multiple instrumental case study

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• Published: 27 June 2011

The case study approach

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

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

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

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

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Home » Case Study – Methods, Examples and Guide

Case Study – Methods, Examples and Guide

Table of Contents

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

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

Types of Case Study

Types and Methods of Case Study are as follows:

Single-Case Study

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

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

Multiple-Case Study

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

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

Exploratory Case Study

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

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

Descriptive Case Study

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

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

Instrumental Case Study

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

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

Case Study Data Collection Methods

Here are some common data collection methods for case studies:

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

Observations

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

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

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

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

How to conduct Case Study Research

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

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

Examples of Case Study

Here are some examples of case study research:

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

Application of Case Study

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

Business and Management

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

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

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

Social Sciences

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

Law and Ethics

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

Purpose of Case Study

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

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

Case studies can also serve other purposes, including:

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

Advantages of Case Study Research

There are several advantages of case study research, including:

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

Limitations of Case Study Research

There are several limitations of case study research, including:

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

About the author

Muhammad Hassan

Researcher, Academic Writer, Web developer

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Qualitative Research Designs

Case study design, using case study design in the applied doctoral experience (ade), applicability of case study design to applied problem of practice, case study design references.

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The field of qualitative research there are a number of research designs (also referred to as “traditions” or “genres”), including case study, phenomenology, narrative inquiry, action research, ethnography, grounded theory, as well as a number of critical genres including Feminist theory, indigenous research, critical race theory and cultural studies. The choice of research design is directly tied to and must be aligned with your research problem and purpose. As Bloomberg & Volpe (2019) explain:

Choice of research design is directly tied to research problem and purpose. As the researcher, you actively create the link among problem, purpose, and design through a process of reflecting on problem and purpose, focusing on researchable questions, and considering how to best address these questions. Thinking along these lines affords a research study methodological congruence (p. 38).

Case study is an in-depth exploration from multiple perspectives of a bounded social phenomenon, be this a social system such as a program, event, institution, organization, or community (Stake, 1995, 2005; Yin, 2018). Case study is employed across disciplines, including education, health care, social work, sociology, and organizational studies. The purpose is to generate understanding and deep insights to inform professional practice, policy development, and community or social action (Bloomberg 2018).

Yin (2018) and Stake (1995, 2005), two of the key proponents of case study methodology, use different terms to describe case studies. Yin categorizes case studies as exploratory or descriptive . The former is used to explore those situations in which the intervention being evaluated has no clear single set of outcomes. The latter is used to describe an intervention or phenomenon and the real-life context in which it occurred. Stake identifies case studies as intrinsic or instrumental , and he proposes that a primary distinction in designing case studies is between single and multiple (or collective) case study designs. A single case study may be an instrumental case study (research focuses on an issue or concern in one bounded case) or an intrinsic case study (the focus is on the case itself because the case presents a unique situation). A longitudinal case study design is chosen when the researcher seeks to examine the same single case at two or more different points in time or to capture trends over time. A multiple case study design is used when a researcher seeks to determine the prevalence or frequency of a particular phenomenon. This approach is useful when cases are used for purposes of a cross-case analysis in order to compare, contrast, and synthesize perspectives regarding the same issue. The focus is on the analysis of diverse cases to determine how these confirm the findings within or between cases, or call the findings into question.

Case study affords significant interaction with research participants, providing an in-depth picture of the phenomenon (Bloomberg & Volpe, 2019). Research is extensive, drawing on multiple methods of data collection, and involves multiple data sources. Triangulation is critical in attempting to obtain an in-depth understanding of the phenomenon under study and adds rigor, breadth, and depth to the study and provides corroborative evidence of the data obtained. Analysis of data can be holistic or embedded—that is, dealing with the whole or parts of the case (Yin, 2018). With multiple cases the typical analytic strategy is to provide detailed description of themes within each case (within-case analysis), followed by thematic analysis across cases (cross-case analysis), providing insights regarding how individual cases are comparable along important dimensions. Research culminates in the production of a detailed description of a setting and its participants, accompanied by an analysis of the data for themes or patterns (Stake, 1995, 2005; Yin, 2018). In addition to thick, rich description, the researcher’s interpretations, conclusions, and recommendations contribute to the reader’s overall understanding of the case study.

Analysis of findings should show that the researcher has attended to all the data, should address the most significant aspects of the case, and should demonstrate familiarity with the prevailing thinking and discourse about the topic. The goal of case study design (as with all qualitative designs) is not generalizability but rather transferability —that is, how (if at all) and in what ways understanding and knowledge can be applied in similar contexts and settings. The qualitative researcher attempts to address the issue of transferability by way of thick, rich description that will provide the basis for a case or cases to have relevance and potential application across a broader context.

Qualitative research methods ask the questions of "what" and "how" a phenomenon is understood in a real-life context (Bloomberg & Volpe, 2019). In the education field, qualitative research methods uncover educational experiences and practices because qualitative research allows the researcher to reveal new knowledge and understanding. Moreover, qualitative descriptive case studies describe, analyze and interpret events that explain the reasoning behind specific phenomena (Bloomberg, 2018). As such, case study design can be the foundation for a rigorous study within the Applied Doctoral Experience (ADE).

Case study design is an appropriate research design to consider when conceptualizing and conducting a dissertation research study that is based on an applied problem of practice with inherent real-life educational implications. Case study researchers study current, real-life cases that are in progress so that they can gather accurate information that is current. This fits well with the ADE program, as students are typically exploring a problem of practice. Because of the flexibility of the methods used, a descriptive design provides the researcher with the opportunity to choose data collection methods that are best suited to a practice-based research purpose, and can include individual interviews, focus groups, observation, surveys, and critical incident questionnaires. Methods are triangulated to contribute to the study’s trustworthiness. In selecting the set of data collection methods, it is important that the researcher carefully consider the alignment between research questions and the type of data that is needed to address these. Each data source is one piece of the “puzzle,” that contributes to the researcher’s holistic understanding of a phenomenon. The various strands of data are woven together holistically to promote a deeper understanding of the case and its application to an educationally-based problem of practice.

Research studies within the Applied Doctoral Experience (ADE) will be practical in nature and focus on problems and issues that inform educational practice.  Many of the types of studies that fall within the ADE framework are exploratory, and align with case study design. Case study design fits very well with applied problems related to educational practice, as the following set of examples illustrate:

Elementary Bilingual Education Teachers’ Self-Efficacy in Teaching English Language Learners: A Qualitative Case Study

The problem to be addressed in the proposed study is that some elementary bilingual education teachers’ beliefs about their lack of preparedness to teach the English language may negatively impact the language proficiency skills of Hispanic ELLs (Ernst-Slavit & Wenger, 2016; Fuchs et al., 2018; Hoque, 2016). The purpose of the proposed qualitative descriptive case study was to explore the perspectives and experiences of elementary bilingual education teachers regarding their perceived lack of preparedness to teach the English language and how this may impact the language proficiency of Hispanic ELLs.

Exploring Minority Teachers Experiences Pertaining to their Value in Education: A Single Case Study of Teachers in New York City

The problem is that minority K-12 teachers are underrepresented in the United States, with research indicating that school leaders and teachers in schools that are populated mainly by black students, staffed mostly by white teachers who may be unprepared to deal with biases and stereotypes that are ingrained in schools (Egalite, Kisida, & Winters, 2015; Milligan & Howley, 2015). The purpose of this qualitative exploratory single case study was to develop a clearer understanding of minority teachers’ experiences concerning the under-representation of minority K-12 teachers in urban school districts in the United States since there are so few of them.

Exploring the Impact of an Urban Teacher Residency Program on Teachers’ Cultural Intelligence: A Qualitative Case Study

The problem to be addressed by this case study is that teacher candidates often report being unprepared and ill-equipped to effectively educate culturally diverse students (Skepple, 2015; Beutel, 2018). The purpose of this study was to explore and gain an in-depth understanding of the perceived impact of an urban teacher residency program in urban Iowa on teachers’ cultural competence using the cultural intelligence (CQ) framework (Earley & Ang, 2003).

Qualitative Case Study that Explores Self-Efficacy and Mentorship on Women in Academic Administrative Leadership Roles

The problem was that female school-level administrators might be less likely to experience mentorship, thereby potentially decreasing their self-efficacy (Bing & Smith, 2019; Brown, 2020; Grant, 2021). The purpose of this case study was to determine to what extent female school-level administrators in the United States who had a mentor have a sense of self-efficacy and to examine the relationship between mentorship and self-efficacy.

Suburban Teacher and Administrator Perceptions of Culturally Responsive Teaching to Promote Connectedness in Students of Color: A Qualitative Case Study

The problem to be addressed in this study is the racial discrimination experienced by students of color in suburban schools and the resulting negative school experience (Jara & Bloomsbury, 2020; Jones, 2019; Kohli et al., 2017; Wandix-White, 2020). The purpose of this case study is to explore how culturally responsive practices can counteract systemic racism and discrimination in suburban schools thereby meeting the needs of students of color by creating positive learning experiences. 

As you can see, all of these studies were well suited to qualitative case study design. In each of these studies, the applied research problem and research purpose were clearly grounded in educational practice as well as directly aligned with qualitative case study methodology. In the Applied Doctoral Experience (ADE), you will be focused on addressing or resolving an educationally relevant research problem of practice. As such, your case study, with clear boundaries, will be one that centers on a real-life authentic problem in your field of practice that you believe is in need of resolution or improvement, and that the outcome thereof will be educationally valuable.

Bloomberg, L. D. (2018). Case study method. In B. B. Frey (Ed.), The SAGE Encyclopedia of educational research, measurement, and evaluation (pp. 237–239). SAGE. https://go.openathens.net/redirector/nu.edu?url=https%3A%2F%2Fmethods.sagepub.com%2FReference%2Fthe-sage-encyclopedia-of-educational-research-measurement-and-evaluation%2Fi4294.xml

Bloomberg, L. D. & Volpe, M. (2019). Completing your qualitative dissertation: A road map from beginning to end . (4th Ed.). SAGE.

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

Stake, R. E. (2005). Qualitative case studies. In N. K. Denzin and Y. S. Lincoln (Eds.), The SAGE handbook of qualitative research (3rd ed., pp. 443–466). SAGE.

Yin, R. (2018). Case study research and applications: Designs and methods. SAGE.

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Types of Case Studies

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

Different Types of Case Studies

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

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

Explanatory

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

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

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

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

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

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

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

Exploratory

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

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

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

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

Multiple-Case Studies or Collective Studies

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

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

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

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

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

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

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

Instrumental

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

What is an example of an instrumental case study?

Focus on the results, not the topic!

Types of Subjects of Case Studies

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Planning A Case Study

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

Selecting a Case

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

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

Who is your audience?

