scholarly articles on case study research

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Case study research for better evaluations of complex interventions: rationale and challenges

• Sara Paparini   ORCID: orcid.org/0000-0002-1909-2481 1 ,
• Judith Green 2 ,
• Chrysanthi Papoutsi 1 ,
• Jamie Murdoch 3 ,
• Mark Petticrew 4 ,
• Trish Greenhalgh 1 ,
• Benjamin Hanckel 5 &
• Sara Shaw 1  

BMC Medicine volume  18 , Article number:  301 ( 2020 ) Cite this article

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The need for better methods for evaluation in health research has been widely recognised. The ‘complexity turn’ has drawn attention to the limitations of relying on causal inference from randomised controlled trials alone for understanding whether, and under which conditions, interventions in complex systems improve health services or the public health, and what mechanisms might link interventions and outcomes. We argue that case study research—currently denigrated as poor evidence—is an under-utilised resource for not only providing evidence about context and transferability, but also for helping strengthen causal inferences when pathways between intervention and effects are likely to be non-linear.

Case study research, as an overall approach, is based on in-depth explorations of complex phenomena in their natural, or real-life, settings. Empirical case studies typically enable dynamic understanding of complex challenges and provide evidence about causal mechanisms and the necessary and sufficient conditions (contexts) for intervention implementation and effects. This is essential evidence not just for researchers concerned about internal and external validity, but also research users in policy and practice who need to know what the likely effects of complex programmes or interventions will be in their settings. The health sciences have much to learn from scholarship on case study methodology in the social sciences. However, there are multiple challenges in fully exploiting the potential learning from case study research. First are misconceptions that case study research can only provide exploratory or descriptive evidence. Second, there is little consensus about what a case study is, and considerable diversity in how empirical case studies are conducted and reported. Finally, as case study researchers typically (and appropriately) focus on thick description (that captures contextual detail), it can be challenging to identify the key messages related to intervention evaluation from case study reports.

Whilst the diversity of published case studies in health services and public health research is rich and productive, we recommend further clarity and specific methodological guidance for those reporting case study research for evaluation audiences.

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The need for methodological development to address the most urgent challenges in health research has been well-documented. Many of the most pressing questions for public health research, where the focus is on system-level determinants [ 1 , 2 ], and for health services research, where provisions typically vary across sites and are provided through interlocking networks of services [ 3 ], require methodological approaches that can attend to complexity. The need for methodological advance has arisen, in part, as a result of the diminishing returns from randomised controlled trials (RCTs) where they have been used to answer questions about the effects of interventions in complex systems [ 4 , 5 , 6 ]. In conditions of complexity, there is limited value in maintaining the current orientation to experimental trial designs in the health sciences as providing ‘gold standard’ evidence of effect.

There are increasing calls for methodological pluralism [ 7 , 8 ], with the recognition that complex intervention and context are not easily or usefully separated (as is often the situation when using trial design), and that system interruptions may have effects that are not reducible to linear causal pathways between intervention and outcome. These calls are reflected in a shifting and contested discourse of trial design, seen with the emergence of realist [ 9 ], adaptive and hybrid (types 1, 2 and 3) [ 10 , 11 ] trials that blend studies of effectiveness with a close consideration of the contexts of implementation. Similarly, process evaluation has now become a core component of complex healthcare intervention trials, reflected in MRC guidance on how to explore implementation, causal mechanisms and context [ 12 ].

Evidence about the context of an intervention is crucial for questions of external validity. As Woolcock [ 4 ] notes, even if RCT designs are accepted as robust for maximising internal validity, questions of transferability (how well the intervention works in different contexts) and generalisability (how well the intervention can be scaled up) remain unanswered [ 5 , 13 ]. For research evidence to have impact on policy and systems organisation, and thus to improve population and patient health, there is an urgent need for better methods for strengthening external validity, including a better understanding of the relationship between intervention and context [ 14 ].

Policymakers, healthcare commissioners and other research users require credible evidence of relevance to their settings and populations [ 15 ], to perform what Rosengarten and Savransky [ 16 ] call ‘careful abstraction’ to the locales that matter for them. They also require robust evidence for understanding complex causal pathways. Case study research, currently under-utilised in public health and health services evaluation, can offer considerable potential for strengthening faith in both external and internal validity. For example, in an empirical case study of how the policy of free bus travel had specific health effects in London, UK, a quasi-experimental evaluation (led by JG) identified how important aspects of context (a good public transport system) and intervention (that it was universal) were necessary conditions for the observed effects, thus providing useful, actionable evidence for decision-makers in other contexts [ 17 ].

The overall approach of case study research is based on the in-depth exploration of complex phenomena in their natural, or ‘real-life’, settings. Empirical case studies typically enable dynamic understanding of complex challenges rather than restricting the focus on narrow problem delineations and simple fixes. Case study research is a diverse and somewhat contested field, with multiple definitions and perspectives grounded in different ways of viewing the world, and involving different combinations of methods. In this paper, we raise awareness of such plurality and highlight the contribution that case study research can make to the evaluation of complex system-level interventions. We review some of the challenges in exploiting the current evidence base from empirical case studies and conclude by recommending that further guidance and minimum reporting criteria for evaluation using case studies, appropriate for audiences in the health sciences, can enhance the take-up of evidence from case study research.

Case study research offers evidence about context, causal inference in complex systems and implementation

Well-conducted and described empirical case studies provide evidence on context, complexity and mechanisms for understanding how, where and why interventions have their observed effects. Recognition of the importance of context for understanding the relationships between interventions and outcomes is hardly new. In 1943, Canguilhem berated an over-reliance on experimental designs for determining universal physiological laws: ‘As if one could determine a phenomenon’s essence apart from its conditions! As if conditions were a mask or frame which changed neither the face nor the picture!’ ([ 18 ] p126). More recently, a concern with context has been expressed in health systems and public health research as part of what has been called the ‘complexity turn’ [ 1 ]: a recognition that many of the most enduring challenges for developing an evidence base require a consideration of system-level effects [ 1 ] and the conceptualisation of interventions as interruptions in systems [ 19 ].

The case study approach is widely recognised as offering an invaluable resource for understanding the dynamic and evolving influence of context on complex, system-level interventions [ 20 , 21 , 22 , 23 ]. Empirically, case studies can directly inform assessments of where, when, how and for whom interventions might be successfully implemented, by helping to specify the necessary and sufficient conditions under which interventions might have effects and to consolidate learning on how interdependencies, emergence and unpredictability can be managed to achieve and sustain desired effects. Case study research has the potential to address four objectives for improving research and reporting of context recently set out by guidance on taking account of context in population health research [ 24 ], that is to (1) improve the appropriateness of intervention development for specific contexts, (2) improve understanding of ‘how’ interventions work, (3) better understand how and why impacts vary across contexts and (4) ensure reports of intervention studies are most useful for decision-makers and researchers.

However, evaluations of complex healthcare interventions have arguably not exploited the full potential of case study research and can learn much from other disciplines. For evaluative research, exploratory case studies have had a traditional role of providing data on ‘process’, or initial ‘hypothesis-generating’ scoping, but might also have an increasing salience for explanatory aims. Across the social and political sciences, different kinds of case studies are undertaken to meet diverse aims (description, exploration or explanation) and across different scales (from small N qualitative studies that aim to elucidate processes, or provide thick description, to more systematic techniques designed for medium-to-large N cases).

Case studies with explanatory aims vary in terms of their positioning within mixed-methods projects, with designs including (but not restricted to) (1) single N of 1 studies of interventions in specific contexts, where the overall design is a case study that may incorporate one or more (randomised or not) comparisons over time and between variables within the case; (2) a series of cases conducted or synthesised to provide explanation from variations between cases; and (3) case studies of particular settings within RCT or quasi-experimental designs to explore variation in effects or implementation.

Detailed qualitative research (typically done as ‘case studies’ within process evaluations) provides evidence for the plausibility of mechanisms [ 25 ], offering theoretical generalisations for how interventions may function under different conditions. Although RCT designs reduce many threats to internal validity, the mechanisms of effect remain opaque, particularly when the causal pathways between ‘intervention’ and ‘effect’ are long and potentially non-linear: case study research has a more fundamental role here, in providing detailed observational evidence for causal claims [ 26 ] as well as producing a rich, nuanced picture of tensions and multiple perspectives [ 8 ].

Longitudinal or cross-case analysis may be best suited for evidence generation in system-level evaluative research. Turner [ 27 ], for instance, reflecting on the complex processes in major system change, has argued for the need for methods that integrate learning across cases, to develop theoretical knowledge that would enable inferences beyond the single case, and to develop generalisable theory about organisational and structural change in health systems. Qualitative Comparative Analysis (QCA) [ 28 ] is one such formal method for deriving causal claims, using set theory mathematics to integrate data from empirical case studies to answer questions about the configurations of causal pathways linking conditions to outcomes [ 29 , 30 ].

Nonetheless, the single N case study, too, provides opportunities for theoretical development [ 31 ], and theoretical generalisation or analytical refinement [ 32 ]. How ‘the case’ and ‘context’ are conceptualised is crucial here. Findings from the single case may seem to be confined to its intrinsic particularities in a specific and distinct context [ 33 ]. However, if such context is viewed as exemplifying wider social and political forces, the single case can be ‘telling’, rather than ‘typical’, and offer insight into a wider issue [ 34 ]. Internal comparisons within the case can offer rich possibilities for logical inferences about causation [ 17 ]. Further, case studies of any size can be used for theory testing through refutation [ 22 ]. The potential lies, then, in utilising the strengths and plurality of case study to support theory-driven research within different methodological paradigms.

Evaluation research in health has much to learn from a range of social sciences where case study methodology has been used to develop various kinds of causal inference. For instance, Gerring [ 35 ] expands on the within-case variations utilised to make causal claims. For Gerring [ 35 ], case studies come into their own with regard to invariant or strong causal claims (such as X is a necessary and/or sufficient condition for Y) rather than for probabilistic causal claims. For the latter (where experimental methods might have an advantage in estimating effect sizes), case studies offer evidence on mechanisms: from observations of X affecting Y, from process tracing or from pattern matching. Case studies also support the study of emergent causation, that is, the multiple interacting properties that account for particular and unexpected outcomes in complex systems, such as in healthcare [ 8 ].

Finally, efficacy (or beliefs about efficacy) is not the only contributor to intervention uptake, with a range of organisational and policy contingencies affecting whether an intervention is likely to be rolled out in practice. Case study research is, therefore, invaluable for learning about contextual contingencies and identifying the conditions necessary for interventions to become normalised (i.e. implemented routinely) in practice [ 36 ].

The challenges in exploiting evidence from case study research

At present, there are significant challenges in exploiting the benefits of case study research in evaluative health research, which relate to status, definition and reporting. Case study research has been marginalised at the bottom of an evidence hierarchy, seen to offer little by way of explanatory power, if nonetheless useful for adding descriptive data on process or providing useful illustrations for policymakers [ 37 ]. This is an opportune moment to revisit this low status. As health researchers are increasingly charged with evaluating ‘natural experiments’—the use of face masks in the response to the COVID-19 pandemic being a recent example [ 38 ]—rather than interventions that take place in settings that can be controlled, research approaches using methods to strengthen causal inference that does not require randomisation become more relevant.

A second challenge for improving the use of case study evidence in evaluative health research is that, as we have seen, what is meant by ‘case study’ varies widely, not only across but also within disciplines. There is indeed little consensus amongst methodologists as to how to define ‘a case study’. Definitions focus, variously, on small sample size or lack of control over the intervention (e.g. [ 39 ] p194), on in-depth study and context [ 40 , 41 ], on the logic of inference used [ 35 ] or on distinct research strategies which incorporate a number of methods to address questions of ‘how’ and ‘why’ [ 42 ]. Moreover, definitions developed for specific disciplines do not capture the range of ways in which case study research is carried out across disciplines. Multiple definitions of case study reflect the richness and diversity of the approach. However, evidence suggests that a lack of consensus across methodologists results in some of the limitations of published reports of empirical case studies [ 43 , 44 ]. Hyett and colleagues [ 43 ], for instance, reviewing reports in qualitative journals, found little match between methodological definitions of case study research and how authors used the term.

This raises the third challenge we identify that case study reports are typically not written in ways that are accessible or useful for the evaluation research community and policymakers. Case studies may not appear in journals widely read by those in the health sciences, either because space constraints preclude the reporting of rich, thick descriptions, or because of the reported lack of willingness of some biomedical journals to publish research that uses qualitative methods [ 45 ], signalling the persistence of the aforementioned evidence hierarchy. Where they do, however, the term ‘case study’ is used to indicate, interchangeably, a qualitative study, an N of 1 sample, or a multi-method, in-depth analysis of one example from a population of phenomena. Definitions of what constitutes the ‘case’ are frequently lacking and appear to be used as a synonym for the settings in which the research is conducted. Despite offering insights for evaluation, the primary aims may not have been evaluative, so the implications may not be explicitly drawn out. Indeed, some case study reports might properly be aiming for thick description without necessarily seeking to inform about context or causality.

Acknowledging plurality and developing guidance

We recognise that definitional and methodological plurality is not only inevitable, but also a necessary and creative reflection of the very different epistemological and disciplinary origins of health researchers, and the aims they have in doing and reporting case study research. Indeed, to provide some clarity, Thomas [ 46 ] has suggested a typology of subject/purpose/approach/process for classifying aims (e.g. evaluative or exploratory), sample rationale and selection and methods for data generation of case studies. We also recognise that the diversity of methods used in case study research, and the necessary focus on narrative reporting, does not lend itself to straightforward development of formal quality or reporting criteria.

Existing checklists for reporting case study research from the social sciences—for example Lincoln and Guba’s [ 47 ] and Stake’s [ 33 ]—are primarily orientated to the quality of narrative produced, and the extent to which they encapsulate thick description, rather than the more pragmatic issues of implications for intervention effects. Those designed for clinical settings, such as the CARE (CAse REports) guidelines, provide specific reporting guidelines for medical case reports about single, or small groups of patients [ 48 ], not for case study research.

The Design of Case Study Research in Health Care (DESCARTE) model [ 44 ] suggests a series of questions to be asked of a case study researcher (including clarity about the philosophy underpinning their research), study design (with a focus on case definition) and analysis (to improve process). The model resembles toolkits for enhancing the quality and robustness of qualitative and mixed-methods research reporting, and it is usefully open-ended and non-prescriptive. However, even if it does include some reflections on context, the model does not fully address aspects of context, logic and causal inference that are perhaps most relevant for evaluative research in health.

Hence, for evaluative research where the aim is to report empirical findings in ways that are intended to be pragmatically useful for health policy and practice, this may be an opportune time to consider how to best navigate plurality around what is (minimally) important to report when publishing empirical case studies, especially with regards to the complex relationships between context and interventions, information that case study research is well placed to provide.

The conventional scientific quest for certainty, predictability and linear causality (maximised in RCT designs) has to be augmented by the study of uncertainty, unpredictability and emergent causality [ 8 ] in complex systems. This will require methodological pluralism, and openness to broadening the evidence base to better understand both causality in and the transferability of system change intervention [ 14 , 20 , 23 , 25 ]. Case study research evidence is essential, yet is currently under exploited in the health sciences. If evaluative health research is to move beyond the current impasse on methods for understanding interventions as interruptions in complex systems, we need to consider in more detail how researchers can conduct and report empirical case studies which do aim to elucidate the contextual factors which interact with interventions to produce particular effects. To this end, supported by the UK’s Medical Research Council, we are embracing the challenge to develop guidance for case study researchers studying complex interventions. Following a meta-narrative review of the literature, we are planning a Delphi study to inform guidance that will, at minimum, cover the value of case study research for evaluating the interrelationship between context and complex system-level interventions; for situating and defining ‘the case’, and generalising from case studies; as well as provide specific guidance on conducting, analysing and reporting case study research. Our hope is that such guidance can support researchers evaluating interventions in complex systems to better exploit the diversity and richness of case study research.

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Abbreviations

Qualitative comparative analysis

Quasi-experimental design

Randomised controlled trial

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This work was funded by the Medical Research Council - MRC Award MR/S014632/1 HCS: Case study, Context and Complex interventions (TRIPLE C). SP was additionally funded by the University of Oxford's Higher Education Innovation Fund (HEIF).

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Paparini, S., Green, J., Papoutsi, C. et al. Case study research for better evaluations of complex interventions: rationale and challenges. BMC Med 18 , 301 (2020). https://doi.org/10.1186/s12916-020-01777-6

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The theory contribution of case study research designs

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The objective of this paper is to highlight similarities and differences across various case study designs and to analyze their respective contributions to theory. Although different designs reveal some common underlying characteristics, a comparison of such case study research designs demonstrates that case study research incorporates different scientific goals and collection and analysis of data. This paper relates this comparison to a more general debate of how different research designs contribute to a theory continuum. The fine-grained analysis demonstrates that case study designs fit differently to the pathway of the theory continuum. The resulting contribution is a portfolio of case study research designs. This portfolio demonstrates the heterogeneous contributions of case study designs. Based on this portfolio, theoretical contributions of case study designs can be better evaluated in terms of understanding, theory-building, theory development, and theory testing.

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1 Introduction

Case study research scientifically investigates into a real-life phenomenon in-depth and within its environmental context. Such a case can be an individual, a group, an organization, an event, a problem, or an anomaly (Burawoy 2009 ; Stake 2005 ; Yin 2014 ). Unlike in experiments, the contextual conditions are not delineated and/or controlled, but part of the investigation. Typical for case study research is non-random sampling; there is no sample that represents a larger population. Contrary to quantitative logic, the case is chosen, because the case is of interest (Stake 2005 ), or it is chosen for theoretical reasons (Eisenhardt and Graebner 2007 ). For within-case and across-case analyses, the emphasis in data collection is on interviews, archives, and (participant) observation (Flick 2009 : 257; Mason 2002 : 84). Case study researchers usually triangulate data as part of their data collection strategy, resulting in a detailed case description (Burns 2000 ; Dooley 2002 ; Eisenhardt 1989 ; Ridder 2016 ; Stake 2005 : 454). Potential advantages of a single case study are seen in the detailed description and analysis to gain a better understanding of “how” and “why” things happen. In single case study research, the opportunity to open a black box arises by looking at deeper causes of the phenomenon (Fiss 2009 ). The case data can lead to the identification of patterns and relationships, creating, extending, or testing a theory (Gomm et al. 2000 ). Potential advantages of multiple case study research are seen in cross-case analysis. A systematic comparison in cross-case analysis reveals similarities and differences and how they affect findings. Each case is analyzed as a single case on its own to compare the mechanisms identified, leading to theoretical conclusions (Vaughan 1992 : 178). As a result, case study research has different objectives in terms of contributing to theory. On the one hand, case study research has its strength in creating theory by expanding constructs and relationships within distinct settings (e.g., in single case studies). On the other hand, case study research is a means of advancing theories by comparing similarities and differences among cases (e.g., in multiple case studies).

Unfortunately, such diverging objectives are often neglected in case study research. Burns ( 2000 : 459) emphasizes: “The case study has unfortunately been used as a ‘catch –all’ category for anything that does not fit into experimental, survey, or historical methods.”

Therefore, this paper compares case study research designs. Such comparisons have been conducted previously regarding their philosophical assumptions and orientations, key elements of case study research, their range of application, and the lacks of methodological procedures in publications. (Baxter and Jack 2008 ; Dooley 2002 ; Dyer and Wilkins 1991 ; Piekkari et al. 2009 ; Welch et al. 2011 ). This paper aims to compare case study research designs regarding their contributions to theory.

Case study research designs will be analyzed regarding their various strengths on a theory continuum. Edmondson and McManus ( 2007 ) initiated a debate on whether the stage of theory fits to research questions, style of data collection, and analyses. Similarly, Colquitt and Zapata-Phelan ( 2007 ) created a taxonomy capturing facets of empirical article’s theoretical contributions by distinguishing between theory-building and theory testing. Corley and Gioia ( 2011 ) extended this debate by focusing on the practicality of theory and the importance of prescience. While these papers consider the whole range of methodological approaches on a higher level, they treat case studies as relatively homogeneous. This paper aims to delve into a deeper level of analysis by solely focusing on case study research designs and their respective fit on this theory continuum. This approach offers a more fine-grained understanding that sheds light on the diversity of case study research designs in terms of their differential theory contributions. Such a deep level of analysis on case study research designs enables more rigor in theory contribution. To analyze alternative case study research designs regarding their contributions to theory, I engage into the following steps:

First, differences between case study research designs are depicted. I outline and compare the case study research designs with regard to the key elements, esp. differences in research questions, frameworks, sampling, data collection, and data analysis. These differences result in a portfolio of various case study research designs.

Second, I outline and substantiate a theory continuum that varies between theory-building, theory development, and testing theory. Based on this continuum, I analyze and discuss each of the case study research designs with regard to their location on the theory continuum. This analysis is based on a detailed differentiation of the phenomenon (inside or outside the theory), the status of the theory, research strategy, and methods.

As a result, the contribution to the literature is a portfolio of case study research designs explicating their unique contributions to theory. The contribution of this paper lies in a fine-grained analysis of the interplay of methods and theory (van Maanen et al. 2007 ) and the methodological fit (Edmondson and McManus 2007 ) of case study designs and the continuum of theory. It demonstrates that different designs have various strengths and that there is a fit between case study designs and different points on a theory continuum. If there is no clarity as to whether a case study design aims at creating, elaborating, extending, or testing theory, the contribution to theory is difficult to identify for authors, reviewers, and readers. Consequently, this paper aims to clarify at which point of the continuum of theory case study research designs can provide distinct contributions that can be identified beyond their traditionally claimed exploratory character.

2 Differences across case study design: a portfolio approach

Only few papers have compared case study research designs so far. In all of these comparisons, the number of designs differs as well as the issues under consideration. In an early debate between Dyer and Wilkins ( 1991 ) and Eisenhardt ( 1991 ), Dyer and Wilkins compared the case study research design by Eisenhardt ( 1989 ) with “classical” case studies. The core of the debate concerns a difference between in-depth single case studies (classical case study) to a focus on the comparison of multiple cases. Dyer and Wilkins ( 1991 : 614) claim that the essence of a case study lies in the careful study of a single case to identify new relationships and, as a result, question the Eisenhardt approach which puts a lot of emphasis on comparison of multiple cases. Eisenhardt, on the contrary, claims that multiple cases allow replication between cases and is, therefore, seen as a means of corroboration of propositions (Eisenhardt 1991 ). Classical case studies prefer deep descriptions of a single case, considering the context to reveal insights into the single case and by that elaborate new theories. The comparison of multiple cases, therefore, tends—in the opinion of Dyer and Wilkens—to surface descriptions. This weakens the possibility of context-related, rich descriptions. While, in classic case study, good stories are the aim, the development of good constructs and their relationships is aimed in Eisenhardt’s approach. Eisenhardt ( 1991 : 627) makes a strong plea on more methodological rigor in case study research, while Dyer and Wilkins ( 1991 : 613) criticize that the new approach “… includes many of the attributes of hypothesis-testing research (e.g., sampling and controls).”

Dooley ( 2002 : 346) briefly takes the case study research designs by Yin (1994) and Eisenhardt ( 1989 ) as exemplars of how the processes of case study research can be applied. The approach by Eisenhardt is seen as an exemplar that advances conceptualization and operationalization in the phases of theory-building, while the approach by Yin is seen as exemplar that advances minimally conceptualized and operationalized existing theory.

Baxter and Jack ( 2008 ) describe the designs by Yin (2003) and Stake ( 1995 ) to demonstrate key elements of qualitative case study. The authors outline and carefully compare the approaches by Yin and Stake in conducting the research process, neglecting philosophical differences and theoretical goals.

Piekkari et al. ( 2009 ) outline the methodological richness of case study research using the approaches of Yin et al. (1998), and Stake. They specifically exhibit the role of philosophical assumptions, establishing differences in conventionally accepted practices of case study research in published papers. The authors analyze 135 published case studies in four international business journals. The analysis reveals that, in contrast to the richness of case study approaches, the majority of published case studies draw on positivistic foundations and are narrowly declared as explorative with a lack of clarity of the theoretical purpose of the case study. Case studies are often designed as multiple case studies with cross-sectional designs based on interviews. In addition to the narrow use of case study research, the authors find out that “… most commonly cited methodological literature is not consistently followed” (Piekkari et al. 2009 : 567).

