CHAPTER TWO

STATE OF THE ART OF QUALITATIVE CASE STUDY METHODOLOGY IN NURSING RESEARCH

Johnathan D. Steppe

Qualitative case study methodology (QCSM) is an approach to research that has become increasingly popular in nursing inquiry. Originating in the field of social sciences, QCSM offers a means to holistically explore complex phenomena within real-world contexts (Anthony & Jack, 2009). This holistic approach aligns well with the nursing perspective, which is often characterized by its holistic view of health and well-being. In an article meant for novice researchers, Baxter and Jack (2008) provided an excellent introduction to QCSM, which examined the philosophical roots that inform the approach. Although several theoretical views of QCSM exist, Baxter and Jack noted that the approaches of Yin (2014) and Stake (1995) predominate. Both of these approaches situate QCSM within a constructivist paradigm (Baxter & Jack, 2008) and both consider multiple sources of data as a defining characteristic of the case study approach (Anthony & Jack, 2009). Conversely, Yin (2014) defines case study methodology in terms of the empirical process, whereas Stake (1995) views the approach in terms of the unit of study (Anthony & Jack, 2009). Nevertheless, both approaches acknowledge the value of QCSM in conducting deep exploration of phenomena that cannot be manipulated or removed from their real-world context (Baxter & Jack, 2008; Stake, 1995; Yin, 2014).

Focusing specifically on nursing research, Anthony and Jack (2009) conducted an excellent integrative review of nursing studies published from 2005 to 2007 that employed a qualitative case study approach. The purpose of this review was to critically appraise the use of QCSM by nurse scholars. Anthony and Jack noted that QCSM has become increasingly prevalent in nursing inquiry, a fact that necessitated such a review. Using a defined set of criteria to produce a manageable yet representative sample of QCSM nursing studies, Anthony and Jack identified a total of 42 such studies to include in their review. The authors discovered that nurse scholars were employing QCSM in a broad range of nursing contexts, including acute care, long-term care, nursing education, community health, nursing research, family care, nursing management, adolescent health, and mental health. Furthermore, their review revealed that nurse scholars were paying increasing attention to issues of rigor within the context of QCSM. Still, confusion surrounding the nature of such inquiry persists, a fact that presents challenges to QCSM implementation (Anthony & Jack, 2009). Anthony and Jack recommended that further appraisal of the use of QCSM in nursing inquiry was warranted. Chan (2009) supported this recommendation, citing the increasing prevalence of QCSM in nursing research as the impetus to continue the work of Anthony and Jack and to further explore QCSM within a nursing context. As Chan (2009) noted:

Clearly, QCSM presents both challenges and opportunities for nurse scholars. When used appropriately, QCSM can be employed to conduct rigorous and empirically based studies that take into account the impact and implications of real-world contexts on the phenomena or concept in question. Furthermore, through the use of several data sources, QCSM allows scholars to investigate phenomena from multiple perspectives. Nevertheless, Yin (2014) cautions that QCSM poses unique challenges to novice researchers who may underestimate the complexity of conducting such research in an appropriately systematic and rigorous manner. Confusion over the nature of QCSM may further complicate the research process for neophyte scholars. To facilitate understanding of how QCSM can be employed by nurse researchers in the generation of new knowledge, the following section offers a review of the current body of nursing research that has used a qualitative case study approach. This section is then followed by a discussion of common trends in QCSM within nursing contexts. Through an exploration of contemporary QCSM nursing inquiry, it is our hope that readers considering QCSM for their own research will be better positioned to take advantage of the unique benefits the approach offers.

CURRENT STATE OF NURSING INQUIRY USING CASE STUDY METHODS

In this section, we offer a review of current nursing studies that have been conducted using a QCSM approach. Initially, the search criteria used by Anthony and Jack (2009) guided a literature review of QCSM that spanned from 2009 to 2015. Databases included in the search were CINAHL, MEDLINE, and PsychInfo. Meaningful keywords and search phrases used to identify relevant articles included “qualitative case study,” “case study,” “qualitative,” and “nursing.” The initial search returned more than 140 articles that met the original criteria set, and so additional exclusionary criteria were established. To generate a manageable yet representative sample of studies, this review was further limited to research that was published in nursing journals during a 3-year period, from 2013 to 2015. Furthermore, only studies that listed a nurse as the primary author were included in the review. Incorporating these criteria, a modified search generated a total of 50 articles for inclusion in this review.

