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Published: 10 November 2020

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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Qualitative
Case studies
Mixed-method
Public health
Health services research
Interventions

BMC Medicine

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Case study research: opening up research opportunities

RAUSP Management Journal

ISSN : 2531-0488

Article publication date: 30 December 2019

Issue publication date: 3 March 2020

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.

Epistemology

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

Emerald Publishing Limited

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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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What Is a Case Study? | Definition, Examples & Methods

What Is a Case Study? | Definition, Examples & Methods

Published on May 8, 2019 by Shona McCombes . Revised on November 20, 2023.

A case study is a detailed study of a specific subject, such as a person, group, place, event, organization, or phenomenon. Case studies are commonly used in social, educational, clinical, and business research.

A case study research design usually involves qualitative methods , but quantitative methods are sometimes also used. Case studies are good for describing , comparing, evaluating and understanding different aspects of a research problem .

When to do a case study, step 1: select a case, step 2: build a theoretical framework, step 3: collect your data, step 4: describe and analyze the case, other interesting articles.

A case study is an appropriate research design when you want to gain concrete, contextual, in-depth knowledge about a specific real-world subject. It allows you to explore the key characteristics, meanings, and implications of the case.

Case studies are often a good choice in a thesis or dissertation . They keep your project focused and manageable when you don’t have the time or resources to do large-scale research.

You might use just one complex case study where you explore a single subject in depth, or conduct multiple case studies to compare and illuminate different aspects of your research problem.

Case study examples
Research question	Case study
What are the ecological effects of wolf reintroduction?	Case study of wolf reintroduction in Yellowstone National Park
How do populist politicians use narratives about history to gain support?	Case studies of Hungarian prime minister Viktor Orbán and US president Donald Trump
How can teachers implement active learning strategies in mixed-level classrooms?	Case study of a local school that promotes active learning
What are the main advantages and disadvantages of wind farms for rural communities?	Case studies of three rural wind farm development projects in different parts of the country
How are viral marketing strategies changing the relationship between companies and consumers?	Case study of the iPhone X marketing campaign
How do experiences of work in the gig economy differ by gender, race and age?	Case studies of Deliveroo and Uber drivers in London

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Once you have developed your problem statement and research questions , you should be ready to choose the specific case that you want to focus on. A good case study should have the potential to:

Provide new or unexpected insights into the subject
Challenge or complicate existing assumptions and theories
Propose practical courses of action to resolve a problem
Open up new directions for future research

TipIf your research is more practical in nature and aims to simultaneously investigate an issue as you solve it, consider conducting action research instead.

Unlike quantitative or experimental research , a strong case study does not require a random or representative sample. In fact, case studies often deliberately focus on unusual, neglected, or outlying cases which may shed new light on the research problem.

Example of an outlying case studyIn the 1960s the town of Roseto, Pennsylvania was discovered to have extremely low rates of heart disease compared to the US average. It became an important case study for understanding previously neglected causes of heart disease.

However, you can also choose a more common or representative case to exemplify a particular category, experience or phenomenon.

Example of a representative case studyIn the 1920s, two sociologists used Muncie, Indiana as a case study of a typical American city that supposedly exemplified the changing culture of the US at the time.

While case studies focus more on concrete details than general theories, they should usually have some connection with theory in the field. This way the case study is not just an isolated description, but is integrated into existing knowledge about the topic. It might aim to:

Exemplify a theory by showing how it explains the case under investigation
Expand on a theory by uncovering new concepts and ideas that need to be incorporated
Challenge a theory by exploring an outlier case that doesn’t fit with established assumptions

To ensure that your analysis of the case has a solid academic grounding, you should conduct a literature review of sources related to the topic and develop a theoretical framework . This means identifying key concepts and theories to guide your analysis and interpretation.

There are many different research methods you can use to collect data on your subject. Case studies tend to focus on qualitative data using methods such as interviews , observations , and analysis of primary and secondary sources (e.g., newspaper articles, photographs, official records). Sometimes a case study will also collect quantitative data.

Example of a mixed methods case studyFor a case study of a wind farm development in a rural area, you could collect quantitative data on employment rates and business revenue, collect qualitative data on local people’s perceptions and experiences, and analyze local and national media coverage of the development.

The aim is to gain as thorough an understanding as possible of the case and its context.

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In writing up the case study, you need to bring together all the relevant aspects to give as complete a picture as possible of the subject.

