qualitative analysis for case study

The Ultimate Guide to Qualitative Research - Part 1: The Basics

• Introduction and overview
• What is qualitative research?
• What is qualitative data?
• Examples of qualitative data
• Qualitative vs. quantitative research
• Mixed methods
• Qualitative research preparation
• Theoretical perspective
• Theoretical framework
• Literature reviews

Research question

• Conceptual framework
• Conceptual vs. theoretical framework

Data collection

• Qualitative research methods
• Focus groups
• Observational research

What is a case study?

Applications for case study research, what is a good case study, process of case study design, benefits and limitations of case studies.

• Ethnographical research
• Ethical considerations
• Confidentiality and privacy
• Power dynamics
• Reflexivity

Case studies

Case studies are essential to qualitative research , offering a lens through which researchers can investigate complex phenomena within their real-life contexts. This chapter explores the concept, purpose, applications, examples, and types of case studies and provides guidance on how to conduct case study research effectively.

Whereas quantitative methods look at phenomena at scale, case study research looks at a concept or phenomenon in considerable detail. While analyzing a single case can help understand one perspective regarding the object of research inquiry, analyzing multiple cases can help obtain a more holistic sense of the topic or issue. Let's provide a basic definition of a case study, then explore its characteristics and role in the qualitative research process.

Definition of a case study

A case study in qualitative research is a strategy of inquiry that involves an in-depth investigation of a phenomenon within its real-world context. It provides researchers with the opportunity to acquire an in-depth understanding of intricate details that might not be as apparent or accessible through other methods of research. The specific case or cases being studied can be a single person, group, or organization – demarcating what constitutes a relevant case worth studying depends on the researcher and their research question .

Among qualitative research methods , a case study relies on multiple sources of evidence, such as documents, artifacts, interviews , or observations , to present a complete and nuanced understanding of the phenomenon under investigation. The objective is to illuminate the readers' understanding of the phenomenon beyond its abstract statistical or theoretical explanations.

Characteristics of case studies

Case studies typically possess a number of distinct characteristics that set them apart from other research methods. These characteristics include a focus on holistic description and explanation, flexibility in the design and data collection methods, reliance on multiple sources of evidence, and emphasis on the context in which the phenomenon occurs.

Furthermore, case studies can often involve a longitudinal examination of the case, meaning they study the case over a period of time. These characteristics allow case studies to yield comprehensive, in-depth, and richly contextualized insights about the phenomenon of interest.

The role of case studies in research

Case studies hold a unique position in the broader landscape of research methods aimed at theory development. They are instrumental when the primary research interest is to gain an intensive, detailed understanding of a phenomenon in its real-life context.

In addition, case studies can serve different purposes within research - they can be used for exploratory, descriptive, or explanatory purposes, depending on the research question and objectives. This flexibility and depth make case studies a valuable tool in the toolkit of qualitative researchers.

Remember, a well-conducted case study can offer a rich, insightful contribution to both academic and practical knowledge through theory development or theory verification, thus enhancing our understanding of complex phenomena in their real-world contexts.

What is the purpose of a case study?

Case study research aims for a more comprehensive understanding of phenomena, requiring various research methods to gather information for qualitative analysis . Ultimately, a case study can allow the researcher to gain insight into a particular object of inquiry and develop a theoretical framework relevant to the research inquiry.

Why use case studies in qualitative research?

Using case studies as a research strategy depends mainly on the nature of the research question and the researcher's access to the data.

Conducting case study research provides a level of detail and contextual richness that other research methods might not offer. They are beneficial when there's a need to understand complex social phenomena within their natural contexts.

The explanatory, exploratory, and descriptive roles of case studies

Case studies can take on various roles depending on the research objectives. They can be exploratory when the research aims to discover new phenomena or define new research questions; they are descriptive when the objective is to depict a phenomenon within its context in a detailed manner; and they can be explanatory if the goal is to understand specific relationships within the studied context. Thus, the versatility of case studies allows researchers to approach their topic from different angles, offering multiple ways to uncover and interpret the data .

The impact of case studies on knowledge development

Case studies play a significant role in knowledge development across various disciplines. Analysis of cases provides an avenue for researchers to explore phenomena within their context based on the collected data.

This can result in the production of rich, practical insights that can be instrumental in both theory-building and practice. Case studies allow researchers to delve into the intricacies and complexities of real-life situations, uncovering insights that might otherwise remain hidden.

Types of case studies

In qualitative research , a case study is not a one-size-fits-all approach. Depending on the nature of the research question and the specific objectives of the study, researchers might choose to use different types of case studies. These types differ in their focus, methodology, and the level of detail they provide about the phenomenon under investigation.

Understanding these types is crucial for selecting the most appropriate approach for your research project and effectively achieving your research goals. Let's briefly look at the main types of case studies.

Exploratory case studies

Exploratory case studies are typically conducted to develop a theory or framework around an understudied phenomenon. They can also serve as a precursor to a larger-scale research project. Exploratory case studies are useful when a researcher wants to identify the key issues or questions which can spur more extensive study or be used to develop propositions for further research. These case studies are characterized by flexibility, allowing researchers to explore various aspects of a phenomenon as they emerge, which can also form the foundation for subsequent studies.

Descriptive case studies

Descriptive case studies aim to provide a complete and accurate representation of a phenomenon or event within its context. These case studies are often based on an established theoretical framework, which guides how data is collected and analyzed. The researcher is concerned with describing the phenomenon in detail, as it occurs naturally, without trying to influence or manipulate it.

Explanatory case studies

Explanatory case studies are focused on explanation - they seek to clarify how or why certain phenomena occur. Often used in complex, real-life situations, they can be particularly valuable in clarifying causal relationships among concepts and understanding the interplay between different factors within a specific context.

Intrinsic, instrumental, and collective case studies

These three categories of case studies focus on the nature and purpose of the study. An intrinsic case study is conducted when a researcher has an inherent interest in the case itself. Instrumental case studies are employed when the case is used to provide insight into a particular issue or phenomenon. A collective case study, on the other hand, involves studying multiple cases simultaneously to investigate some general phenomena.

Each type of case study serves a different purpose and has its own strengths and challenges. The selection of the type should be guided by the research question and objectives, as well as the context and constraints of the research.

The flexibility, depth, and contextual richness offered by case studies make this approach an excellent research method for various fields of study. They enable researchers to investigate real-world phenomena within their specific contexts, capturing nuances that other research methods might miss. Across numerous fields, case studies provide valuable insights into complex issues.

Critical information systems research

Case studies provide a detailed understanding of the role and impact of information systems in different contexts. They offer a platform to explore how information systems are designed, implemented, and used and how they interact with various social, economic, and political factors. Case studies in this field often focus on examining the intricate relationship between technology, organizational processes, and user behavior, helping to uncover insights that can inform better system design and implementation.

Health research

Health research is another field where case studies are highly valuable. They offer a way to explore patient experiences, healthcare delivery processes, and the impact of various interventions in a real-world context.

Case studies can provide a deep understanding of a patient's journey, giving insights into the intricacies of disease progression, treatment effects, and the psychosocial aspects of health and illness.

Asthma research studies

Specifically within medical research, studies on asthma often employ case studies to explore the individual and environmental factors that influence asthma development, management, and outcomes. A case study can provide rich, detailed data about individual patients' experiences, from the triggers and symptoms they experience to the effectiveness of various management strategies. This can be crucial for developing patient-centered asthma care approaches.

Other fields

Apart from the fields mentioned, case studies are also extensively used in business and management research, education research, and political sciences, among many others. They provide an opportunity to delve into the intricacies of real-world situations, allowing for a comprehensive understanding of various phenomena.

Case studies, with their depth and contextual focus, offer unique insights across these varied fields. They allow researchers to illuminate the complexities of real-life situations, contributing to both theory and practice.

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Understanding the key elements of case study design is crucial for conducting rigorous and impactful case study research. A well-structured design guides the researcher through the process, ensuring that the study is methodologically sound and its findings are reliable and valid. The main elements of case study design include the research question , propositions, units of analysis, and the logic linking the data to the propositions.

The research question is the foundation of any research study. A good research question guides the direction of the study and informs the selection of the case, the methods of collecting data, and the analysis techniques. A well-formulated research question in case study research is typically clear, focused, and complex enough to merit further detailed examination of the relevant case(s).

Propositions

Propositions, though not necessary in every case study, provide a direction by stating what we might expect to find in the data collected. They guide how data is collected and analyzed by helping researchers focus on specific aspects of the case. They are particularly important in explanatory case studies, which seek to understand the relationships among concepts within the studied phenomenon.

Units of analysis

The unit of analysis refers to the case, or the main entity or entities that are being analyzed in the study. In case study research, the unit of analysis can be an individual, a group, an organization, a decision, an event, or even a time period. It's crucial to clearly define the unit of analysis, as it shapes the qualitative data analysis process by allowing the researcher to analyze a particular case and synthesize analysis across multiple case studies to draw conclusions.

Argumentation

This refers to the inferential model that allows researchers to draw conclusions from the data. The researcher needs to ensure that there is a clear link between the data, the propositions (if any), and the conclusions drawn. This argumentation is what enables the researcher to make valid and credible inferences about the phenomenon under study.

Understanding and carefully considering these elements in the design phase of a case study can significantly enhance the quality of the research. It can help ensure that the study is methodologically sound and its findings contribute meaningful insights about the case.

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Conducting a case study involves several steps, from defining the research question and selecting the case to collecting and analyzing data . This section outlines these key stages, providing a practical guide on how to conduct case study research.

Defining the research question

The first step in case study research is defining a clear, focused research question. This question should guide the entire research process, from case selection to analysis. It's crucial to ensure that the research question is suitable for a case study approach. Typically, such questions are exploratory or descriptive in nature and focus on understanding a phenomenon within its real-life context.

Selecting and defining the case

The selection of the case should be based on the research question and the objectives of the study. It involves choosing a unique example or a set of examples that provide rich, in-depth data about the phenomenon under investigation. After selecting the case, it's crucial to define it clearly, setting the boundaries of the case, including the time period and the specific context.

Previous research can help guide the case study design. When considering a case study, an example of a case could be taken from previous case study research and used to define cases in a new research inquiry. Considering recently published examples can help understand how to select and define cases effectively.

Developing a detailed case study protocol

A case study protocol outlines the procedures and general rules to be followed during the case study. This includes the data collection methods to be used, the sources of data, and the procedures for analysis. Having a detailed case study protocol ensures consistency and reliability in the study.

The protocol should also consider how to work with the people involved in the research context to grant the research team access to collecting data. As mentioned in previous sections of this guide, establishing rapport is an essential component of qualitative research as it shapes the overall potential for collecting and analyzing data.

Collecting data

Gathering data in case study research often involves multiple sources of evidence, including documents, archival records, interviews, observations, and physical artifacts. This allows for a comprehensive understanding of the case. The process for gathering data should be systematic and carefully documented to ensure the reliability and validity of the study.

Analyzing and interpreting data

The next step is analyzing the data. This involves organizing the data , categorizing it into themes or patterns , and interpreting these patterns to answer the research question. The analysis might also involve comparing the findings with prior research or theoretical propositions.

Writing the case study report

The final step is writing the case study report . This should provide a detailed description of the case, the data, the analysis process, and the findings. The report should be clear, organized, and carefully written to ensure that the reader can understand the case and the conclusions drawn from it.

Each of these steps is crucial in ensuring that the case study research is rigorous, reliable, and provides valuable insights about the case.

The type, depth, and quality of data in your study can significantly influence the validity and utility of the study. In case study research, data is usually collected from multiple sources to provide a comprehensive and nuanced understanding of the case. This section will outline the various methods of collecting data used in case study research and discuss considerations for ensuring the quality of the data.

Interviews are a common method of gathering data in case study research. They can provide rich, in-depth data about the perspectives, experiences, and interpretations of the individuals involved in the case. Interviews can be structured , semi-structured , or unstructured , depending on the research question and the degree of flexibility needed.

Observations

Observations involve the researcher observing the case in its natural setting, providing first-hand information about the case and its context. Observations can provide data that might not be revealed in interviews or documents, such as non-verbal cues or contextual information.

Documents and artifacts

Documents and archival records provide a valuable source of data in case study research. They can include reports, letters, memos, meeting minutes, email correspondence, and various public and private documents related to the case.

These records can provide historical context, corroborate evidence from other sources, and offer insights into the case that might not be apparent from interviews or observations.

Physical artifacts refer to any physical evidence related to the case, such as tools, products, or physical environments. These artifacts can provide tangible insights into the case, complementing the data gathered from other sources.

Ensuring the quality of data collection

Determining the quality of data in case study research requires careful planning and execution. It's crucial to ensure that the data is reliable, accurate, and relevant to the research question. This involves selecting appropriate methods of collecting data, properly training interviewers or observers, and systematically recording and storing the data. It also includes considering ethical issues related to collecting and handling data, such as obtaining informed consent and ensuring the privacy and confidentiality of the participants.

Data analysis

Analyzing case study research involves making sense of the rich, detailed data to answer the research question. This process can be challenging due to the volume and complexity of case study data. However, a systematic and rigorous approach to analysis can ensure that the findings are credible and meaningful. This section outlines the main steps and considerations in analyzing data in case study research.

Organizing the data

The first step in the analysis is organizing the data. This involves sorting the data into manageable sections, often according to the data source or the theme. This step can also involve transcribing interviews, digitizing physical artifacts, or organizing observational data.

Categorizing and coding the data

Once the data is organized, the next step is to categorize or code the data. This involves identifying common themes, patterns, or concepts in the data and assigning codes to relevant data segments. Coding can be done manually or with the help of software tools, and in either case, qualitative analysis software can greatly facilitate the entire coding process. Coding helps to reduce the data to a set of themes or categories that can be more easily analyzed.

Identifying patterns and themes

After coding the data, the researcher looks for patterns or themes in the coded data. This involves comparing and contrasting the codes and looking for relationships or patterns among them. The identified patterns and themes should help answer the research question.

Interpreting the data

Once patterns and themes have been identified, the next step is to interpret these findings. This involves explaining what the patterns or themes mean in the context of the research question and the case. This interpretation should be grounded in the data, but it can also involve drawing on theoretical concepts or prior research.

Verification of the data

The last step in the analysis is verification. This involves checking the accuracy and consistency of the analysis process and confirming that the findings are supported by the data. This can involve re-checking the original data, checking the consistency of codes, or seeking feedback from research participants or peers.

Like any research method , case study research has its strengths and limitations. Researchers must be aware of these, as they can influence the design, conduct, and interpretation of the study.

Understanding the strengths and limitations of case study research can also guide researchers in deciding whether this approach is suitable for their research question . This section outlines some of the key strengths and limitations of case study research.

Benefits include the following:

• Rich, detailed data: One of the main strengths of case study research is that it can generate rich, detailed data about the case. This can provide a deep understanding of the case and its context, which can be valuable in exploring complex phenomena.
• Flexibility: Case study research is flexible in terms of design , data collection , and analysis . A sufficient degree of flexibility allows the researcher to adapt the study according to the case and the emerging findings.
• Real-world context: Case study research involves studying the case in its real-world context, which can provide valuable insights into the interplay between the case and its context.
• Multiple sources of evidence: Case study research often involves collecting data from multiple sources , which can enhance the robustness and validity of the findings.

On the other hand, researchers should consider the following limitations:

• Generalizability: A common criticism of case study research is that its findings might not be generalizable to other cases due to the specificity and uniqueness of each case.
• Time and resource intensive: Case study research can be time and resource intensive due to the depth of the investigation and the amount of collected data.
• Complexity of analysis: The rich, detailed data generated in case study research can make analyzing the data challenging.
• Subjectivity: Given the nature of case study research, there may be a higher degree of subjectivity in interpreting the data , so researchers need to reflect on this and transparently convey to audiences how the research was conducted.

Being aware of these strengths and limitations can help researchers design and conduct case study research effectively and interpret and report the findings appropriately.

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22 Case Study Research: In-Depth Understanding in Context

Helen Simons, School of Education, University of Southampton

• Published: 01 July 2014
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This chapter explores case study as a major approach to research and evaluation. After first noting various contexts in which case studies are commonly used, the chapter focuses on case study research directly Strengths and potential problematic issues are outlined and then key phases of the process. The chapter emphasizes how important it is to design the case, to collect and interpret data in ways that highlight the qualitative, to have an ethical practice that values multiple perspectives and political interests, and to report creatively to facilitate use in policy making and practice. Finally, it explores how to generalize from the single case. Concluding questions center on the need to think more imaginatively about design and the range of methods and forms of reporting requiredto persuade audiences to value qualitative ways of knowing in case study research.

Introduction

This chapter explores case study as a major approach to research and evaluation using primarily qualitative methods, as well as documentary sources, contemporaneous or historical. However, this is not the only way in which case study can be conceived. No one has a monopoly on the term. While sharing a focus on the singular in a particular context, case study has a wide variety of uses, not all associated with research. A case study, in common parlance, documents a particular situation or event in detail in a specific sociopolitical context. The particular can be a person, a classroom, an institution, a program, or a policy. Below I identify different ways in which case study is used before focusing on qualitative case study research in particular. However, first I wish to indicate how I came to advocate and practice this form of research. Origins, context, and opportunity often shape the research processes we endorse. It is helpful for the reader, I think, to know how I came to the perspective I hold.

The Beginnings

I first came to appreciate and enjoy the virtues of case study research when I entered the field of curriculum evaluation and research in the 1970s. The dominant research paradigm for educational research at that time was experimental or quasi- experimental, cost-benefit, or systems analysis, and the dominant curriculum model was aims and objectives ( House, 1993 ). The field was dominated, in effect, by a psychometric view of research in which quantitative methods were preeminent. But the innovative projects we were asked to evaluate (predominantly, but not exclusively, in the humanities) were not amenable to such methodologies. The projects were challenging to the status quo of institutions, involved people interpreting the policy and programs, were implemented differently in different contexts and regions, and had many unexpected effects.

We had no choice but to seek other ways to evaluate these complex programs, and case study was the methodology we found ourselves exploring, in order to understand how the projects were being implemented, why they had positive effects in some regions of the country and not others, and what the outcomes meant in different sociopolitical and cultural contexts. What better way to do this than to talk with people to see how they interpreted the “new” curriculum; to watch how teachers and students put it into practice; to document transactions, outcomes, and unexpected consequences; and to interpret all in the specific context of the case ( Simons, 1971 , 1987 , pp. 55–89). From this point on and in further studies, case study in educational research and evaluation came to be a major methodology for understanding complex educational and social programs. It also extended to other practice professions, such as nursing, health, and social care ( Zucker, 2001 ; Greenhalgh & Worrall, 1997 ; Shaw & Gould, 2001 ). For further details of the evolution of the case study approach and qualitative methodologies in evaluation, see House, 1993 , pp. 2–3; Greene, 2000 ; Simons, 2009 , pp. 14–18; Simons & McCormack, 2007 , pp. 292–311).

This was not exactly the beginning of case study, of course. It has a long history in many disciplines ( Simons, 1980; Ragin, 1992; Gomm, Hammersley, & Foster, 2004 ; Platt, 2007 ), many aspects of which form part of case study practice to this day. But its evolution in the context just described was a major move in the contemporary evolution of the logic of evaluative inquiry ( House, 1980 ). It also coincided with movement toward the qualitative in other disciplines, such as sociology and psychology. This was all part of what Denzin & Lincoln (1994) termed “a quiet methodological revolution” (p. ix) in qualitative inquiry that had been evolving over the course of forty years.

There is a further reason why I continue to advocate and practice case study research and evaluation to this day and that is my personal predilection for trying to understand and represent complexity, for puzzling through the ambiguities that exist in many contexts and programs and for presenting and negotiating different values and interests in fair and just ways.

Put more simply, I like interacting with people, listening to their stories, trials and tribulations—giving them a voice in understanding the contexts and projects with which they are involved, and finding ways to share these with a range of audiences. In other words, the move toward case study methodology described here suited my preference for how I learn.

Concepts and Purposes of Case Study

Before exploring case study as it has come to be established in educational research and evaluation over the past forty years, I wish to acknowledge other uses of case study. More often than not, these relate to purpose, and appropriately so in their different contexts, but many do not have a research intention. For a study to count as research, it would need to be a systematic investigation generating evidence that leads to “new” knowledge that is made public and open to scrutiny. There are many ways to conduct research stemming from different traditions and disciplines, but they all, in different ways, involve these characteristics.

Everyday Usage: Stories We Tell

The most common of these uses of case study is the everyday reference to a person, an anecdote or story illustrative of a particular incident, event, or experience of that person. It is often a short, reported account commonly seen in journalism but also in books exploring a phenomenon, such as recovery from serious accidents or tragedies, where the author chooses to illustrate the story or argument with a “lived” example. This is sometimes written by the author and sometimes by the person whose tale it is. “Let me share with you a story,” is a phrase frequently heard

The spirit behind this common usage and its power to connect can be seen in a report by Tim Adams of the London Olympics opening ceremony’s dramatization by Danny Boyle.

It was the point when we suddenly collectively wised up to the idea that what we are about to receive over the next two weeks was not only about “legacy collateral” and “targeted deliverables,” not about G4S failings and traffic lanes and branding opportunities, but about the second-by-second possibilities of human endeavour and spirit and communality, enacted in multiple places and all at the same time. Stories in other words. ( Adams, 2012 )

This was a collective story, of course, not an individual one, but it does convey some of the major characteristics of case study—that richness of detail, time, place, multiple happenings and experiences—that are also manifest in case study research, although carefully evidenced in the latter instance. We can see from this common usage how people have come to associate case study with story. I return to this thread in the reporting section.

Professions Individual Cases

In professional settings, in health and social care, case studies, often called case histories , are used to accurately record a person’s health or social care history and his or her current symptoms, experience, and treatment. These case histories include facts but also judgments and observations about the person’s reaction to situations or medication. Usually these are confidential. Not dissimilar is the detailed documentation of a case in law, often termed a case precedent when referred to in a court case to support an argument being made. However in law there is a difference in that such case precedents are publicly documented.

Case Studies in Teaching

Exemplars of practice.

In education, but also in health and social care training contexts, case studies have long been used as exemplars of practice. These are brief descriptions with some detail of a person or project’s experience in an area of practice. Though frequently reported accounts, they are based on a person’s experience and sometimes on previous research.

Case scenarios

Management studies are a further context in which case studies are often used. Here, the case is more like a scenario outlining a particular problem situation for the management student to resolve. These scenarios may be based on research but frequently are hypothetical situations used to raise issues for discussion and resolution. What distinguishes these case scenarios and the case exemplars in education from case study research is the intention to use them for teaching purposes.

Country Case Studies

Then there are case studies of programs, projects, and even countries, as in international development, where a whole-country study might be termed a case study or, in the context of the Organization for Economic Co-operation and Development (OECD), where an exploration is conducted of the state of the art of a subject, such as education or environmental science in one or several countries. This may be a contemporaneous study and/or what transpired in a program over a period of time. Such studies often do have a research base but frequently are reported accounts that do not detail the design, methodology, and analysis of the case, as a research case study would do, or report in ways that give readers a vicarious experience of what it was like to be there. Such case studies tend to be more knowledge and information-focused than experiential.

Case Study as History

Closer to a research context is case study as history—what transpired at a certain time in a certain place. This is likely to be supported by documentary evidence but not primary data gathering unless it is an oral history. In education, in the late 1970s, Stenhouse (1978) experimented with a case study archive. Using contemporaneous data gathering, primarily through interviewing, he envisaged this database, which he termed a “case record,” forming an archive from which different individuals,, at some later date, could write a “case study.” This approach uses case study as a documentary source to begin to generate a history of education, as the subtitle of Stenhouse’s 1978 paper indicates “Towards a contemporary history of education.”

Case Study Research

From here on, my focus is on case study research per se, adopting for this purpose the following definition:

Case study is an in-depth exploration from multiple perspectives of the complexity and uniqueness of a particular project, policy, institution or system in a “real-life” context. It is research based, inclusive of different methods and is evidence-led. ( Simons, 2009 , p. 21).

For further related definitions of case study, see Stake (1995) , Merriam (1998), and Chadderton & Torrance (2011) . And for definitions from a slightly different perspective, see Yin (2004) and Thomas (2011a) .

Not Defined by Method or Perspective

The inclusion of different methods in the definition quoted above definition signals that case study research is not defined by methodology or method. What defines case study is its singularity and the concept and boundary of the case. It is theoretically possible to conduct a case study using primarily quantitative data if this is the best way of providing evidence to inform the issues the case is exploring. It is equally possible to conduct case study that is mainly qualitative, to engage people with the experience of the case or to provide a rich portrayal of an event, project, or program.

