holistic case study design

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Continuing to enhance the quality of case study methodology in health services research

Shannon l. sibbald.

1 Faculty of Health Sciences, Western University, London, Ontario, Canada.

2 Department of Family Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.

3 The Schulich Interfaculty Program in Public Health, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.

Stefan Paciocco

Meghan fournie, rachelle van asseldonk, tiffany scurr.

Case study methodology has grown in popularity within Health Services Research (HSR). However, its use and merit as a methodology are frequently criticized due to its flexible approach and inconsistent application. Nevertheless, case study methodology is well suited to HSR because it can track and examine complex relationships, contexts, and systems as they evolve. Applied appropriately, it can help generate information on how multiple forms of knowledge come together to inform decision-making within healthcare contexts. In this article, we aim to demystify case study methodology by outlining its philosophical underpinnings and three foundational approaches. We provide literature-based guidance to decision-makers, policy-makers, and health leaders on how to engage in and critically appraise case study design. We advocate that researchers work in collaboration with health leaders to detail their research process with an aim of strengthening the validity and integrity of case study for its continued and advanced use in HSR.

Introduction

The popularity of case study research methodology in Health Services Research (HSR) has grown over the past 40 years. 1 This may be attributed to a shift towards the use of implementation research and a newfound appreciation of contextual factors affecting the uptake of evidence-based interventions within diverse settings. 2 Incorporating context-specific information on the delivery and implementation of programs can increase the likelihood of success. 3 , 4 Case study methodology is particularly well suited for implementation research in health services because it can provide insight into the nuances of diverse contexts. 5 , 6 In 1999, Yin 7 published a paper on how to enhance the quality of case study in HSR, which was foundational for the emergence of case study in this field. Yin 7 maintains case study is an appropriate methodology in HSR because health systems are constantly evolving, and the multiple affiliations and diverse motivations are difficult to track and understand with traditional linear methodologies.

Despite its increased popularity, there is debate whether a case study is a methodology (ie, a principle or process that guides research) or a method (ie, a tool to answer research questions). Some criticize case study for its high level of flexibility, perceiving it as less rigorous, and maintain that it generates inadequate results. 8 Others have noted issues with quality and consistency in how case studies are conducted and reported. 9 Reporting is often varied and inconsistent, using a mix of approaches such as case reports, case findings, and/or case study. Authors sometimes use incongruent methods of data collection and analysis or use the case study as a default when other methodologies do not fit. 9 , 10 Despite these criticisms, case study methodology is becoming more common as a viable approach for HSR. 11 An abundance of articles and textbooks are available to guide researchers through case study research, including field-specific resources for business, 12 , 13 nursing, 14 and family medicine. 15 However, there remains confusion and a lack of clarity on the key tenets of case study methodology.

Several common philosophical underpinnings have contributed to the development of case study research 1 which has led to different approaches to planning, data collection, and analysis. This presents challenges in assessing quality and rigour for researchers conducting case studies and stakeholders reading results.

This article discusses the various approaches and philosophical underpinnings to case study methodology. Our goal is to explain it in a way that provides guidance for decision-makers, policy-makers, and health leaders on how to understand, critically appraise, and engage in case study research and design, as such guidance is largely absent in the literature. This article is by no means exhaustive or authoritative. Instead, we aim to provide guidance and encourage dialogue around case study methodology, facilitating critical thinking around the variety of approaches and ways quality and rigour can be bolstered for its use within HSR.

Purpose of case study methodology

Case study methodology is often used to develop an in-depth, holistic understanding of a specific phenomenon within a specified context. 11 It focuses on studying one or multiple cases over time and uses an in-depth analysis of multiple information sources. 16 , 17 It is ideal for situations including, but not limited to, exploring under-researched and real-life phenomena, 18 especially when the contexts are complex and the researcher has little control over the phenomena. 19 , 20 Case studies can be useful when researchers want to understand how interventions are implemented in different contexts, and how context shapes the phenomenon of interest.

In addition to demonstrating coherency with the type of questions case study is suited to answer, there are four key tenets to case study methodologies: (1) be transparent in the paradigmatic and theoretical perspectives influencing study design; (2) clearly define the case and phenomenon of interest; (3) clearly define and justify the type of case study design; and (4) use multiple data collection sources and analysis methods to present the findings in ways that are consistent with the methodology and the study’s paradigmatic base. 9 , 16 The goal is to appropriately match the methods to empirical questions and issues and not to universally advocate any single approach for all problems. 21

Approaches to case study methodology

Three authors propose distinct foundational approaches to case study methodology positioned within different paradigms: Yin, 19 , 22 Stake, 5 , 23 and Merriam 24 , 25 ( Table 1 ). Yin is strongly post-positivist whereas Stake and Merriam are grounded in a constructivist paradigm. Researchers should locate their research within a paradigm that explains the philosophies guiding their research 26 and adhere to the underlying paradigmatic assumptions and key tenets of the appropriate author’s methodology. This will enhance the consistency and coherency of the methods and findings. However, researchers often do not report their paradigmatic position, nor do they adhere to one approach. 9 Although deliberately blending methodologies may be defensible and methodologically appropriate, more often it is done in an ad hoc and haphazard way, without consideration for limitations.

Cross-analysis of three case study approaches, adapted from Yazan 2015

The post-positive paradigm postulates there is one reality that can be objectively described and understood by “bracketing” oneself from the research to remove prejudice or bias. 27 Yin focuses on general explanation and prediction, emphasizing the formulation of propositions, akin to hypothesis testing. This approach is best suited for structured and objective data collection 9 , 11 and is often used for mixed-method studies.

Constructivism assumes that the phenomenon of interest is constructed and influenced by local contexts, including the interaction between researchers, individuals, and their environment. 27 It acknowledges multiple interpretations of reality 24 constructed within the context by the researcher and participants which are unlikely to be replicated, should either change. 5 , 20 Stake and Merriam’s constructivist approaches emphasize a story-like rendering of a problem and an iterative process of constructing the case study. 7 This stance values researcher reflexivity and transparency, 28 acknowledging how researchers’ experiences and disciplinary lenses influence their assumptions and beliefs about the nature of the phenomenon and development of the findings.

Defining a case

A key tenet of case study methodology often underemphasized in literature is the importance of defining the case and phenomenon. Researches should clearly describe the case with sufficient detail to allow readers to fully understand the setting and context and determine applicability. Trying to answer a question that is too broad often leads to an unclear definition of the case and phenomenon. 20 Cases should therefore be bound by time and place to ensure rigor and feasibility. 6

Yin 22 defines a case as “a contemporary phenomenon within its real-life context,” (p13) which may contain a single unit of analysis, including individuals, programs, corporations, or clinics 29 (holistic), or be broken into sub-units of analysis, such as projects, meetings, roles, or locations within the case (embedded). 30 Merriam 24 and Stake 5 similarly define a case as a single unit studied within a bounded system. Stake 5 , 23 suggests bounding cases by contexts and experiences where the phenomenon of interest can be a program, process, or experience. However, the line between the case and phenomenon can become muddy. For guidance, Stake 5 , 23 describes the case as the noun or entity and the phenomenon of interest as the verb, functioning, or activity of the case.

Designing the case study approach

Yin’s approach to a case study is rooted in a formal proposition or theory which guides the case and is used to test the outcome. 1 Stake 5 advocates for a flexible design and explicitly states that data collection and analysis may commence at any point. Merriam’s 24 approach blends both Yin and Stake’s, allowing the necessary flexibility in data collection and analysis to meet the needs.

Yin 30 proposed three types of case study approaches—descriptive, explanatory, and exploratory. Each can be designed around single or multiple cases, creating six basic case study methodologies. Descriptive studies provide a rich description of the phenomenon within its context, which can be helpful in developing theories. To test a theory or determine cause and effect relationships, researchers can use an explanatory design. An exploratory model is typically used in the pilot-test phase to develop propositions (eg, Sibbald et al. 31 used this approach to explore interprofessional network complexity). Despite having distinct characteristics, the boundaries between case study types are flexible with significant overlap. 30 Each has five key components: (1) research question; (2) proposition; (3) unit of analysis; (4) logical linking that connects the theory with proposition; and (5) criteria for analyzing findings.

Contrary to Yin, Stake 5 believes the research process cannot be planned in its entirety because research evolves as it is performed. Consequently, researchers can adjust the design of their methods even after data collection has begun. Stake 5 classifies case studies into three categories: intrinsic, instrumental, and collective/multiple. Intrinsic case studies focus on gaining a better understanding of the case. These are often undertaken when the researcher has an interest in a specific case. Instrumental case study is used when the case itself is not of the utmost importance, and the issue or phenomenon (ie, the research question) being explored becomes the focus instead (eg, Paciocco 32 used an instrumental case study to evaluate the implementation of a chronic disease management program). 5 Collective designs are rooted in an instrumental case study and include multiple cases to gain an in-depth understanding of the complexity and particularity of a phenomenon across diverse contexts. 5 , 23 In collective designs, studying similarities and differences between the cases allows the phenomenon to be understood more intimately (for examples of this in the field, see van Zelm et al. 33 and Burrows et al. 34 In addition, Sibbald et al. 35 present an example where a cross-case analysis method is used to compare instrumental cases).

Merriam’s approach is flexible (similar to Stake) as well as stepwise and linear (similar to Yin). She advocates for conducting a literature review before designing the study to better understand the theoretical underpinnings. 24 , 25 Unlike Stake or Yin, Merriam proposes a step-by-step guide for researchers to design a case study. These steps include performing a literature review, creating a theoretical framework, identifying the problem, creating and refining the research question(s), and selecting a study sample that fits the question(s). 24 , 25 , 36

Data collection and analysis

Using multiple data collection methods is a key characteristic of all case study methodology; it enhances the credibility of the findings by allowing different facets and views of the phenomenon to be explored. 23 Common methods include interviews, focus groups, observation, and document analysis. 5 , 37 By seeking patterns within and across data sources, a thick description of the case can be generated to support a greater understanding and interpretation of the whole phenomenon. 5 , 17 , 20 , 23 This technique is called triangulation and is used to explore cases with greater accuracy. 5 Although Stake 5 maintains case study is most often used in qualitative research, Yin 17 supports a mix of both quantitative and qualitative methods to triangulate data. This deliberate convergence of data sources (or mixed methods) allows researchers to find greater depth in their analysis and develop converging lines of inquiry. For example, case studies evaluating interventions commonly use qualitative interviews to describe the implementation process, barriers, and facilitators paired with a quantitative survey of comparative outcomes and effectiveness. 33 , 38 , 39

Yin 30 describes analysis as dependent on the chosen approach, whether it be (1) deductive and rely on theoretical propositions; (2) inductive and analyze data from the “ground up”; (3) organized to create a case description; or (4) used to examine plausible rival explanations. According to Yin’s 40 approach to descriptive case studies, carefully considering theory development is an important part of study design. “Theory” refers to field-relevant propositions, commonly agreed upon assumptions, or fully developed theories. 40 Stake 5 advocates for using the researcher’s intuition and impression to guide analysis through a categorical aggregation and direct interpretation. Merriam 24 uses six different methods to guide the “process of making meaning” (p178) : (1) ethnographic analysis; (2) narrative analysis; (3) phenomenological analysis; (4) constant comparative method; (5) content analysis; and (6) analytic induction.

Drawing upon a theoretical or conceptual framework to inform analysis improves the quality of case study and avoids the risk of description without meaning. 18 Using Stake’s 5 approach, researchers rely on protocols and previous knowledge to help make sense of new ideas; theory can guide the research and assist researchers in understanding how new information fits into existing knowledge.

Practical applications of case study research

Columbia University has recently demonstrated how case studies can help train future health leaders. 41 Case studies encompass components of systems thinking—considering connections and interactions between components of a system, alongside the implications and consequences of those relationships—to equip health leaders with tools to tackle global health issues. 41 Greenwood 42 evaluated Indigenous peoples’ relationship with the healthcare system in British Columbia and used a case study to challenge and educate health leaders across the country to enhance culturally sensitive health service environments.

An important but often omitted step in case study research is an assessment of quality and rigour. We recommend using a framework or set of criteria to assess the rigour of the qualitative research. Suitable resources include Caelli et al., 43 Houghten et al., 44 Ravenek and Rudman, 45 and Tracy. 46

New directions in case study

Although “pragmatic” case studies (ie, utilizing practical and applicable methods) have existed within psychotherapy for some time, 47 , 48 only recently has the applicability of pragmatism as an underlying paradigmatic perspective been considered in HSR. 49 This is marked by uptake of pragmatism in Randomized Control Trials, recognizing that “gold standard” testing conditions do not reflect the reality of clinical settings 50 , 51 nor do a handful of epistemologically guided methodologies suit every research inquiry.

Pragmatism positions the research question as the basis for methodological choices, rather than a theory or epistemology, allowing researchers to pursue the most practical approach to understanding a problem or discovering an actionable solution. 52 Mixed methods are commonly used to create a deeper understanding of the case through converging qualitative and quantitative data. 52 Pragmatic case study is suited to HSR because its flexibility throughout the research process accommodates complexity, ever-changing systems, and disruptions to research plans. 49 , 50 Much like case study, pragmatism has been criticized for its flexibility and use when other approaches are seemingly ill-fit. 53 , 54 Similarly, authors argue that this results from a lack of investigation and proper application rather than a reflection of validity, legitimizing the need for more exploration and conversation among researchers and practitioners. 55

Although occasionally misunderstood as a less rigourous research methodology, 8 case study research is highly flexible and allows for contextual nuances. 5 , 6 Its use is valuable when the researcher desires a thorough understanding of a phenomenon or case bound by context. 11 If needed, multiple similar cases can be studied simultaneously, or one case within another. 16 , 17 There are currently three main approaches to case study, 5 , 17 , 24 each with their own definitions of a case, ontological and epistemological paradigms, methodologies, and data collection and analysis procedures. 37

Individuals’ experiences within health systems are influenced heavily by contextual factors, participant experience, and intricate relationships between different organizations and actors. 55 Case study research is well suited for HSR because it can track and examine these complex relationships and systems as they evolve over time. 6 , 7 It is important that researchers and health leaders using this methodology understand its key tenets and how to conduct a proper case study. Although there are many examples of case study in action, they are often under-reported and, when reported, not rigorously conducted. 9 Thus, decision-makers and health leaders should use these examples with caution. The proper reporting of case studies is necessary to bolster their credibility in HSR literature and provide readers sufficient information to critically assess the methodology. We also call on health leaders who frequently use case studies 56 – 58 to report them in the primary research literature.

