Qualitative case study methodology in nursing research: an integrative review

Exploring the application and significance of case study research in nursing

BACKGROUND

Case study research (CSR) has gained popularity across disciplines due to its ability to provide detailed insights into specific phenomena.

AIM

To explore the philosophy and methodology of CSR, drawing from notable authors who have contributed to its development.

DISCUSSION

This article discusses the characteristics of CSR in terms of design and method in both quantitative and qualitative approaches. It examines CSR's advantages and disadvantages as a research method. It draws on two example case studies to emphasise the use of CSR for exploring complex healthcare and social care settings.

CONCLUSION

CSR has proven valuable in nursing research for investigating complex clinical problems, patient-care scenarios, and organisational dynamics and phenomena.

IMPLICATIONS FOR PRACTICE

CSR provides a methodological framework for nursing research that offers a unique lens for exploring multifaceted, complex issues. This ultimately improves patient care outcomes.

More than a mouth to clean: Case studies of oral health care in an Australian hospital

OBJECTIVE

This study aimed to explore older patients' oral health status, their opinions about oral health care and their experiences with oral health care while in hospital.

BACKGROUND

Improving older adults' oral health is considered an urgent priority at both the national and international levels, especially for hospitalised older patients who have been found to have poor oral health. However, a one-size-fits-all standardised approach to oral care delivery may not be the answer.

MATERIALS AND METHODS

This study was an embedded, multiple-case study, integrating qualitative and quantitative data. Seven patients were recruited from a geriatric ward of an acute hospital in Australia and participated in semi-structured interviews and oral health assessments using the Oral Health Assessment Tool (OHAT) in June-July 2022. Data were analysed descriptively and presented in case summaries.

RESULTS

OHAT assessments identified oral health problems in all patients, but not all patients self-reported problems with their mouths. Each patient valued oral health care, but the reasons given varied. Patients had established, individualised oral health care routines, which they brought to hospital.

CONCLUSION

Clinical observations of patient's oral health status might not match the patient's own judgement of their oral health and, if not explicitly addressed, may mask the need for oral health and hygiene intervention. Assessment and care planning needs to incorporate patients' own perceptions of their oral health and existing oral health care routines. Oral health histories may provide a means of facilitating this person-centred oral health care for older patients in hospital.

Quality of life and unmet needs of late-stage and metastatic colorectal cancer survivors: An integrative review

PROBLEM IDENTIFICATION

The purpose of this review was to identify and synthesize the published literature on Quality of Life (QoL) and unmet needs of late-stage (American Joint Committee on Cancer [AJCC] III) and metastatic (AJCC IV) CRC survivors.

LITERATURE SEARCH

Databases searched included PubMed, CINAHL, and Embase from 2010 to 2023. Articles were included if they focused on self-reported CRC experiences of late-stage and metastatic survivors, identifying 512 articles, of which five met the inclusion criteria.

DATA EVALUATION/SYNTHESIS

Five studies were identified that examined QoL and unmet needs of CRC survivors. Three studies assessed only stage III and IV cases. Core factors that may impact QoL included younger age, emotional support from social circles, and psychological support during post-therapy periods. Unmet needs reported by CRC survivors included help managing distress and psychological support for fear of cancer progression.

CONCLUSIONS

Limited research has explored unmet needs of late-stage and metastatic CRC survivors. Further research is needed to understand patient factors that impact QoL and unmet needs to support best care practices.

Exploring the communication access and participation of a young adult with autism spectrum disorder with limited speech and inpatient nursing staff

This study aimed to describe the nature of interactions between health care professionals and a young adult with autism spectrum disorder with limited speech during an inpatient stay. An observational study was conducted to describe the interactions between a young adult on the autism spectrum and 14 of his inpatient health care providers. Naturalistic video-recordings were taken, and behavioral coding was completed to measure the frequency and type of communication turns taken. The providers took 93% of conversational turns. Most provider turns (76%) were non-obligatory in nature and did not invite the young adult to engage in turn-taking. The young adult only had access to his communication system during one of the 27 interactions (4%); however, when he had access to his system, he demonstrated higher levels of turn-taking. Health care providers should offer patients with limited speech more communicative turns, provide adequate wait time, and ensure communication systems are available during all inpatient interactions.

Concept analysis of conscience-based nursing care: a hybrid approach of Schwartz-Barcott and Kim's hybrid model

BACKGROUND

The nursing profession considers conscience as the foundation and cornerstone of clinical practice, which significantly influences professional decision-making and elevates the level of patient care. However, a precise definition of conscience in the nursing field is lacking, making it challenging to measure. To address this issue, this study employed the hybrid approach of Schwartz Barcott and Kim to analyze the concept of conscience-based nursing care.

METHODS

This approach involves a three-phase process; theoretical, fieldwork, and analytical. A systematic literature review was conducted using electronic databases during the first phase to find relevant papers. The content of 42 articles that met the inclusion criteria was extracted to determine the attributes, antecedents, and consequences of consciousness care using thematic analysis. Based on the working definition as a product of this phase, the plan of doing the fieldwork phase was designed. During this phase, data were collected through interviews with nurses all of whom were responsible for patient care in hospitals. In this phase, 5 participants were chosen for in-depth interviewing by purposeful sampling. Data were analyzed using directed content analysis. The findings of the theoretical and fieldwork phases were integrated and the final definition was derived.