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

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

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

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

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

Determine Research Goals

What type of case study do you plan to do?

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

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

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

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

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

Developing the Case Study

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

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

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

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

Do younger soldiers have higher instances of PTSD?

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

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

Research Notebook

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

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

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

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

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

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

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

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

Planning the Research

The most important parts of the case study are:

1. The case study's questions

2. The study's propositions

3. How information and data will be analyzed

4. The logic behind the propositions

5. How the findings will be interpreted

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

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

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

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

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

2. Procedures for gathering information and conducting interviews.

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

4. A guide for the final case study report.

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

1. Documents and archival records

2. Interviews

3. Direct observations

4. Indirect observations, or observations of subjects

5. Physical artifacts and tools

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

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

Research Strategy

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

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

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

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

Planning Interviews

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

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

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

Informed Consent

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

A fictitious name used to hide ones identity

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

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

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

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

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

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

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

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

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

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Acting on audit & feedback: a qualitative instrumental case study in mental health services in Norway

Monica stolt pedersen.

1 Norwegian National Advisory Unit on Concurrent Substance Abuse and Mental Health Disorders, Innlandet Hospital Trust, P.B. 104, 2340 Brumunddal, Norway

2 Faculty of Medicine, University of Oslo, Oslo, Norway

Anne Landheim

3 Norwegian Centre for Addiction Research, University of Oslo, Oslo, Norway

Merete Møller

4 Østfold Hospital Trust, Grålum, Norway

5 Inland Norway University of Applied Sciences, Campus Elverum, Elverum, Norway

Associated Data

The datasets will not be shared. In recordings or transcripts, individuals are easily identified by their their statements and views. None of the datasets are translated to any other language than Norwegian.

The National Guideline for Assessment, Treatment and Social Rehabilitation of Persons with Concurrent Substance Use and Mental Health Disorders, launched in 2012, is to be implemented in mental health services in Norway. Audit and feedback (A&F) is commonly used as the starting point of an implementation process. It aims to measure the research-practice gap, but its effect varies greatly. Less is known of how audit and feedback is used in natural settings. The aim of this study was to describe and investigate what is discussed and thematised when Quality Improvement (QI) teams in a District Psychiatric Centre (DPC) work to complete an action form as part of an A&F cycle in 2014.

This was an instrumental multiple case study involving four units in a DPC in Norway. We used open non-participant observation of QI team meetings in their natural setting, a total of seven teams and eleven meetings.

The discussions provided health professionals with insight into their own and their colleagues’ practices. They revealed insufficient knowledge of substance-related disorders and experienced unclear role expectations. We found differences in how professional groups sought answers to questions of clinical practice and that they were concerned about whether new tasks fitted in with their routine ways of working.

Acting on A&F provided an opportunity to discuss practice in general, enhancing awareness of good practice. There was a general need for arenas to relate to practice and QI team meetings after A&F may well be a suitable arena for this. Self-assessment audits seem valuable, particular in areas where no benchmarked data exists, and there is a demand for implementation of new guidelines that might change routines and develop new roles. QI teams could benefit from having a unit leader present at meetings. Nurses and social educators and others turn to psychiatrists or psychologists for answers to clinical and organisational questions beyond guidelines, and show less confidence or routine in seeking research-based information. There is a general need to emphasise training in evidence-based practice and information seeking behaviour for all professional groups.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-2862-y) contains supplementary material, which is available to authorized users.

Audit and feedback (A&F) is often the starting point of quality improvement projects. It aims to close the gap between recommended and actual practice. A&F may be defined as a ‘summary of the clinical performance of healthcare provider(s) over a specified period of time’ [ 1 ]. It can be a useful intervention to improve health professionals’ compliance with desired practice and is one of the most widely used strategies for improving practice [ 1 – 3 ]. A&F may be described as a circular process with several stages [ 4 , 5 ]. It is often designed to be a part of a multifaceted improvement strategy, where audit with feedback is theorised to promote health professionals’ motivation to improve practice [ 1 , 6 – 8 ]. Reflecting on results, agreeing on where improvement is needed and producing an improvement plan are essential components of the process.

The past 10–15 years have seen an increasing interest in guideline implementation strategies [ 9 ]. The Norwegian National Health Plan (white paper) states that evidence-based practice is a goal in Norwegian health policy [ 10 ]. Health authorities produce clinical guidelines in order to encourage a more evidence-based practice and more harmonised services [ 6 ]. Clinical guidelines give recommendations for best practice and may be used as benchmarks against which clinical practice may be evaluated [ 11 ]. The Norwegian Directorate of Health is the only organisation with a mandate to develop and disseminate national clinical guidelines in Norway. Recommendations in national guidelines are not legally binding (unless tied to a legal act), but normative by pointing to the desired and recommended courses of action [ 12 ].

Several studies show high co-occurrence between substance use disorders and mental health problems. This is well documented through clinical and epidemiological studies [ 13 – 17 ]. “The National Guideline for Assessment, Treatment and Social Rehabilitation of Persons with Concurrent Substance Use and Mental Health Disorders” [ 18 ] (hereafter the National Guideline) was launched in March 2012 and as one of several initiatives designed to improve services for people with concurrent substance use disorders and mental illness (see Additional file  1 ). The Norwegian National Advisory Unit on Concurrent Substance Abuse and Mental Health Disorders (hereafter the National Advisory Unit) has developed a standardised electronic audit questionnaire mirroring the recommendations in the National Guideline [ 19 ]. This is a pre-determined audit aimed at District Psychiatric Centres (DPC), to support implementation of the National Guideline, and to be used together with an action form.

Despite broad agreement on the importance of guidelines, they are not always easily translated into practice [ 20 ], often referred to as barriers to change [ 21 ]. Several strategies and theories exist as to how recommendations from research might be implemented [ 22 – 24 ], including process models aimed at describing and guiding the process [ 25 ]. A recent Cochrane Review [ 26 ] was unable to identify the effectiveness of implementation strategies in mental health care. The Effective Practice and Organisation of Care (EPOC) Group is a Cochrane Review Group [ 27 ], whose tasks include reviewing implementation strategies aimed at health professionals. One of the implementation strategies are A&F [ 1 ]. A key function of A&F is to identify sub-optimal performance and recognise the need for change [ 8 , 28 , 29 ]. Studies show that the effect of A&F on professional behaviour and patient outcome ranges from little or no effect to a substantial effect [ 1 , 30 ] and this may be due to the characteristics of the behaviour it is targeted at, the healthcare staff audited, their context, the patients/consumers, or the components of the intervention itself [ 31 , 32 ]. A&F may be most effective when the research-practice gap is large, the person responsible for the A&F is a supervisor or colleague, it is conducted more than once, it is given both verbally and in writing, and it includes clear targets as well as an action plan [ 1 , 29 ]. We still do not fully understand the key ingredients of a successful A&F intervention or the mechanisms of action of effective A&F interventions in healthcare [ 7 , 29 ]. Most of the research concerns the effect of A&F and how and when feedback is given. To our knowledge, less is known about how health care professionals discuss and use the results from the A&F when they meet in quality improvement (QI) teams with the purpose of selecting improvement areas, i.e. acting on the results from the audit with the purpose of improving service quality in a mental health care setting.

The aim of this study was to describe and investigate what is discussed and thematised when QI teams in a DPC work to complete an action form as part of an A&F cycle.

The process described followed a common A&F cycle, and this study involved Phases 3 and 4; the audit had been completed, feedback had been given, and QI teams met to fill out action forms (see Fig.  1 ).

An audit-cycle

This was a qualitative, instrumental, multiple case study [ 33 , 34 ]. The phenomenon we sought insight into was part of an improvement process: how QI teams discussed results from A&F and completed action forms in a “natural setting”.

The study took place in a DPC in South-Eastern Norway. The DPC is part of a larger hospital trust and consists of four units, two outpatient units and two inpatient units, each representing a case; where specialist mental health services are offered to approximately 72,000 inhabitants. Each unit is subject to various organisational and professional frameworks and is thus considered a separate case. Meanwhile, they belong to the same DPC, with the same management and the same organisational and legal conditions providing a common external conceptual framework connecting the cases and the activities involved.

The two inpatient units had similar staff in terms of number and type and length of education. In Norwegian inpatient units, nurses and social educators (minimum three-year bachelor’s degree) and assistant nurses are commonly referred to as milieu personnel, while psychologists and psychiatrists are often referred to as therapists. The units had somewhat different groups of patients; one had more patients with psychosis-related disorders and another had more patients within general psychiatry or personality disorders. The staff consisted mainly of milieu personnel and 1–2 therapists in both inpatient units. One outpatient unit was a crisis resolution team (CRT), mainly consisting of staff like nurses, social educators or others with similar relevant qualifications, such as social workers, and had a psychologist and psychiatrist attached to the unit. They reached out from the hospital setting to patients mostly referred from GPs or other hospital departments. The second outpatient unit was mainly staffed by therapists such as a psychiatrists, psychologists or specialist nurses, operating as a general psychiatric outpatient clinic with regular hours and booked appointments.

Recruitment and implementation process

An improvement process for the entire DPC was proposed by the leader group of the Hospital Trust in October 2013 and thereafter agreed upon by the DPC later the same year, with an anticipated start in the units in the beginning of 2014. The decision was to implement the National Guideline guided by the implementation process outlined by the National Advisory Unit. The DPC was selected since they were ready to start an improvement process and we were looking for a site to study the implementation process. The implementation process was owned and executed by the DPC and would have taken place without the research project.

The National Advisory Unit had developed tools to support implementation of the National Guideline as part of the development of the guideline. One was a brief description of an implementation process in stages adapted from the implementation of change model of Grol and colleagues [ 23 ]. This was accompanied by an electronic survey to audit practice in DPCs and a standardised action form with a template of how to use it. The action form contained columns for areas of improvement, goals, actions, progress plan, main responsibility, economic assessments and evaluation. The survey contained 46 questions about screening practices, assessment of target group, integrated treatment, collaboration, use of evidence-based methods and competence requirements, and was a self-report questionnaire. The audit survey was designed to be applicable to mental health services and was available with templates at the National Advisory Unit web site [ 19 ].

An audit of existing practice was conducted in February and March 2014. A project supervisor (MM) from the Health Trust, with special responsibility for concurrent substance abuse and mental health disorders, assisted in the execution of the audit. All four units of the DPC were included in the audit. Feedback of the results was given verbally and in writing by the project supervisor to each unit separately at meetings for the whole unit with unit leaders present. Results were presented at unit level, together with sessions on evidence-based practice, recommendations in the National Guideline and how to conduct an improvement process informed by the Knowledge-to-Action cycle [ 35 ]. The meetings were led by the project supervisor in March 2014.

