How the information will be analyzed will depend on what the topic is. This would vary depending on whether it was a person, group, or organization.

When setting up your research, you will want to follow case study protocol. The protocol should have the following sections:

1. An overview of the case study, including the objectives, topic and issues.

2. Procedures for gathering information and conducting interviews.

3. Questions that will be asked during interviews and data collection.

4. A guide for the final case study report.

When deciding upon which research methods to use, these are the most important:

1. Documents and archival records

2. Interviews

3. Direct observations

4. Indirect observations, or observations of subjects

5. Physical artifacts and tools

Documents could include almost anything, including letters, memos, newspaper articles, Internet articles, other case studies, or any other document germane to the study.

Archival records can include military and service records, company or business records, survey data or census information.

Research Strategy

Before beginning the study you want a clear research strategy. Your best chance at success will be if you use an outline that describes how you will gather your data and how you will answer your research questions.

The researcher should create a list with four or five bullet points that need answers. Consider the approaches for these questions, and the different perspectives you could take.

The researcher should then choose at least two data sources (ideally more). These sources could include interviews, Internet research, and fieldwork or report collection. The more data sources used, the better the quality of the final data.

The researcher then must formulate interview questions that will result in detailed and in-depth answers that will help meet the research goals. A list of 15-20 questions is a good start, but these can and will change as the process flows.

Planning Interviews

The interview process is one of the most important parts of the case study process. But before this can begin, it is imperative the researcher gets informed consent from the subjects.

The process of informed consent means the subject understands their role in the study, and that their story will be used in the case study. You will want to have each subject complete a consent form.

The researcher must explain what the study is trying to achieve, and how their contribution will help the study. If necessary, assure the subject that their information will remain private if requested, and they do not need to use their real name if they are not comfortable with that. Pseudonyms are commonly used in case studies.

Informed Consent

The process by which permission is granted before beginning medical or psychological research

A fictitious name used to hide ones identity

It is important the researcher is clear regarding the expectations of the study participation. For example, are they comfortable on camera? Do they mind if their photo is used in the final written study.

Interviews are one of the most important sources of information for case studies. There are several types of interviews. They are:

Open-ended – This type of interview has the interviewer and subject talking to each other about the subject. The interviewer asks questions, and the subject answers them. But the subject can elaborate and add information whenever they see fit.

A researcher might meet with a subject multiple times, and use the open-ended method. This can be a great way to gain insight into events. However, the researcher mustn't rely solely on the information from the one subject, and be sure to have multiple sources.

Focused – This type of interview is used when the subject is interviewed for a short period of time, and answers a set of questions. This type of interview could be used to verify information learned in an open-ended interview with another subject. Focused interviews are normally done to confirm information, not to gain new information.

Structured – Structured interviews are similar to surveys. These are usually used when collecting data for large groups, like neighborhoods. The questions are decided before hand, and the expected answers are usually simple.

When conducting interviews, the answers are obviously important. But just as important are the observations that can be made. This is one of the reasons in-person interviews are preferable over phone interviews, or Internet or mail surveys.

Ideally, when conducing in-person interviews, more than one researcher should be present. This allows one researcher to focus on observing while the other is interviewing. This is particularly important when interviewing large groups of people.

The researcher must understand going into the case study that the information gained from the interviews might not be valuable. It is possible that once the interviews are completed, the information gained is not relevant.

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What Is a Case Study?

Weighing the pros and cons of this method of research

Kendra Cherry, MS, is a psychosocial rehabilitation specialist, psychology educator, and author of the "Everything Psychology Book."

Cara Lustik is a fact-checker and copywriter.

Verywell / Colleen Tighe

• Pros and Cons

What Types of Case Studies Are Out There?

Where do you find data for a case study, how do i write a psychology case study.

A case study is an in-depth study of one person, group, or event. In a case study, nearly every aspect of the subject's life and history is analyzed to seek patterns and causes of behavior. Case studies can be used in many different fields, including psychology, medicine, education, anthropology, political science, and social work.

The point of a case study is to learn as much as possible about an individual or group so that the information can be generalized to many others. Unfortunately, case studies tend to be highly subjective, and it is sometimes difficult to generalize results to a larger population.

While case studies focus on a single individual or group, they follow a format similar to other types of psychology writing. If you are writing a case study, we got you—here are some rules of APA format to reference.  

At a Glance

A case study, or an in-depth study of a person, group, or event, can be a useful research tool when used wisely. In many cases, case studies are best used in situations where it would be difficult or impossible for you to conduct an experiment. They are helpful for looking at unique situations and allow researchers to gather a lot of˜ information about a specific individual or group of people. However, it's important to be cautious of any bias we draw from them as they are highly subjective.

What Are the Benefits and Limitations of Case Studies?

A case study can have its strengths and weaknesses. Researchers must consider these pros and cons before deciding if this type of study is appropriate for their needs.

One of the greatest advantages of a case study is that it allows researchers to investigate things that are often difficult or impossible to replicate in a lab. Some other benefits of a case study:

• Allows researchers to capture information on the 'how,' 'what,' and 'why,' of something that's implemented
• Gives researchers the chance to collect information on why one strategy might be chosen over another
• Permits researchers to develop hypotheses that can be explored in experimental research

On the other hand, a case study can have some drawbacks:

• It cannot necessarily be generalized to the larger population
• Cannot demonstrate cause and effect
• It may not be scientifically rigorous
• It can lead to bias

Researchers may choose to perform a case study if they want to explore a unique or recently discovered phenomenon. Through their insights, researchers develop additional ideas and study questions that might be explored in future studies.

It's important to remember that the insights from case studies cannot be used to determine cause-and-effect relationships between variables. However, case studies may be used to develop hypotheses that can then be addressed in experimental research.

Case Study Examples

There have been a number of notable case studies in the history of psychology. Much of  Freud's work and theories were developed through individual case studies. Some great examples of case studies in psychology include:

• Anna O : Anna O. was a pseudonym of a woman named Bertha Pappenheim, a patient of a physician named Josef Breuer. While she was never a patient of Freud's, Freud and Breuer discussed her case extensively. The woman was experiencing symptoms of a condition that was then known as hysteria and found that talking about her problems helped relieve her symptoms. Her case played an important part in the development of talk therapy as an approach to mental health treatment.
• Phineas Gage : Phineas Gage was a railroad employee who experienced a terrible accident in which an explosion sent a metal rod through his skull, damaging important portions of his brain. Gage recovered from his accident but was left with serious changes in both personality and behavior.
• Genie : Genie was a young girl subjected to horrific abuse and isolation. The case study of Genie allowed researchers to study whether language learning was possible, even after missing critical periods for language development. Her case also served as an example of how scientific research may interfere with treatment and lead to further abuse of vulnerable individuals.

