qualitative case study strategy

The Ultimate Guide to Qualitative Research - Part 1: The Basics

• Introduction and overview
• What is qualitative research?
• What is qualitative data?
• Examples of qualitative data
• Qualitative vs. quantitative research
• Mixed methods
• Qualitative research preparation
• Theoretical perspective
• Theoretical framework
• Literature reviews

Research question

• Conceptual framework
• Conceptual vs. theoretical framework

Data collection

• Qualitative research methods
• Focus groups
• Observational research

What is a case study?

Applications for case study research, what is a good case study, process of case study design, benefits and limitations of case studies.

• Ethnographical research
• Ethical considerations
• Confidentiality and privacy
• Power dynamics
• Reflexivity

Case studies

Case studies are essential to qualitative research , offering a lens through which researchers can investigate complex phenomena within their real-life contexts. This chapter explores the concept, purpose, applications, examples, and types of case studies and provides guidance on how to conduct case study research effectively.

Whereas quantitative methods look at phenomena at scale, case study research looks at a concept or phenomenon in considerable detail. While analyzing a single case can help understand one perspective regarding the object of research inquiry, analyzing multiple cases can help obtain a more holistic sense of the topic or issue. Let's provide a basic definition of a case study, then explore its characteristics and role in the qualitative research process.

Definition of a case study

A case study in qualitative research is a strategy of inquiry that involves an in-depth investigation of a phenomenon within its real-world context. It provides researchers with the opportunity to acquire an in-depth understanding of intricate details that might not be as apparent or accessible through other methods of research. The specific case or cases being studied can be a single person, group, or organization – demarcating what constitutes a relevant case worth studying depends on the researcher and their research question .

Among qualitative research methods , a case study relies on multiple sources of evidence, such as documents, artifacts, interviews , or observations , to present a complete and nuanced understanding of the phenomenon under investigation. The objective is to illuminate the readers' understanding of the phenomenon beyond its abstract statistical or theoretical explanations.

Characteristics of case studies

Case studies typically possess a number of distinct characteristics that set them apart from other research methods. These characteristics include a focus on holistic description and explanation, flexibility in the design and data collection methods, reliance on multiple sources of evidence, and emphasis on the context in which the phenomenon occurs.

Furthermore, case studies can often involve a longitudinal examination of the case, meaning they study the case over a period of time. These characteristics allow case studies to yield comprehensive, in-depth, and richly contextualized insights about the phenomenon of interest.

The role of case studies in research

Case studies hold a unique position in the broader landscape of research methods aimed at theory development. They are instrumental when the primary research interest is to gain an intensive, detailed understanding of a phenomenon in its real-life context.

In addition, case studies can serve different purposes within research - they can be used for exploratory, descriptive, or explanatory purposes, depending on the research question and objectives. This flexibility and depth make case studies a valuable tool in the toolkit of qualitative researchers.

Remember, a well-conducted case study can offer a rich, insightful contribution to both academic and practical knowledge through theory development or theory verification, thus enhancing our understanding of complex phenomena in their real-world contexts.

What is the purpose of a case study?

Case study research aims for a more comprehensive understanding of phenomena, requiring various research methods to gather information for qualitative analysis . Ultimately, a case study can allow the researcher to gain insight into a particular object of inquiry and develop a theoretical framework relevant to the research inquiry.

Why use case studies in qualitative research?

Using case studies as a research strategy depends mainly on the nature of the research question and the researcher's access to the data.

Conducting case study research provides a level of detail and contextual richness that other research methods might not offer. They are beneficial when there's a need to understand complex social phenomena within their natural contexts.

The explanatory, exploratory, and descriptive roles of case studies

Case studies can take on various roles depending on the research objectives. They can be exploratory when the research aims to discover new phenomena or define new research questions; they are descriptive when the objective is to depict a phenomenon within its context in a detailed manner; and they can be explanatory if the goal is to understand specific relationships within the studied context. Thus, the versatility of case studies allows researchers to approach their topic from different angles, offering multiple ways to uncover and interpret the data .

The impact of case studies on knowledge development

Case studies play a significant role in knowledge development across various disciplines. Analysis of cases provides an avenue for researchers to explore phenomena within their context based on the collected data.

This can result in the production of rich, practical insights that can be instrumental in both theory-building and practice. Case studies allow researchers to delve into the intricacies and complexities of real-life situations, uncovering insights that might otherwise remain hidden.

Types of case studies

In qualitative research , a case study is not a one-size-fits-all approach. Depending on the nature of the research question and the specific objectives of the study, researchers might choose to use different types of case studies. These types differ in their focus, methodology, and the level of detail they provide about the phenomenon under investigation.

Understanding these types is crucial for selecting the most appropriate approach for your research project and effectively achieving your research goals. Let's briefly look at the main types of case studies.

Exploratory case studies

Exploratory case studies are typically conducted to develop a theory or framework around an understudied phenomenon. They can also serve as a precursor to a larger-scale research project. Exploratory case studies are useful when a researcher wants to identify the key issues or questions which can spur more extensive study or be used to develop propositions for further research. These case studies are characterized by flexibility, allowing researchers to explore various aspects of a phenomenon as they emerge, which can also form the foundation for subsequent studies.

Descriptive case studies

Descriptive case studies aim to provide a complete and accurate representation of a phenomenon or event within its context. These case studies are often based on an established theoretical framework, which guides how data is collected and analyzed. The researcher is concerned with describing the phenomenon in detail, as it occurs naturally, without trying to influence or manipulate it.

Explanatory case studies

Explanatory case studies are focused on explanation - they seek to clarify how or why certain phenomena occur. Often used in complex, real-life situations, they can be particularly valuable in clarifying causal relationships among concepts and understanding the interplay between different factors within a specific context.

Intrinsic, instrumental, and collective case studies

These three categories of case studies focus on the nature and purpose of the study. An intrinsic case study is conducted when a researcher has an inherent interest in the case itself. Instrumental case studies are employed when the case is used to provide insight into a particular issue or phenomenon. A collective case study, on the other hand, involves studying multiple cases simultaneously to investigate some general phenomena.

Each type of case study serves a different purpose and has its own strengths and challenges. The selection of the type should be guided by the research question and objectives, as well as the context and constraints of the research.

The flexibility, depth, and contextual richness offered by case studies make this approach an excellent research method for various fields of study. They enable researchers to investigate real-world phenomena within their specific contexts, capturing nuances that other research methods might miss. Across numerous fields, case studies provide valuable insights into complex issues.

Critical information systems research

Case studies provide a detailed understanding of the role and impact of information systems in different contexts. They offer a platform to explore how information systems are designed, implemented, and used and how they interact with various social, economic, and political factors. Case studies in this field often focus on examining the intricate relationship between technology, organizational processes, and user behavior, helping to uncover insights that can inform better system design and implementation.

Health research

Health research is another field where case studies are highly valuable. They offer a way to explore patient experiences, healthcare delivery processes, and the impact of various interventions in a real-world context.

Case studies can provide a deep understanding of a patient's journey, giving insights into the intricacies of disease progression, treatment effects, and the psychosocial aspects of health and illness.

Asthma research studies

Specifically within medical research, studies on asthma often employ case studies to explore the individual and environmental factors that influence asthma development, management, and outcomes. A case study can provide rich, detailed data about individual patients' experiences, from the triggers and symptoms they experience to the effectiveness of various management strategies. This can be crucial for developing patient-centered asthma care approaches.

Other fields

Apart from the fields mentioned, case studies are also extensively used in business and management research, education research, and political sciences, among many others. They provide an opportunity to delve into the intricacies of real-world situations, allowing for a comprehensive understanding of various phenomena.

Case studies, with their depth and contextual focus, offer unique insights across these varied fields. They allow researchers to illuminate the complexities of real-life situations, contributing to both theory and practice.

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Understanding the key elements of case study design is crucial for conducting rigorous and impactful case study research. A well-structured design guides the researcher through the process, ensuring that the study is methodologically sound and its findings are reliable and valid. The main elements of case study design include the research question , propositions, units of analysis, and the logic linking the data to the propositions.

The research question is the foundation of any research study. A good research question guides the direction of the study and informs the selection of the case, the methods of collecting data, and the analysis techniques. A well-formulated research question in case study research is typically clear, focused, and complex enough to merit further detailed examination of the relevant case(s).

Propositions

Propositions, though not necessary in every case study, provide a direction by stating what we might expect to find in the data collected. They guide how data is collected and analyzed by helping researchers focus on specific aspects of the case. They are particularly important in explanatory case studies, which seek to understand the relationships among concepts within the studied phenomenon.

Units of analysis

The unit of analysis refers to the case, or the main entity or entities that are being analyzed in the study. In case study research, the unit of analysis can be an individual, a group, an organization, a decision, an event, or even a time period. It's crucial to clearly define the unit of analysis, as it shapes the qualitative data analysis process by allowing the researcher to analyze a particular case and synthesize analysis across multiple case studies to draw conclusions.

Argumentation

This refers to the inferential model that allows researchers to draw conclusions from the data. The researcher needs to ensure that there is a clear link between the data, the propositions (if any), and the conclusions drawn. This argumentation is what enables the researcher to make valid and credible inferences about the phenomenon under study.

Understanding and carefully considering these elements in the design phase of a case study can significantly enhance the quality of the research. It can help ensure that the study is methodologically sound and its findings contribute meaningful insights about the case.

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Conducting a case study involves several steps, from defining the research question and selecting the case to collecting and analyzing data . This section outlines these key stages, providing a practical guide on how to conduct case study research.

Defining the research question

The first step in case study research is defining a clear, focused research question. This question should guide the entire research process, from case selection to analysis. It's crucial to ensure that the research question is suitable for a case study approach. Typically, such questions are exploratory or descriptive in nature and focus on understanding a phenomenon within its real-life context.

Selecting and defining the case

The selection of the case should be based on the research question and the objectives of the study. It involves choosing a unique example or a set of examples that provide rich, in-depth data about the phenomenon under investigation. After selecting the case, it's crucial to define it clearly, setting the boundaries of the case, including the time period and the specific context.

Previous research can help guide the case study design. When considering a case study, an example of a case could be taken from previous case study research and used to define cases in a new research inquiry. Considering recently published examples can help understand how to select and define cases effectively.

Developing a detailed case study protocol

A case study protocol outlines the procedures and general rules to be followed during the case study. This includes the data collection methods to be used, the sources of data, and the procedures for analysis. Having a detailed case study protocol ensures consistency and reliability in the study.

The protocol should also consider how to work with the people involved in the research context to grant the research team access to collecting data. As mentioned in previous sections of this guide, establishing rapport is an essential component of qualitative research as it shapes the overall potential for collecting and analyzing data.

Collecting data

Gathering data in case study research often involves multiple sources of evidence, including documents, archival records, interviews, observations, and physical artifacts. This allows for a comprehensive understanding of the case. The process for gathering data should be systematic and carefully documented to ensure the reliability and validity of the study.

Analyzing and interpreting data

The next step is analyzing the data. This involves organizing the data , categorizing it into themes or patterns , and interpreting these patterns to answer the research question. The analysis might also involve comparing the findings with prior research or theoretical propositions.

Writing the case study report

The final step is writing the case study report . This should provide a detailed description of the case, the data, the analysis process, and the findings. The report should be clear, organized, and carefully written to ensure that the reader can understand the case and the conclusions drawn from it.

Each of these steps is crucial in ensuring that the case study research is rigorous, reliable, and provides valuable insights about the case.

The type, depth, and quality of data in your study can significantly influence the validity and utility of the study. In case study research, data is usually collected from multiple sources to provide a comprehensive and nuanced understanding of the case. This section will outline the various methods of collecting data used in case study research and discuss considerations for ensuring the quality of the data.

Interviews are a common method of gathering data in case study research. They can provide rich, in-depth data about the perspectives, experiences, and interpretations of the individuals involved in the case. Interviews can be structured , semi-structured , or unstructured , depending on the research question and the degree of flexibility needed.

Observations

Observations involve the researcher observing the case in its natural setting, providing first-hand information about the case and its context. Observations can provide data that might not be revealed in interviews or documents, such as non-verbal cues or contextual information.

Documents and artifacts

Documents and archival records provide a valuable source of data in case study research. They can include reports, letters, memos, meeting minutes, email correspondence, and various public and private documents related to the case.

These records can provide historical context, corroborate evidence from other sources, and offer insights into the case that might not be apparent from interviews or observations.

Physical artifacts refer to any physical evidence related to the case, such as tools, products, or physical environments. These artifacts can provide tangible insights into the case, complementing the data gathered from other sources.

Ensuring the quality of data collection

Determining the quality of data in case study research requires careful planning and execution. It's crucial to ensure that the data is reliable, accurate, and relevant to the research question. This involves selecting appropriate methods of collecting data, properly training interviewers or observers, and systematically recording and storing the data. It also includes considering ethical issues related to collecting and handling data, such as obtaining informed consent and ensuring the privacy and confidentiality of the participants.

Data analysis

Analyzing case study research involves making sense of the rich, detailed data to answer the research question. This process can be challenging due to the volume and complexity of case study data. However, a systematic and rigorous approach to analysis can ensure that the findings are credible and meaningful. This section outlines the main steps and considerations in analyzing data in case study research.

Organizing the data

The first step in the analysis is organizing the data. This involves sorting the data into manageable sections, often according to the data source or the theme. This step can also involve transcribing interviews, digitizing physical artifacts, or organizing observational data.

Categorizing and coding the data

Once the data is organized, the next step is to categorize or code the data. This involves identifying common themes, patterns, or concepts in the data and assigning codes to relevant data segments. Coding can be done manually or with the help of software tools, and in either case, qualitative analysis software can greatly facilitate the entire coding process. Coding helps to reduce the data to a set of themes or categories that can be more easily analyzed.

Identifying patterns and themes

After coding the data, the researcher looks for patterns or themes in the coded data. This involves comparing and contrasting the codes and looking for relationships or patterns among them. The identified patterns and themes should help answer the research question.

Interpreting the data

Once patterns and themes have been identified, the next step is to interpret these findings. This involves explaining what the patterns or themes mean in the context of the research question and the case. This interpretation should be grounded in the data, but it can also involve drawing on theoretical concepts or prior research.

Verification of the data

The last step in the analysis is verification. This involves checking the accuracy and consistency of the analysis process and confirming that the findings are supported by the data. This can involve re-checking the original data, checking the consistency of codes, or seeking feedback from research participants or peers.

Like any research method , case study research has its strengths and limitations. Researchers must be aware of these, as they can influence the design, conduct, and interpretation of the study.

Understanding the strengths and limitations of case study research can also guide researchers in deciding whether this approach is suitable for their research question . This section outlines some of the key strengths and limitations of case study research.

Benefits include the following:

• Rich, detailed data: One of the main strengths of case study research is that it can generate rich, detailed data about the case. This can provide a deep understanding of the case and its context, which can be valuable in exploring complex phenomena.
• Flexibility: Case study research is flexible in terms of design , data collection , and analysis . A sufficient degree of flexibility allows the researcher to adapt the study according to the case and the emerging findings.
• Real-world context: Case study research involves studying the case in its real-world context, which can provide valuable insights into the interplay between the case and its context.
• Multiple sources of evidence: Case study research often involves collecting data from multiple sources , which can enhance the robustness and validity of the findings.

On the other hand, researchers should consider the following limitations:

• Generalizability: A common criticism of case study research is that its findings might not be generalizable to other cases due to the specificity and uniqueness of each case.
• Time and resource intensive: Case study research can be time and resource intensive due to the depth of the investigation and the amount of collected data.
• Complexity of analysis: The rich, detailed data generated in case study research can make analyzing the data challenging.
• Subjectivity: Given the nature of case study research, there may be a higher degree of subjectivity in interpreting the data , so researchers need to reflect on this and transparently convey to audiences how the research was conducted.

Being aware of these strengths and limitations can help researchers design and conduct case study research effectively and interpret and report the findings appropriately.

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Qualitative study design: Case Studies

• Qualitative study design
• Phenomenology
• Grounded theory
• Ethnography
• Narrative inquiry
• Action research

Case Studies

• Field research
• Focus groups
• Observation
• Surveys & questionnaires
• Study Designs Home

In depth description of the experience of a single person, a family, a group, a community or an organisation.

An example of a qualitative case study is a life history which is the story of one specific person.  A case study may be done to highlight a specific issue by telling a story of one person or one group. 

• Oral recording

Ability to explore and describe, in depth, an issue or event. 

Develop an understanding of health, illness and health care in context. 

Single case can be used to develop or disprove a theory. 

Can be used as a model or prototype .  

Limitations

Labour intensive and generates large diverse data sets which can be hard to manage. 

Case studies are seen by many as a weak methodology because they only look at one person or one specific group and aren’t as broad in their participant selection as other methodologies. 

Example questions

This methodology can be used to ask questions about a specific drug or treatment and its effects on an individual.

• Does thalidomide cause birth defects?
• Does exposure to a pesticide lead to cancer?