The DPC formed QI teams from each unit to facilitate the process. Each unit leader selected who should participate in the group. Seven QI teams were set up with participants and meeting schedule, to start about one month after the audit results were presented. The participants in the teams reflected the staff in each unit in terms of education and job position as described above. Only one of the teams (from the CRT) had the unit leader present at QI team meetings, the teams from the general outpatient units had an appointed leader with senior experience, and the inpatient unit teams had a more flat leader structure. A total of 11 meetings were held (see Table  1 ).

Quality Improvement teams in the DPC. Numbers of teams, team members and meetings

Meetings of the QI teams were held in April and May 2014. The purposes of the meetings were outlined by the National Advisory Unit [ 36 ]:

• to discuss the results of the audit and identify any gaps between the recommendations of the guideline and local practice
• to choose areas for improvement on this basis
• to discuss local context and barriers and enablers for the improvement areas
• to choose suitable actions for the goal of improvement
• to discuss how to monitor and evaluate

The discussions in the QI meetings were based on the collected audit data and the participants’ professional and organisational experience. A joint action plan for the DPC was adopted in June 2014 with common areas for improvement, actions, work schedule, responsibilities, budget assessment and evaluation, based on the work conducted in the QI teams. Three improvement areas were selected: 1) Screening the use of substances with AUDIT (Alcohol Use Identification Test) and DUDIT (Drug Use Identification Test), 2) Enhancing knowledge of the treatment of concurrent substance abuse and mental illness, and 3) Strengthening integration between the DPC, substance abuse departments and community health care. The actual implementation phase was planned for autumn 2014 to spring 2015, with a re-audit in spring 2015.

One researcher (MSP) spent some time at the study site before the actual data collection started, attending management meetings and talking to the project supervisor, the unit leaders and the department manager. This was to gain an understanding of the general context of the cases.

Data collection

All seven QI teams, with eleven team meetings, were observed, resulting in 11 h of recordings. The meetings lasted between 36 min and 1 h and 52 min. All were held at the hospital, in familiar environments for the teams.

In this study, we mainly used open non-participant observation to describe and investigate an early stage of an improvement process: how and what the staff discussed when aiming to adopt the recommendations in the National Guideline by filling out the action forms as part of completing the audit cycle. To be able to record words rather than summaries, we used an audio recorder together with the observer’s reflection notes. These were always written on the same day as the meeting, to ensure fresh reflections on the atmosphere, surprising statements and agreements or disagreements in the teams.

One observer (MSP) was present at the meetings. The researcher was unfamiliar with the DPC and its staff before the process started. It was considered important to explain that the researcher was not the one to initiate or decide on the improvement process or to perform the A&F. At her first meeting with a team, the researcher introduced herself, shook hands with all the participants and presented the research project in detail. The researcher has a background as an information scientist in medicine and organisational learning, with a focus on evidence-based practice and implementation. The observer sat at the table together with the participants in the meeting. This enabled open observation without unduly disturbing the process.

Data analysis

The audio recordings from the meetings were transcribed verbatim and in detail. Together with the reflection notes, this formed the data base. Such an analysis relies largely on the spoken word, hence the use of an audio recorder. But the reflection notes were also part of the analysis, to make sense of the atmosphere in the room, the relationship between the participants, etc., and to observe what was not verbalised. The computer software QSR International’s NVivo 10 was used to help to organise the analytical process.

A short, but thorough description of the cases was written, together with necessary context.

The analysis was performed in six steps as a thematic analysis suitable for instrumental case studies [ 33 , 37 ]. Each transcription and reflection notes was read and listened to several times. Codes were assigned to meaningful units in the text, rather generously to ensure that nothing interesting or important was lost at this stage. The codes identified semantic features of the data. Codes were assigned to the data base, case by case. A thorough review of the codes was undertaken, with uncoding and recoding while comparing with the text, to ensure a unified way of labelling and interpreting the text. The third phase was to start searching for themes, by sorting codes into potential themes. The codes could appear across the cases, but were sometimes apparent in just one case and gave a first glance at similarities and differences in the cases. We sought to ascertain whether the codes could form a theme, going back and forth between potential themes, the codes and the dataset. Phase four consisted of reviewing and refining the themes. At this phase, all the data was reread to ensure that the themes fitted with the dataset. In phase five, we defined and named the themes. Phase six was to produce the report. We made adjustments until the end to make sure the analysis and themes had captured the essence.

In a multiple instrumental case study, we are interested in understanding the phenomenon under study [ 38 ]. We sought to shed light on the research question by using multiple cases bound together by organisational belonging and the common activity undertaken. We needed to strike a balance between the particular and the common features of each of our four cases while looking for similarities and differences. We mainly reported on general perspectives where present, in order to form an idea of the use of an audit in a DPC as a whole [ 33 , 38 , 39 ].

The aim of this study was to describe and investigate what is discussed and thematised when QI teams in a DPC work to complete an action form as part of an A&F cycle. The results of the audit showed a mismatch between recommendations in the National Guideline and local practices in several areas. This applied to all units, albeit somewhat differently within the various topics in the audit.

A whole range of issues regarding daily tasks, leader engagement, organisational issues at the unit or the DPC, cooperation, responsibilities and busy schedules were up for debate when the QI teams gathered to discuss their audit results. The audit seemed to prompt much more than just finding improvement areas and filling out action forms. Acting on the audit may thus be seen as important for various purposes, such as allowing for in-depth discussions on different aspects of work.

Eye-opening and sharing practices

When the QI teams gathered, some began immediately to complete the action forms and came back to the audit results afterwards, but most devoted time to the actual process of reflection and discussion of their own unit’s results. They focused on the results showing the largest gaps between recommended and actual practice. It was a realisation of a research-practice gap, an eye-opener.

The staff seemed to become aware of their own practice in a different way through the discussions. Important events in some of the meetings were participants asking about and listening to details of colleagues’ practices. “How do you do this?”, “Are you using the recommended questionnaire or do you ask questions more randomly?” are examples of comments when they began to delve into their own practice. Sometimes they seemed somewhat surprised when listening to each other’s stories about how they perceived everyday tasks or actually performed them in detail. It became clear that practice could sometimes develop in different directions, and that the staff did not necessarily have the same knowledge base for their practice.

Many participants realised for the first time that there existed a standard, i.e. a national guideline; a typical statement was “I wasn’t aware there was a standard for this, I’ve only done what seemed best or what was closest to my previous knowledge or educational background”. Several times there were statements about the newly discovered gap, but they would also literally point at the audit results, holding them up like a proof of practice – or lack of best practice. This awareness seemed to be important in enabling the start of an implementation process, or choosing improvement areas and filling out the action forms as required, representing willingness to take action.

Lack of knowledge and unclear role expectations

Without exception, all QI teams acknowledged their lack of knowledge about the patients with concurrent substance use disorder and mental illness, although some members of staff had experience and expertise in the field. Several of the teams talked about lack of knowledge about substances, their impact and what signs to look for in patients in active intoxication, withdrawal phases or long-term effects.

QI teams from three of the units seemed to be uncertain about the expectations placed on them. What tasks were they expected to perform and what expertise was required in implementing recommendations from the National Guideline? A decision on screening for substance use as an improvement area arose fairly early in the discussions, followed by the question “What do we do when we know?”, i.e. “How do we deal with the awareness that a patient has a concurrent substance use disorder and mental illness?”

In all teams there were discussions related to uncertainty about the participants’ own competence, but they manifested themselves differently in the general outpatient clinic on the one hand, and in the three remaining units on the other. In the latter, the QI teams appeared mainly to be uncertain about what they were supposed to know and work expectations, and we found that the temperature in the discussions sometimes rose concerning expectations from the management and we could see signs of despondency and even anger. These statements usually came after recognition of the research-practice gap from the audit. Some of the employees seemed to feel taken by surprise by the gap, or felt that they should have known already and taken care of this and that this responsibility lay with the management.

We also found insecurity around whether they were actually giving the best treatment to the patients with co-occurring disorders. So when they discussed the audit results, their own practice, and implementation of new recommendations, we noted statements and reflections that what they were used to doing was no longer valid or good enough. We often found that the staff demanded in-service courses and seminars, and stated that they should have been offered this earlier. It was clear that the statements about lack of knowledge arising from the audit results led to a decision to gain enhanced knowledge of the treatment of concurrent substance abuse and mental illness.

The QI teams from the general outpatient clinic also recognised a lack of knowledge in the field of substance use disorders. Otherwise, they recognised themselves as professionals. Their uncertainty was related to whether their expertise was acknowledged by the management and taken into account as they felt it should be. They talked about “we, as professionals”, and we could trace dejection and slight defiance when this topic was discussed in both teams from the general outpatient clinic.

Where to seek answers to clinical questions

The psychiatrists and psychologists seemed to be the ones to “own” the knowledge. They were the ones to keep themselves updated by virtue of education or position. Then the nurses, assistant nurses and social educators could harvest from this knowledge. We found this phenomenon to be present when they were looking for someone to hold educational courses and when they addressed clinical questions to colleagues, and also when they referred to where or whom they got knowledge from. When discussing “best practice”, statements like “psychiatrists have different opinions” appeared. Milieu personnel, nurses and social educators seemed to be used to seeking answers from psychiatrists or psychologists, but found it frustrating when they had divergent opinions on the same matter. It seemed to give rise to confusion and professional insecurity.

None of the professions or QI teams talked about evidence-based practice, systematic reviews or the fact that knowledge might be found in the hospital’s medical library. Some of the teams talked about “building a library”, but less about what should be in it other than certain academic textbooks. There were, however, in some teams references to the National Guideline as a source of knowledge of the area, and it was also held up like a “proof of best practice” with statements like “This is the knowledge base” in a couple of teams. But there were also those who clearly questioned the National Guideline as trustworthy or as a source of best practice.

In the QI teams formed by the outpatient clinic, the discussions were somewhat different. They acknowledged a professional disagreement, and solved the disagreement by either accepting a professional discussion or by simply sweeping the whole disagreement under the rug and accepting differences in practice, mainly due to differences in specialities.

New practices in old systems

All QI teams talked about how the recommendations fitted in with their usual practice and that new ways of working and new practices often felt fragmented and not integrated with current practice. They used the A&F to discuss local practice and possible barriers to new practice, like resources, knowledge of substance abuse, organisation of daily tasks, and lack of time. They assumed that if they put the National Guideline recommendations into practice, it would be uncertain how this would fit in with their usual practice, the way the unit and its tasks were organised – and the way the DPC works. This was perceived as a clear barrier to implementing the recommendations from the Guideline.