RESULTS

The integration of the theoretical and fieldwork phases resulted in identifying four key characteristics of conscience-based nursing care. Firstly, it involves providing professional care with a conscientious approach. Secondly, ethics is at the core of conscience-based care. Thirdly, external spirituality plays a significant role in shaping one's conscience in this context. Finally, conscience-based nursing care is both endogenous and exogenous, with professional commitment being the central focus of care.

CONCLUSION

Conscience-based nursing care is an essential component of ethical care, which elevates clinical practice to professional care. It requires the integration of individual and social values, influenced by personal beliefs and cultural backgrounds, and supported by professional competence, resources, and a conducive organizational atmosphere in the healthcare field. This approach leads to the provision of responsive care, moral integrity, and individual excellence, ultimately culminating in the development of professionalism in nursing.

Qualitative Research Methodology and Applications: A Primer for the Otolaryngologist

OBJECTIVE

Qualitative and mixed methods methodology is becoming more commonplace in otolaryngology as the field strives to understand more complex concepts of the ear, nose, and throat. This methodology can have tremendous utility in studies directed at patient-centered care by offering practical insights and granular detail-directly from patients-which may not be realized by quantitative approaches.

METHODS

Narrative Review.

RESULTS

This review focuses on what questions can be answered by qualitative research, the basics of the underlying principals and different methodologies utilized, and describes the pearls, pitfalls, and rigor of qualitative research.

CONCLUSIONS

This understanding of qualitative inquiry is critical for the otolaryngologist to stay current on what is published and have the ability to include this in their research repertoire. Laryngoscope, 134:27-31, 2024.

Application of case study research and ethnography methods: Lessons learned

While case studies can offer an in-depth investigation of a particular issue in healthcare, cultural context may be overlooked. Researchers may want to consider adding a cultural component to the design aimed at identifying and/or explaining values, beliefs, or traditions influencing the case. The addition of focused ethnography as a supplemental component to the research design is one strategy to examine cultural content. In this article, we provide insights gained from using case study research and focused ethnography in a qualitatively-driven mixed method design. Despite a detailed research plan, there were challenges that hindered the implementation of the design. To help prevent others from experiencing similar methodological challenges, we provide the following lessons learned and recommended strategies: discussion of structured procedures for intentional observations, reflexivity to guide decision-making, and refinement of processes using a pilot study.

Clinical decision-making by fourth-year pharmacy students: Towards an understanding of their uncertainty

INTRODUCTION

Clinical decision-making is a critical process underpinning much of a pharmacist's daily activities. While it is known that pharmacists hesitate to make decisions, it remains unclear whether pharmacy students experience similar hesitancy. The objective of this study was to better understand the phenomenon of decision-making in pharmacy students.

METHODS

This study was designed from a social constructivist paradigm using qualitative case study methodology. The purpose was to investigate issues related to hesitancy in clinical decision-making by fourth-year pharmacy students. Data were collected through observation of students engaging in simulations, post-simulation interviews, and written reflections. Data analysis included multiple stages of coding, followed by pattern identification and discovery of interrelationships.

RESULTS

The primary themes relating to issues in pharmacy student clinical decision-making were relational factors, teaching and learning, degree of certainty, and personal characteristics. Relational factors include elements of relationships with patients and physicians as well as a sense of autonomy. The theme of teaching and learning included the sub-themes of formal education and learning in the real world. Degree of certainty included patient complexity, weighing risks and benefits, comfort in ambiguity, and a lack of information. Finally, personal characteristics associated with decision-making include personal experiences, leadership skills, and confidence.

CONCLUSIONS

Pharmacy education needs to focus on ensuring preceptors can help model comfort in ambiguity, that assessments include the reality of practice, and ensuring ample practice of decision-making in a simulated environment.

Regulating During Crisis: A Qualitative Comparative Case Study of Nursing Regulatory Responses to the COVID-19 Pandemic

Background

The COVID-19 pandemic placed intense pressure on nursing regulatory bodies to ensure an adequate healthcare workforce while maintaining public safety.

Purpose

Our objectives were to analyze regulatory bodies’ responses during the pandemic, examine how nursing regulators conceptualize the public interest during a public health crisis, and explore the influence of a public health crisis on the balancing of regulatory principles. We aimed to develop a clearer understanding of regulating during a crisis by identifying themes within regulatory responses.

Methods

We conducted a qualitative comparative case study examining the pandemic responses of eight nursing regulators in three Canadian provinces and three U.S. states. Data were collected from semi-structured interviews with 19 representatives of nursing regulatory bodies and 206 publicly available documents and analyzed thematically.

Results

Five themes were constructed from the data: (1) risk-based responses to reduce regulatory burden; (2) agility and flexibility in regulatory pandemic responses; (3) working with stakeholders for a systems-based approach; (4) valuing consistency in regulatory approaches across jurisdictions; and (5) the pandemic as a catalyst for innovation. Specifically, we identified that the meaning of “public interest” in the context of high workforce demand was a key consideration for regulators.

Conclusion

Our results demonstrate the intensity of effort involved in nursing regulatory responses and the significant contribution of nursing regulation to the healthcare system’s pandemic response. Our results also indicate a shift in thinking around broader public interest issues, beyond the conduct and competence of individual nurses, to include pressing societal issues. Regulators are beginning to grapple with these longer-term issues and policy tensions.

Remote Moderator and Observer Experiences and Decision-making During Usability Testing of a Web-Based Empathy Training Portal: Content Analysis

Background

COVID-19 restrictions severely curtailed empirical endeavors that involved in-person interaction, such as usability testing sessions for technology development. Researchers and developers found themselves using web-based moderation for usability testing. Skilled remote moderators and observers are fundamental in this approach. However, to date, more empirical work is needed that captures the perceptions and support needs of moderators and observers in testing situations.