The purpose of this article is to advocate for the continued and advanced use of case study in HSR and to provide literature-based guidance for decision-makers, policy-makers, and health leaders on how to engage in, read, and interpret findings from case study research. As health systems progress and evolve, the application of case study research will continue to increase as researchers and health leaders aim to capture the inherent complexities, nuances, and contextual factors. 7

The Advantages and Limitations of Single Case Study Analysis

As Andrew Bennett and Colin Elman have recently noted, qualitative research methods presently enjoy “an almost unprecedented popularity and vitality… in the international relations sub-field”, such that they are now “indisputably prominent, if not pre-eminent” (2010: 499). This is, they suggest, due in no small part to the considerable advantages that case study methods in particular have to offer in studying the “complex and relatively unstructured and infrequent phenomena that lie at the heart of the subfield” (Bennett and Elman, 2007: 171). Using selected examples from within the International Relations literature[1], this paper aims to provide a brief overview of the main principles and distinctive advantages and limitations of single case study analysis. Divided into three inter-related sections, the paper therefore begins by first identifying the underlying principles that serve to constitute the case study as a particular research strategy, noting the somewhat contested nature of the approach in ontological, epistemological, and methodological terms. The second part then looks to the principal single case study types and their associated advantages, including those from within the recent ‘third generation’ of qualitative International Relations (IR) research. The final section of the paper then discusses the most commonly articulated limitations of single case studies; while accepting their susceptibility to criticism, it is however suggested that such weaknesses are somewhat exaggerated. The paper concludes that single case study analysis has a great deal to offer as a means of both understanding and explaining contemporary international relations.

The term ‘case study’, John Gerring has suggested, is “a definitional morass… Evidently, researchers have many different things in mind when they talk about case study research” (2006a: 17). It is possible, however, to distil some of the more commonly-agreed principles. One of the most prominent advocates of case study research, Robert Yin (2009: 14) defines it as “an empirical enquiry 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”. What this definition usefully captures is that case studies are intended – unlike more superficial and generalising methods – to provide a level of detail and understanding, similar to the ethnographer Clifford Geertz’s (1973) notion of ‘thick description’, that allows for the thorough analysis of the complex and particularistic nature of distinct phenomena. Another frequently cited proponent of the approach, Robert Stake, notes that as a form of research the case study “is defined by interest in an individual case, not by the methods of inquiry used”, and that “the object of study is a specific, unique, bounded system” (2008: 443, 445). As such, three key points can be derived from this – respectively concerning issues of ontology, epistemology, and methodology – that are central to the principles of single case study research.

First, the vital notion of ‘boundedness’ when it comes to the particular unit of analysis means that defining principles should incorporate both the synchronic (spatial) and diachronic (temporal) elements of any so-called ‘case’. As Gerring puts it, a case study should be “an intensive study of a single unit… a spatially bounded phenomenon – e.g. a nation-state, revolution, political party, election, or person – observed at a single point in time or over some delimited period of time” (2004: 342). It is important to note, however, that – whereas Gerring refers to a single unit of analysis – it may be that attention also necessarily be given to particular sub-units. This points to the important difference between what Yin refers to as an ‘holistic’ case design, with a single unit of analysis, and an ’embedded’ case design with multiple units of analysis (Yin, 2009: 50-52). The former, for example, would examine only the overall nature of an international organization, whereas the latter would also look to specific departments, programmes, or policies etc.

Secondly, as Tim May notes of the case study approach, “even the most fervent advocates acknowledge that the term has entered into understandings with little specification or discussion of purpose and process” (2011: 220). One of the principal reasons for this, he argues, is the relationship between the use of case studies in social research and the differing epistemological traditions – positivist, interpretivist, and others – within which it has been utilised. Philosophy of science concerns are obviously a complex issue, and beyond the scope of much of this paper. That said, the issue of how it is that we know what we know – of whether or not a single independent reality exists of which we as researchers can seek to provide explanation – does lead us to an important distinction to be made between so-called idiographic and nomothetic case studies (Gerring, 2006b). The former refers to those which purport to explain only a single case, are concerned with particularisation, and hence are typically (although not exclusively) associated with more interpretivist approaches. The latter are those focused studies that reflect upon a larger population and are more concerned with generalisation, as is often so with more positivist approaches[2]. The importance of this distinction, and its relation to the advantages and limitations of single case study analysis, is returned to below.

Thirdly, in methodological terms, given that the case study has often been seen as more of an interpretivist and idiographic tool, it has also been associated with a distinctly qualitative approach (Bryman, 2009: 67-68). However, as Yin notes, case studies can – like all forms of social science research – be exploratory, descriptive, and/or explanatory in nature. It is “a common misconception”, he notes, “that the various research methods should be arrayed hierarchically… many social scientists still deeply believe that case studies are only appropriate for the exploratory phase of an investigation” (Yin, 2009: 6). If case studies can reliably perform any or all three of these roles – and given that their in-depth approach may also require multiple sources of data and the within-case triangulation of methods – then it becomes readily apparent that they should not be limited to only one research paradigm. Exploratory and descriptive studies usually tend toward the qualitative and inductive, whereas explanatory studies are more often quantitative and deductive (David and Sutton, 2011: 165-166). As such, the association of case study analysis with a qualitative approach is a “methodological affinity, not a definitional requirement” (Gerring, 2006a: 36). It is perhaps better to think of case studies as transparadigmatic; it is mistaken to assume single case study analysis to adhere exclusively to a qualitative methodology (or an interpretivist epistemology) even if it – or rather, practitioners of it – may be so inclined. By extension, this also implies that single case study analysis therefore remains an option for a multitude of IR theories and issue areas; it is how this can be put to researchers’ advantage that is the subject of the next section.

Having elucidated the defining principles of the single case study approach, the paper now turns to an overview of its main benefits. As noted above, a lack of consensus still exists within the wider social science literature on the principles and purposes – and by extension the advantages and limitations – of case study research. Given that this paper is directed towards the particular sub-field of International Relations, it suggests Bennett and Elman’s (2010) more discipline-specific understanding of contemporary case study methods as an analytical framework. It begins however, by discussing Harry Eckstein’s seminal (1975) contribution to the potential advantages of the case study approach within the wider social sciences.

Eckstein proposed a taxonomy which usefully identified what he considered to be the five most relevant types of case study. Firstly were so-called configurative-idiographic studies, distinctly interpretivist in orientation and predicated on the assumption that “one cannot attain prediction and control in the natural science sense, but only understanding ( verstehen )… subjective values and modes of cognition are crucial” (1975: 132). Eckstein’s own sceptical view was that any interpreter ‘simply’ considers a body of observations that are not self-explanatory and “without hard rules of interpretation, may discern in them any number of patterns that are more or less equally plausible” (1975: 134). Those of a more post-modernist bent, of course – sharing an “incredulity towards meta-narratives”, in Lyotard’s (1994: xxiv) evocative phrase – would instead suggest that this more free-form approach actually be advantageous in delving into the subtleties and particularities of individual cases.

Eckstein’s four other types of case study, meanwhile, promote a more nomothetic (and positivist) usage. As described, disciplined-configurative studies were essentially about the use of pre-existing general theories, with a case acting “passively, in the main, as a receptacle for putting theories to work” (Eckstein, 1975: 136). As opposed to the opportunity this presented primarily for theory application, Eckstein identified heuristic case studies as explicit theoretical stimulants – thus having instead the intended advantage of theory-building. So-called p lausibility probes entailed preliminary attempts to determine whether initial hypotheses should be considered sound enough to warrant more rigorous and extensive testing. Finally, and perhaps most notably, Eckstein then outlined the idea of crucial case studies , within which he also included the idea of ‘most-likely’ and ‘least-likely’ cases; the essential characteristic of crucial cases being their specific theory-testing function.

Whilst Eckstein’s was an early contribution to refining the case study approach, Yin’s (2009: 47-52) more recent delineation of possible single case designs similarly assigns them roles in the applying, testing, or building of theory, as well as in the study of unique cases[3]. As a subset of the latter, however, Jack Levy (2008) notes that the advantages of idiographic cases are actually twofold. Firstly, as inductive/descriptive cases – akin to Eckstein’s configurative-idiographic cases – whereby they are highly descriptive, lacking in an explicit theoretical framework and therefore taking the form of “total history”. Secondly, they can operate as theory-guided case studies, but ones that seek only to explain or interpret a single historical episode rather than generalise beyond the case. Not only does this therefore incorporate ‘single-outcome’ studies concerned with establishing causal inference (Gerring, 2006b), it also provides room for the more postmodern approaches within IR theory, such as discourse analysis, that may have developed a distinct methodology but do not seek traditional social scientific forms of explanation.

Applying specifically to the state of the field in contemporary IR, Bennett and Elman identify a ‘third generation’ of mainstream qualitative scholars – rooted in a pragmatic scientific realist epistemology and advocating a pluralistic approach to methodology – that have, over the last fifteen years, “revised or added to essentially every aspect of traditional case study research methods” (2010: 502). They identify ‘process tracing’ as having emerged from this as a central method of within-case analysis. As Bennett and Checkel observe, this carries the advantage of offering a methodologically rigorous “analysis of evidence on processes, sequences, and conjunctures of events within a case, for the purposes of either developing or testing hypotheses about causal mechanisms that might causally explain the case” (2012: 10).

Harnessing various methods, process tracing may entail the inductive use of evidence from within a case to develop explanatory hypotheses, and deductive examination of the observable implications of hypothesised causal mechanisms to test their explanatory capability[4]. It involves providing not only a coherent explanation of the key sequential steps in a hypothesised process, but also sensitivity to alternative explanations as well as potential biases in the available evidence (Bennett and Elman 2010: 503-504). John Owen (1994), for example, demonstrates the advantages of process tracing in analysing whether the causal factors underpinning democratic peace theory are – as liberalism suggests – not epiphenomenal, but variously normative, institutional, or some given combination of the two or other unexplained mechanism inherent to liberal states. Within-case process tracing has also been identified as advantageous in addressing the complexity of path-dependent explanations and critical junctures – as for example with the development of political regime types – and their constituent elements of causal possibility, contingency, closure, and constraint (Bennett and Elman, 2006b).

Bennett and Elman (2010: 505-506) also identify the advantages of single case studies that are implicitly comparative: deviant, most-likely, least-likely, and crucial cases. Of these, so-called deviant cases are those whose outcome does not fit with prior theoretical expectations or wider empirical patterns – again, the use of inductive process tracing has the advantage of potentially generating new hypotheses from these, either particular to that individual case or potentially generalisable to a broader population. A classic example here is that of post-independence India as an outlier to the standard modernisation theory of democratisation, which holds that higher levels of socio-economic development are typically required for the transition to, and consolidation of, democratic rule (Lipset, 1959; Diamond, 1992). Absent these factors, MacMillan’s single case study analysis (2008) suggests the particularistic importance of the British colonial heritage, the ideology and leadership of the Indian National Congress, and the size and heterogeneity of the federal state.

Most-likely cases, as per Eckstein above, are those in which a theory is to be considered likely to provide a good explanation if it is to have any application at all, whereas least-likely cases are ‘tough test’ ones in which the posited theory is unlikely to provide good explanation (Bennett and Elman, 2010: 505). Levy (2008) neatly refers to the inferential logic of the least-likely case as the ‘Sinatra inference’ – if a theory can make it here, it can make it anywhere. Conversely, if a theory cannot pass a most-likely case, it is seriously impugned. Single case analysis can therefore be valuable for the testing of theoretical propositions, provided that predictions are relatively precise and measurement error is low (Levy, 2008: 12-13). As Gerring rightly observes of this potential for falsification:

“a positivist orientation toward the work of social science militates toward a greater appreciation of the case study format, not a denigration of that format, as is usually supposed” (Gerring, 2007: 247, emphasis added).

In summary, the various forms of single case study analysis can – through the application of multiple qualitative and/or quantitative research methods – provide a nuanced, empirically-rich, holistic account of specific phenomena. This may be particularly appropriate for those phenomena that are simply less amenable to more superficial measures and tests (or indeed any substantive form of quantification) as well as those for which our reasons for understanding and/or explaining them are irreducibly subjective – as, for example, with many of the normative and ethical issues associated with the practice of international relations. From various epistemological and analytical standpoints, single case study analysis can incorporate both idiographic sui generis cases and, where the potential for generalisation may exist, nomothetic case studies suitable for the testing and building of causal hypotheses. Finally, it should not be ignored that a signal advantage of the case study – with particular relevance to international relations – also exists at a more practical rather than theoretical level. This is, as Eckstein noted, “that it is economical for all resources: money, manpower, time, effort… especially important, of course, if studies are inherently costly, as they are if units are complex collective individuals ” (1975: 149-150, emphasis added).

Limitations

Single case study analysis has, however, been subject to a number of criticisms, the most common of which concern the inter-related issues of methodological rigour, researcher subjectivity, and external validity. With regard to the first point, the prototypical view here is that of Zeev Maoz (2002: 164-165), who suggests that “the use of the case study absolves the author from any kind of methodological considerations. Case studies have become in many cases a synonym for freeform research where anything goes”. The absence of systematic procedures for case study research is something that Yin (2009: 14-15) sees as traditionally the greatest concern due to a relative absence of methodological guidelines. As the previous section suggests, this critique seems somewhat unfair; many contemporary case study practitioners – and representing various strands of IR theory – have increasingly sought to clarify and develop their methodological techniques and epistemological grounding (Bennett and Elman, 2010: 499-500).

A second issue, again also incorporating issues of construct validity, concerns that of the reliability and replicability of various forms of single case study analysis. This is usually tied to a broader critique of qualitative research methods as a whole. However, whereas the latter obviously tend toward an explicitly-acknowledged interpretive basis for meanings, reasons, and understandings:

“quantitative measures appear objective, but only so long as we don’t ask questions about where and how the data were produced… pure objectivity is not a meaningful concept if the goal is to measure intangibles [as] these concepts only exist because we can interpret them” (Berg and Lune, 2010: 340).

