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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.

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• What Is a Case Study? | Definition, Examples & Methods

What Is a Case Study? | Definition, Examples & Methods

Published on May 8, 2019 by Shona McCombes . Revised on November 20, 2023.

A case study is a detailed study of a specific subject, such as a person, group, place, event, organization, or phenomenon. Case studies are commonly used in social, educational, clinical, and business research.

A case study research design usually involves qualitative methods , but quantitative methods are sometimes also used. Case studies are good for describing , comparing, evaluating and understanding different aspects of a research problem .

Table of contents

When to do a case study, step 1: select a case, step 2: build a theoretical framework, step 3: collect your data, step 4: describe and analyze the case, other interesting articles.

A case study is an appropriate research design when you want to gain concrete, contextual, in-depth knowledge about a specific real-world subject. It allows you to explore the key characteristics, meanings, and implications of the case.

Case studies are often a good choice in a thesis or dissertation . They keep your project focused and manageable when you don’t have the time or resources to do large-scale research.

You might use just one complex case study where you explore a single subject in depth, or conduct multiple case studies to compare and illuminate different aspects of your research problem.

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Once you have developed your problem statement and research questions , you should be ready to choose the specific case that you want to focus on. A good case study should have the potential to:

• Provide new or unexpected insights into the subject
• Challenge or complicate existing assumptions and theories
• Propose practical courses of action to resolve a problem
• Open up new directions for future research

TipIf your research is more practical in nature and aims to simultaneously investigate an issue as you solve it, consider conducting action research instead.

Unlike quantitative or experimental research , a strong case study does not require a random or representative sample. In fact, case studies often deliberately focus on unusual, neglected, or outlying cases which may shed new light on the research problem.

Example of an outlying case studyIn the 1960s the town of Roseto, Pennsylvania was discovered to have extremely low rates of heart disease compared to the US average. It became an important case study for understanding previously neglected causes of heart disease.

However, you can also choose a more common or representative case to exemplify a particular category, experience or phenomenon.

Example of a representative case studyIn the 1920s, two sociologists used Muncie, Indiana as a case study of a typical American city that supposedly exemplified the changing culture of the US at the time.

While case studies focus more on concrete details than general theories, they should usually have some connection with theory in the field. This way the case study is not just an isolated description, but is integrated into existing knowledge about the topic. It might aim to:

• Exemplify a theory by showing how it explains the case under investigation
• Expand on a theory by uncovering new concepts and ideas that need to be incorporated
• Challenge a theory by exploring an outlier case that doesn’t fit with established assumptions

To ensure that your analysis of the case has a solid academic grounding, you should conduct a literature review of sources related to the topic and develop a theoretical framework . This means identifying key concepts and theories to guide your analysis and interpretation.

There are many different research methods you can use to collect data on your subject. Case studies tend to focus on qualitative data using methods such as interviews , observations , and analysis of primary and secondary sources (e.g., newspaper articles, photographs, official records). Sometimes a case study will also collect quantitative data.

Example of a mixed methods case studyFor a case study of a wind farm development in a rural area, you could collect quantitative data on employment rates and business revenue, collect qualitative data on local people’s perceptions and experiences, and analyze local and national media coverage of the development.

The aim is to gain as thorough an understanding as possible of the case and its context.

In writing up the case study, you need to bring together all the relevant aspects to give as complete a picture as possible of the subject.

How you report your findings depends on the type of research you are doing. Some case studies are structured like a standard scientific paper or thesis , with separate sections or chapters for the methods , results and discussion .

Others are written in a more narrative style, aiming to explore the case from various angles and analyze its meanings and implications (for example, by using textual analysis or discourse analysis ).

In all cases, though, make sure to give contextual details about the case, connect it back to the literature and theory, and discuss how it fits into wider patterns or debates.

If you want to know more about statistics , methodology , or research bias , make sure to check out some of our other articles with explanations and examples.

• Normal distribution
• Degrees of freedom
• Null hypothesis
• Discourse analysis
• Control groups
• Mixed methods research
• Non-probability sampling
• Quantitative research
• Ecological validity

Research bias

• Rosenthal effect
• Implicit bias
• Cognitive bias
• Selection bias
• Negativity bias
• Status quo bias

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A case study research paper examines a person, place, event, condition, phenomenon, or other type of subject of analysis in order to extrapolate  key themes and results that help predict future trends, illuminate previously hidden issues that can be applied to practice, and/or provide a means for understanding an important research problem with greater clarity. A case study research paper usually examines a single subject of analysis, but case study papers can also be designed as a comparative investigation that shows relationships between two or more subjects. The methods used to study a case can rest within a quantitative, qualitative, or mixed-method investigative paradigm.

Case Studies. Writing@CSU. Colorado State University; Mills, Albert J. , Gabrielle Durepos, and Eiden Wiebe, editors. Encyclopedia of Case Study Research . Thousand Oaks, CA: SAGE Publications, 2010 ; “What is a Case Study?” In Swanborn, Peter G. Case Study Research: What, Why and How? London: SAGE, 2010.

How to Approach Writing a Case Study Research Paper

General information about how to choose a topic to investigate can be found under the " Choosing a Research Problem " tab in the Organizing Your Social Sciences Research Paper writing guide. Review this page because it may help you identify a subject of analysis that can be investigated using a case study design.

However, identifying a case to investigate involves more than choosing the research problem . A case study encompasses a problem contextualized around the application of in-depth analysis, interpretation, and discussion, often resulting in specific recommendations for action or for improving existing conditions. As Seawright and Gerring note, practical considerations such as time and access to information can influence case selection, but these issues should not be the sole factors used in describing the methodological justification for identifying a particular case to study. Given this, selecting a case includes considering the following:

• The case represents an unusual or atypical example of a research problem that requires more in-depth analysis? Cases often represent a topic that rests on the fringes of prior investigations because the case may provide new ways of understanding the research problem. For example, if the research problem is to identify strategies to improve policies that support girl's access to secondary education in predominantly Muslim nations, you could consider using Azerbaijan as a case study rather than selecting a more obvious nation in the Middle East. Doing so may reveal important new insights into recommending how governments in other predominantly Muslim nations can formulate policies that support improved access to education for girls.
• The case provides important insight or illuminate a previously hidden problem? In-depth analysis of a case can be based on the hypothesis that the case study will reveal trends or issues that have not been exposed in prior research or will reveal new and important implications for practice. For example, anecdotal evidence may suggest drug use among homeless veterans is related to their patterns of travel throughout the day. Assuming prior studies have not looked at individual travel choices as a way to study access to illicit drug use, a case study that observes a homeless veteran could reveal how issues of personal mobility choices facilitate regular access to illicit drugs. Note that it is important to conduct a thorough literature review to ensure that your assumption about the need to reveal new insights or previously hidden problems is valid and evidence-based.
• The case challenges and offers a counter-point to prevailing assumptions? Over time, research on any given topic can fall into a trap of developing assumptions based on outdated studies that are still applied to new or changing conditions or the idea that something should simply be accepted as "common sense," even though the issue has not been thoroughly tested in current practice. A case study analysis may offer an opportunity to gather evidence that challenges prevailing assumptions about a research problem and provide a new set of recommendations applied to practice that have not been tested previously. For example, perhaps there has been a long practice among scholars to apply a particular theory in explaining the relationship between two subjects of analysis. Your case could challenge this assumption by applying an innovative theoretical framework [perhaps borrowed from another discipline] to explore whether this approach offers new ways of understanding the research problem. Taking a contrarian stance is one of the most important ways that new knowledge and understanding develops from existing literature.
• The case provides an opportunity to pursue action leading to the resolution of a problem? Another way to think about choosing a case to study is to consider how the results from investigating a particular case may result in findings that reveal ways in which to resolve an existing or emerging problem. For example, studying the case of an unforeseen incident, such as a fatal accident at a railroad crossing, can reveal hidden issues that could be applied to preventative measures that contribute to reducing the chance of accidents in the future. In this example, a case study investigating the accident could lead to a better understanding of where to strategically locate additional signals at other railroad crossings so as to better warn drivers of an approaching train, particularly when visibility is hindered by heavy rain, fog, or at night.
• The case offers a new direction in future research? A case study can be used as a tool for an exploratory investigation that highlights the need for further research about the problem. A case can be used when there are few studies that help predict an outcome or that establish a clear understanding about how best to proceed in addressing a problem. For example, after conducting a thorough literature review [very important!], you discover that little research exists showing the ways in which women contribute to promoting water conservation in rural communities of east central Africa. A case study of how women contribute to saving water in a rural village of Uganda can lay the foundation for understanding the need for more thorough research that documents how women in their roles as cooks and family caregivers think about water as a valuable resource within their community. This example of a case study could also point to the need for scholars to build new theoretical frameworks around the topic [e.g., applying feminist theories of work and family to the issue of water conservation].

Eisenhardt, Kathleen M. “Building Theories from Case Study Research.” Academy of Management Review 14 (October 1989): 532-550; Emmel, Nick. Sampling and Choosing Cases in Qualitative Research: A Realist Approach . Thousand Oaks, CA: SAGE Publications, 2013; Gerring, John. “What Is a Case Study and What Is It Good for?” American Political Science Review 98 (May 2004): 341-354; Mills, Albert J. , Gabrielle Durepos, and Eiden Wiebe, editors. Encyclopedia of Case Study Research . Thousand Oaks, CA: SAGE Publications, 2010; Seawright, Jason and John Gerring. "Case Selection Techniques in Case Study Research." Political Research Quarterly 61 (June 2008): 294-308.

