Case Study Methods for Graduate Students

CHAPTER NINE

CASE STUDY METHODS FOR GRADUATE STUDENTS

Mary de Chesnay and Genie E. Dorman

Research courses for nurse practitioner (NP) students are generally not appreciated by these high-functioning clinicians—at least until they graduate and see what evidence-based practice really means. The authors have taught research and health policy for many years (de Chesnay) and served as the administrator of a master’s degree program and certification reviewer (Dorman), and they regularly receive feedback that the students would prefer to spend more time on clinical skills and little to no time on theory and research courses. NP programs do not include a thesis requirement and many allow for exercises in research rather than full-scale studies or even replication studies. Even doctor of nursing practice programs (DNP) might accept a nonresearch dissertation such as a business plan or a program evaluation plan in lieu of a research project with the rigor of a research doctorate dissertation.

However, if students are to understand and practice from an evidence base, they should have some research content—that means doing something that involves collecting and analyzing data. We can make this process less painless if we encourage case study research as their research competency outcome. Case studies not only teach the research process, but also have the benefit of helping students develop intensive listening skills they can use when confronted with 15-minute patient visit requirements in their future busy practice settings.

CLINICAL CASE STUDIES VERSUS RESEARCH CASE STUDIES

Clinical case studies are a traditional learning activity in medical practice and nursing baccalaureate programs (Eftekhari & Darlison, 2014; Winkelman, Kelley, & Savrin, 2012). The usual model is for a clinician to write up a report on a person of interest or “case” and then present the history, disease progression, and response to treatment to a team of health care professionals who might or might not be on the same unit. Often these presentations are offered as “Grand Rounds,” in which many staff are invited, not just the staff caring for the patient presented.

Eftekhari and Darlison (2014) presented the progression of atrial flutter and mesothelioma in a 69-year-old carpenter. They describe the process of “overshadowing,” which is a term used to describe how cancer diagnosis overshadows comorbid diagnoses, such as heart failure. When the cardiac and oncology specialists reviewed the case together, they redefined the sequence of atrial flutter and decided on a treatment option that was optimal for the patient.

Klepping (2012) presented the case of “Jack,” a 16-year-old male with nasopharyngeal carcinoma who was admitted to a hospice as he was approaching the end of life. She describes a multimethod treatment approach including drug therapy and anxiety alleviation within the context of palliative team care.

It is not a major leap to conduct a research case study on a clinical topic of interest to the student. In this chapter, the author presents the model of teaching research to NPs with the case study approach and to health policy doctoral students, some of whom are NPs earning a research doctorate. The rest of the book consists of examples from the master’s degree and doctoral students themselves.

CURRICULUM

Master’s Degree Sequence

Non-NP students in our program conduct thesis research, but the NPs have a heavy curriculum for the clinical courses and the faculty determined that the best fit for them is a two-semester, two-credit-each sequence beginning in the spring of the first year and ending in the fall of the second year. They write the proposal and go through institutional review board (IRB) during the spring semester and present the study results in the fall, allowing them to graduate on time in December. This allows them to use the summer to collect data if they wish, as the summer is a lighter semester for them. However, the sequence is designed for them to collect data early in the fall. They take the theory course in the spring concurrent with the first research course so they have the theoretical support for whatever study they plan to conduct.

Emphasis in the first course is on reviewing basic quantitative and qualitative designs and methods, data analysis for each type of design, systematically reviewing the literature, linking research with evidence for practice, and theoretical support for research questions. The course is comprehensive and all students complete exercises in both quantitative and qualitative methods as well as a systematic review of the literature on their topics. They have lectures on statistical analysis and content analysis. All prepare an IRB protocol. In the second course, students present their research including how they collected and analyzed data, challenges they faced, and how these were addressed, and develop plans to disseminate results.

At the beginning of the sequence, students are asked whether they are more interested in working with large numbers of subjects, such as in surveys or experiments, or in listening to people tell their stories about various diseases and health issues. When almost all students chose the latter and it was apparent they would choose qualitative designs, they were encouraged to use the case study approach or the life history approach (a life history or even ethnography can be viewed as a case study.) Examples of both are included in this book.

Students were allowed to work in teams of two and all but one student who lived far from campus chose to do so. They could divide the work any way they wished but each would receive the same grade, so they were encouraged to make sure they had a fair distribution of effort. There were no complaints on the final evaluation forms for the sequence. Many commented that they had dreaded the course but came to appreciate what they learned and how they could use what they learned in practice.

The teams whose work is published in this book studied a variety of “cases” that were of interest to themselves and that gave access to appropriate people to interview about their experiences. Tatroe and Elledge traveled to another state to interview a combat veteran who had posttraumatic stress disorder (PTSD) and traumatic brain injury (TBI) from his tours of duty in Afghanistan. He returned home to be trained in how to use a therapy dog and is now a national spokesperson for other combat veterans. Anderson and Chambers interviewed a young woman with Hodgkin’s lymphoma. Kigundu and Sairo were profoundly touched by the story of fellow African immigrants’ loss of a child. Couse and Heard conducted a life history of an older woman living with HIV.

All the students used semistructured interviews and some used limited participant observation. Those who conducted life histories also collected genogram and timeline information, but these were not published in order to protect the privacy of the participants because too much information would identify them.

Doctoral Course in Health Policy

The two chapters written by Kathy Barnett and Amy Pope are based on a fieldwork assignment completed as a requirement for a doctoral-level health policy course. This course provides an orientation to various analytical and substantive components fundamental to health policy. Students develop skills in analysis, application, evaluation, and development of policies related to public health with a focus on issues related to inequalities in health services such as access, costs, utilization, and rationing. Health care policies, methods, and delivery systems are compared within developed and developing countries. Real situations are examined in which specific policy decisions are made by public and private health officials.

Course content includes:

Historical, political, economic, and cultural context of health policy