The question of researcher subjectivity is a valid one, and it may be intended only as a methodological critique of what are obviously less formalised and researcher-independent methods (Verschuren, 2003). Owen (1994) and Layne’s (1994) contradictory process tracing results of interdemocratic war-avoidance during the Anglo-American crisis of 1861 to 1863 – from liberal and realist standpoints respectively – are a useful example. However, it does also rest on certain assumptions that can raise deeper and potentially irreconcilable ontological and epistemological issues. There are, regardless, plenty such as Bent Flyvbjerg (2006: 237) who suggest that the case study contains no greater bias toward verification than other methods of inquiry, and that “on the contrary, experience indicates that the case study contains a greater bias toward falsification of preconceived notions than toward verification”.

The third and arguably most prominent critique of single case study analysis is the issue of external validity or generalisability. How is it that one case can reliably offer anything beyond the particular? “We always do better (or, in the extreme, no worse) with more observation as the basis of our generalization”, as King et al write; “in all social science research and all prediction, it is important that we be as explicit as possible about the degree of uncertainty that accompanies out prediction” (1994: 212). This is an unavoidably valid criticism. It may be that theories which pass a single crucial case study test, for example, require rare antecedent conditions and therefore actually have little explanatory range. These conditions may emerge more clearly, as Van Evera (1997: 51-54) notes, from large-N studies in which cases that lack them present themselves as outliers exhibiting a theory’s cause but without its predicted outcome. As with the case of Indian democratisation above, it would logically be preferable to conduct large-N analysis beforehand to identify that state’s non-representative nature in relation to the broader population.

There are, however, three important qualifiers to the argument about generalisation that deserve particular mention here. The first is that with regard to an idiographic single-outcome case study, as Eckstein notes, the criticism is “mitigated by the fact that its capability to do so [is] never claimed by its exponents; in fact it is often explicitly repudiated” (1975: 134). Criticism of generalisability is of little relevance when the intention is one of particularisation. A second qualifier relates to the difference between statistical and analytical generalisation; single case studies are clearly less appropriate for the former but arguably retain significant utility for the latter – the difference also between explanatory and exploratory, or theory-testing and theory-building, as discussed above. As Gerring puts it, “theory confirmation/disconfirmation is not the case study’s strong suit” (2004: 350). A third qualification relates to the issue of case selection. As Seawright and Gerring (2008) note, the generalisability of case studies can be increased by the strategic selection of cases. Representative or random samples may not be the most appropriate, given that they may not provide the richest insight (or indeed, that a random and unknown deviant case may appear). Instead, and properly used , atypical or extreme cases “often reveal more information because they activate more actors… and more basic mechanisms in the situation studied” (Flyvbjerg, 2006). Of course, this also points to the very serious limitation, as hinted at with the case of India above, that poor case selection may alternatively lead to overgeneralisation and/or grievous misunderstandings of the relationship between variables or processes (Bennett and Elman, 2006a: 460-463).

As Tim May (2011: 226) notes, “the goal for many proponents of case studies […] is to overcome dichotomies between generalizing and particularizing, quantitative and qualitative, deductive and inductive techniques”. Research aims should drive methodological choices, rather than narrow and dogmatic preconceived approaches. As demonstrated above, there are various advantages to both idiographic and nomothetic single case study analyses – notably the empirically-rich, context-specific, holistic accounts that they have to offer, and their contribution to theory-building and, to a lesser extent, that of theory-testing. Furthermore, while they do possess clear limitations, any research method involves necessary trade-offs; the inherent weaknesses of any one method, however, can potentially be offset by situating them within a broader, pluralistic mixed-method research strategy. Whether or not single case studies are used in this fashion, they clearly have a great deal to offer.

References 

Bennett, A. and Checkel, J. T. (2012) ‘Process Tracing: From Philosophical Roots to Best Practice’, Simons Papers in Security and Development, No. 21/2012, School for International Studies, Simon Fraser University: Vancouver.

Bennett, A. and Elman, C. (2006a) ‘Qualitative Research: Recent Developments in Case Study Methods’, Annual Review of Political Science , 9, 455-476.

Bennett, A. and Elman, C. (2006b) ‘Complex Causal Relations and Case Study Methods: The Example of Path Dependence’, Political Analysis , 14, 3, 250-267.

Bennett, A. and Elman, C. (2007) ‘Case Study Methods in the International Relations Subfield’, Comparative Political Studies , 40, 2, 170-195.

Bennett, A. and Elman, C. (2010) Case Study Methods. In C. Reus-Smit and D. Snidal (eds) The Oxford Handbook of International Relations . Oxford University Press: Oxford. Ch. 29.

Berg, B. and Lune, H. (2012) Qualitative Research Methods for the Social Sciences . Pearson: London.

Bryman, A. (2012) Social Research Methods . Oxford University Press: Oxford.

David, M. and Sutton, C. D. (2011) Social Research: An Introduction . SAGE Publications Ltd: London.

Diamond, J. (1992) ‘Economic development and democracy reconsidered’, American Behavioral Scientist , 35, 4/5, 450-499.

Eckstein, H. (1975) Case Study and Theory in Political Science. In R. Gomm, M. Hammersley, and P. Foster (eds) Case Study Method . SAGE Publications Ltd: London.

Flyvbjerg, B. (2006) ‘Five Misunderstandings About Case-Study Research’, Qualitative Inquiry , 12, 2, 219-245.

Geertz, C. (1973) The Interpretation of Cultures: Selected Essays by Clifford Geertz . Basic Books Inc: New York.

Gerring, J. (2004) ‘What is a Case Study and What Is It Good for?’, American Political Science Review , 98, 2, 341-354.

Gerring, J. (2006a) Case Study Research: Principles and Practices . Cambridge University Press: Cambridge.

Gerring, J. (2006b) ‘Single-Outcome Studies: A Methodological Primer’, International Sociology , 21, 5, 707-734.

Gerring, J. (2007) ‘Is There a (Viable) Crucial-Case Method?’, Comparative Political Studies , 40, 3, 231-253.

King, G., Keohane, R. O. and Verba, S. (1994) Designing Social Inquiry: Scientific Inference in Qualitative Research . Princeton University Press: Chichester.

Layne, C. (1994) ‘Kant or Cant: The Myth of the Democratic Peace’, International Security , 19, 2, 5-49.

Levy, J. S. (2008) ‘Case Studies: Types, Designs, and Logics of Inference’, Conflict Management and Peace Science , 25, 1-18.

Lipset, S. M. (1959) ‘Some Social Requisites of Democracy: Economic Development and Political Legitimacy’, The American Political Science Review , 53, 1, 69-105.

Lyotard, J-F. (1984) The Postmodern Condition: A Report on Knowledge . University of Minnesota Press: Minneapolis.

MacMillan, A. (2008) ‘Deviant Democratization in India’, Democratization , 15, 4, 733-749.

Maoz, Z. (2002) Case study methodology in international studies: from storytelling to hypothesis testing. In F. P. Harvey and M. Brecher (eds) Evaluating Methodology in International Studies . University of Michigan Press: Ann Arbor.

May, T. (2011) Social Research: Issues, Methods and Process . Open University Press: Maidenhead.

Owen, J. M. (1994) ‘How Liberalism Produces Democratic Peace’, International Security , 19, 2, 87-125.

Seawright, J. and Gerring, J. (2008) ‘Case Selection Techniques in Case Study Research: A Menu of Qualitative and Quantitative Options’, Political Research Quarterly , 61, 2, 294-308.

Stake, R. E. (2008) Qualitative Case Studies. In N. K. Denzin and Y. S. Lincoln (eds) Strategies of Qualitative Inquiry . Sage Publications: Los Angeles. Ch. 17.

Van Evera, S. (1997) Guide to Methods for Students of Political Science . Cornell University Press: Ithaca.

Verschuren, P. J. M. (2003) ‘Case study as a research strategy: some ambiguities and opportunities’, International Journal of Social Research Methodology , 6, 2, 121-139.

Yin, R. K. (2009) Case Study Research: Design and Methods . SAGE Publications Ltd: London.

[1] The paper follows convention by differentiating between ‘International Relations’ as the academic discipline and ‘international relations’ as the subject of study.

[2] There is some similarity here with Stake’s (2008: 445-447) notion of intrinsic cases, those undertaken for a better understanding of the particular case, and instrumental ones that provide insight for the purposes of a wider external interest.

[3] These may be unique in the idiographic sense, or in nomothetic terms as an exception to the generalising suppositions of either probabilistic or deterministic theories (as per deviant cases, below).

[4] Although there are “philosophical hurdles to mount”, according to Bennett and Checkel, there exists no a priori reason as to why process tracing (as typically grounded in scientific realism) is fundamentally incompatible with various strands of positivism or interpretivism (2012: 18-19). By extension, it can therefore be incorporated by a range of contemporary mainstream IR theories.

— Written by: Ben Willis Written at: University of Plymouth Written for: David Brockington Date written: January 2013

Further Reading on E-International Relations

• Identity in International Conflicts: A Case Study of the Cuban Missile Crisis
• Imperialism’s Legacy in the Study of Contemporary Politics: The Case of Hegemonic Stability Theory
• Recreating a Nation’s Identity Through Symbolism: A Chinese Case Study
• Ontological Insecurity: A Case Study on Israeli-Palestinian Conflict in Jerusalem
• Terrorists or Freedom Fighters: A Case Study of ETA
• A Critical Assessment of Eco-Marxism: A Ghanaian Case Study

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Holistic Design

What is holistic design.

When design teams do holistic design in user experience (UX) design , they take a bird’s-eye view of users’ interactions in their world and the many interconnected factors in their contact with brands. Teams picture how a product/service fits—or might fit—into the wider consumer or user world

“Holistic design takes into account the person, the device, the moment, the ethnographic environment, the physical space as well as human behavior and psychology, i.e. thinking, attitudes, emotions, motivations, abilities, triggers etc., and aims to deliver an optimal experience. At times the entire experience (with a product or brand) is not limited to digital devices but is a mix of digital, real-world brick-and-mortar, and human-to-human interactions.” — Miklos Philips, Principal UX Designer at Toptal

Holistic Design means You Fly High above the Users’ World

Structural architects developed holistic design as a way to do better than build for just one purpose (e.g., to house people). The idea was to examine views of human occupancy from all angles (e.g., energy consumption, mental health). Therefore, they could design buildings tailored to everything the people who used them needed.

In user experience, designers try to work with a better grasp of all the human dimensions that are involved between users and a particular design . They can explore the various angles more realistically than they would if they focused only on catering to a few aspects of what the users experience (e.g., designers creating an impressive user interface (UI) design but not considering other aspects, such as search engine optimization (SEO)). From there, designers can examine the intricate dynamics in users’ different environments to get a better idea of the balance they need to achieve in their design. Then, they can customize feature sets from the insights they discover. With a holistic mindset, your team doesn’t examine isolated aspects of how users use products/services and experience brands. Instead, you consider how these aspects work together. Therefore, you can predict the series of micro-moments users have across all touchpoints during their experience. Industrial designer Yves Behar captured holistic design in seven points, condensed as follows:

Succeed with Holistic Design

To adopt a holistic design approach, organizations may need to change their cultural mindset. Here are the main holistic considerations :

Because one interaction is typically only part of a series auser takes towards a goal, examine where one task fits in overall and make the best entry and exit points (e.g., checkout).

Investigate cause-and-effect chains and get behind users’ eyes with, for example, design thinking . Issues aren’t typically isolated. They can be wicked problems (i.e., extremely intricate). If decision-makers “solve” one problem but fail to consider associated issues , they can cause repercussions .

Design for the transitions between interactions – users access products/services in various circumstances and ways. Twenty-first-century user experiences consist of many user moments where users pursue goals in many ways. Previously, there was one way (e.g., to buy vacations from a bricks-and-mortar travel agent).

Use customer journey maps , user stories , personas and touchpoints matrices to help illustrate the entire user context and the associated systems and tangent issues .

Produce sufficient resources for all touchpoints . For example, the designers of a municipal bicycle system in a city that requires helmets must examine how to supply helmets. Similarly, UX designers must predict both digital and physical aspects of users’ needs.

Design thinking can be a good method to use for holistic design because it helps make sense of the many complex and intertwined human-world realities in which users will access, use and judge designs/products. It can therefore help you address all angles of the user experience—*holistically*.

With holistic design, your aim is to design for a successful UX ecosystem . You should therefore create a branded experience which covers many dimensions of use . You must make designs that offer seamless interactive experiences to facilitate that . A holistic user experience reflects empathy for users . Moreover, it’s proof that a design team has built in the comfort (or delight ) users expect in the flow of actions they take after they discover a brand. To achieve this, your team has to tailor every dimension to match the many independent relationships (i.e., users, their behavior and aims, the other technology they use, etc.) that happen across specific touchpoints .

Learn More about Holistic Design

You can learn more about design thinking with our course here .

This piece shows the challenges involved with holistic design .

Smashing Magazine’s examination of holistic design strategies features a touchpoints matrix .

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What do designers consider when they implement holistic design in user interactions?

• Consider the entire ecosystem of user interactions, including physical and digital touchpoints.
• Design for physical aesthetics only.
• Focus on digital device interactions only.

Why is it important for designers to adopt an interdisciplinary approach in holistic design?

• To exclusively focus on visual design
• To simplify the design process by using fewer disciplines
• To understand and integrate different aspects like psychology, environment and user behavior

How does empathy play a role in holistic design?

• It focuses on the technical aspects of design only.
• It ignores user feedback to prioritize design aesthetics.
• It understands and addresses the emotional and practical needs of users.

Why is continuous user research important in holistic design?

• To complete all research at the beginning of the project
• To gather ongoing feedback that informs and improves the design
• To limit the design to initial assumptions

What long-term considerations should holistic designers keep in mind?

• Limit design focus to current trends in color and typography
• Only the initial user interactions
• The entire lifecycle of the product, including sustainability and end-of-life impact

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Literature on Holistic Design

Here’s the entire UX literature on Holistic Design by the Interaction Design Foundation, collated in one place:

Learn more about Holistic Design

Take a deep dive into Holistic Design with our course Design Thinking: The Ultimate Guide .

Some of the world’s leading brands, such as Apple, Google, Samsung, and General Electric, have rapidly adopted the design thinking approach, and design thinking is being taught at leading universities around the world, including Stanford d.school, Harvard, and MIT. What is design thinking, and why is it so popular and effective?

