intrinsic qualitative case study

The Ultimate Guide to Qualitative Research - Part 1: The Basics

• Introduction and overview
• What is qualitative research?
• What is qualitative data?
• Examples of qualitative data
• Qualitative vs. quantitative research
• Mixed methods
• Qualitative research preparation
• Theoretical perspective
• Theoretical framework
• Literature reviews

Research question

• Conceptual framework
• Conceptual vs. theoretical framework

Data collection

• Qualitative research methods
• Focus groups
• Observational research

What is a case study?

Applications for case study research, what is a good case study, process of case study design, benefits and limitations of case studies.

• Ethnographical research
• Ethical considerations
• Confidentiality and privacy
• Power dynamics
• Reflexivity

Case studies

Case studies are essential to qualitative research , offering a lens through which researchers can investigate complex phenomena within their real-life contexts. This chapter explores the concept, purpose, applications, examples, and types of case studies and provides guidance on how to conduct case study research effectively.

Whereas quantitative methods look at phenomena at scale, case study research looks at a concept or phenomenon in considerable detail. While analyzing a single case can help understand one perspective regarding the object of research inquiry, analyzing multiple cases can help obtain a more holistic sense of the topic or issue. Let's provide a basic definition of a case study, then explore its characteristics and role in the qualitative research process.

Definition of a case study

A case study in qualitative research is a strategy of inquiry that involves an in-depth investigation of a phenomenon within its real-world context. It provides researchers with the opportunity to acquire an in-depth understanding of intricate details that might not be as apparent or accessible through other methods of research. The specific case or cases being studied can be a single person, group, or organization – demarcating what constitutes a relevant case worth studying depends on the researcher and their research question .

Among qualitative research methods , a case study relies on multiple sources of evidence, such as documents, artifacts, interviews , or observations , to present a complete and nuanced understanding of the phenomenon under investigation. The objective is to illuminate the readers' understanding of the phenomenon beyond its abstract statistical or theoretical explanations.

Characteristics of case studies

Case studies typically possess a number of distinct characteristics that set them apart from other research methods. These characteristics include a focus on holistic description and explanation, flexibility in the design and data collection methods, reliance on multiple sources of evidence, and emphasis on the context in which the phenomenon occurs.

Furthermore, case studies can often involve a longitudinal examination of the case, meaning they study the case over a period of time. These characteristics allow case studies to yield comprehensive, in-depth, and richly contextualized insights about the phenomenon of interest.

The role of case studies in research

Case studies hold a unique position in the broader landscape of research methods aimed at theory development. They are instrumental when the primary research interest is to gain an intensive, detailed understanding of a phenomenon in its real-life context.

In addition, case studies can serve different purposes within research - they can be used for exploratory, descriptive, or explanatory purposes, depending on the research question and objectives. This flexibility and depth make case studies a valuable tool in the toolkit of qualitative researchers.

Remember, a well-conducted case study can offer a rich, insightful contribution to both academic and practical knowledge through theory development or theory verification, thus enhancing our understanding of complex phenomena in their real-world contexts.

What is the purpose of a case study?

Case study research aims for a more comprehensive understanding of phenomena, requiring various research methods to gather information for qualitative analysis . Ultimately, a case study can allow the researcher to gain insight into a particular object of inquiry and develop a theoretical framework relevant to the research inquiry.

Why use case studies in qualitative research?

Using case studies as a research strategy depends mainly on the nature of the research question and the researcher's access to the data.

Conducting case study research provides a level of detail and contextual richness that other research methods might not offer. They are beneficial when there's a need to understand complex social phenomena within their natural contexts.

The explanatory, exploratory, and descriptive roles of case studies

Case studies can take on various roles depending on the research objectives. They can be exploratory when the research aims to discover new phenomena or define new research questions; they are descriptive when the objective is to depict a phenomenon within its context in a detailed manner; and they can be explanatory if the goal is to understand specific relationships within the studied context. Thus, the versatility of case studies allows researchers to approach their topic from different angles, offering multiple ways to uncover and interpret the data .

The impact of case studies on knowledge development

Case studies play a significant role in knowledge development across various disciplines. Analysis of cases provides an avenue for researchers to explore phenomena within their context based on the collected data.

This can result in the production of rich, practical insights that can be instrumental in both theory-building and practice. Case studies allow researchers to delve into the intricacies and complexities of real-life situations, uncovering insights that might otherwise remain hidden.

Types of case studies

In qualitative research , a case study is not a one-size-fits-all approach. Depending on the nature of the research question and the specific objectives of the study, researchers might choose to use different types of case studies. These types differ in their focus, methodology, and the level of detail they provide about the phenomenon under investigation.

Understanding these types is crucial for selecting the most appropriate approach for your research project and effectively achieving your research goals. Let's briefly look at the main types of case studies.

Exploratory case studies

Exploratory case studies are typically conducted to develop a theory or framework around an understudied phenomenon. They can also serve as a precursor to a larger-scale research project. Exploratory case studies are useful when a researcher wants to identify the key issues or questions which can spur more extensive study or be used to develop propositions for further research. These case studies are characterized by flexibility, allowing researchers to explore various aspects of a phenomenon as they emerge, which can also form the foundation for subsequent studies.

Descriptive case studies

Descriptive case studies aim to provide a complete and accurate representation of a phenomenon or event within its context. These case studies are often based on an established theoretical framework, which guides how data is collected and analyzed. The researcher is concerned with describing the phenomenon in detail, as it occurs naturally, without trying to influence or manipulate it.

Explanatory case studies

Explanatory case studies are focused on explanation - they seek to clarify how or why certain phenomena occur. Often used in complex, real-life situations, they can be particularly valuable in clarifying causal relationships among concepts and understanding the interplay between different factors within a specific context.

Intrinsic, instrumental, and collective case studies

These three categories of case studies focus on the nature and purpose of the study. An intrinsic case study is conducted when a researcher has an inherent interest in the case itself. Instrumental case studies are employed when the case is used to provide insight into a particular issue or phenomenon. A collective case study, on the other hand, involves studying multiple cases simultaneously to investigate some general phenomena.

Each type of case study serves a different purpose and has its own strengths and challenges. The selection of the type should be guided by the research question and objectives, as well as the context and constraints of the research.

The flexibility, depth, and contextual richness offered by case studies make this approach an excellent research method for various fields of study. They enable researchers to investigate real-world phenomena within their specific contexts, capturing nuances that other research methods might miss. Across numerous fields, case studies provide valuable insights into complex issues.

Critical information systems research

Case studies provide a detailed understanding of the role and impact of information systems in different contexts. They offer a platform to explore how information systems are designed, implemented, and used and how they interact with various social, economic, and political factors. Case studies in this field often focus on examining the intricate relationship between technology, organizational processes, and user behavior, helping to uncover insights that can inform better system design and implementation.

Health research

Health research is another field where case studies are highly valuable. They offer a way to explore patient experiences, healthcare delivery processes, and the impact of various interventions in a real-world context.

Case studies can provide a deep understanding of a patient's journey, giving insights into the intricacies of disease progression, treatment effects, and the psychosocial aspects of health and illness.

Asthma research studies

Specifically within medical research, studies on asthma often employ case studies to explore the individual and environmental factors that influence asthma development, management, and outcomes. A case study can provide rich, detailed data about individual patients' experiences, from the triggers and symptoms they experience to the effectiveness of various management strategies. This can be crucial for developing patient-centered asthma care approaches.

Other fields

Apart from the fields mentioned, case studies are also extensively used in business and management research, education research, and political sciences, among many others. They provide an opportunity to delve into the intricacies of real-world situations, allowing for a comprehensive understanding of various phenomena.

Case studies, with their depth and contextual focus, offer unique insights across these varied fields. They allow researchers to illuminate the complexities of real-life situations, contributing to both theory and practice.

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Understanding the key elements of case study design is crucial for conducting rigorous and impactful case study research. A well-structured design guides the researcher through the process, ensuring that the study is methodologically sound and its findings are reliable and valid. The main elements of case study design include the research question , propositions, units of analysis, and the logic linking the data to the propositions.

The research question is the foundation of any research study. A good research question guides the direction of the study and informs the selection of the case, the methods of collecting data, and the analysis techniques. A well-formulated research question in case study research is typically clear, focused, and complex enough to merit further detailed examination of the relevant case(s).

Propositions

Propositions, though not necessary in every case study, provide a direction by stating what we might expect to find in the data collected. They guide how data is collected and analyzed by helping researchers focus on specific aspects of the case. They are particularly important in explanatory case studies, which seek to understand the relationships among concepts within the studied phenomenon.

Units of analysis

The unit of analysis refers to the case, or the main entity or entities that are being analyzed in the study. In case study research, the unit of analysis can be an individual, a group, an organization, a decision, an event, or even a time period. It's crucial to clearly define the unit of analysis, as it shapes the qualitative data analysis process by allowing the researcher to analyze a particular case and synthesize analysis across multiple case studies to draw conclusions.

Argumentation

This refers to the inferential model that allows researchers to draw conclusions from the data. The researcher needs to ensure that there is a clear link between the data, the propositions (if any), and the conclusions drawn. This argumentation is what enables the researcher to make valid and credible inferences about the phenomenon under study.

Understanding and carefully considering these elements in the design phase of a case study can significantly enhance the quality of the research. It can help ensure that the study is methodologically sound and its findings contribute meaningful insights about the case.

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Conducting a case study involves several steps, from defining the research question and selecting the case to collecting and analyzing data . This section outlines these key stages, providing a practical guide on how to conduct case study research.

Defining the research question

The first step in case study research is defining a clear, focused research question. This question should guide the entire research process, from case selection to analysis. It's crucial to ensure that the research question is suitable for a case study approach. Typically, such questions are exploratory or descriptive in nature and focus on understanding a phenomenon within its real-life context.

Selecting and defining the case

The selection of the case should be based on the research question and the objectives of the study. It involves choosing a unique example or a set of examples that provide rich, in-depth data about the phenomenon under investigation. After selecting the case, it's crucial to define it clearly, setting the boundaries of the case, including the time period and the specific context.

Previous research can help guide the case study design. When considering a case study, an example of a case could be taken from previous case study research and used to define cases in a new research inquiry. Considering recently published examples can help understand how to select and define cases effectively.

Developing a detailed case study protocol

A case study protocol outlines the procedures and general rules to be followed during the case study. This includes the data collection methods to be used, the sources of data, and the procedures for analysis. Having a detailed case study protocol ensures consistency and reliability in the study.

The protocol should also consider how to work with the people involved in the research context to grant the research team access to collecting data. As mentioned in previous sections of this guide, establishing rapport is an essential component of qualitative research as it shapes the overall potential for collecting and analyzing data.

Collecting data

Gathering data in case study research often involves multiple sources of evidence, including documents, archival records, interviews, observations, and physical artifacts. This allows for a comprehensive understanding of the case. The process for gathering data should be systematic and carefully documented to ensure the reliability and validity of the study.

Analyzing and interpreting data

The next step is analyzing the data. This involves organizing the data , categorizing it into themes or patterns , and interpreting these patterns to answer the research question. The analysis might also involve comparing the findings with prior research or theoretical propositions.

Writing the case study report

The final step is writing the case study report . This should provide a detailed description of the case, the data, the analysis process, and the findings. The report should be clear, organized, and carefully written to ensure that the reader can understand the case and the conclusions drawn from it.

Each of these steps is crucial in ensuring that the case study research is rigorous, reliable, and provides valuable insights about the case.

The type, depth, and quality of data in your study can significantly influence the validity and utility of the study. In case study research, data is usually collected from multiple sources to provide a comprehensive and nuanced understanding of the case. This section will outline the various methods of collecting data used in case study research and discuss considerations for ensuring the quality of the data.

Interviews are a common method of gathering data in case study research. They can provide rich, in-depth data about the perspectives, experiences, and interpretations of the individuals involved in the case. Interviews can be structured , semi-structured , or unstructured , depending on the research question and the degree of flexibility needed.

Observations

Observations involve the researcher observing the case in its natural setting, providing first-hand information about the case and its context. Observations can provide data that might not be revealed in interviews or documents, such as non-verbal cues or contextual information.

Documents and artifacts

Documents and archival records provide a valuable source of data in case study research. They can include reports, letters, memos, meeting minutes, email correspondence, and various public and private documents related to the case.

These records can provide historical context, corroborate evidence from other sources, and offer insights into the case that might not be apparent from interviews or observations.

Physical artifacts refer to any physical evidence related to the case, such as tools, products, or physical environments. These artifacts can provide tangible insights into the case, complementing the data gathered from other sources.

Ensuring the quality of data collection

Determining the quality of data in case study research requires careful planning and execution. It's crucial to ensure that the data is reliable, accurate, and relevant to the research question. This involves selecting appropriate methods of collecting data, properly training interviewers or observers, and systematically recording and storing the data. It also includes considering ethical issues related to collecting and handling data, such as obtaining informed consent and ensuring the privacy and confidentiality of the participants.

Data analysis

Analyzing case study research involves making sense of the rich, detailed data to answer the research question. This process can be challenging due to the volume and complexity of case study data. However, a systematic and rigorous approach to analysis can ensure that the findings are credible and meaningful. This section outlines the main steps and considerations in analyzing data in case study research.

Organizing the data

The first step in the analysis is organizing the data. This involves sorting the data into manageable sections, often according to the data source or the theme. This step can also involve transcribing interviews, digitizing physical artifacts, or organizing observational data.

Categorizing and coding the data

Once the data is organized, the next step is to categorize or code the data. This involves identifying common themes, patterns, or concepts in the data and assigning codes to relevant data segments. Coding can be done manually or with the help of software tools, and in either case, qualitative analysis software can greatly facilitate the entire coding process. Coding helps to reduce the data to a set of themes or categories that can be more easily analyzed.

Identifying patterns and themes

After coding the data, the researcher looks for patterns or themes in the coded data. This involves comparing and contrasting the codes and looking for relationships or patterns among them. The identified patterns and themes should help answer the research question.

Interpreting the data

Once patterns and themes have been identified, the next step is to interpret these findings. This involves explaining what the patterns or themes mean in the context of the research question and the case. This interpretation should be grounded in the data, but it can also involve drawing on theoretical concepts or prior research.

Verification of the data

The last step in the analysis is verification. This involves checking the accuracy and consistency of the analysis process and confirming that the findings are supported by the data. This can involve re-checking the original data, checking the consistency of codes, or seeking feedback from research participants or peers.

Like any research method , case study research has its strengths and limitations. Researchers must be aware of these, as they can influence the design, conduct, and interpretation of the study.

Understanding the strengths and limitations of case study research can also guide researchers in deciding whether this approach is suitable for their research question . This section outlines some of the key strengths and limitations of case study research.

Benefits include the following:

• Rich, detailed data: One of the main strengths of case study research is that it can generate rich, detailed data about the case. This can provide a deep understanding of the case and its context, which can be valuable in exploring complex phenomena.
• Flexibility: Case study research is flexible in terms of design , data collection , and analysis . A sufficient degree of flexibility allows the researcher to adapt the study according to the case and the emerging findings.
• Real-world context: Case study research involves studying the case in its real-world context, which can provide valuable insights into the interplay between the case and its context.
• Multiple sources of evidence: Case study research often involves collecting data from multiple sources , which can enhance the robustness and validity of the findings.

On the other hand, researchers should consider the following limitations:

• Generalizability: A common criticism of case study research is that its findings might not be generalizable to other cases due to the specificity and uniqueness of each case.
• Time and resource intensive: Case study research can be time and resource intensive due to the depth of the investigation and the amount of collected data.
• Complexity of analysis: The rich, detailed data generated in case study research can make analyzing the data challenging.
• Subjectivity: Given the nature of case study research, there may be a higher degree of subjectivity in interpreting the data , so researchers need to reflect on this and transparently convey to audiences how the research was conducted.

Being aware of these strengths and limitations can help researchers design and conduct case study research effectively and interpret and report the findings appropriately.

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Chapter 8: Case study

Darshini Ayton

Learning outcomes

Upon completion of this chapter, you should be able to:

• Identify the key terms and concepts used in qualitative case study research.
• Discuss the advantages and disadvantages of qualitative case study research.

What is a case study?

The key concept in a case study is context .

In qualitative research, case studies provide in-depth accounts of events, relationships, experiences or processes. Stemming from the fields of evaluation, political science and law, the aim of a qualitative case study is to explore a phenomenon within the context of the case 1 and to answer how and why research questions. 2 The contextual conditions are relevant to the phenomenon under study and the contextual factors tend to lie with the case. 1 From the outset it is important (a) to determine who or what is your case – this can be a person, program, organisation or group, or a process – and (b) to articulate the phenomenon of interest.

An example of why context is important in understanding the phenomenon of interest is a study of health promotion action by local churches in Victoria, Australia. 3 The phenomenon under study was health promotion action, with 10 churches comprising the cases, which were mapped across the framework of health promotion approaches. 4 The contextual factors included church denomination (Baptist, Church of Christ, Uniting, Anglican, Catholic and Salvation Army), size (small, medium and large), location (rural and metropolitan), partnerships with external organisations (government, local schools and social welfare organisations) and theological orientation (traditional, modern or postmodern), to understand the phenomenon of health promotion action. Data collection took 12 months and involved interviews with 37 church leaders, 10 focus groups with volunteers, 17 instances of participant observation of church activities, including church services, youth events, food banks and community meals, and 12 documentary analyses of church websites, newsletters and annual reports. The case studies identified and illustrated how and why three different expressions of church – traditional, new modern and emerging – led to different levels and types of health promotion activities.

Three prominent qualitative case study methodologists, Robert Stake, Robert Yin and Sharan Merriams, have articulated different approaches to case studies and their underpinning philosophical and paradigmatic assumptions. Table 8 outlines these approaches, based on work by Yazan, 5 whose expanded table covers characteristics of case studies, data collection and analysis.

Table 8.1. Comparison of case study terms used by three key methodologists

Table 8.1 is derived from ‘Three Approaches to Case Study Methods in Education: Yin, Merriam, and Stake ‘  by Bedrettin Yazan,  licensed under CC BY-NC-SA 4.0. 5

There are several forms of qualitative case studies. 1,2

Discovery-led case studies, which:

• describe what is happening in the setting
• explore the key issues affecting people within the setting
• compare settings, to learn from the similarities and differences between them.

Theory-led case studies, which:

• explain the causes of events, processes or relationships within a setting
• illustrate how a particular theory applies to a real-life setting
• experiment with changes in the setting to test specific factors or variables.

Single and collective case studies, where: 2, 9

• the researcher wants to understand a unique phenomenon in detail– known as an intrinsic case study
• the researcher is seeking insight and understanding of a particular situation or phenomenon, known as an illustrative case study or instrumental case study.

In both intrinsic, instrumental and illustrative case studies, the exploration might take place within a single case. In contrast, a collective case study includes multiple individual cases, and the exploration occurs both within and between cases. Collective case studies may include comparative cases, whereby cases are sampled to provide points of comparison for either context or the phenomenon. Embedded case studies are increasingly common within multi-site, randomised controlled trials, where each of the study sites is considered a case.

Multiple forms of data collection and methods of analysis (e.g. thematic, content, framework and constant comparative analyses) can be employed, since case studies are characterised by the depth of knowledge they provide and their nuanced approaches to understanding phenomena within context. 2,5 This approach enables triangulation between data sources (interviews, focus groups, participant observations), researchers and theory. Refer to Chapter 19 for information about triangulation.

Advantages and disadvantages of qualitative case studies

Advantages of using a case study approach include the ability to explore the subtleties and intricacies of complex social situations, and the use of multiple data collection methods and data from multiple sources within the case, which enables rigour through triangulation. Collective case studies enable comparison and contrasting within and across cases.

However, it can be challenging to define the boundaries of the case and to gain appropriate access to the case for the ‘deep dive’ form of analysis. Participant observation, which is a common form of data collection, can lead to observer bias. Data collection can take a long time and may require lengthy times, resources and funding to conduct the study. 9

Table 8.2 provides an example of a single case study and of a collective case study.

Table 8.2. Examples of qualitative case studies

Qualitative case studies provide a study design with diverse methods to examine the contextual factors relevant to understanding the why and how of a phenomenon within a case. The design incorporates single case studies and collective cases, which can also be embedded within randomised controlled trials as a form of process evaluation.

• Creswell J, Hanson W, Clark Plano V et al.. Qualitative research designs: selection and implementation. Couns Psychol  2007;35(2):236-264. doi:10.1177/0011000006287390
• Crowe S, Cresswell K, Robertson A, et al. The case study approach. BMC Med Res Methodol . 2011;11:100. doi:10.1186/1471-2288-11-100
• Ayton D, Manderson L, Smith BJ et al. Health promotion in local churches in Victoria: an exploratory study. Health Soc Care Community . 2016;24(6):728-738. doi:10.1111/hsc.12258
• Keleher H, Murphy C. Understanding Health: A Determinants Approach . Oxford University Press; 2004.
• Yazan B. Three approaches to case study methods in education: Yin, Merriam, and Stake. The Qualitative Report . 2015;20(2):134-152. doi:10.46743/2160-3715/2015.2102
• Stake RE. The A rt of C ase S tudy R esearch . SAGE Publications; 1995.
• Yin RK. Case S tudy R esearch: Design and M ethods . SAGE Publications; 2002.
• Merriam SB. Qualitative R esearch and C ase S tudy A pplications in E ducation . Jossey-Boss; 1998.
• Kekeya J. Qualitative case study research design: the commonalities and differences between collective, intrinsic and instrumental case studies. Contemporary PNG Studies . 2021;36:28-37.
• Nayback-Beebe AM, Yoder LH. The lived experiences of a male survivor of intimate partner violence: a qualitative case study. Medsurg Nurs . 2012;21(2):89-95; quiz 96.
• Clack L, Zingg W, Saint S et al. Implementing infection prevention practices across European hospitals: an in-depth qualitative assessment. BMJ Qual Saf . 2018;27(10):771-780. doi:10.1136/bmjqs-2017-007675

Qualitative Research – a practical guide for health and social care researchers and practitioners Copyright © 2023 by Darshini Ayton is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License , except where otherwise noted.

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Writing a Case Study

What is a case study?

A Case study is: 

• An in-depth research design that primarily uses a qualitative methodology but sometimes​​ includes quantitative methodology.
• Used to examine an identifiable problem confirmed through research.
• Used to investigate an individual, group of people, organization, or event.
• Used to mostly answer "how" and "why" questions.

What are the different types of case studies?

Note: These are the primary case studies. As you continue to research and learn

about case studies you will begin to find a robust list of different types. 

Who are your case study participants?

What is triangulation ? 

Validity and credibility are an essential part of the case study. Therefore, the researcher should include triangulation to ensure trustworthiness while accurately reflecting what the researcher seeks to investigate.

How to write a Case Study?

When developing a case study, there are different ways you could present the information, but remember to include the five parts for your case study.

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The case study approach

Sarah crowe.

1 Division of Primary Care, The University of Nottingham, Nottingham, UK

Kathrin Cresswell

2 Centre for Population Health Sciences, The University of Edinburgh, Edinburgh, UK

Ann Robertson

3 School of Health in Social Science, The University of Edinburgh, Edinburgh, UK

Anthony Avery

Aziz sheikh.

The case study approach allows in-depth, multi-faceted explorations of complex issues in their real-life settings. The value of the case study approach is well recognised in the fields of business, law and policy, but somewhat less so in health services research. Based on our experiences of conducting several health-related case studies, we reflect on the different types of case study design, the specific research questions this approach can help answer, the data sources that tend to be used, and the particular advantages and disadvantages of employing this methodological approach. The paper concludes with key pointers to aid those designing and appraising proposals for conducting case study research, and a checklist to help readers assess the quality of case study reports.

Introduction

The case study approach is particularly useful to employ when there is a need to obtain an in-depth appreciation of an issue, event or phenomenon of interest, in its natural real-life context. Our aim in writing this piece is to provide insights into when to consider employing this approach and an overview of key methodological considerations in relation to the design, planning, analysis, interpretation and reporting of case studies.

The illustrative 'grand round', 'case report' and 'case series' have a long tradition in clinical practice and research. Presenting detailed critiques, typically of one or more patients, aims to provide insights into aspects of the clinical case and, in doing so, illustrate broader lessons that may be learnt. In research, the conceptually-related case study approach can be used, for example, to describe in detail a patient's episode of care, explore professional attitudes to and experiences of a new policy initiative or service development or more generally to 'investigate contemporary phenomena within its real-life context' [ 1 ]. Based on our experiences of conducting a range of case studies, we reflect on when to consider using this approach, discuss the key steps involved and illustrate, with examples, some of the practical challenges of attaining an in-depth understanding of a 'case' as an integrated whole. In keeping with previously published work, we acknowledge the importance of theory to underpin the design, selection, conduct and interpretation of case studies[ 2 ]. In so doing, we make passing reference to the different epistemological approaches used in case study research by key theoreticians and methodologists in this field of enquiry.

This paper is structured around the following main questions: What is a case study? What are case studies used for? How are case studies conducted? What are the potential pitfalls and how can these be avoided? We draw in particular on four of our own recently published examples of case studies (see Tables ​ Tables1, 1 , ​ ,2, 2 , ​ ,3 3 and ​ and4) 4 ) and those of others to illustrate our discussion[ 3 - 7 ].

Example of a case study investigating the reasons for differences in recruitment rates of minority ethnic people in asthma research[ 3 ]

Example of a case study investigating the process of planning and implementing a service in Primary Care Organisations[ 4 ]

Example of a case study investigating the introduction of the electronic health records[ 5 ]

Example of a case study investigating the formal and informal ways students learn about patient safety[ 6 ]

What is a case study?

A case study is a research approach that is used to generate an in-depth, multi-faceted understanding of a complex issue in its real-life context. It is an established research design that is used extensively in a wide variety of disciplines, particularly in the social sciences. A case study can be defined in a variety of ways (Table ​ (Table5), 5 ), the central tenet being the need to explore an event or phenomenon in depth and in its natural context. It is for this reason sometimes referred to as a "naturalistic" design; this is in contrast to an "experimental" design (such as a randomised controlled trial) in which the investigator seeks to exert control over and manipulate the variable(s) of interest.

Definitions of a case study

Stake's work has been particularly influential in defining the case study approach to scientific enquiry. He has helpfully characterised three main types of case study: intrinsic , instrumental and collective [ 8 ]. An intrinsic case study is typically undertaken to learn about a unique phenomenon. The researcher should define the uniqueness of the phenomenon, which distinguishes it from all others. In contrast, the instrumental case study uses a particular case (some of which may be better than others) to gain a broader appreciation of an issue or phenomenon. The collective case study involves studying multiple cases simultaneously or sequentially in an attempt to generate a still broader appreciation of a particular issue.

These are however not necessarily mutually exclusive categories. In the first of our examples (Table ​ (Table1), 1 ), we undertook an intrinsic case study to investigate the issue of recruitment of minority ethnic people into the specific context of asthma research studies, but it developed into a instrumental case study through seeking to understand the issue of recruitment of these marginalised populations more generally, generating a number of the findings that are potentially transferable to other disease contexts[ 3 ]. In contrast, the other three examples (see Tables ​ Tables2, 2 , ​ ,3 3 and ​ and4) 4 ) employed collective case study designs to study the introduction of workforce reconfiguration in primary care, the implementation of electronic health records into hospitals, and to understand the ways in which healthcare students learn about patient safety considerations[ 4 - 6 ]. Although our study focusing on the introduction of General Practitioners with Specialist Interests (Table ​ (Table2) 2 ) was explicitly collective in design (four contrasting primary care organisations were studied), is was also instrumental in that this particular professional group was studied as an exemplar of the more general phenomenon of workforce redesign[ 4 ].

What are case studies used for?

According to Yin, case studies can be used to explain, describe or explore events or phenomena in the everyday contexts in which they occur[ 1 ]. These can, for example, help to understand and explain causal links and pathways resulting from a new policy initiative or service development (see Tables ​ Tables2 2 and ​ and3, 3 , for example)[ 1 ]. In contrast to experimental designs, which seek to test a specific hypothesis through deliberately manipulating the environment (like, for example, in a randomised controlled trial giving a new drug to randomly selected individuals and then comparing outcomes with controls),[ 9 ] the case study approach lends itself well to capturing information on more explanatory ' how ', 'what' and ' why ' questions, such as ' how is the intervention being implemented and received on the ground?'. The case study approach can offer additional insights into what gaps exist in its delivery or why one implementation strategy might be chosen over another. This in turn can help develop or refine theory, as shown in our study of the teaching of patient safety in undergraduate curricula (Table ​ (Table4 4 )[ 6 , 10 ]. Key questions to consider when selecting the most appropriate study design are whether it is desirable or indeed possible to undertake a formal experimental investigation in which individuals and/or organisations are allocated to an intervention or control arm? Or whether the wish is to obtain a more naturalistic understanding of an issue? The former is ideally studied using a controlled experimental design, whereas the latter is more appropriately studied using a case study design.

Case studies may be approached in different ways depending on the epistemological standpoint of the researcher, that is, whether they take a critical (questioning one's own and others' assumptions), interpretivist (trying to understand individual and shared social meanings) or positivist approach (orientating towards the criteria of natural sciences, such as focusing on generalisability considerations) (Table ​ (Table6). 6 ). Whilst such a schema can be conceptually helpful, it may be appropriate to draw on more than one approach in any case study, particularly in the context of conducting health services research. Doolin has, for example, noted that in the context of undertaking interpretative case studies, researchers can usefully draw on a critical, reflective perspective which seeks to take into account the wider social and political environment that has shaped the case[ 11 ].

Example of epistemological approaches that may be used in case study research

How are case studies conducted?

Here, we focus on the main stages of research activity when planning and undertaking a case study; the crucial stages are: defining the case; selecting the case(s); collecting and analysing the data; interpreting data; and reporting the findings.

Defining the case

Carefully formulated research question(s), informed by the existing literature and a prior appreciation of the theoretical issues and setting(s), are all important in appropriately and succinctly defining the case[ 8 , 12 ]. Crucially, each case should have a pre-defined boundary which clarifies the nature and time period covered by the case study (i.e. its scope, beginning and end), the relevant social group, organisation or geographical area of interest to the investigator, the types of evidence to be collected, and the priorities for data collection and analysis (see Table ​ Table7 7 )[ 1 ]. A theory driven approach to defining the case may help generate knowledge that is potentially transferable to a range of clinical contexts and behaviours; using theory is also likely to result in a more informed appreciation of, for example, how and why interventions have succeeded or failed[ 13 ].

Example of a checklist for rating a case study proposal[ 8 ]

For example, in our evaluation of the introduction of electronic health records in English hospitals (Table ​ (Table3), 3 ), we defined our cases as the NHS Trusts that were receiving the new technology[ 5 ]. Our focus was on how the technology was being implemented. However, if the primary research interest had been on the social and organisational dimensions of implementation, we might have defined our case differently as a grouping of healthcare professionals (e.g. doctors and/or nurses). The precise beginning and end of the case may however prove difficult to define. Pursuing this same example, when does the process of implementation and adoption of an electronic health record system really begin or end? Such judgements will inevitably be influenced by a range of factors, including the research question, theory of interest, the scope and richness of the gathered data and the resources available to the research team.

Selecting the case(s)

The decision on how to select the case(s) to study is a very important one that merits some reflection. In an intrinsic case study, the case is selected on its own merits[ 8 ]. The case is selected not because it is representative of other cases, but because of its uniqueness, which is of genuine interest to the researchers. This was, for example, the case in our study of the recruitment of minority ethnic participants into asthma research (Table ​ (Table1) 1 ) as our earlier work had demonstrated the marginalisation of minority ethnic people with asthma, despite evidence of disproportionate asthma morbidity[ 14 , 15 ]. In another example of an intrinsic case study, Hellstrom et al.[ 16 ] studied an elderly married couple living with dementia to explore how dementia had impacted on their understanding of home, their everyday life and their relationships.

For an instrumental case study, selecting a "typical" case can work well[ 8 ]. In contrast to the intrinsic case study, the particular case which is chosen is of less importance than selecting a case that allows the researcher to investigate an issue or phenomenon. For example, in order to gain an understanding of doctors' responses to health policy initiatives, Som undertook an instrumental case study interviewing clinicians who had a range of responsibilities for clinical governance in one NHS acute hospital trust[ 17 ]. Sampling a "deviant" or "atypical" case may however prove even more informative, potentially enabling the researcher to identify causal processes, generate hypotheses and develop theory.

In collective or multiple case studies, a number of cases are carefully selected. This offers the advantage of allowing comparisons to be made across several cases and/or replication. Choosing a "typical" case may enable the findings to be generalised to theory (i.e. analytical generalisation) or to test theory by replicating the findings in a second or even a third case (i.e. replication logic)[ 1 ]. Yin suggests two or three literal replications (i.e. predicting similar results) if the theory is straightforward and five or more if the theory is more subtle. However, critics might argue that selecting 'cases' in this way is insufficiently reflexive and ill-suited to the complexities of contemporary healthcare organisations.

The selected case study site(s) should allow the research team access to the group of individuals, the organisation, the processes or whatever else constitutes the chosen unit of analysis for the study. Access is therefore a central consideration; the researcher needs to come to know the case study site(s) well and to work cooperatively with them. Selected cases need to be not only interesting but also hospitable to the inquiry [ 8 ] if they are to be informative and answer the research question(s). Case study sites may also be pre-selected for the researcher, with decisions being influenced by key stakeholders. For example, our selection of case study sites in the evaluation of the implementation and adoption of electronic health record systems (see Table ​ Table3) 3 ) was heavily influenced by NHS Connecting for Health, the government agency that was responsible for overseeing the National Programme for Information Technology (NPfIT)[ 5 ]. This prominent stakeholder had already selected the NHS sites (through a competitive bidding process) to be early adopters of the electronic health record systems and had negotiated contracts that detailed the deployment timelines.

It is also important to consider in advance the likely burden and risks associated with participation for those who (or the site(s) which) comprise the case study. Of particular importance is the obligation for the researcher to think through the ethical implications of the study (e.g. the risk of inadvertently breaching anonymity or confidentiality) and to ensure that potential participants/participating sites are provided with sufficient information to make an informed choice about joining the study. The outcome of providing this information might be that the emotive burden associated with participation, or the organisational disruption associated with supporting the fieldwork, is considered so high that the individuals or sites decide against participation.

In our example of evaluating implementations of electronic health record systems, given the restricted number of early adopter sites available to us, we sought purposively to select a diverse range of implementation cases among those that were available[ 5 ]. We chose a mixture of teaching, non-teaching and Foundation Trust hospitals, and examples of each of the three electronic health record systems procured centrally by the NPfIT. At one recruited site, it quickly became apparent that access was problematic because of competing demands on that organisation. Recognising the importance of full access and co-operative working for generating rich data, the research team decided not to pursue work at that site and instead to focus on other recruited sites.

Collecting the data

In order to develop a thorough understanding of the case, the case study approach usually involves the collection of multiple sources of evidence, using a range of quantitative (e.g. questionnaires, audits and analysis of routinely collected healthcare data) and more commonly qualitative techniques (e.g. interviews, focus groups and observations). The use of multiple sources of data (data triangulation) has been advocated as a way of increasing the internal validity of a study (i.e. the extent to which the method is appropriate to answer the research question)[ 8 , 18 - 21 ]. An underlying assumption is that data collected in different ways should lead to similar conclusions, and approaching the same issue from different angles can help develop a holistic picture of the phenomenon (Table ​ (Table2 2 )[ 4 ].

Brazier and colleagues used a mixed-methods case study approach to investigate the impact of a cancer care programme[ 22 ]. Here, quantitative measures were collected with questionnaires before, and five months after, the start of the intervention which did not yield any statistically significant results. Qualitative interviews with patients however helped provide an insight into potentially beneficial process-related aspects of the programme, such as greater, perceived patient involvement in care. The authors reported how this case study approach provided a number of contextual factors likely to influence the effectiveness of the intervention and which were not likely to have been obtained from quantitative methods alone.

In collective or multiple case studies, data collection needs to be flexible enough to allow a detailed description of each individual case to be developed (e.g. the nature of different cancer care programmes), before considering the emerging similarities and differences in cross-case comparisons (e.g. to explore why one programme is more effective than another). It is important that data sources from different cases are, where possible, broadly comparable for this purpose even though they may vary in nature and depth.

Analysing, interpreting and reporting case studies

Making sense and offering a coherent interpretation of the typically disparate sources of data (whether qualitative alone or together with quantitative) is far from straightforward. Repeated reviewing and sorting of the voluminous and detail-rich data are integral to the process of analysis. In collective case studies, it is helpful to analyse data relating to the individual component cases first, before making comparisons across cases. Attention needs to be paid to variations within each case and, where relevant, the relationship between different causes, effects and outcomes[ 23 ]. Data will need to be organised and coded to allow the key issues, both derived from the literature and emerging from the dataset, to be easily retrieved at a later stage. An initial coding frame can help capture these issues and can be applied systematically to the whole dataset with the aid of a qualitative data analysis software package.

The Framework approach is a practical approach, comprising of five stages (familiarisation; identifying a thematic framework; indexing; charting; mapping and interpretation) , to managing and analysing large datasets particularly if time is limited, as was the case in our study of recruitment of South Asians into asthma research (Table ​ (Table1 1 )[ 3 , 24 ]. Theoretical frameworks may also play an important role in integrating different sources of data and examining emerging themes. For example, we drew on a socio-technical framework to help explain the connections between different elements - technology; people; and the organisational settings within which they worked - in our study of the introduction of electronic health record systems (Table ​ (Table3 3 )[ 5 ]. Our study of patient safety in undergraduate curricula drew on an evaluation-based approach to design and analysis, which emphasised the importance of the academic, organisational and practice contexts through which students learn (Table ​ (Table4 4 )[ 6 ].

Case study findings can have implications both for theory development and theory testing. They may establish, strengthen or weaken historical explanations of a case and, in certain circumstances, allow theoretical (as opposed to statistical) generalisation beyond the particular cases studied[ 12 ]. These theoretical lenses should not, however, constitute a strait-jacket and the cases should not be "forced to fit" the particular theoretical framework that is being employed.

When reporting findings, it is important to provide the reader with enough contextual information to understand the processes that were followed and how the conclusions were reached. In a collective case study, researchers may choose to present the findings from individual cases separately before amalgamating across cases. Care must be taken to ensure the anonymity of both case sites and individual participants (if agreed in advance) by allocating appropriate codes or withholding descriptors. In the example given in Table ​ Table3, 3 , we decided against providing detailed information on the NHS sites and individual participants in order to avoid the risk of inadvertent disclosure of identities[ 5 , 25 ].

What are the potential pitfalls and how can these be avoided?

The case study approach is, as with all research, not without its limitations. When investigating the formal and informal ways undergraduate students learn about patient safety (Table ​ (Table4), 4 ), for example, we rapidly accumulated a large quantity of data. The volume of data, together with the time restrictions in place, impacted on the depth of analysis that was possible within the available resources. This highlights a more general point of the importance of avoiding the temptation to collect as much data as possible; adequate time also needs to be set aside for data analysis and interpretation of what are often highly complex datasets.

Case study research has sometimes been criticised for lacking scientific rigour and providing little basis for generalisation (i.e. producing findings that may be transferable to other settings)[ 1 ]. There are several ways to address these concerns, including: the use of theoretical sampling (i.e. drawing on a particular conceptual framework); respondent validation (i.e. participants checking emerging findings and the researcher's interpretation, and providing an opinion as to whether they feel these are accurate); and transparency throughout the research process (see Table ​ Table8 8 )[ 8 , 18 - 21 , 23 , 26 ]. Transparency can be achieved by describing in detail the steps involved in case selection, data collection, the reasons for the particular methods chosen, and the researcher's background and level of involvement (i.e. being explicit about how the researcher has influenced data collection and interpretation). Seeking potential, alternative explanations, and being explicit about how interpretations and conclusions were reached, help readers to judge the trustworthiness of the case study report. Stake provides a critique checklist for a case study report (Table ​ (Table9 9 )[ 8 ].

Potential pitfalls and mitigating actions when undertaking case study research

Stake's checklist for assessing the quality of a case study report[ 8 ]

Conclusions

The case study approach allows, amongst other things, critical events, interventions, policy developments and programme-based service reforms to be studied in detail in a real-life context. It should therefore be considered when an experimental design is either inappropriate to answer the research questions posed or impossible to undertake. Considering the frequency with which implementations of innovations are now taking place in healthcare settings and how well the case study approach lends itself to in-depth, complex health service research, we believe this approach should be more widely considered by researchers. Though inherently challenging, the research case study can, if carefully conceptualised and thoughtfully undertaken and reported, yield powerful insights into many important aspects of health and healthcare delivery.

Competing interests

The authors declare that they have no competing interests.

Authors' contributions

AS conceived this article. SC, KC and AR wrote this paper with GH, AA and AS all commenting on various drafts. SC and AS are guarantors.

Pre-publication history

The pre-publication history for this paper can be accessed here:

http://www.biomedcentral.com/1471-2288/11/100/prepub

Acknowledgements

We are grateful to the participants and colleagues who contributed to the individual case studies that we have drawn on. This work received no direct funding, but it has been informed by projects funded by Asthma UK, the NHS Service Delivery Organisation, NHS Connecting for Health Evaluation Programme, and Patient Safety Research Portfolio. We would also like to thank the expert reviewers for their insightful and constructive feedback. Our thanks are also due to Dr. Allison Worth who commented on an earlier draft of this manuscript.

