CHAPTER FOUR
CASE STUDY RESEARCH: A METHODOLOGY FOR NURSING
Camille Cronin
This chapter presents a personal perspective on using case study research for both novice and prospective nurse researchers. My doctoral thesis, Workplace Learning—An Examination of Learning Landscapes (Cronin, 2012) provides a reference point and an example of case study research (CSR). This chapter, after describing the study briefly, focuses on the underlying philosophy, definitions, and justifications for using CSR and why I chose this method. The opportunity to reflect on my work, postdoctoral, is a pleasure and will provide others with insight into a valuable methodology for researching complex health care issues.
A CASE STUDY
For my doctoral research I chose to examine five students’ experiences of 15 health care placements as part of a health care program. As learning environments, these workplaces were explored through observations, interviews, and documents. This study reports on real-life context, which were examined over a 2-year period. This presented rich empirical data offering a pragmatic framework for investigating learning in the workplace.
From carrying out this research, I presented a number of findings, which offered a useful framework to review the complexities that exist within the health care learning environment, how they interact with each other, and the possible impact they may have on learning in the workplace. This piece of work also highlighted the relationship the learner has with the learning environment and learning over time. The work examined the type of individual; their self-awareness; and their level of willingness to learn, which is seen as equally important in the learning environment. I concluded some very suggestive but realistic findings from this study proposing that the learning environment is unpredictable and that learning experiences are random.
Through CSR, qualitative research methods were embraced in a rigorous and systematic manner. Each step of the research protocol was addressed. CSR can be both qualitative and rigorous. This study provided an example of a rigorous qualitative design in which CSR has been used to its full potential. The implications for nursing practice and for research in nursing are that real-life settings can be studied in a systematic and rigorous way and is certainly transferrable to other settings.
A PHILOSOPHY OF PRACTICE
I consider myself to be a learner at all times. There is always something more to discover, which is why life is so exciting and where my source of motivation lies. My interest in teaching has taken me through various paths and has always been a part of my role with colleagues, students, and patients. As a nurse, researcher, or manager, teaching and learning are essential prerequisites for these roles. My doctoral research is the culmination of various walks of my working life in nursing: practice, research, management, and education. With a number of experiences, this augmented the genesis of my work. A number of workplace visits and observations started to seam together. Although on a placement visit, I was observing a student and asked myself: Does this workplace affect practice? If so, how does this affect the students’ learning? How does each work environment affect the student? What about the other students and the other placements? How do these placements help students in their pathway toward becoming a nursing professional? How many students actually make it? Does this then have an impact on nursing recruitment? What about the other health care professions? Do these learners feel adequately prepared? So, this led to my decision to examine learning in the workplace focusing on health care settings.
WHY CSR?
Once it became clear what I was going to research, choosing CSR became straightforward (but getting to this point can take some time). It suited the practical nature of this study (and me which is actually very important to find a design that fits one’s own values and methods) and fitted very well with the variety of health care settings under investigation. CSR provides a practical and systematic way of collecting data in the naturalistic setting. This was very much a key issue as I wanted to be in each place of work collecting data. CSR assumes predetermined experience and knowledge and thus the literature review became a significant chapter in my thesis. Here, I could unload all my preconceptions and assimilate all I know from previous studies, practice, and pedagogy.
The focus of this research study was to conduct an exploration of learning in health care workplaces. The research question was: How do students engage in learning in real-life settings? I ensured a number of objectives were set for data to be collected comprehensively, but in different ways:
To observe and report the learning context where every day face-to-face interactions of students take place in health care settings (hospitals, nursing homes, nurseries)
To examine critical learning incidents
To understand the different experiences and learning in the workplace
Choosing the right research methodology is obviously very important for a dedicated piece of work over a number of years. Although attention is paid to what the research question is asking, one must ensure that both question and method will keep your interest sustained. This was very important to me, so I devoted a great amount of time deciding which philosophical and ethical approach to take. Fundamentally, the research question needed to be answered in the best possible way in order to understand and develop knowledge in this area.
