case study research nursing

Patients’ Lived Experiences During the Transplant and Cellular Therapy Journey pp 9–17 Cite as

Creating a Patient-Centered Case Study

• Jennifer Holl 5 ,
• Lisa Wesinger 6 ,
• Judi Gentes 7 ,
• Carissa Morton 8 &
• Jean Coffey 9  
• First Online: 25 August 2023

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Case studies provide an invaluable record of professional clinical practice and have been used in medicine since the late 1800s to describe both traditional and unusual presentations of specific disease pathologies. In medicine, case studies traditionally take a detached, objective approach to outlining the clinical course of a disease and its treatment. In keeping with the holistic approach to patient care found in nursing and using the theoretical foundations established in Jean Watson’s Theory of Human Caring as well as the Relationship-Based Care Model, this research team sought to revolutionize the case study paradigm and deconstruct the traditional case study approach, placing the patient, instead of the provider, at the center of the narrative. This new case study method intercalates the clinicians’ analysis of the case with the patient’s commentary. This chapter outlines the methods and theoretical underpinnings used to create a patient-centered case study and seeks to provide nurses with a creative alternative to the traditional, objective case study approach. Implications for future research include whether using patient-centered case studies, instead of traditional case studies, provide a valuable learning tool to educate nurses.

• Qualitative research
• Phenomenology
• Relationship-based care

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Hematology/Oncology, Dartmouth Health, Lebanon, NH, USA

Jennifer Holl

Transplant and Cellular Therapy, Dartmouth Health, Lebanon, NH, USA

Lisa Wesinger

Oncology/Hematology, Dartmouth Health, Lebanon, NH, USA

Judi Gentes

Dartmouth Health, Dartmouth Cancer Center, St. Johnsbury, VT, USA

Carissa Morton

School of Nursing, University of Connecticut, Storrs, CT, USA

Jean Coffey

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John M. Hill Jr.

School Nursing, University of Connecticut, Storrs, CT, USA

Thomas Long

Elizabeth B. McGrath

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Holl, J., Wesinger, L., Gentes, J., Morton, C., Coffey, J. (2023). Creating a Patient-Centered Case Study. In: Coffey, J., Hill Jr., J.M., Long, T., McGrath, E.B. (eds) Patients’ Lived Experiences During the Transplant and Cellular Therapy Journey. Springer, Cham. https://doi.org/10.1007/978-3-031-25602-8_2

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Case Study Research Methodology in Nursing Research

Diane G. Cope

Through data collection methods using a holistic approach that focuses on variables in a natural setting, qualitative research methods seek to understand participants’ perceptions and interpretations. Common qualitative research methods include ethnography, phenomenology, grounded theory, and historic research. Another type of methodology that has a similar qualitative approach is case study research, which seeks to understand a phenomenon or case from multiple perspectives within a given real-world context.

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Systematic reviews, preferred reporting items for systematic reviews and meta-analyses, nursing intervention research.

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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.

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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.

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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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Sarah Crowe & Anthony Avery

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

Kathrin Cresswell, Ann Robertson & Aziz Sheikh

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

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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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Case Study Research: A Methodology for Nursing