How you report your findings depends on the type of research you are doing. Some case studies are structured like a standard scientific paper or thesis , with separate sections or chapters for the methods , results and discussion .

Others are written in a more narrative style, aiming to explore the case from various angles and analyze its meanings and implications (for example, by using textual analysis or discourse analysis ).

In all cases, though, make sure to give contextual details about the case, connect it back to the literature and theory, and discuss how it fits into wider patterns or debates.

If you want to know more about statistics , methodology , or research bias , make sure to check out some of our other articles with explanations and examples.

Normal distribution
Degrees of freedom
Null hypothesis
Discourse analysis
Control groups
Mixed methods research
Non-probability sampling
Quantitative research
Ecological validity

Research bias

Rosenthal effect
Implicit bias
Cognitive bias
Selection bias
Negativity bias
Status quo bias

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Published: 27 June 2011

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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The theory contribution of case study research designs

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Published: 16 February 2017
Volume 10 , pages 281–305, ( 2017 )

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Hans-Gerd Ridder 1

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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.

Case Study Research

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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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I thank two anonymous reviewers for their constructive comments. I am grateful for valuable thoughts generously provided by Ann Kristin Zobel.

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Ridder, HG. The theory contribution of case study research designs. Bus Res 10 , 281–305 (2017). https://doi.org/10.1007/s40685-017-0045-z

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BMC Med Res Methodol

The case study approach

Sarah crowe.

1 Division of Primary Care, The University of Nottingham, Nottingham, UK

Kathrin Cresswell

2 Centre for Population Health Sciences, The University of Edinburgh, Edinburgh, UK

Ann Robertson

3 School of Health in Social Science, The University of Edinburgh, Edinburgh, UK

Anthony Avery

Aziz sheikh.

Introduction

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 Tables1, 1 , ,2, 2 , ,3 3 and and4) 4 ) and those of others to illustrate our discussion[ 3 - 7 ].

Example of a case study investigating the reasons for differences in recruitment rates of minority ethnic people in asthma research[ 3 ]

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.

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.

Single intrinsic case study

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

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

Framework approach.

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.

Example of a case study investigating the process of planning and implementing a service in Primary Care Organisations[ 4 ]

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.

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.

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

Four PCOs.

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

Reading, coding and comparison progressed iteratively.

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.

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.

Example of a case study investigating the introduction of the electronic health records[ 5 ]

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.

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.

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

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

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

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

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.

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.

Example of a case study investigating the formal and informal ways students learn about patient safety[ 6 ]

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.
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.
Multi-site, mixed method collective case study.
: 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.
Structured in phases relevant to the three knowledge contexts:
	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.

	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 , which encourages organisations to develop an organisational safety culture in which staff members feel comfortable identifying dangers and reporting hazards.

	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.


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.
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.

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 (Table5), 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.

Definitions of a case study

Author	Definition
Stake[ ]	(p.237)
Yin[ , , ]	(Yin 1999 p. 1211, Yin 1994 p. 13)

	•
	• (Yin 2009 p18)
Miles and Huberman[ ]	(p. 25)
Green and Thorogood[ ]	(p. 284)
George and Bennett[ ]	(p. 17)"

These are however not necessarily mutually exclusive categories. In the first of our examples (Table (Table1), 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 Tables2, 2 , ,3 3 and and4) 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 (Table2) 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 Tables2 2 and and3, 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 (Table4 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 (Table6). 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 ].

Example of epistemological approaches that may be used in case study research

Characteristics	Criticisms	Key references
Involves questioning one's own assumptions taking into account the wider political and social environment.	It can possibly neglect other factors by focussing only on power relationships and may give the researcher a position that is too privileged.	Howcroft and Trauth[ ] Blakie[ ] Doolin[ , ]
Interprets the limiting conditions in relation to power and control that are thought to influence behaviour.		Bloomfield and Best[ ]
Involves understanding meanings/contexts and processes as perceived from different perspectives, trying to understand individual and shared social meanings. Focus is on theory building.	Often difficult to explain unintended consequences and for neglecting surrounding historical contexts	Stake[ ] Doolin[ ]
Involves establishing which variables one wishes to study in advance and seeing whether they fit in with the findings. Focus is often on testing and refining theory on the basis of case study findings.	It does not take into account the role of the researcher in influencing findings.	Yin[ , , ] Shanks and Parr[ ]

How are case studies conducted?

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 Table7 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 ].

