Mobilising context as complex and dynamic in evaluations of complex health interventions

BACKGROUND

The relationship between healthcare interventions and context is widely conceived as involving complex and dynamic interactions over time. However, evaluations of complex health interventions frequently fail to mobilise such complexity, reporting context and interventions as reified and demarcated categories. This raises questions about practices shaping knowledge about context, with implications for who and what we make visible in our research. Viewed through the lens of case study research, we draw on data collected for the Triple C study (focused on Case study, Context and Complex interventions), to critique these practices, and call for system-wide changes in how notions of context are operationalised in evaluations of complex health interventions.

METHODS

The Triple C study was funded by the Medical Research Council to develop case study guidance and reporting principles taking account of context and complexity. As part of this study, a one-day workshop with 58 participants and nine interviews were conducted with those involved in researching, evaluating, publishing, funding and developing policy and practice from case study research. Discussions focused on how to conceptualise and operationalise context within case study evaluations of complex health interventions. Analysis focused on different constructions and connections of context in relation to complex interventions and the wider social forces structuring participant's accounts.

RESULTS

We found knowledge-making practices about context shaped by epistemic and political forces, manifesting as: tensions between articulating complexity and clarity of description; ontological (in)coherence between conceptualisations of context and methods used; and reified versions of context being privileged when communicating with funders, journals, policymakers and publics.

CONCLUSION

We argue that evaluations of complex health interventions urgently requires wide-scale critical reflection on how context is mobilised - by funders, health services researchers, journal editors and policymakers. Connecting with how scholars approach complexity and context across disciplines provides opportunities for creatively expanding the field in which health evaluations are conducted, enabling a critical standpoint to long-established traditions and opening up possibilities for innovating the design of evaluations of complex health interventions.

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.

Exploring the contribution of case study research to the evidence base for occupational therapy: a scoping review

BACKGROUND

Case study research is generating interest to evaluate complex interventions. However, it is not clear how this is being utilized by occupational therapists or how feasible it is to contribute to the evidence base. This scoping review explores case study research within occupational therapy in terms of how it is defined, the methodological characteristics adopted, such as data collection and analysis, and the range of practice contexts in which it is applied. We consider the viability of case study research for contributing to our evidence base.

METHODS

Opinion, text and empirical studies within an occupational therapy practice context were included. A three-step extensive search following Joanna Briggs Institute methodology was conducted in June 2020 and updated in July 2021 across ten databases, websites, peer-reviewed and grey literature from 2016 onwards. Study selection was completed by two independent reviewers. A data extraction table was developed and piloted and data charted to align with research questions. Data extraction was completed by one reviewer and a 10% sample cross checked by another.

RESULTS

Eighty-eight studies were included in the review consisting of (n = 84) empirical case study and (n = 4) non-empirical papers. Case study research has been conducted globally, with a range of populations across different settings. The majority were conducted in a community setting (n = 48/84; 57%) with populations experiencing neurodevelopmental disorder (n = 32/84; 38%), stroke (n = 14/84;17%) and non-diagnosis specific (n = 13/84; 15%). Methodologies adopted quantitative (n = 42/84; 50%), mixed methods (n = 22/84; 26%) and qualitative designs (n = 20/84; 24%). However, identifying the methodology and 'case' was a challenge due to methodological inconsistencies.

CONCLUSIONS

Case study research is useful when large-scale inquiry is not appropriate; for cases of complexity, early intervention efficacy, theory testing or when small participant numbers are available. It appears a viable methodology to contribute to the evidence base for occupation and health as it has been used to evaluate interventions across a breadth of occupational therapy practice contexts. Viability could be enhanced through consistent conduct and reporting to allow pooling of case data. A conceptual model and description of case study research in occupational therapy is proposed to support this.

SYSTEMATIC REVIEW REGISTRATION

Open Science Framework 10.17605/OSF.IO/PCFJ6.

TRIPLE C reporting principles for case study evaluations of the role of context in complex interventions

BACKGROUND

Guidance and reporting principles such as CONSORT (for randomised trials) and PRISMA (for systematic reviews) have greatly improved the reporting, discoverability, transparency and consistency of published research. We sought to develop similar guidance for case study evaluations undertaken to explore the influence of context on the processes and outcomes of complex interventions.