Structure and Writing Style

The purpose of a paper in the social sciences designed around a case study is to thoroughly investigate a subject of analysis in order to reveal a new understanding about the research problem and, in so doing, contributing new knowledge to what is already known from previous studies. In applied social sciences disciplines [e.g., education, social work, public administration, etc.], case studies may also be used to reveal best practices, highlight key programs, or investigate interesting aspects of professional work.

In general, the structure of a case study research paper is not all that different from a standard college-level research paper. However, there are subtle differences you should be aware of. Here are the key elements to organizing and writing a case study research paper.

I.  Introduction

As with any research paper, your introduction should serve as a roadmap for your readers to ascertain the scope and purpose of your study . The introduction to a case study research paper, however, should not only describe the research problem and its significance, but you should also succinctly describe why the case is being used and how it relates to addressing the problem. The two elements should be linked. With this in mind, a good introduction answers these four questions:

• What is being studied? Describe the research problem and describe the subject of analysis [the case] you have chosen to address the problem. Explain how they are linked and what elements of the case will help to expand knowledge and understanding about the problem.
• Why is this topic important to investigate? Describe the significance of the research problem and state why a case study design and the subject of analysis that the paper is designed around is appropriate in addressing the problem.
• What did we know about this topic before I did this study? Provide background that helps lead the reader into the more in-depth literature review to follow. If applicable, summarize prior case study research applied to the research problem and why it fails to adequately address the problem. Describe why your case will be useful. If no prior case studies have been used to address the research problem, explain why you have selected this subject of analysis.
• How will this study advance new knowledge or new ways of understanding? Explain why your case study will be suitable in helping to expand knowledge and understanding about the research problem.

Each of these questions should be addressed in no more than a few paragraphs. Exceptions to this can be when you are addressing a complex research problem or subject of analysis that requires more in-depth background information.

II.  Literature Review

The literature review for a case study research paper is generally structured the same as it is for any college-level research paper. The difference, however, is that the literature review is focused on providing background information and  enabling historical interpretation of the subject of analysis in relation to the research problem the case is intended to address . This includes synthesizing studies that help to:

• Place relevant works in the context of their contribution to understanding the case study being investigated . This would involve summarizing studies that have used a similar subject of analysis to investigate the research problem. If there is literature using the same or a very similar case to study, you need to explain why duplicating past research is important [e.g., conditions have changed; prior studies were conducted long ago, etc.].
• Describe the relationship each work has to the others under consideration that informs the reader why this case is applicable . Your literature review should include a description of any works that support using the case to investigate the research problem and the underlying research questions.
• Identify new ways to interpret prior research using the case study . If applicable, review any research that has examined the research problem using a different research design. Explain how your use of a case study design may reveal new knowledge or a new perspective or that can redirect research in an important new direction.
• Resolve conflicts amongst seemingly contradictory previous studies . This refers to synthesizing any literature that points to unresolved issues of concern about the research problem and describing how the subject of analysis that forms the case study can help resolve these existing contradictions.
• Point the way in fulfilling a need for additional research . Your review should examine any literature that lays a foundation for understanding why your case study design and the subject of analysis around which you have designed your study may reveal a new way of approaching the research problem or offer a perspective that points to the need for additional research.
• Expose any gaps that exist in the literature that the case study could help to fill . Summarize any literature that not only shows how your subject of analysis contributes to understanding the research problem, but how your case contributes to a new way of understanding the problem that prior research has failed to do.
• Locate your own research within the context of existing literature [very important!] . Collectively, your literature review should always place your case study within the larger domain of prior research about the problem. The overarching purpose of reviewing pertinent literature in a case study paper is to demonstrate that you have thoroughly identified and synthesized prior studies in relation to explaining the relevance of the case in addressing the research problem.

III.  Method

In this section, you explain why you selected a particular case [i.e., subject of analysis] and the strategy you used to identify and ultimately decide that your case was appropriate in addressing the research problem. The way you describe the methods used varies depending on the type of subject of analysis that constitutes your case study.

If your subject of analysis is an incident or event . In the social and behavioral sciences, the event or incident that represents the case to be studied is usually bounded by time and place, with a clear beginning and end and with an identifiable location or position relative to its surroundings. The subject of analysis can be a rare or critical event or it can focus on a typical or regular event. The purpose of studying a rare event is to illuminate new ways of thinking about the broader research problem or to test a hypothesis. Critical incident case studies must describe the method by which you identified the event and explain the process by which you determined the validity of this case to inform broader perspectives about the research problem or to reveal new findings. However, the event does not have to be a rare or uniquely significant to support new thinking about the research problem or to challenge an existing hypothesis. For example, Walo, Bull, and Breen conducted a case study to identify and evaluate the direct and indirect economic benefits and costs of a local sports event in the City of Lismore, New South Wales, Australia. The purpose of their study was to provide new insights from measuring the impact of a typical local sports event that prior studies could not measure well because they focused on large "mega-events." Whether the event is rare or not, the methods section should include an explanation of the following characteristics of the event: a) when did it take place; b) what were the underlying circumstances leading to the event; and, c) what were the consequences of the event in relation to the research problem.

If your subject of analysis is a person. Explain why you selected this particular individual to be studied and describe what experiences they have had that provide an opportunity to advance new understandings about the research problem. Mention any background about this person which might help the reader understand the significance of their experiences that make them worthy of study. This includes describing the relationships this person has had with other people, institutions, and/or events that support using them as the subject for a case study research paper. It is particularly important to differentiate the person as the subject of analysis from others and to succinctly explain how the person relates to examining the research problem [e.g., why is one politician in a particular local election used to show an increase in voter turnout from any other candidate running in the election]. Note that these issues apply to a specific group of people used as a case study unit of analysis [e.g., a classroom of students].

If your subject of analysis is a place. In general, a case study that investigates a place suggests a subject of analysis that is unique or special in some way and that this uniqueness can be used to build new understanding or knowledge about the research problem. A case study of a place must not only describe its various attributes relevant to the research problem [e.g., physical, social, historical, cultural, economic, political], but you must state the method by which you determined that this place will illuminate new understandings about the research problem. It is also important to articulate why a particular place as the case for study is being used if similar places also exist [i.e., if you are studying patterns of homeless encampments of veterans in open spaces, explain why you are studying Echo Park in Los Angeles rather than Griffith Park?]. If applicable, describe what type of human activity involving this place makes it a good choice to study [e.g., prior research suggests Echo Park has more homeless veterans].

If your subject of analysis is a phenomenon. A phenomenon refers to a fact, occurrence, or circumstance that can be studied or observed but with the cause or explanation to be in question. In this sense, a phenomenon that forms your subject of analysis can encompass anything that can be observed or presumed to exist but is not fully understood. In the social and behavioral sciences, the case usually focuses on human interaction within a complex physical, social, economic, cultural, or political system. For example, the phenomenon could be the observation that many vehicles used by ISIS fighters are small trucks with English language advertisements on them. The research problem could be that ISIS fighters are difficult to combat because they are highly mobile. The research questions could be how and by what means are these vehicles used by ISIS being supplied to the militants and how might supply lines to these vehicles be cut off? How might knowing the suppliers of these trucks reveal larger networks of collaborators and financial support? A case study of a phenomenon most often encompasses an in-depth analysis of a cause and effect that is grounded in an interactive relationship between people and their environment in some way.

NOTE:   The choice of the case or set of cases to study cannot appear random. Evidence that supports the method by which you identified and chose your subject of analysis should clearly support investigation of the research problem and linked to key findings from your literature review. Be sure to cite any studies that helped you determine that the case you chose was appropriate for examining the problem.

IV.  Discussion

The main elements of your discussion section are generally the same as any research paper, but centered around interpreting and drawing conclusions about the key findings from your analysis of the case study. Note that a general social sciences research paper may contain a separate section to report findings. However, in a paper designed around a case study, it is common to combine a description of the results with the discussion about their implications. The objectives of your discussion section should include the following:

Reiterate the Research Problem/State the Major Findings Briefly reiterate the research problem you are investigating and explain why the subject of analysis around which you designed the case study were used. You should then describe the findings revealed from your study of the case using direct, declarative, and succinct proclamation of the study results. Highlight any findings that were unexpected or especially profound.

Explain the Meaning of the Findings and Why They are Important Systematically explain the meaning of your case study findings and why you believe they are important. Begin this part of the section by repeating what you consider to be your most important or surprising finding first, then systematically review each finding. Be sure to thoroughly extrapolate what your analysis of the case can tell the reader about situations or conditions beyond the actual case that was studied while, at the same time, being careful not to misconstrue or conflate a finding that undermines the external validity of your conclusions.

Relate the Findings to Similar Studies No study in the social sciences is so novel or possesses such a restricted focus that it has absolutely no relation to previously published research. The discussion section should relate your case study results to those found in other studies, particularly if questions raised from prior studies served as the motivation for choosing your subject of analysis. This is important because comparing and contrasting the findings of other studies helps support the overall importance of your results and it highlights how and in what ways your case study design and the subject of analysis differs from prior research about the topic.

Consider Alternative Explanations of the Findings Remember that the purpose of social science research is to discover and not to prove. When writing the discussion section, you should carefully consider all possible explanations revealed by the case study results, rather than just those that fit your hypothesis or prior assumptions and biases. Be alert to what the in-depth analysis of the case may reveal about the research problem, including offering a contrarian perspective to what scholars have stated in prior research if that is how the findings can be interpreted from your case.