At a system level, there were statements about the lack of connected and integrated treatment. Seven questions in the audit survey concerned cooperation and integrated treatment. These particular questions generated discussion in most of the QI teams. All the teams realised that they did not cooperate to any great extent with others, whether GPs, local authorities or substance abuse treatment units. They found that patients with the most severe co-occurring disorders fell between cracks also at a system level, and were thus not receiving appropriate treatment. The audit results were used to discuss how the system worked, especially for people with concurrent substance use disorder and mental illness. Several teams, particularly from the inpatient units, stated that they did not know the system they were working within well enough, and were therefore unable to offer integrated or optimal services, leading to interrupted and fragmented chains of treatment. This was clearly seen as a barrier, but not one they could easily find a solution to. It was considered a management or organisational problem.

We found that acting on A&F stirred up a wealth of discussions around local practice, organisational issues and responsibilities and was also used as a way of showing resistance to management. The QI team meetings were important to gain awareness of local practice and to recognise a lack of knowledge on substance abuse and a neglected group of patients, namely those with concurrent substance use disorder and mental illness, and also to identify unclear role expectations. Health professionals such as nurses, social educators or nursing assistants usually seek knowledge from psychiatrists or psychologists, but get frustrated when the answers diverge depending on whom they ask. There were concerns about whether new tasks arising from the guideline recommendations would fit in with the organisation’s usual way of working and current resources.

Our research concurs with earlier research on quality improvement from various areas of health services [ 40 – 42 ] in that working with an A&F cycle involving completion of action forms in QI meetings was a useful, welcome and necessary opportunity to discuss practice amongst practitioners also in mental health services. It seemed to open the door to negotiations on improvement areas, task allocations and multidisciplinary work and could be considered important steps on the way to implement recommendations from the National Guideline.

Acting on A&F created an awareness of local practice and a standard for practice in a national guideline which is in line with the intentions of an A&F process: to prompt the need for change [ 2 , 29 ]. Although the team members were not instructed to look for the largest gaps in the audit feedback, the QI teams usually ignored the results showing that practice was more or less in line with the guideline, and acted upon the greatest discrepancies, as also shown in previous studies [ 1 , 8 , 28 , 29 ]. As an example, the QI team acted upon results showing gaps in the use of screening tools for detection of substances, and in general knowledge about substances and substance abuse treatment. There were no benchmarked data from other services or national audits to compare the audit results with, and the QI teams therefore discussed the data in a subjective manner. Self-assessments are subjective to bias [ 43 ], and may therefore give poor data quality. We might question whether the addition of audit data from patient records could have given better and perhaps different results, providing a richer and more accurate picture and adding to the team discussions more usefully than self-completed questionnaires alone. However, audits from patient record alone would possibly not give sufficiently accurate data, due to inadequate patient record keeping, reported by the Norwegian Board of Health Supervision [ 44 ] and the Norwegian System of Patient Injury Compensation [ 45 ]. Studies show that self-assessments contribute to professional development, learning and practice change [ 46 ] and are thus a valuable tool. All of the teams had senior staff present and representatives from various professions, which gave the team broad competence and experience of practice and context and added credibility to the meetings and discussions.

Our study found a lack of knowledge on substance related disorders and unclear role expectations among the health professionals. Other studies have found that for example nurses experience a lack of alcohol-related knowledge and skills, which was considered a barrier to the implementation of screening tools [ 47 ], while participants in a Swedish study asked how they were supposed to change clinical practice when they did not have adequate skills to use recommended tools [ 48 ]. The lack of familiarity with the guideline and lack of faith in one’s own influence on the quality of care reported in the feedback are known barriers to implementation [ 32 , 49 ]. The National Guideline came with a strong emphasis on concurrent substance use disorder and mental illness and placed greater responsibility on mental health care for patients with substance use disorders. Tasks and responsibilities, for example screening with appropriate tools to detect substance abuse, previously seemed to lie with one professional group in the DPC, but were now expanded to a larger group of professionals, from only psychologists or psychiatrists to also include nurses or social educators. From other studies we know that interchangeable roles and responsibilities may cause tension and power struggles, but more often interprofessional collaboration is beneficial for team functioning [ 50 ]. For collaboration to be successful, all team members should have a sense of autonomy, suggesting independent and self-determined practice to ensure a true complementary contribution. We may question whether job expectations and professional roles were inadequately formulated from leaders to all professional groups, particularly in the inpatient units. It might also be a general lack of arenas to discuss practice and to develop collaborative practices. Discussions concerning roles and responsibilities might have been more successful if unit leaders had been present at all meetings. Support from management or inspirational team leadership appear to be important in QI teams, bringing different professionals together [ 51 ]. We might also speculate on whether the staff are disclaiming responsibility in not taking national guidelines into account or not readily taking on the responsibility of new tasks or roles in the QI meetings. These issues might not easily be solved with educational courses or improving clinical skills alone, but more general with empowerment of all health professionals in autonomous contribution to collaborative work, which is also addressed by other authors [ 50 , 52 ].

The psychiatrist/psychologist group had legal authority for decision making and patient treatment responsibility, but our findings seem to show that the responsibility was expanded to a “definition of knowledge”. This could be a natural consequence of the responsibility associated with the psychiatrist in a unit (as medical doctors are the only profession legally entitled to prescribe medication). Nurses, social educators, etc. approached the group of psychiatrists and psychologists instead of their own professions or the “evidence”, i.e. clinical guidelines or research, for support in their practice. We know from international studies that physicians and nurses pursue roughly half of the questions they raise in clinical practice [ 53 ], and colleagues are a preferred source for answers [ 53 – 55 ]. Information-seeking behaviour may vary between nurses and physicians; nurses more often ask a colleague for answers to clinical questions, while physicians more often turn to online databases [ 56 ]. A hierarchical system might help to explain the expansion to “all kinds” of knowledge, but also a lack of training in information-seeking behavior, maybe particularly in the group of nurses and social educators.

Integrated treatment requires staff to coordinate collaboration between service providers [ 57 ]. The feeling of a lack of connected and integrated services at a system level found at this DPC is not unfamiliar [ 58 – 62 ]. The National Guideline recommended integrated treatment, which was a responsibility of the DPC, and took a pragmatic approach in stating that different and independent entities should coordinate their services for patients in an orderly manner. The important factor is that the patient experiences the treatment as integrated and connected [ 18 ]. We know that aspects of the guideline itself can be a major barrier to its implementability [ 32 ]. The National Guideline was assessed for implementability by the GLIA instrument [ 63 ], and found to be not easily implemented due to somewhat general recommendations which were not necessarily easy to transfer to practice [ 18 ]. This is therefore a possible explanation for the feeling of lack of connected and integrated services.

Strengths and limitations

A major strength of this study was the natural setting where the A&F cycle took place. This allowed for an exploration of what happened in the QI teams after A&F when the process was organised by the DPC itself, without a research team being part of the project, and thus reflected real people in real settings. In many similar projects, the research team has had an important and visible presence in all parts of the A&F cycle, from setting the standard, auditing practice, giving feedback and facilitating the work of the QI teams and in that way possibly having an impact on the process itself. Case studies are useful for gaining an in-depth understanding of an issue and answering the “how” questions when the behaviour of those involved cannot be, or is not desired to be, manipulated [ 33 ]. They focus on contemporary events in real-life contexts, where the phenomenon of interest is interdependent with the context of study [ 39 ]. An instrumental case is used to illuminate the “problem”; the case itself is not the most important part [ 33 ]. We use the case to understand and answer the research question and it is thus instrumental to accomplishing this understanding [ 34 ].

Qualitative research and case studies may be limited in their generalisability. A common conclusion in implementation research is that the effect of the context makes the findings less relevant in other settings. However, we believe that our study has relevance to other settings in and outside mental health care services, and knowledge gained from this study may contribute to the planning and execution of A&F cycles under similar circumstances.

There are certain considerations involved in choosing a multiple case study design. One is vulnerability, in that that the supposedly common cases may turn out to be less common than originally thought in certain aspects, and thus do not shed light on the research question as expected. However, we believe that the cases in this study are quite representative for many Norwegian DPCs in an initial phase of the implementation process, enabling generalisation to other DPCs. We have described the case in as much detail as necessary to account for this risk and make it transparent. A strength of the study is the use of instrumental multiple cases, allowing for a holistic view of the phenomenon, less dependent on the individual context. It is nevertheless worth noting that the cases are linked to a general context, the DPCs being similar in all cases.

There are strengths of open non-participant observation considered important enough to choose it as a method. Open observation allows for conceptualisation of health professionals behaviour and interaction in their natural environment [ 64 ] and the direct evidence of observed outcomes and processes, as opposed to reported accounts. It may also capture the flavour of the setting and provide specific examples. Open observation, not driven by theory, was enabled by the relatively demarcated units of analysis, the QI team meetings.

There is no doubt that both the use of an audio recorder and the presence of an observer are very noticeable elements in a meeting room (“the researcher effect”). It is uncertain whether the observer or the audio recorder is the more significant element for the participants. The observer not being a health professional, but with extensive experience from administrative parts of health services, gives a possibility for a fresh look at a health care setting, allowing for new insight. We believe the use of an audio recorder and reflection notes immediately after meetings helped to ensure the verifiability and thus the reliability of the observations.

Conclusions

The aim of this study was to describe and investigate what is discussed and thematised when QI teams in a DPC work to complete an action form as part of an A&F cycle. The A&F was based upon current knowledge of the most effective interventions and pre-made tools to support the process. The study showed that acting on A&F provided a welcome opportunity to discuss practice in general, enhancing awareness of good practice. There was a general need for arenas to meet and discuss current practice, best practice and recommendations from guidelines and also how to meet divergent demands in an open and collaborative way. QI team meetings after A&F may well be a suitable arena for this. The study also showed that self-assessment audits seemed valuable, particularly in areas where no benchmarked data exists, and there was a demand for implementation of new guidelines that might change routines and develop new roles. QI teams could benefit from having a supportive leader present at team meetings to provide direction particularly on organisational questions, and team members might also benefit from a general empowerment to autonomous contribution to interprofessional collaboration.

Nurses and social educators turn to psychiatrists or psychologists for answers to clinical and organisational questions beyond the National Guideline, and show less confidence or routine in seeking research-based information. There is a general need to emphasise training in evidence-based practice and information-seeking behaviour for all professional groups. New guidelines will keep coming, putting new demands on staff in mental health care, and increased knowledge in these areas could hopefully lead to less insecurity about roles and practice, and to discussions of audit results based on research-knowledge familiar to all professional groups.

Innlandet Hospital Trust funded the design of the study and collection and analysis of data and in writing the manuscript.

Availability of data and materials

Abbreviations.