Or one can design the case using mixed methods. This increases the options for learning from different ways of knowing and is sometimes preferred by stakeholders who believe it provides a firmer basis for informing policy. This is not necessarily the case but is beyond the scope of this chapter to explore. For further discussion of the complexities of mixing methods and the virtue of using qualitative methods and case study in a mixed method design, see Greene (2007) .

Case study research may also be conducted from different standpoints—realist, interpretivist, or constructivist, for example. My perspective falls within a constructivist, interpretivist framework. What interests me is how I and those in the case perceive and interpret what we find and how we construct or co-construct understandings of the case. This not only suits my predilection for how I see the world, but also my preferred phenomenological approach to interviewing and curiosity about people and how they act in social and professional life.

Qualitative Case Study Research

Qualitative case study research shares many characteristics with other forms of qualitative research, such as narrative, oral history, life history, ethnography, in-depth interview, and observational studies that utilize qualitative methods. However, its focus, purpose, and origins, in educational research at least, are a little different.

The focus is clearly the study of the singular. The purpose is to portray an in-depth view of the quality and complexity of social/educational programs or policies as they are implemented in specific sociopolitical contexts. What makes it qualitative is its emphasis on subjective ways of knowing, particularly the experiential, practical, and presentational rather than the propositional ( Heron, 1992 , 1999 ) to comprehend and communicate what transpired in the case.

Characteristic Features and Advantages

Case study research is not method dependent, as noted earlier, nor is it constrained by resources or time. Although it can be conducted over several years, which provides an opportunity to explore the process of change and explain how and why things happened, it can equally be carried out contemporaneously in a few days, weeks, or months. This flexibility is extremely useful in many contexts, particularly when a change in policy or unforeseen issues in the field require modifying the design.

Flexibility extends to reporting. The case can be written up in different lengths and forms to meet different audience needs and to maximize use (see the section on Reporting). Using the natural language of participants and familiar methods (like interview, observation, oral history) also enables participants to engage in the research process, thereby contributing significantly to the generation of knowledge of the case. As I have indicated elsewhere ( Simons, 2009 ), “This is both a political and epistemological point. It signals a potential shift in the power base of who controls knowledge and recognizes the importance of co-constructing perceived reality through the relationships and joint understandings we create in the field” (p. 23).

Possible Disadvantages

If one is an advocate, identifying advantages of a research approach is easier than pointing out its disadvantages, something detractors are quite keen to do anyway! But no approach is perfect, and here are some of the issues that often trouble people about case study research. The “sample of one” is an obvious issue that worries those convinced that only large samples can constitute valid research and especially if this is to inform policy. Understanding complexity in depth may not be a sufficient counterargument, and I suspect there is little point in trying to persuade otherwise For frequently, this perception is one of epistemological and methodological, if not ideological, preference.

However, there are some genuine concerns that many case researchers face: the difficulty of processing a mass of data; of “telling the truth” in contexts where people may be identifiable; personal involvement, when the researcher is the main instrument of data gathering; and writing reports that are data-based, yet readable in style and length. But one issue that concerns advocates and nonadvocates alike is how inferences are drawn from the single case.

Answers to some of these issues are covered in the sections that follow. Whether they convince may again be a question of preference. However, it is worth noting here that I do not think we should seek to justify these concerns in terms identified by other methodologies. Many of them are intrinsic to the nature and strength of qualitative case study research.

Subjectivity, for instance, both of participants and researcher is inevitable, as it is in many other qualitative methodologies. This is often the basis on which we act. Rather than see this as bias or something to counter, it is an intelligence that is essential to understanding and interpreting the experience of participants and stakeholders. Such subjectivity needs to be disciplined, of course, through procedures that examine both the validity of individuals’ representations of “their truth”, and demonstrate how the researcher took a reflexive approach to monitoring how his or her own values and predilections may have unduly influenced the data.

Types of Case Study

There are numerous types of case study, too many to categorize, I think, as there are overlaps between them. However, attempts have been made to do this and, for those who value typologies, I refer them to Bassey (1999) and, for a more extended typology, to Thomas (2011b) . A slightly different approach is taken by Gomm, Hammersley, and Foster (2004) in annotating the different emphases in major texts on case study. What I prefer to do here is to highlight a few familiar types to focus the discussion that follows on the practice of case study research.

Stake (1995) offers a threefold distinction that is helpful when it comes to practice, he says, because it influences the methods we choose to gather data (p. 4). He distinguishes between an intrinsic case study , one that is studied to learn about the particular case itself and an instrumental case study , in which we choose a case to gain insight into a particular issue (i.e., the case is instrumental to understanding something else; p. 3). The collective case study is what its name suggests: an extension of the instrumental to several cases.

Theory-led or theory-generated case study is similarly self-explanatory, the first starting from a specific theory that is tested through the case; the second constructing a theory through interpretation of data generated in the case. In other words, one ends rather than begins with a theory. In qualitative case study research, this is the more familiar route. The theory of the case becomes the argument or story you will tell.

Evaluation case study requires a slightly longer description as this is my context of practice, one which has influenced the way I conduct case study and what I choose to emphasize in this chapter. An evaluation case study has three essential features: to determine the value of the case, to include and balance different interests and values, and to report findings to a range of stakeholders in ways that they can use. The reasons for this may be found in the interlude that follows, which offers a brief characterization of the social and ethical practice of evaluation and why qualitative methods are so important in this practice.

Interlude: Social and Ethical Practice of Evaluation

Evaluation is a social practice that documents, portrays, and seeks to understand the value of a particular project, program, or policy. This can be determined by different evaluation methodologies, of course. But the value of qualitative case study is that it is possible to discern this value without decontextualizing the data. While the focus of the case is usually a project, program, policy, or some unit within, studies of key individuals, what I term case profiles , may be embedded within the overall case. In some instances, these profiles, or even shorter cameos of individuals, may be quite prominent. For it is through the perceptions, interpretations, and interactions of people that we learn how policies and programs are enacted ( Kushner, 2000 , p. 12). The program is still the main focus of analysis, but, in exploring how individuals play out their different roles in the program, we get closer to the actual experience and meaning of the program in practice.

Case study evaluation is often commissioned from an external source (government department or other agency) keen to know the worth of publicly funded programs and policies to inform future decision making. It needs to be responsive to issues or questions identified by stakeholders, who often have different values and interests in the expected outcomes and appreciate different perspectives of the program in action. The context also is often highly politicized, and interests can conflict. The task of the evaluator in such situations becomes one of including and balancing all interests and values in the program fairly and justly.

This is an inherently political process and requires an ethical practice that offers participants some protection over the personal data they give as part of the research and agreed audiences access to the findings, presented in ways they can understand. Negotiating what information becomes public can be quite difficult in singular settings where people are identifiable and intricate or problematic transactions have been documented. The consequences that ensue from making knowledge public that hitherto was private may be considerable for those in the case. It may also be difficult to portray some of the contextual detail that would enhance understanding for readers.

The ethical stance that underpins the case study research and evaluation I conduct stems from a theory of ethics that emphasizes the centrality of relationships in the specific context and the consequences for individuals, while remaining aware of the research imperative to publicly report. It is essentially an independent democratic process based on the concepts of fairness and justice, in which confidentiality, negotiation, and accessibility are key principles ( MacDonald, 1976 ; Simons, 2009 , pp. 96–111; and Simons 2010 ). The principles are translated into specific procedures to guide the collection, validation, and dissemination of data in the field. These include:

engaging participants and stakeholders in identifying issues to explore and sometimes also in interpreting the data;

documenting how different people interpret and value the program;

negotiating what data becomes public respecting both the individual’s “right to privacy” and the public’s “right to know”;

offering participants opportunities to check how their data are used in the context of reporting;

reporting in language and forms accessible to a wide range of audiences;

disseminating to audiences within and beyond the case.

For further discussion of the ethics of democratic case study evaluation and examples of their use in practice, see Simons (2000 , 2006 , 2009 , chapter 6, 2010 ).

Designing Case Study Research

Design issues in case study sometimes take second place to those of data gathering, the more exciting task perhaps in starting research. However, it is critical to consider the design at the outset, even if changes are required in practice due to the reality of what is encountered in the field. In this sense, the design of case study is emergent, rather than preordinate, shaped and reshaped as understanding of the significance of foreshadowed issues emerges and more are discovered.

Before entering the field, there are a myriad of planning issues to think about related to stakeholders, participants, and audiences. These include whose values matter, whether to engage them in data gathering and interpretation, the style of reporting appropriate for each, and the ethical guidelines that will underpin data collection and reporting. However, here I emphasize only three: the broad focus of the study, what the case is a case of, and framing questions/issues. These are steps often ignored in an enthusiasm to gather data, resulting in a case study that claims to be research but lacks the basic principles required for generation of valid, public knowledge.

Conceptualize the Topic

First, it is important that the topic of the research is conceptualized in a way that it can be researched (i.e., it is not too wide). This seems an obvious point to make, but failure to think through precisely what it is about your research topic you wish to investigate will have a knock-on effect on the framing of the case, data gathering, and interpretation and may lead, in some instances, to not gathering or analyzing data that actually informs the topic. Further conceptualization or reconceptualization may be necessary as the study proceeds, but it is critical to have a clear focus at the outset.

What Constitutes the Case

Second, I think it is important to decide what would constitute the case (i.e., what it is a case of) and where the boundaries of this lie. This often proves more difficult than first appears. And sometimes, partly because of the semifluid nature of the way the case evolves, it is only possible to finally establish what the case is a case of at the end. Nevertheless, it is useful to identify what the case and its boundaries are at the outset to help focus data collection while maintaining an awareness that these may shift. This is emergent design in action.

In deciding the boundary of the case, there are several factors to bear in mind. Is it bounded by an institution or a unit within an institution, by people within an institution, by region, or by project, program or policy,? If we take a school as an example, the case could be comprised of the principal, teachers, and students, or the boundary could be extended to the cleaners, the caretaker, the receptionist, people who often know a great deal about the subnorms and culture of the institution.

If the case is a policy or particular parameter of a policy, the considerations may be slightly different. People will still be paramount—those who generated the policy and those who implemented it—but there is likely also to be a political culture surrounding the policy that had an influence on the way the policy evolved. Would this be part of the case?

Whatever boundary is chosen, this may change in the course of conducting the study when issues arise that can only be understood by going to another level. What transpires in a classroom, for example, if this is the case, is often partly dependent on the support of the school leadership and culture of the institution and this, in turn, to some extent is dependent on what resources are allocated from the local education administration. Much like a series of Russian dolls, one context inside the other.

Unit of analysis

Thinking about what would constitute the unit of analysis— a classroom, an institution, a program, a region—may help in setting the boundaries of the case, and it will certainly help when it comes to analysis. But this is a slightly different issue from deciding what the case is a case of. Taking a health example, the case may be palliative care support, but the unit of analysis the palliative care ward or wards. If you took the palliative care ward as the unit of analysis this would be as much about how palliative care was exercised in this or that ward than issues about palliative care support in general. In other words, you would need to have specific information and context about how this ward was structured and managed to understand how palliative care was conducted in this particular ward. Here, as in the school example above, you would need to consider which of the many people who populate the ward form part of the case—nurses, interns, or doctors only, or does it extend to patients, cleaners, nurse aides, and medical students?

Framing Questions and Issues

The third most important consideration is how to frame the study, and you are likely to do this once you have selected the site or sites for study. There are at least four approaches. You could start with precise questions, foreshadowed issues ( Smith & Pohland, 1974 ), theories, or a program logic. To some extent, your choice will be dictated by the type of case you have chosen, but also by your personal preference for how to conduct it—in either a structured or open way.

Initial questions give structure; foreshadowed issues more freedom to explore. In qualitative case study, foreshadowed issues are more common, allowing scope for issues to change as the study evolves, guided by participants’ perspectives and events in the field. With this perspective, it is more likely that you will generate a theory of the case toward the end, through your interpretation and analysis.

If you are conducting an instrumental case study, staying close to the questions or foreshadowed issues is necessary to be sure you gain data that will illuminate the central focus of the study. This is critical if you are exploring issues across several cases, although it is possible to do a cross-case analysis from cases that have each followed a different route to discovering significant issues.

Opting to start with a theoretical framework provides a basis for formulating questions and issues, but it can also constrain the study to only those questions/issues that fit the framework. The same is true with using program logic to frame the case. This is an approach frequently adopted in evaluation case study where the evaluator, individually or with stakeholders, examines how the aims and objectives of the program relate to the activities designed to promote it and the outcomes and impacts expected. It provides direction, although it can lead to simply confirming what was anticipated, rather than documenting what transpired in the case.

Whichever approach you choose to frame the case, it is useful to think about the rationale or theory for each question and what methods would best enable you to gain an understanding of them. This will not only start a reflexive process of examining your choices—an important aspect of the process of data gathering and interpretation—it will also aid analysis and interpretation further down the track.

Methodology and Methods

Qualitative case study research, as already noted, appeals to subjective ways of knowing and to a primarily qualitative methodology, that captures experiential understanding ( Stake, 2010 , pp. 56–70). It follows that the main methods of data gathering to access this way of knowing will be qualitative. Interviewing, observation, and document analysis are the primary three, often supported by critical incidents, focus groups, cameos, vignettes, diaries/journals, and photographs. Before gathering any primary data, however, it is useful to search relevant existing sources (written or visual) to learn about the antecedents and context of a project, program, or policy as a backdrop to the case. This can sharpen framing questions, avoid unnecessary data gathering, and shorten the time needed in the field.

Given that there are excellent texts on qualitative methods (see, for example, Denzin & Lincoln, 1994 ; Seale, 1999 ; Silverman, 2000 , 2004 ), I will not discuss all potential relevant methods here, but simply focus on the qualities of the primary methods that are particularly appropriate for case study research.

Primary Qualitative Data Gathering Methods

Interviewing.

The most effective style of interviewing in qualitative case study research to gain in-depth data, document multiple perspectives and experiences and explore contested issues is the unstructured interview, active listening and open questioning are paramount, whatever prequestions or foreshadowed issues have been identified. This can include photographs—a useful starting point with certain cultural groups and the less articulate, to encourage them to tell their story through connecting or identifying with something in the image.

The flexibility of unstructured interviewing has three further advantages for understanding participants’ experiences. First, through questioning, probing, listening, and, above all, paying attention to the silences and what they mean, you can get closer to the meaning of participants’ experiences. It is not always what they say.

Second, unstructured interviewing is useful for engaging participants in the process of research. Instead of starting with questions and issues, invite participants to tell their stories or reflect on specific issues, to conduct their own self-evaluative interview, in fact. Not only will they contribute their particular perspective to the case, they will also learn about themselves, thereby making the process of research educative for them as well as for the audiences of the research.

Third, the open-endedness of this style of interviewing has the potential for creating a dialogue between participants and the researcher and between the researcher and the public, if enough of the dialogue is retained in the publication ( Bellah, Madsen, Sullivan, Swidler, & Tipton, 1985 ).

Observations

Observations in case study research are likely to be close-up descriptions of events, activities, and incidents that detail what happens in a particular context. They will record time, place, specific incidents, transactions, and dialogue, and note characteristics of the setting and of people in it without preconceived categories or judgment. No description is devoid of some judgment in selection, of course, but, on the whole, the intent is to describe the scene or event “as it is,” providing a rich, textured description to give readers a sense of what it was like to be there or provide a basis for later interpretation.

Take the following excerpt from a study of the West Bromwich Operatic Society. It is the first night of a new production, The Producers , by this amateur operatic society. This brief excerpt is from a much longer observation of the overture to the first evening’s performance, detailing exactly what the production is, where it is, and why there is such a tremendous sense of atmosphere and expectation surrounding the event. Space prevents including the whole observation, but I hope you can get a glimmer of the passion and excitement that precedes the performance:

Birmingham, late November, 2011, early evening.... Bars and restaurants spruce up for the evening’s trade. There is a chill in the air but the party season is just starting....

A few hundred yards away, past streaming traffic on Suffolk Street, Queensway, an audience is gathering at the New Alexandra Theatre. The foyer windows shine in the orange sodium night. Above each one is the rubric: WORLD CLASS THEATRE.

Inside the preparatory rituals are being observed; sweets chosen, interval drinks ordered and programmes bought. People swap news and titbits about the production.... The bubble of anticipation grows as the 5-minute warning sounds. People make their way to the auditorium. There have been so many nights like this in the past 110 years since a man named William Coutts invested £10,000 to build this palace of dreams.... So many fantasies have been played under this arch: melodramas and pantomimes, musicals and variety.... So many audiences, settling down in their tip-up seats, wanting to be transported away from work, from ordinariness and private troubles.... The dimming lights act like a mother’s hush. You could touch the silence. Boinnng! A spongy thump on a bass drum, and the horns pipe up that catchy, irrepressible, tasteless tune and already you’re singing under your breath, ‘Springtime for Hitler and Germany....’ The orchestra is out of sight in the pit. There’s just the velvet curtain to watch as your fingers tap along. What’s waiting behind? Then it starts it to move. Opening night.... It’s opening night! ( Matarasso, 2012 , pp. 1–2)

For another and different example—a narrative observation of an everyday but unique incident that details date, time, place, and experience—see Simons (2009 , p. 60).

Such naturalistic observations are also useful in contexts where we cannot understand what is going on through interviewing alone—in cultures with which we are less familiar or where key actors may not share our language or have difficulty expressing it. Careful description in these situations can help identify key issues, discover the norms and values that exist in the culture, and, if sufficiently detailed, allow others to cross corroborate what significance we draw from these observations. This last point is very important to avoid the danger in observation of ascribing motivations to people and meanings to transactions.

Finally, naturalistic observations are very important in highly politicized environments, often the case in commissioned evaluation case study, where individuals in interview may try to elude the “truth” or press on you that their view is the “right” view of the situation. In these contexts, naturalistic observations not only enable you to document interactions as you perceive them, but they also provide a cross-check on the veracity of information obtained in interviews.

Document analysis

Analysis of documents, as already intimated, is useful for establishing what historical antecedents might exist to provide a springboard for contemporaneous data gathering. In most cases, existing documents are also extremely pertinent for understanding the policy context.

In a national policy case study I conducted on a major curriculum change, the importance of preexisting documentation was brought home to me sharply when certain documentation initially proved elusive to obtain. It was difficult to believe that it did not exist, as the evolution of the innovation involved several parties who had not worked together before. There was bound, I thought, to be minuted meetings sharing progress and documentation of the “new” curriculum. In the absence of some crucial documents, I began to piece together the story through interviewing. Only there were gaps, and certain issues did not make sense.

It was only when I presented two versions of what I discerned had transpired in the development of this initiative in an interim report eighteen months into the study that things started to change. Subsequent to the meeting at which the report was presented, the “missing” documents started to appear. Suddenly found. What lay behind the “missing documents,” something I suspected from what certain individuals did and did not say in interview, was a major difference of view about how the innovation evolved, who was key in the process, and whose voice was more important in the context. Political differences, in other words, that some stakeholders were trying to keep from me. The emergence of the documents enabled me to finally produce an accurate and fair account.

This is an example of the importance of having access to all relevant documents relating to a program or policy in order to study it fairly. The other major way in which document analysis is useful in case study is for understanding the values, explicit and hidden, in policy and program documents and in the organization where the program or policy is implemented. Not to be ignored as documents are photographs, and these, too, can form the basis of a cultural and value analysis of an organization ( Prosser, 2000 ).

Creative artistic approaches

Increasingly, some case study researchers are employing creative approaches associated with the arts as a means of data gathering and analysis. Artistic approaches have often been used in representing findings, but less frequently in data gathering and interpretation ( Simons & McCormack, 2007 ). A major exception is the work of Richardson (1994) , who sees the very process of writing as an interpretative act, and of Cancienne and Snowber (2003) , who argue for movement as method.

The most familiar of these creative and artistic forms are written—narratives and short stories ( Clandinin & Connelly, 2000 ; Richardson, 1994 ; Sparkes, 2002 ), poems or poetic form ( Butler-Kisber, 2010 ; Duke, 2007 ; Richardson, 1997 ; Sparkes & Douglas, 2007 ), cameos of people, or vignettes of situations. These can be written by participants or by the researcher or developed in partnership. They can also be shared with participants to further interpret the data. But photographs also have a long history in qualitative research for presenting and constructing understanding ( Butler-Kisber, 2010 ; Collier, 1967 ; Prosser, 2000 ; Rugang, 2006 ; Walker, 1993 ).

Less common are other visual forms of gathering data, such as “draw and write” ( Sewell, 2011 ), artefacts, drawings, sketches, paintings, and collages, although all forms are now on the increase. For examples of the use of collage in data gathering, see Duke (2007) and Butler-Kisber (2010) , and for charcoal drawing, Elliott (2008) .

In qualitative inquiry broadly, these creative approaches are now quite common. And in the context of arts and health in particular (see, for example, Frank, 1997 ; Liamputtong & Rumbold, 2008 ; Spouse, 2000 ), we can see how artistic approaches illuminate in-depth understanding. However, in case study research to date, I think narrative forms have tended to be most prominent.

Finally, for capturing the quality and essence of peoples’ experience, nothing could be more revealing than a recording of their voices. Video diaries—self-evaluative portrayals by individuals of their perspectives, feelings, or experience of an event or situation—are a most potent way both of gaining understanding and communicating that to others. It is rather more difficult to gain access for observational videos, but they are useful for documentation and have the potential to engage participants and stakeholders in the interpretation.

Getting It All Together

Case study is so often associated with story or with a report of some event or program that it is easy to forget that much analysis and interpretation has gone on before we reach this point. In many case study reports, this process is hidden, leaving the reader with little evidence on which to assess the validity of the findings and having to trust the one who wrote the tale.

This section briefly outlines possibilities, first, for analyzing and interpreting data, and second, for how to communicate the findings to others. However it is useful to think of these together and indeed, at the start, because decisions about how you report may influence how you choose to make sense of the data. Your choice may also vary according to the context of the study—what is expected or acceptable—and your personal predilections, whether you prefer a more rational than intuitive mode of analysis, for example, or a formal or informal style of writing up that includes images, metaphor, narratives, or poetic forms.

Analyzing and Interpreting Data

When it comes to making sense of data, I make a distinction between analysis—a formal inductive process that seeks to explain—and interpretation, a more intuitive process that gains understanding and insight from a holistic grasp of data, although these may interact and overlap at different stages.

The process, whichever emphasis you choose, is one of reducing or transforming a large amount of data to themes that can encapsulate the overarching meaning in the data. This involves sorting, refining, and refocusing data until they make sense. It starts at the beginning with preliminary hunches, sometimes called “interpretative asides” or “working hypotheses,” later moving to themes, analytic propositions, or a theory of the case.

There are many ways to conduct this process. Two strategies often employed are concept mapping —a means of representing data visually to explore links between related concepts—and progressive focusing ( Parlett & Hamilton, 1976 ), the gradual reframing of initially identified issues into themes that are then further interpreted to generate findings. Each of these strategies tends to have three stages: initial sense making, identification of themes, and examination of patterns and relationships between them.

If taking a formal analytic approach to the task, the data would likely be broken down into segments or datasets (coded and categorized) and then reordered and explored for themes, patterns, and possible propositions. If adopting a more intuitive process, you might focus on identifying insights through metaphors and images, lateral thinking, or puzzling over paradoxes and ambiguities in the data, after first immersing yourself in the total dataset, reading and re-reading interview scripts, observations and field notes to get a sense of the whole. Trying out different forms of making sense through poetry, vignettes, cameos, narratives, collages, and drawing are further creative ways to interpret data, as are photographs taken in the case arranged to explain or tell the story of the case.

Reporting Case Study Research

Narrative structure and story.

As indicated in the introduction, telling a story is often associated with case study and some think this is what a case study is. In one sense, it is and, given that story is the natural way in which we learn ( Okri, 1997 ), it is a useful framework both for gathering data and for communicating case study findings. Not any story will do however. To count as research, it must be authentic, grounded in data, interpreted and analyzed to convey the meaning of the case.

There are several senses in which story is appropriate in qualitative case study: in capturing stories participants tell, in generating a narrative structure that makes sense of the case (i.e., the story you will tell), and in deciding how you communicate this narrative (i.e., in story form). If you choose a written story form (and advice here can be sought from Harrington (2003) and Caulley (2008) ), it needs to be clearly structured, well written, and contain only the detail that is necessary to give readers the vicarious experience of what it was like in the case. If the story is to be communicated in other ways, through, for example, audio or videotape, or computer or personal interaction, the same applies, substituting visual and interpersonal skill for written.

