Practical considerations in case study research: the relationship between methodology and process

Artificial Intelligence Augmented Qualitative Analysis: The Way of the Future?

The artificial intelligence (AI) revolution is here and gathering momentum, thanks to new models of natural language processing (NLP) and rapidly increasing adoption by the public. NLP technology uses statistical analysis of language structures to analyse and generate human language, using text or speech as its source material. It can also be applied to visual mediums like images and videos. A few qualitative research early adopters are beginning to adopt this technology into their work, but our understanding of its potential remains in its infancy. This article will define and describe NLP-based AI and discuss its benefits and limitations for reflexive thematic analysis in health research. While there are many platforms available, ChatGPT is the most well-known and accessible. A worked example using ChatGPT to augment reflexive thematic analysis is provided to illustrate potential application in practice. This article is intended to inspire further conversation around the role of AI in qualitative research and offer practical guidance for researchers seeking to adopt this technology.

Country-level mentoring for advanced practice nursing: A case study

AIM

To describe the mentoring process between the ICN Advanced Practice Nurse Network practice subgroup and the University of Pécs to support the emerging advanced practice role in Hungary, and explore the creation of a mentoring algorithm for faculty and other key stakeholders worldwide who wish to develop advanced practice nursing programs.

BACKGROUND

Advanced practice nurses provide comprehensive clinical care and expand access to care in more than 70 countries. In March of 2017, a representative of the Faculty of Health Sciences of the University of Pécs requested assistance in curricula development for the inaugural advanced practice nursing program in Hungary.

METHODS

A mixed-methods single case study was undertaken. The sources of evidence include interviews, e-mails, review of the literature, and related documents. Qualitative data were analyzed for content, and frequencies were calculated for quantitative indicators.

FINDINGS AND DISCUSSION

The findings highlight the importance of clear communication, development of shared goals, and determination to see the project through. Enriching information was provided by colleagues from diverse global settings. Credibility was gained in Hungary from the support of national and international experts.

CONCLUSION

The mentoring foundation and process facilitated the role development in Hungary and contributed to an increased understanding of advanced practice nurses' scope of practice. The intentional approach and the careful ongoing reflection may lead to future successful endeavors. Multinational engagement and collaborations will promote advanced practice nursing contributions globally.

IMPLICATIONS FOR NURSING POLICY

Mentoring can effectively empower nurses and advanced practice nurses to work to their full capacity. The shared experiences of international mentoring colleagues can contribute to and support the development and acceptance of national policies for the advanced practice nursing roles.

Famílias, gênero e hospitalizações psiquiátricas compulsórias

RESUMO Objetivo: Os papéis relacionados a cuidados nos grupos familiares têm sido, historicamente, uma atribuição de mulheres. Este artigo aborda as especificidades de gênero no cuidado com pacientes no contexto de avaliações por demandas de hospitalizações psiquiátricas compulsórias, a fim de verificar se, nesse contexto, as tarefas de cuidado são, ainda, atribuídas predominantemente a mulheres. Métodos: Este é um estudo observacional, descritivo, de casos múltiplos, que acompanhou 80 atendimentos de famílias em avaliações em processos de hospitalização psiquiátrica compulsória de junho de 2020 a fevereiro de 2022, no município de Alvorada-RS. Resultados: Mulheres estiveram diretamente envolvidas, como requerentes, em 78% dos casos. Em apenas 18 atendimentos não havia mulheres presentes como acompanhantes, mas 14 desses casos não tiveram qualquer rede familiar ou social identificada. A participação predominante de mulheres não pode ser associada à renda do familiar e nem a características dos pacientes ou de sua condição clínica. Em análise de entrevistas de seguimento com familiares, reitera-se que o ato de cuidar se mantém atribuído às mulheres. O acúmulo de papéis a serem desempenhados também foi evidenciado. Conclusões: A delegação do cuidado gera sobrecarga nas mulheres, gerando sentimentos como medo, apreensão e insegurança. Capacitação e sensibilização de equipes para um olhar sistêmico e de gênero, propondo ativamente a inclusão de demais familiares e redistribuição de tarefas, parece fazer parte das possibilidades de cuidado com quem cuida também nesse contexto.