Acknowledge the Study's Limitations You can state the study's limitations in the conclusion section of your paper but describing the limitations of your subject of analysis in the discussion section provides an opportunity to identify the limitations and explain why they are not significant. This part of the discussion section should also note any unanswered questions or issues your case study could not address. More detailed information about how to document any limitations to your research can be found here .

Suggest Areas for Further Research Although your case study may offer important insights about the research problem, there are likely additional questions related to the problem that remain unanswered or findings that unexpectedly revealed themselves as a result of your in-depth analysis of the case. Be sure that the recommendations for further research are linked to the research problem and that you explain why your recommendations are valid in other contexts and based on the original assumptions of your study.

V.  Conclusion

As with any research paper, you should summarize your conclusion in clear, simple language; emphasize how the findings from your case study differs from or supports prior research and why. Do not simply reiterate the discussion section. Provide a synthesis of key findings presented in the paper to show how these converge to address the research problem. If you haven't already done so in the discussion section, be sure to document the limitations of your case study and any need for further research.

The function of your paper's conclusion is to: 1) reiterate the main argument supported by the findings from your case study; 2) state clearly the context, background, and necessity of pursuing the research problem using a case study design in relation to an issue, controversy, or a gap found from reviewing the literature; and, 3) provide a place to persuasively and succinctly restate the significance of your research problem, given that the reader has now been presented with in-depth information about the topic.

Consider the following points to help ensure your conclusion is appropriate:

• If the argument or purpose of your paper is complex, you may need to summarize these points for your reader.
• If prior to your conclusion, you have not yet explained the significance of your findings or if you are proceeding inductively, use the conclusion of your paper to describe your main points and explain their significance.
• Move from a detailed to a general level of consideration of the case study's findings that returns the topic to the context provided by the introduction or within a new context that emerges from your case study findings.

Note that, depending on the discipline you are writing in or the preferences of your professor, the concluding paragraph may contain your final reflections on the evidence presented as it applies to practice or on the essay's central research problem. However, the nature of being introspective about the subject of analysis you have investigated will depend on whether you are explicitly asked to express your observations in this way.

Problems to Avoid

Overgeneralization One of the goals of a case study is to lay a foundation for understanding broader trends and issues applied to similar circumstances. However, be careful when drawing conclusions from your case study. They must be evidence-based and grounded in the results of the study; otherwise, it is merely speculation. Looking at a prior example, it would be incorrect to state that a factor in improving girls access to education in Azerbaijan and the policy implications this may have for improving access in other Muslim nations is due to girls access to social media if there is no documentary evidence from your case study to indicate this. There may be anecdotal evidence that retention rates were better for girls who were engaged with social media, but this observation would only point to the need for further research and would not be a definitive finding if this was not a part of your original research agenda.

Failure to Document Limitations No case is going to reveal all that needs to be understood about a research problem. Therefore, just as you have to clearly state the limitations of a general research study , you must describe the specific limitations inherent in the subject of analysis. For example, the case of studying how women conceptualize the need for water conservation in a village in Uganda could have limited application in other cultural contexts or in areas where fresh water from rivers or lakes is plentiful and, therefore, conservation is understood more in terms of managing access rather than preserving access to a scarce resource.

Failure to Extrapolate All Possible Implications Just as you don't want to over-generalize from your case study findings, you also have to be thorough in the consideration of all possible outcomes or recommendations derived from your findings. If you do not, your reader may question the validity of your analysis, particularly if you failed to document an obvious outcome from your case study research. For example, in the case of studying the accident at the railroad crossing to evaluate where and what types of warning signals should be located, you failed to take into consideration speed limit signage as well as warning signals. When designing your case study, be sure you have thoroughly addressed all aspects of the problem and do not leave gaps in your analysis that leave the reader questioning the results.

Case Studies. Writing@CSU. Colorado State University; Gerring, John. Case Study Research: Principles and Practices . New York: Cambridge University Press, 2007; Merriam, Sharan B. Qualitative Research and Case Study Applications in Education . Rev. ed. San Francisco, CA: Jossey-Bass, 1998; Miller, Lisa L. “The Use of Case Studies in Law and Social Science Research.” Annual Review of Law and Social Science 14 (2018): TBD; Mills, Albert J., Gabrielle Durepos, and Eiden Wiebe, editors. Encyclopedia of Case Study Research . Thousand Oaks, CA: SAGE Publications, 2010; Putney, LeAnn Grogan. "Case Study." In Encyclopedia of Research Design , Neil J. Salkind, editor. (Thousand Oaks, CA: SAGE Publications, 2010), pp. 116-120; Simons, Helen. Case Study Research in Practice . London: SAGE Publications, 2009;  Kratochwill,  Thomas R. and Joel R. Levin, editors. Single-Case Research Design and Analysis: New Development for Psychology and Education .  Hilldsale, NJ: Lawrence Erlbaum Associates, 1992; Swanborn, Peter G. Case Study Research: What, Why and How? London : SAGE, 2010; Yin, Robert K. Case Study Research: Design and Methods . 6th edition. Los Angeles, CA, SAGE Publications, 2014; Walo, Maree, Adrian Bull, and Helen Breen. “Achieving Economic Benefits at Local Events: A Case Study of a Local Sports Event.” Festival Management and Event Tourism 4 (1996): 95-106.

Writing Tip

At Least Five Misconceptions about Case Study Research

Social science case studies are often perceived as limited in their ability to create new knowledge because they are not randomly selected and findings cannot be generalized to larger populations. Flyvbjerg examines five misunderstandings about case study research and systematically "corrects" each one. To quote, these are:

Misunderstanding 1 :  General, theoretical [context-independent] knowledge is more valuable than concrete, practical [context-dependent] knowledge. Misunderstanding 2 :  One cannot generalize on the basis of an individual case; therefore, the case study cannot contribute to scientific development. Misunderstanding 3 :  The case study is most useful for generating hypotheses; that is, in the first stage of a total research process, whereas other methods are more suitable for hypotheses testing and theory building. Misunderstanding 4 :  The case study contains a bias toward verification, that is, a tendency to confirm the researcher’s preconceived notions. Misunderstanding 5 :  It is often difficult to summarize and develop general propositions and theories on the basis of specific case studies [p. 221].

While writing your paper, think introspectively about how you addressed these misconceptions because to do so can help you strengthen the validity and reliability of your research by clarifying issues of case selection, the testing and challenging of existing assumptions, the interpretation of key findings, and the summation of case outcomes. Think of a case study research paper as a complete, in-depth narrative about the specific properties and key characteristics of your subject of analysis applied to the research problem.

Flyvbjerg, Bent. “Five Misunderstandings About Case-Study Research.” Qualitative Inquiry 12 (April 2006): 219-245.

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Writing a Case Study

What is a case study?

A Case study is: 

• An in-depth research design that primarily uses a qualitative methodology but sometimes​​ includes quantitative methodology.
• Used to examine an identifiable problem confirmed through research.
• Used to investigate an individual, group of people, organization, or event.
• Used to mostly answer "how" and "why" questions.

What are the different types of case studies?

Note: These are the primary case studies. As you continue to research and learn

about case studies you will begin to find a robust list of different types. 

Who are your case study participants?

What is triangulation ? 

Validity and credibility are an essential part of the case study. Therefore, the researcher should include triangulation to ensure trustworthiness while accurately reflecting what the researcher seeks to investigate.

How to write a Case Study?

When developing a case study, there are different ways you could present the information, but remember to include the five parts for your case study.

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What Is a Case Study?

Weighing the pros and cons of this method of research

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

Cara Lustik is a fact-checker and copywriter.

Verywell / Colleen Tighe

• Pros and Cons

What Types of Case Studies Are Out There?

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

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

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

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

At a Glance

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

What Are the Benefits and Limitations of Case Studies?

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

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

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

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

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

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

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

Case Study Examples

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

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

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

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

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

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

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

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

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

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

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

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

Section 1: A Case History

This section will have the following structure and content:

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

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

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

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

Section 2: Treatment Plan

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

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

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

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

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

Need More Tips?

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

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

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

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

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

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

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

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Guidelines to the writing of case studies

Dr. brian budgell.

* Département chiropratique, Université du Québec à Trois-Rivières, 3351, boul des Forges, Trois-Rivières, Qc, Canada G9A 5H7

Dr. Brian Budgell, DC, PhD, JCCA Editorial Board

• Introduction

Case studies are an invaluable record of the clinical practices of a profession. While case studies cannot provide specific guidance for the management of successive patients, they are a record of clinical interactions which help us to frame questions for more rigorously designed clinical studies. Case studies also provide valuable teaching material, demonstrating both classical and unusual presentations which may confront the practitioner. Quite obviously, since the overwhelming majority of clinical interactions occur in the field, not in teaching or research facilities, it falls to the field practitioner to record and pass on their experiences. However, field practitioners generally are not well-practised in writing for publication, and so may hesitate to embark on the task of carrying a case study to publication. These guidelines are intended to assist the relatively novice writer – practitioner or student – in efficiently navigating the relatively easy course to publication of a quality case study. Guidelines are not intended to be proscriptive, and so throughout this document we advise what authors “may” or “should” do, rather than what they “must” do. Authors may decide that the particular circumstances of their case study justify digression from our recommendations.

Additional and useful resources for chiropractic case studies include:

• Waalen JK. Single subject research designs. J Can Chirop Assoc 1991; 35(2):95–97.
• Gleberzon BJ. A peer-reviewer’s plea. J Can Chirop Assoc 2006; 50(2):107.
• Merritt L. Case reports: an important contribution to chiropractic literature. J Can Chiropr Assoc 2007; 51(2):72–74.

