When to use a case study approach

According to Yin (2003) a case study design should be considered when the focus of the study is to answer “how” and “why” questions; when the aim is to

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explore contextual conditions relevant to the phenomenon under study, and when the boundaries are not clear between the phenomenon and context.

3.5.3 Defining the case and case boundaries

Yin (2003) and Stake (1995) propose that defining the boundaries of the case is a significant factor of case study methodology. Suggestions on how to bind a case include; time and place (Creswell 2007); time and activity (Stake 1995); and by context (Miles & Huberman, 1994). The case is defined by Miles & Huberman (1994) as, “a phenomenon of some sort occurring in a bounded context. The case is, “in effect, your unit of analysis” (p. 25). The case can be a person or group of individuals, a programme or a particular process. In this study, the case boundary is ‘primary care’, and ‘physical assessment skills’ use within that boundary context.

3.5.4 Determining Unit of Analysis

Differences exist between the two scholar's definitions of the 'unit of analysis' within case study research. Stake's (1995) notion of a 'unit of analysis' is ‘individuals’, experiencing the chosen phenomenon of study. Yin (2003) proposes that the unit of analysis is only one unit, but may be embedded in multiple sub-units. For the purpose of this study the main unit of analysis is CNPs use of PAS (phenomena of interest) in primary care.

3.5.5 Type of Case Study

The commonalities and difference between Yin's (1994 & 2003) and Stake's (1995) types of case studies are appraised in Table 4. There are two main types, single and multiple cases (Yin 2009 & Stake 1995). In multiple case designs, the emphasis is on comparing and contrasting findings, to identify important theoretical features (Thomas 2011). Yin (2009) and Stake (1995)

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advocate the possibility of using a single case design, but the limitation of Stake's (1995) definition is that a single case examines the holistic context only, with a view to understanding it. In comparison Yin’s (2009) definition of the single case offers the researcher a wider scope of examining different sub-units that are embedded, or ‘fit within’ within the case. This means that each sub-unit is connected within the principal unit of analysis

Yin’s (2003) classification of an embedded case design will be used in this study, because it is relevant to the overall aim. These components will be examined in more detail in the following paragraph.

3.5.6 Embedded case study design

An embedded case study design is considered appropriate to meet the aim and scope of this study for the following reasons. The case will be located in real life primary and community health care practices in the south of England. Primary and community care in this part of England involves the widest scope of health care. It has a population of all ages of different socioeconomic and geographic origins. Patients within this case boundary experience acute and chronic physical, mental and social health issues, but mostly multiple chronic diseases. Therefore, primary and community care services are the first point of contact for most people in this area of England

This case boundary has a population of 1.6 million, distributed over the three local authority areas. It has one of the oldest populations in the country with over 25% of the population over 65 years. Frail and elderly population groups account for the majority of healthcare expenditure. One quarter of the population has a long term condition such as diabetes, dementia or lung disease, and 91,700 people aged 75 years+ live alone and experience social

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isolation and loneliness. Around 80% of deaths are from major disease, such as cancer and heart disease, often attributable to lifestyle risk factors such as smoking, excess alcohol or poor diet.

Health authorities have reported that the present model of healthcare in this area of England is not set up to deal with the significant increase in demand in services, related to the large and growing elderly population who live with multiple long-term conditions. The health needs associated with such demographics placed significant demands on local and urgent emergency care services in 2012-13. For example, there were over 125,000 attendances at two local A&E departments; nearly 46,000 emergency admissions and over 80,000 calls to 999 ambulance services, an average increase 3% each year in recent years. People admitted to hospital for illnesses in this area did not require hospital care compared to other areas (NHS England (a) 2013).

Feedback from patients related to difficulties accessing local services because they were confusing and difficult to navigate. Frail patients with complex care needs, carers and user groups in this area of England indicated that patients wanted to be in control of their health, feel safe and be cared for in their own homes. They wanted to be supported by healthcare professionals who could proactively identify care needs, and have input from multidisciplinary health and social care teams, where necessary. To meet the health and social care demands of such population groups placed considerable strain on local GPs who were in short supply. Existing services were stretched beyond capacity, and were expected to treat more patients with complex needs in less time.

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In line with national policy initiatives’ on workforce planning and re-design (DH 2004), and in negotiation with Royal College of Physicians, experienced CNPs were considered ideally placed to manage these patient groups, if trained in skills similar to GPs. These initiatives were based on the concept that experienced CNPs already played a crucial role in caring for some of the most of the vulnerable people within this case boundary, especially housebound patients with LTCs, and frail elderly people registered with GPs. As well as providing direct patient care, CNPs were considered as ideally placed (DH 2010) to improve the quality of life of individual patients to enable them to care for themselves, or with family members by teaching them how to give care to their relatives. They would be expected to play vital leadership roles in fostering a culture of patient-centred practices, which was pivotal in reflecting the needs of defined patient groups within this case boundary. They would be expected to act as clinical role models and demonstrate leadership in the context if clinical decision making, whilst effectively liaising with multidisciplinary teams. A specific objective of specialist community nurses role was to keep LTC and frail elderly patients’ hospitalisation to a minimum (DH 2010).

3.5.7 Unit of Analysis

Therefore, CNPs trained in medical PAS will be the unit of analysis for this case study, because the aim is to understand different perspectives as to how CNPs used medical PAS in practice within this case boundary. To be trained in medical PAS, CNPs' required knowledge of the theoretical foundations, facilitated by trained educators at a University. Moreover, CNPs' required funding for PAS education, and organisational support from

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line mangers to work in a supervisory capacity with experienced GPs or nurse clinicians, to develop competence.

Therefore, an embedded case study design will enable an understanding of the interconnectedness of PAS use for CNPs' in primary care, where the boundaries between roles and relationship are not clearly evident. This will enable the researcher to analyse the data within the case, otherwise known as within case analysis (Yin 2003 & 2009). The ability to engage in analysis in this way will enable the researcher to better illuminate the complexities of the case (Yin 2009).

3.5.8 Sources of evidence

Both Yin (2009) and Stake (1995 & 2006) advise that the conduct of case study research permits the use of a variety of methods of data collection to capture and explore multiple perspectives, but interviews are considered the single most important source of evidence in case study research (Yin 2009).

A discussion on the merits of different sources of interviews will be discussed in Chapter four section 4.9 that follow.

3.5.9 The current case study

Sections 3.4 to 3.4.8 highlighted that defining case study and the conduct of case research is a complex task, but crucial to the phenomenon under study. A methodological justification has been provided, that defines the researcher’s epistemological position and research paradigm. The boundaries of the case have been defined, which is a defining factor of case study method. Specific terms of an embedded case study, with embedded sub-units have been described.

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Two interview methods will be used to capture and explore multiple perspectives of CNPs’ use of medical PAS in primary care, and ‘how’ and ‘why’ research question will be asked. Adequate contextual description of the case will be provided by the researcher throughout the study. This will allow the reader to develop a deeper understanding of the researcher’s perspective and theoretical position in the study.