Example studies

• Choi, T. S. T., Walker, K. Z., & Palermo, C. (2018). Diabetes management in a foreign land: A case study on Chinese Australians. Health & Social Care in the Community, 26(2), e225-e232. 
• Reade, I., Rodgers, W., & Spriggs, K. (2008). New Ideas for High Performance Coaches: A Case Study of Knowledge Transfer in Sport Science.  International Journal of Sports Science & Coaching , 3(3), 335-354. 
• Wingrove, K., Barbour, L., & Palermo, C. (2017). Exploring nutrition capacity in Australia's charitable food sector.  Nutrition & Dietetics , 74(5), 495-501. 
• Green, J., & Thorogood, N. (2018). Qualitative methods for health research (4th ed.). London: SAGE. 
• University of Missouri-St. Louis. Qualitative Research Designs. Retrieved from http://www.umsl.edu/~lindquists/qualdsgn.html   
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Home » Case Study – Methods, Examples and Guide

Case Study – Methods, Examples and Guide

Table of Contents

A case study is a research method that involves an in-depth examination and analysis of a particular phenomenon or case, such as an individual, organization, community, event, or situation.

It is a qualitative research approach that aims to provide a detailed and comprehensive understanding of the case being studied. Case studies typically involve multiple sources of data, including interviews, observations, documents, and artifacts, which are analyzed using various techniques, such as content analysis, thematic analysis, and grounded theory. The findings of a case study are often used to develop theories, inform policy or practice, or generate new research questions.

Types of Case Study

Types and Methods of Case Study are as follows:

Single-Case Study

A single-case study is an in-depth analysis of a single case. This type of case study is useful when the researcher wants to understand a specific phenomenon in detail.

For Example , A researcher might conduct a single-case study on a particular individual to understand their experiences with a particular health condition or a specific organization to explore their management practices. The researcher collects data from multiple sources, such as interviews, observations, and documents, and uses various techniques to analyze the data, such as content analysis or thematic analysis. The findings of a single-case study are often used to generate new research questions, develop theories, or inform policy or practice.

Multiple-Case Study

A multiple-case study involves the analysis of several cases that are similar in nature. This type of case study is useful when the researcher wants to identify similarities and differences between the cases.

For Example, a researcher might conduct a multiple-case study on several companies to explore the factors that contribute to their success or failure. The researcher collects data from each case, compares and contrasts the findings, and uses various techniques to analyze the data, such as comparative analysis or pattern-matching. The findings of a multiple-case study can be used to develop theories, inform policy or practice, or generate new research questions.

Exploratory Case Study

An exploratory case study is used to explore a new or understudied phenomenon. This type of case study is useful when the researcher wants to generate hypotheses or theories about the phenomenon.

For Example, a researcher might conduct an exploratory case study on a new technology to understand its potential impact on society. The researcher collects data from multiple sources, such as interviews, observations, and documents, and uses various techniques to analyze the data, such as grounded theory or content analysis. The findings of an exploratory case study can be used to generate new research questions, develop theories, or inform policy or practice.

Descriptive Case Study

A descriptive case study is used to describe a particular phenomenon in detail. This type of case study is useful when the researcher wants to provide a comprehensive account of the phenomenon.

For Example, a researcher might conduct a descriptive case study on a particular community to understand its social and economic characteristics. The researcher collects data from multiple sources, such as interviews, observations, and documents, and uses various techniques to analyze the data, such as content analysis or thematic analysis. The findings of a descriptive case study can be used to inform policy or practice or generate new research questions.

Instrumental Case Study

An instrumental case study is used to understand a particular phenomenon that is instrumental in achieving a particular goal. This type of case study is useful when the researcher wants to understand the role of the phenomenon in achieving the goal.

For Example, a researcher might conduct an instrumental case study on a particular policy to understand its impact on achieving a particular goal, such as reducing poverty. The researcher collects data from multiple sources, such as interviews, observations, and documents, and uses various techniques to analyze the data, such as content analysis or thematic analysis. The findings of an instrumental case study can be used to inform policy or practice or generate new research questions.

Case Study Data Collection Methods

Here are some common data collection methods for case studies:

Interviews involve asking questions to individuals who have knowledge or experience relevant to the case study. Interviews can be structured (where the same questions are asked to all participants) or unstructured (where the interviewer follows up on the responses with further questions). Interviews can be conducted in person, over the phone, or through video conferencing.

Observations

Observations involve watching and recording the behavior and activities of individuals or groups relevant to the case study. Observations can be participant (where the researcher actively participates in the activities) or non-participant (where the researcher observes from a distance). Observations can be recorded using notes, audio or video recordings, or photographs.

Documents can be used as a source of information for case studies. Documents can include reports, memos, emails, letters, and other written materials related to the case study. Documents can be collected from the case study participants or from public sources.

Surveys involve asking a set of questions to a sample of individuals relevant to the case study. Surveys can be administered in person, over the phone, through mail or email, or online. Surveys can be used to gather information on attitudes, opinions, or behaviors related to the case study.

Artifacts are physical objects relevant to the case study. Artifacts can include tools, equipment, products, or other objects that provide insights into the case study phenomenon.

How to conduct Case Study Research

Conducting a case study research involves several steps that need to be followed to ensure the quality and rigor of the study. Here are the steps to conduct case study research:

• Define the research questions: The first step in conducting a case study research is to define the research questions. The research questions should be specific, measurable, and relevant to the case study phenomenon under investigation.
• Select the case: The next step is to select the case or cases to be studied. The case should be relevant to the research questions and should provide rich and diverse data that can be used to answer the research questions.
• Collect data: Data can be collected using various methods, such as interviews, observations, documents, surveys, and artifacts. The data collection method should be selected based on the research questions and the nature of the case study phenomenon.
• Analyze the data: The data collected from the case study should be analyzed using various techniques, such as content analysis, thematic analysis, or grounded theory. The analysis should be guided by the research questions and should aim to provide insights and conclusions relevant to the research questions.
• Draw conclusions: The conclusions drawn from the case study should be based on the data analysis and should be relevant to the research questions. The conclusions should be supported by evidence and should be clearly stated.
• Validate the findings: The findings of the case study should be validated by reviewing the data and the analysis with participants or other experts in the field. This helps to ensure the validity and reliability of the findings.
• Write the report: The final step is to write the report of the case study research. The report should provide a clear description of the case study phenomenon, the research questions, the data collection methods, the data analysis, the findings, and the conclusions. The report should be written in a clear and concise manner and should follow the guidelines for academic writing.

Examples of Case Study

Here are some examples of case study research:

• The Hawthorne Studies : Conducted between 1924 and 1932, the Hawthorne Studies were a series of case studies conducted by Elton Mayo and his colleagues to examine the impact of work environment on employee productivity. The studies were conducted at the Hawthorne Works plant of the Western Electric Company in Chicago and included interviews, observations, and experiments.
• The Stanford Prison Experiment: Conducted in 1971, the Stanford Prison Experiment was a case study conducted by Philip Zimbardo to examine the psychological effects of power and authority. The study involved simulating a prison environment and assigning participants to the role of guards or prisoners. The study was controversial due to the ethical issues it raised.
• The Challenger Disaster: The Challenger Disaster was a case study conducted to examine the causes of the Space Shuttle Challenger explosion in 1986. The study included interviews, observations, and analysis of data to identify the technical, organizational, and cultural factors that contributed to the disaster.
• The Enron Scandal: The Enron Scandal was a case study conducted to examine the causes of the Enron Corporation’s bankruptcy in 2001. The study included interviews, analysis of financial data, and review of documents to identify the accounting practices, corporate culture, and ethical issues that led to the company’s downfall.
• The Fukushima Nuclear Disaster : The Fukushima Nuclear Disaster was a case study conducted to examine the causes of the nuclear accident that occurred at the Fukushima Daiichi Nuclear Power Plant in Japan in 2011. The study included interviews, analysis of data, and review of documents to identify the technical, organizational, and cultural factors that contributed to the disaster.

Application of Case Study

Case studies have a wide range of applications across various fields and industries. Here are some examples:

Business and Management

Case studies are widely used in business and management to examine real-life situations and develop problem-solving skills. Case studies can help students and professionals to develop a deep understanding of business concepts, theories, and best practices.

Case studies are used in healthcare to examine patient care, treatment options, and outcomes. Case studies can help healthcare professionals to develop critical thinking skills, diagnose complex medical conditions, and develop effective treatment plans.

Case studies are used in education to examine teaching and learning practices. Case studies can help educators to develop effective teaching strategies, evaluate student progress, and identify areas for improvement.

Social Sciences

Case studies are widely used in social sciences to examine human behavior, social phenomena, and cultural practices. Case studies can help researchers to develop theories, test hypotheses, and gain insights into complex social issues.

Law and Ethics

Case studies are used in law and ethics to examine legal and ethical dilemmas. Case studies can help lawyers, policymakers, and ethical professionals to develop critical thinking skills, analyze complex cases, and make informed decisions.

Purpose of Case Study

The purpose of a case study is to provide a detailed analysis of a specific phenomenon, issue, or problem in its real-life context. A case study is a qualitative research method that involves the in-depth exploration and analysis of a particular case, which can be an individual, group, organization, event, or community.

The primary purpose of a case study is to generate a comprehensive and nuanced understanding of the case, including its history, context, and dynamics. Case studies can help researchers to identify and examine the underlying factors, processes, and mechanisms that contribute to the case and its outcomes. This can help to develop a more accurate and detailed understanding of the case, which can inform future research, practice, or policy.

Case studies can also serve other purposes, including:

• Illustrating a theory or concept: Case studies can be used to illustrate and explain theoretical concepts and frameworks, providing concrete examples of how they can be applied in real-life situations.
• Developing hypotheses: Case studies can help to generate hypotheses about the causal relationships between different factors and outcomes, which can be tested through further research.
• Providing insight into complex issues: Case studies can provide insights into complex and multifaceted issues, which may be difficult to understand through other research methods.
• Informing practice or policy: Case studies can be used to inform practice or policy by identifying best practices, lessons learned, or areas for improvement.

Advantages of Case Study Research

There are several advantages of case study research, including:

• In-depth exploration: Case study research allows for a detailed exploration and analysis of a specific phenomenon, issue, or problem in its real-life context. This can provide a comprehensive understanding of the case and its dynamics, which may not be possible through other research methods.
• Rich data: Case study research can generate rich and detailed data, including qualitative data such as interviews, observations, and documents. This can provide a nuanced understanding of the case and its complexity.
• Holistic perspective: Case study research allows for a holistic perspective of the case, taking into account the various factors, processes, and mechanisms that contribute to the case and its outcomes. This can help to develop a more accurate and comprehensive understanding of the case.
• Theory development: Case study research can help to develop and refine theories and concepts by providing empirical evidence and concrete examples of how they can be applied in real-life situations.
• Practical application: Case study research can inform practice or policy by identifying best practices, lessons learned, or areas for improvement.
• Contextualization: Case study research takes into account the specific context in which the case is situated, which can help to understand how the case is influenced by the social, cultural, and historical factors of its environment.

Limitations of Case Study Research

There are several limitations of case study research, including:

• Limited generalizability : Case studies are typically focused on a single case or a small number of cases, which limits the generalizability of the findings. The unique characteristics of the case may not be applicable to other contexts or populations, which may limit the external validity of the research.
• Biased sampling: Case studies may rely on purposive or convenience sampling, which can introduce bias into the sample selection process. This may limit the representativeness of the sample and the generalizability of the findings.
• Subjectivity: Case studies rely on the interpretation of the researcher, which can introduce subjectivity into the analysis. The researcher’s own biases, assumptions, and perspectives may influence the findings, which may limit the objectivity of the research.
• Limited control: Case studies are typically conducted in naturalistic settings, which limits the control that the researcher has over the environment and the variables being studied. This may limit the ability to establish causal relationships between variables.
• Time-consuming: Case studies can be time-consuming to conduct, as they typically involve a detailed exploration and analysis of a specific case. This may limit the feasibility of conducting multiple case studies or conducting case studies in a timely manner.
• Resource-intensive: Case studies may require significant resources, including time, funding, and expertise. This may limit the ability of researchers to conduct case studies in resource-constrained settings.

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Qualitative Methods for Policy Analysis: Case Study Research Strategy

• First Online: 10 April 2022

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• Sarath S. Kodithuwakku 3  

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Many policy researchers are predisposed to use either quantitative or qualitative research methods regardless of the research questions at hand, leading to varying degrees of gaps in their findings and policy recommendations. Qualitative approaches effectively address why and how types of research questions to complement the answers for who , what , where , how many , and how much research questions, obtained using quantitative research methods, enabling researchers to make policy outcomes meaningful and contextually relevant. This chapter introduces the case study as an appropriate research strategy for accommodating qualitative and quantitative methods, followed by a brief account of qualitative research methods.

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Kodithuwakku, S.S. (2022). Qualitative Methods for Policy Analysis: Case Study Research Strategy. In: Weerahewa, J., Jacque, A. (eds) Agricultural Policy Analysis. Springer, Singapore. https://doi.org/10.1007/978-981-16-3284-6_7

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• Published: 02 May 2024

Use of the International IFOMPT Cervical Framework to inform clinical reasoning in postgraduate level physiotherapy students: a qualitative study using think aloud methodology

• Katie L. Kowalski 1 ,
• Heather Gillis 1 ,
• Katherine Henning 1 ,
• Paul Parikh 1 ,
• Jackie Sadi 1 &
• Alison Rushton 1  

BMC Medical Education volume  24 , Article number:  486 ( 2024 ) Cite this article

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Vascular pathologies of the head and neck are rare but can present as musculoskeletal problems. The International Federation of Orthopedic Manipulative Physical Therapists (IFOMPT) Cervical Framework (Framework) aims to assist evidence-based clinical reasoning for safe assessment and management of the cervical spine considering potential for vascular pathology. Clinical reasoning is critical to physiotherapy, and developing high-level clinical reasoning is a priority for postgraduate (post-licensure) educational programs.

To explore the influence of the Framework on clinical reasoning processes in postgraduate physiotherapy students.

Qualitative case study design using think aloud methodology and interpretive description, informed by COnsolidated criteria for REporting Qualitative research. Participants were postgraduate musculoskeletal physiotherapy students who learned about the Framework through standardized delivery. Two cervical spine cases explored clinical reasoning processes. Coding and analysis of transcripts were guided by Elstein’s diagnostic reasoning components and the Postgraduate Musculoskeletal Physiotherapy Practice model. Data were analyzed using thematic analysis (inductive and deductive) for individuals and then across participants, enabling analysis of key steps in clinical reasoning processes and use of the Framework. Trustworthiness was enhanced with multiple strategies (e.g., second researcher challenged codes).

For all participants ( n  = 8), the Framework supported clinical reasoning using primarily hypothetico-deductive processes. It informed vascular hypothesis generation in the patient history and testing the vascular hypothesis through patient history questions and selection of physical examination tests, to inform clarity and support for diagnosis and management. Most participant’s clinical reasoning processes were characterized by high-level features (e.g., prioritization), however there was a continuum of proficiency. Clinical reasoning processes were informed by deep knowledge of the Framework integrated with a breadth of wider knowledge and supported by a range of personal characteristics (e.g., reflection).

Conclusions

Findings support use of the Framework as an educational resource in postgraduate physiotherapy programs to inform clinical reasoning processes for safe and effective assessment and management of cervical spine presentations considering potential for vascular pathology. Individualized approaches may be required to support students, owing to a continuum of clinical reasoning proficiency. Future research is required to explore use of the Framework to inform clinical reasoning processes in learners at different levels.

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Introduction

Musculoskeletal neck pain and headache are highly prevalent and among the most disabling conditions globally that require effective rehabilitation [ 1 , 2 , 3 , 4 ]. A range of rehabilitation professionals, including physiotherapists, assess and manage musculoskeletal neck pain and headache. Assessment of the cervical spine can be a complex process. Patients can present to physiotherapy with vascular pathology masquerading as musculoskeletal pain and dysfunction, as neck pain and/or headache as a common first symptom [ 5 ]. While vascular pathologies of the head and neck are rare [ 6 ], they are important considerations within a cervical spine assessment to facilitate the best possible patient outcomes [ 7 ]. The International IFOMPT (International Federation of Orthopedic Manipulative Physical Therapists) Cervical Framework (Framework) provides guidance in the assessment and management of the cervical spine region, considering the potential for vascular pathologies of the neck and head [ 8 ]. Two separate, but related, risks are considered: risk of misdiagnosis of an existing vascular pathology and risk of serious adverse event following musculoskeletal interventions [ 8 ].

The Framework is a consensus document iteratively developed through rigorous methods and the best contemporary evidence [ 8 ], and is also published as a Position Statement [ 7 ]. Central to the Framework are clinical reasoning and evidence-based practice, providing guidance in the assessment of the cervical spine region, considering the potential for vascular pathologies in advance of planned interventions [ 7 , 8 ]. The Framework was developed and published to be a resource for practicing musculoskeletal clinicians and educators. It has been implemented widely within IFOMPT postgraduate (post-licensure) educational programs, influencing curricula by enabling a comprehensive and systemic approach when considering the potential for vascular pathology [ 9 ]. Frequently reported curricula changes include an emphasis on the patient history and incorporating Framework recommended physical examination tests to evaluate a vascular hypothesis [ 9 ]. The Framework aims to assist musculoskeletal clinicians in their clinical reasoning processes, however no study has investigated students’ use of the Framework to inform their clinical reasoning.