Example of a checklist for rating a case study proposal[ 8 ]

	Clarity: Does the proposal read well?
	Integrity: Do its pieces fit together?
	Attractiveness: Does it pique the reader's interest?
	The case: Is the case adequately defined?
	The issues: Are major research questions identified?
	Data Resource: Are sufficient data sources identified?
	Case Selection: Is the selection plan reasonable?
	Data Gathering: Are data-gathering activities outlined?
	Validation: Is the need and opportunity for triangulation indicated?
	Access: Are arrangements for start-up anticipated?
	Confidentiality: Is there sensitivity to the protection of people?
	Cost: Are time and resource estimates reasonable?

For example, in our evaluation of the introduction of electronic health records in English hospitals (Table (Table3), 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 (Table1) 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.

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 Table3) 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.

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 (Table2 2 )[ 4 ].

Analysing, interpreting and reporting case studies

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 (Table1 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 (Table3 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 (Table4 4 )[ 6 ].

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 Table3, 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 (Table4), 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 Table8 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 (Table9 9 )[ 8 ].

Potential pitfalls and mitigating actions when undertaking case study research

Potential pitfall	Mitigating action
Selecting/conceptualising the wrong case(s) resulting in lack of theoretical generalisations	Developing in-depth knowledge of theoretical and empirical literature, justifying choices made
Collecting large volumes of data that are not relevant to the case or too little to be of any value	Focus data collection in line with research questions, whilst being flexible and allowing different paths to be explored
Defining/bounding the case	Focus on related components (either by time and/or space), be clear what is outside the scope of the case
Lack of rigour	Triangulation, respondent validation, the use of theoretical sampling, transparency throughout the research process
Ethical issues	Anonymise appropriately as cases are often easily identifiable to insiders, informed consent of participants
Integration with theoretical framework	Allow for unexpected issues to emerge and do not force fit, test out preliminary explanations, be clear about epistemological positions in advance

Stake's checklist for assessing the quality of a case study report[ 8 ]

1. Is this report easy to read?

2. Does it fit together, each sentence contributing to the whole?

3. Does this report have a conceptual structure (i.e. themes or issues)?

4. Are its issues developed in a series and scholarly way?

5. Is the case adequately defined?

6. Is there a sense of story to the presentation?

7. Is the reader provided some vicarious experience?

8. Have quotations been used effectively?

9. Are headings, figures, artefacts, appendices, indexes effectively used?

10. Was it edited well, then again with a last minute polish?

11. Has the writer made sound assertions, neither over- or under-interpreting?

12. Has adequate attention been paid to various contexts?

13. Were sufficient raw data presented?

14. Were data sources well chosen and in sufficient number?

15. Do observations and interpretations appear to have been triangulated?

16. Is the role and point of view of the researcher nicely apparent?

17. Is the nature of the intended audience apparent?

18. Is empathy shown for all sides?

19. Are personal intentions examined?

20. Does it appear individuals were put at risk?

Conclusions

Competing interests

The authors declare that they have no competing interests.

Authors' contributions

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.

Pre-publication history

The pre-publication history for this paper can be accessed here:

http://www.biomedcentral.com/1471-2288/11/100/prepub

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More Americans died of gun-related injuries in 2021 than in any other year on record, according to the latest available statistics from the Centers for Disease Control and Prevention (CDC). That included record numbers of both gun murders and gun suicides. Despite the increase in such fatalities, the rate of gun deaths – a statistic that accounts for the nation’s growing population – remained below the levels of earlier decades.

Here’s a closer look at gun deaths in the United States, based on a Pew Research Center analysis of data from the CDC, the FBI and other sources. You can also read key public opinion findings about U.S. gun violence and gun policy .

This Pew Research Center analysis examines the changing number and rate of gun deaths in the United States. It is based primarily on data from the Centers for Disease Control and Prevention (CDC) and the Federal Bureau of Investigation (FBI). The CDC’s statistics are based on information contained in official death certificates, while the FBI’s figures are based on information voluntarily submitted by thousands of police departments around the country.

For the number and rate of gun deaths over time, we relied on mortality statistics in the CDC’s WONDER database covering four distinct time periods: 1968 to 1978 , 1979 to 1998 , 1999 to 2020 , and 2021 . While these statistics are mostly comparable for the full 1968-2021 period, gun murders and suicides between 1968 and 1978 are classified by the CDC as involving firearms and explosives; those between 1979 and 2021 are classified as involving firearms only. Similarly, gun deaths involving law enforcement between 1968 and 1978 exclude those caused by “operations of war”; those between 1979 and 2021 include that category, which refers to gun deaths among military personnel or civilians due to war or civil insurrection in the U.S . All CDC gun death estimates in this analysis are adjusted to account for age differences over time and across states.

