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           649160QHRXXX10.1177/1049732316649160Qualitative Health ResearchMorgan et al.
           research-article2016
                                                          Methods
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   Qualitative Health Research
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   2017, Vol. 27(7) 1060 –1068
                                                          Case Study Observational Research: A                                                                                                                                                                                                                                                                                                                                                                                                                     © The Author(s) 2016 
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   Reprints and permissions: 
                                                          Framework for Conducting Case Study                                                                                                                                                                                                                                                                                                                                                                                                                      sagepub.com/journalsPermissions.nav
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   DOI: 10.1177/1049732316649160
                                                          Research Where Observation Data Are                                                                                                                                                                                                                                                                                                                                                                                                                      journals.sagepub.com/home/qhr
                                                          the Focus
                                                                                                                                                                        1                                                                                                                                       1                                                                                                                                                                 1
                                                          Sonya J. Morgan , Susan R. H. Pullon , Lindsay M. Macdonald ,  
                                                                                                                                                                                          1                                                                                                                           1
                                                          Eileen M. McKinlay , and Ben V. Gray
                                                          Abstract
                                                          Case study research is a comprehensive method that incorporates multiple sources of data to provide detailed 
                                                          accounts of complex research phenomena in real-life contexts. However, current models of case study research 
                                                          do not particularly distinguish the unique contribution observation data can make. Observation methods have the 
                                                          potential to reach beyond other methods that rely largely or solely on self-report. This article describes the distinctive 
                                                          characteristics of case study observational research, a modified form of Yin’s 2014 model of case study research the 
                                                          authors used in a study exploring interprofessional collaboration in primary care. In this approach, observation data 
                                                          are positioned as the central component of the research design. Case study observational research offers a promising 
                                                          approach for researchers in a wide range of health care settings seeking more complete understandings of complex 
                                                          topics, where contextual influences are of primary concern. Future research is needed to refine and evaluate the 
                                                          approach.
                                                          Keywords
                                                          appreciative inquiry; case studies; case study observational research; health care; interprofessional collaboration; 
                                                          naturalistic inquiry; New Zealand; observation; primary health care; research design; qualitative
                                                          Direct observation has been described as the gold standard                                                                                                                                                                                                                                              intensive observation data collection methods with other 
                                                          among qualitative data collection techniques (Murphy &                                                                                                                                                                                                                                                  forms of data collection in a case study or other type of 
                                                          Dingwall, 2007). Observing people in their natural environ-                                                                                                                                                                                                                                             multiple-method design (Hjalmarson, Ahgren, & 
                                                          ment not only avoids problems inherent in self-reported                                                                                                                                                                                                                                                 Kjölsrud, 2013; Kislov, Walshe, & Harvey, 2012). 
                                                          accounts (Mays & Pope, 1995), but can also reveal insights                                                                                                                                                                                                                                              Incorporating multiple qualitative methods generates the 
                                                          not accessible from other data collection methods, such as                                                                                                                                                                                                                                              opportunity for more complete explanations. However, 
                                                          structures, processes, and behaviors the interviewed partici-                                                                                                                                                                                                                                           the unique value of observation methods in multiple-
                                                          pants may well be unaware of themselves (Furlong, 2010).                                                                                                                                                                                                                                                methods research has remained largely unexplored. All 
                                                          Yet, despite now well-documented advantages of observa-                                                                                                                                                                                                                                                 too often, such studies are in fact predominantly inter-
                                                          tion over other forms of qualitative data collection, to date,                                                                                                                                                                                                                                          view driven, failing to use observation data to their full 
                                                          observation methods have been underused (Mulhall, 2003;                                                                                                                                                                                                                                                 potential or not reporting them distinctively (Morgan, 
                                                          Walshe, Ewing, & Griffiths, 2012), and interviews remain                                                                                                                                                                                                                                                Pullon, & McKinlay, 2015; O’Cathain, Murphy, & 
                                                          the most common form of qualitative inquiry in health care                                                                                                                                                                                                                                              Nicholl, 2008).