Clinical reasoning is a critical component to physiotherapy practice as it is fundamental to assessment and diagnosis, enabling physiotherapists to provide safe and effective patient-centered care [ 10 ]. This is particularly important for postgraduate physiotherapy educational programs, where developing a high level of clinical reasoning is a priority for educational curricula [ 11 ] and critical for achieving advanced practice physiotherapy competency [ 12 , 13 , 14 , 15 ]. At this level of physiotherapy, diagnostic reasoning is emphasized as an important component of a high level of clinical reasoning, informed by advanced use of domain-specific knowledge (e.g., propositional, experiential) and supported by a range of personal characteristics (e.g., adaptability, reflective) [ 12 ]. Facilitating the development of clinical reasoning improves physiotherapist’s performance and patient outcomes [ 16 ], underscoring the importance of clinical reasoning to physiotherapy practice. Understanding students’ use of the Framework to inform their clinical reasoning can support optimal implementation of the Framework within educational programs to facilitate safe and effective assessment and management of the cervical spine for patients.

To explore the influence of the Framework on the clinical reasoning processes in postgraduate level physiotherapy students.

Using a qualitative case study design, think aloud case analyses enabled exploration of clinical reasoning processes in postgraduate physiotherapy students. Case study design allows evaluation of experiences in practice, providing knowledge and accounts of practical actions in a specific context [ 17 ]. Case studies offer opportunity to generate situationally dependent understandings of accounts of clinical practice, highlighting the action and interaction that underscore the complexity of clinical decision-making in practice [ 17 ]. This study was informed by an interpretive description methodological approach with thematic analysis [ 18 , 19 ]. Interpretive description is coherent with mixed methods research and pragmatic orientations [ 20 , 21 ], and enables generation of evidence-based disciplinary knowledge and clinical understanding to inform practice [ 18 , 19 , 22 ]. Interpretive description has evolved for use in educational research to generate knowledge of educational experiences and the complexities of health care education to support achievement of educational objectives and professional practice standards [ 23 ]. The COnsolidated criteria for REporting Qualitative research (COREQ) informed the design and reporting of this study [ 24 ].

Research team

All research team members hold physiotherapy qualifications, and most hold advanced qualifications specializing in musculoskeletal physiotherapy. The research team is based in Canada and has varying levels of academic credentials (ranging from Clinical Masters to PhD or equivalent) and occupations (ranging from PhD student to Director of Physical Therapy). The final author (AR) is also an author of the Framework, which represents international and multiprofessional consensus. Authors HG and JS are lecturers on one of the postgraduate programs which students were recruited from. The primary researcher and first author (KK) is a US-trained Physical Therapist and Postdoctoral Research Associate investigating spinal pain and clinical reasoning in the School of Physical Therapy at Western University. Authors KK, KH and PP had no prior relationship with the postgraduate educational programs, students, or the Framework.

Study setting

Western University in London, Ontario, Canada offers a one-year Advanced Health Care Practice (AHCP) postgraduate IFOMPT-approved Comprehensive Musculoskeletal Physiotherapy program (CMP) and a postgraduate Sport and Exercise Medicine (SEM) program. Think aloud case analyses interviews were conducted using Zoom, a viable option for qualitative data collection and audio-video recording of interviews that enables participation for students who live in geographically dispersed areas across Canada [ 25 ]. Interviews with individual participants were conducted by one researcher (KK or KH) in a calm and quiet environment to minimize disruption to the process of thinking aloud [ 26 ].

Participants

AHCP postgraduate musculoskeletal physiotherapy students ≥ 18 years of age in the CMP and SEM programs were recruited via email and an introduction to the research study during class by KK, using purposive sampling to ensure theoretical representation. The purposive sample ensured key characteristics of participants were included, specifically gender, ethnicity, and physiotherapy experience (years, type). AHCP students must have attended standardized teaching about the Framework to be eligible to participate. Exclusion criteria included inability to communicate fluently in English. As think-aloud methodology seeks rich, in-depth data from a small sample [ 27 ], this study sought to recruit 8–10 AHCP students. This range was informed by prior think aloud literature and anticipated to balance diversity of participant characteristics, similarities in musculoskeletal physiotherapy domain knowledge and rich data supporting individual clinical reasoning processes [ 27 , 28 ].

Learning about the IFOMPT Cervical Framework

CMP and SEM programs included standardized teaching of the Framework to inform AHCP students’ clinical reasoning in practice. Delivery included a presentation explaining the Framework, access to the full Framework document [ 8 ], and discussion of its role to inform practice, including a case analysis of a cervical spine clinical presentation, by research team members AR and JS. The full Framework document that is publicly available through IFOMPT [ 8 ] was provided to AHCP students as the Framework Position Statement [ 7 ] was not yet published. Discussion and case analysis was led by AHCP program leads in November 2021 (CMP, including research team member JS) and January 2022 (SEM).

Think aloud case analyses data collection

Using think aloud methodology, the analytical processes of how participants use the Framework to inform clinical reasoning were explored in an interview with one research team member not involved in AHCP educational programs (KK or KH). The think aloud method enables description and explanation of complex information paralleling the clinical reasoning process and has been used previously in musculoskeletal physiotherapy [ 29 , 30 ]. It facilitates the generation of rich verbal [ 27 ]as participants verbalize their clinical reasoning protocols [ 27 , 31 ]. Participants were aware of the aim of the research study and the research team’s clinical and research backgrounds, supporting an open environment for depth of data collection [ 32 ]. There was no prior relationship between participants and research team members conducting interviews.

Participants were instructed to think aloud their analysis of two clinical cases, presented in random order (Supplementary  1 ). Case information was provided in stages to reflect the chronology of assessment of patients in practice (patient history, planning the physical examination, physical examination, treatment). Use of the Framework to inform clinical reasoning was discussed at each stage. The cases enabled participants to identify and discuss features of possible vascular pathology, treatment indications and contraindications/precautions, etc. Two research study team members (HG, PP) developed cases designed to facilitate and elicit clinical reasoning processes in neck and head pain presentations. Cases were tested against the research team to ensure face validity. Cases and think aloud prompts were piloted prior to use with three physiotherapists at varying levels of practice to ensure they were fit for purpose.

Data collection took place from March 30-August 15, 2022, during the final terms of the AHCP programs and an average of 5 months after standardized teaching about the Framework. During case analysis interviews, participants were instructed to constantly think aloud, and if a pause in verbalizations was sustained, they were reminded to “keep thinking aloud” [ 27 ]. As needed, prompts were given to elicit verbalization of participants’ reasoning processes, including use of the Framework to inform their clinical reasoning at each stage of case analysis (Supplementary  2 ). Aside from this, all interactions between participants and researchers minimized to not interfere with the participant’s thought processes [ 27 , 31 ]. When analysis of the first case was complete, the researcher provided the second case, each lasting 35–45 min. A break between cases was offered. During and after interviews, field notes were recorded about initial impressions of the data collection session and potential patterns appearing to emerge [ 33 ].

Data analysis

Data from think aloud interviews were analyzed using thematic analysis [ 30 , 34 ], facilitating identification and analysis of patterns in data and key steps in the clinical reasoning process, including use of the Framework to enable its characterization (Fig.  1 ). As established models of clinical reasoning exist, a hybrid approach to thematic analysis was employed, incorporating inductive and deductive processes [ 35 ], which proceeded according to 5 iterative steps: [ 34 ]

Data analysis steps

Familiarize with data: Audio-visual recordings were transcribed verbatim by a physiotherapist external to the research team. All transcripts were read and re-read several times by one researcher (KK), checking for accuracy by reviewing recordings as required. Field notes supported depth of familiarization with data.

Generate initial codes: Line-by-line coding of transcripts by one researcher (KK) supported generation of initial codes that represented components, patterns and meaning in clinical reasoning processes and use of the Framework. Established preliminary coding models were used as a guide. Elstein’s diagnostic reasoning model [ 36 ] guided generating initial codes of key steps in clinical reasoning processes (Table  1 a) [ 29 , 36 ]. Leveraging richness of data, further codes were generated guided by the Postgraduate Musculoskeletal Physiotherapy Practice model, which describes masters level clinical practice (Table  1 b) [ 12 ]. Codes were refined as data analysis proceeded. All codes were collated within participants along with supporting data.

Generate initial themes within participants: Coded data was inductively grouped into initial themes within each participant, reflecting individual clinical reasoning processes and use of the Framework. This inductive stage enabled a systematic, flexible approach to describe each participant’s unique thinking path, offering insight into the complexities of their clinical reasoning processes. It also provided a comprehensive understanding of the Framework informing clinical reasoning and a rich characterization of its components, aiding the development of robust, nuanced insights [ 35 , 37 , 38 ]. Initial themes were repeatedly revised to ensure they were grounded in and reflected raw data.

Develop, review and refine themes across participants: Initial themes were synthesized across participants to develop themes that represented all participants. Themes were reviewed and refined, returning to initial themes and codes at the individual participant level as needed.

Organize themes into established models: Themes were deductively organized into established clinical reasoning models; first into Elstein’s diagnostic reasoning model, second into the Postgraduate Musculoskeletal Physiotherapy Practice model to characterize themes within each diagnostic reasoning component [ 12 , 36 ].

Trustworthiness of findings

The research study was conducted according to an a priori protocol and additional steps were taken to establish trustworthiness of findings [ 39 ]. Field notes supported deep familiarization with data and served as a means of data source triangulation during analysis [ 40 ]. One researcher coded transcripts and a second researcher challenged codes, with codes and themes rigorously and iteratively reviewed and refined. Frequent debriefing sessions with the research team, reflexive discussions with other researchers and peer scrutiny of initial findings enabled wider perspectives and experiences to shape analysis and interpretation of findings. Several strategies were implemented to minimize the influence of prior relationships between participants and researchers, including author KK recruiting participants, KK and KH collecting/analyzing data, and AR, JS, HG and PP providing input on de-identified data at the stage of synthesis and interpretation.

Nine AHCP postgraduate level students were recruited and participated in data collection. One participant was withdrawn because of unfamiliarity with the standardized teaching session about use of the Framework (no recall of session), despite confirmation of attendance. Data from eight participants were used for analysis (CMP: n  = 6; SEM: n  = 2; Table  2 ), which achieved sample size requirements for think aloud methodology of rich and in-depth data [ 27 , 28 ].

Diagnostic reasoning components

Informed by the Framework, all components of Elstein’s diagnostic reasoning processes [ 36 ] were used by participants, including use of treatment with physiotherapy interventions to aid diagnostic reasoning. An illustrative example is presented in Supplement  3 . Clinical reasoning used primarily hypothetico-deductive processes reflecting a continuum of proficiency, was informed by deep Framework knowledge and breadth of prior knowledge (e.g., experiential), and supported by a range of personal characteristics (e.g., justification for decisions).

Cue acquisition

All participants sought to acquire additional cues early in the patient history, and for some this persisted into the medical history and physical examination. Cue acquisition enabled depth and breadth of understanding patient history information to generate hypotheses and factors contributing to the patient’s pain experience (Table  3 ). All participants asked further questions to understand details of the patients’ pain and their presentation, while some also explored the impact of pain on patient functioning and treatments received to date. There was a high degree of specificity to questions for most participants. Ongoing clinical reasoning processes through a thorough and complete assessment, even if the patient had previously received treatment for similar symptoms, was important for some participants. Cue acquisition was supported by personal characteristics including a patient-centered approach (e.g., understanding the patient’s beliefs about pain) and one participant reflected on their approach to acquiring patient history cues.

Hypothesis generation

Participants generated an average of 4.5 hypotheses per case (range: 2–8) and most hypotheses (77%) were generated rapidly early in the patient history. Knowledge from the Framework about patient history features of vascular pathology informed vascular hypothesis generation in the patient history for all participants in both cases (Table  4 ). Vascular hypotheses were also generated during the past medical history, where risk factors for vascular pathology were identified and interpreted by some participants who had high levels of suspicion for cervical articular involvement. Non-vascular hypotheses were generated during the physical examination by some participants to explain individual physical examination or patient history cues. Deep knowledge of the patient history section in the Framework supported high level of cue identification and interpretation for generating vascular hypotheses. Initial hypotheses were prioritized by some participants, however the level of specificity of hypotheses varied.

Cue evaluation

All participants evaluated cues throughout the patient history and physical examination in relationship to hypotheses generated, indicating use of hypothetico-deductive reasoning processes (Table  5 ). Framework knowledge of patient history features of vascular pathology was used to test vascular hypotheses and aid differential diagnosis. The patient history section supported high level of cue identification and interpretation of patient history features for all but one participant, and generation of further patient history questions for all participants. The level of specificity of these questions was high for all but one participant. Framework knowledge of recommended physical examination tests, including removal of positional testing, supported planning a focused and prioritized physical examination to further test vascular hypotheses for all participants. No participant indicated intention to use positional testing as part of their physical examination. Treatment with physiotherapy interventions served as a form of cue evaluation, and cues were evaluated to inform prognosis for some participants. At times during the physical examination, some participants demonstrated occasional errors or difficulty with cue evaluation by omitting key physical exam tests (e.g., no cranial nerve assessment despite concerns for trigeminal nerve involvement), selecting physical exam tests in advance of hypothesis generation (e.g., cervical spine instability testing), difficulty interpreting cues, or late selection of a physical examination test. Cue acquisition was supported by a range of personal characteristics. Most participants justified selection of physical examination tests, and some self-reflected on their ability to collect useful physical examination information to inform selection of tests. Precaution to the physical examination was identified by all participants but one, which contributed to an adaptable approach, prioritizing patient safety and comfort. Critical analysis of physical examination information aided interpretation within the context of the patient for most participants.

Hypothesis evaluation

All participants used the Framework to evaluate their hypotheses throughout the patient history and physical examination, continuously shifting their level of support for hypotheses (Table  6 , Supplement  4 ). This informed clarity in the overall level of suspicion for vascular pathology or musculoskeletal diagnoses, which were specific for most participants. Response to treatment with physiotherapy interventions served as a form of hypothesis evaluation for most participants who had low level suspicion for vascular pathology, highlighting ongoing reasoning processes. Hypotheses evaluated were prioritized by ranking according to level of suspicion by some participants. Difficulties weighing patient history and physical examination cues to inform judgement on overall level of suspicion for vascular pathology was demonstrated by some participants who reported that incomplete physical examination data and not being able to see the patient contributed to difficulties. Hypothesis evaluation was supported by the personal characteristic of reflection, where some students reflected on the Framework’s emphasis on the patient history to evaluate a vascular hypothesis.

The Framework supported all participants in clinical reasoning related to treatment (Table  7 ). Treatment decisions were always linked to the participant’s overall level of suspicion for vascular pathology or musculoskeletal diagnosis. Framework knowledge supported participants with high level of suspicion for vascular pathology to refer for further investigations. Participants with a musculoskeletal diagnosis kept the patient for physiotherapy interventions. The Framework patient history section supported patient education about symptoms of vascular pathology and safety netting for some participants. Framework knowledge influenced informed consent processes and risk-benefit analysis to support the selection of musculoskeletal physiotherapy interventions, which were specific and prioritized for some participants. Less Framework knowledge related to treatment was demonstrated by some students, generating unclear recommendations regarding the urgency of referral and use of the Framework to inform musculoskeletal physiotherapy interventions. Treatment was supported by a range of personal characteristics. An adaptable approach that prioritized patient safety and was supported by justification was demonstrated in all participants except one. Shared decision-making enabled the selection of physiotherapy interventions, which were patient-centered (individualized, considered whole person, identified future risk for vascular pathology). Communication with the patient’s family doctor facilitated collaborative patient-centered care for most participants.

This is the first study to explore the influence of the Framework on clinical reasoning processes in postgraduate physiotherapy students. The Framework supported clinical reasoning that used primarily hypothetico-deductive processes. The Framework informed vascular hypothesis generation in the patient history and testing the vascular hypothesis through patient history questions and selection of physical examination tests to inform clarity and support for diagnosis and management. Most postgraduate students’ clinical reasoning processes were characterized by high-level features (e.g. specificity, prioritization). However, some demonstrated occasional difficulties or errors, reflecting a continuum of clinical reasoning proficiency. Clinical reasoning processes were informed by deep knowledge of the Framework integrated with a breadth of wider knowledge and supported by a range of personal characteristics (e.g., justification for decisions, reflection).

Use of the Framework to inform clinical reasoning processes

The Framework provided a structured and comprehensive approach to support postgraduate students’ clinical reasoning processes in assessment and management of the cervical spine region, considering the potential for vascular pathology. Patient history and physical examination information was evaluated to inform clarity and support the decision to refer for further vascular investigations or proceed with musculoskeletal physiotherapy diagnosis/interventions. The Framework is not intended to lead to a vascular pathology diagnosis [ 7 , 8 ], and following the Framework does not guarantee vascular pathologies will be identified [ 41 ]. Rather, it aims to support a process of clinical reasoning to elicit and interpret appropriate patient history and physical examination information to estimate the probability of vascular pathology and inform judgement about the need to refer for further investigations [ 7 , 8 , 42 ]. Results of this study suggest the Framework has achieved this aim for postgraduate physiotherapy students.