Such cases demonstrate how case research can be used to study things that researchers could not replicate in experimental settings. In Genie's case, her horrific abuse denied her the opportunity to learn a language at critical points in her development.

This is clearly not something researchers could ethically replicate, but conducting a case study on Genie allowed researchers to study phenomena that are otherwise impossible to reproduce.

There are a few different types of case studies that psychologists and other researchers might use:

• Collective case studies : These involve studying a group of individuals. Researchers might study a group of people in a certain setting or look at an entire community. For example, psychologists might explore how access to resources in a community has affected the collective mental well-being of those who live there.
• Descriptive case studies : These involve starting with a descriptive theory. The subjects are then observed, and the information gathered is compared to the pre-existing theory.
• Explanatory case studies : These   are often used to do causal investigations. In other words, researchers are interested in looking at factors that may have caused certain things to occur.
• Exploratory case studies : These are sometimes used as a prelude to further, more in-depth research. This allows researchers to gather more information before developing their research questions and hypotheses .
• Instrumental case studies : These occur when the individual or group allows researchers to understand more than what is initially obvious to observers.
• Intrinsic case studies : This type of case study is when the researcher has a personal interest in the case. Jean Piaget's observations of his own children are good examples of how an intrinsic case study can contribute to the development of a psychological theory.

The three main case study types often used are intrinsic, instrumental, and collective. Intrinsic case studies are useful for learning about unique cases. Instrumental case studies help look at an individual to learn more about a broader issue. A collective case study can be useful for looking at several cases simultaneously.

The type of case study that psychology researchers use depends on the unique characteristics of the situation and the case itself.

There are a number of different sources and methods that researchers can use to gather information about an individual or group. Six major sources that have been identified by researchers are:

• Archival records : Census records, survey records, and name lists are examples of archival records.
• Direct observation : This strategy involves observing the subject, often in a natural setting . While an individual observer is sometimes used, it is more common to utilize a group of observers.
• Documents : Letters, newspaper articles, administrative records, etc., are the types of documents often used as sources.
• Interviews : Interviews are one of the most important methods for gathering information in case studies. An interview can involve structured survey questions or more open-ended questions.
• Participant observation : When the researcher serves as a participant in events and observes the actions and outcomes, it is called participant observation.
• Physical artifacts : Tools, objects, instruments, and other artifacts are often observed during a direct observation of the subject.

If you have been directed to write a case study for a psychology course, be sure to check with your instructor for any specific guidelines you need to follow. If you are writing your case study for a professional publication, check with the publisher for their specific guidelines for submitting a case study.

Here is a general outline of what should be included in a case study.

Section 1: A Case History

This section will have the following structure and content:

Background information : The first section of your paper will present your client's background. Include factors such as age, gender, work, health status, family mental health history, family and social relationships, drug and alcohol history, life difficulties, goals, and coping skills and weaknesses.

Description of the presenting problem : In the next section of your case study, you will describe the problem or symptoms that the client presented with.

Describe any physical, emotional, or sensory symptoms reported by the client. Thoughts, feelings, and perceptions related to the symptoms should also be noted. Any screening or diagnostic assessments that are used should also be described in detail and all scores reported.

Your diagnosis : Provide your diagnosis and give the appropriate Diagnostic and Statistical Manual code. Explain how you reached your diagnosis, how the client's symptoms fit the diagnostic criteria for the disorder(s), or any possible difficulties in reaching a diagnosis.

Section 2: Treatment Plan

This portion of the paper will address the chosen treatment for the condition. This might also include the theoretical basis for the chosen treatment or any other evidence that might exist to support why this approach was chosen.

• Cognitive behavioral approach : Explain how a cognitive behavioral therapist would approach treatment. Offer background information on cognitive behavioral therapy and describe the treatment sessions, client response, and outcome of this type of treatment. Make note of any difficulties or successes encountered by your client during treatment.
• Humanistic approach : Describe a humanistic approach that could be used to treat your client, such as client-centered therapy . Provide information on the type of treatment you chose, the client's reaction to the treatment, and the end result of this approach. Explain why the treatment was successful or unsuccessful.
• Psychoanalytic approach : Describe how a psychoanalytic therapist would view the client's problem. Provide some background on the psychoanalytic approach and cite relevant references. Explain how psychoanalytic therapy would be used to treat the client, how the client would respond to therapy, and the effectiveness of this treatment approach.
• Pharmacological approach : If treatment primarily involves the use of medications, explain which medications were used and why. Provide background on the effectiveness of these medications and how monotherapy may compare with an approach that combines medications with therapy or other treatments.

This section of a case study should also include information about the treatment goals, process, and outcomes.

When you are writing a case study, you should also include a section where you discuss the case study itself, including the strengths and limitiations of the study. You should note how the findings of your case study might support previous research. 

In your discussion section, you should also describe some of the implications of your case study. What ideas or findings might require further exploration? How might researchers go about exploring some of these questions in additional studies?

Need More Tips?

Here are a few additional pointers to keep in mind when formatting your case study:

• Never refer to the subject of your case study as "the client." Instead, use their name or a pseudonym.
• Read examples of case studies to gain an idea about the style and format.
• Remember to use APA format when citing references .

Crowe S, Cresswell K, Robertson A, Huby G, Avery A, Sheikh A. The case study approach .  BMC Med Res Methodol . 2011;11:100.

Crowe S, Cresswell K, Robertson A, Huby G, Avery A, Sheikh A. The case study approach . BMC Med Res Methodol . 2011 Jun 27;11:100. doi:10.1186/1471-2288-11-100

Gagnon, Yves-Chantal.  The Case Study as Research Method: A Practical Handbook . Canada, Chicago Review Press Incorporated DBA Independent Pub Group, 2010.

Yin, Robert K. Case Study Research and Applications: Design and Methods . United States, SAGE Publications, 2017.