Matching forms of reporting to audience

The art of reporting is strongly connected to usability, so forms of reporting need to connect to the audiences we hope to inform: how they learn, what kind of evidence they value, and what kind of reporting maximizes the chances they will use the findings to promote policies and programs in the interests of beneficiaries. As Okri (1997) further reminds us, the writer only does half the work; the reader does the other (p. 41).

There may be other considerations as well: how open are commissioners to receiving stories of difficulties, as well as success stories? What might they need to hear beyond what is sought in the technical brief? And through what style of reporting would you try and persuade them? If conducting noncommissioned case study research, the scope for different forms of reporting is wider. In academia, for instance, many institutions these days accept creative and artistic forms of reporting when supported by supervisors and appreciated by examiners.

Styles of Reporting

The most obvious form of reporting is linear, often starting with a short executive summary and a brief description of focus and context, followed by methodology, the case study or thematic analysis, findings, and conclusions or implications. Conclusion-led reporting is similar in terms of its formality, but simply starts the other way around. From the conclusions drawn from the analyzed data, it works backward to tell the story through narrative, verbatim, and observational data of how these conclusions were reached. Both have a strong story line. The intent is analytic and explanatory.

Quite a different approach is to engage the reader in the experience and veracity of the case. Rather like constructing a portrait or editing a documentary film, this involves the sifting, constructing, re-ordering of frames, events and episodes to tell a coherent story primarily through interview excerpts, observations, vignettes, and critical incidents that depict what transpired in the case. Interpretation is indirect through the weaving of the data. The story can start at any point provided the underlying narrative structure is maintained to establish coherence ( House, 1980 , p. 116).

Different again, and from the other end of a continuum, is a highly interpretative account that may use similar ways of presenting data but weaves a story from the outset that is highly interpretative. Engaging metaphor, images, short stories, contradictions, paradoxes, and puzzles, it is invariably interesting to read and can be most persuasive. However, the evidence is less visible and therefore less open to alternative interpretations.

Even more persuasive is a case study that uses artistic forms to communicate the story of the case. Paintings, poetic form, drawings, photography, collage, and movement can all be adopted to report findings, whether the data was acquired using these forms or by other means. The arts-based inquiry movement ( Mullen & Finley, 2003 ) has contributed hugely to the validation and legitimation of artistic and creative ways of representing qualitative research findings. The journal Qualitative Inquiry contains many good examples, but see also Liamputtong & Rumbold (2008) . Such artistic forms of representation may not be for everyone or appropriate in some contexts, but they do have the power to engage an audience and the potential to facilitate use.

Generalization in Case Study Research

One of the potential limitations of case study often proposed is that it is impossible to generalize. This is not so. However, the way in which one generalizes from a case is different from that adopted in traditional forms of social science research that utilize large samples (randomly selected) and statistical procedures and which assume regularities in the social world that allow cause and effect to be determined. In this form of research inferences from data are stated as formal propositions that apply to all in the target population. See Donmoyer (1990) for an argument on the restricted nature of this form of generalization when considering single-case studies.

Making inferences from cases with a qualitative data set arises more from a process of interpretation in context, appealing to tacit and situated understanding for acceptance of their validity. Such inferences are possible where the context and experience of the case is richly described so the reader can recognize and connect with the events and experiences portrayed. There are two ways to examine how to reach these generalized understandings. One is to generalize from the case to other cases of a similar or dissimilar nature. The other is to see what we learn in-depth from the uniqueness of the single case itself.

Generalizing from the Single Case

A common approach to generalization and one most akin to a propositional form is cross-case generalization. In a collective or multi-site case study, each case is explored to see if issues that arise in one case also exist in other cases and what interconnecting themes there are between them. This kind of generalization has a degree of abstraction and potential for theorizing and is often welcomed by commissioners of research concerned that findings from the single case do not provide an adequate or “safe” basis for policy determination.

However, there are four additional ways to generalize from the single case, all of which draw more on tacit knowledge and recognition of context, although in different ways. In naturalistic generalization , first proposed by Stake (1978) , generalization is reached on the basis of recognition of similarities and differences to cases with which we are familiar. To enable such recognition, the case needs to feature rich description; people’s voices; and enough detail of time, place, and context to provide a vicarious experience to help readers discern what is similar and dissimilar to their own context ( Stake, 1978 ).

Situated generalization ( Simons, Kushner, Jones, & James, 2003 ) is close to the concept of naturalistic generalization in relying for its generality on retaining a connectedness with the context in which it first evolved. However, it has an extra dimension in a practice context. This notion of generalization was identified in an evaluation of a research project that engaged teachers in and with research. Here, in addition to the usual validity criteria to establish the warrant for the findings, the generalization was seen as dependable if trust existed between those who conducted the research (teachers, in this example) and those thinking about using it (other teachers). In other words, beyond the technical validity of the research, teachers considered using the findings in their own practice because they had confidence in those who generated them. This is a useful way to think about generalization if we wish research findings to improve professional practice.

The next two concepts of generalization— concept and process generalization —relate more to what you discover in making sense of the case. As you interpret and analyze, you begin to generate a theory of the case that makes sense of the whole. Concepts may be identified that make sense in the one case but have equal significance in other cases of a similar kind, even if the contexts are different.

It is the concept that generalizes, not the specific content or context. This may be similar to the process Donmoyer (2008) identifies of “intellectual generalization” (quoted by Butler-Kisber, 2010 , p. 15) to indicate the cognitive understanding one can gain from qualitative accounts even if settings are quite different.

The same is true for generalization of a process. It is possible to identify a significant process in one case (or several cases) that is transferable to other contexts, irrespective of the precise content and contexts of those other cases. An example here is the collaborative model for sustainable school self-evaluation I identified in researching school self-evaluation in a number of schools and countries ( Simons, 2002 ). Schools that successfully sustained school self-evaluation had an infrastructure that was collaborative at all stages of the evaluation process from design to conduct of the study, to analyzing the results and to reporting the findings. This ensured that the whole school was involved and that results were discussed and built into the ongoing development of school policies and practice. In other cases, different processes may be discovered that have applicability in a range of contexts. As with concept generalization, it is the process that generalizes not the substantive content or specific context.

Particularization

The forms of generalization discussed above are useful when we have to justify case study in a research or policy context. But the overarching justification for how we learn from case study is particularization —a rich portrayal of insights and understandings interpreted in the particular context. Several authors have made this point ( Stake, 1995 ; Flyvberg, 2006 ; Simons 2009 ). Stake puts it most sharply when he observes that “The real business of case study is particularization, not generalization” (p. 8), referring here to the main reason for studying the singular, which is to understand the uniqueness of the case itself.

My perspective (explored further in Simons, 1996 ; Simons, 2009 , p. 239; Simons & McCormack, 2007 ) is similar in that I believe the “real” strength of case study lies in the insights we gain from in-depth study of the particular. But I also argue for the universality of such insights—if we get it “right.” By which I mean that if we are able to capture and report the uniqueness, the essence, of the case in all its particularity and present this in a way we can all recognize, we will discover something of universal significance. This is something of a paradox. The more you learn in depth about the particularity of one person, situation, or context, the more likely you are to discover something universal. This process of reaching understanding has support both from the way in which many discoveries are made in science and in how we learn from artists, poets, and novelists, who reach us by communicating a recognizable truth about individuals, human relationships, and/or social contexts.

This concept of particularization is far from new, as the quotation from a preface to a book written in 1908 attests. Stephen Reynolds, the author of A Poor Man’s House , notes that the substance of the book was first recorded in a journal, kept for purposes of fiction, and in letters to one of his friends, but fiction proved an inappropriate medium. He felt that the life and the people were so much better than anything he could invent. The book therefore consists of the journal and letters drawn together to present a picture of a typical poor man’s house and life, much as we might draw together a range of data to present a case study. It is not the substance of the book that concerns us here but the methodological relevance to case study research. Reynolds notes that the conclusions expressed are tentative and possibly go beyond this man’s life, so he thought some explanation of the way he arrived at them was needed:

Educated people usually deal with the poor man’s life deductively; they reason from the general to the particular; and, starting with a theory, religious, philanthropic, political, or what not, they seek, and too easily find, among the millions of poor, specimens—very frequently abnormal—to illustrate their theories. With anything but human beings, that is an excellent method. Human beings, unfortunately, have individualities. They do what, theoretically, they ought not to do, and leave undone those things they ought to do. They are even said to possess souls—untrustworthy things beyond the reach of sociologists. The inductive method—reasoning from the particular to the general... should at least help to counterbalance the psychological superficiality of the deductive method. ( Reynolds, 1908 : preface) 1

Slightly overstated perhaps, but the point is well made. In our search for general laws, we not only lose sight of the uniqueness and humanity of individuals, but reduce them in the process, failing to present their experience in any “real” sense. What is astonishing about the quotation is that it was written over a century ago and yet many still argue today that you cannot generalize from the particular.

Going even further back, in 1798, Blake proclaimed that “To Generalize is to be an Idiot. To Particularize is the Alone Distinction of Merit.” In research, we may not wish to make such a strong distinction: these processes both have their uses in different kinds of research. But there is a major point here for the study of the particular that Wilson (2008) notes in commenting on Blake’s perception when he says: “Favouring the abstract over the concrete, one ‘sees all things only thro’ the narrow chinks of his cavern”’ (referring here to Blake’s The Marriage of Heaven and Hell [1793]; in Wilson, 2008 , p. 62). The danger Wilson is pointing to here is that abstraction relies heavily on what we know from our past understanding of things, and this may prevent us experiencing a concrete event directly or “apprehend[ing] a particular moment” ( Wilson, 2008 , p. 63).

Blake had a different mission, of course, than case researchers, and he was not himself free from abstractions, as Wilson points out, although he fought hard “to break through mental barriers to something unique and living” ( Wilson, 2008 , p. 65). It is this search for the “unique and living” and experiencing the “isness” of the particular that we should take from the Blake example to remind ourselves of the possibility of discovering something “new,” beyond our current understanding of the way things are.

Focusing on particularization does not diminish the usefulness of case study research for policy makers or practitioners. Grounded in recognizable experience, the potential is there to reach a range of audiences and to facilitate use of the findings. It may be more difficult for those who seek formal generalizations that seem to offer a safe basis for policy making to accept case study reports. However, particular stories often hold the key to why policies have or have not worked well in the past. It is not necessary to present long cases—a criticism frequently levelled—to demonstrate the story of the case. Such case stories can be most insightful for policy makers who, like many of us in everyday life, often draw inferences from a single instance or case, whatever the formal evidence presented. “I am reminded of the story of....”

The case for studying the particular to inform practice in professional contexts needs less persuasion because practitioners can recognize the content and context quite readily and make the inference to their own particular context ( Simons et al., 2003 ). In both sets of circumstances—policy and practice—it is more a question of whether the readers of our case research accept the validity of findings determined in this way, how they choose to learn, and our skill in telling the case study story.

Conclusion and Future Directions

In this chapter, I have presented an argument for case study research, making the case, in particular, for using qualitative methods to highlight what it is that qualitative case study research can bring to the study of social and educational programs. I outlined the various ways in which case study is commonly used before focusing directly on case study as a major mode of research inquiry, noting characteristics it shares with other qualitative methodologies, as well as itsdifference and the difficulties it is sometimes perceived to have. The chapter emphasizes the importance of thinking through what the case is, to be sure that the issues explored and the data generated do illuminate this case and not any other.

But there is still more to be done. In particular, I think we need to be more adventurous in how we craft and report the case. I suspect we may have been too cautious in the past in how we justified case study research, borrowing concepts from other disciplines and forms of educational research. More than 40 years on, it is time to take a greater risk—in demonstrating the intrinsic nature of case study and what it can offer to our understanding of human and social situations.

I have already drawn attention to the need to design the case, although this could be developed further to accentuate the uniqueness of the particular case. One way to do this is to feature individuals more in the design itself, not only to explore programs and policies through perspectives of key actors or groups and transactions between them, which to some extent happens already, but also to get them to characterize what makes the context unique. This is the reversal of many a design framework that starts with the logic of a program and takes forward the argument for personal evaluation ( Kushner, 2000 ), noted in the interlude on evaluation. Apart from this attention to design, there are three other issues I think we need to explore further: the warrant for creative methods in case study, more imaginative reporting; and how we learn from a study of the singular.

Warrant for More Creative Methods in Case Study Research

The promise that creative methods have for eliciting in-depth understanding and capturing the unusual, the idiosyncratic, the uniqueness of the case, was mentioned in the methods section. Yet, in case study research, particularly in program and policy contexts, we have few good examples of the use of artistic approaches for eliciting and interpreting data, although more, as acknowledged later, for presenting it. This may be because case study research is often conducted in academic or policy environments, where propositional ways of knowing are more valued.

Using creative and artistic forms in generating and interpreting case study data offers a form of evidence that acknowledges experiential understanding in illuminating the uniqueness of the case. The question is how to establish the warrant for this way of knowing and persuade others of its virtue. The answer is simple. By demonstrating the use of these methods in action, by arguing for a different form of validity that matches the intrinsic nature of the method, and, above all, by good examples.

Representing Findings to Engage Audiences in Learning

In evaluative and research policy contexts, where case study is often the main mode of inquiry or part of a broader study, case study reports often take a formal structure or sometimes, where the context is receptive, a portrayal or interpretative form. But, too often, the qualitative is an add-on to a story told by other means or reduced to issues in which the people who gave rise to the data are no longer seen. However, there are many ways to put them center stage.

Tell good stories and tell them well. Or, let key actors tell their own stories. Explore the different ways technology can help. Make video clips that demonstrate events in context, illustrate interactions between people, give voice to participants—show the reality of the program, in other words. Use graphics to summarize key issues and interactive, cartoon technology, as seen on some TED presentations, to summarize and visually show the complexity of the case. Video diaries were mentioned in the methods section: seeing individuals tell their tales directly is a powerful way of communicating, unhindered by “our” sense making. Tell photo stories. Let the photos convey the narrative, but make sure the structure of the narrative is evident to ensure coherence. These are just the beginnings. Those skilled in information technology could no doubt stretch our imagination further.

One problem and a further question concerns our audiences. Will they accept these modes of communication? Maybe not, in some contexts. However, there are three points I wish to leave you with. First, do not presume that they won’t. If people are fully present in the story and the complexity is not diminished, those reading, watching, or hearing about the case will get the message. If you are worried about how commissioners might respond, remember that they are no different from any other stakeholder or participant when it comes to how they learn from human experience. Witness the reference to Okri (1997) earlier about how we learn.

Second, when you detect that the context requires a more formal presentation of findings, respond according to expectation but also include elements of other forms of presentation. Nudge a little in the direction of creativity. Third, simply take a chance, that risk I spoke about earlier. Challenge the status quo. Find situations and contexts where you can fully represent the qualitative nature of the experience in the cases you study with creative forms of interpretation and representation. And let the audience decide.

Learning from a Study of the Singular

Finally, to return to the issue of “generalization” in case study that worries some audiences. I pointed out in the generalization section several ways in which it is possible to generalize from case study research, not in a formal propositional sense or from a case to a population, but by retaining a connection with the context in which the generalization first arose—that is, to realize in-depth understanding in context in different circumstances and situations. However, I also emphasized that, in many instances, it is particularization from which we learn. That is the point of the singular case study, and it is an art to perceive and craft the case in ways that we can.

Acknowledgments

Parts of this chapter build on ideas first explored in Simons, 2009 .

I am grateful to Bob Williams for pointing out the relevance of this quotation from Reynolds to remind us that “there is nothing new under the sun” and that we sometimes continue to engage endlessly in debates that have been well rehearsed before.

Adams, T. ( 2012 ) ‘ Olympics 2012: Team GB falters but London shines bright on opening day ’, Observer, 29.07.12.

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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 study design: Case Studies

• Qualitative study design
• Phenomenology
• Grounded theory
• Ethnography
• Narrative inquiry
• Action research

Case Studies

• Field research
• Focus groups
• Observation
• Surveys & questionnaires
• Study Designs Home

In depth description of the experience of a single person, a family, a group, a community or an organisation.

An example of a qualitative case study is a life history which is the story of one specific person.  A case study may be done to highlight a specific issue by telling a story of one person or one group. 

• Oral recording

Ability to explore and describe, in depth, an issue or event. 

Develop an understanding of health, illness and health care in context. 

Single case can be used to develop or disprove a theory. 

Can be used as a model or prototype .  

Limitations

Labour intensive and generates large diverse data sets which can be hard to manage. 

Case studies are seen by many as a weak methodology because they only look at one person or one specific group and aren’t as broad in their participant selection as other methodologies. 

Example questions

This methodology can be used to ask questions about a specific drug or treatment and its effects on an individual.

• Does thalidomide cause birth defects?
• Does exposure to a pesticide lead to cancer?

Example studies

• Choi, T. S. T., Walker, K. Z., & Palermo, C. (2018). Diabetes management in a foreign land: A case study on Chinese Australians. Health & Social Care in the Community, 26(2), e225-e232. 
• Reade, I., Rodgers, W., & Spriggs, K. (2008). New Ideas for High Performance Coaches: A Case Study of Knowledge Transfer in Sport Science.  International Journal of Sports Science & Coaching , 3(3), 335-354. 
• Wingrove, K., Barbour, L., & Palermo, C. (2017). Exploring nutrition capacity in Australia's charitable food sector.  Nutrition & Dietetics , 74(5), 495-501. 
• Green, J., & Thorogood, N. (2018). Qualitative methods for health research (4th ed.). London: SAGE. 
• University of Missouri-St. Louis. Qualitative Research Designs. Retrieved from http://www.umsl.edu/~lindquists/qualdsgn.html   
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• Next: Field research >>
• Last Updated: Apr 8, 2024 11:12 AM
• URL: https://deakin.libguides.com/qualitative-study-designs

Research Writing and Analysis

• NVivo Group and Study Sessions
• SPSS This link opens in a new window
• Statistical Analysis Group sessions
• Using Qualtrics
• Dissertation and Data Analysis Group Sessions
• Defense Schedule - Commons Calendar This link opens in a new window
• Research Process Flow Chart
• Research Alignment Chapter 1 This link opens in a new window
• Step 1: Seek Out Evidence
• Step 2: Explain
• Step 3: The Big Picture
• Step 4: Own It
• Step 5: Illustrate
• Annotated Bibliography
• Literature Review This link opens in a new window
• Systematic Reviews & Meta-Analyses
• How to Synthesize and Analyze
• Synthesis and Analysis Practice
• Synthesis and Analysis Group Sessions
• Problem Statement
• Purpose Statement
• Conceptual Framework
• Theoretical Framework
• Quantitative Research Questions
• Qualitative Research Questions
• Trustworthiness of Qualitative Data
• Analysis and Coding Example- Qualitative Data
• Thematic Data Analysis in Qualitative Design
• Dissertation to Journal Article This link opens in a new window
• International Journal of Online Graduate Education (IJOGE) This link opens in a new window
• Journal of Research in Innovative Teaching & Learning (JRIT&L) This link opens in a new window

Writing a Case Study

What is a case study?

A Case study is: 

• An in-depth research design that primarily uses a qualitative methodology but sometimes​​ includes quantitative methodology.
• Used to examine an identifiable problem confirmed through research.
• Used to investigate an individual, group of people, organization, or event.
• Used to mostly answer "how" and "why" questions.

What are the different types of case studies?

Note: These are the primary case studies. As you continue to research and learn

about case studies you will begin to find a robust list of different types. 

Who are your case study participants?

What is triangulation ? 

Validity and credibility are an essential part of the case study. Therefore, the researcher should include triangulation to ensure trustworthiness while accurately reflecting what the researcher seeks to investigate.

How to write a Case Study?

When developing a case study, there are different ways you could present the information, but remember to include the five parts for your case study.

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Open Access

Peer-reviewed

Research Article

Professional regulation in the digital era: A qualitative case study of three professions in Ontario, Canada

Roles Conceptualization, Formal analysis, Funding acquisition, Methodology, Project administration, Supervision, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

Affiliation Faculty of Health Disciplines, Athabasca University, Athabasca, Alberta, Canada

Roles Data curation, Formal analysis, Writing – original draft, Writing – review & editing

Affiliations Faculty of Health Disciplines, Athabasca University, Athabasca, Alberta, Canada, School of Sociological and Anthropological Studies, University of Ottawa, Ottawa, Ontario, Canada

Roles Data curation, Formal analysis, Writing – review & editing

Roles Formal analysis, Writing – original draft, Writing – review & editing

Affiliation Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada

Roles Validation, Writing – review & editing

Affiliation School of Nursing, University of Northern British Columbia, Prince George, British Columbia, Canada

Roles Conceptualization, Visualization, Writing – review & editing

Affiliation Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada

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

Affiliation Department of Sociology, Western University, London, Ontario, Canada

• Kathleen Leslie, 
• Sophia Myles, 
• Abeer A. Alraja, 
• Patrick Chiu, 
• Catharine J. Schiller, 
• Sioban Nelson, 
• Tracey L. Adams

• Published: May 10, 2024
• https://doi.org/10.1371/journal.pone.0303192
• Reader Comments

Technology is transforming service delivery and practice in many regulated professions, altering required skills, scopes of practice, and the organization of professional work. Professional regulators face considerable pressure to facilitate technology-enabled work while adapting to digital changes in their practices and procedures. However, our understanding of how regulators are responding to technology-driven risks and the impact of technology on regulatory policy is limited. To examine the impact of technology and digitalization on regulation, we conducted an exploratory case study of the regulatory bodies for nursing, law, and social work in Ontario, Canada. Data were collected over two phases. First, we collected documents from the regulators’ websites and regulatory consortiums. Second, we conducted key informant interviews with two representatives from each regulator. Data were thematically analyzed to explore the impact of technological change on regulatory activities and policies and to compare how regulatory structure and field shape this impact. Five themes were identified in our analysis: balancing efficiency potential with risks of certain technological advances; the potential for improving regulation through data analytics; considering how to regulate a technologically competent workforce; recalibrating pandemic emergency measures involving technology; and contemplating the future of technology on regulatory policy and practice. Regulators face ongoing challenges with providing equity-based approaches to regulating virtual practice, ensuring practitioners are technologically competent, and leveraging regulatory data to inform decision-making. Policymakers and regulators across Canada and internationally should prioritize risk-balanced policies, guidelines, and practice standards to support professional practice in the digital era.

Citation: Leslie K, Myles S, Alraja AA, Chiu P, Schiller CJ, Nelson S, et al. (2024) Professional regulation in the digital era: A qualitative case study of three professions in Ontario, Canada. PLoS ONE 19(5): e0303192. https://doi.org/10.1371/journal.pone.0303192

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

Received: December 15, 2023; Accepted: April 20, 2024; Published: May 10, 2024

Copyright: © 2024 Leslie 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: The minimum data needed to replicate the study are within the paper and its Supporting information files. However, the raw interview transcripts cannot be made publicly available for ethical reasons because they may contain identifiable or sensitive data. Excerpts from interviews are presented in the paper and additional excerpts can be made available upon reasonable request to the Athabasca University Research Ethics Board (email: [email protected] , phone: 780.213.2033).

Funding: This project was funded by an Insight Development Grant (File # 430-2021-00407) from the Social Sciences and Humanities Research Council of Canada (Principal Investigator KL). The funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Funder URL: https://www.sshrc-crsh.gc.ca/ .

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

Introduction

Technology is rapidly transforming service delivery across regulated professions, altering required skills, scopes of practice, and the organization of professional work [ 1 – 5 ]. Regulatory bodies that govern these professions are under immense pressure to adapt their practices and procedures to facilitate technology-enabled work, while also upholding their mandate to protect the public interest. This urgency has been magnified by the COVID-19 pandemic, which expedited the shift towards virtual practice [ 6 – 8 ] and the scrutiny of professionals’ social media behaviour [ 9 , 10 ]. Regulators must evolve alongside technological advancements to mitigate emerging risks and ensure that new technologies do not negatively impact professional practice or services provided to the public.