The FBI’s statistics about the types of firearms used in gun murders in 2020 come from the bureau’s Crime Data Explorer website . Specifically, they are drawn from the expanded homicide tables of the agency’s 2020 Crime in the United States report . The FBI’s statistics include murders and non-negligent manslaughters involving firearms.

How many people die from gun-related injuries in the U.S. each year?

In 2021, the most recent year for which complete data is available, 48,830 people died from gun-related injuries in the U.S., according to the CDC. That figure includes gun murders and gun suicides, along with three less common types of gun-related deaths tracked by the CDC: those that were accidental, those that involved law enforcement and those whose circumstances could not be determined. The total excludes deaths in which gunshot injuries played a contributing, but not principal, role. (CDC fatality statistics are based on information contained in official death certificates, which identify a single cause of death.)

A pie chart showing that suicides accounted for more than half of U.S. gun deaths in 2021.

What share of U.S. gun deaths are murders and what share are suicides?

Though they tend to get less public attention than gun-related murders, suicides have long accounted for the majority of U.S. gun deaths . In 2021, 54% of all gun-related deaths in the U.S. were suicides (26,328), while 43% were murders (20,958), according to the CDC. The remaining gun deaths that year were accidental (549), involved law enforcement (537) or had undetermined circumstances (458).

What share of all murders and suicides in the U.S. involve a gun?

About eight-in-ten U.S. murders in 2021 – 20,958 out of 26,031, or 81% – involved a firearm. That marked the highest percentage since at least 1968, the earliest year for which the CDC has online records. More than half of all suicides in 2021 – 26,328 out of 48,183, or 55% – also involved a gun, the highest percentage since 2001.

A line chart showing that the U.S. saw a record number of gun suicides and gun murders in 2021.

How has the number of U.S. gun deaths changed over time?

The record 48,830 total gun deaths in 2021 reflect a 23% increase since 2019, before the onset of the coronavirus pandemic .

Gun murders, in particular, have climbed sharply during the pandemic, increasing 45% between 2019 and 2021, while the number of gun suicides rose 10% during that span.

The overall increase in U.S. gun deaths since the beginning of the pandemic includes an especially stark rise in such fatalities among children and teens under the age of 18. Gun deaths among children and teens rose 50% in just two years , from 1,732 in 2019 to 2,590 in 2021.

How has the rate of U.S. gun deaths changed over time?

While 2021 saw the highest total number of gun deaths in the U.S., this statistic does not take into account the nation’s growing population. On a per capita basis, there were 14.6 gun deaths per 100,000 people in 2021 – the highest rate since the early 1990s, but still well below the peak of 16.3 gun deaths per 100,000 people in 1974.

A line chart that shows the U.S. gun suicide and gun murder rates reached near-record highs in 2021.

The gun murder rate in the U.S. remains below its peak level despite rising sharply during the pandemic. There were 6.7 gun murders per 100,000 people in 2021, below the 7.2 recorded in 1974.

The gun suicide rate, on the other hand, is now on par with its historical peak. There were 7.5 gun suicides per 100,000 people in 2021, statistically similar to the 7.7 measured in 1977. (One caveat when considering the 1970s figures: In the CDC’s database, gun murders and gun suicides between 1968 and 1978 are classified as those caused by firearms and explosives. In subsequent years, they are classified as deaths involving firearms only.)

Which states have the highest and lowest gun death rates in the U.S.?

The rate of gun fatalities varies widely from state to state. In 2021, the states with the highest total rates of gun-related deaths – counting murders, suicides and all other categories tracked by the CDC – included Mississippi (33.9 per 100,000 people), Louisiana (29.1), New Mexico (27.8), Alabama (26.4) and Wyoming (26.1). The states with the lowest total rates included Massachusetts (3.4), Hawaii (4.8), New Jersey (5.2), New York (5.4) and Rhode Island (5.6).

A map showing that U.S. gun death rates varied widely by state in 2021.