Evaluating complex interventions in context: systematic, meta-narrative review of case study approaches

BACKGROUND

There is a growing need for methods that acknowledge and successfully capture the dynamic interaction between context and implementation of complex interventions. Case study research has the potential to provide such understanding, enabling in-depth investigation of the particularities of phenomena. However, there is limited guidance on how and when to best use different case study research approaches when evaluating complex interventions. This study aimed to review and synthesise the literature on case study research across relevant disciplines, and determine relevance to the study of contextual influences on complex interventions in health systems and public health research.

METHODS

Systematic meta-narrative review of the literature comprising (i) a scoping review of seminal texts (n = 60) on case study methodology and on context, complexity and interventions, (ii) detailed review of empirical literature on case study, context and complex interventions (n = 71), and (iii) identifying and reviewing 'hybrid papers' (n = 8) focused on the merits and challenges of case study in the evaluation of complex interventions.

RESULTS

We identified four broad (and to some extent overlapping) research traditions, all using case study in a slightly different way and with different goals: 1) developing and testing complex interventions in healthcare; 2) analysing change in organisations; 3) undertaking realist evaluations; 4) studying complex change naturalistically. Each tradition conceptualised context differently-respectively as the backdrop to, or factors impacting on, the intervention; sets of interacting conditions and relationships; circumstances triggering intervention mechanisms; and socially structured practices. Overall, these traditions drew on a small number of case study methodologists and disciplines. Few studies problematised the nature and boundaries of 'the case' and 'context' or considered the implications of such conceptualisations for methods and knowledge production.

CONCLUSIONS

Case study research on complex interventions in healthcare draws on a number of different research traditions, each with different epistemological and methodological preferences. The approach used and consequences for knowledge produced often remains implicit. This has implications for how researchers, practitioners and decision makers understand, implement and evaluate complex interventions in different settings. Deeper engagement with case study research as a methodology is strongly recommended.

Implementation of the Canadian Clinical Practice Guidelines for Nutrition Support: A Multiple Case Study of Barriers and Enablers

BACKGROUND

The Canadian Nutrition Support Clinical Practice Guidelines (CPGs), published in 2003, were designed to improve nutrition support practices in intensive care units (ICUs). However, their impact to date has been modest. This study aimed to identify important barriers and enablers to implementation of these guidelines.

METHODS

Case studies were completed at 4 Canadian ICUs. Semistructured interviews were conducted with 7 key informants at each site. During the interviews, the key informants were asked about their perceptions of the barriers and enablers to implementation of the Canadian Nutrition Support CPGs. Interview transcripts were analyzed qualitatively, using a framework approach.

RESULTS

Resistance to change, lack of awareness, lack of critical care experience, clinical condition of the patient, resource constraints, a slow administrative process, workload, numerous guidelines, complex recommendations, paucity of evidence, and outdated guidelines were cited as the main barriers to guideline implementation. Agreement of the ICU team, easy access to the guidelines, ease of application, incorporation into daily routine, education and training, the dietitian as an opinion leader, and open discussion were identified as the primary enabling factors. Although consistent across all sites, the influence of these factors seemed to differ by site and profession.

CONCLUSIONS

Our findings suggest that implementation of the Canadian Nutrition Support CPGs is profoundly complex and is determined by practitioner, patient, institutional, and guideline factors. Further research is required to quantify the impact of each barrier and enabler and the mechanism by which they influence guideline adherence.

ReseArch with Patient and Public invOlvement: a RealisT evaluation – the RAPPORT study

Background

Patient and public involvement (PPI) is a prerequisite for many funding bodies and NHS research ethics approval. PPI in research is defined as research carried out with or by the public rather than to, about or for them. While the benefits of PPI have been widely discussed, there is a lack of evidence on the impact and outcomes of PPI in research.