C HAPTER F OUR C ASE S TUDY R ESEARCH : A M ETHODOLOGY FOR N URSING Camille Cronin T his chapter presents a personal perspective on using case study research for both novice and prospective nurse researchers. My doctoral thesis, Workplace Learning—An Examination of Learning Landscapes (Cronin, 2012) provides a reference point and an example of case study research (CSR). This chapter, after describing the study briefly, focuses on the underlying philosophy, definitions, and justifications for using CSR and why I chose this method. The opportunity to reflect on my work, postdoctoral, is a pleasure and will provide others with insight into a valuable methodology for researching complex health care issues. A CASE STUDY For my doctoral research I chose to examine five students’ experiences of 15 health care placements as part of a health care program. As learning environments, these workplaces were explored through observations, interviews, and documents. This study reports on real-life context, which were examined over a 2-year period. This presented rich empirical data offering a pragmatic framework for investigating learning in the workplace. From carrying out this research, I presented a number of findings, which offered a useful framework to review the complexities that exist within the health care learning environment, how they interact with each other, and the possible impact they may have on learning in the workplace. This piece of work also highlighted the relationship the learner has with the learning environment and learning over time. The work examined the type of individual; their self-awareness; and their level of willingness to learn, which is seen as equally important in the learning environment. I concluded some very suggestive but realistic findings from this study proposing that the learning environment is unpredictable and that learning experiences are random. Through CSR, qualitative research methods were embraced in a rigorous and systematic manner. Each step of the research protocol was addressed. CSR can be both qualitative and rigorous. This study provided an example of a rigorous qualitative design in which CSR has been used to its full potential. The implications for nursing practice and for research in nursing are that real-life settings can be studied in a systematic and rigorous way and is certainly transferrable to other settings. A PHILOSOPHY OF PRACTICE I consider myself to be a learner at all times. There is always something more to discover, which is why life is so exciting and where my source of motivation lies. My interest in teaching has taken me through various paths and has always been a part of my role with colleagues, students, and patients. As a nurse, researcher, or manager, teaching and learning are essential prerequisites for these roles. My doctoral research is the culmination of various walks of my working life in nursing: practice, research, management, and education. With a number of experiences, this augmented the genesis of my work. A number of workplace visits and observations started to seam together. Although on a placement visit, I was observing a student and asked myself: Does this workplace affect practice? If so, how does this affect the students’ learning? How does each work environment affect the student? What about the other students and the other placements? How do these placements help students in their pathway toward becoming a nursing professional? How many students actually make it? Does this then have an impact on nursing recruitment? What about the other health care professions? Do these learners feel adequately prepared? So, this led to my decision to examine learning in the workplace focusing on health care settings. WHY CSR? Once it became clear what I was going to research, choosing CSR became straightforward (but getting to this point can take some time). It suited the practical nature of this study (and me which is actually very important to find a design that fits one’s own values and methods) and fitted very well with the variety of health care settings under investigation. CSR provides a practical and systematic way of collecting data in the naturalistic setting. This was very much a key issue as I wanted to be in each place of work collecting data. CSR assumes predetermined experience and knowledge and thus the literature review became a significant chapter in my thesis. Here, I could unload all my preconceptions and assimilate all I know from previous studies, practice, and pedagogy. The focus of this research study was to conduct an exploration of learning in health care workplaces. The research question was: How do students engage in learning in real-life settings? I ensured a number of objectives were set for data to be collected comprehensively, but in different ways:         To observe and report the learning context where every day face-to-face interactions of students take place in health care settings (hospitals, nursing homes, nurseries)         To examine critical learning incidents         To understand the different experiences and learning in the workplace Choosing the right research methodology is obviously very important for a dedicated piece of work over a number of years. Although attention is paid to what the research question is asking, one must ensure that both question and method will keep your interest sustained. This was very important to me, so I devoted a great amount of time deciding which philosophical and ethical approach to take. Fundamentally, the research question needed to be answered in the best possible way in order to understand and develop knowledge in this area. Personal philosophical beliefs were examined and how this world is constructed (a huge undertaking at the beginning of my thesis and I really did not know what it meant). But fundamentally I kept asking myself how students learn and engage in the workplace. However, the health care arena is complex; everyone is different and our expectations of each place differ. Are there patterns to learning or is it that we are individual and different? How does learning come together in this busy environment? Is it packaged differently to classroom learning? The workplace can be very different and yet in practice there is heavy reliance on this environment for learning. In practice-based disciplines, such as nursing, the importance of learning in the workplace provides up to half of the educational experience for students undertaking preregistration nurse education programs (Warne et al., 2010). Although objective knowledge can be gained from direct experience, what are we to learn in a health care environment–only facts? The purpose of science is to help people understand the world and their surroundings satisfying the natural curiosity of human beings through empirical data. Although this is possible, this study looks at people’s reality as represented through the eyes of the participants. Here, the importance of viewing the meaning of experience and behavior in context in its full complexity was the point of this study. CSR embraces this and the context becomes the focal point. With this in mind and as an educator, much of the ideas and theory on social constructivism have influenced my own epistemological and ontological stance often influencing ongoing personal and professional development. Social constructivism emphasizes the importance of culture and context in understanding what occurs in society and constructing knowledge based on this understanding (Kukla, 2000). This perspective is closely associated with many contemporary theories, most notably the developmental theories of Vygotsky (1978) and Bruner (1999), and Bandura’s (1989) social cognitive theory. Social constructivism is based on specific assumptions about reality, knowledge, and learning (Kukla, 2000). Here again, CSR embraces the reality where I wanted to collect my data. Constructivism is a theory of knowledge that argues that humans generate knowledge and meaning from an interaction between their experiences and their ideas (Piaget, 1950). Piaget suggests that through the processes of accommodation and assimilation, individuals construct new knowledge from their experiences. According to the theory, accommodation is the process of reframing one’s mental representation of the external world to fit new experiences. Accommodation can be understood as the mechanism by which failure leads to learning: When we act on the expectation that the world operates in one way and it violates our expectations, we often fail, but by accommodating this new experience and reframing our model of the way the world works, we learn from the experience of failure, or others’ failure (Rogoff, 1999). Piaget’s theory of constructivist learning has had wide-ranging impact on learning theory and teaching methods across disciplines. Constructivism is not a particular pedagogy; it is a theory that describes one way of how learning happens; regardless of whether learners are, for example, using their experiences to understand a lecture or follow the instructions to build a model house. In both cases, the theory of constructivism suggests that learners construct knowledge out of their experiences. However, constructivism is often associated with pedagogic approaches that promote learning by doing. In this research, constructivism provides a philosophical framework that has informed the thought process and research strategy for exploring learning environments in health care settings. How Did CSR Fit With My Exploration of Learning? However, in developing this philosophy further, social constructivism views each learner as a unique individual with unique needs and backgrounds, and is seen as complex and multidimensional (Wertsch, 1997). Moreover, social constructivism encourages the learner to arrive at their own version of the truth, which is influenced by their cultural background. This also stresses the importance of the nature of the learner’s social interaction with knowledgeable others. Without the social interaction with other more knowledgeable people (i.e., going to a work placement), it is impossible to acquire social meaning of important symbol systems and learn how to utilize them. From the social constructivist viewpoint, it is thus important to take into account the background and culture of the learner throughout the learning process, as this helps to shape the learner (Wertsch, 1997). Interestingly, Glasersfeld (1989) argues that the responsibility of learning should reside with the learner. This is where the philosophy of social constructivism overlaps into the workplace, emphasizing the importance of the learner being actively involved in the learning process with an element of responsibility. With learning, therefore, being an active social process, Vygotsky’s (1978) work strongly influences social constructivism, suggesting that knowledge is first constructed in a social context and is then appropriated by individuals viewing learning as an