conclusion on importance of case study

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• v.24(6); 2019 Sep

Lessons learnt: examining the use of case study methodology for nursing research in the context of palliative care

Paula brogan.

School of Communication and Media, University of Ulster, Northern Ireland, UK

Felicity Hasson

Institute of Nursing Research, University of Ulster, Northern Ireland, UK

An empirical social research approach, facilitating in-depth exploration of complex, contemporary contextualised phenomena, case study research has been used internationally in healthcare studies across clinical settings, to explore systems and processes of care delivery. In the United Kingdom, case study methods have been championed by nurse researchers, particularly in the context of community nursing and palliative care provision, where its applicability is well established. Yet, dogged by conceptual confusion, case study remains largely underutilised as a research approach.

Drawing on examples from nursing and palliative care studies, this paper clarifies case study research, identifies key concepts and considers lessons learned about its potential for nursing research within the unique and complex palliative and end of life context.

A case study approach offers nurse researchers the opportunity for in-depth, contextualised understanding of the systems and processes which influence their role in palliative care delivery across settings. However, philosophical and conceptual understandings are needed and further training in case study methodology is required to enable researchers to articulate and conduct case study.

Introduction

An empirical social research approach, facilitating in-depth exploration of a contemporary phenomenon ( Yin, 2009 ), case study research has been used internationally in healthcare studies ( Anthony and Jack, 2009 ) to explore systems of palliative care ( Lalor et al., 2013 ), diverse contexts for palliative care delivery ( Sussman et al., 2011 ), roles of professional groups such as pharmacy ( O’Connor et al., 2011 ), the impact of services such as complementary therapy ( Maddalena et al., 2010 ) and nursing (Kaasalainen et al., 2013). In the United Kingdom, case study methods have been championed by nurse researchers ( Payne et al., 2006 ), particularly in the context of community nursing and palliative care provision ( Kennedy, 2005 ; Walshe et al., 2004 , 2008 ) and its applicability to palliative and end-of-life care research is established ( Goodman et al., 2012 ). Suited to the study of complex processes ( Walshe, 2011 ), case study methodology is embedded in professional guidance on the development of complex interventions ( Medical Research Council, 2008 ). Yet, case study is dogged by conceptual confusion (Flyvberg, 2006), and, despite sporadic use, remains underutilised as a research approach in healthcare settings ( Froggatt et al., 2003 ).

Illustrated by examples from nursing and palliative care studies, this paper aims to clarify conceptual understanding and identify key lessons for its application within these unique and complex contexts and, more broadly, for nursing research.

Origins and definitions

French sociologist Frederic Le Play (1806–1882) is associated with the origin of the case study approach ( Hamel et al., 1993 ). Using a purposive sample of working class families and fieldwork methods of observation and individual interview, he sought a contextualised and in-depth understanding of their individual experiences. Each family case study uncovered the unique experience of that family, but each additional family studied was another ‘ case of the lived experience’ of working class families in mid-18th century France. Thereby, Le Play used the lens of individual experience ( Yin, 2013 ) to build comparisons across families and enrich overall understanding of that complex society.

This early glimpse of the case study approach showed it to be a straightforward ‘field investigation’ ( Hamel et al., 1993 ); epistemologically pragmatic as it generated knowledge through data drawn from diverse sources, such as family members, and used the best available data collection methods then, to inform a holistic and contextualised understanding of how people operated within a complex social system ( Stake, 1995 ).

However, defining case study has become increasingly challenging since its expansion into North America in the 1800s ( Platt, 1992 ), and its use across a range of disciplines such as politics ( Gerring, 2004 ), social science ( George and Bennett, 2005 ), education ( Merriam, 1998 ) and healthcare ( Yin, 2013 ). Variously characterised as a case report, data collection method and methodology ( Anthony and Jack, 2009 ), the development of case histories as illustrations in health and social care and in education ( Merriam, 1998 ) has contributed to further confusion for researchers and readers of case study research ( Gomm et al., 2000 ). Critiques of case study note that it lacks a single definition, such that a plethora of discipline dependant interpretations ( Simons, 2009 ) and loose use of the term case study ( Tight, 2010 ) have contributed to confusion and undermined case study credibility. However, Simons ( 2009 , p. 63) advises researchers that case study must be seen within the complex nexus of political, methodological and epistemological convictions that constitute the field of enquiry, and variations of these may be glimpsed in Table 1 as definitions from four eminent and frequently cited case study authors illustrate philosophical and discipline-influenced differences in emphasis. Consequently, the case study definition selected, with its underpinning ontology and epistemology has important implications for the coherent outworking of the overall research design. It is therefore notable that many of the palliative care case studies contained in Table 2 fail to identify any such definition and this may have implications for interpretation of the quality of studies.