Personal philosophical beliefs were examined and how this world is constructed (a huge undertaking at the beginning of my thesis and I really did not know what it meant). But fundamentally I kept asking myself how students learn and engage in the workplace. However, the health care arena is complex; everyone is different and our expectations of each place differ. Are there patterns to learning or is it that we are individual and different? How does learning come together in this busy environment? Is it packaged differently to classroom learning? The workplace can be very different and yet in practice there is heavy reliance on this environment for learning. In practice-based disciplines, such as nursing, the importance of learning in the workplace provides up to half of the educational experience for students undertaking preregistration nurse education programs (Warne et al., 2010).
Although objective knowledge can be gained from direct experience, what are we to learn in a health care environment–only facts? The purpose of science is to help people understand the world and their surroundings satisfying the natural curiosity of human beings through empirical data. Although this is possible, this study looks at people’s reality as represented through the eyes of the participants. Here, the importance of viewing the meaning of experience and behavior in context in its full complexity was the point of this study. CSR embraces this and the context becomes the focal point.
With this in mind and as an educator, much of the ideas and theory on social constructivism have influenced my own epistemological and ontological stance often influencing ongoing personal and professional development. Social constructivism emphasizes the importance of culture and context in understanding what occurs in society and constructing knowledge based on this understanding (Kukla, 2000). This perspective is closely associated with many contemporary theories, most notably the developmental theories of Vygotsky (1978) and Bruner (1999), and Bandura’s (1989) social cognitive theory. Social constructivism is based on specific assumptions about reality, knowledge, and learning (Kukla, 2000). Here again, CSR embraces the reality where I wanted to collect my data.
Constructivism is a theory of knowledge that argues that humans generate knowledge and meaning from an interaction between their experiences and their ideas (Piaget, 1950). Piaget suggests that through the processes of accommodation and assimilation, individuals construct new knowledge from their experiences. According to the theory, accommodation is the process of reframing one’s mental representation of the external world to fit new experiences. Accommodation can be understood as the mechanism by which failure leads to learning: When we act on the expectation that the world operates in one way and it violates our expectations, we often fail, but by accommodating this new experience and reframing our model of the way the world works, we learn from the experience of failure, or others’ failure (Rogoff, 1999). Piaget’s theory of constructivist learning has had wide-ranging impact on learning theory and teaching methods across disciplines.
Constructivism is not a particular pedagogy; it is a theory that describes one way of how learning happens; regardless of whether learners are, for example, using their experiences to understand a lecture or follow the instructions to build a model house. In both cases, the theory of constructivism suggests that learners construct knowledge out of their experiences. However, constructivism is often associated with pedagogic approaches that promote learning by doing. In this research, constructivism provides a philosophical framework that has informed the thought process and research strategy for exploring learning environments in health care settings.
How Did CSR Fit With My Exploration of Learning?
However, in developing this philosophy further, social constructivism views each learner as a unique individual with unique needs and backgrounds, and is seen as complex and multidimensional (Wertsch, 1997). Moreover, social constructivism encourages the learner to arrive at their own version of the truth, which is influenced by their cultural background. This also stresses the importance of the nature of the learner’s social interaction with knowledgeable others. Without the social interaction with other more knowledgeable people (i.e., going to a work placement), it is impossible to acquire social meaning of important symbol systems and learn how to utilize them. From the social constructivist viewpoint, it is thus important to take into account the background and culture of the learner throughout the learning process, as this helps to shape the learner (Wertsch, 1997).
Interestingly, Glasersfeld (1989) argues that the responsibility of learning should reside with the learner. This is where the philosophy of social constructivism overlaps into the workplace, emphasizing the importance of the learner being actively involved in the learning process with an element of responsibility. With learning, therefore, being an active social process, Vygotsky’s (1978) work strongly influences social constructivism, suggesting that knowledge is first constructed in a social context and is then appropriated by individuals viewing learning as an active process (Glasersfeld, 1989; Kukla, 2000). Furthermore, Vygotsky (1978) adds that the most significant moment in the social and practical elements of learning in intellectual development is when speech and practical activity, two previously independent lines of development, converge.