active process (Glasersfeld, 1989; Kukla, 2000). Furthermore, Vygotsky (1978) adds that the most significant moment in the social and practical elements of learning in intellectual development is when speech and practical activity, two previously independent lines of development, converge. Most social constructivist models stress the need for collaboration among learners, which is a contradiction to traditional approaches. One Vygotskian notion that has significant implications for peer collaboration is that of the zone of proximal development in which guidance or collaboration is given with more capable peers, and this contrasts with the fixed biological nature of Piaget’s stages of development. Through a process of “scaffolding” a learner can be extended beyond the limitations of physical maturation to the extent that the development process lags behind the learning process (Vygotsky, 1978). Finally, the social constructivist paradigm views the context in which the learning occurs as central to the learning itself (Kukla, 2000). Knowledge should not be divided into different subjects or compartments, but should be discovered as an integrated whole (Kukla, 2000). This also again underlines the importance of the context in which learning is presented. The world, in which the learner needs to operate, does not approach one in the form of different subjects, but as a complex myriad of facts, problems, dimensions, and perceptions (Wertsch, 1997). This is where Lave’s and Wenger’s (1991) notion of situated learning is directly relevant to learning, specifically those learners who have part of their curriculum taught in the workplace. This constructivist model of learning attempts to “invite learners to a community of practice” so that through authentic activity and social interaction a successful apprenticeship is formed with the learner. Meaningful learning occurs when individuals are engaged in social activities (Kukla, 2000). Instructional models based on the social constructivist perspective stress the need for collaboration among learners and with practitioners in the society (Lave & Wenger, 1991; Kukla, 2000). Lave and Wenger (1991) assert that a society’s practical knowledge is situated in relations among practitioners, their practice, and the social organization and political economy of communities of practice. For this reason, learning should involve such knowledge and practice (Gredler, 1997; Lave & Wenger, 1991). Therefore, this study investigated workplaces where students go to learn. The health care workplace is one example of a complex and unpredictable environment and there is an assumption that learning is “situated” and that there is an application of “appropriated” learning. This is where the methodology of choice, CSR, captured the reality of learning in real-life complex health care settings, the context in which learners (who are also complex beings) go to learn. In this way, CSR can examine complex situations that unfold multifaceted realities. Reality cannot be defined objectively, but subjectively; it is this interpretation of social reality that is important here. With this in mind the ontological stance takes precedence over the epistemological. Within the health care environment, the principles of the natural sciences are difficult to maintain; people cannot be treated as objects and measured objectively. Individual people are involved in the study sharing their views and experiences. Nonetheless, rigor and high-quality research must be applied in order to produce meaningful and pertinent research applicable to contemporary health care. In terms of epistemological influence over this piece of research, the researcher found strong overlaps with some of the methodologies available, namely, phenomenology, ethnography, and grounded theory. Although they do not directly relate to the ontological stance, there are strong influences and similarities among these philosophical methods of inquiry, which were scrutinized at length and were consequently discarded. A Brief Historical Perspective of CSR A case study approach is one of the most frequent research designs applied in social sciences (Burton, 2000). Despite its widespread use, it has changed over time and varies between disciplines and individual researchers (Creswell, 2009; Denzin & Lincoln, 2000; Yin, 2003b). Historically, there have been marked periods of intense use and periods of disuse. During the 1930s, particularly in America with high levels of immigration, poverty, and unemployment, it was associated with The University of Chicago Department of Sociology and, as an approach, it was strongly associated with the field of sociology, but during this time frame, other disciplines raised many questions about its scientific worth. Consequently, this led to a decline in the use of case study as a research methodology. The use of CSR in nursing has been similar to other disciplines, though its peak interest was in the 1960s followed by a rapid decline in its use (Burns & Groves, 1997). We are now seeing its revival, for example, with Newton, Billett, and Ockerby’s (2009) Australian-based case study of six students from a nursing cohort, and my study. Another example is Houghton, Murphy, Shaw, and Casey’s (2015) multiple case study exploring the role of the clinical skills laboratory in preparing students for the real world of practice. There has been some CSR in the further education (FE) sector, which shares some similarities with this area of exploration, namely, Colley et al. (2003) and Hodkinson and James (2003). Both these pieces of research resulted from a project “Transforming Learning Cultures in Further Education,” which aimed to deepen the understanding of the complexities of learning across the FE sector (Hodkinson & James 2003). It was a collaborative partnership among four universities and four FE colleges in England following level 3 programs in child care, health care, electronics, and telecommunications. All the sites had a substantial amount of work-based learning included throughout and data were generated from a cohort and followed for 2 years (Colley et al., 2003). Traditionally, quantitative researchers have argued that the CSR is anecdotal and nonscientific, dismissing the results and findings obtained by this method on the grounds that they lack validity and reliability. The controversy that surrounds its scientific nature is nothing new. Like others, Al Rubaie (2002) argues that the CSR is a completely legitimate method suited in both qualitative and quantitative dichotomies. In fact, Al Rubaie (2002) suggests that it is better suited to a holistic, democratic discipline dealing with the understanding and change of interwoven complexities associated with interpersonal processes that emerge and unfold within a wider social context. Hence, this is why this particular approach suits the complexities of the learning in the workplace. It is somewhat of a paradox because much of what we know about the empirical world is drawn from case studies, and many disciplines still continue to generate a large number of case studies. Yet, according to Gerring (2004) and Burton (2000), the case study is held in low regard or is just simply ignored. A case study might mean that its method is qualitative, with small numbers of participants; that the research may be ethnographic, clinical, participant–observation, or otherwise “in the field” (Yin 2009); the research that is carried out is characterized by process tracing (George and Bennett 2004), in which, as in an audit trail, the steps in the research can readily be followed; and the research can investigate a single case or single phenomenon. Interpretation of CSR has led to arguments resulting in no particular agreement. Although this may be the case, any researcher using CSR must ensure that each step of the research process is transparent. CASE STUDY RESEARCH Definition Defining case study remains problematic because it can constitute a design and a research method. The terms case study, case study method, and case method appear to be used interchangeably in the literature (Hamel, 1993; Yin, 2009). However, it is clear that CSR focuses on specific situations, providing a description of individual or multiple cases. In using this design, the researcher can investigate “everything” in that situation be it individuals, groups, activities, or a specific phenomenon. A distinguishing feature of case study is that although the number of cases may be small (or even one); the number of variables involved is large (Burns & Groves, 1997; Yin, 2009). To start with, I used a definition from Walsh et al. (2000): in-depth data analysis from systematic investigation over time. It describes basically what I summarized and particularly stressed that the “systematic” approach is to be taken. On further reading, Yin’s (2009) work on CSR became prominent in my reading. Yin’s (2003a) definition of a case study “is an empirical inquiry that investigates contemporary phenomena within its real-life context, especially when the boundaries between phenomena and context are not clearly evident” (p. 13). Yin (2009) argues that one of the most powerful uses of the method is to explain real-life, casual links. What this means is that the researcher can appreciate the subjective richness of individuals recounting their experiences in a particular context and the meanings embedded help guide practice. Yin developed his work further producing two research companion books (Yin, 2003a; 2003b), which provide rich and varied material. This has now been updated with a new fourth edition (Yin, 2009), which promotes CSR as a valid research tool. Many researchers quote Yin’s work and arguably it remains at the forefront of case study research. Advantages Gomm et al. (2007) identify three advantages to conducting CSR. First, case studies can take us to places where most of us would not have access or the opportunity to go. They provide enriched experiences of unique situations. Second, case studies allow us to look through the eyes of the researcher. Glesne and Peshkin (1992) recommended that researchers should be as unobtrusive as the wallpaper. In this instance, a poignant piece of reflection comes to mind (see Box 4.1 ). Although we do not in reality see through the researcher’s eyes, we in fact share the researcher’s perspective of the theoretical position in the study. Furthermore, by definition, theory simplifies our understanding of reality. Finally, the third reason why case studies may be preferable is that it is less likely to produce defensiveness and resistance to learning. It is more acceptable because the research reflects real life. All these issues raised bring together what case study is, and Hakim (1987) sums up how focused this CSR is like a spotlight on a unit of analysis. Thus the spotlight (or unit of analysis) is on a group of five learners participating in a 2-year study program in which the completion of work placements is compulsory.  