Objective

The aim of this paper was to identify remote moderator and observer participant experiences and their use of certain tools to capture feedback of users as they interact with the web browser application.

Methods

This research is part of a broader study on an educational web browser application for nursing students to learn perspective taking and enhance their perceptual understanding of a dialogue partner’s thoughts and feelings. The broader study used a quantitative and think-aloud qualitative problem-discovery usability study design. This case study explored written accounts of the remote moderator and observer participants regarding their roles, experiences, and reactions to the testing protocol and their suggestions for improved techniques and strategies for conducting remote usability testing. Content analysis was used to analyze participants’ experiences in the usability testing sessions.

Results

We collected data from 1 remote moderator and 2 remote observers. Five themes were identified: dealing with personal stressors, dealing with user anxiety, maintaining social presence, ethical response to the study protocol, and communication during sessions. The participants offered recommendations for the design of future remote testing activities as well as evidence-informed training materials for usability project personnel.

Conclusions

This study’s findings contribute to a growing body of endeavors to understand human-computer interaction and its impact on remote moderator and observer roles. As technology rapidly advances, more remote usability testing will occur where the knowledge gleaned in this study can have an impact. Recommendations based on moderator and observer participant perspectives identify the need for more evidence-informed training materials for their roles that focus on web-based interpersonal communication skills, execution of user testing protocols, troubleshooting technology and test user issues, proficiency in web conferencing platforms, behavior analysis and feedback technologies, and time management.

Assessment of the obesogenic environment in primary schools: a multi-site case study in Jakarta

BACKGROUND

Childhood overweight and obesity have increasingly been recognized as a significant global public health crisis, including in Asia. This study aimed to assess the obesogenic environment in primary schools in Jakarta, Indonesia.

METHODS

A qualitative, multi-site, case study design was used to capture different elements of the school environment and policies related to obesity, with a focus on nutrition and physical activity. An adaptation of the Primary School Environmental Assessment tool was used. Six primary schools in Jakarta were purposively selected based on their location, socioeconomic status, and type (public or private). In addition to direct observation at each school, interviews were conducted with the principal, physical education teacher, canteen staff, street food vendors, and students.

RESULTS

Among the six schools, two were private and four were public. The most popular foods consumed by students were unhealthy, such as deep-fried foods and sugar-sweetened beverages. Students had easy and constant access to unhealthy foods, whereas only limited variation of healthy foods were available in the school canteen. Some schools also allowed the student to have access to street food vendors. School policies related to healthy eating and physical activities had been implemented, mainly in the form of teaching these topics as part of the school curriculum. However, promotion of healthy eating and physical activities by the schools was still limited.

CONCLUSIONS

This study showed the usefulness of the Primary School Environmental Assessment tool in identifying obesogenic factors in urban area of Indonesia. Effective implementation of guidelines to foster good nutritional practices and healthy lifestyles at school should be prioritized to improve the health and nutritional status of the students.

Patient Involvement During a Pathway of Home-Based Reablement for Older Persons: A Longitudinal Single-Case Study

Background

In recent years, home-based reablement has become an increasingly popular way to provide rehabilitation services. This health care service aims to enable older persons to live longer at home while reducing the need for institutionalization. To ensure the provision of high-quality services, there is a continual need for research on issues of user involvement and co-creation during the pathway of the reablement process.

Purpose

This study focused on user involvement and participation with health care professionals during the reablement process.

Methods

This was a longitudinal, instrumental single-case study, in which one 85-year-old female patient was followed over the pathway of a six-week reablement process. Data were collected at three stages, including the goal-mapping phase, evaluation phase, and three weeks after completing reablement.

Results

Our analyses revealed two themes for the goal-mapping phase (dialogue led by the care provider and main goal), three themes for the implementation phase (the home as the preferred setting, little influence on organizational factors, and participation, influence, and motivation), and three themes for the evaluation phase (patient understanding as a precondition, motivated by weak paternalism, and self-determination requires clear communication).

Conclusion

The patient becomes involved through a partly co-creation process. During this time, they are involved, motivated, and influenced over the pathway of reablement. Health care providers must avoid implementing too much control during the pathway of home-based reablement, as patients have contextual knowledge that care providers do not possess.

The Selection Process and Criteria of Impact Accelerators. An Exploratory Study

Start-up accelerators, a relatively new and competitive type of business incubators, are nowadays considered to be a highly effective way of providing venture support. Start-ups who have been supported through accelerators have an approximately 23% higher survival rate than other new businesses. This positive effect can be explained by the highly selective process accelerators apply when deciding on which venture projects to support. It comes as no surprise that understanding this process and the respective selection criteria is at the core of accelerator/incubator literature within entrepreneurship research. Existing research is however limited to the investigation of commercial accelerators which provide support to start-ups having an economic purpose only. Hence those academic findings cannot be simply extrapolated to accelerators supporting ventures combining economic goals with social and ecological purpose. Given the growing meaning of sustainability entrepreneurship and hence the increasing number of sustainability-oriented accelerators, the above limitation seems to be an important research gap. This paper addresses the above gap by investigating the selection processes and criteria of so-called impact accelerators focusing on the support of start-ups expected to create not only economic outcomes but also positive social and/or environmental impact. Building on existing accelerator literature, we qualitatively investigate the selection processes and criteria of nine European impact accelerators. By comparing our findings with existing research, we identify important differences between the selection approach of commercial and impact accelerators thus contributing to sustainability entrepreneurship research and practice.