                                                          research settings (Morse, 2003; Phillips, Dwan, Hepworth,                                                                                                                                                                                                                                                              The focus of this article is on an observationally driven 
                                                          Pearce, & Hall, 2014; Russell et al., 2012). Undertaking                                                                                                                                                                                                                                                approach to case study research the authors adopted 
                                                          observation, particularly in-depth forms of observation 
                                                          such as traditional ethnography (Savage, 2000), is often                                                                                                                                                                                                                                                1University of Otago, Wellington, New Zealand
                                                          time-consuming, costly, and practically challenging in 
                                                          health care settings (Curry, Nembhard, & Bradley, 2009;                                                                                                                                                                                                                                                 Corresponding Author:
                                                          Morse, 2003; Savage, 2000; Walshe et al., 2012).                                                                                                                                                                                                                                                        Sonya J. Morgan, Department of Primary Health Care and General 
                                                                         More pragmatic contemporary approaches to observa-                                                                                                                                                                                                                                       Practice, University of Otago, Wellington, P.O. Box 7343, Wellington 
                                                                                                                                                                                                                                                                                                                                                                  6242, New Zealand. 
                                                          tional research suitable for health settings combine less                                                                                                                                                                                                                                               Email: sonya.morgan@otago.ac.nz
                 Morgan et al.                                                                                                            1061
                 during the Study of Interprofessional Practice in Primary         depending on the research question. Commonly used 
                 Care (SIPP Study)—a multiple case study designed to               methods include interviews, observation of archival 
                 explore interprofessional collaboration (IPC) in primary          records, and direct observation of study participants (Yin, 
                 care teams in New Zealand. We have coined the term                1994).
                 case study observational research (CSOR) to denote this              Either as part of CSR or as a stand-alone method, 
                 as a distinct form of case study research (CSR). The              observation methods involve directly observing and 
                 approach incorporates both non-participant observation            recording how research participants behave within and 
                 of practice activity and policy documents and the non-            relate to their physical and social environment as it 
                 observation method of interviewing. However, CSOR                 unfolds (Mays & Pope, 1995; Mulhall, 2003). Observation 
                 gives priority and precedence to the collection and analy-        provides “insight into interactions between dyads and 
                 sis of observation data, to better understand complex phe-        groups; illustrates the whole picture; captures context/
                 nomena, such as IPC.                                              process; and informs about the influence of the physical 
                    CSR examines “a contemporary phenomenon in depth               environment” (Mulhall, 2003, p. 307). Approaches to 
                 and in its real-world context” (Yin, 2014, p. 237). Multiple      observation vary according to the philosophical orienta-
                 methods are used to collect data for each “case” or sub-          tion of the research and the role researchers adopt along 
                 ject of study, which is not the same as mixed-method              the continuum of observer to participant (Walshe et al., 
                 research (Morse & Cheek, 2014; Yin, 2014). As a method,           2012). Observation methods may consist of non-partici-
                 CSOR is specific to CSR design. To place our CSOR                 pant observation, where the researcher has no other rela-
                 approach in its methodological context, we first provide          tionship with the group being observed (including 
                 an overview of the two key antecedents to the approach:           shadowing; Quinlan, 2008) through to participant obser-
                 CSR and observation methods. Second, we describe the              vation, where the researcher is also a member of the 
                 informing philosophical approach and the research set-            group being observed (Bloomer, Cross, Endacott, 
                 ting in which CSOR was developed and finally define the           O’Connor, & Moss, 2012). Recording methods range 
                 three distinctive features of the approach.                       from structured template recording to unstructured field 
                                                                                   noting (Walshe et al., 2012). More recently, video-record-
                 Overview: Case Study Research and                                 ing techniques have proved a valuable way to capture 
                 Observation Method                                                observations (Carroll, Iedema, & Kerridge, 2008; Collier, 
                                                                                   Phillips, & Iedema, 2015; Cronin, 2014; Forsyth, Carroll, 
                 CSR is a comprehensive method increasingly applied in             & Reitano, 2009; Iedema et al., 2009).