Design Thinking is not exclusive to designers —all great innovators in literature, art, music, science, engineering and business have practiced it. So, why call it Design Thinking? Well, that’s because design work processes help us systematically extract, teach, learn and apply human-centered techniques to solve problems in a creative and innovative way—in our designs, businesses, countries and lives. And that’s what makes it so special.

The overall goal of this design thinking course is to help you design better products, services, processes, strategies, spaces, architecture, and experiences. Design thinking helps you and your team develop practical and innovative solutions for your problems. It is a human-focused , prototype-driven , innovative design process . Through this course, you will develop a solid understanding of the fundamental phases and methods in design thinking, and you will learn how to implement your newfound knowledge in your professional work life. We will give you lots of examples; we will go into case studies, videos, and other useful material, all of which will help you dive further into design thinking. In fact, this course also includes exclusive video content that we've produced in partnership with design leaders like Alan Dix, William Hudson and Frank Spillers!

This course contains a series of practical exercises that build on one another to create a complete design thinking project. The exercises are optional, but you’ll get invaluable hands-on experience with the methods you encounter in this course if you complete them, because they will teach you to take your first steps as a design thinking practitioner. What’s equally important is you can use your work as a case study for your portfolio to showcase your abilities to future employers! A portfolio is essential if you want to step into or move ahead in a career in the world of human-centered design.

Design thinking methods and strategies belong at every level of the design process . However, design thinking is not an exclusive property of designers—all great innovators in literature, art, music, science, engineering, and business have practiced it. What’s special about design thinking is that designers and designers’ work processes can help us systematically extract, teach, learn, and apply these human-centered techniques in solving problems in a creative and innovative way—in our designs, in our businesses, in our countries, and in our lives.

That means that design thinking is not only for designers but also for creative employees , freelancers , and business leaders . It’s for anyone who seeks to infuse an approach to innovation that is powerful, effective and broadly accessible, one that can be integrated into every level of an organization, product, or service so as to drive new alternatives for businesses and society.

You earn a verifiable and industry-trusted Course Certificate once you complete the course. You can highlight them on your resume, CV, LinkedIn profile or your website .

All open-source articles on Holistic Design

Holistic design - design that goes beyond the problem.

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What Is Holistic Design? The Future of UX or a Buzzword?

min to read

“Holistic design” sounds like a new flashy trend that’s used here and there without a real meaning behind it. However, the term was present long before UX design was born. Some say it was on the scene before the product design became a thing in the 1920s. 

Nowadays, when we started using “product design” for digital products and “industrial design” for furniture, gear, and other hardware things, “holistic design” makes a comeback to UX design. Or has it never gone?

We are an agency full of seasoned UX designers , but “holistic design” is not very easy to explain. Let’s start with the main question:

What is holistic design?

Holistic design is a design approach that suggests looking at the product from different angles, considering all the aspects, stakeholders, and the environment.

However, the definition of holistic design is not enough to really understand the phenomenon. The holistic design combines the approach,  practices, and the philosophy.

Holistic design is not something that happens solely in the design department. It is a synchrony of all the company processes: to provide a holistic user experience, a good-looking UI is not enough, you need a holistic mindset.

The term “holistic design” is often used in architecture, urbanism, and interior design. For example, ancient Greek tractates about urban planning suggested that architects should consider the directions of the winds when projecting the streets of the city in order to create the most comfortable air circulation.

Some of the problems related to holistic design in other spheres can help better understand how holistic design can be applied in the modern digital world.

When projecting an interior, designers should not only think of the clients’ tastes and general style consistency. Here are some of the questions designers have to consider while developing a holistic design:

• Is the neighborhood noisy? Does the apartment need noise isolation?
• Are the materials sustainable? If we put this vintage fridge, would it be possible to fix it if it breaks in 5 years?
• Is the furniture resistant enough to the cat’s claws?

Holistic design is not something that every client wants. It is a long process and requires not only the budget but also time and will to change the corporate processes and even culture. Of course, the company aiming for holistic design should have a high level of UX maturity .

When the decision to adopt a holistic approach is well thought, you can start shifting to new design practices.

Rules of the holistic design approach

• Take into consideration all the stakeholders , not only users or customers. It doesn’t mean that we have to solve everyone’s problems with our product. Yet, we have to be aware of all things happening around us.
• Research methods . When we focus solely on users, individual interview s are a golden standard of UX research. When we decide to take a holistic approach, we have to add other methods to our research, such as ethnographic research. We have to go out in the field to better understand the environment.
• Participative practices . A step forward from taking into account all of the stakeholders is to involve them in the design process. It is likely to be tricky and even messy, but giving such approach a try doesn’t cost much. The promoter of design thinking , David Kelley, pointed out that involving people of different backgrounds significantly benefits the process.
• Sustainability . Most modern companies want to appear sustainable. They introduce the principle in various parts: from corporate responsibility programs to even the production process. There is always room for improvement in sustainability, and holistic design naturally raises the company standards.
• Ecosystem , not just design system. A design system is a great tool for the company, but it applies mostly to the design sphere. It is often used to simplify and unify UI/UX design. Holistic design implies an ecosystem including values, philosophy, and attention to every detail.
• Going beyond digital . Even if we are talking about a highly digitalized company, in the absolute majority of cases holistic design solutions will change physical items, such as offices, and also the human capital.

Real companies. Holistic or not?

As we say that holistic is an idealistic term, it is hard to say that any company at all is really holistic. Yet, there are some that move in that direction. Sometimes these are the same companies that invest in the petroleum industry (nobody said “holistic” was simple). 

Let’s go through some examples to see how far famous companies can get on their way to becoming “holistic”. Is there a way to avoid mentioning Apple in an article about design? Not that we know.

Holistic style. Apple

Apple stands quite close to the holistic design approach. All the products have a clear consistent line, the company has a recognizable style and philosophy. All Apple products sync naturally and gather in an ecosystem: they look similar, they use the same software and user interface, they feel the same. Once people get used to the Apple ecosystem, they have hard times abandoning it.go on using the same products.

However, the sustainability of Apple design is questionable. The company is constantly using the principle of planned obsolescence and its products are not very easy to repair. Also, the well-known method of Apple is to create users’ needs rather than satisfying existing ones. Products are often designed with limitations that require users to adapt to them rather than adapting to users: for example, new Iphones have no power adapters.

Design thinking applied. Bosch

The spectrum of holistic design approach is large. It might be unexpectable to see this company as an example, but there is something we can learn from Bosch, a company with over 150 years history and quite a traditional line of products.

Apart from quality electro domestics, Bosch is known for its success in applying design thinking throughout a large established company. They started with launching a whole “design thinking department” and it changed the processes in the company leading to the redesign of office interiors to adapt to the reshaped collaboration models.

Bosch is now producing a wide range of products apart from washing machines. They construct smart buildings that promote sustainable living. This is a classic understanding of holistic design approach in modern times.

One of the good practices that Bosch adopted is involving people of various profiles in the design process, such as engineers, testers, marketers, scientists. Diverse teams provide the best ground for innovative solutions.

How holistic is Bosch’s approach? They mostly declare the design thinking approach, but being an old German company working with product design, they are well familiar with the notion of holistic design from the first sources. How sustainable is their product? Well, we'll leave it to the environmentalists.

Holistic path of small companies

In this article, we’ll leave apart the interior Feng Shui design companies and will focus on UX. 

One of the companies that declare holistic design to be a cornerstone of their work is Tactile design firm. They see UX as a cross-pollination of various disciplines, from architecture to marketing. No surprise that half of the company consists of industrial designers and engineers.

Designers at Tactile dedicate a lot of attention to studying the context of the product they are working on. Also, they surely go beyond digital as they work a lot on physical interfaces and innovative technologies.

As a UI/UX design agency , we are far from claiming ourselves holistic. However, we do like the approach and it is present in our work.

We always try to do a bit more than the client asks us. Solving the problem is good, but our objective is also to simplify the implementation of the design and think of design accessibility even when it is not in the brief.

Take a look at the case study of Handprinter , a lifestyle app. As the product itself is quite holistic, our approach was similar: we thought about all the stakeholders, thought not only about the principal user’s goal – decreasing the handprint - but also about other aspects, such as a social network of like-minded people.

What to start with?

If you are more than just curious about a holistic approach and want to try adopting it in your company, our advice is to start slow. Here are few steps that will get you closer on the way to holistic design:

• Apply design thinking (you might think it is another buzz word and you’ve heard of it a thousand times already… But check out these design thinking examples from top companies if you have doubts).
• Design system . It’s likely that you already have one, but look at it closer: is it a real system based on philosophy or more of a visual components library? Are the principles of the design system used outside of design software?
• Check if your design is inclusive . Without being inclusive, there is no thinking of a holistic user experience.
• Provide consistent user experience. Make sure that your customers are enjoying interacting with the product at every moment of their journey. Every little thing is important for a holistic user experience. How to get there? Dig deeper into UX research , go beyond competitors’ analysis and user interviews.

The most complicated thing about holistic design is that different people have very different images of it. The second most complicated thing is that the idea of holistic design is rather idealistic: each goal is never final, the path is ongoing. Yet, following this path would bring many pleasant bonuses on the way.

Let me finish with a quote from Karthik Vijayakumar, Founder and Principal, DYT Studios & Host of The Design Your Thinking Podcast.

Holistic design is to see and think of the world in two broad dimensions – as interconnected and evolving systems. Holistic design is formed by and leads to interconnected systems. Evolving nature of holistic design is when the design leads to the evolution of the interconnected systems.

And if you want to talk more about holistic design — or about anything else — we are here .

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• Published: 29 May 2024

Cannabis use in a Canadian long-term care facility: a case study

• Lynda G. Balneaves 1 , 4 ,
• Abeer A. Alraja 1 ,
• Genevieve Thompson 1 ,
• Jamie L. Penner 1 ,
• Philip St. John 2 ,
• Daniella Scerbo 1 &
• Joanne van Dyck 3  

BMC Geriatrics volume  24 , Article number:  467 ( 2024 ) Cite this article

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Metrics details

Following the legalization of cannabis in Canada in 2018, people aged 65 + years reported a significant increase in cannabis consumption. Despite limited research with older adults regarding the therapeutic benefits of cannabis, there is increasing interest and use among this population, particularly for those who have chronic illnesses or are at end of life. Long-term Care (LTC) facilities are required to reflect on their care and policies related to the use of cannabis, and how to address residents’ cannabis use within what they consider to be their home.

Using an exploratory case study design, this study aimed to understand how one LTC facility in western Canada addressed the major policy shift related to medical and non-medical cannabis. The case study, conducted November 2021 to August 2022, included an environmental scan of existing policies and procedures related to cannabis use at the LTC facility, a quantitative survey of Healthcare Providers’ (HCP) knowledge, attitudes, and practices related to cannabis, and qualitative interviews with HCPs and administrators. Quantitative survey data were analyzed using descriptive statistics and content analysis was used to analyze the qualitative data.

A total of 71 HCPs completed the survey and 12 HCPs, including those who functioned as administrators, participated in the interview. The largest knowledge gaps were related to dosing and creating effective treatment plans for residents using cannabis. About half of HCPs reported providing care in the past month to a resident who was taking medical cannabis (54.9%) and a quarter (25.4%) to a resident that was taking non-medical cannabis. The majority of respondents (81.7%) reported that lack of knowledge, education or information about medical cannabis were barriers to medical cannabis use in LTC. From the qualitative data, we identified four key findings regarding HCPs’ attitudes, cannabis access and use, barriers to cannabis use, and non-medical cannabis use.

Conclusions

With the legalization of medical and non-medical cannabis in jurisdictions around the world, LTC facilities will be obligated to develop policies, procedures and healthcare services that are able to accommodate residents’ use of cannabis in a respectful and evidence-informed manner.

Peer Review reports

In October 2018, Canada became the second country to legalize non-medical cannabis [ 1 ]. Despite the increasing interest in cannabis among Canadians of all ages [ 2 ], the percentage of individuals over the age of 15 years reporting cannabis use a year following legalization remained relatively unchanged at 18% [3]. The only age group to report a significant increase in cannabis consumption was those aged 65 + years, with 7.6% reporting cannabis use in the past 3 months [ 3 ] in 2019 compared to 4% in 2018. This upward trend in cannabis use among Canadians 65 years or older was also observed in 2021 [ 4 ].

This increase may reflect a growing acceptance of cannabis among older populations who were previously dissuaded from taking cannabis due to its illegal status as well as limited accessibility through legal means. In addition, the rise in cannabis use among older adults may reflect a harm reduction approach, substituting cannabis for other recreational substances with substantial health risks, such as alcohol [ 5 ]. Moreover, the belief in the potential therapeutic benefits of cannabis [ 6 , 7 , 8 ], such as the management of pain and sleep issues, is becoming increasingly prevalent among older adults. There has been limited research, however, among older adults in Canada to understand this progressive trend in cannabis use and the influencing factors [ 9 ].

Canada has been a world leader in cannabis legalization, launching a federal medical cannabis program in 2001. Since this time, the medical cannabis program has undergone numerous revisions, including how authorization is obtained, what types of products are available, and where cannabis is purchased. Currently, Canadians can seek medical authorization from either a physician or a nurse practitioner, and access a variety of cannabis products, including dried flower, capsules, and oils, which are purchased online through a licensed producer (LP). Some individuals also apply for a personal or designated grow license to produce their own supply of dried cannabis. Outside of the medical authorization program, individuals can access non-medical cannabis through an authorized storefront. It is estimated that over 1 million Canadians are using cannabis for therapeutic purposes [4], with 247,548 individuals officially registered as of March 2022 [ 10 ]. Among the 479,400 individuals over the age of 65 who reported cannabis use in the third quarter of 2019, 52% utilized cannabis exclusively for medical reasons, and another 24% reported using cannabis for both recreational and medical purposes [ 3 ].