Objectives

To determine the types of PPI in funded research, describe key processes, analyse the contextual and temporal dynamics of PPI and explore the experience of PPI in research for all those involved. Mechanisms contributing to the routine incorporation of PPI in the research process were assessed, the impact of PPI on research processes and outcomes evaluated, and barriers and enablers to effective PPI identified.

Design

A three-staged realist evaluation drawing on Normalisation Process Theory to understand how far PPI was embedded within health-care research in six areas: diabetes mellitus, arthritis, cystic fibrosis, dementia, public health and learning disabilities. The first two stages comprised a scoping exercise and online survey to chief investigators to assess current PPI activity. The third stage consisted of case studies tracked over 18 months through interviews and document analysis. The research was conducted in four regions of England.

Participants

Non-commercial studies currently running or completed within the previous 2 years eligible for adoption on the UK Clinical Research Network portfolio. A total of 129 case study participants included researchers and PPI representatives from 22 research studies, and representatives from funding bodies and PPI networks.

Results

In the scoping 51% (n = 92) of studies had evidence of PPI and in the survey 79% (n = 80), with funder requirements and study design the strongest influence on the extent of PPI. There was little transparency about PPI in publicly accessible information. In case studies, context–mechanism–outcome configurations suggested that six salient actions were required for effective PPI. These were a clear purpose, role and structure for PPI; ensuring diversity; whole research team engagement with PPI; mutual understanding and trust between the researchers and lay representatives; ensuring opportunities for PPI throughout the research process; and reflecting on, appraising and evaluating PPI within a research study. PPI models included a ‘one-off’ model with limited PPI, a fully intertwined model in which PPI was fully embedded and an outreach model with lay representatives linking to broader communities. Enabling contexts included funder, topic/design, resources, research host, organisation of PPI and, most importantly, relationships. In some case studies, lack of coherence in defining PPI persisted, with evidence of a dual role of PPI representative/study participant. Evidence of PPI outcomes included changes to study design, improvements to recruitment materials and rates, and dissemination.

Conclusions

Six salient actions were required for effective PPI and were characterised by a shared understanding of moral and methodological purposes of PPI, a key individual co-ordinating PPI, ensuring diversity, a research team positive about PPI input and fully engaged with it, based on relationships that were established and maintained over time, and PPI being evaluated in a proactive and systematic approach. Future work recommendations include exploring the impact of virtual PPI, cost analysis and economic evaluation of the different models of PPI, and a longer-term follow-up study of the outcomes of PPI on research findings and impact on services and clinical practice.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Contexts for Sustainable Implementation of a Colorectal Cancer Screening Program at a Community Health Center

BACKGROUND

"Context" is a mediating construct that significantly influences the initiation and maintenance of program implementation, but it has seldom been studied in process evaluation. This case study describes the contextual factors that encourage or impede the implementation processes of a research-tested program at a Federally Qualified Community Health Center.

METHOD

We conducted 14 key informant interviews with providers, nurses, medical assistants, and clinic staff in leadership and management positions during the 24 months of active implementation. Interview data were analyzed using Atlas.ti software. A written log documenting exposure, adherence, and coverage of the implementation was used to describe implementation fidelity.

RESULTS

Findings indicated that program implementation needs to align with the organization's mission and values. Sensemaking caused individuals to understand the importance of the new process and increased their motivation to follow assigned procedures. Revisions of the implementation process allowed the program to fit better with the clinic's existing workflow. However, permitting flexibility in the delivery of an intervention may result in inconsistent implementation fidelity. In this study, threats to implementation included unanticipated changes in the clinic environment, such as budget cuts to resources and staff turnover as a consequence of the current economic downturn.

CONCLUSIONS

Momentum leading to sustainable implementation requires a continuous team effort and a stable environment; consequently, a successful implementation requires a structure that supports problem solving, communication, and evaluation.