Welch et al. ( 2011 ) develop a typology of theorizing modes in case study methods. Based on the two dimensions “contextualization” and “causal explanation”, they differentiate in their typology between inductive theory-building (Eisenhardt), interpretive sensemaking (Stake), natural experiment (Yin), and contextualised explanation (Ragin/Bhaskar). The typology is used to analyze 199 case studies from three highly ranked journals over a 10-year period for whether the theorizing modes are exercised in the practice of publishing case studies. As a result, the authors identify a strong emphasis on the exploratory function of case studies, neglecting the richness of case study methods to challenge, refine, verify, and test theories (Welch et al. 2011 : 755). In addition, case study methods are not consistently related to theory contribution: “By scrutinising the linguistic elements of texts, we found that case researchers were not always clear and consistent in the way that they wrote up their theorising purpose and process” (Welch et al. 2011 : 756).

As a result, the comparisons reveal a range of case study designs which are rarely discussed. In contrast, published case studies are mainly introduced as exploratory design. Explanatory, interpretivist, and critical/reflexive designs are widely neglected, narrowing the possible applications of case study research. In addition, comparisons containing an analysis of published case studies reveal a low degree in accuracy when applying case study methods.

What is missing is a comparison of case study research designs with regard to differences in the contribution to theory. Case study designs have different purposes in theory contribution. Confusing these potential contributions by inconsistently utilizing the appropriate methods weakens the contribution of case studies to scientific progress and, by that, damages the reputation of case studies.

To conduct such a comparison, I consider the four case study research approaches of Yin, Eisenhardt, Burawoy, and Stake for the following reasons.

These approaches are the main representatives of case study research design outlined in the comparisons elaborated above (Baxter and Jack 2008 ; Dooley 2002 ; Dyer and Wilkins 1991 ; Piekkari et al. 2009 ; Welch et al. 2011 ). I follow especially the argument by Piekkari et al. ( 2009 ) that these approaches contain a broad spectrum of methodological foundations of exploratory, explanatory, interpretivist, and critical/reflexive designs. The chosen approaches have an explicit and detailed methodology which can be reconstructed and compared with regard to their theory contribution. Although there are variations in the application of the designs, to the best of my knowledge, the designs represent the spectrum of case study methodologies. A comparison of these methodologies revealed main distinguishable differences. To highlight these main differences, I summarized these differences into labels of “no theory first”; “gaps and holes”; “social construction of reality”; and “anomalies”.

I did not consider descriptions of case study research in text books which focus more or less on general descriptions of the common characteristics of case studies, but do not emphasize differences in methodologies and theory contribution. In addition, I did not consider so-called “home grown” designs (Eisenhardt 1989 : 534) which lack a systematic and explicit demonstration of the methodology and where “… the hermeneutic process of inference—how all these interviews, archival records, and notes were assembled into a coherent whole, what was counted and what was discounted—remains usually hidden from the reader” (Fiss 2009 : 425).

Finally, although often cited in the methodological section of case studies, books are not considered which concentrate on data analysis in qualitative research per se (Miles et al. 2014 ; Corbin and Strauss 2015 ). Therefore, to analyze the contribution of case study research to the scientific development, it needs to compare explicit methodology. This comparison will be outlined in the following sections with regard to main methodological steps: the role of the case, the collection of data, and the analysis of data.

2.1 Case study research design 1: no theory first

A popular template for building theory from case studies is a paper by Eisenhardt ( 1989 ). It follows a dramaturgy with a precise order of single steps for constructing a case study and is one of the most cited papers in methods sections (Ravenswood 2011 ). This is impressive for two reasons. On the one hand, Eisenhardt herself has provided a broader spectrum of case study research designs in her own empirical papers, for example, by combining theory-building and theory elaboration (Bingham and Eisenhardt 2011 ). On the other hand, she “updated” her design in a paper with Graebner (Eisenhardt and Graebner 2007 ), particularly by extending the range of inductive theory-building. These developments do not seem to be seriously considered by most authors, as differences and elaborations of this spectrum are rarely found in publications. Therefore, in the following, I focus on the standards provided by Eisenhardt ( 1989 ) and Eisenhardt and Graebner ( 2007 ) as exemplary guidelines.

Eisenhardt follows the ideal of ‘no theory first’ to capture the richness of observations without being limited by a theory. The research question may stem from a research gap meaning that the research question is of relevance. Tentative a priori constructs or variables guide the investigation, but no relationships between such constructs or variables are assumed so far: “Thus, investigators should formulate a research problem and possibly specify some potentially important variables, with some reference to extant literature. However, they should avoid thinking about specific relationships between variables and theories as much as possible, especially at the outset of the process” (Eisenhardt 1989 : 536).

Cases are chosen for theoretical reasons: for the likelihood that the cases offer insights into the phenomenon of interest. Theoretical sampling is deemed appropriate for illuminating and extending constructs and identifying relationships for the phenomenon under investigation (Eisenhardt and Graebner 2007 ). Cases are sampled if they provide an unusual phenomenon, replicate findings from other cases, use contrary replication, and eliminate alternative explanations.

With respect to data collection, qualitative data are the primary choice. Data collection is based on triangulation, where interviews, documents, and observations are often combined. A combination of qualitative data and quantitative data is possible as well (Eisenhardt 1989 : 538). Data analysis is conducted via the search for within-case patterns and cross-case patterns. Systematic procedures are conducted to compare the emerging constructs and relationships with the data, eventually leading to new theory.

A good exemplar for this design is the investigation of technology collaborations (Davis and Eisenhardt 2011 ). The purpose of this paper is to understand processes by which technology collaborations support innovations. Eight technology collaborations among ten firms were sampled for theoretical reasons. Qualitative and quantitative data were used from semi-structured interviews, public and private data, materials provided by informants, corporate intranets, and business publications. The data was measured, coded, and triangulated. Writing case histories was a basis for within-case and cross-case analysis. Iteration between cases and emerging theory and considering the relevant literature provided the basis for the development of a theoretical framework.

Another example is the investigation of what is learned in organizational processes (Bingham and Eisenhardt 2011 ). This paper demonstrates that the case study design is not only used for theory-building, but can also be combined with theory elaboration. Based on the lenses of the organizational knowledge literature, organizational routines literature, and heuristics literature, six technology-based ventures were chosen for theoretical reasons. Several data sources were used, especially quantitative and qualitative data from semi-structured interviews, archival data, observations, e-mails, phone calls, and follow-up interviews. Within-case analysis revealed what each firm has learned from process experience. Cross-case analysis revealed emerging patterns from which tentative constructs and propositions were formed. In replication logic constructs and propositions were refined across the cases. When mirroring the findings with the literature, both the emergences of the constructs were compared and unexpected types were considered. The iteration of theory and data as well as the consideration of related research sharpened the theoretical arguments, eventually leading to a theoretical framework. “Thus, we combined theory elaboration (Lee 1999 ) and theory generation (Eisenhardt 1989 )” (Bingham and Eisenhardt 2011 : 1448).

2.2 Case study research design 2: gaps and holes

Contrary to “No Theory First”, case study research design can also aim at specifying gaps or holes in existing theory with the ultimate goal of advancing theoretical explanations (Ridder 2016 ). A well-known template for this case study research design is the book by Yin ( 2014 ). It is a method-orientated handbook of how to design single and multiple case studies with regard to this purpose. Such a case study research design includes: “A ‘how’ and ‘why’ question” (Yin 2014 : 14). Research questions can be identified and shaped using literature to narrow the interest in a specific topic, looking for key studies and identifying questions in these studies. According to Yin’s design, existing theory is the starting point of case study research. In addition, propositions or frameworks provide direction, reflect the theoretical perspective, and guide the search for relevant evidence.

There are different rationales for choosing a single case design (Yin 2014 : 51). Purposeful sampling is conducted if an extreme case or an unusual case is chosen and if rarely observable phenomena can be investigated with regard to unknown matters and their relationships. Common cases allow conclusions for a broader class of cases. Revelatory cases provide the opportunity to investigate into a previously inaccessible inquiry, and the longitudinal study enables one to investigate a single case at several points in time. A rationale for multiple case designs has its strength in replication logic (Yin 2014 : 56). In the case of literal replication, cases are selected to predict similar results. In the case of theoretical replication, cases are selected to predict contrasting results but for theoretical reasons. Yin provides several tactics to increase the reliability (protocol; data base) of the study.

Yin ( 2014 : 103) emphasizes that interviews are one of the most important sources of data collection but considers other sources of qualitative data as well. Data triangulation is designed to narrow problems of construct validity, as multiple sources of data provide multiple measures of the same phenomenon. Yin ( 2014 : 133) offers a number of data analysis strategies (e.g., case description; examining rival explanations) and analytic techniques which are apt to compare the proposed relationships with empirical patterns. Pattern-matching logic compares empirically based patterns with predicted patterns, enabling further data analysis techniques (explanation building, time series analysis, logic models, and cross-case synthesis). In analytical generalization, the theory is compared with the empirical results, leading to the modification or extension of the theory.

An appropriate model for this case study design can be identified in a paper by Ellonen et al. ( 2009 ). The paper is based on the emerging dynamic capability theory. The four cases were chosen for theoretical reasons to deliver an empirical contribution to the dynamic capability theory by investigating the relationship of dynamic capabilities and innovation outcomes. The authors followed a literal replication strategy and identified patterns between dynamic capabilities of the firms and their innovation outcomes.

Shane ( 2000 ) is an author who developed specific propositions from a framework and examined the propositions in eight entrepreneurial cases. Using several sources of interviews and archival data, the author compared the data with the propositions using the pattern-matching logic, which concluded in developing entrepreneurship theory.

2.3 Case study research design 3: social construction of reality

So far, the outlined case study research designs are based on positivist roots, but there is richness and variety in case study research stemming from different philosophical realms. The case study research design by Stake ( 1995 , 2000 , 2005 ), for example, is based on constructivist assumptions and aims to investigate the social construction of reality and meaning (Schwandt 1994 : 125).

According to this philosophical assumption, there is no unique “real world” that preexists independently of human mental activity and symbolic language. The world is a product of socially and historically related interchanges amongst people (social construction). The access to reality is given through social constructions, such as language and shared meanings: “The meaning-making activities themselves are of central interest to social constructionists/constructivists, simply because it is the meaning-making/sense making attributional activities that shape action or (inaction)” (Guba and Lincoln 2005 : 197). Therefore, the researcher is not looking for objective “facts”, nor does he aim at identifying and measuring patterns which can be generalized. Contrarily, the constructivist is researching into specific actions, in specific places, at specific times. The scientist tries to understand the construction and the sharing of meaning (Schwandt 1994 ).

According to Stake ( 2005 ), the direction of the case study is shaped by the interest in the case. In an intrinsic case study, the case itself is of interest. The purpose is not theory-building but curiosity in the case itself. In an instrumental case study, the case itself is of secondary interest. It plays a supportive role, as it facilitates the understanding of a research issue. The case can be typical of other cases. Multiple or collective case study research designs extend the instrumental case study. It is assumed that a number of cases will increase the understanding and support theorizing by comparison of the cases.

The differentiation by Stake ( 1995 , 2005 ) into intrinsic and instrumental cases guides the purposive sampling strategy. In intrinsic case studies, the case is, by definition, already selected. The researcher looks for specific characteristics, aiming for thick descriptions with the opportunity to learn. Representativeness or generalization is not considered. In instrumental case study design, purposive sampling leads to the phenomenon under investigation. In multiple case study designs, the ability to compare cases enhances the opportunity to theorize.

A case study requires an integrated, holistic comprehension of the case complexity. According to Stake ( 2005 ), the case study is constructed by qualitative data, such as observations, interviews, and documents. Triangulation first serves as clarification of meaning. Second, the researcher is interested in the diversity of perceptions.

Two methods of data analysis are considered in such qualitative case study design: direct interpretation and categorical aggregation (Stake 1995 : 74). The primary task of an intrinsic case study is to understand the case. This interpretation is offered to the reader, but the researcher has to provide the material in a sufficient way (thick descriptions), so that the reader can learn from the case as well as draw his or her own conclusions. Readers can thus make some generalizations based on personal and vicarious experiences (“naturalistic generalization”). In instrumental case studies, the understanding of phenomena and relationships leads to categorical aggregation, and the focus is on how the phenomenon exists across several cases.

Greenwood and Suddaby ( 2006 ), for example, used the instrumental case study design by Stake, combining network location theory and dialectical theory. They identified new dynamics creating a process model of elite institutional entrepreneurship.

Ituma et al. ( 2011 ) highlighted the social construction of reality in their study of career success. The majority of career studies have been conducted in Western countries and findings have been acknowledged as universally applicable. The authors demonstrated that realities of managers in other areas are constructed differently. As a result of their study, they provided a contextually sensitive frame for the analysis of career outcomes.

2.4 Case study research design 4: anomalies

Identifying anomalies as a basis for further research is common in management and organization research (Gilbert and Christensen 2005 ). In case study research, the extended case study method is used for this case study research design (Ridder 2016 ). Following Burawoy ( 1991 , 1998 , 2009 ), the research question derives from curiosity. Researchers normally look at what is “interesting” and what is “surprising” in a social situation that existing theory cannot explain. Initially, it is not important whether the expectations develop from some popular belief, stereotype, or from an academic theory. The extended case study research design is guided by anomalies that the previous theory was not able to explain through internal contradictions of theory, theoretical gaps, or silences. An anomaly does not reject theory, but rather demonstrates that the theory is incomplete. Theory is aimed to be improved by “… turning anomalies into exemplars” (Burawoy 1991 : 10).

The theoretical sampling strategy in this case study research design stems from the theoretical failure in confrontation with the site. According to the reflexive design, such cases do not favour individuals or isolated phenomena, but social situations in which a comparative strategy allows the tracing of differences across the cases to external forces.

In the extended case study, the researcher deals with qualitative data, but also considers the broader complex social situation. The researcher engages into a dialogue with the respondents (Burawoy ( 1991 , 1998 , 2009 ). An interview is an intervention into the life of a respondent. By means of mutual interaction it is possible to discover the social order under investigation. The observer has to unpack those situational experiences by means of participant observation and mutual interpretation. This situational comprehension aims at understanding divergent “voices”, reflecting the variety of respondents’ understandings of the social situation.

As in other sciences, these voices have to be aggregated. This aggregation of multiple readings of a single case is conducted by turning the aggregation into social processes: “The move from situation to process is accomplished differently in different reflexive methods, but it is always reliant on existing theory” (Burawoy 2009 : 41). Social processes are now traced to the external field as the conditions of the social processes. Consequently, this leads to the question concerning “… how those micro situations are shaped by wider structures” (Burawoy 1991 : 282). “Reflexive science insists, therefore, on studying the everyday world from the standpoint of its structuration, that is, by regarding it as simultaneously shaped by and shaping an external field of forces” (Burawoy 2009 : 42). Such social fields cannot be held constant, which undermines the idea of replication. The external field is in continuous flux. Accordingly, social forces that influence the social processes are identified, shaping the phenomenon under investigation. Extension of theory does not target representativeness as a relationship of sample and population. Generality in reflexive science is to reconstruct an existing theory: “We begin with our favorite theory but seek not confirmations but refutations that inspire us to deepen that theory. Instead of discovering grounded theory, we elaborate existing theory. We do not worry about the uniqueness of our case, since we are not as interested in its representativeness as its contribution to reconstructing theory. Our theoretical point of departure can range from the folk theory of participants to any abstract law. We consider only that the scientist consider it worth developing” (Burawoy 2009 : 43). Such elaboration stems from the identification of anomalies and offers new predictions with regard to the theory.

It is somewhat surprising that the extended case study design has been neglected in the management literature so far, and it appears that critical reflexive principles have to be resurrected as they have been in other disciplines (see the overview at Wadham and Warren 2014 ). Examples in the management and organization literature are rare. Danneels ( 2011 ) used the extended case study design to extend the dynamic capabilities theory. In his famous Smith Corona case, Danneels shows how a company tried to change its resource base. Based on detailed data, the Smith Corona case provides insights into the resource alteration processes and how dynamic capabilities operate. As a result, the paper fills a process gap in dynamic capability theory. Iterating between data collection and analysis, Danneels revealed resource cognition as an element not considered so far in dynamic capability theory. The use of the extended case study method is limited to the iteration of data and theory. First, there is “running exchange” (Burawoy 1991 : 10) between field notes and analysis. Second, there is iteration between analysis and existing theory. Unlike Burawoy, who aims to reconstruct existing theory on the basis of “emergent anomalies” (Burawoy 1991 : 11) considering social processes and external forces, Danneels confronts the dynamic capabilities literature with the Smith Corona case to extend the theory of dynamic capabilities.

2.5 A comparison of case study research processes

Commonalities and differences emerged from the comparison of the designs. Table  1 provides a brief summary of these main differences and the resulting portfolio of case study research designs which will be discussed in more detail.

There is an extensive range between the different designs regarding the research processes. In “no theory first”, there is a broad and tentative research question with some preliminary variables at the outset. The research question may be modified during the study as well as the variables. This design avoids any propositions regarding relationships.

On the contrary, the research question in “gaps and holes” is strongly related to existing theory, focusing on “how and why” questions. The existing theory contains research gaps which, once identified within the existing theory, lead accordingly to assumed relationships which are the basis for framework and propositions to be matched by empirical data. This broad difference is even more elaborated by a design that aims the “social construction of reality”. There is no research question at the outset, but a curiosity in the case or the case is a facilitator to understand a research issue. This is far away from curiosity in the “anomaly approach”. Here, the research question is inspired by questioning why an anomaly cannot be explained by the existing theory. What kind of gaps, silences, or internal contradictions demonstrates the insufficiency of the existing theory?

Various sampling strategies are used across these case study research designs, including theoretical sampling and purposeful sampling, which serve different objectives. Theoretical sampling in “no theory first” aims at selecting a case or cases that are appropriate to highlight new or extend preliminary constructs and reveal new relationships. There is a distinct difference from theoretical sampling in the “anomalies” approach. Such a sampling strategy aims to choose a case that is a demonstration of the failure of the theory. In “gaps and holes” sampling is highly focused on the purpose of the case study. Extreme and unusual cases have other purposes compared to common cases or revelatory cases. A single case may be chosen to investigate deeply into new phenomena. A multiple case study may serve a replication logic by which the findings have relevance beyond the cases under investigation. In “social construction of reality”, the sampling is purposeful as well, but for different reasons. Either the case is of interest per se or the case represents a good opportunity to understand a theoretical issue.

Although qualitative data are preferred in all of the designs, quantitative data are seen as a possible opportunity to strengthen cases by such data. Nevertheless, in “social construction of reality”, there is a strong emphasis on thick descriptions and a holistic understanding of the case. This is in contrast to a more construct- and variable- oriented collection of data in “no theory first” and “gaps and holes”. In addition, in contrast to that, the “anomaly” approach is the only design that receives data from dialogue between observer and participants and participant observation.

Finally, data analysis lies within a wide range. In “no theory first”, the research process is finalized by inspecting the emerging constructs within the case or across cases. Based on a priory constructs, systematic comparisons reveal patterns and relationships resulting in a tentative theory. On the contrary, in “gaps and holes”, a tentative theory exists. The final analysis concentrates on the matching of the framework or propositions with patterns from the data. While both of these approaches condense data, the approach of “social construction of reality” ends the research process with thick descriptions of the case to learn from the case or with categorical comparisons. In the “anomaly” approach, the data analysis is aggregation of data, but these aggregated data are related to its external field and their pressures and influences by structuration to reconstruct the theory.

As a result, it is unlikely that the specified case study designs contribute to theory in a homogeneous manner. This result will be discussed in light of the question regarding how these case study designs can inform theory at several points of a continuum of theory. This analysis will be outlined in the following sections. In a first step, I review the main elements of a theory continuum. In a second step, I discuss the respective contribution of the previously identified case study research designs to the theory continuum.

3 Elements of a theory continuum

What a theory is and what a theory is not is a classic debate (Sutton and Staw 1995 ; Weick 1995 ). Often, theories are described in terms of understanding relationships between phenomena which have not been or were not well understood before (Chiles 2003 ; Edmondson and McManus 2007 ; Shah and Corley 2006 ), but there is no overall acceptance as to what constitutes a theory. Theory can be seen as a final product or as a continuum, and there is an ongoing effort to define different stages of this continuum (Andersen and Kragh 2010 ; Colquitt and Zapata-Phelan 2007 ; Edmondson and McManus 2007 ; Snow 2004 ; Swedberg 2012 ). In the following section, basic elements of the theory and the construction of the theory continuum are outlined.

3.1 Basic elements of a theory

Most of the debate concerning what a theory is comprises three basic elements (Alvesson and Kärreman 2007 ; Bacharach 1989 ; Dubin 1978 ; Kaplan 1998 ; Suddaby 2010 ; Weick 1989 , 1995 ; Whetten 1989 ). A theory comprises components (concepts and constructs), used to identify the necessary elements of the phenomenon under investigation. The second is relationships between components (concepts and constructs), explaining the how and whys underlying the relationship. Third, temporal and contextual boundaries limit the generalizability of the theory. As a result, definitions of theory emphasize these components, relationships, and boundaries:

“It is a collection of assertions, both verbal and symbolic, that identifies what variables are important for what reasons, specifies how they are interrelated and why, and identifies the conditions under which they should be related or not related” (Campbell 1990 : 65).

“… a system of constructs and variables in which the constructs are related to each other by propositions and the variables are related to each other by hypotheses” (Bacharach 1989 : 498).

“Theory is about the connections among phenomena, a story about why acts, events, structure, and thoughts occur. Theory emphasizes the nature of causal relationships, identifying what comes first as well as the timing of such events” (Sutton and Staw 1995 : 378).

“… theory is a statement of concepts and their interrelationships that shows how and/or why a phenomenon occurs” (Corley and Gioia 2011 : 12).

The terms “constructs” and “concepts” are either used interchangeably or with different meanings. Positivists use “constructs” as a lens for the observation of a phenomenon (Suddaby 2010 ). Such constructs have to be operationalized and measured. Non-positivists often use the term “concept” as a more value neutral term in place of the term construct (Gioia et al. 2013 ; Suddaby 2010 : 354). Non-positivists aim at developing concepts on the basis of data that contain richness and complexity of the observed phenomenon instead of narrow definitions and operationalizations of constructs. Gioia et al. ( 2013 : 16) clarify the demarcation line between constructs and concepts as follows: “By ‘concept,’ we mean a more general, less well-specified notion capturing qualities that describe or explain a phenomenon of theoretical interest. Put simply, in our way of thinking, concepts are precursors to constructs in making sense of organizational worlds—whether as practitioners living in those worlds, researchers trying to investigate them, or theorists working to model them”.

In sum, theories are a systematic combination of components and their relationships within boundaries. The use of the terms constructs and concepts is related to different philosophical assumptions reflected in different types of case study designs.

3.2 Theory continuum

Weick ( 1995 ) makes an important point that theory is more a continuum than a product. In his view, theorizing is a process containing assumptions, accepted principles, and rules of procedures to explain or predict the behavior of a specified set of phenomena. In similar vein, Gilbert and Christensen ( 2005 ) demonstrate the process character of theory. In their view, a first step of theory building is a careful description of the phenomena. Having already observed and described the phenomena, researchers then classify the phenomena into similar categories. In this phase a framework defines categories and relationships amongst phenomena. In the third phase, researchers build theories to understand (causal) relationships, and in this phase, a model or theory asserts what factors drive the phenomena and under what circumstances. The categorization scheme enables the researchers to predict what they will observe. The “test” offers a confirmation under which circumstances the theory is useful. The early drafts of a theory may be vague in terms of the number and adequateness of factors and their relationships. At the end of the continuum, there may be more precise variables and predicted relationships. These theories have to be extended by boundaries considering time and space.

Across that continuum, different research strategies have various strengths. Several classifications in the literature intend to match research strategies to the different phases of a theory continuum (Andersen and Kragh 2010 ; Colquitt and Zapata-Phelan 2007 ; Edmondson and McManus 2007 ; Snow 2004 ; Swedberg 2012 ). These classifications, although there are differences in terms, comprise three phases with distinguishable characteristics.

3.2.1 Building theory

Here, the careful description of the phenomena is the starting point of theorizing. For example, Snow ( 2004 ) puts this phase as theory discovery, where analytic understandings are generated by means of detailed examination of data. Edmondson and McManus ( 2007 ) state the starting phase of a theory as nascent theory providing answers to new questions revealing new connections among phenomena. Therefore, research questions are open and researchers avoid hypotheses predicting relationships between variables. Swedberg ( 2012 ) highlights the necessity of observation and extensive involvement with the phenomenon at the early stage of theory-building. It is an attempt to understand something of interest by observing and interpreting social facts. Creativity and inspiration are necessary conditions to put observations into concepts and outline a tentative theory.

3.2.2 Developing theory

This tentative theory exists in the second phase of the continuum and has to be developed. Several possibilities exist. In theory extension, the preexisting constructs are extended to other groups or other contexts. In theoretical refinement, a modification of existing theoretical perspectives is conducted (Edmondson and McManus ( 2007 ). New antecedents, moderators, mediators, and outcomes are investigated, enhancing the explanation power of the tentative theory.

