types of case studies in qualitative research pdf

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The historical origin and strategy of case study research dates back many years in applied and natural sciences. Its roots are traceable to life sciences such as criminology, medicine, and psychology. In this regard, the case study method is recognized and widely used in social science, especially in political and cultural studies and sociology, and educational research.

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Case Study Research

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Additional Readings

Creswell, J. W., & Creswell, J. D. (2018). Research design: Qualitative, quantitative and mixed methods approaches (5th ed.). Sage.

Harland, T. (2014). Learning about case study methodology to research higher education. Higher Education Research & Development, 33 (6), 1113–1122. https://doi.org/10.1080/07294360.2014.911253

Pan, S., & Tan, B. (2011). Demystifying case research: A structured-pragmatic-situational (SPS) approach to conducting case studies. Information and Organization, 21 , 161–176. https://doi.org/10.1016/j.infoandorg.2011.07.001

Tsang, E. (2013). Case study methodology: Causal explanation, contextualization and theorizing. Journal of International Management, 19 , 195–202. https://doi.org/10.1016/j.intman.2012.08.004

Yin, R. K. (2017). Case study research and applications: Designs and methods (6th ed.). Sage.

Zarnadze, S., Zarnadze, I., Baramidze, L., Sikharulidze, Z., Tabidze, D., & Bakradze, T. (2018). Problem based and case study methodology in medical education. European Scientific Journal, 120–128. https://doi.org/10.19044/esj.2018.c5p9

Online Resources

Case Study Research. https://www.youtube.com/watch?v=RPB3Q9cXmvs

Planning a Case Study. Part 2 of 3 on Case Studies. https://www.youtube.com/watch?v=o1JetXkFAr4

Qualitative analysis of interview data: A step-by-step guide for coding/indexing. https://www.youtube.com/watch?v=DRL4PF2u9XA

Qualitative Case Study. https://www.youtube.com/watch?v=QhvdC4vDjts

Replication or Single Cases. Part 3 of 3 on Case Studies. https://www.youtube.com/watch?v=b5CYZRyOlys

Types of Case Study. Part 1 of 3 on Case Studies. https://www.youtube.com/watch?v=gQfoq7c4UE4

What is case study and how to conduct case study research. https://www.youtube.com/watch?v=kynoEFQNEq8

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Ndame, T. (2023). Case Study. In: Okoko, J.M., Tunison, S., Walker, K.D. (eds) Varieties of Qualitative Research Methods. Springer Texts in Education. Springer, Cham. https://doi.org/10.1007/978-3-031-04394-9_11

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Virtual fcr intervention, interview participants and data collection, nonparticipant observations, virtual fcr improved perceived care delivery and clinical outcomes through increased opportunities for parent engagement, acceptance of virtual fcr by providers grew over time despite the persistent presence of technical challenges, implementation of virtual fcr should be standardized and delivered by the care team to enhance usability, effectiveness, and sustainability, a qualitative intervention evaluation of neonatal virtual family-centered rounds.

FUNDING: Funded by the National Institutes of Health (NIH). This project was supported by a pilot research grant from the University of California Davis Center for Healthcare Policy and Research and Center for Health Technology and the Eunice Kennedy Shriver National Institute of Child Health and Human Development, NIH (grant K23HD101550 to Dr Rosenthal). The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.

CONFLICT OF INTEREST DISCLOSURES: The authors have no conflicts of interest relevant to this article to disclose.

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Jaskiran Ranu , Kristin R. Hoffman , Hadley S. Sauers-Ford , Jacob Williams , Jennifer L. Rosenthal; A Qualitative Intervention Evaluation of Neonatal Virtual Family-Centered Rounds. Hosp Pediatr 2024; e2023007554. https://doi.org/10.1542/hpeds.2023-007554

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To conduct an implementation evaluation of the virtual family-centered rounds (FCR) intervention by exploring the perceptions and experiences of parents and care team providers.