Sustainable childhood obesity prevention through community engagement (SCOPE) program: evaluation of the implementation phase

Childhood obesity rates are steadily rising. Sustainable Childhood Obesity Prevention Through Community Engagement (SCOPE) is a community-based participatory action research (PAR) program aimed at preventing childhood obesity. This study aimed to describe community perspectives on, and elicit feedback about, SCOPE's first phase of implementation in two pilot cities in British Columbia, Canada. A case study was implemented using interviews and questionnaires to obtain feedback about SCOPE from two groups: SCOPE coordinators and stakeholders (i.e., individuals and organizations that were a member of the community and engaged with SCOPE coordinators). Participants were recruited via email and (or) by telephone. Coordinators completed a telephone interview. Stakeholders completed a questionnaire and (or) a telephone interview. Thematic analysis was conducted. Participants included 2 coordinators and 15 stakeholders. Participants similarly interpreted SCOPE as a program focused on raising awareness about childhood obesity prevention, while engaging multiple community sectors. Overall, participants valued the program's role in facilitating networking and partnership development, providing evidence-based resources, technical expertise, and contributing funding. Participants felt that SCOPE is sustainable. However, participants felt that barriers to achieving healthy weights among children included those related to the built environment, and social, behavioral, and economic obstacles. Perspectives on factors that facilitated and acted as barriers to SCOPE's first phase of implementation were obtained from the SCOPE communities and may be used to enhance the sustainability of SCOPE and its applicability to other BC communities.

Oncology nurses' experience of collaboration: A case study

PURPOSE

Changes in the health system have created new models of healthcare delivery such as nurse-led teams. This has resulted in the increased opportunity for enhanced collaboration among nurses. Oncology nurses have a long history of working together, yet little is known about their perceptions about collaboration in the practice setting. This paper aimed to explore and describe the experiences of collaboration among oncology nurses, and to understand the factors that influenced collaboration.

METHOD

Qualitative, case study design was used to study fourteen oncology nurses from one cancer center in Canada. Participants were registered nurses or nurse practitioners, employed full-time or permanent part-time in an oncology nurse role, and working on an in-patient or out-patient unit. Data were collected in 2013 using individual telephone interviews and document reviews.

RESULTS

Thematic analysis revealed two themes: Art of dancing together, and the stumbling point. The first theme related to the facilitators of collaboration including having: regular face-to-face interaction, an existing and/or previous relationship, oncology nursing experience, and good interpersonal skills. The second theme related to the barriers to collaboration such as: role ambiguity, organizational leadership, and multi-generational differences.

CONCLUSIONS

Collaboration is a complex process that does not occur spontaneously. To improve collaboration nursing leadership needs to support and promote opportunities for nurses to build the relationships required to effectively collaborate. It is equally important that individual nurses be willing to collaborate and possess the interpersonal skills required to build and maintain the collaborative relationship despite differences in age, generation, and clinical experience.

A case study of nurse practitioner role implementation in primary care: what happens when new roles are introduced?

Background

At the time of this study (2009) the role of the nurse practitioner was new to the province of British Columbia. The provincial government gave the responsibility for implementing the role to health authorities. Managers of health authorities, many of whom were unfamiliar with the role, were responsible for identifying the need for the NP role, determining how the NP would function, and gaining team members’ acceptance for the new role.

Method

The purpose of the study was to explain the process of nurse practitioner role implementation as it was occurring and to identify factors that could enhance the implementation process. An explanatory, single case study with embedded units of analysis was used. The technique of explanation building was used in data analysis. Three primary health care settings in one health authority in British Columbia were purposively selected. Data sources included semi-structured interviews with participants (n=16) and key documents.

Results

The results demonstrate the complexity of implementing a new role in settings unfamiliar with it. The findings suggest that early in the implementation process and after the nurse practitioner was hired, team members needed to clarify intentions for the role and they looked to senior health authority managers for assistance. Acceptance of the nurse practitioner was facilitated by team members’ prior knowledge of either the role or the individual nurse practitioner. Community health care providers needed to be involved in the implementation process and their acceptance developed as they gained knowledge and understanding of the role.

Conclusion

The findings suggest that the interconnectedness of the concepts of intention, involvement and acceptance influences the implementation process and how the nurse practitioner is able to function in the setting. Without any one of the three concepts not only is implementation difficult, but it is also challenging for the nurse practitioner to fulfill role expectations. Implications for research, policy, practice and education are discussed.