Definitions of case study by four key authors, showing the variation in meaning and interpretation.

Examples of Case Studies (CS) conducted in palliative care contexts.

Case study as a philosophy for the epistemology of knowledge generation

Although frequently linked to naturalistic inquiry ( Lincoln and Guba, 1986 ), interpretative/constructivist philosophy and qualitative methodology ( Stake, 1995 ), case study is not in fact bound to any single research paradigm ( Creswell, 2013 ). It is philosophically pragmatic, such that the case study design should reflect the ontological positions and epistemological considerations of the researchers and their topic of interest ( Luck et al., 2006 ). In practice, this means that case study research may pragmatically employ both qualitative and quantitative methods independently or together in order to respond to the research objectives ( Cooper et al., 2012 ; Simons, 1987 ; Stake, 2006 ). So whilst Table 2 shows that qualitative case studies are common in palliative care, epistemological variation is evident and reflects the study topic, purpose and context of the research. For example, Maddalena et al. (2010) used in-depth interview and discourse analysis to understand individual patient meaning-making; Brogan et al. (2017) used focus groups and thematic analysis as part of an embedded element of a multiple case study, to contrast the diverse perspectives of multi-disciplinary healthcare practitioners on end-of-life decision-making; Sussman et al. (2011) incorporated survey data into a mixed methods multiple case study which explored health system characteristics and quality of care delivery for cancer patients across four regions of Canada. Consequently, it is useful to ‘conceptualise (case study) as an approach to research rather than a methodology in its own right’ ( Rosenberg and Yates, 2007 , p. 448), so that a non-standardised approach exists and the case study design, its boundaries, numbers of cases and methods are guided by the stated underpinning ontological perspectives of the researcher and their topic of interest. The study then flexibly adopts the best methods to gain an in-depth, holistic and contextualised understanding of the phenomenon of interest – the latter objectives being at the core of any definition of case study research.

Key case study concepts and lessons for practice

When considering the utility of a case study approach, research conducted in complex palliative care contexts offers several insights into how central concepts translate to practice.

Contextualised understanding

Drawing on the definitions in Table 1 , Stake emphasised the particularity and intrinsic value of each individual case ( Stake, 1995 ), to emphasise the usefulness of multiple cases to increase insight ( Stake, 2006 ), analyse patterns ( Gerring, 2004 ; George and Bennett, 2005 ) and develop causal hypotheses ( Yin, 2013 ). Yet, whatever the purpose, all case studies are concerned with the crucial relationship between a phenomenon and the environment in which it has occurred. In practice therefore, case study researchers must be concerned with understanding the background systems, structures and processes that influence and interact with the phenomenon under study. This capacity for contextualised and holistic understanding is underpinned by use of multiple data collection methods, such as observation, interview and document review, used simultaneously or sequentially ( Stake, 2006 ; Scholz and Tietje, 2002 ), to mine multiple sources of data, such as participant experience ( Brogan et al., 2017 ; Kaasalainen et al., 2012 ), documents (Lalor et al., 2003) service evaluations ( Walshe et al., 2008 ), and diaries ( Skilbeck and Seymour, 2002 ). This is exemplified in a study by Walshe et al. (2011) , who investigated referral decisions made by community palliative care nurses in the UK, by capturing interview data on the self-reported perspectives of healthcare professionals, in combination with observed team meetings in which decisions were influenced, and review of the written referral policies, protocols and palliative healthcare strategies specific to those decisions. This comprehensive and complex data enabled comparison of decisional processes and their influencing factors both within and across three Primary Care Trusts, thus providing a contemporaneous understanding of the complex relationship between individual nurse's referral decisions and the impact of the organisational and professional systems that underpinned them. Enhancing rigor, such methodological triangulation importantly contributed to the richness of data analysis and the development of assertions which might be drawn from the findings ( Cooper et al., 2012 ; Stake, 2006 ).