• Yin RK. Case study research, design and method. 4. London: Sage Publications Ltd.; 2009. [ Google Scholar ]
• Keen J, Packwood T. Qualitative research; case study evaluation. BMJ. 1995; 311 :444–446. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Sheikh A, Halani L, Bhopal R, Netuveli G, Partridge M, Car J. et al. Facilitating the Recruitment of Minority Ethnic People into Research: Qualitative Case Study of South Asians and Asthma. PLoS Med. 2009; 6 (10):1–11. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Pinnock H, Huby G, Powell A, Kielmann T, Price D, Williams S, The process of planning, development and implementation of a General Practitioner with a Special Interest service in Primary Care Organisations in England and Wales: a comparative prospective case study. Report for the National Co-ordinating Centre for NHS Service Delivery and Organisation R&D (NCCSDO) 2008. http://www.sdo.nihr.ac.uk/files/project/99-final-report.pdf
• Robertson A, Cresswell K, Takian A, Petrakaki D, Crowe S, Cornford T. et al. Prospective evaluation of the implementation and adoption of NHS Connecting for Health's national electronic health record in secondary care in England: interim findings. BMJ. 2010; 41 :c4564. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Pearson P, Steven A, Howe A, Sheikh A, Ashcroft D, Smith P. the Patient Safety Education Study Group. Learning about patient safety: organisational context and culture in the education of healthcare professionals. J Health Serv Res Policy. 2010; 15 :4–10. doi: 10.1258/jhsrp.2009.009052. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• van Harten WH, Casparie TF, Fisscher OA. The evaluation of the introduction of a quality management system: a process-oriented case study in a large rehabilitation hospital. Health Policy. 2002; 60 (1):17–37. doi: 10.1016/S0168-8510(01)00187-7. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Stake RE. The art of case study research. London: Sage Publications Ltd.; 1995. [ Google Scholar ]
• Sheikh A, Smeeth L, Ashcroft R. Randomised controlled trials in primary care: scope and application. Br J Gen Pract. 2002; 52 (482):746–51. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• King G, Keohane R, Verba S. Designing Social Inquiry. Princeton: Princeton University Press; 1996. [ Google Scholar ]
• Doolin B. Information technology as disciplinary technology: being critical in interpretative research on information systems. Journal of Information Technology. 1998; 13 :301–311. doi: 10.1057/jit.1998.8. [ CrossRef ] [ Google Scholar ]
• George AL, Bennett A. Case studies and theory development in the social sciences. Cambridge, MA: MIT Press; 2005. [ Google Scholar ]
• Eccles M. the Improved Clinical Effectiveness through Behavioural Research Group (ICEBeRG) Designing theoretically-informed implementation interventions. Implementation Science. 2006; 1 :1–8. doi: 10.1186/1748-5908-1-1. [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Netuveli G, Hurwitz B, Levy M, Fletcher M, Barnes G, Durham SR, Sheikh A. Ethnic variations in UK asthma frequency, morbidity, and health-service use: a systematic review and meta-analysis. Lancet. 2005; 365 (9456):312–7. [ PubMed ] [ Google Scholar ]
• Sheikh A, Panesar SS, Lasserson T, Netuveli G. Recruitment of ethnic minorities to asthma studies. Thorax. 2004; 59 (7):634. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Hellström I, Nolan M, Lundh U. 'We do things together': A case study of 'couplehood' in dementia. Dementia. 2005; 4 :7–22. doi: 10.1177/1471301205049188. [ CrossRef ] [ Google Scholar ]
• Som CV. Nothing seems to have changed, nothing seems to be changing and perhaps nothing will change in the NHS: doctors' response to clinical governance. International Journal of Public Sector Management. 2005; 18 :463–477. doi: 10.1108/09513550510608903. [ CrossRef ] [ Google Scholar ]
• Lincoln Y, Guba E. Naturalistic inquiry. Newbury Park: Sage Publications; 1985. [ Google Scholar ]
• Barbour RS. Checklists for improving rigour in qualitative research: a case of the tail wagging the dog? BMJ. 2001; 322 :1115–1117. doi: 10.1136/bmj.322.7294.1115. [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Mays N, Pope C. Qualitative research in health care: Assessing quality in qualitative research. BMJ. 2000; 320 :50–52. doi: 10.1136/bmj.320.7226.50. [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Mason J. Qualitative researching. London: Sage; 2002. [ Google Scholar ]
• Brazier A, Cooke K, Moravan V. Using Mixed Methods for Evaluating an Integrative Approach to Cancer Care: A Case Study. Integr Cancer Ther. 2008; 7 :5–17. doi: 10.1177/1534735407313395. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Miles MB, Huberman M. Qualitative data analysis: an expanded sourcebook. 2. CA: Sage Publications Inc.; 1994. [ Google Scholar ]
• Pope C, Ziebland S, Mays N. Analysing qualitative data. Qualitative research in health care. BMJ. 2000; 320 :114–116. doi: 10.1136/bmj.320.7227.114. [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Cresswell KM, Worth A, Sheikh A. Actor-Network Theory and its role in understanding the implementation of information technology developments in healthcare. BMC Med Inform Decis Mak. 2010; 10 (1):67. doi: 10.1186/1472-6947-10-67. [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Malterud K. Qualitative research: standards, challenges, and guidelines. Lancet. 2001; 358 :483–488. doi: 10.1016/S0140-6736(01)05627-6. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Yin R. Case study research: design and methods. 2. Thousand Oaks, CA: Sage Publishing; 1994. [ Google Scholar ]
• Yin R. Enhancing the quality of case studies in health services research. Health Serv Res. 1999; 34 :1209–1224. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Green J, Thorogood N. Qualitative methods for health research. 2. Los Angeles: Sage; 2009. [ Google Scholar ]
• Howcroft D, Trauth E. Handbook of Critical Information Systems Research, Theory and Application. Cheltenham, UK: Northampton, MA, USA: Edward Elgar; 2005. [ Google Scholar ]
• Blakie N. Approaches to Social Enquiry. Cambridge: Polity Press; 1993. [ Google Scholar ]
• Doolin B. Power and resistance in the implementation of a medical management information system. Info Systems J. 2004; 14 :343–362. doi: 10.1111/j.1365-2575.2004.00176.x. [ CrossRef ] [ Google Scholar ]
• Bloomfield BP, Best A. Management consultants: systems development, power and the translation of problems. Sociological Review. 1992; 40 :533–560. [ Google Scholar ]
• Shanks G, Parr A. Proceedings of the European Conference on Information Systems. Naples; 2003. Positivist, single case study research in information systems: A critical analysis. [ Google Scholar ]

Case Study Research

• First Online: 29 September 2022

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• Robert E. White   ORCID: orcid.org/0000-0002-8045-164X 3 &
• Karyn Cooper 4  

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As a footnote to the previous chapter, there is such a beast known as the ethnographic case study. Ethnographic case study has found its way into this chapter rather than into the previous one because of grammatical considerations. Simply put, the “case study” part of the phrase is the noun (with “case” as an adjective defining what kind of study it is), while the “ethnographic” part of the phrase is an adjective defining the type of case study that is being conducted. As such, the case study becomes the methodology, while the ethnography part refers to a method, mode or approach relating to the development of the study.

The experiential account that we get from a case study or qualitative research of a similar vein is just so necessary. How things happen over time and the degree to which they are subject to personality and how they are only gradually perceived as tolerable or intolerable by the communities and the groups that are involved is so important. Robert Stake, University of Illinois, Urbana-Champaign

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Bartlett, L., & Vavrus, F. (2017). Rethinking case study research . Routledge.

Google Scholar  

Bauman, Z. (2000). Liquid modernity . Polity Press.

Bhaskar, R., & Danermark, B. (2006). Metatheory, interdisciplinarity and disability research: A critical realist perspective. Scandinavian Journal of Disability Research, 8 (4), 278–297.

Article   Google Scholar  

Bulmer, M. (1986). The Chicago School of sociology: Institutionalization, diversity, and the rise of sociological research . University of Chicago Press.

Campbell, D. T. (1975). Degrees of freedom and the case study. Comparative Political Studies, 8 (1), 178–191.

Campbell, D. T., & Stanley, J. C. (1966). Experimental and quasi-experimental designs for research . Houghton Mifflin.

Chua, W. F. (1986). Radical developments in accounting thought. The Accounting Review, 61 (4), 601–632.

Creswell, J. W. (2013). Research design: Qualitative, quantitative, and mixed methods approaches (4th ed.). Sage.

Creswell, J. W., & Poth, C. N. (2017). Qualitative inquiry and research design . Sage.

Davey, L. (1991). The application of case study evaluations. Practical Assessment, Research, & Evaluation 2 (9) . Retrieved May 28, 2018, from http://PAREonline.net/getvn.asp?v=2&n=9

Demetriou, H. (2017). The case study. In E. Wilson (Ed.), School-based research: A guide for education students (pp. 124–138). Sage.

Denzin, N. K., & Lincoln, Y. S. (2005). The Sage handbook of qualitative research . Sage.

Flyvbjerg, B. (2004). Five misunderstandings about case-study research. In C. Seale, G. Gobo, J. F. Gubrium, & D. Silverman (Eds.), Qualitative research practice (pp. 420–433). Sage.

Hamel, J., Dufour, S., & Fortin, D. (1993). Case study methods . Sage.

Book   Google Scholar  

Healy, M. E. (1947). Le Play’s contribution to sociology: His method. The American Catholic Sociological Review, 8 (2), 97–110.

Johansson, R. (2003). Case study methodology. [Keynote speech]. In International Conference “Methodologies in Housing Research.” Royal Institute of Technology, Stockholm, September 2003 (pp. 1–14).

Klonoski, R. (2013). The case for case studies: Deriving theory from evidence. Journal of Business Case Studies, 9 (31), 261–266.

McDonough, J., & McDonough, S. (1997). Research methods for English language teachers . Routledge.

Merriam, S. B. (1998). Qualitative research and case study applications in education . Jossey-Bass.

Miles, M. B. (1979). Qualitative data as an attractive nuisance: The problem of analysis. Administrative Science Quarterly, 24 (4), 590–601.

Miles, M. B., & Huberman, A. M. (1994). Qualitative data analysis: An expanded sourcebook (2nd ed.). Sage.

Mills, A. J., Durepos, G. & E. Wiebe (Eds.) (2010). What is a case study? Encyclopedia of case study research, Volumes I and II. Sage.

National Film Board of Canada. (2012, April). Here at home: In search of the real cost of homelessness . [Web documentary]. Retrieved February 9, 2020, from http://athome.nfb.ca/#/athome/home

Popper, K. (2002). Conjectures and refutations: The growth of scientific knowledge . Routledge.

Ridder, H.-G. (2017). The theory contribution of case study research designs. Business Research, 10 (2), 281–305.

Rolls, G. (2005). Classic case studies in psychology . Hodder Education.

Seawright, J., & Gerring, J. (2008). Case-Selection techniques in case study research: A menu of qualitative and quantitative options. Political Research Quarterly, 61 , 294–308.

Stake, R. E. (1995). The art of case study research . Sage.

Stake, R. E. (2005). Multiple case study analysis . Guilford Press.

Swanborn, P. G. (2010). Case study research: What, why and how? Sage.

Thomas, W. I., & Znaniecki, F. (1996). The Polish peasant in Europe and America: A classic work in immigration history . University of Illinois Press.

Yin, R. K. (1981). The case study crisis: Some answers. Administrative Science Quarterly, 26 (1), 58–65.

Yin, R. K. (1991). Advancing rigorous methodologies : A Review of “Towards Rigor in Reviews of Multivocal Literatures….”. Review of Educational Research, 61 (3), 299–305.

Yin, R. K. (1999). Enhancing the quality of case studies in health services research. Health Services Research, 34 (5) Part II, 1209–1224.

Yin, R. K. (2012). Applications of case study research (3rd ed.). Sage.

Yin, R. K. (2014). Case study research: Design and methods (5th ed.). Sage.

Zaretsky, E. (1996). Introduction. In W. I. Thomas & F. Znaniecki (Eds.), The Polish peasant in Europe and America: A classic work in immigration history (pp. vii–xvii). University of Illinois Press.

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A Case in Case Study Methodology

Christine Benedichte Meyer

Norwegian School of Economics and Business Administration

Meyer, C. B. (2001). A Case in Case Study Methodology. Field Methods 13 (4), 329-352.

The purpose of this article is to provide a comprehensive view of the case study process from the researcher’s perspective, emphasizing methodological considerations. As opposed to other qualitative or quantitative research strategies, such as grounded theory or surveys, there are virtually no specific requirements guiding case research. This is both the strength and the weakness of this approach. It is a strength because it allows tailoring the design and data collection procedures to the research questions. On the other hand, this approach has resulted in many poor case studies, leaving it open to criticism, especially from the quantitative field of research. This article argues that there is a particular need in case studies to be explicit about the methodological choices one makes. This implies discussing the wide range of decisions concerned with design requirements, data collection procedures, data analysis, and validity and reliability. The approach here is to illustrate these decisions through a particular case study of two mergers in the financial industry in Norway.

In the past few years, a number of books have been published that give useful guidance in conducting qualitative studies (Gummesson 1988; Cassell & Symon 1994; Miles & Huberman 1994; Creswell 1998; Flick 1998; Rossman & Rallis 1998; Bryman & Burgess 1999; Marshall & Rossman 1999; Denzin & Lincoln 2000). One approach often mentioned is the case study (Yin 1989). Case studies are widely used in organizational studies in the social science disciplines of sociology, industrial relations, and anthropology (Hartley 1994). Such a study consists of detailed investigation of one or more organizations, or groups within organizations, with a view to providing an analysis of the context and processes involved in the phenomenon under study.

As opposed to other qualitative or quantitative research strategies, such as grounded theory (Glaser and Strauss 1967) or surveys (Nachmias & Nachmias 1981), there are virtually no specific requirements guiding case research. Yin (1989) and Eisenhardt (1989) give useful insights into the case study as a research strategy, but leave most of the design decisions on the table. This is both the strength and the weakness of this approach. It is a strength because it allows tailoring the design and data collection procedures to the research questions. On the other hand, this approach has resulted in many poor case studies, leaving it open to criticism, especially from the quantitative field of research (Cook and Campbell 1979). The fact that the case study is a rather loose design implies that there are a number of choices that need to be addressed in a principled way.

Although case studies have become a common research strategy, the scope of methodology sections in articles published in journals is far too limited to give the readers a detailed and comprehensive view of the decisions taken in the particular studies, and, given the format of methodology sections, will remain so. The few books (Yin 1989, 1993; Hamel, Dufour, & Fortin 1993; Stake 1995) and book chapters on case studies (Hartley 1994; Silverman 2000) are, on the other hand, mainly normative and span a broad range of different kinds of case studies. One exception is Pettigrew (1990, 1992), who places the case study in the context of a research tradition (the Warwick process research).

Given the contextual nature of the case study and its strength in addressing contemporary phenomena in real-life contexts, I believe that there is a need for articles that provide a comprehensive overview of the case study process from the researcher’s perspective, emphasizing methodological considerations. This implies addressing the whole range of choices concerning specific design requirements, data collection procedures, data analysis, and validity and reliability.

WHY A CASE STUDY?

Case studies are tailor-made for exploring new processes or behaviors or ones that are little understood (Hartley 1994). Hence, the approach is particularly useful for responding to how and why questions about a contemporary set of events (Leonard-Barton 1990). Moreover, researchers have argued that certain kinds of information can be difficult or even impossible to tackle by means other than qualitative approaches such as the case study (Sykes 1990). Gummesson (1988:76) argues that an important advantage of case study research is the opportunity for a holistic view of the process: “The detailed observations entailed in the case study method enable us to study many different aspects, examine them in relation to each other, view the process within its total environment and also use the researchers’ capacity for ‘verstehen.’ ”

The contextual nature of the case study is illustrated in Yin’s (1993:59) definition of a case study as an empirical inquiry that “investigates a contemporary phenomenon within its real-life context and addresses a situation in which the boundaries between phenomenon and context are not clearly evident.”

The key difference between the case study and other qualitative designs such as grounded theory and ethnography (Glaser & Strauss 1967; Strauss & Corbin 1990; Gioia & Chittipeddi 1991) is that the case study is open to the use of theory or conceptual categories that guide the research and analysis of data. In contrast, grounded theory or ethnography presupposes that theoretical perspectives are grounded in and emerge from firsthand data. Hartley (1994) argues that without a theoretical framework, the researcher is in severe danger of providing description without meaning. Gummesson (1988) says that a lack of preunderstanding will cause the researcher to spend considerable time gathering basic information. This preunderstanding may arise from general knowledge such as theories, models, and concepts or from specific knowledge of institutional conditions and social patterns. According to Gummesson, the key is not to require researchers to have split but dual personalities: “Those who are able to balance on a razor’s edge using their pre-understanding without being its slave” (p. 58).

DESCRIPTION OF THE ILLUSTRATIVE STUDY

The study that will be used for illustrative purposes is a comparative and longitudinal case study of organizational integration in mergers and acquisitions taking place in Norway. The study had two purposes: (1) to identify contextual factors and features of integration that facilitated or impeded organizational integration, and (2) to study how the three dimensions of organizational integration (integration of tasks, unification of power, and integration of cultures and identities) interrelated and evolved over time. Examples of contextual factors were relative power, degree of friendliness, and economic climate. Integration features included factors such as participation, communication, and allocation of positions and functions.

Mergers and acquisitions are inherently complex. Researchers in the field have suggested that managers continuously underestimate the task of integrating the merging organizations in the postintegration process (Haspeslaph & Jemison 1991). The process of organizational integration can lead to sharp interorganizational conflict as the different top management styles, organizational and work unit cultures, systems, and other aspects of organizational life come into contact (Blake & Mounton 1985; Schweiger & Walsh 1990; Cartwright & Cooper 1993). Furthermore, cultural change in mergers and acquisitions is compounded by additional uncertainties, ambiguities, and stress inherent in the combination process (Buono & Bowditch 1989).

I focused on two combinations: one merger and one acquisition. The first case was a merger between two major Norwegian banks, Bergen Bank and DnC (to be named DnB), that started in the late 1980s. The second case was a study of a major acquisition in the insurance industry (i.e., Gjensidige’s acquisition of Forenede), that started in the early 1990s. Both combinations aimed to realize operational synergies though merging the two organizations into one entity. This implied disruption of organizational boundaries and threat to the existing power distribution and organizational cultures.

The study of integration processes in mergers and acquisitions illustrates the need to find a design that opens for exploration of sensitive issues such as power struggles between the two merging organizations. Furthermore, the inherent complexity in the integration process, involving integration of tasks, unification of power, and cultural integration stressed the need for in-depth study of the phenomenon over time. To understand the cultural integration process, the design also had to be linked to the past history of the two organizations.

DESIGN DECISIONS

In the introduction, I stressed that a case is a rather loose design that requires that a number of design choices be made. In this section, I go through the most important choices I faced in the study of organizational integration in mergers and acquisitions. These include: (1) selection of cases; (2) sampling time; (3) choosing business areas, divisions, and sites; and (4) selection of and choices regarding data collection procedures, interviews, documents, and observation.

Selection of Cases

There are several choices involved in selecting cases. First, there is the question of how many cases to include. Second, one must sample cases and decide on a unit of analysis. I will explore these issues subsequently.

Single or Multiple Cases

Case studies can involve single or multiple cases. The problem of single cases is limitations in generalizability and several information-processing biases (Eisenhardt 1989).

One way to respond to these biases is by applying a multi-case approach (Leonard-Barton 1990). Multiple cases augment external validity and help guard against observer biases. Moreover, multi-case sampling adds confidence to findings. By looking at a range of similar and contrasting cases, we can understand a single-case finding, grounding it by specifying how and where and, if possible, why it behaves as it does. (Miles & Huberman 1994)

Given these limitations of the single case study, it is desirable to include more than one case study in the study. However, the desire for depth and a pluralist perspective and tracking the cases over time implies that the number of cases must be fairly few. I chose two cases, which clearly does not support generalizability any more than does one case, but allows for comparison and contrast between the cases as well as a deeper and richer look at each case.

Originally, I planned to include a third case in the study. Due to changes in management during the initial integration process, my access to the case was limited and I left this case entirely. However, a positive side effect was that it allowed a deeper investigation of the two original cases and in hindsight turned out to be a good decision.

Sampling Cases

The logic of sampling cases is fundamentally different from statistical sampling. The logic in case studies involves theoretical sampling, in which the goal is to choose cases that are likely to replicate or extend the emergent theory or to fill theoretical categories and provide examples for polar types (Eisenhardt 1989). Hence, whereas quantitative sampling concerns itself with representativeness, qualitative sampling seeks information richness and selects the cases purposefully rather than randomly (Crabtree and Miller 1992).

The choice of cases was guided by George (1979) and Pettigrew’s (1990) recommendations. The aim was to find cases that matched the three dimensions in the dependent variable and provided variation in the contextual factors, thus representing polar cases.

To match the choice of outcome variable, organizational integration, I chose cases in which the purpose was to fully consolidate the merging parties’ operations. A full consolidation would imply considerable disruption in the organizational boundaries and would be expected to affect the task-related, political, and cultural features of the organizations. As for the contextual factors, the two cases varied in contextual factors such as relative power, friendliness, and economic climate. The DnB merger was a friendly combination between two equal partners in an unfriendly economic climate. Gjensidige’s acquisition of Forenede was, in contrast, an unfriendly and unbalanced acquisition in a friendly economic climate.

Unit of Analysis

Another way to respond to researchers’ and respondents’ biases is to have more than one unit of analysis in each case (Yin 1993). This implies that, in addition to developing contrasts between the cases, researchers can focus on contrasts within the cases (Hartley 1994). In case studies, there is a choice of a holistic or embedded design (Yin 1989). A holistic design examines the global nature of the phenomenon, whereas an embedded design also pays attention to subunit(s).

I used an embedded design to analyze the cases (i.e., within each case, I also gave attention to subunits and subprocesses). In both cases, I compared the combination processes in the various divisions and local networks. Moreover, I compared three distinct change processes in DnB: before the merger, during the initial combination, and two years after the merger. The overall and most important unit of analysis in the two cases was, however, the integration process.

Sampling Time

According to Pettigrew (1990), time sets a reference for what changes can be seen and how those changes are explained. When conducting a case study, there are several important issues to decide when sampling time. The first regards how many times data should be collected, while the second concerns when to enter the organizations. There is also a need to decide whether to collect data on a continuous basis or in distinct periods.

Number of data collections. I studied the process by collecting real time and retrospective data at two points in time, with one-and-a-half- and two-year intervals in the two cases. Collecting data twice had some interesting implications for the interpretations of the data. During the first data collection in the DnB study, for example, I collected retrospective data about the premerger and initial combination phase and real-time data about the second step in the combination process.

Although I gained a picture of how the employees experienced the second stage of the combination process, it was too early to assess the effects of this process at that stage. I entered the organization two years later and found interesting effects that I had not anticipated the first time. Moreover, it was interesting to observe how people’s attitudes toward the merger processes changed over time to be more positive and less emotional.

When to enter the organizations. It would be desirable to have had the opportunity to collect data in the precombination processes. However, researchers are rarely given access in this period due to secrecy. The emphasis in this study was to focus on the postcombination process. As such, the precombination events were classified as contextual factors. This implied that it was most important to collect real-time data after the parties had been given government approval to merge or acquire. What would have been desirable was to gain access earlier in the postcombination process. This was not possible because access had to be negotiated. Due to the change of CEO in the middle of the merger process and the need for renegotiating access, this took longer than expected.

Regarding the second case, I was restricted by the time frame of the study. In essence, I had to choose between entering the combination process as soon as governmental approval was given, or entering the organization at a later stage. In light of the previous studies in the field that have failed to go beyond the initial two years, and given the need to collect data about the cultural integration process, I chose the latter strategy. And I decided to enter the organizations at two distinct periods of time rather than on a continuous basis.

There were several reasons for this approach, some methodological and some practical. First, data collection on a continuous basis would have required use of extensive observation that I didn’t have access to, and getting access to two data collections in DnB was difficult in itself. Second, I had a stay abroad between the first and second data collection in Gjensidige. Collecting data on a continuous basis would probably have allowed for better mapping of the ongoing integration process, but the contrasts between the two different stages in the integration process that I wanted to elaborate would probably be more difficult to detect. In Table 1 I have listed the periods of time in which I collected data in the two combinations.

Sampling Business Areas, Divisions, and Sites

Even when the cases for a study have been chosen, it is often necessary to make further choices within each case to make the cases researchable. The most important criteria that set the boundaries for the study are importance or criticality, relevance, and representativeness. At the time of the data collection, my criteria for making these decisions were not as conscious as they may appear here. Rather, being restricted by time and my own capacity as a researcher, I had to limit the sites and act instinctively. In both cases, I decided to concentrate on the core businesses (criticality criterion) and left out the business units that were only mildly affected by the integration process (relevance criterion). In the choice of regional offices, I used the representativeness criterion as the number of offices widely exceeded the number of sites possible to study. In making these choices, I relied on key informants in the organizations.

SELECTION OF DATA COLLECTION PROCEDURES

The choice of data collection procedures should be guided by the research question and the choice of design. The case study approach typically combines data collection methods such as archives, interviews, questionnaires, and observations (Yin 1989). This triangulated methodology provides stronger substantiation of constructs and hypotheses. However, the choice of data collection methods is also subject to constraints in time, financial resources, and access.

I chose a combination of interviews, archives, and observation, with main emphasis on the first two. Conducting a survey was inappropriate due to the lack of established concepts and indicators. The reason for limited observation, on the other hand, was due to problems in obtaining access early in the study and time and resource constraints. In addition to choosing among several different data collection methods, there are a number of choices to be made for each individual method.

When relying on interviews as the primary data collection method, the issue of building trust between the researcher and the interviewees becomes very important. I addressed this issue by several means. First, I established a procedure of how to approach the interviewees. In most cases, I called them first, then sent out a letter explaining the key features of the project and outlining the broad issues to be addressed in the interview. In this letter, the support from the institution’s top management was also communicated. In most cases, the top management’s support of the project was an important prerequisite for the respondent’s input. Some interviewees did, however, fear that their input would be open to the top management without disguising the information source. Hence, it became important to communicate how I intended to use and store the information.

To establish trust, I also actively used my preunderstanding of the context in the first case and the phenomenon in the second case. As I built up an understanding of the cases, I used this information to gain confidence. The active use of my preunderstanding did, however, pose important challenges in not revealing too much of the research hypotheses and in balancing between asking open-ended questions and appearing knowledgeable.

There are two choices involved in conducting interviews. The first concerns the sampling of interviewees. The second is that you must decide on issues such as the structure of the interviews, use of tape recorder, and involvement of other researchers.

Sampling Interviewees

Following the desire for detailed knowledge of each case and for grasping different participant’s views the aim was, in line with Pettigrew (1990), to apply a pluralist view by describing and analyzing competing versions of reality as seen by actors in the combination processes.

I used four criteria for sampling informants. First, I drew informants from populations representing multiple perspectives. The first data collection in DnB was primarily focused on the top management level. Moreover, most middle managers in the first data collection were employed at the head offices, either in Bergen or Oslo. In the second data collection, I compensated for this skew by including eight local middle managers in the sample. The difference between the number of employees interviewed in DnB and Gjensidige was primarily due to the fact that Gjensidige has three unions, whereas DnB only has one. The distribution of interviewees is outlined in Table 2 .

The second criterion was to use multiple informants. According to Glick et al. (1990), an important advantage of using multiple informants is that the validity of information provided by one informant can be checked against that provided by other informants. Moreover, the validity of the data used by the researcher can be enhanced by resolving the discrepancies among different informants’ reports. Hence, I selected multiple respondents from each perspective.

Third, I focused on key informants who were expected to be knowledgeable about the combination process. These people included top management members, managers, and employees involved in the integration project. To validate the information from these informants, I also used a fourth criterion by selecting managers and employees who had been affected by the process but who were not involved in the project groups.

Structured versus unstructured. In line with the explorative nature of the study, the goal of the interviews was to see the research topic from the perspective of the interviewee, and to understand why he or she came to have this particular perspective. To meet this goal, King (1994:15) recommends that one have “a low degree of structure imposed on the interviewer, a preponderance of open questions, a focus on specific situations and action sequences in the world of the interviewee rather than abstractions and general opinions.” In line with these recommendations, the collection of primary data in this study consists of unstructured interviews.

Using tape recorders and involving other researchers. The majority of the interviews were tape-recorded, and I could thus concentrate fully on asking questions and responding to the interviewees’ answers. In the few interviews that were not tape-recorded, most of which were conducted in the first phase of the DnB-study, two researchers were present. This was useful as we were both able to discuss the interviews later and had feedback on the role of an interviewer.

In hindsight, however, I wish that these interviews had been tape-recorded to maintain the level of accuracy and richness of data. Hence, in the next phases of data collection, I tape-recorded all interviews, with two exceptions (people who strongly opposed the use of this device). All interviews that were tape-recorded were transcribed by me in full, which gave me closeness and a good grasp of the data.

When organizations merge or make acquisitions, there are often a vast number of documents to choose from to build up an understanding of what has happened and to use in the analyses. Furthermore, when firms make acquisitions or merge, they often hire external consultants, each of whom produces more documents. Due to time constraints, it is seldom possible to collect and analyze all these documents, and thus the researcher has to make a selection.

The choice of documentation was guided by my previous experience with merger and acquisition processes and the research question. Hence, obtaining information on the postintegration process was more important than gaining access to the due-diligence analysis. As I learned about the process, I obtained more documents on specific issues. I did not, however, gain access to all the documents I asked for, and, in some cases, documents had been lost or shredded.

The documents were helpful in a number of ways. First, and most important, they were used as inputs to the interview guide and saved me time, because I did not have to ask for facts in the interviews. They were also useful for tracing the history of the organizations and statements made by key people in the organizations. Third, the documents were helpful in counteracting the biases of the interviews. A list of the documents used in writing the cases is shown in Table 3 .

Observation

The major strength of direct observation is that it is unobtrusive and does not require direct interaction with participants (Adler and Adler 1994). Observation produces rigor when it is combined with other methods. When the researcher has access to group processes, direct observation can illuminate the discrepancies between what people said in the interviews and casual conversations and what they actually do (Pettigrew 1990).

As with interviews, there are a number of choices involved in conducting observations. Although I did some observations in the study, I used interviews as the key data collection source. Discussion in this article about observations will thus be somewhat limited. Nevertheless, I faced a number of choices in conducting observations, including type of observation, when to enter, how much observation to conduct, and which groups to observe.

The are four ways in which an observer may gather data: (1) the complete participant who operates covertly, concealing any intention to observe the setting; (2) the participant-as-observer, who forms relationships and participates in activities, but makes no secret of his or her intentions to observe events; (3) the observer-as-participant, who maintains only superficial contact with the people being studied; and (4) the complete observer, who merely stands back and eavesdrops on the proceedings (Waddington 1994).

In this study, I used the second and third ways of observing. The use of the participant-as-observer mode, on which much ethnographic research is based, was rather limited in the study. There were two reasons for this. First, I had limited time available for collecting data, and in my view interviews made more effective use of this limited time than extensive participant observation. Second, people were rather reluctant to let me observe these political and sensitive processes until they knew me better and felt I could be trusted. Indeed, I was dependent on starting the data collection before having built sufficient trust to observe key groups in the integration process. Nevertheless, Gjensidige allowed me to study two employee seminars to acquaint me with the organization. Here I admitted my role as an observer but participated fully in the activities. To achieve variation, I chose two seminars representing polar groups of employees.

As observer-as-participant, I attended a top management meeting at the end of the first data collection in Gjensidige and observed the respondents during interviews and in more informal meetings, such as lunches. All these observations gave me an opportunity to validate the data from the interviews. Observing the top management group was by far the most interesting and rewarding in terms of input.

Both DnB and Gjensidige started to open up for more extensive observation when I was about to finish the data collection. By then, I had built up the trust needed to undertake this approach. Unfortunately, this came a little late for me to take advantage of it.

DATA ANALYSIS

Published studies generally describe research sites and data-collection methods, but give little space to discuss the analysis (Eisenhardt 1989). Thus, one cannot follow how a researcher arrives at the final conclusions from a large volume of field notes (Miles and Huberman 1994).

In this study, I went through the stages by which the data were reduced and analyzed. This involved establishing the chronology, coding, writing up the data according to phases and themes, introducing organizational integration into the analysis, comparing the cases, and applying the theory. I will discuss these phases accordingly.

The first step in the analysis was to establish the chronology of the cases. To do this, I used internal and external documents. I wrote the chronologies up and included appendices in the final report.

The next step was to code the data into phases and themes reflecting the contextual factors and features of integration. For the interviews, this implied marking the text with a specific phase and a theme, and grouping the paragraphs on the same theme and phase together. I followed the same procedure in organizing the documents.

I then wrote up the cases using phases and themes to structure them. Before starting to write up the cases, I scanned the information on each theme, built up the facts and filled in with perceptions and reactions that were illustrative and representative of the data.

The documents were primarily useful in establishing the facts, but they also provided me with some perceptions and reactions that were validated in the interviews. The documents used included internal letters and newsletters as well as articles from the press. The interviews were less factual, as intended, and gave me input to assess perceptions and reactions. The limited observation was useful to validate the data from the interviews. The result of this step was two descriptive cases.

To make each case more analytical, I introduced the three dimensions of organizational integration—integration of tasks, unification of power, and cultural integration—into the analysis. This helped to focus the case and to develop a framework that could be used to compare the cases. The cases were thus structured according to phases, organizational integration, and themes reflecting the factors and features in the study.

I took all these steps to become more familiar with each case as an individual entity. According to Eisenhardt (1989:540), this is a process that “allows the unique patterns of each case to emerge before the investigators push to generalise patterns across cases. In addition it gives investigators a rich familiarity with each case which, in turn, accelerates cross-case comparison.”

The comparison between the cases constituted the next step in the analysis. Here, I used the categories from the case chapters, filled in the features and factors, and compared and contrasted the findings. The idea behind cross-case searching tactics is to force investigators to go beyond initial impressions, especially through the use of structural and diverse lenses on the data. These tactics improve the likelihood of accurate and reliable theory, that is, theory with a close fit to the data (Eisenhardt 1989).

As a result, I had a number of overall themes, concepts, and relationships that had emerged from the within-case analysis and cross-case comparisons. The next step was to compare these emergent findings with theory from the organizational field of mergers and acquisitions, as well as other relevant perspectives.

This method of generalization is known as analytical generalization. In this approach, a previously developed theory is used as a template with which to compare the empirical results of the case study (Yin 1989). This comparison of emergent concepts, theory, or hypotheses with the extant literature involves asking what it is similar to, what it contradicts, and why. The key to this process is to consider a broad range of theory (Eisenhardt 1989). On the whole, linking emergent theory to existent literature enhances the internal validity, generalizability, and theoretical level of theory-building from case research.

According to Eisenhardt (1989), examining literature that conflicts with the emergent literature is important for two reasons. First, the chance of neglecting conflicting findings is reduced. Second, “conflicting results forces researchers into a more creative, frame-breaking mode of thinking than they might otherwise be able to achieve” (p. 544). Similarly, Eisenhardt (1989) claims that literature discussing similar findings is important because it ties together underlying similarities in phenomena not normally associated with each other. The result is often a theory with a stronger internal validity, wider generalizability, and a higher conceptual level.

The analytical generalization in the study included exploring and developing the concepts and examining the relationships between the constructs. In carrying out this analytical generalization, I acted on Eisenhardt’s (1989) recommendation to use a broad range of theory. First, I compared and contrasted the findings with the organizational stream on mergers and acquisition literature. Then I discussed other relevant literatures, including strategic change, power and politics, social justice, and social identity theory to explore how these perspectives could contribute to the understanding of the findings. Finally, I discussed the findings that could not be explained either by the merger and acquisition literature or the four theoretical perspectives.

In every scientific study, questions are raised about whether the study is valid and reliable. The issues of validity and reliability in case studies are just as important as for more deductive designs, but the application is fundamentally different.

VALIDITY AND RELIABILITY

The problems of validity in qualitative studies are related to the fact that most qualitative researchers work alone in the field, they focus on the findings rather than describe how the results were reached, and they are limited in processing information (Miles and Huberman 1994).

Researchers writing about qualitative methods have questioned whether the same criteria can be used for qualitative and quantitative studies (Kirk & Miller 1986; Sykes 1990; Maxwell 1992). The problem with the validity criteria suggested in qualitative research is that there is little consistency across the articles as each author suggests a new set of criteria.

One approach in examining validity and reliability is to apply the criteria used in quantitative research. Hence, the criteria to be examined here are objectivity/intersubjectivity, construct validity, internal validity, external validity, and reliability.

Objectivity/Intersubjectivity

The basic issue of objectivity can be framed as one of relative neutrality and reasonable freedom from unacknowledged research biases (Miles & Huberman 1994). In a real-time longitudinal study, the researcher is in danger of losing objectivity and of becoming too involved with the organization, the people, and the process. Hence, Leonard-Barton (1990) claims that one may be perceived as, and may even become, an advocate rather than an observer.

According to King (1994), however, qualitative research, in seeking to describe and make sense of the world, does not require researchers to strive for objectivity and distance themselves from research participants. Indeed, to do so would make good qualitative research impossible, as the interviewer’s sensitivity to subjective aspects of his or her relationship with the interviewee is an essential part of the research process (King 1994:31).

This does not imply, however, that the issue of possible research bias can be ignored. It is just as important as in a structured quantitative interview that the findings are not simply the product of the researcher’s prejudices and prior experience. One way to guard against this bias is for the researcher to explicitly recognize his or her presuppositions and to make a conscious effort to set these aside in the analysis (Gummesson 1988). Furthermore, rival conclusions should be considered (Miles & Huberman 1994).

My experience from the first phase of the DnB study was that it was difficult to focus the questions and the analysis of the data when the research questions were too vague and broad. As such, developing a framework before collecting the data for the study was useful in guiding the collection and analysis of data. Nevertheless, it was important to be open-minded and receptive to new and surprising data. In the DnB study, for example, the positive effect of the reorganization process on the integration of cultures came as a complete surprise to me and thus needed further elaboration.

I also consciously searched for negative evidence and problems by interviewing outliers (Miles & Huberman 1994) and asking problem-oriented questions. In Gjensidige, the first interviews with the top management revealed a much more positive perception of the cultural integration process than I had expected. To explore whether this was a result of overreliance on elite informants, I continued posing problem-oriented questions to outliers and people at lower levels in the organization. Moreover, I told them about the DnB study to be explicit about my presuppositions.

Another important issue when assessing objectivity is whether other researchers can trace the interpretations made in the case studies, or what is called intersubjectivity. To deal with this issue, Miles & Huberman (1994) suggest that: (1) the study’s general methods and procedures should be described in detail, (2) one should be able to follow the process of analysis, (3) conclusions should be explicitly linked with exhibits of displayed data, and (4) the data from the study should be made available for reanalysis by others.

In response to these requirements, I described the study’s data collection procedures and processing in detail. Then, the primary data were displayed in the written report in the form of quotations and extracts from documents to support and illustrate the interpretations of the data. Because the study was written up in English, I included the Norwegian text in a separate appendix. Finally, all the primary data from the study were accessible for a small group of distinguished researchers.

Construct Validity

Construct validity refers to whether there is substantial evidence that the theoretical paradigm correctly corresponds to observation (Kirk & Miller 1986). In this form of validity, the issue is the legitimacy of the application of a given concept or theory to established facts.

The strength of qualitative research lies in the flexible and responsive interaction between the interviewer and the respondents (Sykes 1990). Thus, meaning can be probed, topics covered easily from a number of angles, and questions made clear for respondents. This is an advantage for exploring the concepts (construct or theoretical validity) and the relationships between them (internal validity). Similarly, Hakim (1987) says the great strength of qualitative research is the validity of data obtained because individuals are interviewed in sufficient detail for the results to be taken as true, correct, and believable reports of their views and experiences.

Construct validity can be strengthened by applying a longitudinal multicase approach, triangulation, and use of feedback loops. The advantage of applying a longitudinal approach is that one gets the opportunity to test sensitivity of construct measures to the passage of time. Leonard-Barton (1990), for example, found that one of her main constructs, communicability, varied across time and relative to different groups of users. Thus, the longitudinal study aided in defining the construct more precisely. By using more than one case study, one can validate stability of construct across situations (Leonard-Barton 1990). Since my study only consists of two case studies, the opportunity to test stability of constructs across cases is somewhat limited. However, the use of more than one unit of analysis helps to overcome this limitation.

Construct validity is strengthened by the use of multiple sources of evidence to build construct measures, which define the construct and distinguish it from other constructs. These multiple sources of evidence can include multiple viewpoints within and across the data sources. My study responds to these requirements in its sampling of interviewees and uses of multiple data sources.

Use of feedback loops implies returning to interviewees with interpretations and developing theory and actively seeking contradictions in data (Crabtree & Miller 1992; King 1994). In DnB, the written report had to be approved by the bank’s top management after the first data collection. Apart from one minor correction, the bank had no objections to the established facts. In their comments on my analysis, some of the top managers expressed the view that the political process had been overemphasized, and that the CEO’s role in initiating a strategic process was undervalued. Hence, an important objective in the second data collection was to explore these comments further. Moreover, the report was not as positive as the management had hoped for, and negotiations had to be conducted to publish the report. The result of these negotiations was that publication of the report was postponed one-and-a-half years.