Implementing an Action Over Inertia Group Program in Community Residential Rehabilitation Services: Group Participant and Facilitator Perspectives

Introduction: A time-use focused intervention, Action Over Inertia (AOI) designed to address restricted activity patterns and support recovery, was adapted for use in Australian community residential mental health services. Method: Qualitative case study research explored the use of AOI groups across three Community Care Units from the perspectives of group participants with enduring mental illness and group facilitators. Fifteen interviews were conducted: five group participants were interviewed twice 4 weeks apart, and five group facilitators on completion of the group intervention. Interview data were analyzed thematically using constant comparative methods. Findings: Two overarching themes, "Making Change" and "Facilitating Change" were identified. Efforts to make change in their lives were supported by participants recognising the value of personally meaningful activities for well-being and of activity experiences that fostered hope and recovery, whereas a sense of "stuckness," time for activities and life events could disrupt "getting me going." For the facilitators, facilitating change involved recognizing inertia as a challenge; getting people going; and looking at how AOI intervention works to impact inertia. Conclusion: AOI in a group format supports participants to identify barriers to more active living; to appreciate how time-use and well-being interrelate; and to reframe and take steps to overcome inertia. Further research should evaluate AOI groups as a means of providing individualized support for activity re-engagement as part of recovery oriented mental health rehabilitation.

Parents' experiences using medical cannabis for their child

BACKGROUND

Parents across the United States use medical cannabis for their children, often without professional guidance. These parents have become more expert on medical cannabis than most health professionals.

PURPOSE

Using a case-study design, this study was conducted to describe the experience of parents using medical cannabis for relief of seizures in their child or dependent.

METHODS

Data were subjected to qualitative content analysis for the identification of patterns and themes.

FINDINGS

Analysis of all data revealed seven themes including "Discovery of Cannabis as a Medication," "Guidance on Dosing," "Costs and Benefits of Cannabis," "Distrust of the Pharmaceutical Industry," "Federal Interference," "God and Cannabis," and "Changing Societal Perceptions about Medical Cannabis."

DISCUSSION

Themes revealed a complex, multifaceted experience. Many parents report benefit from medical cannabis, and are not hindered by the financial costs or uncertainties. Political and social influences have significant impact on the stigmatization and normalization of cannabis.

Lessons learnt: examining the use of case study methodology for nursing research in the context of palliative care

Background

An empirical social research approach, facilitating in-depth exploration of complex, contemporary contextualised phenomena, case study research has been used internationally in healthcare studies across clinical settings, to explore systems and processes of care delivery. In the United Kingdom, case study methods have been championed by nurse researchers, particularly in the context of community nursing and palliative care provision, where its applicability is well established. Yet, dogged by conceptual confusion, case study remains largely underutilised as a research approach.

Method

Drawing on examples from nursing and palliative care studies, this paper clarifies case study research, identifies key concepts and considers lessons learned about its potential for nursing research within the unique and complex palliative and end of life context.

Conclusion

A case study approach offers nurse researchers the opportunity for in-depth, contextualised understanding of the systems and processes which influence their role in palliative care delivery across settings. However, philosophical and conceptual understandings are needed and further training in case study methodology is required to enable researchers to articulate and conduct case study.

How Qualitative Case Study Methodology Informs Occupational Therapy Practice: A Scoping Review

Qualitative case study methodology (QCSM) is a useful research approach that has grown in popularity within the social sciences; however, it has received less attention in the occupational therapy literature. The current scoping review aims to explore how studies utilizing a QCSM help inform occupational therapy knowledge and practice. Electronic searches were conducted in April 2017, and the resultant 388 publications were screened by three reviewers in Covidence. In all, 27 publications met the inclusion criteria and were included in the scoping review. Case studies in the occupational therapy literature have explored phenomena relating to the delivery of intervention, theoretical concepts, clinical reasoning, and education and research methods and were situated in a range of different practice areas and contexts. QCSM is a valuable approach in occupational therapy research that contributes to the body of knowledge and theory that informs occupational therapy practice.

'Menstrual blood is bad and should be cleaned': A qualitative case study on traditional menstrual practices and contextual factors in the rural communities of far-western Nepal

Objective:

Unhealthy menstrual practices and the contexts surrounding them should be explored and clearly understood; this information could be useful while developing and implementing interventions to increase hygienic practices during menstruation and consequently increase health and well-being of women. Therefore, this study was conducted to explore traditional menstrual practices and the contextual factors surrounding the practices in the rural communities of far-western Nepal.

Methods:

This was a qualitative case study conducted in the Achham district of Nepal. Semi-structured interviews were conducted among four women, three men and two female community health volunteers to collect data and thematic analysis was performed to analyze the data.

Results:

We found two commonly reported menstrual practices: seclusion practice (Chhaupadi) and separation practice. In the Chhaupadi practice, women are secluded to stay in a small shed away from the house and restricted to wash or take a bath in public water sources for 5–7 days of the periods, whereas in the separation practice, women can stay in the house, but they still have several restrictions. The contextual factors that were reported to influence the cultural practices are as follows: cultural beliefs that symbolize menstruation as impure, menstrual stigma, poverty, illiteracy, the influence of traditional healers and family members, and limited effect of Chhaupadi elimination interventions. We also found that some development in the reduction of cultural myths and practices is happening, but the rate of change is rather slow.