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• Oncology Nursing Forum
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Case Study Research Methodology in Nursing Research

Diane G. Cope

Through data collection methods using a holistic approach that focuses on variables in a natural setting, qualitative research methods seek to understand participants’ perceptions and interpretations. Common qualitative research methods include ethnography, phenomenology, grounded theory, and historic research. Another type of methodology that has a similar qualitative approach is case study research, which seeks to understand a phenomenon or case from multiple perspectives within a given real-world context.

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Through data collection methods using a holistic approach that focuses on variables in a natural setting, qualitative research methods seek to understand participants’ perceptions and interpretations. Common qualitative research methods include ethnography, phenomenology, grounded theory, and historic research. Another type of methodology that has a similar qualitative approach is case study research, which seeks to understand a phenomenon or case from multiple perspectives within a given real-world context (Taylor & Thomas-Gregory, 2015). Case study research has been described as a flexible but challenging methodology used in social science research. It has had the least attention and support among social science research methods, as a result of a lack of a well-defined protocol, and has had limited use in nursing research (Donnelly & Wiechula, 2012; Taylor & Thomas-Gregory, 2015; Yin, 2012, 2014). Three methodologists, Yin, Merriam, and Stake, have been credited as seminal authors who have provided procedures for case study research (Yazan, 2015). This article will describe and discuss case study research from the perspective of these three methodologists and explore the use of this methodology in nursing research.

The term case study is well known in the nursing profession as a teaching strategy to analyze a patient’s clinical case. Case study research is less employed and is defined similarly by all three methodologists as a research approach that focuses on one phenomenon, variable or set of variables, thing, or case occurring in a defined or bounded context of time and place to gain an understanding of the whole of the phenomenon under investigation (Merriam, 2009; Stake, 1995; Yin, 2014). The phenomenon or case can be a person, a group, an organization, or an event. The overall goal of case study research is to seek the “how” or “why” a phenomenon works, as opposed to other qualitative research approaches that seek to define the “what” of a phenomenon (Polit & Beck, 2012). Case study research usually requires detailed study during an extended period of time in an effort to obtain present and past experiences, situational factors, and interrelationships relevant to the phenomenon. Case study research has been viewed by some authors as a qualitative research methodology (Polit & Beck, 2012), and others view this type of research as flexible, using a mix of qualitative and quantitative evidence (Taylor & Thomas-Gregory, 2015; Yin, 2014).

Case Study Designs

Merriam, Stake, and Yin each have a differing perspective on case study design. Merriam (2009) purports a flexible design that allows researchers to make changes throughout the research process that is based on two or three research questions that construct and guide data collection. Stake’s (1995) design is based on a literature review that is the foundation of the research questions and theoretical framework but assumes that major changes may occur throughout the research as part of a process described as progressive focusing. Yin’s (2014) design is based on a sequence and includes several design options for the researcher. The selection of a case study design is based on the chosen theory and the case to be studied. The first decision is to determine whether the case study will use a single case or multiple cases. The use of a single case study is an appropriate design for certain circumstances, including when the case represents (a) a critical case to test theory, (b) an unusual or unique case, (c) a common case that can capture an understanding of usual circumstances, (d) a revelatory case that previously has been inaccessible, or (e) a longitudinal case (Yin, 2014).

A multiple case design is used when two or more cases are chosen to examine complementary components of the main research question (Yin, 2012). The multiple case design may be selected when the researcher is interested in examining conditions for similar findings that may be replicated or in examining conditions for contrasting cases. When choosing multiple cases, no formula exists to determine the number of cases needed, unlike power analysis to determine sample size (Small, 2009). In general, including more cases in a multiple case study will achieve greater confidence or certainty in a study’s findings. Conversely, the use of fewer cases will yield less confidence or certainty.

Single and multiple case studies can use holistic or embedded designs. A holistic design comprehensively examines a case or cases, and an embedded design also analyzes subunits associated with the case or cases.

Case study research is flexible and can use multiple sources of data. Yin’s (2014) methodology incorporates qualitative and quantitative data sources, and Merriam’s (2009) and Stake’s (1995) methodology exclusively use qualitative data sources. Multiple sources of evidence provide breadth in comprehending a case or cases and enhance confidence in the study findings. Common sources of evidence include direct observations of human behavior or physical environment, interviews, archival records, documents (e.g., newspaper articles, reports), participant observation, participant records, surveys, photographs, videos, or questionnaires.

Data analysis for case study research uses qualitative and quantitative data analysis methods, depending on the selected methodology, with the focus on describing the case or cases. Merriam’s (2009) data analysis is a process of consolidating, reducing, and interpreting procedures that occur simultaneously through data collection and analysis. Six analytic strategies are ethnographic analysis, narrative analysis, phenomenologic analysis, constant comparative method, content analysis, and analytic induction. Stake (1995) similarly employs data collection and analysis procedures through the use of two strategies—categorical aggregation and direct interpretation. Yin (2012) recommends initially categorizing the data then organizing the data by four techniques—pattern matching, explanation building, program logic models, and time–series analysis. Multiple case studies also would include an additional technique called cross-case synthesis to search for any repetition in the case. The final product of case study research is a narrative report that tells the story of the case and enables the reader to fully understand the case from the narrative (Taylor & Thomas-Gregory, 2015).

Methodologic Issues

An important aspect of case study research is ensuring study rigor similar to other qualitative studies. Strategies to ensure rigor include the maintenance of a diary or journal by the researcher to document personal feelings and reactions and minimize researcher bias, expert verification, an audit trail, use of thick descriptions, long-term observation, multisite designs, and member checking to ensure accuracy of findings by the participants (Taylor & Thomas-Gregory, 2015). Another methodologic issue is ensuring content validity. This can be achieved by the researcher’s final report that should include sufficient evidence and display a deep understanding of the case by the researcher.

Application of Case Study Design in Nursing Research

In this issue of Oncology Nursing Forum, Walker, Szanton, and Wenzel (2015) present their study exploring post-treatment normalcy using a multiple case design. The purpose of the study was to develop a better understanding of how adult survivors of early-stage breast and prostate cancers manage the work of recovery, which exemplifies the goal of case study research by asking “how” a phenomenon works. Multiple case study design was used through data collection that included self-reports, biweekly phone interviews, in-depth interviews, and written journals to evaluate existing theoretical knowledge and generate new theoretical knowledge about the process of managing recovery. The authors describe study rigor by illustrating expert validation and a constant comparative process of data analysis. From the data, the authors provide the reader with a detailed, narrative description of how adult survivors work toward normalcy that is engaging and tells the survivors’ story of life post-treatment.