Research exploring the impact of digitalization, artificial intelligence (AI), and other technological changes on professional work is emerging [ 11 – 15 ]. This literature has explored the interplay between traditional professional practice and digital innovation [ 16 , 17 ], the organizational changes induced by digital development [ 13 , 15 , 18 , 19 ], and the emerging digital competencies required by professionals [ 20 , 21 ]. Our previous research has also identified challenges that accompany the expansion of virtual practice, including uncertainty about professional standards, breaches of privacy law and other legal requirements, and concerns about equity and professional ethics [ 6 , 22 , 23 ]. Furthermore, while AI technology has the potential to deliver more efficient and data-driven professional services, the associated risks are just beginning to be explored [ 24 , 25 ]. Notably, the burgeoning use of AI raises issues around privacy, equity, and the integrity of professional practice, all of which have implications for professional regulators. Already there are cases where regulators have needed to respond to the inappropriate use of AI in professional practice [ 26 ]. Technology with the potential to profoundly affect professional practice calls for regulatory practices that are responsive to the changing sociotechnical landscape, including the associated risks, inequities, and uncertainties.

Despite emerging research on digitalization’s impact on professional work, our understanding of how regulatory bodies are responding to technology-driven risks and opportunities remains limited. Responses to these challenges have varied, with some regulators imposing a duty of technological competence [ 27 ], while others have refrained from setting formal tech-centric standards. Standards for virtual practice also vary significantly between regulators, even for the same profession [ 6 ]. In addition to how regulators are working to support registrants in the digital era, regulators may be adopting technology to improve their own regulatory practices. To varying extents, professional regulators are digitizing processes related to registration, complaints management, continuing competence, and discipline. However, the way that professional regulators may be using technology to enhance their own work has received little research attention.

This research aims to address these research gaps by examining how regulatory practices and policies are evolving in response to digitalization, and how regulators can support professionals through significant workplace changes while upholding the public interest. Building on our team’s recent work, including a knowledge synthesis of existing academic and grey literature [ 22 , 23 ] and a review of regulatory guidance around virtual care [ 6 ], this study provides foundational insights into the challenges and opportunities of regulating in a digital era. Understanding these challenges and opportunities can inform professional regulators across various sectors and jurisdictions and guide the development of risk-appropriate policies, guidelines, and standards for modern professional regulation.

We aimed to examine the impact of technology and digitalization on three regulatory bodies in Ontario, Canada through a qualitative comparative case study approach. Our specific objectives were to:

• Explore approaches and policies that these regulators have enacted to address the challenges and opportunities presented by the digital era;
• Describe the effects of technological change on regulatory activities at these regulatory bodies; and
• Compare the regulatory responses to technological change across these regulators.

Our study was guided by Yin’s [ 28 ] structured approach to exploratory case study research, which is well suited to understanding new or less studied areas where the researcher has little or no control over the phenomenon of interest. Case study designs in professional regulatory research can produce comprehensive analyses for examining regulatory reforms and innovations [ 29 ]. In this study, we compared how three professional regulators in Ontario, Canada approached regulating in the public interest in the digital era.

Participants

Participating regulators were the Ontario College of Social Workers and Social Service Workers (OCSW), the Law Society of Ontario (LSO), and the College of Nurses of Ontario (CNO). As an exploratory case study, we sought a variety of professional sectors; law, nursing, and social work offered a diversity of regulatory and professional contexts. These three regulators are each under separate legislative frameworks but share the common context of a single jurisdiction of Ontario. Further, the nature of the professional work being regulated is different, and we expected that technology may be impacting these different work contexts in unique ways. In this way, we could distinguish between issues specific to each regulatory body and cross-cutting themes present across the professional, legislative, and workforce factors that vary between them. Our selection of these three regulatory bodies was thus aimed at achieving what Flyvbjerg [ 30 ] called maximum variation in case study research and is appropriate for exploratory work that can be built upon by examining other professions in more jurisdictions in future projects. A brief description of these regulatory bodies is provided in Table 1 .

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https://doi.org/10.1371/journal.pone.0303192.t001

Data collection

We conducted data collection over two phases. The first phase involved gathering publicly available documents relevant to our research objectives and the second phase involved semi-structured interviews. We started with documents to gain a foundational understanding of how technology intersected with regulatory policy and practice for these three professions, and our interviews provided further insight and contextualization to deepen our understanding.

In the first phase, we identified relevant documents by searching regulators’ websites. We conducted our initial searches between May 2022 and September 2022, reviewing documents back to 2015. The date of 2015 was chosen to capture pre-COVID responses while being feasible given our research funding timeline. We also anticipated limited applicability and availability of older regulatory documents given the rapid change of technology in the past decade. The search was updated in January 2023.

We searched each regulator’s website for keywords based on concepts that fit with our research objectives (e.g., digital, tele*, virtual, tech*) and then specific documents were reviewed in full, including minutes from council meetings, regulatory publications for registrants and the public such as newsletters, and strategic plans. We reviewed each retrieved document for references to other regulatory documents, webpages, or resources that were directly relevant to the impact of technology on the regulator’s policies or practices. In this iterative way, we retrieved regulatory updates and news releases; frequently-asked-questions; policies and policy briefs; council briefing reports and minutes; and practice statements, standards, directives, guidance, and guidelines. We identified 34 documents (nine from the CNO, 15 from the LSO, and ten from the OCSW; see S1 File ) that met our inclusion criteria of relating to our research objectives and being published between 2015 and 2022. Document information was organized in a spreadsheet and copies of all included documents were saved as PDFs to keep a record in case websites changed during analysis. These documents allowed us to identify pivotal milestones and policies related to regulatory responses to technology that were used to inform the development of our interview guide. All documents were publicly available.

In the second phase, we emailed the executive director or registrar from each of the three regulators to explain the study and request an interview with individuals familiar with the regulator’s response to technology and relevant policies and practices. Each executive director agreed to an interview and designated two individuals (total n = 6) from their regulatory body to participate and with whom the research team communicated directly by email. Our sampling strategy was purposive and required study participants to have knowledge about the impact of technology on regulatory practice and policy at their organization, appropriate for our case study research design.

We developed a semi-structured interview guide and shared this with our participants prior to the interview (see S2 File ). The semi-structured interview guide was developed collaboratively by the research team based on our previous research in the field, our recent scoping review on a similar topic, and our preliminary analysis of the Phase 1 documents. The first author (KL, she/her) is an early career researcher with experience conducting qualitative interviews in regulatory research who was supported by senior career qualitative researchers (TLA, SN). Interviews were conducted between 1 January 2023 and 31 March 2023 by the first author (KL), and at least one other research team member attended and took detailed notes (TLA, AA, SM). At the beginning of each interview, the first author (KL) provided participants with background information and reiterated the study purpose and objectives. Interviews were conducted by videoconference software (Microsoft Teams) and lasted approximately 60 minutes. Each interview was recorded and transcribed verbatim.

Data analysis

Following data collection, we analyzed all data (documents, interview transcripts, and field notes) using thematic data analysis [ 31 , 32 ]. In this flexible but rigourous approach to data analysis, the researchers play a key role in knowledge production through prolonged engagement with the data [ 32 ]. Three research team members (KL, AA, SM) independently read all documents, transcripts, and field notes to develop a coding framework, using the categories and concepts from the documents and semi-structured interview guide as a basis. Two research team members (KL, PC) with experience in qualitative data analysis and regulatory research then coded all transcripts independently by hand using colour-coded highlighting. KL and PC collaborated throughout regular discussions to develop themes. Extracts from transcripts were brought together for each theme as it was developed, and information from the documents was used to augment and triangulate these findings. As results were developed for each regulator, we compared and contrasted findings across the cases to identify themes and develop rich descriptions. Finally, we returned to the original transcripts and audio recordings to ensure the identified themes and selected quotes accurately reflected the data. We also identified documentary data from Phase 1 that could be included to support the findings and add context, depth, and breadth to the interview data. Findings were regularly reviewed and refined with the research team throughout the analysis.

Trustworthiness

To ensure the credibility of our findings, we used a multifaceted approach. Data collection and analysis were carried out in a systematic way, including extensive engagement with the transcripts and generating a careful audit trail. Using multiple data sources provides enhanced validity with our findings supported by more than one source of evidence [ 28 , 33 ]. We met regularly as a research team to discuss and verify our analysis; we included thick descriptions of our findings and verbatim quotes to support each theme. The diversity of our team, which includes research and clinical backgrounds in professional regulation, political science, nursing, law, and sociology, provided a range of analytical perspectives to aid in interpreting results. We followed the Consolidated Criteria for Reporting Qualitative Research (COREQ) [ 34 ] to guide the transparent reporting of our methods and findings (see S3 File ).

Ethical considerations

The Athabasca University Research Ethics Board approved the study (File #24794). Each regulatory body contacted agreed to participate and informed written consent was obtained from all interview participants. No one withdrew their participation and only participants and research team members were present during the interviews. The study posed minimal risk to participants as they provided information in their professional capacity and no personal information was collected. To protect participant confidentiality, quotes in the findings are attributed to the regulatory bodies and the professions they represent without using names or position titles. As each regulator represents a single case, we have not differentiated between participants representing the same regulator.

While some research team members are members of the profession of participating regulators, they do not have established relationships with interviewees (prior to study commencement or since study completion), and interviewees were aware of the principal investigator’s (KL) background as a registered nurse and lawyer.

We identified five themes in our analysis of the interview and document data: 1) balancing efficiency potential with risks of certain technological advances; 2) the potential for improving regulation through data analytics; 3) considering how to regulate a technologically competent workforce; 4) recalibrating pandemic emergency measures involving technology; and 5) contemplating the future of technology on regulatory policy and practice. Descriptions of these themes, along with illustrative regulatory responses and quotes, are provided in Table 2 . We also review these themes in detail below, providing context from regulatory documents and quotes from interview transcripts. Quotations have been very lightly edited for grammar.

https://doi.org/10.1371/journal.pone.0303192.t002

Theme 1: Balancing efficiency potential with risks of technological advances

Participants recognized that technological advances may enable regulators to work more efficiently; however, they believed the risks associated with new technologies necessitated a cautious approach. This caution meant that many changes were incorporated slowly, and participants emphasized that even seemingly simple changes, such as online registration processes, were being approached carefully. A participant from the LSO noted that “historically, we’ve been very paper-based, so people would fill out paper applications and they would mail those into us” but the pandemic “accelerated changes that were being considered prior to that, and certainly desired prior to that, and so the application process has moved online.” Similarly, a participant from OCSW described their desire to move away from printing out physical certificates for all registrants, noting “we’re hoping we can transition out of it because it’s a very manual, expensive process that we do across the board for everyone.” However, the potential efficiency gain of digital certificates also came with risk, with the participant noting “then technology comes into play, because how do we ensure that it’s not fraudulent? … There’s always the ability to tamper with it” (OCSW).

Participants also discussed the importance of carefully considering the contexts in which technology should be used to facilitate regulatory operations. Participants from all three regulatory bodies discussed opportunities to automate tasks to free up staff and to improve their response times to registrants, especially for low-risk activities. For example, inquiries related to registration renewals are often straightforward and may not require human interaction. Participants from the CNO and OCSW discussed how technology can create opportunities for registrants to better engage with regulatory bodies and increase the accessibility of standards and guidelines at the point of care.

At the same time, all participants emphasized the need to consider the full context of each situation to assess the appropriate use of technology. One commonality between regulators was the recognition that not everything should be digitalized because regulation also involves a relational component. This requirement for human interaction is especially relevant when dealing with registrants and the public in higher-stakes situations (e.g., investigations and discipline processes). A participant from OCSW noted that technological interactions were appropriate for the “benign stuff” such as registration renewals, but that “there is a balance and if a regulator wants to be sort of relevant, they have to ensure that they are meeting that sort of human need.” A participant from the LSO responded similarly:

I think , probably the answer is that where processes that don’t really require a human touch , so for instance , handing an application in–we can eliminate the human touch there and move those types of things increasingly online . But I think maintaining those sorts of areas where having someone to talk to where you’re having an ethical issue , having a CPD program that you can attend that speaks specifically to your practice area and there are other colleagues there as well , those types of things . I think , that’s probably–to my mind at least–where the balance is . You beef up those areas where [human interaction] is important , and you try to gain those efficiencies in areas where perhaps it’s not so important that you do something in person ( LSO )

Participants’ responses highlighted the value regulators place on using a risk-based approach to carefully assess the suitability and feasibility of integrating technology into regulatory processes: “I think increasingly, as we try to move into new areas with technology, that ensuring that we’re approaching things from a risk-based perspective is very important” (LSO).

The potential of technology to improve efficiency was valued by participants who noted the complexity and resource-intensity of regulatory processes were increasing; however, the risk-adverse nature of regulation meant currently these gains have not yet been fully realized as participants focused more on the potential efficiency gains, should risks be appropriately managed.

Theme 2: The potential for improving regulation through data analytics

In addition to potential efficiency gains, participants highlighted where data could be leveraged to guide decision-making and potentially improve regulatory processes and outcomes. Similar to the cautious approach regulators were taking to the incorporation of new technologies more generally, the discussion of data analytics focused primarily on potential, rather than realized, benefits.

Participants from the CNO discussed the development of a new Insights Engine [ 35 ] that focused on data analytics but was in the very early stages of being used. This new system is meant to provide “more real-time data” that would allow the regulator to “specifically tag pieces of information…where they are coming from, from whom, and that informs how we also develop resources for members” (CNO). A CNO participant noted that the regulator had “lots and lots of data inputs” but these were “not accessible in a way that is as meaningful as we would like them to be in order to drive…our projects or the things that we need to improve or change.” The CNO participant described this as important not only to inform decision-making but to “prioritize our projects, where we kind of put our resources and our people, kind of focus our work so I think that will make us more efficient.”

A participant from the OCSW also noted a change in their current data systems that could, in the future, support data analytics for decision-making:

We’re changing over from our current legacy software into a new CRM [customer relationship management system] this year…we are hoping [the new CRM] will be able to mine the data in that way and be able to identify trends . So even when we’re looking at complaints , registrants , investigations or even something simple like [continuing competence program] completion rates . We have a pretty high completion rate , but let’s say we do have a situation where we have lower completion rates , we can look to see if there are certain regions that have individuals that are not participating as much or things like that . Currently , we can’t do that as simply , but in a future state , we’d want to . So , we have the questions we want to ask . ( OCSW )

In addition to regulators’ plans to use data analytics to improve regulation, we also heard that regulators were using existing data to identify practitioners at risk. As a participant from the LSO noted, “I think we always use data that’s available to us to sort of assess risk and try to get ahead of things and understand where problems exist”. For example, existing data have “clearly shown for many years that the sole practitioners are at the highest risk of being the subject of complaints” and “the causes of this are usually skills-related, not knowledge of the law” (LSO). Using this data, the regulator developed a new competence framework to support the implementation of a practice essentials course to support sole practitioners; at the time of our data collection, this was almost ready to be rolled out.

Theme 3: Considering how to regulate a technologically competent workforce

Beyond considering how to incorporate technology to improve regulatory operations, participants also discussed how to support and regulate their registrants in an increasingly digitalized world. Participants from all three regulatory bodies discussed the factors that have influenced their regulatory approaches as technology changes how their registrants practiced. Participants discussed the importance of assessing the most appropriate level of regulation to balance their mandate of protecting the public while ensuring that they do not create barriers in practice. This is sometimes termed right touch or risk-based regulation.

One key consideration was the legislative framework under which regulatory bodies operate and how this impacted regulators’ ability to respond nimbly. A participant from the LSO described their broad bylaw-making power under the Law Society Act and the way it allowed the regulator “quite a bit of flexibility…[to] be fairly nimble when we need to be…basically to allow access to justice to continue when no one could meet in person” during the pandemic. For example, the LSO facilitated emergency Orders in Council to allow virtual execution and witnessing of wills [ 36 ] provided legislative interpretation regarding virtual client identification [ 37 ], and guided registrants about requirements for virtual notarizing and commissioning [ 38 ].

Other factors influencing regulators’ decision-making included their existing strategies for modernizing standards and the influence of collaborative work between regulators. Participants from the CNO highlighted pre-pandemic work that was done in collaboration with other regulators to develop guidelines and competencies for compassion in the digital healthcare age. This work informed their ongoing reforms for technology-enabled practice and virtual care as the regulator worked to modernize practice standards [ 39 ].

Similarly, a participant from the LSO spoke about the influence of the Federation of Law Societies of Canada on discussions around technological competence. In 2019, this Federation added commentary to the duty of competency in its Model Code of Professional Conduct; this commentary required lawyers to have an understanding of and ability to use technology relevant to the nature and area of the lawyer’s practice and responsibility [ 40 ]. The commentary further required that lawyers understand the risks and benefits associated with relevant technology. Different legal regulators across Canada began to adopt this duty of technological competence, and the LSO adopted it in 2022. As one LSO participant described:

In general , we try and stay fairly close to [the model code] , certainly with the basics , because , you know , that’s what a national model code is supposed to do . And in this one , we were actually slow to adopt it because we had a technological taskforce…And then we also had a competence taskforce—the competence taskforce was intended to look at if our competence standards and programs were suitable for the next 20 years…the tech competence requirement was part of that report…So that was the impetus for this particular change to our rules . ( LSO )

An important element of this commentary to the competence rule is that legal professionals must understand technology relevant to their area of practice. One participant from the LSO discussed the importance of this approach given the nuances in different law practice areas. This participant noted that the regulator was not assessing technological competence because “depending on practice area, it’s often not entirely clear how we would assess it anyway” since some areas of legal practice required uses of very specific technologies (e.g., the Ontario Teranet system to transfer title in real estate law) “whereas there are other areas of law where, in theory at least, you could probably still get by with a typewriter and dictaphone” (LSO).

In contrast to the LSO’s specific inclusion of technology in its commentary to the duty of competence, the OCSW and CNO described how their current standards were broad enough to generally cover technological competence. The Council of the OCSW specifically decided not to adopt the model technology guidelines for social work published by the Association of Social Work Boards in 2015 [ 41 ], opting “instead to produce resources to help support members in their practice and to apply those standards to technology or any other issue” (OCSW). One participant from the OCSW described how this decision was made:

I think one of the convincing reasons for that was the current edition of our standards of practice refers to diskettes , which is such a great example of why you don’t want standards of practice to be too specific , because they’ll be out of date before the ink dries , I guess . And so I think that has been the approach that our college has taken—that technology competence and technology really doesn’t warrant its own standalone standard because it applies to other standards such as record keeping boundaries , competence and integrity , and confidentiality . ( OCSW )

Despite differences in approaches to technological competence, participants from all three regulatory bodies spoke about their role in supporting their registrants’ professional practice by developing guidance around technology and virtual practice. In deciding what practice resources were needed, regulators responded based on registrant inquiries and the level of perceived risk. For example, a participant from the LSO discussed how they use inquiries from their practice management helpline to inform their continuing professional development offerings and regulatory resources.

Participants from the OCSW discussed how they encourage registrants to identify learning needs associated with technology when completing their continuing professional development program. Our review of OCSW newsletters showed ongoing encouragement of members to review resources on topics such as using communication technology in practice, selecting online platforms for virtual services, and practice standard considerations for navigating COVID-19 [ 42 – 46 ]. Participants from the OCSW also highlighted measures they took to ensure social workers from other Canadian jurisdictions were registered with OCSW before providing virtual services to clients in Ontario. This enabled the regulator to address issues related to professional conduct since “we can’t minimize the risks involved in electronic practice—they’re huge…so it is probably extra important that those people be registered in Ontario” (OCSW).

In developing practice support and guidance, participants discussed whether they had a role in providing guidance on specific technologies. There were differences in perspectives between regulators. For example, participants from the CNO discussed that it was not within their mandate to endorse or provide guidance on specific technologies:

Questions about which [technology platform] I should be using—we don’t regulate that , right ? We don’t say one thing is better than the other . We don’t endorse certain products . So that also becomes a challenge as well , what do we tell them in order to assess what is appropriate ? It goes back to your accountabilities . Does it meet those standards that you’re obligated to follow in order to assess whether this application or technology is appropriate and is safe for you to use ? ( CNO )

Participants from the LSO spoke about their technology resource centre [ 47 ] that provided guidance on selecting technology for practice, technology use, data protection, cybersecurity, cloud computing, and working remotely. While this was a departure from the level of guidance provided historically, this participant felt it was necessary to guide legal professionals on what was required to meet the standard of professional competence.

We’ve also tried to sort of help people along , in terms of what was created at the Technology Resource Centre…that was sort of a bit of a departure for us , because we got into really looking at specific products and…even suggesting to people that these are products that you can use in certain areas to help facilitate your practice . And traditionally , that hadn’t been our approach . Our approach was much more of satisfy yourself—go out there and see what’s out there kind of approach . So , we’ve tried to help nudge people in the right direction and give them a better idea of what we mean by technological competence . But that has certainly been a challenge . ( LSO )

Thus, while all three regulators operate within the same province, their approach to regulating a technologically competent workforce differed, creating differences in standards and resources provided to registrants regarding technology.

Theme 4: Recalibrating pandemic emergency measures involving technology

In many ways, the COVID-19 pandemic accelerated the use of virtual technologies and impacted various aspects of regulatory operations, including entry-to-practice, registration, continuing competence, and complaints and discipline proceedings. Different perspectives emerged about whether specific regulatory functions should remain virtual or return to pre-pandemic in-person norms. A recurring theme was the need to strike a balance between both modalities.

I think through all of this , whether it’s hearings or discipline or entry to practice , I think there’s increasingly this feeling that… some form of hybrid is probably where the sweet spot is , and I think we need to figure out where that is , and figure out what’s going to stay online , what’s going to stay remote and what should be in-person . And I suspect it’ll take some time to really figure that out . ( LSO )

Since a core function of regulatory bodies is to ensure that applicants meet the required entry-to-practice competencies, regulators found themselves grappling with the consequences of changes to the delivery of education and practicums during the pandemic. Participants from the CNO discussed how the lack of evidence on the outcomes of simulated clinical experiences created challenges for ensuring graduates were prepared competently:

Is there a break point in terms of safety ? And there is research out there [but] none of it is conclusive . There certainly are some jurisdictions that have gone the route of saying , you know , 50% of your clinical can be simulation . We haven’t designated a percentage yet . ( CNO )

Participants from the LSO also experienced challenges as education, placements and articling shifted online. In some cases, applicants were called to the bar after completing their legal education and training remotely. While these changes were necessary due to the pandemic, participants discussed the need to re-assess to determine the best approach going forward.

The pandemic also meant that some regulators shifted to online entry-to-practice exams, but this raised risks related to the security of exams and the appropriateness of the testing environment. The CNO did not adopt remote proctoring and participants noted they “weren’t comfortable at the time with the kind of research that’s out there in terms of security and the whole process around remote proctoring. And we are well aware that there are other regulators—both nursing and outside of nursing—that are doing it. So it’s something we’re exploring” (CNO). The LSO was one of the regulators that adopted remote proctoring and experienced an “exam cheating scandal…where we received information and materials to suggest that there had been cheating involved in some of our licensing examinations…And we’re now no longer doing testing online.” While the OCSW does not currently require an entry-to-practice exam, participants spoke about their interest in exploring how digitalization might impact future exam requirements that were being considered.

In considering the use of technology to increase efficiencies during the licensure process, one participant from the LSO identified the need to attend to equity considerations:

I think the other place where you really see that tension playing out is in the equity space … for , particularly , students who are going through the licensing process . If you are in one of these marginalized groups , you can … face more barriers , you can become more anxious about dealing with what feels like the behemoth , the impersonal behemoth , of the Law Society … So that’s a tension and because efficiency is highly valued … I think , how we are trying to deal with that is to have a personal engagement as needed . The trick is to determine when it’s needed . I don’t think it’s hard to find a sympathetic ear actually at the Law Society , but to know when that intervention is required—that’s , I think , the real challenge . ( LSO )

In addition to changes to entry-to-practice and registration/licensure, regulators’ investigation, discipline, and conduct processes were significantly disrupted by the pandemic as many of these shifted from in-person to virtual formats. This shift to virtual formats provided some advantages that participants described, such as “levelling the playing field” (CNO) for those who lived far from the regulatory body and potentially easing anxiety to facilitate more open conversations.

Participants from the CNO and LSO highlighted the potential negative consequences of virtual hearings such as increased ‘Zoom fatigue’, perceptions of informality, and barriers for individuals who live in areas with unreliable internet access. A participant from the CNO mentioned concerns about whether virtual hearings would have the same level of seriousness as an in-person meeting. These concerns were shared by those at the LSO:

When you walk into a courtroom , and you see that the judge sitting up there and there’s a sense of formality to it , versus getting on a Zoom call with a bunch of heads from shoulders up . That may not feel like you’re getting the same hearing that you might have in person . So , I think there’s definitely a balance there . ( LSO )

In general, regulators seemed to be striving for a balanced approach to post-pandemic recalibrations. Advantages, disadvantages, and risks associated with in-person and virtual modalities are becoming clearer and are helping inform this recalibration process.