3.2.3 Test of theories

Constructs and relationships are well developed to a mature state; measures are precise and operationalized. Such theories are empirically tested with elaborate methods, and research questions are more precise. In the quantitative realm, testing of hypotheses is conducted and statistical analysis is the usual methodological foundation. Recently, researchers criticize that testing theories has become the major focus of scientists today (Delbridge and Fiss 2013 ); testing theories does not only happen to mature theory but to intermediate theory as well. The boundary between theory development and theory testing is not always so clear. While theory development is adding new components to a theory and elaborating the measures, testing a theory implies precise measures, variables, and predicted relationships considering time and space (Gilbert and Christensen ( 2005 ). It will be of interest whether case studies are eligible to test theories as well.

To summarize: there is a conversation as to where on a continuum of theory development, various methods are required to target different contributions to theory (methodological fit). In this discussion, case study research designs have been discussed as a homogeneous set that mostly contributes to theory-building in an exploratory manner. Hence, what is missing is a more differentiated analysis of how case study methodology fits into this conversation, particularly how case study research methodologically fits theory development and theory testing beyond its widely assumed explorative role. In the following section, the above types of case study research designs will be discussed with regard to their positions across the theory continuum.

This distinction adds to existing literature by demonstrating that case study research does not only contribute to theory-building, but also to the development of tentative theories and to the testing of theories. This distinction leads to the next question: is there any interplay between case study research designs and their contributions to the theory continuum? This paper aims at reconciling this interplay with regard to case study design by mirroring phases of a theory continuum with specific types of case study research designs as outlined above. The importance of the interplay between theory and method lies in the capacity to generate and shape theory, while theory can generate and shape method. “In this long march, theory and method surely matter, for they are the tools with which we build both our representations and understandings of organizational life and our reputations” (van Maanen et al. 2007 : 1145). Theory is not the same as methods, but a relationship of this interplay can broaden or restrict both parts of the equation (Swedberg 2012 : 7).

In the following, I discuss how the above-delineated case study research designs unfold their capacities and contribute differently to the theory continuum to build, develop, and test theory.

4 Discussion of the contribution of case study research to a theory continuum

Case study research is diverse with distinct contributions to the continuum of theory. The following table provides the main differences in terms of contributions to theory and specifically locates the case study research designs on the theory continuum (Table  2 ).

In the following, I outline how these specific contributions of case study designs provide better opportunities to enhance the rigor of building theory, developing theory, testing, and reconstructing theory.

4.1 Building theory

In building theory, the phenomenon is new or not understood so far. There is no theory which explains the phenomenon. At the very beginning of the theory continuum, there is curiosity in the phenomenon itself. I focus on the intrinsic case study design which is located in the social construction of reality approach on the very early phase of the theory continuum, as intrinsic case study research design is not theory-building per se but curiosity in the case itself. It is not the purpose of the intrinsic case study to identify abstract concepts and relationships; the specific research strategy lies in the observation and description of a case and the primary method is observation, enabling understanding from personal and vicarious experience. This meets long lasting complaints concerning the lack of (new) theory in management and organization research and signals that the gap between research and management practice is growing. It is argued that the complexity of the reality is not adequately captured (Suddaby et al. 2011 ). It is claimed that management and organization research systematically neglect the dialogue with practice and, as a result, miss new trends or recognize important trends with delay (Corley and Gioia 2011 ).

The specific case study research design’s contribution to theory is in building concrete, context-dependent knowledge with regard to the identification of new phenomena and trends. Openness with regard to the new phenomena, avoiding theoretical preconceptions but building insights out of data, enables the elaboration of meanings and the construction of realities in intrinsic case studies. Intrinsic case studies will enhance the understanding by researcher and reader concerning new phenomena.

The “No Theory First” case study research design is a classic and often cited candidate for building theory. As the phenomenon is new and in the absence of a theory, qualitative data are inspected for aggregation and interpretation. In instrumental case study design, a number of cases will increase the understanding and support building theories by description, aggregation, and interpretation (Stake 2000 ). New themes and concepts are revealed by case descriptions, interviews, documents, and observations, and the analysis of the data enables the specific contribution of the case study design through a constructivist perspective in theory-building.

Although the design by Eisenhardt ( 1989 ) stems from other philosophical assumptions and there are variations and developments in this design, there is still an overwhelming tendency to quote and to stick to her research strategy which aims developing new constructs and new relationships out of real-life cases. Data are collected mainly by interviews, documents, and observations. From within-site analysis and cross-case analysis, themes, concepts, and relationships emerge. Shaping hypotheses comprises: “… refining the definition of the construct and (…) building evidence which measures the construct in each case” (Eisenhardt 1989 : 541). Having identified the emerged constructs, the emergent relationships between constructs are verified in each case. The underlying logic is validation by replication. Cases are treated as experiments in which the hypotheses are replicated case by case. In replication logic cases that confirm the emergent relationships enhance confidence in the validity of the relationships. Disconfirmation of the relationships leads to refinement of the theory. This is similar to Yin’s replication logic, but targets the precision and measurement of constructs and the emerging relationships with regard to the emerging theory. The building of a theory concludes in an understanding of the dynamics underlying the relationship; the primary theoretical reasons for why the relationships exist (Huy 2012 ). Finally, a visual theory with “boxes and arrows” (Eisenhardt and Graebner 2007 ) may visually demonstrate the emerged theory. The theory-building process is finalized by iterating case data, emerging theory, and extant literature.

The “No Theory First” and “Social Construction of Reality” case study research designs, although they represent different philosophical assumptions, adequately fit the theory-building phase concerning new phenomena. The main contribution of case study designs in this phase of the theory continuum lies in the generation of tentative theories.

Case studies at this point of the theory continuum, therefore, have to demonstrate: why the phenomenon is new or of interest; that no previous theory that explains the phenomenon exists; how and why detailed descriptions enhance the understanding of the phenomenon; and how and why new concepts (constructs) and new relationships will enhance our understanding of the phenomenon.

As a result, it has to be demonstrated that the research strategy is in sync with an investigation of a new phenomenon, building a tentative theory.

4.2 Developing theory

In the “Gaps and Holes” case study research design, the phenomenon is partially understood. There is a tentative theory and the research strategy is theory driven. Compared to the theory-building phase, the existence and not the development of propositions differentiate this design along the continuum. The prediction comes first, out of an existing theory. The research strategy and the data have to be confronted by pattern-matching. Pattern-matching is a means to compare the theoretically based predictions with the data in the site: “For case study analysis, one of the most preferred techniques is to use a pattern-matching logic. Such a logic (…) compares an empirically based pattern–that is, one based on the findings from your case study–with a predicted one made before you collected your data (….)” (Yin 2014 : 143). The comparison of propositions and the rich case material is the ground for new elements or relationships within the tentative theory.

Such findings aim to enhance the scientific usefulness of the theory (Corley and Gioia 2011 ). To enhance the validity of the new elements or relationships of the tentative theory, literal replication is a means to confirm the new findings. By that, the theory is developed by new antecedents, moderators, mediators, or outcomes. This modification or extension of the theory contributes to the analytical generalization of the theory.

If new cases provide similar results, the search for regularities is based on more solid ground. Therefore, the strength of case study research in “Gaps and Holes” lies in search for mechanisms in their specific context which can reveal causes and effects more precisely.

The “Gaps and Holes” case study research design is an adequate candidate for this phase of the theory continuum. Case studies at this point of the theory continuum, therefore, have to outline the tentative theory; to demonstrate the lacks and gaps of the tentative theory; to specify how and why the tentative theory is aimed to be extended and/or modified; to develop theoretically based propositions which guide the investigation; and to evaluate new elements, relationships, and mechanisms related to the previous theory (analytical generalization).

As a result and compared to theory-building, a different research strategy exists. While in theory building the research strategy is based on the eliciting of concepts (constructs) and relationships out of data, in theory development, it has to be demonstrated that the research strategy aims to identify new elements and relationships within a tentative theory, identifying mechanisms which explain the phenomenon more precisely.

4.3 Test of theory

In “Gaps and Holes” and “Anomalies”, an extended theory exists. The phenomenon is understood. There is no search for additional components or relationships. Mechanisms seem to explain the functioning or processes of the phenomenon. The research strategy is focused on testing whether the theory holds under different circumstances or under different conditions. Such a test of theories is mainly the domain of experimental and quantitative studies. It is based on previously developed constructs and variables which are the foundation for stating specific testable hypotheses and testing the relations on the basis of quantitative data sets. As a result, highly sophisticated statistical tools enable falsification of the theory. Therefore, testing theory in “Gaps and Holes” is restricted on specific events.

Single case can serve as a test. There is a debate in case study research whether the test of theories is related to the falsification logic of Karl Popper (Flyvbjerg 2006 ; Tsang 2013 ). Another stream of the debate is related to theoretical generalizability (Hillebrand et al. 2001 ; Welch et al. 2011 ). More specifically, test in” Gaps and Holes” is analogous to a single experiment if a single case represents a critical case. If the theory has specified a clear set of propositions and defines the exact conditions within which the theory might explain the phenomena under investigation, a single case study, testing the theory, can confirm or challenge the theory. In sum Yin states: “Overall, the single-case design is eminently justifiable under certain conditions—where the case represents (a) a critical test of existing theory, …” (Yin 2014 : 56). In their survey in the field of International Business, Welch et al. conclude: “In addition, the widespread assumption that the role of the case study lies only in the exploratory, theory-building phase of research downplays its potential to propose causal mechanisms and linkages, and test existing theories” (Welch et al. 2011 : 755).

In multiple case studies, a theoretical replication is a test of theory by comparing the findings with new cases. If a series of cases have revealed pattern-matching between propositions and the data, theoretical replication can be revealed by new waves of cases with contrasting propositions. If the contrasting propositions reveal contrasting results, the findings of the first wave are confirmed. Several possibilities exist to test the initial findings of multiple case studies using different lenses from inside and outside the management realm (Corley and Gioia 2011 ; LePine and Wilcox-King 2010 ; Okhuysen and Bonardi 2011 ; Zahra and Newey 2009 ), but have not become a standard in case study research.

In rival explanations, rival theoretical propositions are developed as a test of the previous theory. This can be distinguished from theoretical replication where contrasting propositions aim to confirm the initial findings. This can, as well, be distinguished from developing theory where rival explanations might develop theory by the elimination of possible influences (interventions, implementations). The rich data enable one to identify internal and external interventions that might be responsible for the findings. Alternative explanations in a new series of cases enable to test, whether a theory “different from the original theory explains the results better (…)” (Yin 2014 : 141).

As a result, it astonishes that theoretical replication and rival explanations, being one of the strengths of case study research, are rarely used. Although the general debate about “lenses” has informed the discussion about theory contributions, this paper demonstrates that there is a wide range of possible integration of vertical or horizontal lenses in case study research design. Case study research designs aiming to test theories have to outline modes of replication and the elimination of rival explanations.

The “anomaly approach” is placed in the final phase of the theory testing, as well. In this approach, a theory exists, but the theory fails to explain anomalies. Burawoy goes a step further. While Yin ( 2014 ) sees a critical case as a test that challenges or contradicts a well formulated theory, in Burawoy’s approach, in contrast to falsification logic (Popper 2002 ), the theory is not rejected but reconstructed. Burawoy relates extended case study design to society and history. Existing theory is challenged by intervention into the social field. Identifying processes of historical roots and social circumstances and considering external forces by structuration lead to the reconstruction of the theory.

It is surprising that this design has been neglected so far in management research. Is there no need to reflect social tensions and distortions in management research? While case study research has, per definition, to investigate phenomena in its natural environment, it is hard to understand why this design has widely been ignored in management and organization research. As a result, testing theory in case study research has to demonstrate that an extended theory exists; a critical case or an anomaly can challenge the theory; theoretical replication and rival explanations will be means to contradict or confirm the theory; and societal circumstances and external forces explain the anomaly.

Compared to theory-building (new concepts/constructs and relationships out of data) and theory development (new elements and relationships within a tentative theory), testing theory challenges extended theory by empirical investigations into failures and anomalies that the current theory cannot explain.

5 Conclusion

Case studies provide a better understanding of phenomena regarding concrete context-dependent knowledge (Andersen and Kragh 2010 ; Flyvbjerg 2006 : 224), but as literature reviews indicate, there is still confusion regarding the adequate utilization of case study methodology (Welch et al. 2011 ). This can be interpreted in a way that authors and even reviewers are not always aware of the methodological fit in case study research. Case study research is mainly narrowed to its “explorative” function, neglecting the scope of possibilities that case study research provides. The claim for more homogeneity of specified rules in case study research misses the important aspect that a method is not a means in itself, but aims at providing improved theories (van Maanen et al. 2007 ). This paper contributes to the fit of case study research designs and the theory continuum regarding the following issues.

5.1 Heterogeneity of case study designs

Although case study research, overall, has similar characteristics, it incorporates various case study research designs that have heterogeneous theoretical goals and use various elements to reach these goals. The analysis revealed that the classical understanding, whereby case study research is adequate for the “exploration” of a theory and quantitative research is adequate for “testing” theory, is oversimplified. Therefore, the theoretical goals of case study research have to be outlined precisely. This study demonstrates that there is variety of case study research designs that have thus far been largely neglected. Case study researchers can utilize the entire spectrum, but have to consider how the phenomenon is related to the theory continuum.

Case study researchers have to demonstrate how they describe new or surprising phenomena, develop new constructs and relationships, add constructs (variables), antecedents, outcomes, moderators, or mediators to a tentative theory, challenge a theory by a critical case, theoretical replication or discarding rival explanations, and reconstruct a theory by tracking failures and anomalies to external circumstances.

5.2 Methodological fit

The rigor of the case study can be enhanced by considering the specific contribution of various case study research designs in each phase of the theory continuum. This paper provides a portfolio of case study research designs that enables researchers and reviewers to evaluate whether the case study arsenal has been adequately located:

At an early phase of the theory continuum, case studies have their strengths in rich descriptions and investigations into new or surprising empirical phenomena and trends. Researchers and readers can benefit from such rich descriptions in understanding and analyzing these phenomena.

Next, on the theory continuum, there is the well-known contribution of case study research in building tentative theory by eliciting constructs or concepts and their relationships out of data.

Third, development of theories is strongly related to literal replication. Strict comparisons, on the one hand, and controlled theoretical advancement, on the other hand, enable the identification of mechanisms, strengthen the notions of causality, and provide generalizable statements.

Fourth, there are specific circumstances under which case study approaches enable one to test theories. This is to confront the theory with a critical case, to test findings of pattern-matching by theoretical replication and discarding rival explanations. Therefore, “Gaps and Holes” provide the opportunity for developing and testing theories through case study design on the theory continuum.

Finally, testing and contradicting theory are not the final rejection of a theory, but is the basis for reconstructing theory by means of case study design. Anomalies can be traced to historical sources, social processes, and external forces.

This paper demonstrates that the precise interplay of case study research designs and theory contributions on the theory continuum is a prerequisite for the contribution of case study research to better theories. If case study research design is differentiated from qualitative research, the intended contribution to theory is stated and designs that fit the aimed contribution to theory are outlined and substantiated; this will critically enhance the rigor of case study research.

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Case study research: opening up research opportunities

RAUSP Management Journal

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The case study approach has been widely used in management studies and the social sciences more generally. However, there are still doubts about when and how case studies should be used. This paper aims to discuss this approach, its various uses and applications, in light of epistemological principles, as well as the criteria for rigor and validity.

Design/methodology/approach

This paper discusses the various concepts of case and case studies in the methods literature and addresses the different uses of cases in relation to epistemological principles and criteria for rigor and validity.

The use of this research approach can be based on several epistemologies, provided the researcher attends to the internal coherence between method and epistemology, or what the authors call “alignment.”

Originality/value

This study offers a number of implications for the practice of management research, as it shows how the case study approach does not commit the researcher to particular data collection or interpretation methods. Furthermore, the use of cases can be justified according to multiple epistemological orientations.

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Takahashi, A.R.W. and Araujo, L. (2020), "Case study research: opening up research opportunities", RAUSP Management Journal , Vol. 55 No. 1, pp. 100-111. https://doi.org/10.1108/RAUSP-05-2019-0109

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Copyright © 2019, Adriana Roseli Wünsch Takahashi and Luis Araujo.

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1. Introduction

The case study as a research method or strategy brings us to question the very term “case”: after all, what is a case? A case-based approach places accords the case a central role in the research process ( Ragin, 1992 ). However, doubts still remain about the status of cases according to different epistemologies and types of research designs.

Despite these doubts, the case study is ever present in the management literature and represents the main method of management research in Brazil ( Coraiola, Sander, Maccali, & Bulgacov, 2013 ). Between 2001 and 2010, 2,407 articles (83.14 per cent of qualitative research) were published in conferences and management journals as case studies (Takahashi & Semprebom, 2013 ). A search on Spell.org.br for the term “case study” under title, abstract or keywords, for the period ranging from January 2010 to July 2019, yielded 3,040 articles published in the management field. Doing research using case studies, allows the researcher to immerse him/herself in the context and gain intensive knowledge of a phenomenon, which in turn demands suitable methodological principles ( Freitas et al. , 2017 ).

Our objective in this paper is to discuss notions of what constitutes a case and its various applications, considering epistemological positions as well as criteria for rigor and validity. The alignment between these dimensions is put forward as a principle advocating coherence among all phases of the research process.

This article makes two contributions. First, we suggest that there are several epistemological justifications for using case studies. Second, we show that the quality and rigor of academic research with case studies are directly related to the alignment between epistemology and research design rather than to choices of specific forms of data collection or analysis. The article is structured as follows: the following four sections discuss concepts of what is a case, its uses, epistemological grounding as well as rigor and quality criteria. The brief conclusions summarize the debate and invite the reader to delve into the literature on the case study method as a way of furthering our understanding of contemporary management phenomena.

2. What is a case study?

The debate over what constitutes a case in social science is a long-standing one. In 1988, Howard Becker and Charles Ragin organized a workshop to discuss the status of the case as a social science method. As the discussion was inconclusive, they posed the question “What is a case?” to a select group of eight social scientists in 1989, and later to participants in a symposium on the subject. Participants were unable to come up with a consensual answer. Since then, we have witnessed that further debates and different answers have emerged. The original question led to an even broader issue: “How do we, as social scientists, produce results and seem to know what we know?” ( Ragin, 1992 , p. 16).

An important step that may help us start a reflection on what is a case is to consider the phenomena we are looking at. To do that, we must know something about what we want to understand and how we might study it. The answer may be a causal explanation, a description of what was observed or a narrative of what has been experienced. In any case, there will always be a story to be told, as the choice of the case study method demands an answer to what the case is about.

A case may be defined ex ante , prior to the start of the research process, as in Yin’s (2015) classical definition. But, there is no compelling reason as to why cases must be defined ex ante . Ragin (1992 , p. 217) proposed the notion of “casing,” to indicate that what the case is emerges from the research process:

Rather than attempt to delineate the many different meanings of the term “case” in a formal taxonomy, in this essay I offer instead a view of cases that follows from the idea implicit in many of the contributions – that concocting cases is a varied but routine social scientific activity. […] The approach of this essay is that this activity, which I call “casing”, should be viewed in practical terms as a research tactic. It is selectively invoked at many different junctures in the research process, usually to resolve difficult issues in linking ideas and evidence.

In other words, “casing” is tied to the researcher’s practice, to the way he/she delimits or declares a case as a significant outcome of a process. In 2013, Ragin revisited the 1992 concept of “casing” and explored its multiple possibilities of use, paying particular attention to “negative cases.”

According to Ragin (1992) , a case can be centered on a phenomenon or a population. In the first scenario, cases are representative of a phenomenon, and are selected based on what can be empirically observed. The process highlights different aspects of cases and obscures others according to the research design, and allows for the complexity, specificity and context of the phenomenon to be explored. In the alternative, population-focused scenario, the selection of cases precedes the research. Both positive and negative cases are considered in exploring a phenomenon, with the definition of the set of cases dependent on theory and the central objective to build generalizations. As a passing note, it is worth mentioning here that a study of multiple cases requires a definition of the unit of analysis a priori . Otherwise, it will not be possible to make cross-case comparisons.

These two approaches entail differences that go beyond the mere opposition of quantitative and qualitative data, as a case often includes both types of data. Thus, the confusion about how to conceive cases is associated with Ragin’s (1992) notion of “small vs large N,” or McKeown’s (1999) “statistical worldview” – the notion that relevant findings are only those that can be made about a population based on the analysis of representative samples. In the same vein, Byrne (2013) argues that we cannot generate nomothetic laws that apply in all circumstances, periods and locations, and that no social science method can claim to generate invariant laws. According to the same author, case studies can help us understand that there is more than one ideographic variety and help make social science useful. Generalizations still matter, but they should be understood as part of defining the research scope, and that scope points to the limitations of knowledge produced and consumed in concrete time and space.

Thus, what defines the orientation and the use of cases is not the mere choice of type of data, whether quantitative or qualitative, but the orientation of the study. A statistical worldview sees cases as data units ( Byrne, 2013 ). Put differently, there is a clear distinction between statistical and qualitative worldviews; the use of quantitative data does not by itself means that the research is (quasi) statistical, or uses a deductive logic:

Case-based methods are useful, and represent, among other things, a way of moving beyond a useless and destructive tradition in the social sciences that have set quantitative and qualitative modes of exploration, interpretation, and explanation against each other ( Byrne, 2013 , p. 9).

Other authors advocate different understandings of what a case study is. To some, it is a research method, to others it is a research strategy ( Creswell, 1998 ). Sharan Merrian and Robert Yin, among others, began to write about case study research as a methodology in the 1980s (Merrian, 2009), while authors such as Eisenhardt (1989) called it a research strategy. Stake (2003) sees the case study not as a method, but as a choice of what to be studied, the unit of study. Regardless of their differences, these authors agree that case studies should be restricted to a particular context as they aim to provide an in-depth knowledge of a given phenomenon: “A case study is an in-depth description and analysis of a bounded system” (Merrian, 2009, p. 40). According to Merrian, a qualitative case study can be defined by the process through which the research is carried out, by the unit of analysis or the final product, as the choice ultimately depends on what the researcher wants to know. As a product of research, it involves the analysis of a given entity, phenomenon or social unit.

Thus, whether it is an organization, an individual, a context or a phenomenon, single or multiple, one must delimit it, and also choose between possible types and configurations (Merrian, 2009; Yin, 2015 ). A case study may be descriptive, exploratory, explanatory, single or multiple ( Yin, 2015 ); intrinsic, instrumental or collective ( Stake, 2003 ); and confirm or build theory ( Eisenhardt, 1989 ).

both went through the same process of implementing computer labs intended for the use of information and communication technologies in 2007;

both took part in the same regional program (Paraná Digital); and

they shared similar characteristics regarding location (operation in the same neighborhood of a city), number of students, number of teachers and technicians and laboratory sizes.

However, the two institutions differed in the number of hours of program use, with one of them displaying a significant number of hours/use while the other showed a modest number, according to secondary data for the period 2007-2013. Despite the context being similar and the procedures for implementing the technology being the same, the mechanisms of social integration – an idiosyncratic factor of each institution – were different in each case. This explained differences in their use of resource, processes of organizational learning and capacity to absorb new knowledge.

On the other hand, multiple case studies seek evidence in different contexts and do not necessarily require direct comparisons ( Stake, 2003 ). Rather, there is a search for patterns of convergence and divergence that permeate all the cases, as the same issues are explored in every case. Cases can be added progressively until theoretical saturation is achieved. An example is of a study that investigated how entrepreneurial opportunity and management skills were developed through entrepreneurial learning ( Zampier & Takahashi, 2014 ). The authors conducted nine case studies, based on primary and secondary data, with each one analyzed separately, so a search for patterns could be undertaken. The convergence aspects found were: the predominant way of transforming experience into knowledge was exploitation; managerial skills were developed through by taking advantages of opportunities; and career orientation encompassed more than one style. As for divergence patterns: the experience of success and failure influenced entrepreneurs differently; the prevailing rationality logic of influence was different; and the combination of styles in career orientation was diverse.

A full discussion of choice of case study design is outside the scope of this article. For the sake of illustration, we make a brief mention to other selection criteria such as the purpose of the research, the state of the art of the research theme, the time and resources involved and the preferred epistemological position of the researcher. In the next section, we look at the possibilities of carrying out case studies in line with various epistemological traditions, as the answers to the “what is a case?” question reveal varied methodological commitments as well as diverse epistemological and ontological positions ( Ragin, 2013 ).