METHODS

A range of experts were recruited to an online Delphi panel, sampling for maximum diversity in disciplines (e.g. public health, health services research, organisational studies), settings (e.g. country), and sectors (e.g. academic, policy, third sector). To inform panel deliberations, we prepared background materials based on: [a] a systematic meta-narrative review of empirical and methodological literatures on case study, context and complex interventions; [b] the collective experience of a network of health systems and public health researchers; and [c] the established RAMESES II standards (which cover one kind of case study). We developed a list of topics and issues based on these sources and encouraged panel members to provide free text comments. Their feedback informed development of a set of items in the form of questions for potential inclusion in the reporting principles. We circulated these by email, asking panel members to rank each potential item twice (for relevance and validity) on a 7-point Likert scale. This sequence was repeated twice.

RESULTS

We recruited 51 panel members from 50 organisations across 12 countries, who brought experience of a range of case study research methods and applications. 26 completed all three Delphi rounds, reaching over 80% consensus on 16 items covering title, abstract, definitions of terms, philosophical assumptions, research question(s), rationale, how context and complexity relates to the intervention, ethical approval, empirical methods, findings, use of theory, generalisability and transferability, researcher perspective and influence, conclusions and recommendations, and funding and conflicts of interest.

CONCLUSION

The 'Triple C' (Case study, Context, Complex interventions) reporting principles recognise that case studies are undertaken in different ways for different purposes and based on different philosophical assumptions. They are designed to be enabling rather than prescriptive, and to make case study evaluation reporting on context and complex health interventions more comprehensive, accessible and useable.

There and back again. Examining the development of employee commitment during a prolonged crisis

To effectively function and adapt in crises, healthcare organizations rely on the skills and commitment of their workforce. Yet, our current understanding of how employees' workplace commitment is affected by and evolves throughout the course of a crisis remains limited. In this paper, we explore the commitment of hospital staff to an important workplace target, the COVID-19 crisis response, and show how this commitment develops over time. We report on an exploratory case study of hospital staff in a heavily hit region of the Netherlands. We conducted interviews with hospital executives, management, medical and support staff to uncover the issues hospitals faced in recruiting staff to provide COVID-19 care throughout the first and second wave of the crisis. Our findings suggest that while staff initially exhibited high levels of commitment to aiding in the crisis effort, staff were perceived to exhibit lower levels of commitment in the second wave, complicating the provision of COVID-19 care. We unveil three contributing factors to this shift, namely: competing demands, energy depletion and a lack of support and appreciation. Our findings suggest that while staff were initially willing to dedicate themselves and take responsibility for the crisis effort, as their other more stable commitments became more salient in the second wave, their willingness to dedicate limited resources to the crisis effort decreased. In our discussion, we examine the implications of our findings for the literature on workplace commitment, and advance our understanding of employee workplace commitment during crises.

Case study research: Building the occupational therapy evidence base one case at a time

BACKGROUND

There is growing recognition in healthcare that evidence from randomised controlled trials may not be appropriate to answer the full spectrum of practice-based questions and a more pluralistic approach is needed.

AIM

To consider the use of case study research in contributing to the occupational therapy evidence base.

MATERIAL AND METHODS

A critical discussion of the current state of evidence-based practice in occupational therapy and exploration of a viable approach to case study research is used.

RESULTS

Case study research can capture the context and complexity of occupational therapy practice. Cases can then be pooled to make a substantial contribution to the evidence base.

CONCLUSIONS

Occupational therapists should consider the use of case study research to produce practice related, meaningful research. Journal editorial boards need to be mindful of the value of high-quality case study research when considering publication priorities in occupational therapy literature.

SIGNIFICANCE

Highlights a changing landscape in the literature about how best to conduct research in health and social care, particularly for complex interventions and describes a pragmatic approach to case study research for occupational therapy.