Despite the lack of a well-defined protocol for case study research, Merriam, Stake, and Yin provide similar yet distinctive philosophies and procedures that researchers can use when embarking on a case study research project. Walker et al. (2015) provide an excellent exemplar of executing case study research in oncology through the investigation of the illness trajectory framework and how survivors work toward normalcy after treatment. Through this research approach, oncology nursing knowledge can benefit from a better understanding of the “how” and “why” of numerous phenomena that have implications for nursing practice and ultimately improve patient outcomes.

Donnelly, F., & Wiechula, R. (2012). Clinical placement and case study methodology: A complex affair. Nurse Education Today, 32, 873–877.

Merriam, S.B. (2009). Qualitative research: A guide to design and implementation. San Francisco, CA: Jossey-Bass.

Polit, D.F., & Beck, C.T. (2012). Nursing research: Generating and assessing evidence for nursing practice (9th ed.). Philadelphia, PA: Lippincott Williams and Wilkins.

Small, M.L. (2009). How many cases do I need? On science and the logic of case selection in field-based research. Ethnography, 10, 5–38. doi:10.1177/1466138108099586

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

Taylor, R., & Thomas-Gregory, A. (2015). Case study research. Nursing Standard, 29(41), 36–40.

Walker, R., Szanton, S.L., & Wenzel, J. (2015). Working toward normalcy post-treatment: A qualitative study of older adult breast and prostate cancer survivors [Online exclusive]. Oncology Nursing Forum, 42, E358–E367. doi:10.1188/15.ONF.E358-E367

Yazan, B. (2015). Three approaches to case study methods in education: Yin, Merriam, and Stake. Qualitative Report, 20, 134–152.

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

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

About the Author(s)

Diane G. Cope, PhD, ARNP, BC, AOCNP®, is an oncology nurse practitioner at the Florida Cancer Specialists and Research Institute in Fort Myers. No financial relationships to disclose. Cope can be reached at [email protected] , with copy to editor at [email protected] .

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Case study research

Affiliation.

• 1 Faculty of Health, Social Care and Education, Anglia Ruskin University, Cambridge, England.
• PMID: 26058651
• DOI: 10.7748/ns.29.41.36.e8856

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

Keywords: Case study research; case study research approaches; nursing protocols; research design; research methodologies; rigour.

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Qualitative case study data analysis: an example from practice, catherine houghton lecturer, school of nursing and midwifery, national university of ireland, galway, republic of ireland, kathy murphy professor of nursing, national university of ireland, galway, ireland, david shaw lecturer, open university, milton keynes, uk, dympna casey senior lecturer, national university of ireland, galway, ireland.

Aim To illustrate an approach to data analysis in qualitative case study methodology.

Background There is often little detail in case study research about how data were analysed. However, it is important that comprehensive analysis procedures are used because there are often large sets of data from multiple sources of evidence. Furthermore, the ability to describe in detail how the analysis was conducted ensures rigour in reporting qualitative research.

Data sources The research example used is a multiple case study that explored the role of the clinical skills laboratory in preparing students for the real world of practice. Data analysis was conducted using a framework guided by the four stages of analysis outlined by Morse ( 1994 ): comprehending, synthesising, theorising and recontextualising. The specific strategies for analysis in these stages centred on the work of Miles and Huberman ( 1994 ), which has been successfully used in case study research. The data were managed using NVivo software.

Review methods Literature examining qualitative data analysis was reviewed and strategies illustrated by the case study example provided.

Discussion Each stage of the analysis framework is described with illustration from the research example for the purpose of highlighting the benefits of a systematic approach to handling large data sets from multiple sources.

Conclusion By providing an example of how each stage of the analysis was conducted, it is hoped that researchers will be able to consider the benefits of such an approach to their own case study analysis.

Implications for research/practice This paper illustrates specific strategies that can be employed when conducting data analysis in case study research and other qualitative research designs.

Nurse Researcher . 22, 5, 8-12. doi: 10.7748/nr.22.5.8.e1307

This article has been subject to double blind peer review

None declared

Received: 02 February 2014

Accepted: 16 April 2014

Case study data analysis - case study research methodology - clinical skills research - qualitative case study methodology - qualitative data analysis - qualitative research

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Nursing Students’ Views and Suggestions About Case-Based Learning Integrated Into the Nursing Process: A Qualitative Study

Rukiye burucu.

1 Department of Nursing, Necmettin Erbakan University, Seydişehir Faculty of Health Science, Konya, Turkey

Selda Arslan

2 Department of Nursing, Necmettin Erbakan University, Faculty of Nursing, Konya, Turkey

This study aimed to evaluate students’ views and suggestions about case-based learning.

: The research was planned by using qualitative method of phenomenological type. Case-based learning was integrated into the nursing process and implemented in four sessions, and then, students’ views and suggestions were collected. In the interview, a semi-structured interview form was used, in-depth interviews were made, and the data were evaluated by qualitative data analysis. Phenomelogical approach of Colazzi was used in the analyzes and Huberman method was applied. The COREQ was used to analyze and report the qualitative data. The sample consisted of second-year students in the nursing department of a public university in Anatolia in the academic year 2017-2018. Participants attended the case-based learning program. A focus group interview was conducted with 10 of the participants.

Participants are 10 students with a mean age of 19.86 ± 0.78 years. A total of 65 opinions and suggestions were presented during the focus group meeting. These were grouped under two main and seven sub-themes. Participants had positive views on the program and gave practical suggestions.

Case-based learning integrated into the nursing process is a practical nursing method that helps students learn and understand the nursing process better and approach patients from a holistic perspective.

Introduction

The goal of nursing education is to encourage students to develop personal and professional skills (Sharif & Masoumi, 2005). Using nursing students’ teaching methods of choice promotes learning, ensures learning retention, and improves academic performance (Vizeshfar & Torabizadeh, 2018). Different methods should be used for high-quality nursing education ( Azizi et al. , 2018 ; Holland et al. , 2017 ). One of these methods is case-based learning (CBL) ( Aluisio et al. , 2016 ; Hong & Yu, 2017 ), which allows students to acquire academic knowledge (Yoo & Park, 2015), develop critical thinking ( Chan et al. , 2016 ; Hong & Yu, 2017 ) and problem-solving skills (Yoo & Park, 2015), and improve professional self-efficacy ( Kim, 2018 ). Cases can be taught through brainstorming, group discussions, concept maps (Laver & Croxon, 2015), role play ( Kim, 2018 ; Tucker et al. , 2015 ), simulation and software ( Tucker et al. , 2015 ), and demonstration ( MacDonnell et al. , 2010 ).

