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Case Study – Methods, Examples and Guide

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

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

Types of Case Study

Types and Methods of Case Study are as follows:

Single-Case Study

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

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

Multiple-Case Study

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

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

Exploratory Case Study

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

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

Descriptive Case Study

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

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

Instrumental Case Study

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

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

Case Study Data Collection Methods

Here are some common data collection methods for case studies:

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

Observations

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

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

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

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

How to conduct Case Study Research

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

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

Examples of Case Study

Here are some examples of case study research:

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

Application of Case Study

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

Business and Management

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

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

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

Social Sciences

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

Law and Ethics

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

Purpose of Case Study

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

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

Case studies can also serve other purposes, including:

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

Advantages of Case Study Research

There are several advantages of case study research, including:

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

Limitations of Case Study Research

There are several limitations of case study research, including:

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

About the author

Muhammad Hassan

Researcher, Academic Writer, Web developer

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22 Case Study Research: In-Depth Understanding in Context

Helen Simons, School of Education, University of Southampton

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

Introduction

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

The Beginnings

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

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

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

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

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

Concepts and Purposes of Case Study

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

Everyday Usage: Stories We Tell

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

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

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

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

Professions Individual Cases

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

Case Studies in Teaching

Exemplars of practice.

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

Case scenarios

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

Country Case Studies

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

Case Study as History

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

Case Study Research

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

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

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

Not Defined by Method or Perspective

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

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

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

Qualitative Case Study Research

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

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

Characteristic Features and Advantages

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

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

Possible Disadvantages

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

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

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

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

Types of Case Study

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

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

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

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

Interlude: Social and Ethical Practice of Evaluation

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

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

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

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

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

documenting how different people interpret and value the program;

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

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

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

disseminating to audiences within and beyond the case.

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

Designing Case Study Research

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

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

Conceptualize the Topic

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

What Constitutes the Case

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

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

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

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

Unit of analysis

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

Framing Questions and Issues

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

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

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

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

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

Methodology and Methods

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

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

Primary Qualitative Data Gathering Methods

Interviewing.

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

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

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

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

Observations

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

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

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

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

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

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

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

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

Document analysis

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

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

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

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

Creative artistic approaches

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

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

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

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

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

Getting It All Together

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

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

Analyzing and Interpreting Data

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

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

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

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

Reporting Case Study Research

Narrative structure and story.

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

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

Matching forms of reporting to audience

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

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

Styles of Reporting

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

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

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

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

Generalization in Case Study Research

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

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

Generalizing from the Single Case

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

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

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

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

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

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

Particularization

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

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

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

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

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

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

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

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

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

Conclusion and Future Directions

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

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

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

Warrant for More Creative Methods in Case Study Research

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

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

Representing Findings to Engage Audiences in Learning

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

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

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

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

Learning from a Study of the Singular

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

Acknowledgments

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

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

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

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Case Study Strategy

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This chapter contains an introduction to the research strategy that builds this study and discussion on the issues that frame the research process. As an essential method for social science inquiry, especially for the process and context of documenting and analyzing, a case study approach is chosen as the research strategy. The following chapter presents the rationales of the choice of research strategy, selection of cases, data collection and methods of data analysis, as well as some validity and reliability issues relating to the study.

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The case study approach

Sarah crowe.

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

Kathrin Cresswell

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

Ann Robertson

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

Anthony Avery

Aziz sheikh.

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.

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 ​ Tables1, 1 , ​ ,2, 2 , ​ ,3 3 and ​ and4) 4 ) and those of others to illustrate our discussion[ 3 - 7 ].

Example of a case study investigating the reasons for differences in recruitment rates of minority ethnic people in asthma research[ 3 ]

Example of a case study investigating the process of planning and implementing a service in Primary Care Organisations[ 4 ]

Example of a case study investigating the introduction of the electronic health records[ 5 ]

Example of a case study investigating the formal and informal ways students learn about patient safety[ 6 ]

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 ​ (Table5), 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.

Definitions of a case study

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 ​ (Table1), 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 ​ Tables2, 2 , ​ ,3 3 and ​ and4) 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 ​ (Table2) 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 ​ Tables2 2 and ​ and3, 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 ​ (Table4 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 ​ (Table6). 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 ].