Teaching as a system: COVID-19 as a lens into teacher change

In the spring of 2020, schools and universities around the world were closed because of the COVID-19 pandemic. The relative lockdown affected more than 1.5 billion learners as teachers and students sheltered at home for several weeks. As schooling moved online, teachers were forced to change how they taught. In the research presented here, we focus on university mathematics professors, and we analyze how their practice, knowledge, and beliefs intertwine and change under these circumstances. More specifically, the context of the pandemic and the relative lockdown provides us with the experimental basis to argue that the new practice affected both knowledge and beliefs of mathematics teachers and that practice, knowledge, and beliefs form a system. Being part of a system, the reactions to change in practice can be of two types, namely, the system as a whole tries to resist change, or the system as a whole changes - and it changes significantly. The research presented here proposes a model for describing and analyzing what we called a teaching system and examines three cases that help to better depict the systemic nature of teaching.

'Hello, my name is …': an exploratory case study of inter-professional student experiences in practice

BACKGROUND

The 'Hello my name is …' campaign emphasises the importance of compassionate care and focuses on health professionals introducing themselves to patients. Research has found that using names is key to providing individuals with a sense of belonging and can be vital in ensuring patient safety.

OBJECTIVE

To investigate the student experience of having 'Hello my name is …' printed on student uniforms and implement this campaign in practice.

DESIGN

A case study was used to capture the experiences of 40 multiprofessional healthcare students in practice. Participants were asked to complete a reflective diary during their first week in practice and attend a focus group with 4-8 other students.

SETTING

A higher education institution in the north east of England with students from adult, child and learning disability nursing, occupational therapy, physiotherapy and midwifery programmes, in a variety of clinical placements throughout the region.

FINDINGS

The implementation of the campaign and logo branding on the uniforms of students resulted in an increase in the number of times students were addressed by their name in practice. Participants reported that the study helped them to quickly develop a sense of belonging when on placement, and aided them in delivering compassionate care. Occasions when patient safety was improved were also reported.

CONCLUSION

The use of names is a key feature in human relationships and the delivery of compassionate care, and the authors advocate use of the 'Hello my name is …' campaign for all health professionals.

On systematically building a controlled natural language for functional requirements

Natural language (NL) is pervasive in software requirements specifications (SRSs). However, despite its popularity and widespread use, NL is highly prone to quality issues such as vagueness, ambiguity, and incompleteness. Controlled natural languages (CNLs) have been proposed as a way to prevent quality problems in requirements documents, while maintaining the flexibility to write and communicate requirements in an intuitive and universally understood manner. In collaboration with an industrial partner from the financial domain, we systematically develop and evaluate a CNL, named Rimay, intended at helping analysts write functional requirements. We rely on Grounded Theory for building Rimay and follow well-known guidelines for conducting and reporting industrial case study research. Our main contributions are: (1) a qualitative methodology to systematically define a CNL for functional requirements; this methodology is intended to be general for use across information-system domains, (2) a CNL grammar to represent functional requirements; this grammar is derived from our experience in the financial domain, but should be applicable, possibly with adaptations, to other information-system domains, and (3) an empirical evaluation of our CNL (Rimay) through an industrial case study. Our contributions draw on 15 representative SRSs, collectively containing 3215 NL requirements statements from the financial domain. Our evaluation shows that Rimay is expressive enough to capture, on average, 88% (405 out of 460) of the NL requirements statements in four previously unseen SRSs from the financial domain.

Tackling the void: the importance of addressing absences in the field of health professions education research

Many processes and practices in the field of health professions education have been based more on tradition and assumption than on evidence and theory. As the field matures, researchers are increasingly seeking evidence to support various teaching and assessment methods. However, there is a tendency to focus on a limited set of topics, leaving other areas under-examined and limiting our understanding of the field. By explicitly examining areas that are undescribed, i.e. absences in the literature, researchers and scholars have the potential to enrich our practice and our field's understanding of what counts as legitimate research. Using the theoretical framework of Bourdieu's concept of field, we conducted an instrumental case study of three published research projects that each had a finding of absence. We examined each case individually, and then analyzed across cases. Our dataset included published papers, peer-review feedback, and reflective notes. Each of the cases interrogated a different form of absence: absence of content, absence of research, and absence of evidence. While the typology suggests that each absence was different, there were similarities across cases in terms of challenges in 'proving' the reality of the absence and some disbelief or discomfort with accepting the findings as rigorous and/or legitimate. Absence research has potential to add to our theoretical and methodological approaches to the field. This type of research is potentially an exciting and productive new way for scholars to shed light on aspects of health professions education that have received limited attention to date.

