What is a case study?
A case study is a research approach that is used to generate an in-depth, multi-faceted understanding of a complex issue in its real-life context. It is an established research design that is used extensively in a wide variety of disciplines, particularly in the social sciences. A case study can be defined in a variety of ways (Table 5), the central tenet being the need to explore an event or phenomenon in depth and in its natural context. It is for this reason sometimes referred to as a "naturalistic" design; this is in contrast to an "experimental" design (such as a randomised controlled trial) in which the investigator seeks to exert control over and manipulate the variable(s) of interest.
Stake's work has been particularly influential in defining the case study approach to scientific enquiry. He has helpfully characterised three main types of case study: intrinsic, instrumental and collective. An intrinsic case study is typically undertaken to learn about a unique phenomenon. The researcher should define the uniqueness of the phenomenon, which distinguishes it from all others. In contrast, the instrumental case study uses a particular case (some of which may be better than others) to gain a broader appreciation of an issue or phenomenon. The collective case study involves studying multiple cases simultaneously or sequentially in an attempt to generate a still broader appreciation of a particular issue.
These are however not necessarily mutually exclusive categories. In the first of our examples (Table 1), we undertook an intrinsic case study to investigate the issue of recruitment of minority ethnic people into the specific context of asthma research studies, but it developed into a instrumental case study through seeking to understand the issue of recruitment of these marginalised populations more generally, generating a number of the findings that are potentially transferable to other disease contexts. In contrast, the other three examples (see Tables 2, 3 and 4) employed collective case study designs to study the introduction of workforce reconfiguration in primary care, the implementation of electronic health records into hospitals, and to understand the ways in which healthcare students learn about patient safety considerations[4-6]. Although our study focusing on the introduction of General Practitioners with Specialist Interests (Table 2) was explicitly collective in design (four contrasting primary care organisations were studied), is was also instrumental in that this particular professional group was studied as an exemplar of the more general phenomenon of workforce redesign.
What are case studies used for?
According to Yin, case studies can be used to explain, describe or explore events or phenomena in the everyday contexts in which they occur. These can, for example, help to understand and explain causal links and pathways resulting from a new policy initiative or service development (see Tables 2 and 3, for example). In contrast to experimental designs, which seek to test a specific hypothesis through deliberately manipulating the environment (like, for example, in a randomised controlled trial giving a new drug to randomly selected individuals and then comparing outcomes with controls), the case study approach lends itself well to capturing information on more explanatory 'how', 'what' and 'why' questions, such as 'how is the intervention being implemented and received on the ground?'. The case study approach can offer additional insights into what gaps exist in its delivery or why one implementation strategy might be chosen over another. This in turn can help develop or refine theory, as shown in our study of the teaching of patient safety in undergraduate curricula (Table 4)[6,10]. Key questions to consider when selecting the most appropriate study design are whether it is desirable or indeed possible to undertake a formal experimental investigation in which individuals and/or organisations are allocated to an intervention or control arm? Or whether the wish is to obtain a more naturalistic understanding of an issue? The former is ideally studied using a controlled experimental design, whereas the latter is more appropriately studied using a case study design.
Case studies may be approached in different ways depending on the epistemological standpoint of the researcher, that is, whether they take a critical (questioning one's own and others' assumptions), interpretivist (trying to understand individual and shared social meanings) or positivist approach (orientating towards the criteria of natural sciences, such as focusing on generalisability considerations) (Table 6). Whilst such a schema can be conceptually helpful, it may be appropriate to draw on more than one approach in any case study, particularly in the context of conducting health services research. Doolin has, for example, noted that in the context of undertaking interpretative case studies, researchers can usefully draw on a critical, reflective perspective which seeks to take into account the wider social and political environment that has shaped the case.
Example of epistemological approaches that may be used in case study research
How are case studies conducted?
Here, we focus on the main stages of research activity when planning and undertaking a case study; the crucial stages are: defining the case; selecting the case(s); collecting and analysing the data; interpreting data; and reporting the findings.
Defining the case
Carefully formulated research question(s), informed by the existing literature and a prior appreciation of the theoretical issues and setting(s), are all important in appropriately and succinctly defining the case[8,12]. Crucially, each case should have a pre-defined boundary which clarifies the nature and time period covered by the case study (i.e. its scope, beginning and end), the relevant social group, organisation or geographical area of interest to the investigator, the types of evidence to be collected, and the priorities for data collection and analysis (see Table 7). A theory driven approach to defining the case may help generate knowledge that is potentially transferable to a range of clinical contexts and behaviours; using theory is also likely to result in a more informed appreciation of, for example, how and why interventions have succeeded or failed.
Example of a checklist for rating a case study proposal
For example, in our evaluation of the introduction of electronic health records in English hospitals (Table 3), we defined our cases as the NHS Trusts that were receiving the new technology. Our focus was on how the technology was being implemented. However, if the primary research interest had been on the social and organisational dimensions of implementation, we might have defined our case differently as a grouping of healthcare professionals (e.g. doctors and/or nurses). The precise beginning and end of the case may however prove difficult to define. Pursuing this same example, when does the process of implementation and adoption of an electronic health record system really begin or end? Such judgements will inevitably be influenced by a range of factors, including the research question, theory of interest, the scope and richness of the gathered data and the resources available to the research team.
Selecting the case(s)
The decision on how to select the case(s) to study is a very important one that merits some reflection. In an intrinsic case study, the case is selected on its own merits. The case is selected not because it is representative of other cases, but because of its uniqueness, which is of genuine interest to the researchers. This was, for example, the case in our study of the recruitment of minority ethnic participants into asthma research (Table 1) as our earlier work had demonstrated the marginalisation of minority ethnic people with asthma, despite evidence of disproportionate asthma morbidity[14,15]. In another example of an intrinsic case study, Hellstrom et al. studied an elderly married couple living with dementia to explore how dementia had impacted on their understanding of home, their everyday life and their relationships.