Conclusion:

Most of the Nepalese women, especially in the rural areas of far-western Nepal, are forced to follow the harmful menstrual practices because of the socio-cultural context surrounding their lives. We believe the findings of this study would be relevant in terms of developing and implementing further menstrual health-related, community-based interventions that will be responsive to the local cultural context, beliefs, and practices.

Development of non-technical skills through virtual patients for undergraduate nursing students: An exploratory study

INTRODUCTION

Non-technical skills (NTS) are fundamental requirements for health professional graduates for safe and competent practice. Technology enhanced simulation, including virtual patients (VPs), is suggested to be effective in developing NTS.

PURPOSE

The purpose of this paper is to explore what participants learnt about NTS following interactions with the VPs in the case study.

DESIGN

Case study methodology was used to explore learning by undergraduate nursing students related to NTS following interactions with VPs. First- (n = 40) and third-year (n = 31) undergraduate nursing students from two universities in Victoria, Australia agreed to participate in focus groups and interviews. These were audio-recorded, transcribed and then underwent framework analysis. A priori codes in the framework used NTS categories including communication, situation awareness, teamwork, decision-making skills, leadership, managing stress and coping with fatigue.

FINDINGS

Overall, students in both years and universities reported that interactions with VPs developed knowledge and skills across all categories of NTS to varying degrees. Third-year students suggested that interactions with VPs enabled development of knowledge and skills, as well as practise of selected NTS in the clinical setting.

CONCLUSION

Interactions with VPs across the curriculum may assist undergraduate nursing students in developing knowledge, skill and practice of NTS categories including communication, situation awareness, teamwork, decision-making skills and duty, advocacy and empathy.

Implementation of a comprehensive program to improve coordination of care in an urban academic health care system

Purpose Academic healthcare systems face great challenges in coordinating services across a continuum of care that spans hospital, community providers, home and chronic care facilities. The Johns Hopkins Community Health Partnership (J-CHiP) was created to improve coordination of acute, sub-acute and ambulatory care for patients, and improve the health of high-risk patients in surrounding neighborhoods. The paper aims to discuss this issue. Design/methodology/approach J-CHiP targeted adults admitted to the Johns Hopkins Hospital and Johns Hopkins Bayview Medical Center, patients discharged to participating skilled nursing facilities (SNFs), and high-risk Medicare and Medicaid patients receiving primary care in eight nearby outpatient sites. The primary drivers of the program were redesigned acute care delivery, seamless transitions of care and deployment of community care teams. Findings Acute care interventions included risk screening, multidisciplinary care planning, pharmacist-driven medication management, patient/family education, communication with next provider and care coordination protocols for common conditions. Transition interventions included post-discharge health plans, hand-offs and follow-up with primary care providers, Transition Guides, a patient access line and collaboration with SNFs. Community interventions involved forming multidisciplinary care coordination teams, integrated behavioral care and new partnerships with community-based organizations. Originality/value This paper offers a detailed description of the design and implementation of a complex program to improve care coordination for high-risk patients in an urban setting. The case studies feature findings from each intervention that promoted patient engagement, strengthened collaboration with community-based organizations and improved coordination of care.

Student midwives' experiences in relation to assessment of maternal postnatal genital tract health: A case study analysis

OBJECTIVE

to explore student midwives' experiences of postnatal genital tract assessment within midwifery preregistration curricula.

DESIGN

a single, instrumental case study design was employed involving final year student midwives. Ethical approval was gained from the Higher Education Institution at the data collection site. Sampling was purposeful and data were collected using a survey (n = 25); narrative style in depth interviews (n = 11), review of programme documentation and a student midwife / researcher data workshop.

SETTING

one Higher Education Institution in the north of England.

FINDINGS

three themes were identified from the data analysis, awareness of assessment methods, accessing learning opportunities and actualisation of learning. The awareness theme highlights that most students were aware of potential signs and symptoms associated with genital tract assessment and health however; difficulties were identified concerning assessment of lochia, encountering sequential assessments and recognising potential for deterioration. This awareness was influenced by access to practice based learning opportunities. Access differed due to variation in postnatal provision, service pressures and variety in mentor practices regarding selecting and creating learning opportunities. This study suggests actualisation of learning and confidence in genital tract assessment was achieved when opportunities to integrate theory and practice occurred. Actualisation was hindered by limited allocation of curriculum time specifically for postnatal maternal assessment content and assessment strategies in comparison to other aspects of midwifery knowledge.

CONCLUSIONS

student midwives' experiences, awareness and learning actualisation varied in relation to the development of knowledge and confidence in maternal postnatal genital tract assessment. While clinical and theoretical learning opportunities were available, access and experience varied and limitations were identified. A number of recommendations are outlined to enhance the students learning experiences in practice and HEI settings, which address placement planning, mentor preparation, the student voice and supporting curricula documentation.

A research method to explore midwives' views of national maternity service reforms

BACKGROUND

Priorities of the National Maternity Services Plan (NMSP) are a significant contrast to current standard hospital maternity service provision. This paper demonstrates the applicability of case study methods to explore the views of midwives during a period of midwifery reform.

AIM

This research aims to highlight key findings and insights surrounding recommended changes facing midwives that can be shared with education providers to incorporate strategies into education programs to ensure contemporary midwifery practice.

METHODS

Exploratory Case Study methodology was employed using ethical processes and designing semi-structured interview questions to explore participants' views. Purposive sampling ensured participants were currently practicing midwives in order to reflect the perspective and intent of this study. Data were analysed and findings presented in categories and subcategories.