Results from the review are summarized as follows. Much like Anthony and Jack (2009), this review identified a broad range of nursing settings and issues in which QCSM has been employed as a research methodology. These settings included acute care, long-term care, mental health, community health, nursing education, peripartum/perinatal care, and professional/workplace issues. When a study overlapped two nursing areas, that study was categorized based on its primary focus. For example, a study conducted in the community health setting that explored implementation of an undergraduate learning strategy was categorized as nursing education.

Acute/Inpatient Care

QCSM studies conducted in acute care settings represented a large percentage of the studies identified for this review. First, Dionne-Odom, Willis, Bakitas, Crandall, and Grace (2015) chose a qualitative case study design to examine surrogate decision making (SDM) within the context of end-of-life issues in the intensive care unit (ICU). The case study approach allowed the researchers to make within- and cross-case comparisons to provide a deeper understanding of the complex psychological processes underlying SDM for terminally ill patients. The researchers recruited 19 informants who had served as SDMs for adult patients who had died in the ICU setting. Cognitive task analysis was used to conduct and analyze semi-structured interviews, which were digitally recorded and evaluated for common themes. Findings were then organized into a conceptual model that represented the SDM process. Results from this study have the potential to inform development of interventions designed to support SDM during end-of-life care.

Adams, Bailey, Anderson, and Thygeson (2013) also examined end-of-life issues in the ICU setting using a QCSM approach, this time from the perspective of both health care providers (HCPs) and family members. The study’s stated purpose was to “describe the behavior of HCPs and responses of family members through the lens of Adaptive Leadership in a prospective case study of a patient transitioning from curative to palliative care” (Adams et al., 2013, p. 330). The researchers used a single case study design that focused on four family members, a nurse, and two physicians of one terminally ill patient. Data were collected using family group conferences and narrative interviews. During data analysis, the researchers employed Adaptive Leadership as a framework for understanding behaviors employed by health care providers to assist families during end-of-life care. The Adaptive Leadership model views organizations and individuals as complex adaptive systems that must confront technical and adaptive challenges through successful self-organization (Adams et al., 2013; Bailey et al., 2012; Thygeson, Morrissey, & Ulstad, 2010). The study findings supported the use of Adaptive Leadership behaviors to facilitate successful adaptation and coping in families facing the loss of a loved one.

Furthermore, within an ICU context, Nesbitt (2013) investigated nurses’ experiences with journal clubs and how such participation influenced professional development. Using a two-site, multiple case study design, the researcher recruited 70 health care professionals (64 nurses) who participated in journal clubs in two Canadian ICUs for a 6-month period. Data-collection methods included six semi-structured interviews with each informant, two focus groups, field notes, anonymous surveys, and document review. Five major themes emerged from data analysis: community, incentive, confidence, impact on practice, and reflection. Findings demonstrated that participation in journal clubs increase nurses’ confidence, competency, and motivation to read research articles, as well as foster an atmosphere of community. Gains in competency were thought to be modest. The researchers concluded that implementation of journal clubs in conjunction with other educational strategies would have a greater impact on competency than just journal clubs alone.

Similar to the study by Adams et al. (2013), Rudolfsson (2014) used a single case study design to elucidate one nurse’s perception of the perioperative patient experience. Rudolfsson selected a QCSM approach for its advantages in providing an in-depth description of a particular phenomenon within specific real-world contexts (Rudolfsson, 2014; Stake, 1995; Yin, 2014). A unique characteristic of this particular study was that the researcher was both the narrator/informant of the case as well as the interpreter/researcher. Thus, the study not only focused on the perception of the perioperative nurse, but also on how that nurse interpreted the situation. The researcher adopted a hermeneutic approach to data analysis, which permitted new insights to arise from the experience. A key finding of this study was that patients experience shame related to body image even before arriving in the operating room.