By Kendra Cherry, MSEd Kendra Cherry, MS, is a psychosocial rehabilitation specialist, psychology educator, and author of the "Everything Psychology Book."

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

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

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

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

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

Definitions of qualitative case study research

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

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

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

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

Current methodological issues in qualitative case study research

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

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

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

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

Assessment of rigour

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

Framework for assessing quality in qualitative case study research.

Adapted from Stake ( 1995 , p. 131).

Study design

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

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

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

Search strategy

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

Outcomes of search of qualitative methods journals.

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

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

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

Case study methodology or method

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

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

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

Case study of something particular and case selection

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

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

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

Contextually bound case study

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

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

Article synopsis of case study research using Stake's tradition

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

Article synopsis of case study research using Yin's tradition

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

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

Researcher and case interactions and triangulation

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

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

Study design inconsistent with methodology

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

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

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

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

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

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

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

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

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

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

Limitations of the review

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

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

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

Conflict of interest and funding

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

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• Open access
• Published: 28 October 2022

Enabling mental health task-sharing: a collective case study of undergraduate clinical associate training programmes in South Africa

• Saiendhra Vasudevan Moodley 1 ,
• Jacqueline Wolvaardt 1 &
• Christoffel Grobler 1  

BMC Medical Education volume  22 , Article number:  745 ( 2022 ) Cite this article

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There is a shortage of the human resources needed to deliver mental health services which is likely to be exacerbated by COVID-19. Due to mental health workforce shortages, task-shifting and task-sharing approaches have been implemented in a number of countries. Clinical associates, a mid-level cadre working under the supervision of medical practitioners, could play a role in delivering mental health services but it is not clear if they are adequately prepared. This study explored the mental health curriculum content of the undergraduate clinical associate training programmes in South Africa and the views of key informants of the adequacy of training in mental health.

A qualitative collective case study approach was utilised for this multisite study at the three universities in South Africa offering clinical associate degrees. The study consisted of in-depth interviews utilising videoconferencing of individuals involved in each programme and a document review. Thematic analysis of the data was conducted.

Nineteen interviews were conducted. Mental health formed part of the curriculum in all three programmes with the bulk of the training taking place in the final year of the three-year degree. Facility-based training ranged from two weeks to four weeks with one university only using hospitals with mental health units while two universities used hospitals at which the students were based for the year regardless of potential mental health exposure they would receive. The list of curricula inclusions extended to seldom-seen conditions. The quality of training and supervision appeared site-dependant and only one university set minimum experiential targets.

There is a basis on which to build the competencies and skills regarding mental health in this cadre. A training model that integrates mental health early in the undergraduate curriculum, focuses on common conditions and those with high disease burden, includes time in a mental health unit, provides facility-based trainers with detailed guidance to improve standardisation, and includes specific experiential targets that are monitored will enhance the potential utility of this cadre.

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Mental and addictive disorders affect a substantial proportion of the world’s population and are major contributors to the global burden of disease [ 1 ]. It was estimated that a total of 162.5 million disability adjusted life years (DALYs) were due to mental and addictive disorders which is 6.8% of the total DALYs in 2016 [ 1 ]. In sub-Saharan Africa there was a 113.9% increase in total DALYs lost between 1990 and 2017 due to mental disorders [ 2 ]. Psychiatric epidemiological data for South Africa (SA) is limited, but the available data suggests that mental illness is a significant problem. The most recent nationally representative mental health data comes from the National Income Dynamics Study (NIDS) which only screens for depression [ 3 ]. In the fourth wave of the NIDS (2014–2015), 26% of adult participants were found to have significant depressive symptoms [ 3 ]. Suicide data provides an indication of mental illness burden [ 4 , 5 ] and SA’s crude suicide mortality rate in 2016 was 11.6 per 100 000 population - higher than the global average of 10.6 per 100 000 population [ 6 ]. COVID-19 is likely to result in a rise in mental illness in SA as the pandemic and social distancing measures have resulted in stress, loneliness, and a reduction in social interactions which are known to increase the risk of mental illness [ 7 ].

There is a worldwide shortage of the human resources needed to deliver essential mental health interventions [ 8 ], and this shortage is a critical barrier preventing low- and middle- income countries from improving their mental health services [ 9 , 10 ]. According to the World Health Organization [ 11 ], SA had 1.52 psychiatrists per 100 000 population in 2017. While this is above the global median, it falls short of the South African Society of Psychiatrists recommended target of 3.0 per 100 000 population [ 12 ]. It was reported that in 2019, 70% of psychiatrists in SA were servicing the small private sector [ 12 ]. As with the health workforce in general in SA, there is an urban-rural maldistribution of mental health human resources [ 13 , 14 ].

Task shifting and task sharing approaches have been implemented in many countries in order to address mental health workforce shortages. More efficient use can be made of the health workforce by moving appropriate tasks to health workers who have fewer qualifications and have undergone shorter training [ 15 ]. The types of non-specialist health workers who deliver mental health services elsewhere include medical officers, nurses, and lay health workers [ 8 , 16 ]. These workers have contributed to mental health services in various settings including clinics, community outreach services and halfway homes [ 8 , 16 ]. The mental health tasks performed by these non-specialist health workers differ and depend on their level of training [ 8 , 16 ]. These tasks include prevention, detection, and treatment of mental disorders [ 8 , 16 ]. In a Cochrane systematic review assessing primary-level worker interventions in mental health, the authors found that there may be potential benefit to the use of primary-level workers in treatment of some adult mental disorders including depression and anxiety, depression related to pregnancy and childbirth, mental disorders in humanitarian settings, and severe mental disorders such as schizophrenia but further evidence is needed [ 17 ].

South Africa has extensive experience of using of task shifting and task sharing approaches in addressing its HIV epidemic including the use of nurses to initiate anti-retroviral therapy and lay health workers to deliver a number of health promotion interventions [ 18 , 19 ]. Over the last decade, task sharing approaches have been increasingly explored as an option to deliver mental health services in South Africa [ 20 ]. Examples of these approaches include registered counsellors providing problem-solving therapy in the treatment of antenatal common mental disorders [ 21 ], a group-based Interpersonal Therapy intervention for depression delivered by lay HIV counsellors [ 22 ], and mental health counselling to patients with chronic disease(s) which was delivered by community health workers. [ 23 ] A study in five countries (including South Africa) found that the use of non-specialist health workers in mental health service delivery was perceived as acceptable and feasible by stakeholders if certain conditions are met including adequate training, the provision of ongoing supportive supervision, and adequate compensation.[ 24 ].