The Framework supported postgraduate students in using primarily hypothetico-deductive diagnostic reasoning processes. This is expected given the diversity of vascular pathology clinical presentations precluding a definite clinical pattern and inherent complexity as a potential masquerader of a musculoskeletal problem [ 7 ]. It is also consistent with prior research investigating clinical reasoning processes in musculoskeletal physiotherapy postgraduate students [ 12 ] and clinical experts [ 29 ] where hypothetico-deductive and pattern recognition diagnostic reasoning are employed according to the demands of the clinical situation [ 10 ]. Diagnostic reasoning of most postgraduate students in this study demonstrated features suggestive of high-level clinical reasoning in musculoskeletal physiotherapy [ 12 ], including ongoing reasoning with high-level cue identification and interpretation, specificity and prioritization during assessment and treatment, use of physiotherapy interventions to aid diagnostic reasoning, and prognosis determination [ 12 , 29 , 43 ]. Expert physiotherapy practice has been further described as using a dialectical model of clinical reasoning with seamless transitions between clinical reasoning strategies [ 44 ]. While diagnostic reasoning was a focus in this study, postgraduate students considered a breadth of information as important to their reasoning (e.g., patient’s perspectives of the reason for their pain). This suggests wider reasoning strategies (e.g., narrative, collaborative) were employed to enable shared decision-making within the context of patient-centered care.

Study findings also highlighted a continuum of proficiency in use of the Framework to inform clinical reasoning processes. Not all students demonstrated all characteristics of high-level clinical reasoning and there are suggestions of incomplete reasoning processes, for example occasional errors in evaluating cues. Some students offered explanations such as incomplete case information as factors contributing to difficulties with clinical reasoning processes. However, the ability to critically evaluate incomplete and potentially conflicting clinical information is consistently identified as an advanced clinical practice competency [ 14 , 43 ]. A continuum of proficiency in clinical reasoning in musculoskeletal physiotherapy is supported by wider healthcare professions describing acquisition and application of clinical knowledge and skills as a developmental continuum of clinical competence progressing from novice to expert [ 45 , 46 ]. The range of years of clinical practice experience in this cohort of students (3–14 years) or prior completed postgraduate education may have contributed to the continuum of proficiency, as high-quality and diverse experiential learning is essential for the development of high-level clinical reasoning [ 14 , 47 ].

Deep knowledge of the Framework informs clinical reasoning processes

Postgraduate students demonstrated deep Framework knowledge to inform clinical reasoning processes. All students demonstrated knowledge of patient history features of vascular pathology, recommended physical examination tests to test a vascular hypothesis, and the need to refer if there is a high level of suspicion for vascular pathology. A key development in the recent Framework update is the removal of the recommendation to perform positional testing [ 8 ]. All students demonstrated knowledge of this development, and none wanted to test a vascular hypothesis with positional testing. Most also demonstrated Framework knowledge about considerations for planning treatment with physiotherapy interventions (e.g., risk-benefit analysis, informed consent), though not all, which underscores the continuum of proficiency in postgraduate students. Rich organization of multidimensional knowledge is a required component for high level clinical reasoning and is characteristic of expert physiotherapy practice [ 10 , 48 , 49 ]. Most postgraduate physiotherapy students displayed this expert practice characteristic through integration of deep Framework knowledge with a breadth of prior knowledge (e.g., experiential, propositional) to inform clinical reasoning processes. This highlights the utility of the Framework in postgraduate physiotherapy education to develop advanced level evidence-based knowledge informing clinical reasoning processes for safe assessment and management of the cervical spine, considering the potential for vascular pathology [ 9 , 8 , 50 , 51 , 52 ].

Framework supports personal characteristics to facilitate integration of knowledge and clinical reasoning

The Framework supported personal characteristics of postgraduate students, which are key drivers for the complex integration of advanced knowledge and high-level clinical reasoning [ 10 , 12 , 48 ]. For all students, the Framework supported justification for decisions and patient-centered care, emphasizing a whole-person approach and shared decision-making. Further demonstrating a continuum of proficiency, the Framework supported a wider breadth of personal characteristics for some students, including critical analysis, reflection, self-analysis, and adaptability. These personal characteristics illustrate the interwoven cognitive and metacognitive skills that influence and support a high level of clinical reasoning [ 10 , 12 ] and the development of clinical expertise [ 48 , 53 ]. For example [ 54 ], reflection is critical to developing high-level clinical reasoning and advanced level practice [ 12 , 55 ]. Postgraduate students reflected on prior knowledge, experiences, and action within the context of current Framework knowledge, emphasizing active engagement in cognitive processes to inform clinical reasoning processes. Reflection-in-action is highlighted by self-analysis and adaptability. These characteristics require continuous cognitive processing to consider personal strengths and limitations in the context of the patient and evidence-based practice, adapting the clinical encounter as required [ 53 , 55 ]. These findings highlight use of the Framework in postgraduate education to support development of personal characteristics that are indicative of an advanced level of clinical practice [ 12 ].

Synthesis of findings

Derived from synthesis of research study findings and informed by the Postgraduate Musculoskeletal Physiotherapy Practice model [ 12 ], use of the Framework to inform clinical reasoning processes in postgraduate students is illustrated in Fig.  2 . Overlapping clinical reasoning, knowledge and personal characteristic components emphasize the complex interaction of factors contributing to clinical reasoning processes. Personal characteristics of postgraduate students underpin clinical reasoning and knowledge, highlighting their role in facilitating the integration of these two components. Bolded subcomponents indicate convergence of results reflecting all postgraduate students and underscores the variability among postgraduate students contributing to a continuum of clinical reasoning proficiency. The relative weighting of the components is approximately equal to balance the breadth and convergence of subcomponents. Synthesis of findings align with the Postgraduate Musculoskeletal Physiotherapy Practice model [ 12 ], though some differences exist. Limited personal characteristics were identified in this study with little convergence across students, which may be due to the objective of this study and the case analysis approach.

Use of the Framework to inform clinical reasoning in postgraduate level musculoskeletal physiotherapy students. Adapted from the Postgraduate Musculoskeletal Physiotherapy Practice model [ 12 ].

Strengths and limitations

Think aloud case analyses enabled situationally dependent understanding of the Framework to inform clinical reasoning processes in postgraduate level students [ 17 ], considering the rare potential for vascular pathology. A limitation of this approach was the standardized nature of case information provided to students, which may have influenced clinical reasoning processes. Future research studies may consider patient case simulation to address this limitation [ 30 ]. Interviews were conducted during the second half of the postgraduate educational program, and this timing could have influenced clinical reasoning processes compared to if interviews were conducted at the end of the program. Future research can explore use of the Framework to inform clinical reasoning processes in established advanced practice physiotherapists. The sample size of this study aligns with recommendations for think aloud methodology [ 27 , 28 ], achieved rich data, and purposive sampling enabled wide representation of key characteristics (e.g., gender, ethnicity, country of training, physiotherapy experiences), which enhances transferability of findings. Students were aware of the study objective in advance of interviews which may have contributed to a heightened level of awareness of vascular pathology. The prior relationship between students and researchers may have also influenced results, however several strategies were implemented to minimize this influence.

Implications

The Framework is widely implemented within IFOMPT postgraduate educational programs and has led to important shifts in educational curricula [ 9 ]. Findings of this study support use of the Framework as an educational resource in postgraduate physiotherapy programs to inform clinical reasoning processes for safe and effective assessment and management of cervical spine presentations considering the potential for vascular pathology. Individualized approaches may be required to support each student, owing to a continuum of clinical reasoning proficiency. As the Framework was written for practicing musculoskeletal clinicians, future research is required to explore use of the Framework to inform clinical reasoning in learners at different levels, for example entry-level physiotherapy students.

The Framework supported clinical reasoning that used primarily hypothetico-deductive processes in postgraduate physiotherapy students. It informed vascular hypothesis generation in the patient history and testing the vascular hypothesis through patient history questions and selection of physical examination tests, to inform clarity and support for diagnosis and management. Most postgraduate students clinical reasoning processes were characterized as high-level, informed by deep Framework knowledge integrated with a breadth of wider knowledge, and supported by a range of personal characteristics to facilitate the integration of advanced knowledge and high-level clinical reasoning. Future research is required to explore use of the Framework to inform clinical reasoning in learners at different levels.

Data availability

The dataset used and analyzed during the current study are available from the corresponding author on reasonable request.

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Acknowledgements

The authors would like to acknowledge study participants and the transcriptionist for their time in completing and transcribing think aloud interviews.

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Katie L. Kowalski, Heather Gillis, Katherine Henning, Paul Parikh, Jackie Sadi & Alison Rushton

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Katie Kowalski: Conceptualization, methodology, validation, formal analysis, investigation, data curation, writing– original draft, visualization, project administration. Heather Gillis: Validation, resources, writing– review & editing. Katherine Henning: Investigation, formal analysis, writing– review & editing. Paul Parikh: Validation, resources, writing– review & editing. Jackie Sadi: Validation, resources, writing– review & editing. Alison Rushton: Conceptualization, methodology, validation, writing– review & editing, supervision.

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Author AR is an author of the IFOMPT Cervical Framework. Authors JS and HG are lecturers on the AHCP CMP program. AR and JS led standardized teaching of the Framework. Measures to reduce the influence of potential competing interests on the conduct and results of this study included: the Framework representing international and multiprofessional consensus, recruitment of participants by author KK, data collection and analysis completed by KK with input from AR, JS and HG at the stage of data synthesis and interpretation, and wider peer scrutiny of initial findings. KK, KH and PP have no potential competing interests.

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Kowalski, K.L., Gillis, H., Henning, K. et al. Use of the International IFOMPT Cervical Framework to inform clinical reasoning in postgraduate level physiotherapy students: a qualitative study using think aloud methodology. BMC Med Educ 24 , 486 (2024). https://doi.org/10.1186/s12909-024-05399-x

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Working from home during COVID-19: boundary management tactics and energy resources management strategies reported by public service employees in a qualitative study

• Laura Seinsche 1 ,
• Kristina Schubin 1 ,
• Jana Neumann 1 &
• Holger Pfaff 1  

BMC Public Health volume  24 , Article number:  1249 ( 2024 ) Cite this article

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Metrics details

Increased working from home has imposed new challenges on public service employees, while also granting opportunities for job crafting. Grounding on the Job Demands-Resources model and Hobfoll’s Conservation of Resources theory this exploratory research aims to investigate the work-nonwork balance of employees one and a half years after the outbreak of the COVID-19 pandemic. Therefore, the research focus lies on employees’ job crafting strategies to optimize their working from home experience concerning boundary management and energy resource management.

Twelve semi-structured telephone interviews were conducted with public service employees from different sectors in Germany. The experiences were content analyzed using the software MaxQDA and inductive and deductive categories were derived.

Boundary management comprised different strategies such as communicative (e.g., negotiating work time), physical (e.g., going to the garden), temporal (e.g., logging off in between the work day) and behavioral (e.g., prioritizing tasks) strategies. The job crafting strategies regarding energy management included preventing exhaustion (e.g. taking breaks), healthy cooking and energy management in case of sickness (e.g. deciding on sick leave).

Conclusions

This qualitative case study enriches research on job crafting by offering insights on boundary tactics and energy resources management strategies for remote working during the COVID-19 pandemic. The results point out different starting points for employees and decision makers, how a work-nonwork balance, energy management and thus employees’ wellbeing may be increased when working from home in the future.

Trial registration

The study design and methodology were approved by the Ethics Committee of the University of Cologne and the study was prospectively registered (Ref No. 21-1417_1).

Peer Review reports

The COVID-19 pandemic has expedited the shift of work processes towards a remote working setup in Europe [ 1 ]. Consequently, this has resulted in a collision between conventional work-life boundaries and new work demands and resources that employees had to face [ 2 ]. Especially for German public service employees working from home (WFH) was new during the pandemic [ 3 , 4 ]. Moreover, the transition to WFH has, for numerous individuals, particularly during periods of isolation or partial confinement, entailed a complete blending of work and personal life, as well as the necessity to accept the loss of role boundaries [ 5 ]. The blurring of work and non-work can have negative impacts on employees’ mental health [ 6 , 7 , 8 ]. When WFH during the pandemic, public service employees reported work-related fatigue due to blurred boundaries and work-home conflict [ 9 ] as well as increased stress and pressure [ 10 ] associated with high work demands. However, at the same time job resources such as work autonomy and increased time flexibility are provided in a flexible WFH environment [ 11 , 12 ]. This freedom in work design can be used by employees to proactively craft their jobs by adjusting the working conditions to their needs and thus support the handling of high work demands [ 13 , 14 ]. Hence, this study aims to investigate strategies of public service employees handling WFH. More specifically, we aim to investigate strategies for boundary management and energy resources management. For this purpose, we need to draw on a broad theoretical foundation that is introduced in the following sections.

First, the Job Demands-Resources model (JD-R model) is introduced briefly as a general framework for this study. Since the change to WFH brought about a change in the work conditions of public service employees, the JD-R model, as an established model in the scientific community, provides a helpful perspective for the analyses of job demands, job resources and their impact on employees’ health. Second, we focus on job crafting strategies as an integrative part of the JD-R model and argue for a particular emphasis on strategies targeting the management of boundaries and energy during WFH as a research interest. Third, the Conservation of Resources (COR) theory is introduced as it provides a valuable link between the two different job crafting strategies boundary management and energy resources management.

Job demands-resources model (JD-R model) and job crafting

The JD-R model divides job characteristics in two factors, namely job demands and job resources [ 15 , 16 ]. While job demands consume energy and are related to psychological costs, job resources refer to motivational aspects of the job that are functional to achieve goals or reduce psychological costs such as support of colleagues or job autonomy [ 15 ]. The model is widely used [ 17 ] and can explain the impact of job demands on employees’ health on a long-term and short-term basis through a health impairment process. Furthermore, job resources can buffer the negative health effects of job demands [ 17 , 18 ]. In relation to the WFH environment described above, higher job demands may have caused work-related fatigue, while blurred boundaries can be seen as job demands and increased job autonomy as a job resource that may be able to buffer job demands.

Later, job crafting has been integrated in the JD-R model. Job crafting is a “proactive behavior through which employees change their work environment and is more specifically conceptualized as strategies that individuals use to shape their job characteristics (i.e., job demands and resources) to regulate their motivation and energy level” [ 19 , p. 457]. There are three categories to classify adaptive strategies to cope with high work demands [ 19 , 20 , 21 ]: (a) dealing with depleted resources (e.g., coping strategies, recovery); (b) work and non-work boundary management (e.g., segmentation); and (c) altering job characteristics (e.g., job crafting). All these strategies have been integrated by de Bloom et al. [ 13 ] in an integrative needs model of job crafting separating the different goals, motives and dimensions of job crafting. Psychological needs as motives for job crafting can be either approach or avoidance needs [ 22 ]. Avoidance needs concentrate on reducing physical or psychological strain and are based on the desire to avoid a negative state. In order to minimize strain and the following exhaustion, employees can therefore seek recovery in form of detachment, stress reduction or relaxation [ 13 , 23 , 24 ]. According to the model of de Bloom et al. [ 13 ], there are job crafting strategies that secure optimal functioning for employees at work. Dealing with depleted resources and boundary management are named as such strategies. Boundary management is situated at the interface between the home and work domain, while energy management strategies can also be applied during work time. Since employees work from home, a focus on the interface between both domains and securing optimal functioning during the new situation with excessive WFH seems promising as a research interest.

Thus, in this study we will focus on strategies that target (a) dealing with depleted resources (energy resources management) and (b) support boundary management between work and non-work (boundary management). In the following the two job crafting strategies and their outcomes are presented in detail, before the connection between COR theory and the JD-R model is established. Then the aim and research questions of the study are explained.

Boundary management, energy resources management and outcomes

In general, job crafting behavior has been found to be a protective factor for employees’ mental health [ 25 ] due to the reduction of psychological distress [ 22 , 26 ], burnout [ 27 , 28 ], and exhaustion [ 29 , 30 ]. For an overview of the positive outcomes of job crafting on employees’ health and mental health such as effects on well-being, resilience, vitality, reduced fatigue, reduced distress [ 13 , 14 ]. According to de Bloom et al. [ 13 ] other studies that have investigated job crafting at the work interface level focused on boundary crafting behaviors [ 31 , 32 ], work–family integration strategies [ 33 , 34 ] and boundary work tactics [ 35 ]. Especially, the later qualitative study by Kreiner et al. developed categories to classify boundary tactics, namely behavioral (e.g. using other people, leveraging technology), temporal (e.g. controlling work time), physical (e.g. manipulating physical space) and communicative tactics (e.g. setting expectations). These categories will be used to classify boundary tactics of the interviewed public service employees during the COVID-19 pandemic. Results of other studies have shown, that involuntarily working more from home can lead to blurred boundaries [ 34 ] and a segmentation between work and non-work could be a useful strategy for employees to protect their wellbeing [ 33 , 36 , 37 ].