Portions of these guidelines were derived from Budgell B. Writing a biomedical research paper. Tokyo: Springer Japan KK, 2008.

General Instructions

This set of guidelines provides both instructions and a template for the writing of case reports for publication. You might want to skip forward and take a quick look at the template now, as we will be using it as the basis for your own case study later on. While the guidelines and template contain much detail, your finished case study should be only 500 to 1,500 words in length. Therefore, you will need to write efficiently and avoid unnecessarily flowery language.

These guidelines for the writing of case studies are designed to be consistent with the “Uniform Requirements for Manuscripts Submitted to Biomedical Journals” referenced elsewhere in the JCCA instructions to authors.

After this brief introduction, the guidelines below will follow the headings of our template. Hence, it is possible to work section by section through the template to quickly produce a first draft of your study. To begin with, however, you must have a clear sense of the value of the study which you wish to describe. Therefore, before beginning to write the study itself, you should gather all of the materials relevant to the case – clinical notes, lab reports, x-rays etc. – and form a clear picture of the story that you wish to share with your profession. At the most superficial level, you may want to ask yourself “What is interesting about this case?” Keep your answer in mind as your write, because sometimes we become lost in our writing and forget the message that we want to convey.

Another important general rule for writing case studies is to stick to the facts. A case study should be a fairly modest description of what actually happened. Speculation about underlying mechanisms of the disease process or treatment should be restrained. Field practitioners and students are seldom well-prepared to discuss physiology or pathology. This is best left to experts in those fields. The thing of greatest value that you can provide to your colleagues is an honest record of clinical events.

Finally, remember that a case study is primarily a chronicle of a patient’s progress, not a story about chiropractic. Editorial or promotional remarks do not belong in a case study, no matter how great our enthusiasm. It is best to simply tell the story and let the outcome speak for itself. With these points in mind, let’s begin the process of writing the case study:

• Title: The title page will contain the full title of the article. Remember that many people may find our article by searching on the internet. They may have to decide, just by looking at the title, whether or not they want to access the full article. A title which is vague or non-specific may not attract their attention. Thus, our title should contain the phrase “case study,” “case report” or “case series” as is appropriate to the contents. The two most common formats of titles are nominal and compound. A nominal title is a single phrase, for example “A case study of hypertension which responded to spinal manipulation.” A compound title consists of two phrases in succession, for example “Response of hypertension to spinal manipulation: a case study.” Keep in mind that titles of articles in leading journals average between 8 and 9 words in length.
• Other contents for the title page should be as in the general JCCA instructions to authors. Remember that for a case study, we would not expect to have more than one or two authors. In order to be listed as an author, a person must have an intellectual stake in the writing – at the very least they must be able to explain and even defend the article. Someone who has only provided technical assistance, as valuable as that may be, may be acknowledged at the end of the article, but would not be listed as an author. Contact information – either home or institutional – should be provided for each author along with the authors’ academic qualifications. If there is more than one author, one author must be identified as the corresponding author – the person whom people should contact if they have questions or comments about the study.
• Key words: Provide key words under which the article will be listed. These are the words which would be used when searching for the article using a search engine such as Medline. When practical, we should choose key words from a standard list of keywords, such as MeSH (Medical subject headings). A copy of MeSH is available in most libraries. If we can’t access a copy and we want to make sure that our keywords are included in the MeSH library, we can visit this address: http://www.ncbi.nlm.nih.gov:80/entrez/meshbrowser.cgi

A narrative abstract consists of a short version of the whole paper. There are no headings within the narrative abstract. The author simply tries to summarize the paper into a story which flows logically.

A structured abstract uses subheadings. Structured abstracts are becoming more popular for basic scientific and clinical studies, since they standardize the abstract and ensure that certain information is included. This is very useful for readers who search for articles on the internet. Often the abstract is displayed by a search engine, and on the basis of the abstract the reader will decide whether or not to download the full article (which may require payment of a fee). With a structured abstract, the reader is more likely to be given the information which they need to decide whether to go on to the full article, and so this style is encouraged. The JCCA recommends the use of structured abstracts for case studies.

Since they are summaries, both narrative and structured abstracts are easier to write once we have finished the rest of the article. We include a template for a structured abstract and encourage authors to make use of it. Our sub-headings will be:

• Introduction: This consists of one or two sentences to describe the context of the case and summarize the entire article.
• Case presentation: Several sentences describe the history and results of any examinations performed. The working diagnosis and management of the case are described.
• Management and Outcome: Simply describe the course of the patient’s complaint. Where possible, make reference to any outcome measures which you used to objectively demonstrate how the patient’s condition evolved through the course of management.
• Discussion: Synthesize the foregoing subsections and explain both correlations and apparent inconsistencies. If appropriate to the case, within one or two sentences describe the lessons to be learned.
• Introduction: At the beginning of these guidelines we suggested that we need to have a clear idea of what is particularly interesting about the case we want to describe. The introduction is where we convey this to the reader. It is useful to begin by placing the study in a historical or social context. If similar cases have been reported previously, we describe them briefly. If there is something especially challenging about the diagnosis or management of the condition that we are describing, now is our chance to bring that out. Each time we refer to a previous study, we cite the reference (usually at the end of the sentence). Our introduction doesn’t need to be more than a few paragraphs long, and our objective is to have the reader understand clearly, but in a general sense, why it is useful for them to be reading about this case.

The next step is to describe the results of our clinical examination. Again, we should write in an efficient narrative style, restricting ourselves to the relevant information. It is not necessary to include every detail in our clinical notes.

If we are using a named orthopedic or neurological test, it is best to both name and describe the test (since some people may know the test by a different name). Also, we should describe the actual results, since not all readers will have the same understanding of what constitutes a “positive” or “negative” result.

X-rays or other images are only helpful if they are clear enough to be easily reproduced and if they are accompanied by a legend. Be sure that any information that might identify a patient is removed before the image is submitted.

At this point, or at the beginning of the next section, we will want to present our working diagnosis or clinical impression of the patient.

It is useful for the reader to know how long the patient was under care and how many times they were treated. Additionally, we should be as specific as possible in describing the treatment that we used. It does not help the reader to simply say that the patient received “chiropractic care.” Exactly what treatment did we use? If we used spinal manipulation, it is best to name the technique, if a common name exists, and also to describe the manipulation. Remember that our case study may be read by people who are not familiar with spinal manipulation, and, even within chiropractic circles, nomenclature for technique is not well standardized.

We may want to include the patient’s own reports of improvement or worsening. However, whenever possible we should try to use a well-validated method of measuring their improvement. For case studies, it may be possible to use data from visual analogue scales (VAS) for pain, or a journal of medication usage.

It is useful to include in this section an indication of how and why treatment finished. Did we decide to terminate care, and if so, why? Did the patient withdraw from care or did we refer them to another practitioner?

• Discussion: In this section we may want to identify any questions that the case raises. It is not our duty to provide a complete physiological explanation for everything that we observed. This is usually impossible. Nor should we feel obligated to list or generate all of the possible hypotheses that might explain the course of the patient’s condition. If there is a well established item of physiology or pathology which illuminates the case, we certainly include it, but remember that we are writing what is primarily a clinical chronicle, not a basic scientific paper. Finally, we summarize the lessons learned from this case.
• Acknowledgments: If someone provided assistance with the preparation of the case study, we thank them briefly. It is neither necessary nor conventional to thank the patient (although we appreciate what they have taught us). It would generally be regarded as excessive and inappropriate to thank others, such as teachers or colleagues who did not directly participate in preparation of the paper.

A popular search engine for English-language references is Medline: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi

• Legends: If we used any tables, figures or photographs, they should be accompanied by a succinct explanation. A good rule for graphs is that they should contain sufficient information to be generally decipherable without reference to a legend.
• Tables, figures and photographs should be included at the end of the manuscript.
• Permissions: If any tables, figures or photographs, or substantial quotations, have been borrowed from other publications, we must include a letter of permission from the publisher. Also, if we use any photographs which might identify a patient, we will need their written permission.

In addition, patient consent to publish the case report is also required.

Running Header:

• Name, academic degrees and affiliation

Name, address and telephone number of corresponding author

Disclaimers

Statement that patient consent was obtained

Sources of financial support, if any

Key words: (limit of five)

Abstract: (maximum of 150 words)

• Case Presentation
• Management and Outcome

Introduction:

Provide a context for the case and describe any similar cases previously reported.

Case Presentation:

• Introductory sentence: e.g. This 25 year old female office worker presented for the treatment of recurrent headaches.
• Describe the essential nature of the complaint, including location, intensity and associated symptoms: e.g. Her headaches are primarily in the suboccipital region, bilaterally but worse on the right. Sometimes there is radiation towards the right temple. She describes the pain as having an intensity of up to 5 out of ten, accompanied by a feeling of tension in the back of the head. When the pain is particularly bad, she feels that her vision is blurred.
• Further development of history including details of time and circumstances of onset, and the evolution of the complaint: e.g. This problem began to develop three years ago when she commenced work as a data entry clerk. Her headaches have increased in frequency in the past year, now occurring three to four days per week.
• Describe relieving and aggravating factors, including responses to other treatment: e.g. The pain seems to be worse towards the end of the work day and is aggravated by stress. Aspirin provides some relieve. She has not sought any other treatment.
• Include other health history, if relevant: e.g. Otherwise the patient reports that she is in good health.
• Include family history, if relevant: e.g. There is no family history of headaches.
• Summarize the results of examination, which might include general observation and postural analysis, orthopedic exam, neurological exam and chiropractic examination (static and motion palpation): e.g. Examination revealed an otherwise fit-looking young woman with slight anterior carriage of the head. Cervical active ranges of motion were full and painless except for some slight restriction of left lateral bending and rotation of the head to the left. These motions were accompanied by discomfort in the right side of the neck. Cervical compression of the neck in the neutral position did not create discomfort. However, compression of the neck in right rotation and extension produced some right suboccipital pain. Cranial nerve examination was normal. Upper limb motor, sensory and reflex functions were normal. With the patient in the supine position, static palpation revealed tender trigger points bilaterally in the cervical musculature and right trapezius. Motion palpation revealed restrictions of right and left rotation in the upper cervical spine, and restriction of left lateral bending in the mid to lower cervical spine. Blood pressure was 110/70. Houle’s test (holding the neck in extension and rotation for 30 seconds) did not produce nystagmus or dizziness. There were no carotid bruits.
• The patient was diagnosed with cervicogenic headache due to chronic postural strain.