For an instrumental case study, selecting a "typical" case can work well. In contrast to the intrinsic case study, the particular case which is chosen is of less importance than selecting a case that allows the researcher to investigate an issue or phenomenon. For example, in order to gain an understanding of doctors' responses to health policy initiatives, Som undertook an instrumental case study interviewing clinicians who had a range of responsibilities for clinical governance in one NHS acute hospital trust. Sampling a "deviant" or "atypical" case may however prove even more informative, potentially enabling the researcher to identify causal processes, generate hypotheses and develop theory.
In collective or multiple case studies, a number of cases are carefully selected. This offers the advantage of allowing comparisons to be made across several cases and/or replication. Choosing a "typical" case may enable the findings to be generalised to theory (i.e. analytical generalisation) or to test theory by replicating the findings in a second or even a third case (i.e. replication logic). Yin suggests two or three literal replications (i.e. predicting similar results) if the theory is straightforward and five or more if the theory is more subtle. However, critics might argue that selecting 'cases' in this way is insufficiently reflexive and ill-suited to the complexities of contemporary healthcare organisations.
The selected case study site(s) should allow the research team access to the group of individuals, the organisation, the processes or whatever else constitutes the chosen unit of analysis for the study. Access is therefore a central consideration; the researcher needs to come to know the case study site(s) well and to work cooperatively with them. Selected cases need to be not only interesting but also hospitable to the inquiry  if they are to be informative and answer the research question(s). Case study sites may also be pre-selected for the researcher, with decisions being influenced by key stakeholders. For example, our selection of case study sites in the evaluation of the implementation and adoption of electronic health record systems (see Table 3) was heavily influenced by NHS Connecting for Health, the government agency that was responsible for overseeing the National Programme for Information Technology (NPfIT). This prominent stakeholder had already selected the NHS sites (through a competitive bidding process) to be early adopters of the electronic health record systems and had negotiated contracts that detailed the deployment timelines.
It is also important to consider in advance the likely burden and risks associated with participation for those who (or the site(s) which) comprise the case study. Of particular importance is the obligation for the researcher to think through the ethical implications of the study (e.g. the risk of inadvertently breaching anonymity or confidentiality) and to ensure that potential participants/participating sites are provided with sufficient information to make an informed choice about joining the study. The outcome of providing this information might be that the emotive burden associated with participation, or the organisational disruption associated with supporting the fieldwork, is considered so high that the individuals or sites decide against participation.
In our example of evaluating implementations of electronic health record systems, given the restricted number of early adopter sites available to us, we sought purposively to select a diverse range of implementation cases among those that were available. We chose a mixture of teaching, non-teaching and Foundation Trust hospitals, and examples of each of the three electronic health record systems procured centrally by the NPfIT. At one recruited site, it quickly became apparent that access was problematic because of competing demands on that organisation. Recognising the importance of full access and co-operative working for generating rich data, the research team decided not to pursue work at that site and instead to focus on other recruited sites.
Collecting the data
In order to develop a thorough understanding of the case, the case study approach usually involves the collection of multiple sources of evidence, using a range of quantitative (e.g. questionnaires, audits and analysis of routinely collected healthcare data) and more commonly qualitative techniques (e.g. interviews, focus groups and observations). The use of multiple sources of data (data triangulation) has been advocated as a way of increasing the internal validity of a study (i.e. the extent to which the method is appropriate to answer the research question)[8,18-21]. An underlying assumption is that data collected in different ways should lead to similar conclusions, and approaching the same issue from different angles can help develop a holistic picture of the phenomenon (Table 2).
Brazier and colleagues used a mixed-methods case study approach to investigate the impact of a cancer care programme. Here, quantitative measures were collected with questionnaires before, and five months after, the start of the intervention which did not yield any statistically significant results. Qualitative interviews with patients however helped provide an insight into potentially beneficial process-related aspects of the programme, such as greater, perceived patient involvement in care. The authors reported how this case study approach provided a number of contextual factors likely to influence the effectiveness of the intervention and which were not likely to have been obtained from quantitative methods alone.
In collective or multiple case studies, data collection needs to be flexible enough to allow a detailed description of each individual case to be developed (e.g. the nature of different cancer care programmes), before considering the emerging similarities and differences in cross-case comparisons (e.g. to explore why one programme is more effective than another). It is important that data sources from different cases are, where possible, broadly comparable for this purpose even though they may vary in nature and depth.
Analysing, interpreting and reporting case studies
Making sense and offering a coherent interpretation of the typically disparate sources of data (whether qualitative alone or together with quantitative) is far from straightforward. Repeated reviewing and sorting of the voluminous and detail-rich data are integral to the process of analysis. In collective case studies, it is helpful to analyse data relating to the individual component cases first, before making comparisons across cases. Attention needs to be paid to variations within each case and, where relevant, the relationship between different causes, effects and outcomes. Data will need to be organised and coded to allow the key issues, both derived from the literature and emerging from the dataset, to be easily retrieved at a later stage. An initial coding frame can help capture these issues and can be applied systematically to the whole dataset with the aid of a qualitative data analysis software package.
The Framework approach is a practical approach, comprising of five stages (familiarisation; identifying a thematic framework; indexing; charting; mapping and interpretation), to managing and analysing large datasets particularly if time is limited, as was the case in our study of recruitment of South Asians into asthma research (Table 1)[3,24]. Theoretical frameworks may also play an important role in integrating different sources of data and examining emerging themes. For example, we drew on a socio-technical framework to help explain the connections between different elements - technology; people; and the organisational settings within which they worked - in our study of the introduction of electronic health record systems (Table 3). Our study of patient safety in undergraduate curricula drew on an evaluation-based approach to design and analysis, which emphasised the importance of the academic, organisational and practice contexts through which students learn (Table 4).
Case study findings can have implications both for theory development and theory testing. They may establish, strengthen or weaken historical explanations of a case and, in certain circumstances, allow theoretical (as opposed to statistical) generalisation beyond the particular cases studied. These theoretical lenses should not, however, constitute a strait-jacket and the cases should not be "forced to fit" the particular theoretical framework that is being employed.