Conceptual framework of acute care nurse practitioner role enactment, boundary work, and perceptions of team effectiveness

AIM

This article describes a new conceptual framework for acute care nurse practitioner role enactment, boundary work and perceptions of team effectiveness.

BACKGROUND

Acute care nurse practitioners contribute positively to patient care by enacting an expanded scope of practise. Researchers have found both positive and negative reactions to the introduction of acute care nurse practitioners in healthcare teams. The process of role enactment, shifting role boundaries, and perceptions of team effectiveness has been studied disparately. A framework linking team structures and processes to desirable outcomes is needed.

DATA SOURCES

Literature was obtained by searching CINAHL, PsycInfo, MedLine, PubMed, British Nursing Index, Cochrane Library, JSTOR Archive, Web of Science, and Google Scholar from 1985-2010. A descriptive multiple-case study was completed from March 2009-May 2009.

DISCUSSION

A new conceptual framework describing how role enactment and boundary work affect perceptions of team effectiveness was developed by combining theoretical and empirical sources. The framework proposes proximal indicators used by team members to assess their team's performance.

IMPLICATIONS FOR NURSING

The framework identifies the inter-related dimensions and concepts that different stakeholders need to consider when introducing nurse practitioners in healthcare teams. Further study is needed to identify team-level outcomes that reflect the contributions of all providers to quality patient care, and explore the patients' and families' perceptions of team effectiveness following the introduction of acute care nurse practitioners.

CONCLUSION

The new framework can guide decision-making and research related to the structures, processes, and outcomes of nurse practitioner roles in healthcare teams.

Exploring the Role of Informants in Interpretive Case Study Research in IS

Recent information systems research calls for interaction between the researcher and the informants in interpretive case study research. In line with Van de Ven's call for engaged scholarship, we Investigate how to involve the informants in case studies, not only for the collection of facts, but also in the co-construction and interpretation of the case narrative. The paper builds on a longitudinal case study, in which we explored an approach of extensive informant involvement. Using the ladder of analytical abstraction as our analytical tool, we discuss how an extended involvement of informants may enrich the Interpretive process In case study research, and increase the relevance of the findings. We discuss how and under what conditions this form of involvement may take place, and potential challenges of this approach.

Why is it difficult to implement e-health initiatives? A qualitative study

BACKGROUND

The use of information and communication technologies in healthcare is seen as essential for high quality and cost-effective healthcare. However, implementation of e-health initiatives has often been problematic, with many failing to demonstrate predicted benefits. This study aimed to explore and understand the experiences of implementers -- the senior managers and other staff charged with implementing e-health initiatives and their assessment of factors which promote or inhibit the successful implementation, embedding, and integration of e-health initiatives.

METHODS

We used a case study methodology, using semi-structured interviews with implementers for data collection. Case studies were selected to provide a range of healthcare contexts (primary, secondary, community care), e-health initiatives, and degrees of normalization. The initiatives studied were Picture Archiving and Communication System (PACS) in secondary care, a Community Nurse Information System (CNIS) in community care, and Choose and Book (C&B) across the primary-secondary care interface. Implementers were selected to provide a range of seniority, including chief executive officers, middle managers, and staff with 'on the ground' experience. Interview data were analyzed using a framework derived from Normalization Process Theory (NPT).

RESULTS

Twenty-three interviews were completed across the three case studies. There were wide differences in experiences of implementation and embedding across these case studies; these differences were well explained by collective action components of NPT. New technology was most likely to 'normalize' where implementers perceived that it had a positive impact on interactions between professionals and patients and between different professional groups, and fit well with the organisational goals and skill sets of existing staff. However, where implementers perceived problems in one or more of these areas, they also perceived a lower level of normalization.

CONCLUSIONS

Implementers had rich understandings of barriers and facilitators to successful implementation of e-health initiatives, and their views should continue to be sought in future research. NPT can be used to explain observed variations in implementation processes, and may be useful in drawing planners' attention to potential problems with a view to addressing them during implementation planning.