Example of epistemological approaches that may be used in case study research

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 ​ Table7 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 ].

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

For example, in our evaluation of the introduction of electronic health records in English hospitals (Table ​ (Table3), 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 ​ (Table1) 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 ​ Table3) 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 ​ (Table2 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 ​ (Table1 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 ​ (Table3 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 ​ (Table4 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 ​ Table3, 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 ​ (Table4), 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 ​ Table8 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 ​ (Table9 9 )[ 8 ].

Potential pitfalls and mitigating actions when undertaking case study research

Stake's checklist for assessing the quality of a case study report[ 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.

Competing interests

The authors declare that they have no competing interests.

Authors' contributions

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.

Pre-publication history

The pre-publication history for this paper can be accessed here:

http://www.biomedcentral.com/1471-2288/11/100/prepub

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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The case study as a research strategy

Affiliation.

• 1 Centre for Health Promotion Research, Halmstad University, Sweden.
• PMID: 9275815
• DOI: 10.1111/j.1471-6712.1997.tb00423.x

A research strategy seldom used in the caring sciences is the case study. A case study is an empirical in-depth inquiry about an individual, family, group or organization. It is preferable when 'how' and 'why' questions are asked. The case study is mainly used to explain those causal links in real-life intervention that are too complex for either the survey or experimental strategies. Like other research strategies, its design includes questions or propositions, units of analysis, the logic linking the data to the questions or propositions, and the interpretations of the outcomes. A case study can be reported as a single case or as a compilation of a series of cases. In conclusion, a case study is a simple and excellent way for a care professional to present him or herself to the scientific world.

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Creating a Corporate Social Responsibility Program with Real Impact

• Emilio Marti,
• David Risi,
• Eva Schlindwein,
• Andromachi Athanasopoulou

Lessons from multinational companies that adapted their CSR practices based on local feedback and knowledge.

Exploring the critical role of experimentation in Corporate Social Responsibility (CSR), research on four multinational companies reveals a stark difference in CSR effectiveness. Successful companies integrate an experimental approach, constantly adapting their CSR practices based on local feedback and knowledge. This strategy fosters genuine community engagement and responsive initiatives, as seen in a mining company’s impactful HIV/AIDS program. Conversely, companies that rely on standardized, inflexible CSR methods often fail to achieve their goals, demonstrated by a failed partnership due to local corruption in another mining company. The study recommends encouraging broad employee participation in CSR and fostering a culture that values CSR’s long-term business benefits. It also suggests that sustainable investors and ESG rating agencies should focus on assessing companies’ experimental approaches to CSR, going beyond current practices to examine the involvement of diverse employees in both developing and adapting CSR initiatives. Overall, embracing a dynamic, data-driven approach to CSR is essential for meaningful social and environmental impact.

By now, almost all large companies are engaged in corporate social responsibility (CSR): they have CSR policies, employ CSR staff, engage in activities that aim to have a positive impact on the environment and society, and write CSR reports. However, the evolution of CSR has brought forth new challenges. A stark contrast to two decades ago, when the primary concern was the sheer neglect of CSR, the current issue lies in the ineffective execution of these practices. Why do some companies implement CSR in ways that create a positive impact on the environment and society, while others fail to do so? Our research reveals that experimentation is critical for impactful CSR, which has implications for both companies that implement CSR and companies that externally monitor these CSR activities, such as sustainable investors and ESG rating agencies.

• EM Emilio Marti is an assistant professor at the Rotterdam School of Management (RSM) at Erasmus University Rotterdam.
• DR David Risi is a professor at the Bern University of Applied Sciences and a habilitated lecturer at the University of St. Gallen. His research focuses on how companies organize CSR and sustainability.
• ES Eva Schlindwein is a professor at the Bern University of Applied Sciences and a postdoctoral fellow at the University of Oxford. Her research focuses on how organizations navigate tensions between business and society.
• AA Andromachi Athanasopoulou is an associate professor at Queen Mary University of London and an associate fellow at the University of Oxford. Her research focuses on how individuals manage their leadership careers and make ethically charged decisions.