Several studies have highlighted the benefits of various strategies for relaxation and recovery from work stress (for a review of recovery research, s [ 38 , 39 ]). Specifically, engaging in physical activity has been shown to promote detachment from work and enhance relaxation levels [ 38 , 40 , 41 ]. Taking rest breaks is also effective in preventing fatigue and maintaining employee performance levels [ 42 , 43 ]. The quality of these breaks is enhanced when employees have control over their activities and engage in what they prefer [ 44 , 45 ]. Spending time in nature or outdoors is identified as one of the most effective methods for recuperating from job stress [ 46 ]. Furthermore, Bennett et al. [ 47 ] discovered that support from supervisors in recovery can help employees mentally distance themselves from work more easily. Moreover, employees have the potential to experience recovery while working through work-related strategies (such as checking emails) or taking micro-breaks (like having a snack) [ 48 , 49 ]. According to a study of Fritz et al. [ 48 ] the five most common micro-breaks that were not work-related were: “(1) drink some water, (2) have a snack, (3) go to the bathroom, (4) drink a caffeinated beverage, and (5) do some form of physical activity including walks or stretching” (p. 33). Research by Op den Kamp et al. [ 50 ] indicates that individuals can actively regulate their physical and mental energy levels, and that engaging in such self-management can enhance their work performance.

Conservation of resources (COR) theory

The COR theory by Hobfoll explains that individuals can only utilize limited resources (e.g. motivation, time, energy), which they have to distribute over their life domains [ 51 ]. Thus, job crafting can help to conserve resources by reduction or elimination of job demands that deplete their resources. Additionally, it can expand valuable resources and lead to an optimized resource management. For example, in a WFH environment gained time flexibility enables employees to adjust the work day start and end times to accommodate both work-related and non-work-related demands. In turn, this can support employees to optimize their recovery from work [ 52 ]. In the JD-R model the buffer effect of job resources on job demands, that can decrease exhaustion, relates to the COR theory where the (anticipated) loss of resources results in experienced stress. Furthermore, the COR theory concurs with the boundary theory [ 53 , 54 , 55 ]. It proposes that employees should separate life domains – especially the border between work and non-work. The underlying idea is similar to the COR theory in the way, that resources are limited. Thus, borders allow humans to strike a balance between the demands of different domains in order to prevent exhaustion and foster wellbeing [ 31 , 54 ].

Aim and research questions

Based on these broad theoretical perspectives, we argue that the COVID-19 pandemic has led to an increase of WFH, where boundary management and energy management may have become more important. Since WFH was mandatory during certain phases of the COVID-19 pandemic, this situation is ideal to gain more knowledge about applied boundary management and energy management when WFH. To prevent exhaustion, proactively engaging in job crafting behaviors such as boundary management and energy resources management might be the key to enhance employees’ wellbeing when WFH during the COVID-19 pandemic and in the future. This study stands out because it specifically examines public service employees, a group not extensively covered in existing literature [ 56 , 57 ]. Its qualitative approach is valuable as it provides in-depth, contextual insights, particularly important in understanding the impacts of the shift to WFH on this workforce segment. To our knowledge, strategies of public service employees to deal with WFH have been researched in a qualitative approach in Australia and the Philippines [ 58 , 59 ]. However, research investigating the link between recovery experiences and job crafting activities on boundary management is still scarce [ 60 , 61 ].

Due to the COVID-19 development and increased WFH we sought to generate more knowledge about public service employees’ strategies to improve their work-home balance and optimize energy levels. Therefore, we investigate the tactics employees utilize to manage the interface between work and nonwork. Additionally, we are interested in strategies that support employees to replenish their energy during WFH. The underlying idea is, that employees need functioning boundary management tactics in order to be able to refill their energy levels. The special situation during the pandemic made WFH mandatory for many employees, albeit employees had the choice to WFH during less restricted phases of the pandemic. However, the mostly mandatory character of WFH should be considered in this study. Hence, we derived the following research questions:

How do public service employees manage boundaries between work and home life when working from home during the COVID-19 pandemic?

How do employees manage their energy levels when working from home during the COVID-19 pandemic?

The same sample and procedure were also used in our article analyzing job crafting behaviors of public service employees during COVID-19 [ 62 ], in which a different theoretical focus, namely time-spatial job crafting (s [ 63 ]). was applied. In the former study, the sample and procedure are described in detail according to the qualitative reporting guidelines (COREQ) by Tong et al. [ 64 ]. In the following, the methodological approach is briefly summarized.

Study design

Our research employed a qualitative method to explore our research questions, aligning with the interpretivist paradigm. This paradigm suggests that reality is a social construct shaped by individuals who assign meanings to their experiences, perceiving the social world through these constructs [ 65 , 66 ]. Therefore, we used problem-centered interviews to grasp the social reality from the perspectives of individuals, focusing on their perceptions, actions, and thought processes concerning a specific topic, while maintaining an unbiased stance [ 67 ]. Given the scarcity of existing research on this subject [ 68 , 69 , 70 ], an exploratory approach was considered suitable. This approach is likely to yield rich and detailed insights into the experiences and strategies of public service employees who work from home [ 71 ]. The study design and methodology were approved by the Ethics Committee of the University of Cologne and the study was prospectively registered (Ref No. 21-1417_1).

Participants and procedure

All of the participants provided their email address and consent to participate in further studies during a web-based survey on WFH in Spring 2021. Hence, they were contacted for this interview study in autumn 2021. We applied a purpose sampling strategy aiming at achieving maximal variation in our sample [ 72 ]. Sampling criteria were gender, age, leadership position and current job position. Additionally, the duration of WFH in the agency and participants’ perception of how their agency implemented WFH was taken into consideration. One exclusion criterion was applied, sorting out employees who could not or only partially complete their tasks at home. The final sample is depicted in Table  1 .

All of the interviewees were invited via email, in which they received information regarding the study. After they provided their informed consent, they were invited to provide dates to schedule the telephone interviews.

Data collection

The semi-structured interview guideline (see Additional File 1 ) was developed on the basis of a prior quantitative study [ 73 ]. Beside a first warm-up question, the interview guideline encompassed four main topics on work organization, leadership and collaboration, scope of action and health. Each topic was opened with a narrative impulse question and invited participants to share their experiences with WFH. The guideline was handled flexibly, giving the interviewees the opportunity to include their own topics and maintaining narrative flow. Nevertheless, the semi-structured guideline ensured a certain comparability between the interviews [ 67 , 72 ]. The interviews were carried out from December 2021 to February 2022 by three researchers (L.S., K.S., J.N.) via telephone due to the COVID-19 related social restrictions. During the data collection only the research team was present and field notes were taken. On average the interviews lasted between 26 and 60 min. For the analysis the audio-taped interviews were transcribed verbatim by a professional transcription service.

Data analysis

Data was analyzed using qualitative content analysis by Kuckartz [ 74 ] and the software MAXQDA 2022 (VERBI GmbH, Berlin, Germany) [ 75 ]. Several coding rounds were applied, where initially the first author developed a preliminary category system. Then the second author (K.S.) commented and revised the categories. In a second coding round all of the interviews were coded by the first author and then discussed until the coding scheme was finalized. Deductive categories were derived from literature (e.g. “communicative” or “temporal boundary tactics” by Kreiner et al. [ 35 ]), while new inductive categories were formed from the data material.

The interview quotes were translated from German into English by the first author. All categories and example quotes can be found in Additional file 2 .

In the following the results are reported in the order of the deductive categories on boundary work tactics and energy management. To provide a clear overview, we created a diagram with the main categories and sub-categories (Fig.  1 ).

Overview of the main and sub-categories

Boundary work tactics

Public service employees reported to utilize different strategies to craft their work-nonwork balance when WFH. In the following, the strategies of the sub-categories “communicative”, “physical”, “temporal”, “behavioral”, “no tactic” and “situation COVID-19” are being reported.

Communicative

The communicative crafting strategies relate to the management of peoples’ expectations in regard to possible boundary violations [ 35 ]. The public service employees had different communication partners, with whom expectations had to be managed. First, there were work relations with other colleagues or inhouse clients. One interviewee stated that inhouse colleagues “ place an order so late […], you have no choice but to call them the next morning ” (interview 5). Therefore, the negotiation starts after placing the order to manage the required working time and set the work boundaries.

Besides the communication with other employees, the legitimation by culture played a role. Thus, the working time culture in a certain agency can shape the work boundaries:

“…the usual agreements - no e-mails after 8 p.m. and none before 6 a.m. - that is the agreement with us .” (interview 12).

A work culture with fixed rules regarding work-related availability may be able to prevent pressure and the delimitation of core hours. Especially, employees that seek a clear boundary management style may be attracted by work cultures offering guidelines. Additionally, one employee explained that the transition to a home-based work environment during lockdown stages of the COVID-19 pandemic had no impact on work culture:

“ It’s a business, you know when you’re working and most of the customers or press people or people involved know exactly when you’re where. It’s not something that changes overnight.” (interview 7).

In this case, the transition to working from home did not change the work culture and remained the same. Moreover, the interviewee mentions that the habits of an agency do not change overnight and it is known by other colleagues, when a person can be contacted at best. In interview 1 the role of the supervisor is brought up, as a means to find an agreement regarding working time:

“…because I have (.) personally enforced for myself, I have decided, enforced and agreed with my employer, (.) how my working time is structured.” (interview 1).

Within teams, arrangements took place such as team times that had been agreed upon (s. interview 12). Another way was to openly communicate break hours and linked availability to the team:

“So I can actually regulate it quite well when I work from home and I have also briefed my colleagues so far, that they know I always take a long lunch break and I have already found some imitators, exactly.” (interview 9).

This brief insight indicates that new work habits limiting work boundaries were formed also for the entire team, when WFH. Technology supported the communicative boundary tactics as calendar access could help team members to see, on which days someone was present at the office (s. interview 4). Furthermore, the status in the collaborative software Microsoft teams or Skype was used to show availabilities (s. interview 5). One interviewee stated:

“It’s actually the case that everyone goes online in the morning and then you can indicate on Skype that you’re now available in green or that you’re now at work, that you’re in red or that you’ll be right back in yellow or something. But I have to say that most people forget that.” (interview 11).

Even when setting the status was simple, it was still not flawless as the employee mentioned that “ most people forget that ”.

Another boundary tactic concerned the communication with family. One interviewee mentioned that his spouse worked in the same agency and thus shared the same flexible working conditions. Therefore, it was easy for them to divide chores and alternate who “ walks the dog at lunchtime ” (interview 6).

According to Kreiner et al. (2009) physical boundary tactics can be used to manipulate physical space in form of creating or reducing physical distance to the work place or using items (e.g. calenders, photos) to integrate or separate the domains. The public service employees reported boundary tactics concerning the physical aspects of the work environment when WFH. For some it was the action to “ close the computer and call it a day ” (interview 9), while others needed a strict separation of work and living space:

“And that’s different than when you’re in the office. You leave the house in the morning, then you’re at work, then you can completely block out home and when you finish work and come home again, you’re back in your private life.” (interview 1).

When WFH, interviewee 9 found an adapted physical strategy for WFH days:

“I make myself a cup of coffee, have breakfast, and now I try to separate things strictly. So that I really do have breakfast first and then sit down in my study to start things off separately, so to speak. So that I don’t start reading the first emails during breakfast, exactly.” (interview 9).

On the contrary, for some employees the physical separation does not seem to be necessary at home:

“I like to work at the dining table, but only when it’s clear that I’ll be alone, I am alone all the time. I also don’t like to spread everything out and then I have to somehow put it away again so that I can continue working upstairs.” (interview 3).

Similarly, interviewee 6 explained that he has no physical separation of working and private life, but rather “set [his office on site] up very privately”.

A physical strategy also encompassed to get away from the work place in order to spend breaks outside of home. For example, interviewee 8 commented:

“If I have my lunch break at home, I can go shopping in the meantime, I can go for a walk anywhere, but just also take a walk to another agency or go to the doctor or things like that.” (interview 8).

Sometimes employees made use of a physical strategy in order to have a clear transition phase. Thus, one employee explained how she went to the bakery instead of commuting (s. interview 9).

Temporal boundary tactics encompass the controlling of work time by manipulating schedules (e.g. banking time from one domain to be used later) or removing oneself from work/home for a specific amount of time [ 35 ]. Regarding temporal boundary management tactics there were different characteristics. Thus, employees made use of temporal flexibility that was given within usual working hours:

“And that might be easier to plan, if I work from home and I could simply offer support in a more self-determined way that you can have a sick child brought over to you or something and then somehow postpone the work a bit.” (interview 3).

As interviewee 3 suggested a postponement of work, the use of time flexibility was closely linked to taking small breaks or blocking off time from work. In this regard one employee stated:

“You’ve logged out, right? That is not working time. And it is permitted to work between 6:30 a.m. and 8:00 p.m. and the number of interruptions and the duration of the interruptions do not matter.” (interview 6).

For some employees temporal flexibility advanced to a total delimitation of core hours:

“That means that under certain circumstances I still check e-mails or something at 10 p.m. and possibly also still answer .” (interview 3)”.

One employee in a leadership position reported that she “ would be available on weekends as well” (interview 2).

For a higher control of work-life boundaries and working time, interviewee 8 made a decision:

“And now there quite consciously to say, I for myself, go away from these times and try to use again the classic work time, between 9 and 18 o’clock, as I did it earlier in the office also, hands tied.” (interview 8).

Behavioral tactics describe the use of technology or other people’s skills to facilitate boundary work and prioritizing the demands of either work or home domain [ 35 ]. Employees utilized different behaviors to ensure their work-life boundary tactics that were either based on technological equipment or planning their day by structuring and prioritizing tasks. When using technology, one employee reported to set the phone to flight mode to be not available (s. interview 1). Interviewee 6 explained that logging off the system is not the same as being unavailable for calls:

“Whereas the logging in and out, that’s purely a time recording thing. I can log out and theoretically still be available. If I don’t want to be available, then I have to set our communication tool accordingly. I can then set an “absent mode” where no calls reach me, right?” (interview 6).

Besides using communication technology, employees planned their work days to have a structure:

“That it is clear what I have to do today. I think it is important for working from home to plan the day: That it’s also clear, when I’m going to stop working. So that the danger does not exist, that one/ It is important that one, I find, that one sets a beginning and an end point for work and then also takes a break and plans the day accordingly.” (interview 3).

The setting of priorities was also mentioned when WFH:

“One must also organize and structure oneself at one’s workplace. Perhaps also to set priorities.” (interview 1).

As for the private tasks, there may be less coordination needed, as one was at home, if “the parcel delivery guy comes or when the chimney sweep makes an appointment” (interview 6).

No tactic and Situation COVID-19

Even though employees have developed their own strategies to handle WFH and blurred work-life boundaries, there were situations, where strategies could simply not be applied:

“But as I said, you’re just at home and the doorbell rings once in a while. Then someone comes who wants something from you, who brings you something or delivers something, or, or, or. So you have to mentally switch back and forth a bit.” (interview 1).

The blur of boundaries could not always be prevented as it occurred unforeseen. One of the interviewees also reported lacking a strategy:

“And then it was often the case that this saved working time [due to omission of commuting] was instead converted into office work, i.e. real work in front of the computer. In other words, I worked more. ” (interview 8).

For him the saved working time resulted in more work hours. In other cases, the COVID-19 pandemic has led to the delimitation of work hours:

“It already starts with all these extensions of the work time, that I write emails on Saturdays or at ten in the evening, [that] was due to this special situation [COVID-19] and I think we all agree that we don’t want that.” (interview 8).

Besides the above reported results one employee mentioned an employer-initiated boundary tactic. In this case the agency shut off the mail server between 8 pm and 6 am to prevent employees sending emails late at night (interview 7). For the sake of completeness, we included this circumstance in this paper, but the focus will remain on employee-initiated boundary strategies.

Energy resources management

The results indicate, that public service employees used different strategies to manage their energy levels when WFH. The four main sub-categories were “preventing exhaustion”, “physical exercise”, “healthy cooking and eating” and “tendency to WFH when sick”.

Preventing exhaustion

One factor that helped employees to prevent exhaustion when WFH was the ability to follow their own rhythm. This included to start the work day according to their own needs:

“Yes, so early bird, that’s not my thing at all, right? So, and now I can also reconcile that better with work than when I am at the office.” (interview 12).

Another strategy to prevent exhaustion was to integrate time for relaxation. One of the employees mentioned that she took a power nap at home, if she felt exhausted:

“So, now I’m going to do a half hour power nap, lay down on my bed and really get away from it all, and then I’m also fitter.” (interview 3).

Besides sensing the body’s need for rest, taking a conscious break could refill depleted energy levels. In this manner interviewee 1 stated regarding lunch break:

“I consciously take a lunch break at noon.” (interview 1).

The lunch break may have been also used for other activities to leave thoughts of work behind, such as:

“I kind of go out in the garden and take my break there, raking leaves or something depending on the season or I sit in the sun for half an hour or I go to the mailbox.” (interview 5).

Additionally, the public service employees took time for small breaks during their work day. These breaks could be handled more flexibly (s. interview 10). Interviewee 9 explained her working strategy of dividing tasks and work time by inserting small breaks:

“So it’s just simple/ Well, I personally have the feeling that I can simply divide my time more freely. I can say in a much more relaxed way, I’ll do this task now, then I’ll do that task, then I’ll do the next task, and if I need another ten-minute break, I’ll go out on the balcony and get some fresh air.” (interview 9).