CBL is a method of learning through analysis of a situation that has been or is likely to be experienced ( Kırımsoy et al. , 2013 ). It is a student-centered method that involves the teaching of a topic through a scenario, resulting in improved learning outcomes and decision-making skills (Kanbay & Okanli, 2017), and in permanent and in-depth learning ( Aluisio et al. , 2016 ). CBL promotes active engagement and self-assessment and decision-making, allowing students to gain insight into how they should react in real life situations (Oermann & Kuzu Kurban, 2015). Nurse education should be based on theoretical and practical training to provide students with the opportunity to put their knowledge to use. However, not all students get the chance to encounter all cases in clinical settings. To overcome this problem, nursing education should incorporate the CBL ( Altınbaş & Derya İster, 2020 ), which, however, has not been sufficiently studied so far ( Majeed, 2014 ). It is recommended that researchers provide the CBL to nursing students and then find out about their views and recommendations on it ( Altınbaş & Derya İster, 2020 ). Collecting and analyzing qualitative data is a recommended method of evaluating views and recommendations ( Chan et al. , 2016 ). Qualitative methods are used to collect data on the environment, processes, and perceptions ( Karataş, 2015 ), and can also be applied to data on teaching methods. Students’ views can provide important information about the effectiveness of a method and help create a framework to overcome its shortcomings ( Chan et al. , 2016 ; Kermansaravi et al. , 2015 ; Raymond et al. , 2018 b; van Hooft et al. , 2018 ). Investigating students’ opinions about a teaching method causes them to feel stressed, but also encourages them to improve themselves ( Gholami et al. , 2017 ). This study aimed to determine what nursing students thought about the CBL and what kind of suggestions they would offer to improve it.

Research Questions

• What kind of method do nursing students think the CBL is?
• What do nursing students suggest about the CBL?

Study Design

This was a qualitative study that employed phenomenology.

Nursing education varies across countries. Nursing programs in Turkey offer a 4-year undergraduate education. The sample for this study consisted of second-year nursing students from a public university in Turkey. Purposive sampling does not set a limit on the sample size, but it is believed that too large a sample can make interpretation challenging ( Baltacı, 2018 ). Therefore, this study was completed with 10 volunteers after the CBL intervention.

Data Collection

Prior to the CBL intervention, a detailed lesson plan was developed (Appendix 1) and integrated into the nursing process. Each CBL session lasted 100 minutes. An expert was consulted for the cases in the CBL program (Appendix 2). The integration of the cases into the CBL program was based on the Nursing Interventions Classification, Nursing Outcomes Classification, and NANDA-International (NANDA-I) ( Bulechek et al. , 2017 ; Carpenito-Moyet, 2012). The sample was divided into two for the CBL program, which was applied in classrooms between February and May 2018. One week after the CBL program, a focus-group interview (120 minutes) was conducted with 10 of the 37 participants. The focus-group interview was held using a semi-structured interview form (Appendix 3), for which an expert was consulted (Appendix 2). The interview was audio-recorded. Notes were taken during the interview. One of the researchers acted as a director, while the other acted as a reporter during the interview. Data were collected by the focus-group interview method. It is impossible to prevent respondents from interacting in the focus-group interviews. To minimize this, the researchers asked the interview questions and received answers in order. There were two focus groups of five respondents each. Data collection was terminated when no more data adding new information or insight was forthcoming (data saturation) (Yağar & Dökme, 2018). The interviews were held at the participants’ convenience, so that they would feel comfortable answering the questions. A semi-structured interview form was used during the interviews for consistency. An interview flow template was used for flow and order. Whenever the researchers were in doubt, they consulted with an academic specialized in qualitative research.

In this research, a semi-structured interview form was used to collect the data. There are four questions in this form;

• Can I learn your positive and negative feelings and thoughts about the “case-based teaching method?”
• Have you been taught such a lesson before?
• Compare the “case-based teaching method” with your current courses. What are the differences between the two courses?
• What are your suggestions for this method?

For confirmation, results should be corroborated by those of other studies (Creswell, 2017). Therefore, the researchers discussed the results in line with the related literature.

Reliability

Interrater reliability was calculated for both the semi-structured interview form and the themes using the formula [Reliability = (number of agreements)/(number of agreements + number of disagreements) × 100] (Arastaman et al., 2018; Guba, 1981 ; Ocak & Kutlu Kalender, 2017 ). The interrater reliability was higher than 80, indicating acceptable reliability. Both researchers analyzed the data independently and then combined it based on the order specified by encoders ( Table 1 ). The researchers consulted with an academic specialized in qualitative research to reach a consensus on the parts on which they had disagreed during coding. Bias was reduced using Colaizzi’s phenomenological methodology, which consists of seven steps: (1) recording data, (2) determining significant statements, (3) making sense of the statements, (4) classifying themes into groups, (5) improving the groups, (6) stating the phenomenon clearly, and (7) constructing a fundamental structure ( Onat Kocabıyık, 2016 ).

Colaizzi’s Method of Data Analysis

Statistical Analysis

Themes were developed and categorized. Data were analyzed using conventional qualitative data analysis ( Sönmez & Alacapınar, 2014 ). In the qualitative data analysis, Colaizzi’s phenomenological methodology was used to disclose the meaning attributed by respondents to the intervention in question ( Demir et al. , 2017 ). Colaizzi’s phenomenological methodology is used to reveal the meaning attributed by people to an event/phenomenon ( Onat Kocabıyık, 2016 ). The Consolidated Criteria for Reporting Qualitative Research, which is a 32-item checklist, was used to analyze and report the qualitative data ( Tong et al. , 2007 ).

Ethical Consideration

The study was approved by the Non-Clinical Research Ethics Committee of the Faculty of Health Sciences of Selçuk University (2017/58). Written permission was obtained from the department of nursing. Written informed consent was obtained from participants. The researchers kept the names of the respondents anonymous during data report and kept the audio-recordings and transcripts in encrypted files on their computers.