We conducted a qualitative descriptive study using a thematic analysis of unobtrusive observations of rounding encounters and semi-structured interviews with the parents of discharged infants and members of the neonatal care team. Eligible participants had used virtual FCR at least once. Five research team members independently performed focused coding and memo writing of transcripts and observation fieldnotes. The team met weekly to compare and refine codes, update the interview guide, develop tentative categories, and discuss the theoretical direction.

We conducted 406 minutes of unobtrusive observations and 21 interviews with parents, physicians, neonatal nurse practitioners, bedside nurses, dieticians, and pharmacists. Three themes and 13 subthemes emerged from the analysis: (1) virtual FCR improved perceived care delivery and clinical outcomes through increased opportunities for parent engagement, (2) the acceptance of virtual FCR by providers grew over time despite the persistent presence of technical challenges, and (3) the implementation of virtual FCR should be standardized and delivered by the care team to enhance usability, effectiveness, and sustainability.

Virtual FCR is perceived by NICU parents and care team providers to be a valuable intervention that can enhance family centered care. The identified virtual FCR implementation strategies should be tested in further studies.

Family-centered rounds (FCR) are a standard of care in pediatrics and require the presence and engagement of families at the bedside. 1   FCR benefits include improved communication, care plan follow-through, parent or guardian (referred to as “parent” hereafter) satisfaction, and provider efficiency. 2 , 3   Admission to the NICU can be a stressor for parents. NICU parents are at increased risk for anxiety, depression, posttraumatic stress disorder, and other perinatal mood anxiety disorders. 4 – 7   Parents often have difficulty being at bedside during the hospitalization because of these mental health conditions, competing responsibilities at home and work, geographical distance from the hospital, and financial limitations. 8 , 9   Additionally, the infrequent presence of parents in the NICU during FCR was worsened during the coronavirus disease 2019 pandemic. 10   In addition, some hospitals modified FCR practices to promote social distancing, excluding parents from rounds despite parental presence at the bedside. 11  

The use of telehealth to permit families to join FCR virtually is a strategy to overcome the barriers to being physically present in the NICU. 12   Virtual FCR allows parents to be engaged in their infant’s care remotely through videoconferencing platforms that are compliant with the Health Insurance Portability and Accountability Act (HIPAA). Research suggests that virtual FCR can increase parent attendance at rounds, shorten NICU length of stay, and improve parents’ experience. 12   There is a limited information, however, on the implementation of virtual FCR from the perspectives of the individuals using this technology. The body of literature on virtual FCR in the NICU mostly examines the use of telehealth to virtually bring NICU providers, not family members, to the patient’s bedside. 13 – 17   A qualitative exploration of perspectives and experiences would elucidate the benefits and challenges of virtual FCR and aid in future implementation strategies. We aimed to conduct a qualitative implementation evaluation of the virtual FCR intervention by exploring the perceptions and experiences of parents and providers with experience using this telehealth intervention in the NICU.

We conducted a qualitative descriptive study using semi-structured interviews, nonparticipant observations, and thematic analysis. This study was conducted as part of a NICU virtual FCR pilot trial (ClinicalTrials.gov identifier NCT04265677). The quantitative trial results are reported separately. 12   The university’s institutional review board approved this study.

This study took place at a quaternary care children’s hospital in Northern California with a 49-bed level IV NICU. This NICU is the referral center for neonates across a 33-county region covering 65 000 square miles. The hospital admits >900 neonatal patients annually. FCR is conducted daily for each hospitalized neonate; parents are invited to attend FCR. FCR is attended by care team members, including a neonatologist, neonatal–perinatal fellow, neonatal nurse practitioner, pediatric resident(s), bedside nurse, dietician, and pharmacist.