Using medical reality television as a technology-enhanced learning strategy to provide authentic patient care experiences during clinical placements: a case study research investigation

BACKGROUND

Over the last decade, the use of technology-enhanced learning (TEL) has rapidly expanded and diversified. Since the COVID-19 pandemic, there is a growing demand for distance and online learning strategies to support and even replace learning experiences previously afforded by clinical placements and clerkships. An intriguing but under-researched modality is the use of medical reality television to provide authentic experiences of patient care. This strategy does not feature in published medical educational literature, though promising research is emerging from other disciplines.

METHODOLOGY

A programme of learning using medical reality television clips to facilitate case-based learning was developed according to the principles of 'anchored instruction', a technology-based educational theory. Clips were taken from the UK television show '24 hours in A&E'. Medical students' learning experiences were investigated using a qualitative approach addressing the following research questions: - What is the perceived emotional experience of medical students when watching reality television in an educational context? - How do medical students relate their experience of watching reality television in a formal educational setting to their perceived learning needs in the clinical environment? A case study research methodology was adopted within the interpretivist paradigm. Data were triangulated from semi-structured interviews with students and non-participant observation of the teaching session. Field notes and transcripts were analysed through an inductive thematic analysis.

RESULTS

In response to the medical reality television, a diverse range of emotions were expressed including: excitement, amusement, concern, nervousness, sadness and joy. Students identified gaps in their clinical knowledge such as interpreting results, practical aspects of prescribing and end of life care. Key themes were increased student engagement and a promotion of holistic care practices.

DISCUSSION

Students perceived reality television as a highly realistic and relatable medium and an enjoyable, memorable way to contextualise learning from the classroom to real life, a finding mirrored in previous studies in other fields. The high degree of emotion expressed may explain the improved subjective memorability of the cases.

CONCLUSION

Medical reality television offers a unique means of engaging students by providing authentic experiences of patient care and should be valued alongside other technology-enhanced learning strategies.

The epilepsy specialist nurse: A mixed-methods case study on the role and activities

PURPOSE

To describe the role and activities of epilepsy specialist nurses (ESNs) operating as a team in the setting of a hospital specialising in the diagnosis and management of seizure disorders.

METHODS

We conducted a descriptive mixed-methods embedded single case study. We recruited 9 ESNs, 14 of their professional colleagues and 9 'key informants' to analyse their perceptions of the role and activities of ESNs. We collected data through interviews, questionnaires, observations, and documentation. The study was conducted at the Filadelfia Epilepsy Hospital, Denmark.

RESULTS

The team of ESNs offers holistic care to patients and their caregivers regarding the clinical, social, and emotional aspects of epilepsy. The ESNs are integrated in a multidisciplinary team and promote collaboration among the team members. ESNs also contribute to organisational aspects and perform research activities.

CONCLUSION

A structured group of ESNs can operate effectively and extensively in a specialised hospital setting. Our findings contribute to clarifying the description of the ESN's role, and provide an example of how ESNs can be incorporated into a hospital's organisational structure.

The personal motif in naturalistic case study research: developing "innerstandings" in woman's compulsive behaviour

Purpose: The purpose of this article is to show case study research focused on persons as a case and our personal engagement with the case can improve our innerstandings and understanding of person-centred care. Method: We present the methodology and epistemology of naturalistic case study research and illuminate this approach with the case study of Ellen, a young, Dutch, white-middle class woman with a compulsive disorder. We combine naturalistic case study research with the personal narratives of those involved in the research, including ourselves, and interpreted through a feminist and gender lens. Results: The case study research enhanced the personal and mutual understanding of all involved, including the researchers. Feminist and gender theory revealed the hidden personal motif for the choice of the case, and led to a re-viewing of the original story, offering a re-storying. Conclusion: We conclude that the personal motif as well as the use of our personal experiences to understand the case deserve more attention in case study research to address the complex interplay of social and intrapsychic dimensions, and develop more in-depth innerstandings for all engaged.