Four studies used QCSM to explore complex experiences and challenges faced by nurses working in acute care settings. First, Hoyle and Grant (2015) conducted a study that aimed “to understand nurses’ views and experiences of four treatment targets in the emergency department and how this impacts clinical decision making throughout acute secondary care hospitals” (p. 2211). The researchers interviewed 31 informants from three acute care specialties at a large hospital in Scotland. Employing a case study approach informed by Yin (2014) to provide a holistic perspective within a real-world context, the researchers used the hospital as the case unit for the study. Overall, informants perceived treatment time targets as unhelpful and potentially detrimental to patient care. Informants reported breaching treatment target guidelines in cases where acutely ill patients required more care. Emergency nurses bore the most responsibility in meeting treatment targets, a fact that created significant burden for these nurses. The researchers recommended that policy makers reevaluate implementation of treatment time targets to ensure appropriateness. In addition, health care providers breaching such targets to ensure patient safety should be immune from negative repercussions, and the burden arising from these target programs should be more evenly distributed.

A second study that examined experiences of acute care nurses was conducted by White, Pesut, and Rush (2014). In this study, the researchers explored the experiences of post-anesthesia care unit (PACU) nurses caring for ICU patients within the PACU setting. The researchers recruited six PACU nurses who participated in semi-structured interviews designed to elicit information about informant experience with ICU patients. Findings revealed that these nurses caring for ICU patients in a PACU setting often felt unable to provide the appropriate level of care given the limitations of the setting. This inability was related to nurses having the knowledge to provide appropriate care but lacking the resources to do so. The researchers noted that the study highlights the need for a planned change process that could provide PACU nurses access to resources and support needed to care for overflow ICU patients within the PACU setting.

A third study by Droskinis (2013) explored issues faced by diploma nurses working in acute care settings. Droskinis selected a QCSM approach because of its potential to provide authentic empirical data about complex issues within a real-life context. A single informant was recruited for the study, and phenomenological interviews were conducted via e-mail using semi-structured, open-ended questioning. Findings from the study revealed two major themes. The first theme, progressive transformation, related to changing educational requirements and increased responsibilities within the nursing profession. The second theme, technological innovation, represented informant experience with technological revolutions that have transformed nursing care. Overall, the researcher concluded that awareness of the needs of diploma-prepared nurses could contribute to better integration of these nurses within the current health care environment.

Finally, Powell (2013) investigated the experiences of night-shift nurses, with a particular focus on work satisfaction and professional relationships in an acute care setting. The researchers adopted a case study approach that was informed by the perspective of constructivist theory to provide night-shift nurses the opportunity to voice their own unique reality. Fourteen nurses participated in semi-structured interviews that were reinforced and collated with self-completed diaries. Four major themes emerged during data analysis: the importance of work relationships, the impact of the working environment, common work practices, and the personal impact of working nights. Informants reported feeling less supported by leadership than dayshift nurses, with fewer opportunities for engagement and professional development. In addition, working conditions for night-shift nurses appeared inferior to those experienced by day shift. Nevertheless, findings also demonstrated strong collegial relationships among night-shift nurses. The researchers concluded that facilities should capitalize on these strong relationships, while implementing strategies to improve support and working environments of night-shift nurses.

Turning to issues of nursing leadership, this literature review uncovered two studies that dealt with the relationship between nursing leadership and implementation of best-practice/evidence-based quality improvement programs. First, a study by Fleiszer, Semenic, Ritchie, Richer, and Denis (2015) aimed to describe the impact of nursing leader actions on the sustainability of best practice initiatives in the acute care setting. Thirty-nine informants participated in a multiple case study that used semi-structured interviews, document analysis, and field observations. The study’s purpose was to provide insight into the influence of nursing leader actions on the long-term success of best practice guideline programs across four acute care units. Data analysis revealed that successful strategies for sustaining such programs included those that maintained priorities and reinforced program expectations. In doing so, these strategies promoted learning and accountability in the workplace. A key implication of the study was the importance of nursing leadership actions in addressing issues of patient care through implementation and maintenance of best practice initiatives.