The experiences from the first data collection in the DnB had some consequences. I was more cautious and brought up the problems of confidentiality and the need to publish at the outset of the Gjensidige study. Also, I had to struggle to get access to the DnB case for the second data collection and some of the information I asked for was not released. At Gjensidige, I sent a preliminary draft of the case chapter to the corporation’s top management for comments, in addition to having second interviews with a small number of people. Beside testing out the factual description, these sessions gave me the opportunity to test out the theoretical categories established as a result of the within-case analysis.

Internal Validity

Internal validity concerns the validity of the postulated relationships among the concepts. The main problem of internal validity as a criterion in qualitative research is that it is often not open to scrutiny. According to Sykes (1990), the researcher can always provide a plausible account and, with careful editing, may ensure its coherence. Recognition of this problem has led to calls for better documentation of the processes of data collection, the data itself, and the interpretative contribution of the researcher. The discussion of how I met these requirements was outlined in the section on objectivity/subjectivity above.

However, there are some advantages in using qualitative methods, too. First, the flexible and responsive methods of data collection allow cross-checking and amplification of information from individual units as it is generated. Respondents’ opinions and understandings can be thoroughly explored. The internal validity results from strategies that eliminate ambiguity and contradiction, filling in detail and establishing strong connections in data.

Second, the longitudinal study enables one to track cause and effect. Moreover, it can make one aware of intervening variables (Leonard-Barton 1990). Eisenhardt (1989:542) states, “Just as hypothesis testing research an apparent relationship may simply be a spurious correlation or may reflect the impact of some third variable on each of the other two. Therefore, it is important to discover the underlying reasons for why the relationship exists.”

Generalizability

According to Mitchell (1983), case studies are not based on statistical inference. Quite the contrary, the inferring process turns exclusively on the theoretically necessary links among the features in the case study. The validity of the extrapolation depends not on the typicality or representativeness of the case but on the cogency of the theoretical reasoning. Hartley (1994:225) claims, “The detailed knowledge of the organization and especially the knowledge about the processes underlying the behaviour and its context can help to specify the conditions under which behaviour can be expected to occur. In other words, the generalisation is about theoretical propositions not about populations.”

Generalizability is normally based on the assumption that this theory may be useful in making sense of similar persons or situations (Maxwell 1992). One way to increase the generalizability is to apply a multicase approach (Leonard-Barton 1990). The advantage of this approach is that one can replicate the findings from one case study to another. This replication logic is similar to that used on multiple experiments (Yin 1993).

Given the choice of two case studies, the generalizability criterion is not supported in this study. Through the discussion of my choices, I have tried to show that I had to strike a balance between the need for depth and mapping changes over time and the number of cases. In doing so, I deliberately chose to provide a deeper and richer look at each case, allowing the reader to make judgments about the applicability rather than making a case for generalizability.

Reliability

Reliability focuses on whether the process of the study is consistent and reasonably stable over time and across researchers and methods (Miles & Huberman 1994). In the context of qualitative research, reliability is concerned with two questions (Sykes 1990): Could the same study carried out by two researchers produce the same findings? and Could a study be repeated using the same researcher and respondents to yield the same findings?

The problem of reliability in qualitative research is that differences between replicated studies using different researchers are to be expected. However, while it may not be surprising that different researchers generate different findings and reach different conclusions, controlling for reliability may still be relevant. Kirk and Miller’s (1986:311) definition takes into account the particular relationship between the researcher’s orientation, the generation of data, and its interpretation:

For reliability to be calculated, it is incumbent on the scientific investigator to document his or her procedure. This must be accomplished at such a level of abstraction that the loci of decisions internal to the project are made apparent. The curious public deserves to know how the qualitative researcher prepares him or herself for the endeavour, and how the data is collected and analysed.

The study addresses these requirements by discussing my point of departure regarding experience and framework, the sampling and data collection procedures, and data analysis.

Case studies often lack academic rigor and are, as such, regarded as inferior to more rigorous methods where there are more specific guidelines for collecting and analyzing data. These criticisms stress that there is a need to be very explicit about the choices one makes and the need to justify them.

One reason why case studies are criticized may be that researchers disagree about the definition and the purpose of carrying out case studies. Case studies have been regarded as a design (Cook and Campbell 1979), as a qualitative methodology (Cassell and Symon 1994), as a particular data collection procedure (Andersen 1997), and as a research strategy (Yin 1989). Furthermore, the purpose for carrying out case studies is unclear. Some regard case studies as supplements to more rigorous qualitative studies to be carried out in the early stage of the research process; others claim that it can be used for multiple purposes and as a research strategy in its own right (Gummesson 1988; Yin 1989). Given this unclear status, researchers need to be very clear about their interpretation of the case study and the purpose of carrying out the study.

This article has taken Yin’s (1989) definition of the case study as a research strategy as a starting point and argued that the choice of the case study should be guided by the research question(s). In the illustrative study, I used a case study strategy because of a need to explore sensitive, ill-defined concepts in depth, over time, taking into account the context and history of the mergers and the existing knowledge about the phenomenon. However, the choice of a case study strategy extended rather than limited the number of decisions to be made. In Schramm’s (1971, cited in Yin 1989:22–23) words, “The essence of a case study, the central tendency among all types of case study, is that it tries to illuminate a decision or set of decisions, why they were taken, how they were implemented, and with what result.”

Hence, the purpose of this article has been to illustrate the wide range of decisions that need to be made in the context of a particular case study and to discuss the methodological considerations linked to these decisions. I argue that there is a particular need in case studies to be explicit about the methodological choices one makes and that these choices can be best illustrated through a case study of the case study strategy.

As in all case studies, however, there are limitations to the generalizability of using one particular case study for illustrative purposes. As such, the strength of linking the methodological considerations to a specific context and phenomenon also becomes a weakness. However, I would argue that the questions raised in this article are applicable to many case studies, but that the answers are very likely to vary. The design choices are shown in Table 4 . Hence, researchers choosing a longitudinal, comparative case study need to address the same set of questions with regard to design, data collection procedures, and analysis, but they are likely to come up with other conclusions, given their different research questions.

Adler, P. A., and P. Adler. 1994. Observational techniques. In Handbook of qualitative research, edited by N. K. Denzin and Y. S. Lincoln, 377–92. London: Sage.

Andersen, S. S. 1997. Case-studier og generalisering: Forskningsstrategi og design (Case studies and generalization: Research strategy and design). Bergen, Norway: Fagbokforlaget.

Blake, R. R., and J. S. Mounton. 1985. How to achieve integration on the human side of the merger. Organizational Dynamics 13 (3): 41–56.

Bryman, A., and R. G. Burgess. 1999. Qualitative research. London: Sage.

Buono, A. F., and J. L. Bowditch. 1989. The human side of mergers and acquisitions. San Francisco: Jossey-Bass.

Cartwright, S., and C. L. Cooper. 1993. The psychological impact of mergers and acquisitions on the individual: A study of building society managers. Human Relations 46 (3): 327–47.

Cassell, C., and G. Symon, eds. 1994. Qualitative methods in organizational research: A practical guide. London: Sage.

Cook, T. D., and D. T. Campbell. 1979. Quasi experimentation: Design & analysis issues for field settings. Boston: Houghton Mifflin.

Crabtree, B. F., and W. L. Miller. 1992. Primary care research: A multimethod typology and qualitative road map. In Doing qualitative research: Methods for primary care, edited by B. F. Crabtree and W. L. Miller, 3–28. Vol. 3. Thousand Oaks, CA: Sage.

Creswell, J. W. 1998. Qualitative inquiry and research design: Choosing among five traditions. Thousand Oaks, CA: Sage.

Denzin, N. K., and L. S. Lincoln. 2000. Handbook of qualitative research. London: Sage.

Eisenhardt, K. M. 1989. Building theories from case study research. Academy of Management Review 14 (4): 532–50.

Flick, U. 1998. An introduction to qualitative research. London: Sage.

George, A. L. 1979. Case studies and theory development: The method of structured, focused comparison. In Diplomacy: New approaches in history, theory, and policy, edited by P. G. Lauren, 43–68. New York: Free Press.

Gioia, D. A., and K. Chittipeddi. 1991. Sensemaking and sensegiving in strategic change initiation. Strategic Management Journal 12:433–48.

Glaser, B. G., and A. L. Strauss. 1967. The discovery of grounded theory: Strategies for qualitative research. Chicago: Aldine.

Glick, W. H, G. P. Huber, C. C. Miller, D. H. Doty, and K. M. Sutcliffe. 1990. Studying changes in organizational design and effectiveness: Retrospective event histories and periodic assessments. Organization Science 1 (3): 293–312.

Gummesson, E. 1988. Qualitative methods in management research. Lund, Norway: Studentlitteratur, Chartwell-Bratt.

Hakim, C. 1987. Research design. Strategies and choices in the design of social research. Boston: Unwin Hyman.

Hamel, J., S. Dufour, and D. Fortin. 1993. Case study methods. London: Sage.

Hartley, J. F. 1994. Case studies in organizational research. In Qualitative methods in organizational research: A practical guide, edited by C. Cassell and G. Symon, 209–29. London: Sage.

Haspeslaph, P., and D. B. Jemison. 1991. The challenge of renewal through acquisitions. Planning Review 19 (2): 27–32.

King, N. 1994. The qualitative research interview. In Qualitative methods in organizational research: A practical guide, edited by C. Cassell and G. Symon, 14–36. London: Sage.

Kirk, J., and M. L. Miller. 1986. Reliability and validity in qualitative research. Qualitative Research Methods Series 1. London: Sage.

Leonard-Barton, D. 1990.Adual methodology for case studies: Synergistic use of a longitudinal single site with replicated multiple sites. Organization Science 1 (3): 248–66.

Marshall, C., and G. B. Rossman. 1999. Designing qualitative research. London: Sage.

Maxwell, J. A. 1992. Understanding and validity in qualitative research. Harvard Educational Review 62 (3): 279–99.

Miles, M. B., and A. M. Huberman. 1994. Qualitative data analysis. 2d ed. London: Sage.

Mitchell, J. C. 1983. Case and situation analysis. Sociology Review 51 (2): 187–211.

Nachmias, C., and D. Nachmias. 1981. Research methods in the social sciences. London: Edward Arnhold.

Pettigrew, A. M. 1990. Longitudinal field research on change: Theory and practice. Organization Science 1 (3): 267–92.

___. (1992). The character and significance of strategic process research. Strategic Management Journal 13:5–16.

Rossman, G. B., and S. F. Rallis. 1998. Learning in the field: An introduction to qualitative research. Thousand Oaks, CA: Sage.

Schramm, W. 1971. Notes on case studies for instructional media projects. Working paper for Academy of Educational Development, Washington DC.

Schweiger, D. M., and J. P. Walsh. 1990. Mergers and acquisitions: An interdisciplinary view. In Research in personnel and human resource management, edited by G. R. Ferris and K. M. Rowland, 41–107. Greenwich, CT: JAI.

Silverman, D. 2000. Doing qualitative research: A practical handbook. London: Sage.

Stake, R. E. 1995. The art of case study research. London: Sage.

Strauss, A. L., and J. Corbin. 1990. Basics of qualitative research: Grounded theory procedures and techniques. Newbury Park, CA: Sage.

Sykes, W. 1990. Validity and reliability in qualitative market research: A review of the literature. Journal of the Market Research Society 32 (3): 289–328.

Waddington, D. 1994. Participant observation. In Qualitative methods in organizational research, edited by C. Cassell and G. Symon, 107–22. London: Sage.

Yin, R. K. 1989. Case study research: Design and methods. Applied Social Research Series, Vol. 5. London: Sage.

___. 1993. Applications of case study research. Applied Social Research Series, Vol. 34. London: Sage.

Christine Benedichte Meyer is an associate professor in the Department of Strategy and Management in the Norwegian School of Economics and Business Administration, Bergen-Sandviken, Norway. Her research interests are mergers and acquisitions, strategic change, and qualitative research. Recent publications include: “Allocation Processes in Mergers and Acquisitions: An Organisational Justice Perspective” (British Journal of Management 2001) and “Motives for Acquisitions in the Norwegian Financial Industry” (CEMS Business Review 1997).

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Home » Case Study – Methods, Examples and Guide

Case Study – Methods, Examples and Guide

Table of Contents

A case study is a research method that involves an in-depth examination and analysis of a particular phenomenon or case, such as an individual, organization, community, event, or situation.

It is a qualitative research approach that aims to provide a detailed and comprehensive understanding of the case being studied. Case studies typically involve multiple sources of data, including interviews, observations, documents, and artifacts, which are analyzed using various techniques, such as content analysis, thematic analysis, and grounded theory. The findings of a case study are often used to develop theories, inform policy or practice, or generate new research questions.

Types of Case Study

Types and Methods of Case Study are as follows:

Single-Case Study

A single-case study is an in-depth analysis of a single case. This type of case study is useful when the researcher wants to understand a specific phenomenon in detail.

For Example , A researcher might conduct a single-case study on a particular individual to understand their experiences with a particular health condition or a specific organization to explore their management practices. The researcher collects data from multiple sources, such as interviews, observations, and documents, and uses various techniques to analyze the data, such as content analysis or thematic analysis. The findings of a single-case study are often used to generate new research questions, develop theories, or inform policy or practice.

Multiple-Case Study

A multiple-case study involves the analysis of several cases that are similar in nature. This type of case study is useful when the researcher wants to identify similarities and differences between the cases.

For Example, a researcher might conduct a multiple-case study on several companies to explore the factors that contribute to their success or failure. The researcher collects data from each case, compares and contrasts the findings, and uses various techniques to analyze the data, such as comparative analysis or pattern-matching. The findings of a multiple-case study can be used to develop theories, inform policy or practice, or generate new research questions.

Exploratory Case Study

An exploratory case study is used to explore a new or understudied phenomenon. This type of case study is useful when the researcher wants to generate hypotheses or theories about the phenomenon.

For Example, a researcher might conduct an exploratory case study on a new technology to understand its potential impact on society. The researcher collects data from multiple sources, such as interviews, observations, and documents, and uses various techniques to analyze the data, such as grounded theory or content analysis. The findings of an exploratory case study can be used to generate new research questions, develop theories, or inform policy or practice.

Descriptive Case Study

A descriptive case study is used to describe a particular phenomenon in detail. This type of case study is useful when the researcher wants to provide a comprehensive account of the phenomenon.

For Example, a researcher might conduct a descriptive case study on a particular community to understand its social and economic characteristics. The researcher collects data from multiple sources, such as interviews, observations, and documents, and uses various techniques to analyze the data, such as content analysis or thematic analysis. The findings of a descriptive case study can be used to inform policy or practice or generate new research questions.

Instrumental Case Study

An instrumental case study is used to understand a particular phenomenon that is instrumental in achieving a particular goal. This type of case study is useful when the researcher wants to understand the role of the phenomenon in achieving the goal.

For Example, a researcher might conduct an instrumental case study on a particular policy to understand its impact on achieving a particular goal, such as reducing poverty. The researcher collects data from multiple sources, such as interviews, observations, and documents, and uses various techniques to analyze the data, such as content analysis or thematic analysis. The findings of an instrumental case study can be used to inform policy or practice or generate new research questions.

Case Study Data Collection Methods

Here are some common data collection methods for case studies:

Interviews involve asking questions to individuals who have knowledge or experience relevant to the case study. Interviews can be structured (where the same questions are asked to all participants) or unstructured (where the interviewer follows up on the responses with further questions). Interviews can be conducted in person, over the phone, or through video conferencing.

Observations

Observations involve watching and recording the behavior and activities of individuals or groups relevant to the case study. Observations can be participant (where the researcher actively participates in the activities) or non-participant (where the researcher observes from a distance). Observations can be recorded using notes, audio or video recordings, or photographs.

Documents can be used as a source of information for case studies. Documents can include reports, memos, emails, letters, and other written materials related to the case study. Documents can be collected from the case study participants or from public sources.

Surveys involve asking a set of questions to a sample of individuals relevant to the case study. Surveys can be administered in person, over the phone, through mail or email, or online. Surveys can be used to gather information on attitudes, opinions, or behaviors related to the case study.

Artifacts are physical objects relevant to the case study. Artifacts can include tools, equipment, products, or other objects that provide insights into the case study phenomenon.

How to conduct Case Study Research

Conducting a case study research involves several steps that need to be followed to ensure the quality and rigor of the study. Here are the steps to conduct case study research:

• Define the research questions: The first step in conducting a case study research is to define the research questions. The research questions should be specific, measurable, and relevant to the case study phenomenon under investigation.
• Select the case: The next step is to select the case or cases to be studied. The case should be relevant to the research questions and should provide rich and diverse data that can be used to answer the research questions.
• Collect data: Data can be collected using various methods, such as interviews, observations, documents, surveys, and artifacts. The data collection method should be selected based on the research questions and the nature of the case study phenomenon.
• Analyze the data: The data collected from the case study should be analyzed using various techniques, such as content analysis, thematic analysis, or grounded theory. The analysis should be guided by the research questions and should aim to provide insights and conclusions relevant to the research questions.
• Draw conclusions: The conclusions drawn from the case study should be based on the data analysis and should be relevant to the research questions. The conclusions should be supported by evidence and should be clearly stated.
• Validate the findings: The findings of the case study should be validated by reviewing the data and the analysis with participants or other experts in the field. This helps to ensure the validity and reliability of the findings.
• Write the report: The final step is to write the report of the case study research. The report should provide a clear description of the case study phenomenon, the research questions, the data collection methods, the data analysis, the findings, and the conclusions. The report should be written in a clear and concise manner and should follow the guidelines for academic writing.

Examples of Case Study

Here are some examples of case study research:

• The Hawthorne Studies : Conducted between 1924 and 1932, the Hawthorne Studies were a series of case studies conducted by Elton Mayo and his colleagues to examine the impact of work environment on employee productivity. The studies were conducted at the Hawthorne Works plant of the Western Electric Company in Chicago and included interviews, observations, and experiments.
• The Stanford Prison Experiment: Conducted in 1971, the Stanford Prison Experiment was a case study conducted by Philip Zimbardo to examine the psychological effects of power and authority. The study involved simulating a prison environment and assigning participants to the role of guards or prisoners. The study was controversial due to the ethical issues it raised.
• The Challenger Disaster: The Challenger Disaster was a case study conducted to examine the causes of the Space Shuttle Challenger explosion in 1986. The study included interviews, observations, and analysis of data to identify the technical, organizational, and cultural factors that contributed to the disaster.
• The Enron Scandal: The Enron Scandal was a case study conducted to examine the causes of the Enron Corporation’s bankruptcy in 2001. The study included interviews, analysis of financial data, and review of documents to identify the accounting practices, corporate culture, and ethical issues that led to the company’s downfall.
• The Fukushima Nuclear Disaster : The Fukushima Nuclear Disaster was a case study conducted to examine the causes of the nuclear accident that occurred at the Fukushima Daiichi Nuclear Power Plant in Japan in 2011. The study included interviews, analysis of data, and review of documents to identify the technical, organizational, and cultural factors that contributed to the disaster.

Application of Case Study

Case studies have a wide range of applications across various fields and industries. Here are some examples:

Business and Management

Case studies are widely used in business and management to examine real-life situations and develop problem-solving skills. Case studies can help students and professionals to develop a deep understanding of business concepts, theories, and best practices.

Case studies are used in healthcare to examine patient care, treatment options, and outcomes. Case studies can help healthcare professionals to develop critical thinking skills, diagnose complex medical conditions, and develop effective treatment plans.

Case studies are used in education to examine teaching and learning practices. Case studies can help educators to develop effective teaching strategies, evaluate student progress, and identify areas for improvement.

Social Sciences

Case studies are widely used in social sciences to examine human behavior, social phenomena, and cultural practices. Case studies can help researchers to develop theories, test hypotheses, and gain insights into complex social issues.

Law and Ethics

Case studies are used in law and ethics to examine legal and ethical dilemmas. Case studies can help lawyers, policymakers, and ethical professionals to develop critical thinking skills, analyze complex cases, and make informed decisions.

Purpose of Case Study

The purpose of a case study is to provide a detailed analysis of a specific phenomenon, issue, or problem in its real-life context. A case study is a qualitative research method that involves the in-depth exploration and analysis of a particular case, which can be an individual, group, organization, event, or community.

The primary purpose of a case study is to generate a comprehensive and nuanced understanding of the case, including its history, context, and dynamics. Case studies can help researchers to identify and examine the underlying factors, processes, and mechanisms that contribute to the case and its outcomes. This can help to develop a more accurate and detailed understanding of the case, which can inform future research, practice, or policy.

Case studies can also serve other purposes, including:

• Illustrating a theory or concept: Case studies can be used to illustrate and explain theoretical concepts and frameworks, providing concrete examples of how they can be applied in real-life situations.
• Developing hypotheses: Case studies can help to generate hypotheses about the causal relationships between different factors and outcomes, which can be tested through further research.
• Providing insight into complex issues: Case studies can provide insights into complex and multifaceted issues, which may be difficult to understand through other research methods.
• Informing practice or policy: Case studies can be used to inform practice or policy by identifying best practices, lessons learned, or areas for improvement.

Advantages of Case Study Research

There are several advantages of case study research, including:

• In-depth exploration: Case study research allows for a detailed exploration and analysis of a specific phenomenon, issue, or problem in its real-life context. This can provide a comprehensive understanding of the case and its dynamics, which may not be possible through other research methods.
• Rich data: Case study research can generate rich and detailed data, including qualitative data such as interviews, observations, and documents. This can provide a nuanced understanding of the case and its complexity.
• Holistic perspective: Case study research allows for a holistic perspective of the case, taking into account the various factors, processes, and mechanisms that contribute to the case and its outcomes. This can help to develop a more accurate and comprehensive understanding of the case.
• Theory development: Case study research can help to develop and refine theories and concepts by providing empirical evidence and concrete examples of how they can be applied in real-life situations.
• Practical application: Case study research can inform practice or policy by identifying best practices, lessons learned, or areas for improvement.
• Contextualization: Case study research takes into account the specific context in which the case is situated, which can help to understand how the case is influenced by the social, cultural, and historical factors of its environment.

Limitations of Case Study Research

There are several limitations of case study research, including:

• Limited generalizability : Case studies are typically focused on a single case or a small number of cases, which limits the generalizability of the findings. The unique characteristics of the case may not be applicable to other contexts or populations, which may limit the external validity of the research.
• Biased sampling: Case studies may rely on purposive or convenience sampling, which can introduce bias into the sample selection process. This may limit the representativeness of the sample and the generalizability of the findings.
• Subjectivity: Case studies rely on the interpretation of the researcher, which can introduce subjectivity into the analysis. The researcher’s own biases, assumptions, and perspectives may influence the findings, which may limit the objectivity of the research.
• Limited control: Case studies are typically conducted in naturalistic settings, which limits the control that the researcher has over the environment and the variables being studied. This may limit the ability to establish causal relationships between variables.
• Time-consuming: Case studies can be time-consuming to conduct, as they typically involve a detailed exploration and analysis of a specific case. This may limit the feasibility of conducting multiple case studies or conducting case studies in a timely manner.
• Resource-intensive: Case studies may require significant resources, including time, funding, and expertise. This may limit the ability of researchers to conduct case studies in resource-constrained settings.

About the author

Muhammad Hassan

Researcher, Academic Writer, Web developer

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Prof. Keith S. Taber's site

Intrinsic case studies

A topic in research methodology

A case study is an enquiry into one specific instance among many. Sometimes the case is selected because it is the specific case we wish to know about. There is something special about that case that makes it worth investigating. Such cases are described as intrinsic cases.

"The case is given…we need to learn about that particular case" Stake, 1995: p.3

A case may be intrinsically interesting because it is special and unusual among others – and so we wish to investigate it because of its special nature.

"Sometimes … (intrinsic) cases may be selected because they have been identified as special in some sense, and the researchers want to see if they can find out why: for example why one teacher gets especially impressive learning outcomes." Taber, 2014

Alternatively, a case may be inherently interesting to us (but perhaps less so to our readers), because it the case which relates to our own practice or experience. That is, the case may be inevitable because we are undertaking primarily context-directed research (rather than theory-directed research)

Sources cited:

• Stake, R. E. (1995). The Art of Case Study Research . Thousand Oaks, California: Sage.
• Taber, K. S. (2014). Methodological issues in science education research: a perspective from the philosophy of science. In M. R. Matthews (Ed.), International Handbook of Research in History, Philosophy and Science Teaching (Vol. 3, pp. 1839-1893). Dordrecht: Springer Netherlands."

My introduction to educational research:

Taber, K. S. (2013).  Classroom-based Research and Evidence-based Practice: An introduction (2nd ed.).  London: Sage.

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Types of Case Studies

There are several different types of case studies, as well as several types of subjects of case studies. We will investigate each type in this article.

Different Types of Case Studies

There are several types of case studies, each differing from each other based on the hypothesis and/or thesis to be proved. It is also possible for types of case studies to overlap each other.

Each of the following types of cases can be used in any field or discipline. Whether it is psychology, business or the arts, the type of case study can apply to any field.

Explanatory

The explanatory case study focuses on an explanation for a question or a phenomenon. Basically put, an explanatory case study is 1 + 1 = 2. The results are not up for interpretation.

A case study with a person or group would not be explanatory, as with humans, there will always be variables. There are always small variances that cannot be explained.

However, event case studies can be explanatory. For example, let's say a certain automobile has a series of crashes that are caused by faulty brakes. All of the crashes are a result of brakes not being effective on icy roads.

What kind of case study is explanatory? Think of an example of an explanatory case study that could be done today

When developing the case study, the researcher will explain the crash, and the detailed causes of the brake failure. They will investigate what actions caused the brakes to fail, and what actions could have been taken to prevent the failure.

Other car companies could then use this case study to better understand what makes brakes fail. When designing safer products, looking to past failures is an excellent way to ensure similar mistakes are not made.

The same can be said for other safety issues in cars. There was a time when cars did not have seatbelts. The process to get seatbelts required in all cars started with a case study! The same can be said about airbags and collapsible steering columns. They all began with a case study that lead to larger research, and eventual change.

Exploratory

An exploratory case study is usually the precursor to a formal, large-scale research project. The case study's goal is to prove that further investigation is necessary.

For example, an exploratory case study could be done on veterans coming home from active combat. Researchers are aware that these vets have PTSD, and are aware that the actions of war are what cause PTSD. Beyond that, they do not know if certain wartime activities are more likely to contribute to PTSD than others.

For an exploratory case study, the researcher could develop a study that certain war events are more likely to cause PTSD. Once that is demonstrated, a large-scale research project could be done to determine which events are most likely to cause PTSD.

Exploratory case studies are very popular in psychology and the social sciences. Psychologists are always looking for better ways to treat their patients, and exploratory studies allow them to research new ideas or theories.

Multiple-Case Studies or Collective Studies

Multiple case or collective studies use information from different studies to formulate the case for a new study. The use of past studies allows additional information without needing to spend more time and money on additional studies.

Using the PTSD issue again is an excellent example of a collective study. When studying what contributes most to wartime PTSD, a researcher could use case studies from different war. For instance, studies about PTSD in WW2 vets, Persian Gulf War vets, and Vietnam vets could provide an excellent sampling of which wartime activities are most likely to cause PTSD.

If a multiple case study on vets was done with vets from the Vietnam War, the Persian Gulf War, and the Iraq War, and it was determined the vets from Vietnam had much less PTSD, what could be inferred?

Furthermore, this type of study could uncover differences as well. For example, a researcher might find that veterans who serve in the Middle East are more likely to suffer a certain type of ailment. Or perhaps, that veterans who served with large platoons were more likely to suffer from PTSD than veterans who served in smaller platoons.

An intrinsic case study is the study of a case wherein the subject itself is the primary interest. The "Genie" case is an example of this. The study wasn't so much about psychology, but about Genie herself, and how her experiences shaped who she was.

Genie is the topic. Genie is what the researchers are interested in, and what their readers will be most interested in. When the researchers started the study, they didn't know what they would find.

They asked the question…"If a child is never introduced to language during the crucial first years of life, can they acquire language skills when they are older?" When they met Genie, they didn't know the answer to that question.

Instrumental

An instrumental case study uses a case to gain insights into a phenomenon. For example, a researcher interested in child obesity rates might set up a study with middle school students and an exercise program. In this case, the children and the exercise program are not the focus. The focus is learning the relationship between children and exercise, and why certain children become obese.

What is an example of an instrumental case study?

Focus on the results, not the topic!

Types of Subjects of Case Studies

There are generally five different types of case studies, and the subjects that they address. Every case study, whether explanatory or exploratory, or intrinsic or instrumental, fits into one of these five groups. These are:

Person – This type of study focuses on one particular individual. This case study would use several types of research to determine an outcome.

The best example of a person case is the "Genie" case study. Again, "Genie" was a 13-year-old girl who was discovered by social services in Los Angeles in 1970. Her father believed her to be mentally retarded, and therefore locked her in a room without any kind of stimulation. She was never nourished or cared for in any way. If she made a noise, she was beaten.

When "Genie" was discovered, child development specialists wanted to learn as much as possible about how her experiences contributed to her physical, emotional and mental health. They also wanted to learn about her language skills. She had no form of language when she was found, she only grunted. The study would determine whether or not she could learn language skills at the age of 13.

Since Genie was placed in a children's hospital, many different clinicians could observe her. In addition, researchers were able to interview the few people who did have contact with Genie and would be able to gather whatever background information was available.

This case study is still one of the most valuable in all of child development. Since it would be impossible to conduct this type of research with a healthy child, the information garnered from Genie's case is invaluable.

Group – This type of study focuses on a group of people. This could be a family, a group or friends, or even coworkers.

An example of this type of case study would be the uncontacted tribes of Indians in the Peruvian and Brazilian rainforest. These tribes have never had any modern contact. Therefore, there is a great interest to study them.

Scientists would be interested in just about every facet of their lives. How do they cook, how do they make clothing, how do they make tools and weapons. Also, doing psychological and emotional research would be interesting. However, because so few of these tribes exist, no one is contacting them for research. For now, all research is done observationally.

If a researcher wanted to study uncontacted Indian tribes, and could only observe the subjects, what type of observations should be made?

Location – This type of study focuses on a place, and how and why people use the place.

For example, many case studies have been done about Siberia, and the people who live there. Siberia is a cold and barren place in northern Russia, and it is considered the most difficult place to live in the world. Studying the location, and it's weather and people can help other people learn how to live with extreme weather and isolation.

Location studies can also be done on locations that are facing some kind of change. For example, a case study could be done on Alaska, and whether the state is seeing the effects of climate change.

Another type of study that could be done in Alaska is how the environment changes as population increases. Geographers and those interested in population growth often do these case studies.

Organization/Company – This type of study focuses on a business or an organization. This could include the people who work for the company, or an event that occurred at the organization.

An excellent example of this type of case study is Enron. Enron was one of the largest energy company's in the United States, when it was discovered that executives at the company were fraudulently reporting the company's accounting numbers.

Once the fraud was uncovered, investigators discovered willful and systematic corruption that caused the collapse of Enron, as well as their financial auditors, Arthur Andersen. The fraud was so severe that the top executives of the company were sentenced to prison.

This type of case study is used by accountants, auditors, financiers, as well as business students, in order to learn how such a large company could get away with committing such a serious case of corporate fraud for as long as they did. It can also be looked at from a psychological standpoint, as it is interesting to learn why the executives took the large risks that they took.

Most company or organization case studies are done for business purposes. In fact, in many business schools, such as Harvard Business School, students learn by the case method, which is the study of case studies. They learn how to solve business problems by studying the cases of businesses that either survived the same problem, or one that didn't survive the problem.

Event – This type of study focuses on an event, whether cultural or societal, and how it affects those that are affected by it. An example would be the Tylenol cyanide scandal. This event affected Johnson & Johnson, the parent company, as well as the public at large.

The case study would detail the events of the scandal, and more specifically, what management at Johnson & Johnson did to correct the problem. To this day, when a company experiences a large public relations scandal, they look to the Tylenol case study to learn how they managed to survive the scandal.

A very popular topic for case studies was the events of September 11 th . There were studies in almost all of the different types of research studies.

Obviously the event itself was a very popular topic. It was important to learn what lead up to the event, and how best to proven it from happening in the future. These studies are not only important to the U.S. government, but to other governments hoping to prevent terrorism in their countries.

Planning A Case Study

You have decided that you want to research and write a case study. Now what? In this section you will learn how to plan and organize a research case study.

Selecting a Case

The first step is to choose the subject, topic or case. You will want to choose a topic that is interesting to you, and a topic that would be of interest to your potential audience. Ideally you have a passion for the topic, as then you will better understand the issues surrounding the topic, and which resources would be most successful in the study.

You also must choose a topic that would be of interest to a large number of people. You want your case study to reach as large an audience as possible, and a topic that is of interest to just a few people will not have a very large reach. One of the goals of a case study is to reach as many people as possible.

Who is your audience?

Are you trying to reach the layperson? Or are you trying to reach other professionals in your field? Your audience will help determine the topic you choose.

If you are writing a case study that is looking for ways to lower rates of child obesity, who is your audience?

If you are writing a psychology case study, you must consider whether your audience will have the intellectual skills to understand the information in the case. Does your audience know the vocabulary of psychology? Do they understand the processes and structure of the field?

You want your audience to have as much general knowledge as possible. When it comes time to write the case study, you may have to spend some time defining and explaining terms that might be unfamiliar to the audience.

Lastly, when selecting a topic you do not want to choose a topic that is very old. Current topics are always the most interesting, so if your topic is more than 5-10 years old, you might want to consider a newer topic. If you choose an older topic, you must ask yourself what new and valuable information do you bring to the older topic, and is it relevant and necessary.

Determine Research Goals

What type of case study do you plan to do?

An illustrative case study will examine an unfamiliar case in order to help others understand it. For example, a case study of a veteran with PTSD can be used to help new therapists better understand what veterans experience.

An exploratory case study is a preliminary project that will be the precursor to a larger study in the future. For example, a case study could be done challenging the efficacy of different therapy methods for vets with PTSD. Once the study is complete, a larger study could be done on whichever method was most effective.

A critical instance case focuses on a unique case that doesn't have a predetermined purpose. For example, a vet with an incredibly severe case of PTSD could be studied to find ways to treat his condition.

Ethics are a large part of the case study process, and most case studies require ethical approval. This approval usually comes from the institution or department the researcher works for. Many universities and research institutions have ethics oversight departments. They will require you to prove that you will not harm your study subjects or participants.

This should be done even if the case study is on an older subject. Sometimes publishing new studies can cause harm to the original participants. Regardless of your personal feelings, it is essential the project is brought to the ethics department to ensure your project can proceed safely.

Developing the Case Study

Once you have your topic, it is time to start planning and developing the study. This process will be different depending on what type of case study you are planning to do. For thissection, we will assume a psychological case study, as most case studies are based on the psychological model.

Once you have the topic, it is time to ask yourself some questions. What question do you want to answer with the study?

For example, a researcher is considering a case study about PTSD in veterans. The topic is PTSD in veterans. What questions could be asked?

Do veterans from Middle Eastern wars suffer greater instances of PTSD?

Do younger soldiers have higher instances of PTSD?

Does the length of the tour effect the severity of PTSD?

Each of these questions is a viable question, and finding the answers, or the possible answers, would be helpful for both psychologists and veterans who suffer from PTSD.

Research Notebook

1. What is the background of the case study? Who requested the study to be done and why? What industry is the study in, and where will the study take place?

2. What is the problem that needs a solution? What is the situation, and what are the risks?

3. What questions are required to analyze the problem? What questions might the reader of the study have? What questions might colleagues have?

4. What tools are required to analyze the problem? Is data analysis necessary?

5. What is your current knowledge about the problem or situation? How much background information do you need to procure? How will you obtain this background info?

6. What other information do you need to know to successfully complete the study?

7. How do you plan to present the report? Will it be a simple written report, or will you add PowerPoint presentations or images or videos? When is the report due? Are you giving yourself enough time to complete the project?

The research notebook is the heart of the study. Other organizational methods can be utilized, such as Microsoft Excel, but a physical notebook should always be kept as well.

Planning the Research

The most important parts of the case study are:

1. The case study's questions

2. The study's propositions

3. How information and data will be analyzed

4. The logic behind the propositions

5. How the findings will be interpreted

The study's questions should be either a "how" or "why" question, and their definition is the researchers first job. These questions will help determine the study's goals.

Not every case study has a proposition. If you are doing an exploratory study, you will not have propositions. Instead, you will have a stated purpose, which will determine whether your study is successful, or not.

How the information will be analyzed will depend on what the topic is. This would vary depending on whether it was a person, group, or organization.

When setting up your research, you will want to follow case study protocol. The protocol should have the following sections:

1. An overview of the case study, including the objectives, topic and issues.

2. Procedures for gathering information and conducting interviews.

3. Questions that will be asked during interviews and data collection.

4. A guide for the final case study report.

When deciding upon which research methods to use, these are the most important:

1. Documents and archival records

2. Interviews

3. Direct observations

4. Indirect observations, or observations of subjects

5. Physical artifacts and tools

Documents could include almost anything, including letters, memos, newspaper articles, Internet articles, other case studies, or any other document germane to the study.

Archival records can include military and service records, company or business records, survey data or census information.

Research Strategy

Before beginning the study you want a clear research strategy. Your best chance at success will be if you use an outline that describes how you will gather your data and how you will answer your research questions.

The researcher should create a list with four or five bullet points that need answers. Consider the approaches for these questions, and the different perspectives you could take.

The researcher should then choose at least two data sources (ideally more). These sources could include interviews, Internet research, and fieldwork or report collection. The more data sources used, the better the quality of the final data.

The researcher then must formulate interview questions that will result in detailed and in-depth answers that will help meet the research goals. A list of 15-20 questions is a good start, but these can and will change as the process flows.

Planning Interviews

The interview process is one of the most important parts of the case study process. But before this can begin, it is imperative the researcher gets informed consent from the subjects.

The process of informed consent means the subject understands their role in the study, and that their story will be used in the case study. You will want to have each subject complete a consent form.

The researcher must explain what the study is trying to achieve, and how their contribution will help the study. If necessary, assure the subject that their information will remain private if requested, and they do not need to use their real name if they are not comfortable with that. Pseudonyms are commonly used in case studies.

Informed Consent

The process by which permission is granted before beginning medical or psychological research

A fictitious name used to hide ones identity

It is important the researcher is clear regarding the expectations of the study participation. For example, are they comfortable on camera? Do they mind if their photo is used in the final written study.

Interviews are one of the most important sources of information for case studies. There are several types of interviews. They are:

Open-ended – This type of interview has the interviewer and subject talking to each other about the subject. The interviewer asks questions, and the subject answers them. But the subject can elaborate and add information whenever they see fit.

A researcher might meet with a subject multiple times, and use the open-ended method. This can be a great way to gain insight into events. However, the researcher mustn't rely solely on the information from the one subject, and be sure to have multiple sources.

Focused – This type of interview is used when the subject is interviewed for a short period of time, and answers a set of questions. This type of interview could be used to verify information learned in an open-ended interview with another subject. Focused interviews are normally done to confirm information, not to gain new information.

Structured – Structured interviews are similar to surveys. These are usually used when collecting data for large groups, like neighborhoods. The questions are decided before hand, and the expected answers are usually simple.

When conducting interviews, the answers are obviously important. But just as important are the observations that can be made. This is one of the reasons in-person interviews are preferable over phone interviews, or Internet or mail surveys.

Ideally, when conducing in-person interviews, more than one researcher should be present. This allows one researcher to focus on observing while the other is interviewing. This is particularly important when interviewing large groups of people.

The researcher must understand going into the case study that the information gained from the interviews might not be valuable. It is possible that once the interviews are completed, the information gained is not relevant.

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Research Design Review

A discussion of qualitative & quantitative research design, case study research: an internal-external classification.

The following is a modified excerpt from Applied Qualitative Research Design: A Total Quality Framework Approach (Roller & Lavrakas, 2015, pp. 295-298).

Salmons mentions the work of Robert Yin and Robert Stake. The typologies of Yin (2014) and Stake (1995) are “two key approaches” in case study research that “ensure that the topic of interest is well explored, and that the essence of the phenomenon is revealed” (Baxter & Jack, 2008, p. 545). Yin (2014) outlines four fundamental types of case studies on the basis of the number of cases and units of analysis in the study design. Specifically, Yin’s typology consists of two types of single-case designs – a type with one unit of analysis (Type 1) and a type with multiple units of analysis (Type 2) – and two types of multiple-case designs – those with one unit of analysis (Type 3) and those with more than one (Type 4). Yin believes that theory development is “highly desired” in case study design and therefore selecting cases for a multiple-case design, for example, involves choosing cases that are expected to return results that support or challenge a theoretical proposition or construct.

Where Yin (2014) emphasizes theoretical development and the ability to say something beyond the specific cases studied, Stake (2006) asserts that “the power of case study is its attention to the local situation, not in how it represents other cases in general” (p. 8). Stake (1995) divides case studies into three types: intrinsic – a single case (an individual, group, organization, event, or other entity) that is important in its own right, not necessarily because of its potential predictive theoretical powers; instrumental – a single case where the focus is on going beyond the case to understand a broader phenomenon of interest; and collective – a multiple case version of instrumental where the focus is on learning about a phenomenon. Unlike Yin, Stake is not linking his case studies to the idea of testing preconceived theories but rather to the idea of using the peculiarities of any particular case to illuminate the phenomenon and magnify the understanding of the research topic.

An overarching differentiator in the Yin and Stake typologies is the extent to which case study outcomes are intended to tell the researcher something that is solely about the case itself – that is, the outcomes are “internalized” to the particular case – or the outcomes are intended to tell the researcher something beyond the case, either by facilitating theory development and/or enlightening the researcher’s understanding of a broader phenomenon – that is, the outcomes are “externalized” to situations outside the case.