Examining the motivations and future career aspirations of Qatari pharmacy students and alumni: A case study

INTRODUCTION

The Global Pharmacy Workforce report published by the International Pharmaceutical Federation indicated pharmacy workforce shortages and called forstrengthening workforce planning. The low percentage of Qatari students in the College of Pharmacy at Qatar University could negatively impact the fulfilment of the Qatar National Vision and the United Nations' Goals. The aim of this research is to examine the motivations of Qatari pharmacy students and alumni to study pharmacy, and to understand their perceptions of the profession and career aspirations.

METHODS

A qualitative case study research was conducted. Data were collected by focus groups and semi-structured interviews, and were analysed thematically.

RESULTS

Research findings suggested that increasing the national workforce was the main motive for students to study pharmacy. The participants' perceptions of the profession varied from pharmacy being a drug sales profession to it being a healthcare profession. Participants' career aspirations included pursuing graduate studies, working in hospitals, and working in academia. The participants were generally satisfied with studying pharmacy, which encouraged them to recommend the major to others. However, the participants were challenged by the lack of societal recognition of pharmacy and by misperceptions about Qatari students, which motivated them to further demonstrate their competencies.

CONCLUSIONS

This study will facilitate the understanding of factors that motivate and demotivate Qatari students from joining the pharmacy major and their career aspirations, which will ultimately enhance the development of recruitment strategies geared towards attracting a larger number of qualified and highly motivated Qataris into the pharmacy profession.

Potential for identification of memory problems in the cancer clinic to enable improved treatment experience and outcomes: Mixed methods case study research

PURPOSE

To inform improvement in cancer treatment experience and outcomes for people with dementia or milder cognitive impairment. People with dementia, compared to those without, experience more side effects from cancer treatment and have poorer outcomes including poorer survival.

METHODS

The research was a mixed methods exploratory case study. Each case was a cancer treatment in a person with memory loss, a common symptom of dementia. Observations were conducted in 30 clinic sessions at one cancer centre between September 2014 and February 2015. Thirty-three encounters between people with a memory problem and a staff member were observed and ten consultations recorded. Interviews were conducted with five staff members and six people receiving cancer treatment, five accompanied by their carer. Analysis, informed by hermeneutic phenomenology, enabled the treatment pathway to be mapped and modelled to reveal sites for intervention.

FINDINGS

Five potential sites of intervention were identified in the treatment pathway. Five actions at the sites of intervention that may improve patient experience and outcomes include, raising awareness of common problems for people with cognitive impairment receiving cancer treatment, encouraging disclosure of memory problems, staff training to identify memory problems and to know what to do, offering tools and techniques to aid self-management of memory problems, and addressing carer support needs.

CONCLUSION

Embedding biomedical treatment of cancer within a dementia-friendly psychosocial system may enable safe cancer treatment for a greater number of people with dementia or milder cognitive impairment.

Case studies in psychotherapy training using Austria as an example

BACKGROUND

Case studies (CS) are relevant for the development of theoretical and practical competencies in psychotherapy. Despite rapid progress in the development of methods and principles for establishing CS in the last three decades, research into the aims of CS, especially in training, or how CS are to be conducted is rare.

AIM

To elucidate the form and methodology of CS, the objectives of CS used in training institutions (TI), and if/how TIs handle therapist allegiance. Also, this preliminary investigation will suggest avenues for further research and attempt to establish certain guidelines.

METHODS

In order to counteract researcher bias and enlarge the question-pool, a focus group was established. The recorded and transcribed text was analyzed with Mayring’s method of qualitative content analysis, and the generated categories were formulated as questions. The resulting questionnaire with both qualitative and quantitative queries was sent out (after pre-testing) to all 39 Austrian TIs that provide professional psychotherapy training. The answers and text passages received were then also categorized with qualitative content analysis. Data analysis was discussed by a peer group consisting of three psychotherapists trained in differing schools of psychotherapeutic methods.