When reporting findings, it is important to provide the reader with enough contextual information to understand the processes that were followed and how the conclusions were reached. In a collective case study, researchers may choose to present the findings from individual cases separately before amalgamating across cases. Care must be taken to ensure the anonymity of both case sites and individual participants (if agreed in advance) by allocating appropriate codes or withholding descriptors. In the example given in Table 3, we decided against providing detailed information on the NHS sites and individual participants in order to avoid the risk of inadvertent disclosure of identities[5,25].
What are the potential pitfalls and how can these be avoided?
The case study approach is, as with all research, not without its limitations. When investigating the formal and informal ways undergraduate students learn about patient safety (Table 4), for example, we rapidly accumulated a large quantity of data. The volume of data, together with the time restrictions in place, impacted on the depth of analysis that was possible within the available resources. This highlights a more general point of the importance of avoiding the temptation to collect as much data as possible; adequate time also needs to be set aside for data analysis and interpretation of what are often highly complex datasets.
Case study research has sometimes been criticised for lacking scientific rigour and providing little basis for generalisation (i.e. producing findings that may be transferable to other settings). There are several ways to address these concerns, including: the use of theoretical sampling (i.e. drawing on a particular conceptual framework); respondent validation (i.e. participants checking emerging findings and the researcher's interpretation, and providing an opinion as to whether they feel these are accurate); and transparency throughout the research process (see Table 8)[8,18-21,23,26]. Transparency can be achieved by describing in detail the steps involved in case selection, data collection, the reasons for the particular methods chosen, and the researcher's background and level of involvement (i.e. being explicit about how the researcher has influenced data collection and interpretation). Seeking potential, alternative explanations, and being explicit about how interpretations and conclusions were reached, help readers to judge the trustworthiness of the case study report. Stake provides a critique checklist for a case study report (Table 9).
Potential pitfalls and mitigating actions when undertaking case study research
Stake's checklist for assessing the quality of a case study report
Volume 18, No. 1, Art. 19 – January 2017
Case Study Research: Foundations and Methodological Orientations
Helena Harrison, Melanie Birks, Richard Franklin & Jane Mills
Abstract: Over the last forty years, case study research has undergone substantial methodological development. This evolution has resulted in a pragmatic, flexible research approach, capable of providing comprehensive in-depth understanding of a diverse range of issues across a number of disciplines. Change and progress have stemmed from parallel influences of historical transformations in approaches to research and individual researcher's preferences, perspectives, and interpretations of this design. Researchers who have contributed to the development of case study research come from diverse disciplines with different philosophical perspectives, resulting in a variety of definitions and approaches. For the researcher new to using case study, such variety can create a confusing platform for its application. In this article, we explore the evolution of case study research, discuss methodological variations, and summarize key elements with the aim of providing guidance on the available options for researchers wanting to use case study in their work.
Key words: case study; method; methodology; nursing research; qualitative; research design; research
Table of Contents
2. History and Evolution
3. Foundational Concepts
3.1 Definitions and descriptions
3.2 Methodology or method
3.3 Philosophical orientation
3.4 Philosophical variation
3.4.1 YIN: Realist—postpositivist
3.4.2 MERRIAM: Pragmatic constructivist
3.4.3 STAKE: Relativist—constructivist/interpretivist
4. Common Characteristics of Case Study Research
Case study research has grown in reputation as an effective methodology to investigate and understand complex issues in real world settings. Case study designs have been used across a number of disciplines, particularly the social sciences, education, business, law, and health, to address a wide range of research questions. Consequently, over the last 40 years, through the application of a variety of methodological approaches, case study research has undergone substantial development. Change and progress have stemmed from parallel influences from historical approaches to research and individual researcher's preferences, perspectives on, and interpretations of case study research. Central to these variations is the underpinning ontological and epistemological orientations of those involved in the evolution of case study research. Researchers who have contributed to the development of case study research come from diverse disciplines and their philosophical underpinnings have created variety and diversity in approaches used. Consequently, various designs have been proposed for preparing, planning, and conducting case study research with advice on key considerations for achieving success. As a result, while case study research has evolved to be a pragmatic, flexible research approach, the variation in definition, application, validity, and purposefulness can create a confusing platform for its use. 
In this article, we examine each of these issues in turn, with the aim of improving our understanding of case study research and clarifying the requisite tenets to consider when designing a case study. We begin with an overview of the history and evolution of case study research, followed by a discussion of the methodological and philosophical variations found within case study designs. We end with a summary of the common characteristics of case study research and a table that brings together the fundamental elements that we found common in all case study approaches to research. 
2. History and Evolution
Case study research as a strategy for methodological exploration, according to FLYVBJERG (2011) "has been around as long as recorded history" (p.302). Contemporary case study research is said to have its origins in qualitative approaches to research in the disciplines of anthropology, history, psychology, and sociology (MERRIAM, 1998; SIMONS, 2009; STEWART, 2014). Historical examples of case study stem as far back as the early nineteenth century with the biography of Charles DARWIN (STEWART, 2014). Most attribute the origins of case study research to studies undertaken in anthropology and social sciences in the early twentieth century when lengthy, detailed ethnographic studies of individuals and cultures were conducted using this design (JOHANSSON, 2003, MERRIAM, 2009; SIMONS, 2009; STEWART, 2014). Sociologists and anthropologists investigated people's lives, experiences, and how they understood the social and cultural context of their world, with the aim of gaining insight into how individuals interpreted and attributed meaning to their experiences and constructed their worlds (JOHANSSON, 2003; SIMONS, 2009). Such investigations were conducted in the natural setting of those experiences with results presented descriptively or as a narrative (MERRIAM, 2009). The most notable case studies include THOMAS and ZNANIECKI's (1958 [1918-1920]) study of Polish peasants in Europe and America and, the ethnographic work by MALINOWSKI (1913) in the Trobriand Islands in Melanesia that spanned over several years (CRESWELL, HANSON, PLANO CLARK & MORALES, 2007; JOHANSSON, 2003; STEWART, 2014). 
