1. Journal of Advanced Nursing, 2000, 31(4), 926±934 Methodological issues in nursing research
A case for case studies: exploring the use
of case study design in community nursing
research
Ann Bergen BA MSc RGN DipN DNCert Cert Ed DNT
Honorary Research Fellow
and Alison While BSc MSc PhD RGN RHV
Professor of Community Nursing, Research in Health and Social Care Section,
Florence Nightingale School of Nursing and Midwifery,
King's College London, London, England
Accepted for publication 17 September 1999
BERGEN A. & WHILE A. (2000) Journal of Advanced Nursing 31(4), 926±934
A case for case studies: exploring the use of case study design in community
nursing research
The case study has become an accepted vehicle for conducting research in a
variety of disciplines. However, the meaning behind the term is not always
made explicit by researchers and this has given rise to a number of assumptions
which are open to challenge, and to questions about the robustness of the
method. This paper explores some of the issues arising from one particular
de®nition of case study research, used in a study by Yin which examined the
practice of case management in community nursing. Four main areas are
discussed. First, de®ning `case' is seen to pose questions about the relationship
of the phenomenon to its context, the degree of researcher control over case
de®nition, the limits to what may constitute a `case' and what is meant by the
term `unit of analysis'. Second, the relevance of external validity to case study
research is supported through the use of a number of tactics, in particular Yin's
concept of replication logic, which involves generalizing to theory, rather than
to empirical data. Third, the use of method triangulation (multiple methods of
data collection) is advanced as a means of enhancing construct validity in
research where data converge around a particular theory. Finally, the relation-
ship of the case study to theory construction, through the prior development of
`propositions' is discussed. Each of these issues is applied to the design and
conduct of a research study based closely on Yin's multiple case study
framework. Thirteen `cases' were selected of case management practice and data
were collected through interviews and examination of literature and docu-
mentation, to explore the suitability of community nurses for the role. It is
concluded that, given the appropriate subject matter, context and research aims,
the case study method may be seen as a credible option in nursing research.
Correspondence: Ann Bergen, Florence Nightingale School of Nursing and
Midwifery, King's College London, James Clerk Maxwell Building, Waterloo
Road, London SE1 8WA, England.
926 Ó 2000 Blackwell Science Ltd

2. Methodological issues in nursing research Case study design
Keywords: case, case management, case study, unit of analysis, research
methods, nursing, health care
account of the Chicago School of Sociology, has illustrated
INTRODUCTION
this in putting forward their view:
The case study is a familiar yet elusive approach to
In essence, the term `case study' referred to the collection of
research. It is familiar because it has been promoted by
detailed, relatively unstructured information from a range of
researchers and writers from a number of disciplines, for
sources about a particular individual, group or institution,
example education (Ball 1983, Burgess 1985, Hammersley
usually including the accounts of subjects themselves.
1986, Stake 1995), experimental psychology (Barlow &
(Hammersley 1989 p. 93)
Hersen 1984, Robson 1993, Yin 1994) and nursing (Hutch-
inson 1990, Ross & Tissier 1994, Woods 1998). It is It may be suggested that `relatively unstructured infor-
elusive, at least in nursing, because the case study method mation' sits uneasily with the traditional de®nition of
is usually only given minimal attention in general research as a systematic process, involving discipline and
research textbooks (for example Polit & Hungler 1999, structure (for example Macleod Clark & Hockey 1989,
Burns & Grove 1997) and because much research Powers & Knapp 1990), aimed at extending a given body of
appearing in academic nursing journals which claims to knowledge. This is not to say that Hammersley himself
use the design fails either to de®ne the author's interpret- supported the view of the Chicago School Ð indeed his
ation, or to offer a rationale (Woods 1997). earlier collection of case studies in classroom research
Stake (1994, 1995), who has written extensively on the (Hammersley 1986), which included a variety of approa-
case study method, has commented that: `labels contribute ches, does not indicate any particular view. Nevertheless,
little understanding of what researchers do' (Stake 1994 his edited collection of school studies (Hammersley 1983)
p. 236), implying the need to describe and justify a chosen appears to support the placing of case study research
research method, rather than assume an accepted ®rmly within the qualitative (and, more speci®cally, the
meaning. This is particularly true when the method in ethnographic) paradigm (Ball 1983).
question Ð unlike, for example, the questionnaire or This is a not uncommon position amongst researchers. In
experiment Ð has different interpretations. Thus: nursing, the case study has been categorized by Parse et al.