3. Epistemological positioning of case study research

Ontology and epistemology are like skin, not a garment to be occasionally worn ( Marsh & Furlong, 2002 ). According to these authors, ontology and epistemology guide the choice of theory and method because they cannot or should not be worn as a garment. Hence, one must practice philosophical “self-knowledge” to recognize one’s vision of what the world is and of how knowledge of that world is accessed and validated. Ontological and epistemological positions are relevant in that they involve the positioning of the researcher in social science and the phenomena he or she chooses to study. These positions do not tend to vary from one project to another although they can certainly change over time for a single researcher.

Ontology is the starting point from which the epistemological and methodological positions of the research arise ( Grix, 2002 ). Ontology expresses a view of the world, what constitutes reality, nature and the image one has of social reality; it is a theory of being ( Marsh & Furlong, 2002 ). The central question is the nature of the world out there regardless of our ability to access it. An essentialist or foundationalist ontology acknowledges that there are differences that persist over time and these differences are what underpin the construction of social life. An opposing, anti-foundationalist position presumes that the differences found are socially constructed and may vary – i.e. they are not essential but specific to a given culture at a given time ( Marsh & Furlong, 2002 ).

Epistemology is centered around a theory of knowledge, focusing on the process of acquiring and validating knowledge ( Grix, 2002 ). Positivists look at social phenomena as a world of causal relations where there is a single truth to be accessed and confirmed. In this tradition, case studies test hypotheses and rely on deductive approaches and quantitative data collection and analysis techniques. Scholars in the field of anthropology and observation-based qualitative studies proposed alternative epistemologies based on notions of the social world as a set of manifold and ever-changing processes. In management studies since the 1970s, the gradual acceptance of qualitative research has generated a diverse range of research methods and conceptions of the individual and society ( Godoy, 1995 ).

The interpretative tradition, in direct opposition to positivism, argues that there is no single objective truth to be discovered about the social world. The social world and our knowledge of it are the product of social constructions. Thus, the social world is constituted by interactions, and our knowledge is hermeneutic as the world does not exist independent of our knowledge ( Marsh & Furlong, 2002 ). The implication is that it is not possible to access social phenomena through objective, detached methods. Instead, the interaction mechanisms and relationships that make up social constructions have to be studied. Deductive approaches, hypothesis testing and quantitative methods are not relevant here. Hermeneutics, on the other hand, is highly relevant as it allows the analysis of the individual’s interpretation, of sayings, texts and actions, even though interpretation is always the “truth” of a subject. Methods such as ethnographic case studies, interviews and observations as data collection techniques should feed research designs according to interpretivism. It is worth pointing out that we are to a large extent, caricaturing polar opposites rather characterizing a range of epistemological alternatives, such as realism, conventionalism and symbolic interactionism.

If diverse ontologies and epistemologies serve as a guide to research approaches, including data collection and analysis methods, and if they should be regarded as skin rather than clothing, how does one make choices regarding case studies? What are case studies, what type of knowledge they provide and so on? The views of case study authors are not always explicit on this point, so we must delve into their texts to glean what their positions might be.

Two of the cited authors in case study research are Robert Yin and Kathleen Eisenhardt. Eisenhardt (1989) argues that a case study can serve to provide a description, test or generate a theory, the latter being the most relevant in contributing to the advancement of knowledge in a given area. She uses terms such as populations and samples, control variables, hypotheses and generalization of findings and even suggests an ideal number of case studies to allow for theory construction through replication. Although Eisenhardt includes observation and interview among her recommended data collection techniques, the approach is firmly anchored in a positivist epistemology:

Third, particularly in comparison with Strauss (1987) and Van Maanen (1988), the process described here adopts a positivist view of research. That is, the process is directed toward the development of testable hypotheses and theory which are generalizable across settings. In contrast, authors like Strauss and Van Maanen are more concerned that a rich, complex description of the specific cases under study evolve and they appear less concerned with development of generalizable theory ( Eisenhardt, 1989 , p. 546).

This position attracted a fair amount of criticism. Dyer & Wilkins (1991) in a critique of Eisenhardt’s (1989) article focused on the following aspects: there is no relevant justification for the number of cases recommended; it is the depth and not the number of cases that provides an actual contribution to theory; and the researcher’s purpose should be to get closer to the setting and interpret it. According to the same authors, discrepancies from prior expectations are also important as they lead researchers to reflect on existing theories. Eisenhardt & Graebner (2007 , p. 25) revisit the argument for the construction of a theory from multiple cases:

A major reason for the popularity and relevance of theory building from case studies is that it is one of the best (if not the best) of the bridges from rich qualitative evidence to mainstream deductive research.

Although they recognize the importance of single-case research to explore phenomena under unique or rare circumstances, they reaffirm the strength of multiple case designs as it is through them that better accuracy and generalization can be reached.

Likewise, Robert Yin emphasizes the importance of variables, triangulation in the search for “truth” and generalizable theoretical propositions. Yin (2015 , p. 18) suggests that the case study method may be appropriate for different epistemological orientations, although much of his work seems to invoke a realist epistemology. Authors such as Merrian (2009) and Stake (2003) suggest an interpretative version of case studies. Stake (2003) looks at cases as a qualitative option, where the most relevant criterion of case selection should be the opportunity to learn and understand a phenomenon. A case is not just a research method or strategy; it is a researcher’s choice about what will be studied:

Even if my definition of case study was agreed upon, and it is not, the term case and study defy full specification (Kemmis, 1980). A case study is both a process of inquiry about the case and the product of that inquiry ( Stake, 2003 , p. 136).

Later, Stake (2003 , p. 156) argues that:

[…] the purpose of a case report is not to represent the world, but to represent the case. […] The utility of case research to practitioners and policy makers is in its extension of experience.

Still according to Stake (2003 , pp. 140-141), to do justice to complex views of social phenomena, it is necessary to analyze the context and relate it to the case, to look for what is peculiar rather than common in cases to delimit their boundaries, to plan the data collection looking for what is common and unusual about facts, what could be valuable whether it is unique or common:

Reflecting upon the pertinent literature, I find case study methodology written largely by people who presume that the research should contribute to scientific generalization. The bulk of case study work, however, is done by individuals who have intrinsic interest in the case and little interest in the advance of science. Their designs aim the inquiry toward understanding of what is important about that case within its own world, which is seldom the same as the worlds of researchers and theorists. Those designs develop what is perceived to be the case’s own issues, contexts, and interpretations, its thick descriptions . In contrast, the methods of instrumental case study draw the researcher toward illustrating how the concerns of researchers and theorists are manifest in the case. Because the critical issues are more likely to be know in advance and following disciplinary expectations, such a design can take greater advantage of already developed instruments and preconceived coding schemes.

The aforementioned authors were listed to illustrate differences and sometimes opposing positions on case research. These differences are not restricted to a choice between positivism and interpretivism. It is worth noting that Ragin’s (2013 , p. 523) approach to “casing” is compatible with the realistic research perspective:

In essence, to posit cases is to engage in ontological speculation regarding what is obdurately real but only partially and indirectly accessible through social science. Bringing a realist perspective to the case question deepens and enriches the dialogue, clarifying some key issues while sweeping others aside.

cases are actual entities, reflecting their operations of real causal mechanism and process patterns;

case studies are interactive processes and are open to revisions and refinements; and

social phenomena are complex, contingent and context-specific.

Ragin (2013 , p. 532) concludes:

Lurking behind my discussion of negative case, populations, and possibility analysis is the implication that treating cases as members of given (and fixed) populations and seeking to infer the properties of populations may be a largely illusory exercise. While demographers have made good use of the concept of population, and continue to do so, it is not clear how much the utility of the concept extends beyond their domain. In case-oriented work, the notion of fixed populations of cases (observations) has much less analytic utility than simply “the set of relevant cases,” a grouping that must be specified or constructed by the researcher. The demarcation of this set, as the work of case-oriented researchers illustrates, is always tentative, fluid, and open to debate. It is only by casing social phenomena that social scientists perceive the homogeneity that allows analysis to proceed.

In summary, case studies are relevant and potentially compatible with a range of different epistemologies. Researchers’ ontological and epistemological positions will guide their choice of theory, methodologies and research techniques, as well as their research practices. The same applies to the choice of authors describing the research method and this choice should be coherent. We call this research alignment , an attribute that must be judged on the internal coherence of the author of a study, and not necessarily its evaluator. The following figure illustrates the interrelationship between the elements of a study necessary for an alignment ( Figure 1 ).

In addition to this broader aspect of the research as a whole, other factors should be part of the researcher’s concern, such as the rigor and quality of case studies. We will look into these in the next section taking into account their relevance to the different epistemologies.

4. Rigor and quality in case studies

Traditionally, at least in positivist studies, validity and reliability are the relevant quality criteria to judge research. Validity can be understood as external, internal and construct. External validity means identifying whether the findings of a study are generalizable to other studies using the logic of replication in multiple case studies. Internal validity may be established through the theoretical underpinning of existing relationships and it involves the use of protocols for the development and execution of case studies. Construct validity implies defining the operational measurement criteria to establish a chain of evidence, such as the use of multiple sources of evidence ( Eisenhardt, 1989 ; Yin, 2015 ). Reliability implies conducting other case studies, instead of just replicating results, to minimize the errors and bias of a study through case study protocols and the development of a case database ( Yin, 2015 ).

Several criticisms have been directed toward case studies, such as lack of rigor, lack of generalization potential, external validity and researcher bias. Case studies are often deemed to be unreliable because of a lack of rigor ( Seuring, 2008 ). Flyvbjerg (2006 , p. 219) addresses five misunderstandings about case-study research, and concludes that:

[…] a scientific discipline without a large number of thoroughly executed case studies is a discipline without systematic production of exemplars, and a discipline without exemplars is an ineffective one.

theoretical knowledge is more valuable than concrete, practical knowledge;

the case study cannot contribute to scientific development because it is not possible to generalize on the basis of an individual case;

the case study is more useful for generating rather than testing hypotheses;

the case study contains a tendency to confirm the researcher’s preconceived notions; and

it is difficult to summarize and develop general propositions and theories based on case studies.

These criticisms question the validity of the case study as a scientific method and should be corrected.

The critique of case studies is often framed from the standpoint of what Ragin (2000) labeled large-N research. The logic of small-N research, to which case studies belong, is different. Cases benefit from depth rather than breadth as they: provide theoretical and empirical knowledge; contribute to theory through propositions; serve not only to confirm knowledge, but also to challenge and overturn preconceived notions; and the difficulty in summarizing their conclusions is because of the complexity of the phenomena studies and not an intrinsic limitation of the method.

Thus, case studies do not seek large-scale generalizations as that is not their purpose. And yet, this is a limitation from a positivist perspective as there is an external reality to be “apprehended” and valid conclusions to be extracted for an entire population. If positivism is the epistemology of choice, the rigor of a case study can be demonstrated by detailing the criteria used for internal and external validity, construct validity and reliability ( Gibbert & Ruigrok, 2010 ; Gibbert, Ruigrok, & Wicki, 2008 ). An example can be seen in case studies in the area of information systems, where there is a predominant orientation of positivist approaches to this method ( Pozzebon & Freitas, 1998 ). In this area, rigor also involves the definition of a unit of analysis, type of research, number of cases, selection of sites, definition of data collection and analysis procedures, definition of the research protocol and writing a final report. Creswell (1998) presents a checklist for researchers to assess whether the study was well written, if it has reliability and validity and if it followed methodological protocols.

In case studies with a non-positivist orientation, rigor can be achieved through careful alignment (coherence among ontology, epistemology, theory and method). Moreover, the concepts of validity can be understood as concern and care in formulating research, research development and research results ( Ollaik & Ziller, 2012 ), and to achieve internal coherence ( Gibbert et al. , 2008 ). The consistency between data collection and interpretation, and the observed reality also help these studies meet coherence and rigor criteria. Siggelkow (2007) argues that a case study should be persuasive and that even a single case study may be a powerful example to contest a widely held view. To him, the value of a single case study or studies with few cases can be attained by their potential to provide conceptual insights and coherence to the internal logic of conceptual arguments: “[…] a paper should allow a reader to see the world, and not just the literature, in a new way” ( Siggelkow, 2007 , p. 23).

Interpretative studies should not be justified by criteria derived from positivism as they are based on a different ontology and epistemology ( Sandberg, 2005 ). The rejection of an interpretive epistemology leads to the rejection of an objective reality: “As Bengtsson points out, the life-world is the subjects’ experience of reality, at the same time as it is objective in the sense that it is an intersubjective world” ( Sandberg, 2005 , p. 47). In this event, how can one demonstrate what positivists call validity and reliability? What would be the criteria to justify knowledge as truth, produced by research in this epistemology? Sandberg (2005 , p. 62) suggests an answer based on phenomenology:

This was demonstrated first by explicating life-world and intentionality as the basic assumptions underlying the interpretative research tradition. Second, based on those assumptions, truth as intentional fulfillment, consisting of perceived fulfillment, fulfillment in practice, and indeterminate fulfillment, was proposed. Third, based on the proposed truth constellation, communicative, pragmatic, and transgressive validity and reliability as interpretative awareness were presented as the most appropriate criteria for justifying knowledge produced within interpretative approach. Finally, the phenomenological epoché was suggested as a strategy for achieving these criteria.

From this standpoint, the research site must be chosen according to its uniqueness so that one can obtain relevant insights that no other site could provide ( Siggelkow, 2007 ). Furthermore, the view of what is being studied is at the center of the researcher’s attention to understand its “truth,” inserted in a given context.

The case researcher is someone who can reduce the probability of misinterpretations by analyzing multiple perceptions, searches for data triangulation to check for the reliability of interpretations ( Stake, 2003 ). It is worth pointing out that this is not an option for studies that specifically seek the individual’s experience in relation to organizational phenomena.

In short, there are different ways of seeking rigor and quality in case studies, depending on the researcher’s worldview. These different forms pervade everything from the research design, the choice of research questions, the theory or theories to look at a phenomenon, research methods, the data collection and analysis techniques, to the type and style of research report produced. Validity can also take on different forms. While positivism is concerned with validity of the research question and results, interpretivism emphasizes research processes without neglecting the importance of the articulation of pertinent research questions and the sound interpretation of results ( Ollaik & Ziller, 2012 ). The means to achieve this can be diverse, such as triangulation (of multiple theories, multiple methods, multiple data sources or multiple investigators), pre-tests of data collection instrument, pilot case, study protocol, detailed description of procedures such as field diary in observations, researcher positioning (reflexivity), theoretical-empirical consistency, thick description and transferability.

5. Conclusions

The central objective of this article was to discuss concepts of case study research, their potential and various uses, taking into account different epistemologies as well as criteria of rigor and validity. Although the literature on methodology in general and on case studies in particular, is voluminous, it is not easy to relate this approach to epistemology. In addition, method manuals often focus on the details of various case study approaches which confuse things further.

Faced with this scenario, we have tried to address some central points in this debate and present various ways of using case studies according to the preferred epistemology of the researcher. We emphasize that this understanding depends on how a case is defined and the particular epistemological orientation that underpins that conceptualization. We have argued that whatever the epistemological orientation is, it is possible to meet appropriate criteria of research rigor and quality provided there is an alignment among the different elements of the research process. Furthermore, multiple data collection techniques can be used in in single or multiple case study designs. Data collection techniques or the type of data collected do not define the method or whether cases should be used for theory-building or theory-testing.

Finally, we encourage researchers to consider case study research as one way to foster immersion in phenomena and their contexts, stressing that the approach does not imply a commitment to a particular epistemology or type of research, such as qualitative or quantitative. Case study research allows for numerous possibilities, and should be celebrated for that diversity rather than pigeon-holed as a monolithic research method.

The interrelationship between the building blocks of research

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Author contributions: Both authors contributed equally.

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Case study research

Affiliation.

• 1 Faculty of Health, Social Care and Education, Anglia Ruskin University, Cambridge, England.
• PMID: 26058651
• DOI: 10.7748/ns.29.41.36.e8856

This article describes case study research for nursing and healthcare practice. Case study research offers the researcher an approach by which a phenomenon can be investigated from multiple perspectives within a bounded context, allowing the researcher to provide a 'thick' description of the phenomenon. Although case study research is a flexible approach for the investigation of complex nursing and healthcare issues, it has methodological challenges, often associated with the multiple methods used in individual studies. These are explored through examples of case study research carried out in practice and education settings. An overview of what constitutes 'good' case study research is proposed.

Keywords: Case study research; case study research approaches; nursing protocols; research design; research methodologies; rigour.

• Case-Control Studies*
• Education, Nursing
• Nursing Research / education*
• Research Design*

The case study approach

• Sarah Crowe 1 ,
• Kathrin Cresswell 2 ,
• Ann Robertson 2 ,
• Guro Huby 3 ,
• Anthony Avery 1 &
• Aziz Sheikh 2  

BMC Medical Research Methodology volume  11 , Article number:  100 ( 2011 ) Cite this article

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The case study approach allows in-depth, multi-faceted explorations of complex issues in their real-life settings. The value of the case study approach is well recognised in the fields of business, law and policy, but somewhat less so in health services research. Based on our experiences of conducting several health-related case studies, we reflect on the different types of case study design, the specific research questions this approach can help answer, the data sources that tend to be used, and the particular advantages and disadvantages of employing this methodological approach. The paper concludes with key pointers to aid those designing and appraising proposals for conducting case study research, and a checklist to help readers assess the quality of case study reports.

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Introduction

The case study approach is particularly useful to employ when there is a need to obtain an in-depth appreciation of an issue, event or phenomenon of interest, in its natural real-life context. Our aim in writing this piece is to provide insights into when to consider employing this approach and an overview of key methodological considerations in relation to the design, planning, analysis, interpretation and reporting of case studies.

The illustrative 'grand round', 'case report' and 'case series' have a long tradition in clinical practice and research. Presenting detailed critiques, typically of one or more patients, aims to provide insights into aspects of the clinical case and, in doing so, illustrate broader lessons that may be learnt. In research, the conceptually-related case study approach can be used, for example, to describe in detail a patient's episode of care, explore professional attitudes to and experiences of a new policy initiative or service development or more generally to 'investigate contemporary phenomena within its real-life context' [ 1 ]. Based on our experiences of conducting a range of case studies, we reflect on when to consider using this approach, discuss the key steps involved and illustrate, with examples, some of the practical challenges of attaining an in-depth understanding of a 'case' as an integrated whole. In keeping with previously published work, we acknowledge the importance of theory to underpin the design, selection, conduct and interpretation of case studies[ 2 ]. In so doing, we make passing reference to the different epistemological approaches used in case study research by key theoreticians and methodologists in this field of enquiry.

This paper is structured around the following main questions: What is a case study? What are case studies used for? How are case studies conducted? What are the potential pitfalls and how can these be avoided? We draw in particular on four of our own recently published examples of case studies (see Tables 1 , 2 , 3 and 4 ) and those of others to illustrate our discussion[ 3 – 7 ].

What is a case study?

A case study is a research approach that is used to generate an in-depth, multi-faceted understanding of a complex issue in its real-life context. It is an established research design that is used extensively in a wide variety of disciplines, particularly in the social sciences. A case study can be defined in a variety of ways (Table 5 ), the central tenet being the need to explore an event or phenomenon in depth and in its natural context. It is for this reason sometimes referred to as a "naturalistic" design; this is in contrast to an "experimental" design (such as a randomised controlled trial) in which the investigator seeks to exert control over and manipulate the variable(s) of interest.

Stake's work has been particularly influential in defining the case study approach to scientific enquiry. He has helpfully characterised three main types of case study: intrinsic , instrumental and collective [ 8 ]. An intrinsic case study is typically undertaken to learn about a unique phenomenon. The researcher should define the uniqueness of the phenomenon, which distinguishes it from all others. In contrast, the instrumental case study uses a particular case (some of which may be better than others) to gain a broader appreciation of an issue or phenomenon. The collective case study involves studying multiple cases simultaneously or sequentially in an attempt to generate a still broader appreciation of a particular issue.

These are however not necessarily mutually exclusive categories. In the first of our examples (Table 1 ), we undertook an intrinsic case study to investigate the issue of recruitment of minority ethnic people into the specific context of asthma research studies, but it developed into a instrumental case study through seeking to understand the issue of recruitment of these marginalised populations more generally, generating a number of the findings that are potentially transferable to other disease contexts[ 3 ]. In contrast, the other three examples (see Tables 2 , 3 and 4 ) employed collective case study designs to study the introduction of workforce reconfiguration in primary care, the implementation of electronic health records into hospitals, and to understand the ways in which healthcare students learn about patient safety considerations[ 4 – 6 ]. Although our study focusing on the introduction of General Practitioners with Specialist Interests (Table 2 ) was explicitly collective in design (four contrasting primary care organisations were studied), is was also instrumental in that this particular professional group was studied as an exemplar of the more general phenomenon of workforce redesign[ 4 ].

What are case studies used for?

According to Yin, case studies can be used to explain, describe or explore events or phenomena in the everyday contexts in which they occur[ 1 ]. These can, for example, help to understand and explain causal links and pathways resulting from a new policy initiative or service development (see Tables 2 and 3 , for example)[ 1 ]. In contrast to experimental designs, which seek to test a specific hypothesis through deliberately manipulating the environment (like, for example, in a randomised controlled trial giving a new drug to randomly selected individuals and then comparing outcomes with controls),[ 9 ] the case study approach lends itself well to capturing information on more explanatory ' how ', 'what' and ' why ' questions, such as ' how is the intervention being implemented and received on the ground?'. The case study approach can offer additional insights into what gaps exist in its delivery or why one implementation strategy might be chosen over another. This in turn can help develop or refine theory, as shown in our study of the teaching of patient safety in undergraduate curricula (Table 4 )[ 6 , 10 ]. Key questions to consider when selecting the most appropriate study design are whether it is desirable or indeed possible to undertake a formal experimental investigation in which individuals and/or organisations are allocated to an intervention or control arm? Or whether the wish is to obtain a more naturalistic understanding of an issue? The former is ideally studied using a controlled experimental design, whereas the latter is more appropriately studied using a case study design.

Case studies may be approached in different ways depending on the epistemological standpoint of the researcher, that is, whether they take a critical (questioning one's own and others' assumptions), interpretivist (trying to understand individual and shared social meanings) or positivist approach (orientating towards the criteria of natural sciences, such as focusing on generalisability considerations) (Table 6 ). Whilst such a schema can be conceptually helpful, it may be appropriate to draw on more than one approach in any case study, particularly in the context of conducting health services research. Doolin has, for example, noted that in the context of undertaking interpretative case studies, researchers can usefully draw on a critical, reflective perspective which seeks to take into account the wider social and political environment that has shaped the case[ 11 ].

How are case studies conducted?

Here, we focus on the main stages of research activity when planning and undertaking a case study; the crucial stages are: defining the case; selecting the case(s); collecting and analysing the data; interpreting data; and reporting the findings.

Defining the case

Carefully formulated research question(s), informed by the existing literature and a prior appreciation of the theoretical issues and setting(s), are all important in appropriately and succinctly defining the case[ 8 , 12 ]. Crucially, each case should have a pre-defined boundary which clarifies the nature and time period covered by the case study (i.e. its scope, beginning and end), the relevant social group, organisation or geographical area of interest to the investigator, the types of evidence to be collected, and the priorities for data collection and analysis (see Table 7 )[ 1 ]. A theory driven approach to defining the case may help generate knowledge that is potentially transferable to a range of clinical contexts and behaviours; using theory is also likely to result in a more informed appreciation of, for example, how and why interventions have succeeded or failed[ 13 ].

For example, in our evaluation of the introduction of electronic health records in English hospitals (Table 3 ), we defined our cases as the NHS Trusts that were receiving the new technology[ 5 ]. Our focus was on how the technology was being implemented. However, if the primary research interest had been on the social and organisational dimensions of implementation, we might have defined our case differently as a grouping of healthcare professionals (e.g. doctors and/or nurses). The precise beginning and end of the case may however prove difficult to define. Pursuing this same example, when does the process of implementation and adoption of an electronic health record system really begin or end? Such judgements will inevitably be influenced by a range of factors, including the research question, theory of interest, the scope and richness of the gathered data and the resources available to the research team.

Selecting the case(s)

The decision on how to select the case(s) to study is a very important one that merits some reflection. In an intrinsic case study, the case is selected on its own merits[ 8 ]. The case is selected not because it is representative of other cases, but because of its uniqueness, which is of genuine interest to the researchers. This was, for example, the case in our study of the recruitment of minority ethnic participants into asthma research (Table 1 ) as our earlier work had demonstrated the marginalisation of minority ethnic people with asthma, despite evidence of disproportionate asthma morbidity[ 14 , 15 ]. In another example of an intrinsic case study, Hellstrom et al.[ 16 ] studied an elderly married couple living with dementia to explore how dementia had impacted on their understanding of home, their everyday life and their relationships.