Additional file

Information on The National Guideline for Assessment, Treatment and Social Rehabilitation of Persons with Concurrent Substance Use and Mental Health Disorders. (DOCX 16 kb)

Authors’ contributions

AL and LL participated in the design of the study and formulation of the research question and drafted the manuscript. MM participated in the acquisition of data and participated in coordination of the study and helped to draft the manuscript. MSP conceived the study, and participated in its design and formulation of the research question. She performed the observations and analysis and drafted the manuscript. The final version was prepared and revised by all authors and all authors approved for submission.

Ethics approval and consent to participate

The study was supported by Innlandet Hospital Trust, and approved by the Data Protection Officer for Research at Oslo University Hospital. All of the staff observed in meetings, managers and R&D nurses at the site of study signed a declaration of consent.

Consent for publication

Not applicable

Competing interests

AL has been a member of the working group at The Norwegian Directorate of Health who produced the National guideline for assessment, treatment and social rehabilitation of persons with concurrent substance use and mental health disorders, launched in 2012. None of the other authors have competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Contributor Information

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Case Study Research: Single or Multiple?

Https://doi.org/10.5281/zenodo.7106698.

Definition of a Case Study

A case study is a methodological research approach used to generate an in-depth understanding of a contemporary issue or phenomenon in a bounded system.

A case study is one of the most widely used and accepted means of qualitative research methods in the social sciences (Bloomberg & Volpe, 2022). 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 (Crowe et al., 2011). Case studies provide researchers with an opportunity for greater depth of understanding of an issue (Stake, 2010). The case study design is preferred as a research strategy when “how,” “why,” and “what” questions are the interest of the researcher (Yin, 2018).

The two most prominent case study scholars are Robert E. Stake and Robert K. Yin. While case study research has been conducted for some time, Stake established accepted procedures for case study research in 1995 and has produced numerous articles and books about case study methodology and analysis. Two of Stake’s works that continue to impact the academic community are his books, “The Art of Case Study Research,” and, “Multiple Case Study Analysis.” Yin emerged as a leading scholar in case study research and is still producing academic literature today, as he utilizes both quantitative and qualitative approaches to the methodology. Yin’s significant contributions to the development of case study research includes the titles, “Case Study Research and Applications: Designs and Methods,” “Applications of Case Study Research,” and, “The Case Study Anthology.”

Characteristics of a Case Study

• The identification of a case is bounded (a case within a bounded system, which means what is being studied can be defined or described within specific parameters (Creswell & Poth, 2018). A case must be bounded by time and place.
• A case study should provide an in-depth understanding of the case.
• Data is collected through various means, including interviews, focus groups, field notes, documents, autobiographies, historical documents, videos, and more.
• Data analysis differs depending on the case under study. In fact, many case studies are both qualitative and quantitative.
• The successful identification of themes is critical to producing effective descriptions in case study research.
• Case studies offer conclusions provided by the researcher regarding the meaning derived from the case and are important because case studies have continuity in nature.

Types of Case Studies

Case studies are typically defined by the intent of the case analysis. There are three types of case studies: (single) instrumental case study, collective (multiple) case study, and intrinsic case study.

In a single instrumental case study, the researcher focuses on an issue or concern and then selects one bounded case to illustrate the issue (Creswell & Poth, 2018). If the researcher only wants to study one single thing (such as single person from a specific group) or a single group (for example a specific group of people within a bounded system), a single case study is the best choice (Yin, 2017).

In a multiple case study. the researcher selects multiple cases to illustrate the one issue or concern (Creswell & Poth, 2018). Multiple case studies can be used to either augur contrasting results for expected reasons or augur similar results in the studies (Yin, 2017).

In an intrinsic case study, the focus is on the case itself because the case presents a unique situation, thus resembling the focus of narrative research but maintaining the analytic procedures of a case study (Creswell & Poth, 2018).

Bloomberg, L. D., & Volpe, M. (2022).  Completing your qualitative dissertation: A road map from beginning to end . SAGE.

Creswell, J. W., & Poth, C. N. (2018).  Qualitative inquiry and research design: Choosing among five approaches . SAGE.

Crowe, S., Cresswell, K., Robertson, A., Huby, G., Avery, A., & Sheikh, A. (2011). The case study approach.  BMC medical research methodology ,  11 , 100.  https://doi.org/10.1186/1471-2288-11-100 .

Stake, R. E. (2010).  The art of case study research . SAGE.

Yin, R. K. (2018).  Case Study Research and Applications: Designs and Methods  (6th ed.). Sage.

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Open Access

Peer-reviewed

Research Article

The use and application of intensive care unit diaries: An instrumental multiple case study

Roles Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Writing – original draft

Affiliations Intensive Care Department, County Hospital, Region Kalmar County, Kalmar, Sweden, Department of Health and Caring Sciences, Linnaeus University, Kalmar, Sweden

Roles Conceptualization, Formal analysis, Funding acquisition, Investigation, Methodology, Resources, Supervision, Validation, Writing – review & editing

Affiliations Intensive Care Department, County Hospital, Region Kalmar County, Kalmar, Sweden, Department of Health and Caring Sciences, Linnaeus University, Kalmar, Sweden, Research Section, Region Kalmar County, Kalmar, Sweden

Roles Conceptualization, Formal analysis, Methodology, Supervision, Validation, Visualization, Writing – review & editing

Affiliations Department of Health and Caring Sciences, Linnaeus University, Kalmar, Sweden, Swedish Family Care Competence Centre, Kalmar, Sweden

Roles Conceptualization, Formal analysis, Methodology, Supervision, Validation, Writing – review & editing

* E-mail: [email protected]

• Maria Johansson, 
• Ingrid Wåhlin, 
• Lennart Magnusson, 
• Elizabeth Hanson

• Published: February 29, 2024
• https://doi.org/10.1371/journal.pone.0298538
• Reader Comments

Aims and objectives

The study aim was to explore the use of an Intensive Care Unit (ICU) diary within four different ICUs units in Sweden and thereby contribute to practice guidelines regarding the structure, content and use of an ICU diary.

ICU diaries are used to aid psychological recovery among critical care patients, but differences remain in diary writing both within and across countries. Few studies have focused on the combined views and experiences of ICU patients, family members and nursing staff about the use of ICU diaries.

An instrumental multiple case study design was employed.

Three focus groups interviews were carried out with 8 former patients and their family members (n = 5) from the research settings. Individual interviews were carried out with 2 patients, a family member and a nurse respectively. Observations, field notes, documentary analysis and conversations with nursing staff were also conducted. Consolidated criteria for reporting qualitative research (COREQ) was followed.

The qualitative findings firstly consisted of a matrix and descriptive text of the four ICU contexts and current practices. This highlighted that there were similarities regarding the aims and objectives of the diaries. However, differences existed across the case study sites about how the ICU diary was developed and implemented. Namely, the use of photographs and when to commence a diary. Second, a thematic analysis of the qualitative data regarding patients’ and family members’ use of the ICU diary, resulted in four themes: i) the diary was used to take in and fully understand the situation; ii) the diary was an opportunity to assimilate warm, personalised and human care; iii) the diary was used to manage existential issues; and iv) the diary was a tool in daily activities.

Conclusions

Analysis of the instrumental case study data led to the identification of core areas for inclusion in ICU diary practice guidelines.

Citation: Johansson M, Wåhlin I, Magnusson L, Hanson E (2024) The use and application of intensive care unit diaries: An instrumental multiple case study. PLoS ONE 19(2): e0298538. https://doi.org/10.1371/journal.pone.0298538

Editor: Sascha Köpke, University Hospital Cologne: Uniklinik Koln, GERMANY

Received: April 20, 2023; Accepted: January 25, 2024; Published: February 29, 2024

Copyright: © 2024 Johansson et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: Data cannot be shared publicly because of the risk of identifying individual study participants. Data requests may be sent to the head of research at Region Kalmar County, Professor Cecilia Fagerström: [email protected] .

Funding: The first author was partly financed for her PhD education of which this study forms a part by the Health Research Council of South East Sweden and Kalmar County Council. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript".

Competing interests: The authors have declared that no competing interests exist.

Introduction

Intensive Care Unit (ICU) diaries are increasingly being used in intensive and critical care nursing practice as an intervention that may facilitate the patient’s psychological recovery. Namely, by describing what happened to them in the ICU and about their health condition [ 1 – 3 ] with the aim of helping to put possible unpleasant memories into context [ 4 ]. The authoring of diaries may help both patients and family members process the critical illness experience during and after the time in the ICU [ 1 , 5 – 7 ] as well as support family members’ bereavement process when the patient does not survive [ 6 – 8 ]. Due to the COVID 19 pandemic, some ICUs opened up fewer diaries because of worries about infection control and due to excessive workload. In addition, visiting restrictions limited the use of diaries written by family members [ 9 ]. However, web-based solutions are under development and may in the future become a replacement for or supplement to hard copy diaries [ 10 ]. A hard copy diary is described as a handwritten booklet written in collaboration with nurses/staff members and family to the unconscious patient based on a chronology of clinical and social events that occurred during the ICU stay [ 6 ]).

Qualitative studies have highlighted how the written content in the diaries helped patients to realize what they had undergone, provided a sense of coherence and understanding after a critical illness [ 11 – 13 ] and acted as a support in the process of setting up realistic goals for recovery [ 7 , 11 , 14 ]. According to Backman & Walther [ 6 ] if photos are added, they might augment the information and help to make sense of the information provided, akin to a reality check. The diaries could also convey a feeling of humanised care despite being immersed in a technological environment [ 15 ].

Earlier quantitative studies have revealed how the diaries reduced the occurrence of patient post-traumatic stress, depression, and anxiety related to critical illness and critical care [ 16 , 17 ] as well as aid the wellbeing of their relatives [ 18 , 19 ] and improved patient health-related quality of life after a critical illness [ 20 ].Overall, the quantitative studies have been criticised due to small sample sizes and differences in the diary’s application [ 21 , 22 ]. Thus, it remains unclear as to the efficacy of ICU diaries in reducing PTSD, anxiety and depresession in patients and family members [ 9 ]. The majority of previous studies consist of mainly qualitative studies, which highlight that the diary helped to fill in the memory gap of the patients [ 6 , 7 , 23 ]. Also, the diaries assisted the patient when working through their ICU experiences [ 14 , 24 ] and at the same time provided individual or improved quality care [ 14 , 24 ]. Taken together, considerable diversities remain in diary writing both within and between countries which make it difficult to draw comparisons among the existing empirical studies. A major identified barrier regarding the use of ICU diaries for health care professionals is lack of dedicated time, which was further exacerbated during the COVID-19 pandemic [ 9 ]. A consensus exists on the need for guidelines to support diary writing for use in current critical care nursing practice [ 25 – 27 ]. In this regard, the international ICU diary network (established in 2012 by a group of ICU nurses as a non-profit organisation) acts as a vehicle to help with the implementation of ICU diaries via coordinating information, projects and new empirical studies for interested health care staff [ 28 ].