Physical Exercise

Some public service employees used their lunch break to do physical exercise. The physical exercise helped them to replenish their energy for the rest of the work day. For example, interviewee 11 reported:

“And because I can now work from home, I use this break for my exercise, which I used to only be able to do in the evening when I was at home. And now I do it at lunchtime and almost every lunchtime. And then I’m logged off for an hour and a half or two hours. And then I continue to work afterwards. And that’s actually a good thing, because then you’re fit again, at least that’s how it is for me.” (interview 11).

Other employees integrated an exercise at the gym in their weekly work plan (s. interview 1), whereas working at home also offers an opportunity for exercise. Therefore, online meetings can be attended while standing up or even moving around the house:

“And apart from that, I find the fact that I can move around when I want to move around, not sitting in a WebEX session - if I do it standing up, I’m much more mobile, more agile and that’s pleasant.” (interview 12).

Similarly, one employee reported that she used phone calls to integrate physical exercise in her work day instead of sitting at her desk:

“… someone calls and you talk on the phone and then of course you walk a bit. You walk around the house and look out of the window or get yourself a glass of water or something.” (interview 5).

For other employees having a dog worked as a strategy for exercise, since the dog needed to be taken outside regularly (s. interview 6, interview 2) and others just went for a work during lunch break (s. interview 8).

Healthy cooking and eating

When WFH the lunch break can be used to prepare fresh food. Thus, one interviewee reported that she experienced a healthier life style when working at home than being on business trips:

“But now when you’re at home like that, you can make yourself a cauliflower soup and make yourself a salad or something like that and eat, I think, healthier.” (interview 2).

Tendency to WFH when sick

When employees felt sick, their energy levels may have been low and they adapted their working habits or strategies accordingly. By presenting a case and asking the following question (“You notice cold symptoms in yourself. Would you go to work?”), we prompted employees to find out, how and why their decisions varied about calling in sick, when they worked from home. We separated the answers in the following main categories: “support of colleagues”, “decision for sick leave” and “decision against sick leave”. The support of colleagues was treated as a separate aspect, while the initial decision for employees seemed to be, if they should take a sick leave or not. When they decided against sick leave, there were different reasons and motivations to work - whether working on site or WFH.

First, the aspect to be available for the support of colleagues was a consideration, whether one stayed at home with or without sick leave. For one employee that was simply a matter of collegiality:

“And of course, everyone has a telephone with them, even if they are ill, and can answer a call if someone wants to know something or a colleague wants to know where to find something. But that has nothing to do with duty, it has to do with collegiality.” (interview 7).

Second, the decision for sick leave seemed to depend on the individual feeling and assessment of the illness. Therefore, interviewee 6 explained, where he would draw a line. If he felt too weak to sit down, even at the desk at home, he would call in sick:

“I felt like I was coming down with the flu, right? I was at least a little weak and dull and noticed that when you lie down, you feel better than when you sit or stand. So then I would not have sat down at the desk.” (interview 6).

Another strategy was to continue WFH and assess the sickness over the course of days. In this manner one employee decided to withdraw himself from work, “if it doesn’t get better after two, three days […] then cure it by calling in sick ” (interview 1).

Third, the decision against sick leave encompassed a variety of reasons. Some provided reasons were special to the situation when working at home or on site. Initially, the severity of sickness also seemed to be an indicator for the decision to work:

“So now if I have a little bit of a cold and a little bit of a cough and maybe a sore throat, but no headache or aching limbs, I would work.” (interview 9).

As for working on site one interviewee stated, that he also went to work because of waiting tasks:

“But with a slight cold I went to work, yes because I wanted to get my work done.” (interview 11).

Therefore, the measures to prevent the spread of COVID-19 acted as a barrier for employees to show up to work with cold symptoms:

“ Because I would probably go to work with it, but there is the clear announcement in the current time that even with slight cold symptoms we must not come to the office.” (interview 4).

Before the pandemic, employees may have gone to work with a cold. One of the employees stated that he had his own office in the company and thus “would also have gone to work [before the pandemic]” (interview 6).

Except for the COVID-19 prevention measures, there were other reasons that public service employees referred to, when explaining WFH while being sick. WFH seemed to function as an alternative for a sick leave:

“In the past, you could have alternatively just taken a sick leave. You wouldn’t have been able to work from home. And now, I think, if you’re in such a floating state, okay, you have the feeling that you’re not actually sick, but you also don’t want to be suspected of infecting others, then you just work from home at that moment.” (interview 5).

Especially, the means to take care of oneself were different when employees worked from home. Interviewee 8 gave an insight on his strategy:

“That means this “I’m just going to check something” and I can decide for myself whether I’m going to sit there for half an hour and just briefly check emails or whether I’m actually going to sit down at the computer for four, five, six hours.” (interview 8).

The adjustment of the work day according to the own feeling of the health state was possible when WFH. Similarly, interviewee 11 told that he took a nap in between, which was also only possible at home, while one employee reported, that WFH offered more opportunities to treat oneself:

“Working from home gives you much better opportunities to treat certain types of colds, for example. For example, I could inhale much more easily here or things like that, you know? I can actually do that while working from home and still work. And you can’t usually do all these things as well or at all in the office. And that’s a difference, yes.” (interview 1).

The aim of this study was to generate more knowledge about public service employees’ strategies to improve their work-home balance and optimize energy levels while WFH. This qualitative study provides several key learnings: (1) The study contributes to the growing body of literature of real WFH experiences during COVID-19 pandemic. (2) It provides valuable insights to boundary management tactics and energy management of employees. (3) The results offer practical guidance for employers and employees, how to optimize WFH conditions in the future. (4) The study provides implications for further research in determining effective WFH strategies. In the following, the research questions are answered.

How do public service employees manage boundaries between work and home life when working from home?

Similarly to the results of Kreiner et al. [ 35 ] the results indicate that public service employees utilized behavioral, temporal, communicative and physical boundary work tactics when WFH. Regarding behavioral strategies no signs were found for the category “using other people” [ 35 ], whereas “leveraging technology” was an implemented strategy when WFH. Additionally, “planning the day” was - referring to the WFH setting - rather implemented by creating a daily schedule or prioritizing tasks. Thus, more sub-categories were formed for public service employees when WFH.

Temporal boundary strategies (“controlling work time”, “finding respite”, [ 35 ]) were present strategies in the sample. In the study’s sample, employees can utilize little breaks, including those as brief as a lunch break, on a daily basis. Concurring with the findings of Kreiner et al. [ 35 ], the temporal removal from work could be used with a physical tactic such as getting a physical distance (e.g. using lunch break for a walk).

Within the communicative tactics, different people (e.g. supervisor, team, family) played a role. The management of expectations and finding agreements with the team was essential in this category. During WFH there is an interesting interplay between the categories “communicative”, “temporal” and “behavioral”. Public service employees utilize technology to regulate their work-related availability, which is a behavioral strategy. Simultaneously, the use of collaborating software such as Microsoft teams serves as a means to communicate their availability to team members and co-workers. Thus, setting a status implies a communicative function; it signals “that I’m available: Aha, I’m already there now” (interview 5) such as the turning on/ turning off the office light on site. Simultaneously, it imposes new challenges, since the participants stated, that co-workers often forget to change their status. Forgetting to indicate the status can either result in not being seen as available or being reached during leisure time. The last may result in working overtime or work life delimitation, if borders are not protected. “Protecting private time” is a strategy that has been found to significantly influence employees’ subjective wellbeing [ 31 ]. Furthermore, in the WFH setting “log in/ log out” can be part of a temporal boundary strategy. If the non-availability is communicated, it allows employees to withdraw from work for a certain amount of time such as a lunch break used for exercise.

Physical tactics that are used, depend on the want of employees to integrate or separate life domains [ 35 ]. The former authors state that individuals create their own ideal level of work-home integration or segmentation. In the same regard, the experiences of the interviewees show different styles of wanted integration or segmentation of the work and home domain. For some it is important to have a physical border between these two life domains, while others enjoy temporal flexibility and even voluntarily tend to work life delimitation in their physical space. The two categories “no tactic” and “situation COVID-19”, which showed that boundary work tactics could not be applied, add to the existing main categories under the circumstances of mandatory WFH during this period. When WFH, the boundaries between work and private life are blurred to a massive extent, since the physical separation is lacking. Therefore, strategies may exist to handle boundaries, but in unpredicted situations such as the ring of the doorbell, the plans of employees to separate domains are disrupted. These situations are challenging for employees who prefer a separation of life domains.

Working conditions that may support successful boundary management are team culture and work hours culture, if there is a well-established limit of work time. These results are consistent with other studies that suggest the framing of boundaries can be socially shared and norms can be established [ 76 ].

It is proposed, that a reciprocal relationship exists between the boundary tactics [ 35 ]. This kind of relationship can be found in the communicative and behavioral tactics as the communication of boundaries or setting the phone to flight mode automatically reduces the challenge of boundary management. Likewise, the temporal removal from the work space for breaks serves as one of the energy management strategies that are presented below. In the following the link between boundary tactics and energy resources management will be discussed drawing on the theoretical background.

How do employees manage their energy levels when working from home?

Public service employees reported various strategies to either minimize exhaustion, integrate health behaviors during their work day or how they dealt with their energy level during sickness. Other studies found microbreaks to be effective in replenishing energy levels [ 49 ]. Similarly, public service employees found ways to withdraw from work by inserting small breaks, mainly in form of physical activity such as going to the mailbox or on the balcony. Nevertheless, physical exercise was reported in a separate category, since employees had many ways to replenish their energy through exercise. Physical activity in particular leads to detachment from work and high levels of relaxation [ 38 , 40 , 41 ]. Rest breaks can prevent fatigue and help to sustain the performance level of employees [ 42 , 43 ]. In the same manner employees report that they start fresh into the second half of the work day after their lunch break or exercise (s. interview 11, interview 5). The use of the temporal flexibility and short periods of withdrawing from work serves not only as a temporal boundary style. For example, a small break from work might work as a combined strategy as it (1) refills the energy level and (2) serves as a moment of leaving thoughts of work behind, if the break is taken outside on the balcony and (3) simultaneously is a physical boundary tactic as one physically steps out of the working area.

This example concurs with COR theory [ 51 ] and boundary theory [ 53 , 54 , 55 ] as employees can conserve their resources by taking a break and withdrawing temporarily from work and striking a balance between work and non-work domain. If both theories are taken into account, boundary management needs to be applied at the right time in order to keep individuals from suffering under exhaustion. Boundary management tactics show, how the employees manage the borderline between WFH and living at home, whereas the energy management strategies go beyond the mere handling of borders, but can explain in which regard employees apply strategies to keep their energy reserves and stay healthy during WFH. Additionally, other studies refer to the protective function of job crafting for employees’ mental health, e.g. by reducing exhaustion [ 25 , 29 , 30 ]. If the categories are integrated in the JDR model, the blurred work and life domains impact employees as a job demand when WFH, while boundary management and energy resources management can function as strategies to reduce exhaustion. Therefore, job resources such as autonomy or support from colleagues (e.g. if private time is agreed on and protected), can buffer the negative effect on employees’ health. Consequently, they can minimize the anticipated loss of resources, that results in stress according to COR theory.

WFH is able to provide more autonomy as a job resource and control for employees to spend their breaks according to their preferences. For experiencing a deep relaxation and recovery, it is crucial that employees experience control during their break and engage in a preferred activity [ 44 , 45 ]. One of the most effective ways to recover from job stress seems to be spending time in nature or outdoors [ 46 ], which may also be easier to achieve when WFH such as walking the dog or just sitting in the garden (s. interview 2, interview 6).

The tendency to work from home while sick was bound to employees’ own assessment of severity of the illness. From employees’ perspectives, WFH has been an alternative to being on sick leave, because it offers the opportunity to take care of the body’s need for rest. For example, alternatives to medication or a nap could be taken in between the work day. In this case, boundary management tactics that allow a temporal removal from work are simultaneously used with strategies to replenish employees’ energy levels. Another link is proposed through the work-related availability, even when employees are sick. Here the boundary is permeable to support colleagues. However, these practices suggest the emergence of a culture of presenteeism in remote work settings, where employees continue working even when ill [ 77 ]. Working on-site may act as a safeguard, not only by allowing clearer boundaries and reducing the need for extended availability, but also by protecting employees from the risks of presenteeism that come with WFH [ 78 ]. In a traditional workplace, managers can step in and send unwell employees home, fulfilling their duty of care. In contrast, when working remotely, monitoring of employees is more challenging, placing greater reliance on individual responsibility. Employees who work from home while sick prioritize their work over their health, a phenomenon known as interested self-endangerment [ 79 ]. The blurring of work-life boundaries in a home office setting increases health risks, including self-endangerment and mental strain [ 80 ], while also enabling employees to make use of different resources to care for oneself.

Recommendations for future research

In this paper we identified boundary work tactics that employees use when WFH and therefore expanded the understanding of boundary management during the COVID-19 pandemic. We found specific tactics that may be useful to optimize WFH arrangements. Additionally, the findings provide insights into the possible connections between the categories and combined strategies (e.g., behavioral and temporal boundary tactics or temporal boundary tactics and energy management) when WFH. Further research could explore how boundary strategies interact with each other and potentially reinforce one another, leading to the development of a model to better understand these dynamics. Further research could also investigate problematic areas, where boundary tactics fail or focus on specific preferences such as work-home integration or segregation [ 35 ].

Linking our findings to the JD-R model and Hobfoll’s COR theory, a strong boundary management may support conserving resources and using them for leisure. Thus, employees may experience a better recovery experience, if they have the energy to exercise even after a full work day and stay healthy in the long term. To our knowledge, research investigating the link between recovery experiences and job crafting activities is still scarce [ 60 ].

More studies investigating the relationships between leisure, health and successful boundary tactics and energy management are necessary to determine, when the line between work and non-work should be drawn to maximize positive effects for employees and employers. Therefore, an additional testing of the relationships, the theoretical framework and the transferability of results to other groups of employees or sectors would be appropriate by using quantitative research methods. Moreover, boundary tactics and energy management should be investigated more thoroughly in hybrid work settings to identify the most effective working conditions in terms of available job resources, job demands, utilized job crafting strategies and an optimized recovery experience. Since WFH had a mandatory character in our study, research on hybrid work settings can provide a more differentiated picture of possible job crafting strategies in different professions. Diary studies could be used to measure stress indicators and exhaustion as well as daily job crafting strategies to define individual types and an effective handling of WFH.

In their qualitative study on archetypes of sickness attendance, Ruhle and Süß [ 81 ] discovered that employees have become more sensitive regarding working on site because of the COVID-19 measures, but still they are not inclined to call in sick when they are at home. More research in form of larger quantitative samples or longitudinal designs will be necessary to fully understand these habits and underlying culture. Therefore, a closer look at interested self-endangerment when WFH will be helpful as well. In addition, larger case studies could explore different types of organizational culture (supporting/hindering boundary management or interested self-endangerment behaviors).

Recommendations for practice

The study provides insights into employees’ individual boundary and energy management styles. These experiences may support other employees in finding their own valuable strategy to manage the blurring of work-life boundaries or staying vital and active when WFH. Furthermore, employers should offer information to raise employees’ awareness regarding these possible strategies and health benefits that derive from the application of boundary work tactics and energy management strategies. Bennett et al. [ 47 ] found out, that employees can easily mentally distance from work, when supervisors support their recovery. If supervisors take care of themselves, this self-care behavior also may be adapted by employees, since supervisors act as role models for health promoting behavior [ 82 ]. Similarly, supervisors should provide job resources and encourage employees to take microbreaks [ 49 ] as this strengthens the rest break intention as well [ 42 ].

Another approach is to train employees in applying these work-related strategies [ 49 ], strengthen their skills such as time management or self-regulation or to enable employees to negotiate their work time or work-family arrangements more freely [ 33 ]. The reported employer measure to shut off the e-mail server appears to be a last resort of protection of employees’ recovery time and health. Instead, a corporate culture, where the communication and management of boundaries is possible and encouraged in the team and organization should prevent those drastic measures.

The tendency to work from home when sick, shows that employees were much more sensitized to not go to work because of the COVID-19 prevention measures. At the same time, they are inclined to not always call in sick, but work from home even if they are ill. Here it is important that employees are trained in health literacy, which can be seen as prerequisite for self-care behavior [ 83 ]. They need to be able to manage their energy resources and apply strategies, because only if they know the bottom of their resources and know their own body well, this strategy of self-assessment can work out when employees become sick. Additionally, supervisors need to be sensitive in order to look out for employees so employees do not wear themselves out, when they are WFH while sick. In this regard, it is important for employers to see employees face-to-face from time to time and thus be able to assess their state of health.