For an instrumental case study, selecting a "typical" case can work well[ 8 ]. In contrast to the intrinsic case study, the particular case which is chosen is of less importance than selecting a case that allows the researcher to investigate an issue or phenomenon. For example, in order to gain an understanding of doctors' responses to health policy initiatives, Som undertook an instrumental case study interviewing clinicians who had a range of responsibilities for clinical governance in one NHS acute hospital trust[ 17 ]. Sampling a "deviant" or "atypical" case may however prove even more informative, potentially enabling the researcher to identify causal processes, generate hypotheses and develop theory.

In collective or multiple case studies, a number of cases are carefully selected. This offers the advantage of allowing comparisons to be made across several cases and/or replication. Choosing a "typical" case may enable the findings to be generalised to theory (i.e. analytical generalisation) or to test theory by replicating the findings in a second or even a third case (i.e. replication logic)[ 1 ]. Yin suggests two or three literal replications (i.e. predicting similar results) if the theory is straightforward and five or more if the theory is more subtle. However, critics might argue that selecting 'cases' in this way is insufficiently reflexive and ill-suited to the complexities of contemporary healthcare organisations.

The selected case study site(s) should allow the research team access to the group of individuals, the organisation, the processes or whatever else constitutes the chosen unit of analysis for the study. Access is therefore a central consideration; the researcher needs to come to know the case study site(s) well and to work cooperatively with them. Selected cases need to be not only interesting but also hospitable to the inquiry [ 8 ] if they are to be informative and answer the research question(s). Case study sites may also be pre-selected for the researcher, with decisions being influenced by key stakeholders. For example, our selection of case study sites in the evaluation of the implementation and adoption of electronic health record systems (see Table 3 ) was heavily influenced by NHS Connecting for Health, the government agency that was responsible for overseeing the National Programme for Information Technology (NPfIT)[ 5 ]. This prominent stakeholder had already selected the NHS sites (through a competitive bidding process) to be early adopters of the electronic health record systems and had negotiated contracts that detailed the deployment timelines.

It is also important to consider in advance the likely burden and risks associated with participation for those who (or the site(s) which) comprise the case study. Of particular importance is the obligation for the researcher to think through the ethical implications of the study (e.g. the risk of inadvertently breaching anonymity or confidentiality) and to ensure that potential participants/participating sites are provided with sufficient information to make an informed choice about joining the study. The outcome of providing this information might be that the emotive burden associated with participation, or the organisational disruption associated with supporting the fieldwork, is considered so high that the individuals or sites decide against participation.

In our example of evaluating implementations of electronic health record systems, given the restricted number of early adopter sites available to us, we sought purposively to select a diverse range of implementation cases among those that were available[ 5 ]. We chose a mixture of teaching, non-teaching and Foundation Trust hospitals, and examples of each of the three electronic health record systems procured centrally by the NPfIT. At one recruited site, it quickly became apparent that access was problematic because of competing demands on that organisation. Recognising the importance of full access and co-operative working for generating rich data, the research team decided not to pursue work at that site and instead to focus on other recruited sites.

Collecting the data

In order to develop a thorough understanding of the case, the case study approach usually involves the collection of multiple sources of evidence, using a range of quantitative (e.g. questionnaires, audits and analysis of routinely collected healthcare data) and more commonly qualitative techniques (e.g. interviews, focus groups and observations). The use of multiple sources of data (data triangulation) has been advocated as a way of increasing the internal validity of a study (i.e. the extent to which the method is appropriate to answer the research question)[ 8 , 18 – 21 ]. An underlying assumption is that data collected in different ways should lead to similar conclusions, and approaching the same issue from different angles can help develop a holistic picture of the phenomenon (Table 2 )[ 4 ].

Brazier and colleagues used a mixed-methods case study approach to investigate the impact of a cancer care programme[ 22 ]. Here, quantitative measures were collected with questionnaires before, and five months after, the start of the intervention which did not yield any statistically significant results. Qualitative interviews with patients however helped provide an insight into potentially beneficial process-related aspects of the programme, such as greater, perceived patient involvement in care. The authors reported how this case study approach provided a number of contextual factors likely to influence the effectiveness of the intervention and which were not likely to have been obtained from quantitative methods alone.

In collective or multiple case studies, data collection needs to be flexible enough to allow a detailed description of each individual case to be developed (e.g. the nature of different cancer care programmes), before considering the emerging similarities and differences in cross-case comparisons (e.g. to explore why one programme is more effective than another). It is important that data sources from different cases are, where possible, broadly comparable for this purpose even though they may vary in nature and depth.

Analysing, interpreting and reporting case studies

Making sense and offering a coherent interpretation of the typically disparate sources of data (whether qualitative alone or together with quantitative) is far from straightforward. Repeated reviewing and sorting of the voluminous and detail-rich data are integral to the process of analysis. In collective case studies, it is helpful to analyse data relating to the individual component cases first, before making comparisons across cases. Attention needs to be paid to variations within each case and, where relevant, the relationship between different causes, effects and outcomes[ 23 ]. Data will need to be organised and coded to allow the key issues, both derived from the literature and emerging from the dataset, to be easily retrieved at a later stage. An initial coding frame can help capture these issues and can be applied systematically to the whole dataset with the aid of a qualitative data analysis software package.

The Framework approach is a practical approach, comprising of five stages (familiarisation; identifying a thematic framework; indexing; charting; mapping and interpretation) , to managing and analysing large datasets particularly if time is limited, as was the case in our study of recruitment of South Asians into asthma research (Table 1 )[ 3 , 24 ]. Theoretical frameworks may also play an important role in integrating different sources of data and examining emerging themes. For example, we drew on a socio-technical framework to help explain the connections between different elements - technology; people; and the organisational settings within which they worked - in our study of the introduction of electronic health record systems (Table 3 )[ 5 ]. Our study of patient safety in undergraduate curricula drew on an evaluation-based approach to design and analysis, which emphasised the importance of the academic, organisational and practice contexts through which students learn (Table 4 )[ 6 ].

Case study findings can have implications both for theory development and theory testing. They may establish, strengthen or weaken historical explanations of a case and, in certain circumstances, allow theoretical (as opposed to statistical) generalisation beyond the particular cases studied[ 12 ]. These theoretical lenses should not, however, constitute a strait-jacket and the cases should not be "forced to fit" the particular theoretical framework that is being employed.

When reporting findings, it is important to provide the reader with enough contextual information to understand the processes that were followed and how the conclusions were reached. In a collective case study, researchers may choose to present the findings from individual cases separately before amalgamating across cases. Care must be taken to ensure the anonymity of both case sites and individual participants (if agreed in advance) by allocating appropriate codes or withholding descriptors. In the example given in Table 3 , we decided against providing detailed information on the NHS sites and individual participants in order to avoid the risk of inadvertent disclosure of identities[ 5 , 25 ].

What are the potential pitfalls and how can these be avoided?

The case study approach is, as with all research, not without its limitations. When investigating the formal and informal ways undergraduate students learn about patient safety (Table 4 ), for example, we rapidly accumulated a large quantity of data. The volume of data, together with the time restrictions in place, impacted on the depth of analysis that was possible within the available resources. This highlights a more general point of the importance of avoiding the temptation to collect as much data as possible; adequate time also needs to be set aside for data analysis and interpretation of what are often highly complex datasets.

Case study research has sometimes been criticised for lacking scientific rigour and providing little basis for generalisation (i.e. producing findings that may be transferable to other settings)[ 1 ]. There are several ways to address these concerns, including: the use of theoretical sampling (i.e. drawing on a particular conceptual framework); respondent validation (i.e. participants checking emerging findings and the researcher's interpretation, and providing an opinion as to whether they feel these are accurate); and transparency throughout the research process (see Table 8 )[ 8 , 18 – 21 , 23 , 26 ]. Transparency can be achieved by describing in detail the steps involved in case selection, data collection, the reasons for the particular methods chosen, and the researcher's background and level of involvement (i.e. being explicit about how the researcher has influenced data collection and interpretation). Seeking potential, alternative explanations, and being explicit about how interpretations and conclusions were reached, help readers to judge the trustworthiness of the case study report. Stake provides a critique checklist for a case study report (Table 9 )[ 8 ].

Conclusions

The case study approach allows, amongst other things, critical events, interventions, policy developments and programme-based service reforms to be studied in detail in a real-life context. It should therefore be considered when an experimental design is either inappropriate to answer the research questions posed or impossible to undertake. Considering the frequency with which implementations of innovations are now taking place in healthcare settings and how well the case study approach lends itself to in-depth, complex health service research, we believe this approach should be more widely considered by researchers. Though inherently challenging, the research case study can, if carefully conceptualised and thoughtfully undertaken and reported, yield powerful insights into many important aspects of health and healthcare delivery.

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Acknowledgements

We are grateful to the participants and colleagues who contributed to the individual case studies that we have drawn on. This work received no direct funding, but it has been informed by projects funded by Asthma UK, the NHS Service Delivery Organisation, NHS Connecting for Health Evaluation Programme, and Patient Safety Research Portfolio. We would also like to thank the expert reviewers for their insightful and constructive feedback. Our thanks are also due to Dr. Allison Worth who commented on an earlier draft of this manuscript.

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AS conceived this article. SC, KC and AR wrote this paper with GH, AA and AS all commenting on various drafts. SC and AS are guarantors.

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Crowe, S., Cresswell, K., Robertson, A. et al. The case study approach. BMC Med Res Methodol 11 , 100 (2011). https://doi.org/10.1186/1471-2288-11-100

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Deciphering the influence: academic stress and its role in shaping learning approaches among nursing students: a cross-sectional study

• Rawhia Salah Dogham 1 ,
• Heba Fakieh Mansy Ali 1 ,
• Asmaa Saber Ghaly 3 ,
• Nermine M. Elcokany 2 ,
• Mohamed Mahmoud Seweid 4 &
• Ayman Mohamed El-Ashry   ORCID: orcid.org/0000-0001-7718-4942 5  

BMC Nursing volume  23 , Article number:  249 ( 2024 ) Cite this article

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Nursing education presents unique challenges, including high levels of academic stress and varied learning approaches among students. Understanding the relationship between academic stress and learning approaches is crucial for enhancing nursing education effectiveness and student well-being.

This study aimed to investigate the prevalence of academic stress and its correlation with learning approaches among nursing students.

Design and Method

A cross-sectional descriptive correlation research design was employed. A convenient sample of 1010 nursing students participated, completing socio-demographic data, the Perceived Stress Scale (PSS), and the Revised Study Process Questionnaire (R-SPQ-2 F).

Most nursing students experienced moderate academic stress (56.3%) and exhibited moderate levels of deep learning approaches (55.0%). Stress from a lack of professional knowledge and skills negatively correlates with deep learning approaches (r = -0.392) and positively correlates with surface learning approaches (r = 0.365). Female students showed higher deep learning approach scores, while male students exhibited higher surface learning approach scores. Age, gender, educational level, and academic stress significantly influenced learning approaches.

Academic stress significantly impacts learning approaches among nursing students. Strategies addressing stressors and promoting healthy learning approaches are essential for enhancing nursing education and student well-being.

Nursing implication

Understanding academic stress’s impact on nursing students’ learning approaches enables tailored interventions. Recognizing stressors informs strategies for promoting adaptive coping, fostering deep learning, and creating supportive environments. Integrating stress management, mentorship, and counseling enhances student well-being and nursing education quality.

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Introduction

Nursing education is a demanding field that requires students to acquire extensive knowledge and skills to provide competent and compassionate care. Nursing education curriculum involves high-stress environments that can significantly impact students’ learning approaches and academic performance [ 1 , 2 ]. Numerous studies have investigated learning approaches in nursing education, highlighting the importance of identifying individual students’ preferred approaches. The most studied learning approaches include deep, surface, and strategic approaches. Deep learning approaches involve students actively seeking meaning, making connections, and critically analyzing information. Surface learning approaches focus on memorization and reproducing information without a more profound understanding. Strategic learning approaches aim to achieve high grades by adopting specific strategies, such as memorization techniques or time management skills [ 3 , 4 , 5 ].

Nursing education stands out due to its focus on practical training, where the blend of academic and clinical coursework becomes a significant stressor for students, despite academic stress being shared among all university students [ 6 , 7 , 8 ]. Consequently, nursing students are recognized as prone to high-stress levels. Stress is the physiological and psychological response that occurs when a biological control system identifies a deviation between the desired (target) state and the actual state of a fitness-critical variable, whether that discrepancy arises internally or externally to the human [ 9 ]. Stress levels can vary from objective threats to subjective appraisals, making it a highly personalized response to circumstances. Failure to manage these demands leads to stress imbalance [ 10 ].

Nursing students face three primary stressors during their education: academic, clinical, and personal/social stress. Academic stress is caused by the fear of failure in exams, assessments, and training, as well as workload concerns [ 11 ]. Clinical stress, on the other hand, arises from work-related difficulties such as coping with death, fear of failure, and interpersonal dynamics within the organization. Personal and social stressors are caused by an imbalance between home and school, financial hardships, and other factors. Throughout their education, nursing students have to deal with heavy workloads, time constraints, clinical placements, and high academic expectations. Multiple studies have shown that nursing students experience higher stress levels compared to students in other fields [ 12 , 13 , 14 ].

Research has examined the relationship between academic stress and coping strategies among nursing students, but no studies focus specifically on the learning approach and academic stress. However, existing literature suggests that students interested in nursing tend to experience lower levels of academic stress [ 7 ]. Therefore, interest in nursing can lead to deep learning approaches, which promote a comprehensive understanding of the subject matter, allowing students to feel more confident and less overwhelmed by coursework and exams. Conversely, students employing surface learning approaches may experience higher stress levels due to the reliance on memorization [ 3 ].

Understanding the interplay between academic stress and learning approaches among nursing students is essential for designing effective educational interventions. Nursing educators can foster deep learning approaches by incorporating active learning strategies, critical thinking exercises, and reflection activities into the curriculum [ 15 ]. Creating supportive learning environments encouraging collaboration, self-care, and stress management techniques can help alleviate academic stress. Additionally, providing mentorship and counselling services tailored to nursing students’ unique challenges can contribute to their overall well-being and academic success [ 16 , 17 , 18 ].

Despite the scarcity of research focusing on the link between academic stress and learning methods in nursing students, it’s crucial to identify the unique stressors they encounter. The intensity of these stressors can be connected to the learning strategies employed by these students. Academic stress and learning approach are intertwined aspects of the student experience. While academic stress can influence learning approaches, the choice of learning approach can also impact the level of academic stress experienced. By understanding this relationship and implementing strategies to promote healthy learning approaches and manage academic stress, educators and institutions can foster an environment conducive to deep learning and student well-being.

Hence, this study aims to investigate the correlation between academic stress and learning approaches experienced by nursing students.

Study objectives

Assess the levels of academic stress among nursing students.

Assess the learning approaches among nursing students.

Identify the relationship between academic stress and learning approach among nursing students.

Identify the effect of academic stress and related factors on learning approach and among nursing students.

Materials and methods

Research design.

A cross-sectional descriptive correlation research design adhering to the STROBE guidelines was used for this study.

A research project was conducted at Alexandria Nursing College, situated in Egypt. The college adheres to the national standards for nursing education and functions under the jurisdiction of the Egyptian Ministry of Higher Education. Alexandria Nursing College comprises nine specialized nursing departments that offer various nursing specializations. These departments include Nursing Administration, Community Health Nursing, Gerontological Nursing, Medical-Surgical Nursing, Critical Care Nursing, Pediatric Nursing, Obstetric and Gynecological Nursing, Nursing Education, and Psychiatric Nursing and Mental Health. The credit hour system is the fundamental basis of both undergraduate and graduate programs. This framework guarantees a thorough evaluation of academic outcomes by providing an organized structure for tracking academic progress and conducting analyses.

Participants and sample size calculation

The researchers used the Epi Info 7 program to calculate the sample size. The calculations were based on specific parameters such as a population size of 9886 students for the academic year 2022–2023, an expected frequency of 50%, a maximum margin of error of 5%, and a confidence coefficient of 99.9%. Based on these parameters, the program indicated that a minimum sample size of 976 students was required. As a result, the researchers recruited a convenient sample of 1010 nursing students from different academic levels during the 2022–2023 academic year [ 19 ]. This sample size was larger than the minimum required, which could help to increase the accuracy and reliability of the study results. Participation in the study required enrollment in a nursing program and voluntary agreement to take part. The exclusion criteria included individuals with mental illnesses based on their response and those who failed to complete the questionnaires.

socio-demographic data that include students’ age, sex, educational level, hours of sleep at night, hours spent studying, and GPA from the previous semester.

Tool two: the perceived stress scale (PSS)

It was initially created by Sheu et al. (1997) to gauge the level and nature of stress perceived by nursing students attending Taiwanese universities [ 20 ]. It comprises 29 items rated on a 5-point Likert scale, where (0 = never, 1 = rarely, 2 = sometimes, 3 = reasonably often, and 4 = very often), with a total score ranging from 0 to 116. The cut-off points of levels of perceived stress scale according to score percentage were low < 33.33%, moderate 33.33–66.66%, and high more than 66.66%. Higher scores indicate higher stress levels. The items are categorized into six subscales reflecting different sources of stress. The first subscale assesses “stress stemming from lack of professional knowledge and skills” and includes 3 items. The second subscale evaluates “stress from caring for patients” with 8 items. The third subscale measures “stress from assignments and workload” with 5 items. The fourth subscale focuses on “stress from interactions with teachers and nursing staff” with 6 items. The fifth subscale gauges “stress from the clinical environment” with 3 items. The sixth subscale addresses “stress from peers and daily life” with 4 items. El-Ashry et al. (2022) reported an excellent internal consistency reliability of 0.83 [ 21 ]. Two bilingual translators translated the English version of the scale into Arabic and then back-translated it into English by two other independent translators to verify its accuracy. The suitability of the translated version was confirmed through a confirmatory factor analysis (CFA), which yielded goodness-of-fit indices such as a comparative fit index (CFI) of 0.712, a Tucker-Lewis index (TLI) of 0.812, and a root mean square error of approximation (RMSEA) of 0.100.

Tool three: revised study process questionnaire (R-SPQ-2 F)

It was developed by Biggs et al. (2001). It examines deep and surface learning approaches using only 20 questions; each subscale contains 10 questions [ 22 ]. On a 5-point Likert scale ranging from 0 (never or only rarely true of me) to 4 (always or almost always accurate of me). The total score ranged from 0 to 80, with a higher score reflecting more deep or surface learning approaches. The cut-off points of levels of revised study process questionnaire according to score percentage were low < 33%, moderate 33–66%, and high more than 66%. Biggs et al. (2001) found that Cronbach alpha value was 0.73 for deep learning approach and 0.64 for the surface learning approach, which was considered acceptable. Two translators fluent in English and Arabic initially translated a scale from English to Arabic. To ensure the accuracy of the translation, they translated it back into English. The translated version’s appropriateness was evaluated using a confirmatory factor analysis (CFA). The CFA produced several goodness-of-fit indices, including a Comparative Fit Index (CFI) of 0.790, a Tucker-Lewis Index (TLI) of 0.912, and a Root Mean Square Error of Approximation (RMSEA) of 0.100. Comparative Fit Index (CFI) of 0.790, a Tucker-Lewis Index (TLI) of 0.912, and a Root Mean Square Error of Approximation (RMSEA) of 0.100.

Ethical considerations

The Alexandria University College of Nursing’s Research Ethics Committee provided ethical permission before the study’s implementation. Furthermore, pertinent authorities acquired ethical approval at participating nursing institutions. The vice deans of the participating institutions provided written informed consent attesting to institutional support and authority. By giving written informed consent, participants confirmed they were taking part voluntarily. Strict protocols were followed to protect participants’ privacy during the whole investigation. The obtained personal data was kept private and available only to the study team. Ensuring participants’ privacy and anonymity was of utmost importance.

Tools validity

The researchers created tool one after reviewing pertinent literature. Two bilingual translators independently translated the English version into Arabic to evaluate the applicability of the academic stress and learning approach tools for Arabic-speaking populations. To assure accuracy, two additional impartial translators back-translated the translation into English. They were also assessed by a five-person jury of professionals from the education and psychiatric nursing departments. The scales were found to have sufficiently evaluated the intended structures by the jury.

Pilot study

A preliminary investigation involved 100 nursing student applicants, distinct from the final sample, to gauge the efficacy, clarity, and potential obstacles in utilizing the research instruments. The pilot findings indicated that the instruments were accurate, comprehensible, and suitable for the target demographic. Additionally, Cronbach’s Alpha was utilized to further assess the instruments’ reliability, demonstrating internal solid consistency for both the learning approaches and academic stress tools, with values of 0.91 and 0.85, respectively.

Data collection

The researchers convened with each qualified student in a relaxed, unoccupied classroom in their respective college settings. Following a briefing on the study’s objectives, the students filled out the datasheet. The interviews typically lasted 15 to 20 min.

Data analysis

The data collected were analyzed using IBM SPSS software version 26.0. Following data entry, a thorough examination and verification were undertaken to ensure accuracy. The normality of quantitative data distributions was assessed using Kolmogorov-Smirnov tests. Cronbach’s Alpha was employed to evaluate the reliability and internal consistency of the study instruments. Descriptive statistics, including means (M), standard deviations (SD), and frequencies/percentages, were computed to summarize academic stress and learning approaches for categorical data. Student’s t-tests compared scores between two groups for normally distributed variables, while One-way ANOVA compared scores across more than two categories of a categorical variable. Pearson’s correlation coefficient determined the strength and direction of associations between customarily distributed quantitative variables. Hierarchical regression analysis identified the primary independent factors influencing learning approaches. Statistical significance was determined at the 5% (p < 0.05).

Table  1 presents socio-demographic data for a group of 1010 nursing students. The age distribution shows that 38.8% of the students were between 18 and 21 years old, 32.9% were between 21 and 24 years old, and 28.3% were between 24 and 28 years old, with an average age of approximately 22.79. Regarding gender, most of the students were female (77%), while 23% were male. The students were distributed across different educational years, a majority of 34.4% in the second year, followed by 29.4% in the fourth year. The students’ hours spent studying were found to be approximately two-thirds (67%) of the students who studied between 3 and 6 h. Similarly, sleep patterns differ among the students; more than three-quarters (77.3%) of students sleep between 5- to more than 7 h, and only 2.4% sleep less than 2 h per night. Finally, the student’s Grade Point Average (GPA) from the previous semester was also provided. 21% of the students had a GPA between 2 and 2.5, 40.9% had a GPA between 2.5 and 3, and 38.1% had a GPA between 3 and 3.5.

Figure  1 provides the learning approach level among nursing students. In terms of learning approach, most students (55.0%) exhibited a moderate level of deep learning approach, followed by 25.9% with a high level and 19.1% with a low level. The surface learning approach was more prevalent, with 47.8% of students showing a moderate level, 41.7% showing a low level, and only 10.5% exhibiting a high level.

Nursing students? levels of learning approach (N=1010)

Figure  2 provides the types of academic stress levels among nursing students. Among nursing students, various stressors significantly impact their academic experiences. Foremost among these stressors are the pressure and demands associated with academic assignments and workload, with 30.8% of students attributing their high stress levels to these factors. Challenges within the clinical environment are closely behind, contributing significantly to high stress levels among 25.7% of nursing students. Interactions with peers and daily life stressors also weigh heavily on students, ranking third among sources of high stress, with 21.5% of students citing this as a significant factor. Similarly, interaction with teachers and nursing staff closely follow, contributing to high-stress levels for 20.3% of nursing students. While still significant, stress from taking care of patients ranks slightly lower, with 16.7% of students reporting it as a significant factor contributing to their academic stress. At the lowest end of the ranking, but still notable, is stress from a perceived lack of professional knowledge and skills, with 15.9% of students experiencing high stress in this area.

Nursing students? levels of academic stress subtypes (N=1010)

Figure  3 provides the total levels of academic stress among nursing students. The majority of students experienced moderate academic stress (56.3%), followed by those experiencing low academic stress (29.9%), and a minority experienced high academic stress (13.8%).

Nursing students? levels of total academic stress (N=1010)

Table  2 displays the correlation between academic stress subscales and deep and surface learning approaches among 1010 nursing students. All stress subscales exhibited a negative correlation regarding the deep learning approach, indicating that the inclination toward deep learning decreases with increasing stress levels. The most significant negative correlation was observed with stress stemming from the lack of professional knowledge and skills (r=-0.392, p < 0.001), followed by stress from the clinical environment (r=-0.109, p = 0.001), stress from assignments and workload (r=-0.103, p = 0.001), stress from peers and daily life (r=-0.095, p = 0.002), and stress from patient care responsibilities (r=-0.093, p = 0.003). The weakest negative correlation was found with stress from interactions with teachers and nursing staff (r=-0.083, p = 0.009). Conversely, concerning the surface learning approach, all stress subscales displayed a positive correlation, indicating that heightened stress levels corresponded with an increased tendency toward superficial learning. The most substantial positive correlation was observed with stress related to the lack of professional knowledge and skills (r = 0.365, p < 0.001), followed by stress from patient care responsibilities (r = 0.334, p < 0.001), overall stress (r = 0.355, p < 0.001), stress from interactions with teachers and nursing staff (r = 0.262, p < 0.001), stress from assignments and workload (r = 0.262, p < 0.001), and stress from the clinical environment (r = 0.254, p < 0.001). The weakest positive correlation was noted with stress stemming from peers and daily life (r = 0.186, p < 0.001).