This internal-external classification, and its relationship to the Yin and Stake typologies, is shown below.

In this internal-external classification, an intrinsic case study as defined by Stake, with its emphasis on what can be learned about the specific case itself, is classified as an internal type of design because the research findings will only be used to inform that specific case. An example of an internal case study is research that a healthcare organization might conduct to investigate its new patient-referral program to inform their need for new social media solutions.

Stake’s instrumental and collective case study types as well as Yin’s case study designs (i.e., types 1-4), with their emphasis on projecting case study results to something outside the case (i.e., a theory or phenomenon), are classified as external case study designs because the researcher’s primary focus is on extending the outcomes beyond the specific cases(s). For example, an external case study might be conducted with one or two state government department(s) to understand the impact of a newly-implemented, more restrictive sick-leave policy on all state employees.

The internal-external classification is one way to think broadly about case study design. Regardless of the design model, however, case study researchers would do well to clearly articulate, as Salmons states, the “methodological foundations” of their designs.

Baxter, P., & Jack, S. (2008). Qualitative case study methodology: Study design and implementation for novice researchers. The Qualitative Report , 13 (4), 544–559.

Roller, M. R., & Lavrakas, P. J. (2015). Applied qualitative research design: A total quality framework approach . New York: Guilford Press.

Stake, R. E. (1995). The art of case study research . Thousand Oaks, CA: Sage Publications.

Yin, R. K. (2014). Case study research: Design and methods (5th ed.). Thousand Oaks, CA: Sage Publications.

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• Open access
• Published: 27 June 2011

The case study approach

• Sarah Crowe 1 ,
• Kathrin Cresswell 2 ,
• Ann Robertson 2 ,
• Guro Huby 3 ,
• Anthony Avery 1 &
• Aziz Sheikh 2  

BMC Medical Research Methodology volume  11 , Article number:  100 ( 2011 ) Cite this article

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The case study approach allows in-depth, multi-faceted explorations of complex issues in their real-life settings. The value of the case study approach is well recognised in the fields of business, law and policy, but somewhat less so in health services research. Based on our experiences of conducting several health-related case studies, we reflect on the different types of case study design, the specific research questions this approach can help answer, the data sources that tend to be used, and the particular advantages and disadvantages of employing this methodological approach. The paper concludes with key pointers to aid those designing and appraising proposals for conducting case study research, and a checklist to help readers assess the quality of case study reports.

Peer Review reports

Introduction

The case study approach is particularly useful to employ when there is a need to obtain an in-depth appreciation of an issue, event or phenomenon of interest, in its natural real-life context. Our aim in writing this piece is to provide insights into when to consider employing this approach and an overview of key methodological considerations in relation to the design, planning, analysis, interpretation and reporting of case studies.

The illustrative 'grand round', 'case report' and 'case series' have a long tradition in clinical practice and research. Presenting detailed critiques, typically of one or more patients, aims to provide insights into aspects of the clinical case and, in doing so, illustrate broader lessons that may be learnt. In research, the conceptually-related case study approach can be used, for example, to describe in detail a patient's episode of care, explore professional attitudes to and experiences of a new policy initiative or service development or more generally to 'investigate contemporary phenomena within its real-life context' [ 1 ]. Based on our experiences of conducting a range of case studies, we reflect on when to consider using this approach, discuss the key steps involved and illustrate, with examples, some of the practical challenges of attaining an in-depth understanding of a 'case' as an integrated whole. In keeping with previously published work, we acknowledge the importance of theory to underpin the design, selection, conduct and interpretation of case studies[ 2 ]. In so doing, we make passing reference to the different epistemological approaches used in case study research by key theoreticians and methodologists in this field of enquiry.

This paper is structured around the following main questions: What is a case study? What are case studies used for? How are case studies conducted? What are the potential pitfalls and how can these be avoided? We draw in particular on four of our own recently published examples of case studies (see Tables 1 , 2 , 3 and 4 ) and those of others to illustrate our discussion[ 3 – 7 ].

What is a case study?

A case study is a research approach that is used to generate an in-depth, multi-faceted understanding of a complex issue in its real-life context. It is an established research design that is used extensively in a wide variety of disciplines, particularly in the social sciences. A case study can be defined in a variety of ways (Table 5 ), the central tenet being the need to explore an event or phenomenon in depth and in its natural context. It is for this reason sometimes referred to as a "naturalistic" design; this is in contrast to an "experimental" design (such as a randomised controlled trial) in which the investigator seeks to exert control over and manipulate the variable(s) of interest.

Stake's work has been particularly influential in defining the case study approach to scientific enquiry. He has helpfully characterised three main types of case study: intrinsic , instrumental and collective [ 8 ]. An intrinsic case study is typically undertaken to learn about a unique phenomenon. The researcher should define the uniqueness of the phenomenon, which distinguishes it from all others. In contrast, the instrumental case study uses a particular case (some of which may be better than others) to gain a broader appreciation of an issue or phenomenon. The collective case study involves studying multiple cases simultaneously or sequentially in an attempt to generate a still broader appreciation of a particular issue.

These are however not necessarily mutually exclusive categories. In the first of our examples (Table 1 ), we undertook an intrinsic case study to investigate the issue of recruitment of minority ethnic people into the specific context of asthma research studies, but it developed into a instrumental case study through seeking to understand the issue of recruitment of these marginalised populations more generally, generating a number of the findings that are potentially transferable to other disease contexts[ 3 ]. In contrast, the other three examples (see Tables 2 , 3 and 4 ) employed collective case study designs to study the introduction of workforce reconfiguration in primary care, the implementation of electronic health records into hospitals, and to understand the ways in which healthcare students learn about patient safety considerations[ 4 – 6 ]. Although our study focusing on the introduction of General Practitioners with Specialist Interests (Table 2 ) was explicitly collective in design (four contrasting primary care organisations were studied), is was also instrumental in that this particular professional group was studied as an exemplar of the more general phenomenon of workforce redesign[ 4 ].

What are case studies used for?

According to Yin, case studies can be used to explain, describe or explore events or phenomena in the everyday contexts in which they occur[ 1 ]. These can, for example, help to understand and explain causal links and pathways resulting from a new policy initiative or service development (see Tables 2 and 3 , for example)[ 1 ]. In contrast to experimental designs, which seek to test a specific hypothesis through deliberately manipulating the environment (like, for example, in a randomised controlled trial giving a new drug to randomly selected individuals and then comparing outcomes with controls),[ 9 ] the case study approach lends itself well to capturing information on more explanatory ' how ', 'what' and ' why ' questions, such as ' how is the intervention being implemented and received on the ground?'. The case study approach can offer additional insights into what gaps exist in its delivery or why one implementation strategy might be chosen over another. This in turn can help develop or refine theory, as shown in our study of the teaching of patient safety in undergraduate curricula (Table 4 )[ 6 , 10 ]. Key questions to consider when selecting the most appropriate study design are whether it is desirable or indeed possible to undertake a formal experimental investigation in which individuals and/or organisations are allocated to an intervention or control arm? Or whether the wish is to obtain a more naturalistic understanding of an issue? The former is ideally studied using a controlled experimental design, whereas the latter is more appropriately studied using a case study design.

Case studies may be approached in different ways depending on the epistemological standpoint of the researcher, that is, whether they take a critical (questioning one's own and others' assumptions), interpretivist (trying to understand individual and shared social meanings) or positivist approach (orientating towards the criteria of natural sciences, such as focusing on generalisability considerations) (Table 6 ). Whilst such a schema can be conceptually helpful, it may be appropriate to draw on more than one approach in any case study, particularly in the context of conducting health services research. Doolin has, for example, noted that in the context of undertaking interpretative case studies, researchers can usefully draw on a critical, reflective perspective which seeks to take into account the wider social and political environment that has shaped the case[ 11 ].

How are case studies conducted?

Here, we focus on the main stages of research activity when planning and undertaking a case study; the crucial stages are: defining the case; selecting the case(s); collecting and analysing the data; interpreting data; and reporting the findings.

Defining the case

Carefully formulated research question(s), informed by the existing literature and a prior appreciation of the theoretical issues and setting(s), are all important in appropriately and succinctly defining the case[ 8 , 12 ]. Crucially, each case should have a pre-defined boundary which clarifies the nature and time period covered by the case study (i.e. its scope, beginning and end), the relevant social group, organisation or geographical area of interest to the investigator, the types of evidence to be collected, and the priorities for data collection and analysis (see Table 7 )[ 1 ]. A theory driven approach to defining the case may help generate knowledge that is potentially transferable to a range of clinical contexts and behaviours; using theory is also likely to result in a more informed appreciation of, for example, how and why interventions have succeeded or failed[ 13 ].

For example, in our evaluation of the introduction of electronic health records in English hospitals (Table 3 ), we defined our cases as the NHS Trusts that were receiving the new technology[ 5 ]. Our focus was on how the technology was being implemented. However, if the primary research interest had been on the social and organisational dimensions of implementation, we might have defined our case differently as a grouping of healthcare professionals (e.g. doctors and/or nurses). The precise beginning and end of the case may however prove difficult to define. Pursuing this same example, when does the process of implementation and adoption of an electronic health record system really begin or end? Such judgements will inevitably be influenced by a range of factors, including the research question, theory of interest, the scope and richness of the gathered data and the resources available to the research team.

Selecting the case(s)

The decision on how to select the case(s) to study is a very important one that merits some reflection. In an intrinsic case study, the case is selected on its own merits[ 8 ]. The case is selected not because it is representative of other cases, but because of its uniqueness, which is of genuine interest to the researchers. This was, for example, the case in our study of the recruitment of minority ethnic participants into asthma research (Table 1 ) as our earlier work had demonstrated the marginalisation of minority ethnic people with asthma, despite evidence of disproportionate asthma morbidity[ 14 , 15 ]. In another example of an intrinsic case study, Hellstrom et al.[ 16 ] studied an elderly married couple living with dementia to explore how dementia had impacted on their understanding of home, their everyday life and their relationships.

For an instrumental case study, selecting a "typical" case can work well[ 8 ]. In contrast to the intrinsic case study, the particular case which is chosen is of less importance than selecting a case that allows the researcher to investigate an issue or phenomenon. For example, in order to gain an understanding of doctors' responses to health policy initiatives, Som undertook an instrumental case study interviewing clinicians who had a range of responsibilities for clinical governance in one NHS acute hospital trust[ 17 ]. Sampling a "deviant" or "atypical" case may however prove even more informative, potentially enabling the researcher to identify causal processes, generate hypotheses and develop theory.

In collective or multiple case studies, a number of cases are carefully selected. This offers the advantage of allowing comparisons to be made across several cases and/or replication. Choosing a "typical" case may enable the findings to be generalised to theory (i.e. analytical generalisation) or to test theory by replicating the findings in a second or even a third case (i.e. replication logic)[ 1 ]. Yin suggests two or three literal replications (i.e. predicting similar results) if the theory is straightforward and five or more if the theory is more subtle. However, critics might argue that selecting 'cases' in this way is insufficiently reflexive and ill-suited to the complexities of contemporary healthcare organisations.

The selected case study site(s) should allow the research team access to the group of individuals, the organisation, the processes or whatever else constitutes the chosen unit of analysis for the study. Access is therefore a central consideration; the researcher needs to come to know the case study site(s) well and to work cooperatively with them. Selected cases need to be not only interesting but also hospitable to the inquiry [ 8 ] if they are to be informative and answer the research question(s). Case study sites may also be pre-selected for the researcher, with decisions being influenced by key stakeholders. For example, our selection of case study sites in the evaluation of the implementation and adoption of electronic health record systems (see Table 3 ) was heavily influenced by NHS Connecting for Health, the government agency that was responsible for overseeing the National Programme for Information Technology (NPfIT)[ 5 ]. This prominent stakeholder had already selected the NHS sites (through a competitive bidding process) to be early adopters of the electronic health record systems and had negotiated contracts that detailed the deployment timelines.

It is also important to consider in advance the likely burden and risks associated with participation for those who (or the site(s) which) comprise the case study. Of particular importance is the obligation for the researcher to think through the ethical implications of the study (e.g. the risk of inadvertently breaching anonymity or confidentiality) and to ensure that potential participants/participating sites are provided with sufficient information to make an informed choice about joining the study. The outcome of providing this information might be that the emotive burden associated with participation, or the organisational disruption associated with supporting the fieldwork, is considered so high that the individuals or sites decide against participation.

In our example of evaluating implementations of electronic health record systems, given the restricted number of early adopter sites available to us, we sought purposively to select a diverse range of implementation cases among those that were available[ 5 ]. We chose a mixture of teaching, non-teaching and Foundation Trust hospitals, and examples of each of the three electronic health record systems procured centrally by the NPfIT. At one recruited site, it quickly became apparent that access was problematic because of competing demands on that organisation. Recognising the importance of full access and co-operative working for generating rich data, the research team decided not to pursue work at that site and instead to focus on other recruited sites.

Collecting the data

In order to develop a thorough understanding of the case, the case study approach usually involves the collection of multiple sources of evidence, using a range of quantitative (e.g. questionnaires, audits and analysis of routinely collected healthcare data) and more commonly qualitative techniques (e.g. interviews, focus groups and observations). The use of multiple sources of data (data triangulation) has been advocated as a way of increasing the internal validity of a study (i.e. the extent to which the method is appropriate to answer the research question)[ 8 , 18 – 21 ]. An underlying assumption is that data collected in different ways should lead to similar conclusions, and approaching the same issue from different angles can help develop a holistic picture of the phenomenon (Table 2 )[ 4 ].

Brazier and colleagues used a mixed-methods case study approach to investigate the impact of a cancer care programme[ 22 ]. Here, quantitative measures were collected with questionnaires before, and five months after, the start of the intervention which did not yield any statistically significant results. Qualitative interviews with patients however helped provide an insight into potentially beneficial process-related aspects of the programme, such as greater, perceived patient involvement in care. The authors reported how this case study approach provided a number of contextual factors likely to influence the effectiveness of the intervention and which were not likely to have been obtained from quantitative methods alone.

In collective or multiple case studies, data collection needs to be flexible enough to allow a detailed description of each individual case to be developed (e.g. the nature of different cancer care programmes), before considering the emerging similarities and differences in cross-case comparisons (e.g. to explore why one programme is more effective than another). It is important that data sources from different cases are, where possible, broadly comparable for this purpose even though they may vary in nature and depth.

Analysing, interpreting and reporting case studies

Making sense and offering a coherent interpretation of the typically disparate sources of data (whether qualitative alone or together with quantitative) is far from straightforward. Repeated reviewing and sorting of the voluminous and detail-rich data are integral to the process of analysis. In collective case studies, it is helpful to analyse data relating to the individual component cases first, before making comparisons across cases. Attention needs to be paid to variations within each case and, where relevant, the relationship between different causes, effects and outcomes[ 23 ]. Data will need to be organised and coded to allow the key issues, both derived from the literature and emerging from the dataset, to be easily retrieved at a later stage. An initial coding frame can help capture these issues and can be applied systematically to the whole dataset with the aid of a qualitative data analysis software package.

The Framework approach is a practical approach, comprising of five stages (familiarisation; identifying a thematic framework; indexing; charting; mapping and interpretation) , to managing and analysing large datasets particularly if time is limited, as was the case in our study of recruitment of South Asians into asthma research (Table 1 )[ 3 , 24 ]. Theoretical frameworks may also play an important role in integrating different sources of data and examining emerging themes. For example, we drew on a socio-technical framework to help explain the connections between different elements - technology; people; and the organisational settings within which they worked - in our study of the introduction of electronic health record systems (Table 3 )[ 5 ]. Our study of patient safety in undergraduate curricula drew on an evaluation-based approach to design and analysis, which emphasised the importance of the academic, organisational and practice contexts through which students learn (Table 4 )[ 6 ].

Case study findings can have implications both for theory development and theory testing. They may establish, strengthen or weaken historical explanations of a case and, in certain circumstances, allow theoretical (as opposed to statistical) generalisation beyond the particular cases studied[ 12 ]. These theoretical lenses should not, however, constitute a strait-jacket and the cases should not be "forced to fit" the particular theoretical framework that is being employed.

When reporting findings, it is important to provide the reader with enough contextual information to understand the processes that were followed and how the conclusions were reached. In a collective case study, researchers may choose to present the findings from individual cases separately before amalgamating across cases. Care must be taken to ensure the anonymity of both case sites and individual participants (if agreed in advance) by allocating appropriate codes or withholding descriptors. In the example given in Table 3 , we decided against providing detailed information on the NHS sites and individual participants in order to avoid the risk of inadvertent disclosure of identities[ 5 , 25 ].

What are the potential pitfalls and how can these be avoided?

The case study approach is, as with all research, not without its limitations. When investigating the formal and informal ways undergraduate students learn about patient safety (Table 4 ), for example, we rapidly accumulated a large quantity of data. The volume of data, together with the time restrictions in place, impacted on the depth of analysis that was possible within the available resources. This highlights a more general point of the importance of avoiding the temptation to collect as much data as possible; adequate time also needs to be set aside for data analysis and interpretation of what are often highly complex datasets.

Case study research has sometimes been criticised for lacking scientific rigour and providing little basis for generalisation (i.e. producing findings that may be transferable to other settings)[ 1 ]. There are several ways to address these concerns, including: the use of theoretical sampling (i.e. drawing on a particular conceptual framework); respondent validation (i.e. participants checking emerging findings and the researcher's interpretation, and providing an opinion as to whether they feel these are accurate); and transparency throughout the research process (see Table 8 )[ 8 , 18 – 21 , 23 , 26 ]. Transparency can be achieved by describing in detail the steps involved in case selection, data collection, the reasons for the particular methods chosen, and the researcher's background and level of involvement (i.e. being explicit about how the researcher has influenced data collection and interpretation). Seeking potential, alternative explanations, and being explicit about how interpretations and conclusions were reached, help readers to judge the trustworthiness of the case study report. Stake provides a critique checklist for a case study report (Table 9 )[ 8 ].

Conclusions

The case study approach allows, amongst other things, critical events, interventions, policy developments and programme-based service reforms to be studied in detail in a real-life context. It should therefore be considered when an experimental design is either inappropriate to answer the research questions posed or impossible to undertake. Considering the frequency with which implementations of innovations are now taking place in healthcare settings and how well the case study approach lends itself to in-depth, complex health service research, we believe this approach should be more widely considered by researchers. Though inherently challenging, the research case study can, if carefully conceptualised and thoughtfully undertaken and reported, yield powerful insights into many important aspects of health and healthcare delivery.

Yin RK: Case study research, design and method. 2009, London: Sage Publications Ltd., 4

Google Scholar  

Keen J, Packwood T: Qualitative research; case study evaluation. BMJ. 1995, 311: 444-446.

Article   CAS   PubMed   PubMed Central   Google Scholar  

Sheikh A, Halani L, Bhopal R, Netuveli G, Partridge M, Car J, et al: Facilitating the Recruitment of Minority Ethnic People into Research: Qualitative Case Study of South Asians and Asthma. PLoS Med. 2009, 6 (10): 1-11.

Article   Google Scholar  

Pinnock H, Huby G, Powell A, Kielmann T, Price D, Williams S, et al: The process of planning, development and implementation of a General Practitioner with a Special Interest service in Primary Care Organisations in England and Wales: a comparative prospective case study. Report for the National Co-ordinating Centre for NHS Service Delivery and Organisation R&D (NCCSDO). 2008, [ http://www.sdo.nihr.ac.uk/files/project/99-final-report.pdf ]

Robertson A, Cresswell K, Takian A, Petrakaki D, Crowe S, Cornford T, et al: Prospective evaluation of the implementation and adoption of NHS Connecting for Health's national electronic health record in secondary care in England: interim findings. BMJ. 2010, 41: c4564-

Pearson P, Steven A, Howe A, Sheikh A, Ashcroft D, Smith P, the Patient Safety Education Study Group: Learning about patient safety: organisational context and culture in the education of healthcare professionals. J Health Serv Res Policy. 2010, 15: 4-10. 10.1258/jhsrp.2009.009052.

Article   PubMed   Google Scholar  

van Harten WH, Casparie TF, Fisscher OA: The evaluation of the introduction of a quality management system: a process-oriented case study in a large rehabilitation hospital. Health Policy. 2002, 60 (1): 17-37. 10.1016/S0168-8510(01)00187-7.

Stake RE: The art of case study research. 1995, London: Sage Publications Ltd.

Sheikh A, Smeeth L, Ashcroft R: Randomised controlled trials in primary care: scope and application. Br J Gen Pract. 2002, 52 (482): 746-51.

PubMed   PubMed Central   Google Scholar  

King G, Keohane R, Verba S: Designing Social Inquiry. 1996, Princeton: Princeton University Press

Doolin B: Information technology as disciplinary technology: being critical in interpretative research on information systems. Journal of Information Technology. 1998, 13: 301-311. 10.1057/jit.1998.8.

George AL, Bennett A: Case studies and theory development in the social sciences. 2005, Cambridge, MA: MIT Press

Eccles M, the Improved Clinical Effectiveness through Behavioural Research Group (ICEBeRG): Designing theoretically-informed implementation interventions. Implementation Science. 2006, 1: 1-8. 10.1186/1748-5908-1-1.

Article   PubMed Central   Google Scholar  

Netuveli G, Hurwitz B, Levy M, Fletcher M, Barnes G, Durham SR, Sheikh A: Ethnic variations in UK asthma frequency, morbidity, and health-service use: a systematic review and meta-analysis. Lancet. 2005, 365 (9456): 312-7.

Sheikh A, Panesar SS, Lasserson T, Netuveli G: Recruitment of ethnic minorities to asthma studies. Thorax. 2004, 59 (7): 634-

CAS   PubMed   PubMed Central   Google Scholar  

Hellström I, Nolan M, Lundh U: 'We do things together': A case study of 'couplehood' in dementia. Dementia. 2005, 4: 7-22. 10.1177/1471301205049188.

Som CV: Nothing seems to have changed, nothing seems to be changing and perhaps nothing will change in the NHS: doctors' response to clinical governance. International Journal of Public Sector Management. 2005, 18: 463-477. 10.1108/09513550510608903.

Lincoln Y, Guba E: Naturalistic inquiry. 1985, Newbury Park: Sage Publications

Barbour RS: Checklists for improving rigour in qualitative research: a case of the tail wagging the dog?. BMJ. 2001, 322: 1115-1117. 10.1136/bmj.322.7294.1115.

Mays N, Pope C: Qualitative research in health care: Assessing quality in qualitative research. BMJ. 2000, 320: 50-52. 10.1136/bmj.320.7226.50.

Mason J: Qualitative researching. 2002, London: Sage

Brazier A, Cooke K, Moravan V: Using Mixed Methods for Evaluating an Integrative Approach to Cancer Care: A Case Study. Integr Cancer Ther. 2008, 7: 5-17. 10.1177/1534735407313395.

Miles MB, Huberman M: Qualitative data analysis: an expanded sourcebook. 1994, CA: Sage Publications Inc., 2

Pope C, Ziebland S, Mays N: Analysing qualitative data. Qualitative research in health care. BMJ. 2000, 320: 114-116. 10.1136/bmj.320.7227.114.

Cresswell KM, Worth A, Sheikh A: Actor-Network Theory and its role in understanding the implementation of information technology developments in healthcare. BMC Med Inform Decis Mak. 2010, 10 (1): 67-10.1186/1472-6947-10-67.

Article   PubMed   PubMed Central   Google Scholar  

Malterud K: Qualitative research: standards, challenges, and guidelines. Lancet. 2001, 358: 483-488. 10.1016/S0140-6736(01)05627-6.

Article   CAS   PubMed   Google Scholar  

Yin R: Case study research: design and methods. 1994, Thousand Oaks, CA: Sage Publishing, 2

Yin R: Enhancing the quality of case studies in health services research. Health Serv Res. 1999, 34: 1209-1224.

Green J, Thorogood N: Qualitative methods for health research. 2009, Los Angeles: Sage, 2

Howcroft D, Trauth E: Handbook of Critical Information Systems Research, Theory and Application. 2005, Cheltenham, UK: Northampton, MA, USA: Edward Elgar

Book   Google Scholar  

Blakie N: Approaches to Social Enquiry. 1993, Cambridge: Polity Press

Doolin B: Power and resistance in the implementation of a medical management information system. Info Systems J. 2004, 14: 343-362. 10.1111/j.1365-2575.2004.00176.x.

Bloomfield BP, Best A: Management consultants: systems development, power and the translation of problems. Sociological Review. 1992, 40: 533-560.

Shanks G, Parr A: Positivist, single case study research in information systems: A critical analysis. Proceedings of the European Conference on Information Systems. 2003, Naples

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Acknowledgements

We are grateful to the participants and colleagues who contributed to the individual case studies that we have drawn on. This work received no direct funding, but it has been informed by projects funded by Asthma UK, the NHS Service Delivery Organisation, NHS Connecting for Health Evaluation Programme, and Patient Safety Research Portfolio. We would also like to thank the expert reviewers for their insightful and constructive feedback. Our thanks are also due to Dr. Allison Worth who commented on an earlier draft of this manuscript.

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AS conceived this article. SC, KC and AR wrote this paper with GH, AA and AS all commenting on various drafts. SC and AS are guarantors.

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Crowe, S., Cresswell, K., Robertson, A. et al. The case study approach. BMC Med Res Methodol 11 , 100 (2011). https://doi.org/10.1186/1471-2288-11-100

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Qualitative Case Study Methodology: Study Design and Implementation for Novice Researchers

Qualitative case study methodology provides tools for researchers to study complex phenomena within their contexts. When the approach is applied correctly, it becomes a valuable method for health science research to develop theory, evaluate programs, and develop interventions. The purpose of this paper is to guide the novice researcher in identifying the key elements for designing and implementing qualitative case study research projects. An overview of the types of case study designs is provided along with general recommendations for writing the research questions, developing propositions, determining the " case " under study, binding the case and a discussion of data sources and triangulation. To facilitate application of these principles, clear examples of research questions, study propositions and the different types of case study designs are provided. Key Words: Case Study and Qualitative Methods Introduction To graduate students and researchers unfamiliar with case study methodology, there is often misunderstanding about what a case study is and how it, as a form of qualitative research, can inform professional practice or evidence-informed decision making in both clinical and policy realms. In a graduate level introductory qualitative research methods course, we have listened to novice researchers describe their views of case studies and their perceptions of it as a method only to be used to study individuals or specific historical events, or as a teaching strategy to holistically understand exemplary " cases. " It has been a privilege to teach these students that rigorous qualitative case studies afford researchers opportunities to explore or describe a phenomenon in context using a variety of data sources. It allows the researcher to explore individuals or organizations, simple through complex interventions, relationships, communities, or programs (Yin, 2003) and supports the deconstruction and the subsequent reconstruction of various phenomena. This approach is valuable for health science research to develop theory, evaluate programs, and develop interventions because of its flexibility and rigor.

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Using unfolding case studies to develop critical thinking for Graduate Entry Nursing students: an educational design research study

• Rachel Macdiarmid   ORCID: orcid.org/0000-0003-4791-7417 1 ,
• Eamon Merrick   ORCID: orcid.org/0000-0003-4269-6360 2 , 3 &
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BMC Nursing volume  23 , Article number:  399 ( 2024 ) Cite this article

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Graduate Entry Nursing (GEN) programmes have been introduced as another entry point to nurse registration. In the development of a new GEN programme, a problem-based approach to learning was used to develop critical thinking and clinical reasoning skills of motivated and academically capable students.

To explore and evaluate the design and delivery of course material delivered to GEN students embedded in authentic learning pedagogy from the perspectives of both GEN students and academic staff using an unfolding case study approach.

An educational design research approach was used to explore the learning experiences of GEN students using an unfolding case study approach situated in experiential pedagogy and the teaching experiences of the academics who designed it. Data were collected through semi-structured interviews with students once they had finished the course and weekly reflective diary recordings by academic staff throughout implementation. Thematic analysis was used to analyse the data.

Student reflections highlighted that this cohort had insight into how they learned and were comfortable voicing their needs to academic staff. While the unfolding case studies were not liked by all participants, for some it offered a unique learning opportunity; particularly when scaffolded with podcasts, simulation labs, tutorials and clinical placements. Staff reflections primarily aligned with student experiences.

The gaps highlighted in the delivery of the course suggest that a blended pedagogical approach to graduate entry nurse education is required. Specifically, GEN students are aware of the learning needs and are happy to express these to academic staff, thus suggesting that engaging with a co-design curriculum approach will benefit future cohorts.

Peer Review reports

Graduate entry nursing students begin their degrees as experienced learners and must develop critical thinking skills within the shortened degree time frame.

What is already known

Graduate entry students are experienced and academically capable learners who begin with a diverse range of life and career experiences.

What this paper adds

Graduate entry students would benefit by being involved in curriculum design to acknowledge the unique skill set that they bring.

Introduction

Graduate Entry Nursing (GEN) degrees, or second degrees leading to eligibility for nursing registration, have recently been introduced to New Zealand. GEN students are known to be academically capable, motivated, and driven, bringing with them a range of life experiences, and have often had significant careers before enrolment [ 1 , 2 ]. Previous research has identified that teaching and learning methods must be carefully planned and innovative [ 1 ].

Pre-registration nursing education programmes prepare nursing students to provide safe nursing care with crucial skills expected of nursing graduates, including critical thinking and clinical reasoning. Clinical reasoning enables students to approach clinical issues with a problem-solving lens that relies on gathering assessment data and intervening and evaluating the patient’s response to the intervention [ 3 ].

Problem-Based Learning (PBL) aligns with the fundamental elements of authentic learning approaches [ 4 ], where learning is situated in real-world contexts [ 5 ]. Problem-based learning is considered to be an experiential teaching and learning approach that helps students develop a critical lens and clinical reasoning skills [ 6 , 7 ]. The use of PBL in nursing education is well established with previous research focused on students’ experiences and satisfaction [ 8 ]; factors that facilitate or hinder students' learning [ 9 ]; and the development of critical thinking skills [ 10 ].

Graduate entry nursing students report enjoyment of the active learning sets that enabled discussion surrounding case studies, scenarios, and practice issues [ 11 ]. Cangelosi’s [ 12 ] phenomenological study found that although time-poor, GEN students welcomed learning opportunities that were not traditional and facilitated their development and growth.

However, there is conflicting evidence regarding the effectiveness of PBL in nursing. For example, McCormick et al. [ 13 ] compared undergraduate student performance using differing teaching approaches, such as unfolding simulation scenarios versus recorded lectures and found these to be of benefit to students. Carter and Welch [ 14 ] compared the results of associate degree nursing students who attended lectures to those whose learning was informed by an unfolding case study. In contrast to McCormick’s et al.’s [ 13 ] earlier positive results, these authors found both groups of students performed worse in the post-test.

As previous research has identified that new graduate nurses do not always have critical thinking skills, using an unfolding case study approach can reflect the reality of clinical practice where not all the relevant information is known at the first encounter with the patient [ 14 , 15 , 16 ].

Nonetheless, while several studies have investigated the use of unfolding case studies in undergraduate preregistration programmes there is little evidence that supports the use of these with more academically capable GEN students. This article reports on a qualitative interpretivist study that used an educational design methodology to explore the experiences of GEN students who participated in the programme of learning and the experiences of the academics who designed it.

Educational Design Research (EDR) is an iterative, pragmatic, and reflective methodology well suited to small projects [ 17 ]. It has arisen from design-based research and can include both quantitative and qualitative data collection methods. EDR was selected as it fitted with our desire to develop new ways of teaching alongside gaining feedback from both academic staff and students. In the first phase of this research, we redesigned the teaching and learning strategies for a component of the GEN programme [ 18 ].

EDR has four phases (Table  1 ) [ 17 ]:

Aims and objectives

The study aimed to explore and evaluate the design and delivery of course material delivered to GEN students embedded in authentic learning pedagogy from the perspectives of both GEN students and academic staff using an unfolding case study approach.

Theoretical framework

To enable the development of clinical reasoning skills a scaffolded learning approach was implemented that involved unfolding case studies designed to represent the health needs of the New Zealand population, thus, encouraging critical thinking. Unfolding case studies reflective of situations that students might face in the future were used to encourage students to consider and analyse information, provoke further questioning and identify the information required to narrow their inquiries [ 14 , 15 ]. Supported by this evidence the academic staff built a learning environment where a regular teaching schedule (two days of lectures and one day of clinical labs per week), was complemented with online resources. Initial questions about the case study were provided on the learning management system. Students attended simulations where they responded to the case and answered questions critical to unpacking the ‘patients’ reality. Alongside the unfolding case studies were podcasts where experts were interviewed on topics related to the case. Tutorials enabled students to collaboratively construct answers and share their perspectives; at the end of each week students shared their answers in an online discussion forum.

Methods and setting

This study was conducted at an education facility in New Zealand offering undergraduate and GEN programmes. The participants are academics involved in the design and delivery of the course and one cohort of students of the GEN programme. This article reports on Phase 2 and 3 of the EDR approach, the academic staff’s reflective diary during course delivery, and students' feedback after the course was completed the first time. The methods were reported using the Consolidated Criteria for Reporting Qualitative Studies (COREQ) [ 19 ].

Participants

Purposeful sampling was used as the researchers were keen to explore the experiences of a specific GEN cohort [ 20 ]. Academic staff involved in the weekly reflective diaries are also the research team ( n  = 3). All students in the identified cohort ( n  = 7) were invited to participate, totalling ten possible participants. Student participants were approached via an advertisement on the university’s learning management system. Students were asked to contact the research assistant, who was separate from the academic staff and was not involved in the delivery of the GEN programme; five students agreed to participate. A $20 petrol voucher was offered to those who participated.

Data collection and analysis

In keeping with education design methodology, the authors met weekly to reflect on their experiences of delivering the content and guiding students. The weekly reflective conversations, between 60–90 min in length, followed a simple format of ‘what worked, what didn’t work, and what would we (as academic staff) change?’ Face to face student interviews were conducted by the research assistant at a time and place convenient to the students using semi-structured questions that were developed by the research team (see Additional file 1 ).

The semi-structured interviews ( n  = 5) and reflective meetings ( n  = 9) were recorded and transcribed verbatim by a research assistant who had signed a confidentiality agreement. All identifying information was deleted from the transcripts by the research assistant before the research team reviewed the data; each recording and transcript was allocated a unique identifier, for example ‘participant one’.

Thematic analysis [ 21 , 22 ] was used to analyse the data. First, the research team independently read the transcribed interviews to familiarise themselves with the data and identified initial codes. Second, the researchers met and reviewed all transcripts to identify themes and reached consensus on the themes emerging from the data. Themes were established once more than 50% of the participants stated the same issue/thought/perception. A matrix was developed whereby common themes were identified, with quotes demonstrating the themes collated to establish an audit trail.

Reflexivity

Central to this study given the proximity of staff to this student cohort, a reflexive stance was essential. Reflexivity is an engendered practice and was used in this instance not to influence the direction and outcome of the research but to allow the researchers to engage in the data to produce viable and valuable outcomes for future staff and students. Specifically, this reflexive practice provided a means for the research to be rigorous through the consideration of the vulnerability of the participating student cohort, thus inciting reflection-before-action [ 23 ].

Ethical considerations

Ethical approval for this study was obtained from the Auckland University of Technology Ethics Committee (AUTEC) (19/233). Given the potential power differential in the student/staff relationship present, participants were approached via an online advertisement and followed up by an independent research assistant. This is key to the success of the project, as such research undertakings have the potential for conflict of interest to exist [ 24 ]. The academic staff recordings were also undertaken with the knowledge that these would remain confidential to the participants and transcriber only, with a memorandum of understanding completed to this effect. Participant information sheets were given to students interested in joining the study to ensure they knew what it entailed and how their safety and identity would be managed. Written consent was obtained before the interviews were undertaken, with oral consent obtained at the beginning of each interview.

Three dominant themes emerged, which focused on the experiences of both GEN students and teaching staff. These were:

Reflective learning: Students and staff ability to clarify what worked and what did not work

Evaluation of learning: Students and staff being insightful about their ways of learning and needs

Challenges: Planning and delivering appropriate content for GEN students is challenging for teaching staff.

Within these overarching themes, subthemes were developed and will be presented in the following data results (Table 2 ).

Reflective learning

The exploration of student and staff experiences and responses to the unfolding case studies unearths what worked and what was problematic for both parties.

Unfolding case study as problem-based approach

The student experiences of using an unfolding case study approach were divided. Some students enjoyed the case scenarios but did not necessarily find them beneficial in terms of knowledge advancement as.

“ I personally, like the case studies but personally I didn’t really find that they enhanced my learning in like the clinical setting ” (P1)

or that they were relevant to clinical practice in that.

“… some of it was definitely relatable but I just found it was very different in the clinical setting compared with doing this theoretical case setting ” (P1).

A second student supported this idea that the case studies did not add practical clinical knowledge value as.

“ I mean for me the case studies weren’t challenging…I didn’t think the case studies added anything extra into my practice, they didn’t challenge my clinical reasoning or anything like that ” (P2).

Of note was that those students with previous professional healthcare backgrounds found the use of an unfolding case study approach problematic in that.

“ I found that quite a challenge. I think because with my clinical background I was sort of going straight into, yeah like I wanted more information so you know I probably would have preferred…to have a different case study every week or have all the information…and I’d be like well what about this, what about that? ” (P5).

Participant One, however, noted that while the case studies may not have added knowledge value, they were helpful at times as.

“ …one example is we learnt about arterial blood gases and then I was on placement I came across that literally [on] day one, so was really nice to be able to put something that I’d learnt in class into practice ” (P1).

While some students were less keen on the case study approach and found them hard work, others thought they provided opportunities to encourage discussion, clinical reasoning, and autonomous thinking as.

“ there was no right or wrong answer, you just had to prove your point to say I think it is this because of this, and someone else can say something else and just kind of still prove it because it was a quite grey [area] but I actually found that it really got us thinking ” (P3).

Moreover, the same participant acknowledged that.

“…I think that’s the whole idea of the course [GEN Programme] because at this level they shouldn’t be spoon-feeding you…you should be able to think for yourself and reason things out ” (P3).

Although some discord was present with regard to the case study approach, one participant did acknowledge the value of being able to break down a huge scenario into manageable sections to enhance understanding and clinical decision-making, as.

“ when you break it down it makes it easier to kind of work out what you’re going to do and what steps you’re going to do ” (P4), and that “ because you start looking at the smaller things that you need to do rather than just the big bits ” (P4).

It appears, however, that staff involved in the programme of learning were pleased with the overall notion that problem-based learning approach offered a ‘practical’ means through which to discuss what is the hands-on job of nursing. Specifically,

“ the second session around child abuse and recognising child abuse…took me a bit by surprise as I wasn’t expecting that to go very well and it went extraordinarily well, mostly because it was case based again and story based ” (L1).

Moreover, with regard to encouraging discussion and clinical reasoning at a postgraduate level,

“ I think we’ve really pulled out the difference [of] what we’re expecting of them [GEN students] as opposed to what they may have been used to” (L1).

Use of podcasts

While the use of technology is not necessarily a completely new strategy in tertiary education, here we have linked podcasts recorded with experts in their fields which related to the unfolding case studies, Again, however, there was division in the value of podcast recordings, with some students really enjoying them, saying.

“ I liked the podcasts yeah, I found the podcasts really good especially when there was [sic] different people talking about it, yeah...podcasts are good, like to just chuck on in the car or at the gym ” (P2).

Moreover, some found them easy to listen to because.

“… it’s a different way to learn because like you’ve got YouTube videos and you’ve got books and stuff but podcasts are kind of like easy ” (P2).

Some students found the podcasts particularly engaging saying.

…I just remember listening to it and I think I was in the car and I had stopped because I was on my way home…and I was still listening to it in the garage like when I was home and I was like oh this is a really interesting podcast ” (P2).

Participant three also thought podcasts a positive addition to the resources saying.

“ yeah they were helpful…there was one I listened to…they were talking about dying…I know that [one of the lecturers’] kind of research is kind of talking about death, euthanasia and all this kind of thing, and for some reasons, I don’t know why, maybe that’s why I still remember, I can say it’s the only podcast I really listened to and it was really good because it gave me a good insight as to what is happening… ” (P3)

This positive response was also noted in face-to-face class time as one staff member reported that.

“ they [the students] loved the person who was interviewed, and the feedback was it was really nice to hear a conversation about different perspectives ” (L1).

Yet, not all students were of this opinion, with some advising the podcasts were too long (approximately 60 min each), that they can be distracting, that they preferred videos and images or an in-person discussion, saying.

“ I find podcasts…I tend to switch off a bit, a bit quicker than if I was watching something, I would probably prefer, rather than watching a podcast [sic] I’d rather have an in-class discussion with the person” (P4).

Participant one said that they too struggled with podcasts because.

“ I’m more visual so I like to look at things and see like a slide I guess or what they’re talking about or, so I sort of zone out when it’s just talking and nothing to look at, so that’s what I personally struggle with, they [podcasts] are helpful it’s just I’m more a visual learner ” (P1).

While there were some negative responses to the podcasts, another participant acknowledged their value but offered their own solutions to learning, saying that.

“ I listened to a few podcasts that were put up, because they’re just easy to listen to ” (P2).

but felt that overall there were insufficient resources made available to students and therefore.

“ just went to YouTube and just, any concepts that I was unfamiliar with or stuff in class that we went over and when I went home I was like [I have] no idea what they talked about, I just found my own videos on YouTube… ” (P2).

Evaluation of learning

Learning experiences are unique to each GEN student, as are those experienced by the teaching staff. The data collected highlighted this clearly from both perspectives, offering a particularly strong insight into how this cohort of students’ function.