Despite the growing interest in cannabis as a therapeutic agent, there has been limited human research due to its illegal status in many countries, as well as the challenges posed by the complexity of the cannabis plant compared to single agent, pharmaceutical forms of cannabis (e.g., nabilone) [ 11 , 12 ]. Notwithstanding these challenges, there is emergent research on the potential role of cannabis-based medicines in the management of health conditions common among older adults, including osteoarthritis [ 13 ], sleep disorders [ 14 ], dementia [ 15 ], and Parkinson’s [ 16 , 17 ], which are also prevalent among individuals residing at long-term care (LTC) facilities. For example, several studies have found cannabis-based medicines to significantly reduce neuropsychiatric symptoms and improve quality of life among people living with Alzheimer’s Disease [ 18 , 19 , 20 ]. Cannabis may also play a significant role at end of life in not only alleviating physical symptoms, such as pain, nausea and vomiting, and appetite loss, but also addressing the emotional and existential issues that may arise [ 21 ]. It has also been proposed that cannabis may have a therapeutic role among rehabilitative populations who often reside in LTC settings, including those with spinal cord injuries [ 22 , 23 ] and traumatic brain injury [ 24 ]. The evidence base surrounding cannabis as a therapeutic agent, however, remains limited with few large randomized clinical trials conducted to date.

Cannabis is not a benign substance and may pose risk to older adults, especially those living with frailty or cognitive impairment. Given the known cognitive effects of tetrahydrocannabinol (THC), a cannabinoid found in many forms of cannabis, adults living in long-term and rehabilitative care settings may experience somnolence, confusion, and fatigue [ 25 ]. Cannabis high in THC may also negatively impact motor coordination and increase the risk of falls, especially among those with impaired balance and walking ability [ 25 ]. As research advances on cannabis, there has been growing awareness of its negative interactions with certain medications [ 26 ], which can pose a significant issue among older clients prone to polypharmacy. Lastly, numerous health conditions are contraindicated with cannabis use, including heart disease, and a personal or family history of psychosis, schizophrenia, or bipolar disorder [ 27 ].

Despite limited research with older adults regarding the therapeutic benefits of cannabis, there is increasing interest and use among this population, particularly for those who have chronic illnesses. As adults age, they are more likely to experience multimorbidity, and a significant number of older adults spend their last years of life residing in a LTC facility [ 28 , 29 ]. LTC facilities are, thus, placed in a unique position. While these facilities are considered medical institutions that provide evidence-informed supportive health care, they have also become home for individuals who are no longer able to reside safely in the community. Increasingly, these types of facilities are challenged to create home-like environments and offer residents the opportunity and autonomy to engage in potentially risky health behaviours [ 30 ]; behaviours that individuals in the community have the independence and legal right to choose, such as alcohol or tobacco consumption. With the legalization of non-medical cannabis and the growing interest in the potential of cannabis to manage challenging health conditions, it behooves LTC facilities to reflect on their care and policies related to the use of legal substances, such as cannabis, and how to address residents’ cannabis use within what they consider to be their home.

The overarching aim of this case study was to understand how one LTC facility, and its healthcare professionals (HCPs) and administrators, addressed the major policy shift in Canada related to medical and non-medical cannabis. Specific research questions included: (1) What are the experiences and perceptions of HCPs and administrators regarding the use of medical and non-medical cannabis at LTC settings?; (2) What are the perceived barriers/facilitators to medical and non-medical cannabis use at LTC facilities from the perspective of HCPs and administrators?; and (3) What are the educational needs, attitudes, and practices of HCPs at LTC facilities related to medical and non-medical cannabis?

Research design and setting

An exploratory case study design was utilized in this study. This type of case study is used to explore those situations in which the phenomenon being evaluated has no clear or single set of outcomes [ 31 ]. The case selected for this study was a large LTC facility in Western Canada. This 387-bed residential facility provides 24/7 care to a diverse population, including older adults with cognitive and physical disabilities, individuals recovering from stroke and traumatic brain injury, and those requiring end-of-life care. Individuals with these various conditions may reside in several units, including palliative care, rehabilitation, personal care home, and complex chronic care. The case study included an environmental scan of existing policies and procedures related to medical and non-medical cannabis use at the LTC facility, a quantitative survey of HCPs’ knowledge, attitudes, and practices related to medical and non-medical cannabis, and qualitative interviews with HCPs and administrators. The qualitative interviews were informed by qualitative descriptive methodology [ 32 ] and explored HCPs’ and administrators’ experiences, beliefs, perceptions regarding cannabis use in LTC, and the related barriers and facilitators.

Sample and recruitment

For the survey, a convenience sample was drawn from the entire population of accredited HCPs working in the selected facility. Eligibility criteria included being 18 + years, able to read/speak English, currently employed and providing care at the LTC facility, and able to provide informed written consent. Study participants were recruited through an emailed letter of invitation, posters placed in staff areas, and in-person presentations by a research assistant. From participants who took part in the survey, a subsample of HCPs, including administrators, who expressed interest in taking part in an interview was selected. The data collection period was from November 2021 and August 2022.

Data collection

For the environmental scan, facility administrators were approached via an emailed letter and asked to identify relevant policies and procedures related to cannabis use within their LTC facility. Policies relevant to both residents’ use of cannabis and HCPs’ practice related to medical and non-medical cannabis were requested. Provincial and federal cannabis policies were also collected.

The survey was modified from a questionnaire utilized in two national studies that examined Canadian physicians’ and nurse practitioners’ knowledge, attitudes, and perceptions of the associated barriers and facilitators related to medical cannabis use, as well as their preferences regarding medical cannabis education [ 33 , 34 ]. This survey has been found to be internally consistent, with Cronbach’s alphas of 0.70 to 0.92 reported across subscales [ 33 , 34 ]. Slight word changes were made to reflect the fact that individuals living in LTC facility are referred to as residents, not patients, and the name of the facility was used to orientate the questions towards HCPs’ attitudes and practices related to cannabis use within the LTC setting.

Survey items were added that assessed HCPs’ practices related to addressing residents’ and family members’ questions about cannabis, as well as requests for medical cannabis authorization and follow-up care. A demographic survey that assessed gender, age, professional designation, years in practice, area(s) of practice, and education related to medical cannabis was included. The survey was available in hard copy (Supplementary Material 1 ) as well as online through the software program, Qualtrics®.

An interview guide was developed by the research team, which included a facility administrator and HCP, and was informed by the literature and previous cannabis research conducted by members of the research team [ 35 ] (Supplementary Material 2 ). Due to the COVID-19 pandemic, all but one interview was conducted by the project coordinator (AAA) via Zoom, with one interview occurring over the phone. The interviews were 20–30 min in length and were digitally recorded and transcribed verbatim. Both the survey and interview were completed at times preferred by the respondents, including within and outside work time. No honoraria were provided for study participants.

Data analysis

The policies identified through the environmental scan were reviewed and summarized in table format, with similarities, contradictions and gaps identified.

Quantitative survey data was uploaded into the statistical program, SPSS® v.25. Descriptive statistics were used to summarize demographic information, knowledge about medical cannabis and related attitudes, perceived barriers and facilitators, practice experiences, and preferred educational approaches.

Perceived knowledge gap was calculated by computing the difference between perceived current and desired knowledge levels (i.e., “the level of knowledge you desire” about medical cannabis). Rather than using averages, the knowledge gap was calculated based on how much greater an individual’s desired knowledge level was compared to their current knowledge level [ 36 ]. Only response pairs (i.e., current and desired knowledge) were used, and responses where the desired level was lower than the current level were excluded. To further elucidate, the knowledge gap was calculated by having each respondent’s current knowledge level response subtracted from their desired knowledge level response.

Prior to the onset of qualitative data analysis, the accuracy of the transcripts was checked by listening to the digital recordings. Content analysis was used to analyze the qualitative data [ 37 ], with two team members (AAA and LGB) independently reading the transcripts and developing a preliminary coding scheme. Constant comparison of new and existing data ensured consistency, relevance, and comprehensiveness of emerging codes. Several strategies were applied to ensure rigour in the qualitative analysis. To increase credibility, a team member with expertise in qualitative inquiry (LGB) monitored the qualitative data and its analysis. Confirmability was addressed by using the participants’ own words throughout the process of data analysis, interpretation, and description. An audit trail was kept documenting the activities of the study, including data analysis decisions.

Environmental scan of cannabis-related policies

Administrators at the LTC facility provided the research team with the policies and procedures that addressed the management and use of medical and non-medical cannabis within the facility. The guiding policy adopted by the LTC facility was a generic policy applicable to all sites and facilities governed by a regional health authority. This policy, entitled “Patient Use of Medical Cannabis (Marijuana)” was issued in June 2020. The policy, which aimed to provide individuals with “reasonable access to medical cannabis”, outlined numerous issues that might arise with institutional cannabis use, including “ordering, labeling, packaging, storage, security, administration, documentation and monitoring requirements for the use of medical cannabis”. Key aspects of the policy are summarised in a table found in the Supplementary Material section (Supplementary Material 3 ).

Other relevant policies that were reviewed included the standards of practice issued by the provincial college of nurses and the college of physicians and surgeons [ 38 , 39 , 40 ], which provided direction to HCPs working in LTC about their scope of practice regarding medical and non-medical cannabis. The regional health authority’s smoke-free policy [ 41 ] also informed how inhaled forms of medical and non-medical cannabis were addressed, requiring residents to leave the facility grounds to smoke or vape cannabis. Lastly, the overarching federal Cannabis Act and Regulations provided guidance to both administrators and HCPs regarding the Canadian regulations specific to medical and non-medical cannabis [ 1 , 42 ]. Together, existing facility, regional, and national policies created a context in which cannabis was framed as neither a medicine nor a controlled substance, but something unique and complex that must be navigated by residents, family members and staff in LTC settings.

Quantitative survey

Demographic characteristics.

From the approximately 318 eligible HCPs employed at the LTC facility, a total of 71 participants consented and completed the survey, yielding a response rate of 22.3%. With regards to response rate by profession, pharmacists (50.0%) and social workers (42.9%) were best represented, followed by physicians (23.1%), nurses (21.0%), and PT/OT (11.4%).

Most respondents were women (71.8%), registered nurses (62.0%) and worked within the palliative care unit (76.1%) at the facility. The average age of the sample was 40.9 years and the largest proportion of the sample had worked in the LTC facility for 5 or less years. See Table  1 for additional details.

Knowledge about medical cannabis

HCPs reported being most knowledgeable about the therapeutic potential of cannabis (3.1/5.0), potential risks of medical cannabis (2.9/5.0), and the different ways to administer medical cannabis (2.9/5.0). They reported being least knowledgeable about the dosing of medical cannabis (2.0/5.0), how to create effective treatment plans related to medical cannabis (2.1/5.0), and the similarities and differences between different forms of cannabis products and prescription cannabinoid medications (2.2/5.0). The top three ranked knowledge gaps mirrored the items ranked lowest with regards to knowledge (see Table  2 ). Overall, there was high interest in gaining more medical cannabis knowledge, with all knowledge items scoring greater than 4 on desired knowledge level.

Practice experiences with medical cannabis

About half of HCPs reported providing care in the past month to a resident who was taking medical cannabis (54.9%) and a quarter (25.4%) to a resident that was taking non-medical cannabis. Over 60% had been approached by a resident and/or a family member to discuss the potential use of medical cannabis; however, few HCPs reported initiating these conversations. Moreover, when asked if they felt comfortable discussing medical cannabis, 32.4% of HCPs disagreed (data not shown). Less than 20% reported helping residents, either directly or indirectly, to use medical cannabis and a very small proportion (1.3–2.8%) reported assisting residents’ consumption of non-medical cannabis. With regards to authorizing the use of medical cannabis or prescribing cannabinoid medication, which in Canada can be done by either a physician or nurse practitioner, just over half of physicians reported supporting residents’ access to these types of treatment. See Table  3 for additional details.

Barriers to medical cannabis use in long-term care

Lack of knowledge, education or information about medical cannabis were reported to be barriers to medical cannabis use in LTC by most HCPs (81.7%). Moreover, the uncertain risks and benefits of medical cannabis and the lack of clinical guidelines were also perceived as barriers by 66.2% and 63.4% of HCPs, respectively. The complete list of barriers is presented in Table  4 .

Education about medical cannabis

Most of the HCPs agreed that additional education on medical cannabis would increase their comfort with discussing this treatment option with residents and family members (87.4%; data not shown). With regards to indirectly or directly administering medical cannabis to a resident, most HCPs for which this fell within their scope of practice also reported they would feel more comfortable if they had further education (59.2% and 56.4%, respectively; data not shown).

Over half of HCPs had not received any prior education related to medical cannabis (54.9%). Those that had, received it from conferences or workshops (65.6%), books or journal articles (43.8%) or through a colleague (37.5%). While almost half the sample (49.3%) reported receiving information from peer-reviewed sources, nearly a quarter received information about medical cannabis from a non-peer reviewed source or from a resident or family member. Some participants also received information from a cannabis industry source. Table  5 provides additional details.

The preferred sources of medical cannabis education were online learning programs (i.e., continuing education) (74.6%), monographs (66.2%), and topic-specific one-pagers (64.8%). See Fig.  1 for further details.

Percentage of respondents indicating prefered method of cannabis education*

Qualitative findings

A total of 12 HCPs were interviewed regarding their perceptions and experiences related to medical and non-medical cannabis in the LTC facility. This included 3 HCPs who were administrators, 6 nurses, 1 physician, 1 social worker and 1 pharmacist. Four main themes were identified.

Attitudes regarding medical cannabis: cautious support

There were mixed attitudes regarding the potential role of medical cannabis in general and in LTC populations. While some HCPs felt medical cannabis was a “good idea” for which there was beginning research regarding its health benefits, other HCPs believed additional high-quality evidence was needed prior to medical cannabis becoming a therapeutic option.

I think it’s [medical cannabis] the fair option, it helps some people, but it doesn’t help others. So, I think we need a bit more evidence and a bit more research and having it available sort of allows for that research to occur (Physician; PC07).

There appeared to be greater acceptance for medical cannabis use by individuals at end of life compared to those not considered immediately palliative (i.e., living with dementia, stroke, or traumatic brain injury), the latter of which comprise the majority of the people living in LTC settings. For individuals receiving palliative care, some HCPs perceived medical cannabis to be beneficial in managing pain, nausea, and anxiety, as well as reducing the use of other medications that may be problematic (e.g., opioids) due to their side effects. The potential value of medical cannabis in “adding quality of life and living” at the end of life was also mentioned.

I’m working on the palliative care unit right now. A lot of patients that I’ve seen use it [medical cannabis] for anxiety purposes, or for nausea… some people find beneficial. So, I’ve seen it – people find it helpful for those reasons, and then they have to take less of their other medications. So, if it’s worked well for them and that’s what they prefer to do, then I think it should be an option for people, especially if some people find it beneficial. (Registered nurse; PC03)

Within the context of LTC, several HCPs also spoke of the importance of respecting residents’ autonomy and previous experiences taking medical cannabis. The reality of a LTC facility being a resident’s “home” was particularly influential in HCPs’ support of medical cannabis being included as part of a holistic approach to care.