Details about the virtual FCR intervention have been previously published. 12   Briefly, we used Zoom (San Jose, California) as the secure software interface. Parents downloaded Zoom onto their personal computer or smart device. The NICU care team used Zoom on a computer on wheels with a speaker and pan-tilt-zoom camera. Virtual FCR were available for parents to attend Monday through Friday. A research coordinator messaged parents with ∼15 minute warnings before the start of rounds for their neonate and admitted parent(s) from the virtual waiting room to establish a bidirectional audio and visual connection. Parents could participate in virtual FCR as frequently as they chose. They could also participate in FCR in person, if desired. Although most NICU care team members attended FCR in person, the dietician and pharmacist routinely attended FCR virtually.

We used maximum variation sampling to identify parents and care team members with varied use of the virtual FCR intervention. We aimed to include participants who had used virtual FCR only once or twice, as well as those who had used it more frequently, exceeding 10 to 15 times. Participants’ use of virtual FCR occurred between March 2020 and October 2020. We also used sequential sampling. The initial recruitment targeted parents, neonatal attending physicians, and neonatal nurse practitioners. We subsequently sampled pediatric residents, neonatal fellows, bedside nurses, pharmacists, and dieticians to further explore topics that arose in the initial interviews.

One-on-one interviews ∼45 minutes in duration were conducted from June 2020 to February 2021. Participants were recruited via e-mail. Eligible participants were aged 18 years and older and English-speaking. Interviews were conducted via videoconference by research team members who had no previous interaction with the subjects; these team members included a NICU fellow and a telehealth research analyst with extensive qualitative experience. Interviews were audio recorded and transcribed. We used an interview guide that included questions to solicit information related to (1) general experiences with and perceptions about virtual FCR as well as (2) the dimensions of the Medical Research Council guidance framework (ie, implementation, mechanisms of impact, context). 18   The Medical Research Council guidance framework is a widely recognized framework that can be applied to evaluate the implementation of health care interventions. We used 2 interview guides: one designed for parents and another for providers. Participants provided verbal informed consent. Interviews were conducted until thematic saturation was reached.

Data collection also consisted of unobtrusive observations to gain understanding of virtual FCR implementation, impact, and context, as experienced by the NICU care team members and parents. Observations were conducted in July and August 2020. They consisted of focused observations of both virtual FCR and standard in-person FCR and were conducted for both rounding encounters with and without parent attendance. We included observations of rounding encounters without parents to generate a point of comparison. The observer wrote detailed objective and subjective field notes on a template and answered post-observation questions immediately after each rounding encounter ( Supplemental Information ). The objective section was for factual, concrete observation data. The subjective section was for the observer to document their personal interpretations, impressions, questions, and ideas about the observation. Rationale for using unobtrusive observations was to prioritize minimizing any disruption or influence on the behavior under study. We wanted to reduce potential interference that could result from the observer’s presence.

Data were analyzed iteratively by using a constant comparative approach 19 , 20   and a combination of deductive and inductive analysis. 21   The analysis team consisted of the 2 interviewers plus 3 additional researchers: a NICU attending with telehealth research expertise, a pediatric hospitalist attending who leads digital health equity programs for the hospital, and the pilot trial research coordinator. We developed an initial codebook of a priori codes related to the Medical Research Council guidance framework dimensions of implementation, mechanisms of impact, and context. The 5 research team members independently conducted memo writing and coding of the initial 5 texts using the a priori codes while identifying emergent codes. These initial texts consisted of 3 parent interview transcripts plus fieldnotes from 2 days of observation. The team met to ensure consensus on the application of codes, refine dimensions of existing codes, add new codes, develop categories, identify theoretical direction, and draft and refine a logic model of the virtual FCR intervention. Disagreements among the team members were resolved through discussions to understand viewpoints, deliberate, and ultimately achieve consensus. We adapted the interview guide to explore emerging topics; the final version of the guide is provided in the Supplemental Information . We then resumed independent memo writing and coding followed by team meetings; this iterative process was repeated with every 2 to 5 texts. We revisited previous texts as new codes were identified. We identified linkages and patterns between the codes to develop our analytic themes. This process continued until we achieved thematic saturation, 22   whereby the data coalesced around similar themes. We used ATLAS.ti to organize and store coding and data analysis. We conducted peer validation of the logic model until no further adjustments were suggested.