(1985) as an example of the descriptive method within the
¼ custom is not so strong that researchers (other than graduate
qualitative framework. She saw the purpose of the method
students) will get into trouble by calling anything they please a
as the in-depth investigation of a particular unit or institu-
case study. (Stake 1994 p. 237)
tion, a view subsequently accepted by other writers (for
The aim of this paper is to clarify what is meant by the example, Hutchinson 1990, Powers & Knapp 1990).
label `case study research', through an exploration of its In contrast stands Yin's (p. 13) de®nition, which saw the
de®ning characteristics and some of the issues arising case study as an empirical enquiry that:
from its application. The discussion will be illustrated
· investigates a contemporary phenomenon within its
with particular reference to the work of one of the chief
real-life context; when
proponents of the method, R. K. Yin, and to a particular
· the boundaries between phenomenon and context are
research study making use of case study principles,
not clearly evident.
which sought to identify the current and potential rele-
vance and value of case management to community His de®nition was further elaborated in a second set of
nursing. conditions (Ying 1994 p. 13). The case study enquiry:
· copes with the technically distinctive situation in
DEFINING CASE STUDY RESEARCH which there will be many more variables of interest
than data points, and as one result
A variety of schools of thought have in¯uenced the
· relies on multiple sources of evidence, with data
development of the case study method throughout the
converging in a triangulating fashion; and as another
19th and 20th centuries, from disciplines as disparate as
result
anthropology and sociology, on the one hand
· bene®ts from the prior development of theoretical
(Hammersley 1989, Hamel et al. 1993), to pure science
propositions to guide data collection and analysis.
and the single case experiment on the other (Barlow &
Hersen 1984). This poses problems when seeking a This at once differentiates case study research, not only
de®nition of the method and Hammersley (1989), in his from experimental and quasi-experimental designs, which
Ó 2000 Blackwell Science Ltd, Journal of Advanced Nursing, 31(4), 926±934 927

3. A. Bergen and A. While
aim to divorce the phenomenon under study from its
Case and context
context, but also from historical research, which does not
study contemporary events, and surveys, which attempt to In stating, in his de®nition, that the boundaries between
limit the number of variables under investigation. Yin phenomena and context are not clearly demarcated, Yin
subsequently challenged many of the commonly held (1994 p. 13) seemed clear that the case study would
assumptions about case study research; it was not to be necessarily include data relating to that context because
seen as synonymous with ethnography, nor did it always the researcher `deliberately wanted to cover contextual
focus on one single person, group or institution. Finally, conditions'. This appears to have marked a development
though in-depth in nature, data were certainly not to be in Yin's thinking, since the ®rst and revised editions of his
seen as lacking structure. basic text (Yin 1984, 1989) failed to mention this inclu-
However, though persuasive and comprehensively siveness, while his later book of applications of case study
explored, Yin's concept of case study research does bear method (Yin 1993) implied the point only through the
scrutiny, particularly in the context of any particular addition to his de®nition for the ®rst time of the clause
application. Four major areas of debate will therefore be about variables and data points (see above). At the same
considered in relation to the strategy adopted in a piece of time, his emphasis on the need clearly to de®ne the case
empirical research. These issues focus on: (i) case and meant that case-related and context-related data were not
context; (ii) external validity; (iii) triangulation; and to be treated in the same way.