Management and Outcome:

• Describe as specifically as possible the treatment provided, including the nature of the treatment, and the frequency and duration of care: e.g. The patient undertook a course of treatment consisting of cervical and upper thoracic spinal manipulation three times per week for two weeks. Manipulation was accompanied by trigger point therapy to the paraspinal muscles and stretching of the upper trapezius. Additionally, advice was provided concerning maintenance of proper posture at work. The patient was also instructed in the use of a cervical pillow.
• If possible, refer to objective measures of the patient’s progress: e.g. The patient maintained a headache diary indicating that she had two headaches during the first week of care, and one headache the following week. Furthermore the intensity of her headaches declined throughout the course of treatment.
• Describe the resolution of care: e.g. Based on the patient’s reported progress during the first two weeks of care, she received an additional two treatments in each of the subsequent two weeks. During the last week of care she experienced no headaches and reported feeling generally more energetic than before commencing care. Following a total of four weeks of care (10 treatments) she was discharged.

Discussion:

Synthesize foregoing sections: e.g. The distinction between migraine and cervicogenic headache is not always clear. However, this case demonstrates several features …

Summarize the case and any lessons learned: e.g. This case demonstrates a classical presentation of cervicogenic headache which resolved quickly with a course of spinal manipulation, supportive soft-tissue therapy and postural advice.

References: (using Vancouver style) e.g.

1 Terret AGJ. Vertebrogenic hearing deficit, the spine and spinal manipulation therapy: a search to validate the DD Palmer/Harvey Lillard experience. Chiropr J Aust 2002; 32:14–26.

Legends: (tables, figures or images are numbered according to the order in which they appear in the text.) e.g.

Figure 1: Intensity of headaches as recorded on a visual analogue scale (vertical axis) versus time (horizontal axis) during the four weeks that the patient was under care. Treatment was given on days 1, 3, 5, 8, 10, 12, 15, 18, 22 and 25. Headache frequency and intensity is seen to fall over time.

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• Case Study | Definition, Examples & Methods

Case Study | Definition, Examples & Methods

Published on 5 May 2022 by Shona McCombes . Revised on 30 January 2023.

A case study is a detailed study of a specific subject, such as a person, group, place, event, organisation, or phenomenon. Case studies are commonly used in social, educational, clinical, and business research.

A case study research design usually involves qualitative methods , but quantitative methods are sometimes also used. Case studies are good for describing , comparing, evaluating, and understanding different aspects of a research problem .

Table of contents

When to do a case study, step 1: select a case, step 2: build a theoretical framework, step 3: collect your data, step 4: describe and analyse the case.

A case study is an appropriate research design when you want to gain concrete, contextual, in-depth knowledge about a specific real-world subject. It allows you to explore the key characteristics, meanings, and implications of the case.

Case studies are often a good choice in a thesis or dissertation . They keep your project focused and manageable when you don’t have the time or resources to do large-scale research.

You might use just one complex case study where you explore a single subject in depth, or conduct multiple case studies to compare and illuminate different aspects of your research problem.

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Once you have developed your problem statement and research questions , you should be ready to choose the specific case that you want to focus on. A good case study should have the potential to:

• Provide new or unexpected insights into the subject
• Challenge or complicate existing assumptions and theories
• Propose practical courses of action to resolve a problem
• Open up new directions for future research

Unlike quantitative or experimental research, a strong case study does not require a random or representative sample. In fact, case studies often deliberately focus on unusual, neglected, or outlying cases which may shed new light on the research problem.

If you find yourself aiming to simultaneously investigate and solve an issue, consider conducting action research . As its name suggests, action research conducts research and takes action at the same time, and is highly iterative and flexible. 

However, you can also choose a more common or representative case to exemplify a particular category, experience, or phenomenon.

While case studies focus more on concrete details than general theories, they should usually have some connection with theory in the field. This way the case study is not just an isolated description, but is integrated into existing knowledge about the topic. It might aim to:

• Exemplify a theory by showing how it explains the case under investigation
• Expand on a theory by uncovering new concepts and ideas that need to be incorporated
• Challenge a theory by exploring an outlier case that doesn’t fit with established assumptions

To ensure that your analysis of the case has a solid academic grounding, you should conduct a literature review of sources related to the topic and develop a theoretical framework . This means identifying key concepts and theories to guide your analysis and interpretation.

There are many different research methods you can use to collect data on your subject. Case studies tend to focus on qualitative data using methods such as interviews, observations, and analysis of primary and secondary sources (e.g., newspaper articles, photographs, official records). Sometimes a case study will also collect quantitative data .

The aim is to gain as thorough an understanding as possible of the case and its context.

In writing up the case study, you need to bring together all the relevant aspects to give as complete a picture as possible of the subject.

How you report your findings depends on the type of research you are doing. Some case studies are structured like a standard scientific paper or thesis, with separate sections or chapters for the methods , results , and discussion .

Others are written in a more narrative style, aiming to explore the case from various angles and analyse its meanings and implications (for example, by using textual analysis or discourse analysis ).

In all cases, though, make sure to give contextual details about the case, connect it back to the literature and theory, and discuss how it fits into wider patterns or debates.

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• Open access
• Published: 27 June 2011

The case study approach

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

BMC Medical Research Methodology volume  11 , Article number:  100 ( 2011 ) Cite this article

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

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Introduction

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

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

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

What is a case study?

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

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

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

What are case studies used for?

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

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

How are case studies conducted?

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

Defining the case

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

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

Selecting the case(s)

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

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

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

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

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

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

Collecting the data

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

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

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

Analysing, interpreting and reporting case studies

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

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

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

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

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

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

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

Conclusions

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

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Acknowledgements

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

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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 associate professor at the Rotterdam School of Management, Erasmus University. His research focuses on corporate sustainability with a specific focus on sustainable investing.
• 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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Published on 4.4.2024 in Vol 26 (2024)

Impacts of an Acute Care Telenursing Program on Discharge, Patient Experience, and Nursing Experience: Retrospective Cohort Comparison Study

Authors of this article:

Original Paper

• Courtenay R Bruce, MA, JD   ; 
• Steve Klahn, RN, MBA   ; 
• Lindsay Randle, MBA   ; 
• Xin Li, BS   ; 
• Kelkar Sayali, BS   ; 
• Barbara Johnson, BSN, MBA, DNP   ; 
• Melissa Gomez, MBA   ; 
• Meagan Howard, MHA   ; 
• Roberta Schwartz, PhD   ; 
• Farzan Sasangohar, PhD  

Houston Methodist, Houston, TX, United States

Corresponding Author:

Courtenay R Bruce, MA, JD

Houston Methodist

8100 Greenbriar Drive

Houston, TX, 77030

United States

Phone: 1 281 620 9040

Email: [email protected]

Background: Despite widespread growth of televisits and telemedicine, it is unclear how telenursing could be applied to augment nurse labor and support nursing.

Objective: This study evaluated a large-scale acute care telenurse (ACTN) program to support web-based admission and discharge processes for hospitalized patients.

Methods: A retrospective, observational cohort comparison was performed in a large academic hospital system (approximately 2100 beds) in Houston, Texas, comparing patients in our pilot units for the ACTN program (telenursing cohort) between June 15, 2022, and December 31, 2022, with patients who did not participate (nontelenursing cohort) in the same units and timeframe. We used a case mix index analysis to confirm comparable patient cases between groups. The outcomes investigated were patient experience, measured using the Hospital Consumer Assessment of Health Care Providers and Systems (HCAHCPS) survey; nursing experience, measured by a web-based questionnaire with quantitative multiple-choice and qualitative open-ended questions; time of discharge during the day (from electronic health record data); and duration of discharge education processes.

Results: Case mix index analysis found no significant case differences between cohorts ( P =.75). For the first 4 units that rolled out in phase 1, all units experienced improvement in at least 4 and up to 7 HCAHCPS domains. Scores for “communication with doctors” and “would recommend hospital” were improved significantly ( P =.03 and P =.04, respectively) in 1 unit in phase 1. The impact of telenursing in phases 2 and 3 was mixed. However, “communication with doctors” was significantly improved in 2 units ( P =.049 and P =.002), and the overall rating of the hospital and the ”would recommend hospital” scores were significantly improved in 1 unit ( P =.02 and P =04, respectively). Of 289 nurses who were invited to participate in the survey, 106 completed the nursing experience survey (response rate 106/289, 36.7%). Of the 106 nurses, 101 (95.3%) indicated that the ACTN program was very helpful or somewhat helpful to them as bedside nurses. The only noticeable difference between the telenursing and nontelenursing cohorts for the time of day discharge was a shift in the volume of patients discharged before 2 PM compared to those discharged after 2 PM at a hospital-wide level. The ACTN admissions averaged 12 minutes and 6 seconds (SD 7 min and 29 s), and the discharges averaged 14 minutes and 51 seconds (SD 8 min and 10 s). The average duration for ACTN calls was 13 minutes and 17 seconds (SD 7 min and 52 s). Traditional cohort standard practice (nontelenursing cohort) of a bedside nurse engaging in discharge and admission processes was 45 minutes, consistent with our preimplementation time study.