We interviewed 21 individuals, of which 8 (38.1%) were parents ( Table 1 ). Among these 8 parents, their experience with using virtual FCR ranged from 1 to 19 virtual FCR encounters. The mean (SD) of the number of virtual encounters among parent interviewees was 10.1 (6.9). Care team providers included registered nurses, dieticians, pharmacists, pediatric residents, neonatal nurse practitioners, neonatal fellows, and attending physicians. Among interviewees, 70% were female and 80% were <40 years of age, and 63% of parents had a college degree or higher. A total of 406 minutes of observations were conducted. Observations included 61 rounding encounters, of which 10 (16.4%) and 12 (19.7%) had at least 1 parent in attendance virtually and in-person, respectively. From the qualitative data, 3 themes and 13 subthemes emerged, which are discussed below. Table 2 reveals exemplary quotes that support each theme and subtheme. The logic model of the virtual FCR intervention is shown in Fig 1 .

Demographic Characteristics of Interviewees

Themes and Subthemes With Supporting Quotes

Logic model of the virtual FCR intervention to improve parental and infant outcomes (↑, increases or improvements; ↓, decreases or reductions).

Virtual FCR was perceived to provide parents with key principles of family-centered care, including collaboration, information sharing, support, and flexibility. Virtual FCR addressed families’ unique needs to be more engaged in their child’s care. Parents and providers explained how virtual FCR helped parents overcome barriers to joining rounds in person due to geographic distance from the hospital and competing responsibilities. Families felt that virtual FCR enabled them to communicate more with the team because they were able to attend FCR more frequently. This increased communication from increased FCR attendance improved their understanding of their infant’s care and, thus, their ability to engage. Parents appreciated that virtual FCR made it so they did not have to receive information second-hand from their partner. Families liked the flexibility virtual FCR provided relative to in-person FCR, allowing them to focus on their self-care and other priorities. Observations revealed that some parents attended virtual FCR alongside extended family members. These additional family members listened to the care plan, asked questions, and supported the infant’s parent during FCR. Consistent with NICU visitor policies, standard in-person FCR encounters did not include extended family members.

Parents and providers shared that virtual FCR fostered a relationship between the family and care team by offering increased opportunities for engagement and information sharing. Families explained that receiving information from the team earlier in the day also helped ease them before their in-person visit in the NICU. Parents explained how virtual FCR enabled them to have clear direction and plans for their infant’s hospitalization and the necessary milestones to be achieved before discharge. Parents and providers stated that virtual FCR conversations facilitated discharge planning by allowing the collective team to work with the family to complete tasks and teachings for discharge. Care team members also believed that virtual FCR improved multidisciplinary teamwork by facilitating multidirectional conversations between all members of the care team, including the parents, resulting in a comprehensive and agreed on plan of care.

Parents and providers shared how virtual FCR promoted the clinical outcome of the neonate receiving breastmilk. They explained how FCR included daily discussions about the neonate’s growth and nutrition. Participants stated that such discussions promoted the use of breastmilk by highlighting its benefit and provided positive reinforcement for mothers as they worked on breastfeeding and pumping. Parents participated in these discussions more frequently because the option to attend FCR virtually increased their ability to join FCR. Interview data and observation data revealed that these discussions were also times to troubleshoot breastmilk feeding issues and keep the team informed of the breastmilk supply so parents would know when to bring more milk into the NICU. For example, observation data from a virtual FCR encounter noted how the mother learned during FCR that she was permitted to provide her infant with her expressed breastmilk. Before this virtual encounter, she had thought that her breastmilk was not to be consumed by her infant; however, the care team clarified this misunderstanding during FCR.