Approaches to learning

It was evident that these GEN students were aware of their approach to learning and that perhaps the structure of the teaching module did not align with their needs as.

“ I’m not really the best at utilising online things I’m a really hands on learner and things like a lecture…but you know if it’s yeah, more like class time, it’s sort of more my, my learning style [I] guess ” (P5).

A number of students were able to identify that they were visual learners as.

“ I use videos more because I guess I’m more of a visual learner as well and I learn better by seeing things instead of reading a huge article, I think that [videos] it helps me a bit more” (P4).

Another student, however, preferred a discussion based approach as opposed to either videos or podcasts saying that.

“ if it’s interesting, if it’s a topic that you can like relate to [through a podcast] or something it’s fine, but for me I just switch off not really taking a lot of the information [in] whereas in a discussion setting you can ask questions and you can interact with the person, yeah I find that would be a bit more helpful ” (P4).

This approach to learning through discussion was also noted when the teaching staff reflected on their experiences in that in one teaching session the GEN students.

“ were engaged, they were round a table with the second speaker talking and what I think enabled the discussion was that she [the speaker] was using her data as stories and so she was reading them, actually she got them [the students] to read them out” (L3).

The notion of learning styles, however, was not as linear as being visual or auditory or practical, as one student noted that a combination of styles was preferable to enhance learning, saying that.

“ if we weren’t able to have lectures like a recorded lecture so that there was a PowerPoint and just someone actually talking you through it, like I know there’s the YouTube videos…some of them were a little bit helpful, but like I just felt that sometimes we missed the teaching aspect of it. There’s a lot of self-directed stuff but definitely like a recorded lecture every week to go along with the readings and extra videos to watch ” (P5).

Students as insightful and engaged

While GEN students are known for their tenacity and ability to cope with the pressure and fast paced delivery, some students discovered that this did not necessarily equate with their preferred approach to learning. This cohort of GEN students were insightful in terms of their strengths and weaknesses in relation to knowledge acquisition. The use of the unfolding case studies, however, caused some frustrations as.

“ for me it was challenging in the fact that I felt I actually got frustrated because I’m thinking well I want to know this, I want to know that and yeah not getting all the information that I wanted at the time ” (P5).

This participant went further, saying that.

“ I definitely found that difficult [lack of information] I felt like [I] wasn’t getting as much information as I wanted to be able to make my clinical decisions ” (P5),

however this may have been due to the student’s background as their.

“my background is in paramedicine ” where “ we get a lot of information in a very short amount of time ” (P5).

Some fundamental issues were raised by the participants in terms of how much study is required for them to acquire the new knowledge. As one student highlighted,

“ I have a really terrible memory, so I kind of need to listen to things a few times or write it down and then watch a video and do some more reading and then like it’s good having another element to get into your brain you know ” (P2).

For one student, a solution to this was to ensure they did their preparation before attending class as.

“ you’re supposed to have read these things before coming to class, some people don’t but my kind of person, I’d read before coming to class and I tended to answer those questions so the critical, analytical part of me would be trying to find out and come up with a reasonable answer…” (P3).

For another participant, they took an alternative pathway to learning as they.

“ I just watch it and I don’t take [it in], it just sits in the back of my head because sometimes it’s building on top of previous knowledge so just, I just watch it to see if I can gain anything from that, I don’t necessarily take down notes or anything, but I just watch it so that it’s there you know ” (P4).

The pace of content delivery appeared problematic for some students, especially in relation to the practical sessions, with one student highlighting that.

“ personally I didn’t’ really like it and most of the time they were rushing, I was always like can I write this down to go back home to like really make sense of it and then sometimes obviously, sometimes I would have to say can I stay back and practice this thing again [as] I didn’t grab it as quickly as others did and the essence of the labs is that it’s grab all of these things ” (P3).

Challenges: Teaching staff experiences of GEN student learning

While on the whole the teaching staff were able to gauge the learning needs of this GEN cohort, the expectations of both parties did not always align, with one staff member reporting that.

“ the two biggest challenges was [sic] getting them [the students] to unpack already learned behaviour and [to] acknowledge their own limitations or bias ” (L1),

however by the end of the semester the same staff member reported that.

“ I think we made a lot of progress in getting them to acknowledge how they learn ” (L1).

Moreover, the challenges anticipated in teaching GEN students were not those that transpired in that.

“ I actually thought going into the first paper I was pretty excited as to how it was going to roll out, the problems I encountered were not the problems I anticipated ” (L3).

The vocality of this cohort was tangible, however, when content did not meet their needs, interest or expectations with the students saying,

“ that they didn’t do the materials because it wasn’t of interest to them and requested other teaching very much related to the assignment as opposed to anything else …” (L1).

It was expected that the GEN students would be participatory both in class and online irrespective of their ways of learning, but there was a difference in both responses and comfort with this form of engagement. One student that talked about the unfolding case study and the online component of assessment as being problematic said that.

“.. we had to put up about 250 words of something related to the case study every week and then we spoke to someone else, [I] didn’t really like the responses…I didn’t really like having to respond to someone else ” (P3).

Yet in contrast to this statement, the teaching staff were delighted that.

“…actually I got some fantastic questions from one of the students…emailed to me on Monday night about the case that was online for them, questions that I didn’t talk about in [the] lecture, I didn’t introduce the concept…they’re talking about concepts that are currently undergoing international clinical trials” (L1).

This study explored the experiences of both GEN students and academics using unfolding case studies situated in experiential learning pedagogy. The use of unfolding case studies supported with podcasts embraced our idea of developing content situated in real-life contexts. Learning was scaffolded using different teaching approaches such as podcasts, and experiential simulated learning, to offer learners multiple ways of engaging with content. Scaffolding is recognised as learning material being broken into smaller chunks of learning and in this way aligns with case-based learning [ 25 ]. In this way, we hoped that not only would students engage in problem-solving, and develop clinical decision-making skills [ 26 , 27 ], but that they would also achieve deep and lifelong learning and ultimately have an ‘aha’ moment when it all made sense.

Reflections on using an unfolding case study approach

Findings were divided, with some students enjoying the unfolding case studies and others describing them as not sufficiently challenging. The scaffolded learning approach that we developed incorporated a range of teaching approaches that enabled them to engage with the content in a way that fitted in with their lifestyle, even if the teaching method did not align with their individual learning preferences. Students reported differing views about the case studies; some enjoyed the unfolding nature while others wanted more context and direction to feel that they could make an informed clinical decision. Nonetheless, even though they did not like information being presented in smaller chunks one student recognised it meant they analysed the information they received more deeply.

Other learning tools such as podcasts were not always valued by participants and yet, the fact that students were able to provide feedback on their use does indicate that they at least attempted to engage with them.

Student reflections indicate that perhaps the use of unfolding case studies as a learning approach is not the solution to engagement, and that often more traditional teaching methods were preferred Indeed, Hobbs and Robinson’s [ 28 ] study of undergraduate nursing students in the US supported Carter and Welch’s [ 14 ] findings that the use of unfolding case studies were of no direct benefit, whilst Ellis et al.’s., [ 29 ] study confirmed that for final year nurse practitioner students unfolding case studies were beneficial in developing critical thinking and stimulating clinical reasoning. Considering these two conflicting findings, further consideration is needed of how to engage highly motivated GEN students.

As such, our results suggest it can be difficult to predict the needs of the GEN students given the diversity of their previous academic qualifications, career, and often significant life experience they bring to the programme [ 30 , 31 ]. Interestingly students in this study simultaneously demonstrated insight into their needs supporting their previous academic study experience and felt sufficiently secure to voice them, which supports evidence found in D’Antonio et al.’s [ 32 ] study. This suggests that GEN students’ capabilities need to be embraced and incorporated when planning curriculum and scaffolding learning. Anecdotally, we have found that students embrace experiential learning such as that offered in simulation labs whether this involves the use of simulated manikins or not, it seems the hands-on learning offers not only the opportunity to experience simulated reality but also fosters collaboration and problem solving with peers that enables them to dwell in learning of what it is to be a nurse.

Graduate entry students recognised as experienced learners

Our students were not overwhelmingly supportive of the pedagogical approach of unfolding case studies we adopted. As previously recognised GEN students are experienced learners and whilst having differing educational backgrounds bring individual experience and knowledge of their own approach to their learning. Nonetheless, the value of their previous learning experience appears problematic in that those learned behaviours and attitudes need to be refocused to engage with learning how to become a nurse, as demonstrated in the academic staff reflections. Despite this background experience and perceived confidence, some students reflected that online engagement that involved exploring the case studies in discussion forums with colleagues was uncomfortable. This was surprising to the academic staff and contrasted sharply with their reflections on the activity but has been previously noted by Boling et al., [ 33 ].

Implications

Given the disparity that exists between student and academic staff experiences, as demonstrated in our study, co-designing content delivery may offer a progressive solution. By engaging ‘students as partners’ it offers them a much deeper level of involvement in future teaching delivery through collaboration and reciprocation of ideas, thus culminating in appropriate curriculum design [ 34 ]. Collaborating with students in course design might facilitate students learning as they become cognisant of the active engagement of academic staff [ 9 , 10 , 35 ]. In the future, we aim to involve students in any curriculum review and course development to ensure their perspectives influence curriculum design and content delivery.

Even so, our initial intention of scaffolding learning by offering different ways for students to engage with content is supported by recent research by Dong et al. [ 36 ] who found that students performed better academically in a flipped classroom. This point, in association with our findings, suggests that the best approach to content delivery for graduate entry nursing students is to ensure students are involved in curriculum and course design alongside the delivery of learning experiences that are well facilitated and supported by faculty so that students are aware of the expectations, required of them, and importantly how they will be assessed.

Limitations

We acknowledge that the sample size in this study is small in terms of generalisability. However, our findings offer interesting, detailed and in-depth insights into the experiences and needs of both GEN students and the academic staff involved in the development and delivery of educational material. Further work needs to be undertaken to evaluate the experiences of GEN students from a range of educational providers. A longitudinal study has been undertaken to explore the motivations and experiences of GEN students in Australasia [ 37 ], which will also support these findings regarding the learning needs of GEN students.

This study has provided a platform through which academics and GEN students can share their insights of teaching and learning experiences. The results offer a clear insight into what these students expect and need to expedite their learning and how teaching staff must respond. While participants' views were somewhat mixed in relation to the use of unfolding case studies and scaffolded learning these results demonstrate how GEN students are aware of their personal ways of learning and how this translates in terms of education needs. The sharing of these experiences provides an insightful lens through which to re-evaluate pedagogical approaches for GEN students. As such, we suggest that to meet the needs of GEN student’s not only is a blended pedagogical approach appropriate but expanding education design boundaries further through a co-design focused approach to GEN programme design.

Availability for data and materials

The datasets generated and analysed during the current study are not publicly available due privacy and ethical restrictions of the participants, but are available from the corresponding author on reasonable request.

Downey KM, Asselin ME. Accelerated master’s programs in nursing for non-nurses: An integrative review of students’ and faculty’s perceptions. J Prof Nurs. 2015;31(3):215–25. Available from: https://doi.org/10.1016/j.profnurs.2014.10.002 .

Pellico LH, Terrill E, White P, Rico J. Integrative review of graduate entry programs. J Nursg Educ. 2012;51(1):29–37. Available from:  https://doi.org/10.3928/01484834-20111130-01 .

Article   Google Scholar  

Levett-Jones T, Hoffman K, Dempsey J, Jeong SYS, Noble D, Norton CA, et al. The ‘five rights’ of clinical reasoning: An educational model to enhance nursing students’ ability to identify and manage clinically ‘at risk’ patients. Nurse Educ Today. 2010;30(6):515–20.

Article   PubMed   Google Scholar  

Smith SB, Kennedy S. Authentic teaching to promote active learning: Redesign of an online RN to BSN evidence-based practice nursing course. J Prof Nurs. 2020;36(2):56–61. Available from:  https://doi.org/10.1016/j.profnurs.2019.07.005 .

Herrington J, Reeves TC, Oliver R. Authentic Learning Environments. In: Spector J, Merrill M, Elen J, Bishop M, editors. Handbook of Research on Educational Communications and Technology. New York: Springer; 2014. p. 401–12.

Chapter   Google Scholar  

Herrington J, Reeves TC, Oliver R. A guide to authentic e-learning. London and New York: Routledge; 2009.

Book   Google Scholar  

Merisier S, Larue C, Boyer L. How does questioning influence nursing students’ clinical reasoning in problem-based learning? A scoping review.  Nurse Educ Today. 2018;65:108–15.

Spiers JA, Williams B, Gibson B, Kabotoff W, McIlwraith D, Sculley A, et al. Graduate nurses’ learning trajectories and experiences of problem-based learning: A focused ethnography study. Int J Nurs Stud. 2014;51(11):1462–71. Available from:  https://doi.org/10.1016/j.ijnurstu.2014.03.002 .

Article   CAS   PubMed   Google Scholar  

Svensson J, Axén A, Andersson EK, Hjelm M. Nursing students’ experiences of what influences achievement of learning outcomes in a problem-based learning context: A qualitative descriptive study. Nurs Open. 2021;8(4):1863–9.  Available from:  https://doi.org/10.1002/nop2.842 .

Article   PubMed   PubMed Central   Google Scholar  

Martyn J, Terwijn R, Kek MYCA, Huijser H. Exploring the relationships between teaching, approaches to learning and critical thinking in a problem-based learning foundation nursing course. Nurse Educ Today. 2014;34(5):829–35. Available from:  https://doi.org/10.1016/j.nedt.2013.04.023 .

Maddison C, Strang G. Do action learning sets facilitate collaborative, deliberative learning?: A focus group evaluation of Graduate Entry Pre-registration Nursing (GEN) students’ experience. Nurse Educ  Pract. 2018;28:285–91. Available from: https://doi.org/10.1016/j.nepr.2017.10.023 .

Cangelosi PR. Voices of graduates from second-degree baccalaureate nursing programmes. J Prof Nurs. 2007;23(2):91–7.

McCormick MJ, de Slavy JR, Fuller B. Embracing technology: Using an unfolding case simulation to enhance nursing students’ learning about Parkinson Disease. J Neurosci Nurs. 2013;45(1):14–20. Available from:  https://doi.org/10.1097/JNN.0b013e318275b220 .

Carter JT, Welch S. The effectiveness of unfolding case studies on ADN nursing students’ level of knowledge and critical thinking skills. Teach Learn Nurs. 2016;11:143–6. Available from: https://doi.org/10.1016/j.teln.2016.05.004 .

Carr KC. Using the unfolding case study in midwifery education. J Midwifery Womens Health. 2015;60:283–90. Available from: https://doi.org/10.1111/jmwh.12293 .

Yousey YK. The use of unfolding case studies: Innovation in online undergraduate nursing education. J Nurs EducPract. 2013;3(4):21–9. Available from:  https://doi.org/10.5430/jnep.v3n4p21 .

McKenney S, Reeves T. Conducting Educational Design Research. 2nd ed. New York: Routledge; 2018. Available from: http://ebookcentral.proquest.com .

Macdiarmid R, Winnington R, Cochrane T, Merrick E. Using educational design research to develop authentic learning for graduate entry students in New Zealand. Nurse Educ Prac. 2021; 51(01) Available from: https://doi.org/10.1016/j.nepr.2021.102965

Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual Health Care. 2007;19(6):349–57.

Parahoo K. Nursing Research: principles, process and issues. 3rd ed. London: Palgrave MacMillan; 2014.

Braun V, Clarke V, Hayfield N, Terry G. Thematic analysis. In: Liamputtong P, editor. Handbook of Research Methods in Health Social Sciences. Singapore: Springer; 2019. p. 843–60.

Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006;3(2):77–101. Available from: https://doi.org/10.1191/1478088706qp063oa .

Edwards S. Reflecting differently. New dimensions: reflection-before-action and reflection-beyond-action. Int Prac Dev J. 2017;7(1):1–14. Available from:  https://doi.org/10.19043/ipdj.71.002 .

Ferguson LM, Yonge O, Myrick F. Students’ involvement in faculty research: Ethical and methodological issues. Int J Qual Methods. 2004;3(4):56–8.

Coffman S, Iommi M, Morrow K. Scaffolding as active learning in nursing education. Teach Learn Nurs. 2023;18(1):232–7.

Bowman K. Use of online unfolding case studies to foster critical thinking. J Nurs Educ. 2017;56(11):701–2.

Gonslaz L, Nielsen A, Lasatar K. Developing students clinical reasoning skills: A faculty guide. J Nurse Educ. 2021;60(9):485–93. Available from: https://doi.org/10.3928/01484834-20210708-01 .

Hobbs J, Robinson C. Learning and Transfer Effects of an Unfolding Case Study in an Adult Health Nursing Course. Nurs Educ Perspect. 2022;43(1):47–8. Available from: https://doi.org/10.1097/01.NEP.0000000000000801 .

Ellis M, Hampton D, Makowski A, Falls C, Tovar E, Scott L, et al. Using unfolding case scenarios to promote clinical reasoning for nurse practitioner students. J Am Assoc Nurse Pract. 2023;35(1):55–62. Available from:  https://doi.org/10.1097/JXX.0000000000000806 .

Macdiarmid R, Turner R, Winnington R, McClunie-Trust P, Donaldson A, et al. What motivates people to commence a graduate entry nursing programme: a mixed method scoping review. BMC Nurs. 2021;20:47. Available from: https://doi.org/10.1186/s12912-021-00564-9 .

Winnington R, Shannon K, Turner R, Jarden R, McClunie-Trust P, Merrick E, Donaldson A, Macdiarmid R. Learning experiences of first year graduate entry nursing students in New Zealand and Australia: a qualitative case study. BMC Nurs. 2023;22:74. Available from: https://doi.org/10.1186/s12912-023-01233-9 .

D’Antonio P, Beal MW, Underwood PW, Ward FR, McKelvey M, Guthrie B, et al. Great expectations: points of congruencies and discrepancies between incoming accelerated second-degree nursing students and faculty. J Nurs Educ. 2010;49(12):713–7. Available from https://doi.org/10.3928/01484834-20100831-08 .

Boling EC, Hough M, Krinsky H, Saleem H, Stevens M. Cutting the distance in distance education: Perspective on what promotes positive online learning experiences. Int Higher Educ. 2012;15(2):118–26. Available from:  https://doi.org/10.1016/j.iheduc.2011.11.006 .

Bovill C. Co-creation in learning and teaching: the case for a whole-class approach in higher education. High Educ. 2020;79:1023–37. https://doi.org/10.1007/s10734-019-00453-w .

Paige JB, Smith RO. Nurse faculty experiences in problem-based learning: An interpretive phenomenologic analysis. Nurs Educ Perspect. 2013;34(4):233–9.

PubMed   Google Scholar  

Dong Y, Yin H, Du S, Wang A. The effects of flipped classroom characterized by situational and collaborative learning in a community nursing course: A quasi-experimental design. Nurse Educ Today. 2021;105. Available from:  https://doi.org/10.1016/j.nedt.2021.105037

Macdiarmid R, McClunie-Trust P, Shannon K, Winnington R, Donaldson A, Jarden R, et al. What Motivates People to Start a Graduate Entry Nursing Programme: An Interpretive Multi-Centred Case Study. SAGE Open Nursing. 2021;7. Available from:  https://doi.org/10.1177/23779608211011310 .

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RM*: Conceptualisation, methodology, investigation, formal analysis, writing original draft and review/editing. EM: Conceptualisation, methodology, investigation, formal analysis, writing original draft and review/editing. RW: Conceptualisation, methodology, investigation formal analysis, writing original draft and review/editing. The author(s) read and approved the final manuscript.

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Macdiarmid, R., Merrick, E. & Winnington, R. Using unfolding case studies to develop critical thinking for Graduate Entry Nursing students: an educational design research study. BMC Nurs 23 , 399 (2024). https://doi.org/10.1186/s12912-024-02076-8

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Personalized daily hand movement training methods and effects: a case study.

1. Introduction

• Future Orientation: In addition to recalling happy moments, incorporate discussions about future expectations and goals to help patients connect past positive experiences with future objectives.
• Diverse Experiences: Introduce the life experiences of others, such as reading literary works or watching movies, to help patients form new memory images and enrich their psychological experience.
• Cognitive Restructuring: Combine cognitive behavioral techniques to restructure patients’ thoughts and behaviors, aiding them in better coping with life’s challenges.
• Establish a complete customer journey.
• Confirm key content of the journey.
• Formulate negative customer journey propositions.
• Propose binary flip models.
• Extract positive customer values.
• Depict the desired customer journey: Design and realize the entire process of the desired customer experience based on positive customer values.

2.1. Theoretical Innovation

2.1.1. happiness memory therapy (hmt) and implementation.

• Memory Recollection: Guide participants to recall a happy moment, focusing on helping the patient construct happy memories. If the patient’s own memories are highly unrelated to the training, relevant happy memories can be constructed through others’ experiences. Enhance the vividness and realism of the recall by engaging multiple senses and motor stimuli such as visual, auditory, olfactory, and movement. Describe the scene, people, and emotional experiences of that moment in detail.
• Happiness Reenactment: Recreate the happy moment in daily life by converting the happy memory into a daily life activity, enhancing the emotional experience of the memory, and promoting hand movement participation. Focus on the operability of reenacting it in a daily life context. This process requires the collaboration of PCMT.
• Recording and Reflection: Participants record their daily emotional experiences and training-related data, forming a log for subsequent analysis and adjustment of the training program.

2.1.2. Positive Creation Mirror Theory (PCMT) and Implementation

• Current Self: Based on the memory recollection, obtain situational fragments of the patient’s happy memories, evaluate the patient’s current hand function status, and identify specific difficulties related to happy memories in daily life.
• Reflective Self: Through the reverse thinking of Mirror Theory, highly relevant segments obtained at the current stage are filtered. These core segments are identified by researchers who analyze their importance through scoring after communicating with the patient, envisioning a more ideal situation than the current state (in this case, using the Non-One Mirror Transition M[~1]). Typically, one of the two types of mirror transition mechanisms is selected to analyze the problem based on the specific circumstances.
• Aspirational Self: Based on the ideal situation obtained in the Reflective Self stage, combine the patient’s personal needs and life background to achieve specific rehabilitation goals and training plans in the form of a game.

2.1.3. Life Game Design

• Bilateral Coordination Training: Design tasks in the game that require cooperation between both hands, helping the affected hand to work together with the healthy hand to complete daily life tasks, thereby enhancing hand function.
• Self-completion of Tasks: Through game design, cultivate the patient’s ability to independently complete daily life tasks, thereby boosting confidence and self-acceptance awareness.

2.2. Experiment-Related Information

2.3. experimental design.

• Finding Leaves: The patient searches for leaves from different trees outdoors, especially leaves with insect bites.
• Picking Leaves: Use fingers to pinch and pick the leaves, placing them into a basket.
• Making Bookmarks: After air-drying the collected leaves, make them into bookmarks.
• Criteria for Success: Successfully picking a complete leaf (the affected thumb pad and the pad of the same-side index finger are able to perform a pinching action).
• Pressing Potatoes: The patient uses the affected hand to press potatoes.
• Cutting: Use the healthy hand to cut the potatoes into pieces.
• Cooking: Follow the patient’s favorite recipe to make potato chicken nuggets.
• Criteria for Success: Successfully preparing a complete dish.
• Household Activities: Actively identify and perform household chores, such as mopping, sweeping, drawing curtains, pouring tea, delivering napkins, distributing utensils, charging mobile phones, cleaning tables, etc.
• Scoring System: Successfully helping earns 5 points, and being helped deducts 5 points, with each person starting at 100 points.
• Game Rewards: At the end of the game, the person with the highest score can make a small, realizable request from the other participants.
• Criteria for Success: Achieving a final score of over 50 points by the tester.

2.4. Data Process

2.4.1. pre-test and post-test data collection, 2.4.2. data analysis.

• The Overall Model Explanation

4. Discussion

4.1. compare data for pre and post.

• Subjective Well-Being (SWLS)

4.2. Regression Analysis

5. conclusions, author contributions, institutional review board statement, informed consent statement, data availability statement, conflicts of interest.

• Feigin, V.L.; Krishnamurthi, R.V.; Parmar, P.; Norrving, B.; Mensah, G.A.; Bennett, D.A.; Barker-Collo, S.; Moran, A.E.; Sacco, R.L.; Truelsen, T.; et al. Update on the Global Burden of Ischemic and Hemorrhagic Stroke in 1990–2013: The GBD 2013 Study. Neuroepidemiology 2015 , 45 , 161–176. [ Google Scholar ] [ CrossRef ]
• Zhang, Y.; Chen, L.; Ji, C.; Wang, F.; Yuan, P.; He, M. Factors Influencing the Compliance of Functional Exercises in Young and Middle-Aged Patients with Hemorrhagic Stroke and Path Analysis. J. Nurs. Sci. 2020 , 29 , 6–10. Available online: http://manu68.magtech.com.cn/Jwk3_hlxb (accessed on 1 January 2024).
• Wang, Y.; Li, Z.; Gu, H.; Zhai, Y.; Jiang, Y.; Zhou, Q.; Zhao, X.; Wang, Y.; Yang, X.; Wang, C.; et al. China Stroke Report 2020 (Chinese Edition). Chin. J. Stroke 2022 , 17 , 433–447. [ Google Scholar ]
• Secciani, N.; Brogi, C.; Pagliai, M.; Buonamici, F.; Gerli, F.; Vannetti, F.; Bianchini, M.; Volpe, Y.; Ridolfi, A. Wearable Robots: An Original Mechatronic Design of a Hand Exoskeleton for Assistive and Rehabilitative Purposes. Front. Neurorobotics 2021 , 15 , 750385. [ Google Scholar ] [ CrossRef ]
• Barreda-Galvez, T.; Terrazas-Rodas, D. Novel Technologies of Exoskeleton Systems Applied to Rehabilitation for Hand Therapies: A Technological Review. In Proceedings of the 2023 International Seminar on Intelligent Technology and Its Applications (ISITIA), Surabaya, Indonesia, 26–27 July 2023; IEEE: Piscataway, NJ, USA, 2023; pp. 328–335. [ Google Scholar ] [ CrossRef ]
• Cheng, L.; Chen, M.; Li, Z. Design and Control of a Wearable Hand Rehabilitation Robot. IEEE Access 2018 , 6 , 74039–74050. [ Google Scholar ] [ CrossRef ]
• Blake, D.T.; Byl, N.N.; Merzenich, M.M. Representation of the Hand in the Cerebral Cortex. Behav. Brain Res. 2002 , 135 , 179–184. [ Google Scholar ] [ CrossRef ]
• Nakagawa, M.; Sasaki, R.; Tsuiki, S.; Miyaguchi, S.; Kojima, S.; Saito, K.; Inukai, Y.; Onishi, H. Effects of Passive Finger Movement on Cortical Excitability. Front. Hum. Neurosci. 2017 , 11 , 216. [ Google Scholar ] [ CrossRef ]
• Arbuckle, S.A.; Weiler, J.; Kirk, E.A.; Rice, C.L.; Schieber, M.; Pruszynski, J.A.; Ejaz, N.; Diedrichsen, J. Structure of Population Activity in Primary Motor Cortex for Single Finger Flexion and Extension. J. Neurosci. 2020 , 40 , 9210–9223. [ Google Scholar ] [ CrossRef ]
• Zaman, T.; Mukhtar, T.; Waseem Zaman, M.; Shahid, M.N.; Bibi, S.; Fatima, A. Effects of Task-Oriented Training on Dexterous Movements of Hands in Post-Stroke Patients. Int. J. Neurosci. 2022 , 134 , 175–183. [ Google Scholar ] [ CrossRef ]
• Yan, T.; Jin, D. Neurorehabilitation Technology , 1st ed.; Electronic Industry Press: Beijing, China, 2019. [ Google Scholar ]
• Jia, J. Introduction to Hand Function Rehabilitation , 1st ed.; Electronic Industry Press: Beijing, China, 2019. [ Google Scholar ]
• Sollerman, C.; Ejeskär, A. Sollerman Hand Function Test: A Standardised Method and its Use in Tetraplegic Patients. Scand. J. Plast. Reconstr. Surg. Hand Surg. 1995 , 29 , 167–176. [ Google Scholar ] [ CrossRef ]
• Van der Kemp, J.; Kruithof, W.J.; Nijboer, T.C.W.; van Bennekom, C.A.M.; van Heugten, C.; Visser-Meily, J.M.A. Return to Work after Mild-to-Moderate Stroke: Work Satisfaction and Predictive Factors. Neuropsychol. Rehabil. 2019 , 29 , 638–653. [ Google Scholar ] [ CrossRef ]
• Zhang, X.; Dai, J.; Li, X.; Li, H.; Fu, H.; Pan, G.; Zhang, N.; Yang, R.; Xu, J. sEMG-Based Shoulder-Elbow Composite Motion Pattern Recognition and Control Methods for Upper Limb Rehabilitation Robot. Assem. Autom. 2019 , 39 , 394–400. [ Google Scholar ] [ CrossRef ]
• Sui, M.; Ouyang, Y.; Jin, H.; Chai, Z.; Wei, C.; Li, J.; Xu, M.; Li, W.; Wang, L.; Zhang, S. A Soft-Packaged and Portable Rehabilitation Glove Capable of Closed-Loop Fine Motor Skills. Nat. Mach. Intell. 2023 , 5 , 1149–1160. [ Google Scholar ]
• Liu, Z. Human Factors Engineering Study on Exoskeleton Upper Limb Motor Function Rehabilitation System. Ph.D. Thesis, Donghua University, Shanghai, China, 2017. [ Google Scholar ]
• Song, X.; Van De Ven, S.S.; Liu, L.; Wouda, F.J.; Wang, H.; Shull, P.B. Activities of Daily Living-Based Rehabilitation System for Arm and Hand Motor Function Retraining After Stroke. IEEE Trans. Neural Syst. Rehabil. Eng. 2022 , 30 , 621–631. [ Google Scholar ] [ CrossRef ]
• Rojek, I.; Dorożyński, J.; Mikołajewski, D.; Kotlarz, P. Overview of 3D Printed Exoskeleton Materials and Opportunities for Their AI-Based Optimization. Appl. Sci. 2023 , 13 , 48384. [ Google Scholar ] [ CrossRef ]
• Pacchierotti, C.; Sinclair, S.; Solazzi, M.; Frisoli, A.; Hayward, V.; Prattichizzo, D. Wearable Haptic Systems for the Fingertip and the Hand: Taxonomy, Review, and Perspectives. IEEE Trans. Haptics 2017 , 10 , 580–600. [ Google Scholar ] [ CrossRef ]
• Fischer, H.C.; Stubblefield, K.; Kline, T.; Luo, X.; Kenyon, R.V.; Kamper, D.G. Hand Rehabilitation Following Stroke: A Pilot Study of Assisted Finger Extension Training in a Virtual Environment. Top. Stroke Rehabil. 2007 , 14 , 1–12. [ Google Scholar ] [ CrossRef ]
• Du Plessis, T.; Djouani, K.; Oosthuizen, C. A Review of Active Hand Exoskeletons for Rehabilitation and Assistance. Robotics 2021 , 10 , 40. [ Google Scholar ] [ CrossRef ]
• Wang, H.; Chen, P.; Li, Y.; Sun, B.; Liao, Z.; Niu, B.; Niu, J. New Rehabilitation Assessment Method of the End-Effector Finger Rehabilitation Robot Based on Multi-Sensor Source. Healthcare 2021 , 9 , 1251. [ Google Scholar ] [ CrossRef ]
• Mathew, M.; Thomas, M.J.; Navaneeth, M.G.; Sulaiman, S.; Amudhan, A.N.; Sudheer, A.P. A systematic review of technological advancements in signal sensing, actuation, control and training methods in robotic exoskeletons for rehabilitation. Ind. Robot 2023 , 50 , 432–455. [ Google Scholar ] [ CrossRef ]
• Xie, Y.; Yang, Y.-X.; Jiang, H.; Duan, X.-Y.; Gu, L.-J.; Qing, W.; Zhang, B.; Wang, Y.-X. Brain-machine interface-based training for improving upper extremity function after stroke: A meta-analysis of randomized controlled trials. Front. Neurosci. 2022 , 16 , 949575. [ Google Scholar ] [ CrossRef ]
• Li, C. Study on Patient Engagement and Concentration in Robot-Assisted Neurorehabilitation. Master’s Thesis, Tsinghua University, Beijing, China, 2017. [ Google Scholar ]
• Pareek, S.; Manjunath, H.; Esfahani, E.T.; Kesavadas, T. MyoTrack: Realtime Estimation of Subject Participation in Robotic Rehabilitation Using sEMG and IMU. IEEE Access 2019 , 7 , 76030–76041. [ Google Scholar ] [ CrossRef ]
• Rahman, A.; Al-Jumaily, A. Design and Development of a Bilateral Therapeutic Hand Device for Stroke Rehabilitation. Int. J. Adv. Robot. Syst. 2013 , 10 , 405. [ Google Scholar ] [ CrossRef ]
• Suarez-Escobar, M.; Rendon-Velez, E. An overview of robotic/mechanical devices for post-stroke thumb rehabilitation. Disabil. Rehabil. Assist. Technol. 2018 , 13 , 683–703. [ Google Scholar ] [ CrossRef ]
• Laver, K.E.; George, S.; Thomas, S.; Deutsch, J.E.; Crotty, M. Virtual reality for stroke rehabilitation. Cochrane Database Syst. Rev. 2015 , 2015 , CD008349. [ Google Scholar ] [ CrossRef ]
• Shull, P.B.; Jiang, S.; Zhu, Y.; Zhu, X. Hand Gesture Recognition and Finger Angle Estimation via Wrist-Worn Modified Barometric Pressure Sensing. IEEE Trans. Neural Syst. Rehabil. Eng. 2019 , 27 , 724–732. [ Google Scholar ] [ CrossRef ]
• Gao, Q.; Jiang, S.; Shull, P.B. Simultaneous Hand Gesture Classification and Finger Angle Estimation via a Novel Dual-Output Deep Learning Model. Sensors 2020 , 20 , 2972. [ Google Scholar ] [ CrossRef ]
• Hwang, C.H.; Seong, J.W.; Son, D.-S. Individual finger synchronized robot-assisted hand rehabilitation in subacute to chronic stroke: A prospective randomized clinical trial of efficacy. Clin. Rehabil. 2012 , 26 , 696–704. [ Google Scholar ] [ CrossRef ]
• Li, M.; Xie, H.; Luo, Q.; Huang, G.; Xu, G.; Cheng, Y.; Li, J. A Qualitative Study on the Humanistic Care Needs of Patients with Stroke and Their Families. J. Multidiscip. Healthc. 2023 , 16 , 717–730. [ Google Scholar ] [ CrossRef ]
• Li, H.J.; Zhang, Y.; Zhang, B.B.; Zhang, H.Y.; Yu, Z.J.; Wang, R.H. Progress of Self-transcendence Theory in the Field of Nursing. Nurs. Res. 2019 , 33 , 282–285. [ Google Scholar ]
• Viard, A.; Allen, A.P.; Doyle, C.M.; Naveau, M.; Bokde, A.L.W.; Platel, H.; Eustache, F.; Commins, S.; Roche, R.A.P. Autobiographical Cerebral Network Activation in Older Adults Before and After Reminiscence Therapy: A Preliminary Report. Biol. Res. Nurs. 2024 , 26 , 257–269. [ Google Scholar ] [ CrossRef ]
• Wu, D.-M.; Hu, X.-Y. Application Status and Prospects of Reminiscence Therapy in China. Chin. J. Gerontol. 2017 , 37 , 3893–3895. [ Google Scholar ]
• Chen, K.-Y.; Wang, D.-H. Research Progress on Spiritual Well-being of the Elderly. J. Nurs. 2023 , 38 , 120–123. [ Google Scholar ]
• Lv, X.-Y.; Liu, T.; Xie, X.F.; Huang, L.; Zhang, F.Y. Reminiscence Healing: The Healing Effect of Past Travel Experiences on the Unhappiness of the Elderly. J. Tour. 2023 , 38 , 74–89. [ Google Scholar ]
• Guidi, J.; Rafanelli, C.; Fava, G.A. The clinical role of well-being therapy. Nord. J. Psychiatry 2018 , 72 , 447–453. [ Google Scholar ] [ CrossRef ]
• Lu, D.-B. Positive Creation: Mirror Theory ; Tsinghua University Press: Beijing, China, 2015. [ Google Scholar ]
• Lu, D.-B. Positive Creation of Mirror Theory. Packag. Eng. 2021 , 42 , 16–24. [ Google Scholar ]
• Zhao, Y.-L.; Sun, Y.; Lu, D.-B. Design of Chest Measurement Device Based on Mirror Theory. Packag. Eng. 2021 , 42 , 70–77. [ Google Scholar ]
• Liu, D.; Yan, B.; Liu, C.; Li, Z.H. Design Research of Elderly Bathroom Product Service System Based on Positive Creation Mirror Theory. Technol. Horiz. 2019 , 15 , 127–129. [ Google Scholar ]
• Zhang, J.-Y. Research on the Production of Music Audio Programs Based on Positive Creation Mirror Theory. Da Guan (Forum) 2020 , 3 , 34–35. [ Google Scholar ]
• Wu, Q.-H. Positive Creation-Based Benign Variation Strategy Management Model. Ph.D. Thesis, National Cheng Kung University, Tainan, Taiwan, 2018. [ Google Scholar ]
• Diener, E.; Emmons, R.A.; Larsen, R.J.; Griffin, S. The Satisfaction with Life Scale. J. Pers. Assess. 1985 , 49 , 71–75. [ Google Scholar ] [ CrossRef ]
• Lyubomirsky, S.; Lepper, H.S. A measure of subjective happiness: Preliminary reliability and construct validation. Soc. Indic. Res. 1999 , 46 , 137–155. [ Google Scholar ] [ CrossRef ]
• Watson, D.; Clark, L.A.; Tellegen, A. Development and validation of brief measures of positive and negative affect: The PANAS scales. J. Pers. Soc. Psychol. 1988 , 54 , 1063–1070. [ Google Scholar ] [ CrossRef ]
• Ryff, C.D. Happiness is everything, or is it? Explorations on the meaning of psychological well-being. J. Pers. Soc. Psychol. 1989 , 57 , 1069–1081. [ Google Scholar ] [ CrossRef ]
• Hudak, P.L.; Amadio, P.C.; Bombardier, C. Development of an upper extremity outcome measure: The DASH (disabilities of the arm, shoulder, and hand). Am. J. Ind. Med. 1996 , 29 , 602–608. [ Google Scholar ] [ CrossRef ]

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Wei, H.; Chen, K.; Chen, Z.-H.; Luh, D.-B. Personalized Daily Hand Movement Training Methods and Effects: A Case Study. Appl. Sci. 2024 , 14 , 5297. https://doi.org/10.3390/app14125297

Wei H, Chen K, Chen Z-H, Luh D-B. Personalized Daily Hand Movement Training Methods and Effects: A Case Study. Applied Sciences . 2024; 14(12):5297. https://doi.org/10.3390/app14125297

Wei, Hua, Kun Chen, Zi-Hao Chen, and Ding-Bang Luh. 2024. "Personalized Daily Hand Movement Training Methods and Effects: A Case Study" Applied Sciences 14, no. 12: 5297. https://doi.org/10.3390/app14125297

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• Open access
• Published: 11 June 2024

Perception of enhanced learning in medicine through integrating of virtual patients: an exploratory study on knowledge acquisition and transfer

• Zhien Li 1 ,
• Maryam Asoodar 1 ,
• Nynke de Jong 2 ,
• Tom Keulers 3 ,
• Xian Liu 1 &
• Diana Dolmans 1  

BMC Medical Education volume  24 , Article number:  647 ( 2024 ) Cite this article

265 Accesses

Metrics details

Introduction

Virtual Patients (VPs) have been shown to improve various aspects of medical learning, however, research has scarcely delved into the specific factors that facilitate the knowledge gain and transfer of knowledge from the classroom to real-world applications. This exploratory study aims to understand the impact of integrating VPs into classroom learning on students’ perceptions of knowledge acquisition and transfer.

The study was integrated into an elective course on “Personalized Medicine in Cancer Treatment and Care,” employing a qualitative and quantitative approach. Twenty-two second-year medical undergraduates engaged in a VP session, which included role modeling, practice with various authentic cases, group discussion on feedback, and a plenary session. Student perceptions of their learning were measured through surveys and focus group interviews and analyzed using descriptive statistics and thematic analysis.

Quantitative data shows that students highly valued the role modeling introduction, scoring it 4.42 out of 5, and acknowledged the practice with VPs in enhancing their subject matter understanding, with an average score of 4.0 out of 5. However, students’ reflections on peer dialogue on feedback received mixed reviews, averaging a score of 3.24 out of 5. Qualitative analysis (of focus-group interviews) unearthed the following four themes: ‘Which steps to take in clinical reasoning’, ‘Challenging their reasoning to enhance deeper understanding’, ‘Transfer of knowledge ‘, and ' Enhance Reasoning through Reflections’. Quantitative and qualitative data are cohered.

The study demonstrates evidence for the improvement of learning by incorporating VPs with learning activities. This integration enhances students’ perceptions of knowledge acquisition and transfer, thereby potentially elevating students’ preparedness for real-world clinical settings. Key facets like expert role modeling and various authentic case exposures were valued for fostering a deeper understanding and active engagement, though with some mixed responses towards peer feedback discussions. While the preliminary findings are encouraging, the necessity for further research to refine feedback mechanisms and explore a broader spectrum of medical disciplines with larger sample sizes is underscored. This exploration lays a groundwork for future endeavors aimed at optimizing VP-based learning experiences in medical education.