Theme 5: Contemplating the future of technology in regulatory policy and practice

Participants described their curiosity in wanting to learn more about the impact on public protection as technologies like AI continue to evolve and become more commonplace. Participants described specific areas they were watching to learn more about how technology was impacting professional practice, such as how the therapeutic relationship might “look different when practicing in a more technological environment” (CNO). A participant from the LSO was interested in exploring “whether virtual proceedings have impacted incarceration rates, and release versus bail, or other outcomes” and whether digital products such as online “will kits” help people in the way they are intended.

Participants highlighted opportunities for increased collaboration between regulators to streamline and harmonize processes and to share data to support evidence-based regulatory policy across professions. For example, one participant from the CNO said “I think there’s always been that collaboration amongst different regulators, but having data, I think, provides this objective piece as well, which I think will be helpful for sure.” A participant from the OCSW described the importance of working together given the similarities in regulatory functions and services, especially across health profession regulators:

In essence , even though we’re regulating different professions , we’re all regulating . So , when you’re thinking of technology and the use of social media and some of the expectations we have from our professionals , specifically health , it would be good if those regulatory bodies could come together and say , you know , here’s the spectrum of our expectations . Here’s how we’ve been monitoring this spectrum . Let’s talk about it as a unit…We may be regulating different professionals , but we’re all running organizations . The operations of each of these organizations are extremely similar and overlap . ( OCSW )

A participant from OCSW expressed a desire for regulation to become more forward-thinking around technology: “Often regulators are sort of the last ones around the corner with a lot of the updates……there’s no reason the regulator can’t be the cutting edge in some of this.” One more innovative approach to staying on top of technological changes was the LSO’s Access to Innovation program which created a regulatory sandbox for innovative technological legal services [ 48 ]. While, at the time of our interview, this sandbox did not yet have evaluation data available, this way of providing a safe space to support innovative technology is meant to provide insight into new risks and opportunities related to technology.

Technology can potentially revolutionize professional work and the regulation of that work. However, technological change has simultaneously created tensions around the application of AI, data analytics, technological competence, social media use, and other dimensions of professional practice and regulation [ 49 ]. The results of our study have underscored the wide-ranging implications of technology on regulatory practices, with changes to entry-to-practice and registration/licensing, practice standards and guidance, practitioner support, continuing professional development, and disciplinary practices and procedures. Regulators are grappling with how to respond to technological changes in the practice of the professionals they regulate, while simultaneously experiencing technologically mediated changes to internal processes.

Concerns about risk may slow progress

Our findings illustrate that regulators are in the early stages of exploring the opportunities and risks that technology has on daily operations. Although regulators from different sectors have adopted technology at varied paces, the literature suggests that many have begun exploring the potential value of technology, including AI, in supporting regulatory operations and decision-making [ 50 – 55 ]. Regulation is becoming increasingly complex and resource-intensive, and our findings suggest that participants are hopeful that integrating technology into regulatory operations will provide a means to enhance efficiency. While participants noted that there are areas where technology can be integrated more easily, they also highlighted the importance of carefully studying the impacts of technology on functions that carry a greater risk of producing undesirable outcomes. This finding aligns with research by van der Gaag et al. that found regulators were concerned that AI could introduce errors and biases, jeopardize public trust, and perpetuate systemic inequities [ 56 ]. Our participants noted a need to take a risk-based approach to the advantages and disadvantages of adopting technology to support decision-making. While risk aversion may be necessary for higher-stakes regulatory processes, it may slow progress in adopting technological enhancements that could drive needed efficiency gains in increasingly resource-constrained environments.

Ensuring an equity-based approach to virtual practice and processes

The rapid expansion of virtual services influenced our participants’ responses to regulating technology use among professionals. In the context of the health and social care sectors, the pandemic accelerated the proliferation of virtual care options. In the context of law, evidence from before the pandemic suggests that, increasingly, lawyers are operating virtual legal offices rather than those of traditional brick-and-mortar [ 57 ]. Technology use in practice raises important questions about privacy, confidentiality, boundaries, informed consent, continuity of services, and new complexities for addressing malpractice and complaints [ 6 , 57 – 59 ]. While our participants discussed that technology does not necessarily require the development of unique standards of practice, this is an area that regulators will be required to re-evaluate as new risks and challenges emerge.

The introduction of virtual practice also raises unique equity concerns, potentially expanding access but in unequal ways [ 60 ]. Regulators have a role in ensuring that regulatory decisions do not perpetuate systemic inequities [ 61 ]. Our previous research on for-profit virtual care in Canada found that equity has not been adequately considered within standards from medical regulators [ 6 , 22 ]. Equity considerations must be embedded in regulatory decision-making as technology continues to evolve, and many of these considerations apply to regulatory policies and practices (e.g., virtual discipline hearings) as well as regulating virtual practice.

Our participants also described varied approaches to virtual training experiences and entry-to-practice exams, and this was an area where participants noted disparate approaches were common even across regulators in the same field. A growing body of literature across various professions suggests that there are advantages and lessons to be learned from virtual training models, including virtual reality. More evidence is needed to support informed regulatory decision-making in this evolving area of technology-enabled training and assessing entry-to-practice competency. For nursing, social work, and law, training usually requires hands-on, practical experience that may be difficult to gain in a virtual or simulated setting; however, there may be advantages to innovative virtual training models [ 62 ]. There may also be lessons that can be learned from professions, such as paramedicine, that use training via virtual reality to help establish competence [ 63 – 65 ].

Varied approaches to ensuring technologically competent professionals

As regulators work to strike a balanced approach for enabling professionals to deliver virtual services, practitioners themselves must build technological competence. As discussed by our participants, regulators expect registrants to have the required knowledge and skills related to technology but the approaches regulators have taken to ensure that registrants have this competence differed. Scholars have explored the knowledge needs and competencies that members of their professions require to function in an increasingly digitalized world [ 59 , 66 , 67 ]. As discussed by our participants, technological competence will look different depending on each practice setting. However, with growing interprofessional collaboration, regulators within and across sectors have an opportunity to work together to share evidence and explore how competencies can be harmonized to ensure greater consistency amongst professionals.

Aside from being competent in using technology to deliver professional services, social media introduces implications for how regulated professionals interact with the public to maintain public trust. Many professional regulators have developed standards of practice to outline responsibilities and accountabilities due to increased complaints and findings of unprofessional conduct centred on inappropriate social media use [ 9 , 68 – 71 ]. High-profile conduct cases have sparked considerable debate about the need to balance professionals’ freedom of expression and speech with their obligations to maintain public trust. Social media can be a powerful platform for fostering professional networks, continuing education, and advocacy to encourage system improvements. At the same time, it can potentially cause significant social harm. Regulators will continue to need to evaluate how they approach registrants who use social media in ways that push the boundaries of conventional views of professionalism.

Opportunities to leverage regulatory data

Participants discussed the opportunities that technology can bring in facilitating better use of regulatory data to inform decision-making, though many challenges–including adequate knowledge and resources, addressing privacy concerns, and ensuring data platform interoperability–remain to realize this potential. Beyond the use of data analytics to inform internal regulatory policies and processes, regulators have an opportunity to leverage data to inform broader social goals such as workforce planning. Within the health and social care sectors, the importance of standardized health workforce data for integrated workforce planning has been recognized by scholars [ 72 – 74 ] and has become a priority for federal, provincial, and territorial governments in Canada [ 75 – 77 ]. Promising practices exist in other jurisdictions such as the United States and Australia where national databases and datasets are used, and Canada has recently announced pan-Canadian databases for physician and nursing data [ 75 , 78 ]. These data support inter-jurisdictional labour mobility and awareness of registration status and malpractice or disciplinary histories. The collection of standardized data can also provide meaningful input on issues such as the mental health of the workforce, a priority mentioned by all our participants. In addition, equity must be a priority, and the collection of enhanced demographic data could facilitate better understanding of the diversity of the workforce and the inequities that exist to inform policy and research needs.

Limitations and future research

The transferability of these findings should be interpreted carefully when applying to other regulatory contexts within and outside of Canada. Our participant sample was small and meant to provide foundational insights into how regulators are navigating an increasingly digitalized world. Members of our team are currently engaged in two funded research projects that build on this foundational work, one that expands the current study to survey and interview regulators across Canada, and one examining whether ethical codes and guidelines from regulators provide sufficient guidance for practitioners when they encounter challenges related to technology in practice. The implications of technology on professional regulation will require monitoring and evaluation over time to examine how technological innovations impact all facets of regulation and professional work.

Our case study explored how three Ontario professional regulators operating within different legislative frameworks are navigating technology in the digital era. Cross-sectoral participants provided theoretical and pragmatic insights for regulating in the digital era and the role regulators can and should play in digitally enabled professional practice. These insights provided an understanding of how these regulatory bodies are responding to the challenges of upholding their mandate to regulate in the public interest during rapid digital evolution. Our analysis identified five themes: balancing efficiency potential with risks of certain technological advances; the potential for improving regulation through data analytics; considering how to regulate a technologically competent workforce; recalibrating pandemic emergency measures involving technology; and contemplating the future of technology on regulatory policy and practice. Regulators will continue to grapple with considerations about technology used to facilitate regulatory functions, balancing consumer demands amid emerging risks posed by technology, producing technologically competent workforces, and informing workforce planning via regulatory data. Policymakers and regulators across Canada and internationally should prioritize risk-balanced policies, guidelines, and practice standards for modern professional regulation.

Supporting information

S1 file. description of regulatory documents..

https://doi.org/10.1371/journal.pone.0303192.s001

S2 File. Semi-structured interview guide.

https://doi.org/10.1371/journal.pone.0303192.s002

S3 File. COREQ checklist.

Consolidated criteria for reporting qualitative studies (COREQ): 32-item checklist.

https://doi.org/10.1371/journal.pone.0303192.s003

Acknowledgments

We gratefully acknowledge and thank our interview participants for generously sharing their time and insights with us.

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Assessing the perceived value of a user-led educational intervention to support recovery in a Swedish psychiatric organization: A qualitative case study

Affiliations.

• 1 Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet, Stockholm, Sweden.
• 2 North Stockholm Psychiatry, Health Care Services Stockholm County, Stockholm, Sweden.
• 3 Division for Learning, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden.
• PMID: 38695287
• PMCID: PMC11064016
• DOI: 10.1111/hex.14064

Introduction: Many people with mental health issues recover and re-establish their identity and find hope and meaning in life, irrespective of symptom burden. Recovery can be supported through learning and education, aiming at strengthening self-management and coping skills. Such education offered by peers with lived experience is rare and scarcely reported. The aim was to assess the perceived value of an educational intervention, called the Patient School (PS), organized within a psychiatry organization by employed patient peers with lived experience.

Methods: A qualitative case study based on interviews with people with mental health issues (n = 8), peer-organizers (n = 4) and healthcare professionals (n = 4), and documents such as schedules and educational materials were used. First, the interviews were transcribed and analyzed using inductive conventional content analysis. Second, the findings were synthesized into a programme theory, illustrated in a logic model.

Results: The perceived value of the PS was related to the willingness of peer-organizers to share their own experiences, a sense of belonging, sharing with like-minded and new knowledge, practical skills, roles and attitudes acquired. These experiences were empowering, decreased stigma and reassured user participants that one's identity is not defined by mental health issues. This increased self-confidence paves the way for increased self-management and creates a potential for a more efficient use of healthcare services.

Conclusion: We conclude that this PS, organized within a psychiatry organization by salaried peers, achieved the same positive results as those reported in the literature and showed the value of having peer-organizers being part of the staff.

Patient or public contribution: This research was performed in a partnership between academic researchers and persons with user experience of psychiatric services, engaged in the educational intervention in the focus of the study. The research plan was co-designed, and the analysis of the data collected was performed in collaboration. The participation of the co-researchers with user experience gave the project team access to the study site, provided the team with insights into to study context and contributed with an understanding promoting the interpretation of the findings.

Keywords: Patient School; Recovery College; coping; educational intervention; empowerment; mental health; stigma reduction.

© 2024 The Authors. Health Expectations published by John Wiley & Sons Ltd.

Publication types

• Research Support, Non-U.S. Gov't
• Adaptation, Psychological
• Interviews as Topic
• Mental Disorders* / therapy
• Middle Aged
• Patient Education as Topic
• Peer Group*
• Qualitative Research*
• Self-Management

Grants and funding

• 2018-01472/This work was supported by the Swedish Research Council for Health, Working Life and Welfare (FORTE) under Grant Number 2018-01472.

• Open access
• Published: 09 May 2024

Examining the feasibility of assisted index case testing for HIV case-finding: a qualitative analysis of barriers and facilitators to implementation in Malawi

• Caroline J. Meek 1 , 2 ,
• Tiwonge E. Mbeya Munkhondya 3 ,
• Mtisunge Mphande 4 ,
• Tapiwa A. Tembo 4 ,
• Mike Chitani 4 ,
• Milenka Jean-Baptiste 2 ,
• Dhrutika Vansia 4 ,
• Caroline Kumbuyo 4 ,
• Jiayu Wang 2 ,
• Katherine R. Simon 4 ,
• Sarah E. Rutstein 5 ,
• Clare Barrington 2 ,
• Maria H. Kim 4 ,
• Vivian F. Go 2 &
• Nora E. Rosenberg 2  

BMC Health Services Research volume  24 , Article number:  606 ( 2024 ) Cite this article

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Metrics details

Assisted index case testing (ICT), in which health care workers take an active role in referring at-risk contacts of people living with HIV for HIV testing services, has been widely recognized as an evidence-based intervention with high potential to increase status awareness in people living with HIV. While the available evidence from eastern and southern Africa suggests that assisted ICT can be an effective, efficient, cost-effective, acceptable, and low-risk strategy to implement in the region, it reveals that feasibility barriers to implementation exist. This study aims to inform the design of implementation strategies to mitigate these feasibility barriers by examining “assisting” health care workers’ experiences of how barriers manifest throughout the assisted ICT process, as well as their perceptions of potential opportunities to facilitate feasibility.

In-depth interviews were conducted with 26 lay health care workers delivering assisted ICT in Malawian health facilities. Interviews explored health care workers’ experiences counseling index clients and tracing these clients’ contacts, aiming to inform development of a blended learning implementation package. Transcripts were inductively analyzed using Dedoose coding software to identify and describe key factors influencing feasibility of assisted ICT. Analysis included multiple rounds of coding and iteration with the data collection team.

Participants reported a variety of barriers to feasibility of assisted index case testing implementation, including sensitivities around discussing ICT with clients, privacy concerns, limited time for assisted index case testing amid high workloads, poor quality contact information, and logistical obstacles to tracing. Participants also reported several health care worker characteristics that facilitate feasibility (knowledge, interpersonal skills, non-stigmatizing attitudes and behaviors, and a sense of purpose), as well as identified process improvements with the potential to mitigate barriers.

Conclusions

Maximizing assisted ICT’s potential to increase status awareness in people living with HIV requires equipping health care workers with effective training and support to address and overcome the many feasibility barriers that they face in implementation. Findings demonstrate the need for, as well as inform the development of, implementation strategies to mitigate barriers and promote facilitators to feasibility of assisted ICT.

Trial registration

NCT05343390. Date of registration: April 25, 2022.

Peer Review reports

Introduction

To streamline progress towards its goal of ending AIDS as a public health threat by 2030, the Joint United Nations Programme on HIV/AIDS (UNAIDS) launched a set of HIV testing and treatment targets [ 1 ]. Adopted by United Nations member states in June 2021, the targets call for 95% of all people living with HIV (PLHIV) to know their HIV status, 95% of all PLHIV to be accessing sustained antiretroviral therapy (ART), and 95% of all people receiving ART to achieve viral suppression by 2025 [ 2 ]. Eastern and southern Africa has seen promising regional progress towards these targets in recent years, and the region is approaching the first target related to status awareness in PLHIV- in 2022, 92% of PLHIV in the region were aware of their status [ 3 ]. However, several countries in the region lag behind [ 4 ], and as 2025 approaches, it is critical to scale up adoption of evidence-based interventions to sustain and accelerate progress.

Index case testing (ICT), which targets provision of HIV testing services (HTS) for sexual partners, biological children, and other contacts of known PLHIV (“index clients”), is a widely recognized evidence-based intervention used to identify PLHIV by streamlining testing efforts to populations most at risk [ 5 , 6 , 7 ]. Traditional approaches to ICT rely on passive referral, in which index clients invite their contacts for testing [ 5 ]. However, the World Health Organization (WHO) and the President’s Emergency Plan for HIV/AIDS Relief (PEPFAR) have both recommended assisted approaches to ICT [ 6 , 8 , 9 , 10 ], in which health care workers (HCWs) take an active role in referral of at-risk contacts for testing, due to evidence of improved effectiveness in identifying PLHIV compared to passive approaches [ 10 , 11 , 12 , 13 , 14 ]. As a result, there have been several efforts to scale assisted ICT throughout eastern and southern Africa in recent years [ 15 , 16 , 17 , 18 , 19 , 20 ]. In addition to evidence indicating that assisted ICT can be effective in increasing HIV testing and case-finding [ 16 , 17 , 21 , 22 , 23 , 24 ], implementation evidence [ 25 ] from the region suggests that assisted ICT can be an efficient [ 14 ], acceptable [ 5 , 13 , 15 , 18 , 20 , 21 , 26 ], cost-effective [ 27 ], and low-risk [ 21 , 22 , 24 , 28 , 29 ] strategy to promote PLHIV status awareness. However, the few studies that focus on feasibility, or the extent to which HCWs can successfully carry out assisted ICT [ 25 ], suggest that barriers exist to feasibility of effective implementation [ 18 , 19 , 20 , 30 , 31 , 32 ]. Developing informed implementation strategies to mitigate these barriers requires more detailed examination of how these barriers manifest throughout the assisted ICT process, as well as of potential opportunities to facilitate feasibility, from the perspective of the HCWs who are doing the “assisting”.

This qualitative analysis addresses this need for further detail by exploring “assisting” HCWs’ perspectives of factors that influence the feasibility of assisted ICT, with a unique focus on informing development of effective implementation strategies to best support assisted ICT delivery in the context of an implementation science trial in Malawi.

This study was conducted in the Machinga and Balaka districts of Malawi. Malawi is a country in southeastern Africa in which 7.1% of the population lives with HIV and 94% of PLHIV know their status [ 4 ]. Machinga and Balaka are two relatively densely populated districts in the southern region of Malawi [ 33 ] with HIV prevalence rates similar to the national average [ 34 ]. We selected Machinga and Balaka because they are prototypical of districts in Malawi implementing Ministry of Health programs with support from an implementing partner.

Malawi has a long-established passive ICT program, and in 2019 the country also adopted an assisted component, known as voluntary assisted partner notification, as part of its national HIV testing policy [ 32 ]. In Malawi, ICT is conducted through the following four methods, voluntarily selected by the index client: 1) passive referral, in which HCWs encourage the index client to refer partners for voluntary HTS, 2) contract referral, in which HCWs establish an informal ‘contract’ with index clients that agrees upon a date that the HCW can contact the contact clients if they have not yet presented for HTS; 3) provider referral, in which HCWs contact and offer voluntary HTS to contact clients; and 3) dual referral, in which HCWs accompany and provide support to index clients in disclosing their status and offering HTS to their partners [ 8 ]. 

While Malawi has one of the lowest rates of qualified clinical HCWs globally (< 5 clinicians per 100,000 people) [ 35 ], the country has a strong track record of shifting HTS tasks to lay HCWs, who have been informally trained to perform certain health care delivery functions but do not have a formal professional/para-professional certification or tertiary education degree, in order to mitigate this limited medical workforce capacity [ 32 , 36 ]. In Malawi, lay HCW roles include HIV Diagnostic Assistants (who are primarily responsible for HIV testing and counseling, including index case counseling) and community health workers (who are responsible for a wider variety of tasks, including index case counseling and contact tracing) [ 32 ]. Non-governmental organization implementing partners, such as the Tingathe Program, play a critical role in harnessing Malawian lay HCW capacity to rapidly and efficiently scale up HTS, including assisted ICT [ 32 , 37 , 38 , 39 ].

Study design

Data for this analysis were collected as part of formative research for a two-arm cluster randomized control trial examining a blended learning implementation package as a strategy for building HCW capacity in assisted ICT [ 40 ]. Earlier work [ 32 ] established the theoretical basis for testing the blended learning implementation package, which combines individual asynchronous modules with synchronous small-group interactive sessions to enhance training and foster continuous quality improvement. The formative research presented in this paper aimed to further explore factors influencing feasibility of the assisted ICT from the perspective of HCWs in order to inform development of the blended learning implementation package.

Prior to the start of the trial (October-December 2021), the research team conducted 26 in-depth interviews (IDIs) with lay HCWs at 14 of the 34 facilities included in the parent trial. We purposively selected different types of facilities (hospitals, health centers, and dispensaries) in both districts and from both randomization arms, as this served as a qualitative baseline for a randomized trial. Within these facilities, we worked with facility supervisors to purposively select HCWs who were actively engaged in Malawi’s ICT program from the larger sample of HCWs eligible for the parent trial (had to be at least 18 years old, employed full-time at one of the health facilities included in the parent trial, and involved in counseling index clients and/or tracing their contacts). The parent trial enrolled 306 HCWs, who were primarily staff hired by Tingathe Program to support facilities implementing Malawi’s national HIV program.

Data collection

IDIs were conducted by three trained Malawian interviewers in a private setting using a semi-structured guide. IDIs were conducted over the phone when possible ( n  = 18) or in-person at sites with limited phone service ( n  = 8). The semi-structured guide was developed for this study through a series of rigorous, iterative discussions among the research team (Additional file 1 ). The questions used for this analysis were a subset of a larger interview. The interview guide questions for this analysis explored HCWs’ experiences with assisted ICT, including barriers and facilitators to implementation. Probing separately about the processes of counseling index clients and tracing their contacts, interviewers asked questions such as “What is the first thing that comes to mind when you think of counseling index clients/tracing contacts?”, “What aspects do you [like/not like] about…?” and “What do your colleagues say about…?”. When appropriate, interviewers probed further about how specific factors mentioned by the participant facilitate or impede the ICT implementation experience.

The IDIs lasted from 60–90 min and were conducted in Chichewa, a local language in Malawi. Eleven audio recordings were transcribed verbatim in Chichewa before being translated into English and 15 recordings were directly translated and transcribed into English. Interviewers summarized each IDI after it was completed, and these summaries were discussed with the research team routinely.

Data analysis

The research team first reviewed all of the interview summaries individually and then met multiple times to discuss initial observations, refining the research question and scope of analysis. A US-based analyst (CJM) with training in qualitative analysis used an inductive approach to develop a codebook, deriving broad codes from the implementation factors mentioned by participants throughout their interviews. Along with focused examination of the transcripts, she consulted team members who had conducted the IDIs with questions or clarifications. CJM regularly met with Malawian team members (TEMM, MM, TAT) who possess the contextual expertise necessary to verify and enhance meaning. She used the Dedoose (2019) web application to engage in multiple rounds of coding, starting with codes representing broad implementation factors and then further refining the codebook as needed to capture the nuanced manifestations of these barriers and facilitators. Throughout codebook development and refinement, the analyst engaged in memoing to track first impressions, thought processes, and coding decisions. The analyst presented the codebook and multiple rounds of draft results to the research team. All transcripts and applied codes were also reviewed in detail by additional team members (MJB, DV). Additional refinements to the codebook and results interpretations were iteratively made based on team feedback.

Ethical clearance

Ethical clearance was provided by UNC’s IRB, Malawi’s National Health Sciences Research Committee, and the Baylor College of Medicine IRB. Written informed consent was obtained from all participants in the main study and interviewers confirmed verbal consent before starting the IDIs.

Participant characteristics are described in Table  1 below.

Factors influencing feasibility of assisted ICT: barriers and facilitators

Participants described a variety of barriers and facilitators to feasibility of assisted ICT, manifesting across the index client counseling and contact client tracing phases of the implementation process. Identified barriers included sensitivities around discussing ICT with clients, privacy concerns, limited time for ICT amid high workloads, poor quality contact information, and logistical obstacles to tracing. In addition to these barriers, participants also described several HCW characteristics that facilitated feasibility: ICT knowledge, interpersonal skills, positive attitudes towards clients, and sense of purpose. Barriers and facilitators are mapped to the ICT process in Fig.  1 and described in greater detail in further sections.

