Case Study Design

In line with the study methodology (see above) and in order to address the study questions in a natural setting , a constructivist case study design was used. Such a design is effective when the issues of the problem under investigation are

overlapping and have not previously been examined (e.g. hospital nurses, gender and the health organisation itself ) (Fisher and Ziviani, 2004). The constructivist case study design explores a phenomenon within its context using multiple data sources to identify the constructs of the realities. This fits with the methods triangulation

strategy explained earlier.

The medical systems and cultural systems differ from one society to another and sometimes within the same sectors of the same society (Kim-Godwin et al, 2001). This implies that in-depth constructivist case study design is desirable. In light of this, the current research has exclusively focused on one hospital with the boundaries of a specific culture

Unlike descriptive case study design, in this research exploration does not only describe the reality of hospital nurses’ role in prompting patients’ health but also it attempts to explore those contributing factors to this role. Thus a fuller picture can be captured about hospital nurses’ role in health promotion.

Other scholars (Denzin, 1994, Gillis and Jackson, 2002,Bergen and While, 2000, Yin, 2003) propose that such a design is effective when a contemporary phenomenon is to be studied in its natural context and the focus is in understanding the dynamic interaction between different individuals in that setting. More specifically, the case study design is recommended when : (1)“How” and “Why” questions are being asked to examine a multifaceted problem in a specific culture (2) When the link between the participants and the “real-life context” is not evident and (3) when the researcher has little control over events. (Bergen and While, 2000, Yin, 1994, 2003,). When the nature of the current research and its aims are examined against the above criteria, it is apparent that such as a design is effective for this study. For example, the study was undertaken in a natural setting located in a certain culture. Likewise, it is not possible to control the events as they happen (e.g. patients’ admission and discharge procedures). Indeed, the relationship between nurses, patients and the hospital as an organisation is not clear. Consequently such a design was deemed as the most appropriate design to utilize in this research.

However, this decision has not only been rationalised by the above discussion but also upon an evaluation of the applicability of other research approaches. Although ethnographic approach has a potential to study a complex health problem within a natural and a cultural setting (Polit et al, 2001), it has been ruled out. Although Willis, (2007) argues that case studies are much more similar to ethnography than dissimilar, the success of the latter depends on specific criteria which should be met. Ethnographic research can require the researcher to spend a long time (e.g. months and even years) in the field using participant observation (Gillis and Jackson, 2002). This is in order to create the “perfect spy” which enables the researcher to obtain all the knowledge necessary on a daily basis (Denzin, 1994). However, the current study

is time limited and such a form of observation has not been used for cultural and methodological reasons given later in this chapter.

Action research is an effective research design to evaluate health promotion program and create a tested action plan (Whitehead et al, 2003a). However, as action research is cyclical in nature (fact finding, action and reflection which generate a new

inquiry), it may take longer to complete and thus more resources are needed to achieve its goals (Whitehead et al 2003a). Action research needs to show that a certain health problem has been resolved as a result of a specific intervention. In this study, whilst a conceptual model that might contribute to the development of

hospital nurses’ role in health promotion is proposed, the aim of the study was to understand their role in health promotion rather than to examine a certain program or actions to bring about measurable organisational change ( Gillis and Jackson, 2002).

Further, whilst the phenomenological approach could be suitable to address nurses’ and patients’ experiences of health promotion (Burns and Grove, 2001), it does not suit other research questions. Some of them simply do not have an exclusive focus on participant’s experience that fits phenomenological criteria (Racher and

Robinson, 2002). For example, the study attempts to highlight the nurses’ attitudes towards health promotion in relation to the overall hospital functional role.

Finally, using both deductive and inductive methods in this research within the framework of a phenomenology approach could raise paradigmatic problems. This is because the principles of such an approach are purely inductive in which data are collected at a micro level (Denzin and Lincoln, 2000).

By contrast a constructivist case study design in this study has significant flexibility. Diverse methods can be utilised regardless of their methodological ideologies as long as they explore and test different realities of hospital nurses’ role in health promotion (Guba and Lincoln, 1994, Yin, 2003). That is, in this study, the emerging constructs of hospital nurses’ role in health promotion are examined against the existing literature as well as tested quantitatively within the case study borders (surgical and medical wards).

In order to examine in-depth certain events at a “micro level”, a unit analysis has been used. Each setting (e.g. surgical and medical wards) within the hospital context has been considered as case study. That is each case study has its own uniqueness and a contribution to make (Yin, 1994). Such a tactic enables cross case analysis as well as comparisons to be made among diverse settings (Bergen and While, 2000, Yin, 2003). However, it should be noted that previous studies have been criticized on the ground of the exclusive focus on one setting (Maidwell, 1996, Cross, 2005, Irvine, 2007). It can be argued therefore that this study might offer a more coherent picture about the nature of nurses’ role in promoting health and contributing factors.

4.4.1 Problems with Case Study Design

As the case with other research approaches (see above), case study design has its own problems to be considered. These are detailed below: