Graham Martin SAPPHIRE Group Department of Health Sciences University of Leicester

1. Case study methods in theory and practiceFrom sampling to understanding in clinical genetics and service user involvement Graham Martin SAPPHIRE Group Department of Health Sciences University of Leicester

2. Background • Case study methods now well established • Plenty of ‘bibles’ to choose from… • Yin, Eisenhardt, Gerring, Ragin, Flyvbjerg etc. • …and a few great schisms too • constructivist v positivist(ish) denominations • How to navigate these many paths? • How to apply the principles of case study methods to generate sound, defensible empirical understandings in practice?

3. A few key analytical advantages of case study approaches • Using comparison to examine the role of factors posited as influential / determinative • Developing a rich understanding of how factors interact in specific contexts in practice • Theory testing (in specific contexts) and theory building (through inductive reasoning and open-ended fieldwork) • Comprehensiveness and concreteness helps to ensure relevance and validity of research

4. The studies • Sustainability of NHS genetics services • Follow-up study from earlier evaluation of clinical-genetics start-up projects to explore and develop theory around sustaining and embedding organisational change in healthcare • Theoretically informed subsample of four cases from an earlier sample of 11 cases1 • Service user involvement in cancer-genetics services • Study to explore and develop theory about the role, realisation and influence of patient and public involvement • Involved fieldwork in entire ‘population’ of cancer-genetics services funded by DoH and Macmillan (n=7), followed by analysis of a subsample of these which involved face-to-face involvement (n=5)2 • Martin GP, Weaver S, Currie G, Finn R, McDonald R. Innovation sustainability in challenging healthcare contexts: embedding clinically led change in routine practice. Health Services Management Research 2013 in press. • Martin GP, Finn R. Patients as team members: opportunities, challenges and paradoxes of including patients in multi-professional health-care teams. Sociology of Health & Illness 2011; 33: 1050-1065.

5. Case study theory in research practice • The strengths and weaknesses of (my application of) case study methods in: • Sampling • Fieldwork and data collection • Analysis and reasoning • Presentation • Some reflections implications for others deploying case study methods in similar fields

6. Sampling Study 1 (sustainability) • Approach to sampling was • pragmatic (following up existing relationships and building on existing insights) • empirically informed (based on ideas about sustainability generated in the original evaluation) • theoretical (premised on [our reading of] the existing literature, and factors purported to be important) • Four cases chosen that • contrast and align along two most important variables • contain interesting wider contextual variation • are likely to ‘produce the goods’

8. Sampling (continued) • Is such ‘uncontrolled variance’ a problem? • Perhaps—but probably only if your analytical logic is deductive/positivistic • But it does need to be acknowledged and addressed Study 2 (user involvement) • Existence of an accessible and researchable ‘population’ of cases removes the quandaries of selecting a sample • But it only defers the analytical challenges associated with the uncontrollable variance—the messiness—of real-life cases

9. Fieldwork and data collection Study 1 (sustainability) • Predominantly interview based • Rapid study (15 months); reliant on existing contacts and snowball sampling • Fewer interviewees in some cases than others (range 5-14) • The lens of prior data analysis: focusing or colouring? • Potential for rather a particular view of a case?

10. Fieldwork and data collection (cont.) Study 2 (user involvement) • Longer time-frame; more ‘holistic’ and longitudinal data collection • Interviews, observations, documents • And yet—the same anxieties about what has been missed, what has been hidden, what is being prioritised: the classic concerns of the qualitative researcher! • How to balance pragmatism with the (ever-present) urge to collect more data and reach a ‘complete’ picture of the case?

11. Analysis and reasoning • Extensive analytical work undertaken in both studies (team-based in study 1; individual in study 2) • Some of the key elements of comparative case analysis very helpful in achieving insight, e.g. • Seeking within-group similarities and inter-group differences • Selecting pairs of apparently similar cases and noting similarities and differences • This revealed stark contrasts between cases, and clear evidence about the mechanisms that gave rise to these

12. Study 1 (sustainability)

13. Analysis and reasoning (continued) • The risk of ‘premature confirmation’ is mitigated by robust methods and adherence to principles of good qualitative research • Exposure to the data is the best antidote to preconception! • Yet there remains the risk of partial perspective, of overlooking alternative explanations, of confirming expectations (or preferring ‘novel contributions’ that are more likely to be published!)

14. Study 2 (user involvement) y c x1 x2 x3 xn

15. Analysis and reasoning (continued) • Is the generation of theoretical propositions that follow a causal-explanatory logic a problem? • Probably not, unless • you’re a radical constructivist (in which case even heuristic rules have no generalisability) • you’re an unreconstructed positivist (in which case the propositions will disappoint, as they’re not determinative) • it reflects a rushed, reductivist analytical process that takes a short cut to explanatory relationships without due process: • taking time to develop deep familiarity with data • paying attention to mechanisms, not just patterns • having care for disconfirming cases • etc.

16. Presentation • Good presentation necessitates simplification, whether producing a ‘map’ or a ‘guide’ • Caution and qualification is always needed, but this does not preclude sincere argument for a particular, well evidenced, interpretation • Transparency can never be complete, but can underwrite trust in the author’s account

17. Concluding reflections • Adaptability is helpful, as is a liberal approach to data collection and reasoning (though it may not impress epistemological purists) • Embrace the uncontrolled variance! • A case study is only as good as its methods • Simple presentation is a critical asset; simplistic analysis is a fatal flaw

18. Graham Martin 0116 252 3207 graham.martin@le.ac.uk www.le.ac.uk/people/gpm7