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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