Conceptual diagram mapping feasibility barriers and facilitators to the ICT process

Feasibility barriers

Sensitivities around discussing ict with clients.

Participants described ICT as a highly sensitive topic to approach with clients. Many expressed a feeling of uncertainty around how open index clients will be to sharing information about their contacts, as well as how contacts will react when approached for HTS. When asked about difficult aspects of counseling index clients, many HCWs mentioned clients’ hesitance or declination to participate in assisted ICT and share their contacts. Further, several HCWs mentioned that some index clients would provide false contact information. These index client behaviors were often attributed to confidentiality concerns, fear of unwanted status disclosure, and fear of the resulting implications of status disclosure: “They behave that way because they think you will be telling other people about their status…they also think that since you know it means their life is done, you will be looking at them differently .” Populations commonly identified as particularly likely to hesitate, refuse, or provide false information included youth (described as “ shy ” “ thinking they know a lot ” and “ difficult to reveal their contacts ”) and newly diagnosed clients (“it may be hard for them to accept [their HIV diagnosis]” ). One participant suggested that efforts to pair index clients with same-sex HCWs could make them more comfortable to discuss their contacts.

When asked about the first things that come to mind when starting to trace contacts, many participants discussed wondering how they will be received by the contact and preparing themselves to approach the contact. When conducting provider or contract referral, HCWs described a variety of challenging reactions that can occur when they approach a contact for HTS- including delay or refusal of testing, excessive questioning about the identity of the index client who referred them for testing, and even anger or aggression. Particularly mentioned in the context of male clients, these kinds of reactions can lead to stress and uncertain next steps for HCWs: “I was very tensed up. I was wondering to myself what was going to happen…he was talking with anger.”

Participants also noted the unique sensitivities inherent in conducting dual referral and interacting with sexual partners of index clients, explaining that HIV disclosure can create acute conflict in couples due to perceived blame and assumptions of infidelity. They recounted these scenarios as particularly difficult to navigate, with high stakes that require high-quality counseling skills: “sometimes if you do not have good counseling the marriage happens to get to an end.” . Some participants discussed concern about index client risk of intimate partner violence (IPV) upon partner disclosure: “they think that if they go home and [disclose their HIV status], the marriage will end right there, or for some getting to a point of [being] beaten.”

Privacy concerns

Participants also reported that clients highly value privacy, which can be difficult to secure throughout the ICT process. In the facility, while participants largely indicated that counseling index clients was much more successful when conducted in a private area, many reported limited availability of private counseling space. One participant described this challenge: “ if I’m counseling an index client and people keep coming into the room…this compromises the whole thing because the client becomes uncomfortable in the end.” Some HCWs mentioned working around this issue through use of screens, “do-not-disturb” signs, outdoor spots, and tents.

Participants also noted maintaining privacy as a challenge when tracing contact clients in the field, as they sometimes find clients in a situation that is not conducive to private conversations. One participant described: “ we get to the house and find that there are 4, 5 people with our [contact client]…it doesn’t go well…That is a mission gone wrong. ” Participants also noted that HCWs are also often easily recognizable in the community due to their bikes and cars, which exacerbates the risk of compromising privacy. To address privacy challenges in the community, participants reported strategies to increase discretion, including dressing to blend in with the community, preparing an alternate reason to be looking for the client, and offering HTS to multiple people or households to avoid singling out one person.

Limited time for ICT amid high workloads

Some participants indicated that strained staffing capacity leads HCWs to have to perform multiple roles, expressing challenges in balancing their ICT work with their other tasks. As one participant described, “Sometimes it is found that you are assigned a task here at the hospital to screen anyone who comes for blood testing, but you are also supposed to follow up [with] the contacts the same day- so it becomes a problem…you fail to follow up [with] the contacts.” Some also described being the only, or one of few staff responsible for ICT: “You’re doing this work alone, so you can see that it is a big task to do it single-handedly.” The need to counsel each index client individually, as a result of confidentiality concerns, further increases workload for the limited staff assigned to this work. Further, HCWs often described contact tracing in the field as time-consuming and physically taxing, which leaves them less time and energy for counseling. Many HCWs noted the need to hire more staff dedicated to ICT work.

High workloads also resulted in shorter appointments and less time to counsel index clients, which participants reported limits the opportunity for rapport that facilitates openness or probes for detailed information about sexual partners. Participants emphasized the importance of having enough time to meaningfully engage with index clients: “For counseling you cannot have a limit to say, ‘I will talk to him for 5 min only.’ …That is not counseling then. You are supposed to stay up until…you feel that this [person] is fulfilled.” . In addition, high workload can reduce the capacity of HCWs to deliver quality counseling: “So you find that as you go along with the counseling, you can do better with the first three clients but the rest, you are tired and you do short cuts.”

High workloads also lead to longer queues, which may deter clients from coming into the clinic or cause them to leave before receiving services: “Sometimes because of shortage of staff, it happens that you have been assigned a certain task that you were supposed to do but at the same time there are clients who were supposed to be counseled. As a result, because you spent more time on the other task as a result you lose out some of the clients because you find that they have gone.” In response to long queues, several participants described ‘fast-tracking’ contact clients who come in for HTS in effort to maximize case-finding by prioritizing those who have been identified as at risk of HIV.

Poor quality contact information

Participants repeatedly discussed the importance of eliciting accurate information about a person’s sexual partners, including where, when, and how to best contact them. As one participant said, “ Once the index has given us the wrong information then everything cannot work, it becomes wrong…if he gives us full information [with] the right details then everything becomes successful and happens without a problem. ” Adequate information is a critical component of the ICT process, and incorrect or incomplete information delays or prevents communication with contact clients.

Inadequate information, which can include incorrect or incomplete names, phone numbers, physical addresses, and contextual details, can arise from a variety of scenarios. Most participants mentioned index clients providing incorrect information as a concern. This occurred either intentionally to avoid disclosure or unintentionally if information was not known. Poor quality contact information also results from insufficient probing and poor documentation, which is often exacerbated by aforementioned HCW time and energy constraints. In one participant’s words, “The person who has enlisted the contact…is the key person who can make sure that our tracing is made easy.” Participants noted the pivotal role of the original HCW who first interacts with the index client in not only eliciting correct locator information but also eliciting detailed contextual information. For example, details about a contact client’s profession are helpful to trace the client at a time when they will likely be at home. Other helpful information included nicknames, HIV testing history, and notes about confidentiality concerns.

Logistical obstacles to tracing

Some contact clients are reached by phone whereas others must be physically traced in the community. Some participants reported difficulty with tracing via phone, frequently citing network problems and lack of sufficient airtime allocated by the facility. Participants also reported that some clients were unreachable by phone, necessitating physical tracing. Physically tracing a contact client requires a larger investment of resources than phone tracing, especially when the client lives at a far distance from the clinic. Participants frequently discussed having to travel far distances to reach contact clients, an issue some saw as exacerbated by people who travel to clinics at far distances due to privacy concerns.

While most participants reported walking or biking to reach contact clients in the community, some mentioned using a motorcycle or Tingathe vehicle. However, access to vehicles is often limited and these transportation methods require additional expenses for fuel. Walking or biking was also reported to expose HCWs to inclement weather, including hot or rainy seasons, and potential safety risks such as violence.

Participants reported that traveling far distances can be physically taxing and time-consuming, sometimes rendering them too tired or busy to attend to other tasks. Frequent travel influenced HCW morale, particularly when a tracing effort did not result in successfully recruiting a contact client. Participants frequently described this perception of wasted time and energy as “ painful ”, with the level of distress often portrayed as increasing with the distance travelled. As one HCW said, “You [can] find out that he gave a false address. That is painful because it means you have done nothing for the person, you travelled for nothing.”

HCWs described multiple approaches used to strategically allocate limited resources for long distances. These approaches included waiting to physically trace until there are multiple clients in a particular area, reserving vehicle use for longer trips, and coordinating across HCWs to map out contact client locations. HCWs also mentioned provision of rain gear and sun protection to mitigate uncomfortable travel. Another approach involved allocating contact tracing to HCWs based in the same communities as the contact clients.

Feasibility facilitators

Hcw knowledge about ict.

Participants reported that HCWs with a thorough understanding of ICT’s rationale and purpose can facilitate client openness. Clients were more likely to engage with HCWs about assisted ICT if they understood the benefits to themselves and their loved ones. One HCW stated, “If the person understands why we need the information, they will give us accurate information.”

Participants also discussed the value of deep HCW familiarity with ICT procedures and processes, particularly regarding screening clients for IPV and choosing referral method. One participant described the importance of clearly explaining various referral methods to clients: “So…people come and choose the method they like…when you explain things clearly it is like the index client is free to choose a method which the contact can use for testing”. Thorough knowledge of available referral methods allows HCWs to actively engage with index clients to discuss strategies to refer contacts in a way that fits their unique confidentiality needs, which was framed as particularly important when IPV is identified as a concern. Multiple participants suggested the use of flipcharts or videos, saying these would save limited HCW time and energy, fill information gaps, and provide clients with a visual aid to supplement the counseling. Others suggested recurring opportunities for training, to continuously “refresh” their ICT knowledge in order to facilitate implementation.

HCW interpersonal skills

In addition, HCWs’ ability to navigate sensitive conversations about HIV was noted as a key facilitator of successful implementation. Interpersonal skills were mentioned as mitigating the role’s day-to-day uncertainty by preparing HCWs to engage with clients, especially newly diagnosed clients: “ I need to counsel them skillfully so that they understand what I mean regardless that they have just tested positive for HIV.”

When discussing strategies to build HCW skills in counseling index clients and tracing contact clients, participants suggested establishing regular opportunities to discuss challenges and share approaches to address these challenges: “ I think that there should be much effort on the [HCWs] doing [ICT]. For example, what do I mean, they should be having a meeting with the facility people to ask what challenges are you facing and how can we end them?”. Another participant further elaborated, saying “We should be able to share experiences with our [colleagues] so that we can all learn from one another. And also, there are other people who are really brilliant at their job. Those people ought to come visit us and see how we are doing. That is very motivating.”

HCW non-stigmatizing attitudes and behaviors

Participants also highlighted the role of empathy and non-judgement in building trust with clients: “ Put yourself in that other person’s shoes. In so doing, the counseling session goes well. Understanding that person, that what is happening to them can also happen to you. ”. Participants viewed trust-building as critical to facilitating client comfort and openness: “if they trust you enough, they will give you the right information.” Further, participants associated HCW assurance of confidentiality with promoting trust and greater information sharing: “ Also assuring them on the issue of confidentiality because confidentiality is a paramount. If there will not be confidentiality then the clients will not reveal.”

HCW sense of purpose

Lastly, several participants reported that a sense of purpose and desire to help people motivated them to overcome the challenges of delivering assisted ICT. One participant said, “ Some of these jobs are a ministry. Counseling is not easy. You just need to tell yourself that you are there to help that person. ” Many seemed to take comfort in the knowledge that their labors, however taxing, would ultimately allow people to know their status, take control of their health, and prevent the spread of HIV. Participants framed the sense of fulfillment from successful ICT implementation as a mitigating factor amidst challenges: “ If [the contact client] has accepted it then I feel that mostly I have achieved the aim of being in the health field…that is why it is appealing to me ”.

Participants described a variety of barriers to assisted ICT implementation, including sensitivities around discussing ICT with clients, privacy concerns, limited time for ICT amid high workloads, poor quality contact information, and logistical obstacles to tracing. These barriers manifested across each step of the process of counseling index clients and tracing contacts. However, participants also identified HCW characteristics and process improvements that can mitigate these barriers.

Further, participants’ descriptions of the assisted ICT process revealed the intimately interconnected nature of factors that influence feasibility of assisted ICT. Sensitivities around HIV, privacy limitations, time constraints, and HCW characteristics all contribute to the extent to which counseling index clients elicits adequate information to facilitate contact tracing. Information quality has implications for HCW capacity, as inadequate information can lead to wasted resources, including HCW time and energy, on contact tracing. The opportunity cost of wasted efforts, which increases as the distance from which the contact client lives from the clinic increases, depletes HCW morale. The resulting acceleration of burnout, which is already fueled by busy workloads and the inherent uncertainty of day-to-day ICT work, further impairs HCW capacity to effectively engage in quality counseling that elicits adequate information from index clients. This interconnectedness suggests that efforts to mitigate barriers at any step of the assisted ICT process may have the potential to ripple across the whole process.

Participants’ descriptions of client confidentiality and privacy concerns, as well as fear of consequences of disclosure, align with previous studies that emphasize stigma as a key barrier to assisted ICT [ 15 , 18 , 19 , 20 , 30 , 31 ] and the overall HIV testing and treatment cascade [ 41 ]. Our findings suggest that anticipated stigma, or the fear of discrimination upon disclosure [ 42 ], drives several key barriers to feasibility of assisted ICT implementation. Previous studies also highlight the key role of HCWs in mitigating barriers related to anticipated stigma; noting the key role of HCW ICT knowledge, interpersonal skills, and non-stigmatizing attitudes/behaviors in securing informed consent from clients for ICT, tailoring the referral strategy to minimize risk to client confidentiality and safety, building trust and rapport with the client, and eliciting accurate contact information from index clients to facilitate contact tracing [ 18 , 19 , 20 , 30 ].

Our findings also reflect previous evidence of logistical challenges related to limited time, space, and resources that can present barriers to feasibility for HCWs [ 18 , 19 , 20 , 30 , 31 ]. Participants in the current study described these logistical challenges as perpetuating HCW burnout, making it harder for them to engage in effective counseling. Cumulative evidence of barriers across different settings (further validated by this study) suggests that assisted ICT implementation may pose greater burden on HCWs than previously thought [ 7 ]. However, our findings also suggest that strategic investment in targeted implementation strategies has the potential to help overcome these feasibility barriers.

In our own work, these findings affirmed the rationale for and informed the development of the blended learning implementation package tested in our trial [ 40 , 43 ]. Findings indicated the need for evidence-based training and support to promote HCW capacity to foster facilitating characteristics. Participants discussed the value of "refresher" opportunities in building knowledge, as well as the value of learning from other’s experiences. The blended learning implementation package balances both needs by providing time for HCWs to master ICT knowledge and skills with a combination of asynchronous, digitally delivered content (which allows for continuous review as a "refresher") and in-person sessions (which allow for sharing, practicing, and feedback). Our findings also highlight the value of flexible referral methods that align with the client’s needs, so our training content includes a detailed description of each referral method process. Further, our training content emphasizes client-centered, non-judgmental counseling as our findings add to cumulative evidence of stigma as a key barrier to assisted ICT implementation [ 41 ].

In addition, participants frequently mentioned informal workarounds currently in use to mitigate barriers or offered up ideas for potential solutions to try. Our blended learning implementation package streamlines these problem-solving processes by offering monthly continuous quality improvement sessions at each facility in our enhanced arm. These sessions allow for structured time to discuss identified barriers, share ideas to mitigate barriers, and develop solutions for sustained process improvement tailored to their specific setting. Initial focus areas for continuous quality improvement discussions include use of space, staffing, allocation of airtime and vehicles, and documentation, which were identified as barriers to feasibility in the current study.

Our study provides a uniquely in-depth examination of HCWs’ experiences implementing assisted ICT, exploring how barriers can manifest and interact with each other at each step of the process to hinder successful implementation. Further, our study has a highly actionable focus on informing development of implementation strategies to support HCWs implementing assisted ICT. Our study also has limitations. Firstly, while our sole focus on HCWs allowed for deeper exploration of assisted ICT from the perspective of those actually implementing it on the ground, this meant that our analysis did not include perspectives of index or contact clients. In addition, we did not conduct sub-group analyses as interpretation of results would be limited by our small sample size.

Assisted ICT has been widely recognized as an evidence-based intervention with high promise to increase PLHIV status awareness [ 5 , 6 , 7 , 10 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 23 , 24 , 26 , 27 , 28 , 29 ], which is important as countries in eastern and southern Africa strive to reach global UNAIDS targets. Study findings support cumulative evidence that HCWs face a variety of feasibility barriers to assisted ICT implementation in the region; further, the study’s uniquely in-depth focus on the experiences of those doing the “assisting” enhances understanding of how these barriers manifest and informs the development of implementation strategies to mitigate these barriers. Maximizing assisted ICT’s potential to increase HIV testing requires equipping HCWs with effective training and support to address and overcome the many feasibility barriers they face in implementation. Findings demonstrate the need for, as well as inform the development of, implementation strategies to mitigate barriers and promote facilitators to feasibility of assisted ICT.

Availability of data and materials

Qualitative data on which this analysis is based, as well as data collection materials and codebooks, are available from the last author upon reasonable request. The interview guide is included as an additional file.

Abbreviations

Acquired Immunodeficiency Syndrome

Antiretroviral Therapy

Health Care Worker

Human Immunodeficiency Virus

HIV Testing Services

Index Case Testing

In-Depth Interview

Intimate Partner Violence

Institutional Review Board

President’s Emergency Plan for HIV/AIDS Relief

People Living With HIV

Joint United Nations Programme on HIV/AIDS

World Health Organization

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Acknowledgements

We are grateful to the Malawian health care workers who shared their experiences through in-depth interviews, as well as to the study team members in Malawi and the United States for their contributions.

Research reported in this publication was funded by the National Institutes of Health (R01 MH124526) with support from the University of North Carolina at Chapel Hill Center for AIDS Research (P30 AI50410) and the Fogarty International Center of the National Institutes of Health (D43 TW010060 and R01 MH115793-04). The funders had no role in trial design, data collection and analysis, decision to publish or preparation of the manuscript.

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Caroline J. Meek

Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA

Caroline J. Meek, Milenka Jean-Baptiste, Jiayu Wang, Clare Barrington, Vivian F. Go & Nora E. Rosenberg

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Tiwonge E. Mbeya Munkhondya

Baylor College of Medicine Children’s Foundation, Lilongwe, Malawi

Mtisunge Mphande, Tapiwa A. Tembo, Mike Chitani, Dhrutika Vansia, Caroline Kumbuyo, Katherine R. Simon & Maria H. Kim

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Contributions

TAT, KRS, SER, MHK, VFG, and NER contributed to overall study conceptualization, with CJM, CB, and NER leading conceptualization of the analysis presented in this study. Material preparation and data collection were performed by TEMM, MM, TAT, MC, and CK. Analysis was led by CJM with support from MJB and DV. The first draft of the manuscript was written by CJM with consultation from NER, TEMM, MM, TAT, MJB, and DV. JW provided quantitative analysis support for participant characteristics. All authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

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Correspondence to Caroline J. Meek .

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Ethical clearance was provided by the Malawi National Health Science Research Committee (NHSRC; #20/06/2566), University of North Carolina Institution Review Board (UNC IRB; #20–1810) and the Baylor College of Medicine institutional review board (Baylor IRB; H-48800). The procedures used in this study adhere to the tenets of the Declaration of Helsinki. Written informed consent for participation was obtained from all study participants prior to enrollment in the parent study. Interviewers also engaged in informal verbal discussion of consent immediately ahead of in-depth interviews.

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Use of the International IFOMPT Cervical Framework to inform clinical reasoning in postgraduate level physiotherapy students: a qualitative study using think aloud methodology

• Katie L. Kowalski 1 ,
• Heather Gillis 1 ,
• Katherine Henning 1 ,
• Paul Parikh 1 ,
• Jackie Sadi 1 &
• Alison Rushton 1  

BMC Medical Education volume  24 , Article number:  486 ( 2024 ) Cite this article

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Vascular pathologies of the head and neck are rare but can present as musculoskeletal problems. The International Federation of Orthopedic Manipulative Physical Therapists (IFOMPT) Cervical Framework (Framework) aims to assist evidence-based clinical reasoning for safe assessment and management of the cervical spine considering potential for vascular pathology. Clinical reasoning is critical to physiotherapy, and developing high-level clinical reasoning is a priority for postgraduate (post-licensure) educational programs.

To explore the influence of the Framework on clinical reasoning processes in postgraduate physiotherapy students.

Qualitative case study design using think aloud methodology and interpretive description, informed by COnsolidated criteria for REporting Qualitative research. Participants were postgraduate musculoskeletal physiotherapy students who learned about the Framework through standardized delivery. Two cervical spine cases explored clinical reasoning processes. Coding and analysis of transcripts were guided by Elstein’s diagnostic reasoning components and the Postgraduate Musculoskeletal Physiotherapy Practice model. Data were analyzed using thematic analysis (inductive and deductive) for individuals and then across participants, enabling analysis of key steps in clinical reasoning processes and use of the Framework. Trustworthiness was enhanced with multiple strategies (e.g., second researcher challenged codes).

For all participants ( n  = 8), the Framework supported clinical reasoning using primarily hypothetico-deductive processes. It informed vascular hypothesis generation in the patient history and testing the vascular hypothesis through patient history questions and selection of physical examination tests, to inform clarity and support for diagnosis and management. Most participant’s clinical reasoning processes were characterized by high-level features (e.g., prioritization), however there was a continuum of proficiency. Clinical reasoning processes were informed by deep knowledge of the Framework integrated with a breadth of wider knowledge and supported by a range of personal characteristics (e.g., reflection).

Conclusions

Findings support use of the Framework as an educational resource in postgraduate physiotherapy programs to inform clinical reasoning processes for safe and effective assessment and management of cervical spine presentations considering potential for vascular pathology. Individualized approaches may be required to support students, owing to a continuum of clinical reasoning proficiency. Future research is required to explore use of the Framework to inform clinical reasoning processes in learners at different levels.

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Introduction

Musculoskeletal neck pain and headache are highly prevalent and among the most disabling conditions globally that require effective rehabilitation [ 1 , 2 , 3 , 4 ]. A range of rehabilitation professionals, including physiotherapists, assess and manage musculoskeletal neck pain and headache. Assessment of the cervical spine can be a complex process. Patients can present to physiotherapy with vascular pathology masquerading as musculoskeletal pain and dysfunction, as neck pain and/or headache as a common first symptom [ 5 ]. While vascular pathologies of the head and neck are rare [ 6 ], they are important considerations within a cervical spine assessment to facilitate the best possible patient outcomes [ 7 ]. The International IFOMPT (International Federation of Orthopedic Manipulative Physical Therapists) Cervical Framework (Framework) provides guidance in the assessment and management of the cervical spine region, considering the potential for vascular pathologies of the neck and head [ 8 ]. Two separate, but related, risks are considered: risk of misdiagnosis of an existing vascular pathology and risk of serious adverse event following musculoskeletal interventions [ 8 ].

The Framework is a consensus document iteratively developed through rigorous methods and the best contemporary evidence [ 8 ], and is also published as a Position Statement [ 7 ]. Central to the Framework are clinical reasoning and evidence-based practice, providing guidance in the assessment of the cervical spine region, considering the potential for vascular pathologies in advance of planned interventions [ 7 , 8 ]. The Framework was developed and published to be a resource for practicing musculoskeletal clinicians and educators. It has been implemented widely within IFOMPT postgraduate (post-licensure) educational programs, influencing curricula by enabling a comprehensive and systemic approach when considering the potential for vascular pathology [ 9 ]. Frequently reported curricula changes include an emphasis on the patient history and incorporating Framework recommended physical examination tests to evaluate a vascular hypothesis [ 9 ]. The Framework aims to assist musculoskeletal clinicians in their clinical reasoning processes, however no study has investigated students’ use of the Framework to inform their clinical reasoning.

Clinical reasoning is a critical component to physiotherapy practice as it is fundamental to assessment and diagnosis, enabling physiotherapists to provide safe and effective patient-centered care [ 10 ]. This is particularly important for postgraduate physiotherapy educational programs, where developing a high level of clinical reasoning is a priority for educational curricula [ 11 ] and critical for achieving advanced practice physiotherapy competency [ 12 , 13 , 14 , 15 ]. At this level of physiotherapy, diagnostic reasoning is emphasized as an important component of a high level of clinical reasoning, informed by advanced use of domain-specific knowledge (e.g., propositional, experiential) and supported by a range of personal characteristics (e.g., adaptability, reflective) [ 12 ]. Facilitating the development of clinical reasoning improves physiotherapist’s performance and patient outcomes [ 16 ], underscoring the importance of clinical reasoning to physiotherapy practice. Understanding students’ use of the Framework to inform their clinical reasoning can support optimal implementation of the Framework within educational programs to facilitate safe and effective assessment and management of the cervical spine for patients.