With the emergence and dominance of positivism in science in the late 1940s and 1950s, quantitative methods became a popular focus for the social sciences. As a result, surveys, experiments, and statistical methods anchored in quantitative approaches were favored and considered more rigorous than qualitative designs (JOHANSSON, 2003). The dominance of research using experimental designs continued through the 1960s and 1970s with quantitative empirical results considered to be gold standard evidence. Case studies continued to be used during this time, however usually as a method within quantitative studies or referred to as descriptive research to study a specific phenomenon (MERRIAM, 2009). At the same time, case study research was often criticized for its inability to support generalizability and thus considered to provide limited validity and value as a research design (JOHANSSON, 2003; MERRIAM, 2009; STEWART, 2014). This context led to a philosophical division in research approaches: those supporting positivism and quantitative approaches and those aligned with qualitative methods embedded in constructivist and interpretivist paradigms. 
Antecedents of modern day case study research are most often cited as being conducted in the Chicago School of Sociology between the 1920-1950s (STEWART, 2014). Here, anthropologists practiced their methods on university cultures or by conducting lengthy case studies involving field-based observations of groups with the aim of understanding their social and cultural lives (CRESWELL et al., 2007; JOHANSSON, 2003; STEWART, 2014). Parallel to the use of case studies in anthropology, medicine and disciplines in the social sciences such as sociology, education and political science also embraced case study as a form of inquiry (ANTHONY & JACK, 2009; BROWN, 2008; CRESWELL et al., 2007; GEORGE & BENNETT, 2005; GERRING, 2004; SIMONS, 2009; YIN, 2014). 
A second generation of case study researchers emerged with the advent of grounded theory methodology (GLASER & STRAUSS, 1967). Grounded theory "merged qualitative field study methods from the Chicago School of Sociology with quantitative methods of data analysis" (JOHANSSON, 2003, p.8), resulting in an inductive methodology that used detailed systematic procedures to analyze data. This renewed interest in qualitative methodology led to a revival in the use of case study in a number of disciplines (ANTHONY & JACK, 2009; GEORGE & BENNETT, 2005; JOHANSSON, 2003; MERRIAM, 2009; STAKE, 1995). According to JOHANSSON (2003), Robert YIN followed this progress, and drawing on scientific approaches to research gained from his background in the social sciences, applied experimental logic to naturalistic inquiry, and blended this with qualitative methods, further bridging the methodological gap and strengthening the methodological quality of case study research. He presented a structured process for undertaking case study research where formal propositions or theories guide the research process and are tested as part of the outcome, highlighting his realist approach to qualitative case study research. While still qualitative and inductive, it was deterministic in nature with an emphasis on cause and effect, testing theories, and an apprehension of the truth (BROWN, 2008; YIN, 2014). 
Similarly, the uptake of case study research in the political sciences, particularly during the 1980's and 1990’s, led to a more integrated methodological approach with the aim of theoretical development and testing (GEORGE & BENNETT, 2005). The integration of formal, statistical, and narrative methods in a single study, combined with the use of empirical methods for case selection and causal inference, demonstrated the versatility of case study design and made a significant contribution to its methodological evolution (ibid.). Similarly, case studies in international relations integrated rigorous, standardized methods with statistical and formal methods, including qualitative comparative analysis and process tracing to improve understanding of world politics (BENNETT & ELMAN, 2007; GERRING, 2004; LEVY, 2007). According to GEORGE and BENNETT (2005) "scholars have formalized case study methods more completely and linked them to underlying arguments in the philosophy of science" (p.6). The continued use of case study to understand the complexities of institutions, practices, processes, and relations in politics, has demonstrated the utility of case study for researching complex issues, and testing causal mechanisms that can be applied across varied disciplines. 
Corresponding with these developments, in the 1970's, educational research embraced case study as a way to evaluate curriculum design and innovation (MERRIAM, 2009; SIMONS, 2009; STAKE, 1995). Methods were required that could be used to explore factors such as participants' perspectives and the influence of socio-political contexts on curriculum successes and failures (SIMONS, 2009). Development of case study research in education, focused on the need to determine the impact of educational programs and provide relevant evidence for policy and practice decisions that supported social and educational change in the United Kingdom and the United States (ibid.). The most significant contributors to this field were STAKE (1995, 2006) and MERRIAM (1998, 2009). STAKE (1995), an educational psychologist with an interest in developing program evaluation methods, used a constructivist orientation to case study. This resulted in placing more emphasis on inductive exploration, discovery, and holistic analysis that was presented in thick descriptions of the case. Similarly, MERRIAM (1998, 2009) used case study research to explore and evaluate educational programs. MERRIAM's approach emphasized defining and understanding the case through the products of inquiry and drew on the work of both YIN and STAKE. MERRIAM (2009) described case study research by its characteristics: particularistic, descriptive and heuristic, highlighting the purpose and qualitative nature of case study research, the focus on a specific entity and, the motivation to understand and describe the findings. Similar to STAKE (1995, 2006), MERRIAM (1998, 2009) was not as structured in her approach as YIN (2014), but promoted the use of a theoretical framework or research questions to guide the case study and organized, systematic data collection to manage the process of inquiry. 
Simple in theory yet complex in nature, the planning, preparation and execution of case study research has developed to a point where the continued application of case study research across a number of professions particularly education, health, and social sciences, has provided a unique platform for credible research endeavors. Case study research has grown in sophistication and is viewed as a valid form of inquiry to explore a broad scope of complex issues, particularly when human behavior and social interactions are central to understanding topics of interest (ANTHONY & JACK, 2009; FLYVBJERG, 2011; GEORGE & BENNETT, 2005; LUCK, JACKSON & USHER, 2006; MERRIAM, 2009; STAKE, 2006; YIN, 2014). 
In Figure 1, developed by JOHANSSON (2003) and adapted for this discussion, a summary of the evolution of case study across a timeline dating back to 1600 is displayed. Key contributors to case study research and major contextual influences on its evolution are included. As the figure highlights, early case studies were conducted in the social sciences. With the dominance of logical positivism from the 1940's through to the 1960's and 1970's case study methodology was viewed with skepticism and criticism. The development of grounded theory in the 1960's led to a resurgence in case study research, with its application in the social sciences, education, and the humanities. Over the last 50 years, case study has been re-established as a credible, valid research design that facilitates the exploration of complex issues.