RESULTS

94% of Austrian institutes use CS as part of their psychotherapeutic training. Understanding of the term “case study” is inconsistent and has a wide variety of interpretations. CS serve mainly: (1) For observation of training/progress in therapeutic practice and knowledge/acquisition of the theory specific to each psychotherapeutic school; (2) To improve (self-)reflection capabilities; and (3) To expand theoretical knowledge. Most of the CS written are not accessible for students nor for the research community. More than two thirds of the CS take only the position of the author into account (the client’s position is not described). 15.5 % of the TIs do not consider researcher or therapist allegiance at all.

CONCLUSION

A more precise formulation of the term case study is needed in psychotherapeutic training. The training therapists play a key function, as they exemplify and teach how to deal with distorting factors. General guidelines as to how to conduct CS in training institutions would provide more direction to students, increase scientific rigor, and enhance synergistic effects.

Understanding health professional role integration in complex adaptive systems: a multiple-case study of physician assistants in Ontario, Canada

BACKGROUND

To meet the complex needs of healthcare delivery, the Ministry of Health and Long Term Care (MOHLTC) introduced Physician Assistants (PAs) into the Ontario health care system in 2006 with the goal of helping to increase access to care, decrease wait times, improve continuity of care and provide a flexible addition to the healthcare workforce. The characterization of healthcare organizations as complex adaptive systems (CAS) may offer insight into the relationships and interactions that optimize and restrict successful PA integration. The aim of this study is to explore the integration of PAs across multiple case settings and to understand the role of PAs within complex adaptive systems.

METHODS

An exploratory, multiple-case study was used to examine PA role integration in four settings: family medicine, emergency medicine, general surgery, and inpatient medicine. Interviews were conducted with 46 healthcare providers and administrators across 13 hospitals and 6 family medicine clinics in Ontario, Canada. Analysis was conducted in three phases including an inductive thematic analysis within each of the four cases, a cross-case thematic analysis, and a broader, deductive exploration of cross-case patterns pertaining to specific complexity theory principles of interest.

RESULTS

Forty-six health care providers were interviewed across 19 different healthcare sites. Support for PA contributions across various health care settings, the importance of role awareness, supervisory relationship attributes, and role vulnerability are interconnected and dynamic. Findings represent the experiences of PAs and other healthcare providers, and demonstrate how the PAs willingness to work and ability to build relationships allows for the establishment of interprofessional, collaborative, and person-centered care. As a self-organizing agent in complex adaptive systems (i.e., health organizations), PA role exploration revealed patterns of team behavior, non-linear interconnections, open relationships, dynamic systems, and the legacy of role implementation as defined by complexity theory.

CONCLUSIONS

By exploring the role of PAs across multiple sites, the complexity theory lens concurrently fosters an awareness of emerging patterns, relationships and non-linear interactions within the defined context of the Ontario healthcare system. By establishing collaborative, interprofessional care models in hospital and community settings, PAs are making a significant contribution to Ontario healthcare settings.

Innovations in maternal and child health: case studies from Uganda

Background

Nearly 300 children and 20 mothers die from preventable causes daily, in Uganda. Communities often identify and introduce pragmatic and lasting solutions to such challenging health problems. However, little is known of these solutions beyond their immediate surroundings. If local and pragmatic innovations were scaled-up, they could contribute to better health outcomes for larger populations. In 2017 an open call was made for local examples of community-based solutions that contribute to improving maternal and child health in Uganda. In this article, we describe three top innovative community-based solutions and their contributions to maternal health.

Main text

In this study, all innovations were implemented by non-government entities. Two case studies highlight the importance of bringing reproductive health and maternal delivery services closer to populations, through providing accessible shelters and maternity waiting homes in isolated areas. The third case study focuses on bringing obstetric imaging services to lower level rural health facilities, which usually do not provide this service, through task-shifting certain sonography services to midwives. Various health system and policy relevant lessons are highlighted.

Conclusions

The described case studies show how delays in access to health care by pregnant women in rural communities can be systematically removed, to improve pregnancy and delivery outcomes. Emphasis should be put on identification, capacity building and research to support the scale up of these community-based health solutions.