Most social constructivist models stress the need for collaboration among learners, which is a contradiction to traditional approaches. One Vygotskian notion that has significant implications for peer collaboration is that of the zone of proximal development in which guidance or collaboration is given with more capable peers, and this contrasts with the fixed biological nature of Piaget’s stages of development. Through a process of “scaffolding” a learner can be extended beyond the limitations of physical maturation to the extent that the development process lags behind the learning process (Vygotsky, 1978).
Finally, the social constructivist paradigm views the context in which the learning occurs as central to the learning itself (Kukla, 2000). Knowledge should not be divided into different subjects or compartments, but should be discovered as an integrated whole (Kukla, 2000). This also again underlines the importance of the context in which learning is presented. The world, in which the learner needs to operate, does not approach one in the form of different subjects, but as a complex myriad of facts, problems, dimensions, and perceptions (Wertsch, 1997). This is where Lave’s and Wenger’s (1991) notion of situated learning is directly relevant to learning, specifically those learners who have part of their curriculum taught in the workplace. This constructivist model of learning attempts to “invite learners to a community of practice” so that through authentic activity and social interaction a successful apprenticeship is formed with the learner. Meaningful learning occurs when individuals are engaged in social activities (Kukla, 2000).
Instructional models based on the social constructivist perspective stress the need for collaboration among learners and with practitioners in the society (Lave & Wenger, 1991; Kukla, 2000). Lave and Wenger (1991) assert that a society’s practical knowledge is situated in relations among practitioners, their practice, and the social organization and political economy of communities of practice. For this reason, learning should involve such knowledge and practice (Gredler, 1997; Lave & Wenger, 1991).
Therefore, this study investigated workplaces where students go to learn. The health care workplace is one example of a complex and unpredictable environment and there is an assumption that learning is “situated” and that there is an application of “appropriated” learning. This is where the methodology of choice, CSR, captured the reality of learning in real-life complex health care settings, the context in which learners (who are also complex beings) go to learn. In this way, CSR can examine complex situations that unfold multifaceted realities.
Reality cannot be defined objectively, but subjectively; it is this interpretation of social reality that is important here. With this in mind the ontological stance takes precedence over the epistemological. Within the health care environment, the principles of the natural sciences are difficult to maintain; people cannot be treated as objects and measured objectively. Individual people are involved in the study sharing their views and experiences. Nonetheless, rigor and high-quality research must be applied in order to produce meaningful and pertinent research applicable to contemporary health care.
In terms of epistemological influence over this piece of research, the researcher found strong overlaps with some of the methodologies available, namely, phenomenology, ethnography, and grounded theory. Although they do not directly relate to the ontological stance, there are strong influences and similarities among these philosophical methods of inquiry, which were scrutinized at length and were consequently discarded.
A Brief Historical Perspective of CSR
A case study approach is one of the most frequent research designs applied in social sciences (Burton, 2000). Despite its widespread use, it has changed over time and varies between disciplines and individual researchers (Creswell, 2009; Denzin & Lincoln, 2000; Yin, 2003b). Historically, there have been marked periods of intense use and periods of disuse. During the 1930s, particularly in America with high levels of immigration, poverty, and unemployment, it was associated with The University of Chicago Department of Sociology and, as an approach, it was strongly associated with the field of sociology, but during this time frame, other disciplines raised many questions about its scientific worth. Consequently, this led to a decline in the use of case study as a research methodology.
The use of CSR in nursing has been similar to other disciplines, though its peak interest was in the 1960s followed by a rapid decline in its use (Burns & Groves, 1997). We are now seeing its revival, for example, with Newton, Billett, and Ockerby’s (2009) Australian-based case study of six students from a nursing cohort, and my study. Another example is Houghton, Murphy, Shaw, and Casey’s (2015) multiple case study exploring the role of the clinical skills laboratory in preparing students for the real world of practice. There has been some CSR in the further education (FE) sector, which shares some similarities with this area of exploration, namely, Colley et al. (2003) and Hodkinson and James (2003). Both these pieces of research resulted from a project “Transforming Learning Cultures in Further Education,” which aimed to deepen the understanding of the complexities of learning across the FE sector (Hodkinson & James 2003). It was a collaborative partnership among four universities and four FE colleges in England following level 3 programs in child care, health care, electronics, and telecommunications. All the sites had a substantial amount of work-based learning included throughout and data were generated from a cohort and followed for 2 years (Colley et al., 2003).
