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Case study methods in theory and practiceFrom sampling to understanding in clinical genetics and service user involvement

Graham MartinSAPPHIRE GroupDepartment of Health SciencesUniversity of Leicester

Background

• Case study methods now well established

• Plenty of ‘bibles’ to choose from…– Yin, Eisenhardt, Gerring, Ragin, Flyvbjerg etc.

• …and a few great schisms too– constructivist v positivist(ish) denominations

• How to navigate these many paths?

• How to apply the principles of case study methods to generate sound, defensible empirical understandings in practice?

A few key analytical advantages of case study approaches• Using comparison to examine the role of

factors posited as influential / determinative

• Developing a rich understanding of how factors interact in specific contexts in practice

• Theory testing (in specific contexts) and theory building (through inductive reasoning and open-ended fieldwork)

• Comprehensiveness and concreteness helps to ensure relevance and validity of research

The studies

1. Sustainability of NHS genetics services– Follow-up study from earlier evaluation of clinical-genetics

start-up projects to explore and develop theory around sustaining and embedding organisational change in healthcare

– Theoretically informed subsample of four cases from an earlier sample of 11 cases1

2. Service user involvement in cancer-genetics services– Study to explore and develop theory about the role, realisation

and influence of patient and public involvement– Involved fieldwork in entire ‘population’ of cancer-genetics

services funded by DoH and Macmillan (n=7), followed by analysis of a subsample of these which involved face-to-face involvement (n=5)2

1. Martin GP, Weaver S, Currie G, Finn R, McDonald R. Innovation sustainability in challenging healthcare contexts: embedding clinically led change in routine practice. Health Services Management Research 2013 in press.

2. Martin GP, Finn R. Patients as team members: opportunities, challenges and paradoxes of including patients in multi-professional health-care teams. Sociology of Health & Illness 2011; 33: 1050-1065.

Case study theory in research practice• The strengths and weaknesses of (my

application of) case study methods in:– Sampling– Fieldwork and data collection– Analysis and reasoning– Presentation

• Some reflections implications for others deploying case study methods in similar fields

Sampling

Study 1 (sustainability)

• Approach to sampling was– pragmatic (following up existing relationships and

building on existing insights)– empirically informed (based on ideas about

sustainability generated in the original evaluation)– theoretical (premised on [our reading of] the existing

literature, and factors purported to be important)

• Four cases chosen that– contrast and align along two most important variables– contain interesting wider contextual variation– are likely to ‘produce the goods’

Organisational innovation based on evidence-based model

Locally designed organisational innovation

Primary care-based organisational innovation

Case A Clinical speciality: cancer

genetics Led by a nurse Commissioned by PCT

Case B General primary care genetics Led by a general practitioner Commissioned by PCT initially,

funding currently halted

Hospital-based organisational innovation

Case C (tertiary care) Clinical speciality: cancer

genetics Led by a clinical geneticist Commissioned by a

consortium of PCTs

Case D (secondary care) Other clinical speciality* Jointly led by genetics and

mainstream consultants Funded through integration into

mainstream service

Sampling (continued)

• Is such ‘uncontrolled variance’ a problem?– Perhaps—but probably only if your analytical logic is

deductive/positivistic– But it does need to be acknowledged and addressed

Study 2 (user involvement)

• Existence of an accessible and researchable ‘population’ of cases removes the quandaries of selecting a sample

• But it only defers the analytical challenges associated with the uncontrollable variance—the messiness—of real-life cases

Fieldwork and data collection

Study 1 (sustainability)

• Predominantly interview based

• Rapid study (15 months); reliant on existing contacts and snowball sampling

• Fewer interviewees in some cases than others (range 5-14)

• The lens of prior data analysis: focusing or colouring?

• Potential for rather a particular view of a case?

Fieldwork and data collection (cont.)Study 2 (user involvement)

• Longer time-frame; more ‘holistic’ and longitudinal data collection

• Interviews, observations, documents

• And yet—the same anxieties about what has been missed, what has been hidden, what is being prioritised: the classic concerns of the qualitative researcher!

• How to balance pragmatism with the (ever-present) urge to collect more data and reach a ‘complete’ picture of the case?

Analysis and reasoning

• Extensive analytical work undertaken in both studies (team-based in study 1; individual in study 2)

• Some of the key elements of comparative case analysis very helpful in achieving insight, e.g.– Seeking within-group similarities and inter-group

differences– Selecting pairs of apparently similar cases and noting

similarities and differences

• This revealed stark contrasts between cases, and clear evidence about the mechanisms that gave rise to these

Study 1 (sustainability)Sustained cases 1 Intermediate

cases 2-3Unsustained case 4

Outcome • Ongoing service provision

• Funding from core departmental budget

• Ongoing service provision

• Funding from a mixture of sources

• Service provision suspended

• No funding from any source

Setting • Hospital department (clearly bounded)

• PCTs bound together by cancer networks

• PCTs

Leadership • Medical consultants

• Consultant in one case; nurse in another

• Purposive: care taken to find the ‘right’ kind of user

Wider support

• Consultants have power, status and influence within department

• Leads have limited individual power, but strong networks of ‘champions’ (inc. decision makers)

• Limited individual power, weak support from decision makers

Organisational context

• Stable • Turbulent • Turbulent

Analysis and reasoning (continued)• The risk of ‘premature confirmation’ is

mitigated by robust methods and adherence to principles of good qualitative research

• Exposure to the data is the best antidote to preconception!

• Yet there remains the risk of partial perspective, of overlooking alternative explanations, of confirming expectations (or preferring ‘novel contributions’ that are more likely to be published!)

Study 2 (user involvement)Cases 1-4 Case 5 (positive outlier)

Features • ‘Instrumental’ user involvement

• Limited user influence• Frustration for users and staff

• Consensus-based user involvement

• Considerable user influence• Contentment and mutual

regard

‘Global’ context

• Policy context demands PPI• Reporting encourages ‘tick

boxes’

• Policy context demands PPI• Reporting encourages ‘tick

boxes’

Recruitment of users

• Opportunistic: we need a user, quick!

• Purposive: care taken to find the ‘right’ kind of user

Background of users

• Diverse• No prior relationship with staff

• Specific: both are previous cancer-genetics patients, known to staff

Process • Infrequent meetings• User involvement confined to

specific points in agenda• Little intervening contact

between staff and users

• Much more frequent meetings• User involvement actively

encouraged throughout• Ongoing professional and social

contact between staff and users

y

c

x1

x2

x3

xn

Analysis and reasoning (continued)• Is the generation of theoretical propositions

that follow a causal-explanatory logic a problem?

• Probably not, unless– you’re a radical constructivist (in which case even

heuristic rules have no generalisability)– you’re an unreconstructed positivist (in which case the

propositions will disappoint, as they’re not determinative)

– it reflects a rushed, reductivist analytical process that takes a short cut to explanatory relationships without due process:

• taking time to develop deep familiarity with data• paying attention to mechanisms, not just patterns• having care for disconfirming cases• etc.

Presentation

• Good presentation necessitates simplification, whether producing a ‘map’ or a ‘guide’

• Caution and qualification is always needed, but this does not preclude sincere argument for a particular, well evidenced, interpretation

• Transparency can never be complete, but can underwrite trust in the author’s account

Concluding reflections

• Adaptability is helpful, as is a liberal approach to data collection and reasoning (though it may not impress epistemological purists)

• Embrace the uncontrolled variance!

• A case study is only as good as its methods

• Simple presentation is a critical asset; simplistic analysis is a fatal flaw

Graham Martin0116 252 3207

graham.martin@le.ac.ukwww.le.ac.uk/people/gpm7