Process-focused

Flexible data collection methods, linked to the research purpose, enables case study researchers to gather both historical and real-time data in a variety of ways. For example, Kennedy’s longitudinal case study ( Kennedy, 2002 ) observed snapshots of the initial and follow-up assessment conducted by 11 district nurses over the subsequent 12 months, enabling an exploration of the outcome and impact of their decision-making, demonstrating the usefulness of case study to understand complex roles and processes which are fluid and elusive ( Yin, 2013 ), or otherwise difficult to capture, particularly in the intimate interpersonal contexts where nursing happens.

Analytic frame

Palliative care studies reviewed frequently report the use of thematic analysis. However, whilst this approach is certainly useful to process data generated in qualitative case studies, the approach to analysis must be congruent with the research design and reflect the purpose of the research and methods used. Moreover, beyond decisions about use of thematic analysis or descriptive statistics etc., in case study, important decisions must be made about the analytic frame of the research. Gerring’s definition (2004) set out the analytic frame in which the cases studied might be understood, explaining that each unit of analysis (or case), sheds light on other units (or cases). Thus defined, an individual case offers intrinsically valuable information about a phenomenon ( Stake, 1995 ) and the purposeful selection of cases is central to case study design. This is because, viewed from a certain angle, each case is also a case of something else, such that the findings have broader implications ( Gerring, 2004 ; Simons, 2009 , 1987 ; Yin, 2013 ). In practice, this means that the case and what it is a case of, must be clearly identified and well defined at the outset of a study, since this has implications for the relevance of findings. This can be seen in a study by O’Connor et al., (2011) , who considered the perceived role of community pharmacists in palliative care teams in Australia. Each unique case included multi-disciplinary healthcare team members, such as pharmacists, doctors and nurses working in localities, whose perspectives were sought. Each locality group was a case of community pharmacy provision in palliative care settings in Australia, and findings had implications for the planning of community services overall. So, insight development was possible at an individual, group and organisational level, and inferences were made directly in relation to the parameters of that case study.

The addition of several carefully selected cases, as in multiple case studies, offers the opportunity to analyse data gained within and across cases ( Stake, 2006 ). Case selection may be made in order to explore similarities and contrasting perspectives ( Brogan et al., 2017 ), understand the various impacts of geographical differences ( Sussman et al., 2011 ), and different organisational influences ( Walshe et al., 2008 ). However, whilst repetition of data across cases may reinforce propositions made at the outset of a study, the purpose of increasing the number of cases in case study research is primarily about increasing insight development into the complexity of a phenomenon ( Stake, 2006 ). Since case study is the study of a boundaried phenomenon ( Yin, 2013 ), establishing the analytic frame then underpins the selection criteria for potentially useful cases. Such clarification is essential since it provides the lens through which to focus research ( Gerring, 2004 ; Scholz and Tietje, 2002 ; Stake, 2006 ) and permits key decisions to be made about data which may be included and that which is not applicable.

However, significantly, this information is rarely articulated within published case studies in palliative care. This is an important issue for the quality of case study research, since description of the process of refining case study parameters, establishing clear boundaries of the case, articulating propositions based on existing literature, identifying the sources of data (people, records, policies, etc.) and the ways in which data would be captured, establishes clarity and underpins a rigorous, systematic and comprehensive process ( Gibbert et al., 2008 ), which can usefully contribute to practice and policy development ( George and Bennett, 2005 ).

Shaped by organisational systems, intimate settings and significant life stage contexts, the interconnection between context and participant experience of palliative care is one example of a process of healthcare provision that is often complex, subtle and elusive ( Walshe et al., 2011 ). Case studies conducted in these swiftly changing contexts illustrate several characteristics of case study research, which make it an appropriate methodological option for nurse researchers, providing the opportunity for in-depth, contextualised understanding of the systems and processes which influence their role in palliative care delivery across settings ( Walshe et al., 2004 ) and many others who seek a contextualised, contemporaneous understanding of any complex role or process ( Yin, 2013 ; Simons, 2009 ). This fieldwork-based approach has the potential to achieve depth and breadth of insight through the pragmatic, but carefully planned and articulated, use of multiple methods of data collection in order to answer the research question ( Stake, 2006 ) when analysed systematically within a frame determined at the outset by the definition of the case and its boundaries ( Gerring, 2004 ). Yet, the methodological flexibility that is advantageous in complex contexts, may be misunderstood ( Hammersley, 2012 ), particularly where terminology is unclear ( Lather, 1996 ) or where description of the systematic and rigorous application of the approach is missing from the report ( Morrow, 2005 ). Taken as an example of one area of healthcare research, evidence suggests that palliative care studies that deal meaningfully with underpinning philosophical perspectives for their selected case study approach, or which articulate coherent links between the defined case, its boundaries and the analytical frame are rare. The impact of such omissions may be the perpetuation of confusion and out-dated perceptions about the personality and quality of case study research ( King et al., 1994 ), with implications for its wider adoption by nurses in healthcare research. Further training in case study methodology is required to promote philosophical and conceptual understanding, and to enable researchers to fully articulate, conduct and report case study, to underpin its credibility, relevance and future use ( Hammersley et al., 2000 ; Stake and Turnbull, 1982).