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This paper is in the following e-collection/theme issue:

Published on 1.4.2024 in Vol 26 (2024)

The Challenges in Using eHealth Decision Resources for Surrogate Decision-Making in the Intensive Care Unit

Authors of this article:

• Wan-Na Sun 1 , MSN   ; 
• Chi-Yin Kao 2 , PhD  

1 Department of Nursing, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan

2 Department of Nursing, College of Medicine, National Cheng Kung University, Tainan, Taiwan

Corresponding Author:

Chi-Yin Kao, PhD

Department of Nursing, College of Medicine

National Cheng Kung University

1 University Road

Tainan, 701

Phone: 886 6 2353535 ext 5843

Fax:886 6 2377550

Email: [email protected]

The mortality rate in intensive care units (ICUs) is notably high, with patients often relying on surrogates for critical medical decisions due to their compromised state. This paper provides a comprehensive overview of eHealth. The challenges of applying eHealth tools, including economic disparities and information inaccuracies are addressed. This study then introduces eHealth literacy and the assessment tools to evaluate users’ capability and literacy levels in using eHealth resources. A clinical scenario involving surrogate decision-making is presented. This simulated case involves a patient with a hemorrhagic stroke who has lost consciousness and requires medical procedures such as tracheostomy. However, due to the medical surrogate’s lack of familiarity with eHealth devices and limited literacy in using eHealth resources, difficulties arise in assisting the patient in making medical decisions. This scenario highlights challenges related to eHealth literacy and solution strategies are proposed. In conclusion, effective ICU decision-making with eHealth tools requires a careful balance between efficiency with inclusivity. Tailoring communication strategies and providing diverse materials are essential for effective eHealth decision resources in the ICU setting. Health professionals should adopt a patient-centered approach to enhance the decision-making experience, particularly for individuals with limited eHealth literacy.

Introduction

Decision-making by patient surrogates.

The mortality rate of patients in intensive care units (ICUs) exceeds that of those in the general wards. The Society of Critical Care Medicine reported a mortality rate ranging from 10% to 29% in adult ICUs [ 1 ]. In Taiwan, the mortality rate in ICUs is 11.6% [ 2 ]. The patients in ICUs, grappling with impaired cardiopulmonary functions and severe illness, are in critical condition and are typically physically vulnerable or even in an unconscious state [ 3 ]. They depend on the health care team for basic daily activities such as eating and toileting. In addition, given their critical condition, a variety of complex medical treatments such as endotracheal intubation and ventilator use, are often required to maintain their vital signs [ 4 ]. Coupled with the administration of multiple medications, patients often find it challenging to express their preferences. If patients have not previously provided an advance directive, they must rely on surrogates for medical decisions. Statistics indicate that 95% of surrogates make at least one major medical decision upon the patient’s ICU admission [ 4 ]. Another study highlights that surrogates are involved in up to 71% of medical decisions within the first 48 hours of the patient’s ICU stay [ 5 , 6 ], underscoring the prevalence of surrogates in guiding medical choice decisions for critically ill patients. However, the decision-making process places significant pressure on surrogates, forcing them to reach medical decisions quickly in collaboration with health professionals [ 5 , 6 ]. This pressure can lead to conflicts in decision-making and potentially disrupt the harmony of the medical-patient relationship, all exacerbated by the psychological strain of the possible loss of a loved one and time constraints.

Miller et al [ 4 ] noted that 30% of surrogates experienced anxiety and depression, and up to 50% even developed posttraumatic stress disorder. In addition, surrogates possess varying levels of information and knowledge regarding medical treatment, which can influence their capacity to assess and participate in medical decision-making, consequently affecting their ability to comprehend information while communicating with health professionals and making decisions on behalf of the patients [ 7 ].

However, with the advancement of health care technology and the catalyzing effect of the pandemic, the use of eHealth tools to assist surrogates in decision-making has become a trend. However, it may pose several challenges. For instance, surrogates may require time to learn to use these eHealth tools effectively [ 8 , 9 ]. Health care professionals must provide effective training and support to ensure that surrogates can fully use these tools. During the use of eHealth tools, there should also be a mechanism for immediate clarification if any doubts arise [ 8 , 10 ]. Furthermore, despite the use of eHealth tools, face-to-face communication remains essential for surrogates. Through in-person observations, one can understand and clarify considerations related to medical interventions stemming from different cultures and family backgrounds [ 10 ]. This is vital to genuinely assist surrogates in making informed decisions.

