CHAPTER SIX

CONDUCTING CASE STUDY RESEARCH: AN EXEMPLAR

Esther Sangster-Gormley

Nursing scholars use research to validate, refine, and extend nursing knowledge and test theories. Knowledge developed through research contributes to nurses’ understand of the discipline and practice. This knowledge informs the development and implementation of nursing interventions that promote high-quality outcomes for patients, families, providers, and health care systems (Burns & Grove, 2001; Twinn, 2003). Today nurse researchers use quantitative and qualitative approaches, as well as mixed methods, in knowledge development (Twinn, 2003).

Qualitative research is relatively new to nursing; indeed early nurse researchers exclusively used quantitative research methods (Hutchinson, 2001; Morse & Richards, 2002). Over the years, nurse researchers have debated how best to pursue nursing knowledge development, and which approach (qualitative vs. quantitative) was more appropriate to generate knowledge of nursing’s unique contributions to health care (Hutchinson, 2001). No doubt these debates continue today as some researchers continue to maintain a dualist position of privileging one approach over others (Johnson & Onwuegbuzie, 2004).

Quantitative and qualitative research each has distinct, classical methods associated with how research is conducted. For example, quantitative researchers employ standardized instruments and/or conduct randomized-controlled trials to measure the effects of variables or interventions on outcomes. Research findings are determined using odds ratios, inferential statistics, and other methods (Burns & Grove, 2001). Qualitative research is associated with methods such as grounded theory, phenomenology, and ethnography (Hutchinson, 2001). Qualitative researchers have sustained interactions with participants, use interviews, observations, and other unstructured approaches. Findings incorporate participants’ language and perspectives (Guba & Lincoln, 1989).

Increasingly, nurse researchers are finding case study research (CSR) a useful method that allows the flexibility to mix qualitative and quantitative data, for example, surveys and interviews, to explain a phenomena (Stake, 1995; Yin, 2009). Nonetheless, what seems to be missing in nursing research is a clear definition of CSR and how it is conducted. In this chapter, I use my research to illustrate how I used CSR to explain nurse practitioner (NP) role implementation in one provincial health authority in Canada. At the time of this study, NP role implementation was in its early stages, having been introduced 4 years earlier. Thus, this was a unique opportunity to study the process of implementing a new role into the health care system in its early stages. The study was completed in partial fulfillment of my doctoral studies and was my first experience using CSR.

DEFINING CASE STUDY RESEARCH

Early sociologists described CSR as a collection and presentation of detailed, unstructured data obtained from multiple sources to analyze social phenomena in its natural setting, and at a specific time and place (Hammersley, 1989; Ragin, 1992). Today researchers continue to select CSR to study complex phenomenon in the environment in which participants exist, be that work place, home, or community. It allows researchers to obtain multiple perspectives, explore the meanings people attach to the phenomenon of interest, as well as contextual complexity (Creswell & Miller, 2000; Stake, 1995).

Defining the Case

Stake and Yin, two proponents of CSR, have been cited by nurse researchers as offering direction for conducting CSR (Gangeness & Yurkovich 2006; Hewitt-Taylor, 2002; Jones & Lyons, 2004; Zucker, 2001). Stake defines a case as an intrinsic or illustrative-bounded interactive system, with clear boundaries of where the case begins and ends. Intrinsic case studies are conducted to gain a better understanding of a particular phenomenon, whereas an illustrative case provides insight into an issue and facilitates understanding of something other than the case (Stake, 1995). Issues are identified to guide the study and the case is structured to reveal information, determine uniqueness, uncover shortcomings or merit, or facilitate planning for future inquiry (Stake, 1995). Yin begins by asking the question, “What is this case of?” It is necessary to predetermine what is to be studied and why, recognizing the study could be of individuals, organizations, processes, or policies (Yin, 2009).

Yin defines CSR as exploratory, descriptive, or explanatory and constructs cases as single or multiple with embedded multiple units of analysis or holistic with a single unit of analysis. According to Yin, a single case is similar to conducting a single experiment, and multiple cases represent multiple experiments and follow replication logic (Yin, 2009). Exploratory case studies answer “what” questions and are used to develop hypotheses and test propositions for further inquiry. Descriptive case studies are used to describe phenomena within their context, and explanatory case studies are used to answer “how” and “why” questions, as well as understand cause-and-effect relationships (Yin, 2009).

Whether using Yin’s or Stake’s approach to CSR, the researcher first clarifies and defines the case to be studied. For example, I wanted to study how NP role implementation occurred in a health authority. I wanted to understand why it was successfully implemented in some settings and not in others. As a result of my study, I wanted to ultimately explain the process used by health authority managers and those working in the setting in which new NPs were hired, to incorporate a new role into the mix of other health professionals who were often unfamiliar with the NP role and how the NP would function within the setting.

In my research, I made the decision to follow Yin’s approach to CSR and the case I studied was the process of NP role implementation in primary care settings. I selected one provincial health authority for the study, thus a single case study. However, I selected multiple primary care settings within the health authority that had implemented the NP role. Consequently, I used a single case study with three embedded units of analysis (primary care settings). The use of three different settings contributed to the robustness of the study (Yin, 2009), and allowed me to explain more fully the complexity of the process than if I had selected one setting (Baxter & Jack, 2008). Had I selected one setting my intent would have been to explore how the process of role implementation occurred in that particular setting because perhaps something unusual occurred during or after the hiring of the NP. Stake might consider this an intrinsic case study.

Bounding of the Case

Bounding the case refers to limiting what the researcher will and will not study. Limitations may include the amount of time the researcher has to conduct the study and funding. Granting agencies usually expect research to be completed within a predetermined time frame. The funds available determine whether or not the researcher is available to travel and spend time in settings and pay research assistants and other administrative costs. In addition to these limitations, the clearer the researcher is on what is to be studied, the easier it is to bound or limit the case.

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