Strengths and limitations

Strengths of the study are the close orientation to literature findings and theoretical grounding of the empirical findings. However, concerning the qualitative findings a number of limitations must be considered. These findings are not universally applicable to other groups or settings (outside of public service employees in certain agencies in Germany), indicating the need for more quantitative studies or additional qualitative case studies in diverse business environments. The sample size and composition also present constraints, as many participants were over 50 years old and without children at home. Comparing the sample with the demographic features of public service employees in 2021, 42.3% of public service employees in Germany were between 45 and 59 years old and represent a major part of the professional group [ 84 ]. Hence, the age group represents a large portion of the public service employees. Interestingly, around 57% of the public service employees are women, but they are underrepresented in our study. One possible explanation is that only 46% of women serve in the higher service and 36% have a leadership position [ 84 ]. This suggests more investigation is needed since boundary management tactics can differ, examining various age groups is essential, particularly considering potential work-family conflicts and the home environment. There is also a possibility of selection bias in choosing interview participants, as those who volunteered may have preferred WFH and may have been more interested in the subject. Furthermore, the interviews were conducted at a specific time, capturing only the perspectives of public service employees WFH one year after the COVID-19 pandemic began. A notable strength of the study is the involvement of three researchers in conducting and coding the interviews, which helps mitigate subjective bias. The use of qualitative reporting criteria and a semi-structured interview guide ensured a standardized process. Moreover, the research is based on the JD-R model and Hobfoll’s widely recognized COR theory, adding value to the existing body of knowledge. The findings offer insights into boundary management tactics and energy resource management strategies for remote working during the COVID-19 pandemic. This qualitative study identifies patterns and provides directions for future research aimed at improving the work conditions and health of public employees WFH.

This qualitative case study enriches research on job crafting by offering insights on boundary tactics and energy resources management strategies for remote working during the COVID-19 pandemic. Findings reveal that public service employees developed personal crafting strategies to cope with boundary management and energy resources management when WFH, including physical, behavioral, communicative or temporal strategies. Strategies aiming at energy resources management included preventing exhaustion, physical exercise and also managing WFH when employees were sick. Drawing on the JDR model and Hobfoll’s COR theory, this qualitative study identifies patterns and various opportunities and risks for health when WFH - aspects that are particularly relevant as remote work is likely to remain in the future. Furthermore, it provides directions for future research and practice aimed at enhancing the work conditions and wellbeing of public employees WFH.

Data availability

The datasets generated and/or analyzed during the current study are not publicly available due to the personal information and sensitive information from employers and employees, comprehended in the interviews and which could in theory be might be traced back to individual respondents. The original data is only available on site after contact with the corresponding author on reasonable request, to ensure data access complies with the procedures of the General Data Protection Regulation (GDPR). All information analyzed during this study is included in this published article and its supplementary information files.

Abbreviations

Conservation of resources theory

Job Demands-Resources model

• Working from home

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Acknowledgements

The authors thank all public service employees for their participation in this qualitative study. The authors are grateful that Mona Annies (MA) supported them in the transcription process of the interviews.

Open Access funding enabled and organized by Projekt DEAL.

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LS and KS contributed to the conception and design of the study and performed the content analysis. LS, KS, and JN administered the project and carried out the investigation. LS wrote the first draft of the manuscript and prepared the visualization. HP supervised the project. All authors contributed to the manuscript revision, read, and approved the submitted version.

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Seinsche, L., Schubin, K., Neumann, J. et al. Working from home during COVID-19: boundary management tactics and energy resources management strategies reported by public service employees in a qualitative study. BMC Public Health 24 , 1249 (2024). https://doi.org/10.1186/s12889-024-18744-y

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• Energy management
• Boundary management
• Work-home conflict
• Work delimitation
• Public service

BMC Public Health

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• Published: 09 May 2024

Examining the feasibility of assisted index case testing for HIV case-finding: a qualitative analysis of barriers and facilitators to implementation in Malawi

• Caroline J. Meek 1 , 2 ,
• Tiwonge E. Mbeya Munkhondya 3 ,
• Mtisunge Mphande 4 ,
• Tapiwa A. Tembo 4 ,
• Mike Chitani 4 ,
• Milenka Jean-Baptiste 2 ,
• Dhrutika Vansia 4 ,
• Caroline Kumbuyo 4 ,
• Jiayu Wang 2 ,
• Katherine R. Simon 4 ,
• Sarah E. Rutstein 5 ,
• Clare Barrington 2 ,
• Maria H. Kim 4 ,
• Vivian F. Go 2 &
• Nora E. Rosenberg 2  

BMC Health Services Research volume  24 , Article number:  606 ( 2024 ) Cite this article

Metrics details

Assisted index case testing (ICT), in which health care workers take an active role in referring at-risk contacts of people living with HIV for HIV testing services, has been widely recognized as an evidence-based intervention with high potential to increase status awareness in people living with HIV. While the available evidence from eastern and southern Africa suggests that assisted ICT can be an effective, efficient, cost-effective, acceptable, and low-risk strategy to implement in the region, it reveals that feasibility barriers to implementation exist. This study aims to inform the design of implementation strategies to mitigate these feasibility barriers by examining “assisting” health care workers’ experiences of how barriers manifest throughout the assisted ICT process, as well as their perceptions of potential opportunities to facilitate feasibility.

In-depth interviews were conducted with 26 lay health care workers delivering assisted ICT in Malawian health facilities. Interviews explored health care workers’ experiences counseling index clients and tracing these clients’ contacts, aiming to inform development of a blended learning implementation package. Transcripts were inductively analyzed using Dedoose coding software to identify and describe key factors influencing feasibility of assisted ICT. Analysis included multiple rounds of coding and iteration with the data collection team.

Participants reported a variety of barriers to feasibility of assisted index case testing implementation, including sensitivities around discussing ICT with clients, privacy concerns, limited time for assisted index case testing amid high workloads, poor quality contact information, and logistical obstacles to tracing. Participants also reported several health care worker characteristics that facilitate feasibility (knowledge, interpersonal skills, non-stigmatizing attitudes and behaviors, and a sense of purpose), as well as identified process improvements with the potential to mitigate barriers.

Conclusions

Maximizing assisted ICT’s potential to increase status awareness in people living with HIV requires equipping health care workers with effective training and support to address and overcome the many feasibility barriers that they face in implementation. Findings demonstrate the need for, as well as inform the development of, implementation strategies to mitigate barriers and promote facilitators to feasibility of assisted ICT.

Trial registration

NCT05343390. Date of registration: April 25, 2022.

Peer Review reports

Introduction

To streamline progress towards its goal of ending AIDS as a public health threat by 2030, the Joint United Nations Programme on HIV/AIDS (UNAIDS) launched a set of HIV testing and treatment targets [ 1 ]. Adopted by United Nations member states in June 2021, the targets call for 95% of all people living with HIV (PLHIV) to know their HIV status, 95% of all PLHIV to be accessing sustained antiretroviral therapy (ART), and 95% of all people receiving ART to achieve viral suppression by 2025 [ 2 ]. Eastern and southern Africa has seen promising regional progress towards these targets in recent years, and the region is approaching the first target related to status awareness in PLHIV- in 2022, 92% of PLHIV in the region were aware of their status [ 3 ]. However, several countries in the region lag behind [ 4 ], and as 2025 approaches, it is critical to scale up adoption of evidence-based interventions to sustain and accelerate progress.

Index case testing (ICT), which targets provision of HIV testing services (HTS) for sexual partners, biological children, and other contacts of known PLHIV (“index clients”), is a widely recognized evidence-based intervention used to identify PLHIV by streamlining testing efforts to populations most at risk [ 5 , 6 , 7 ]. Traditional approaches to ICT rely on passive referral, in which index clients invite their contacts for testing [ 5 ]. However, the World Health Organization (WHO) and the President’s Emergency Plan for HIV/AIDS Relief (PEPFAR) have both recommended assisted approaches to ICT [ 6 , 8 , 9 , 10 ], in which health care workers (HCWs) take an active role in referral of at-risk contacts for testing, due to evidence of improved effectiveness in identifying PLHIV compared to passive approaches [ 10 , 11 , 12 , 13 , 14 ]. As a result, there have been several efforts to scale assisted ICT throughout eastern and southern Africa in recent years [ 15 , 16 , 17 , 18 , 19 , 20 ]. In addition to evidence indicating that assisted ICT can be effective in increasing HIV testing and case-finding [ 16 , 17 , 21 , 22 , 23 , 24 ], implementation evidence [ 25 ] from the region suggests that assisted ICT can be an efficient [ 14 ], acceptable [ 5 , 13 , 15 , 18 , 20 , 21 , 26 ], cost-effective [ 27 ], and low-risk [ 21 , 22 , 24 , 28 , 29 ] strategy to promote PLHIV status awareness. However, the few studies that focus on feasibility, or the extent to which HCWs can successfully carry out assisted ICT [ 25 ], suggest that barriers exist to feasibility of effective implementation [ 18 , 19 , 20 , 30 , 31 , 32 ]. Developing informed implementation strategies to mitigate these barriers requires more detailed examination of how these barriers manifest throughout the assisted ICT process, as well as of potential opportunities to facilitate feasibility, from the perspective of the HCWs who are doing the “assisting”.

This qualitative analysis addresses this need for further detail by exploring “assisting” HCWs’ perspectives of factors that influence the feasibility of assisted ICT, with a unique focus on informing development of effective implementation strategies to best support assisted ICT delivery in the context of an implementation science trial in Malawi.

This study was conducted in the Machinga and Balaka districts of Malawi. Malawi is a country in southeastern Africa in which 7.1% of the population lives with HIV and 94% of PLHIV know their status [ 4 ]. Machinga and Balaka are two relatively densely populated districts in the southern region of Malawi [ 33 ] with HIV prevalence rates similar to the national average [ 34 ]. We selected Machinga and Balaka because they are prototypical of districts in Malawi implementing Ministry of Health programs with support from an implementing partner.

Malawi has a long-established passive ICT program, and in 2019 the country also adopted an assisted component, known as voluntary assisted partner notification, as part of its national HIV testing policy [ 32 ]. In Malawi, ICT is conducted through the following four methods, voluntarily selected by the index client: 1) passive referral, in which HCWs encourage the index client to refer partners for voluntary HTS, 2) contract referral, in which HCWs establish an informal ‘contract’ with index clients that agrees upon a date that the HCW can contact the contact clients if they have not yet presented for HTS; 3) provider referral, in which HCWs contact and offer voluntary HTS to contact clients; and 3) dual referral, in which HCWs accompany and provide support to index clients in disclosing their status and offering HTS to their partners [ 8 ]. 

While Malawi has one of the lowest rates of qualified clinical HCWs globally (< 5 clinicians per 100,000 people) [ 35 ], the country has a strong track record of shifting HTS tasks to lay HCWs, who have been informally trained to perform certain health care delivery functions but do not have a formal professional/para-professional certification or tertiary education degree, in order to mitigate this limited medical workforce capacity [ 32 , 36 ]. In Malawi, lay HCW roles include HIV Diagnostic Assistants (who are primarily responsible for HIV testing and counseling, including index case counseling) and community health workers (who are responsible for a wider variety of tasks, including index case counseling and contact tracing) [ 32 ]. Non-governmental organization implementing partners, such as the Tingathe Program, play a critical role in harnessing Malawian lay HCW capacity to rapidly and efficiently scale up HTS, including assisted ICT [ 32 , 37 , 38 , 39 ].

Study design

Data for this analysis were collected as part of formative research for a two-arm cluster randomized control trial examining a blended learning implementation package as a strategy for building HCW capacity in assisted ICT [ 40 ]. Earlier work [ 32 ] established the theoretical basis for testing the blended learning implementation package, which combines individual asynchronous modules with synchronous small-group interactive sessions to enhance training and foster continuous quality improvement. The formative research presented in this paper aimed to further explore factors influencing feasibility of the assisted ICT from the perspective of HCWs in order to inform development of the blended learning implementation package.

Prior to the start of the trial (October-December 2021), the research team conducted 26 in-depth interviews (IDIs) with lay HCWs at 14 of the 34 facilities included in the parent trial. We purposively selected different types of facilities (hospitals, health centers, and dispensaries) in both districts and from both randomization arms, as this served as a qualitative baseline for a randomized trial. Within these facilities, we worked with facility supervisors to purposively select HCWs who were actively engaged in Malawi’s ICT program from the larger sample of HCWs eligible for the parent trial (had to be at least 18 years old, employed full-time at one of the health facilities included in the parent trial, and involved in counseling index clients and/or tracing their contacts). The parent trial enrolled 306 HCWs, who were primarily staff hired by Tingathe Program to support facilities implementing Malawi’s national HIV program.

Data collection

IDIs were conducted by three trained Malawian interviewers in a private setting using a semi-structured guide. IDIs were conducted over the phone when possible ( n  = 18) or in-person at sites with limited phone service ( n  = 8). The semi-structured guide was developed for this study through a series of rigorous, iterative discussions among the research team (Additional file 1 ). The questions used for this analysis were a subset of a larger interview. The interview guide questions for this analysis explored HCWs’ experiences with assisted ICT, including barriers and facilitators to implementation. Probing separately about the processes of counseling index clients and tracing their contacts, interviewers asked questions such as “What is the first thing that comes to mind when you think of counseling index clients/tracing contacts?”, “What aspects do you [like/not like] about…?” and “What do your colleagues say about…?”. When appropriate, interviewers probed further about how specific factors mentioned by the participant facilitate or impede the ICT implementation experience.

The IDIs lasted from 60–90 min and were conducted in Chichewa, a local language in Malawi. Eleven audio recordings were transcribed verbatim in Chichewa before being translated into English and 15 recordings were directly translated and transcribed into English. Interviewers summarized each IDI after it was completed, and these summaries were discussed with the research team routinely.

Data analysis

The research team first reviewed all of the interview summaries individually and then met multiple times to discuss initial observations, refining the research question and scope of analysis. A US-based analyst (CJM) with training in qualitative analysis used an inductive approach to develop a codebook, deriving broad codes from the implementation factors mentioned by participants throughout their interviews. Along with focused examination of the transcripts, she consulted team members who had conducted the IDIs with questions or clarifications. CJM regularly met with Malawian team members (TEMM, MM, TAT) who possess the contextual expertise necessary to verify and enhance meaning. She used the Dedoose (2019) web application to engage in multiple rounds of coding, starting with codes representing broad implementation factors and then further refining the codebook as needed to capture the nuanced manifestations of these barriers and facilitators. Throughout codebook development and refinement, the analyst engaged in memoing to track first impressions, thought processes, and coding decisions. The analyst presented the codebook and multiple rounds of draft results to the research team. All transcripts and applied codes were also reviewed in detail by additional team members (MJB, DV). Additional refinements to the codebook and results interpretations were iteratively made based on team feedback.

Ethical clearance

Ethical clearance was provided by UNC’s IRB, Malawi’s National Health Sciences Research Committee, and the Baylor College of Medicine IRB. Written informed consent was obtained from all participants in the main study and interviewers confirmed verbal consent before starting the IDIs.

Participant characteristics are described in Table  1 below.

Factors influencing feasibility of assisted ICT: barriers and facilitators

Participants described a variety of barriers and facilitators to feasibility of assisted ICT, manifesting across the index client counseling and contact client tracing phases of the implementation process. Identified barriers included sensitivities around discussing ICT with clients, privacy concerns, limited time for ICT amid high workloads, poor quality contact information, and logistical obstacles to tracing. In addition to these barriers, participants also described several HCW characteristics that facilitated feasibility: ICT knowledge, interpersonal skills, positive attitudes towards clients, and sense of purpose. Barriers and facilitators are mapped to the ICT process in Fig.  1 and described in greater detail in further sections.

Conceptual diagram mapping feasibility barriers and facilitators to the ICT process

Feasibility barriers

Sensitivities around discussing ict with clients.

Participants described ICT as a highly sensitive topic to approach with clients. Many expressed a feeling of uncertainty around how open index clients will be to sharing information about their contacts, as well as how contacts will react when approached for HTS. When asked about difficult aspects of counseling index clients, many HCWs mentioned clients’ hesitance or declination to participate in assisted ICT and share their contacts. Further, several HCWs mentioned that some index clients would provide false contact information. These index client behaviors were often attributed to confidentiality concerns, fear of unwanted status disclosure, and fear of the resulting implications of status disclosure: “They behave that way because they think you will be telling other people about their status…they also think that since you know it means their life is done, you will be looking at them differently .” Populations commonly identified as particularly likely to hesitate, refuse, or provide false information included youth (described as “ shy ” “ thinking they know a lot ” and “ difficult to reveal their contacts ”) and newly diagnosed clients (“it may be hard for them to accept [their HIV diagnosis]” ). One participant suggested that efforts to pair index clients with same-sex HCWs could make them more comfortable to discuss their contacts.

When asked about the first things that come to mind when starting to trace contacts, many participants discussed wondering how they will be received by the contact and preparing themselves to approach the contact. When conducting provider or contract referral, HCWs described a variety of challenging reactions that can occur when they approach a contact for HTS- including delay or refusal of testing, excessive questioning about the identity of the index client who referred them for testing, and even anger or aggression. Particularly mentioned in the context of male clients, these kinds of reactions can lead to stress and uncertain next steps for HCWs: “I was very tensed up. I was wondering to myself what was going to happen…he was talking with anger.”

Participants also noted the unique sensitivities inherent in conducting dual referral and interacting with sexual partners of index clients, explaining that HIV disclosure can create acute conflict in couples due to perceived blame and assumptions of infidelity. They recounted these scenarios as particularly difficult to navigate, with high stakes that require high-quality counseling skills: “sometimes if you do not have good counseling the marriage happens to get to an end.” . Some participants discussed concern about index client risk of intimate partner violence (IPV) upon partner disclosure: “they think that if they go home and [disclose their HIV status], the marriage will end right there, or for some getting to a point of [being] beaten.”