The overall aim is to explore the use of the ICU diary within four different ICU units in Sweden, and thereby contribute to practice guidelines regarding its structure, content and use.

The research questions were as follows:

• What are the current practices surrounding the use of a diary in the chosen ICU settings? What local guidelines exist (if any) and in what ways (if any) are they implemented in clinical practice?
• What strengths or positive aspects are identified by nursing staff, former patients, and family members of ICU patients with regards to current practices in the chosen research settings concerning the use of an ICU diary?
• Further, what are the challenges or drawbacks that are identified by nursing staff, former patients and family members of ICU patients with regards to current practices in the chosen research settings concerning the use of an ICU diary?
• What are the core areas for consideration arising from this multiple case study that can be taken up in future development work concerning national clinical practice guidelines on the use of the ICU diary?

An instrumental multiple case study design was adopted for the study. An instrumental case study enables a contemporary phenomenon to be investigated in-depth and in its real-world context–in this instance, the use of ICU diaries. Further, a multiple case study approach was chosen as it enabled the researchers to explore similarities and differences in the individuals’ experiences within cases and compare and contrast the experiences across cases [ 29 ]. A case study design provides opportunities to use multiple data sources to answer ‘how’ and ‘why’ questions- in this case, about ICU diary use, implementation and how to further develop the diary. The use of several data sources may also enhance data credibility to reach a holistic understanding of the phenomenon [ 29 , 30 ]. The use of evidence from multiple sources also means a kind of triangulation, where the findings have been supported by more than a single source of evidence [ 28 ]. This study followed Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups [ 31 ] (See S1 Table ).

Study setting

There are approximately 41070 admissions to 82 adult intensive care units in Sweden annually [ 32 ]. ICUs are situated in university, county and district hospitals. County and district hospitals have general ICUs. The ICUs in university hospitals may have a range of specialized ICUs, for example; burns ICU, neurosurgical ICU, medical ICU, surgery ICU and thoracic surgical ICU. The specialized ICUs serve other hospitals in their region when specialized care is required. The study took place in 2018 between March and October at four different Swedish ICUs (units A, B, C and D) in four ICU settings, equal to four cases where the ICU diary has been developed and implemented. Henceforth, ICU settings are called cases, which means everything associated with the settings, such as documents, observations, notes, routines, interviews, and study participants. One ICU setting was a university hospital, and three were county hospitals (See Table 1 ).

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https://doi.org/10.1371/journal.pone.0298538.t001

The included cases were purposively selected as they were representative of a diversity of care provision, context, and implementation practices of the ICU diary [ 29 ]. All participant hospitals were in the same geographical region of Sweden which covers an approximate radius of 170 km by 46954 km 2 , and they all formed part of a regional research collaborative initiative financed by the involved health care regions to stimulate closer cooperation concerning health care research. Nursing staff consisted of specialist critical care nurses with a bachelor level degree and assistant nurses. The staff-patient ratio at the time of the study was between 1.0 and 1.2. Medical staff consisted of 1–2 chief intensive care specialists and several junior physicians and at the units there were 1–2 head nurses of the department. There were no psychologists attached to the ICU units. Nurses, physicians, and nurse assistants provided psychological support to patients and their family members. ICU diaries have been used at the participating units for between 25–30 years.

Data collection

A protocol for conducting a multiple case study was established (See S2 Table ) in accordance with Yin’s (29). The protocol was a procedural guide for collecting data for a case, including a set of field questions to be addressed by the researcher (first author, MJ). The role of the protocol was also a standardised agenda for the researcher’s line of inquiry to increase reliability [ 29 ]. The data sources included observations, field notes, documents, informal, unstructured field interviews, a telephone interview, individual interviews, focus group interviews and a text message. A trusted external secretary with prior experience as a medical secretary transcribed the recordings.

Observations.

The first author (MJ) engaged in direct observations of selected cases for approximately 24–32 hours respectively in the ICUs (B, C, D). MJ was working clinically at that time in ICU A, and was subsequently familiar with the unit thus needed no assistance in collecting documents.

Field notes.

Field notes consisted of a continuous record of responses reported from the different units according to the study protocol. They were written by MJ both in the ICU but also directly after each observation period.

Collected documents included pamphlets related to the patient in critical care, documents about patient diary guidelines and informed consent forms about diary writing/photography.

Informal field interviews.

The field interviews took the form of spontaneous, informal conversations which described the nursing staff’s views and experiences of how the ICU diary was used within everyday nursing practice on their respective unit. These informal interviews were not audio-taped but rather written up in the form of field notes by the first author (MJ).

Individual interviews.

An interview was conducted with one patient and their family members recruited via telephone from the ICU follow-up programme at one of the ICU settings. The interview was based on the questions from the study protocol but reformulated into open-ended questions ( S2 Table ). Moreover, an interview with a nurse with experience of developing diary implementation in Sweden was carried out in the same way. The interviews were audio-taped with the participants’ permission, ranging from 60–70 minutes in duration and subsequently transcribed verbatim. These participants were originally invited to the focus group interviews but were prevented from attending for various reasons. Nevertheless, they wished to communicate their experience of using the diary. A telephone interview/conversation and a textual message from a former patient were also included in the data. Field notes were duly written directly after the telephone conversation had taken place.

Focus group interviews.

Three focus group interviews with a total of 8 patients and 5 family members at the participant hospitals were conducted to explore the use of an ICU diary in the respective care settings. The design of the ICU diary was developed in keeping with each unit’s guidelines and practices. The participants were only aware of the version they had received from their respective ICU. Nurses from the individual ICU follow-up programme recruited the participants via telephone. Information about the focus group sample is provided in S3 Table .

Patients had been discharged for a period of seven to fourteen months depending on their recovery process and were invited to bring family members with them to the focus group session. The inclusion criteria for patients and family members included; being a former ICU patient, having an ICU diary, being willing to share their experiences and aged 18 years or older.

In accordance with Krueger & Casey [ 33 ], open-ended questions were posed in order to allow for explanations, descriptions and illustrations relating to ICU diary writing and practices. Key questions included the following; how was it to read/write in the diary? When was the diary handed over? When were the photos handed over? What are your thoughts about the content in the diary? MJ moderated all focus group interviews. The second author (IW), a critical care nurse specialist with a PhD in caring sciences, operated as an assistant moderator and concluded the interview by briefly summarizing the main points and asked if the summary reflected what participants had experienced in the group [ 33 ]. Interviews were audiotaped, and were of 86–127 minutes in duration. The data were transcribed verbatim. Unstructured field notes were written by MJ directly after the interviews to document key remarks and reflections, such as something surprising and/or unexpected to MJ or how a group’s responses were similar to or different from earlier focus group sessions [ 33 ].

Data analysis

In keeping with Yin’s [ 29 ] recommendation with case study analysis work, the authors duly returned to the core research questions. To help answer the first research question, the extensive amount of practical information from the observational studies, documents and informal, and unstructured field interviews were systematised with the help of a matrix (see Table 2 below) developed from the study protocol (See S2 Table ) [ 29 ].

https://doi.org/10.1371/journal.pone.0298538.t002

Second, to answer the remaining research questions (2, 3 and 4), a thematic analysis, inspired by Braun and Clark [ 34 ], was conducted of the qualitative data from the focus group interviews, individual interviews, telephone interview, and textual message [ 34 ]. This approach was deemed suitable for identifying, reporting and interpreting patterns of meaning within the transcribed data. It was also chosen for being a flexible yet rigorous method for examining the perspectives of different research participants, highlighting similarities and differences and also generating unanticipated insights [ 34 ].

The analysis commenced with repeated reading to be familiar with all aspects of the data. Thereafter, a coding process began using highlighters and writing notes on the texts. Extracts that demonstrated each code were brought together in Word documents, one for each pattern. An extract might be uncoded, coded once, or coded many times as it was relevant. This way, all the codes with their extracts were organised in their document. The documents were organised into theme piles. In the final step of the analysis, core themes were developed that reflected patients’ and family members’ use of the ICU diary (See Fig 1 below).

https://doi.org/10.1371/journal.pone.0298538.g001

Ethical considerations

The study was conducted in compliance with the established ethical guidelines of the Declaration of Helsinki [ 35 ] and the Regional Ethical Committee in Linköping, Sweden provided formal ethical approval for the study (Dnr 2017/550-31). The clinical medical director at each of the respective units was informed about the study and approved the study. Potential focus group participants were recruited through the respective ICU’s follow-up services, and the hospital with the strategically optimal location was chosen for the interviews. Participants were financially compensated for their travel costs.

Information about the study was repeated verbally to participants prior to the start of the observation study and the interviews. Voluntary participation, informed consent, confidential treatment of all data and the right of participants to withdraw at any time without repercussion to their care or working situation (as appropriate) and appropriate storage of the qualitative data were all emphasised. Informed oral consent by the observation participants was witnessed by the first author and consisted of the participants verbally stating that they agreed to the first author observing activities and interactions involving the participant as part of her research study. Informed oral consent by the interview participants was also witnessed by the first author and consisted of the interview participants verbally agreeing to take part in an interview as part of the first author’s research study. Verbal consents were documented by the first author as part of her methodological field notes and as approved by the regional ethics committee. As the first author was working as a critical care nurse in ICU A, qualitative interviews were not carried out in this particular setting [ 36 ].

Table 2 below provides an overview matrix of the main similarities and differences regarding the structure, content, and ICU diary use within participating ICU settings arising from the systematized observational study, documentary and informal field interview data as outlined above. The matrix is supplemented with a written summary description of the four ICU contexts and main current practices drawn from the qualitative data. Core findings from a thematic analysis of the qualitative data are subsequently presented.

ICU contexts

It was self-evident by nursing staff in all ICUs to involve family members in writing/reading the diary without them feeling obliged to write. Family members might come and go around the clock at some units, but in others, staff agreed on their visiting times. ICU nursing staff had diverse experiences of diary writing from 10 to 23 years. Prepared diaries were readily available on the ICUs in a room intended for follow-up services.

Staff from the general ICUs’ follow-up services had regularly networked since 2012, together with another two ICUs in the region in order to exchange experiences about diary implementation and follow-up services. At that time, all participant ICUs had the same members in the follow-up services and in the diary group who prepared and were responsible for diary implementation.

Nursing staff at each ICU had established their own purpose statement in the absence of national guidelines on patient diaries. Diary writing had been realised as a spontaneous initiative by nursing staff, and the activity had advanced often through “learning by doing”. The assumption being that the patient needed to know and come to terms with what happened while they were in ICU. Also, family members needed help to also understand and process the patient’s stay.