Stetler, Ritchie, Rycroft-Malone, and Charns (2014) also explored the impact of nursing leader actions on quality improvement programs, this time from the perspective of institutionalizing evidence-based practice (EBP) guidelines. The study used a multiple case study design that presented two contrasting acute care cases. The first case was a hospital widely known for its successful implementation and use of EBP guidelines, while the second case was a hospital characterized as a beginner in the use of formalized EBP. Data collection included multiple interviews with nurse leaders as well as focus groups with staff nurses. Findings demonstrated the complexity of leadership behaviors and actions that influence successful implementation of EBP. These actions cut across hierarchical levels, and included the efforts of both nurse administrators and staff nurses.

Another study related to quality improvement was conducted by Ireland, Kirkpatrick, Boblin, and Robertson (2013), who investigated the implementation of fall-prevention initiatives in three acute care hospitals located in Ontario, Canada. The researchers defined the case unit as implementation of best practice fall-prevention guidelines, while the three hospitals served as the contextual boundaries of the case. As with many of the previously discussed studies, Ireland et al. (2013) identified the appropriateness of a QCSM approach to investigate complex real-world situations within a specific context. Ninety-five nurses (both administrative and bedside) participated in interviews and focus groups, and also provided documentation and artifacts for data analysis. The researchers noted that triangulation via multiple data sources enhanced rigor of study findings, a claim supported by Stake (1995). Data analysis suggested four recommendations related to falls-prevention interventions:

Related to the subject of nursing leadership, Maxwell, Baillie, Rickard, and McLaren (2013) studied the impact of social identity in achieving acceptance and workplace jurisdiction within two acute care hospitals. Using a multiple case study design, the researchers defined each hospital as a separate case, while two new specialty nursing roles constituted embedded units within the study. According to the researchers “the use of data from different sources is a classic strength of case study design” (Maxwell et al., 2013); accordingly, this study used a significant number of data collection methods, including semi-structured interviews, nonparticipant observation, partial-participant observation, organizational document review, and follow-up interviews. Two distinct role types were identified during data analysis: a “fixer” role and a “niche” role, each of which faced distinct challenges in establishing workplace jurisdiction. Furthermore, workplace jurisdiction was influenced by four different types of workplace identities. These included professional, specialty, organizational, and relational identities. These findings illustrate the need for facilities to support social processes that facilitate acceptance and legitimacy of new nursing roles within acute care settings.

Continuing with research conducted within acute care contexts, Velloso, Ceci, and Alves (2013) explored power configurations within a Brazilian emergency care system with the aim of understanding how such configurations impacted development of the new health care system. Semi-structured interviews and field observations comprised the data-collection strategies of this qualitative case study, which was informed by the work of Foucault (1979). The 31 informants participating in the study included nurses, nursing assistants, ambulance drivers, and physicians. Discourse analysis of the data highlighted the impact of hierarchical surveillance in shaping emergency care practices, which in turn influenced the nature of power relationships within the system. The researchers noted that study findings suggested that supporting flexibility in power relations within health care systems may be necessary in creating a system responsive to the dynamic health issues of contemporary society.

Tobiano, Chaboyer, and McMurray (2013) employed QCSM to understand family member perceptions of bedside shift reports in an Australian hospital. The researchers recruited eight informants who had a family member admitted to an inpatient rehabilitation ward. Data-collection methods included observations, field notes, and guided interviews using open-ended questioning. This combination of data collection methods was employed as a recognized strategy to enhance rigor of study findings (Yin, 2014). Data gathered from individual informants were regarded as separate cases, leading to a multiple case study design. Analysis of common threads among cases revealed three major themes: understanding the situation, interaction with nursing staff, and finding value. In turn, each of these major themes had several associated subthemes. The researchers concluded that families value inclusion and the chance to participate in their loved one’s care, and that effective use of bedside shift reports can support a family-centered nursing approach.

