8

Case Studies

Introduction

Case studies are part of a particular style of descriptive, qualitative research. Descriptive research is that which seeks only to describe and inform (as opposed to testing a hypothesis or attempting prediction). The main value of such description, perhaps, is to ‘illuminate’ a situation, a culture or a group of people – sometimes, the case study approach is used to describe a single person’s situation. The case study can make

the reader think and allow him or her to ask questions such as ‘does this study record things that are similar or different to my own experience’ and ‘what can I use from this study to inform my own practice’.

What remains clear is that anyone using the qualitative, case study approach should never be tempted to generalise from such work. It is tempting, at the end of any research report, to offer recommendations – either general recommendations or ones specifically for practice. The researcher who offers case studies, however, can only ever say (in so many words): ‘Look! This is what I found and this is what happened in one situation, at one time in history: make of it what you will!’ Given that case studies are only usually about a small number of people, a specific situation or place, the ‘findings’ that are reported can never be generalised out to larger populations. It is the case that another researcher, on another day, may have described things differently. Similarly, on another day, the situation, itself, might have been different. People and places change over time. The case study can only ever offer a glimpse of what life was like for a limited number of people, in a very particular place at a very specific time. Naturally, this can be an extremely useful insight in itself, and may guide practice if one’s circumstances are similar to those of the case study situation.

Case studies can be used in at least two ways. First, they can be used as ‘illustrations’ in a larger study. Second, they can be used as the main data collection, analysis and reporting method. Both approaches are now elaborated.

The case study as ‘illustration’

In qualitative research – and particularly, perhaps, in ethnography (which is described in the next chapter) – the researcher often finds that one of his or her respondents or one of the places he visits rewards him or her with considerably more – or more detailed – data. For example, a particular interviewee may be able to answer questions in considerably greater depth than his colleagues or a college that is visited is more ‘open’ to the researcher. In these cases, it is sometimes useful to use such ‘outstanding’ sets of data in the form of a case study. Such a case study may offer a more detailed account of the principle being – more generally – described by the researcher in his or her presentation of findings.

However, a caveat needs to be added here. Very often (unless the researcher has planned a particular case study, in advance), the material used in a case-study-as-illustration, will not be typical of the points under discussion. The person, for example, who offers a very in-depth interview, may be more extrovert than a number of his colleagues or, perhaps, have very strong views on the topic in hand. Thus, it becomes important not simply to offer a case study, using this material, as a

‘typical example’ of what is being discussed. The case study must be presented only as a single example of a person’s or place’s situation. Indeed, the researcher may want to highlight, in his or her text, the ways in which this case study differs from the other data being presented or, of course, the ways in which it is similar. Always, as we have noted, the researcher must resist any temptation to generalise from a case study and resist making suggestions as to how others might change their practice as a result of reading the case study. It must be emphasised that the case study can only offer one illustration of a given but specific situation.

The point just made might usefully be made about all qualitative research. Qualitative research is useful in illustrating and describing. It can help offer a particular and sometimes historical view of people, places and things. However, it is never safe to generalise from qualitative findings. Even if findings appear to ‘replicate’ the findings of another study, they do not. The sampling and analysis methods used in qualitative research make this impossible. An apparent ‘replication study’ is not really any such thing: it is quite possibly coincidence at work if a researcher’s findings are very similar to another’s.

The case-study-as-illustration, within a larger study, can be developed in a variety of ways. First, the case study can be a boxed section, within the findings section of the study and, rather literally, serve as an illustration. The main body of the text will refer the reader to this boxed section and thus point to it as an in-depth example of what he or she found. The account, within the box, will often contain a descriptive passage about the person(s) involved or the place being described. It will then give an account of what happened and of the outcome of the described events. When the case study is drawn from an interview, it is possible to present the data verbatim. Thus, the boxed section will contain a short transcript of the interview and report both the interviewer and the interviewee’s words. Those words may or may not be followed by a short discussion of the transcription – perhaps relating it back to the body of the research report.

Second, the case study can be offered as a separate section within a research report. This allows the researcher more space to develop an in-depth account of a specific place, person or event. However, it is normally the case that reporting qualitative findings takes up a lot of words. The researcher should bear in mind that most research is usually reported (in published format) in journals. This means that the research has to be extremely economical with words. The student who completes a dissertation or thesis may want to include the case study in that research report but choose not to use it in a paper submitted to a journal. Alternatively, he or she may choose to publish the case study as a separate paper.

Third, the case study within a research report can be the result of a planned activity. The researcher might decide, for example, to interview one or two respondents in greater depth than would be the case with others. In this way, he or she plans, in advance, the nature of his or her case study material. The researcher may draw up a specific pro forma to enable him or her to collect data in a relatively systematic way. Such a pro forma may contain background and/or biographical information about each case study subject, followed by the respondents’ views and ideas. In doing this, the researcher stands to present uniform case studies, both in terms of length and layout.

The case study as a research method

The alternative position is for the researcher to use the case study method as the main research method in a particular study. Here, a decision will have been made to describe, in considerable detail, a particular person, group of people, place or object. For example, a midwife, in considering the experience of pregnancy, may follow the experience of one or more pregnant women through their pregnancies. He or she may ask that person or persons to keep diaries of their thoughts, feelings and actions, interview them at regular intervals and ask for further interviews after the birth of the baby.

As is often the case in qualitative research, the researcher may use lesser or greater structure in the collection of data. The midwife, for example, in advising pregnant women about keeping diaries may (a) offer them a format for recording their thoughts, feelings and actions or (b) simply ask them to regularly ‘write in your diary’. These two approaches are likely to yield different sorts of findings. Data collected from the more structured approach are likely to be easier to analyse, whilst ‘freeform’ data are often very difficult to categorise and report. However, the amount and depth of the data obtained may be much greater in the second approach.