Written guidelines were found in one ICU and comprised inclusion, exclusion criteria, writing style, informed consent, the process around photographing, and handover of the diaries. Another unit was developing written guidelines, but the other units had only oral guidelines about the structure, content, and use of the diary. Experienced nursing staff communicated informal guidelines to new employees and less experienced ICU nursing staff. The absence of clear, written guidelines meant that many patients did not receive a diary because of the hesitation in deciding which patients should get a diary and how to prioritise the process. The uncertainty was expressed as a cause of frustration among the participant nursing staff.

Diary structure.

The diary was an A5 notebook, lined, laminated cardboard folder, and spiral bounded or bound. Some ICU nursing staff had chosen a picture of a well-known sight from the town to act as the cover. Others had chosen colourful images such as flowers or trees. The ICU diaries’ format was open, only blank pages, handwritten, and without any editing (that is, there was no one responsible who approved the diary before it was handed over to the patient). On the initial page/s, the diary included dedication to the patient and the patient’s name.

Next, diaries usually contained a summary and a reason for the patient’s admission to ICU and daily entries. The summary and closing framed the diary’s story about the time in ICU. There was also a glossary, and in three of four ICUs, generic photos on the most common ICU medical equipment.

Diary content

All diaries contained a page called ‘Who am I? What is important for me?’ The page asked for the patient’s sleep habits, favourite sports, favourite food and drinks, music, and philosophy on life which family members were requested to complete. The diaries in some ICUs comprised the 24-hour circle in the ICU with an associated timeframe. This information highlighted that the activities varied around the clock and explained that somebody was always nearby the patient. Next followed the narratives of daily activities with and around the critically ill patient, which formed a central part of the diary. The narratives contained information about medical treatment, daily care of the patient, information about progression, such as mobilising out of bed, conversely how the patient’s condition had deteriorated, and that the patient was approaching death.

Other entries were psychosocial, which expressed and confirmed the presence of the family members at the bedside. Family members added information about what happened at home or greetings from other family members. Entries included reflections around the weather, seasons, Swedish festivals, sports events together with entries of a more personal nature. Staff members who wrote the entry included the whole team, dated, and signed the note. A unique contribution from staff at one ICU was a poem at the end of the diary intended to provide a respectful content if diary entries were sparse.

Use of the diary

All units kept the diaries at the patient’s bedside so that nursing staff and family members could write whenever they wanted to. The diary was seen as the patient’s property and was not deemed to be part of the patient’s medical records. Written or oral guidelines stated that a diary should be offered to the patient when they were expected to be cared for >72 hours or for those who ‘needed’ it. In one ICU, there was an ambition to open up a diary to all patients admitted to the ICU, especially patients cared for following a cardiac arrest, which meant a shorter care stay than three days. Care of patients with cardiac arrests denoted heavy sedation, ventilation and connection to a range of cannulas and tubes for about 24–36 hours and then awoken. In general, this group were deemed to benefit from a diary.

The nursing staff did not open an ICU diary for patients with severe brain injuries, and dementia, poor prognosis nor for patients who did not speak/understand Swedish. Often, some nursing staff commenced a diary immediately when a patient was admitted to ICU, but sometimes days elapsed, and the diary writing did not take place. Reason/s for the delay included lack of time or difficulties to start the diary as the summary was deemed to be the most essential and extensive aspect. In some units, assistant nurses frequently opened a diary as they had more time to initiate the process than the registered nurses.

Two ICUs kept registers about patients who had a diary. This included a checklist with the patient’s name and informed consent given by family members to photograph the patient. The checklist was stored in a diary file in the staff room and accessed by nursing staff who belonged to the diary group. Other ICUs asked family members for informed consent orally in conjunction with information about the diary without any written documentation. The consensus was that the photographing was a part of the treatment and therefore did not necessitate permission from the patient or family members, thereby facilitating the prompt starting of a diary and with photographs. However, the patient was required to give retrospective consent once they were sufficiently well enough to receive the diary.

Use of photographs

All staff from the four ICUs used photos to augment the written content. Nursing staff were aware of the photos’ supportive role and that the patients frequently requested more pictures. Usually, the first photographs were taken when the patient was fully sedated, ventilated, and linked to a range of tubes and cannulas. Subsequent photos were taken on significant events and progressions during the ICU stay. Typically, the patient was photographed at a distance so as not to expose the patient at an inappropriate angle.

However, nursing staff at one ICU meant that the pictures should be realistic, and nursing staff should go close to the patient when photographing because the patient needed to recognise themself. The photos should assist as a ‘reality check’ when setting goals for recovery.

Three ICUs used a digital camera with memory, where nursing staff might print out the photograph straightaway and then delete the original from the memory card. The fourth ICU moved and stored the pictures in image management on a desktop. At one ICU, the pictures were pasted in the diary immediately, close to the written text, so that text and image interacted. Sometimes, photos were collected in an envelope at the back of the diary.

Another ICU used mounted the photos directly in their context in the diary but left the other side empty. This made it possible for the patient to remove the picture but without destroying any existing text.

In contrast, two ICUs did not include the photos directly in the diaries. The rationale being that the patient needed a ‘face to face’ meeting with ICU nursing staff and an explanation of the photos to fully understand the pictures and be allowed to ask any questions. Otherwise, they feared that the patient might be frightened or re-traumatised if no explanations was given. Another reason for the personal meeting was to obtain retrospective consent for the pictures. If the patient refused the photos, they were destroyed.

Handover process

The diary followed the patient by the nursing staff placing the diary at the end of the bed or giving it to family members on transfer to the general ward. Diary group/follow-up service staff visited the patient at the ward when they were transferred from the ICU. During this visit, the photographs were discussed in those cases they were not included in the diary. If the patient wanted the photos at that time, they were handed over. Otherwise, the pictures were discussed at the follow-up service later and then handed over. Patients who did not attend any follow up service received their photos by mail at home, if they requested them.Family members where the patient did not survive, received a telephone call about 6–8 weeks after the patient’ death and were invited to the follow-up service to discuss the patient’s stay at the ICU.

Thematic analysis findings

Four interconnected themes were derived from the qualitative thematic analysis that reflected patients’ and family members’ use of the ICU diary. The themes are represented in the following sections and highlighted in Fig 1 below. Participants are cited using the number of the focus group and P (atient), S (pouse) number identifier.

The diary was used to take in and fully understand the situation.

The chronology in the diary and the everyday language were understood as valuable characteristics because family members expressed feeling unsure about specific dates and events during their family member’s ICU stay. Even in the diary, patients and family members sometimes had difficulty distinguishing specific dates. A positive aspect of the ICU diary highlighted by participants was the ability to read and re-read the information to assimilate it.

That you can go and look in the diary a little now and then and think about it ( I/S1)

Patients and family members requested ongoing summaries in the diary, as the information was sometimes perceived to be insufficient or irregularly provided, especially during more extended periods of stay. The diary was mainly experienced as a tool to help process the time in ICU by describing what daily life looked like, which was not included in the medical records.

Patients described dreams, nightmares and unreal experiences that caused long-standing problems post-ICU discharge despite a few other more positive memories. This meant that patients and family members had different experiences of events which sometimes led to misunderstandings among families. However, patients expressed missing entries with sufficient personal details which described confused thoughts they had expressed and what the thoughts were about, so they might orientate themselves. Patients expressed a need to know that these confused thoughts were often of a frequent occurrence.

The nursing staff explained to my wife and children–but nothing in the diary , about the confused thoughts . They said it calmly , and that he’s going to recognize you . ( II/P3) .

All patients and family members emphasized how important the summary was, which told the story prior to admission and why the ICU admission had taken place. Despite this, patients and their family members experienced that critical and life-threatening episodes were sometimes neglected, and they wanted more realistic adjectives to be used such as “deadly condition” and “hovering between life and death” to understand how critically ill the patient was. Another drawback relating to missing information was the setting’s description with its sounds, sights, machines and bed. In other words, former patients wanted to have events clarified, which were known to be the source of nightmares, distorted thoughts and hallucinations; as an example, the ICU bed was often experienced as a container, boat or a railway truck. The ICU diary became a way of summarizing and making countless details visible in a single concrete picture. It was considered as a reliable document against which to check their personal memories of their ICU stay.

The diary is fantastic; without it , I would not have known anything . The wife has a hard time reading the diary . The children also find it difficult . ( I/P2) .

The photographs were expressed by patients as being personal and they offered them a window into the past to fully understand their history. All insisted that it was important that photos were tightly connected to the written texts. Some had received photos in bulk (in envelopes) connected with the follow-up services, to insert them independently in the diary.

I had a need to get a whole of the ICU stay . I got loose pictures that I could not put into context ( telephone interview)

In general, patients wanted realistic photographs without embellishments because they wanted to know their actual health status in order to set realistic rehabilitation goals. They also requested close-ups to be able to recognize themselves, otherwise, they argued that it could be anyone in the photo. Patients with realistic pictures of themselves with all the equipment, expressed that it did not feel so scary anymore.

Yes , but then that’s not pleasant , you see it’s me , but further away , then it wouldn’t have been easy to see that it was me ( II/P2) .

The diary was an opportunity to assimilate the warmth, personalized and human care.

Patients and family members found the diary to be personally touching. They explained that naming the patient in each entry gave identity and a personal touch to the diary. They found an unexpected kindness in the staff’s diary writing which deeply moved them. The diary was thoughtful and often well-written with warmth that patients expressed that they would carry with them for life.

They (nursing staff) really showed from the bottom of their hearts that they liked me , that I’m important ( II/P2) .

The diary bore traces of the authors’ varying ability to express themselves, which participant patients and family members appreciated. Family members felt that the nursing staff was there for them all the time, even if it was for the patient’s sake. The diary testified that the patient was cared for with respect and not as an object. For family members, the diary was considered a symbol of human care and hope in situations where the outcome for the patient was uncertain during the ICU stay.

We can read in the diary . ‘We see a slight improvement’ . This little word is so important ( I/S2)

Some former patients proudly read descriptions such as “the ward’s trump card”, “the ward’s sunshine story”, which further underscored the personalized caring and how sick the patient had been and survived the trauma. Others read about how the nursing staff washed the hair of unconscious patients, helped with the first shower, provided offers of TV watching and fulfilled requests for particular drinks.

I think it’s nice to read . Today you have sat on the edge of the bed , and it’s the nursing staff who wrote . They (nursing staff) care so much about one . It warms . ( I P3) .

Patients emphasized the importance of the family members’ notes. However, many family members admitted that they could not write in the diary themselves. They expressed that they were too sad and worried, but they experienced it was good to read the nursing staff’s entries as they found it to be sign of hope among all the sorrow. Patients felt that family members had been well-taken care of. Patients and family members expressed that the support and empathy that they could make out in the diary acted as a long-standing form of support for them.

The diary was used to manage existential issues.