I guess because people live at [LTC facility’s name], that is their home and if they were at home in the community, they would be able to access it [medical cannabis]. (Registered nurse, PC02)

I think it’s a part of people’s lives. And I think if we’re allowing people to have certain things and keeping it as part of their treatment because if you look at a holistic view, preventing somebody from doing something that they’ve been doing for many years is not going to help them be accepting of other types of therapies. (Pharmacist, PC09)

Some HCPs also perceived medical cannabis as offering an alternative to medical treatments that were not consistently effective in managing challenging health conditions, such as dementia and agitation.

HCPs’ attitudes towards medical cannabis varied across different products and routes of administration. Given the existing smoke-free policy at the facility, HCPs were more supportive of edibles, oils, oral sprays or topical creams and lotions than any form of inhaled medical cannabis (i.e., smoking and vaping). They were concerned not only about lung health, environmental exposure, and maintaining a scent-free facility, but also about how to safely manage vulnerable residents travelling off the facility’s property to smoke or vape.

Medical cannabis access and use: concern, confusion, and limited conversations

According to HCPs interviewed, most residents using medical cannabis obtained their authorization prior to moving to LTC. Individuals who sought authorization after arriving at the facility struggled to have their requests acknowledged or addressed by the health care team. As one nurse shared:

I do remember I had a resident that did ask about it [medical cannabis]. And whenever it was kind of brought up, it didn’t seem to be acknowledged all the time. Or there were people who didn’t like the idea of having a resident on it. (Registered nurse; PC06)

Conversations about medical cannabis were perceived to be severely limited by the culture surrounding medical cannabis at the LTC facility. The lack of open discussion about medical cannabis was seen by some to create conflict and negatively impact the development of trust between residents, family members, and the health care team: “ Without that discussion, it does create conflict within the team and between the physician and family, and perhaps that could impact the trusting relationship” (Administrator; PA03). Further, several HCPs expressed the belief that conversations about non-pharmacological forms of medical cannabis could not be initiated by them due to policy issues; residents who expressed interest but did not have prior authorization were instead directed towards pharmaceutical forms of cannabis.

There have been residents who have asked about using cannabis. And as I said, you can’t initiate it, if they’re going to get it on their own, fair enough. That’s pretty much been the experience I’ve had with residents with just non-pharmaceutical medical cannabis . (Physician, PC07)

The only HCP-initiated conversations about medical cannabis mentioned were those occurring between pharmacists and residents, which focused on the potential side effects, benefits, and “red flags” to watch out for, such as allergic reactions.

HCPs shared that for those residents with authorization, they or a support person were responsible for ordering the medical cannabis product from an LP, which would then send the product to either the resident at the LTC facility or to their support person’s home. The cannabis product was then stored in a locked drawer in the resident’s room if they were self-administering or in a medication room if nursing staff were assisting with administration. According to one pharmacist, the pharmacy department was not permitted, due to existing federal regulations, to either directly order or dispense medical cannabis:

No, we don’t dispense any cannabis. It’s considered resident’s own. So, we don’t acquire it for them. They have to directly be the holders of it and have it provided to them directly. And I think that has more to do with the regulations within Canada, the resident has to have certain type of documentation in order to have medical cannabis. So, it’s directly to them, we’re not able to order it for them or anything like that on their behalf. (Pharmacist; PC09)

With regards to the type of medical cannabis products permitted in the facility, due to non-smoking policies and concerns about safety issues and the “smell”, combustible forms and inhaled routes of administration (i.e., joints, vaporizers, vape pens) were not allowed; instead, ingestible forms were mentioned most frequently by HCPs.

There was some confusion and concerns expressed regarding the storage and disposal of medical cannabis, which may have reflected changes in facility policies over time. Some HCPs expressed concerns about the storage of cannabis in residents’ rooms and the lack of “safeguards” to limit potential diversion and allow an accurate “count” of medical cannabis.

We have to go into our Pyxis machine to retrieve a key to open that drawer. So, by going by that you’re able to know who’s actually accessed the key, but once the key is out you have no idea how many people have used that key and accessed that drawer before it’s gone back. You have no way of knowing how much cannabis has been taken out [of the drawer] or used, because you know there’s no way to measure it. So that’s a huge problem, I find. (Registered nurse; PC01)

This nurse was particularly concerned about the potential risk of being accused of diversion:

I’m not worried about people abusing it, it’s more the worry of being accused. You know, like, if a resident says, ‘why is my cannabis running out already, I thought I had enough for a few more weeks?’ and we’re like, ‘I don’t know’, right? There’s the potential for that sort of thing to happen. (Registered nurse; PC01)

There was also a perception that there was a lack of direction from the facility regarding the appropriate disposal of medical cannabis. Most believed residents or family members were expected to remove any unused product once the resident was no longer at the facility. When such disposal was not possible, the policy was to destroy the cannabis product in a manner similar to narcotics or other controlled substances. However, variations in practice occurred with some HCPs described “throwing it in the trash” or using a medical waste disposal bin with or without a witness.

Barriers to medical cannabis use: safety, stigma and lack of knowledge

Numerous barriers to the use of medical cannabis by LTC residents were identified by HCPs. Foremost, the policies related to how cannabis products were ordered, accessed, stored, and administered were perceived to be complicated and created barriers to residents wanting to take medical cannabis, particularly those without family support. The inability of the LTC facility to order medical cannabis on behalf of a resident was perceived to be especially problematic, as described by one registered nurse:

I know when it became legal, there were a few residents who have inquired about it, but they didn’t have the family resources in place to be able to get it because I believe there’s some hoops that you have to go through to be able to have it medically prescribed in getting it on to the unit. And so, the ones who were interested in it didn’t have those supports in place, so they weren’t able to get it prescribed for them. (Registered nurse; PC05)

The lack of awareness and understanding of the regional policies related to medical cannabis by some of the clinical staff was also seen as being problematic. As one registered nurse shared:

My only concern is that there’s a lot of rules around being able to administer and how it’s [medical cannabis] administered, which can again make things a bit complicated. I would say that’s probably my biggest concern is just it’s hard to remember everything that you have to do when you’re trying to administer it or helping a resident. So, you don’t get involved. (Registered nurse; PC06)

Several HCPs attributed the lack of awareness about cannabis policy to the onset of the COVID-19 pandemic, which overshadowed all other health issues within their facility: “ Everybody’s been so focused on COVID for a year and a half that there hasn’t been really time to really think about or educate on other things. ” (Registered nurse; PC01).

HCPs suggested that more “straight forward” and tailored policies were needed that simplified how medical cannabis was managed. Having facility-specific policies would acknowledge the uniqueness of the LTC population, who may have cognitive impairment, limited social support, and complex healthcare plans. As one nurse shared: “ If it’s a dementia patient, they can’t really administer it on their own. So how do we follow the policy to help the patient take the cannabis? How would we know when they would want to take it PRN?” (Registered nurse; PC03). It was also recommended that the policy that prevented the facility from directly ordering and supplying medical cannabis required revision so that LTC residents were not reliant on family members to gain access. Lastly, several HCPs suggested that medical cannabis policies need to be well advertised and additional training developed for clinical staff to enhance their awareness and comfort level in providing appropriate and supportive care.

There needs to be a training session… staff have to read through them [cannabis policies] and get instructions about them, sort of like a self-learning activity. But that is not part of what we do when orienting. (Registered nurse; PC02)

Another perceived barrier frequently mentioned by HCPs was their lack of knowledge regarding the potential risks and benefits of medical cannabis. There was limited understanding about the effects of medical cannabis, how it may interact with other medications and health conditions, what side effects could arise, as well as basic information about starting dose, titration, and difference between THC and cannabidiol (CBD). Without such information, HCPs were perceived to be very hesitant about recommending or supporting medical cannabis as a treatment alternative for LTC residents:

There’s lots of unknown, that’s the problem. If there were more specifics about the recreational and the medical use of cannabis, then I think health care professionals would be more likely to want to provide it to the residents. But if not, then that’s kind of what’s hindering health care professionals to provide it. (Registered nurse; PC08)

There was also substantial discussion by HCPs regarding the “stigma” that they perceived to exist within the facility regarding medical cannabis. As described by one pharmacist: “ I think the understanding of cannabis, regardless of if it’s medical or anything, it’s still considered in many people’s minds as an illicit drug. It hasn’t shaken that. And I think there’s a lot of stereotypes around the type of people that use cannabis” (Pharmacist; PC09). The stigmatization of medical cannabis was perceived to be particularly pronounced among the medical staff, which led to what was described as a “hands-off approach” with regards to authorizing medical cannabis.

Almost all HCPs and administrators interviewed recommended that education programming and resources for HCPs be developed to address the lingering stigma associated with cannabis and the knowledge gaps that exist about medical cannabis and associated policies. Several participants recommended that education initiatives should first target physicians, who were responsible for authorizing medical cannabis in the facility. Physicians were perceived to need education on when and for whom medical cannabis would be appropriate, the latest evidence regarding efficacy and safety (i.e., drug interactions), and what their obligations and responsibilities were as the authorizing HCP. Participants also thought that all HCPs could benefit from additional training regarding medical cannabis, including the different types of cannabinoids and products, the process of titration, and dosing. Some of the nurses interviewed also expressed the need for education about the legal implications of medical cannabis and their role regarding provision and administration:

I think the legal implications of cannabis use, I think that would be a good focus for the nursing group – so that they understood what their obligations were, what they could be held accountable for, those kinds of things. (Administrator; PA02)

Finally, numerous HCPs spoke of the need for “safeguards” and clear policies and procedures to ensure that clinical staff were aware of what type of medical cannabis products residents were taking, what was the “right dose”, and the possibility of cannabis interacting with other medications. As shared by one pharmacist:

So that we know that this patient is on it because there are potential drug interactions with other things that patients are taking. So, we just have to be cautious and aware that patients are doing this. Because especially right now with studies, there haven’t been a lot of great studies on drug interactions. (Pharmacist; PC09)

Non-medical cannabis use: balancing autonomy and safety

HCPs were asked about their attitudes and experiences about residents’ use of non-medical cannabis in the facility. Two disparate points of view became apparent – those that perceived non-medical cannabis as a legal substance that should be available to LTC residents given the facility was their home and those that saw non-medical cannabis as a stigmatized substance that could lead to problematic use and disruptions in the care environment.

Because it is somebody’s home and so you’re trying to honour and match what their lifestyle and aspects of their life at home were and matching that here [LTC facility]. The bad is, while it is somebody’s home, it’s the next person’s home too, and so it’s trying to balance that, right? In an institutional setting, trying to make it as home-like as possible but, at the same time, you know, monitoring and matching for what everyone’s needs are. (Registered nurse; PA01)

Professionally, I think that it creates issues in terms of trying to police the use of recreational cannabis. In terms of smoking cigarette tobacco, that’s an issue in itself. We’re a non-smoking facility. So, adding cannabis to the mix creates issues…having staff perhaps exposed or other people exposed if people are using cannabis indoors or where they’re not supposed. Or if they want to access and use cannabis outside, who’s going to take them for that? Because that creates exposure too for staff or others who may have to escort them. (Registered nurse; PA03)

HCPs frequently mentioned the complexity of managing residents’ non-medical use of cannabis given the facility’s non-smoking policy that required residents to leave the facility grounds to use inhaled forms of cannabis. With staff unable to transport residents outside, concerns were raised regarding the safety of residents, particularly in the winter months, and who would be responsible for their transfer in and out of the facility as well as monitoring how much cannabis was consumed. In addition, residents’ access to non-medical cannabis was again dependent on having a support person that was able and willing to transport the product to the facility, posing a potential equity issue for some residents:

If someone’s wanting to go smoke outside, then mobility might be an issue. If they don’t have the right wheelchair or family to take them outside for that. If they have the access. Like, if they need family to go and buy it and bring it to them, that could be more of an access issue depending on their family support. (Registered nurse; PC03)

There was specific concern expressed for individuals in the rehabilitation units who may have pre-existing substance use issues. For these individuals, HCPs were concerned that allowing access to non-medical cannabis could add to an already complex care plan. In addition, with many vulnerable residents living at the facility, concerns were raised regarding them being “incredibly suggestible” to others encouraging their consumption of cannabis:

These people – they have an addiction. For sure they’re making choices, but those choices are influenced by physical withdrawal or influenced by stress; they’re influenced by lots of things. So, I would hate to put residents in a position where that was one other [non-medical cannabis] thing they had to contend with during the rehab stay. (Administrator, PA02)

The use of cannabis for therapeutic and recreational purposes is becoming more prevalent within older adult populations, both in the community as well as within healthcare institutions. There has also been growing interest in the possible role of medical cannabis for select chronic, rehabilitative, and palliative health conditions, frequently found among individuals residing within LTC settings. LTC facilities, thus, face the complex practice and policy implications associated with a substance that has been surrounded in controversy for close to a century. This case study is among the first to explore in one LTC facility in Western Canada how cannabis use is being addressed following the legalization of non-medical cannabis products, and what challenges exist. It provides an important snapshot of the complexities surrounding cannabis use in LTC and a foundation for future research.

Cannabis use in LTC settings: a clash of cultures

One challenge experienced by people residing in LTC facilities is the tension that exists between social and medical models of care that most facilities are founded on. Historically, LTC facilities have operated as what Goffman [ 43 ] termed “total institutions”, places where every aspect of a person’s life was controlled by others, paternalism dominated, and the medical needs of people were what drove care practices. Aspects of the total institution still exist, as noted in this case study, whereby cannabis use is in the control of the HCPs; it is dispensed during medication administration times rather than being freely available for use by the resident when they so desire as would be in a person’s home. In trying to create more home-like environments and meet the broad range of social and emotional needs of residents, resident-centred care practices and relational models of care have emerged [ 44 ]. Within this milieu, resident autonomy and choice are at the forefront and HCPs are there to assist, rather than take control of residents’ daily lives. In the most ideal settings, behaviours that are considered ‘risky’, like alcohol consumption, are treated as social experiences, not care tasks to be managed [ 45 ]. The tension arises, however, that despite the desire to be resident-centred, most LTC facilities are highly regulated by governments, putting limits to resident choice and, therefore, their autonomy [ 45 ]. While HCPs in our study acknowledged that residents should have the right to use medical or non-medical cannabis, the regional and institutional policies surrounding safety and the rights of other residents and staff to not be exposed to potentially risky behaviour underscored many of their views. LTC facilities would be wise to consider the principles of dignity of risk [ 46 ] with relation to cannabis consumption/use along the frail elderly population that reside in the home.