Exploring early interprofessional socialization: a pilot study of student's experiences in medical history taking

Traditional hierarchies and structures in healthcare, as well as traditional professional socialization practices, continue to create barriers to effective interprofessional collaboration. Nevertheless, some studies indicate that early socialization with other health professionals can build bridges and improve understanding of each other's roles and contributions to patient care. This pilot study aimed to gain insights into the nursing and medical students' experiences of interprofessional medical history taking during a collective learning activity. A descriptive case study was conducted using modified interviews based on the speed-dating (SD) technique to explore participants' reasons for the choice of profession (SD1) and experiences of interprofessional history taking (SD2). Data were digitally captured using audio-recordings. An inductive-deductive approach to qualitative content analysis of transcribed responses was undertaken. Eighteen students (medicine n = 6; nursing n = 12) participated. Two main categories with sub-themes emerged from the inductive SD1 analysis: (a) reasons for choosing a career and (b) knowledge about professions. The SD2 deductive analysis identified three major categories with sub-themes: (a) breaking down barriers, (b) interprofessional role learning - interprofessional collaboration and (c) dual-identity development. Our findings showed that early interprofessional socialization of students supported their learning about the complementary roles of doctors and nurses and enabled them to gain early experiences of interprofessional teamwork.

Case study research in the social sciences

In this paper, we offer an introduction to case study research in the social sciences. We begin with a discussion of the definition of case study research. Next, we point to various purposes that case study research may serve in the social sciences and then turn to outline the main philosophical issues raised by case study research. Finally, we briefly present the papers in this special issue.

An exploration of providing mental health skills in a generic advanced clinical practice programme

BACKGROUND

advanced clinical practitioners (ACPs) are expected to be competent in their holistic assessment and management of individuals, which includes those with both physical and mental health problems. A mental health component was introduced within a generic advanced practitioner programme to support the development of mental health skills required by advanced clinical practitioners in training (ACPiTs).

AIMS

this research investigated the efficacy of content specific to mental health within an MSc ACP generic programme.

METHODS

a single case study approach was adopted, which used a purposive sample of 10 ACPiTs to explore personal beliefs and experiences using semistructured interviews. Verbatim transcription was undertaken followed by content and thematic analysis.

FINDINGS

Themes emerged included communication skills, and increased competence and self-awareness.

CONCLUSION

insights provided by the ACPiTs showed they recognised the value of mental health teaching and exposure within their training programme in advancing their knowledge and skillset and, ultimately, increasing confidence in their clinical practice.

Transmasculine Voice Modification: A Case Study

This case study measured the effects of manual laryngeal therapy on the fundamental frequency (f_o), formant frequencies, estimated vocal tract length, and listener perception of masculinity of a 32-year-old transmasculine individual. The participant began testosterone therapy 1.5 years prior to the study. Two therapy approaches were administered sequentially in a single session: (1) passive circumlaryngeal massage and manual laryngeal reposturing, and (2) active laryngeal reposturing with voicing. Acoustic recordings were collected before and after each treatment and 3 days after the session. Speaking f_o decreased from 124 Hz to 120 Hz after passive training, and to 108 Hz after active training. Estimated vocal tract length increased from 17.0 cm to 17.3 cm after passive training, and to 19.4 cm after active training. Eight listeners evaluated the masculinity of the participant's speech; his voice was rated as most masculine at the end of the training session. All measures returned to baseline at follow-up. Overall, both acoustic and perceptual changes were observed in one transmasculine individual who participated in manual laryngeal therapy, even after significant testosterone-induced voice changes had already occurred; however, changes were not maintained in the follow-up. This study adds to scant literature on effective approaches to and proposed outcome measures for voice masculinization in transmasculine individuals.

Fundamentals of case study research in family medicine and community health

The aim of this article is to introduce family medicine researchers to case study research, a rigorous research methodology commonly used in the social and health sciences and only distantly related to clinical case reports. The article begins with an overview of case study in the social and health sciences, including its definition, potential applications, historical background and core features. This is followed by a 10-step description of the process of conducting a case study project illustrated using a case study conducted about a teaching programme executed to teach international family medicine resident learners sensitive examination skills. Steps for conducting a case study include (1) conducting a literature review; (2) formulating the research questions; (3) ensuring that a case study is appropriate; (4) determining the type of case study design; (5) defining boundaries of the case(s) and selecting the case(s); (6) preparing for data collection; (7) collecting and organising the data; (8) analysing the data; (9) writing the case study report; and (10) appraising the quality. Case study research is a highly flexible and powerful research tool available to family medicine researchers for a variety of applications.

