Methods of Research – Case Study

Context: Minority ethnic people experience considerably greater morbidity from asthma than the White majority population. Research has shown however that these minority ethnic populations are likely to be under-represented in research undertaken in the UK; there is comparatively less marginalisation in the US.

Objective: To investigate approaches to bolster recruitment of South Asians into UK asthma studies through qualitative research with US and UK researchers, and UK community leaders.

Study design: Single intrinsic case study

The case: Centred on the issue of recruitment of South Asian people with asthma.

Data collection: In-depth interviews were conducted with asthma researchers from the UK and US. A supplementary questionnaire was also provided to researchers.

Analysis: Framework approach.

Key findings: Barriers to ethnic minority recruitment were found to centre around:

   1. The attitudes of the researchers’ towards inclusion: The majority of UK researchers interviewed were generally supportive of the idea of recruiting ethnically diverse participants but expressed major concerns about the practicalities of achieving this; in contrast, the US researchers appeared much more committed to the policy of inclusion.

   2. Stereotypes and prejudices: We found that some of the UK researchers’ perceptions of ethnic minorities may have influenced their decisions on whether to approach individuals from particular ethnic groups. These stereotypes centred on issues to do with, amongst others, language barriers and lack of altruism.

   3. Demographic, political and socioeconomic contexts of the two countries: Researchers suggested that the demographic profile of ethnic minorities, their political engagement and the different configuration of the health services in the UK and the US may have contributed to differential rates.

   4. Above all, however, it appeared that the overriding importance of the US National Institute of Health’s policy to mandate the inclusion of minority ethnic people (and women) had a major impact on shaping the attitudes and in turn the experiences of US researchers’; the absence of any similar mandate in the UK meant that UK-based researchers had not been forced to challenge their existing practices and they were hence unable to overcome any stereotypical/prejudicial attitudes through experiential learning.

Context: Health work forces globally are needing to reorganise and reconfigure in order to meet the challenges posed by the increased numbers of people living with long-term conditions in an efficient and sustainable manner. Through studying the introduction of General Practitioners with a Special Interest in respiratory disorders, this study aimed to provide insights into this important issue by focusing on community respiratory service development.

Objective: To understand and compare the process of workforce change in respiratory services and the impact on patient experience (specifically in relation to the role of general practitioners with special interests) in a theoretically selected sample of Primary Care Organisations (PCOs), in order to derive models of good practice in planning and the implementation of a broad range of workforce issues.

Study design: Multiple-case design of respiratory services in health regions in England and Wales.

The cases: Four PCOs.

Data collection: Face-to-face and telephone interviews, e-mail discussions, local documents, patient diaries, news items identified from local and national websites, national workshop.

Analysis: Reading, coding and comparison progressed iteratively.

Key findings:

   1. In the screening phase of this study (which involved semi-structured telephone interviews with the person responsible for driving the reconfiguration of respiratory services in 30 PCOs), the barriers of financial deficit, organisational uncertainty, disengaged clinicians and contradictory policies proved insurmountable for many PCOs to developing sustainable services. A key rationale for PCO re-organisation in 2006 was to strengthen their commissioning function and those of clinicians through Practice-Based Commissioning. However, the turbulence, which surrounded reorganisation was found to have the opposite desired effect.

   2. Implementing workforce reconfiguration was strongly influenced by the negotiation and contest among local clinicians and managers about “ownership” of work and income.

   3. Despite the intention to make the commissioning system more transparent, personal relationships based on common professional interests, past work history, friendships and collegiality, remained as key drivers for sustainable innovation in service development.

Main limitations: It was only possible to undertake in-depth work in a selective number of PCOs and, even within these selected PCOs, it was not possible to interview all informants of potential interest and/or obtain all relevant documents. This work was conducted in the early stages of a major NHS reorganisation in England and Wales and thus, events are likely to have continued to evolve beyond the study period; we therefore cannot claim to have seen any of the stories through to their conclusion.

Context: Healthcare systems globally are moving from paper-based record systems to electronic health record systems. In 2002, the NHS in England embarked on the most ambitious and expensive IT-based transformation in healthcare in history seeking to introduce electronic health records into all hospitals in England by 2010.

Objectives: To describe and evaluate the implementation and adoption of detailed electronic health records in secondary care in England and thereby provide formative feedback for local and national rollout of the NHS Care Records Service.

Study design: A mixed methods, longitudinal, multi-site, socio-technical collective case study.

The cases: Five NHS acute hospital and mental health Trusts that have been the focus of early implementation efforts.

Data collection: Semi-structured interviews, documentary data and field notes, observations and quantitative data.

Analysis: Qualitative data were analysed thematically using a socio-technical coding matrix, combined with additional themes that emerged from the data.

Key findings:

   1. Hospital electronic health record systems have developed and been implemented far more slowly than was originally envisioned.

   2. The top-down, government-led standardised approach needed to evolve to admit more variation and greater local choice for hospitals in order to support local service delivery.

   3. A range of adverse consequences were associated with the centrally negotiated contracts, which excluded the hospitals in question.

   4. The unrealistic, politically driven, timeline (implementation over 10 years) was found to be a major source of frustration for developers, implementers and healthcare managers and professionals alike.

Main limitations: We were unable to access details of the contracts between government departments and the Local Service Providers responsible for delivering and implementing the software systems. This, in turn, made it difficult to develop a holistic understanding of some key issues impacting on the overall slow roll-out of the NHS Care Record Service. Early adopters may also have differed in important ways from NHS hospitals that planned to join the National Programme for Information Technology and implement the NHS Care Records Service at a later point in time.

Context: There is a need to reduce the disease burden associated with iatrogenic harm and considering that healthcare education represents perhaps the most sustained patient safety initiative ever undertaken, it is important to develop a better appreciation of the ways in which undergraduate and newly qualified professionals receive and make sense of the education they receive.

Objectives: To investigate the formal and informal ways pre-registration students from a range of healthcare professions (medicine, nursing, physiotherapy and pharmacy) learn about patient safety in order to become safe practitioners.

Study design: Multi-site, mixed method collective case study.

The cases: Eight case studies (two for each professional group) were carried out in educational provider sites considering different programmes, practice environments and models of teaching and learning.

Data collection and analysis: Structured in phases relevant to the three knowledge contexts:

Phase 1: Academic context

Documentary evidence (including undergraduate curricula, handbooks and module outlines), complemented with a range of views (from course leads, tutors and students) and observations in a range of academic settings.

Phase 2a: Organisational context

Policy and management views of patient safety and influences on patient safety education and practice. NHS policies included, for example, implementation of the National Patient Safety Agency’s Seven Steps to Patient Safety, which encourages organisations to develop an organisational safety culture in which staff members feel comfortable identifying dangers and reporting hazards.

Phase 2b: Practice context

The cultures to which students are exposed i.e. patient safety in relation to day-to-day working. NHS initiatives included, for example, a hand washing initiative or introduction of infection control measures.

Key findings:

   1. Practical, informal, learning opportunities were valued by students. On the whole, however, students were not exposed to nor engaged with important NHS initiatives such as risk management activities and incident reporting schemes.

   2. NHS policy appeared to have been taken seriously by course leaders. Patient safety materials were incorporated into both formal and informal curricula, albeit largely implicit rather than explicit.

   3. Resource issues and peer pressure were found to influence safe practice. Variations were also found to exist in students’ experiences and the quality of the supervision available.

Main limitations: The curriculum and organisational documents collected differed between sites, which possibly reflected gatekeeper influences at each site. The recruitment of participants for focus group discussions proved difficult, so interviews or paired discussions were used as a substitute.