Peer Review reports

In Medical Education, a persistent challenge lies in the bridge between acquiring theoretical knowledge and applying it in real-world clinical scenarios. Many medical students struggle with translating their classroom learning into practical settings. The primary challenge lies in effectively translating the concepts students have learned into authentic patient interactions. This gap is particularly concerning because it affects the quality of patient care, as medical students are not just learning to acquire knowledge but must be able to apply this knowledge in complex healthcare settings.

One approach to address this challenge is the use of Virtual Patients (VPs), a computer-based simulation of real-life clinical scenarios for students to train clinical skills [ 1 ]. Research has shown that using VPs in the classroom can effectively improve various aspects of learning, from core knowledge and clinical reasoning to decision-making skills and knowledge transfer [ 2 , 3 , 4 , 5 ]. The VPs provide students with the opportunity to practice skills in a safe and controlled simulation environment.

Recent studies have focused on optimizing the design and arrangement of VPs as part of learning activities to facilitate both knowledge acquisition and retention [ 6 , 7 , 8 ]. For instance, Verkuyl, Hughes [ 8 ] demonstrated that using VPs as gamification tools can improve students’ confidence, engagement, and satisfaction.

However, studies focusing on the specific factors that contribute to these improvements when integrating VPs into the classroom are limited, particularly in understanding how to use VPs in the classroom to facilitate the transfer of knowledge students’ gain from the class to the subsequent studying stage of their education and eventual practice.

Acquisition and transfer of knowledge are critical factors in medical education, as medical students must be able to apply their knowledge and skills to real-world clinical scenarios [ 9 ]. Research suggests that for the effective transfer of knowledge, students should be immersed in authentic environments, enabling the transition of learned competencies to advanced stages [ 10 , 11 , 12 , 13 ].

Despite the consensus on the efficacy of VPs as a tool, there is a gap in understanding how to integrate VPs in the classroom to optimize students’ learning, especially in facilitating learning transfer. The effectiveness of VPs is not just in their use but also in how they are used by students to enhance their understanding on how to reason and make decisions about medical treatments when dealing with clinical cases. Without a clear and deep understanding, we risk underutilizing their potential and losing opportunities for medical students to become well prepared for real-world clinical scenarios.

Certain elements, such as role modeling instruction [ 14 , 15 , 16 ], using various authentic cases [ 17 , 18 , 19 ], and engaging in peer discussions on feedback [ 20 , 21 , 22 ], emerge as potential key components that could be integrated to maximize the knowledge acquisition via VPs. For instance, Stalmeijer, Dolmans [ 23 ] show how an expert, serving as a role model, provides guidance that facilitates student learning by demonstrating clinical skills and reasoning out loud. While there is ample evidence supporting the advantages of inclusion of VPs in education, there is not enough research focusing on the detailed aspects of effective instructional design techniques. This paper delves into these components, seeking to understand how the VP integration influences students’ learning and knowledge transfer. Figure  1 shows the theoretical framework of how integrating VPs in class affects students’ learning and might impact the transfer of learning in a simulated VP environment to practice.

Relationship of implementing, impact factor, and transfer of training

This exploratory study aims to investigate how instructional design elements such as role modeling, various authentic cases, and peer dialogues on feedback within VP sessions affect students’ learning from the learner’s perceptions. The core research question in this study focuses on how the implementation of role modeling, various authentic cases, and peer dialogue on feedback in VPs, influences learners’ perception of knowledge gain and transfer in personalized medicine.

The study was conducted at Maastricht University in the elective course, “Personalized Medicine in Cancer Treatment and Care”. This course is open to second-year undergraduate medical students of Maastricht University.

Participants

Initially, 24 students enrolled in this course for the academic year of 2022–2023, and 22 students participated in the Virtual Patient session. In total, 19 students voluntarily completed the survey designed to evaluate their experiences and perceptions of the Virtual Patients session. Thereafter, 9 of the 19 survey respondents voluntarily agreed to participate in three focus group interviews, with 2–4 students in each focus group. Students were informed that participation in this research study had no impact on student’s academic performance or their continuation in their studies.

Intervention

The instructional approach for the VP cases was structured in a specific format for the students. Figure  2 shows the instructional design for VP integration. The first stage was a role-modeling phase, where an expert demonstrated the clinical reasoning process using VP Case A. This was followed by a practice session where students worked in pairs on two different VP cases (Case B and C). After that, students formed two larger groups each including 5 or 6 students, and discussed the system feedback that was provided by VP platform. Finally, the expert summarized the session and addressed students’ questions. The whole intervention lasted 120 min. Figure  1 gives an overview of the intervention steps.

The flow of integrated virtual patient session

1. Role modeling (30 min): The intervention started with an expert, a clinician with teaching experience, demonstrating a clinical case (Case A) and showing the clinical reasoning process by thinking aloud. The expert served as a role model in showcasing the approach toward clinical problem-solving, provided supportive information, and demonstrated how to proceed through the case. The aim of the role modeling session was to empower students to apply the insights and methodology gained from experts in case A to solve subsequent cases (case B and case C), Although these cases shared similarities in underlying principles, they diverged on patient characteristics such as age, complications, and smoking history that can influence patient treatment outcomes.

2 and 3. Two VP pair tasks (20 min each): In this segment, the 22 participating students were paired, resulting in 11 pairs. These pairs were then divided into two groups. Group 1 (6 pairs) and group 2 (5 pairs) alternated in going through Case B and Case C to account for the practice effect. These cases were variations of the clinical cases introduced during the role-modeling demonstration, differing in patient characteristics such as age, complications, and smoking history to challenge the students’ reasoning. Students were encouraged to work collaboratively.

4. Feedback discussion (30 min): Upon completion of the VP cases, an automated feedback is immediately provided about the reasoning analysis. Participants were instructed to save this feedback for later discussion. After that, Students were organized into groups of six, based on the sequence in which they engaged with the cases. For instance, those who first practiced with Case B and then proceeded to Case C formed Group (1) Conversely, students who started with case C and then moved on to case B were assembled into Group (2) To foster meaningful dialogue, students engaged in discussions focused on the feedback generated by the Virtual Patient system, guided by a printed discussion guide distributed to each group (see Appendix 2 ). The discussion aimed to deepen students’ understanding and enrich their conversations about the cases they had just completed.

5. Plenary (15 min): This part lasted 15 min. Hosted by the expert to summarize the session and address questions or doubts raised by students.

During the practice and discussion sessions, the expert circulated among the groups to offer additional guidance and support.

The virtual patient cases

Three Virtual Patient (VP) cases (Case A, B, and C) were created to enhance students’ comprehension of specific concepts, knowledge, and skills in clinical reasoning. The VP practice was developed on the P-Scribe ( www.pscribe.nl ) learning platform, a web-based e-learning system based in the Netherlands. The platform facilitates the design and implementation of text-based VP sessions (Appendix 4 ).

While these cases shared a foundation on authentic head and neck cancer treatment, they were characterized by varying patient characteristics in terms of age, gender, and medical history (anamnesis).

VP case flow chart

Within each VP case, students were presented with a scenario related to neck cancer. Figure  3 shows the chart of a VP case. Each case starts with an overview of the patient and their medical history which students had to use to make an initial assessment. After this, students encountered a mix of multiple-choice and open-ended practice questions. These questions guided students in planning diagnostics, formulating a diagnosis, and devising a treatment plan tailored to the patient’s specific needs. Immediate feedback was provided after students submitted each response, and comprehensive summative feedback was given at the conclusion of each case to foster understanding and learning from any potential misjudgments or oversights (See Appendix 4 ).

Measurement instruments

Learning-perception survey : The survey (Appendix 1 ) consisted of 20 items, structured into five primary sections: general experience, intended learning outcome, role modeling, practicing with various authentic cases, and reflection on peer dialogue around feedback. The first item asked about students’ general experience through the whole session. The second item focused on their perception of intended learning outcomes. Six items then focused on the students’ perceptions of learning through role modeling followed by 5 items addressing perceptions related to their learning on practicing with authentic cases. The final seven items explored students’ perception of learning from dialogue around feedback. Participants indicated their level of agreement for each statement using a 5-point Likert scale: 1 denoting “Strongly Disagree”, 2 for “Disagree”, 3 for “Neutral”, 4 for “Agree”, and 5 for “Strongly Agree”. For interpretation, average scores below 3 were considered as “in need for improvement”, those of 4 or higher as ‘good’, and those between 3 and 4 as ‘neutral’.

Focus group interviews : Three focus group interviews (Appendix 3 ) were conducted to dive deeper into students’ perceptions of their learning experience, knowledge gain, and knowledge transfer in real-world settings. The focus group took place after the survey and the survey data did not affect the development of the focus group questions. In focus group 1, two students, in focus group 2, two students and in focus group 3, five students participated. The interviews were structured around a series of questions that explored students’ perceptions of their learning across specifically designed sections. These sections included Role Modeling, Practice with Various Authentic Cases, and Dialogue around Feedback. The structure aimed to understand students’ perspectives on each key component of the learning sections.

The analysis of the survey data was conducted by calculating the mean, standard deviation, and the Alpha Coefficient for the responses pertaining to each of the five key dimensions of the survey. The mean score provided an indicator of the average student perception, while the standard deviation offered insights into the variability of the responses. The Alpha Coefficient, a measure of internal consistency, was computed to assess the reliability of the survey dimensions. Through these statistical measures, an overall understanding of the students’ perceptions regarding the various aspects of the Virtual Patients was attained, facilitating a robust analysis aligned with the research objectives.

The focus-group interview data were analyzed following the thematic analysis procedure set out by Braun and Clarke [ 24 ]: (1) familiarize yourself with your data, (2) generate initial codes, (3) search for themes, (4) review themes, (5) define and name themes, and (6) produce the report. The interview was guided by pre-existing frameworks or theories in medical education. This ensured the capture of major aspects of the VP learning experience as underscored in the existing literature: role modeling, using various authentic cases, and peer dialogue around feedback [ 16 , 17 , 18 , 20 , 21 ]. The focus group interview was recorded, transcribed, and coded by three team members and ordered in initial themes (Z.L, M.A, and X.L). These themes were discussed with the larger team. We used a process of inductive and deductive analysis and used the three design principles of role modeling, practice with various authentic cases, and group discussion on feedback as sensitizing concepts to study the data [ 24 ]. Thereafter, quantitative and qualitative analyses were collectively appraised, compared, and checked for inconsistencies. In this triangulation, the themes identified in focus-group interviews were explanatory to the descriptive statistics of the survey.

Trustworthiness

Several measures were taken to enhance the study’s trustworthiness. First, triangulation was achieved by employing multiple data collection methods, including surveys and focus group interviews. The interview data collection continued until saturation was reached, ensuring a comprehensive understanding of the student’s experiences and perceptions. Secondly, the coding process followed an iterative approach. Team members initially coded transcripts independently, and then met to reach a consensus before moving on to code subsequent transcripts. Three researchers conducted the coding independently to minimize bias and enhance the validity of the findings. Finally, a member check among a sample of the focus group interviewees was conducted. In response to the question asking whether they agreed with summaries of preliminary results and would provide comments, confirmatory responses were received as well as some minor additional comments and clarifications. The latter were taken into account in the analysis and interpretation of the data.

Ethical approval

The Maastricht University Ethical Committee reviewed and approved this study. The approval number is FHML-REC/2023/021.

The findings from both the survey data and focus group interviews were presented to explore students’ perceptions of the effectiveness of the Virtual Patient (VP) Session in enhancing their clinical reasoning skills.

Survey data

The survey explored students’ perceptions across five key dimensions: General Experience, Intended Learning Outcome, Role Modeling, Practicing with Various Authentic Cases, and students’ reflection on Peer Dialogue around Feedback. The students scored the VP sessions on 20 items (Table  1 ). The scores varied between M = 2.95 to M = 4.58, on a scale of 1–5.

For the General Experience of Virtual Patient Session (Items Q1-Q2) the average score was M = 4.13 (SD = 0.70). Specifically, the overall experience was positively rated at M = 4.11. The component that assessed the improvement of clinical reasoning skills received an average score of M = 4.16.

Regarding the Students’ Perception of Learning from Role Modeling (Items Q3-Q8), the average score was M = 4.38 (SD = 0.61). Students agreed that the expert demonstration at the start of the session helped them understand the intended learning outcomes and was useful in guiding them through the Virtual Patient cases, with scores ranging from M = 4.26 to M = 4.58.

Students’ perception of learning from practicing with various authentic cases (Items Q9-Q13), received an average score of M = 4.00 (SD = 0.86). The scores measured the students’ perception of how well the provided Virtual Patient cases matched their current level of understanding, enhanced their comprehension of the subject matter, and helped them grasp the complexities inherent in real-world clinical scenarios.

For their perception of learning from Peer Dialogue around Feedback (Questions 14–20), the average score was M = 3.24 (SD = 1.05). These scores measure the students’ perception of the effectiveness of peer dialogue in enhancing understanding, generating strategies to address feedback, and prioritizing areas of improvement.

Focus group interview data

The interviews revealed five themes: ' Which steps to take in clinical reasoning’, ' Asking challenging questions to enhance deeper understanding of knowledge’, ‘The variety in cases helps to enhance transfer to the real world’, and ‘Deeper understanding of reasoning through reflections’.

Which steps to take in clinical reasoning

Students acknowledged the expert’s initial demonstration helped them to develop structured knowledge and gain understanding of the clinical reasoning process.

I think it (Role modeling) helps to find a pattern in clinical reasoning as well. At first, it (the expert) explained to us. For example, are there possible lymph nodes? Yes or no. Then you need to do this and this…Then you can make kind of…pattern that differs for the diagnosis and the prognosis. So you can make kind of a diagram in your head. Which you can use later on. And your knowledge becomes more structured. (Focus Group 2, Student B)

Students also perceived that the integrated practice with Virtual Patients helped them to anticipate the subsequent steps in clinical reasoning. They indicated the patterns learned through practicing with virtual Patients helped them understand the procedures they needed to follow to evaluate the patient.

I think now I know the steps which they (the procedural) followed to evaluate the patient, so first we can do this and then that. First, you determine the TNM (Tumour, Node, Metastasis) staging and do the endoscopy, then the TNM staging, and then you make the treatment plan. Now it’s more clear how they do those steps. (Focus Group 1, Student A)

Moreover, students thought the pair work and dialogue helped them think and clarify with each other what steps they needed to do in clinical reasoning when they had different opinions.

Yeah, that (pair working) was really nice because you can discuss, like I think do this and the other one says, you know, I think do that step, and then you’re already discussing the answers which is really nice to have. (The discussion) really make you think about the steps. (Focus Group 1, Student b)

Challenging their reasoning to enhance deeper understanding

Students reported how the course design differed from other blocks. According to the students, the VP practice was particularly beneficial in helping them integrate knowledge, and make the knowledge their own.

It (the VP practice) helps you to integrate knowledge because other blocks are really only lectures, they are all listening and listening. So the virtual patient was really nice to make this stuff our own. (Focus Group 2, Student A)

Students indicated the examples given by the expert helped them get a better understanding of the more detailed TNM (Tumor, Node, Metastasis) table, that are used in clinical reasoning.

Yeah, she (the expert) gave examples and guided the reading of the tables for TNM (Tumor, Node, Metastasis) staging, and those were also in the Virtual Patient cases, but because she already used them once and explained how we have to use them, it became more clear to us, what these tables are for and how they are used (Focus Group 1, Student B) .

The students noted that in VP practice sessions, compared with passive learning in traditional lectures, they were challenged to engage directly with the material by making clinical decisions, such as selecting appropriate tests to reach a diagnosis.

In lectures, we passively learn the trajectory from symptoms to diagnosis. During Virtual Patient practice, we actively process it. So you have to make decisions and select the test etc. (Focus Group 2, Student B)

Students indicated that practicing with the VP cases challenged them to look up information and reasoned by themselves. They gave an example of the imaging practice in which they were tasked with examining specific body parts in medical images on their own, they thought they were challenged to reason about what they saw instead of getting the information directly.

Yeah, also the (medical) imaging in the assignments where you need to look at a specific part of the body, normally you just see a picture and someone says, yeah, this is the stomach or this is the heart, whatever, and now you need to look it up yourself and think about it yourself, what you see, so that really helps. (Focus Group 1, Student B)

Furthermore, they emphasized the questions asked by experts challenged them to think, put the knowledge in their own words and apply the knowledge with their own reasoning.

The questions she (the expert) asked really make you think about the things she’s learning(teaching). So if she asks questions, you’re really thinking, and yeah, you’re challenged to put it in your own words. (Focus Group 1, Student B) For instance, she (the expert) asked questions that not from official guidelines, instead, it came from where widely doctor worked and her personal experiences. I applied what she said with my own reasoning behind it. (Focus Group 2, Student B)

Transfer of knowledge

Students perceived that practicing with VP cases in different situations offered them hands-on experience, where they actively engaged with various situations, which prepared them for future patient interactions.

Having cases that are closer to the real world, like the comorbidity we discussed, would make it more realistic. (For instance, ) What if he also has obesity or diabetes? Those are the patients that we are going to see in the future. So it helps out a lot to have those different conditions as well. (Focus Group 2, Student B)

Students also indicated their preference for the structured approach of the VP session, where an initial demonstration by an expert, sharing their clinical experience, followed by hands-on practice with VP cases was perceived to enhance transfer to practice. This method, as described by the student, bridged the gap between theoretical knowledge and practical application. They think this structure made the knowledge clear and further helped them to transfer their knowledge from theory to practice.

You (the Virtual Patient session that integrated with role modeling, authentic VP practice, and peer discussion around feedback) made it (the clinical reasoning) clear for me because of the first case we discussed with the teacher. Well, he discussed it and showed us how to think, and how to get things from certain perspectives with risk factors, age, et cetera. And then we do it ourselves. We had to find out what was wrong and go on. So I quite liked it. It gave me a deeper understanding. (Focus Group 3, Student A)

Students indicated the sense of practical immersion is amplified by the “side information that you don’t really need” (Focus Group 3, Student E) from the cases. They highlighted the side information represented the interaction with real patients and made them think of clinical situations in real-world settings.

(Side) information would be more realistic, also side information that you don’t really need because a patient also tells you a lot of things, and some of those things aren’t as important, but you still need to decide if they are important or not. What do you see, why do you see it, what’s different than normal. (Focus Group 3, Student E)

Moreover, several students indicated that the hypothetical “what-if” discussions during the role modeling session helped them with reasoning, prompting them to consider complications that might arise in real-life medical situations.

So for example, about age, it’s more difficult to do a treatment above 70. (What if that patient) has things like smoking history and that kind of stuff. I think it’s really valuable because you have already had an example about it (Demonstrating Case A). (Focus Group 1, Student A)

Students indicated that the diagnosis practice in VP led them to realize the difference in real-world scenarios. They said while in the simulated environment might seem easy to choose multiple diagnostic options, in the real world, medical professionals must make more selective decisions due to limitations. They think this experience taught them to think of prioritizing and decision-making in a realistic medical setting.

Yeah, maybe also there (in VP cases) were also a question about which imaging techniques you would use and then it was Echo or CT, MRI, there was also an option where you could listen to the lungs and some of the people also checked that one, but it isn’t really necessary, so you think it only takes one minute, so why not, but in the real world there isn’t always time to do everything, so it’s also good to think what is really necessary and what’s not. (Focus Group 1, Student A)

Enhance reasoning through reflections

During the VP session, students received feedback and conducted conversations around the feedback provided by the Virtual Patient system. Students thought the peer dialogues around feedback provided opportunities for collective reflection and insights, allowing them to pinpoint areas of improvement.

I thought that (the peer dialogue) was really useful, because sometimes one person, for example, when the teacher explains everything, you don’t pick up everything he says. She (your peer) might pick up a different thing, and I pick up a different thing, and we can ask each other, do you know how this works? So I thought that was really useful. (Focus Group 3, Student B)

The students emphasized the importance of expressing and discussing different opinions. They noted that such interactions could provide new insights and perspectives that they would not have considered independently, thereby enriching their understanding.

When you do have different opinions, I think they (your peers) can give you insight that you maybe didn’t have for yourself. So you can add to each other’s knowledge. If somebody has another view, then we can discuss it. It (the discussion) brightens my tunnel view. Also having to say it (the knowledge) out loud and explaining your thoughts to someone else can also help, I think. (Focus Group 2, Student A)

When talking about the peer dialogues around feedback during the VP session, Some students highlighted the benefits of immediate feedback, which provided them with clarity and instant validation. However, others saw value in delayed feedback, as it fostered discussion and multiple interpretations.

I liked that the Virtual Patient program, that it gave you immediate feedback. That was really handy. And I also liked the discussion afterward so we could speak about it a bit more (Focus Group 3, Student B) . There was immediate feedback on most questions, so you knew if you had been correct or wrong. But for the learning process it might be handy to have that after the group discussion, because now we all have the same answer. (Focus Group 2, Student B)

The study demonstrated the perception of students’ learning and knowledge transfer by integrating VP cases with role modeling introductions, and peer dialogue around feedback, specifically in the context of personalized medicine in cancer treatment and care. The survey reflected a positive learning experience and students reported they gained a better understanding of the clinical reasoning process as well as which steps to take when dealing with a clinical case through this specific course design with integration of VP cases. Qualitative data showed that the integration of VPs into the educational setting clearly shifted the students from being passive observers in a traditional lecture-based format to active participants in a simulated clinical environment. This shift is in line with previous research findings, which suggest that the use of VPs in clinical training actively engages learners and encourages the application of their knowledge [ 4 ].

The quantitative data revealed that students highly valued the role modeling session, as indicated by the high average scores. Qualitative data explained that the role modeling session enabled students to not only observe the clinical process being demonstrated but also to engage in active thinking by interacting with the expert. As discussed by Cruess, Cruess [ 15 ], role modeling not only consciously imparts knowledge but also unconsciously influences students’ attitudes and behaviors, making the learning experience more relatable to the clinical environment. In this study, by sharing clinical reasoning and personal anecdotes during the class, experts made the learning experience more relatable to the clinical environment that students would face in the future. This mirrored the role modeling research by Morgenroth, Ryan [ 25 ] which emphasizes the importance of role models in shaping the self-concept and motivation of individuals. Moreover, the qualitative data showed that the demonstration by the expert serves as a fundamental pre-knowledge for students to cover the knowledge gap and prepare them with the following practice. This finding aligns with van Merrienboer’s scaffolding concept emphasizing the importance of initial expert guidance in learning processes [ 16 ].

Followed by the role modeling demonstration, students practiced on two VP cases in pairs and perceived that the VP practice enhanced their clinical reasoning skills, and also helped them understand the real-world clinical setting. The result showed that the variety and real-life complexity of cases in the VP sessions were perceived to be essential for students’ knowledge gain and transfer. The positive perception of various authentic cases aligns with previous research highlighting the importance of exposure to diverse and authentic scenarios in medical training [ 17 , 18 ]. Moreover, the hypothetical “what-if” scenarios further enhanced students’ analytical abilities, preparing them for the multifaceted challenges they would encounter in real-world medical situations. Survey responses (Q10, mean = 4.37; Q13, mean = 4.05 in Table  1 ) indicated a consensus among students on the improvement with this practice in understanding and applying knowledge. Our findings corroborate with Jonassen and Hernandez-Serrano [ 26 ]’s study emphasis on the importance of authentic learning environments for effective knowledge transfer.

After the practice, students discussed the feedback provided by the VP system. Despite its mixed quantitative reception, the peer dialogue on feedback was qualitatively found to be a vital component for promoting critical thinking, discussion, and reflection. The Feedback from the VPs, both immediate and delayed, along with peer dialogue, emerged as crucial elements in students’ learning process. In this study, students showed different preferences for receiving feedback. Some students preferred immediate feedback, however, others preferred delayed feedback. How feedback was provided notably influenced peer interactions. Given that immediate feedback was dispensed upon submission of answers, the peer dialogues automatically started when students noticed disparities or encountered obstacles. Such dialogues not only served to resolve ambiguities but also fostered collective reflection, enhancing comprehension of the subject. By vocalizing their thoughts and engaging in active discussions, students were able to solidify their understanding and uncover nuances they might have missed otherwise. This aligns with the importance of engaging in peer discussions on feedback as outlined in the theoretical background [ 20 , 21 , 22 ].

When looking at the integration of VP cases with the particular course design, students perceived that the expert demonstration, followed by VP practice, and peer dialogue around feedback fostered a comprehensive understanding, allowing them to integrate diverse clinical knowledge, which in turn promoted understanding. The “Watch-think-do-reflect” structure not only ensured better knowledge retention but also enhanced students’ enthusiasm towards the subject. Observing model demonstrations enabled students to assimilate clinical nuances and contemplate real-world applications. Subsequent hands-on practice with VP cases fortified their cognitive structures, honing their clinical reasoning. Ultimately, students perceived that reflective peer discussions on feedback solidified their learnings, enhancing knowledge retention.

Limitations

This study employed a survey and focus group interviews that provided a comprehensive understanding of students’ perceptions of learning. However, there are several limitations. The study had a small sample size and was conducted in the context of an elective course, which may limit the generalizability of the findings. Furthermore, the study was exploratory in nature and did not measure actual learning outcomes or long-term retention, which are critical aspects of educational impact.

Implications for future research

Future research should investigate whether integrating Virtual Patients (VPs) into classroom activities enhance student learning outcomes by incorporating learning assessments and involving larger and more diverse participant groups to validate our findings. Additionally, a deeper analysis of students’ reasoning processes and interactions could provide insights into how and why knowledge gain and transfer are fostered or hindered. Furthermore, it is also important to understand the most beneficial moment for integrating VPs into educational settings to enhance transfer from a simulated to a real practice setting. This understanding could inform the development of more effective educational strategies and interventions.

The integration of Virtual Patients into classroom learning appears to offer a promising approach to enrich medical education. Key elements such as role modeling and various authentic cases contribute positively to students’ perception of learning, as well as peer dialogue on feedback. However, the approach to peer dialogue on feedback may need to be refined for more consistent benefits. Furthermore, studies with larger sample sizes and broader participant groups are essential to provide robust support for the efficacy of this educational approach and its components.

Data availability

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Cook DA, Triola MM. Virtual patients: a critical literature review and proposed next steps. Med Educ. 2009;43(4):303–11.

Article   Google Scholar  

Garrett BM, Callear D. The value of intelligent multimedia simulation for teaching clinical decision-making skills. Nurse Educ Today. 2001;21(5):382–90.

Peddle M, Bearman M, Nestel D. Virtual patients and nontechnical skills in undergraduate health professional education: an integrative review. Clin Simul Nurs. 2016;12(9):400–10.

Sanders CL, Kleinert HL, Free T, Slusher I, Clevenger K, Johnson S, et al. Caring for children with intellectual and developmental disabilities: virtual patient instruction improves students’ knowledge and comfort level. J Pediatr Nurs. 2007;22(6):457–66.

Sijstermans R, Jaspers MWM, Bloemendaal PM, Schoonderwaldt EM. Training inter-physician communication using the dynamic patient Simulator®. Int J Med Informatics. 2007;76(5):336–43.

Buttussi F, Chittaro L. Effects of different types of virtual reality display on presence and learning in a safety training scenario. IEEE Trans Vis Comput Graph. 2017;24(2):1063–76.

Makransky G, Bonde MT, Wulff JS, Wandall J, Hood M, Creed PA, et al. Simulation based virtual learning environment in medical genetics counseling: an example of bridging the gap between theory and practice in medical education. BMC Med Educ. 2016;16(1):1–9.

Verkuyl M, Hughes M, Tsui J, Betts L, St-Amant O, Lapum JL. Virtual gaming simulation in nursing education: a focus group study. J Nurs Educ. 2017;56(5):274–80.

Burke LA, Hutchins HM. Training transfer: an integrative literature review. Hum Resour Dev Rev. 2007;6(3):263–96.

Durning SJ, Artino AR Jr, Schuwirth L, Van Der Vleuten C. Clarifying assumptions to enhance our understanding and assessment of clinical reasoning. Acad Med. 2013;88(4):442–8.

Marei HF, Donkers J, Al-Eraky MM, van Merrienboer JJ. The effectiveness of sequencing virtual patients with lectures in a deductive or inductive learning approach. Med Teach. 2017;39(12):1268–74.

Marei HF, Donkers J, Al-Eraky MM, Van Merrienboer JJ. Collaborative use of virtual patients after a lecture enhances learning with minimal investment of cognitive load. Med Teach. 2019;41(3):332–9.

Tolsgaard MG, Jepsen RM, Rasmussen MB, Kayser L, Fors U, Laursen LC, et al. The effect of constructing versus solving virtual patient cases on transfer of learning: a randomized trial. Perspect Med Educ. 2016;5:33–8.

Burgess A, Oates K, Goulston K. Role modelling in medical education: the importance of teaching skills. Clin Teach. 2016;13(2):134–7.

Cruess SR, Cruess RL, Steinert Y. Role modelling—making the most of a powerful teaching strategy. BMJ. 2008;336(7646):718–21.

Van Merriënboer JJ, Kirschner PA. Ten steps to complex learning: a systematic approach to four-component instructional design: Routledge; 2017.

Google Scholar  

Berman NB, Durning SJ, Fischer MR, Huwendiek S, Triola MM. The role for virtual patients in the future of medical education. Acad Med. 2016;91(9):1217–22.

Lowell VL, Yang M. Authentic learning experiences to improve online instructor’s performance and self-efficacy: the design of an online mentoring program. TechTrends. 2023;67(1):112–23.

Sevy-Biloon J, Chroman T. Authentic use of technology to improve EFL communication and motivation through international language exchange video chat. Teach Engl Technol. 2019;19(2):44–58.

Dmoshinskaia N, Gijlers H, de Jong T. Giving feedback on peers’ concept maps as a learning experience: does quality of reviewed concept maps matter? Learn Environ Res. 2022;25(3):823–40.

Foster A, Chaudhary N, Kim T, Waller JL, Wong J, Borish M, et al. Using virtual patients to teach empathy: a randomized controlled study to enhance medical students’ empathic communication. Simul Healthc. 2016;11(3):181–9.

Schillings M, Roebertsen H, Savelberg H, Whittingham J, Dolmans D. Peer-to-peer dialogue about teachers’ written feedback enhances students’ understanding on how to improve writing skills. Educational Stud. 2020;46(6):693–707.

Stalmeijer RE, Dolmans DH, Snellen-Balendong HA, van Santen-Hoeufft M, Wolfhagen IH, Scherpbier AJ. Clinical teaching based on principles of cognitive apprenticeship: views of experienced clinical teachers. Acad Med. 2013;88(6):861–5.

Braun V, Clarke V. Using thematic analysis in psychology. Qualitative Res Psychol. 2006;3(2):77–101.

Morgenroth T, Ryan MK, Peters K. The motivational theory of role modeling: how role models influence role aspirants’ goals. Rev Gen Psychol. 2015;19(4):465–83.

Jonassen DH, Hernandez-Serrano J. Case-based reasoning and instructional design: using stories to support problem solving. Education Tech Research Dev. 2002;50(2):65–77.

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Acknowledgements

Thanks to all the participants and education workers who contributed to the study. ZL was supported by a scholarship granted by the China Scholarship Council. Thanks for the support of my family, and thanks Ang Li for joining our family.

ZL was supported by a scholarship granted by the China Scholarship Council (CSC, 202208440100).

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ZL, MA, DD, and NJ conceived of the presented idea. MA and DD verified the analytical methods. TK and ZL contribute to the creation of learning materials. ZL analyzed the data and drafted the manuscript under the supervision of MA and DD. All authors contributed to the article and approved the submitted version.

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Li, Z., Asoodar, M., de Jong, N. et al. Perception of enhanced learning in medicine through integrating of virtual patients: an exploratory study on knowledge acquisition and transfer. BMC Med Educ 24 , 647 (2024). https://doi.org/10.1186/s12909-024-05624-7

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DOI : https://doi.org/10.1186/s12909-024-05624-7

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Chevron corporation's (nyse:cvx) intrinsic value is potentially 59% above its share price, key insights.

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The US$184 analyst price target for CVX is 25% less than our estimate of fair value

In this article we are going to estimate the intrinsic value of Chevron Corporation ( NYSE:CVX ) by projecting its future cash flows and then discounting them to today's value. Our analysis will employ the Discounted Cash Flow (DCF) model. Models like these may appear beyond the comprehension of a lay person, but they're fairly easy to follow.

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A DCF is all about the idea that a dollar in the future is less valuable than a dollar today, and so the sum of these future cash flows is then discounted to today's value:

10-year free cash flow (FCF) forecast

("Est" = FCF growth rate estimated by Simply Wall St) Present Value of 10-year Cash Flow (PVCF) = US$179b

After calculating the present value of future cash flows in the initial 10-year period, we need to calculate the Terminal Value, which accounts for all future cash flows beyond the first stage. The Gordon Growth formula is used to calculate Terminal Value at a future annual growth rate equal to the 5-year average of the 10-year government bond yield of 2.4%. We discount the terminal cash flows to today's value at a cost of equity of 7.6%.

Terminal Value (TV) = FCF 2033 × (1 + g) ÷ (r – g) = US$28b× (1 + 2.4%) ÷ (7.6%– 2.4%) = US$563b

Present Value of Terminal Value (PVTV) = TV / (1 + r) 10 = US$563b÷ ( 1 + 7.6%) 10 = US$272b

The total value, or equity value, is then the sum of the present value of the future cash flows, which in this case is US$450b. To get the intrinsic value per share, we divide this by the total number of shares outstanding. Compared to the current share price of US$153, the company appears quite undervalued at a 37% discount to where the stock price trades currently. Remember though, that this is just an approximate valuation, and like any complex formula - garbage in, garbage out.

The Assumptions

The calculation above is very dependent on two assumptions. The first is the discount rate and the other is the cash flows. You don't have to agree with these inputs, I recommend redoing the calculations yourself and playing with them. The DCF also does not consider the possible cyclicality of an industry, or a company's future capital requirements, so it does not give a full picture of a company's potential performance. Given that we are looking at Chevron as potential shareholders, the cost of equity is used as the discount rate, rather than the cost of capital (or weighted average cost of capital, WACC) which accounts for debt. In this calculation we've used 7.6%, which is based on a levered beta of 1.125. Beta is a measure of a stock's volatility, compared to the market as a whole. We get our beta from the industry average beta of globally comparable companies, with an imposed limit between 0.8 and 2.0, which is a reasonable range for a stable business.

SWOT Analysis for Chevron

Debt is not viewed as a risk.

Dividends are covered by earnings and cash flows.

Earnings declined over the past year.

Dividend is low compared to the top 25% of dividend payers in the Oil and Gas market.

Opportunity

Annual earnings are forecast to grow for the next 3 years.

Good value based on P/E ratio and estimated fair value.

Annual earnings are forecast to grow slower than the American market.

Looking Ahead:

Whilst important, the DCF calculation ideally won't be the sole piece of analysis you scrutinize for a company. It's not possible to obtain a foolproof valuation with a DCF model. Instead the best use for a DCF model is to test certain assumptions and theories to see if they would lead to the company being undervalued or overvalued. For instance, if the terminal value growth rate is adjusted slightly, it can dramatically alter the overall result. Can we work out why the company is trading at a discount to intrinsic value? For Chevron, we've compiled three important items you should consider:

Risks : Take risks, for example - Chevron has 2 warning signs we think you should be aware of.

Management :Have insiders been ramping up their shares to take advantage of the market's sentiment for CVX's future outlook? Check out our management and board analysis with insights on CEO compensation and governance factors.

Other High Quality Alternatives : Do you like a good all-rounder? Explore our interactive list of high quality stocks to get an idea of what else is out there you may be missing!

PS. The Simply Wall St app conducts a discounted cash flow valuation for every stock on the NYSE every day. If you want to find the calculation for other stocks just search here .

Have feedback on this article? Concerned about the content? Get in touch with us directly. Alternatively, email editorial-team (at) simplywallst.com. This article by Simply Wall St is general in nature. We provide commentary based on historical data and analyst forecasts only using an unbiased methodology and our articles are not intended to be financial advice. It does not constitute a recommendation to buy or sell any stock, and does not take account of your objectives, or your financial situation. We aim to bring you long-term focused analysis driven by fundamental data. Note that our analysis may not factor in the latest price-sensitive company announcements or qualitative material. Simply Wall St has no position in any stocks mentioned.

Have feedback on this article? Concerned about the content? Get in touch with us directly. Alternatively, email [email protected]

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• Open access
• Published: 20 June 2024

Motives and modifying factors for giving or rejecting psychiatric diagnoses in general medicine and psychiatry – a qualitative interview study

• Hannah Tebartz van Elst   ORCID: orcid.org/0009-0003-8392-4080 1 ,
• Claudia Niehoff 1 &
• Jost Steinhäuser 1  

BMC Psychiatry volume  24 , Article number:  461 ( 2024 ) Cite this article

Metrics details

There is a discussion among general practitioners and psychiatrists regarding over-diagnosing versus under-reporting of psychiatric diagnoses. A deeper understanding of this topic is relevant for providing reasonable health care and for planning future studies. A crucial factor to understanding this discussion is the difference in the prevalence of a disease in each sector. One way to attain knowledge about such prevalences is the analysis of routine care data of the sector in question. However, diagnosis-related data might be modified by several additional influencing factors.

This study aims to explore what kind of motives and modifying factors play a role for or against giving psychiatric diagnoses in psychiatric and general medical settings.

Twenty-six semi-structured interviews were conducted with German physicians in the fields of general medicine and psychiatry. Interviews were analysed using content analysis.

The analysis revealed three major motivational categories for finding a diagnosis: (1) “objective matters” such as “categorisation for research”; (2) “functional and performance-related factors” such as “requirement for medication”, “billing aspects” that go with certain diagnoses or “access to adequate care” and (3) “Individual factors” such as the “personality of a physician”. Similarly, factors emerged that lead to not making psychiatric diagnoses like “fear of stigmatization among patients” or “detrimental insurance status with psychiatric diagnosis”. Additionally participants mentioned other reasons for “not diagnosing a psychiatric diagnosis“, such as “coding of other clinical pictures”.

The diagnostic process is a complex phenomenon that goes far beyond the identification of medical findings. This insight should be considered when processing and interpreting secondary data for designing health care systems or designing a study.

Peer Review reports

It is generally assumed that a medical diagnosis identifies a fact or names a condition or a disease, which then forms the basis for further treatment. In practice, however, the process of making a diagnosis is not exclusively based on empirical facts but depends on multiple factors. They may depend on the disease concept of the physician or of the patient, the physician’s overall diagnostic goal, the physician’s age and general diagnostic style and behavior, the consideration of what the impact of the diagnosis on the patient might be and aspects of the health care system [ 1 , 2 , 3 , 4 , 5 , 6 ].

Other relevant aspects might also influence a diagnosis, such as concerns about causing fear in patients or the fear of stigmatizing consequences [ 7 , 8 ]. Furthermore, the problem of “diagnostic uncertainty”, which may lead to a diagnosis not being made is also known [ 9 ].

Psychiatric diseases are of particular relevance, since their definition and detection are complex and more affected by the personal beliefs and attitudes of physicians and the background of patients [ 4 , 10 , 11 , 12 , 13 ].

The majority of people with mental health problems and potentially diagnosable mental disorders see and are treated by general practitioners (GPs) [ 14 ]. Studies show that in Germany, depending on the psychiatric diagnosis, 55–97% of patients with mental disorders are treated by GPs exclusively and are not seen by specialists [ 15 ].

Within the specialist field of psychiatry, there is concern regarding over-diagnosing [ 16 ]. Some authors pose the question of whether the harm of psychiatric over-diagnosis may outweigh the benefits [ 17 , 18 ] and whether physicians may struggle to distinguish between mental illness and typical behavior [ 19 , 20 ].

In contrast in the past, studies addressed whether or not GPs under-diagnose psychiatric diseases [ 21 , 22 , 23 ].

The German healthcare system operates on a social insurance model, funded through dedicated contributions [ 24 ]. Depending on their income, patients have the freedom to choose between statutory and private health insurance companies, as well as their preferred physicians in primary (general) or secondary (specialist) health care sector. Consultations with GPs or psychiatrists are covered by the respective insurance. The doctors’ remuneration is determined primarily by the contact with the patient and is financed by the Association of Statutory Health Insurance Physicians [ 5 ]. The amount of money that might be earned is budgeted for each specialty. However, diagnoses nonetheless are an important justification for billing a contact. In Germany, psychiatric diagnoses are coded under the International Statistical Classification of Diseases and Related Health Problems (ICD-10) [ 25 ], commonly referred to as “F-diagnoses”.

One obvious way to explain differences in experiencing over- or under-diagnosing from the perspective of a different specialty is that diagnostic and testing procedures used in the specialized field of psychiatry are not directly transferable to the prevalences in primary care. Since the prevalence of psychiatric disorders is considerably lower in the general practice setting, the false positive rate for screening tests is significantly higher [ 26 ]. For example when using a test validated in a specialized psychiatric setting in the more low-prevalence range of GPs, only one third of those diagnosed by the instrument are actually ill [ 23 ].

There is a considerable amount of literature dealing with the topic of psychiatric diagnoses per se (see additional file 1 in supplement ).

However, to meet the demands in mental health care, a profound knowledge about prevalences is necessary. Apart from specific research projects, routine care data to analyze the prevalences of diseases are still in their infancy in Germany [ 27 , 28 , 29 ].

