The research design chosen for this study is the Case Study using ethnographic field work as a method. A case study has been defined as ‘‘…an empirical inquiry that investigates a contemporary phenomenon within its real-life context, especially when the boundaries between phenomenon and context are not clearly evident’’ (Yin, 2009, p.18). In this case study, the boundary is the ward and the
practice being explored is the use of infection control protocol and guidelines to manage the spread ofClostridium difficileinfection.
Being able to study what is going on within a real-life context is important due to the influence that organisational culture and the surrounding environment has on behaviour (Yin, 2009). The use of a case study is important to understand the complexity of influences, particularly in relation to the ward context and how this influences the way that infection control protocols and guidelines are put into practice.
The use of an in-depth case study was chosen as the most appropriate design for conducting empirical research within the interpretivist tradition to produce a rich description of the phenomena under investigation. According to Yin (2009), case studies can be descriptive, exploratory or explanatory and a case can comprise single or multiple units. This study uses a single site as its case, as it aims to provide depth rather than breadth of knowledge. This is in contrast to the use of multiple case studies, which would be more appropriate where the concern is to allow theoretical replication and cross-case comparisons (Yin, 2009). This case study will be simultaneously descriptive, exploratory and explanatory. The aim is to describe, explore, understand and explain the difficulties and dilemmas that stakeholders experience in relation to putting into practice the infection control protocols and guidelines on the hospital ward to prevent Clostridium difficile infection. It may be defined as aninstrumentalcase study, as the focus will be on
the insights that individuals within the case can provide, and the identification of improved practice. The possibility for generalisation of the findings to other similar settings (Stake, 1995) is discussed on p.116 and in Chapter Five (See Study Limitations, p.407), by providing a ‘thick description’ (Geertz, 1973) of the study findings.
There are several reasons for choosing a case study design. Firstly, understanding human behaviour is a complex process and the case study acknowledges that behaviour is partly shaped by the context (Luck et al., 2006). To understand the use of protocols and guidelines it will be necessary to understand how relationships and processes within the setting influence the action taken (Denscombe, 2003). The naturalistic style of case study research allows human behaviour, thoughts and feelings to be studied in a given situation as it exists, rather than studying phenomena under artificially generated circumstances (Denscombe, 2003). A case study is therefore appropriate for examining complexity and the practical application of knowledge (Luck et al., 2006) in a complex environment such as healthcare.
Secondly, the case study is appropriate when ‘how’ or ‘why’ questions are put forward and when there is lack of control over events taking place within the environment (Yin, 2009) such as a hospital ward.
Thirdly, a case study is a flexible approach which provides the ability to deal with multiple sources of evidence, as no one source of evidence is likely to be sufficient on its own to capture the whole context (Gillham, 2000). A variety of research methods can therefore be used to investigate the relationships and processes of interest, providing a more holistic account of ‘‘what is going on’’ rather than dealing with isolated factors (Denscombe, 2003). Luck et al. (2006) argue that‘‘…because any set of methods that will help to develop understanding can be used, a case study is a bridge that spans the research paradigms’’(p.105). Case studies can be qualitative or quantitative (Yin, 2009) or both. This case study will be a qualitative inquiry, using multiple methods to provide a holistic, meaningful and rich knowledge about events taking place within the boundary of the case.
Finally, a case study draws attention to what can be specifically learned from the case. The detailed workings of the relationships and processes leading to certain outcomes can be emphasised in the case description and explanations given as to why certain outcomes happen (Yin, 2009). To achieve this, behavioural theories, models and a framework from psychology were used to guide the collection and analysis of the data. However, an open mind was maintained concerning their value as although theory is a way of seeing, it may exclude other ways of seeing.
The literature review identified that the majority of studies using theories from psychology have used a quantitative approach without consideration of the
context. The aim of this study is to use several qualitative methods using Michie et al’s (2005) behavioural change framework to explore factors that may be influencing the behaviour of staff on the ward in relation to infection control practice, taking into account the context.
Consideration needs to be given as to why this study is being framed as a case study, rather than as ethnography or grounded theory. Approaches such as grounded theory (Glaser and Strauss, 1967) are used to develop theory; however theory building is not an aim of this study. Case studies and ethnography appear to have similar elements. Both are holistic interpretive approaches concerned with providing rich detailed knowledge about phenomena and culture is important. Both approaches can use interviews, non-participant or participant observation and document review, and common methods of analysis are used. Cohen and Court (2003) suggest the major difference between case study and ethnography is the intention of the study. They propose that whilst ethnography is inward looking, the case study is outward looking. They suggest that ethnography is more concerned with the extraction of the unknown rules within a culture and is more descriptive, although it can also be explanatory (Cohen and Court, 2003). However, a case study, is also concerned with culture, it can be explanatory in nature, although it can also be descriptive (Yin, 2009). The distinction between the two is therefore blurred. It could be argued that case study and ethnography differ because they have different philosophical underpinnings and therefore use different methods. For example, a case study can be based on positivism and use
surveys as a method of data collection, whereas use of surveys within ethnography is unlikely.
In the current study, a case study was identified as the most suitable design using ethnographic methods, for the reasons previously described. An additional reason is that the original intention of the study was to compare two wards and a case study design is useful to compare multiple cases (Yin, 2009). Due to difficulties with the field work one case study was used in this study (See Negotiating Access p.128 for an explanation). Despite the strength of this approach, there are potential limitations which need to be considered.