Cannabis policies and LTC: one size doesn’t fit all

The cannabis policies developed at the advent of legalization, without consideration of the unique populations and healthcare challenges that exist within LTC facilities, created numerous barriers to residents accessing and using cannabis, as well as for HCPs attempting to provide appropriate care. One of the most significant challenges experienced by LTC residents in our study was the inability to obtain a medical cannabis authorization from a physician working in the facility. Another significant challenge was the regional policy that medical cannabis could not be couriered directly to the LTC pharmacy; instead, the resident or their support persons were responsible for ordering and bringing cannabis products into the facility. Both challenges created enormous inequity in which residents that lacked the physical and cognitive ability to obtain authorization and order medical cannabis from an LP or were without a support person willing and able to obtain medical cannabis on their behalf, were unable to access medical cannabis. Given the nature of LTC populations, these policies led to only a few residents being able to access and use medical cannabis as part of their care.

Another policy that had substantial safety implications for residents wanting to use inhaled forms of cannabis was the regional and institutional no smoking policies that prevented both tobacco and cannabis products from being consumed within the centre as well as on the grounds. As a result, residents had to make their own way, or be accompanied by a support person, to walk approximately 300 m to the public sidewalk where they were allowed to smoke or vape cannabis. With the LTC facility located in a region where winter temperatures can reach − 35 Celsius and sidewalks are covered in snow and ice, this poses significant risk for residents who may be at heightened risk of falls and utilizing assisted walking devices. Similar safety implications of smoke-free policies have been identified in previous research [ 47 ].

Lastly, the policies surrounding the storage and self-administration of medical cannabis for those residents with the physical and emotional capacity (or with a support person willing to administer) may pose potential safety and liability risks and contribute to the concerns held by some HCPs about the use of cannabis in LTC. While residents’ autonomy must be respected, as well as their own expertise with regards to medical cannabis use, the value of standardized medication protocols to ensure the safety of residents as well as to inform care decisions must be acknowledged. The tension experienced in balancing LTC residents’ autonomy with health and safety concerns in the context of substance use has been cited in a recent scoping review [ 48 ] as well as prior research that has examined the use of tobacco in residential care settings [ 49 ].

The policy-related challenges identified by study participants suggest that consultations with LTC residents, families and HCPs are urgently needed to develop and refine cannabis policies that address the needs and reality of individuals living and receiving care in LTC. Future policy reviews must balance LTC residents’ autonomy with the safety issues associated with cannabis use (i.e., dignity of risk), particularly among older adults and those with cognitive and physical impairments. Approaching cannabis policies and procedures in LTC from a harm reduction perspective [ 50 ] with regards to supporting safer consumption of medical cannabis (e.g., route of administration, designated consumption areas) may also be important. Further, the unique context of LTC must also be acknowledged in that for many residents, a LTC facility is their home, and will continue to be so until the end of their lives. But the shared nature of a LTC setting requires that some boundaries be established to protect all residents, as well as those working within LTC. From a staff perspective, a review of policies related to the administration and documentation of cannabis use is needed to protect them from claims of diversion as well as other medicolegal challenges.

Cannabis knowledge gap and stigma in LTC

Across both the quantitative and qualitative data, the gap in knowledge regarding cannabis and the need for continuing education for HCPs working in LTC were readily apparent. When HCPs are unfamiliar about the various forms of medical cannabis, appropriate dosing and titration schedules, and routes of administration, they are hindered in their ability to engage in shared decision making with LTC residents as well as provide high-quality care [ 51 , 52 , 53 , 54 ]. Education is particularly needed that is tailored to the unique risks and benefits of medical cannabis use among LTC populations, including those living with physical and cognitive impairment. Older adults may be more sensitive to the side effects of cannabis due to changes in how medications and drugs are metabolised, and the predominance of polypharmacy among those residing in LTC may further complicate how individuals respond to cannabis [ 55 ]. Therefore, HCPs working in LTC must be aware of how cannabis use may impact individuals’ mobility, memory, and behaviour, as well as the potential for dependency, particularly among those who have experienced substance use issues in the past.

Beyond basic education regarding cannabis and its effects, HCPs must also become aware and informed about existing federal, regional, and institutional policies as well as professional practice standards regarding both medical and non-medical cannabis. The study findings highlighted the uncertainty many HCPs experienced regarding how medical and non-medical cannabis was to be accessed, authorized, administered, stored, and disposed within the LTC facility and what was within their professional scope of practice. Legal concerns about liability, workplace safety, and diversion were also raised.

It is important that future cannabis education programs targeting LTC settings also address the underlying stigma and stereotypes that still surround cannabis use [ 56 , 57 ], despite the existence of a medical cannabis program in Canada for over 20 years and the recent legalization of non-medical cannabis. Experiential training that promotes non-judgmental communication that avoids stigmatizing language (e.g., user, addict, marijuana) and considers both the risks and benefits of cannabis use, particularly within the context of end-of-life care, will help address the stigma that HCPs and LTC residents and families may hold towards cannabis.

With the legalization of cannabis in many regions around the world, it is imperative that undergraduate health professional training programs include information about both medical and non-medical cannabis. Currently, there is a knowledge gap among HCPs due to the lack of standardized curriculum for medical cannabis across nursing or medical schools [ 35 , 58 ]. Understanding such foundational knowledge such as the endocannabinoid system, the different forms and types of cannabis, and the potential health effects will enable physicians, nurses, pharmacists and other HCPs to engage in informed conversations with individuals and families both within and beyond LTC [ 33 ]. In addition, the development of continuing education programs focused on cannabis will ensure practicing HCPs have current knowledge about cannabis, including existing policies and programs relevant to medical and non-medical cannabis. For example, the Canadian Coalition for Seniors’ Mental Health created asynchronous e-learning modules to provide evidence-based knowledge for various clinicians [ 59 ].

Non-medical cannabis use in LTC: it’s legal but…

Despite non-medical cannabis being a legal substance for over three years in Canada at the time of the case study, the use of non-medical cannabis by LTC residents was considered controversial amongst the HCPs interviewed. Not only were HCPs limited in their ability to support the use of non-medical cannabis due to regional policies that prohibited non-medical cannabis consumption at any healthcare facility and surrounding grounds but concerns about potential safety risks and disruptions to the care environment made some HCPs hesitant about supporting residents’ use of non-medical cannabis.

Notwithstanding these challenges, at least a quarter of HCPs surveyed reported providing care to a LTC resident who used non-medical cannabis, which suggests that regulatory and policy changes are required to ensure there is equity across LTC residents who may express interest in non-medical cannabis, as well as to address the unique safety and care issues associated with recreational cannabis use in LTC populations. Similar to medical cannabis, LTC residents’ autonomy must be considered in future policy changes related to non-medical cannabis to facilitate care that is free from stigma and bias, respects residents’ rights to make informed decisions and to live with risk, and to create a home-like environment where residents can engage in activities that were an important part of their lives before entering LTC.

Lessons can be drawn from literature that has examined the use of other legal substances, such as alcohol and tobacco in LTC [ 48 , 60 ], and the need to develop person-centered care plans that ensure the safety of the individual, fellow residents, and the healthcare team.

Limitations

Like all case studies, the findings cannot be extrapolated to other LTC settings and populations. Given that this study was undertaken in Canada, which has a socialized healthcare system and legalized both medical and non-medical cannabis, the experiences and attitudes of HCPs who participated may be unique and limit the generalizability of the findings. However, there are lessons to be learned regarding the challenges that residents in LTC facilities face in using medical and non-medical cannabis, as well as the potential need for both education and policy reform to better support HCPs in providing appropriate, safe, and person-centred care of LTC residents. In addition, the collection of both quantitative and qualitative data allowed triangulation during the data analysis and helped improved the rigor of the findings [ 61 ]. Recruitment and data collection for this study also occurred during the height of the COVID-19 pandemic. Therefore, the response rate was lower than desired and there was limited diversity among study participants with regards health profession designation. However, the proportion of physicians, nurses, pharmacists, and other allied health professions reflected the overall staff composition of the LTC facility.

Implications for future research

Beyond the policy and practice implications discussed earlier, the study findings also point to the urgent need for research focused on cannabis use among populations commonly found within LTC settings. The lack of evidence regarding the potential health effects of cannabis in the management of diseases such as dementia, arthritis, Parkinson’s, traumatic brain injury, and multiple sclerosis led many of the HCPs interviewed to be hesitant about authorizing and supervising cannabis use for LTC residents living with these conditions. While there is a growing number of studies being undertaken focused on medical cannabis, many are limited by their sample size and study design. It is only through high-quality clinical trials that evaluate the efficacy and safety of medical cannabis that a change in practice will occur.

Future medical cannabis research must also be developed in a manner that is inclusive of older adults and those living in LTC. The exclusion of such populations from clinical research has been previously identified as problematic [ 62 ], resulting in research findings that lack generalizability and pose challenges in determining the applicability of research to older adults who may be living with numerous co-morbidities and using multiple medications. While the inclusion of older adults in medical cannabis clinical trials may be more methodologically and ethically challenging, it will lead to evidence that will inform both future policies and practices.

Lastly, our case study offers insight into the reality and challenges of cannabis use by residents of one LTC facility. Additional research across different jurisdictions is needed to explore how LTC settings are addressing cannabis use and to learn from their experiences. We encourage the continued use of mixed methods study designs to ensure the experiences and perspectives of residents, family members and HCPs are captured alongside administrative data related to medical and non-medical cannabis use.

With the legalization of medical and non-medical cannabis in jurisdictions around the world, LTC facilities will be obligated to develop policies, procedures and healthcare services that are able to accommodate residents’ use of cannabis in a respectful and evidence-informed manner. Balancing the safety concerns against the potential therapeutic value of cannabis, as well as considering residents’ autonomy and the home-like environment of LTC, will be important considerations in how cannabis use is addressed and regulated. Our case study highlights the lack of knowledge, inequities, and stigma that continue to surround cannabis in LTC. There is an urgent need for research that not only explores the potential risks and benefits of cannabis, but also informs the development of more nuanced and equitable policies and education resources that will support reasonable and informed access to medical and non-medical cannabis for older adults and others living in LTC.

Data availability

The datasets generated and analysed during the current study are not publicly available due to the small sample size drawn from one health care facility but are available from the corresponding author on reasonable request.

Abbreviations

Cannabidiol

Healthcare provider

Long–term care

Tetrahydrocannabinol

Licensed Producer

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Acknowledgements

The authors would like to thank the healthcare professionals that graciously took the time to share their thoughts about cannabis use in long-term care settings. In addition, Ms. Sina Barkman, Chief Human Resources Officer, Riverview Health Centre, helped the research team navigate the complexity of conducting research in long-term care settings during the COVID-19 pandemic.

Funding for this study was received from the Riverview Health Centre Foundation.

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“L.G.B, G.T, J.P and P.StJ. conceptualised the study. A.A.A. and D.S. engaged in recruitment and data collection activities. L.G.B. and A.A.A. analysed and interpreted the quantitative and qualitative data and developed a first draft of the manuscript, with assistance from G.T. All authors read and approved the final manuscript.”

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Ethical approval for the study was obtained from the University of Manitoba Research Ethics Board (R1-2021:011 (HS24693)) and was approved by the Riverview Health Centre Research Committee. Implied consent was received from participants who completed the survey and written informed consent was obtained from all participants who completed an interview. We confirm that all methods were performed in accordance with the relevant ethical guidelines and regulations, (i.e., Tri-Council Policy Statement).

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Balneaves, L.G., Alraja, A.A., Thompson, G. et al. Cannabis use in a Canadian long-term care facility: a case study. BMC Geriatr 24 , 467 (2024). https://doi.org/10.1186/s12877-024-05074-2

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In their session, Polucci and Sargent shared their latest findings, exploring how design elements such as colors, textures, lighting and sound might differently activate individuals with hyper- or hypo-sensitivities, or those who prefer less or more stimuli. They highlighted common pain points, often overlooked sensory inputs and key approaches to addressing neurodiversity in the office.

Sargent pointed out the intentionality of using “Neuroflexibility” instead of “Neurodiversity” in their SXSW presentation title. “What we found over the last eight years is that every single person in this room is constantly assaulted by sensory stimulation. You don’t have to be at the ends of the spectrum to be annoyed by sound, temperature or light,” she said. “But what might be annoying for someone who is neurotypical might be debilitating to someone with ADHD, Tourettes or another condition.”

When HOK began researching neuroinclusive environments, one in eight people were considered neurodivergent. Today, that ratio is one in five—yet many are never diagnosed. “We are starting to realize how massive of a percentage of the population is impacted by this,” said Sargent. “But you’d be in really good company, because they tend to be entrepreneurs, outside-the-box thinkers and super creative. Many of them have a hyperfocus.”

As children, we were taught that humans have five senses. Polucci pointed out, however, that there are actually eight senses that we all experience. In addition to the well-known five (sight, hearing, touch, taste and smell), he said three more senses play a crucial role in how we interact with our environment.

The first additional sense is interoception, which Polucci referred to as how we feel on the inside and how our body reacts to various stimuli. For instance, based on our internal sensations, we may feel a sense of comfort or discomfort.

The second sense is the awareness of our surroundings and how we perceive the space around us. This includes the sensation of objects or people being too close or feeling confined in a tight space.

Lastly, Polucci explained how our sense of position and balance, known as proprioception, is essential for navigating and interacting with our environment. This sense allows us to understand where our body is in relation to the space around us.

Sargent emphasized that designing for the extreme sensory needs of neurodivergent individuals ultimately benefits everyone. “This is not just about doing something for the 20% that might be neurodivergent,” she said. “This is about making spaces more functional for 100% of the people that are in your spaces by truly understanding how the elements in that environment are impacting us, and how we can design to do things better.”

Listen to an audio recording  of Polucci and Sargent’s “The Future of the Workplace is Neuroflexible” SXSW 2024 presentation.