Contrary to providers’ initial concerns about potential prolonged rounds, they were pleasantly surprised to realize that virtual FCR integrated seamlessly into their workflow and did not extend the duration of rounds. Over time, providers started recognizing that it improved efficiency by allowing providers to have discussions with families during rounds rather than reaching out to them later in the day. Virtual FCR was perceived to also allow for cohesive messaging to parents. A frequently mentioned advantage of virtual FCR was that parents were more likely to attend FCR and thus be able to communicate with the multidisciplinary day shift care team, leading to fewer care plan questions directed to night shift providers, which they were sometimes unable to answer.

Maintaining privacy and complying with HIPAA were potential concerns expressed by care team providers. Participants shared that despite their original concerns about privacy, they realized that virtual FCR was no less private than in-person rounds. Observation data suggested that the care team would step aside to move the telehealth computer and the bedside team to a relatively more private location if people were nearby who should not be included in a rounding conversation. Virtual FCR did require increased vigilance, as the virtual team did not have a 360-degree view of the room. The virtual and bedside teams communicated with each other before starting intimate conversations and stayed informed about changes in the environment.

Technical challenges pertaining to video and audio existed. Providers shared they routinely made adjustments to the telehealth equipment or positioning of the speaking care team member to maximize sound and video quality. Background noises improved over time with increased awareness of the need to minimize side conversations. Another issue that improved over time was the awareness of the camera placement avoiding windows to minimize backlight effects. Observation data aligned with these findings about technical issues. Parents attending virtual FCR often had facial expressions and body language suggesting that they had challenges hearing the speaking care team member. Despite ongoing technical challenges, both providers and parents expressed a strong acceptance of virtual FCR.

Parents and providers suggested ways to improve the virtual FCR process. Users noted that a telehealth cart with a smaller footprint would be easier to maneuver. Others suggested improving the audio with a more sensitive system or by using audio sets for each member of the rounding team.

Parents and providers highlighted that, as with in-person FCR, it is important to introduce members of the team and their roles at the beginning of each virtual rounding encounter. Observation data revealed that team introductions rarely occurred both for in-person and virtual FCR. In addition, many participants expressed that some parents and providers turned off their video camera during FCR. An overwhelming majority of interviewees expressed that standard practice should be to have all users enable their video feature. Participants felt that the video made the experience more personal and made the conversation more fluid by seeing visual cues. Observation data aligned with this finding. Observation fieldnotes noted how virtual FCR encounters with parents whose camera was turned off had relatively lower parent interaction and bidirectional communication with the care team, when compared with those whose camera was turned on. During one observed FCR encounter, in which a mother participated virtually with her camera turned off, it was noted that the care team discussed her in the third person as if she were not present (virtually). This use of third-person language was not observed in other virtual FCR encounters when parents had their cameras enabled. Fieldnotes additionally highlighted that the bedside care team members consistently avoided looking at the camera when parents’ cameras were disabled, even when they were positioned directly in front of the telehealth equipment.

Participants suggested ways to enhance the advertisement of virtual FCR to facilitate accessibility. Many parents suggested reaching out to parents at various timepoints to reassess interest in using virtual FCR. As the initial shock of NICU admission eases, parents may have more bandwidth to learn about different resources and programs. Also, as admission duration lengthens, parents may be more inclined to use virtual FCR as other responsibilities increasingly keep them away from the NICU. Lastly, participants shared how social workers and nurses can play a crucial role in offering virtual FCR; these providers are in close contact with parents and may be aware of barriers that would hinder their ability to be at bedside for FCR.