Clinical associates are a potential option to expand mental health services in South Africa. Clinical associates are mid-level health workers in the non-physician clinician category trained through a three-year Bachelor of Medicine in Clinical Practice (BMCP) degree at Walter Sisulu University and the Bachelor of Clinical Medical Practice (BCMP) degree at the University of Pretoria and University of Witwatersrand [ 25 ]. The first cohort of clinical associates entered the SA health system in 2011 [ 25 ]. The focus of clinical associate training in South Africa is the diagnosis and management of common medical conditions with the training preparing them to deliver services at district hospitals and at primary care level [ 26 ]. Their curricula use problem-based learning in the clinical context to apply their basic health sciences knowledge [ 26 ]. Similar cadres are found elsewhere in Africa (e.g. community health officers and community health extension workers in Nigeria, and clinical officers in Kenya and Uganda) though there is variation in the types of institutions doing the training and the quality of training [ 27 ]. South African clinical associates may have a greater depth of theoretical health sciences training as they complete a university degree. In general, this cadre of health worker in Africa provides diagnosis and treatment at primary healthcare facilities (clinics and health centres) and district hospital outpatient departments [ 27 ]. They are frontline health professionals who are the interface between patients and higher level care.

The available evidence suggests that SA has a high prevalence of mental disorders and these are a significant contributor to the disease burden and the COVID-19 pandemic is likely to exacerbate this. South Africa has a shortage of specialist mental health professionals with public-private sector and urban-rural maldistribution. Task sharing approaches are critical to ensure mental health service provision in underserved areas. The role of clinical associates in mental health service provision is currently ill defined and they are possibly an under-utilised resource in mental health task sharing approaches. While mental health does form part of their scope of practice [ 28 ], the extent or utility of the training is not clear. This study explored the mental health curriculum content of the undergraduate clinical associate training programmes in SA and the views of key informants of the adequacy of training in mental health.

Study design

A collective case study approach was utilised. According to Creswell and Poth[ 29 ], case study research is a qualitative approach that explores one or more contemporary, real-life bounded case or cases over time through in-depth data collection utilising multiple data sources. A collective case study is one in which multiple cases show different perspectives [ 29 ].

Study setting

All the universities offering clinical associate degrees: Walter Sisulu University, the University of Pretoria and the University of Witwatersrand.

Study population and sampling

Each of the clinical associate training programmes was considered a ‘case’. In-depth interviews were conducted with individuals involved in each programme. Purposive sampling was utilised. Participants were selected on the basis of being able to provide information on the mental health content of each programme. A BCMP academic co-ordinator from each university assisted in identifying the relevant individuals. For each programme, the following individuals were considered for inclusion:

BCMP/BMCP academic co-ordinators.

The individual(s) responsible for mental health teaching.

The 2020 final year class representative.

BCMP/BMCP site-based co-ordinators/supervisors at selected rotation sites.

The clinicians providing mental health training at selected rotation sites.

Measurement tools and data collection

Data were obtained from a combination of documents (such as study guides) and key informant in-depth interviews. BCMP/BMCP co-ordinators at the three universities were asked to provide the relevant documents. Interviews were conducted using videoconferencing. Participants were informed how data would be used/stored, and how privacy would be protected in line with Blackstone’s guidance [ 30 ]. The interview included questions on the aspects of mental health covered in the curriculum, the formal teaching in mental health, the practical training provided in mental health, and participant views on the adequacy of the mental health component of the curriculum and any gaps in the teaching. Interviews were audio recorded and hand-written notes were taken. The documents were reviewed to obtain data on the psychiatric disorders covered in the curriculum, training in the relevant procedures (skills) listed in the clinical associates scope of practice[ 28 ], training (if any) on mental health screening tools, and the types of assessments (oral/clinical/written) and their respective weightings for psychiatry component of the curriculum.

Data management and analysis

The interviews were professionally transcribed and the documents and transcriptions were imported to Atlas.ti software. Codes were allocated to significant statements in the transcribed in-depth interviews and to significant information in the documents obtained [ 31 ] Data analysis used the approach outlined by Creswell and Poth [ 29 ] for case study research. The generated codes were then aggregated into categories and utilised to generate themes [ 29 ]. Direct interpretation (drawing meaning from a single instance) was employed [ 29 ]. Cross-case theme analysis was done to identify similarities and differences between the programmes and naturalistic generalisations related to what was learnt from the cases were developed[ 29 ].

Processes to ensure quality of research

Frambach et al. [ 32 ] outlines various techniques that can be used in qualitative research to address the quality criteria of credibility, transferability, dependability and confirmability. Techniques used in this study were data triangulation (in-depth interviews of staff and students together with document review), iterative data analysis, peer debriefing, and maintaining an audit trail.

Participants

A total of 19 interviews were conducted across the three universities offering the Bachelor of Clinical Medical Practice/Bachelor of Medicine in Clinical Practice(BCMP/BMCP) degree between 25 March 2021 and 29 July 2021. For each programme, a mixture of university-based and facility-based personnel were interviewed as well as the class representative of the previous (2020) graduating class. Eleven documents were reviewed. The number of interviews conducted and documents reviewed for each programme are shown in Table  1 . In order to maintain confidentiality, the universities have not been named when presenting results but have been randomly designated as A, B or C.

Timing of mental health in the curriculum

University a.

In Year 1 some generic skills considered useful in mental health such as biopsychosocial assessment, communication and counselling are introduced. The mini-mental state exam is covered in their neurology block. In Year 2, they build on their counselling skills to include bereavement, grief and loss as well as substance use and have possible interaction with mental health patients during rotations e.g. emergency department and internal medicine. The formal mental health component of the curriculum takes place in Year 3 and includes both university-based teaching and facility-based practical training which has its drawbacks: “I think that we integrate it a little bit too late, personally, because our students do start interacting with mental health patients already in the first year.” (P10).