To explore the influence of the Framework on the clinical reasoning processes in postgraduate level physiotherapy students.

Using a qualitative case study design, think aloud case analyses enabled exploration of clinical reasoning processes in postgraduate physiotherapy students. Case study design allows evaluation of experiences in practice, providing knowledge and accounts of practical actions in a specific context [ 17 ]. Case studies offer opportunity to generate situationally dependent understandings of accounts of clinical practice, highlighting the action and interaction that underscore the complexity of clinical decision-making in practice [ 17 ]. This study was informed by an interpretive description methodological approach with thematic analysis [ 18 , 19 ]. Interpretive description is coherent with mixed methods research and pragmatic orientations [ 20 , 21 ], and enables generation of evidence-based disciplinary knowledge and clinical understanding to inform practice [ 18 , 19 , 22 ]. Interpretive description has evolved for use in educational research to generate knowledge of educational experiences and the complexities of health care education to support achievement of educational objectives and professional practice standards [ 23 ]. The COnsolidated criteria for REporting Qualitative research (COREQ) informed the design and reporting of this study [ 24 ].

Research team

All research team members hold physiotherapy qualifications, and most hold advanced qualifications specializing in musculoskeletal physiotherapy. The research team is based in Canada and has varying levels of academic credentials (ranging from Clinical Masters to PhD or equivalent) and occupations (ranging from PhD student to Director of Physical Therapy). The final author (AR) is also an author of the Framework, which represents international and multiprofessional consensus. Authors HG and JS are lecturers on one of the postgraduate programs which students were recruited from. The primary researcher and first author (KK) is a US-trained Physical Therapist and Postdoctoral Research Associate investigating spinal pain and clinical reasoning in the School of Physical Therapy at Western University. Authors KK, KH and PP had no prior relationship with the postgraduate educational programs, students, or the Framework.

Study setting

Western University in London, Ontario, Canada offers a one-year Advanced Health Care Practice (AHCP) postgraduate IFOMPT-approved Comprehensive Musculoskeletal Physiotherapy program (CMP) and a postgraduate Sport and Exercise Medicine (SEM) program. Think aloud case analyses interviews were conducted using Zoom, a viable option for qualitative data collection and audio-video recording of interviews that enables participation for students who live in geographically dispersed areas across Canada [ 25 ]. Interviews with individual participants were conducted by one researcher (KK or KH) in a calm and quiet environment to minimize disruption to the process of thinking aloud [ 26 ].

Participants

AHCP postgraduate musculoskeletal physiotherapy students ≥ 18 years of age in the CMP and SEM programs were recruited via email and an introduction to the research study during class by KK, using purposive sampling to ensure theoretical representation. The purposive sample ensured key characteristics of participants were included, specifically gender, ethnicity, and physiotherapy experience (years, type). AHCP students must have attended standardized teaching about the Framework to be eligible to participate. Exclusion criteria included inability to communicate fluently in English. As think-aloud methodology seeks rich, in-depth data from a small sample [ 27 ], this study sought to recruit 8–10 AHCP students. This range was informed by prior think aloud literature and anticipated to balance diversity of participant characteristics, similarities in musculoskeletal physiotherapy domain knowledge and rich data supporting individual clinical reasoning processes [ 27 , 28 ].

Learning about the IFOMPT Cervical Framework

CMP and SEM programs included standardized teaching of the Framework to inform AHCP students’ clinical reasoning in practice. Delivery included a presentation explaining the Framework, access to the full Framework document [ 8 ], and discussion of its role to inform practice, including a case analysis of a cervical spine clinical presentation, by research team members AR and JS. The full Framework document that is publicly available through IFOMPT [ 8 ] was provided to AHCP students as the Framework Position Statement [ 7 ] was not yet published. Discussion and case analysis was led by AHCP program leads in November 2021 (CMP, including research team member JS) and January 2022 (SEM).

Think aloud case analyses data collection

Using think aloud methodology, the analytical processes of how participants use the Framework to inform clinical reasoning were explored in an interview with one research team member not involved in AHCP educational programs (KK or KH). The think aloud method enables description and explanation of complex information paralleling the clinical reasoning process and has been used previously in musculoskeletal physiotherapy [ 29 , 30 ]. It facilitates the generation of rich verbal [ 27 ]as participants verbalize their clinical reasoning protocols [ 27 , 31 ]. Participants were aware of the aim of the research study and the research team’s clinical and research backgrounds, supporting an open environment for depth of data collection [ 32 ]. There was no prior relationship between participants and research team members conducting interviews.

Participants were instructed to think aloud their analysis of two clinical cases, presented in random order (Supplementary  1 ). Case information was provided in stages to reflect the chronology of assessment of patients in practice (patient history, planning the physical examination, physical examination, treatment). Use of the Framework to inform clinical reasoning was discussed at each stage. The cases enabled participants to identify and discuss features of possible vascular pathology, treatment indications and contraindications/precautions, etc. Two research study team members (HG, PP) developed cases designed to facilitate and elicit clinical reasoning processes in neck and head pain presentations. Cases were tested against the research team to ensure face validity. Cases and think aloud prompts were piloted prior to use with three physiotherapists at varying levels of practice to ensure they were fit for purpose.

Data collection took place from March 30-August 15, 2022, during the final terms of the AHCP programs and an average of 5 months after standardized teaching about the Framework. During case analysis interviews, participants were instructed to constantly think aloud, and if a pause in verbalizations was sustained, they were reminded to “keep thinking aloud” [ 27 ]. As needed, prompts were given to elicit verbalization of participants’ reasoning processes, including use of the Framework to inform their clinical reasoning at each stage of case analysis (Supplementary  2 ). Aside from this, all interactions between participants and researchers minimized to not interfere with the participant’s thought processes [ 27 , 31 ]. When analysis of the first case was complete, the researcher provided the second case, each lasting 35–45 min. A break between cases was offered. During and after interviews, field notes were recorded about initial impressions of the data collection session and potential patterns appearing to emerge [ 33 ].

Data analysis

Data from think aloud interviews were analyzed using thematic analysis [ 30 , 34 ], facilitating identification and analysis of patterns in data and key steps in the clinical reasoning process, including use of the Framework to enable its characterization (Fig.  1 ). As established models of clinical reasoning exist, a hybrid approach to thematic analysis was employed, incorporating inductive and deductive processes [ 35 ], which proceeded according to 5 iterative steps: [ 34 ]

Data analysis steps

Familiarize with data: Audio-visual recordings were transcribed verbatim by a physiotherapist external to the research team. All transcripts were read and re-read several times by one researcher (KK), checking for accuracy by reviewing recordings as required. Field notes supported depth of familiarization with data.

Generate initial codes: Line-by-line coding of transcripts by one researcher (KK) supported generation of initial codes that represented components, patterns and meaning in clinical reasoning processes and use of the Framework. Established preliminary coding models were used as a guide. Elstein’s diagnostic reasoning model [ 36 ] guided generating initial codes of key steps in clinical reasoning processes (Table  1 a) [ 29 , 36 ]. Leveraging richness of data, further codes were generated guided by the Postgraduate Musculoskeletal Physiotherapy Practice model, which describes masters level clinical practice (Table  1 b) [ 12 ]. Codes were refined as data analysis proceeded. All codes were collated within participants along with supporting data.

Generate initial themes within participants: Coded data was inductively grouped into initial themes within each participant, reflecting individual clinical reasoning processes and use of the Framework. This inductive stage enabled a systematic, flexible approach to describe each participant’s unique thinking path, offering insight into the complexities of their clinical reasoning processes. It also provided a comprehensive understanding of the Framework informing clinical reasoning and a rich characterization of its components, aiding the development of robust, nuanced insights [ 35 , 37 , 38 ]. Initial themes were repeatedly revised to ensure they were grounded in and reflected raw data.

Develop, review and refine themes across participants: Initial themes were synthesized across participants to develop themes that represented all participants. Themes were reviewed and refined, returning to initial themes and codes at the individual participant level as needed.

Organize themes into established models: Themes were deductively organized into established clinical reasoning models; first into Elstein’s diagnostic reasoning model, second into the Postgraduate Musculoskeletal Physiotherapy Practice model to characterize themes within each diagnostic reasoning component [ 12 , 36 ].

Trustworthiness of findings

The research study was conducted according to an a priori protocol and additional steps were taken to establish trustworthiness of findings [ 39 ]. Field notes supported deep familiarization with data and served as a means of data source triangulation during analysis [ 40 ]. One researcher coded transcripts and a second researcher challenged codes, with codes and themes rigorously and iteratively reviewed and refined. Frequent debriefing sessions with the research team, reflexive discussions with other researchers and peer scrutiny of initial findings enabled wider perspectives and experiences to shape analysis and interpretation of findings. Several strategies were implemented to minimize the influence of prior relationships between participants and researchers, including author KK recruiting participants, KK and KH collecting/analyzing data, and AR, JS, HG and PP providing input on de-identified data at the stage of synthesis and interpretation.

Nine AHCP postgraduate level students were recruited and participated in data collection. One participant was withdrawn because of unfamiliarity with the standardized teaching session about use of the Framework (no recall of session), despite confirmation of attendance. Data from eight participants were used for analysis (CMP: n  = 6; SEM: n  = 2; Table  2 ), which achieved sample size requirements for think aloud methodology of rich and in-depth data [ 27 , 28 ].

Diagnostic reasoning components

Informed by the Framework, all components of Elstein’s diagnostic reasoning processes [ 36 ] were used by participants, including use of treatment with physiotherapy interventions to aid diagnostic reasoning. An illustrative example is presented in Supplement  3 . Clinical reasoning used primarily hypothetico-deductive processes reflecting a continuum of proficiency, was informed by deep Framework knowledge and breadth of prior knowledge (e.g., experiential), and supported by a range of personal characteristics (e.g., justification for decisions).

Cue acquisition

All participants sought to acquire additional cues early in the patient history, and for some this persisted into the medical history and physical examination. Cue acquisition enabled depth and breadth of understanding patient history information to generate hypotheses and factors contributing to the patient’s pain experience (Table  3 ). All participants asked further questions to understand details of the patients’ pain and their presentation, while some also explored the impact of pain on patient functioning and treatments received to date. There was a high degree of specificity to questions for most participants. Ongoing clinical reasoning processes through a thorough and complete assessment, even if the patient had previously received treatment for similar symptoms, was important for some participants. Cue acquisition was supported by personal characteristics including a patient-centered approach (e.g., understanding the patient’s beliefs about pain) and one participant reflected on their approach to acquiring patient history cues.

Hypothesis generation

Participants generated an average of 4.5 hypotheses per case (range: 2–8) and most hypotheses (77%) were generated rapidly early in the patient history. Knowledge from the Framework about patient history features of vascular pathology informed vascular hypothesis generation in the patient history for all participants in both cases (Table  4 ). Vascular hypotheses were also generated during the past medical history, where risk factors for vascular pathology were identified and interpreted by some participants who had high levels of suspicion for cervical articular involvement. Non-vascular hypotheses were generated during the physical examination by some participants to explain individual physical examination or patient history cues. Deep knowledge of the patient history section in the Framework supported high level of cue identification and interpretation for generating vascular hypotheses. Initial hypotheses were prioritized by some participants, however the level of specificity of hypotheses varied.

Cue evaluation

All participants evaluated cues throughout the patient history and physical examination in relationship to hypotheses generated, indicating use of hypothetico-deductive reasoning processes (Table  5 ). Framework knowledge of patient history features of vascular pathology was used to test vascular hypotheses and aid differential diagnosis. The patient history section supported high level of cue identification and interpretation of patient history features for all but one participant, and generation of further patient history questions for all participants. The level of specificity of these questions was high for all but one participant. Framework knowledge of recommended physical examination tests, including removal of positional testing, supported planning a focused and prioritized physical examination to further test vascular hypotheses for all participants. No participant indicated intention to use positional testing as part of their physical examination. Treatment with physiotherapy interventions served as a form of cue evaluation, and cues were evaluated to inform prognosis for some participants. At times during the physical examination, some participants demonstrated occasional errors or difficulty with cue evaluation by omitting key physical exam tests (e.g., no cranial nerve assessment despite concerns for trigeminal nerve involvement), selecting physical exam tests in advance of hypothesis generation (e.g., cervical spine instability testing), difficulty interpreting cues, or late selection of a physical examination test. Cue acquisition was supported by a range of personal characteristics. Most participants justified selection of physical examination tests, and some self-reflected on their ability to collect useful physical examination information to inform selection of tests. Precaution to the physical examination was identified by all participants but one, which contributed to an adaptable approach, prioritizing patient safety and comfort. Critical analysis of physical examination information aided interpretation within the context of the patient for most participants.

Hypothesis evaluation

All participants used the Framework to evaluate their hypotheses throughout the patient history and physical examination, continuously shifting their level of support for hypotheses (Table  6 , Supplement  4 ). This informed clarity in the overall level of suspicion for vascular pathology or musculoskeletal diagnoses, which were specific for most participants. Response to treatment with physiotherapy interventions served as a form of hypothesis evaluation for most participants who had low level suspicion for vascular pathology, highlighting ongoing reasoning processes. Hypotheses evaluated were prioritized by ranking according to level of suspicion by some participants. Difficulties weighing patient history and physical examination cues to inform judgement on overall level of suspicion for vascular pathology was demonstrated by some participants who reported that incomplete physical examination data and not being able to see the patient contributed to difficulties. Hypothesis evaluation was supported by the personal characteristic of reflection, where some students reflected on the Framework’s emphasis on the patient history to evaluate a vascular hypothesis.

The Framework supported all participants in clinical reasoning related to treatment (Table  7 ). Treatment decisions were always linked to the participant’s overall level of suspicion for vascular pathology or musculoskeletal diagnosis. Framework knowledge supported participants with high level of suspicion for vascular pathology to refer for further investigations. Participants with a musculoskeletal diagnosis kept the patient for physiotherapy interventions. The Framework patient history section supported patient education about symptoms of vascular pathology and safety netting for some participants. Framework knowledge influenced informed consent processes and risk-benefit analysis to support the selection of musculoskeletal physiotherapy interventions, which were specific and prioritized for some participants. Less Framework knowledge related to treatment was demonstrated by some students, generating unclear recommendations regarding the urgency of referral and use of the Framework to inform musculoskeletal physiotherapy interventions. Treatment was supported by a range of personal characteristics. An adaptable approach that prioritized patient safety and was supported by justification was demonstrated in all participants except one. Shared decision-making enabled the selection of physiotherapy interventions, which were patient-centered (individualized, considered whole person, identified future risk for vascular pathology). Communication with the patient’s family doctor facilitated collaborative patient-centered care for most participants.

This is the first study to explore the influence of the Framework on clinical reasoning processes in postgraduate physiotherapy students. The Framework supported clinical reasoning that used primarily hypothetico-deductive processes. The Framework informed vascular hypothesis generation in the patient history and testing the vascular hypothesis through patient history questions and selection of physical examination tests to inform clarity and support for diagnosis and management. Most postgraduate students’ clinical reasoning processes were characterized by high-level features (e.g. specificity, prioritization). However, some demonstrated occasional difficulties or errors, reflecting a continuum of clinical reasoning proficiency. Clinical reasoning processes were informed by deep knowledge of the Framework integrated with a breadth of wider knowledge and supported by a range of personal characteristics (e.g., justification for decisions, reflection).

Use of the Framework to inform clinical reasoning processes

The Framework provided a structured and comprehensive approach to support postgraduate students’ clinical reasoning processes in assessment and management of the cervical spine region, considering the potential for vascular pathology. Patient history and physical examination information was evaluated to inform clarity and support the decision to refer for further vascular investigations or proceed with musculoskeletal physiotherapy diagnosis/interventions. The Framework is not intended to lead to a vascular pathology diagnosis [ 7 , 8 ], and following the Framework does not guarantee vascular pathologies will be identified [ 41 ]. Rather, it aims to support a process of clinical reasoning to elicit and interpret appropriate patient history and physical examination information to estimate the probability of vascular pathology and inform judgement about the need to refer for further investigations [ 7 , 8 , 42 ]. Results of this study suggest the Framework has achieved this aim for postgraduate physiotherapy students.

The Framework supported postgraduate students in using primarily hypothetico-deductive diagnostic reasoning processes. This is expected given the diversity of vascular pathology clinical presentations precluding a definite clinical pattern and inherent complexity as a potential masquerader of a musculoskeletal problem [ 7 ]. It is also consistent with prior research investigating clinical reasoning processes in musculoskeletal physiotherapy postgraduate students [ 12 ] and clinical experts [ 29 ] where hypothetico-deductive and pattern recognition diagnostic reasoning are employed according to the demands of the clinical situation [ 10 ]. Diagnostic reasoning of most postgraduate students in this study demonstrated features suggestive of high-level clinical reasoning in musculoskeletal physiotherapy [ 12 ], including ongoing reasoning with high-level cue identification and interpretation, specificity and prioritization during assessment and treatment, use of physiotherapy interventions to aid diagnostic reasoning, and prognosis determination [ 12 , 29 , 43 ]. Expert physiotherapy practice has been further described as using a dialectical model of clinical reasoning with seamless transitions between clinical reasoning strategies [ 44 ]. While diagnostic reasoning was a focus in this study, postgraduate students considered a breadth of information as important to their reasoning (e.g., patient’s perspectives of the reason for their pain). This suggests wider reasoning strategies (e.g., narrative, collaborative) were employed to enable shared decision-making within the context of patient-centered care.

Study findings also highlighted a continuum of proficiency in use of the Framework to inform clinical reasoning processes. Not all students demonstrated all characteristics of high-level clinical reasoning and there are suggestions of incomplete reasoning processes, for example occasional errors in evaluating cues. Some students offered explanations such as incomplete case information as factors contributing to difficulties with clinical reasoning processes. However, the ability to critically evaluate incomplete and potentially conflicting clinical information is consistently identified as an advanced clinical practice competency [ 14 , 43 ]. A continuum of proficiency in clinical reasoning in musculoskeletal physiotherapy is supported by wider healthcare professions describing acquisition and application of clinical knowledge and skills as a developmental continuum of clinical competence progressing from novice to expert [ 45 , 46 ]. The range of years of clinical practice experience in this cohort of students (3–14 years) or prior completed postgraduate education may have contributed to the continuum of proficiency, as high-quality and diverse experiential learning is essential for the development of high-level clinical reasoning [ 14 , 47 ].

Deep knowledge of the Framework informs clinical reasoning processes

Postgraduate students demonstrated deep Framework knowledge to inform clinical reasoning processes. All students demonstrated knowledge of patient history features of vascular pathology, recommended physical examination tests to test a vascular hypothesis, and the need to refer if there is a high level of suspicion for vascular pathology. A key development in the recent Framework update is the removal of the recommendation to perform positional testing [ 8 ]. All students demonstrated knowledge of this development, and none wanted to test a vascular hypothesis with positional testing. Most also demonstrated Framework knowledge about considerations for planning treatment with physiotherapy interventions (e.g., risk-benefit analysis, informed consent), though not all, which underscores the continuum of proficiency in postgraduate students. Rich organization of multidimensional knowledge is a required component for high level clinical reasoning and is characteristic of expert physiotherapy practice [ 10 , 48 , 49 ]. Most postgraduate physiotherapy students displayed this expert practice characteristic through integration of deep Framework knowledge with a breadth of prior knowledge (e.g., experiential, propositional) to inform clinical reasoning processes. This highlights the utility of the Framework in postgraduate physiotherapy education to develop advanced level evidence-based knowledge informing clinical reasoning processes for safe assessment and management of the cervical spine, considering the potential for vascular pathology [ 9 , 8 , 50 , 51 , 52 ].

Framework supports personal characteristics to facilitate integration of knowledge and clinical reasoning

The Framework supported personal characteristics of postgraduate students, which are key drivers for the complex integration of advanced knowledge and high-level clinical reasoning [ 10 , 12 , 48 ]. For all students, the Framework supported justification for decisions and patient-centered care, emphasizing a whole-person approach and shared decision-making. Further demonstrating a continuum of proficiency, the Framework supported a wider breadth of personal characteristics for some students, including critical analysis, reflection, self-analysis, and adaptability. These personal characteristics illustrate the interwoven cognitive and metacognitive skills that influence and support a high level of clinical reasoning [ 10 , 12 ] and the development of clinical expertise [ 48 , 53 ]. For example [ 54 ], reflection is critical to developing high-level clinical reasoning and advanced level practice [ 12 , 55 ]. Postgraduate students reflected on prior knowledge, experiences, and action within the context of current Framework knowledge, emphasizing active engagement in cognitive processes to inform clinical reasoning processes. Reflection-in-action is highlighted by self-analysis and adaptability. These characteristics require continuous cognitive processing to consider personal strengths and limitations in the context of the patient and evidence-based practice, adapting the clinical encounter as required [ 53 , 55 ]. These findings highlight use of the Framework in postgraduate education to support development of personal characteristics that are indicative of an advanced level of clinical practice [ 12 ].

Synthesis of findings

Derived from synthesis of research study findings and informed by the Postgraduate Musculoskeletal Physiotherapy Practice model [ 12 ], use of the Framework to inform clinical reasoning processes in postgraduate students is illustrated in Fig.  2 . Overlapping clinical reasoning, knowledge and personal characteristic components emphasize the complex interaction of factors contributing to clinical reasoning processes. Personal characteristics of postgraduate students underpin clinical reasoning and knowledge, highlighting their role in facilitating the integration of these two components. Bolded subcomponents indicate convergence of results reflecting all postgraduate students and underscores the variability among postgraduate students contributing to a continuum of clinical reasoning proficiency. The relative weighting of the components is approximately equal to balance the breadth and convergence of subcomponents. Synthesis of findings align with the Postgraduate Musculoskeletal Physiotherapy Practice model [ 12 ], though some differences exist. Limited personal characteristics were identified in this study with little convergence across students, which may be due to the objective of this study and the case analysis approach.

Use of the Framework to inform clinical reasoning in postgraduate level musculoskeletal physiotherapy students. Adapted from the Postgraduate Musculoskeletal Physiotherapy Practice model [ 12 ].

Strengths and limitations

Think aloud case analyses enabled situationally dependent understanding of the Framework to inform clinical reasoning processes in postgraduate level students [ 17 ], considering the rare potential for vascular pathology. A limitation of this approach was the standardized nature of case information provided to students, which may have influenced clinical reasoning processes. Future research studies may consider patient case simulation to address this limitation [ 30 ]. Interviews were conducted during the second half of the postgraduate educational program, and this timing could have influenced clinical reasoning processes compared to if interviews were conducted at the end of the program. Future research can explore use of the Framework to inform clinical reasoning processes in established advanced practice physiotherapists. The sample size of this study aligns with recommendations for think aloud methodology [ 27 , 28 ], achieved rich data, and purposive sampling enabled wide representation of key characteristics (e.g., gender, ethnicity, country of training, physiotherapy experiences), which enhances transferability of findings. Students were aware of the study objective in advance of interviews which may have contributed to a heightened level of awareness of vascular pathology. The prior relationship between students and researchers may have also influenced results, however several strategies were implemented to minimize this influence.

Implications

The Framework is widely implemented within IFOMPT postgraduate educational programs and has led to important shifts in educational curricula [ 9 ]. Findings of this study support use of the Framework as an educational resource in postgraduate physiotherapy programs to inform clinical reasoning processes for safe and effective assessment and management of cervical spine presentations considering the potential for vascular pathology. Individualized approaches may be required to support each student, owing to a continuum of clinical reasoning proficiency. As the Framework was written for practicing musculoskeletal clinicians, future research is required to explore use of the Framework to inform clinical reasoning in learners at different levels, for example entry-level physiotherapy students.

The Framework supported clinical reasoning that used primarily hypothetico-deductive processes in postgraduate physiotherapy students. It informed vascular hypothesis generation in the patient history and testing the vascular hypothesis through patient history questions and selection of physical examination tests, to inform clarity and support for diagnosis and management. Most postgraduate students clinical reasoning processes were characterized as high-level, informed by deep Framework knowledge integrated with a breadth of wider knowledge, and supported by a range of personal characteristics to facilitate the integration of advanced knowledge and high-level clinical reasoning. Future research is required to explore use of the Framework to inform clinical reasoning in learners at different levels.

Data availability

The dataset used and analyzed during the current study are available from the corresponding author on reasonable request.

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The authors would like to acknowledge study participants and the transcriptionist for their time in completing and transcribing think aloud interviews.