The results are somewhat different when looking at gun murder and gun suicide rates separately. The places with the highest gun murder rates in 2021 included the District of Columbia (22.3 per 100,000 people), Mississippi (21.2), Louisiana (18.4), Alabama (13.9) and New Mexico (11.7). Those with the lowest gun murder rates included Massachusetts (1.5), Idaho (1.5), Hawaii (1.6), Utah (2.1) and Iowa (2.2). Rate estimates are not available for Maine, New Hampshire, Vermont or Wyoming.

The states with the highest gun suicide rates in 2021 included Wyoming (22.8 per 100,000 people), Montana (21.1), Alaska (19.9), New Mexico (13.9) and Oklahoma (13.7). The states with the lowest gun suicide rates were Massachusetts (1.7), New Jersey (1.9), New York (2.0), Hawaii (2.8) and Connecticut (2.9). Rate estimates are not available for the District of Columbia.

How does the gun death rate in the U.S. compare with other countries?

The gun death rate in the U.S. is much higher than in most other nations, particularly developed nations. But it is still far below the rates in several Latin American countries, according to a 2018 study of 195 countries and territories by researchers at the Institute for Health Metrics and Evaluation at the University of Washington.

The U.S. gun death rate was 10.6 per 100,000 people in 2016, the most recent year in the study, which used a somewhat different methodology from the CDC. That was far higher than in countries such as Canada (2.1 per 100,000) and Australia (1.0), as well as European nations such as France (2.7), Germany (0.9) and Spain (0.6). But the rate in the U.S. was much lower than in El Salvador (39.2 per 100,000 people), Venezuela (38.7), Guatemala (32.3), Colombia (25.9) and Honduras (22.5), the study found. Overall, the U.S. ranked 20th in its gun fatality rate that year .

How many people are killed in mass shootings in the U.S. every year?

This is a difficult question to answer because there is no single, agreed-upon definition of the term “mass shooting.” Definitions can vary depending on factors including the number of victims and the circumstances of the shooting.

The FBI collects data on “active shooter incidents,” which it defines as “one or more individuals actively engaged in killing or attempting to kill people in a populated area.” Using the FBI’s definition, 103 people – excluding the shooters – died in such incidents in 2021 .

The Gun Violence Archive, an online database of gun violence incidents in the U.S., defines mass shootings as incidents in which four or more people are shot, even if no one was killed (again excluding the shooters). Using this definition, 706 people died in these incidents in 2021 .

Regardless of the definition being used, fatalities in mass shooting incidents in the U.S. account for a small fraction of all gun murders that occur nationwide each year.

How has the number of mass shootings in the U.S. changed over time?

A bar chart showing that active shooter incidents have become more common in the U.S. in recent years.

The same definitional issue that makes it challenging to calculate mass shooting fatalities comes into play when trying to determine the frequency of U.S. mass shootings over time. The unpredictability of these incidents also complicates matters: As Rand Corp. noted in a research brief , “Chance variability in the annual number of mass shooting incidents makes it challenging to discern a clear trend, and trend estimates will be sensitive to outliers and to the time frame chosen for analysis.”

The FBI found an increase in active shooter incidents between 2000 and 2021. There were three such incidents in 2000. By 2021, that figure had increased to 61.

Which types of firearms are most commonly used in gun murders in the U.S.?

In 2020, the most recent year for which the FBI has published data, handguns were involved in 59% of the 13,620 U.S. gun murders and non-negligent manslaughters for which data is available. Rifles – the category that includes guns sometimes referred to as “assault weapons” – were involved in 3% of firearm murders. Shotguns were involved in 1%. The remainder of gun homicides and non-negligent manslaughters (36%) involved other kinds of firearms or those classified as “type not stated.”

It’s important to note that the FBI’s statistics do not capture the details on all gun murders in the U.S. each year. The FBI’s data is based on information voluntarily submitted by police departments around the country, and not all agencies participate or provide complete information each year.

Note: This is an update of a post originally published on Aug. 16, 2019.

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John Gramlich is an associate director at Pew Research Center .

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Case Study Research

1 Introduction

2 Differences across case study design: a portfolio approach

2.1 Case study research design 1: no theory first

2.2 Case study research design 2: gaps and holes

2.3 Case study research design 3: social construction of reality

2.4 Case study research design 4: anomalies

2.5 A comparison of case study research processes

3 Elements of a theory continuum

3.1 Basic elements of a theory

3.2 Theory continuum

3.2.1 Building theory

3.2.2 Developing theory

3.2.3 Test of theories

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