Key points for policy, practice and/or research

• Case study is well suited to nursing research in palliative care contexts, where in-depth understanding of participant experience, complex systems and processes of care within changing contexts is needed.
• Not bound to any single paradigm, nor defined by any methodology, case study’s pragmatism and flexibility makes it useful for studies in palliative care.
• Training is needed in the underpinning philosophical and conceptual basis of case study methodology, in order to articulate, conduct and report credible case study research, and take advantage of the opportunities it offers for the conduct of palliative and end-of-life care research.

Paula Brogan is a Lecturer in counselling and communication in the School of Communication and Media, and was recently appointed as Faculty Partnership Manager, University of Ulster. Dual qualified as a Registered Nurse with specialism in District Nursing and as a Counsellor/couple psychotherapist (Reg MBACPaccred), she has over 30 years’ clinical practice experience in community palliative care nursing and the provision of psychological care to patients and families dealing with palliative and chronic illness. Having worked across statutory, voluntary and private sectors, her PhD focused on multi-disciplinary decision-making at the end of life with patients and families in the community setting. Currently secretary of the Palliative Care Research Forum for Northern Ireland (PCRFNI), Paula’s ongoing research interests include communication and co-constructed decision-making in palliative and chronic illness, and the psychological support of individuals, couples, patient-family groups and multi-disciplinary staff responding to challenges of advanced progressive illness.

Felicity Hasson is a Senior Lecturer in the Institute of Nursing Research at the University of Ulster with 20 years’ experience in research. A social researcher by background, she has extensive experience and knowledge of qualitative, quantitative and mixed method research and has been involved in numerous research studies in palliative and end-of-life care. She completed her MSc in 1996 and her PhD from University of Ulster in 2012. Felicity sits on the Council of Partners for the All Ireland Institute of Hospice and the Palliative Care Palliative Care Research Network (PCRN) and is an executive board member for the UK Palliative Care Research Society. She holds an editorial board position on Futures and Foresight Science. Felicity has an established publication track recorded and successful history of grant applications. Her research interests include nurse and assistant workforce, workforce training, palliative care and chronic illness (malignant and non-malignant with patients, families and multi-disciplinary health care professionals) and public awareness of palliative care and end of life issues.

Sonja McIlfatrick is a Professor in Nursing and Palliative Care and has recently been appointed as the Head of School of Nursing at University of Ulster. She is an experienced clinical academic with experience in nursing and palliative care practice, education and research. She previously worked as the Head of Research for the All Ireland Institute of Hospice and Palliative Care (2011-2014) and led the establishment of the All Ireland Palliative Care Research Network (PCRN) and is the current Chair of the Strategic Scientific Committee for the PCRN (AIIHPC). Sonja is an Executive Board member for the UK, Palliative Care Research Society and is member of the Research Scientific Advisory Committee for Marie Curie, UK. Sonja holds an Editorial Board position on the International Journal of Palliative Nursing and Journal of Research in Nursing. Professor McIlfatrick has published widely in academic and professional journals focused on palliative care research and has a successful history of grant acquisition. Sonja has a keen interest in doctoral education and is the current President of the International Network of Doctoral Education in Nursing (INDEN). Her research interests include, palliative care in chronic illness, decision making at end of life; public awareness of palliative care and psychosocial support for family caregivers affected by advanced disease.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Ethics statement

Ethical permission was not required for this paper.

The author(s) received no financial support for the research, authorship, and/or publication of this article.

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