University B

At University B, there is no formal teaching related to mental health in Years 1 and 2. “ They will meet patients on the wards and in the casualty. But it is not one of the things that we teach them ” (P11). The view was that students would generally not be interested in mental health before the module which is in the third year:

“ You can teach someone, it doesn’t mean that people are going to learn that thing. So, they don’t learn to do it per se until they come to this module in which they have to do it, or they have to know, or they can’t pass the module…we don’t touch this topic until year three, they’re like, okay, I don’t need this now.” (P15).

University C

University C introduces students to some aspects of mental health history taking, the mini-mental state examination, and the psychosocial (three-stage) assessment in Year 1. Communication skills and basic medical psychology are also included. Neurology is a theme (Year 2) where a few relevant aspects of psychiatry are touched on. Again, the bulk of mental health is included in Year 3. The lack of integration of into the earlier years comes at a cost:

“…as a student you don’t do psych in first and second year. All of a sudden you’re doing psych in the final year, so you get surprised of all of the list of conditions that you have of psych, and you don’t know, you’ve never been exposed to any of them, you’ve never focused on any of them. So you don’t know which one is important and which one is of serious concern, which one is of emergency or what.” (P19)

There was strong support that students should be formally introduced to some aspects of the mental health curriculum earlier in their programme. An earlier start would allow them to take advantage of the mental health learning opportunities in the wards and emergency departments and to integrate knowledge better. However, this would also need a change of mindset from students as noted by one interviewee: “I do think sometimes students compartmentalise too much and they lose opportunities to learn, even though it’s not immediately relevant in terms of an upcoming exam” (P17).

Mental disorders included in the curriculum

The mental disorders that are included in the curriculum were extracted from the documents received (Table  2 ). The lists of disorders are fairly similar with all three lists including the common mental disorders viz. depressive disorders, anxiety disorders, and substance-related disorders. Schizophrenia is also included in all three curricula. An interviewee from University C raised a concern regarding the scope: “… it’s basically the whole mental health book in there, all the topics, all the diseases, all the conditions are there, it’s just like how do you squeeze them in into short time? ” (P18).

Based on the interviews it is apparent that practical exposure to patients with these conditions varies significantly by site. It ranges from district hospitals without a psychiatric unit and exposure to only a limited number of these conditions/presentations (e.g. acute psychosis, suicidal behaviour) to those at a tertiary hospital with a broad range of the disorders.

Competencies and skills

The mental health (and related) competencies and skills planned for by each university were reviewed using both the documents and the interview data (Table  3 ). Based on this examination, all three universities include learning opportunities for all the elements of the mental health assessment. Universities A and C use electronic logbooks where students need to record patients seen and procedures done but do not specify minimum numbers. University B uses a manual logbook with minimum requirements e.g. “sedate five aggressive patients”.

University-based teaching

There is theoretical block at the start of Year 3 on campus that includes one week of mental health which consists of formal lectures, videos and case-based learning. The teaching is currently done by one of the BCMP/BMCP co-ordinators who is a clinical associate. Psychiatrists from the local academic hospital only give input on the teaching material. Lectures given include mental health ethics and pharmacology of psychiatric drugs. A case-based approach is used to teach mental disorders with the theory being discussed before a case discussion. Extensive use is made of videos including a psychiatric interview:

“…. so pre-Covid, in a classroom setting, we would watch the video together, I’d stop the video and then we would go through the mental status exam together, so that students could fully consult with that patient in the video as though they were doing it in real life. And then we’d diagnose the patient together, assess then according to DSM criteria, and then discuss the management around that patient …and that condition as a whole. ” (P03)

Due to the COVID-19 pandemic, contact teaching was limited. Students were given the videos to view on their own. Synchronous online sessions were held to discuss each of the conditions. On campus skills teaching was permitted and students attended a simulated ward session which included a simulated mental health patient that they had to assess and manage.

There is a didactic period at the start of third year on campus in which seven themes are covered including mental health. Due to COVID-19 and political instability on campus, all mental health teaching shifted to the health facilities where students were based. Prior to that, it was unclear how much mental health content was taught during the didactic period, but one interviewee estimated 20 hours (done by the family physicians, medical officers, and clinical associates).

A foundation week covering multiple clinical discipline in Year 3 includes a two-hour introductory lecture on mental health. They also receive a lecture in their third year on substance use and harm reduction. The mental health lecture is given by a psychiatrist based at the local academic hospital and was presented in a synchronous online format during the pandemic. The lecture includes an approach to mental health assessment, classification system, some interviewing skills and an overview of some common mental disorders. There was some concern expressed that this was not adequate: “ I’m slightly biased here because I think that it’s a very superficial overview that we give. And given the scope of mental health problems, you know, it’s probably not enough .” (P06).

Facility-based teaching and practical training

There is a two-week mental health rotation in Year 3 to a psychiatric unit. Two of these units are in district hospitals, one is a regional hospital and the fourth is an academic hospital. The model used by University A is different from Universities B and C where the students have their mental health module at whichever hospital they are based for the year. One of the interviewees outline the rationale for University A’s different approach: “ …we’re looking to place our students in a location where there is a department, there is a consultant, where there is opportunity for students to really be engaged and learn.” (P13).

The two-week mental health rotation at University A is shorter than the other specialties (generally four weeks), which was considered sub-optimal:

“ Never enough. Never, ever enough. I know every time I tell the preceptors it’s two weeks, they’re like that’s not nearly enough to do a psych rotation … But two weeks to grasp psychiatry and to grasp mental health, is definitely not enough time.” (P10)

Each facility has a university-employed site facilitator who co-ordinates rotations but hospital-employed preceptors supervise and train the students. The preceptors are either psychiatric consultants or medical officers working in psychiatry unit. The students’ activities vary depending on the facility but generally consist of assessing mental health patients (in the wards, outpatient departments and/or emergency departments), attending patient rounds, and presenting patients to their preceptors. There is a preceptor manual provided by the university but it seems preceptors are left to their own devices to some extent as the training is:

“… very site dependent, which becomes very difficult to get students to get to the same objectives because in the clinical setting there are some MOs (medical officers) who really love teaching and involve the clinical associate students in the ward round, in consultations, and students become quite comfortable with psych. Versus a hospital like (the academic hospital), they get a little bit lost and there’s medical students, there’s registrars, there’s interns, so the ward round doesn’t become as beneficial for them unless there’s something who’s a bit more inclusive in their teaching .” (P03)