Use of eHealth Tools in Decision-Making

The term “eHealth” has gained popularity. In 2016, the World Health Organization (WHO) introduced the term to encompass the latest advancements in medical technology, particularly the use of information and communication technology (ICT) to enhance the function and efficiency of the health care system. eHealth encompasses more than just internet medicine; it also includes telehealth and telemedicine. It is a dynamic field that is in a constant state of evolution, signifying not only technological progress but also shifts in how we envision improving the health care landscape as well [ 11 , 12 ].

Scholars regard eHealth as an emerging domain of this generation. It is considered a highly convenient, easily accessible, and user-friendly tool that captures the attention of users [ 11 , 12 ]. Among the most widely used eHealth services is the dissemination of health care information through means such as QR codes, videos, and websites [ 9 ]. Many developing countries are transitioning away from paper-based methods, integrating hospital data through ICT, replacing conventional patient care models, and using technology to alleviate the workload on nursing staff to reduce unnecessary costs for individuals and society and alleviate economic and medical burdens. Research has revealed that over 50% of users seek health- or disease-related information through eHealth while up to 60% make decisions based on the information they find [ 8 ]. Moreover, in high-income countries, nearly 80% of adults regularly use the internet to access health information [ 10 ].

Furthermore, by disseminating pertinent medical and disease-related information through internet platforms and other channels, health professionals can enhance health care knowledge among the public, patients, and their families. This fosters greater awareness of illnesses and facilitates immediate diagnosis and treatment for health concerns, which significantly augments health literacy and diminishes the number of patients facing serious illnesses [ 10 ]. In recent years, there has been extensive use of the patient decision aid tools developed using eHealth technology. Some scholars even highlight the potential for eHealth to enhance equitable medical care for remote areas and among patients with limited mobility [ 10 ].

Nevertheless, health professionals should carefully consider whether eHealth is suitable for all groups and diseases as a decision-making tool. This is an issue that warrants our attention, as indiscriminate use across all demographics might not be advisable.

Challenges of Applying eHealth Tools

The application of eHealth tools can present a range of challenges, including economic disparities, information inaccuracies, and the potential exclusion of specific groups. For instance, government agencies should formulate policies and ensure the provision of adequate equipment. Failure to do so may result in unequal access to eHealth tools, favoring higher socioeconomic groups while leaving lower socioeconomic groups without access. This misalignment with the principle of equitable health care is a concern, as some medical institutions may initially refuse to offer services for marginalized groups such as Black communities and low-income individuals [ 9 ]. Consequently, a comprehensive support system should be in place before the implementation of eHealth tools.

When conveying medical and disease-related information, it is crucial to consider the risk of patients’ privacy being compromised or the possibility of conveying inaccurate and misleading messages [ 9 ]. For instance, Ruppert et al [ 13 ] searched for medical information on the social platform YouTube, focusing on terms such as skin cancer and sunscreen. Their findings indicated that up to 40% of the messages contained misinformation and 20% of the messages were potentially misleading [ 13 ]. Swartzendruber et al [ 14 ] explored the Women’s Resource Center of China and found that up to 53% of the content provided incorrect information about breast cancer treatment, with 84% of the website content being dedicated to advertising programs.

These findings underscore the fact that, despite the eHealth revolution, there are still numerous unresolved issues that require attention. In addition to effectively harnessing technology for caregiving, careful planning is essential to address the potential pitfalls associated with technology. In this era, where eHealth is a prevailing trend, it is crucial to consider how we can make better and more user-friendly use of it. Therefore, there is a need for tools to assess the suitability of patients for using eHealth tools.

eHealth Literacy and Assessment Tools

As medical technology advances, an increasing number of countries are actively promoting national health literacy through ICT. However, the main purpose of using eHealth technologies is to empower users to make informed health decisions by finding, comprehending, and discerning relevant health information, and then applying this knowledge to address health-related concerns [ 15 ]. It is important to note that eHealth differs from traditional health literacy in that it entails using electronic resources to access, understand, and distinguish pertinent health information and then apply this knowledge to deal with health issues [ 15 , 16 ]. It is a dynamic process influenced by factors such as the user's background, knowledge, educational level, and health status, and it can lead to different motivations and strategies in various contexts [ 15 , 17 ].