(iv) the relationship to theory, and are roughly equivalent This poses challenges for the researcher, not least
to the four major sections of Yin's de®nition. The discus- because his examples in the `applications' book (Yin
sion will be preceded by a brief outline of the study's 1993) fail to illustrate in detail how this principle should
subject matter. be operationalized. Nevertheless, Yin's unfolding theory
is perhaps more helpful than that of Stake, who wrote, on
the one hand, about the case as `a bounded system' (Stake
THE RESEARCH STUDY: CASE MANAGEMENT
1995 p. 2) and `the boundaries of the case' (Stake 1994
AND COMMUNITY NURSING
p. 237), while referring, on the other hand, to the `in®n-
The term `case management' (or the government's more itely complex' nature of case and context, where `the
recently preferred usage `care management') has, over the phenomena are ¯uid and elusive' (Stake 1995 p. 33).
last 10 years, become familiar to community nurses in all Contextual issues were shown in the literature to be
specialisms. This is largely due to the prominence it was important to the phenomenon of case management, in the
given in the White Paper Caring for People (Department form of national policy, professional theory and local
of Health, DoH 1989), where it was proposed, along with organizational structures, so Yin's speci®c counsel of
joint assessment, as the `cornerstone of high quality care' inclusion would certainly seem appropriate here.
(para.1á11). The government was not prescriptive about Most researchers appear to support Yin's emphasis on
the professional background most appropriate for the the importance of a clear de®nition of `the case'. However,
case manager role; however, the research undertaken to experts differ as to whether this should be imposed by the
date displays, in the main, a social services' orientation. researcher or be evolutionary in nature. Hamel et al.
Although there is evidence of nurses undertaking case (1993) recommended the active selection of the ideal case
management, the nursing perspective has not been a in order to grasp the object of study and that the researcher
feature of either individual projects nor reviews (for intervene to produce a de®nition rather than having it
example, Challis 1994, Phillips & Penhale 1996). imposed by the ®eld or key informants. Robson (1993),
A search of the literature (Bergen 1992) highlighted a who, in many respects, comes closer to Yin in his
number of questions relating to the potential of commu- conceptualization of the case study than most other
nity nurses within the case management remit. It was writers, has referred to both `prestructured' and `emergent'
these questions which the research study attempted to designs, with a necessary trade-off between looseness and
address. selectivity, meaning that most research falls somewhere
The research was based on a multiphase design, further between these two extremes. But Robson's `real world'
details of which may be found elsewhere (Bergen 1993, research leaves room for a type of pragmatism which Yin
1994, 1995, 1997). The case studies comprised the third would probably denounce as unsatisfactory.
phase (following a telephone survey and a questionnaire Although not overtly allied to one particular camp here,
survey) and aimed to provide an in-depth analysis of case Yin implied researcher control over the case de®nition in
management projects involving community nurses along a his assertion that it should follow logically from the nature
number of parameters identi®ed in the literature and the of the research question and focus on the possession of
earlier phases. The issues confronting the researcher in characteristics of interest. Moreover, so that ®ndings can
this undertaking are addressed in terms of the four main be compared with previous research, `key de®nitions
areas of debate identi®ed above. should not be idiosyncratic. Rather, each case study¼.
928 Ó 2000 Blackwell Science Ltd, Journal of Advanced Nursing, 31(4), 926±934

4. Methodological issues in nursing research Case study design
should be similar to those previously studied by others'
(Yin 1994 p. 25). This approach would sit readily with the
subject of case management, as it appears in the literature.
In seeking a de®nition, the question arises of whether
anything (within, perhaps, the above limitations) can be a
case if so designated. Stake (1995) strongly countered this
position with the example of a teacher who, he suggested,
could appropriately constitute a case, but not her teaching,
since this would lack speci®city. Interestingly, Yin (1994)
disagreed with this assertion, claiming Stake himself to be
too broad in his approach. Yin's wording, in a footnote to
the subject of de®nitions, implied that Stake failed to
differentiate the case study (a research method) and the
case (its object). De®ning the former in terms of an entity Figure 1 Basic types of design for case studies.
would mean that any object could then be labelled a case
study regardless of methodology used. This would clearly the `case within a case' as he studied classroom, teacher
belittle the discipline. The case, on the other hand, and pupil in order to build up the picture of the school
according to Yin (1994 p. 22) `can be some event or entity itself. Stake is one of only a few researchers, like Yin, to
that is less well de®ned than a single individual' (the detail the case study approach in action, which is both
usual choice and that adopted by Stake) and `case studies useful for other researchers and adds credibility to their
have been done about decisions, about programs, about theory.