Based on the documents, University B has a three-week facility-based mental health module in Year 3. However, interviewee responses varied as to whether the module at the facility was actually three or four weeks. This uncertainty was possibly due to time for the didactic campus-based component (which had not taken place in recent years) being added to time spent at the facility. There was a general concern whether this was sufficient:

“… my main concern is that we spend only one month in these topics, only one time in three years, and one month. So it’s like, when the students go over these topics, or over this module, they don’t really go back again…it’s not like pneumonia they can keep seeing pneumonia every day, right? and studying through three years, and TB they study TB through the three years and several times.” (P15)

The students do their mental health rotation at the hospital that they are based at. University B uses three district hospital and one regional hospital for training. Only the latter has a mental health unit. To maintain consistency, students are not placed in that mental health unit but follow a similar programme to students placed at facilities without a mental health unit. The rationale is that “their scope of practice may not necessarily need them to be on the mental health unit…” (P14). Despite attempts to standardise training at different sites, one interviewee did concede that “… the amount of exposure they will have to patients who need mental health services varies by hospital site. ” (P11).

There are academic staff (“tutor-lecturers”) appointed by the university at each of the training facilities. These are either medical officers or clinical associates who are responsible for training across the specialties. Teaching consists of problem-based learning (PBL) and topic presentations. Students clerk patients with a mental health presentation, and present to the tutor-lecturer and class as part of PBL. The differential diagnoses, psychosocial assessment, and management plan is then discussed and learning needs identified. A standard list is used for the topic presentations. The student representative expressed some misgivings about the presentations:

“…the whole thing of we present certain topics, this is also a bit of a problem sometimes, because we ourselves do the research, and it’s the first time we’re encountering this topic thoroughly, so you do your own research and everything…it doesn’t make it as effective as if maybe we had the lecture first.” (P09)

The amount of practical mental health training appears to be limited. The students may or may not opportunistically encounter mental health patients in the emergency and outpatient departments and one participant acknowledged “…it is possible for some students to go through the year, or to go through the course, without really handling mental health patients. ” (P11).

Students at University C have a four-week mental health rotation in Year 3. The rotation is split into two weeks in the wards, one week in the emergency department and one week in the outpatients’ department at the hospital they are based. Fifteen (or in some years more) hospitals are utilised for training and range from district to tertiary levels and may or may not have a dedicated mental health unit. Some students spend a week in a community-based substance use programme instead of the outpatients’ department.

At each facility, there is an identified family medicine practitioner who is responsible for ensuring training but in practice students are often “… siphoned off to somebody else who may or may be not be interested really in the training of clinical associates” (P04). At some facilities, a psychiatrist or mental health nurse may be present to assist during the mental health rotation though it is generally medical officers. The students are expected to sit in on patient rounds and psychiatric interviews that are being done by the doctors as well as clerk and present mental health patients. The module guide indicates that students are required to have a “mental health longitudinal patient” with a chronic mental illness who they follow up for several months including doing a home visit. This aspect did not feature strongly in the interviews, so it is not clear how well this is implemented.

A key concern raised by interviewees was the variability in mental health training at the different sites and there was particular concern about students placed at rural facilities:

“So, it varies a lot with respect to what they ultimately get exposed to during that four weeks…it really depends upon where they’ve been placed. And the majority of it, I think it varies, I mean, incredibly.” (P04).

“ My own view, from the programme perspective, I think programme looks great, the way it’s structured. But in practice I don’t think they have enough support once they go off into the rural facilities .” (P18).

The class representative stressed the importance of student agency in maximizing the benefit of the mental health and other rotations “You have to, as an individual in (BCMP/BMCP), you have to be knowledge-driven, you need to, out of your own will look for patients that will give you the proper exposure you’re looking for” (P05). She noted that doctors are then more likely to assist students with this attitude.

The assessments specifically for mental health at the three universities are shown in Table  4 along with other key features of the three programmes. At University A, mental health is also included in objective structured clinical examinations (OSCE). There are three OSCEs in the third-year and each usually have a mental health station e.g. a consultation with a simulated psychiatric patient. At the end of the third-year, the students at all three universities have a Clinical Associate National Examination (CANE) which includes mental health (blueprinted as 11% of the mark allocation of the written papers). The CANE consists of an Multiple Choice Question (MCQ) paper and a Modified Essay Question (MEQ) paper. All universities have independent (but similar) final OSCE exams. University A has a 12–14 station OSCE which usually has a mental health station. University B confirmed that a mental health station was included in their final OSCE the previous year. The final OSCE at University C usually includes at least one mental health station. There was some concern regarding assessments and examinations in general at University C as it was felt there was a lack of alignment between clinical practice and what they are assessed on. There was some acknowledgement of the missed opportunity of bedside assessment and the need for workplace-based assessments: “ I think we’ve been talking about workplace assessment, I think those are good…those are perhaps one of the ways forward. ” (P17).

Training adequacy and competency to provide mental health services

Besides issues linked to starting mental health training at a late stage of the programme and duration of the mental health rotation, other gaps noted by interviewees included inadequate theoretical component, a lack of exposure to child psychiatry and personality disorders, counselling at a “ very surface level ” (P10), and limited training on the substances that could be abused. There were differing views on whether the training as a whole was adequate and whether graduates are likely to be competent to deliver mental health services: “So I don’t think it’s adequately covered. I think the clinical associates can add a lot of value to a mental health department and I think our curriculum doesn’t fully allow for them to see that, but it also doesn’t allow for us to fully go into the theory.” (P03).

The identified gaps in training included training related to childhood behavioural disorders, and dementia. There were differing views on whether mood disorders were a gap or not. One interviewee thought that students would struggle to manage mental health patients in the wards as they do not receive that exposure during their mental health training. There were differing views on training adequacy and competency to practice:

“ I believe it’s adequately covered, because they are prepared to do what is required in their scope of practice in terms of the 72-hour assessment, and then they refer the patients to the specialist. So we are actually covering well, that’s my view. ” (P14).

“ I will say that they can do emergency management, but even that one, at the time of graduation and going out there, they are not very comfortable with that yet. They’re not. ” (P11).

