Case study

Case study designs are widely used in nursing research to explore standards of health care practices and to identify existing needs and challenges in delivery of quality care (Casey & Houghton, 2010). Since the aim of this study was to inquire how students are prepared by nursing educators to approach spiritual care a case study design was judged to be most appropriate. Case study is distinctively useful in evaluating and exploring the nature of underlying issues with reference to an identified phenomenon (Yin 2009, 2014; Robson & McCartan 2016). The case study approach was appropriate to explore the underlying factors perceived to influence students’ learning in this area. A case study approach allows the researcher to explain and explore the causal relationships of

underlying determinants with real life interventions (Robson & McCartan, 2016). It enables exploration of the environmental factors influencing professional engagement for both student and educators. Case study as a research design that allows the researcher to evaluate the strengths and limitations of the subject studied in context.

63

Case studies can be used to enable some generalisation of the studied phenomena rather than particularising the situation to a given space, time and group (Yin, 2014). The case study approach has been defined as follows:

Case study is an empirical inquiry that investigates a contemporary phenomenon in depth and within its real-life context, especially when the boundaries between phenomenon and context are not clearly evident… Case study copes with technically distinctive situations in which there will be many more variables of interest than data points and, as one result relies on multiple sources of evidence with data needing to converge in a triangulating fashion, and as another result benefits from the prior development of theoretical positions to guide data collection and analysis (Yin, 2014, p.17).

The research aimed to gather evidence from student nurses, nursing educators and curriculum documents to explore how spirituality is integrated in nursing education and what is the relationship between these data sources in each case. Yin’s definition fitted in with my research question as it allowed me to investigate all these three areas in depth and to explore underlying factors.

Several approaches to conducting a case study can be found in social and health sciences (Stakes, 2000; Yin, 2014; Robson & McCartan, 2016). The following section explains my choice of an

exploratory multiple case study design proposed by Yin (2009, 2014) rather than other possible case study methods.

3.2.5.1 Types of Case Studies

Yin (2009, 2014) provided a structured and comprehensive approach to using case study design. According to Yin (2009, 2014), there are four types of designs for case studies. These are, single case (holistic) design, single case (embedded) designs, multiple case (holistic) designs and multiple case (embedded) designs. A single case study is conducted where a critical or specific case has to be examined as a representative case. A single case study is holistic when the unit of study is

approached as a whole. If there are sub units selected to be studied within a single case study, this is known as an embedded case study design. If a study examines more than one single case, it is

64

designated a multiple case studies design. A single case study could also be used as a pilot case study before conducting multiple case studies.

Multiple case studies can also be holistic or embedded in nature, focusing on the whole unit or

various sub units in its each case. In multiple case studies, cases can be selected for literal replication (similar findings) or theoretical replications (contrasting results). To develop a replication strategy, a theoretical framework is required. According to Yin (2009 p. 54) a “theoretical framework should state the conditions under which a particular phenomenon is likely to be found (literal replication) as well as the conditions when it is not likely to be found (a theoretical replication)”. Yin, also describes that once the theoretical framework is developed then individual cases should be identified to follow the

specified research design and data collection process. In multiple case studies, each case study finding guides the conclusion and addresses the nature and scope of pre-set propositions.

Case studies could also be classified as intrinsic, instrumental or collective (Stakes, 2000). A case study could be intrinsic if it related to the interest of the researcher, not what a case may illuminate. On the contrary, an instrumental case study design allows the researcher to identify and investigate the case in order to provide more insight regarding the situation studied. For an instrumental, case study the researcher finds purposive cases that can best explore the particular research question. Collective case studies are used to study a number of cases so that results and findings could be compared (Creswell, 1998). The present study could be described as both instrumental and collective. Using a multiple case study design was judged to be most appropriate to explore the underlying challenges of integrating spiritual care ideas in nursing education. As instrumental case study approach allows the researcher to focus on a specific inquiry and the case provides the overall understanding to explore the underlying issue (Creswell,1998). A case, in a case study could be an individual, an event, an entity or an organisation (Robson & McCartan, 2016). For this study, each case was a university, where an undergraduate nursing programme was offered. A case may reveal variation in programmes offered, diverse perspectives from the stake holders and variety in

programme components and the basic framework or philosophy of the course. For this study, the stakeholders were the student nurses, nursing educators and the programme components were the

65

curriculum documents. These were used as the basis for designing an instrumental case study (Creswell, 1998).

Multiple cases were approached to inquire about the level of integration, perceived challenges and barriers with reference to spiritual care in undergraduate nursing education. Multiple case studies enable more compelling and robust evidence to be gathered. The rationale was based on considering literal replication and constructing internal and external validity using a qualitative methodology, which is unique to Yin’s (2009, 2014), case study design. Yin’s case study approach is discussed below in detail.