Figure 1: The history and evolution of case study research (JOHANSSON, 2003, p.7) 
3. Foundational Concepts
While over time the contributions of researchers from varied disciplines have helped to develop and strengthen case study research, the variety of disciplinary backgrounds has also added complexity, particularly around how case study research is defined, described, and applied in practice. In the sections that follow, the nature of this complexity in explored. 
3.1 Definitions and descriptions
There are a number of definitions and descriptions presented across the literature, which can create confusion when attempting to understand case study research. The most common definitions come from the work of YIN (2014), STAKE (1995), and MERRIAM (2009). YIN's two-part definition (2014) focuses on the scope, process, and methodological characteristics of case study research, emphasizing the nature of inquiry as being empirical, and the importance of context to the case. On the other hand, STAKE (1995) takes a more flexible stance and while concerned with rigor in the processes, maintains a focus on what is studied (the case) rather than how it is studied (the method). For STAKE case study research is "the study of the particularity and complexity of a single case, coming to understand its activity within important circumstances" (p.xi). MERRIAM (2009) includes what is studied and the products of the research when defining case study as: "... an in depth description and analysis of a bounded system" (p.40). Like STAKE, MERRIAM emphasizes the defining feature of case study research as being the object of the study (the bounded system; i.e., the case) adding that case study research focuses on a particular thing and that the product of an investigation should be descriptive and heuristic in nature. In discussing the proliferation of definitions (and subsequent confusion), FLYVBJERG (2011) contends that using a simple definition might be a more useful approach, citing the MERRIAM-WEBSTER DICTIONARY's (2009) definition, as an example that captures the key requisites in the context of research: "an intensive analysis of an individual unit (as a person or community) stressing developmental factors in relation to environment" (p.103). These varied definitions stem from the researchers' differing approaches to developing case study methodology and often reflect the elements they emphasize as central to their designs. The diversity of approaches subsequently adds diversity to definition and description. 
3.2 Methodology or method
A further challenge to understanding case study research relates to it being referred to and used as both a methodology and a method. MILLS (2014) distinguishes methods as procedures and techniques employed in the study, while methodology is the lens through which the researcher views and makes decisions about the study. Given the variation in definitions and descriptions, referring to case study research as a methodology and/or a single method can be perplexing, misleading, and at times counterproductive (ANTHONY & JACK, 2009; BOBLIN, IRELAND, KIRKPATRICK & ROBERTSON, 2013; FLYVBJERG, 2011). Furthermore, advocates of case study encourage the use of both quantitative and qualitative methods within their designs adding further obscurity to the question of methodology (MERRIAM, 1998; STAKE, 1995; STEWART, 2014; YIN, 2014). 
The ambiguity about case study being either or both a methodology and method, is compounded by the terminology used in discussions about case study. Across the literature, case study is referred to as a methodology and a method, an approach, research and research design, research strategy, and/or a form of inquiry (ANTHONY & JACK, 2009; BROWN, 2008; CRESWELL, 2014; GERRING, 2004; MERRIAM, 2009; SIMONS, 2009, STAKE, 1995, 2006; STEWART, 2014; YIN, 2014). Often these terms are used interchangeably without definitional clarity. For example, YIN (2014) discusses case study research and in the context of presenting case study, refers to it as a research method while emphasizing the procedures used. He does not use the terms methodology or strategy. CRESWELL (2014) refers to case studies as a qualitative design, while others use the term case study (FLYVBJERG, 2011; STAKE, 1995, 2006; STEWART, 2014), qualitative case study (MERRIAM, 2009), or describe case study as an approach (SIMONS, 2009). This mixed use of terminology is confusing given the definitional separations between methodology and methods and the varied application of case study in research endeavors. 
Prominent case study researchers do however emphasize that an overarching methodology shapes a case study design and that multiple sources of data and methods can be used (MERRIAM, 2009; STAKE, 2006; YIN, 2014), thus providing the distinction between the two. This distinction accentuates the need for researchers to describe the particular underpinning methodology adopted and to clarify the alignment of chosen methods used with their philosophical assumptions and their chosen approach. Exploring the philosophical orientation of case study research and variations in different case study approaches can help to clarify these differences, and promote a better understanding of how to apply these principles in practice. 
3.3 Philosophical orientation
Many methodologies are aligned with specific philosophical positions that guide the research process. Case study, however, has a practical versatility in its agnostic approach whereby "it is not assigned to a fixed ontological, epistemological or methodological position" (ROSENBERG & YATES, 2007, p.447). Philosophically, case study research can be orientated from a realist or positivist perspective where the researcher holds the view that there is one single reality, which is independent of the individual and can be apprehended, studied and measured, through to a relativist or interpretivist perspective. A relativist or interpretivist perspective adopts the premises that multiple realities and meanings exist, which depend on and are co-created by the researcher (LINCOLN, LYNHAM & GUBA, 2011; YIN, 2014). This philosophical versatility provides the researcher with the opportunity to decide the methodological orientation used in the conduct of the case study (STEWART, 2014; YIN, 2014). Examples of this choice are discussed later where the philosophical variations of MERRIAM (2009), STAKE (1995), and YIN (2014) are explicated. 
In the context of healthcare research and specifically nursing, LUCK et al. (2006) describe case study research as "a bridge across paradigms" (p.103). As a result, some case study approaches are either quantitatively or qualitatively orientated while others encompass both qualitative and quantitative aims and methods (MERRIAM, 2009; MILES, HUBERMAN & SALDANA, 2014; YIN, 2014). DENZIN and LINCOLN (2011) emphasize the qualitative essence of case study, while acknowledging its evolution and fluidity with regard to accommodating varied ontologies, epistemologies, methodologies, and methods. This ability to accommodate a range of philosophical positions is seen as an advantage whereby case study enables the opportunity to design research that can be specifically tailored to the inherent complexity of the research problem (ANTHONY & JACK, 2009; CASEY & HOUGHTON, 2010; FLYVBJERG, 2011; FARQUHAR, 2012; LUCK et al., 2006; MERRIAM, 2009; STAKE, 2006; YIN, 2014). 