the implementation process and about organizational In the case management research illustrated here, the
change'. issue was dealt with in two ways. First, it was decided to
There is a substantial difference here, and this broader adopt Yin's (and Stake's) notion of designating a unit
view was felt to hold potential for the present study, smaller than the case for purposes of analysis, in order to
where case management practice, within a given location build up the case picture. Thus the case (community nurse
(case study site), rather than the practitioner, would case management practice within the case study site) was
provide the most useful focus because the research ques- subdivided into its component parts (the practices of
tion revolved around professional theory and practice individual case managers). In order to be clear about
from two disciplines (nursing and case management) and terminology, the former (the case) was termed the main
their interrelationship. Individual practitioners could be unit and the latter (individual practice) a subunit
seen as the vehicles for this practice. (Figure 2). This overcomes Yin's rather confusing and
Discussion about de®ning `the case' prompts clari®ca- various references to the `unit', `embedded units' and, in
tion of other terminology, in particular the term `unit of one instance, `subunits' (Yin 1994 p. 41). However, unlike
analysis'. This latter term is one example of research Yin and Stake in their implications (though the point was
terminology which is commonly used and accepted, but
rarely de®ned. Yin appeared, initially, to imply equiv-
alence with case in his reference to `the de®nition of the
unit of analysis (and therefore of the case)¼' (Yin 1994
p. 22, authors' emphasis) and this may be taken further as
read in his summary of the same section, where he
referred to `the unit of analysis (or the case itself)¼' (Yin
1994 p. 44).
However, in a later discussion on different types of case
study designs, Yin described a 2 ´ 2 matrix, where the
horizontal axis represented single and multiple case
designs, while the vertical axis differentiated between
`holistic' and `embedded' designs, since `within these two
types [that is, single and multiple case designs] there can
also be unitary or multiple units of analysis' (Figure 1)
(Yin 1994 p. 38). In other words, there is an implication
that the case may be disaggregated for the purpose of
analysis. This is a point not addressed by the other main
writers on case study research, although Stake's (1995)
illustrative vignette of Harper School made reference to Figure 2 The case and the context.
Ó 2000 Blackwell Science Ltd, Journal of Advanced Nursing, 31(4), 926±934 929

5. A. Bergen and A. While
Figure 3 Variables, data points and multiple sources of evidence.
made explicit by neither) the unit and subunit were data on professional disciplinary theory and national
qualitatively the same, that is, comprised of case manage- policy, respectively (though interviews could provide
ment practice, rather than, for example, individuals. It was further information on how these were operationalized).
thought this provided the sounder rationale for overall Thus the data collection methods equated with each of the
conclusions about the case. multiple sources of evidence used, while the individual
Second, the term `unit of analysis', like the term `case', sources of data within these methods equated to what Yin
was rede®ned to embrace two distinct meanings, and here termed `data points'. Although Yin failed to de®ne this
the terminology of Moser & Kalton (1971) was found term, this interpretation is consistent with his usage. For
helpful. This differentiated sampling units (the sources of national policy documentation this meant the White Paper
data collection) and units of enquiry (the subjects or (DoH 1989), statute (the NHS & Community Care Act 1990)
variables to be measured). Thus, units of enquiry and implementation guidance (for example DoH/SSI
comprised the case as the main unit and individual case 1991); for literature this meant papers on case manage-
management practices as the subunits. Since data about ment, nursing and research, for local documentation this
the relevant contexts were also to be included, these were meant policies, protocols and standards, and for interview
termed contextual units (of enquiry). Determination of the data this meant interviews with the individual nurse-case
sampling units depended on the chosen methods of data managers, their line managers, patients and carers.
collection, and in this instance it seemed that interviews A schema of this terminology used in the research design
with case management project participants had the best is depicted in Figure 3 and 17 case study sites were
potential to elicit the type of data required to expand on identi®ed from the questionnaire data for in-depth ana-
the questionnaire replies and ful®l the research aims. This lysis, based on this plan.