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Katie Kowalski: Conceptualization, methodology, validation, formal analysis, investigation, data curation, writing– original draft, visualization, project administration. Heather Gillis: Validation, resources, writing– review & editing. Katherine Henning: Investigation, formal analysis, writing– review & editing. Paul Parikh: Validation, resources, writing– review & editing. Jackie Sadi: Validation, resources, writing– review & editing. Alison Rushton: Conceptualization, methodology, validation, writing– review & editing, supervision.

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Author AR is an author of the IFOMPT Cervical Framework. Authors JS and HG are lecturers on the AHCP CMP program. AR and JS led standardized teaching of the Framework. Measures to reduce the influence of potential competing interests on the conduct and results of this study included: the Framework representing international and multiprofessional consensus, recruitment of participants by author KK, data collection and analysis completed by KK with input from AR, JS and HG at the stage of data synthesis and interpretation, and wider peer scrutiny of initial findings. KK, KH and PP have no potential competing interests.

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Kowalski, K.L., Gillis, H., Henning, K. et al. Use of the International IFOMPT Cervical Framework to inform clinical reasoning in postgraduate level physiotherapy students: a qualitative study using think aloud methodology. BMC Med Educ 24 , 486 (2024). https://doi.org/10.1186/s12909-024-05399-x

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Qualitative analysis is a challenging, yet crucial aspect of advancing research in the field of Human-Computer Interaction (HCI). Recent studies show that large language models (LLMs) can perform qualitative coding within existing schemes, but their potential for collaborative human-LLM discovery and new insight generation in qualitative analysis is still underexplored. To bridge this gap and advance qualitative analysis by harnessing the power of LLMs, we propose CHALET, a novel methodology that leverages the human-LLM collaboration paradigm to facilitate conceptualization and empower qualitative research. The CHALET approach involves LLM-supported data collection, performing both human and LLM deductive coding to identify disagreements, and performing collaborative inductive coding on these disagreement cases to derive new conceptual insights. We validated the effectiveness of CHALET through its application to the attribution model of mental-illness stigma, uncovering implicit stigmatization themes on cognitive, emotional and behavioral dimensions. We discuss the implications for future research, methodology, and the transdisciplinary opportunities CHALET presents for the HCI community and beyond.

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Abstract: Qualitative analysis is a challenging, yet crucial aspect of advancing research in the field of Human-Computer Interaction (HCI). Recent studies show that large language models (LLMs) can perform qualitative coding within existing schemes, but their potential for collaborative human-LLM discovery and new insight generation in qualitative analysis is still underexplored. To bridge this gap and advance qualitative analysis by harnessing the power of LLMs, we propose CHALET, a novel methodology that leverages the human-LLM collaboration paradigm to facilitate conceptualization and empower qualitative research. The CHALET approach involves LLM-supported data collection, performing both human and LLM deductive coding to identify disagreements, and performing collaborative inductive coding on these disagreement cases to derive new conceptual insights. We validated the effectiveness of CHALET through its application to the attribution model of mental-illness stigma, uncovering implicit stigmatization themes on cognitive, emotional and behavioral dimensions. We discuss the implications for future research, methodology, and the transdisciplinary opportunities CHALET presents for the HCI community and beyond.

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Real estate developments in residential architecture: a case study of Jeddah

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Home should be a place for social activities that satisfy both physical and social needs. Real estate developers in Jeddah currently show little consideration for cultural and social patterns of users in residential interior layouts. Therefore, this study aims to investigate apartments released by real estate developers in Jeddah from users’ perspectives. Qualitative and quantitative approaches are applied through in-depth interviews with 21 participants. The interviews investigate participants’ satisfaction, desire to make changes, reasons for making changes, and reasons for not making changes. This study finds that the majority of participants want to make changes to the layout of their homes owing to social activities. The SPSS analysis shows that most participants are less satisfied with the home layouts of RED than homes that are self-built, with a statistical significance of P = 0.002. This study recommends that RED companies should consider open spaces when designing apartments for sale so as to allow users to divide the interior layouts of reception and living zones according to their needs. In order to achieve this by RED, the study recommends more study by electrical engineer for electricity switches location, architects for window location, and construction engineers for column arrangement.

Article Highlights

This study investigates satisfaction with apartments bought in Jeddah, Saudi Arabia.

The study discusses finding in comparison between self-builder and Real estate- developer.

The study conducts 21 interviews with residents and applies a mixed qualitative– quantitative approach for the analysis.

The study discussed privacy, safety and room size or layout as factors for making changes.

In this study a self-builder refers to an owner who deals with a contractor to build a home on their land.

RED refers to Real estate developers

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1 Introduction

Home is the most important place for all people, as it is where they perform most of their activities, such as sleeping, eating, relaxing, cooking, and working. In the Middle East, major, economic and social changes have occurred over the last 10 years, with major shifts in the cities of most countries [ 1 ]. As a result, noticeable changes in economy and culture have occurred, reflecting people’s behaviors and lifestyles, including those related to housing [ 2 ]. Based on these changes, the Saudi 2030 vision aims to increase the number of Saudis who own homes, a common dream in Saudi Arabia [ 3 ].

Many studies have discussed the provision of affordable housing design. They have highlighted insufficient housing as a major issue in many countries [ 4 , 5 ]. For instance, Mulliner and Algrnas [ 6 ] investigated whether housing design fulfill residents’ need and results in housing satisfaction. Ali [ 7 ] argued that home design quality requires further investigation. Other studies, stated that professionals do not focus on thermal comfort or sustainability as much as they care about finishing, building quality, internal layout, and design [ 4 , 8 ]. Meanwhile, many studies have asserted that internal layout and residents’ needs at home are not considered in current design in different countries [ 4 , 5 , 9 , 10 , 11 , 12 ]. In Saudi Arabia, public-private partnership is established to increase the involvement of private sector in order to help in financing and providing affordable house [ 13 ].

2 Factors influencing home purchases

Al-Nahdi, Nyakwende [ 11 ] studied the factors that influence the purchase of homes in Saudi Arabia. He asserts that attitude, subjective norms, perceived behavioral control, and finance are the major factors guiding Saudi consumers to purchase real estate. Many studies agree that attitude is a major factor influencing people ’s home [ 11 , 14 , 15 ]. Attitude is defined as a person favoring or disfavoring an action [ 16 ]. It is also defined as the way in which a person reacts to an object [ 17 ]. Therefore, customers compare the available service with what they expect; if they feel that the provided service does not meet their expectations, it would dissatisfy them. However, if customers meet their expectations and feel satisfied, they purchase from a service provider [ 18 ]. This is in line with [ 19 ], who asserted that purchasers’ feelings are a factor affecting those who buy prefabricated houses. This indicates that the psychological mechanisms underpinning human needs must be considered in home design to fulfill essential human needs [ 20 ]. Meanwhile, many studies have discussed how cultural values and changes in social lifestyles affect people’s preferences for home [ 21 , 22 ] as home reflects social changes [ 2 ].

2.1 Society and culture

Some studies have claimed that a residence is an image that shows the connection between the built environment and cultural values. Therefore, the residence is a window that shows the relationship between culture and the built environment according, create community identity[ 23 ].

This does not end as a building face; it also continues to the interior layout as culture can be recognized from the home layout [ 24 ]. The interior Layout of a residence is a major indicator of its culture and lifestyle [ 22 , 25 ]. Shehab and Kandar [ 21 ] found a strong relationship between home layouts and social changes in Jordan. According to Yazdanfar and Naserdoost [ 26 ] homes are places where people perform their social activities, but there is a noticeable ignorance of the behavioral, cultural, and residential patterns of users in the contemporary design construction industry. Many studies have discussed the relationship between the home and sociocultural values that affect user activities. These factors vary from social norms, cultural values, lifestyles, social status, social network, hospitality, gender segregation, safety, and privacy [2, 9, 21, 22, 24, 25].

The governments of some countries, such as Nigeria, have started to encourage optimal housing design to accommodate user preferences, leading to the production of homes that consider the sociocultural attributes of residence [ 27 ]. According to Mnea and Zairul [ 4 ] architectural design that fulfills social needs in Saudi Arabia is called “ socially based design, ” as many studies have confirmed the importance of home, health, and social factors that reflect home design housing [ 4 , 28 ]. Abed, Obeidat [ 12 ] found that sociocultural factors play a major role in residents’ satisfaction and unit layout transformation. The author asserts that sociocultural factors lead people to change their home layouts. The four main reasons for layout transformation are gender segregation, privacy, social networking, and safety. The quantitative and qualitative analyses in this study revealed that privacy is a major social factor in the internal layout.

The issue of privacy has been addressed in many studies, as it plays a major role in spatial design. It is one of the reasons why residents change their interior layout after renting or buying a home [ 2 , 9 ]. Although privacy is important to all humans, it is highly connected to religion and culture in the Middle East [ 29 , 30 , 31 ].

2.2 Layout transformation

Layout transformation differs from rearrangement. rearrangement changes the color of walls or furniture. Meanwhile, structural transformations, such as breaking or adding walls, result in home layout transformation, which can occur over time in a series of processes [ 32 ] . Others have defined residential layout changes as the process of expanding or modifying interior or exterior layout arrangements. These changes can occur in small or large parts of a home, leading to structural changes. This is done for various reasons such as social, growth, and self-expression [ 33 ]. Similarly, Makachia [ 34 ], van Griethuijsen [ 35 ] concurred that this transformation is a result of the physical, behavioral, and cultural needs of residents. Therefore, understanding residents’ social and physical needs helps create relationships between the motivational factors for users and the housing layout. According to Abed, Obeidat [ 12 ] layout transformation is a common phenomenon that require s” identification in terms of cause and effect ”.

Other studies have discussed cultural changes and home layouts in the Western and Eastern regions [ 2 , 12 , 24 , 31 ]. Additionally, Rapoport [ 36 ] states that home layouts can be supportive or disruptive of residents’ social and cultural needs. Therefore, changes in culture

should be considered in housing design, as it is an important determinant of residents’ satisfaction [ 22 ]. Coming along with Farhat and Alaeddine [ 37 ] claimed that respect for users’ needs should be considered in many aspects, including psychological and economic aspects. Privacy is considered a major psychological and physical aspect affecting residents’ comfort. Privacy is either visual or physical and is a major part of cultural and religious beliefs [ 2 , 30 , 31 ]. This is in line with other studies that have found that ignoring cultural needs, such as privacy, leads to residents’ dissatisfaction and making changes in their home layout [ 2 , 12 ]. Privacy requires gender segregation between the same family or between the family and guests [ 2 , 12 , 31 , 38 ]. Tomah, Ismail [ 29 ] assessed home layouts in Amman to discover how new domestic designs affect users’ privacy in their homes. He analyzed different home layouts in terms of privacy and functional zones. This study found that the number of zones and privacy increased in the homes. He asserted that there is a real need to study different space layouts to achieve a high level of privacy, which will result in an increase in the quality of life.

Avogo [ 39 ] highlighted that transforming the layout of public homes is an essential part of human life. In the same context, a study by Obeidat, Abed [ 9 ] highlighted the importance of creating levels of flexibility in public residential layouts. He asserted that if architects consider residents' satisfaction and spatial flexibility in their design, they can help stakeholders understand these points during the planning and design stages. Minami [ 10 ] investigated layout changes in different types of apartments in Japan and found that the room layout changed in most cases to increase the size of living rooms or private rooms. He also found that most layout changes occur after children become older and leave home. They moved the partitioning wall to separate the two rooms to adapt to the changing needs of the residents. Similarly, Agyefi-Mensah S [ 40 ] asserted that most residents modified their home layout after moving home to fulfill their needs.

The concept of flexibility in home design involves creating movable parts or open plans [ 41 ]. For example, in traditional Malay housing, social and religious values are reflected through the application of spatial flexibility. Flexibility refers to an open plan with fewer walls and boundaries to create open spaces [ 42 ]. Flexible domestic practices provide an opportunity for users to participate in their home design, such as arranging their living areas according to their needs and life changes. This indicates that flexible housing helps users develop a sense of belonging to their living space, as they can adapt it according to their different demands [ 41 ].

Studies have investigated the concept of layout transformation from a historical perspective, such as [ 2 ] or from socioeconomic, cost, and price policies [ 3 ]. Other studies in Japan, Jordon investigated the phenomena of home layout transformation according to their culture needs [ 9 , 10 , 24 ]. Despite the importance of such studies, little attention has been paid to home layout transformations in Saudi Arabia. Mohanna [ 43 ]studies housing preferences across Saudi Arabia in Dammam. The study found that of the three types of homes–villas, detached duplexes, and semi-detached duplexes–detached duplexes are most preferred for nuclear families. However, the statistics show that apartments are the most purchased type of residence in Jeddah. Therefore, this study focuses on home layout transformation, particularly in Jeddah City, which is the second most important city in the Kingdom of Saudi Arabia. In addition, the

city has faced a boom in apartments designed by real-estate developers over the last 10 years. The high cost of houses in Jeddah has led people to buy apartments.

2.3 Domestics in Jeddah

Jeddah City is located on the west coast of Saudi Arabia and experiences hot and humid weather [ 44 ]. It is the second largest urban area and an important commercial center in the Kingdom [ 45 ]. The Population in Jeddah has grown rapidly over the last 10 years, reaching an estimated 3,712,917 million. The number of people who owned apartments in Jeddah was 109, 870, and 39,464, respectively. Meanwhile, the number of people who own a house is 65,184 and 24, 426 rent a house [ 46 ]. This shows that Apartment is more preferred by people in Jeddah even if they dream of owning a house due to high cost of living [ 47 ]. This made the release of apartments a trend in Jeddah City, as finance is a major factor affecting customers’ decisions when purchasing housing. Similarly, Paço [ 48 ] claims that finance is sometimes the most influential purchaser decision when buying a home. In Saudi Arabia, most reports assert high demand in the real estate market for real estate units, especially residences, write the number of home needs [ 49 ]. To help Saudis own their homes by providing funds. This fund is called the Real Estate Development Fund (REDF). It reached 500, 000 SR with no interest. The condition for this fund, which takes a maximum of 25 years to return, is to be above 21 years old and did not receive the fund before, so it was once per life. However, people seek homes that fulfill their needs; therefore, it is important to investigate the factors guiding people to buy a home in the Saudi market [ 11 ]. Therefore, this study aims to investigate satisfaction with apartments bought in Jeddah from users’ perception in relation to type of builder either self-builder and Real estate-developer as little studies have been conducted to discuss this subject. In order to fulfill this gap in Knowledge, the study conducted 21 interviews with residents and apply a mixed qualitative– quantitative approach to analyze reasons for making changes in home is such as privacy, safety, and room size or layout, and obstacles for not making changes.

3 Methodology

This study applied a mixed-method qualitative and quantitative approach to investigate participants’ satisfaction with their purchased apartments. It also discusses participants’ desire to make changes and reasons for making changes or for not being able to make them. Face-to-face, in-depth, semi-structured interviews were conducted with space owners (only females). Spatial architecture plans of the participants' apartments were discussed through interviews to help them discuss the issues in the apartment plan; however, most plans could not be displayed here, as most participants requested.

3.1 Interviews

The research explained study objectives, aim, and role of participants in the study. A verbal consent upon starting interview was obtained from all participants. The researcher conducted in- depth semi-structured interviews with 21 residents who owned apartments in Jeddah to collect the data required for the study. The interview questions were presented in Arabic because most

participants spoke Arabic only. All Interviews were conducted face-to-face, and the participants brought a printed copy of the apartment floor plan. The interviews lasted 30–45 min. The aim of these interviews was to understand why residents changed the layout of their apartments either before or after they lived in it. NVivi 12 software was used to analyze the data and identify the main points from the participants’ discussions. Interviews were conducted after obtaining permission from participants. the following axes are addressed:

First axis: Demographic questions, gender, age, family members, and type of home.

Second axes: years living in the apartments, type of builder.

Third axes: satisfaction with the apartments.

Fourth axis: The three major factors for layout transformation are privacy, safety, room size, and flat layout.

Fifth axes: obstacle that stops them from making the change.

A previous study discussed the reasons for layout changes, such as privacy, safety, hospitality, and social values, as shown in Table 1 . The reasons discussed in this study are safety, privacy, room size, and flat layout.

3.2 Study sample

A total of 21 female were interviewed to represent the study sample. Table 2 organizes participants according to their demographic information, age, family members, and type of home.

3.3 Data analysis

Analysis of the interview transcript theme organization was performed using NVivo 12. NVivo helps the researcher to categorize, count, and organize the number of participants who discussed certain themes or gave similar answers. The analysis was performed in five steps as shown in Fig. 1 . First, participants were asked whether they were self-builders or real estate developers. It discussed the participants’ desire to make changes (whether they did or did not). Subsequently, the changes made by the participants and the reasons for these changes were analyzed. Subsequently, we discuss the reasons for these changes. It is important to highlight whether these changes were related to the type of builder used. Also, the author’s observation of current floor plans for RED that is for sale is analyzed.

Source: Author (2024)

Steps of data analysis.

3.4 Statistical analysis

To support the interview findings, a statistical analysis of the 21 participants was performed to determine whether the type of builder or years of living in the flat created any significant differences in terms of the need for layout transformation or participants’ satisfaction. SPSS software was used to perform statistical analysis (version 27). A chi-square test was used to examine the participants’ satisfaction and type of builder or years of living in the flat, which resulted in any significant differences needed for layout transformation. The data presented in the results are frequencies. Statistical significance was set at be statistically significant.

4 Results and discussion

4.1 type of builder.

Table 3 illustrates that the majority of participants (6%) had bought their homes in the last 5 years through a real estate development company. Only 47% of participants had self-built. It is important to note that 28% participant out of 47% owned a home 10 years previously. This indicates that real estate developers were more likely to be major sellers in the last 5 years. It was also found that the most common age for buying a home was 40 years and older. This could be because time was needed to save money, as participants mentioned. It is also found that 13 out of 21 own home in east and south zone of Jeddah. This is because homes in these zones are less expensive than those in the northern or western zones of the city. This is in line with the two most influential factors affecting buyer decisions to own a house: location and price (Nowilaty and Saci [ 50 ]). Finance is a strong factor affecting home purchases in Saudi Arabia [ 11 ].

4.2 Layout transformation

Previous studies have revealed that the lack of sociocultural considerations in designing houses’ internal layouts limits residents’ satisfaction [ 2 , 22 , 30 ]. Users change their residential interior layout in public housing because of a lack of flexibility [ 51 ]. Other studies have revealed that gender segregation and privacy are two major factors for layout transformations in residence [ 9 , 12 ]. Previous studies have discussed reasons for layout changes, including privacy, safety, hospitality, and social values [ 9 , 12 ]. Safety affects housing layout, as it makes residents cover balconies and add new entrances [ 12 ].

In this study, Fig. 2 shows compares the desire to make changes in relation to years of residence and type of builder. The majority of participants (50%) who bought homes from real estate developers wanted to make up to four changes within less than 5 years of living. Meanwhile, only 20% participants who had built their own homes wanted to make changes. Fig. 3 Privacy was the main reason, with 63% citing this as the reason for changes, followed by apartment layout and room size (44%) and safety (40%). Participants discussed that the room size is much larger if it is built by a self-builder, especially before 10 years. Regarding safety, Fig. 4 illustrates that 45% of participants claimed that in real estate developer apartments, windows had no safety iron on the outside to protect children, as in the past for self-built homes. Furthermore, an open kitchen was an issue for 31% of participants, as they found that it was not safe for children. In addition to safety, Fig. 5 shows that,18% of participants found that open kitchens were not private if there were guests.

Reasons for making changes.

Number of changes participants want to make at their home in relation to years of residence and type of builder.

Safety issues in participants home design.

Privacy issues with participants’ home design.

In the last 5 years, flat layout and room size have decreased. This is in line with Minami [ 10 ], who found that in Japan, residents change their home layout to increase the size of living rooms or private rooms. In align with Minami, observation in this study indicates that breaking walls to make one large room from two rooms was a common change among the participants. Participants made this change in the reception and dining rooms. Table 4 shows the observation of architectural and constructional Issues at participants' floor plan. It highlights that distance between two columns is small, which will not help if residence want to open two rooms to become one big room. It also shows that the number of doors can be an issue when arranging furniture. Additionally, big façade window with no safe balcony for cleaning needs more study by architects. One of the most important observations that roof apartments do not have big window for view, which is also recommended by residences. Hence, the internal design does not provide enough space for domestic Worker room, storage spaces for machines such as Vacuum, and laundry room. Bedroom must have enough space for closet to store clothes. Therefore, Specialists in designing interior spaces must intervene in the design, meaning that the plans can be presented as competitions in architecture colleges in the Kingdom of Saudi Arabia to come up with the best design that is compatible with the needs of the Saudi family.

The SPSS analysis in Table 5 shows the main causes of the changes in houses. Among safety, privacy, and number of rooms, only privacy was statistically significant (P=0.02). For individuals who made changes in their houses, privacy scored the lowest at 2.8± 1.6 whereas for individuals who did not apply changes, privacy scored higher at 4.2±1.1.

4.3 Data presented as mean and stander division

Table 6 presents the relationships between satisfaction, years of living, and type of builder. General satisfaction was not related to years of living or the type of builder. A statistical significant correlation was observed between satisfaction with distribution and type of builder, where individuals who bought their homes from real estate developers had a lower satisfaction score of 1.8± 1.2 compared with self-builders, who scored 3.9± 1.3 (P=0.002).

4.4 Reasons for not making changes

As Al-Nahdi, Nyakwende [ 11 ], Paço [ 48 ], Abd Rahman, Sulong [ 52 ] showed, finance is the main reason users buy houses or flats. This study found that financial reasons were a major reason for not making changes in the participants’ homes after purchasing, as shown in Fig. 6 . This indicates that 59% of participants claimed that they could not make changes because of financial reasons. Then, 50% cited building rules for making external changes, such as making a balcony because a window was large and could not be cleaned from the outside, necessitating a small balcony. Time and leaving home were cited least often as the reasons at 27% and 13%, respectively.

Reasons for not making changes.

The SPSS analysis in Table 7 represents the barriers to not making changes to the house. Although there were no statistically significant differences between individuals who made changes and those who did not (P>0.05), the financial barriers for not making changes scored highest at 4.2±1.4, followed by building rules 4±1.6, going out 3±1.6, and time 2.6±1.5.

5 Conclusion

The Saudi 2030 vision aims to increase the number of Saudis who own home, a common dream in Saudi Arabia [ 3 ]. This makes home ownership an important investment for Saudi families, as most people spend a considerable amount of time at home. Thus, home design should consider residents’ needs [ 12 ]. Mulliner and Algrnas [ 6 ] investigated whether housing design fulfills residents’ needs and results in housing satisfaction. Ali [ 7 ] argued that home design quality requires further investigation. Meanwhile, many studies have asserted that internal layout and residents’ needs at home are not considered in the current design of homes in different countries [ 4 , 5 , 9 , 10 , 11 , 12 ]. In aligned with the above studies, this study revealed that participants; needs should be considered by real estate developers in Jeddah. This study discussed participants’ need for layout transformation in their own apartments in Jeddah. A qualitative approach was employed to conduct interviews with 21 female residents. The study found that the majority of participants wanted to make changes to their homes owing to considerations of privacy, safety, and room size or layout. However, this is another expense on top of the high cost of buying a home. The study found that financial reasons were the main reasons constraining the study participants from making changes to their homes. Residents were not fully satisfied with the layout of most apartments designed for sale in Jeddah. The were differences in satisfaction of house distribution between homes bought from real estate developers and self-built homes, where self-builders were more satisfied than those who bought from real estate developers.

In Conclusion, it is important to highlight that this study is only limited to on city, which is Jeddah. Further studies need to be conducted in different cities of Saudi Arabia. Also, the study recommends that real estate development companies should consider open spaces in the design of apartments for sale to allow users to divide the interior layouts of reception and living zones according to their needs.

6 Recommendations

This study also recommends Stakeholders more survey about open space sale apartments.

Further research by construction engineers to study column arrangement, as this is one of the obstacles to making changes.

Study by electrical engineers is recommended as switches location for open space is important.

Availability of data and materials

Data are available upon reasonable request from corresponding author.

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Shatwan, A.M. Real estate developments in residential architecture: a case study of Jeddah. J. Umm Al-Qura Univ. Eng.Archit. (2024). https://doi.org/10.1007/s43995-024-00059-z

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Received : 12 February 2024

Accepted : 31 March 2024

Published : 08 May 2024

DOI : https://doi.org/10.1007/s43995-024-00059-z

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