“It’s a Feel. That’s What a Lot of Our Evidence Would Consist of ”: Public Health Practitioners’ Perspectives on Evidence

This article describes how evidence is defined and used in two British Columbia public health departments during the implementation of a Healthy Living initiative in 2009. Through interviews with 21 public health staff and decision makers, the author sought to investigate how “evidence” was defined by both frontline and management staff and how it was used in decision making. The authors found public health staff, particularly frontline practitioners, to be drawn to grassroots and local “lived experience” evidence. This tacit wisdom, in combination with evidence from academia and clinical evidence accessed through disciplinary or professional networks, offered a knowledge transition opportunity to inform decision making, rather than what can be characterized in the literature as unidirectional knowledge translation. It is often difficult for staff to digest and interpret research as part of their work day because of the volume and density of information that typically counts as evidence. Moreover, there exist challenges to identify and gather indicators as evidence of their work.

Toward a Theory of Change Readiness

This research article describes and constructs a model of performance readiness. The goal of this article is to illustrate how one might meet the challenges of change effectively. The author explores the factors and principles driving the positive transformational change of a high-performing soccer team. Framed by theories of cognitive appraisal, stress, and coping, the study reveals critical variables to the change readiness process to be appraisal, focus, and perceived control. By inquiring deeply into individual appraisals of a change, it may be possible to facilitate a focal shift from “resistance” to “resolution” and from a desire for “power over” a change to a recognition of one's “power to” change effectively.

Linking data to decision-making: applying qualitative data analysis methods and software to identify mechanisms for using outcomes data

A multiple case study was conducted to examine how staff in child out-of-home care programs used data from an Outcomes Management System (OMS) and other sources to inform decision-making. Data collection consisted of thirty-seven semi-structured interviews with clinicians, managers, and directors from two treatment foster care programs and two residential treatment centers, and individuals involved with developing the OMS; and observations of clinical and quality management meetings. Case study and grounded theory methodology guided analyses. The application of qualitative data analysis software is described. Results show that although staff rarely used data from the OMS, they did rely on other sources of systematically collected information to inform clinical, quality management, and program decisions. Analyses of how staff used these data suggest that improving the utility of OMS will involve encouraging staff to participate in data-based decision-making, and designing and implementing OMS in a manner that reflects how decision-making processes operate.

Different paths to high-quality care: three archetypes of top-performing practice sites

PURPOSE

Primary care practices use different approaches in their quest for high-quality care. Previous work in the Practice Partner Research Network (PPRNet) found that improved outcomes are associated with strategies to prioritize performance, involve staff, redesign elements of the delivery system, make patients active partners in guideline adherence, and use tools embedded in the electronic medical record. The aim of this study was to examine variations in the adoption of improvements among sites achieving the best outcomes.

METHODS

This study used an observational case study design. A practice-level measure of adherence to clinical guidelines was used to identify the highest performing practices in a network of internal and family medicine practices participating in a national demonstration project. We analyzed qualitative and quantitative information derived from project documents, field notes, and evaluation questionnaires to develop and compare case studies.

RESULTS

Nine cases are described. All use many of the same improvement strategies. Differences in the way improvements are organized define 3 distinct archetypes: the Technophiles, the Motivated Team, and the Care Enterprise. There is no single approach that explains the superior performance of high-performing practices, though each has adopted variations of PPRNet's improvement model.

CONCLUSIONS

Practices will vary in their path to high-quality care. The archetypes could prove to be a useful guide to other practices selecting an overall quality improvement approach.

'It's okay, it helps me to breathe': the experience of home ventilation from a child's perspective

There are few studies that focus on children's subjective responses to home ventilation and how this in turn affects their daily lives. This multiple case study explored the experience of home ventilation from the children's perspective. Data were collected from five children through observation and audiotaped interviews. Children expressed their physical and emotional relationship with the ventilator, stating: 'It's okay. It helps me to breathe' - a theme that had a number of distinct dimensions. Other themes included the medicalization of childhood, being a child and hopes for the future. Unlike other study findings to date, the children in this study concluded that the technology was only one small part of their lives. Nurses must ensure that these children have an opportunity to communicate their perspectives, in order to provide care that is clinically effective and child-centered.