RESULTS

Case Study methodology enables an in-depth understanding of a phenomenon to be explored within a natural context. The participants of this study formed a single unit of analysis to ensure the research makes a worthwhile contribution to the profession of midwifery.

CONCLUSION

This paper demonstrates that Case Study methodology is a valid research approach to exploring the views of midwives employed in standard care settings during a period of national reform. The rigorous processes and versatility of Case Study methodology ensured a systematic, critical enquiry was undertaken to gain understanding of the views of participants in implementing the NMSP. This understanding is reflective of the real life contexts of midwives to promote understanding and provide a body of knowledge where there is ambiguity and uncertainty.

Case Study Observational Research: A Framework for Conducting Case Study Research Where Observation Data Are the Focus

Case study research is a comprehensive method that incorporates multiple sources of data to provide detailed accounts of complex research phenomena in real-life contexts. However, current models of case study research do not particularly distinguish the unique contribution observation data can make. Observation methods have the potential to reach beyond other methods that rely largely or solely on self-report. This article describes the distinctive characteristics of case study observational research, a modified form of Yin's 2014 model of case study research the authors used in a study exploring interprofessional collaboration in primary care. In this approach, observation data are positioned as the central component of the research design. Case study observational research offers a promising approach for researchers in a wide range of health care settings seeking more complete understandings of complex topics, where contextual influences are of primary concern. Future research is needed to refine and evaluate the approach.

Attending to power differentials: How NP-led group medical visits can influence the management of chronic conditions

Objective

In Canada, primary care reform has encouraged innovations, including nurse practitioners (NPs) and group medical visits (GMVs). NP‐led GMVs provide an opportunity to examine barriers and enablers to implementing this innovation in primary care.

Design

An instrumental case study design (n=3): two cases where NPs were using GMVs and one case where NPs were not using GMVs, was completed. In‐depth interviews with patients and providers (N=24) and 10 hours of direct observation were completed. Interpretive descriptive methods were used to analyse data.

Results/Findings

Two main themes were identified: (i) acquisition of knowledge and (ii) GMVs help shift relationships between patients and health‐care providers. Participants discussed how patients and providers learn from one another to facilitate self‐management of chronic conditions. They also discussed how the GMV shifts inherent power differentials between providers and between patients and providers.

Discussion

NP‐led GMVs are a method of care delivery that harness NPs’ professional agency through increased leadership and interprofessional collaboration. GMVs also facilitate an environment that is patient‐centred and interprofessional, providing patients with increased confidence to manage their chronic conditions. The GMV provides the opportunity to meet both team‐based and patient‐centred health‐care objectives and may disrupt inherent power differentials that exist in primary care.

The healthcare team's perception of the role of the perioperative nurse: A qualitative study

The surgical process requires the coordination of a number of professionals who understand their own roles and responsibilities, as well as those of the team. In the perioperative setting, expectations are established around behaviors and competencies of every team member. These expectations are influenced by knowledge, training and experience, and may ultimately influence results and the ability to adapt and respond to work demands. In Chile, there exists an ambiguity and lack of definition in the role of the nurse. The objective of this study was to examine the healthcare team's perception of the current role of the perioperative nurse, as well as the expected and desired characteristics of the role from the team's perspective. A qualitative, descriptive case study was carried out, using semi-structured interviews conducted with a purposive sample of surgeons, anaesthesiologists, professional nurses and technical nurses from three hospitals in Santiago, Chile. The accounts were analysed using an inductive, thematic format. It was found that the current perioperative nursing role, with a predominance of administrative charting, recordkeeping and guidelines for the management of safety, quality control and human and material resources, restricts direct patient care. Expected characteristics of the role included comprehensive theoretical and practical training and the development of relational skills for teamwork, direct patient care and advocacy in the surgical context. These results provided initial steps towards redefining the role of the perioperative nurse, strengthening collaborative efforts and optimising patient care during a time of high vulnerability.

Developing the DESCARTE Model: The Design of Case Study Research in Health Care

Case study is a long-established research tradition which predates the recent surge in mixed-methods research. Although a myriad of nuanced definitions of case study exist, seminal case study authors agree that the use of multiple data sources typify this research approach. The expansive case study literature demonstrates a lack of clarity and guidance in designing and reporting this approach to research. Informed by two reviews of the current health care literature, we posit that methodological description in case studies principally focuses on description of case study typology, which impedes the construction of methodologically clear and rigorous case studies. We draw from the case study and mixed-methods literature to develop the DESCARTE model as an innovative approach to the design, conduct, and reporting of case studies in health care. We examine how case study fits within the overall enterprise of qualitatively driven mixed-methods research, and the potential strengths of the model are considered.

A methodological review of qualitative case study methodology in midwifery research

AIM

To explore the use and application of case study research in midwifery.

BACKGROUND

Case study research provides rich data for the analysis of complex issues and interventions in the healthcare disciplines; however, a gap in the midwifery research literature was identified.

DESIGN

A methodological review of midwifery case study research using recognized templates, frameworks and reporting guidelines facilitated comprehensive analysis.

DATA SOURCES

An electronic database search using the date range January 2005-December 2014: Maternal and Infant Care, CINAHL Plus, Academic Search Complete, Web of Knowledge, SCOPUS, Medline, Health Collection (Informit), Cochrane Library Health Source: Nursing/Academic Edition, Wiley online and ProQuest Central.