Neglected children with severe obesity have a right to health: Is foster home an alternative?-A qualitative study

OBJECTIVE

To explore key person's perspectives of foster home placement or notification of risk of harm to Social Services of children with severe obesity.

METHODS

This case study research was performed in the southwest of Sweden and based on interviews with nine informants: a foster home youth, two foster parents, a social worker, two hospital social workers, a pediatric physician, a pediatric nurse, and a psychologist. Content analysis was used for narrative evaluations, within- and cross case analyses and displays.

RESULTS

Positive health outcomes of the foster home placement were described as a healthy and normalized weight status, a physically and socially active life, and an optimistic outlook on the future. The foster parents made no major changes in their family routines, but applied an authoritative parenting style regarding limit setting about sweets and food portions and supporting physical activity. The professionals described children with severe obesity as having suffered parental as well as societal neglect. Their biological parents lacked the ability to undertake necessary lifestyle changes. Neglected investigations into learning disabilities and neuropsychiatric disorders were seen in the school and healthcare sector, and better collaboration with the Social Services after a report of harm might be a potential for future improvements. Rival discourses were underlying the (in) decision regarding foster home placement.

CONCLUSION

A child's right to health was a strong discourse for acting when a child was at risk for harm, but parental rights are strong when relocation to a foster home is judged to be necessary.

Mothers' Experiences with Pastoral Care in Cases of Child Sexual Abuse

This article reports on case study research with four mothers who asked for help from their pastors when they learned, or had reason to believe, that their husbands had sexually abused children in their families. In their own words, mothers gave accounts of how the pastors responded. Some were helpful and knowledgeable, some appeared bewildered, and others were hostile and blaming toward the women. This article will sensitize pastors and other pastoral counselors to issues that child sexual abuse raises. In addition, the research responds to Mahoney's (J Marriage Fam 72:805-827, 2010) observations about the scarcity of knowledge on whether religion helps or harms families during times of stress.

Case study research

This article describes case study research for nursing and healthcare practice. Case study research offers the researcher an approach by which a phenomenon can be investigated from multiple perspectives within a bounded context, allowing the researcher to provide a 'thick' description of the phenomenon. Although case study research is a flexible approach for the investigation of complex nursing and healthcare issues, it has methodological challenges, often associated with the multiple methods used in individual studies. These are explored through examples of case study research carried out in practice and education settings. An overview of what constitutes 'good' case study research is proposed.

Exploring interprofessional practices in rapid response systems: a case study protocol

AIM

To describe the development of a proposed case study protocol investigating interprofessional relationships in a rapid response system (RRS) in a socioculturally complex clinical environment.

BACKGROUND

Suboptimal care of deteriorating ward patients remains a concern for many acute healthcare organisations. Despite the advent of RRSs, emergency response teams are not always used to their full potential. How and why interprofessional relationships influence practices associated with the care and management of ward patients at risk of clinical deterioration requires investigation.

DATA SOURCES

Theoretical and empirical literature describing case study research and RRSs. Review methods An integrative review approach of the literature, focusing on key terms relating to 'case study research' and 'rapid response system', provided context and informed development of the study protocol.

DISCUSSION

A single-site mixed-method instrumental case study protocol was developed using methodological triangulation and a multi-level model to examine interprofessional relationships between a broad range of stakeholders. Concurrent data collection and analysis will occur using document review of clinical scenarios, non-participant observations and semi-structured interviews.

CONCLUSION

Case study research is an effective method for investigating socioculturally complex clinical environments. A strength of this approach is the flexibility in the choice of methods, which allows the researcher to build the design most suitable for the subjects or phenomena being investigated. Although this flexibility may be considered a potential weakness, rigour can be achieved by application of the strategies described.

IMPLICATIONS FOR RESEARCH/PRACTICE

Findings from this research will provide rich descriptive insights into RRS relationships and healthcare professional practices during day-to-day management of acute ward patients at risk of or experiencing clinical deterioration. Description of this structured case study research approach will also inform other researchers.