was identi®ed as a principle data collection method in
case study research by Stake (1995). In addition, the
External validity
scrutiny of documentation relating to local policies and
protocols provided contextual data on local organizational An understanding of the nature of the sampling unit is
structures and practices. crucial to an understanding of the nature of external
The literature on case management and national policy validity within case study design. Critics have argued that
documents already reviewed supplied further contextual case study research is a poor basis for generalization
930 Ó 2000 Blackwell Science Ltd, Journal of Advanced Nursing, 31(4), 926±934

6. Methodological issues in nursing research Case study design
(Stake 1995) but this criticism is based on traditional Yin (1994) advanced the notion of generalizability in
sampling theory, itself based on the representativeness of case study design through his idea of analytical general-
sample selection and the consequent ability to make ization. The vast number of variables under study in
inferences about a population. Since case selection is comparison to the number of data points available has
based largely on other factors, as noted above, the question already been seen to make statistical generalization
arises as to whether generalizability is a redundant impossible, but generalization at the level of theory (rather
concept in this context. than empirical data) becomes possible providing a the-
Most proponents would dispute this view, although the oretical framework is developed ®rst. Yin outlined a
terminology may need to be changed. Stake (1995 p. 7) number of strategies for achieving this and in multiple
suggested that the purpose of much research, not just case case study design the favoured approach is a two-stage
study approaches, is seldom an entirely new under- process. The ®rst stage consists of `pattern matching',
standing of phenomena, but rather a `re®nement of whereby `several pieces of information from the same case
understanding'. This is particularly so with what he may be related to some theoretical proposition' (Yin 1994
termed the collective case study design, where several p. 25) and this strengthens the internal validity of the
cases are selected in order that `by counterexample [each] research where causal relationships are being examined.
case study invites modi®cation of the generalization¼' The second stage consists of replication logic, which is
though `a positive example is likely neither to establish a analogous to multiple experiments, where the results of
generalization nor to modify one, but may increase the the entire case are compared both with other cases and
con®dence that readers have in their (or the researcher's) with the proposed theory. Literal replication occurs where
generalization' (Stake 1995 p. 8). there are predicted similar results. Theoretical replication
Stake (1995) identi®ed two further types of case study occurs where there are contrasting results for predictable
which developed his conceptualization of external validity reasons, and if the cases do not produce results as
as applied to this method. The `intrinsic' study is a `given' predicted, then the initial theory must be revised and
in the sense that there is little researcher in¯uence over retested with another set of cases. An important point
case selection, and the researcher is interested in it: `not with replication logic is that data from sub-units are not
because by studying it we learn about other cases or about pooled across cases, but analysed within cases prior to a
some general problem, but because we need to learn about cross-case analysis at the main unit level.
that particular case' (Stake 1995 p. 3). Analysis is based This approach seemed suitable for the study of case
upon the direct interpretation of this individual instance management. In many ways the research question and the
alone. The `instrumental study, on the other hand, is case de®nition could be seen in terms of Stake's instru-
chosen to answer a speci®c research question, and it is the mental study, where the issue (case management practice),
underlying issue it exempli®es, rather than the case itself, rather than the particular case, provided the focus. Find-
which is important. Analysis is based on a search for ings from one case would also become more meaningful
patterns across a number of cases and for a re®nement of through the use of replication logic, use being made of
understanding through what Stake (1995 p. 74) termed both the literature already reviewed to develop a frame-
`categorical aggregation of instances'. Thus case studies are work, and the ®ndings from the survey stages to provide a
of interest for both their uniqueness and their commonality number of suitable cases, thought to possess the charac-
but, as with the positivist approach, a single case as a teristics under examination. However, both stages of Yin's
negative example can limit generalizability. analytical strategy need to be further detailed, and can be
Hamel et al. (1993 p. 34) similarly developed a two-fold discussed under the remaining two sections of his de®ni-
terminology in their view of the purpose of case study tion given above.