                 health sciences research (Anthony & Jack, 2009; Boblin,              Compared with observation methods, non-observation 
                 Ireland, Kirkpatrick, & Robertson, 2013; Carolan, Forbat,         (self-report) qualitative methods, such as interviews or 
                 & Smith, 2016) to investigate “how” or “why” qualitative          focus groups, are typically less challenging to undertake 
                 research questions, “when the investigator has little con-        but are subject to participant reporting problems (Curry 
                 trol over events and when the focus is on a contemporary          et al., 2009; Morse, 2003; Walshe et al., 2012; see Table 1 
                 phenomenon within some real-life context” (Yin, 1994,             for summarized strengths and challenges of observation 
                 p. 1). In this way, CSR differs from other research meth-         vs. self-report methods). Thus, observation methods 
                 ods, such as experiments, which purposefully separate a           stand in a class of their own. Observation allows the 
                 phenomenon from its context. In CSR context is inextri-           researcher to actually see what people do rather than what 
                 cably linked to the phenomena under investigation and,            they say they do (Caldwell & Atwal, 2005; Mulhall, 
                 therefore, is crucial to understanding real-world cases           2003; Walshe et al., 2012). Systematically observing peo-
                 (Yin, 2014).                                                      ple in naturally occurring contexts can reveal much more 
                    Several models of CSR exist, each emphasizing differ-          information than individuals may recall, be aware of, 
                 ent philosophical positions (Abma & Stake, 2014).                 choose to report, or decide is relevant than with other 
                 Within the health care arena, Yin’s (1994) model is com-          self-report data collection methods (Mays & Pope, 1995; 
                 monly described and used. Case studies can include either         Morse, 2003; Mulhall, 2003).
                 single- or multiple-case designs. Depending on the con-              In a health care context, observation methods enable 
                 text, multiple cases can provide greater confidence in            the exploration of elements of health care that are not 
                 findings generated from the overall study (Yin, 2014). A          possible by relying on self-report methods (Oandasan 
                 characteristic feature of CSR, the collection of data using       et al., 2009; Russell et al., 2012), providing insights into 
                 multiple sources for each case (Carolan et al., 2016),            the complexity of clinical practice (Dowell, Macdonald, 
                 allows triangulation of evidence. Triangulation improves          Stubbe, Plumridge, & Dew, 2007; Lingard, Reznick, 
                 the accuracy and completeness of the case study, strength-        Espin, Regehr, & De Vito, 2002). For instance, observa-
                 ening the credibility of the research findings (Cronin,           tion methods have been used to observe various aspects 
                 2014; Yin, 2014). Sources of data collected vary                  of the interaction between professionals and patients 
              1062                                                                                                 Qualitative Health Research 27(7)
              Table 1. Observation Versus Self-Report Data Collection Methods: Strengths and Challenges.
              Observation Methods                                                                         Self-Report Methods
              Strengths                                     Challenges                          Strengths                        Challenges
              Allows direct examination of                                         Allows participants to describe  Relies on the information 
                                                 Time-consuming, expensive, and 
                behavior/activity in real time     ethically challenging in some     their own perceptions and          participants are willing to talk 
              Provides information about           settings                          views about the topic of           about, aware of, or able to 
                topics participants may          Hawthorne effect—participants  interest                                recall
                be unwilling to talk about,        may change their behavior       Relatively straightforward to      Interview/focus group content is 
                unaware of, or unable to recall when they know they are              undertake                          influenced by the perspective 
              Undertaken in naturally                              a                                                    of the interviewer/other 
                                                   being observed
                occurring contexts—allows        Field noted/video-recorded                                             participants
                examination of contextual          observations are influenced by                                     Does not capture context
                factors                            what the observer chooses to 
                                                   record/analyze
              a
               Landsberger (1958).
              during medical consultations (Dowell et al., 2007;                      2006, p. 2). It has been shown to improve patient satisfac-
              Morgan, 2013). They have also been found to be particu-                 tion (Proudfoot et al., 2007) and health outcomes (Strasser 
              larly useful for research involving vulnerable patients                 et al., 2008), yet IPC is far from integral to everyday 
              where the least intrusion or stress on participants is                  practice (Xyrichis & Lowton, 2008).