The goal of this study was to identify reasons and motives for giving or rejecting psychiatric diagnoses in the different settings of GPs and psychiatrists. The rationale for this was that with a better understanding of the process of diagnosis, the understanding of routine care data as a source for the assessment of prevalence of psychiatric diseases as well as designing studies will improve.

To identify theoretical concepts from the literature, publications related to the topic were screened (for details see additional file 1 in supplement ) and complemented by searching cross references, internet browsers and e-books.

The following basic hypotheses were the basis of the semi structured guiding questions:

In addition to identifying a medical condition or illness, other factors play a qualitatively relevant role in the diagnosis of psychiatric disorders [ 30 ].

There are also specific reasons for not making such diagnoses, even though they would be indicated from a medical point of view [ 31 ].

The questions of the interview guide were therefore derived from informed concepts in the literature search as seen in the additional column in Table  1 and complemented by the authors own experiences (HTVE, medical student and doctoral thesis candidate; CN, MD and GP trainee; JS, GP and experienced in qualitative research).

The interview guideline covered aspects that might influence the process of assigning a psychiatric diagnosis. Open questions were formulated to allow detailed and rich responses by the physicians.

The interview guideline was revised by two experienced researchers in the field and finalized to include 12 questions (for details see Table  1 ).

We conducted semi-structured interviews focusing on the dynamics of physicians’ diagnostic processes in generating psychiatric diagnoses. For this study we let ourselves be guided by the COREQ-checklist (Consolidated Criteria for Reporting Qualitative Studies). The motives behind those dynamics were explored using the principles of the qualitative content analysis as described by Mayring [ 38 ].

Participant selection and recruitment

Physicians from the fields of psychiatry and general medicine were informed about the option to participate in the study both verbally (e.g. at the Congress of the German College of General Practice and Family Physicians in the year 2021) and by mail via a convenient network of colleagues in three German states (Baden-Württemberg, Bavaria, Schleswig-Holstein). Apart from this convenient sampling approach, a snowball system was also used. The main aim was to reach an equal number of psychiatrists and GPs.

Interview procedure

Telephone interviews were conducted with all participants who got in touch and who signed and returned the consent forms and met the inclusion criteria, such as medical qualification as GP or psychiatrist according to the German medical system and sufficient knowledge of German for the purpose of the interview. The telephone interviews took place from June to December 2021. They were performed by the same researcher (HTVE), who was trained in interviewing by the Institute of Family Medicine in Lübeck. Interviews were recorded with a voice recorder (“Voice Tracer DVT6110”), pseudonymized and transcribed using the transcription software f4 (version 4.2.). Three of the participants knew HTVE. In order to standardize the transcripts, they were created according to the transcription rules of the Institute of Family Medicine at the University of Lübeck. The interviews conducted were scheduled to last 30–45 min.

Data analysis

Subsequently, the transcripts were analyzed based on the principles of content analysis according to Mayring [ 38 ]. The participants quotes were cited to illustrate the results and each quote was identified by a pseudonymized number. The concepts of the interview guide were predetermined and therefore the first step of the analysis was deductive.

The essential content passages were identified and assigned to a main category as a coding unit. The coding unit was defined as a new subcategory or assigned to an existing subcategory. The main categories and subcategories were modified during the process if necessary to improve comprehensibility. It was also possible to develop new main categories and subcategories inductively. At the end of the process, a coding system with new main and sub-categories and corresponding anchor quotations was created. This process was carried out by two scientists independently of each other (HTVE & CN).

Once the development of the category system was complete, all the material marked as relevant in terms of content was reviewed again to ensure that no important content was overlooked in the structured summarization processes. At the end of the evaluation process, the independently created category systems were compared and discussed in a group process with an additional scientist (JS). In several meetings, both systems were discussed in detail, debated and merged in order to develop a final consensus version of the category system. In the course of these sessions, the different categories were assigned to four different thematic areas, which were derived from the main categories and guiding questions.

Ethical considerations

The Ethics Committee of the University of Lübeck approved the ethics application in April 2021 (Az. 21–120).

12 GPs and 14 psychiatrists took part in the study. Five physicians initially interested in the study did not participate, giving no reason. 54% of the participants were female with the average age of the participants being 54 years. On average, participants had 24 years of work experience. Further details of the demographics of our participants are presented in Table  2 .

The interviews lasted 30 min on average. GP interviews lasted 32 min on average (between 19 and 53 min) and psychiatrist interviews lasted 27 min (between 20 and 36 min).

The content analysis of all interviews revealed four major thematic domains: (i) Motives and modifying factors for giving or rejecting a psychiatric diagnosis, (ii) Methodological aspects of finding a diagnostic conclusion, (iii) Subjectively perceived diagnostic and therapeutic expectations in the medical system (physician’s perspective) and respective interprofessional cooperation issues, and (iv) Expectations of patients with psychiatric symptoms in the general medicine and psychiatric setting.

In this paper, we concentrate on the results of the first domain to focus on our main research question. In this domain, we identified three main categories in the process of giving or rejecting a diagnosis with five subcategories illustrated in Fig.  1 and detailed with several codes in Table  3 .

Motives and modifying factors that play a role for giving or rejecting psychiatric diagnoses. Model consisting of main and sub-categories of qualitative content analysis

Motives for diagnosing psychiatric disorders

Three different main categories could be identified that positively motivated physicians to attribute a psychiatric diagnosis:

Diagnosis as an objective matter

In our inductive analysis process, we defined diagnosis as an objective matter related to the determination of a fact. When asked why diagnoses were allocated, some of the responses addressed its objective nature.

In general, diagnoses serve to categorize patients, i.e. disease patterns, in order to distinguish them from one other. Other physicians mentioned that generating a diagnosis is indispensable for international research and communication.

“The aim is to form groups that are as uniform as possible so that they can be researched in the broadest sense.” P11 (P = Psychiatrist) .

Functional and performance-related factors

Functional and performance-related factors refer to different functions resulting from the diagnosis. In this context, it means that the content of the function has an intended mode of action or purpose.

Functional therapeutic factors

Most importantly, the diagnosis was seen as the basis for treatment by some physicians. This means that the diagnosis implicated specific action following guidelines and recommendations for the physicians like medications, illness prescriptions, psychotherapy and much more. Especially the sub-category of diagnosis as a condition for medication was mentioned frequently. In some statements physicians pointed out that there were situations where they were not convinced of the correctness of the diagnosis but still needed it in order to prescribe a certain drug.

“Or he has anxiety attacks that I do not yet consider sufficient to diagnose an anxiety disorder, but feel that I want to give him something for the exam so that he can simply pass it and get over this hurdle, so I make the appropriate diagnosis so that I can prescribe the medication. So that’s a functional diagnosis, if you like, and not a factual one.” P4 .

Functional administrative factors

Administrative tasks involve overseeing and organizing personal affairs or those of someone else, typically within a structured setting such as government agencies or organizations, in this case within the health care system as well as with insurance companies.

A related point was the requirement of a diagnosis for billing purposes from health insurance companies or the Ambulatory Health association, which practically forces physicians to make a diagnosis. Many physicians emphasized that they often felt they had to diagnose diseases they were not convinced of because of this billing pressure.

“Because you are really forced by the system to at least commit to one (…) so you can’t write: he came to see me but I don’t know what he has. That means you can’t bill for that.” P14 . “You can write a suspected diagnosis first. But after a quarter, i.e. after three months, the KV demands that you check it and make a confirmed diagnosis or drop it.” P13 .

(KV ◊ Association of Statutory Health Insurance Physicians)

In the German healthcare system some diagnoses generate more money for the treating physician than other diagnoses, which can lead to incentivization of specific diagnoses.

“And then there was a figure that implied money per patient per quarter if the patient had certain rather more serious diagnoses. Of course, this has, how shall I say, given a slight distortion to the more severe diagnoses.” P1 .

Some GPs emphasized the great influence of administrative needs of insurance companies on allocation of a diagnosis, one example being disability insurance.

“So if someone is unable to work because of a mental illness and this drags on for a certain period of time, then this also forces a diagnosis.” GP2 .

However, health insurers also required psychiatric diagnoses for certain services, which led physicians to make them.

“I can’t code it under a flu-like infection or normal exhaustion R53 for example, it wouldn’t get waved through, so it really has to be an adjustment disorder, it has to be, yes exactly, it has to be an F-diagnosis, so that the health insurance company says: “All right, it’s justified, we’ll pay for the psychotherapy”.” GP12 .

Information-providing factors

The term “information-providing factors” refers to the social or informative benefit for the recipients of the diagnosis, which is created by passing on the diagnosis and the information it contains. This means that the diagnoses include different treatment or therapy options, which can be helpful when communicating with other colleagues, but also with patients, and can help the patient understand more quickly.

“So if I say: “Someone has schizophrenia”, this is different from me saying to a colleague: “He has severe depression with psychotic symptoms”, for example. I think both have psychotic symptoms, but they have a different status and therefore a different value in treatment.” TNP10 .

Another aspect mentioned by the participants was that a psychiatric diagnosis can be a relief not only for the patient but also people around them, such as friends and partners, since the diagnosis may help them understand the patient’s behavior better. As an example, one physician spoke about the relieving effect of a diagnosis for the patient’s relatives, who as a consequence no longer blamed themselves.

Individual factors

Individual factors do not primarily relate to objective facts or specific functions of a diagnosis, but rather to individual framework conditions across situations.

Individual physician-dependent factors

In the interviews, it became apparent that there were also diagnostic styles that differed not only between the two specialist domains, but also within them. Some physicians justified this different way of thinking about and making diagnoses with individual differences of the physicians themselves. As an example, the individual personality of the physician was mentioned. Psychiatrists in particular seemed to have an intrinsic claim to make a diagnosis.

“When I interview someone and want to find out what they have, then for me, somehow the requirement is that I want to have a diagnosis” P5 .

Other structural differences, such as the self-image of the physician to be tolerant towards psychiatric diagnoses, also had an impact on making a diagnosis. Other individual factors were experience and expertise, as well as the generation of the physician.

“For example, with young general practitioners (…) I have the feeling that it is different, that they are already more informed about (…) that psychiatric diagnoses are just more of an option.” P2 .

The school of training also had an effect. In some universities, for example, some diagnoses were categorically excluded, which led the physicians to continue this practice in their later work.

“Well, I grew up as a purely behavioral psychiatrist. Also because I studied in < city>, where psychiatrists and psychosomatics are, at least on the face of it, mortal enemies. And as a consequence, I diagnose very few of these so-called somatoform disorders.” P11 .

One psychiatrist described a situation where other psychiatrists had given a diagnosis of a personality disorder to a difficult patient because they themselves were frustrated with the treatment, and diagnosing a personality disorder offered an excuse for the treatment failure.

“I have also often experienced that specifically borderline disorders, or also narcissistic personality, personality disorders – were given, more as a reaction to the annoyance of dealing with the patient for weeks, that you didn’t get on properly: “Ah, he must have a personality disorder.”” P11 .

Motives for not diagnosing

It also became apparent that there were several motives for not attributing diagnoses.

Objective matters

Many participants criticised the inaccuracy of psychiatric diagnoses as they often represent a mixture of norm variants and disease-like conditions. The different classification systems of the ICD and the Diagnostic and Statistical Manual of Mental Disorders (DSM) and their different categorisations were often cited as evidence of the model-like nature of the diagnostic categories. Syndrome diagnoses, which are common in the psychiatric field, were often taken up as a construct.

“Diagnoses are always, especially in psychiatry (…) almost always syndrome diagnoses, which means that there is often a certain vagueness in it and it is always a construct.” P8 .

Many physicians mentioned the problem that there are no intermediates between normal and pathological ratings in the coding systems. This led to physicians assigning diagnoses that they themselves doubted were real in order to obtain certain services for patients. Some physicians wanted alternative diagnoses that would better reflect these intermediate states.

“If I think that the patient has a condition that, unfortunately, if it were coded, could be a mental disorder, I mean now like a grief reaction or, you can be in a bad mood, that this is then immediately an F-diagnosis, there is nothing that can be coded so reasonably.” GP12 .

Some stated that many clinical pictures to be diagnosed according to the guidelines were often explainable and normal in the individual context. However, the health system would often turn this into a disease by forcing a diagnosis, even though physicians would normally regard this as a normal variant of health.

Some psychiatrists reported that insurance status also influenced whether or not the diagnosis was made. E.g. as patients being privately insured may receive their coded diagnosis with their invoice directly after contacting the physician for billing purposes together with the report on diagnostic findings. Whereas this is not the case for patients with a statutory health insurance.

Many physicians reported that they were cautious when making diagnoses, as the diagnosis could no longer be removed from the insurance companies’ patient records. Access to certain insurances, such as occupational disability or life insurance, could be more difficult or no longer possible. In addition, certain diagnoses can make it more difficult or even impossible to take out a loan or to become a civil servant.

“Then, of course, a confirmed diagnosis from my side would have consequences, not only in terms of stigmatization, but also, for example, for insurance companies or something like that later on. Once something like that is in there, it’s hard to get it out again.” GP2 .

The issue of stigmatization played a major role in the interviews. Physicians from both specialist areas reported that the fear of stigmatization influenced them when making a diagnosis. First, some physicians mentioned that especially the patients were afraid of experiencing stigmatization. At the same time, however, there was also mentioning of potential prejudice by other physicians if they were to read the diagnosis in the patient’s file.

“Let’s say a physiotherapist gets a prescription for physiotherapy and it says: F45.1 chronic pain disorder with psychological stress, then this might prejudice them against the patient.” GP12 .

Alternatives to not diagnosing psychiatric disorders

Because of the above-mentioned stigmatization on many levels, alternative ways of dealing with diagnoses were reported in the interviews. Often, for example, a more harmless diagnosis from the psychiatric classification system was chosen instead of the more valid one:

“Then I do try to merely classify it as an adjustment disorder, which is of course also a psychiatric diagnosis, but certainly the least disabling one for someone when it shows up in the health insurance documentation.” P8 .

Sometimes, however, the physicians chose a completely different diagnosis in order to guarantee the functional goal, e.g. sick leave.

“If I have a student who comes to me with love sickness, then I tell him quite clearly: “I’ll give you (…) a sick note. But I’ll put down stomach pain or flu.” GP12 .

This study supports the assumption that the diagnostic process is a complex phenomenon that goes far beyond the identification of medical facts. It suggests that routine care data, derived from the primary and specialist care system, do have important limitations. This insight needs to be considered when interpreting secondary data.

In our study, three different categories of motives for the diagnosis or non-diagnosis of psychiatric disorders were identified (objective factors, functional and performance-related factors and individual factors).

It is already known that diagnoses may also depend on other factors such as collegial norms, economic incentives, prodigious traditions or expectations of patients [14]. Psychodynamic and phenomenological elements can also play a role in the process between physician and patient when making diagnoses [15]. Therefore, the diagnostic process is much more complex and includes many facets, amongst others the need to understand patients [ 3 , 41 , 42 , 43 , 44 ].

This is an important limitation regarding the understanding of prevalence provided by routine care data in scientific literature. When reading international classification systems such as the ICD-system or the DSM-system [ 45 , 46 ], different S3-guidelines [ 47 ] or standard medical textbooks [ 35 ], reference is basically made to the presence or absence of medical findings when diagnostic entities are operationalized. However, the results of this study suggests that this is not always the case. This illustrates that it might be problematic to regard diagnostic data deriving from the primary and spezialized medical care system as representing true medical fact. The different views on over-diagnosis in specialized psychiatry and under-diagnosis in general medicine mentioned at the beginning [ 9 , 16 , 17 , 19 , 22 , 23 ] could thus be put in a different light. Our results suggest that physicians might be exposed to different influences such as individual or administrative aspects that lead them to make or not make certain diagnoses. Future studies should also address whether the experienced prevalence leads to an additional bias regarding the impression of under- or over-reporting of diagnoses.

A major topic in the interviews was functional and performance-related factors and in particular administrative functions of psychiatric diagnoses. Participants mentioned incentivization and billing implications of a diagnosis, but also referred to it as being a precondition before many health insurance companies will offer certain patient support services. This observation is in line with similar propositions in the literature, where implications of diagnoses for pensions, disability certificates, assessments of degrees of disability, death certificates etc. have been implicated [ 41 ]. It also became clear that individual factors such as individual physician-dependent factors also have an impact on the diagnostic process. This is in line with an Australian study with GPs which also found that diagnoses are highly dependent on individual characteristics of the physicians, such as age, sex and practice organization [ 48 ]. Other studies point out that patient-dependent factors like sex and race may also influence the diagnosis [ 11 , 12 ].

Among the motives found against making a diagnosis, the individual physician-dependent one was particularly prominent. Here, fear of stigmatization at various levels was mentioned many times, which led physicians to either not allocate diagnoses at all or to deviate and trivialize them. The literature confirms the feared stigmatization in various areas of social reality [ 7 , 49 , 50 ] such as the workplace [ 51 , 52 ] as well as experiences of discrimination in different areas of life and interpersonal relationships [ 53 ]. Another study found that physicians too exhibit stigmatizing behavior towards people with psychiatric disorders [ 33 ]. Yet another factor speaking against making psychiatric diagnoses were administrative factors. In this context the negative economic consequences of psychiatric diagnoses, which result from structural disadvantages in the regulations of insurance policies such as private life, health or occupational disability insurance have been pointed out [ 54 ]. In addition, it might well prove impossible to enter certain areas of civil service or specific professions like jobs in the police with such conditions.

It must also be emphasized that some participants reported that higher billing figures for certain diagnoses led them to code more severe diagnoses. However, not all countries rely on a multitude of health insurances, for instance Denmark, Sweden, and Norway. Given these obvious far-reaching detrimental consequences of psychiatric diagnoses, it is remarkable that there is still very little literature on this topic complex. More research is needed to better understand the impact of administrative factors like the incentives of the healthcare system and the influence of insurance conditions on making diagnoses.

If there are differences between the two medical specialties in the way of making a diagnosis, as suggested by research by Davidson and Fosgerau [ 21 ], this should be addressed in future studies.

Strengths and limitations

According to our literature search and to the best of our knowledge, to date there are no comparable studies that have explicitly and empirically dealt with the motives and modifying factors for giving or rejecting psychiatric diagnoses in the settings of psychiatric and GP out-patient care. In terms of socio-demographics, the gender and age distribution of the participants in this study is comparable regarding physicians and their specializations in Germany. Selection bias cannot be ruled out as a convenient sampling method was used. Therefore, participants who had already dealt intensively with the topic of psychiatric diagnoses might have rather participated. The interviewer was familiar with three participants which may have potentially influenced the interview dynamic.

Further quantitative studies could build on our suggested categorical model and extend it to analyze the role of socio-demographic factors or items like further specializations or places of medical training in detail. Due to the methodological limitations, no conclusions can be drawn for Germany or other countries since people in different geographical, social or cultural settings may face different structural and social realities and thus think differently about diagnosing. We can’t rule out that using a different qualitative approach other than telephone interviews e.g. face to face would have led to additional information.

Finally, all researchers are working in the field of family medicine, which might be a source of bias within the analysis due to their generalist perspective.

This study adds further weight to the notion that the diagnostic process is a complex phenomenon that goes far beyond the identification of medical facts or categorical diseases, which is especially clinically important for post-graduate trainees.

We were able to identify three different categories of motives to diagnose or not to diagnose psychiatric disorders (objective matters, functional as well as performance-related factors and individual factors). As a consequence, this may indicate that routine care data should be treated with a degree of caution if used to draw conclusions regarding health care demands or study design.

Also, given that psychiatric diagnoses affect the self-image, identity and self-worth of people much more than most other medical diagnoses, this insight is of utmost importance in general medicine and psychiatry. Stakeholders in the medical system should contemplate this and realize that the diagnostic process also depends on which sector of the medical system they work in.

Data availability

The dataset used and/or analysed during the current study are available from the corresponding author on reasonable request.

Abbreviations

Diagnostic and Statistical Manual of Mental Disordersl

General practitioner

International Statistical Classification of Diseases and Related Health Problems

Kassenärztliche Vereinigung = Association of Statutory Health Insurance Physicians)

Psychiatrist

Balint M. Der Arzt, sein patient und die Krankheit. Zwölfte Auflage. Stuttgart: Klett-Cotta; 2019. 502 S. (Fachbuch Klett-Cotta).

Google Scholar  

Alarcon RD. Culture and psychiatric diagnosis. Impact on DSM-IV and ICD-10. Psychiatr Clin North Am September. 1995;18(3):449–65.

Article   CAS   Google Scholar  

Dunn G. Patterns of psychiatric diagnosis in general practice: the Second National Morbidity Survey. Psychol Med August. 1986;16(3):573–81.

Zaninotto L, Altobrando A. Four Core concepts in Psychiatric diagnosis. Psychopathol 29 Dezember. 2021;55(2):73–81.

Article   Google Scholar  

Blümel M, Spranger A, Achstetter K, Maresso A, Busse R. Health System Review 2020.

Bohman B. Clinicians’ perceptions and practices of diagnostic assessment in psychiatric services. BMC Psychiatry 23 März. 2023;23(1):191.

Farley-Toombs C. The stigma of a psychiatric diagnosis: prevalence, implications and nursing interventions in clinical care settings. Crit Care Nurs Clin North Am März. 2012;24(1):149–56.

Rüsch N, Heland-Graef M, Berg-Peer J. Das Stigma psychischer Erkrankung: Strategien gegen Ausgrenzung und Diskriminierung: wissenschaftsbasiertes Sachbuch. 1. Auflage. München: Elsevier; 2021. 312 S.

Jutel A. Uncertainty and the inconvenient facts of diagnosis. Endeavour. 2021;45.

Choi MR, Eun HJ, Yoo TP, Yun Y, Wood C, Kase M. u. a. The effects of sociodemographic factors on psychiatric diagnosis. Psychiatry Investig September. 2012;9(3):199–208.

DelBello MP, Lopez-Larson MP, Soutullo CA, Strakowski SM. Effects of race on psychiatric diagnosis of hospitalized adolescents: a retrospective chart review. J Child Adolesc Psychopharmacol. 2001;11(1):95–103.

Article   CAS   PubMed   Google Scholar  

Warner R. Racial and sexual bias in psychiatric diagnosis: psychiatrists and other mental health professionals compared by race, sex, and discipline. J Nerv Ment Dis Mai. 1979;167(5):303–10.

Gupta M, Potter N, Goyer S. Diagnostic reasoning in Psychiatry: acknowledging an Explicit Role for Intersubjective Knowing. Philos Psychiatry Psychol 1 März. 2019;26:49–64.

Younès N, Hardy-Bayle MC, Falissard B, Kovess V, Chaillet MP, Gasquet I. Differing mental health practice among general practitioners, private psychiatrists and public psychiatrists. BMC Public Health 7 Oktober. 2005;5:104.

Gaebel W, Kowitz S, Fritze J, Zielasek J. Use of Health Care services by people with Mental Illness. Dtsch Ärztebl Int November. 2013;110(47):799–808.

John Brodersen, Lisa M, Schwartz C, Heneghan J, William O’Sullivan JK, Aronson. Steven Woloshin. Overdiagnosis: what it is and what it isn’t. BMJ Evid-Based Med 1 Februar. 2018;23(1):1.

Kazda L, Bell K, Thomas R, McGeechan K, Sims R, Barratt A. Overdiagnosis of Attention-Deficit/Hyperactivity disorder in children and adolescents: a systematic scoping review. JAMA Netw Open 1 April. 2021;4(4):e215335.

Frances A. Saving normal: an Insider’s revolt against out-of-control Psychiatric diagnosis, DSM-5, Big Pharma, and the medicalization of ordinary life. Repr: Mariner Books; 2014. p. 352.

Freckelton I. Overdiagnosis in Psychiatry: how modern Psychiatry Lost its way while creating a diagnosis for almost all of Life’s misfortunes, by Paris Joel. Psychiatry Psychol Law 15 Mai. 2018;25(2):325–7.

Rose NS. Our psychiatric future: the politics of mental health. Cambridge: polity; 2019.

Davidsen AS, Fosgerau CF. What is depression? Psychiatrists’ and GPs’ experiences of diagnosis and the diagnostic process. Int J Qual Stud Health Well-Being. 2014;9:24866.

Article   PubMed   Google Scholar  

Scott J, Jennings T, Standart S, Ward R, Goldberg D. The impact of training in problem-based interviewing on the detection and management of psychological problems presenting in primary care. Br J Gen Pract J R Coll Gen Pract Juni. 1999;49(443):441–5.

CAS   Google Scholar  

Wiesemann A, Hensler S. Diskreditierende Versorgungsstudien in Deutschen Hausarztpraxen. ZFA - Z Für Allg Dezember. 2003;79(12):579–85.

van der Zee J, Kroneman MW. Bismarck or Beveridge: a beauty contest between dinosaurs. BMC Health Serv Res 26 Juni. 2007;7:94.

Weltgesundheitsorganisation, Dilling H, Mombour W, Schmidt M. Internationale Klassifikation psychischer Störungen - ICD-10 Kapitel V (F), klinisch-diagnostische Leitlinien zitieren. 10. Aufl. Hogrefe (Göttingen); 2015.

Mitchell AJ, Coyne JC. Screening for depression in clinical practice: an evidence-based guide. Oxford; New York: Oxford University Press; 2010. p. 395.

Laux G, editor. Herausgeber. Versorgungsforschung in Der Hausarztpraxis: Ergebnisse aus dem CONTENT-Projekt 2006–2009. München: Springer; 2010. 112 S.

Strumann C, Blickle PG, von Meißner WCG, Steinhäuser J. The use of routine data from primary care practices in Germany to analyze the impact of the outbreak of SARS-CoV-2 on the utilization of primary care services for patients with type 2 diabetes mellitus. BMC Prim Care 16 Dezember. 2022;23(1):327.

Slagman A, Hoffmann F, Horenkamp-Sonntag D, Swart E, Vogt V, Herrmann WJ. Analyse Von Routinedaten in Der Gesundheitsforschung: Validität, Generalisierbarkeit Und Herausforderungen. Z Für Allg 1 April. 2023;99(2):86–92.

McPherson S, Armstrong D. General practitioner management of depression: a systematic review. Qual Health Res August. 2012;22(8):1150–9.

Miedema B (BO), Tatemichi S, Thomas-Maclean R, Stoppard J, editors. Barriers to Treating Depression in the Family Physician’s Office. Can J Commun Ment Health. April 2004;23(1):37–46.

Goetz K, Mahnkopf J, Kornitzky A, Steinhäuser J. Difficult medical encounters and job satisfaction - results of a cross sectional study with general practitioners in Germany. BMC Fam Pract 9 Mai. 2018;19:57.

Lauber C, Anthony M, Ajdacic-Gross V, Rössler W. What about psychiatrists’ attitude to mentally ill people? Eur Psychiatry J Assoc Eur Psychiatr November. 2004;19(7):423–7.

Mader FH, Brückner T, Scherer M, editors. Programmierte Diagnostik in der Allgemeinmedizin: 92 Checklisten nach Braun für Anamnese, Untersuchung und Dokumentation. 6., vollständig überarbeitete und erweiterte Auflage. Berlin [Heidelberg]: Springer; 2019. 287 S.

Berger M, Angenendt J, editors. Psychische Erkrankungen: Klinik und Therapie. 3. Auflage. München Jena: Elsevier, Urban & Fischer; 2009. 1204 S.

Koch K, Miksch A, Schürmann C, Joos S, Sawicki PT. The German Health Care System in International Comparison. Dtsch Ärztebl Int April. 2011;108(15):255–61.

Younes N, Gasquet I, Gaudebout P, Chaillet MP, Kovess V, Falissard B. u. a. General practitioners’ opinions on their practice in mental health and their collaboration with mental health professionals. BMC Fam Pract 2 Mai. 2005;6(1):18.

Mayring P. Qualitative Inhaltsanalyse: Grundlagen und Techniken. 12., überarbeitete Auflage. Weinheim Basel: Beltz; 2015. 152 S.

KBV - Alter [Internet]. Kassenärztliche Bundesvereinigung (KBV); [zitiert 13. Februar 2024]. Alter. Verfügbar unter: https://gesundheitsdaten.kbv.de/cms/html/16397.php .

Teney C, Bürkin K, Becker R, Möser S, Lenkewitz S. Ärztinnen Und Ärzte in Deutschland: erste Ergebnisse Einer Bundesweiten Umfrage zu Beruflichen Erfahrungen, Zufriedenheit Und Einstellungen. Bremen: Universität Bremen, SOCIUM Forschungszentrum Ungleichheit und Sozialpolitik; 2017. p. 51.

Donner-Banzhoff N. Die ärztliche Diagnose: Erfahrung - Evidenz - Ritual. 1. Auflage. Bern: Hogrefe; 2022. 356 S. (Programmbereich Medizin).

North CS, Surís AM. Advances in Psychiatric diagnosis: past, Present, and Future. Behav Sci Basel Switz 26 April. 2017;7(2):27.

Hengeveld MW, Beekman ATF. [Psychiatric diagnosis: personalised by definition]. Tijdschr Voor Psychiatr. 2018;60(3):151–5.

Mason A, Liu D, Kasteridis P, Goddard M, Jacobs R, Wittenberg R. u. a. investigating the impact of primary care payments on underdiagnosis in dementia: a difference-in-differences analysis. Int J Geriatr Psychiatry August. 2018;33(8):1090–7.

Harrison J, Weber S, Jakob R, Chute C. ICD-11: an international classification of diseases for the twenty-first century. BMC Med Inf Decis Mak. 9. November 2021;21.

American Psychiatric Association. Herausgeber. Diagnostic and statistical manual of mental disorders: DSM-5. 5th ed. Washington, D.C: American Psychiatric Association; 2013. p. 947.

Book   Google Scholar  

DGPPN BÄK KBV, AWMF, Härter M, Schorr S, Schneider F, Herausgeber. S3-Leitlinie/Nationale VersorgungsLeitlinie Unipolare Depression [Internet]. Berlin, Heidelberg: Springer; 2017 [zitiert 11. März 2023]. Verfügbar unter: http://link.springer.com/ https://doi.org/10.1007/978-3-662-52906-5 .

Davenport TA, Hickie IB, Naismith SL, Hadzi-Pavloviv D, Scott EM. Variability and predictors of mental disorder rates and medical practitioner responses across Australian general practices. Med J Aust 16 Juli. 2001;175(S1):S37–41.

Hazell CM, Berry C, Bogen-Johnston L, Banerjee M. Creating a hierarchy of mental health stigma: testing the effect of psychiatric diagnosis on stigma. BJPsych Open 26 September. 2022;8(5):e174.

O’Connor C, Kadianaki I, Maunder K, McNicholas F. How does psychiatric diagnosis affect young people’s self-concept and social identity? A systematic review and synthesis of the qualitative literature. Soc Sci Med 1982 September. 2018;212:94–119.

Baer N. Würden Sie einen psychisch behinderten Menschen anstellen? Z Für Sozialhilfe [Internet]. 2007 [zitiert 26. Januar 2023]; Verfügbar unter: https://www.e-periodica.ch/digbib/view?pid=zes-003:2007:104 ::192.

Brohan E, Henderson C, Wheat K, Malcolm E, Clement S, Barley EA. u. a. systematic review of beliefs, behaviours and influencing factors associated with disclosure of a mental health problem in the workplace. BMC Psychiatry 16 Februar. 2012;12(1):11.

Lasalvia A, Zoppei S, Van Bortel T, Bonetto C, Cristofalo D, Wahlbeck K. u. a. global pattern of experienced and anticipated discrimination reported by people with major depressive disorder: a cross-sectional survey. Lancet Lond Engl 5 Januar. 2013;381(9860):55–62.

Sautermeister J, Skuban T, Lenz V, Herausgeber. Handbuch psychiatrisches Grundwissen für die Seelsorge. Freiburg Basel Wien: Herder; 2018. p. 752.

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Acknowledgements

We would like to thank all the participants who took part in the study, the people that helped with contacting physicians, the people who helped transcribe the interviews and the whole team at the Institute of Family Medicine in Lübeck, who were always available to help and answer questions.

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HTVE conducted the interviews and transcribed the material. HTVE and CN analyzed the data. In a joint group process with JS, the consensus version was produced with all findings. HTVE wrote the first draft of the manuscript, which was critically reviewed and approved by CN and JS. JS was the supervisor throughout the whole study and developed the study design.

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Tebartz van Elst, H., Niehoff, C. & Steinhäuser, J. Motives and modifying factors for giving or rejecting psychiatric diagnoses in general medicine and psychiatry – a qualitative interview study. BMC Psychiatry 24 , 461 (2024). https://doi.org/10.1186/s12888-024-05900-2

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Stress-related experiences and intentions to quit studies among female married postgraduate distance education students in Ghana

• Eugene Adu Henaku 1 ,
• Francis Sambah 2 ,
• Frank Quansah 3 ,
• Edmond Kwesi Agormedah 4 ,
• Medina Srem-Sai 5 ,
• John Elvis Hagan Jr. 6 , 7 ,
• Francis Ankomah 8 , 9 ,
• Vera Rosemary Ankomah-Sey 10 &
• Thomas Schack 7  

BMC Psychology volume  12 , Article number:  348 ( 2024 ) Cite this article

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Although postgraduate studies have been shown to be associated with stressful experiences, students reading programmes through the distance and e-learning mode experience greater levels of stress due to several reasons. These stressful encounters might be heightened in female married postgraduates on distance education programmes due to other family-work-related engagements. This study investigated the stress-related experiences and intentions to quit studies among female married students on a distance education programme in Ghana.

Using a sequential explanatory mixed-methods design, 164 married postgraduate distance education students were sampled to participate by responding to a questionnaire. Follow-up interviews were conducted with 10 participants to offer insight into the quantitative findings. Quantitative data were analysed using descriptive statistics, including frequency and percentages, while the qualitative data were thematically analysed.

Stress was prevalent among the female married distance education students, with the majority having intentions of quitting their studies. The stressors identified ranged from personal (i.e., work and family demands) to institutional ones (i.e., academic load, unresolved complaints and high financial demands from the programme).

Conclusions

Key findings suggest that female married postgraduate distance education students perform multiple roles as full-time employees with family and academic demands that can negatively impact their health and academic work. Implications and recommendations of the findings are discussed.

Peer Review reports

Introduction

The popularity of distance learning has grown recently. Parallel to this growth, advocates for education reform, including educators, policymakers and researchers, are increasingly calling for an action in response to the psychological consequences (stress) and intention to discontinue studies (student attrition or dropout rate) in the distance education space. Although distance education students enjoy a more flexible learning environment, they nonetheless experience stress, which influences their psychological well-being and academic progress [ 1 , 2 ]. Stress in this study reflects the conceptualization provided by Lazarus and Folkman [ 3 ] as “a particular relationship between the person and the environment that is judged by the person as burdensome or exceeding his or her capacity or resources to cope with the situation at hand” (p. 19). Thus, the disproportion between demands and resources is characterized as stress [ 4 ]. More specifically, we describe “educational or academic stress as the sensation of being overburdened by school workloads or demands”.

Studies have reported that students enrolled in distance education worldwide have been shown to experience high levels of stress [ 5 , 6 , 7 ]. Given that males and females react to stress differently [ 8 ], scholars have found that female distance learners exhibit higher levels of academic stress than their male counterparts [ 9 , 10 , 11 ]. Particularly, married women enrolled in distance education programmes are also more likely than men to experience and exhibit symptoms of depression, anxiety, discomfort, and stress [ 12 , 13 ]. These stressors are linked to several internal (e.g., personal goals, expectations, standards) [ 2 , 14 ] and external stressors (e.g., excessive academic workload and assignments, time constraints, financial issues, attending to family-related responsibilities, and other social issues) [ 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 14 ]. Although educational stress can be beneficial because it challenges students and motivates students to succeed [ 24 ], it can also have negative effects on student learning [ 25 , 26 ], judgment and adaptive function [ 23 ] and lead to examination malpractices, and engaging in inappropriate school behaviours [ 26 , 27 , 28 ]. Stress can cause unhealthy behaviours [ 29 , 30 ] and is linked to students’ intentions to drop out of school [ 31 , 32 ].

In higher education, the intention of distance education students to quit or drop out is on the rise [ 33 , 34 , 35 , 36 ]. In this current investigation, students’ intention to quit a study is defined as “the perceived or subjective probability that a student will drop out of the programme in which they have enrolled and the frequency of having that thought”. According to earlier research reports [ 37 , 38 ], dropping out of school has a negative impact on students’ self-esteem, psychological, emotional, and social well-being. This outcome has a negative impact on learning, unemployment, and lower standard of living. Extant researchers have found that distance education students’ intention to quit studies or drop out is related to several factors, including psychological consequences such as stress and burnout symptoms [ 39 , 40 , 41 , 42 , 43 , 44 ]. Swani et al. [ 45 ] established that stress reduces students’ satisfaction and intention to stay on their programme. In Peru, it was found that most distance education students withdrew from their studies due to mental health-related reasons [ 34 , 46 , 47 ]. In Brazil, De Souza et al. [ 48 ] showed that distance education students’ dropout intention was influenced by negative affectivity (i.e., symptoms of depression, anxiety, and stress). The effect of academic stress on the intention to quit studying was attributed to several reasons, such as conflicts between study, work/employment, and family commitments [ 49 , 50 ]. The online and distance education literature points to the challenges of balancing work, study, and family responsibilities as the reasons for dropping out of a university [ 49 , 50 , 51 , 52 ].

Due to inadequate or deteriorating facilities, universities in developing economies, such as Ghana, have had to deal with the unpleasant responsibility of rejecting qualified applicants [ 53 ]. As a result, various universities use distance education as one of the most effective teaching methods to expand access to tertiary education to meet the growing demands of professional education [ 54 , 55 ]. Most educators believe that traditional on-campus education and training can be improved by distance learning. Distance education has become a way for existing and new educational establishments to admit working-class students ever since it was introduced [ 56 ]. In Ghana, for example, the majority of distance learners are adults who are married, parents, or employed (working), placing a huge demand on their learning time. Thus, these learners are likely to frequently face psychological, socio-religious, and financial/economic difficulties, as a result of creating a balance between work, school, and social lives. In fact, previous studies in Ghana have confirmed that student mothers in distance education face challenges such as the inability to regularly attend face-to-face lectures due to exhaustion, poor health of their children, and the lack of lactation rooms for breastfeeding [ 57 ]. Other findings have shown that married students were more stressed than unmarried students due to institutional, instructional, social, psychological, financial and family/marriage problems [ 54 , 58 , 59 ]. Obviously, these conflicts put a lot of pressure on these learners and negatively impact their academic performance [ 60 , 61 , 62 ].

During face-to-face interactions with female married distance students in some of the distance education campuses of one of the public universities in Ghana, they complained of headaches, lack of sleep, and fatigue due to poor educational services received from the university. Accordingly, frustrated distance learners who are unable to cope with the stress may delay on or withdraw from the academic programme, thereby squandering their investment and jeopardizing their educational goals [ 63 , 64 ]. Studies on distance education in Ghana have focused mainly on stress, struggles and coping strategies [ 54 , 57 , 62 ], challenges and coping strategies [ 59 ], satisfaction and choice of distance programme [ 53 , 60 ], students’ learning with information communication technology [ 65 ], and student mode of learning [ 66 ]. Yet issues of how these stressors manisfest and intentions to quit the programme have not been extensively investigated, especially with a unique population like female married women. Given this premise, this study examined female married postgraduate distance education students’ stress-related experiences and intention to quit studies. The current inquiry (1) explored the work-related activities of female married distance education students, (2) identified school-related perceived stressors of female married distance education students and (3) examined the intentions of female married distance education students to quit their programme. Investigating the role of educational stress on intentions to quit or drop out is especially relevant as dropout intentions may be seen as a coping mechanism in response to stress (escape-avoidance coping) [ 67 ].

Methods and materials

Study design.

The research adopted the sequential explanatory mixed-methods design, which started with a quantitative study followed by a purposeful qualitative phase based on the findings from the first stage. The use of this research design is justified because the investigators are interested in the attainment of both in-depth stress-related experiences and general realities that characterise the numerous loci of distance education students’ challenges in Ghana that research to date has marginalised [ 68 , 69 , 70 ]. Given the sparse research on this research theme across the sample, using the sequential explanatory mixed-methods approach is recognised as the most preferred design for this detailed inquiry. The subsequent sections of the methods have been structured into the quantitative and qualitative phases. The point of integration for this research is at the study design level (via explanatory sequential), method level (via the building approach) and interpretation stage (through the contiguous integration method).

Quantitative phase

Participants’ information.

The study sampled 164 female married distance education students from the University of Cape Coast (UCC), Cape Coast, Ghana. In terms of age, the youngest respondent was 23 years, whereas the oldest was 53 years old. The mean age was 35 years ( SD =  6.08), indicating that the majority of the participants were in their middle adulthood stage. The participants’ reported number of children were 0 ( n =  28, 17.1%), 1 ( n =  30, 18.3%), 2 ( n =  52, 31.7%), 3( n =  37, 22.6%), and 4 ( n =  17, 10.4%). The mean number of children was 2 with a standard deviation of 0.23. Over 90% of the respondents were Christians ( n =  150, 91.5%), with 7.3% being Muslims ( n =  12) and 1.2% being atheists ( n =  2).

Inclusion criteria

Due to the nature of the study population, the following inclusion criteria were used: (1) the student should be a registered postgraduate student in the selected institution, (2) the participant should be reading a postgraduate programme with both taught courses and research work (i.e., project work, dissertation or thesis), and (3) the participants must be of sound mind to give consent of participation.