research, which was to move `from local to global'. Here,
the case study was `only microscopic for want of a
Triangulation
suf®cient number of cases' (Hamel et al. 1993 p. 34),
although the authors added that the number was not The use of triangulation in order to undertake the `pattern-
paramount providing each case was suitable for the aim. matching' analysis was said by Yin (1994) to strengthen
However, to Hamel et al. (1993) the single case could also the construct validity of the research Ð the establishment
be seen as representative in its own right provided that of the correct operational measures for the concepts being
there was suf®ciently detailed description, since this studied. Although Yin followed the commonly accepted
would lead to a clearer understanding and hence to typology of triangulation (data triangulation, investigator
explanation. The use of terms such as `explanation of its triangulation, theory triangulation and methodological
properties' (Hamel et al. 1993 p. 37) and `relationships triangulation), his de®nition of these terms differed from
that link the parts' (Hamel et al. 1993 p. 39) is strongly other exponents. Yin (1994) advocated what he termed
suggestive of Yin's (1994) much more explicit view of data triangulation for the case study, though his
subunits within a case. illustration of this on page 93 featured different methods
Ó 2000 Blackwell Science Ltd, Journal of Advanced Nursing, 31(4), 926±934 931

7. A. Bergen and A. While
(interviews, surveys, observation, records, etc.), equival-
Relationship to theory
ent to what Polit & Hungler (1999), for example, termed
`methodological triangulation'. To Polit and Hungler, data To Yin, the relationship of the case study to theory
triangulation implied one method (for example, inter- development, made explicit in the last of his de®ning
viewing) but using multiple data sources (for example, key clauses, underpinned the assumptions underlying his
informants). Powers & Knapp (1990) implied that both other assertions about the method. The limitations of the
usages are acceptable, but made the point that there is no scienti®c method, and a tendency by many researchers to
clear agreement on the meaning of triangulation in view the case study as part of the naturalistic research
research and it is used in very different ways. Therefore, paradigm, have already been noted. Nevertheless, Yin's
those who use the device must specify its meaning within (1994) favoured analytical device of generalizing to some
their work. preformulated theory through replication logic strongly
The purpose, as well as the type, of triangulation in any suggests an adherence to the positivist approach, a
research needs to be made clear, since it affects the logic of conclusion which is further enhanced by his reference to
the overall design. Both Powers & Knapp (1990) and a similarity between the case study method and multiple
Redfern & Norman (1994) have pointed out a dual appli- experiments.
cation here, namely, con®rmation and/or completeness. Yin (1994) accepted that case studies may be descriptive
Con®rmation occurs where data converge around a partic- in nature (indeed, the seminal Street Corner Society of
ular theory or proposition and strengthen its claim to be Whyte (1955), often quoted in literature on the case study,
upheld. Where the aim is completeness, a method is falls into this category) the emphasis in his writing was
selected for its unique contribution to the research ques- clearly on the explanatory case study. This, like the
tion and assists in building up the picture through the experiment, deals with `how' and `why' questions, as
highlighting of new, and different, theory. Yin (1994) opposed to `who', `what', `how many' or `how much'
appeared to follow the convergent theorists in his illus- questions, which deal with frequencies and incidences
tration of convergence and non-convergence. and are therefore more suitable to survey type approaches.
Yin (1994) suggested that the `sources of evidence' Questions alone, however, according to Yin, do not point
suitable for case study research were almost unlimited, to what a researcher should study and therefore there is a
and discussed speci®cally six sources Ð documentation, need to develop `propositions' about the research, which
archival records, direct observation, participant observa- re¯ect an important theoretical issue. Only where a topic
tion, interviews and physical artefacts. Though he is the subject of `exploration' Ð and this condition may
detailed their relative strengths and weaknesses, he exist in experiments and surveys as well as case studies Ð
concluded that no single source had advantage over the does a study have a legitimate reason for not having any
rest. Other writers on case study methods have adopted propositions, though, even here, there should be a clear
the same position and Hutchinson (1990) added that it is purpose to guide data collection.
the depth and breadth of evidence supporting the case The role of theory development, prior to the conduct of
study, rather than a de®nitive method, which is important. data collection, is one point of difference, to Yin (1994),
For case management research it was felt helpful to between case studies and related methods, such as
triangulate both data collection methods and data sources, ethnography and grounded theory, although, like these,
with the object of convergence around the framework the case study may also be used for theory-building. This,
constructed from the literature. As noted above, semi- with other comparative parameters, is clear in his ®gure
structured interviews were selected as the major feature, illustrating these methods (reproduced in Figure 4) which,
conducted with different key informants (data sources) with the additional property of contextual inclusiveness,
from each case and covering the same issues as the initial makes the case study unique among research strategies.