The lack of emphasis on mental health teaching, minimal formal teaching and inadequate guidance as to the areas to focus on were identified as gaps at University C. One of the interviewees noted that “ … right now I think the message that we’re sending to our students based upon the way we teach the programme is that mental health is not that important, and it’s only important for four weeks out of your entire education.” (P04) This sentiment was echoed by one of the site facilitators: “So the exposure and opportunities are also playing the part there, but also the university itself doesn’t place enough emphasis or guide in terms of that.” (P19).

Concerns were raised that students may not be exposed to mental health patients at some hospitals beyond the immediate management in emergency departments. It was noted that “… a lot of their mental health knowledge, I think comes from them reading about it as opposed to actually experiencing those patients.” (P04) A concern was raised about their diagnostic ability:

“ So, for instance, they may not necessarily be able to identify that somebody, say, has got a general anxiety disorder, or sometimes to some extent, even just depression. It’s very difficult for them to be able to pick up those nuances at the very beginning. And my view is that there ends up being a lot of misdiagnoses from them because they’re not trained adequately to do that.” (P04)

There were varying responses on whether training adequately prepared clinical associates from this institution with respect to mental health with some reliance on reputation rather than evidence: “I definitely think that if we passed the final OSCEs and the final exam papers, I feel like we all definitely have the necessary knowledge, because (University C’s) assignments were not easy. So if we got through I feel like we should trust the university and their level of assessment to tell us that we are competent.” (P05).

While others reflected on the future utility of their graduates: “ If they are expected to manage patients on their own as, you know, quasi-medical practitioners, then I think a lot more work should go into training them to do it effectively.” (P06).

The interviews and documents confirmed that mental health is a component of all three curricula. In all three programmes, virtually all mental health teaching and training occurs in the final year of the three-year degree. This design feature was considered a missed opportunity for earlier learning in other rotations. There was almost universal support for integrating mental health earlier in the curriculum. Given that individuals with chronic physical illness are at high risk for depression and anxiety and individuals with serious mental illness are at high risk for a number of chronic physical conditions [ 33 ], it would be ideal to integrate mental health as early as the first year. This educational strategy would help in preparing clinical associates to provide holistic care from an early stage in their training. As frontline health professionals, it would assist them to detect the contribution of mental health to a range of presentations and conditions and enable them to manage these co-morbidities. While there may be limitations as to how mental health content can be feasibly included in the earlier years, it may be possible to introduce them to mental health history taking, the mental status examination as well as the common mental disorders.

There is clearly a gap at University C with only two formal lectures on mental health compared to University A who has a week of formal teaching on campus and University B who has an extended period of facility-based formal teaching. The lack of formal teaching at University C might explain why an interviewee pointed out the lack of guidance as an issue as the students need to determine what is important on their own. While two lectures are clearly insufficient, some argument can be made to rationalise the conditions that are included in the curricula at all three universities. The utility of including uncommon disorders that clinical associates are unlikely to encounter or would not be required to manage is questionable. Rather, burden of disease data and prevalence data provide guidance. Results from the Global Burden of Disease Study 2017 suggest that depressive disorders, anxiety disorders, substance use disorders and schizophrenia form the prime inclusions as the mental illnesses that rank within the twenty leading causes of years with disability for males and females [ 34 ]. South African prevalence data suggest anxiety, mood, and substance use disorders are disorders that health workers are likely to encounter [ 35 ].

With respect to facility-based training for mental health, each university uses a different approach. The approach adopted by University A ensures students get practical exposure to a mental health unit and thus guarantees a wider variety of mental disorders. University B uses a more theoretical approach to their psychiatric block with very limited practical exposure which is usually coincidental. University C uses a number of sites with considerable variation in training depending on where a student is placed and distinct lack of standardisation compared to Universities A and B. As acknowledged by the interviewees at University A, the two-week mental health rotation is short (but guaranteed) but ideally needs to extended. Universities B and C allocate more time to mental health but most of the practical learning is by chance. Spending at least some of the time (e.g. two weeks) allocated to mental health in a hospital with a mental health unit would guarantee opportunities to learn.

Clinical associates’ scope of practice includes taking a history, performing an examination, performing diagnostic procedures, formulating a diagnosis, developing a management plan and performing specified procedures under supervision [ 28 ]. The list of procedures includes “Mental health examination”, “Mental Health History”, “Mini Mental State (MMS) examination” and “Counselling - family /mental health”[ 28 ]. All three universities include these in their curricula but the concern is the authentic application of these in practice. There is no indication in the literature reviewed on what an ideal split between mental health theory and practice would be for this cadre. It was notable that no evidence was found of suicide risk assessment being covered given South Africa’s high suicide rate [ 6 ]. In comparison, Canada includes suicide assessment in the competency profile of their physician assistants [ 36 ]. While all three universities utilise procedure or log books, only one has set specific experiential targets. Setting specific targets for mental health would ensure adequate practical exposure and help identify facilities where the opportunities to learn are too limited or where supervision is inadequate.

It is not clear how well the mental health training of South African clinical associates compares to equivalent cadres in other countries as information is not readily available. Though psychiatry is included in the competency profile of Canadian physician assistants, there is no indication of the duration of the mental health training they should receive [ 36 ]. Similarly, it is not clear how much mental health training Ethiopian health officers receive, but it is likely to be limited given that mental health services have not been a priority until recently [ 37 ]. A situational analysis of clinical officers (and nurses) working in primary care in Kenya found they had only a small amount of basic training in mental health [ 38 ]. A survey of non-specialist health workers in Malawi which included medical assistants found just 12% had received training in mental health [ 39 ]. Training in psychiatry varies widely between American physician programmes with some programmes offering comprehensive didactic teaching and clinical training while others offer only a small amount of didactic teaching with limited clinical opportunities in primary care settings [ 40 ]. The United Kingdom physician associate curriculum requires a minimum of only 90 hours in psychiatry out of 3 200 hours of teaching [ 41 ]. It is not clear how much of this is practical though their training does involve problem-based learning sessions, role-play scenarios and mental health consultations during general practice clinical placements [ 42 ].