Conclusions: This study shows that ACTN programs are feasible and associated with improved outcomes for patient and nursing experience and reducing time allocated to admission and discharge education.

Introduction

Telemedicine, particularly video televisits, has greatly expanded in the wake of the COVID-19 pandemic [ 1 , 2 ]. Televisits have shown promise as a robust, practical, efficacious, and scalable alternative to in-person office visits that could ameliorate labor supply shortages [ 3 , 4 ]. The published evidence suggests a generally positive attitude toward televisit appointments for chronic care, focused on addressing financial and transportation barriers and improving patients’ access to care [ 5 - 7 ]. Despite the promise shown by televisits, limited attention has been paid to applying this method in the acute care setting and, in particular, on how this promising technology can be leveraged to support nurses.

Estimates suggest that approximately 200,000 open nursing positions will become available each year between 2021 and 2031 [ 8 ]. Telenursing can augment nursing labor supply, decrease nursing workload, maintain patient and nurse safety, and positively impact nursing and patient experiences [ 9 ]. However, the impact of telenursing on outcomes in acute care settings remains a research gap.

To address this gap, this study aimed to evaluate the outcomes associated with a large-scale acute care telenurse (ACTN) program to support web-based admission and discharge processes for hospitalized patients compared to patients who did not undergo the ACTN program intervention. Admission and discharge are 2 substantive and time-consuming acute care nursing tasks that involve tedious documentation in the electronic health record (EHR) and extensive interaction with patients and families to gather history and provide patient education [ 10 , 11 ]. We aimed to develop an ACTN program to augment nursing care by conducting admission and discharge processes through telenursing in a large health system. Subsequently, we discuss the impacts on 4 end points: patient experience, nursing experience, time of discharge during the day, and length of time for discharge education processes. We hypothesized that the ACTN program would be associated with higher patient experience scores and improved nursing experience compared to standard admission and discharge practices.

This study was conducted in a large academic hospital system (approximately 2100 beds) in Houston, Texas. The preimplementation methods are reported more extensively in the studies by Hehman et al [ 12 ] and Schwartz et al [ 13 ]. Program implementation was first informed by nursing time and workload surveys and pilot implementation in 4 comparatively understaffed units. The chief innovation officer, along with nursing leaders and ACTN program administrators, met with the bedside nursing staff of these 4 understaffed units to solicit their input on where and how ACTN would add value to their workflow. Bedside nursing staff provided critical input on admission processes that could be delegated to individuals working remotely with no perceived negative impact on patient experience. We conducted participatory workflow design sessions with bedside nursing staff on the ACTN program to cocreate workflow integration points where the remote team could assist [ 13 ].

Pilot Implementation and Procedures

Before implementation, the ACTN administrators trained bedside nurses in pilot units by demonstrating the use of technology during shift huddles. Then, the trainers presented slides on contact information and available support and provided a role demarcation process map, showing what the remote telenurse staff would be doing compared to what the bedside nurses needed to do to launch and conduct discharge education. Furthermore, the trainers invited the nursing staff to observe several discharges to learn how to conduct them. A software with Health Insurance Portability and Accountability Act compliance was uploaded to iPads (Apple Inc) and stored on each unit. Handheld iPads were available, and roaming iPads were made available for patients who could not hold an iPad.

The pilot implementation was staggered in a phased rollout, consisting of 3 sequenced phases, as shown in Figure 1 . Upon admission, the acute care bedside nurse contextualized the ACTN program with patients and families by handing the patient an iPad with a preloaded remote program app (Caregility) and then pressing a soft key to allow the ACTN to enter the patient’s room via the iPad screen. The ACTN introduced themselves, completed the nursing admission profile in the EHR, placed a request for a consultation, and notified the bedside nurse that the admission was completed using secure SMS text messaging [ 13 ]. A similar process was followed for discharge workflow processes, where the ACTN completed patient education on discharge instructions, confirmed the patient’s pharmacy details, confirmed discharge transportation, and arranged for departure.

Bedside nurses used their discretion regarding which patients would be appropriate for the ACTN program. They based this determination principally on whether documentation was needed and whether the patient could benefit from the undivided attention the ACTN program could afford. Furthermore, they excluded patients from the ACTN program if the patients expressed discomfort using an iPad. After the initial rollout, patients’ input was sought on their experience with the ACTN program to identify where and how improvements could be made, and this feedback was incorporated into iterative revisions in subsequent rollouts.

Pilot Outcomes Monitoring

A retrospective, observational cohort comparison was performed, in which all patients in our pilot units for the ACTN program (telenursing cohort) between June 15, 2022, and December 31, 2022, were compared with all patients who did not participate (nontelenursing cohort) in the same units in the same timeframe.

Our primary outcomes were patient experience and nursing experience. Patient experience scope was any process observable by patients [ 14 ]. We compared patient experiences in the telenursing and nontelenursing cohorts by evaluating patients’ responses to the widely used Hospital Consumer Assessment of Health Care Providers and Systems (HCAHPS) survey [ 15 ], which represented 8 aspects (called dimensions) of patient satisfaction. Each dimension was measured using a continuous variable (0 to 100 points).

For the telenursing cohort, we analyzed bedside nurses’ collective responses using a Forms (Microsoft Corp) survey conducted in April 2023. The survey consisted of 5 questions, asking them to indicate whether the ACTN program was helpful using a Likert scale with 5 items (very helpful to very unhelpful). Nurses were asked to provide open-ended comments to explain the reasons for their evaluation. At the end of the survey, we included 2 open-ended fields for nurses to describe opportunities for improvement in future rollouts and provide any additional comments.

Furthermore, we explored the time at which discharge occurred using the EHR admission, discharge, and transfer date and time. We compared the hour of the day the patient was discharged in the telenursing cohort with the hour of the day the patient was discharged in the nontelenursing cohort, hypothesizing a priori that patients might be discharged earlier in the day in the telenursing cohort. Finally, we analyzed the duration of discharge education for both cohorts, measured in minutes.

Data Analysis

The patient demographic data were available for all patients. To confirm that the telenursing cohort had similar patient demographics as the nontelenursing cohort (and therefore to confirm that nurse biases in patient selection for the ACTN program were unlikely), we conducted a case mix index (CMI) evaluation. We first isolated the population of both cohorts into adults (aged ≥18 y). We compared only those patients who were discharged home and excluded those who were on extracorporeal membrane oxygenation or those who underwent a tracheostomy. The remaining population was evaluated to determine whether there was a difference in patient acuity and severity. After confirming that patient acuity and severity were of no significant difference, we included the inpatient and observation populations to evaluate the intervention results.

For the patient experience data, independent sample t tests (2-tailed) were used to compare the telenursing and nontelenursing cohorts across different HCAHPS dimensions and units. Analysis was conducted using R software (R Foundation for Statistical Computing). For the nursing experience survey data, we used Excel (Microsoft Corp) to analyze the responses to multiple-choice, discrete questions and thematic analysis to evaluate the open-text fields. Thematic analysis allows for eliciting key themes that emerge based on recurring statements [ 16 ]. The analysis followed an inductive approach. This approach uses open-ended questions, allowing themes to emerge with a few previously articulated assumptions on responses. Given the limited content, CRB served as the primary coder. Coding labels were used for data contextualizing, allowing for new themes to emerge throughout the coding process, using a codebook [ 16 , 17 ]. We stored emergent patterns and themes in an electronic format.

Ethical Considerations

The hospital’s review board determined that the ACTN pilot would not be considered regulated human subjects research. All data reported in this study were aggregated and deidentified.

The demographics of the telenursing and nontelenursing cohorts were relatively similar. Both cohorts had an average age of 60 years with an SD of 16.91; had a similar distribution in race and ethnicity (approximately 92/2319, 3.96% Asian; 525/2319, 22.64% Black; 425/2319, 18.33% Hispanic; 70/2319, 3.02% Native American, declined to identify, or other categories; and 1202/2319, 51.83% White); and had a similar distribution in female participants versus male participants (1249/2319, 53.86% vs 1070/2319, 46.14%). To further understand the population, the CMI analysis for acuity and severity showed that the CMI was slightly higher in the telenursing cohort than in the nontelenursing cohort, but the difference was not statistically significant ( P =.75).

Patient Experience

Among the first 4 units that rolled out in phase 1, all units experienced improvement in at least 4 and up to 7 HCAHPS domains (Table S1 in Multimedia Appendix 1 ). On average, 6 out of 8 HCAHPS domains were improved for patients in the telenursing cohort. All 4 units experienced improvements in the “overall rating” domain, and 3 of the 4 units experienced improvements in “likelihood to recommend” domain for patients in the telenursing cohort compared to those in the nontelenursing cohort within the same units. The improvement scores ranged from 1.4% for the neurosurgery unit (36 beds) to 11.6% for the medical unit (37 beds). Furthermore, all 4 units in the first phase of roll out experienced improved scores in the “responsiveness” domain by >4 points (ranging from 5% to 10.1%). A total of 2 out of the 4 units also experienced improvements in the “communication with nurses” (ranging from 1.7% to 3%) and “communication about medicines” (ranging from 3.3% to 11.7%) domains. The 2 units that did not experience improvement in the communication domains were the combined medical and surgery neurology and neurosurgical units (36 beds). Only the neurosurgical unit showed statistically significant improvements in 2 dimensions: “communication with doctors” ( P =.03) and “would recommend hospital” ( P =.04).