The focus-group interview was conducted with 10 participants (2 men and 8 women) with a mean age of 19.86 ± 0.78 years. In the focus-group interview, the respondents presented 65 views and recommendations, categorized into two main themes; “Opinions” and “Suggestions.” The theme “opinions” consisted of four subthemes; “The CBL program helped me acquire more academic knowledge and learn the nursing process better”; “The CBL program increased my motivation and appealed to me”; “It was good that the CBL classes were not crowded”; and “The question–answer (Q&A) during the CBL class was helpful.” Theme “suggestions” consisted of three subthemes; “The CBL should be integrated into the current curriculum”; “Nurses and instructors should be role models for students”; and “The CBL nursing education should be offered to other students as well.” The respondents stated that they had never had a case-based course before. Respondents 5 and 7 did not answer question 3, while respondent 8 did not answer question 4. Table 1 shows the distribution of the responses and themes.

Theme 1 Opinions

Subtheme: The CBL program helped me acquire more academic knowledge and learn the nursing process better: All respondents stated that the CBL program made them more aware and knowledgeable about academic content, nursing process, and care planning. The following are direct quotations from three respondents:

• Respondent 1: “...I‘ve learned to approach patients from a holistic perspective and to tackle not only complications but also psychological and social problems, and now I can combine parts and see things as a whole...”
• Respondent 2: “….I didn’t know how to use the nursing process when planning care, but the CBL is helping me manage care now, it‘s also increased my knowledge on medication and helped me understand what nursing diagnosis is…”
• Respondent 10: “…I can plan care more easily and distinguish between descriptive and related factors. I got to see what I’d been (doing wrong during care planning. I used to get bored planning care, but the CBL program helped me better understand the nursing process. The nursing diagnosis book is too general and confusing. It is too broad, but now I understand that I can go beyond that knowledge and that it is practically possible…”

Subtheme: The CBL program increased my motivation and appealed to me : The respondents noted that they felt more confident when they saw that they could easily reach the teacher and ask him/her questions to plan care without fear of being graded. The following are direct quotations from three respondents:

• Respondent 3: “…I was more efficient because I had no fear of being graded, I was more comfortable during the internship than usual ... The CBL classes were more active than others, I was more motivated and engaged because I had no fear of being graded…”
• Respondent 4: “… It was a privilege for me to participate in this training. No one had the chance to do as thorough an examination as the students attending this training, which was an advantage. …”
• Respondent 6: “…I liked it when I saw that I could plan care, it motivates me now…”

Subtheme: It was good that the CBL classes were not crowded: The respondents saw it as a great advantage that they had all their questions answered because the CBL classes were not crowded. The following are direct quotations from three respondents:

• Respondent 2: “…In other classes, we would ask our questions in haste and get some answers because the classes were too crowded, but in the CBL class we could ask our questions in detail.…”
• Respondent 6: “… the CBL class was less crowded than others, and so it was more like a Q&A type of class, so they were more efficient. Besides, the group of 37 was divided into two, which was very good for the CBL class.…”
• Respondent 10: “…we all asked and answered questions, everybody got to talk, which is not possible in other classes because they are too crowded…”

Subtheme: The Q&A during the CBL class was helpful: The respondents remarked that Q&A in the CBL class was better for them because all their questions were answered, which promoted their learning. The following are direct quotations from three respondents:

• Respondent 6: “…theoretical classes were very intense, and the instructors would think that we knew about theory, and so, they sometimes wouldn’t answer our questions, and those classes offered nothing much when it comes to practice, but in the CBL class we examined what was taught in theory, and I thought that I could put it into practice…”
• Respondent 7: “…we always had time constraints in other classes, but in the CBL class we got to ask all our questions one by one and got answers, I mean we kind of had to ask questions, but in the end, we learned…”
• Respondent 10: “…we had Q&A throughout the CBL class, which was very productive, I got to ask all the questions I had in mind and got answers to all of them …”

Theme 2 Suggestions

Subtheme: the CBL should be integrated into the existing curriculum: All but respondents 1 and 8 recommended that the CBL should be integrated into clinical practice or offered by the current curriculum as an elective course. The following are direct quotations from three respondents.

• Respondent 2: “…the CBL should be integrated into the curriculum, there is no need to make extra time for it, I mean, I had to come to school for the CBL class apart from the courses I already have, so it was kind of a hurdle for me…”
• Respondent 5: “… the CBL should be offered as an elective course, and students could be split into groups of 30 and work on cases …”
• Respondent 7: “…In the first week of clinical practice, the instructor should bring a case and present it to her students, just like what we have in the CBL, and tell them that she expects the same from them …”

Subtheme: Nurses and instructors should be role models for students: Respondents 1, 6, 7, and 10 stated that clinical nurses and instructors should adopt a common language and serve as role models for the nursing process and care planning. The following are direct quotations from three respondents:

• Respondent 1: “…nurses should be role models for this…”
• Respondent 6: “… instructors should use a common language and be role models when it comes to planning care.”
• Respondent 7: “… we plan care, but each instructor says something different about it and has different styles... We don‘t even know which one is right and which one is wrong, but they are supposed to serve as models…”

Subtheme: the CBL nursing education should be offered to other students as well: Respondents 4, 7, 9, and 10 highlighted that the CBL program should be offered to all students because they all have difficulty in learning the nursing process and planning care. The following are direct quotations from three respondents:

• Respondent 4: “…we now know it and can put it into practice, but we couldn‘t do it at all in our first year, so nursing students of all grades should attend the CBL program...”
• Respondent 7: “… I believe that other students should also learn these things because no one had taught them to us before, and we didn‘t get to learn them in other classes. There should be a case group or something like that could discuss cases with younger students once a week…”
• Respondent 9: “…care planning is hard for all students, so older students should help younger students with it, so peer education could be helpful …”

The discussion is based on the summarized data in Table 2 .

Distribution of Participants’ Opinions and Suggestions

Note: * Themes and subthemes.

CBL makes nursing students more knowledgeable and prone to teamwork, helps them with better clinical performance, develops more positive attitudes toward clinical practice, helps them understand the holistic approach better and improve themselves professionally ( Forsgren et al. , 2014 ), resulting in higher learning retention, quality of care, and patient safety ( Ward et al. , 2018 ). The more the students know, the more motivated they are, further facilitating learning ( Holland et al. , 2017 ). People who acquire new knowledge are likely to develop more positive attitudes and better skills ( Patiraki et al. , 2017 ). Adequate and comfortable learning environments support motivation ( Palumbo, 2018 ; Raymond et al. , 2018 a), minimize communication problems, and contribute to high-quality care (Sharif & Masoumi, 2005).