              desired (Bloomer et al., 2012; Bloomer, Doman, &                           At the outset, the research approach drew on both nat-
              Endacott, 2013; Walshe et al., 2012).                                   uralistic inquiry (Lincoln & Guba, 1985) and apprecia-
                  Some well-conducted studies have used observation                   tive inquiry (Cooperrider & Srivastva, 1987). Naturalistic 
              methods to examine professional practice and communi-                   inquiry contends that “realities are wholes that cannot be 
              cation between health professionals such as team func-                  understood in isolation from their contexts” (Lincoln & 
              tioning/communication in the operating room (Lingard                    Guba, 1985, p. 39). Consistent with the interpretivist tra-
              et al., 2004), ward rounds (Carroll et al., 2008), rehabili-            dition of naturalistic inquiry (Lincoln & Guba, 1985), the 
              tation settings (Sinclair, Lingard, & Mohabeer, 2009),                  aim of the research was to explore the observed nature of 
              and primary care settings (Oandasan et al., 2009; Russell               collaboration between practice team members in context 
              et al., 2012). Nonetheless, in many health care research                from multiple perspectives. Appreciative inquiry exam-
              studies incorporating both observation and other forms of               ines what works well in an organization and acknowl-
              data collection, the observation data are only mentioned                edges but does not focus on problems (Cooperrider & 
              in passing and are therefore underexploited, often taking               Srivastva, 1987). Informed by the principles of this 
              a “back seat” to interview data (Morgan et al., 2015).                  approach, we sought to identify key elements influencing 
              Thus, for the study next described, an approach to con-                 effective IPC. A secondary aim was to investigate whether 
              ducting CSR was required that would combine the                         well-established interprofessional competencies devel-
              strengths of different methods but specifically prioritize              oped in Canada (Canadian Interprofessional Health 
              the observation data.                                                   Collaborative [CIHC], 2010) were evident in the every-
                                                                                      day practice of primary care teams in a New Zealand con-
              Development of the CSOR                                                 text. To extend beyond elements of personal 
              Framework: The SIPP Study                                               interprofessional relationships and intrinsic team factors 
                                                                                      that have been well captured by numerous interview-
              The SIPP Study conducted in 2012–2014 explored feasi-                   based studies, observation methods were incorporated 
              ble methods of investigating elements of IPC in primary                 from the outset in the design of the research. However, as 
              care practice (Pullon, Morgan, Macdonald, McKinlay, &                   conventional case study models, such as Yin (2014), do 
              Gray, 2016). CSR (Yin, 2014) was originally selected as                 not distinguish observation data from other types of data 
              an appropriate method, using a multiple case study                      collection in terms of their unique significance and poten-
              design. IPC is challenging to investigate, and the essen-               tial, we modified Yin’s CSR method. This observation-
              tial elements of effective IPC remain obscure (Morgan                   ally driven, sequential approach to CSR explicitly 
              et al., 2015). IPC has been described as “an active and                 positions the observation data as the central component 
              ongoing partnership, often between people from diverse                  of the research design, where observation data are both 
              backgrounds, who work together to solve problems or                     collected and analyzed prior to augmenting by other non-
              provide services” (Barr et al., 2005, as cited in Ødegard,              observation methods.
                 Morgan et al.                                                                                                       1063
                 Study Participants and Data Collection                         promptly circulated to the research team for review, who 
                 Three widely diverse general practices in a New Zealand        in turn added comments and observations, which were 
                 region were approached to participate in the study and all     circulated to all members.
                 agreed to take part, constituting the “cases” included in         Following observations of informal staff interactions, 
                 the study. The practices were purposively selected on the      practices chose which regular practice meeting would be 
                 premise that they were already successfully engaged in         video-recorded by the research nurse on two successive 
                                                                                occasions. Different types of meetings were chosen at 
                 some interprofessional activity, increasing the potential      each practice (i.e., a small team of three to five members; 
                 learnings from the cases (Cooperrider & Srivastva, 1987;       a medium sized team of six to 14 members, and a large 
                 Lincoln & Guba, 1985). Practices varied with respect to        team of 15+ members) and included different discipline 
                 geographical location, size of enrolled patient population,    mixes. Assurance was given as to secure encrypted stor-
                 business model, ownership/governance, and workforce            age of video and other data. The research team met regu-
                 composition. Data collection at each practice included         larly to review and discuss the video-recorded meetings, 
                 non-participant unstructured observation (Mays & Pope,         and selected sequences were transcribed verbatim. 