For the 7 units that rolled out during phase 2, only 1 orthopedic surgery unit (28 beds) experienced improvements in every domain (ranging from 0.9% to 12.5%). Medical observation unit 1 also improved in 5 areas. However, only improvements in “communication with doctors” ( P =.002), “overall rating of hospital” ( P =.02), and “would recommend hospital” ( P =.04) were statistically significant . The remaining units experienced improvements in some domains for the telenursing cohort compared to the nontelenursing cohort, with no improvement in other domains. However, the scores for “communication with nurses” and “communication with doctors” domains were improved for most of the units that rolled out in phase 2 (Table S2 in Multimedia Appendix 1 ).

For the 2 units that rolled out in phase 3, both of which were surgical cardiac units with 36 beds, 1 unit experienced improvement in every domain except “responsiveness” (ranging from 1% to 12%). The other unit only experienced improvement in the “communication with doctors” (4.9%) and “care transitions” domains (1.1%). However, none of these improvements were statistically significant (Table S3 in Multimedia Appendix 1 ).

Nursing Experience

Of the 289 nurses who were invited to participate in the survey, 106 completed the survey (36.7% response rate). Of the 106 nurses, 101 (95.3%) indicated that the ACTN program was “very helpful” or “somewhat helpful” to them as bedside nurses.

Quantitative Findings

The main reasons nurses gave for the program’s helpfulness included that it saved them time (94/106, 88.7%), allowed them to focus on more urgent clinical needs (90/106, 84.9%), allowed them to focus on activities they felt were more in line with their skill level (55/106, 51.9%), and allowed patients to have undivided attention for their discharge education (52/106, 49.1%). Among the 5 nurses who indicated that the ACTN program was somewhat unhelpful or very unhelpful, 3 (60%) indicated that workflows were not clear or needed further refinement or clarification. Furthermore, the nurse respondents shared several barriers and provided opportunities for improvement, with 91 (85.8%) out of 106 nurses offering suggestions.

Qualitative Findings

For the free-text explanation fields, all but 3 nurses (103/106, 97.2%) provided additional comments on the ACTN program helpfulness. Three themes emerged from the qualitative analysis of the free-text comments: (1) most of the nurses’ comments reflected that telenurses help bedside nurses save time, (2) respondents indicated that extra hands provided emotional and physical support in providing patient care, and (3) respondents perceived an improvement in patient safety by having a telenurse who could “catch missed” issues.

Time Saving

One of the perceived benefits of the telenursing program was saving time. One nurse said the following:

... Just putting in home medications alone takes up so much time. This new telenurse service helps [save time]

Several nurses highlighted that admission and discharge processes are so complex and time-consuming that shifting this work to the ACTN program freed nurses to perform other activities, as reflected by this nurse:

The tele RN is able to spend as much time possible sufficiently educating an admission or discharge while allowing me time to respond to the needs of my other patients saving me time on one patient especially charting.

Emotional and Physical Support

For the second theme, several responses focused less on time management and perceived efficiencies and instead centered more on the emotional appeal and support in having an extra hand, as one nurse mentioned:

Being in such a fast-paced unit, it can be a bit stressful with so many discharges and admissions. Having a helpful hand is beneficial.

Improved Patient Safety

Finally, the third theme was perceived improvement in patient safety by having a telenurse who could “catch missed” issues (eg, an incorrectly identified pharmacy details), simultaneously allowing the primary bedside nurse to focus more intensely on other needs, essentially creating a 2-fold safety promotion. Some nurses noted that they could begin carrying out orders while the telenurses began completing the admission, facilitating quicker treatment and resolution of care needs, thereby improving the safety and quality of care. One nurse mentioned the following:

Allows [telenurses] to take on thorough and accurate admissions, while also preventing any rushing the patient might experience from the primary RN.

When asked for areas of improvement, the most recurring theme was having 24 hours of support during the weekend and during the week. The second theme for improvement was the reduced time to connect to a telenurse. The third theme was the availability of iPads. Nurses mentioned that iPads could sometimes be unavailable in patients’ rooms or they may not be fully charged.

Time of Discharge

The time of day distribution is presented in Figure 2 . The only noticeable difference between the telenursing and nontelenursing cohorts was a shift in the volume of patients discharged before 2 PM compared with those discharged after 2 PM at a hospital-wide level ( Table 1 ). At an individual unit level, these results were not consistent and could be further explored by patient population and their needs to discharge. The variation was further illustrated when reviewing the length of stay of patients in the telenursing and nontelenursing cohorts. Only 5 out of the 12 units showed a decrease in the average inpatient length of stay.

Discharge Length

The ACTN admissions averaged 12 minutes and 6 seconds (SD 7 min and 29 s), and the discharges averaged 14 minutes and 51 seconds (SD 8 min and 10 s). The average duration for ACTN calls was 13 minutes and 17 seconds (SD 7 min and 52 s). Traditional cohort standard practice of a bedside nurse engaging in discharge and admission processes was 45 minutes, consistent with our preimplementation nursing time study.

Principal Findings

Our results suggest that the ACTN program was associated with positive nursing experiences because it saved time. Furthermore, the ACTN program was associated with higher HCAHPS scores in several domains but only in the first series of units that piloted the intervention. In phase 1, the improvement in “communication with doctors” and “would recommend hospital” scores in 1 unit was statistically significant. In phase 2, the improvement in “communication with doctors” score was significant in 2 units and that in “overall rating of hospital” and “would recommend hospital” scores were significant in 1 unit. The time of day discharge was nearly the same in both the telenursing and nontelenursing cohorts. The duration for discharge processes was less than half in the ACTN cohort compared to the nonintervention cohort.

At the time of writing this paper, the United States was experiencing a critical nursing shortage that will likely reach an epidemic level in the next few decades [ 8 ]. Despite the promise shown by telenursing, to our knowledge, only 1 existing paper documents the impact of ACTN programs on HCAHPS-measured patient satisfaction using a small cohort of patients in a single, time-limited pre- and posttelenursing analysis [ 18 ]. A study by Schuelke et al [ 18 ] revealed a 6.2% increase in “communication with meds” and 12.7% increase in “communication with nursing” domain scores; other HCAHPS domains were not evaluated. This research builds upon the promising work of Schuelke et al [ 18 ], evaluating the impact of an ACTN program on several units with a much larger cohort of patients using a staggered rollout and comparing all HCAHPS domains between telenursing and nontelenursing cohorts within the same time frame and in the same units.

By conducting granular HCAHPS analyses, we identified what we believed to be a time sequence variability in that units that rolled out in phase 1 performed considerably stronger in HCAHPS impacts than units that rolled out in later phases. An explanation for this sequence effect might be that some later adopters had less potential for high effect size, given that the first 4 units of the rollout were specifically chosen for their staffing problems compared to later units. ACTN support might have augmented the staffing support to such a degree that allowed the impacts of the program to be more salient. An alternative explanation is that the early adopters and promoters tend to have greater diffusion uptake, greater saturation and adoptability, and greater impacts compared to late adopters or those resistant to adoption [ 19 , 20 ]. Our anecdotal evidence suggests that early adopters might have wanted the telenursing program to succeed; therefore, they applied consistent implementation practices to ensure success. Adopters in later stages were more aware of barriers and potential downsides and might have been more ambivalent about telenursing and, therefore, less likely to modify their behaviors to promote the telenursing program’s success.

Another interesting finding was that the ACTN program seemed to be effective for both medical and surgical units of all specialties. Phase 1 was a mix of medical and surgical units; however, all units experienced increases in scores. Phases 2 and 3 experienced mixed results, without a clear lead for one specialty over the other. This may suggest that ACTN programs are broadly applicable across acute settings and that success depends most crucially on the need and desire of unit leaders.

Our time of day discharge findings showed only a few quantitative positive efficiencies. However, our discharge duration analysis and nursing experience survey results showed that ACTN has major time-saving benefits for nurses, suggesting a discrepancy between perceived and actual time savings versus time-of-day discharge savings. One explanation for this discrepancy may be that many factors beyond nursing impact the time of the day a patient is discharged; therefore, while the bedside nurses’ time is saved, the remaining discharge processes beyond nurses remain unaffected. Specifically, there are 3 segments of time during discharge processes: (1) the time for the discharge order and medication reconciliation [ 21 ] to the time the after-visit summary (AVS) is populated and printed [ 22 ]; (2) the time the AVS is completed and printed to the time the discharge instructions are provided; and (3) the time from providing the discharge instructions to the actual discharge ( Figure 3 ). Notably, telenurses’ involvement is currently limited to only the second segment of time. Specifically, telenurses’ involvement is not initiated until the AVS is printed by the nurse, which means that telenurses cannot positively impact any discharge activity that occurs between the time the discharge order is written and the time the AVS is printed. However, there are inefficiencies and bottlenecks in discharge processes that occur well before the AVS is printed [ 23 , 24 ]. For instance, the discharging physician may write a conditional discharge order early in the morning, listing conditions that cannot be fulfilled within a few hours or it may take bedside nursing longer than anticipated time to print the AVS.