Aluisio et al. (2016) divided Indian nursing students into three groups (CBL, standard training, and simulation) to teach them about disasters. They found that the CBL group had the highest knowledge score (55.3 ± 11.3), followed by the simulation (46.9 ± 10.6) and standard training (43.8 ± 11.0) groups. Lee et al. (2020) provided nurses working in nursing homes with the CBL (integrated with online and simulation training) on interventions for heart attacks, and found that the participants felt more competent after the training (post-CBL = 4.11 ± 0.37) than before (pre-CBL = 3.79 ± 0.41) and had higher post-CBL knowledge scores (12.82 ± 2.03) than pre-CBL knowledge scores (10.06 ± 2.28). Therefore, they concluded that the CBL integrated with online and simulation training improved nurses’ knowledge and promoted their learning. Kim and Yang (2020) provided nurses with training based on a case of dementia and found that the training helped nurses learn more about dementia ( z = −4.86, p < .001) and interventions for dementia ( z = −4.55, p < .001) and develop more positive attitudes toward people with dementia ( t = −3.04, p = .003). Nursing students are expected to acquire knowledge and put them into practice in the nursing process. Therefore, we can state that the CBL integrated into the nursing process can contribute to nurses’ education.

Cases appeal to students ( Chan et al. , 2016 ; Gholami et al. , 2017 ) and satisfy their expectations ( Hong & Yu, 2017 ). CBL helps nurses make fewer mistakes ( Patiraki et al. , 2017 ; Uysal et al. , 2016 ) and makes them more motivated ( Cui et al. , 2018 ), and therefore, it should be an integral part of nursing education ( McLean, 2016 ). Focus-group interviews are of significance for detecting the strengths and weaknesses of nursing interventions, correcting errors, eliminating deficiencies, and developing new programs. Opinions and suggestions about methods are sound guides that allow us to see the errors and weaknesses of interventions, helping us generate strategies for reform and revise curricula ( Azizi et al. , 2018 ).

Class size is an important factor affecting education and communication during education because the greater the class size, the less time the teacher has for each student ( Raymond et al. , 2018 a), resulting in reduced learning and motivation. However, because class size remains be an important factor, correct planning ( Kocaman & Yurumezoglu, 2015 ; Palumbo, 2018 ) and Q&A is recommended to overcome this problem. Q&A-based classes can increase students’ awareness, concentration, confidence, and self-assessment capacity ( Kaddoura, 2011 ). In short, educational conditions (setting, time, class size, etc.) play a key role in learning ( Gholami et al. , 2017 ). Therefore, education programs should be based on small class size.

The nursing process and care planning provide a common language for nurses and improve the profession through evidence-based protocols ( Patiraki et al. , 2017 ). Nursing students make more mistakes than are acceptable because they cannot clarify the nursing diagnosis while performing the nursing process ( Andsoy et al. , 2013 ). A common language makes nursing care more visible, standardized and record-based, and better understood. This helps both healthcare professionals and instructors meet at a common point and serve as role models ( van Hooft et al. , 2018 ). Nursing students think of the nursing process as too abstract, hard-to-understand, and challenging. This suggests that we need a more concrete educational paradigm ( Zamanzadeh et al. , 2015 ), and we believe we can use the CBL to teach the nursing process.

Nurses and instructors should serve as role models and use a common language to help students put the nursing process into practice. Especially, first- and second-year students find it difficult to comprehend the nursing process and planning care, and therefore, need support ( Andsoy et al. , 2013 ; Patiraki et al. , 2017 ; Uysal et al. , 2016 ). Student communities play an important role in making students socially aware and collaborative, and thus support learning ( Mohan Bursalı & Aksel, 2016 ). Case communities and peer education can provide nursing students with the support in question. Integrating the CBL into the curriculum can be a promising alternative for nursing students.

Conclusion and Recommendations

CBL promotes nursing students’ learning and makes them more motivated because they enjoy Q&A sessions and interaction during CBL-based lectures. They believe that the CBL should be integrated into the existing curriculum and that instructors and nurses should be role models as they put the nursing process in practice. CBL turns abstract concepts of the nursing process into tangible and visual representations. Nursing students think that sharing with younger students what they learn from CBL-based lectures can help those students learn the nursing process more easily.

As a result, it would be appropriate for CBL to be integrated into the existing curriculum and used to train both students and nurses in small groups.

Ethics Committee Approval

Ethics committee approval was obtained from the Non-Clinical Research Ethics Committee of the Faculty of Health Sciences of Selçuk University (2017/58).

Author Contributions

Concept – R.B., S.A.; Design – R.B., S.A.; Supervision – S.A.; Resources – R.B., S.A.; Materials – R.B., S.A.; Data Collection and/or Processing – R.B., S.A.; Interpretation – R.B., S.A.; Literature Search – R.B.; Writing Manuscript – R.B.; Critical Review – S.A.

Appendix 1: CBL Sample Curriculum

Case presentation and analysis (100 Min)

• Showing the case electronically to the group one day prior to intervention
• Remembering the case (10 Min)
• Presenting the theory of disease (10 Min)
• Presenting medications used (15 Min)
• Sorting out the patient problems (15 Min)
• Diagnosis Nursing of NANDA and determining interventions (35 Min)
• Identifying descriptive and etiological factors (10 Min)
• Evaluation and summary (5 Min)

Objectives of the CBL Program

Appendix 2: expert list.

• Prof. Veysel Sönmez, Hacettepe University, Faculty of Education, retired
• Prof. Füsun Gülderen Alacapınar, Necmettin Erbakan University, Faculty of Education
• Assoc. Prof. Selda Arslan, Selçuk University, Faculty of Nursing
• Assoc. Prof. Şerife Kurşun, Selçuk University, Faculty of Nursing
• Assoc. Prof. Pınar Zorba Bahçeli, Selçuk University, Faculty of Nursing

Appendix 3: Semi-structured Interview Form Items

• Could you please tell us about your positive and negative emotions and thoughts about the case-based learning program?
• Have you ever had such a course before?
• Please, compare the case-based learning program with your current courses. What is the difference between them?
• What suggestions can you make concerning the case-based learning program?

Funding Statement

The authors declared that this study has received no financial support.

Informed Consent: Written consent was obtained from students who participated in this study.

Conflict of Interest: The authors have no conflicts of interest to declare.

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