While task sharing in mental health in South Africa has tended to focus on counselling interventions delivered by community health workers or lay health workers, the clinical training and background of clinical associates offers different possibilities at district hospitals and at primary care level. These include assessment and diagnosis, referral to higher levels of care when indicated, management of co-morbid mental and physical illness, and the prescribing of pharmacological treatment in addition to counselling interventions. There is evidence to support the involvement of primary health professionals in the collaborative care of adults with common mental disorders as well as primary health professional-led or collaborative care of adults with severe mental disorders and training should, therefore, be strengthened with respect to depression, anxiety and schizophrenia in order to allow clinical associates to deliver evidence-based interventions at primary level [ 17 ]. Improving clinical associates’ ability to detect and treat depression would also be critical in suicide prevention [ 43 , 44 ]. All three universities offer some basic counselling training. Strengthening this component of their training may not only enable clinical associates to provide evidence-based counselling interventions such as problem solving for depression [ 45 , 46 ] or motivational interviewing for substance use [ 47 ] themselves but may also enable them to supervise lay counsellors.

Qualified clinical associates may only be able to play a limited role in mental health service provision currently given the training gaps identified. However, strengthening of the mental health component of the three undergraduate programmes could see that role broadened for future graduates. Clinical associates who have already graduated may benefit from short courses to close some of the gaps. An advanced qualification such as Honours degree and/or a clinical specialisation for clinical associates in mental health should be considered given the concerning high prevalence of mental health disorders. The researchers intend to conduct further research to inform a conceptual framework for the provision of mental health services by clinical associates.

Limitations

We purposively sampled participants from the three programmes to provide us with a comprehensive overview of their mental health training programme. However, we did not include participants from each of the training sites and there may be discrepancies between individual training sites and our global findings for the programme e.g. certain competencies that were covered in a particular programme may not have been covered at a particular site. All three programmes had been impacted by COVID-19. While we tried to elicit a description of the programmes pre-COVID-19 and during COVID-19, this was not possible with all participants. The document review was limited by what was submitted by BCMP/BMCP co-ordinators.

The mental health training received by clinical associate students in SA varied between the three training programmes as well as within programmes with a number of areas identified for potential improvement. We recommend a model that integrates mental health as early as possible in the curriculum to maximise learning opportunities, focuses on common conditions and those that that contribute substantially to disease burden, includes compulsory rotations in mental health units, provides facility-based trainers with detailed guidance to standardise teaching across training sites, and includes specific experiential targets for the number of mental health procedures that are monitored using paper or electronic logbooks. Strengthened undergraduate clinical associate training programmes in mental health will provide the potential for their utilisation in task-sharing approaches in mental health services in SA.

Data availability

The dataset generated and analysed for this study are not publicly available in order to protect the confidentiality of the participants but are available from the corresponding author on reasonable request.

Abbreviations

Bachelor of Clinical Medical Practice.

Bachelor of Medicine in Clinical Practice.

Disability-adjusted life years.

National Income Dynamics Survey.

South Africa.

World Health Organization.

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Acknowledgements

We wish to thank Prof. Crick Lund for his advice during the conceptualisation phase of the research and Ms Cané Lake for transcription of the interviews.

SVM has funding from the University of Pretoria - University Capacity Development Programme (for PhD-related costs).

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SVM conceptualised the research. SVM developed the methods (including the interview guide) with input from JW and CG. SVM conducted the in-depth interviews. SVM analysed the data with guidance from JW. SVM wrote the first draft of the paper with subsequent input from JW and CG. All authors reviewed the manuscript.

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Moodley, S.V., Wolvaardt, J. & Grobler, C. Enabling mental health task-sharing: a collective case study of undergraduate clinical associate training programmes in South Africa. BMC Med Educ 22 , 745 (2022). https://doi.org/10.1186/s12909-022-03806-9

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The case study approach

• Sarah Crowe 1 ,
• Kathrin Cresswell 2 ,
• Ann Robertson 2 ,
• Guro Huby 3 ,
• Anthony Avery 1 &
• Aziz Sheikh 2  

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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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Acknowledgements

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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Division of Primary Care, The University of Nottingham, Nottingham, UK

Sarah Crowe & Anthony Avery

Centre for Population Health Sciences, The University of Edinburgh, Edinburgh, UK

Kathrin Cresswell, Ann Robertson & Aziz Sheikh

School of Health in Social Science, The University of Edinburgh, Edinburgh, UK

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Correspondence to Sarah Crowe .

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The authors declare that they have no competing interests.

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AS conceived this article. SC, KC and AR wrote this paper with GH, AA and AS all commenting on various drafts. SC and AS are guarantors.

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Crowe, S., Cresswell, K., Robertson, A. et al. The case study approach. BMC Med Res Methodol 11 , 100 (2011). https://doi.org/10.1186/1471-2288-11-100

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Received : 29 November 2010

Accepted : 27 June 2011

Published : 27 June 2011

DOI : https://doi.org/10.1186/1471-2288-11-100

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A collective case study of nursing students with learning disabilities

Affiliation.

• 1 Franciscan University of Steubenville, Steubenville, Ohio, USA. [email protected]
• PMID: 14535146

This collective case study described the meaning of being a nursing student with a learning disability and examined how baccalaureate nursing students with learning disabilities experienced various aspects of the nursing program. It also examined how their disabilities and previous educational and personal experiences influenced the meaning that they gave to their educational experiences. Seven nursing students were interviewed, completed a demographic data form, and submitted various artifacts (test scores, evaluation reports, and curriculum-based material) for document analysis. The researcher used Stake's model for collective case study research and analysis (1). Data analysis revealed five themes: 1) struggle, 2) learning how to learn with LD, 3) issues concerning time, 4) social support, and 5) personal stories. Theme clusters and individual variations were identified for each theme. Document analysis revealed that participants had average to above average intellectual functioning with an ability-achievement discrepancy among standardized test scores. Participants noted that direct instruction, structure, consistency, clear directions, organization, and a positive instructor attitude assisted learning. Anxiety, social isolation from peers, and limited time to process and complete work were problems faced by the participants.

Publication types

• Research Support, Non-U.S. Gov't
• Adaptation, Psychological*
• Attitude of Health Personnel*
• Disabled Persons / education
• Disabled Persons / psychology*
• Education, Nursing, Baccalaureate / methods
• Education, Nursing, Baccalaureate / standards*
• Education, Special
• Educational Status
• Faculty, Nursing / standards
• Interprofessional Relations
• Learning Disabilities / psychology*
• Needs Assessment
• Nursing Education Research
• Self Efficacy
• Social Support
• Students, Nursing / psychology*
• Surveys and Questionnaires
• Teaching / methods
• Teaching / standards