Several providers expressed that the high acceptability of virtual FCR was mainly due to its delivery by a research coordinator. The coordinator provided technical support for parents and the NICU care team. Interviews and observations highlighted how parents relied on the coordinator to stay informed on approximate rounding times. The care team relied on the coordinator to let parents into the virtual encounter at the correct time to join rounds; this detail was crucial for minimizing privacy concerns. Participants expressed that the coordinator role led to efficient and timely rounds. Observation data similarly revealed that the coordinator facilitated the seamless integration of virtual FCR into rounding workflows in that the coordinator would verbally inform the care team that parents were in the virtual waiting room join. This notification would occur while the care team walked from one infant to the next infant. The care team did not take any additional steps for a virtual FCR encounter aside from acknowledging their awareness that a parent would join virtually. Care team providers shared during interviews that they could not deliver virtual FCR without a coordinator. Consequently, their inclination to use virtual FCR after the trial, and thus, without a coordinator to facilitate it, was low.

Our qualitative implementation evaluation of the virtual FCR intervention identified perceived benefits of using this intervention, as well as opportunities to improve its implementation. Virtual FCR was thought to improve care delivery and clinical outcomes through increased opportunities for parent engagement. It was perceived to provide parents with key principles of family-centered care, including collaboration, information sharing, support, and flexibility. Our parent participants ubiquitously shared that virtual FCR allowed them the flexibility they needed to participate in their infant’s care when they may not have been able to otherwise. Parents expressed how the offering of virtual FCR provided a sense of inclusion and belief that the NICU team encouraged their participation and considered them an integral part of their infant’s care team. Although both parents and providers thought virtual FCR had various benefits over in person FCR, adjustments are required in the implementation of virtual FCR to enhance usability and effectiveness. Additionally, virtual FCR should be delivered by the NICU care team to promote provider adoption and sustainability.

Virtual FCR was perceived to enhance in-person standards of FCR predominantly through enhancing core concepts of family-centered care. These concepts include listening to and honoring family perspectives, sharing timely and complete information, and encouraging family participation in patient care and decision making. 23 , 24   Despite family-centered care being the standard of care, there are barriers to its consistent use. Sigurdson et al interviewed parents to understand experiences in the NICU within a framework of family-centered care. Families discussed that socioeconomics and personal responsibilities, such as jobs and childcare, hindered their visitation to the unit. 25   Virtual FCR is a potential solution to such challenges.

The body of literature on virtual FCR in the NICU includes multiple studies wherein NICU providers virtually attended FCR at the bedside. 13 – 17   Aside from our pilot trial, 12   few trials have virtually brought family to bedside in the NICU. However, the authors of previous studies have examined virtual FCR in non-NICU settings. 26 – 32   The authors of one proof-of-concept study examined virtual FCR in the pediatric ICU among 13 families. 26   Those findings aligned with the results of our present study; parents reported that virtual FCR in the pediatric ICU provided them with reassurance about their hospitalized child’s care and improved their communication with the care team. The authors of another pediatric study examined virtual FCR use in the pediatric cardiac ICU. 32   Again, the findings aligned with our present study in that virtual FCR was perceived to not impede the care team’s workflow. The authors of other studies have tested virtual FCR for adult oncology patients. 27 , 29 – 31   Although these authors suggested that virtual FCR was well received by patients and families, barriers to adoption were noted. Provider adoption barriers included time, culture, and change in work routines. 27   Barriers to adoption among family members included the belief that physical presence was irreplaceable. 28   This finding of a preference for in-person presence did not emerge in our present study; however, many of our parent participants shared how they would join FCR virtually and subsequently visit in person later in the day. Thus, many of our parent participants used virtual FCR in addition to in-person engagement rather than a substitute for it.

Our participants perceived that virtual FCR improved care delivery. Parents and providers described how virtual FCR improved parent–provider communication, discharge readiness, and breastmilk feeding. These findings are consistent with the quantitative results from our virtual FCR randomized controlled pilot trial. 12   The qualitative interviews elucidated that the pathway to the benefits demonstrated in the pilot trial is due to increased opportunities for engagement. However, previous research suggests that not all families benefit from increased virtual connection. Remote baby viewing programs can cause some parents to experience increased anxiety. 33 , 34   As such, it is important to be aware of the subset of parents who may be harmed by virtual connections.