However, if only a limited number of people participate in or use the eHealth tools, the goal of universalization for these tools is compromised; accordingly, it is important to assess users’ capability and literacy level to provide them with appropriate eHealth tools to enhance their health literacy.

Norman and Skinner [ 15 ] introduced the eHealth Literacy Lily Model ( Figure 1 ), which consists of 2 categories, analytic and context-specific. The model comprises 6 various components of literacy: traditional, information, media, health, computer, and scientific. The analytic components (traditional, information, and media) mainly evaluate the users’ fundamental skills and are not directly tied to the content of health literacy. In contrast, the context-specific components (health, computer, and scientific) are more focused on context-specific and computational skills. The following section elaborates on these 6 components of the eHealth Literacy Lily Model. Table 1 provides more details.

Substantiating science-based online health messages in health literacy is a common approach, but it can be a significant challenge for individuals who lack adequate education. This is particularly true since users without these 6 core skills could face difficulties or obstacles when trying to adopt eHealth [ 9 , 15 ]. For this reason, assessing users’ health literacy has become an essential step before implementing eHealth, and the availability of quantitative data enables health professionals to provide evidence-based and useful eHealth tools for users.

Norman and Skinner [ 15 ] developed the eHealth Literacy Scale in English, although it has been subsequently translated into multiple languages including Amharic, traditional and simplified Chinese, Dutch, German, Greek, Hebrew, Hungarian, Indonesian, Italian, Korean, Persian, Polish, Portuguese, Norwegian, and Swedish [ 18 ]. The questionnaire consists of 8 questions rated on a 5-point Likert scale, ranging from 1 for “Not useful at all” to 5 for “Very Useful.” A total score range is 0-40, with higher scores indicating a better ability to use eHealth. A score of ≤31 points indicates a lower level of eHealth literacy. Previous studies have reported a high internal consistency coefficient α of .88 [ 19 , 20 ]. Further details are provided in Table 2 .

a 1: not useful at all.

b 2: not useful.

c 3: unsure.

d 4: useful.

e 5: very useful.

Clinical Scenario

In this section, we present a simulated clinical scenario to address the challenges associated with applying an eHealth tool. We then use the eHealth Literacy Lily Model and the eHealth Literacy Scale to analyze the situation and propose potential solutions.

Yuliya, a 68-year-old woman, lives with her husband, Eric. Their 2 children are working abroad, and they communicate via internet phone calls. Yuliya does not have any underlying medical conditions and regularly attends government-provided health checkups, following the advice of her neighbors. Her primary sources of health information are her children and neighbors.

Eric, on the other hand, has a complex medical history, including diabetes, chronic kidney disease stage IV, and congestive heart failure stage 2 according to the New York Heart Association. In 2020, Yuliya returned home to find Eric unconscious. After Eric was sent to the emergency room, his cognitive alertness was unclear, EVM of Glasgow Coma Scale (GCS) was E1V2M3; he was then diagnosed with COVID-19 (cycle threshold value 19.5 / polymerase chain reaction showed positive) and acute respiratory failure with chest x-ray showing pneumonia and SpO 2 range of 77%-82%. The doctor performed tracheal intubation with a ventilator, and Eric was subsequently transferred to the ICU. The doctor informed Yuliya that Eric's consciousness had not recovered and that he needed a computed tomography (CT) scan. The doctor hoped that Yuliya could make an immediate decision regarding the CT scan after the explanation. However, Yuliya was terrified and did not understand the doctor's explanation; nevertheless, she consented to the CT scan. Sadly, Eric was diagnosed with a hemorrhagic stroke of basal ganglia, and even after 2 weeks, he was still unable to breathe spontaneously due to the stroke and he remained in an unconscious state. The doctor recommended a tracheostomy for Eric, proposing that Eric needed long-term care in the future. However, Yuliya was faced with a difficult decision regarding the procedure.