Out of the mainstream: low-income, lone mothers' life experiences and perspectives on heart health

Cardiovascular disease remains a health issue in North America, particularly for marginalized citizens. Although lifestyle issues and behavioral risk reduction continue to dominate prevention initiatives, an emerging literature suggests that contextual factors such as poverty and social exclusion also influence health. Using group and personal interviews (N = 38), this research explored the social and economic contexts shaping heart health-related experiences from the perspectives of low-income, lone mothers. The transcripts were analyzed using McKinlay and Marceau's upstream-midstream-downstream framework. The overriding pattern characterizing lone mothers' discussions was that the women felt out of the mainstream of everyday life. They lacked the resources and power to effect change, particularly regarding heart health behaviors that were not perceived to be a priority compared to more pressing survival issues. Results are discussed in terms of concepts from the population health and social determinants literature, concluding with policy implications for enhancing health while living in poverty.

Case study: a bridge across the paradigms

Case study as a teaching and research tool has an extensive history in health and social sciences. Despite its suitability for many of the research questions that face nurses, nurses have not fully embraced case study as a comprehensive approach for research. The vagaries of the real-life clinical setting can confound methodologically purist researchers. Case study provides a milieu in which nurse researchers can respond to these vagaries and move towards a paradigmatic openness. In this paper, we argue that case study offers, as yet, under-explored and under-utilised potential as a bridge across the traditional research paradigms. We argue that case study has broad research application and epistemological, ontological and methodological flexibility. When used as a research approach, case study is both the process and end product of research. It provides a delineated boundary for inquiry, and a structural process within which any methods appropriate to investigating a research area can be applied.

Case studies: a research strategy appropriate for palliative care?

Selecting an appropriate research strategy is key to ensuring that research questions are addressed in a way which has value and is congruent with the overall topic, questions and purpose of the research. This paper will argue that there are situations when a case study strategy is appropriate to use in palliative care research. These include: when complex situations need to be addressed; when context is central to the study; when multiple perspectives need to be recognized; when the design needs to be flexible; when the research needs to be congruent with clinical practice; when there is no strong theory to which to appeal; and when other methodologies could be difficult to conduct. Using case study strategies rigorously and appropriately can contribute to knowledge in a way which is sensitive to the complex, context-dependent and multiprofessional nature of palliative care.

Using the case-study methodology to teach ethics to public health students

This article uses the case-study methodology as a strategy to facilitate examination of ethical principles that underlie developmental risk research carried out among adolescents. Description of the ethical dilemmas that arose during the implementation of a longitudinal randomized controlled trial is presented along with discussion guidelines. As youth were being enrolled and the trial was being conducted, it was noted that a small but significant number had responded "yes" to a question on suicidal ideation. After review by the Institutional Review Boards overseeing the trial, it was decided that confidentiality had to be breached. A revised protocol was implemented explicitly stating that confidentiality would be broken if a youth reported suicidal ideation. The number of youth reporting suicidal ideation after the consent form was amended decreased significantly. Presentation of this research by use of the case study method sensitizes students to issues that arise at the intersection of disease prevention and health promotion intervention research.

Advancing nursing scholarship through the interpretation of imaginative literature: ancestral connectedness and the survival of the sufferer

Imaginative literature has played an important role in nursing practice and education since the time of Florence Nightingale. Used primarily as an exemplar, however, its potential has not been realized fully by nurses. This article addresses the use of imaginative literature in scholarly inquiry. Often considered the aegis of literary critics and philosophers, the formal discipline of literary criticism enables the nurse to identify concepts and to generate theoretic explanations about human phenomena. The relationship between the ancestor and the survival of the sufferer is illustrated using Morrison's literary and cultural paradigm applied to selected novels. Implications for practice are identified.