Traditionally, quantitative researchers have argued that the CSR is anecdotal and nonscientific, dismissing the results and findings obtained by this method on the grounds that they lack validity and reliability. The controversy that surrounds its scientific nature is nothing new. Like others, Al Rubaie (2002) argues that the CSR is a completely legitimate method suited in both qualitative and quantitative dichotomies. In fact, Al Rubaie (2002) suggests that it is better suited to a holistic, democratic discipline dealing with the understanding and change of interwoven complexities associated with interpersonal processes that emerge and unfold within a wider social context. Hence, this is why this particular approach suits the complexities of the learning in the workplace.
It is somewhat of a paradox because much of what we know about the empirical world is drawn from case studies, and many disciplines still continue to generate a large number of case studies. Yet, according to Gerring (2004) and Burton (2000), the case study is held in low regard or is just simply ignored. A case study might mean that its method is qualitative, with small numbers of participants; that the research may be ethnographic, clinical, participant–observation, or otherwise “in the field” (Yin 2009); the research that is carried out is characterized by process tracing (George and Bennett 2004), in which, as in an audit trail, the steps in the research can readily be followed; and the research can investigate a single case or single phenomenon. Interpretation of CSR has led to arguments resulting in no particular agreement. Although this may be the case, any researcher using CSR must ensure that each step of the research process is transparent.
CASE STUDY RESEARCH
Definition
Defining case study remains problematic because it can constitute a design and a research method. The terms case study, case study method, and case method appear to be used interchangeably in the literature (Hamel, 1993; Yin, 2009). However, it is clear that CSR focuses on specific situations, providing a description of individual or multiple cases. In using this design, the researcher can investigate “everything” in that situation be it individuals, groups, activities, or a specific phenomenon. A distinguishing feature of case study is that although the number of cases may be small (or even one); the number of variables involved is large (Burns & Groves, 1997; Yin, 2009).
To start with, I used a definition from Walsh et al. (2000): in-depth data analysis from systematic investigation over time. It describes basically what I summarized and particularly stressed that the “systematic” approach is to be taken. On further reading, Yin’s (2009) work on CSR became prominent in my reading. Yin’s (2003a) definition of a case study “is an empirical inquiry that investigates contemporary phenomena within its real-life context, especially when the boundaries between phenomena and context are not clearly evident” (p. 13). Yin (2009) argues that one of the most powerful uses of the method is to explain real-life, casual links. What this means is that the researcher can appreciate the subjective richness of individuals recounting their experiences in a particular context and the meanings embedded help guide practice. Yin developed his work further producing two research companion books (Yin, 2003a; 2003b), which provide rich and varied material. This has now been updated with a new fourth edition (Yin, 2009), which promotes CSR as a valid research tool. Many researchers quote Yin’s work and arguably it remains at the forefront of case study research.
Advantages
Gomm et al. (2007) identify three advantages to conducting CSR. First, case studies can take us to places where most of us would not have access or the opportunity to go. They provide enriched experiences of unique situations. Second, case studies allow us to look through the eyes of the researcher. Glesne and Peshkin (1992) recommended that researchers should be as unobtrusive as the wallpaper. In this instance, a poignant piece of reflection comes to mind (see Box 4.1).
Although we do not in reality see through the researcher’s eyes, we in fact share the researcher’s perspective of the theoretical position in the study. Furthermore, by definition, theory simplifies our understanding of reality. Finally, the third reason why case studies may be preferable is that it is less likely to produce defensiveness and resistance to learning. It is more acceptable because the research reflects real life. All these issues raised bring together what case study is, and Hakim (1987) sums up how focused this CSR is like a spotlight on a unit of analysis. Thus the spotlight (or unit of analysis) is on a group of five learners participating in a 2-year study program in which the completion of work placements is compulsory.