REVIEW METHODS

Narrative evaluation was undertaken. Clearly worded questions reflected the problem and purpose. The application, strengths and limitations of case study methods were identified through a quality appraisal process.

RESULTS

The review identified both case study research's applicability to midwifery and its low uptake, especially in clinical studies. Many papers included the necessary criteria to achieve rigour. The included measures of authenticity and methodology were varied. A high standard of authenticity was observed, suggesting authors considered these elements to be routine inclusions. Technical aspects were lacking in many papers, namely a lack of reflexivity and incomplete transparency of processes.

CONCLUSION

This review raises the profile of case study research in midwifery. Midwives will be encouraged to explore if case study research is suitable for their investigation. The raised profile will demonstrate further applicability; encourage support and wider adoption in the midwifery setting.

An organizational perspective on the long-term sustainability of a nursing best practice guidelines program: a case study

BACKGROUND

Many healthcare innovations are not sustained over the long term, wasting costly implementation efforts and often desperately-needed initial improvements. Although there have been advances in knowledge about innovation implementation, there has been considerably less attention focused on understanding what happens following the early stages of change. Research is needed to determine how to improve the 'staying power' of healthcare innovations. As almost no empirical knowledge exists about innovation sustainability in nursing, the purpose of our study was to understand how a nursing best practice guidelines (BPG) program was sustained over a long-term period in an acute healthcare centre.

METHODS

We conducted a qualitative descriptive case study to examine the program's sustainability at the nursing department level of the organization. The organization was a large, urban, multi-site acute care centre in Canada. The patient safety-oriented BPG program, initiated in 2004, consisted of an organization-wide implementation of three BPGs: falls prevention, pressure ulcer prevention, and pain management. Data were collected eight years following program initiation through 14 key informant interviews, document reviews, and observations. We developed a framework for the sustainability of healthcare innovations to guide data collection and content analysis.

RESULTS

Program sustainability entailed a combination of three essential characteristics: benefits, institutionalization, and development. A constellation of 11 factors most influenced the long-term sustainability of the program. These factors were innovation-, context-, leadership-, and process-related. Three key interactions between factors influencing program sustainability and characteristics of program sustainability accounted for how the program had been sustained. These interactions were between: leadership commitment and benefits; complementarity of leadership actions and both institutionalization and development; and a reflection-and-course-correction strategy and development.

CONCLUSIONS

Study findings indicate that the successful initial implementation of an organizational program does not automatically lead to longer-term program sustainability. The persistent, complementary, and aligned actions of committed leaders, in a variety of roles across a health centre department, seem necessary. Organizational leaders should consider a broad conceptualization of sustainability that extends beyond program institutionalization and/or program benefits. The development of an organizational program may be necessary for its long-term survival.

Rigorous, robust and systematic: Qualitative research and its contribution to burn care. An integrative review

Qualitative methods are progressively being implemented by researchers for exploration within healthcare. However, there has been a longstanding and wide-ranging debate concerning the relative merits of qualitative research within the health care literature. This integrative review aimed to exam the contribution of qualitative research in burns care and subsequent rehabilitation. Studies were identified using an electronic search strategy using the databases PubMed, Cumulative Index of Nursing and Allied Health Literature (CINAHL), Excerpta Medica database (EMBASE) and Scopus of peer reviewed primary research in English between 2009 to April 2014 using Whittemore and Knafl's integrative review method as a guide for analysis. From the 298 papers identified, 26 research papers met the inclusion criteria. Across all studies there was an average of 22 participants involved in each study with a range of 6-53 participants conducted across 12 nations that focussed on burns prevention, paediatric burns, appropriate acquisition and delivery of burns care, pain and psychosocial implications of burns trauma. Careful and rigorous application of qualitative methodologies promotes and enriches the development of burns knowledge. In particular, the key elements in qualitative methodological process and its publication are critical in disseminating credible and methodologically sound qualitative research.

A sustainable dietetics bridging program: development and implementation in Atlantic Canada

A provincial focus on immigration and improved foreign credential recognition has led to an investigation of best practices and subsequent recommendations for the development and implementation of a sustainable university-based bridging program for internationally educated dietitians in Atlantic Canada. Data were collected from various sources and used to inform program decisions and direction. An advisory framework was established through a core group representing dietetics education and regulation and internationalization. Subsequently, a key stakeholder group was formed. As a result of this collaboration and research, a dietetics bridging framework was developed and a program pilot tested. Lessons learned may inform similar endeavours and highlight the importance of collaborative leadership and collaboration among multiple stakeholders, and of creatively addressing program sustainability issues while keeping learners (internationally educated dietitians) at the centre.

Prevention of involuntary admission through Family Group Conferencing: a qualitative case study in community mental health nursing

AIM

To understand whether and how Family Group Conferencing might contribute to the social embedding of clients with mental illness.

BACKGROUND

Ensuring the social integration of psychiatric clients is a key aspect of community mental health nursing. Family Group Conferencing has potency to create conditions for clients' social embedding and subsequently can prevent coercive measures.

DESIGN

A naturalistic qualitative case study on the process of one conference that was part of 41 conferences that had been organized and studied from January 2011-September 2013 in a public mental health care setting in the north of the Netherlands.

METHODS

Semi-structured interviews (N = 20) were conducted with four stakeholder groups (N = 13) involved in a conference on liveability problems in a local neighbourhood wherein a man with schizophrenia resides.