Case study research is most often described as qualitative inquiry (CRESWELL, 2014; DENZIN & LINCOLN, 2011; MERRIAM, 2009; MILES et al., 2014; STAKE, 2006). Qualitative paradigms are broad and can encompass exploratory, explanatory, interpretive, or descriptive aims. Examples include narrative research, phenomenology, grounded theory, and ethnography (DENZIN & LINCOLN, 2011). Each methodology is unique in approach depending on the ontological and epistemological stance, however all stem from the motivation to explore, seek understanding, and establish the meaning of experiences from the perspective of those involved (ibid.; see also MERRIAM, 2009). For this purpose, qualitative researchers can employ a broad scope of methods and interpretative practices in any one study, although they typically include observations, interviews, and analysis of participants' words (DENZIN & LINCOLN, 2011; MERRIAM, 2009). DENZIN and LINCOLN (2011, pp. 8-10) summarize the characteristics of qualitative research into five key attributes:
reducing the use of positivist or post positivist perspectives;
accepting postmodern sensibilities;
capturing the individual's point of view;
examining the constraints of everyday life;
securing rich descriptions. 
These attributes are commonly exemplified in case study research. The fundamental goal of case study research is to conduct an in-depth analysis of an issue, within its context with a view to understand the issue from the perspective of participants (MERRIAM, 2009; SIMONS, 2009; STAKE, 2006, YIN, 2014). Like other forms of qualitative research, the researcher will seek to explore, understand and present the participants' perspectives and get close to them in their natural setting (CRESWELL, 2013). Interaction between participants and the researcher is required to generate data, which is an indication of the researcher's level of connection to and being immersed in the field. Because of this, constructivism and interpretivism commonly permeate the implementation of this research design. Methods used in case study to facilitate achieving the aim of co-constructing data most often include observations, interviews, focus groups, document and artifact analysis (MERRIAM, 2009; SIMONS, 2009; STAKE, 1995; 2006; STEWART, 2014; YIN, 2014). The researcher's perceptions and interpretations become part of the research and as a result, a subjective and interpretive orientation flows throughout the inquiry (CRESWELL, 2014). Subjectivity is openly acknowledged and to manage this, the researcher embraces a reflexive stance within the study, adopting methods such as memoing and journaling that support this position (DENZIN & LINCOLN, 2011; MILES et al., 2014, STAKE, 2006; YIN, 2014). 
3.4 Philosophical variation
In choosing a methodological position, careful consideration of the different case study approaches is required to determine the design that best addresses the aim of the study, and that aligns with the researcher's worldview. The goal of this alignment is to engender coherence between the researcher's philosophical position, their research question, design, and methods to be used in the study (FARQUHAR, 2012; LUCK et al., 2006; STEWART, 2014; YIN, 2014). To assist in understanding and achieving this alignment, the qualitative case study approaches developed by YIN (2014), STAKE (1995) and MERRIAM (1998, 2009) are explored in the following sections. Examples are provided of how these researchers' philosophical orientation influences the application of case study in practice. 
3.4.1 YIN: Realist—postpositivist
YIN (2014) conceptualizes case study research as a form of social science. Post-positivism is evident in how he defines "case study as a form of empirical inquiry" (p.16). YIN himself describes his approach to case study as using a "realist perspective" (p.17) and focuses on maintaining objectivity in the methodological processes within the design. 
Postpositivist qualitative researchers conduct research that embraces the ideals of objectivity and the generalizability of results (ELLINGSON, 2011). The goal of a postpositivist researcher is to use science as a way to apprehend the nature of reality while understanding that all measurement is imperfect. Therefore, emphasis is placed on using multiple methods with triangulation to circumvent errors and understand what is happening in reality as close as possible to the "truth" (LINCOLN et al., 2011). The researcher will often categorize qualitative data to create quantitative data that can then be analyzed using statistical methods. Validity of research results are verified through the scrutiny of others and, as such, adherence to mechanisms that ensure rigor in data collection and analysis is vital. Furthermore, postpositivists accept that everyone is inherently biased in worldviews, which ultimately influence how the methods used are deployed. Interaction with research subjects therefore needs to be minimized and subjectivity managed to avoid biasing the results (ibid.). 
Embedded within YIN's (2014) case study design are the hallmarks of a postpositivist approach to research: seeking rival explanations and falsifying hypotheses, the capability for replication with a multiple case study design, the pursuit of generalizations (if required), minimizing levels of subjectivity, and the use of multiple methods of qualitative and quantitative data collection and analysis. While objectivity is a goal, YIN also recognizes the descriptive and interpretive elements of case study. According to YIN what makes case study research distinct from experimental studies is the case study is investigated in context, examined in its "real world setting" (p.16). Selection of cases is based on the purpose of the research and related to the theoretical propositions about the topic of interest. YIN suggests careful screening in the selection of cases to ensure specific relevance to the issues of interest and the use of replication logic: cases are chosen to produce anticipated contrasting findings (theoretical replication) or similar findings (literal replication). Precision, process, and practicality are core attributes of YIN's approach to case study. Design features are sequentially structured and motivated by empirical application. This positioning reflects the axiology of postpositivism where maintaining intellectual honesty, managing bias, and acknowledging limitations, coupled with meticulous data collection and accurate reporting are critical elements in the conduct of research (KILLAM, 2013; YIN, 2014). 