Another study identified in the literature review addressed issues faced by older patients being discharged after hip fracture surgery. Popejoy, Marek, and Scott-Cawiezell (2013) conducted a longitudinal, multiple case study that investigated problems experienced by older adults transitioning through different levels of care following a hip fracture. A total of 21 informants were recruited for the study, and data were collected using participant interview and chart reviews. Interviews were conducted in person or by phone, and were scheduled during the immediate postoperative period, and that at post-discharge intervals of 2 weeks, 3 months, and 12 months. Three major transition patterns were identified: from home to hospital to inpatient rehabilitation, from home to hospital to nursing home, and from nursing home to hospital. Common problems experienced at all levels of transition included depression, delirium, pressure ulcers, weight loss, urinary incontinence, and falls. The researchers recommended that transitional care should enhance patient and family involvement during transitions.

Finally, parents experience significant stress when faced with the hospitalization of their child, and these challenges are exacerbated when one of the parents is a nurse. Lines, Mannix, and Giles (2015) considered the unique experiences of nurses who have had a child hospitalized for an acute illness. For this case study, the researchers recruited six nurses who participated in semi-structured interviews. The results of these interviews were thematically analyzed to identify commonalities among informant experiences. Informants characterized their situation as taking on a dual role, that of the parent–nurse; role conflict often emerged as the informants felt torn between these roles. The expertise of the informants compelled them to seek higher levels of care for their children, a fact that increased stress levels. The researchers concluded that health care professionals need to acknowledge and respond to the unique needs of the nurse–parents of pediatric patients.

Long-Term/Elder Care

Two studies investigated issues of long-term care placement using a QCSM approach. First, Mamier and Winslow (2014) used a single case study design to examine divergent perspectives of a family caregiver and a health care professional within the context of long-term care placement decision making. Informants in the study included a woman caring for her husband, who had been diagnosed with Alzheimer’s disease, as well as a social worker who led a support group attended by the couple. The researchers constructed this revelatory case study from data collected during three interviews (two with the caregiver and one with the social worker). Data analysis was conducted from a grounded theory perspective and revealed 11 major categories in which divergent perspectives of decision making fell. Although some congruence between the perspectives of the social worker and the caregiver was identified, significant differences were also evident. A key finding of this study was that health care professionals may not be aware of the particular needs of caregivers facing long-term placement decisions, and that caregivers could benefit from anticipatory guidance before events necessitate long-term placement.

A second study by Koplow et al. (2015) explored caregiver experiences after long-term care placement of a loved one. Two caregivers were recruited as informants and constituted two separate, contrasting cases made up of a caregiver–care recipient dyad. Informants were purposefully selected to exemplify a smooth transition and a difficult transition within the context of long-term care placement. Data were collected through interviews conducted shortly after placement and again 3 months later. Similarities and differences between the two cases centered around four major issues: the relationship between caregiver and his or her loved one before long-term placement, factors contributing to the placement decision, continuing involvement in the loved one’s care after placement, and available support systems for the caregiver. Implications of the study included the need for nurses and other health care professionals to understand caregiver perspective and the issues that can facilitate smooth transition for families facing long-term placement of a loved one.

Also, within the long-term care context, Tayab and Narushima (2015) used a QCSM approach to explore perceptions and practices of cultural competence among personal support workers (PSWs) working in a long-term care facility in Ontario, Canada. The long-term care facility constituted the case of the study, while six of the facility’s employees served as key informants. The researchers employed multiple methods of data collection to increase study rigor; these methods included focus groups, document review, and semi-structured interviews of key informants. Findings from the study revealed a strong link between cultural competence and patient-centered care, multiple definitions of cultural competence that existed among PSWs, and organizational factors that impacted the development of cultural competence among employees. The researchers concluded that further education and research is needed to elucidate the meaning of cultural competence for PSWs and how their understanding of the concept impacts patient care.

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