questionnaire, but in greater depth. Additionally, docu- Ultimately, of course, the question of theory develop-
mentation was scrutinized pertaining to case management ment must be addressed by all researchers if one is to
practice within the case study site (mission statements, accept the received de®nition of research. Interestingly,
assessment forms, protocols, etc.). Observation, another even the proponents of the ethnographic case study
data collection method common to the case study, was appear near to Yin's position when pushed to defend
discounted on the grounds that case management practice their logic on this point. Hamel et al. (1993) commented
would be dif®cult to de®ne operationally, and suf®ciently that validating a theory is at the core of the methodological
inclusively for the purposes of an observation schedule. con¯ict, and advanced their own notion of theoretical
Further, the inferences made from observed behaviour validation as a way of dealing with the inadequacy of the
may have had subjectivity bias in an area given to different single case study as explanatory theory. While still
interpretations. Interviews, on the other hand, allowed the holding that `all theories are ultimately based on a
respondent to speak within his/her own conceptualization particular case or object' (Hamel et al. 1993 p. 29) the
of the phenomenon, and to make this explicit. theory so produced may be validated by others to assess
932 Ó 2000 Blackwell Science Ltd, Journal of Advanced Nursing, 31(4), 926±934

8. Methodological issues in nursing research Case study design
Figure 4 Differences in ass-
umptions among four eval-
uation methods (Yin 1993
p. 64).
their general applicability. As with Yin, Hamel et al.
CONCLUSION
(1993) saw knowledge generated in this way as not based
on empirical elements but on a set of proposals or abstract The entire process of case study conduct, in this research,
theories. from design through to data collection and analysis, was
One point thus almost universally accepted by case thus largely in keeping with Yin's (1994) recommended
study theorists is that there is some relationship between procedures. However, this did not signify uncritical
the study and theory, be it theory-testing or theory- acceptance of the interpretation; indeed there were some
generating. Hutchinson (1990) has made a useful distinc- issues, in particular Yin's use of terminology, which it
tion between the case study and case history on this point, was felt needed to be re-examined and clari®ed in order to
the latter often taking an atheoretical stance. She pointed be `usable'. However, overall, Yin's conceptualization of
out, however, that case histories are often claimed, erro- case study research was found to be more comprehen-
neously, as case studies by their authors, and readers sively stated than other accounts of the method found in
therefore need to be on their guard when reading nursing the literature. Its application to a speci®c piece of
research making such claims. research has, it is felt, given the appropriate subject
In researching case management, use was made of the matter, context and research aims Ð shown it to be a
existent theory reviewed in the literature. Although this method as credible and robust as other, perhaps more
did not constitute grand theory on the scale often familiar, approaches.
associated with discipline-speci®c research, Yin
accepted that this would often be the case, and that
lesser research ®ndings could still be useful. Theory References
applied at two levels. First, commonly used parameters
Ball S.J. (1983) Case study research in education; some notes and
for describing case management projects were adopted problems. In The Ethnography of Schooling (Hammersley M.
in structuring the descriptive elements of the interview ed.), Studies in Education Ltd, Drif®eld, Northumberside.
schedule. In addition, recurring issues from the litera- Barlow D.H. & Hersen M. (1984) Single Case Experimental
ture were used to trigger discussion where respondent Designs. Strategies for Studying Behaviour Change 2nd edn.
perceptions on role value and appropriateness were Pergamon Press, New York.
required. Second, and more generally, the factors Bergen A. (1992) Case management in community care: concepts,
appearing as contextual variables in the literature, and practices and implications for nursing. Journal of Advanced
hence as units of enquiry in the data collection plan, Nursing 175, 1106±1113.
were, by their nature, instrumental in the construction Bergen A. (1993) Towards community care Ð methodological and
sampling issues in obtaining a preliminary overview of current
of the theoretical framework for the whole study
nursing practice. Health and Social Care in the Community
(already illustrated in Figure 3). The underlying `pro-
1, 307±318.
positions', as Yin would term them, concerned the way Bergen A. (1994) Case management in the community: identifying
in which these variables combined to address the a role for nursing. Journal of Clinical Nursing 3, 251±257.
research question, namely under what circumstances Bergen A. (1995) A Study to Identify the Current and Potential
case managment may or may not be an appropriate role Relevance and Value of Case Management to Community
for nurses. Nursing. Queen's Nursing Institute, London.