Table  3 outlines the association between the socio-demographic characteristics of nursing students and their deep and surface learning approaches. Concerning age, statistically significant differences were observed in deep and surface learning approaches (F = 3.661, p = 0.003 and F = 7.983, p < 0.001, respectively). Gender also demonstrated significant differences in deep and surface learning approaches (t = 3.290, p = 0.001 and t = 8.638, p < 0.001, respectively). Female students exhibited higher scores in the deep learning approach (31.59 ± 8.28) compared to male students (29.59 ± 7.73), while male students had higher scores in the surface learning approach (29.97 ± 7.36) compared to female students (24.90 ± 7.97). Educational level exhibited statistically significant differences in deep and surface learning approaches (F = 5.599, p = 0.001 and F = 17.284, p < 0.001, respectively). Both deep and surface learning approach scores increased with higher educational levels. The duration of study hours demonstrated significant differences only in the surface learning approach (F = 3.550, p = 0.014), with scores increasing as study hours increased. However, no significant difference was observed in the deep learning approach (F = 0.861, p = 0.461). Hours of sleep per night and GPA from the previous semester did not exhibit statistically significant differences in deep or surface learning approaches.

Table  4 presents a multivariate linear regression analysis examining the factors influencing the learning approach among 1110 nursing students. The deep learning approach was positively influenced by age, gender (being female), educational year level, and stress from teachers and nursing staff, as indicated by their positive coefficients and significant p-values (p < 0.05). However, it was negatively influenced by stress from a lack of professional knowledge and skills. The other factors do not significantly influence the deep learning approach. On the other hand, the surface learning approach was positively influenced by gender (being female), educational year level, stress from lack of professional knowledge and skills, stress from assignments and workload, and stress from taking care of patients, as indicated by their positive coefficients and significant p-values (p < 0.05). However, it was negatively influenced by gender (being male). The other factors do not significantly influence the surface learning approach. The adjusted R-squared values indicated that the variables in the model explain 17.8% of the variance in the deep learning approach and 25.5% in the surface learning approach. Both models were statistically significant (p < 0.001).

Nursing students’ academic stress and learning approaches are essential to planning for effective and efficient learning. Nursing education also aims to develop knowledgeable and competent students with problem-solving and critical-thinking skills.

The study’s findings highlight the significant presence of stress among nursing students, with a majority experiencing moderate to severe levels of academic stress. This aligns with previous research indicating that academic stress is prevalent among nursing students. For instance, Zheng et al. (2022) observed moderated stress levels in nursing students during clinical placements [ 23 ], while El-Ashry et al. (2022) found that nearly all first-year nursing students in Egypt experienced severe academic stress [ 21 ]. Conversely, Ali and El-Sherbini (2018) reported that over three-quarters of nursing students faced high academic stress. The complexity of the nursing program likely contributes to these stress levels [ 24 ].

The current study revealed that nursing students identified the highest sources of academic stress as workload from assignments and the stress of caring for patients. This aligns with Banu et al.‘s (2015) findings, where academic demands, assignments, examinations, high workload, and combining clinical work with patient interaction were cited as everyday stressors [ 25 ]. Additionally, Anaman-Torgbor et al. (2021) identified lectures, assignments, and examinations as predictors of academic stress through logistic regression analysis. These stressors may stem from nursing programs emphasizing the development of highly qualified graduates who acquire knowledge, values, and skills through classroom and clinical experiences [ 26 ].

The results regarding learning approaches indicate that most nursing students predominantly employed the deep learning approach. Despite acknowledging a surface learning approach among the participants in the present study, the prevalence of deep learning was higher. This inclination toward the deep learning approach is anticipated in nursing students due to their engagement with advanced courses, requiring retention, integration, and transfer of information at elevated levels. The deep learning approach correlates with a gratifying learning experience and contributes to higher academic achievements [ 3 ]. Moreover, the nursing program’s emphasis on active learning strategies fosters critical thinking, problem-solving, and decision-making skills. These findings align with Mahmoud et al.‘s (2019) study, reporting a significant presence (83.31%) of the deep learning approach among undergraduate nursing students at King Khalid University’s Faculty of Nursing [ 27 ]. Additionally, Mohamed &Morsi (2019) found that most nursing students at Benha University’s Faculty of Nursing embraced the deep learning approach (65.4%) compared to the surface learning approach [ 28 ].

The study observed a negative correlation between the deep learning approach and the overall mean stress score, contrasting with a positive correlation between surface learning approaches and overall stress levels. Elevated academic stress levels may diminish motivation and engagement in the learning process, potentially leading students to feel overwhelmed, disinterested, or burned out, prompting a shift toward a surface learning approach. This finding resonates with previous research indicating that nursing students who actively seek positive academic support strategies during academic stress have better prospects for success than those who do not [ 29 ]. Nebhinani et al. (2020) identified interface concerns and academic workload as significant stress-related factors. Notably, only an interest in nursing demonstrated a significant association with stress levels, with participants interested in nursing primarily employing adaptive coping strategies compared to non-interested students.

The current research reveals a statistically significant inverse relationship between different dimensions of academic stress and adopting the deep learning approach. The most substantial negative correlation was observed with stress arising from a lack of professional knowledge and skills, succeeded by stress associated with the clinical environment, assignments, and workload. Nursing students encounter diverse stressors, including delivering patient care, handling assignments and workloads, navigating challenging interactions with staff and faculty, perceived inadequacies in clinical proficiency, and facing examinations [ 30 ].

In the current study, the multivariate linear regression analysis reveals that various factors positively influence the deep learning approach, including age, female gender, educational year level, and stress from teachers and nursing staff. In contrast, stress from a lack of professional knowledge and skills exert a negative influence. Conversely, the surface learning approach is positively influenced by female gender, educational year level, stress from lack of professional knowledge and skills, stress from assignments and workload, and stress from taking care of patients, but negatively affected by male gender. The models explain 17.8% and 25.5% of the variance in the deep and surface learning approaches, respectively, and both are statistically significant. These findings underscore the intricate interplay of demographic and stress-related factors in shaping nursing students’ learning approaches. High workloads and patient care responsibilities may compel students to prioritize completing tasks over deep comprehension. This pressure could lead to a surface learning approach as students focus on meeting immediate demands rather than engaging deeply with course material. This observation aligns with the findings of Alsayed et al. (2021), who identified age, gender, and study year as significant factors influencing students’ learning approaches.

Deep learners often demonstrate better self-regulation skills, such as effective time management, goal setting, and seeking support when needed. These skills can help manage academic stress and maintain a balanced learning approach. These are supported by studies that studied the effect of coping strategies on stress levels [ 6 , 31 , 32 ]. On the contrary, Pacheco-Castillo et al. study (2021) found a strong significant relationship between academic stressors and students’ level of performance. That study also proved that the more academic stress a student faces, the lower their academic achievement.

Strengths and limitations of the study

This study has lots of advantages. It provides insightful information about the educational experiences of Egyptian nursing students, a demographic that has yet to receive much research. The study’s limited generalizability to other people or nations stems from its concentration on this particular group. This might be addressed in future studies by using a more varied sample. Another drawback is the dependence on self-reported metrics, which may contain biases and mistakes. Although the cross-sectional design offers a moment-in-time view of the problem, it cannot determine causation or evaluate changes over time. To address this, longitudinal research may be carried out.

Notwithstanding these drawbacks, the study substantially contributes to the expanding knowledge of academic stress and nursing students’ learning styles. Additional research is needed to determine teaching strategies that improve deep-learning approaches among nursing students. A qualitative study is required to analyze learning approaches and factors that may influence nursing students’ selection of learning approaches.

According to the present study’s findings, nursing students encounter considerable academic stress, primarily stemming from heavy assignments and workload, as well as interactions with teachers and nursing staff. Additionally, it was observed that students who experience lower levels of academic stress typically adopt a deep learning approach, whereas those facing higher stress levels tend to resort to a surface learning approach. Demographic factors such as age, gender, and educational level influence nursing students’ choice of learning approach. Specifically, female students are more inclined towards deep learning, whereas male students prefer surface learning. Moreover, deep and surface learning approach scores show an upward trend with increasing educational levels and study hours. Academic stress emerges as a significant determinant shaping the adoption of learning approaches among nursing students.

Implications in nursing practice

Nursing programs should consider integrating stress management techniques into their curriculum. Providing students with resources and skills to cope with academic stress can improve their well-being and academic performance. Educators can incorporate teaching strategies that promote deep learning approaches, such as problem-based learning, critical thinking exercises, and active learning methods. These approaches help students engage more deeply with course material and reduce reliance on surface learning techniques. Recognizing the gender differences in learning approaches, nursing programs can offer gender-specific support services and resources. For example, providing targeted workshops or counseling services that address male and female nursing students’ unique stressors and learning needs. Implementing mentorship programs and peer support groups can create a supportive environment where students can share experiences, seek advice, and receive encouragement from their peers and faculty members. Encouraging students to reflect on their learning processes and identify effective study strategies can help them develop metacognitive skills and become more self-directed learners. Faculty members can facilitate this process by incorporating reflective exercises into the curriculum. Nursing faculty and staff should receive training on recognizing signs of academic stress among students and providing appropriate support and resources. Additionally, professional development opportunities can help educators stay updated on evidence-based teaching strategies and practical interventions for addressing student stress.

Data availability

The datasets generated and/or analysed during the current study are not publicly available due to restrictions imposed by the institutional review board to protect participant confidentiality, but are available from the corresponding author on reasonable request.

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Acknowledgements

Our sincere thanks go to all the nursing students in the study. We also want to thank Dr/ Rasha Badry for their statistical analysis help and contribution to this study.

The research was not funded by public, commercial, or non-profit organizations.

Open access funding provided by The Science, Technology & Innovation Funding Authority (STDF) in cooperation with The Egyptian Knowledge Bank (EKB).

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Nursing Education, Faculty of Nursing, Alexandria University, Alexandria, Egypt

Rawhia Salah Dogham & Heba Fakieh Mansy Ali

Critical Care & Emergency Nursing, Faculty of Nursing, Alexandria University, Alexandria, Egypt

Nermine M. Elcokany

Obstetrics and Gynecology Nursing, Faculty of Nursing, Alexandria University, Alexandria, Egypt

Asmaa Saber Ghaly

Faculty of Nursing, Beni-Suef University, Beni-Suef, Egypt

Mohamed Mahmoud Seweid

Psychiatric and Mental Health Nursing, Faculty of Nursing, Alexandria University, Alexandria, Egypt

Ayman Mohamed El-Ashry

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Contributions

Ayman M. El-Ashry & Rawhia S. Dogham: conceptualization, preparation, and data collection; methodology; investigation; formal analysis; data analysis; writing-original draft; writing-manuscript; and editing. Heba F. Mansy Ali & Asmaa S. Ghaly: conceptualization, preparation, methodology, investigation, writing-original draft, writing-review, and editing. Nermine M. Elcokany & Mohamed M. Seweid: Methodology, investigation, formal analysis, data collection, writing-manuscript & editing. All authors reviewed the manuscript and accept for publication.

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Correspondence to Ayman Mohamed El-Ashry .

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Ethics approval and consent to participate.

The research adhered to the guidelines and regulations outlined in the Declaration of Helsinki (DoH-Oct2008). The Faculty of Nursing’s Research Ethical Committee (REC) at Alexandria University approved data collection in this study (IRB00013620/95/9/2022). Participants were required to sign an informed written consent form, which included an explanation of the research and an assessment of their understanding.

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Dogham, R.S., Ali, H.F.M., Ghaly, A.S. et al. Deciphering the influence: academic stress and its role in shaping learning approaches among nursing students: a cross-sectional study. BMC Nurs 23 , 249 (2024). https://doi.org/10.1186/s12912-024-01885-1

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ORIGINAL RESEARCH article

This article is part of the research topic.

Traditional Knowledge in Food Activism and Governance

Indigenous values and perspectives for strengthening food security and sovereignty: Learning from a community-based case study of Miskoziibiing (Bloodvein River First Nation), Manitoba, Canada Provisionally Accepted

• 1 Other, Canada
• 2 University of Winnipeg, Canada

The final, formatted version of the article will be published soon.

Despite food security being a significant challenge among many First Nations communities on Turtle Island, there needs to be more empirical, community-based research that underscores the role of traditional food systems and associated values and teachings in Manitoban communities through an Indigenous lens. This research addresses that gap by building upon Indigenous perspectives and knowledges on the status and future directions of food security and sovereignty in Misko-ziibiing (Bloodvein River First Nation). Guided by Indigenous research protocol and using a qualitative research approach, ten in-depth interviews with Bloodvein River First Nation (BVR) and Winnipeg Elders were conducted. Data was also sourced through discussions with local council members, participant observation, and field visits during 2017. The fundamental values and traditional teachings associated with food sovereignty within the community are aligned with the spirit of sharing, including sharing ethics and protocols, social learning within the community, and intergenerational transmission. In recent years, changing environmental, developmental activity, government policies and laws, lifestyle changes and affordability dynamics have continued to threaten the self-determination and food sovereignty of Indigenous peoples in the community. Their perspectives, teachings, and voices are rarely present in any scholarly work. Enhanced intergenerational transmission of traditional teachings, education and language revitalization, and local leadership involvement can strengthen these social and cultural values to enhance Indigenous food security and sovereignty in Miskoziibiing. This research identifies the knowledge and views of Elders, hunters, trappers and fishers, contributing to the current studies associated with traditional food systems and teachings. Strengthening social and cultural traditions and values is vital in working towards Indigenous food governance, sovereignty, and revitalization of their Indigenous food systems.

Keywords: Indigenous values1, social values2, cultural values3, food sovereingty4, food system governance5, Indigenous food security6, traditional foods7, self-determination8

Received: 13 Oct 2023; Accepted: 22 Apr 2024.

Copyright: © 2024 Young, Shukla and Wilson. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

* Correspondence: PhD. Shailesh Shukla, University of Winnipeg, Winnipeg, R3B 2E9, Manitoba, Canada

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Case Study Analysis as an Effective Teaching Strategy: Perceptions of Undergraduate Nursing Students From a Middle Eastern Country

Vidya seshan.

1 Maternal and Child Health Department, College of Nursing, Sultan Qaboos University, P.O. Box 66 Al-Khoudh, Postal Code 123, Muscat, Oman

Gerald Amandu Matua

2 Fundamentals and Administration Department, College of Nursing, Sultan Qaboos University, P.O. Box 66 Al-Khoudh, Postal Code 123, Muscat, Oman

Divya Raghavan

Judie arulappan, iman al hashmi, erna judith roach, sheeba elizebath sunderraj, emi john prince.

3 Griffith University, Nathan Campus, Queensland 4111

Background: Case study analysis is an active, problem-based, student-centered, teacher-facilitated teaching strategy preferred in undergraduate programs as they help the students in developing critical thinking skills. Objective: It determined the effectiveness of case study analysis as an effective teacher-facilitated strategy in an undergraduate nursing program. Methodology: A descriptive qualitative research design using focus group discussion method guided the study. The sample included undergraduate nursing students enrolled in the Maternal Health Nursing Course during the Academic Years 2017 and 2018. The researcher used a purposive sampling technique and a total of 22 students participated in the study, through five (5) focus groups, with each focus group comprising between four to six nursing students. Results: In total, nine subthemes emerged from the three themes. The themes were “Knowledge development”, “Critical thinking and Problem solving”, and “Communication and Collaboration”. Regarding “Knowledge development”, the students perceived case study analysis method as contributing toward deeper understanding of the course content thereby helping to reduce the gap between theory and practice especially during clinical placement. The “Enhanced critical thinking ability” on the other hand implies that case study analysis increased student's ability to think critically and aroused problem-solving interest in the learners. The “Communication and Collaboration” theme implies that case study analysis allowed students to share their views, opinions, and experiences with others and this enabled them to communicate better with others and to respect other's ideas which further enhanced their team building capacities. Conclusion: This method is effective for imparting professional knowledge and skills in undergraduate nursing education and it results in deeper level of learning and helps in the application of theoretical knowledge into clinical practice. It also broadened students’ perspectives, improved their cooperation capacity and their communication with each other. Finally, it enhanced student's judgment and critical thinking skills which is key for their success.

Introduction/Background

Recently, educators started to advocate for teaching modalities that not only transfer knowledge ( Shirani Bidabadi et al., 2016 ), but also foster critical and higher-order thinking and student-centered learning ( Wang & Farmer, 2008 ; Onweh & Akpan, 2014). Therefore, educators need to utilize proven teaching strategies to produce positive outcomes for learners (Onweh & Akpan, 2014). Informed by this view point, a teaching strategy is considered effective if it results in purposeful learning ( Centra, 1993 ; Sajjad, 2010 ) and allows the teacher to create situations that promote appropriate learning (Braskamp & Ory, 1994) to achieve the desired outcome ( Hodges et al., 2020 ). Since teaching methods impact student learning significantly, educators need to continuously test the effectives of their teaching strategies to ensure desired learning outcomes for their students given today's dynamic learning environments ( Farashahi & Tajeddin, 2018 ).

In this study, the researchers sought to study the effectiveness of case study analysis as an active, problem-based, student-centered, teacher-facilitated strategy in a baccalaureate-nursing program. This choice of teaching method is supported by the fact that nowadays, active teaching-learning is preferred in undergraduate programs because, they not only make students more powerful actors in professional life ( Bean, 2011 ; Yang et al., 2013 ), but they actually help learners to develop critical thinking skills ( Clarke, 2010 ). In fact, students who undergo such teaching approaches usually become more resourceful in integrating theory with practice, especially as they solve their case scenarios ( Chen et al., 2019 ; Farashahi & Tajeddin, 2018 ; Savery, 2019 ).

Review of Literature

As a pedagogical strategy, case studies allow the learner to integrate theory with real-life situations as they devise solutions to the carefully designed scenarios ( Farashahi & Tajeddin, 2018 ; Hermens & Clarke, 2009). Another important known observation is that case-study-based teaching exposes students to different cases, decision contexts and the environment to experience teamwork and interpersonal relations as “they learn by doing” thus benefiting from possibilities that traditional lectures hardly create ( Farashahi & Tajeddin, 2018 ; Garrison & Kanuka, 2004 ).

Another merit associated with case study method of teaching is the fact that students can apply and test their perspectives and knowledge in line with the tenets of Kolb et al.'s (2014) “experiential learning model”. This model advocates for the use of practical experience as the source of one's learning and development. Proponents of case study-based teaching note that unlike passive lectures where student input is limited, case studies allow them to draw from their own experience leading to the development of higher-order thinking and retention of knowledge.

Case scenario-based teaching also encourages learners to engage in reflective practice as they cooperate with others to solve the cases and share views during case scenario analysis and presentation ( MsDade, 1995 ).

This method results in “idea marriage” as learners articulate their views about the case scenario. This “idea marriage” phenomenon occurs through knowledge transfer from one situation to another as learners analyze scenarios, compare notes with each other, and develop multiple perspectives of the case scenario. In fact, recent evidence shows that authentic case-scenarios help learners to acquire problem solving and collaborative capabilities, including the ability to express their own views firmly and respectfully, which is vital for future success in both professional and personal lives ( Eronen et al., 2019 ; Yajima & Takahashi, 2017 ). In recognition of this higher education trend toward student-focused learning, educators are now increasingly expected to incorporate different strategies in their teaching.

This study demonstrated that when well implemented, educators can use active learning strategies like case study analysis to aid critical thinking, problem-solving, and collaborative capabilities in undergraduate students. This study is significant because the findings will help educators in the country and in the region to incorporate active learning strategies such as case study analysis to aid critical thinking, problem-solving, and collaborative capabilities in undergraduate students. Besides, most studies on the case study method in nursing literature mostly employ quantitative methods. The shortage of published research on the case study method in the Arabian Gulf region and the scanty use of qualitative methods further justify why we adopted the focus group method for inquiry.

A descriptive qualitative research design using focus group discussion method guided the study. The authors chose this method because it is not only inexpensive, flexible, stimulating but it is also known to help with information recall and results in rich data ( Matua et al., 2014 ; Streubert & Carpenter, 2011 ). Furthermore, as evidenced in the literature, the focus group discussion method is often used when there is a need to gain an in-depth understanding of poorly understood phenomena as the case in our study. The choice of this method is further supported by the scarcity of published research related to the use of case study analysis as a teaching strategy in the Middle Eastern region, thereby further justifying the need for an exploratory research approach for our study.

As a recommended strategy, the researchers generated data from information-rich purposively selected group of baccalaureate nursing students who had experienced both traditional lectures and cased-based teaching approaches. The focus group interviews allowed the study participants to express their experiences and perspectives in their own words. In addition, the investigators integrated participants’ self-reported experiences with their own observations and this enhanced the study findings ( Morgan & Bottorff, 2010 ; Nyumba et al., 2018 ; Parker & Tritter, 2006 ).

Eligibility Criteria

In order to be eligible to participate in the study, the participants had to:

• be a baccalaureate nursing student in College of Nursing, Sultan Qaboos University
• register for Maternity Nursing Course in 2017 and 2018.
• attend all the Case Study Analysis sessions in the courses before the study.
• show a willingness to participate in the study voluntarily and share their views freely.

The population included the undergraduate nursing students enrolled in the Maternal Health Nursing Course during the Academic Years 2017 and 2018.

The researcher used a purposive sampling technique to choose participants who were capable of actively participating and discussing their views in the focus group interviews. This technique enabled the researchers to select participants who could provide rich information and insights about case study analysis method as an effective teaching strategy. The final study sample included baccalaureate nursing students who agreed to participate in the study by signing a written informed consent. In total, twenty-two (22) students participated in the study, through five focus groups, with each focus group comprising between four and six students. The number of participants was determined by the stage at which data saturation was reached. The point of data saturation is when no new information emerges from additional participants interviewed ( Saunders et al., 2018 ).Focus group interviews were stopped once data saturation was achieved. Qualitative research design with focus group discussion allowed the researchers to generate data from information-rich purposively selected group of baccalaureate nursing students who had experienced both traditional lectures and case-based teaching approaches. The focus group interviews allowed the study participants to express their perspectives in their own words. In addition, the investigators enhanced the study findings by integrating participants’ self-reported experiences with the researchers’ own observations and notes during the study.

The study took place at College of Nursing; Sultan Qaboos University, Oman's premier public university, in Muscat. This is the only setting chosen for the study. The participants are the students who were enrolled in Maternal Health Nursing course during 2017 and 2018. The interviews occurred in the teaching rooms after official class hours. Students who did not participate in the study learnt the course content using the traditional lecture based method.

Ethical Considerations

Permission to conduct the study was granted by the College Research and Ethics Committee (XXXX). Prior to the interviews, each participant was informed about the purpose, benefits as well as the risks associated with participating in the study and clarifications were made by the principal researcher. After completing this ethical requirement, each student who accepted to participate in the study proceeded to sign an informed consent form signifying that their participation in the focus group interview was entirely voluntary and based on free will.

The anonymity of study participants and confidentiality of their data was upheld throughout the focus group interviews and during data analysis. To enhance confidentiality and anonymity of the data, each participant was assigned a unique code number which was used throughout data analysis and reporting phases. To further assure the confidentiality of the research data and anonymity of the participants, all research-related data were kept safe, under lock and key and through digital password protection, with unhindered access only available to the research team.

Research Intervention

In Fall 2017 and Spring 2018 semesters, as a method of teaching Maternal Health Nursing course, all students participated in two group-based case study analysis exercises which were implemented in the 7 th and 13 th weeks. This was done after the students were introduced to the case study method using a sample case study prior to the study. The instructor explained to the students how to solve the sample problem, including how to accomplish the role-specific competencies in the courses through case study analysis. In both weeks, each group consisting of six to seven students was assigned to different case scenarios to analyze and work on, after which they presented their collective solution to the case scenarios to the larger class of 40 students. The case scenarios used in both weeks were peer-reviewed by the researchers prior to the study.