FINDINGS

To prevent an involuntary admission to a psychiatric ward of a man with schizophrenia, neighbourhood residents requested a family group conference between themselves, the sister of the man and the mental health organization. As a possible conference aggravated psychotic problems, it was decided to organize it without the client. Nine months after the conference, liveability problems in the neighbourhood had been reduced and coercive measures adverted. The conference strengthened the community and resulted in a plan countering liveability problems.

CONCLUSION

The case indicates that social embedding of clients with severe psychiatric problems can be strengthened by Family Group Conferencing and that hence coercive measures can be prevented. A shift is required from working with the individual client to a community driven approach.

Exploring ward nurses' perceptions of continuing education in clinical settings

BACKGROUND

Health care systems demand that nurses are flexible skilful workers who maintain currency and competency in order to deliver safe effective patient centered care. Nurses must continually build best practice into their care and acquire lifelong learning. Often this learning is acquired within the work environment and is facilitated by the clinical nurse educator. Understanding clinical nurses' values and needs of continuing education is necessary to ensure appropriate education service delivery and thus enhance patient care.

OBJECTIVES

To explore clinical ward-based nurses' values and perceptions towards continuing education and what factors impact on continuing education in the ward.

DESIGN

A case study approach was utilized.

SETTING

A major teaching hospital in Melbourne, Australia.

PARTICIPANTS

A range of clinical nursing staff (n=23).

METHODS

Four focus groups and six semi-structured individual interviews were undertaken. Focus group interviews explored participants' values and perceptions on continuing education through a values clarification tool. Thematic analysis of interviews was undertaken to identify themes and cluster data.

RESULTS

Three central themes: 'culture and attitudes', 'what is learning?' and 'being there-being seen', emerged reflecting staffs' values and perceptions of education and learning in the workplace.

CONCLUSIONS

Multiple factors influence ward nurses' ability and motivation to incorporate lifelong learning into their practice. Despite variance in nurses' values and perceptions of CE in clinical environments, CE was perceived as important. Nurses yearned for changes to facilitate lifelong learning and cultivate a learning culture. Clinical nurse educators need to be cognizant of adult learners' characteristics such as values, beliefs, needs and potential barriers, to effectively facilitate support in a challenging and complex learning environment. Organizational support is essential so ward managers in conjunction with educational departments can promote and sustain continuing education, lifelong learning and a culture conducive to learning.

Does the knowledge-to-action (KTA) framework facilitate physical demands analysis development for firefighter injury management and return-to-work planning?

PURPOSE

Employers are tasked with developing injury management and return-to-work (RTW) programs in response to occupational health and safety policies. Physical demands analyses (PDAs) are the cornerstone of injury management and RTW development. Synthesizing and contextualizing policy knowledge for use in occupational program development, including PDAs, is challenging due to multiple stakeholder involvement. Few studies have used a knowledge translation theoretical framework to facilitate policy-based interventions in occupational contexts. The primary aim of this case study was to identify how constructs of the knowledge-to-action (KTA) framework were reflected in employer stakeholder-researcher collaborations during development of a firefighter PDA.

METHODS

Four stakeholder meetings were conducted with employee participants who had experience using PDAs in their occupational role. Directed content analysis informed analyses of meeting minutes, stakeholder views and personal reflections recorded throughout the case.

RESULTS

Existing knowledge sources including local data, stakeholder experiences, policies and priorities were synthesized and tailored to develop a PDA in response to the barriers and facilitators identified by the firefighters. The flexibility of the KTA framework and synthesis of multiple knowledge sources were identified strengths. The KTA Action cycle was useful in directing the overall process but insufficient for directing the specific aspects of PDA development. Integration of specific PDA guidelines into the process provided explicit direction on best practices in tailoring the PDA and knowledge synthesis. Although the themes of the KTA framework were confirmed in our analysis, order modification of the KTA components was required. Despite a complex context with divergent perspectives successful implementation of a draft PDA was achieved.

CONCLUSIONS

The KTA framework facilitated knowledge synthesis and PDA development but specific standards and modifications to the KTA framework were needed to enhance process structure. Flexibility for modification and integration of PDA practice guidelines were identified as assets of the KTA framework during its application.

Interdisciplinary medical social work: a working taxonomy

Findings from a year-long exploratory study aimed at describing universal functions of medical social work with interdisciplinary teams in acute care settings are reported here. A universal taxonomy of interdisciplinary social work skills and competencies was empirically identified through a participatory action research framework. Findings support previous conceptual descriptions of medical social work's overarching and historical role to help interdisciplinary teams in acute care to consider patients' home environment, knowledge, beliefs, culture, and resources during assessment, treatment, and discharge planning. The empirically determined taxonomy reported is intended to provide social workers a framework with which to articulate and evaluate their core competencies on interdisciplinary medical teams.

Using Stake's qualitative case study approach to explore implementation of evidence-based practice

Although the use of qualitative case study research has increased during the past decade, researchers have primarily reported on their findings, with less attention given to methods. When methods were described, they followed the principles of Yin; researchers paid less attention to the equally important work of Stake. When Stake's methods were acknowledged, researchers frequently used them along with Yin's. Concurrent application of their methods did not take into account differences in the philosophies of these two case study researchers. Yin's research is postpositivist whereas Stake's is constructivist. Thus, the philosophical assumptions they used to guide their work were different. In this article we describe how we used Stake's approach to explore the implementation of a falls-prevention best-practice guideline. We focus on our decisions and their congruence with Stake's recommendations, embed our decisions within the context of researching this phenomenon, describe rationale for our decisions, and present lessons learned.