To facilitate Yuliya’s understanding, the nurse provided her with a QR code to access a video. The nurse emphasized that the video contained information about tracheostomy procedures and care. Yuliya was instructed to watch the video and decide whether Eric should undergo the tracheostomy. However, Yuliya encountered challenges as she was unfamiliar with how to use the QR code, and she had limited literacy skills, with her only means of communication being in Taiwanese. Additionally, the video was in Chinese, which further compounded her difficulties. This left her with numerous unanswered questions and uncertainties.

Due to the time difference, Yuliya could not communicate with her children abroad in a timely manner, so upon returning home, Yuliya sought assistance from her neighbors to watch the video, but unfortunately, her neighbors could not operate the QR code either. Instead, they shared their limited knowledge of tracheostomy surgery, drawing from soap opera scenarios. This misconception led Yuliya to believe that patients who had strokes must be bedridden and entirely dependent on others for care.

Meanwhile, the Health Bureau contacted her and requested her to use a social distancing app to monitor Eric’s condition. Yuliya informed the contact person that she did not know how to use mobile phone apps or browse the internet.

Analysis of the Problem

After evaluating this case using the eHealth Literacy Lily Model and the eHealth Literacy Scale, it became clear that Yulia faced challenges in 6 components of literacy ( Table 3 ). Additionally, Yuliya’s total score on the eHealth Literacy Scale was 8, indicating her limited ability to use eHealth resources effectively.

Solution Strategies for This Clinical Scenario

According to the analytic type.

For individuals with limited traditional, information, and media literacy skills, it is highly recommended to facilitate communication through family meetings. Family meetings can provide comprehensive opportunities for health professionals, patients, or decision makers to exchange information, explain treatments, and clarify questions [ 21 ]. Effective communication skills are crucial in this process, and health professionals should use listening skills, questioning skills, and effective message delivery to enhance understanding and facilitate shared decision-making.

Listening Skills

Health professionals should encourage patients or surrogates to express their thoughts and concerns. By creating a safe space for open dialogue, they can increase the patients’ or surrogates’ willingness to communicate and provide emotional support. Observing nonverbal cues and summarizing patient or surrogate expectations can help ensure effective communication.

Questioning Skills

The use of open-ended and closed-ended questions is essential to discuss and clarify the patient's preferences and concerns. This approach allows health professionals to gain insight into patients’ or surrogates’ thoughts and needs.

Sending Messages

Health professionals must provide clear and understandable explanations of treatment options, avoiding the use of medical jargon or technical terms [ 22 ]. By offering evidence-based information and using empirical medical research findings to illustrate the advantages and disadvantages of each treatment option, they can empower patients to make informed decisions [ 23 ].

In this clinical scenario, the health professionals did not provide an appropriate environment or sufficient time for Yuliya to discuss Eric's medical treatment and address her concerns. Instead, they simply offered a QR code to access a video, assuming it would efficiently convey the necessary information. By using effective communication strategies during family meetings and providing patient-centered explanations and support, health professionals can significantly improve the decision-making process for patients with limited eHealth literacy.

According to the Context-Specific Type

Individuals with health, computer, and scientific literacy deficits might face significant challenges in accessing essential medical information, potentially leading to difficulties and delays in making informed medical decisions. To enhance individuals’ health literacy in such cases, the government can use various strategies including television advertisements, hospital promotions, public health clinic campaigns, and even celebrity endorsements to increase public awareness and understanding of health-related topics [ 2 ].

In the presented clinical scenario, health professionals could take a proactive approach by providing Yuliya with various prepared materials such as notebooks, pictures, DVDs, videos, QR codes, and apps. They should offer guidance on using these tools effectively and assess Yuliya’s understanding of the information provided by eHealth decision resources. The development of decision aids should adhere to specific criteria, including a rigorous and systematic process, the provision of scientific information and data on medical options, assistance in clarifying decision makers’ intentions and preferences, transparency regarding potential conflicts of interest, the avoidance of biased language that might lead to the selection of a particular medical option, and the exclusion of medical jargon or technical terms. Decision aids should provide evidence-based information to empower patients or surrogates to make informed choices [ 24 ].