Pilot Study

A group of three students participated as a pilot group for the study. However, the students who participated in the pilot study were not included in the final study as is general the principle with qualitative inquiry because of possible prior exposure “contamination”. The purpose of piloting was to gather data to provide guidance for a substantive study focusing on testing the data collection procedure, the interview process including the sequence and number of questions and probes and recording equipment efficacy. After the pilot phase, the lessons learned from the pilot were incorporated to ensure smooth operations during the actual focus group interview ( Malmqvist et al., 2019 .

Data Collection

The focus group interviews took place after the target population was exposed to case study analysis method in Maternal Health Nursing course during the Fall 2017 and Spring 2018 semesters. Before data collection began, the research team pilot tested the focus group interview guide to ensure that all the guide questions were clear and well understood by study participants.

In total, five (5) focus groups participated in the study, with each group comprising between four and six students. The focus group interviews lasted between 60 and 90 min. In addition to the interview guide questions, participants’ responses to unanswered questions were elicited using prompts to facilitate information flow whenever required. As a best practice, all the interviews were audio-recorded in addition to extensive field notes taken by one of the researchers. The focus group interviews continued until data saturation occurred in all the five (5) focus groups.

Credibility

In this study, participant's descriptions were digitally audio recorded to ensure that no information was lost. In order to ensure that the results are accurate, verbatim transcriptions of the audio recordings were done supported by interview notes. Furthermore, interpretations of the researcher were verified and supported with existing literature with oversight from the research team.

Transferability

The researcher provided a detailed description about the study settings, participants, sampling technique, and the process of data collection and analyses. The researcher used verbatim quotes from various participants to aid the transferability of the results.

Dependability

The researcher ensured that the research process is clearly documented, traceable, and logical to achieve dependability of the research findings. Furthermore, the researcher transparently described the research steps, procedures and process from the start of the research project to the reporting of the findings.

Confirmability

In this study, confirmability of the study findings was achieved through the researcher's efforts to make the findings credible, dependable, and transferable.

Data Analysis

Data were analyzed manually after the lead researcher integrated the verbatim transcriptions with the extensive field notes to form the final data set. Data were analyzed thematically under three thematic areas of a) knowledge development; b) critical thinking and problem solving; and (c) communication and collaboration, which are linked to the study objectives. The researchers used the Six (6) steps approach to conduct a trustworthy thematic analysis: (1) familiarization with the research data, (2) generating initial codes, (3) searching for themes, (4) reviewing the themes, (5) defining and naming themes, (6) writing the report ( Nowell et al., 2017 ).

The analysis process started with each team member individually reading and re-reading the transcripts several times and then identifying meaning units linked to the three thematic areas. The co-authors then discussed in-depth the various meaning units linked to the thematic statements until consensus was reached and final themes emerged based on the study objectives.

A total of 22 undergraduate third-year baccalaureate nursing students who were enrolled in the Maternal Health Nursing Course during the Academic Years 2017 and 2018 participated in the study, through five focus groups, with each group comprising four to six students. Of these, 59% were females and 41% were males. In total, nine subthemes emerged from the three themes. Under knowledge development, emerged the subthemes, “ deepened understanding of content ; “ reduced gap between theory and practice” and “ improved test-taking ability ”. While under Critical thinking and problem solving, emerged the subthemes, “ enhanced critical thinking ability ” and “ heightened curiosity”. The third thematic area of communication and collaboration yielded, “ improved communication ability ”; “ enhanced team-building capacity ”; “ effective collaboration” and “ improved presentation skills ”, details of which are summarized in Table 1 .

Table 1.

Objective Linked Themes and Student Perceptions of Outcome Case Study Analysis.

Theme 1: Knowledge Development

In terms of knowledge development, students expressed delight at the inclusion of case study analysis as a method during their regular theory class. The first subtheme related to knowledge development that supports the adoption of the case study approach is its perceived benefit of ‘ deepened understanding of content ’ by the students as vividly described by this participant:

“ I was able to perform well in the in-course exams as this teaching method enhanced my understanding of the content rather than memorizing ” (FGD#3).

The second subtheme related to knowledge development was informed by participants’ observation that teaching them using case study analysis method ‘ reduced the gap between theory and practice’. This participant's claim stem from the realization that, a case study scenario his group analyzed in the previous week helped him and his colleagues to competently deal with a similar situation during clinical placement the following week, as articulated below:

“ You see when I was caring for mothers in antenatal unit, I could understand the condition better and could plan her care well because me and my group already analyzed a similar situation in class last week which the teacher gave us, this made our work easier in the ward”. (FGD#7).

Another student added that:

“ It was useful as what is taught in the theory class could be applied to the clinical cases.”

This ‘theory-practice’ connection was particularly useful in helping students to better understand how to manage patients with different health conditions. Interestingly, the students reported that they were more likely to link a correct nursing care plan to patients whose conditions were close to the case study scenarios they had already studied in class as herein affirmed:

“ …when in the hospital I felt I could perceive the treatment modality and plan for [a particular] nursing care well when I [had] discussed with my team members and referred the textbook resource while performing case study discussion”. (FGD#17).

In a similar way, another student added:

“…I could relate with the condition I have seen in the clinical area. So this has given me a chance to recall the condition and relate the theory to practice”. (FGD#2) .

The other subtheme closely related to case study scenarios as helping to deepen participant's understanding of the course content, is the notion that this teaching strategy also resulted in ‘ improved test taking-ability’ as this participant's verbatim statement confirms:

“ I could answer the questions related to the cases discussed [much] better during in-course exams. Also [the case scenarios] helped me a great deal to critically think and answer my exam papers” (FGD#11).

Theme 2: Critical Thinking and Problem Solving

In this subtheme, students found the case study analysis as an excellent method to learn disease conditions in the two courses. This perceived success with the case study approach is associated with the method's ability to ‘ enhance students’ critical thinking ability’ as this student declares:

“ This method of teaching increased my ability to think critically as the cases are the situations, where we need to think to solve the situation”. (FGD#5)

This enhanced critical thinking ability attributed to case study scenario analysis was also manifested during patient care where students felt it allowed them to experience a “ flow of patient care” leading to better patient management planning as would typically occur during case scenario analysis. In support of this finding, a participant mentioned that:

“ …I could easily connect the flow of patient care provided and hence was able to plan for [his] management as often required during case study discussion” (FGD#12)

Another subtheme linked with this theme is the “ heightened curiosity” associated with the case scenario discussions. It was clear from the findings that the cases aroused curiosity in the mind of the students. This heightened interest meant that during class discussion, baccalaureate nursing students became active learners, eager to discover the next set of action as herein affirmed:

“… from the beginning of discussion with the group, I was eager to find the answer to questions presented and wanted to learn the best way for patient management” (FGD#14)

Theme 3: Communication and Collaboration

In terms of its impact on student communication, the subtheme revealed that case study analysis resulted in “ improved communication ability” among the nursing students . This enhanced ability of students to exchange ideas with each other may be attributed to the close interaction required to discuss and solve their assigned case scenarios as described by the participant below:

“ as [case study analysis] was done in the way of group discussion, I felt me and my friends communicated more within the group as we discussed our condition. We also learnt from each other, and we became better with time.” (FGD#21).

The next subtheme further augments the notion that case study analysis activities helped to “ enhance team-building capacity” of students as this participant affirmatively narrates:

“ students have the opportunity to meet face to face to share their views, opinion, and their experience, as this build on the way they can communicate with each other and respect each other's opinions and enhance team-building”. (FGD#19).

Another subtheme revealed from the findings show that the small groups in which the case analysis occurs allowed the learners to have deeper and more focused conversations with one another, resulting in “ an effective collaboration between students” as herein declared:

“ We could collaborate effectively as we further went into a deep conversation on the case to solve”. (FGD#16).

Similarly, another student noted that:

“ …discussion of case scenarios helped us to prepare better for clinical postings and simulation lab experience” (FGD#5) .

A fourth subtheme related to communication found that students also identified that case study analysis resulted in “ improved presentation skills”. This is attributed in part to the preparation students have to go through as part of their routine case study discussion activities, which include organizing their presentations and justifying and integrating their ideas. Besides readying themselves for case presentations, the advice, motivation, and encouragement such students receive from their faculty members and colleagues makes them better presenters as confirmed below:

“ …teachers gave us enough time to prepare, hence I was able to present in front of the class regarding the finding from our group.” (FGD#16).

In this study, the researches explored learner's perspectives on how one of the active teaching strategies, case study analysis method impacted their knowledge development, critical thinking, and problem solving as well as communication and collaboration ability.

Knowledge Development

In terms of knowledge development, the nursing students perceived case study analysis as contributing toward: (a) deeper understanding of content, (b) reducing gap between theory and practice, and (c) improving test-taking ability. Deeper learning” implies better grasping and retention of course content. It may also imply a deeper understanding of course content combined with learner's ability to apply that understanding to new problems including grasping core competencies expected in future practice situations (Rickles et al., 2019; Rittle-Johnson et al., 2020 ). Deeper learning therefore occurs due to the disequilibrium created by the case scenario, which is usually different from what the learner already knows ( Hattie, 2017 ). Hence, by “forcing” students to compare and discuss various options in the quest to solve the “imbalance” embedded in case scenarios, students dig deeper in their current understanding of a given content including its application to the broader context ( Manalo, 2019 ). This movement to a deeper level of understanding arises from carefully crafted case scenarios that instructors use to stimulate learning in the desired area (Nottingham, 2017; Rittle-Johnson et al., 2020 ). The present study demonstrated that indeed such carefully crafted case study scenarios did encourage students to engage more deeply with course content. This finding supports the call by educators to adopt case study as an effective strategy.

Another finding that case study analysis method helps in “ reducing the gap between theory and practice ” implies that the method helps students to maintain a proper balance between theory and practice, where they can see how theoretical knowledge has direct practical application in the clinical area. Ajani and Moez (2011) argue that to enable students to link theory and practice effectively, nurse educators should introduce them to different aspects of knowledge and practice as with case study analysis. This dual exposure ensures that students are proficient in theory and clinical skills. This finding further amplifies the call for educators to adequately prepare students to match the demands and realities of modern clinical environments ( Hickey, 2010 ). This expectation can be met by ensuring that student's knowledge and skills that are congruent with hospital requirements ( Factor et al., 2017 ) through adoption of case study analysis method which allows integration of clinical knowledge in classroom discussion on regular basis.

The third finding, related to “improved test taking ability”, implies that case study analysis helped them to perform better in their examination, noting that their experience of going through case scenario analysis helped them to answer similar cases discussed in class much better during examinations. Martinez-Rodrigo et al. (2017) report similar findings in a study conducted among Spanish electrical engineering students who were introduced to problem-based cooperative learning strategies, which is similar to case study analysis method. Analysis of student's results showed that their grades and pass rates increased considerably compared to previous years where traditional lecture-based method was used. Similar results were reported by Bonney (2015) in an even earlier study conducted among biology students in Kings Borough community college students, in New York, United States. When student's performance in examination questions covered by case studies was compared with class-room discussions, and text-book reading, case study analysis approach was significantly more effective compared to traditional methods in aiding students’ performance in their examinations. This finding therefore further demonstrates that case study analysis method indeed improves student's test taking ability.

Critical Thinking and Problem Solving

In terms of critical thinking and problem-solving ability, the use of case study analysis resulted in two subthemes: (a) enhanced critical thinking ability and (b) heightened learner curiosity. The “ enhanced critical thinking ability” implies that case analysis increased student's ability to think critically as they navigated through the case scenarios. This observation agrees with the findings of an earlier questionnaire-based study conducted among 145 undergraduate business administration students at Chittagong University, Bangladesh, that showed 81% of respondents agree that case study analysis develops critical thinking ability and enables students to do better problem analysis ( Muhiuddin & Jahan, 2006 ). This observation agrees with the findings of an earlier study conducted among 145 undergraduate business administration students at Chittagong University, Bangladesh. The study showed that 81% of respondents agreed that case study analysis facilitated the development of critical thinking ability in the learners and enabled the students to perform better with problem analysis ( Muhiuddin & Jahan, 2006 ).

More recently, Suwono et al. (2017) found similar results in a quasi-experimental research conducted at a Malaysian university. The research findings showed that there was a significant difference in biological literacy and critical thinking skills between the students taught using socio-biological case-based learning and those taught using traditional lecture-based learning. The researchers concluded that case-based learning enhanced the biological literacy and critical thinking skills of the students. The current study adds to the existing pedagogical knowledge base that case study methodology can indeed help to deepen learner's critical thinking and problem solving ability.

The second subtheme related to “ heightened learner curiosity” seems to suggest that the case studies aroused problem-solving interest in learners. This observation agrees with two earlier studies by Tiwari et al. (2006) and Flanagan and McCausland (2007) who both reported that most students enjoyed case-based teaching. The authors add that the case study method also improved student's clinical reasoning, diagnostic interpretation of patient information as well as their ability to think logically when presented a challenge in the classroom and in the clinical area. Jackson and Ward (2012) similarly reported that first year engineering undergraduates experienced enhanced student motivation. The findings also revealed that the students venturing self-efficacy increased much like their awareness of the importance of key aspects of the course for their future careers. The authors conclude that the case-based method appears to motivate students to autonomously gather, analyze and present data to solve a given case. The researchers observed enhanced personal and collaborative efforts among the learners, including improved communication ability. Further still, learners were more willing to challenge conventional wisdom, and showed higher “softer” skills after exposure to case analysis based teaching method. These findings like that of the current study indicate that teaching using case based analysis approach indeed motivates students to engage more in their learning, there by resulting in deeper learning.

Communication and Collaboration

Case study analysis is also perceived to result in: (a) improved communication ability; (b) enhanced team -building capacity, (c) effective collaboration ability, and (d) enhanced presentation skills. The “ improved communication ability ” manifested in learners being better able to exchange ideas with peers, communicating their views more clearly and collaborating more effectively with their colleagues to address any challenges that arise. Fini et al. (2018) report comparable results in a study involving engineering students who were subjected to case scenario brainstorming activities about sustainability concepts and their implications in transportation engineering in selected courses. The results show that this intervention significantly improved student's communication skills besides their higher-order cognitive, self-efficacy and teamwork skills. The researchers concluded that involving students in brainstorming activities related to problem identification including their practical implications, is an effective teaching strategy. Similarly, a Korean study by Park and Choi (2018) that sought to analyze the effects of case-based communication training involving 112 sophomore nursing students concluded that case-based training program improved the students’ critical thinking ability and communication competence. This finding seems to support further the use of case based teaching as an effective teaching-learning strategy.

The “ enhanced team-building capacity” arose from the opportunity students had in sharing their views, opinions, and experiences where they learned to communicate with each other and respect each other's ideas which further enhance team building. Fini et al. (2018) similarly noted that increased teamwork levels were seen among their study respondents when the researchers subjected engineering students to case scenario based-brainstorming activities as occurs with case study analysis teaching. Likewise, Lairamore et al. (2013) report similar results in their study that showed that case study analysis method increased team work ability and readiness among students from five health disciplines in a US-based study.

The finding that case study analysis teaching method resulted in “ effective collaboration ability” among students manifested as students entered into deep conversation as they solved the case scenarios. Rezaee and Mosalanejad (2015) assert that such innovative learning strategies result in noticeable educational outcomes, such as greater satisfaction with and enjoyment of the learning process ( Wellmon et al., 2012 ). Further, positive attitudes toward learning and collaboration have been noted leading to deeper learning as students prepare for case discussions ( Rezaee & Mosalanejad, 2015 ). This results show that case study analysis can be utilized by educators to foster professional collaboration among their learners, which is one of the key expectations of new graduates today.

The finding associated with “improved presentation skills” is consistent with the results of a descriptive study in Saudi Arabia that compared case study and traditional lectures in the teaching of physiology course to undergraduate nursing students. The researchers found that case-based teaching improved student’ overall knowledge and performance in the course including facilitating the acquisition of skills compared to traditional lectures ( Majeed, 2014 ). Noblitt et al. (2010) report similar findings in their study that compares traditional presentation approach with the case study method for developing and improving student's oral communication skills. This finding extends our understanding that case study method improves learners’ presentation skills.

The study was limited to level third year nursing students belonging to only one college and the sample size, which might limit the transferability of the study findings to other settings.

Implications for Practice

These study findings add to the existing body of knowledge that places case study based teaching as a tested method that promotes perception learning where students’ senses are engaged as a result of the real-life and authentic clinical scenarios ( Malesela, 2009 ), resulting in deeper learning and achievement of long-lasting knowledge ( Fiscus, 2018 ). The students reported that case scenario discussions broadened their perspectives, improved their cooperation capacity and communication with each other. This teaching method, in turn, offers students an opportunity to enhance their judgment and critical thinking skills by applying theory into practice.

These skills are critically important because nurses need to have the necessary knowledge and skills to plan high quality care for their patients to achieve a speedy recovery. In order to attain this educational goal, nurse educators have to prepare students through different student- centered strategies. The findings of our study appear to show that when appropriately used, case-based teaching results in acquisition of disciplinary knowledge manifested by deepened understanding of course content, as well as reducing the gap between theory and practice and enhancing learner's test-taking-ability. The study also showed that cased based teaching enhanced learner's critical thinking ability and curiosity to seek and acquire a deeper knowledge. Finally, the study results indicate that case study analysis results in improved communication and enhanced team-building capacity, collaborative ability and improved oral communication and presentation skills. The study findings and related evidence from literature show that case study analysis is well- suited approach for imparting knowledge and skills in baccalaureate nursing education.

This study evaluated the usefulness of Case Study Analysis as a teaching strategy. We found that this method of teaching helps encourages deeper learning among students. For instructors, it provides the opportunity to tailor learning experiences for students to undertake in depth study in order to stimulate deeper understanding of the desired content. The researchers conclude that if the cases are carefully selected according to the level of the students, and are written realistically and creatively and the group discussions keep students well engaged, case study analysis method is more effective than other traditional lecture methods in facilitating deeper and transferable learning/skills acquisition in undergraduate courses.

Conflict of Interest: The authors declare no conflict of interest.

ORCID iD: Judie Arulappan https://orcid.org/0000-0003-2788-2755

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Key facts about the abortion debate in America

The U.S. Supreme Court’s June 2022 ruling to overturn Roe v. Wade – the decision that had guaranteed a constitutional right to an abortion for nearly 50 years – has shifted the legal battle over abortion to the states, with some prohibiting the procedure and others moving to safeguard it.

As the nation’s post-Roe chapter begins, here are key facts about Americans’ views on abortion, based on two Pew Research Center polls: one conducted from June 25-July 4 , just after this year’s high court ruling, and one conducted in March , before an earlier leaked draft of the opinion became public.

This analysis primarily draws from two Pew Research Center surveys, one surveying 10,441 U.S. adults conducted March 7-13, 2022, and another surveying 6,174 U.S. adults conducted June 27-July 4, 2022. Here are the questions used for the March survey , along with responses, and the questions used for the survey from June and July , along with responses.

Everyone who took part in these surveys is a member of the Center’s American Trends Panel (ATP), an online survey panel that is recruited through national, random sampling of residential addresses. This way nearly all U.S. adults have a chance of selection. The survey is weighted to be representative of the U.S. adult population by gender, race, ethnicity, partisan affiliation, education and other categories.  Read more about the ATP’s methodology .

A majority of the U.S. public disapproves of the Supreme Court’s decision to overturn Roe. About six-in-ten adults (57%) disapprove of the court’s decision that the U.S. Constitution does not guarantee a right to abortion and that abortion laws can be set by states, including 43% who strongly disapprove, according to the summer survey. About four-in-ten (41%) approve, including 25% who strongly approve.

About eight-in-ten Democrats and Democratic-leaning independents (82%) disapprove of the court’s decision, including nearly two-thirds (66%) who strongly disapprove. Most Republicans and GOP leaners (70%) approve , including 48% who strongly approve.

Most women (62%) disapprove of the decision to end the federal right to an abortion. More than twice as many women strongly disapprove of the court’s decision (47%) as strongly approve of it (21%). Opinion among men is more divided: 52% disapprove (37% strongly), while 47% approve (28% strongly).

About six-in-ten Americans (62%) say abortion should be legal in all or most cases, according to the summer survey – little changed since the March survey conducted just before the ruling. That includes 29% of Americans who say it should be legal in all cases and 33% who say it should be legal in most cases. About a third of U.S. adults (36%) say abortion should be illegal in all (8%) or most (28%) cases.

Generally, Americans’ views of whether abortion should be legal remained relatively unchanged in the past few years , though support fluctuated somewhat in previous decades.

Relatively few Americans take an absolutist view on the legality of abortion – either supporting or opposing it at all times, regardless of circumstances. The March survey found that support or opposition to abortion varies substantially depending on such circumstances as when an abortion takes place during a pregnancy, whether the pregnancy is life-threatening or whether a baby would have severe health problems.

While Republicans’ and Democrats’ views on the legality of abortion have long differed, the 46 percentage point partisan gap today is considerably larger than it was in the recent past, according to the survey conducted after the court’s ruling. The wider gap has been largely driven by Democrats: Today, 84% of Democrats say abortion should be legal in all or most cases, up from 72% in 2016 and 63% in 2007. Republicans’ views have shown far less change over time: Currently, 38% of Republicans say abortion should be legal in all or most cases, nearly identical to the 39% who said this in 2007.

However, the partisan divisions over whether abortion should generally be legal tell only part of the story. According to the March survey, sizable shares of Democrats favor restrictions on abortion under certain circumstances, while majorities of Republicans favor abortion being legal in some situations , such as in cases of rape or when the pregnancy is life-threatening.

There are wide religious divides in views of whether abortion should be legal , the summer survey found. An overwhelming share of religiously unaffiliated adults (83%) say abortion should be legal in all or most cases, as do six-in-ten Catholics. Protestants are divided in their views: 48% say it should be legal in all or most cases, while 50% say it should be illegal in all or most cases. Majorities of Black Protestants (71%) and White non-evangelical Protestants (61%) take the position that abortion should be legal in all or most cases, while about three-quarters of White evangelicals (73%) say it should be illegal in all (20%) or most cases (53%).

In the March survey, 72% of White evangelicals said that the statement “human life begins at conception, so a fetus is a person with rights” reflected their views extremely or very well . That’s much greater than the share of White non-evangelical Protestants (32%), Black Protestants (38%) and Catholics (44%) who said the same. Overall, 38% of Americans said that statement matched their views extremely or very well.

Catholics, meanwhile, are divided along religious and political lines in their attitudes about abortion, according to the same survey. Catholics who attend Mass regularly are among the country’s strongest opponents of abortion being legal, and they are also more likely than those who attend less frequently to believe that life begins at conception and that a fetus has rights. Catholic Republicans, meanwhile, are far more conservative on a range of abortion questions than are Catholic Democrats.

Women (66%) are more likely than men (57%) to say abortion should be legal in most or all cases, according to the survey conducted after the court’s ruling.

More than half of U.S. adults – including 60% of women and 51% of men – said in March that women should have a greater say than men in setting abortion policy . Just 3% of U.S. adults said men should have more influence over abortion policy than women, with the remainder (39%) saying women and men should have equal say.

The March survey also found that by some measures, women report being closer to the abortion issue than men . For example, women were more likely than men to say they had given “a lot” of thought to issues around abortion prior to taking the survey (40% vs. 30%). They were also considerably more likely than men to say they personally knew someone (such as a close friend, family member or themselves) who had had an abortion (66% vs. 51%) – a gender gap that was evident across age groups, political parties and religious groups.

Relatively few Americans view the morality of abortion in stark terms , the March survey found. Overall, just 7% of all U.S. adults say having an abortion is morally acceptable in all cases, and 13% say it is morally wrong in all cases. A third say that having an abortion is morally wrong in most cases, while about a quarter (24%) say it is morally acceptable in most cases. An additional 21% do not consider having an abortion a moral issue.

Among Republicans, most (68%) say that having an abortion is morally wrong either in most (48%) or all cases (20%). Only about three-in-ten Democrats (29%) hold a similar view. Instead, about four-in-ten Democrats say having an abortion is morally  acceptable  in most (32%) or all (11%) cases, while an additional 28% say it is not a moral issue. 

White evangelical Protestants overwhelmingly say having an abortion is morally wrong in most (51%) or all cases (30%). A slim majority of Catholics (53%) also view having an abortion as morally wrong, but many also say it is morally acceptable in most (24%) or all cases (4%), or that it is not a moral issue (17%). Among religiously unaffiliated Americans, about three-quarters see having an abortion as morally acceptable (45%) or not a moral issue (32%).

• Religion & Abortion

What the data says about abortion in the U.S.

Support for legal abortion is widespread in many countries, especially in europe, nearly a year after roe’s demise, americans’ views of abortion access increasingly vary by where they live, by more than two-to-one, americans say medication abortion should be legal in their state, most latinos say democrats care about them and work hard for their vote, far fewer say so of gop, most popular.