ONEder Grant: A Case Study

HOK was recently awarded a  ONEder grant  to further test our design principles and develop comprehensive guidelines for a more neuroinclusive workplace. This pioneering research, an evolution of nearly a decade studying how the built environment impacts workers across the cognitive spectrum, serves as a model for best practices and practical strategies to accommodate a diverse range of sensory processing needs and cognitive styles.

The ONEder grant has enabled HOK’s team to evaluate and refine design guidelines from previous research and work .  Using real-world pilot spaces, our investigation engaged both neurodiverse and neurotypical employees in focus groups, surveys and pre- and post-occupancy evaluations to validate and analyze how the built environment impacts the cognitive and sensory experience. The findings from the ONEder grant provide practical examples in managing, renovating and building new facilities with a special focus on supporting a broad spectrum of sensory processing challenges and various neuro-distinctions, serving as a resource for clients and the design community.

HOK’s guidelines offer an actionable and scalable approach to assessing the opportunities for accommodations and determining steps to improve inclusion. Key considerations include providing choice, access to daylight, a mix of quiet and more active spaces, adjustable lighting, ergonomic furnishings and biophilic references. The guidelines also emphasize strategic planning to reduce visual and auditory distractions and zoning to prioritize important connection points and lines of sight. Findings from the ONEder grant research test recommendations for practically implementing these considerations by evaluating operational interventions, access points, planning, circulation, furniture, wayfinding and other design elements such as materiality, color and acoustics.

As neurodiversity takes center stage in the conversation around diversity and inclusivity, HOK’s iterative process provides clients a research-based framework for implementing user feedback and performance data to improve the overall spatial experience. From steps for inclusion and six modalities of work to spatial sequencing and the most effective operational strategies and design adjustments, this latest research is our next step in investigating practical applications that optimize the workplace.

In this video, Sargent explains the impact of workplace design on employee performance and engagement, describing how thoughtful design can better support individuals across the cognitive spectrum.

Note: Neurodiversity is a term used to describe a broad range of conditions, some of which likely will be unresponsive to design solutions. HOK’s approach to inclusive design is based on our experience as designers and architects with the objective of providing a wide range of options for users with different needs. Any attempt to address the needs of neurodiverse individuals should also include review of human resources policies, implementation of technology solutions and building operations among other considerations. HOK does not represent that any design solution discussed in this publication is capable of achieving any specific outcome for an individual user.

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Proposing new design and retrofitting objectives for seismic design of hospital structures: a case study of Imam Khomeini Hospital in Eslamabad-e Gharb

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This paper compares two methods for retrofitting an existing hospital concrete structure to improve its seismic performance: internal and external retrofitting. Internal retrofitting involves adding chevron braces, reinforcing shear walls with Fibre-reinforced plastic coating, and wrapping the walls, columns, and beams using steel jackets. External retrofitting uses two braced exterior steel frames connected to the concrete building using dampers. The paper also proposes a new design objective for hospital structures that ensures immediate occupancy performance level under earthquake hazard level-1 and prevents collapse under higher ground motion intensity. The paper evaluates the base structure, the two retrofitting schemes, and the proposed design method using pushover and nonlinear dynamic analyses under 20 selected earthquake records. The paper then compares the probabilistic seismic risk models using fragility curves. The results show that external retrofitting is more effective and economical than internal retrofitting and that the proposed design objective can significantly reduce the seismic risk of hospital structures.

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Seismic Performance Assessment of Commonly Used Structural Systems and Retrofitting Techniques Using Pushover Analysis

Comparative study on the seismic performance assessment of existing buildings with and without retrofit strategies

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The data that support the findings of this study are not publicly available due to technical reasons. The data are stored in a proprietary format that requires specialized software and hardware to access and process. Data are available from the corresponding author [Seyed Bahram Beheshti Aval] upon reasonable request and with the provision of adequate resources.

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Mehrjoo, M., Aval, S.B.B. Proposing new design and retrofitting objectives for seismic design of hospital structures: a case study of Imam Khomeini Hospital in Eslamabad-e Gharb. Bull Earthquake Eng (2024). https://doi.org/10.1007/s10518-024-01892-2

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The state of AI in early 2024: Gen AI adoption spikes and starts to generate value

If 2023 was the year the world discovered generative AI (gen AI) , 2024 is the year organizations truly began using—and deriving business value from—this new technology. In the latest McKinsey Global Survey  on AI, 65 percent of respondents report that their organizations are regularly using gen AI, nearly double the percentage from our previous survey just ten months ago. Respondents’ expectations for gen AI’s impact remain as high as they were last year , with three-quarters predicting that gen AI will lead to significant or disruptive change in their industries in the years ahead.

About the authors

This article is a collaborative effort by Alex Singla , Alexander Sukharevsky , Lareina Yee , and Michael Chui , with Bryce Hall , representing views from QuantumBlack, AI by McKinsey, and McKinsey Digital.

Organizations are already seeing material benefits from gen AI use, reporting both cost decreases and revenue jumps in the business units deploying the technology. The survey also provides insights into the kinds of risks presented by gen AI—most notably, inaccuracy—as well as the emerging practices of top performers to mitigate those challenges and capture value.

AI adoption surges

Interest in generative AI has also brightened the spotlight on a broader set of AI capabilities. For the past six years, AI adoption by respondents’ organizations has hovered at about 50 percent. This year, the survey finds that adoption has jumped to 72 percent (Exhibit 1). And the interest is truly global in scope. Our 2023 survey found that AI adoption did not reach 66 percent in any region; however, this year more than two-thirds of respondents in nearly every region say their organizations are using AI. 1 Organizations based in Central and South America are the exception, with 58 percent of respondents working for organizations based in Central and South America reporting AI adoption. Looking by industry, the biggest increase in adoption can be found in professional services. 2 Includes respondents working for organizations focused on human resources, legal services, management consulting, market research, R&D, tax preparation, and training.

Also, responses suggest that companies are now using AI in more parts of the business. Half of respondents say their organizations have adopted AI in two or more business functions, up from less than a third of respondents in 2023 (Exhibit 2).

Gen AI adoption is most common in the functions where it can create the most value

Most respondents now report that their organizations—and they as individuals—are using gen AI. Sixty-five percent of respondents say their organizations are regularly using gen AI in at least one business function, up from one-third last year. The average organization using gen AI is doing so in two functions, most often in marketing and sales and in product and service development—two functions in which previous research  determined that gen AI adoption could generate the most value 3 “ The economic potential of generative AI: The next productivity frontier ,” McKinsey, June 14, 2023. —as well as in IT (Exhibit 3). The biggest increase from 2023 is found in marketing and sales, where reported adoption has more than doubled. Yet across functions, only two use cases, both within marketing and sales, are reported by 15 percent or more of respondents.

Gen AI also is weaving its way into respondents’ personal lives. Compared with 2023, respondents are much more likely to be using gen AI at work and even more likely to be using gen AI both at work and in their personal lives (Exhibit 4). The survey finds upticks in gen AI use across all regions, with the largest increases in Asia–Pacific and Greater China. Respondents at the highest seniority levels, meanwhile, show larger jumps in the use of gen Al tools for work and outside of work compared with their midlevel-management peers. Looking at specific industries, respondents working in energy and materials and in professional services report the largest increase in gen AI use.

Investments in gen AI and analytical AI are beginning to create value

The latest survey also shows how different industries are budgeting for gen AI. Responses suggest that, in many industries, organizations are about equally as likely to be investing more than 5 percent of their digital budgets in gen AI as they are in nongenerative, analytical-AI solutions (Exhibit 5). Yet in most industries, larger shares of respondents report that their organizations spend more than 20 percent on analytical AI than on gen AI. Looking ahead, most respondents—67 percent—expect their organizations to invest more in AI over the next three years.

Where are those investments paying off? For the first time, our latest survey explored the value created by gen AI use by business function. The function in which the largest share of respondents report seeing cost decreases is human resources. Respondents most commonly report meaningful revenue increases (of more than 5 percent) in supply chain and inventory management (Exhibit 6). For analytical AI, respondents most often report seeing cost benefits in service operations—in line with what we found last year —as well as meaningful revenue increases from AI use in marketing and sales.

Inaccuracy: The most recognized and experienced risk of gen AI use

As businesses begin to see the benefits of gen AI, they’re also recognizing the diverse risks associated with the technology. These can range from data management risks such as data privacy, bias, or intellectual property (IP) infringement to model management risks, which tend to focus on inaccurate output or lack of explainability. A third big risk category is security and incorrect use.

Respondents to the latest survey are more likely than they were last year to say their organizations consider inaccuracy and IP infringement to be relevant to their use of gen AI, and about half continue to view cybersecurity as a risk (Exhibit 7).

Conversely, respondents are less likely than they were last year to say their organizations consider workforce and labor displacement to be relevant risks and are not increasing efforts to mitigate them.

In fact, inaccuracy— which can affect use cases across the gen AI value chain , ranging from customer journeys and summarization to coding and creative content—is the only risk that respondents are significantly more likely than last year to say their organizations are actively working to mitigate.

Some organizations have already experienced negative consequences from the use of gen AI, with 44 percent of respondents saying their organizations have experienced at least one consequence (Exhibit 8). Respondents most often report inaccuracy as a risk that has affected their organizations, followed by cybersecurity and explainability.

Our previous research has found that there are several elements of governance that can help in scaling gen AI use responsibly, yet few respondents report having these risk-related practices in place. 4 “ Implementing generative AI with speed and safety ,” McKinsey Quarterly , March 13, 2024. For example, just 18 percent say their organizations have an enterprise-wide council or board with the authority to make decisions involving responsible AI governance, and only one-third say gen AI risk awareness and risk mitigation controls are required skill sets for technical talent.

Bringing gen AI capabilities to bear

The latest survey also sought to understand how, and how quickly, organizations are deploying these new gen AI tools. We have found three archetypes for implementing gen AI solutions : takers use off-the-shelf, publicly available solutions; shapers customize those tools with proprietary data and systems; and makers develop their own foundation models from scratch. 5 “ Technology’s generational moment with generative AI: A CIO and CTO guide ,” McKinsey, July 11, 2023. Across most industries, the survey results suggest that organizations are finding off-the-shelf offerings applicable to their business needs—though many are pursuing opportunities to customize models or even develop their own (Exhibit 9). About half of reported gen AI uses within respondents’ business functions are utilizing off-the-shelf, publicly available models or tools, with little or no customization. Respondents in energy and materials, technology, and media and telecommunications are more likely to report significant customization or tuning of publicly available models or developing their own proprietary models to address specific business needs.

Respondents most often report that their organizations required one to four months from the start of a project to put gen AI into production, though the time it takes varies by business function (Exhibit 10). It also depends upon the approach for acquiring those capabilities. Not surprisingly, reported uses of highly customized or proprietary models are 1.5 times more likely than off-the-shelf, publicly available models to take five months or more to implement.

Gen AI high performers are excelling despite facing challenges

Gen AI is a new technology, and organizations are still early in the journey of pursuing its opportunities and scaling it across functions. So it’s little surprise that only a small subset of respondents (46 out of 876) report that a meaningful share of their organizations’ EBIT can be attributed to their deployment of gen AI. Still, these gen AI leaders are worth examining closely. These, after all, are the early movers, who already attribute more than 10 percent of their organizations’ EBIT to their use of gen AI. Forty-two percent of these high performers say more than 20 percent of their EBIT is attributable to their use of nongenerative, analytical AI, and they span industries and regions—though most are at organizations with less than $1 billion in annual revenue. The AI-related practices at these organizations can offer guidance to those looking to create value from gen AI adoption at their own organizations.

To start, gen AI high performers are using gen AI in more business functions—an average of three functions, while others average two. They, like other organizations, are most likely to use gen AI in marketing and sales and product or service development, but they’re much more likely than others to use gen AI solutions in risk, legal, and compliance; in strategy and corporate finance; and in supply chain and inventory management. They’re more than three times as likely as others to be using gen AI in activities ranging from processing of accounting documents and risk assessment to R&D testing and pricing and promotions. While, overall, about half of reported gen AI applications within business functions are utilizing publicly available models or tools, gen AI high performers are less likely to use those off-the-shelf options than to either implement significantly customized versions of those tools or to develop their own proprietary foundation models.

What else are these high performers doing differently? For one thing, they are paying more attention to gen-AI-related risks. Perhaps because they are further along on their journeys, they are more likely than others to say their organizations have experienced every negative consequence from gen AI we asked about, from cybersecurity and personal privacy to explainability and IP infringement. Given that, they are more likely than others to report that their organizations consider those risks, as well as regulatory compliance, environmental impacts, and political stability, to be relevant to their gen AI use, and they say they take steps to mitigate more risks than others do.

Gen AI high performers are also much more likely to say their organizations follow a set of risk-related best practices (Exhibit 11). For example, they are nearly twice as likely as others to involve the legal function and embed risk reviews early on in the development of gen AI solutions—that is, to “ shift left .” They’re also much more likely than others to employ a wide range of other best practices, from strategy-related practices to those related to scaling.

In addition to experiencing the risks of gen AI adoption, high performers have encountered other challenges that can serve as warnings to others (Exhibit 12). Seventy percent say they have experienced difficulties with data, including defining processes for data governance, developing the ability to quickly integrate data into AI models, and an insufficient amount of training data, highlighting the essential role that data play in capturing value. High performers are also more likely than others to report experiencing challenges with their operating models, such as implementing agile ways of working and effective sprint performance management.

About the research

The online survey was in the field from February 22 to March 5, 2024, and garnered responses from 1,363 participants representing the full range of regions, industries, company sizes, functional specialties, and tenures. Of those respondents, 981 said their organizations had adopted AI in at least one business function, and 878 said their organizations were regularly using gen AI in at least one function. To adjust for differences in response rates, the data are weighted by the contribution of each respondent’s nation to global GDP.

Alex Singla and Alexander Sukharevsky  are global coleaders of QuantumBlack, AI by McKinsey, and senior partners in McKinsey’s Chicago and London offices, respectively; Lareina Yee  is a senior partner in the Bay Area office, where Michael Chui , a McKinsey Global Institute partner, is a partner; and Bryce Hall  is an associate partner in the Washington, DC, office.

They wish to thank Kaitlin Noe, Larry Kanter, Mallika Jhamb, and Shinjini Srivastava for their contributions to this work.

This article was edited by Heather Hanselman, a senior editor in McKinsey’s Atlanta office.

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