Spiritual issues about the meaning of life emerged for patients experiencing a life-threatening illness, especially when the trauma was lived through and vividly described in the diary. Some of the patients had experienced a near death experience on a visit related to cardiac arrest and asked themselves. Why did I get sick? Why did I survive? The patients might go back and look in the diary from time to time and tend to ask themselves the same existential questions. Patients admitted that it was often serious issues that were raised and that were difficult to share with “outsiders”. Patients and family members believed that one must have been there to fully understand. The pictures in the diary might explain the problematic situation and the ever-present threat of death. They explained that the diary “sharpened the mind”, to pay intention to how fragile life could be and how quickly it could change.

However , it was strange to me; why did I get this disease . I kept thinking , why did I have a cardiac arrest ? For twenty years I haven´t had anything , but suddenly I got it ( II/P2) .

Family members admitted that it caused a disturbance in the family, when a member was ill with a life-threatening illness but that the family was brought together by reading the diary. Some patients noted that they found it challenging yet exciting to read what they had been through in the diary and experienced gratitude that they were alive and believed that life was now too short to dwell on existential issues. Patients admitted that they were not afraid of the future and felt that the experience had empowered them in a way as they now appreciated life even more. Even for family members, existential issues could deeply touch them as illustrated by the following quotation.

Mum , where do you have the diary ? So , she can crawl away for herself , so she is 27 , and then I see how a few tears fall , and then she comes and holds me , says mother , I’m so glad you’re here ( II/P3) .

The diary was used as a tool in daily activities.

Family members described the diary as a tool for information and communication during the ICU stay. To access, understand and take in the medical information. They found the diary glossary to be useful as it often explained the use of medical terms, which eased conversations with nursing staff and provided a feeling of being included. Family members described the diary as available when needed and that they used the diary as a company, comfort and sometimes as an intimate friend at the ICU.

It was great to not just sit alone in the waiting room spending time and biting nails . It was great to have a diary available ( III/S1) .

The diary was viewed by family members as something to keep them occupied with instead of constantly following the monitoring screens and as a way of overcoming uncertainty. Family admitted that they wrote not only for the sick person but also for their own sake to unload their personal worries and thoughts.

On discharge home from hospital, participants explained that the diary became a basis for the patient to ask questions. The diary also became a support for family members to be able to account for the course of events. The diary was perceived as a reliable document about the time spent in ICU. Pictures of family members showed that they had been there during the critical illness.

All visits are listed here . I think it is vital that all the sons are in the pictures and not just S and I ( I/S2) .

However, the diary could evoke unpleasant memories for some patients, which caused the diary to be set aside.

I experienced the diary as a bit silly initially , but now I can get hurt by it when I look at it; the trauma remains and gets even more challenging . (I/P2)

A participant former patient had used the pictures in the diary as proof of how ill they had been in their effort to convince persons in authority. Others had let family members and friends read the diary themselves, as they had not been able to tell and re-tell their story.

The aim of the study was to explore the use of the ICU diary within four different ICUs units in Sweden and thereby contribute to practice guidelines regarding its structure, content and use. The practice recommendations arising from the study findings can be summarised into three areas, namely the need for guidelines, guidelines outlining the content of the diary, and how the diary making process reflected the approach of person-centred care. Each will be considered in turn. This is followed by a discussion of the study’s main methodological considerations.

The need for practical guidelines

The study revealed that it was left to the discretion of the nurse caring for the patient if a diary was opened up. The rather haphazard selection of patients for keeping a diary has previously been demonstrated in Scandinavian surveys 1 [ 4 , 24 ]. National guidelines could act as a support for priority setting and to provide guidance as to whom and when to open up an ICU diary. A common standard would make it possible to follow up on the diary as a caring intervention continuously and systematically. National guidelines may pay attention to the diary making process and so increase awareness among nursing staff that the diary can act as a useful debriefing tool and as a help in reorientation for the patients [ 1 , 2 , 17 , 23 ].

Based on the study findings, family members’ roles in the ICU setting are important to highlight in the national guidelines, including the promotion and support of their active participation in the writing, including the start-up of the diary. It is known from previous studies that family members benefit from the diary [ 5 – 7 ] and that the diary may also act as bereavement support if the patient should die [ 8 ].

In the current study, patients with severe critical illness, (little chance of survival), dementia, and people with learning disabilities were automatically excluded. Therefore, guidelines need to outline that the diary may also benefit family members and then the green light is given to commence a diary to broader groups of patients. Further, it is regarded as a human right to be provided equal treatment as a Swedish inhabitant, and this approach would also include patients with other languages [ 37 ]. The diary may be translated in some way and/or compiled with more pictures and generic pictures.

The study highlighted that guidelines need to be flexible, only stating certain main principles and being considered for every person admitted to the ICU. Further, it showed how practical knowledge sustained the writing as patient categories cared for shorter periods than three days were included. An example is patients having had a cardiac arrest, who were deemed to need follow-up support as this group of patients tended to develop both cognitive and emotional difficulties [ 38 ].

Guidelines outlining the content of the diary

The study revealed that patients and their families requested relevant, realistic content with close-up pictures in the diary because they wanted to know the main details to gain a better understanding of the patient’s illness and what happened to them during their ICU stay. The findings were contradictory to those of the nursing staff, in keeping with a previous study that demonstrated how the staff weighed every word to avoid harming the patient in any way [ 39 ]. It has been previously noted how nursing staff experienced diary writing as “complicated in its simplicity”, due to difficulties finding “the right words” in writing and at the same time providing comfort and confidence that patients and family members needed both during and post the ICU stay [ 40 ]. Further, it was noted that pictures were often taken at a distance and avoided being taken of a patient with a swollen face, which is in line with previous findings [ 14 , 26 ]. This poses the question of whether nursing staff are overly cautious with regards to diary content to avoid causing the patient any potential offence or distress. In addition to the diary content.

The process of photographing highlighted the main differences between the four cases and were related to local legal and ethical considerations. Previous research highlighted that photography caused additional considerations and units removed pictures in the diaries that were taken without prior consent and that could potentially impinge on patient privacy [ 12 , 14 ]. On the other hand, patients who were provided photographs appreciated them and wanted additional ones [ 41 ]. Previous studies have demonstrated the value of pictures noting that photographs added realism and neutralized frightening fantasies [ 42 ] and that the diary with its text and photos can be seen to be important to induce post-experience reflections [ 43 ].

How the diary making process reflected the approach of person-centred care

The participant family members in the study underscored how they were naturally offered to participate actively in care by reading/writing in the diary. In this way, they experienced themselves as valuable and equal partners. Writing the diaries was about doing an intervention with patients and their families in partnership rather than ‘to’ them. Family members highlighted the personality of the critically ill patient, and together with the nursing staff, they helped to meet the patient’s needs for information and support. Writing a personal diary is in line with current healthcare policy concerning people-centred care, which means putting patients and their families at the centre of decisions and working alongside them to secure the best possible outcome [ 44 ]. Establishing a partnership in the ICU was challenging because the patient was not awake and unable to tell their life story. However, the diary and the page with questions ‘Who am I? What is important to me? were created to understand the patient as a human being with physical, psychological, and existential needs. This information was often captured from family members and used to tailor conversation topics, activities and motivational features in daily nursing care. Likewise, the diary itself may be regarded as documentation of a piece of life that would otherwise have been unknown to the patient.

Patients expressed feeling cared for when they read a diary written primarily for them as the diaries were dedicated to the patient. The writing helped to maintain a feeling of togetherness among the family members and nursing staff, which has been expressed in previous studies [ 8 , 45 , 46 ]. The belief that diaries are a caring activity was coined by Roulin, Hurst & Spirig [ 47 ] as writers from different backgrounds took part in an everyday activity for the patient’s benefit. A personal diary with personal photographs also demonstrates that the nursing staff has been willing to go that extra mile for the patient [ 12 ]. Diary writing also created a caring relationship between the patient, family members and nursing staff [ 48 ].

Methodological considerations

The study was carried out by using a qualitative multiple case study methodology, where the study protocol acted as a guide helping the first author in carrying out the data collection from a single case as one of several in the multiple-case study approach [ 29 ]. It can also be seen as a way of increasing the reliability of the case study research and a possibility to replicate findings across cases. Multiple methods of data collection, for example, the combination of focus groups, the individual interviews and notes from observational studies were used to identify similar, different, or complementary views and experiences across the different participant groups. The approach allowed for methodological triangulation and increased the likelihood that findings were credible [ 29 , 30 ].

Limitations.

A study limitation is that the four ICU settings were located in one geographical area of Sweden so that the degree of transferability of the findings to other settings can be questioned. Nevertheless, the study likely reflects the different use of ICU diaries in Sweden. Further, it can be argued that the findings are applicable to other ICU settings with similar publicly financed health care systems. The study can be considered as a first step in a longer-term research and practice development work towards national guidelines regarding the use of the ICU diary.

The first author (MJ) was an ICU nurse at one of the participating clinics, so it could be argued that she potentially lacked objectivity and was biased in her data collection and analysis activities due to her insider knowledge of ICU A [ 36 ]. Nevertheless, MJ kept detailed field notes which included reflections of her researcher role in the settings which were duly discussed on a regular basis with her doctoral supervisors. Also, it can be argued that MJ’s insider knowledge was an advantage as she was familiar with the ICU context so that she was also able to ask relevant questions and was able to have an in-depth understanding of participants’ responses and actions.

Based on the findings it can be argued that clinical practice guidelines concerning ICU diaries would help to ensure their wider and more consistent use for all ICU patients, as opposed to a more selective groups of ICU patients. Second, they would help to make the role of family members more transparent and valued. Finally, they would provide concrete guidance to nursing staff about how best to write in the ICU diary to ensure relevant, real-world content bringing the human element and aiding with genuine person-centered care.

Relevance to clinical practice

The findings are intended to act as an impetus for future practice development work concerning ICU diary guidelines in ICU settings in other health care regions in Sweden and internationally in countries with a similar health care system to that of Sweden. The aim being to help facilitate and promote nursing staff’s everyday clinical practices concerning ICU diary writing in keeping with a person-centred approach.

Supporting information

S1 table. consolidated criteria for reporting qualitative research (coreq): a 32-item checklist for interviews and focus groups..

https://doi.org/10.1371/journal.pone.0298538.s001

S2 Table. Study protocol for instrumental multiple case study.

https://doi.org/10.1371/journal.pone.0298538.s002

S3 Table. Description of focus group interview participants.

https://doi.org/10.1371/journal.pone.0298538.s003

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Hood, M. (2009). Case Study. In: Heigham, J., Croker, R.A. (eds) Qualitative Research in Applied Linguistics. Palgrave Macmillan, London. https://doi.org/10.1057/9780230239517_4

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