Similarly, interviews can range from ‘very structured’ – in which case the data collection method can become almost the use of a ‘verbal questionnaire’ – to totally unstructured (in which the researcher has no previously worked out agenda for the interview and opens it with a very broad, open question such as ‘I am interested in anything you can tell me about your thoughts on X’ [where ‘X’ is the topic focused on in the study]). Again, the same pros and cons apply. Very tightly structured interviews are less likely to yield rich or in-depth data, but are likely to be easier to analyse. Totally unstructured interviews are likely to reveal different and often idiosyncratic findings but are likely to be difficult to categorise and analyse.

Depending on the amount of autonomy that the researcher can exercise, it is possible to supplement case studies in various ways. For example, the researcher may want to include photographs or even sound track material to further illuminate the case study material. These approaches can offer a more three-dimensional picture within the case study. However, it is impossible to know how the consumer of such a report is going to respond to seeing photographs or hearing sounds. It might be felt that such an approach further adds to the subjectivity of the report. It might be borne in mind, however, that many other forms of reporting about other people, do include illustrations: travel writing and journalism are frequently supplemented in this way and such illustrations serve to ‘personalise’ the reporting. A topic for consideration is, indeed, the degree to which some forms of qualitative research (and case study) differ from, or are similar to, travel writing and journalism. Both media seek to report ‘honestly’ about their subject matter (as does qualitative research). Both often offer historical, theoretical or political background information about the topic or place under discussion – again, as is the case in qualitative research reporting. Finally, in both journalism and qualitative research, the author/researcher recognises their role within the situation they are examining and reporting on, and does not seek to be remote or objective in the way which is often associated with quantitative research. Their role in the research and reporting is seen as a valid contribution to our understanding. One important difference, perhaps, is that travel writers – in particular – are, presumably, seeking to entertain as well as inform their readers. Researchers, on the other hand, should, presumably, be dedicated to reporting, as closely as possible, ‘things as they are’ or, at least, ‘things as they appear to be’ – regardless of whether or not their research writing is in any sense entertaining.

Drawbacks

There are, of course, some drawbacks with the case study approach – whether it is of the illustrative sort of the ‘stand-alone’ variety. If, for example, the researcher depends upon one person to supply the data for a case study, there is a danger that the person may (a) withdraw from the study, (b) default on recording data, (c) move from the district, or even (d) die. If any of these things happen, then the research is put in jeopardy.

Choosing a sample – either in terms of a person, persons or place(s) can also be difficult. People agreeing to be the single focus of a research study may not be typical of the group to which they belong. Similarly, focusing on one organisation or one place will inevitably lead to comparisons between that organisation or place and others. I (PB) found this a particular problem when describing Thai healthcare education (in an ethnographic study). I realised that it was almost impossible to describe that system without, at the same time, comparing it to the UK or American system of education. This may not necessarily be a problem, but it can lead to a debate about the ‘rightness’ or ‘wrongness’ of a given system. Such value judgements often fall in favour of the system from which the researcher is reporting. The challenge, then, in case studies, is to attempt to describe a single person, place, event or thing, without too much comparison with others. The point is, perhaps, to describe, describe, describe and attempt to offer very little analysis or value judgement. However, in reality, such a task is difficult to attempt and even less likely to be an achievable outcome.

A further problem is that, at the outset, the single-person study might appear to be an interesting one that will yield considerable, in depth, data. However, the reality might be that such data is not gleaned and that it becomes difficult to justify the reporting of a story that turns out to be fairly shallow or monotonous. This is not to suggest the other people’s lives are necessarily boring but to highlight the fact that the case study approach may not answer the initial research question. It may be the case that the case study exploration turns out to produce little that is exploratory.

A further possible problem with the single-case-study approach (in the qualitative style) is the degree to which other researchers (and publishers) accept it as a valid form or research. If some of them do not, it may be difficult to have the final work published. Perhaps the most extreme version of the single-case-study approach, which both of us have come across, was a study in which the researcher used himself as the focus of study. The research report consisted of a reporting of that person’s own views and thoughts. The idea of such an enterprise raises considerable questions about our own ability to stand back from ourselves and, in any real sense, report accurately and objectively what we are researching. On the other hand, some might claim that qualitative research – and particularly the case study approach – lacks objectivity, anyway. Thus, the ‘researcher as focus for study’ might be acceptable. On balance, though, it is safe to say that such an approach does not, as yet, have universal appeal as a research method in healthcare and the neophyte researcher might be well advised not to use it. Generally, careful thought should be given to the selection of any method of data collection and analysis and the limitations of the case study approach should not be underestimated.

It should be noted that, sometimes, the term ‘case study’ is used to refer to a study of a single organisation (see Cooke, 2006, for an example of a case study of three NHS institutions using multiple data collection approaches). In this approach, a range of methods are used, including interviews, observation and the study of organisational documentation. In this way, a picture of the entire organisation is built up. Another term that has been used for this approach is illuminative evaluation. This form of evaluation is usually used in the study of a school or other educational institution. Its aim, as it suggests, is to illuminate the workings of the organisation, from all angles: from the students’,from the teachers’, from the managers’ and from the point of view of any other stakeholders.

To what degree might the case study approach be said to add to the ‘evidence base’ of evidence-based healthcare? Certainly, as we have seen, the findings from any form of qualitative study cannot be generalised to larger populations¹. We have also noted, however, that qualitative studies – and, perhaps, in particular, the case study, can have illuminative qualities. Case studies can show healthcare workers a particular view of what happens in medicine and healthcare. This they can do in a similar way to the use of pictures in books. The case study is often a graphic and easily understood way of capturing a particular moment in history and in a particular context.

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