3.4.2 MERRIAM: Pragmatic constructivist
MERRIAM (1998) maintains a constructivist approach to case study research, whereby the researcher assumes that reality is constructed intersubjectively through meanings and understandings developed socially and experientially. Like YIN (2014), MERRIAM (1998, 2009) asserts that when information is plentiful and concepts abstract, it is important to utilize processes that help interpret, sort, and manage information and that adapt findings to convey clarity and applicability to the results. In this way, MERRIAM's perspective brings forth a pragmatic approach to constructivist inquiry. MERRIAM (2009) acknowledges case study research can use both quantitative and qualitative methods; however, when working on qualitative case studies, methods aimed at generating inductive reasoning and interpretation rather than testing hypothesis take priority. Cases are selected based on the research purpose and question, and for what they could reveal about the phenomenon or topic of interest. The aim is to provide a rich holistic description that illuminates one's understanding of the phenomena (MERRIAM, 1998). Interviews are the most common form of qualitative data collection, although MERRIAM does not stipulate prioritizing a particular method for data collection or analysis, she does emphasize the importance of rigorous procedures to frame the research process. Advocating for careful planning, development, and execution of case study research, MERRIAM (1998, 2009) discusses the pragmatic structures that ensure case study research is manageable, rigorous, credible, and applicable. Processes such as descriptive, thematic and content analysis, and triangulation are significant in ensuring the quality of a study, therefore, methods of data collection and analysis need to be organized and systematized with a detailed chain of evidence (MERRIAM, 2009). Theoretical frameworks or research questions are used and drawn from the literature or discipline (MERRIAM, 1998). According to BROWN (2008), Merriam's style brings forth a practical application of pluralistic strategies that guide pragmatic constructivist research to derive knowledge about an area of inquiry. 
3.4.3 STAKE: Relativist—constructivist/interpretivist
STAKE (1995, 2006) has an approach to case study research that is qualitative and closely aligned with a constructivist and interpretivist orientation. While having a disciplined approach to the process and acknowledging that case study can use quantitative methods, STAKE's approach is underpinned by a strong motivation for discovering meaning and understanding of experiences in context. The role of the researcher in producing this knowledge is critical, and STAKE emphasizes the researcher's interpretive role as essential in the process. An interpretative position views reality as multiple and subjective, based on meanings and understanding. Knowledge generated from the research process is relative to the time and context of the study and the researcher is interactive and participates in the study. In terms of epistemology, STAKE argues that situation shapes activity, experience, and one's interpretation of the case. For STAKE (2006), to understand the case "requires experiencing the activity of the case as it occurs in its context and in its particular situation" (p.2). The researcher attempts to capture her or his interpreted reality of the case, while studying the case situationally enables an examination of the integrated system in which the case unfolds. Similar to YIN (2014) and MERRIAM (2009), a case or cases are selected for what they can reveal about topic of interest and depend on the aim and conditions of the study. A case is selected because it is interesting in itself or can facilitate the understanding of something else; it is instrumental in providing insight on an issue (STAKE, 2006). 
For STAKE, multiple sources and methods of data collection and analysis can be used, however, interviews and observations are the preferred and dominant data collection method. In seeking understanding and meaning, the researcher is positioned with participants as a partner in the discovery and generation of knowledge, where both direct interpretations, and categorical or thematic grouping of findings are used. STAKE (1995) recommends vignettes—episodes of storytelling—to illustrate aspects of the case and thick descriptions to convey findings, a further illustration of his constructivist and interpretivist approach to case study research. 
BROWN (2007) suggests the three approaches used by these seminal researchers rest along a quantitative-qualitative continuum where the postpositivist methodology of YIN (2014) sits at one end, STAKE's interpretivist design (1995, 2006) sits at the other end and MERRIAM (1998, 2009) who as a pragmatic constructivist draws on the elements of both, rests toward the center. BROWN (2008) sums up the influences of each, saying that "case study research is supported by the pragmatic approach of Merriam, informed by the rigour of Yin and enriched by the creative interpretation described by Stake" (p.9). While some may argue that mixing qualitative and quantitative methods could threaten the veracity of the research (BOBLIN et al., 2013; SANDELOWSKI, 2011), MERRIAM's approach demonstrates that when the integrity of the design is robust, methodological flexibility can be accommodated. 
4. Common Characteristics of Case Study Research
Despite variation in the approaches of the different exponents of case study, there are characteristics common to all of them. Case study research is consistently described as a versatile form of qualitative inquiry most suitable for a comprehensive, holistic, and in-depth investigation of a complex issue (phenomena, event, situation, organization, program individual or group) in context, where the boundary between the context and issue is unclear and contains many variables (CRESWELL, 2014; FLYVBJERG, 2011; MERRIAM, 2009; SIMONS, 2009; STAKE, 2006; YIN, 2014). Case study research can be used to study a range of topics and purposes (SIMONS, 2009; STAKE, 2006; STEWART, 2014) however, the essential requisite for employing case study stems from one's motivation to illuminate understanding of complex phenomena (MERRIAM, 2009; STAKE, 2006; YIN, 2014). Primarily exploratory and explanatory in nature, case study is used to gain an understanding of the issue in real life settings and recommended to answer how andwhy or less frequently what research questions (FLYVBJERG, 2011; MERRIAM, 2009; SIMONS, 2009; STAKE, 2006; STEWART, 2014; YIN 2014). 
Defining the case (unit of analysis or object of the study) and bounding the case can be difficult as many points of interest and variables intersect and overlap in case study research. Developing research questions and/or propositions to select the case, identify the focus, and refine the boundaries is recommended to effectively establish these elements in the research design (MERRIAM, 2009; STAKE, 2006; YIN, 2014). Bounding the case is essential to focusing, framing, and managing data collection and analysis. This involves being selective and specific in identifying the parameters of the case including the participant/s, location and/or process to be explored, and establishing the timeframe for investigating the case (MERRIAM, 2009; STAKE, 2006; YIN, 2014). 
The use of multiple methods to collect and analyze data are encouraged and found to be mutually informative in case study research where together they provide a more synergistic and comprehensive view of the issue being studied (FLYVBJERG, 2011; MERRIAM, 2009; STAKE, 2006; YIN, 2014). How the methods are used will vary and depend on the research purpose and design, which is often a variation of a single or multiple case study research design. Interviews and focus groups, observations, and exploring artifacts are most commonly employed to collect and generate data with triangulation of methods and data, however, this is not exclusive. 
The fundamental elements of case study research (Table 1) are evident in the approaches of MERRIAM (2009), STAKE (1995, 2006), and YIN (2014) as well as other case study researchers who have contributed to the development and discussion of case study research (CRESWELL, 2013, 2014; FLYVBJERG, 2011; GEORGE & BENNETT, 2007; MILES et al., 2014; SIMONS, 2009). These elements delineate case study from other forms of research and inform the critical aspects of the research design and execution.