The potential time burden of FCR is of utmost concern to health care providers. Although parent attendance at FCR may increase rounding times, it can improve efficiency and save time later in the day. 35   Our providers similarly thought virtual FCR improved their daily workflow by reducing the amount of time spent updating parents after rounds. Our present qualitative findings are consistent with our team’s recent pilot trial quantitative data, which revealed that virtual FCR did not burden the team with longer durations of rounding times. 12  

The research coordinator’s role in coordinating virtual FCR heavily impacted the high acceptance of virtual FCR and perceived efficiency of virtual rounding. The coordinator updated families with estimated rounding times and managed the Zoom platform. However, this reliance on the coordinator posed limitations on the scalability and sustainability of virtual FCR. Also, the coordinator’s role in implementing virtual FCR not only influenced the feasibility of intervention delivery but also parents’ perceived value of FCR. This personnel resource may not be available for many NICUs. It will be important to explore other virtual platforms and implementation strategies that require less coordination and can be easily delivered by the NICU care team members. Future implementation research should investigate strategies that leverage the care team as facilitators of virtual FCR. Additionally, lower resource NICU settings might not have the equipment needed to conduct videoconferencing for virtual FCR. Research examining audio-only communication during FCR is warranted.

Research is also needed to examine the delivery and impact of virtual FCR with diverse parent populations. This study was limited to parents who used virtual FCR at least once. These parents had a preferred language of English and had access to digital equipment and internet. Interviewee demographics were also skewed toward younger individuals with a college degree. This population likely did not reflect individuals who are more likely to encounter difficulties with using virtual FCR, including those with low digital literacy, a lack of devices, or connectivity issues. The authors of additional studies need to examine how to be inclusive of diverse populations, so that all infants and their families can equitably benefit from these telehealth solutions.

Additional study limitations include that the study occurred during the coronavirus disease 2019 pandemic. Perceptions might reflect this unique pandemic context. Observation data collection was limited to a 2-month period. Ongoing observation data might have captured additional FCR practice changes over time that were not revealed in interviews. Lastly, the participants in this study only provide perspectives from individuals who successfully used the intervention to attend FCR. Perspectives from parents who did not use the intervention and who did not attend FCR during their infant’s hospitalization would have provided additional insights.

In summary, despite the promise of virtual FCR to improve care delivery and clinical outcomes, implementation strategies must be revised to enhance the usability, effectiveness, and sustainability of virtual FCR. This implementation evaluation suggests that virtual FCR is highly acceptable in the NICU but importantly, elucidated areas of improvement to maximize the impact of the intervention.

Dr Ranu conducted data collection, analysis, and interpretation, and drafted the initial manuscript; Dr Hoffman and Ms Sauers-Ford conceptualized the design of the study and conducted data analysis and interpretation; Mr Williams recruited participants and conducted data collection, analysis, and interpretation; Dr Rosenthal conceptualized the design of the study, supervised data collection, and conducted data analysis and interpretation; and all authors reviewed and revised the manuscript, approved the final manuscript as submitted, and agree to be accountable for all aspects of the work.

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• Understand the risks of polysubstance use
• Reduce stigma around recovery and treatment

Explore and download Stop Overdose and other educational materials on CDC's Overdose Resource Exchange .

• Centers for Disease Control and Prevention, National Center for Health Statistics. National Vital Statistics System, Mortality 2018-2021 on CDC WONDER Online Database, released in 2023. Data are from the Multiple Cause of Death Files, 2018-2021, as compiled from data provided by the 57 vital statistics jurisdictions through the Vital Statistics Cooperative Program. Accessed at http://wonder.cdc.gov/mcd-icd10-expanded.html on Mar 5, 2024

Every day, drugs claim hundreds of lives. The Stop Overdose website educates drug users on fentanyl, naloxone, polysubstance use, and dealing with stigma.