                 1995) of informal practice activity (field notes), meetings    Practice documents (e.g., policies, terms of reference, 
                 (video-recorded), and policy document review (field            floor plans) were viewed and summarized as separate 
                 notes). Observation-informed individual semi-structured        field notes. Finally, observation-informed interviews 
                 interviews (audio-recorded) were undertaken only after         were undertaken with a range of practice staff and tran-
                 other observation data collection was complete. Consent        scribed verbatim. Ethical approval was granted by the 
                 to participate in the study and have informal practice         University of Otago Health Ethics Committee, CEN/11/
                 activity observed was obtained from the practice as a          EXP/038.
                 whole following presentation of the proposed study by             Data consisted of a total of 32 hours of field-noted 
                 the research team at a practice meeting. Staff then indi-      observation of informal practice activity, 6 hours of 
                 vidually consented to the video-recorded meetings and          video-recorded team meetings, 17 individual interviews 
                 interviews (Pullon et al., 2016).                              (duration ranging from 24 to 48 minutes), and 43 
                    Direct observation of informal staff interactions at        reviewed documents. To support the process of analysis, 
                 each practice were made by a research nurse with a pro-        all of these separate items of data, including videos, 
                 fessional background who was both familiar with the rou-       were imported into the software program NVivo 9 
                 tines and sensitivities of the clinical environment and had    (Bazeley & Jackson, 2013). Preliminary case-specific 
                 extensive experience collecting naturalistic observation       findings were presented back to each participating prac-
                 data in primary care settings. The research nurse had no       tice, and the ensuing discussion further informed and 
                 prior relationship with the selected practices. Her role and   strengthened the credibility of study findings (Boblin 
                 the purpose of the observations, including the apprecia-       et al., 2013; Houghton, Casey, Shaw, & Murphy, 2013). 
                 tive nature of the research, were explained to participants    Study results have been reported elsewhere (Pullon 
                 during the initial meeting with the study team. Because        et al., 2016).
                 we sought to examine how participants naturally inter-            The remainder of this article focuses on the three fea-
                 acted with each other, the research nurse situated herself     tures of the CSOR approach that differentiate it from con-
                 unobtrusively in the practice and had limited interaction      ventional CSR: (a) Observation data are collected prior to 
                 with participants. Observations were undertaken in as          and inform the subsequent collection of non-observation 
                 many of the “common” areas of the practice as possible,        data, (b) observation data determine the analytic frame-
                 excluding consulting rooms. They were also undertaken          work, and (c) observation data are explicitly referenced in 
                 at different times of the day and week. Consultations with     the final results. Examples from the SIPP Study are used 
                 patients were not observed. Observations recorded were         to illustrate how following this framework afforded pre-
                 governed by the research nurse’s interaction with and          cedence to the observation data.
                 growing knowledge of the context. They were not guided 
                 by predefined tools or templates (Lincoln & Guba, 1985).       Distinctive Features of the CSOR 
                 Observations were recorded initially as handwritten            Framework
                 detailed verbatim field notes with time markers. These 
                 notes were supplemented with post-observation summa-           The three key characteristics of CSOR differentiate it 
                 ries generated immediately following the observation           from conventional CSR and allow the observation data 
                 period and incorporated the research nurse’s reflections       to contribute uniquely to the case study findings. The 
                 on her own feelings, actions, and responses to the situa-      first difference between traditional CSR and CSOR 
                 tions observed (Lincoln & Guba, 1985; Mays & Pope,             emerges when it comes to collecting the case study 
                 1995). These field notes and reflective summaries were         evidence.
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...Qhrxxx qualitative health researchmorgan et al research article methods vol case study observational a the author s reprints and permissions framework for conducting sagepub com journalspermissions nav doi where observation data are journals home qhr focus sonya j morgan susan r h pullon lindsay m macdonald eileen mckinlay ben v gray abstract is comprehensive method that incorporates multiple sources of to provide detailed accounts complex phenomena in real life contexts however current models do not particularly distinguish unique contribution can make have potential reach beyond other rely largely or solely on self report this describes distinctive characteristics modified form yin model authors used exploring interprofessional collaboration primary care approach positioned as central component design offers promising researchers wide range settings seeking more complete understandings topics contextual influences concern future needed refine evaluate keywords appreciative inquiry st...

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