Research instrument: Questionnaire

A questionnaire was designed and validated by the investigators for the quantitative phase of the research. The questionnaire had a number of items which were aligned with the research objectives. First, the demographic section was created, which had three items on the participants’ background information, namely, age, religion and the number of children. Other items were designed to obtain the work-related schedules of the respondents. Sample items include: What is your employment status (full-time vs. part-time vs. unemployed)? How many days do you spend at work, if you are working? How many hours do you spend at work, if you are working? Another section of the questionnaire asked participants to indicate, from a list of school-related stressors, the ones which place much burden on them. The instruction was “Rate the following school activity/activities on the extent to which they place much burden on you?” using a scale of 0 to 5, with 0 depicting no burden and 5 signifying huge burden. The options included attending lectures, engaging in individual or group presentations, presenting/submitting term papers, writing quizzes and exams and carrying out mandatory research work (e.g., dissertation, thesis). The last question was, “How often do you feel stressed by the activities of this programme?”. The items were developed based on extensive literature review related to the field of stress and distance education [ 49 , 50 , 54 , 57 , 62 ]. The questionnaire was developed adhering to the BRUSO approach (Brief, Relevant, Unambiguous, Specific and Objective) as have been adopted and utilised in previous studies [ 71 ]. Further, the content validity of the questionnaire was also established by experts in the fields of research methodology, clinical and health psychology, distance education, and quantitative psychology. The review comments, suggestions and recommendations were incorporated to improve the quality of the instrument [ 72 ]. As a preliminary check, five female married distance education students were identified and the questionnaire was administered to them. After the administration, their inputs concerning the clarity and understanding of the items were provided, which further shaped the items and the questionnaire.

Data collection procedures

All participants who identified themselves as satisfying all the inclusion criteria were contacted to participate in the study. Whereas some participants opted for an online version of the questionnaire (which was sent to their emails using Google forms), others preferred hard copies which were administered to them in class. The participants were assured of confidentiality, anonymity and volition, and consent was obtained through signing a consent form. After the questionnaire administration, the participants were asked to optionally indicate whether they would be willing to participate in the second phase (i.e., qualitative component) of the research. Those who gave such consent were required to provide other personal contact details on their questionnaire. About 44.5% ( n =  73) of them indicated their willingness to participate in the qualitative phase of the research. Ethical approval was sought from the Institutional Review Board of the University of Cape Coast, Ghana, with reference number UCCIRB/EXT/2020/25.

Quantitative data analysis

The data retrieved from the participants were screened for data entry errors. All inconsistent data were removed from the dataset. The quantitative data were analysed using descriptive statistics, including frequency, percentage, mean, standard deviation, and correlational analysis. Bar and pie graphs were used to represent some portions of the data to address the objectives. More precisely, the frequency counts and percentage of the responses were computed on a number of work-related activities (e.g., number of days, how many hours of work, working full time, part-time or unemployed) in order to address research objective one. For research objective two, responses on the various stressors encountered by the female distance education students were summarised using mean and standard deviation. Whereas a correlational analysis was perfomed to examine the association among the identified stressors, frequency counts were used to assess the degree of stress they encountered; these are additional analyses to address the second objective. Data on the last research objective was analysed using frequency and percentage counts to tally the responses provided on the students’ intentions to quit their programme.

Qualitative phase

The qualitative phase was drawn from the face-to-face interview and phone interview data collected from participants who opted to be part of the second phase of the research. This follow-up interview was necessary based on the following objectives: (1) to explain why most participants experienced stress, and (2) reasons for their intentions to quit the postgraduate programme, as shown in the first phase of the study.

Participants’ selection

The study purposefully selected individuals who opted to be part of the second phase. Although 73 participants opted to be part, we could not reach 30 of the participants through the contact information they provided. Out of the remaining 43, 11 of them had earlier indicated that they had not been stressed and had never thought of quitting the programme. Based on data saturation, we interviewed 10 out of the 32 participants who were available and willing to be interviewed face-to-face or via phone due to distance. It must be noted that all 32 had mentioned in the quantitative phase that they were experiencing stress and as well had intentions of quitting the programme.

Research instrument: Interview guide

A semi-structured interview guide was used to gather data from participants during the second phase of the study. Per the nature of the research design, the interview guide was carefully developed by the investigators based on the outcome of the quantitative phase of the research. The instrument focused on understanding participants’ stress and thoughts of quitting the programme as a follow-up on the initial survey. The interview questions bothered on getting in-depth information about the stress and stressors encountered in their schooling. The interview guide was first independently validated by experts in the fields of research methodology, clinical and health psychology, distance education, and educational psychology. Secondly, these experts together with the investigators had extensive discussion on the developed interview guide, afterwhich modifications were made accordingly.

Before the interview, participants were contacted and informed about the interviews. The participants and the researchers discussed and scheduled the date and time for the interviews, prioritising participants’ convenience to ensure their maximum cooperation and participation. Due to the difficulties of physical location of the homes of the study participants most ( n =  7) of the participants were interviewed via phone based on preference, while the remaining ( n =  3) were interviewed face-to-face. Participants consented to be interviewed and audiotaped by signing a consent form sent via WhatsApp and email to participants who were interviewed via phone. A hard copy of the consent form was made available for participants who were interviewed face-to-face to sign.

Qualitative data analysis

Transcripts were coded and thematically analysed using both manual and computer-assisted qualitative data analysis. To address the qualitative research objectives, a thematic analysis was carried out using the MAXQDA qualitative software for coding and development of themes. The qualitative data collected was first transcribed verbatim [ 73 ]. We read through the entire data to familiarise ourselves with the data, after which important sections were coded [ 74 ]. Initially, 84 codes were developed. These codes were then organised into two major themes [ 74 ]. The first major theme had five sub-themes, while the second major theme has two sub-themes (See Table  1 ). To ensure the trustworthiness of the qualitative results, the results were sent to participants to check the accuracy of the results regarding their experiences [ 75 , 76 ]. Participants’ feedback did not have any significant influence on our findings. Students experiencing stress, as indicated in the quantitative phase, were involved in the qualitative phase to ensure the transferability of the findings to a similar population. Pseudonyms were also used to anonymise the identity of the participants.

Quantitative results

Work-related activities of female married distance education students.

Three indicators were examined to understand the work activities of the participants. These indicators were the employment status of the participants, the number of days of working (if they are employed) and the number of hours they worked. The details of the analysis are shown in Table  2 .

A greater percentage of the participants were employed in full-time jobs (86%), with less than 10% working as part-time workers (9.8%) (see Table  2 ). Very few participants were unemployed ( n  = 7, 4.3%). The majority of the students worked 5 days a week ( n  = 128, 78%). Others reported working 6 days ( n  = 14, 8.5%) and 7 days ( n  = 15, 9.1%) within the week. Concerning the number of hours, it was revealed that most of the participants worked 8 h or more within the day. For example, 48.8% worked for 8 h, 15.2% worked for 9 h and 15.2% again worked for 10 h. Some also reported working for 11 h (1.8%) and 12 h (7.3%) in a day.

School-related perceived stressors on female married distance education students

The study examined 5 main school-related perceived stressors of postgraduate studies and attempted to understand which of them placed much stress on them. The study also explored how burdens on a particular school activity could spill over to other related activities. The results are shown in Table  3 .

As shown in Table  3 , it was discovered that conducting research work placed the highest stress on the students ( M  = 3.49, SD  = 1.41), followed by writing examinations ( M  = 2.74, SD  = 1.51) and attending lectures ( M  = 2.48, SD =  1.50). Producing term papers and doing individual or group presentations in class were considered the least in terms of stress. Further results also showed significant positive relationships among the school activities regarding the associated stressful ratings. In particular, the relationship coefficients ranged from 0.173 to 0.529, suggesting that when there is a higher stress level associated with any of the activities, it is likely that other activities would also place a huge burden on the students.

The respondents were also asked to indicate how stressful they felt being on the programme. As depicted in Fig.  1 , it was revealed that about two-thirds of the female married distance education students felt much stressed (66.5%). Other participants also reported being moderately stressed (25.6%) and only 4.3% of them indicated less stressed. About 3.7% of the participants mentioned that they were not stressed at all.

Degree of stress encountered on the postgraduate programme

Intentions of female married DE students to quit their programme

The study also sought to assess respondents’ intentions to terminate their postgraduate studies due to its stressful nature and other associated factors. The graphical analysis as depicted in Fig.  2 showed that about 21% of the students had intentions to quit the programme, at all time ( n =  35). Furthermore, a larger proportion of the students reiterated that they sometimes have thoughts of quitting their postgraduate studies ( n =  85, 52%). However, some students reported that they had never thought of quitting the programme ( n =  44, 27%).

Intentions to quit postgraduate studies

Qualitative results

Participants’ views and explanation of themes.

Distance education allows students and teachers flexibility regarding place, time and pace of learning [ 54 , 77 ]. Distance education students/learners choose not to attend the traditional classroom or face-to-face schooling for several reasons, such as time constraints, geography, family demands and work requirements [ 78 ]. In turn, students have the advantage of deciding their learning. This suggests that distance education’s flexibility will reduce stress (distress). However, this was not the case for the study participants. Instead, the themes that emerged from the data show that most participants experienced stress. Hence, participants thought of quitting the programme. Two major themes and five sub-themes were generated after coding and categorisation of the codes. These themes and sub-themes are presented in Table  1 .

Institutional/administrative stressors

Inconsistent schedules, academic workload, unresolved complaints, financial strain and discouragement, were the primary sources of the institutional/administrative stressors which made the study participants think of quitting the programme. In addition, participants spoke about how they are stressed due to the administrative activities of the distance education programme.

Inconsistent schedules

Participants explained that their thoughts of quitting the programme emanate from the stress they experience due to inconsistent schedules and postponement of activities such as the distribution of course materials, quizzes and examinations. Some participants said:

“…it is much stress when you prepare for an examination and just a day before the examination it is postponed…” (Keziah).

“…they [ referring to the University management ] are not consistent with the timetable they give us; they keep changing and that stresses me because it makes me keep changing my schedules at work …” (Hannah).

Another participant illustrated how students are stressed:

“The organisation of the school and the way of distributing modules [referring to reading materials] is appalling because it prevents us from studying since we don’t have the modules only to receive a module a week before the exam”. (Anita)

Unresolved complaints

Consumers expect that when they express their dissatisfaction about products, services or staffs of an organisation or institution, it would be acknowledged and the necessary actions carried out to ensure their satisfaction or grievances addressed. This makes the organisation or institution accountable to the public, improving its reputation and strengthening public confidence [ 79 ]. However, the findings of this study show that students’ complaints were unresolved. The participants explained that the unresolved complaint stresses them, so they thought of quitting the programme. Some participants expressed:

“Sometimes, if you have a problem, you complain several times, but it wouldn’t be solved until you go to the main campus.” (Keziah).

Another participant added that

“…also, some papers haven’t appeared on my results slip [transcript], and getting help to resolve it has taken me a year, but still it has not been resolved, and in fact, it frustrates me…” (Rebecca).

Academic workload

Most of the participants in this study reported being stressed due to the academic workload. They explained that many topics are taught within a day, so they have to spend much time reading their course materials. In addition, the participants explained that they are also given several assignments to complete, which adds to their workload. The following are extracts from the participants’ interviews:

“Yes, I once thought of stopping because of the workload. Sometimes, many different topics are taught on the same day, and I have three or more assignments to do at a time which I have little time for…” (Hannah).

“…I am thinking of stopping because the workload is too much for me to handle. We are given too many assignments.” (Rebecca).

The findings of this study imply that the distance education students involved in this study need much time to meet their academic demands. Hence, if a student enrolled on a distance education programme because of time constrain, as it has been identified by some studies [ 7 , 80 ] as one of the reasons why some individuals opt for distance education/learning, then it is likely that those individuals might put their thought of quitting the programme into action.

Financial strain

Financial strain was an issue of concern to some participants. The participants explained that stress resulting from financial difficulties fuels their intentions to quit the programme. They complained of expensive tuition fees and limited time of payment. According to some participants:

“Another reason is that the school fees [tuition fees] is too much [expensive] as compared to other institutions that offer a similar programme.” (Bridgit). “Also, the amount of fees is expensive and the duration to make payment before our courses are registered is too short for raising that amount to pay the fees” (Leticia).

Discouragement

Many students hope to secure better employment or be promoted in their careers or work after graduation. In this study, most of the participants are workers seeking to upgrade themselves or enhancing their professional development but have to opt for distance education due to work schedules. However, a participant shared her concerns about how some teachers discourage them. She explained that some lecturers retort that they would not be upgraded because her degree was obtained through distance education. She said:

“You know, most of us are teachers and want to upgrade, but it’s too stressful and it hurt to hear some of our teachers saying that after the distance programme, it won’t send you anywhere using your certificate…” (Anna).

Personal stressors

An advantage of distance education/learning is the flexibility of time and the opportunity for students to plan their learning and complete their academic courses at their own pace [ 81 ]. Therefore individuals who are not able to attend traditional face-to-face school due to but not limited to, work, financial, geographic, family and time constraints usually opt for distance education so that they can achieve their academic goals without interfering with or disrupting their personal everyday life [ 81 ]. However, our analysis revealed that work/employment and family demands (sub-themes) were the personal stressors that made participants consider quitting the programme.

Work/employment

Strain resulting from work/employment was a significant personal stressor, according to most of the participants. During our interview, most participants explained that they had thought of quitting their programme because combining work and academics was challenging since both require time and attention. They added that sometimes they have to be at work, and at the same time, they have to be at lectures. A participant illustrated how the combination of her work and academic work stresses her:

“ I am a worker; throughout the week, I am at work and leave (close from work) around 6 pm or even beyond. Therefore, sometimes it is not easy to get time to learn. Also, sometimes deadlines given for the submission of assignments are very short, putting us under a lot of pressure and stress. For that reason, it occurred to me once to quit. But I still gathered the strength to go on. (Leticia)

Some participants added:

“It is stressful combining examinations, projects, presentations, assignments, quizzes, managing my family, monetary issues, and online lectures…” Sometimes I feel I should just give up.” (Dorine).

A participant also said:

“I have no time at all; every day, I am busy. I go to work from Monday to Friday and sometimes close very late and tired, so I am not able to study…” (Anna).

Family demands

Participants explained that combining family demands such as cooking and taking care of children with academic work such as completing assignments and attending lectures is strenuous, so sometimes, they are tempted to quit studies. A participant illustrated how the need to meet her family demands and academic work stresses her:

“…also, I have to take care of the family and make sure our home is in order. So, it is very stressful to do all of these and assignments, prepare for quizzes and examinations.” (Anna).

Another participant said:

“I have thoughts of stopping because I hardly get someone to take care of my kids on Saturdays as my husband, too, is a health professional who goes to work on Saturdays. Travelling from my place of residence to Ho [the capital of the Volta Region where the study centre is located] along with my little children, is stressful” (Gloria).

Another participant, who looked frustrated, said

“Sometimes, I want to quit because of family pressure, especially when I am learning. ” (Bridgit).

The current inquiry investigated the work-related activities of female married distance education students, identify school-related perceived stressors of female married distance education students and examine their intentions to quit their programme. The findings indicate that the majority of the female married postgraduate students were full-time workers, with many working five days a week and eight hours a day. Additionally, the study findings showed that most of the students reported that conducting research imposes a higher burden of stress with the least reported stressors been term papers and individual/group presentations. Further, the research findings revealed that the majority of the students sometimes thought of quitting their postgraduate studies with few indicating they never thought of quitting the programme. The findings in this study are novel as it provides a qualitative perspective to help deepen the understanding of stress-related experiences of postgraduate students in the distance education programme. The general implication of these findings is that participants who enrolled on the distance education programme enjoy the benefit it offers about time flexibility [ 54 , 78 , 80 ], however, in meeting family demands, they become disappointed at a point of their studies. This latter outcome is a result of the possible effect of stress arising from the various demands (i.e., academic, work and family management) that impose a psychological burden that affects one’s quality of life. This result may therefore lead to attrition from the programme, poor academic performance, suicidal ideation, role conflict, decreased intrinsic motivation and many more negative tendencies. For instance, the findings showed that the majority of the students were in full-time employment, working five days a week and eight hours a day. This work-related engagement, when combined with academic demands, more so at the postgraduate level, may manifest negative physical, psychological and academic impacts [ 59 , 82 ]. Though related studies are rare to contrast, one analogous study found increased working hours and days to be associated with stress [ 83 ], which was also confirmed in the qualitative finding. Moreover, most female postgraduate distance education students have family-related responsibilities, such as nursing babies, which further compound their academic challenges. Plausibly, this observation could be the reason majority of the participants reported their intentions of quitting the programme. This argument is buttressed by qualitative findings, where the participants reiterated the stressful demand of caring for the family as an impediment to their academic progression. Alabi et al. [ 83 ] argued that the socio-cultural discrimination against women in Africa challenges their higher academic achievements. Since married women are entirely saddled with family care responsibilities which have a competing interest against their higher academic demands, therefore, these demands compel most women not to pursue higher education. These women opt for programmes like distance education just to be available at home to take care of the family, which comes with stressful demands [ 84 ].

Invariably, the findings revealed that most participants sometimes have thoughts of quitting their postgraduate education, with few indicating never thought of quitting the programme. This outcome means that the students may have reached a mental state of distress due to dissipated intrinsic and extrinsic motivated factors and poor system support either from the school, workplace and family support systems. By providing interventions that have proved to reduce stress and improve coping mechanisms and stress management, educational institutions can attempt to reduce the academic-related stress experienced by students. Also, extant literature has shown that educational programmes that increase students’ stress-coping abilities and skills directly and favourably affect academic achievement and reduce health risks [ 85 , 86 , 87 ]. For instance, a meta-analysis of 19 randomised controlled trials or quasi-experimental research discovered that student coping abilities were enhanced and stress symptoms were reduced by school programmes aimed at stress management [ 88 ]. A similar study in South Africa upheld the findings of the present study. For example, Silinda and Brubacher [ 89 ] found that postgraduate students in distance education programmes considered quitting the programme due to the accompanying overbearing stress and lack of support to mitigate challenges. The similarity in the finding may be due to the cross-cultural nature of academic-related stress issues. That notwithstanding, few students in the present study indicated no intention to quit the programme, which is a positive sign of resilience and noteworthy for further investigation in future research to find out their motivation. This outcome supports the assertion of Beccaria et al. [ 90 ] that these few students may be actively engaging in protective or resilience strategies to cope with their stressors, a situation worthy of emulation by others. Therefore, academic institutions running distance education programmes are encouraged to design and implement policies as well as active coping interventions that are learner-specific since individual students have different skills and motivation levels.

In furtherance, the findings also showed that most students reported that conducting research imposes a higher burden of stress with the least reported stressors being term papers and individual/group presentations. This result concurs with Silinda et al.’s [ 91 ] findings, where distance education students reported that dissertation and thesis writing imposes higher stress on them. The qualitative findings of Silinda and co’s study identified uncertainty about the research/writing process along with insufficient support from supervisors as their stressors and the reason for their intention to quit the programme. This link was confirmed in the qualitative aspect of the present study, where participants intimated institutional stressors such as inconsistent schedules, academic workload, unresolved complaints, and financial strain as precursors for their stress and intentions to abrogate their various programmes. These findings revealed the lack of or inadequate student support systems within the distance education programme of postgraduate education in Ghana. Besides, even if these support systems are available, they may not be effective in ameliorating the academic stress of students and need to be reviewed. This situation has been advocated for by the international “Healthy Universities” movement, which promotes the university’s role as a resource for promoting health and well-being among students, faculty, and the general society through instruction, research, information exchange, and institutional practice and not just strictly academics to the neglect of the students’ well-being [ 89 ].

The findings imply that institutions offering postgraduate distance learning programmes in Ghana should aid their students by providing training or counselling services that would cater for the needs of the distance learners, such as how to balance academic work with family and employment duties through integrated planning. Other implications include enhancing supervisors’ support of distance learning postgraduate students, such as through better communication, faster feedback delivery, and clearer correspondence, to help ensure that these students receive the guidance they need when writing their dissertation or thesis.

Strengths and limitations

The study’s relevance and strengths are bolstered using a two-prong mixed-methods perspective of evidence gathering to deepen and broaden understanding of the stress-related phenomena. Despite the study’s advantages, a few restrictions must be highlighted. First, it is structured as a cross-sectional design that examines the real world at a certain period. Such a strategy does not investigate longitudinal variations in perceived stressors across time. Also, we cannot completely rule out information bias because the data were gathered via self-administered questionnaires and/or devices. However, non of these limitations invalidate the findings of the study.

Conclusion and recommendations

This study investigated work-related activities of female married distance education students, identified school-related perceived stressors of female married distance education students and examined the intentions of female married distance education students to quit their programme. It can be concluded from this study that female postgraduate distance education students perform multiple roles as full-time employees with family and academic demands that can have a negative health and academic impact. Also, the majority of female postgraduate distance education students have a high propensity to quit their studies due to a lack of support from both academics and family. Lastly, conducting research imposes a high burden of stress on the participants compared to other academic-related activities.

Therefore, postgraduate distance learning students are encouraged to focus more on using active or functional coping strategies (e.g., integrated planning) rather than adopting behavioural disengagement. Active coping will assist distance learners to better initiate forearmed preparations for similar situations in the future and acquire relevant abilities to manage potential stressors. Also, orientation programmes on active coping methods offered by educational institutions and employers will be highly beneficial in helping distant learners achieve this aim. It is also advised that educational institutions provide academic counsellors to distant learners. These counsellors will advise distant learners on how to handle or manage their difficulties while pursuing their academic goals.

Data availability

Anonymized data is available upon reasonable request through the corresponding author.

Boutsika M, Kadianaki A. Drivers and Barriers to Distance Learning implementation: A Case Study at TEI of Athens. Masters Thesis, Lund University, 2019.

Misigo BL. Gender difference in the perceived level of stress and coping strategies among university students in Kenya: a case of public universities. Int Acad J Social Sci Educ. 2015;1(4):44–52.

Google Scholar  

Lazarus RS, Folkman S. Stress, appraisal, and coping. New York: Springer; 1984.

Lazarus RS. Stress, appraisal, and coping. Folkman, Susan. New York: Springer; 1999.

Chemutai LB, Mulambula SM. The determination of academic stress levels by gender and year of study. A case of Kenyan university students. Am Int J Social Sci. 2020;9(4):16–22. https://doi.org/10.30845/aijss.v9n4p3 .

Article   Google Scholar  

Stallman HM. Psychological distress in university students: a comparison with general population data. Aust Psychol. 2010;45:249–57.

Vazquez FL, Otero P, Diaz O. Psychological distress and related factors in female college students. J Am Coll Health. 2012;60(3):219–25.

Article   PubMed   Google Scholar  

Afifi M. Gender differences in mental health. Singapore Med J. 2007;48(5):385.

PubMed   Google Scholar  

Karaman MA, Lerma E, Vela JC, Watson CJ. Predictors of academic stress among college students. J Coll Couns. 2019;22(1):41–55.

Mahmoud JSR, Staten RT, Hall LA, Lennie TA. The relationship amon young adult college students’ depression, anxiety, stress, demographics, life satisfaction, and coping styles. Issues Ment Health Nurs. 2012;33(3):149–56.

Mazumdar H, Gogoi D, Buragohain L, Haloi N. A comparative study on stress and its contributing factors among the graduate and post-graduate students. Adv Appl Sci Res. 2012;3(1):399–406.

Ibrahim Ahmed K, Kelly Shona J, Adams Clive E, Glazebrook Cris. A systematic review of studies of depression prevalence in university students. J Psychiatr Res. 2013;47(3):391–400.

Elmer T, Mepham K, Stadtfeld C. Students under lockdown: comparisons of students’ social networks and mental health before and during the COVID-19 crisis in Switzerland. PLoS ONE. 2020;15 (7).

Wangeri T, Kimani E, Mutweleli SM. Transitional challenges facing first year university students in Kenyan public universites: a case of Kenyatta University. Interdisciplinary Rev Econ Manage. 2012;2(1):7.

Ankoma-Sey VR, Quansah F, Aheto KS. Efficacies of technology-based instruction in the University of Cape Coast distance education. Programme Staff Educational Dev Int. 2018;22(3):97–111. http://journal.netsed.net/ojs/index.php/sedi/article/view/6 .

Ankoma-Sey VR, Essilfie G, Quansah F, Nugba RM. Distance education students’ readiness for online learning at the University of Cape Coast, Ghana. In: Muniandy B, Awabil G, Mandela R, Afutu-Kotey R, Muyaka J, editors. Handbook of research on distance education in Ghana. Accra: Sub-Saharan African; 2022. pp. 42–65.

Chao RC. Research managing perceived stress among college students: the roles of social support and dysfunctional coping. J Coll Couns. 2012;15:5–22. https://doi.org/10.1002/j.2161-1882.2012.00002.x .

Beltman S, Poulton E. Take a step back: teacher strategies for managing heightened emotions. Australian Educational Researcher. 2019,46(661 – 79).

Quansah F, Ankoma-Sey VR, Aheto SK. Perception of distance education students of their involvement in assessment decisions in Ghana. Asian J Distance Educ. 2017;12(1):17–24. http://www.asianjde.org/ojs/index.php/AsianJDE/article/view/237 .

Ribeiro IJ, Pereira R, Freire IV, de Oliveira BG, Casotti CA, Boery EN. Stress and quality of life among university students: a systematic literature review. Health Professions Educ. 2018;4(2):70–7.

Smith KJ, Rosenberg DL, Timothy HG. An Assessment of the Psychometric properties of the perceived stress Scale-10 (PSS10) with business and accounting students. Acc Perspect. 2014;13(1):29–59. https://doi.org/10.1111/1911-3838.12023 .

Sumaila J, Ankoma-Sey VR, Asamoah D, Quansah F. Conducting research work as a requirement for university undergraduate studies: challenges of distance education students in Ghana. Open Educ Stud. 2020;2(1):149–58. https://doi.org/10.1515/edu-2020-0112 .

Emerson DJ, Hair JF Jr, Smith KJ. Psychological distress, burnout, and business student turnover: the role of resilience as a coping mechanism. Res High Educt. 2023;64(2):228–59.

Edjah K, Ankomah F, Domey E, Laryea JE. Stress and its impact on academic and social life of undergraduate university students in Ghana: a structural equation modeling Approach. Open Educ Stud. 2020;2:37–44. https://doi.org/10.1515/edu-2020-0100 .

Regehr C, Glancy D, Pitts A. Interventions to reduce stress in university students: a review and meta-analysis. J Affect Disord. 2013;148:1–11. https://doi.org/10.1016/j.jad.2012.11.026 .

Vaez M, Laflamme L. Experienced stress, psychological symptoms, self-rated health and academic achievement: a longitudinal study of Swedish university students. Soc Behav Personal. 2008;36:83–196.

Rourke MO, Hammond S, Flynn SO, Boylan G. The medical student stress profile: a tool for stress audit in medical training. Med Educ. 2010;44:1027–37. https://doi.org/10.1111/j.1365-2923.2010.03734.x .

Soliman M. Perception of stress and coping strategies by medical students at King Saud University, Riyadh, Saudi Arabia. J Taibah Univ Med Sci. 2014;9(1):30–5. https://doi.org/10.1016/j.jtumed.2013.09.006 .

Nguyen-Michel ST, Unger JB, Hamilton J, Spruijt-Metz D. Associations between physical activity and perceived stress/hassles in college students. Stress Health. 2006;22:179–88.

Gustems-Carnicer. Jose, Caterina Calderón, and Diego Calderón-Garrido. Stress, coping strategies and academic achievement in teacher education students. Eur J Teacher Educ. 2019;42(3):375–90.

Chartrand JM. An empirical test of a model of nontraditional student adjustment. J Couns Psychol. 1992;39:193e202.

Sandler ME. Career decision-making self-efficacy, perceived stress, and an integrated model of student persistence: a structural model of finances, attitudes, behavior, and career development. Res High Educt. 2000;41:537e580.

Costa OSD, Gouveia LB. Modelos De retenção de estudantes: abordagens e perspectivas. Revista Eletrônica De Administração. 2018;24(3):155–82. https://doi.org/10.1590/1413-2311.226.85489 .

Del Savio AA, Galantini K, Pachas A. Exploring the relationship between mental health-related problems and undergraduate student dropout: a case study within a civil engineering program. Heliyon. 2022;8:e09504. https://doi.org/10.1016/j.heliyon.2022.e09504 .

Article   PubMed   PubMed Central   Google Scholar  

Chi D, Randall C, Hill C. Dental trainees’ mental health and intention to leave their programs during the COVID-19 pandemic. J Am Dent Assoc. 2021;152(7):526–34.

Hovdhaugen E. Transfer and dropout: different forms of student departure in Norway. Stud High Educ. 2009;34(1):1–17.

Ayala JC, Manzano G. Academic performance of first-year university students: the influence of resilience and engagement. High Educ Res Dev. 2018.

Belfield C, Levin HM. The price we pay: Economic and social consequences of inadequate education. Washington, D.C.: Brookings Institution; 2007.

Mostert K, Pienaar J. The moderating effect of social support on the relationship between burnout, intention to drop out, and satisfaction with studies of first-year university students. J Psychol Afr. 2020;30(3):197–202.

Turhan D, et al. University students’ profiles of burnout symptoms amid the COVID-19 pandemic in Germany and their relation to concurrent study behavior and experiences. Int J Educational Res. 2022;116:102081. https://doi.org/10.1016/j.ijer.2022.102081 .

Alves SA, Sinval J, Lucas Neto L, Marôco J, Ferreira AG, Oliveira P. Burnout and dropout intention in medical students: the protective role of academic engagement. BMC Med Educ. 2022;22:83. https://doi.org/10.1186/s12909-021-03094-9 .

Ishii T, Tachikawa H, Shiratori Y, Hori T, Aiba M, Kuga K, Arai T. What kinds of factors affect the academic outcomes of university students with mental disorders? A retrospective study based on medical records. Asian J Psychiatr. 2018;32:67–72.

Parviainen M, Aunola K, Torppa M, Poikkeus AM, Vasalampi K. Symptoms of psychological ill-being and school dropout intentions among upper secondary education students: a person-centered approach. Learn Individual Differences. 2020;80:101853. https://doi.org/10.1016/j.lindif.2020.101853 .

Roso-Bas F, Jiménez AP, García-Buades E. Emotional variables, dropout and academic performance in Spanish nursing students. Nurse Educ Today. 2016;37:53–8. https://doi.org/10.1016/j.nedt.2015.11.021 .

Swani K, Wamwara W, Goodrich K, Schiller S, Dinsmore J. Understanding business student retention during COVID-19: roles of service quality, college brand, and academic satisfaction, and stress. Serv Mark Q. 2022;43(3):329–52. https://doi.org/10.1080/15332969.2021.1993559 .

Leon-Jimenez F, Jara-Romero LE, Chang-Davila D, Chichon-Peralta JL, Piedra- Hidalgo MF. Tamizaje De Salud mental mediante El test MINI en estudiantes De Medicina. Fac Med. 2012;73(3):191–6.

Necochea Oca ~ na Y, Nervi Condori C, Tuesta Echeandía V, Olazabal Valera L, Rodríguez Carrasco J, Gastelo Davila A, Leon-Jimenez F. Frecuencia y características del abandono estudiantil en Una Escuela De Medicina De Lambayeque, 2006–2014. Rev Med Hered. 2017;28(3):171–7.

De Souza MGB, Aquino CVMG, Da Silva CRM. Negative affectivity and dropout intention among accounting science students during the covid-19 pandemic. Florianópolis, SC. 2022;21, 1–19, e3314, 2022. https://doi.org/10.16930/2237-7662202233142 .

Coates H, Ransom L, Dropout DNA, and the genetics of effective support (AUSSE Research Briefing. 2011; vol. 11). Retrieved from http://research.acer.edu.au/cgi/viewcontent.cgi?article=1000&context=ausse

Robotham D. Stress among higher education students: towards a research agenda. High Educ. 2008;56:735–46. https://doi.org/10.1007/s10734-008-9137-1 .

Tones M, Fraser J, Elder R, White K. Supporting mature-aged students from a low socioeconomic background. High Educ. 2009;58:505–29. https://doi.org/10.1007/s10734-009-9208-y .

Waterhouse P, Samra R, Lucassen M. Distance education students’ satisfaction: Do work and family roles matter? Distance Education. 2022;43:1, 56–77, https://doi.org/10.1080/01587919.2021.2020622Waterhouse 2022.

Segbenya M, Oduro GKT, Peniana GFK. Proximity and choice of College of Distance Education (CoDE) of the University of Cape Coast for further studies. Int J Educational Manage. 2019;33(5):1012–34.

Kwaah CY, Essilfie G. Stress and coping strategies among Distance Education students at the University of Cape Coast, Ghana. Turkish Online J Distance Education-TOJDE. 2017;18(3):120–34. https://doi.org/10.17718/tojde.328942 .

Kumi-Yeboah A. A look at the trend of distance and adult education in Ghana. Int Forum Teach Stud. 2010;6(1):19–28.

Segbenya M, Nyieku IE. Demographic determinants of job satisfaction among part-time academic staff of the College of Distance Education, University of Cape Coast. In: Muniandy G, Awabil J, Kumar R, Mandela RL, Afutu-Kotey, Muyaka J, editors. Handbook of Research on Distance Education in Ghana. Accra Ghana, Sub-Saharan African Publishers; 2021. pp. 1–25.

Dankyi JK, Dankyi LA, Minadzi VM. Struggles and coping strategies of student mothers at the University of Cape Coast Distance Education, Ghana. Creative Educ. 2019;10:2484–94. https://doi.org/10.4236/ce.2019.1011176 .

Mends-Brew E, Asabere NY. The effectiveness of distance education in Ghana. Sci J Appl Math Stat. 2016;4(4):159–67.

Segbenya M, Anokye FA. Challenges and coping strategies among distance education learners: implication for human resources managers. Curr Psychol. 2022. https://doi.org/10.1007/s12144-022-03794-5cost .

Segbenya M, Peniana F. Graduates’ satisfaction with components of Distance Education programmes pursued with the University of Cape Coast. In: Muniandy G, Awabil J, Kumar R, Mandela RL, Afutu-Kotey, Muyaka J, editors. Handbook of Research on Distance Education in Ghana. Accra Ghana, Sub-Saharan African Publishers; 2021. pp. 1–25.

Panchabakesan S. Problems and prospective in distance education in India in the 21st century. Probl Educ 21st Century. 2011;30:113–22.

Torto BA. Problems of part-time students in Ghana: implications for distance education. Turkish Online J Distance Distance Educ. 2009;10(10):175–91.

Harisson DM. Tutorial attendance and student performance. Toronto: University of Toronto; 2008.

Mamhute R. The challenges of pregnant and nursing adult learners: a case study of Morgenter teachers’ college. Stellenbosch: Stellenbosch University; 2011.

Owusu-Boateng W, Essel R, Mensah J. The challenges distant students face as they combine studies with work: the experience of teachers pursuing tertiary distance education at The University of Cape Coast, Ghana. Malaysian J Distance Educ. 2010;12(1):13–35.

Agyemang BK. Providing information communication technology support to distance education students: a case of the University of Ghana, Legon. Turkish Online J Distance Distance Educ. 2010;11(3):129–46.

Folkman S, Lazarus RS. Manual for the ways of coping questionnaire. Palo Alto, CA: Consulting Psychologists; 1988.

Addadey JA, Quansah F, Nugba RM, Ankoma-Sey VR. Trapped in the ‘Web’: challenges of Grade 9 pupils in choosing a course to pursue in senior high schools in Ghana. Open Educ Stud. 2022;4(1):106–19.

Creswell JW, Clark VLP. Designing and conducting mixed methods research. 3rd ed. Thousand Oaks, California: SAGE Publications, Inc; 2018.

Hancock AM. When multiplication doesn’t equal quick addition: examining intersectionality as a research paradigm. Perspect. Politics. 2007;5:63–79.

Quansah F, Anin SK, Hagan JE Jr, Agormedah EK, Oduro P, Srem-Sai M, Frimpong JB, Schack T. Analysis of COVID-19 risk perception and its correlates among University students in Ghana. COVID. 2022;2:1125–38. https://doi.org/10.3390/covid2080083 .

Dunn JGH, Bouffard M, Rogers WT. Assessing item content-relevance in Sport psychology scale-construction research: issues and recommendations. Meas Phys Educ Exerc Sci. 1999;3:15–36.

Creswell JW, Hanson WE, Clark Plano VL, Morales A. Qualitative research designs: selection and implementation. Couns Psychol. 2007;35(2):236–64.

Braun V, Clarke V. Using thematic analysis in psychology. Qualitative Res Psychol. 2006;3(2):77–101.

Birt L, Scott S, Cavers D, Campbell C, Walter F. Member checking: a tool to enhance trustworthiness or merely a nod to validation? Qual Health Res. 2016;26(13):1802–11.

Candela AG. Exploring the function of member checking. Qualitative Rep. 2019;24(3):619–28.

Turan Z, Kucuk S, Cilligol Karabey S. The university students’ self-regulated effort, flexibility and satisfaction in distance education. Int J Educational Technol High Educ. 2022;19(1):1–19.

Mupinga DM. Distance education in high schools: benefits, challenges, and suggestions. Clearing House: J Educational Strategies Issues Ideas. 2005;78(3):105–9.

Australia OW. Effective Handling of Complaints Made to Your Organisation—An Overview. 2017.

Western Cooperative for Educational Telecommunications [WCET]. Distance education: A consumer’s guide. 2004. http://www.wcet.info/Resources/publications/conguide/ .

Vlasenko L, Bozhok N. Advantages and disadvantages of distance learning. 2014.

Michaela C, Pascoe SE, Hetrick, Alexandra G, Parker. The impact of stress on students in secondary school and higher education. Int J Adolescence Youth. 2020;25(1):104–12. https://doi.org/10.1080/02673843.2019.1596823 .

Matsushita M, Yamamura S. The relationship between long working hours and stress responses in Junior High School teachers: a Nationwide Survey in Japan. Front Psychol. 2022;12:775522.

Alabi OJ, Seedat-Khan M, Abdullahi AA. The lived experiences of postgraduate female students at the University of Kwazulu Natal, Durban, South Africa. Heliyon. 2019;5(11), e02731.

Hanson TL, Austin GA. Health risks, resilience, and the academic performance index (California healthy kids survey factsheet 1). Los Alamitos, CA: WestEd. 2002; Retrieve from http://surveydata.wested.org/resources/factsheet.pdf .

Perry Y, Werner-Seidler A, Calear A, Mackinnon A, King C, Scott J, Batterham PJ. Preventing depression in final year secondary students: school-based randomized controlled trial. Journal of Medical Internet Research 2017;1911, e369. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/29097357 .

Weare K, Gray G. What works in developing children’s emotional and social competence and wellbeing? 2003;Southampton. UK: National Children’s Bureau © NCB; 2015.

Kraag G, Zeegers MP, Kok G, Hosman C, Abu-Saad HH. School programs targeting stress management in children and adolescents: A meta-analysis. Journal of School Psychology. 2006;44(6), 449–472. Retrieved from http://www.sciencedirect.com/science/article/pii/S0022440506000690 .

Silinda FT, Brubacher MR. Distance learning postgraduate student stress while writing a dissertation or thesis. Int J E-Learning Distance Educ. 2016;32(1):1–14.

Beccaria L, Rogers C, Burton L, Beccaria G. Role of health-promoting behaviours for on-campus and distance education students. Distance Educ. 2016;37(1):22–40. https://doi.org/10.1080/01587919.2016.1158768 .

Dooris M. (2001) The health promoting university: a critical exploration of theory and practice. Health Educ. 2001;101: 51–60.

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Acknowledgements

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Open Access funding enabled and organized by Projekt DEAL. The study received no external funding. However, the authors sincerely thank Bielefeld University, Germany for providing financial support through the Institutional Open Access Publication Fund for the article processing charge (APC).

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Department of Family Life Management Education, University of Education, P. O. Box 25, Winneba, Ghana

Eugene Adu Henaku

College of Public Health, Medical and Veterinary Sciences, James Cook University, Townsville, QLD, 4811, Australia

Francis Sambah

Department of Educational Foundations, University of Education, P. O. Box 25, Winneba, Ghana

Frank Quansah

Department of Business & Social Sciences Education, University of Cape Coast, PMB Cape Coast, Cape Coast, Ghana

Edmond Kwesi Agormedah

Department of Health, Physical Education, Recreation and Sports, University of Education, P. O. Box 25, Winneba, Ghana

Medina Srem-Sai

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John Elvis Hagan Jr.

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John Elvis Hagan Jr. & Thomas Schack

Department of Education and Psychology, University of Cape Coast, PMB Cape Coast, Cape Coast, Ghana

Francis Ankomah

Department of Educational Studies, Patton College of Education, Ohio University, 45701, Athens, OH, USA

College of Distance Education, University of Cape Coast, PMB Cape Coast, Cape Coast, Ghana

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E.A.H. F.Q., and J.E.H. conceived the idea. E.A.H. and F.Q. performed the analysis. E.A.H., F.S., F.Q., E.K.A., M.S.S., J.E.H., F.A., V.A.S., and T.S. prepared the initial draft of the manuscript. All authors thoroughly revised and approved the final version of the manuscript.

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Adu Henaku, E., Sambah, F., Quansah, F. et al. Stress-related experiences and intentions to quit studies among female married postgraduate distance education students in Ghana. BMC Psychol 12 , 348 (2024). https://doi.org/10.1186/s40359-024-01839-x

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Received : 19 January 2023

Accepted : 31 May 2024

Published : 14 June 2024

DOI : https://doi.org/10.1186/s40359-024-01839-x

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