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Article Contents

1 introduction, 2 reminder on classical operads, 3 polydifferential functor, 4 deformation complexes, 5 kontsevich graph complexes, 6 kontsevich graph complex from the operad of lie algebras, 7 gutt quantizations, 8 on the unique non-trivial deformation of the map |$i$|, acknowledgments.

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From the Lie Operad to the Grothendieck–Teichmüller Group

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Vincent Wolff, From the Lie Operad to the Grothendieck–Teichmüller Group, International Mathematics Research Notices , Volume 2024, Issue 8, April 2024, Pages 6496–6521, https://doi.org/10.1093/imrn/rnad225

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We study the deformation complex of the natural morphism from the degree |$d$| shifted Lie operad to its polydifferential version, and prove that it is quasi-isomorphic to the Kontsevich graph complex |$\textbf {GC}_{d}$|⁠ . In particular, we show that in the case |$d=2$| the Grothendieck–Teichmüller group |$\textbf {GRT}_{1}$| is a symmetry group (up to homotopy) of the aforementioned morphism. We also prove that in the case |$d=1$|⁠ , corresponding to the usual Lie algebras, the natural morphism admits a unique homotopy non-trivial deformation, which is described explicitly with the help of the universal enveloping construction. Finally, we prove the rigidity of the strongly homotopy version of the universal enveloping functor in the Lie theory.

The theory of operads, props, and graph complexes underwent a rapid development in recent years; its applications can be seen nowadays almost everywhere [ 11 , 12 , 23 ]: in algebraic topology, in homological algebra, in (algebraic) geometry, in string topology, in deformation theory, in quantization theory, etc. This theory unifies several ideas from various areas in mathematics.

The first main (and perhaps, very surprising) result of this paper says that the deformation complex |$\textbf {Def}(\textbf {Lie}_{d} \stackrel {i}{\rightarrow } \mathcal {O}_{c}(\textbf {Lie}_{d}))$| of the above natural morphism can be identified (via an explicit quasi-isomorphism shown in § 6 ) with M. Kontsevich’s famous graph complex |$\textbf {GC}_{d}$| ! In particular, this result implies that the mysterious Grothendieck–Teichmüller group acts non-trivially and almost faithfully on homotopy classes of the map |$i$|⁠ .

This result gives us one of the simplest incarnations of the Grothendieck–Teichmüller group, and explains, perhaps, why it occurs in two seemingly different deformation quantization problems, the universal quantization of Poisson structures (solved by M. Kontsevich in [ 9 ]) and the universal quantization of Lie bialgebras (formulated by V. Drinfeld and solved by Etingov–Kazhdan in [ 5 ]) as both these theories involve |$\mathcal {O}(\textbf {Lie})$| as a sub-structure.

The universal enveloping construction associates to a Lie algebra |$V$| the corresponding associative algebra |$\mathfrak {U}(V)$|⁠ , which is isomorphic by the Poincaré–Birkhoff–Witt (PBW) theorem to the symmetric tensor algebra |$\odot V$|⁠ . Hence, it is not that surprising that this construction can be described in terms of the operad |$\mathcal {O}(\textbf {Lie})$|⁠ . Indeed, following S. Gutt [ 6 ] and K. Vinay [ 7 ], one first interprets the universal enveloping algebra construction |$\mathfrak {U}(V)$| as a star product construction on |$\odot V$| given in terms of polydifferential operators. Second, one notices that this interpretation can be encoded as a morphism of operads |$\textbf {Ass} \rightarrow \textbf {End}_{\odot V}$| satisfying some non-triviality condition. The point is that this map factors through some morphism |$\textbf {Ass} \rightarrow \mathcal {O}(\textbf {Lie})$| and the canonical map |$\mathcal {O}(\textbf {Lie}) \rightarrow \textbf {End}_{\odot V}$| induced by the functor |$\mathcal {O}$| applied to the given representation of |$\textbf {Lie}$| in |$V$|⁠ . Hence, all subtleties of the universal enveloping functor |$\mathfrak {U}$| get encoded into the morphism of operads |$\textbf {Ass} \rightarrow \mathcal {O}(\textbf {Lie})$| satisfying some non-triviality condition (see § 7 below).

We study in this paper the deformation complex |$\textbf {Def}(\textbf {Ass} \stackrel {\mathcal {U}}{\rightarrow } \mathcal {O}(\textbf {Lie}))$| and prove that its cohomology is one-dimensional, the unique cohomology class corresponding to the rescaling freedom of the Lie bracket. The conclusion is that the morphism |$\mathcal {U}$| is unique (up to gauge equivalence). This result is not surprising, of course. One can infer it from the classification theorem of Kontsevich formality maps given in terms of the graph complex |$\textbf {GC}_{2}$| [ 4 ]. So we just give a new very short proof of this uniqueness. This proof has a small advantage that it carries over to |$\textbf {Lie}_{\infty }$| straightforwardly.

There are several constructions generalizing the universal enveloping functor from Lie algebras (controlled by the operad |$\textbf {Lie}$|⁠ ) to strongly homotopy Lie algebras (which are controlled by |$\textbf {Lie}_{\infty }$|⁠ , the minimal resolution of |$\textbf {Lie}$|⁠ ). All constructions involve the notion of strongly homotopy associative algebras, which was introduced by J. Stasheff in [ 20 ] and which are controlled by the dg operad |$\textbf {Ass}_{\infty }$|⁠ , the minimal resolution of |$\textbf {Ass}$|⁠ . One such generalization of the functor |$\mathfrak {U}$| is offered by M. Kontsevich formality map applied to linear polyvector fields; that generalization uses, in general, graphs with wheels, but, as has been proven by B. Shoikhet [ 19 ], the graphs with wheels can be removed so that one gets a strongly homotopy extension of the functor |$\mathfrak {U}$|⁠ , which works well for infinite dimensional |$\textbf {Lie}_{\infty }$| algebras. Another construction was given by V. Baranovsky [ 2 ] as the cobar construction of the Cartan–Chevalley–Eilenberg coalgebra associated to an |$\textbf {Lie}_{\infty }$| algebra, by J. M. Moreno-Fernández [ 17 ] as an |$\textbf {Ass}_{\infty }$| algebra isomorphic as graded vector spaces to the free symmetric algebra associated to an |$\textbf {Lie}_{\infty }$| algebra and by T. Lada and M. Markl in [ 10 ].

These constructions can be understood as a morphism of operads |$\textbf {Ass}_{\infty } \rightarrow \mathcal {O}(\textbf {Lie}_{\infty })$|⁠ . We study the deformation complex of any of these two maps and prove that it is quasi-isomorphic to the deformation complex of the map considered in |$(\ref {eqGuttMorphism})$|⁠ , implying that all constructions are gauge equivalent. Moreover, any other attempt to construct such a generalization satisfying some natural conditions must be gauge equivalent to these ones as the cohomology of the complex |$\textbf {Def}(\textbf {Ass}_{\infty } \rightarrow \mathcal {O}(\textbf {Lie}_{\infty }))$| is one-dimensional (see Corollary 7.8 ). This cohomology result is in a full agreement with the derived PBW theorem established by A. Khoroshkin and P. Tamaroff in [ 8 ].

Let us remind the reader the construction of two classical operads [ 11 , 12 ].

Representations of |$\textbf {Ass}_{\infty }$| in a dg vector space |$V$| are precisely the strongly homotopy associative algebras introduced by J. Stasheff in [ 20 ].

This map will be used in Section 8 .

The black vertices are called internal vertices and edges between internal vertices are called internal edges . By erasing all white vertices, we obtain a collection of disjoint trees, which will be called internal irreducible components (i.i.c.).

Note that for |$d$| even we implicitly assume an ordering of the internal edges as well as an ordering of the in-edges of the white out-vertex (up to a sign). For |$d$| odd, we assume implicitly an ordering of the internal vertices as well as an ordering (up to a sign) of the out-edges attached to each white in-vertex.

The compositions |$\Gamma _{1} \circ _{i} \Gamma _{2}$| in |$\mathcal {O}(\textbf {Lie}_{d})$| work as follows: first, we erase the white out-vertex of |$\Gamma _{2}$| and the |$i$| th white in-vertex of |$\Gamma _{1}$|⁠ . This step creates many “hanging” out-edges in |$\Gamma _{2}$| and in-edges in |$\Gamma _{1}$|⁠ . Second, we sum over all possible attachments of the hanging out-edges of |$\Gamma _{2}$| to the hanging in-edges of |$\Gamma _{1}$| and the white out-vertex of |$\Gamma _{1}$|⁠ . Finally, we sum over all attachments of remaining in-edges of |$\Gamma _{1}$| to the white in-vertices of |$\Gamma _{2}$|⁠ .

We define |$\mathcal {O}_{c}(\textbf {Lie}_{d})$| to be the suboperad spanned by connected graphs, that is, we assume that the graphs remain connected when we erase the white output vertex.

In any case, we see that the Jacobi identity is mapped to zero.

We recall the following facts:

Combining these two facts we see that |$H(\textbf {Def}(\textbf {HoLie}_{d} \rightarrow \textbf {HoLie}_{d}))$| is one-dimensional.

where |$V_{\textrm {in}}(\Gamma )$| denotes the set of white input vertices of |$\Gamma $|⁠ .

We recall some facts about the operad of graphs and graph complexes. For completeness, we recall the definition of a directed graph:

|$H(\Gamma )$| is a finite set of half-edges ,

• 2) |$\sqcup $| is a partition of |$H(\Gamma )$| $$ \begin{align*} & H(\Gamma)=\bigsqcup_{v \in V(\Gamma)}{H(v)}, \end{align*}$$ parametrized by a set |$V(\Gamma )$| called the set of vertices of |$\Gamma $|⁠ . For a vertex |$v$|⁠ , the set |$H(v)$| is called the set of half-edges attached to |$v$| . The valency of a vertex |$v$| is defined to be the cardinality of |$H(v)$|⁠ .

|$\tau :H(\Gamma ) \rightarrow H(\Gamma )$| is an involution. The orbits of cardinality two are called the (internal) edges and the set of edges is denoted by |$E(\Gamma )$|⁠ . The orbits of cardinality one are called hairs and the set of hairs is denoted by |$L(\Gamma )$|

If |$L(\Gamma )=\emptyset $|⁠ , then |$\Gamma $| is simply called a graph . A graph |$\Gamma $| is called directed if each edge |$e=(h,\tau (h))$| comes with a choice of an ordering of half-edges.

If |$d$| is even, elements of |$\textbf {Gra}_{d}$| can be seen as undirected graphs with edges having degree |$1-d$| together with an ordering of the edges up to an even permutation, while an odd permutation acts by multiplication by |$-1$|⁠ .

If |$d$| is odd, |$\textbf {Gra}_{d}$| consists of directed graphs where changing the direction of an edge yields a multiplication by |$-1$|⁠ .

The operadic composition |$\Gamma _{1} \, \circ _{v} \, \Gamma _{2}$| works by substituting the graph |$\Gamma _{2}$| in the vertex |$v$| of |$\Gamma _{1}$| and by summing over all possibilities of attaching the edges of |$v$| to the vertices of |$\Gamma _{2}$|⁠ .

Elements of |$\textbf {fcGC}_{d}$| can be interpreted as connected graphs together with an ordering of the edges, up to an even permutation when |$d$| is even. For |$d$| odd, we have an ordering of the vertices, up to even permutations, together with a choice on the orientation of each edge, up to a flip yielding a multiplication by |$-1$|⁠ .

We consider the subcomplex |$\textbf {GC}_{d} \subset \textbf {fcGC}_{d}$| spanned by connected graphs with vertices having valency at least |$3$|⁠ . Let |$(\textbf {GC}_{d}^{2}:=\bigoplus _{\substack {p \geq 1 \\ p \equiv 2d+1 \mod 4}}{\mathbb {K}[d-p]},0)$|⁠ . It has been shown [ 21 ] that the natural projection |$\textbf {fcGC}_{d} \rightarrow \textbf {GC}_{d}^{\geq 2}:=\textbf {GC}_{d} \oplus \textbf {GC}_{d}^{2}$| is a quasi-isomorphism, that is, |$H(\textbf {GC}^{\geq 2}_{d})=H(\textbf {fcGC}_{d})$|⁠ .

We recall the definition of the Grothendieck–Teichmüller group [ 21 ].

Consider |$\mathbb {F}_{2}=\mathbb {K}\langle \langle X,Y \rangle \rangle $| the completed free associative algebra generated by |$X,Y$|⁠ . Define a coproduct |$\Delta $| by setting |$\Delta X=X \otimes 1 + 1 \otimes X$| and |$\Delta Y = Y \otimes 1 + 1 \otimes Y$|⁠ . An element |$\alpha \in \mathbb {F}_{2}$| is called group-like if |$\Delta \alpha =\alpha \otimes \alpha $|⁠ .

We also need the Drinfeld–Kohno Lie algebra |$t_{n}$| defined by generators |$t_{ij}=t_{ji}$| for |$1 \leq i, j \leq n$|⁠ , |$i \neq j$|⁠ , which satisfy |$[t_{ij},t_{ik}+t_{kj}]=0$| and |$[t_{ij},t_{kl}]=0$| for any distinct |$i,j,k,l$|⁠ .

We can now state the following theorem concerning the cohomology of |$\textbf {GC}_{d}$|⁠ .

T. Willwacher ,[ 21 ]

where |$\Gamma ^{p}$| is a linear combination of graphs with exactly one vertex of valency |$p$| and all other vertices of valency strictly less than |$p$| and |$\lambda _{p}$| is some coefficient.

There is a relation between the operad of graphs and the operad |$\mathcal {O}(\textbf {Lie}_{d})$|⁠ .

  Lemma 6.1. Let |$I$| be the ideal in the operad |$\mathcal {O}_{c}(\textbf {Lie}_{d})$| generated by graphs having at least one internal edge. Then the quotient operad can be identified with the operad |$\textbf {Gra}_{d}$|⁠ , that is, $$ \begin{align*} & \mathcal{O}_{c}(\textbf{Lie}_{d})/I \cong \textbf{Gra}_{d}. \end{align*}$$

Conversely, given a generator |$g \in \textbf {Gra}_{d}$|⁠ , we can construct a generator |$\Gamma \in \mathcal {O}_{c}(\textbf {Lie}_{d})$| with white input vertices corresponding the vertices of |$g$| and each edge corresponds to one irreducible component between the two output vertices. It follows that |$\alpha $| defines a bijection on generators and it remains to show that it respects operadic compositions. By its very definition as qoutient operad, for generators |$\Gamma _{1},\Gamma _{2} \in \mathcal {O}_{c}(\textbf {Lie}_{d})$|⁠ , the operadic composition |$\Gamma _{1} \circ _{i} \Gamma _{2}$| is given by erasing input vertex |$i$| of |$\Gamma _{1}$| and summing over all attachments of the hanging edges to the input vertices of |$\Gamma _{2}$|⁠ . This corresponds by definition of |$\textbf {Gra}_{d}$| to the operadic composition |$\alpha (\Gamma _{1}) \circ _{i} \alpha (\Gamma _{2})$| and the result follows.

We can now state the main theorem:

The map |$F$| is a quasi-isomorphism.

Recall that the natural projection |$\textbf {fcGC}_{d} \rightarrow \textbf {GC}_{d}^{\geq 2}=\textbf {GC}_{d}^{2} \oplus \textbf {GC}_{d}$| is a quasi-isomorphism and thus it is enough to show that the map |$C:=\textbf {Def}(\textbf {Lie}_{d} \rightarrow \mathcal {O}_{c}(\textbf {Lie}_{d})) \rightarrow \textbf {GC}_{d}^{\geq 2}$| is a quasi-isomorphism.

An edge between a white vertex and a star vertex is called star edge . Note that by construction, there are no edges between star vertices.

The complex |$C$| splits as a direct sum |$C=(C^{\leq 1},\delta ) \oplus (C^{\geq 2},\delta )$| where |$C^{\leq 1}$| is generated by graphs with all white vertices having valency less or equal to |$1$| and |$C^{\geq 2}$| is generated by graphs with at least one white vertex of valency at least |$2$|⁠ .

Hence, it is enough to prove that the restriction |$f:(C^{\geq 2},\delta ) \rightarrow (\textbf {GC}_{d}^{2},0) \oplus (\textbf {GC}_{d},\delta )$| is a quasi-isomorphism. On the right-hand side, we consider a filtration on the number of vertices. Then on the first page the induced differential vanishes and the second page is equal to |$(\textbf {GC}_{d}^{2},0) \oplus (\textbf {GC}_{d},\delta )$|⁠ .

Hence, the number of white vertices of valency at least |$3$| can decrease by |$1$| but note that an internal edge needs to be created. In this case, the number |$F_{-p}$| increases by |$1$| and hence is respected by the differential.

As the differential does not create new univalent vertices, we see that the differential |$\delta _{0}$| on the first page can only create new white bivalent vertices. As the number of star vertices is preserved, we have a direct sum decomposition |$\text {gr}C^{\geq 2}=\bigoplus _{N \geq 0}{C_{N}}$| where |$C_{N}$| is the subcomplex spanned by graphs with |$N$| star vertices. It has been proven in [ 21 ] that |$H(C_{0},\delta _{0})=\textbf {GC}_{d}^{2} \oplus \textbf {GC}_{d}$|⁠ . It remains to show that |$(\bigoplus _{N \geq 1}{C_{N}},\delta _{0})$| is acyclic.

where we omit the summands creating a univalent vertex.

are not cocycles and we conclude that |$(\bigoplus _{N \geq 1}{C_{N}},\delta _{0})$| is acyclic.

where |$H^{\ast }(C_{0}\delta _{0}) \cong \textbf {GC}_{d}^{2} \oplus \textbf {GC}_{d}$| as vector spaces and |$\delta _{1}$| is the differential that increases the value of the parameter of the filtration by |$1$|⁠ . Hence, |$\delta _{1}$| cannot create new star vertices (as this gives an increase by at least |$2$|⁠ ) and thus |$\delta _{1}$| can only split white vertices as the usual differential in |$\textbf {GC}_{d}$|⁠ . Finally, this shows that we have an isomorphism of complexes on the second page and the result follows.

The different types of antennas.

As a corollary, we obtain the following:

  Corollary 6.4. $$ \begin{align*} & H^{\bullet}(\textbf{Def}(\textbf{Lie}_{d} \stackrel{i}{\rightarrow} \mathcal{O}_{c}(\textbf{Lie}_{d})))= \textbf{GC}_{d}^{2} \oplus H^{\bullet}(\textbf{GC}_{d}) \end{align*}$$ In particular, $$ \begin{align*} & H^{0}(\textbf{Lie}_{2} \rightarrow \mathcal{O}(\textbf{Lie}_{2})))=\mathfrak{g}\mathfrak{r}\mathfrak{t}_{1}. \end{align*}$$

lie in |$H^{2}(\textbf {GC}_{d}^{2}) \oplus H^{2}(\textbf {GC}_{d})$|⁠ .

This obstruction cohomology class cannot be hit when we try to extend the infinitesimal deformation |$\Delta $| to a genuine deformation (cf. [ 22 ] Section |$5$|⁠ ). Hence, we conclude that the standard morphism |$i:\textbf {Lie} \rightarrow \mathcal {O}_{c}(\textbf {Lie})$| admits precisely one (up to homotopy equivalence) non-trivial deformation. Remarkably, this unique non-trivial deformation is directly related to the universal enveloping construction and the PBW theorem as we show in Section 8 .

The spaces |$\odot V$| and |$\mathcal {U}V$| are related as vector spaces by the PBW theorem:

As a vector space |$\odot V \cong \mathcal {U}V$|⁠ .

• 1) If |$v_{1},v_{2} \in V$|⁠ , then $$ \begin{align}& v_{1} \ast v_{2} = v_{1} \odot v_{2} + \frac{\hbar}{2}[v_{1},v_{2}].\end{align}$$ (5)
• 2) Let |$e^{v_{1}},e^{v_{2}}\in C^{\infty }_{V}$|⁠ . Then $$ \begin{align*} & e^{v_{1}} \ast e^{v_{2}}=e^{\text{CBH}(v_{1},v_{2})}, \end{align*}$$ where |$\text {CBH}(v_{1},v_{2})$| denotes the Campbell–Baker–Hausdorff series $$ \begin{align*} & \text{CBH}(v_{1},v_{2})=v_{1}+v_{2}+\frac{\hbar}{2}[v_{1},v_{2}] + \frac{\hbar^{2}}{12}([v_{1},[v_{1},v_{2}]]+[[v_{1},v_{2}],v_{2}])+\cdots. \end{align*}$$

This motivates the following definition:

Any morphism of operads |$\mathcal {U}:\textbf {Ass} \rightarrow \mathcal {O}(\textbf {Lie})$| satisfying |$(\ref {eqnTrivialOperads})$| is called an S. Gutt quantization .

That the standard universal enveloping construction gives us an example of such a quantization was first noticed by Simone Gutt in [ 6 ]. We classify below all such quantizations up to homotopy equivalence, and prove that they are all gauge equivalent to the universal enveloping one.

Let |$U$| be an S. Gutt quantization. Then the cohomology of |$\textbf {Def}(\textbf {Ass} \rightarrow \mathcal {O}(\textbf {Lie}))$| is one-dimensional.

This follows from the fact that the two terms with a disconnected white vertex only differ swapping |$i_{1}$| and |$i_{2}$| and thus by the skew-symmetrization of labels of white vertices these terms are opposites. In particular, |$\delta _{i}(\Gamma )=0$| and |$d_{0}(\Gamma )=0$| if all white vertices are univalent.

This complex can be identified with the one in which white vertices are removed and where the outputs are symmetrized and the inputs are skew-symmetrized. This space can be identified with the deformation complex of the prop extension of |$\textbf {Lie}$|⁠ , |$\textbf {Def}(\textbf {Lie} \rightarrow \textbf {Lie})_{\text {prop}}$|⁠ , which in turn is isomorphic, as proven in [ 14 ], to |$\odot (\textbf {Def}(\textbf {Lie} \rightarrow \textbf {Lie})_{\text {operad}}[-1])[1]$|⁠ . Since we are working over a field, we see that the cohomology of this space is one-dimensional as the cohomology of |$\textbf {Def}(\textbf {Lie} \rightarrow \textbf {Lie})_{\text {operad}}$| is concentrated in degree 1.

  Corollary 7.5. Let |$U$| be an S. Gutt quantization. Then the map $$ \begin{align*} & \textbf{Def}(\textbf{Lie} \rightarrow \textbf{Lie}) \longrightarrow \textbf{Def}(\textbf{Ass} \stackrel{U}{\rightarrow} \mathcal{O}(\textbf{Lie})) \end{align*}$$ is a quasi-isomorphism.

We will now generalize the above results to |$\textbf {Lie}_{\infty }$| and |$\textbf {Ass}_{\infty }$| structures.

Let |$V$| be a |$\mathbb {Z}$| -graded vector space.

The constructions given by Baranovsky [ 2 ], Moreno-Fernández [ 17 ], and Lada and Markl [ 10 ] can be interpreted as such a map.

The Kontsevich formality map [ 9 ] implies this formula, but as a map to a wheeled version |$\mathcal {O}(\textbf {Lie}_{\infty }^{\circlearrowright })$|⁠ , which is ill-defined for infinite-dimensional Lie algebras. This was resolved by Shoikhet in [ 19 ] by showing that wheels can be set to zero and thus we get a map of the desired form.

  Corollary 7.8. Let |$\varphi $| be a homotopy S. Gutt quantization. Then the complex |$\textbf {Def}(\textbf {Ass}_{\infty } \stackrel {\varphi }{\rightarrow } \mathcal {O}(\textbf {Lie}_{\infty }))$| is one-dimensional. In particular, the map $$ \begin{align*} & \textbf{Def}(\textbf{Ass}_{\infty} \stackrel{\varphi}{\rightarrow} \mathcal{O}(\textbf{Lie}_{\infty})) \cong \textbf{Def}(\textbf{Lie}_{\infty} \rightarrow \textbf{Lie}_{\infty}) \end{align*}$$ is a quasi-isomorphism.

By Theorem 7.4 , the cohomology |$H(\textbf {Def}(\textbf {Ass} \stackrel {\mathcal {U}}{\rightarrow } \mathcal {O}(\textbf {Lie})))$| is one-dimensional and the result follows.

This result fully agrees with the PBW theorem obtained in [ 8 ] using the bar-cobar duality in the homotopy theory of operads.

is precisely the unique homotopy non-trivial deformation of the naive map |$i$|⁠ . Thus, we proved the following theorem:

where the first arrow is the canonical map of operads, and the second arrow is the universal enveloping map.

I would like to thank my supervisor Sergei Merkulov for suggesting this topic and for many encouraging discussions and the anonymous referees for their helpful comments and suggestions.

Communicated by Prof. Michael Finkelberg

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