Privacy concerns

Participants also reported that clients highly value privacy, which can be difficult to secure throughout the ICT process. In the facility, while participants largely indicated that counseling index clients was much more successful when conducted in a private area, many reported limited availability of private counseling space. One participant described this challenge: “ if I’m counseling an index client and people keep coming into the room…this compromises the whole thing because the client becomes uncomfortable in the end.” Some HCWs mentioned working around this issue through use of screens, “do-not-disturb” signs, outdoor spots, and tents.

Participants also noted maintaining privacy as a challenge when tracing contact clients in the field, as they sometimes find clients in a situation that is not conducive to private conversations. One participant described: “ we get to the house and find that there are 4, 5 people with our [contact client]…it doesn’t go well…That is a mission gone wrong. ” Participants also noted that HCWs are also often easily recognizable in the community due to their bikes and cars, which exacerbates the risk of compromising privacy. To address privacy challenges in the community, participants reported strategies to increase discretion, including dressing to blend in with the community, preparing an alternate reason to be looking for the client, and offering HTS to multiple people or households to avoid singling out one person.

Limited time for ICT amid high workloads

Some participants indicated that strained staffing capacity leads HCWs to have to perform multiple roles, expressing challenges in balancing their ICT work with their other tasks. As one participant described, “Sometimes it is found that you are assigned a task here at the hospital to screen anyone who comes for blood testing, but you are also supposed to follow up [with] the contacts the same day- so it becomes a problem…you fail to follow up [with] the contacts.” Some also described being the only, or one of few staff responsible for ICT: “You’re doing this work alone, so you can see that it is a big task to do it single-handedly.” The need to counsel each index client individually, as a result of confidentiality concerns, further increases workload for the limited staff assigned to this work. Further, HCWs often described contact tracing in the field as time-consuming and physically taxing, which leaves them less time and energy for counseling. Many HCWs noted the need to hire more staff dedicated to ICT work.

High workloads also resulted in shorter appointments and less time to counsel index clients, which participants reported limits the opportunity for rapport that facilitates openness or probes for detailed information about sexual partners. Participants emphasized the importance of having enough time to meaningfully engage with index clients: “For counseling you cannot have a limit to say, ‘I will talk to him for 5 min only.’ …That is not counseling then. You are supposed to stay up until…you feel that this [person] is fulfilled.” . In addition, high workload can reduce the capacity of HCWs to deliver quality counseling: “So you find that as you go along with the counseling, you can do better with the first three clients but the rest, you are tired and you do short cuts.”

High workloads also lead to longer queues, which may deter clients from coming into the clinic or cause them to leave before receiving services: “Sometimes because of shortage of staff, it happens that you have been assigned a certain task that you were supposed to do but at the same time there are clients who were supposed to be counseled. As a result, because you spent more time on the other task as a result you lose out some of the clients because you find that they have gone.” In response to long queues, several participants described ‘fast-tracking’ contact clients who come in for HTS in effort to maximize case-finding by prioritizing those who have been identified as at risk of HIV.

Poor quality contact information

Participants repeatedly discussed the importance of eliciting accurate information about a person’s sexual partners, including where, when, and how to best contact them. As one participant said, “ Once the index has given us the wrong information then everything cannot work, it becomes wrong…if he gives us full information [with] the right details then everything becomes successful and happens without a problem. ” Adequate information is a critical component of the ICT process, and incorrect or incomplete information delays or prevents communication with contact clients.

Inadequate information, which can include incorrect or incomplete names, phone numbers, physical addresses, and contextual details, can arise from a variety of scenarios. Most participants mentioned index clients providing incorrect information as a concern. This occurred either intentionally to avoid disclosure or unintentionally if information was not known. Poor quality contact information also results from insufficient probing and poor documentation, which is often exacerbated by aforementioned HCW time and energy constraints. In one participant’s words, “The person who has enlisted the contact…is the key person who can make sure that our tracing is made easy.” Participants noted the pivotal role of the original HCW who first interacts with the index client in not only eliciting correct locator information but also eliciting detailed contextual information. For example, details about a contact client’s profession are helpful to trace the client at a time when they will likely be at home. Other helpful information included nicknames, HIV testing history, and notes about confidentiality concerns.

Logistical obstacles to tracing

Some contact clients are reached by phone whereas others must be physically traced in the community. Some participants reported difficulty with tracing via phone, frequently citing network problems and lack of sufficient airtime allocated by the facility. Participants also reported that some clients were unreachable by phone, necessitating physical tracing. Physically tracing a contact client requires a larger investment of resources than phone tracing, especially when the client lives at a far distance from the clinic. Participants frequently discussed having to travel far distances to reach contact clients, an issue some saw as exacerbated by people who travel to clinics at far distances due to privacy concerns.

While most participants reported walking or biking to reach contact clients in the community, some mentioned using a motorcycle or Tingathe vehicle. However, access to vehicles is often limited and these transportation methods require additional expenses for fuel. Walking or biking was also reported to expose HCWs to inclement weather, including hot or rainy seasons, and potential safety risks such as violence.

Participants reported that traveling far distances can be physically taxing and time-consuming, sometimes rendering them too tired or busy to attend to other tasks. Frequent travel influenced HCW morale, particularly when a tracing effort did not result in successfully recruiting a contact client. Participants frequently described this perception of wasted time and energy as “ painful ”, with the level of distress often portrayed as increasing with the distance travelled. As one HCW said, “You [can] find out that he gave a false address. That is painful because it means you have done nothing for the person, you travelled for nothing.”

HCWs described multiple approaches used to strategically allocate limited resources for long distances. These approaches included waiting to physically trace until there are multiple clients in a particular area, reserving vehicle use for longer trips, and coordinating across HCWs to map out contact client locations. HCWs also mentioned provision of rain gear and sun protection to mitigate uncomfortable travel. Another approach involved allocating contact tracing to HCWs based in the same communities as the contact clients.

Feasibility facilitators

Hcw knowledge about ict.

Participants reported that HCWs with a thorough understanding of ICT’s rationale and purpose can facilitate client openness. Clients were more likely to engage with HCWs about assisted ICT if they understood the benefits to themselves and their loved ones. One HCW stated, “If the person understands why we need the information, they will give us accurate information.”

Participants also discussed the value of deep HCW familiarity with ICT procedures and processes, particularly regarding screening clients for IPV and choosing referral method. One participant described the importance of clearly explaining various referral methods to clients: “So…people come and choose the method they like…when you explain things clearly it is like the index client is free to choose a method which the contact can use for testing”. Thorough knowledge of available referral methods allows HCWs to actively engage with index clients to discuss strategies to refer contacts in a way that fits their unique confidentiality needs, which was framed as particularly important when IPV is identified as a concern. Multiple participants suggested the use of flipcharts or videos, saying these would save limited HCW time and energy, fill information gaps, and provide clients with a visual aid to supplement the counseling. Others suggested recurring opportunities for training, to continuously “refresh” their ICT knowledge in order to facilitate implementation.

HCW interpersonal skills

In addition, HCWs’ ability to navigate sensitive conversations about HIV was noted as a key facilitator of successful implementation. Interpersonal skills were mentioned as mitigating the role’s day-to-day uncertainty by preparing HCWs to engage with clients, especially newly diagnosed clients: “ I need to counsel them skillfully so that they understand what I mean regardless that they have just tested positive for HIV.”

When discussing strategies to build HCW skills in counseling index clients and tracing contact clients, participants suggested establishing regular opportunities to discuss challenges and share approaches to address these challenges: “ I think that there should be much effort on the [HCWs] doing [ICT]. For example, what do I mean, they should be having a meeting with the facility people to ask what challenges are you facing and how can we end them?”. Another participant further elaborated, saying “We should be able to share experiences with our [colleagues] so that we can all learn from one another. And also, there are other people who are really brilliant at their job. Those people ought to come visit us and see how we are doing. That is very motivating.”

HCW non-stigmatizing attitudes and behaviors

Participants also highlighted the role of empathy and non-judgement in building trust with clients: “ Put yourself in that other person’s shoes. In so doing, the counseling session goes well. Understanding that person, that what is happening to them can also happen to you. ”. Participants viewed trust-building as critical to facilitating client comfort and openness: “if they trust you enough, they will give you the right information.” Further, participants associated HCW assurance of confidentiality with promoting trust and greater information sharing: “ Also assuring them on the issue of confidentiality because confidentiality is a paramount. If there will not be confidentiality then the clients will not reveal.”

HCW sense of purpose

Lastly, several participants reported that a sense of purpose and desire to help people motivated them to overcome the challenges of delivering assisted ICT. One participant said, “ Some of these jobs are a ministry. Counseling is not easy. You just need to tell yourself that you are there to help that person. ” Many seemed to take comfort in the knowledge that their labors, however taxing, would ultimately allow people to know their status, take control of their health, and prevent the spread of HIV. Participants framed the sense of fulfillment from successful ICT implementation as a mitigating factor amidst challenges: “ If [the contact client] has accepted it then I feel that mostly I have achieved the aim of being in the health field…that is why it is appealing to me ”.

Participants described a variety of barriers to assisted ICT implementation, including sensitivities around discussing ICT with clients, privacy concerns, limited time for ICT amid high workloads, poor quality contact information, and logistical obstacles to tracing. These barriers manifested across each step of the process of counseling index clients and tracing contacts. However, participants also identified HCW characteristics and process improvements that can mitigate these barriers.

Further, participants’ descriptions of the assisted ICT process revealed the intimately interconnected nature of factors that influence feasibility of assisted ICT. Sensitivities around HIV, privacy limitations, time constraints, and HCW characteristics all contribute to the extent to which counseling index clients elicits adequate information to facilitate contact tracing. Information quality has implications for HCW capacity, as inadequate information can lead to wasted resources, including HCW time and energy, on contact tracing. The opportunity cost of wasted efforts, which increases as the distance from which the contact client lives from the clinic increases, depletes HCW morale. The resulting acceleration of burnout, which is already fueled by busy workloads and the inherent uncertainty of day-to-day ICT work, further impairs HCW capacity to effectively engage in quality counseling that elicits adequate information from index clients. This interconnectedness suggests that efforts to mitigate barriers at any step of the assisted ICT process may have the potential to ripple across the whole process.

Participants’ descriptions of client confidentiality and privacy concerns, as well as fear of consequences of disclosure, align with previous studies that emphasize stigma as a key barrier to assisted ICT [ 15 , 18 , 19 , 20 , 30 , 31 ] and the overall HIV testing and treatment cascade [ 41 ]. Our findings suggest that anticipated stigma, or the fear of discrimination upon disclosure [ 42 ], drives several key barriers to feasibility of assisted ICT implementation. Previous studies also highlight the key role of HCWs in mitigating barriers related to anticipated stigma; noting the key role of HCW ICT knowledge, interpersonal skills, and non-stigmatizing attitudes/behaviors in securing informed consent from clients for ICT, tailoring the referral strategy to minimize risk to client confidentiality and safety, building trust and rapport with the client, and eliciting accurate contact information from index clients to facilitate contact tracing [ 18 , 19 , 20 , 30 ].

Our findings also reflect previous evidence of logistical challenges related to limited time, space, and resources that can present barriers to feasibility for HCWs [ 18 , 19 , 20 , 30 , 31 ]. Participants in the current study described these logistical challenges as perpetuating HCW burnout, making it harder for them to engage in effective counseling. Cumulative evidence of barriers across different settings (further validated by this study) suggests that assisted ICT implementation may pose greater burden on HCWs than previously thought [ 7 ]. However, our findings also suggest that strategic investment in targeted implementation strategies has the potential to help overcome these feasibility barriers.

In our own work, these findings affirmed the rationale for and informed the development of the blended learning implementation package tested in our trial [ 40 , 43 ]. Findings indicated the need for evidence-based training and support to promote HCW capacity to foster facilitating characteristics. Participants discussed the value of "refresher" opportunities in building knowledge, as well as the value of learning from other’s experiences. The blended learning implementation package balances both needs by providing time for HCWs to master ICT knowledge and skills with a combination of asynchronous, digitally delivered content (which allows for continuous review as a "refresher") and in-person sessions (which allow for sharing, practicing, and feedback). Our findings also highlight the value of flexible referral methods that align with the client’s needs, so our training content includes a detailed description of each referral method process. Further, our training content emphasizes client-centered, non-judgmental counseling as our findings add to cumulative evidence of stigma as a key barrier to assisted ICT implementation [ 41 ].

In addition, participants frequently mentioned informal workarounds currently in use to mitigate barriers or offered up ideas for potential solutions to try. Our blended learning implementation package streamlines these problem-solving processes by offering monthly continuous quality improvement sessions at each facility in our enhanced arm. These sessions allow for structured time to discuss identified barriers, share ideas to mitigate barriers, and develop solutions for sustained process improvement tailored to their specific setting. Initial focus areas for continuous quality improvement discussions include use of space, staffing, allocation of airtime and vehicles, and documentation, which were identified as barriers to feasibility in the current study.

Our study provides a uniquely in-depth examination of HCWs’ experiences implementing assisted ICT, exploring how barriers can manifest and interact with each other at each step of the process to hinder successful implementation. Further, our study has a highly actionable focus on informing development of implementation strategies to support HCWs implementing assisted ICT. Our study also has limitations. Firstly, while our sole focus on HCWs allowed for deeper exploration of assisted ICT from the perspective of those actually implementing it on the ground, this meant that our analysis did not include perspectives of index or contact clients. In addition, we did not conduct sub-group analyses as interpretation of results would be limited by our small sample size.

Assisted ICT has been widely recognized as an evidence-based intervention with high promise to increase PLHIV status awareness [ 5 , 6 , 7 , 10 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 23 , 24 , 26 , 27 , 28 , 29 ], which is important as countries in eastern and southern Africa strive to reach global UNAIDS targets. Study findings support cumulative evidence that HCWs face a variety of feasibility barriers to assisted ICT implementation in the region; further, the study’s uniquely in-depth focus on the experiences of those doing the “assisting” enhances understanding of how these barriers manifest and informs the development of implementation strategies to mitigate these barriers. Maximizing assisted ICT’s potential to increase HIV testing requires equipping HCWs with effective training and support to address and overcome the many feasibility barriers they face in implementation. Findings demonstrate the need for, as well as inform the development of, implementation strategies to mitigate barriers and promote facilitators to feasibility of assisted ICT.

Availability of data and materials

Qualitative data on which this analysis is based, as well as data collection materials and codebooks, are available from the last author upon reasonable request. The interview guide is included as an additional file.

Abbreviations

Acquired Immunodeficiency Syndrome

Antiretroviral Therapy

Health Care Worker

Human Immunodeficiency Virus

HIV Testing Services

Index Case Testing

In-Depth Interview

Intimate Partner Violence

Institutional Review Board

President’s Emergency Plan for HIV/AIDS Relief

People Living With HIV

Joint United Nations Programme on HIV/AIDS

World Health Organization

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Acknowledgements

We are grateful to the Malawian health care workers who shared their experiences through in-depth interviews, as well as to the study team members in Malawi and the United States for their contributions.

Research reported in this publication was funded by the National Institutes of Health (R01 MH124526) with support from the University of North Carolina at Chapel Hill Center for AIDS Research (P30 AI50410) and the Fogarty International Center of the National Institutes of Health (D43 TW010060 and R01 MH115793-04). The funders had no role in trial design, data collection and analysis, decision to publish or preparation of the manuscript.

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Caroline J. Meek

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Caroline J. Meek, Milenka Jean-Baptiste, Jiayu Wang, Clare Barrington, Vivian F. Go & Nora E. Rosenberg

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Tiwonge E. Mbeya Munkhondya

Baylor College of Medicine Children’s Foundation, Lilongwe, Malawi

Mtisunge Mphande, Tapiwa A. Tembo, Mike Chitani, Dhrutika Vansia, Caroline Kumbuyo, Katherine R. Simon & Maria H. Kim

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Contributions

TAT, KRS, SER, MHK, VFG, and NER contributed to overall study conceptualization, with CJM, CB, and NER leading conceptualization of the analysis presented in this study. Material preparation and data collection were performed by TEMM, MM, TAT, MC, and CK. Analysis was led by CJM with support from MJB and DV. The first draft of the manuscript was written by CJM with consultation from NER, TEMM, MM, TAT, MJB, and DV. JW provided quantitative analysis support for participant characteristics. All authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

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Correspondence to Caroline J. Meek .

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Ethical clearance was provided by the Malawi National Health Science Research Committee (NHSRC; #20/06/2566), University of North Carolina Institution Review Board (UNC IRB; #20–1810) and the Baylor College of Medicine institutional review board (Baylor IRB; H-48800). The procedures used in this study adhere to the tenets of the Declaration of Helsinki. Written informed consent for participation was obtained from all study participants prior to enrollment in the parent study. Interviewers also engaged in informal verbal discussion of consent immediately ahead of in-depth interviews.

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Meek, C.J., Munkhondya, T.E.M., Mphande, M. et al. Examining the feasibility of assisted index case testing for HIV case-finding: a qualitative analysis of barriers and facilitators to implementation in Malawi. BMC Health Serv Res 24 , 606 (2024). https://doi.org/10.1186/s12913-024-10988-z

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Received : 31 August 2023

Accepted : 12 April 2024

Published : 09 May 2024

DOI : https://doi.org/10.1186/s12913-024-10988-z

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