Object of the case study identified as the entity of interest or unit of analysis
Program, individual, group, social situation, organization, event, phenomena, or process
A bounded system
Bounded by time, space, and activity
Encompasses a system of connections
Bounding applies frames to manage contextual variables
Boundaries between the case and context can be blurred
Studied in context
Studied in its real life setting or natural environment
Context is significant to understanding the case
Contextual variables include political, economic, social, cultural, historical, and/or organizational factors
Chosen for intensive analysis of an issue
Fieldwork is intrinsic to the process of the inquiry
Subjectivity a consistent thread—varies in depth and engagement depending on the philosophical orientation of the research, purpose, and methods
Reflexive techniques pivotal to credibility and research process
Selecting the case
Based on the purpose and conditions of the study
Involves decisions about people, settings, events, phenomena, social processes
Scope: single, within case and multiple case sampling
Broad: capture ordinary, unique, varied and/or accessible aspects
Methods: specified criteria, methodical and purposive; replication logic: theoretical or literal replication (YIN, 2014)
Multiple sources of evidence
Multiple sources of evidence for comprehensive depth and breadth of inquiry
Methods of data collection: interviews, observations, focus groups, artifact and document review, questionnaires and/or surveys
Methods of analysis: vary and depend on data collection methods and cases; need to be systematic and rigorous
Triangulation highly valued and commonly employed
Case study design
Descriptive, exploratory, explanatory, illustrative, evaluative
Single or multiple cases
Embedded or holistic (YIN, 2014)
Particularistic, heuristic, descriptive (MERRIAM, 1998, 2009)
Intrinsic, instrumental, and collective (STAKE, 1995, 2006)
Table 1: Case study elements and descriptors 
A final, critical point when conducting case study research is the importance of careful preparation and planning, coupled with the development of a systematic implementation structure (FLYVBJERG, 2011; MERRIAM, 2009; STAKE, 2006; STEWART, 2014; YIN, 2014). As discussed earlier, ensuring the alignment of philosophy and methodology with the research purpose and methods employed underpins a rigorous research process (STEWART, 2014). Clarity in this alignment is fundamental to ensuring the veracity of the research and depends on the design developed. During this process, researchers are encouraged to "logically justify their philosophical position, research design and include a coherent argument for inclusion of varying research methods" (LUCK et al., 2006, p.107). Study propositions, theory, research or issue questions work as a conceptual framework and need to align with the case to guide the design and determine methods of data collection and analysis (STAKE, 2006; STEWART, 2014; YIN, 2014). Maintaining meticulous records and a systematic chain of evidence over the duration of the study is critical; as is being able to access, present and explain procedures supports the ethical integrity and rigor of the research and findings (MERRIAM, 2009; STEWART, 2014; YIN, 2014). Collective alignment of these elements articulates a justifiable framework for the research study and cultivates trustworthiness and the validity, reliability and credibility of the research findings. 
Considering these fundamental elements and common approaches to case study research, the definition from CRESWELL et al. (2007) seems to best capture the full depth and breadth of case study concepts and descriptions. The authors describe case study as "a methodology, a type of design in qualitative research, an object of study and a product of the inquiry" (p.245). They conclude with a definition that collates the hallmarks of key approaches and represents the core features of a case study:
"Case study research is a qualitative approach in which the investigator explores a bounded system (a case) or multiple bounded systems (cases) over time through detailed, in-depth data collection involving multiple sources of information (e.g., observations, interviews, audiovisual material, and documents and reports) and reports a case description and case-based themes" (ibid.). 
Since the 1980's a broad scope of case study approaches have developed. This range accentuates the flexibility of case study research as a distinct form of inquiry that enables comprehensive and in-depth insight into a diverse range of issues across a number of disciplines. While differences exist in some areas, commonalities are evident that can guide the application of a case study research design. Key contributors to the development of case study agree that the focus of a case study is the detailed inquiry of a unit of analysis as a bounded system (the case), over time, within its context. The versatility of case study research to accommodate the researcher's philosophical position presents a unique platform for a range of studies that can generate greater insights into areas of inquiry. With the capacity to tailor approaches, case study designs can address a wide range of questions that ask why, what, and how of an issue and assist researchers to explore, explain, describe, evaluate, and theorize about complex issues in context. Outcomes can lead to an in-depth understanding of behaviors, processes, practices, and relationships in context. Professions including the social sciences, education, health, law, management, business, and urban planning have embraced case study research, demonstrating these outcomes. Ongoing application of and sound debate about the value, validity, and capability of case study research have strengthened the efficacy of case study approaches as powerful forms of qualitative research. 
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Helena HARRISON, MN(Ed) is a PhD candidate in the College of Healthcare Sciences, Division of Tropical Health and Medicine, James Cook University, Australia. Her research interests include undergraduate and postgraduate nurse education with her current study focusing on the practice readiness of new graduate registered nurses in Australia.
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Melanie Birks, PhD is professor and Head of Nursing, Midwifery and Nutrition at James Cook University, Australia. Her research interests are in the areas of accessibility, innovation, relevance and quality in nursing education.
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Richard Franklin, Ph.D. is an associate professor at the College of Public Health, Medical & Veterinary Sciences at James Cook University. Richard's public health projects have explored injury prevention and safety promotion and focused areas of farm safety, rural safety, occupational health and safety, falls, disasters, health promotion, and alcohol and aquatic safety. Richard's research interests include translating evidence into practice, epidemiological, program and product evaluation, surveillance and using mixed methods research for solving real world problems.
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Jane Mills, PhD is professor and Pro Vice Chancellor of the College of Health at Massey University in New Zealand. Her research interests are primary health care, public health and health systems strengthening.
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Harrison, Helena; Birks, Melanie; Franklin, Richard & Mills, Jane (2017). Case Study Research: Foundations and Methodological Orientations [34 paragraphs]. Forum Qualitative Sozialforschung / Forum: Qualitative Social Research, 18(1), Art. 19,