Ó 2000 Blackwell Science Ltd, Journal of Advanced Nursing, 31(4), 926±934 933

9. A. Bergen and A. While
Bergen A. (1997) The role of community nurses as care managers. Phillips J. & Penhale B. (1996) Reviewing Case Management for
British Journal of Community Health Nursing 2(10), 466±474. Older People. Jessica Kingsley/British Society of Gerontology,
Burgess R. (1985) Case study and curriculum research; some London.
issues for teacher researchers. In Issues in Educational Polit D.F. & Hungler B.P. (1999) Nursing Research. Principles and
Research (Burgess R. ed.), The Falmer Press, London, Methods 6th edn. Lippincott, Philadelphia.
pp. 177±196. Powers B.A. & Knapp T.R. (1990) A Dictionary of Nursing Theory
Burns N. & Grove S.K. (1997) The Practice of Nursing Research. and Research. Sage, Newbury Park, California.
Conduct, Critique and Utilization. W.B. Saunders, Philadelphia. Redfern S.J. & Norman I.J. (1994) Validity through triangulation.
Challis D. (1994) Case management Ð a review of UK develop- Nurse Researcher 2, 41±56.
ments and issues. In Caring for People in the Community Ð The Robson C. (1993) Real World Research. A Resource for Social
New Welfare (Titterton M. ed.), Jessica Kingsley, London, Scientists and Practitioner-Researchers. Blackwell Science,
pp. 91±112. Oxford.
DoH (1989) Caring for People: Community Care in the Next Ross F. & Tissier J. (1994) Monitoring and Action Research
Decade and Beyond. Cm 849. Her Majesty's Stationery Of®ce, Project of Assessment and Care Management in Two North
London. Battersea GP Practices. St George's Hospital Medical School,
DoH/SSI (1991) Care Management and Assessment. Practitioners' London.
Guide. Her Majesty's Stationery Of®ce, London. Stake R.E. (1994) Case studies. In Handbook of Qualitative
Hamel J., Dufour S. & Fortin D. (1993) Case Study Methods. Research (Denzin N.K. & Lincoln Y.S. eds), Sage, Thousand
Qualitative Research Methods Series No. 32. Sage, Newbury Oaks.
Park, California. Stake R.E. (1995) The Art of Case Study Research. Sage, Thousand
Hammersley M. (1986) Case Studies in Classroom Research. Open Oaks, California.
University Press, Milton Keynes. Whyte W. (1955) Street Corner Society. University of Chicago
Hammersley M. (1989) The Dilemma of Qualitative Research. Press, Chicago.
Herbert Blumer and the Chicago Tradition. Routledge, London. Woods L.P. (1997) Designing and conducting case study research
Hutchinson S.A. (1990) The case study approach. In Advancing in nursing. Nursing Times Research 2, 48±56.
Nursing Science Through Research, Volume 2 (Moody L.E. ed.), Woods L.P. (1998) Implementing advanced practice: identifying
Sage, Newbury Park, California. the factors that facilitate and inhibit the process. Journal of
Macleod Clark J. & Hockey L. (1989) Further Research for Nursing: Clinical Nursing 7, 265±274.
A New Guide for the Enquiring Nurse. Education for Care Yin R.K. (1993) Applications of Case Study Research. Applied
Series. Scutari Press, London. Social Research Methods Series, Volume 34. Sage, Newbury
Moser G.A. & Kalton G. (1971) Survey Methods in Social Inves- Park.
tigation 2nd edn. Heinemann, London. Yin R.K. (1984, 1989, 1994) Case Study Research: Design and
Parse R.R., Coyne A.B. & Smith M.J. (1985) Nursing Research Ð Methods. Applied Social Research Methods Series, Volume 5.
Qualitative Methods. Brady Communications, Maryland. Sage, Thousand Oaks, California.
934 Ó 2000 Blackwell Science Ltd, Journal of Advanced Nursing, 31(4), 926±934