To create a wider cascade effect for positively impacting the discharge processes for all segments of time, we are currently trying to obtain greater transparency through EHR reporting in what occurs for segments 1 and 3. For instance, at present, we know that at least 2 hospitals in our 8-hospital system have high incidence rates of conditional discharge orders that should be reduced. One hospital anecdotally reports that the discharging physician identifies incorrect pharmacies, which requires a nurse to send the scripts back to the discharging pharmacist to reconcile before discharge education can occur [ 25 ]; however, the prevalence and location of these issues remain speculative. Segment 3 is a black box of time [ 26 ]—the time it takes for hospital transport or an ambulance to arrive and move the patient to their destination and the time it takes for the family to pick up the patient. All these factors impact the discharge processes and need to be fully elucidated, explored, and streamlined. Furthermore, we hope to facilitate processes that enable telenurses to print the AVS, to remove the dependency on bedside nurses to begin the discharge education process.

Limitations

This study has several noteworthy limitations. First, the study was conducted in 1 health system and the results may not be generalizable to other settings with different patient populations, processes, and implementation strategies [ 27 ]. Second, in this study, we did not control for other factors that could impact patient and provider satisfaction as well as discharge times; telenursing can only improve upon one component in a complex set of factors limiting discharge efficiency and satisfaction outcomes. Finally, participating nurses were aware of the ongoing study, and this knowledge might have affected their behavior [ 28 ].

Future Directions

After the completion of this pilot study, the ACTN admission and discharge program has been rolled out to pilot medical units and all surgical and observation units. Our rationale for expansion rested on the premise that nursing experience is important to maintain and strengthen, particularly at a time when turnover is high in the health care industry in general. It is important to reduce staff inefficiencies in workload as a means of preserving or strengthening organizational morale and cost saving. Because our nursing experience findings for the ACTN program heavily supported the program, this served as the primary motivation for expansion. The nursing experience findings, coupled with the findings related to time-savings in discharge education and modest improvement, though not negative, in the HCAHPS findings for the ACTN program compared to the nontelenursing cohort, further supported expansion.

The initial scope for expansion included a complete system-wide implementation for all admissions and discharges. Furthermore, we are planning to expand the ACTN program beyond admissions and discharges. Responsive to qualitative feedback reported earlier, the next phase of the ACTN program will add safeguards on high-risk medications by having telenurses conduct double-checks, skin assessments, hourly rounding assistance, and auditing of safety functions and educational activities. These activities were chosen because they are time-intensive for nursing staff on the patient floors. Additional support in these areas would be a staff morale booster in addition to improved efficiencies for bedside nursing. Conducting hourly rounding using the ACTN program will require more time and resources; however, conducting high-quality, uninterrupted hourly rounds is known to be effective at improving patient safety and patient experience outcomes [ 29 ]. Therefore, we suspect that the ACTN program will have some positive impacts if rounds are consistently conducted, even if conducted virtually.

In addition, the ACTNs have been motivating other specialties to adopt or consider a similar program as the ACTN program to support stretched staffing. These specialties include respiratory care, in which virtual support can quickly identify patients in need of intensive on-site support; pharmacy, in which direct communication with staff on medications and patient training can happen through virtual means; infection control, in which room environments can be reviewed through virtual audits, moving quickly from floor to floor; and guest relations and spiritual care, in which patients can be visited virtually upon patient request. Furthermore, physicians who wish to either virtually enter inpatient rooms during their clinic days or from home can quickly drop in to see patients using the virtual program. For these groups to further develop advanced inpatient telemedicine programs, additional technology will be required, including cameras that can zoom into various portions of the room and advanced sound capabilities. Future work could expand programs similar to ACTN to specialties such as respiratory therapy, pharmacy, infection prevention, and spiritual care.

Conclusions

This study provides preliminary evidence suggesting that telenursing may effectively address nursing shortages in acute care settings and positively impact patient and provider satisfaction as well as admission and discharge times. More work is needed to validate the findings in other settings, use other satisfaction metrics, and investigate the impact of telenursing on the quality of care and cost.

Acknowledgments

The authors would like to thank Jacob M Kolman, MA, ISMPP CMPP, senior scientific writer, Houston Methodist Academic Institute, for the critical review and for providing formatting feedback on this manuscript. The authors would also like to thank Amir Hossein Javid for his help with statistical analysis.

Data Availability

Data sharing is not applicable as no data sets were generated during this study.

Authors' Contributions

All authors were involved in the conceptualization, review and approval, and writing of the manuscript. LR, BJ, MG, RS, SK, and MH were extensively involved in the implementation of the project. BJ, MH, SK, and MG conducted the training. SK and XL conducted the analyses. CRB wrote and edited the manuscript, inserted and refined the citations, and provided critical feedback during implementation and analyses. CRB and FS were involved in all stages of writing and publication. All authors meaningfully contributed to the drafting, writing, brainstorming, executing, finalizing, and approving of the manuscript.

Conflicts of Interest

None declared.

Additional outcome information for Hospital Consumer Assessment of Health Care Providers and Systems, time of day discharges, and discharge education processes.

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Abbreviations

Edited by T de Azevedo Cardoso, G Eysenbach; submitted 06.11.23; peer-reviewed by C Jensen; comments to author 08.12.23; revised version received 16.01.24; accepted 17.02.24; published 04.04.24.

©Courtenay R Bruce, Steve Klahn, Lindsay Randle, Xin Li, Kelkar Sayali, Barbara Johnson, Melissa Gomez, Meagan Howard, Roberta Schwartz, Farzan Sasangohar. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 04.04.2024.

This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in the Journal of Medical Internet Research, is properly cited. The complete bibliographic information, a link to the original publication on https://www.jmir.org/, as well as this copyright and license information must be included.

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Title: leveraging corpus metadata to detect template-based translation: an exploratory case study of the egyptian arabic wikipedia edition.

Abstract: Wikipedia articles (content pages) are commonly used corpora in Natural Language Processing (NLP) research, especially in low-resource languages other than English. Yet, a few research studies have studied the three Arabic Wikipedia editions, Arabic Wikipedia (AR), Egyptian Arabic Wikipedia (ARZ), and Moroccan Arabic Wikipedia (ARY), and documented issues in the Egyptian Arabic Wikipedia edition regarding the massive automatic creation of its articles using template-based translation from English to Arabic without human involvement, overwhelming the Egyptian Arabic Wikipedia with articles that do not only have low-quality content but also with articles that do not represent the Egyptian people, their culture, and their dialect. In this paper, we aim to mitigate the problem of template translation that occurred in the Egyptian Arabic Wikipedia by identifying these template-translated articles and their characteristics through exploratory analysis and building automatic detection systems. We first explore the content of the three Arabic Wikipedia editions in terms of density, quality, and human contributions and utilize the resulting insights to build multivariate machine learning classifiers leveraging articles' metadata to detect the template-translated articles automatically. We then publicly deploy and host the best-performing classifier, XGBoost, as an online application called EGYPTIAN WIKIPEDIA SCANNER and release the extracted, filtered, and labeled datasets to the research community to benefit from our datasets and the online, web-based detection system.

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Unconventional Resources: Provenance Analysis, Sediment Transport, Reservoir Evaluation, Geo-energy

Identification of Milankovitch sedimentary cycle in Fengcheng Formation, Mahu Depression: a case study of well Maye 1 Provisionally Accepted

• 1 PetroChina Xinjiang Oilfield Company, China
• 2 School of Geosciences, Yangtze University, China

The final, formatted version of the article will be published soon.

The sedimentary cycle of Fengcheng Formation in Junggar Basin changes rapidly and is difficult to identify. The low classification accuracy of high-frequency fine-grained sedimentary cycles restricts the exploration of unconventional shale oil and gas.Full-interval coring of well Maye 1 provides a solid foundation for small-layer research. This paper studies the high-frequency sedimentary cycles of the Milan Kovacevic in the Fengcheng Formation using techniques such as spectral analysis and wavelet transformation, and establishes a high-resolution astronomical age scale. The study reveals the control of orbital periodic changes on organic matter in mudstone, and based on this, identifies the sweet spots. Using the 405ka long-period eccentricity, 100ka short-period eccentricity, and 42736a long-period axial tilt as semi-quantitative criteria for the fourth, fifth, and sixth-order sequence division, the Fengcheng Formation is divided into two fourth-order sequence cycles, nine fifth-order sequence cycles, and 16 sixth-order sequence cycles. The application of the 405ka long-period eccentricity reveals two large-scale lake regression-transgression sedimentary cycles in the regional Fengcheng Formation, and a maximum lake flooding surface in the middle period of Feng II, corresponding to high organic matter abundance and great hydrocarbon generation potential. The application of the 100ka short-period eccentricity identifies eight sweet spot intervals in the Fengcheng Formation of Well Maye 1, which is consistent with the nuclear magnetic interpretation results. The research provides a semi-quantitative basis for the identification of high-frequency sedimentary cycles and sweet spot intervals in the Fengcheng Formation of the Mahu depression in the Junggar Basin, and provides a reference for the subsequent division of highfrequency fine-grained sedimentary cycles.

Keywords: Junggar Basin, Fengcheng Formation, Shale oil, Sedimentary cycle, Milankovitch, Sweet spot recognition Junggar Basin

Received: 24 Feb 2024; Accepted: 02 Apr 2024.

Copyright: © 2024 Wang and Chen. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

* Correspondence: Mx. Ran Wang, PetroChina Xinjiang Oilfield Company, Karamay, China

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