Given the current global trend of an aging population, such decision-making aids are suitable for individuals older than 60 years, as they often have a higher demand for health care information. When creating these aids, it is essential to consider 3 critical components, economic costs, health and recovery aspects, and social and environmental support. Despite the increasing availability of technology-based decision-making aids, printed materials in large print, colorful chart cards, or brochures remain the most widely accepted format among patients and their surrogates, especially for more elderly populations [ 25 ].

Summaries of This Case

In this clinic scenario, health professionals did not consider Yuliya’s eHealth literacy when providing appropriate resources, even though she needed to make immediate decisions. To address this issue in the future, we recommend the following actions: first, health professionals should take the time to explain the conditions for a patient's admission to the ICU thoroughly. This includes providing clear information about the patient’s medical condition, the available treatment options, and the potential risks and benefits associated with each choice. Second, when circumstances permit, health professionals should engage in open and transparent communication with patients and their families. They should offer opportunities for patients to ask questions and express their concerns regarding daily urgent medical treatment decisions. Third, it is crucial to provide Yuliya and patients like her with sufficient and understandable information that empowers them to make informed decisions about their health care. This may involve using plain language, visual aids, or written materials to enhance their understanding.

By implementing these recommendations, health professionals could improve the overall patient experience and facilitate more effective shared decision-making, especially for individuals with limited eHealth literacy like Yuliya.

Recommendations for eHealth Issues in ICUs

Based on current development trends, the use of eHealth tools has become an irresistible trend. To address this issue in the future, we recommend the following actions: (1) education and training: ensure that all health professionals receive appropriate training on how to use eHealth tools; (2) when developing eHealth tools, it is crucial to ensure that the provided content is accurate, aligns with the needs and expectations of surrogates, and enhances usability through a user-friendly interface. Additionally, having real time technical support for clarification is essential to prevent any disruptions for surrogates during usage; and (3) conduct regular assessments of the eHealth tools and establish an evaluation framework that incorporates data and feedback for continuous updates and adjustments based on the surrogates' needs.

In summary, effectively integrating eHealth tools can improve the quality and efficiency of ICU care. However, it is imperative to ensure that these tools not only meet medical standards but also consider patient privacy and data security. Therefore, strategies such as education, interoperability, security, and user-friendliness are key to successfully meeting surrogates' expectations with eHealth tools.

Conclusions

In conclusion, the challenges associated with using eHealth decision resources to assist surrogates in ICU decision-making are multifaceted and require careful consideration. The high mortality rate in ICUs, when coupled with critical conditions, compels swift decision-making by surrogates, and the increasing popularity of eHealth tools adds complexity to this process.

The application of eHealth tools brings both opportunities and challenges. While these tools have the potential to disseminate important medical information and improve health care knowledge, they also present economic, informational, and inclusivity challenges. Economic disparities, information inaccuracies, and the risk of excluding specific groups must be addressed to ensure equitable access and benefit for all.

The eHealth Literacy Lily Model and the eHealth Literacy Scale are valuable tools for assessing individuals’ capability and literacy levels in using eHealth resources. To improve decision-making for individuals with limited eHealth literacy, both analytic and context-specific approaches are recommended. Effective communication through family meetings via using listening and questioning skills and providing patient-centered explanations can all enhance understanding and facilitate shared decision-making. Additionally, proactive measures such as using various materials, realia, and decision-making aids, can improve literacy in the health, computer, and scientific dimensions.

In summary, recognizing the time constraints and high-stakes nature of ICU decision-making, it is crucial to strike a balance between leveraging eHealth tools for efficiency and ensuring inclusivity. Health professionals should adopt a patient-centered approach, considering the diverse literacy levels and needs of individuals, especially those with limited eHealth literacy. Tailoring communication strategies, providing diverse materials, and assessing eHealth literacy levels using tools like the eHealth Literacy Scale are essential steps toward enhancing the effectiveness of eHealth decision resources in the ICU setting.

Conflicts of Interest

None declared.

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Abbreviations

Edited by A Mavragani; submitted 08.03.23; peer-reviewed by A Van Dongen, Y Chu, C Hudak; comments to author 21.06.23; revised version received 23.11.23; accepted 29.01.24; published 01.04.24.

©Wan-Na Sun, Chi-Yin Kao. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 01.04.2024.

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