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Case Study – Methods, Examples and Guide

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A case study is a research method that involves an in-depth examination and analysis of a particular phenomenon or case, such as an individual, organization, community, event, or situation.

It is a qualitative research approach that aims to provide a detailed and comprehensive understanding of the case being studied. Case studies typically involve multiple sources of data, including interviews, observations, documents, and artifacts, which are analyzed using various techniques, such as content analysis, thematic analysis, and grounded theory. The findings of a case study are often used to develop theories, inform policy or practice, or generate new research questions.

Types of Case Study

Types and Methods of Case Study are as follows:

Single-Case Study

A single-case study is an in-depth analysis of a single case. This type of case study is useful when the researcher wants to understand a specific phenomenon in detail.

For Example , A researcher might conduct a single-case study on a particular individual to understand their experiences with a particular health condition or a specific organization to explore their management practices. The researcher collects data from multiple sources, such as interviews, observations, and documents, and uses various techniques to analyze the data, such as content analysis or thematic analysis. The findings of a single-case study are often used to generate new research questions, develop theories, or inform policy or practice.

Multiple-Case Study

A multiple-case study involves the analysis of several cases that are similar in nature. This type of case study is useful when the researcher wants to identify similarities and differences between the cases.

For Example, a researcher might conduct a multiple-case study on several companies to explore the factors that contribute to their success or failure. The researcher collects data from each case, compares and contrasts the findings, and uses various techniques to analyze the data, such as comparative analysis or pattern-matching. The findings of a multiple-case study can be used to develop theories, inform policy or practice, or generate new research questions.

Exploratory Case Study

An exploratory case study is used to explore a new or understudied phenomenon. This type of case study is useful when the researcher wants to generate hypotheses or theories about the phenomenon.

For Example, a researcher might conduct an exploratory case study on a new technology to understand its potential impact on society. The researcher collects data from multiple sources, such as interviews, observations, and documents, and uses various techniques to analyze the data, such as grounded theory or content analysis. The findings of an exploratory case study can be used to generate new research questions, develop theories, or inform policy or practice.

Descriptive Case Study

A descriptive case study is used to describe a particular phenomenon in detail. This type of case study is useful when the researcher wants to provide a comprehensive account of the phenomenon.

For Example, a researcher might conduct a descriptive case study on a particular community to understand its social and economic characteristics. The researcher collects data from multiple sources, such as interviews, observations, and documents, and uses various techniques to analyze the data, such as content analysis or thematic analysis. The findings of a descriptive case study can be used to inform policy or practice or generate new research questions.

Instrumental Case Study

An instrumental case study is used to understand a particular phenomenon that is instrumental in achieving a particular goal. This type of case study is useful when the researcher wants to understand the role of the phenomenon in achieving the goal.

For Example, a researcher might conduct an instrumental case study on a particular policy to understand its impact on achieving a particular goal, such as reducing poverty. The researcher collects data from multiple sources, such as interviews, observations, and documents, and uses various techniques to analyze the data, such as content analysis or thematic analysis. The findings of an instrumental case study can be used to inform policy or practice or generate new research questions.

Case Study Data Collection Methods

Here are some common data collection methods for case studies:

Interviews involve asking questions to individuals who have knowledge or experience relevant to the case study. Interviews can be structured (where the same questions are asked to all participants) or unstructured (where the interviewer follows up on the responses with further questions). Interviews can be conducted in person, over the phone, or through video conferencing.

Observations

Observations involve watching and recording the behavior and activities of individuals or groups relevant to the case study. Observations can be participant (where the researcher actively participates in the activities) or non-participant (where the researcher observes from a distance). Observations can be recorded using notes, audio or video recordings, or photographs.

Documents can be used as a source of information for case studies. Documents can include reports, memos, emails, letters, and other written materials related to the case study. Documents can be collected from the case study participants or from public sources.

Surveys involve asking a set of questions to a sample of individuals relevant to the case study. Surveys can be administered in person, over the phone, through mail or email, or online. Surveys can be used to gather information on attitudes, opinions, or behaviors related to the case study.

Artifacts are physical objects relevant to the case study. Artifacts can include tools, equipment, products, or other objects that provide insights into the case study phenomenon.

How to conduct Case Study Research

Conducting a case study research involves several steps that need to be followed to ensure the quality and rigor of the study. Here are the steps to conduct case study research:

• Define the research questions: The first step in conducting a case study research is to define the research questions. The research questions should be specific, measurable, and relevant to the case study phenomenon under investigation.
• Select the case: The next step is to select the case or cases to be studied. The case should be relevant to the research questions and should provide rich and diverse data that can be used to answer the research questions.
• Collect data: Data can be collected using various methods, such as interviews, observations, documents, surveys, and artifacts. The data collection method should be selected based on the research questions and the nature of the case study phenomenon.
• Analyze the data: The data collected from the case study should be analyzed using various techniques, such as content analysis, thematic analysis, or grounded theory. The analysis should be guided by the research questions and should aim to provide insights and conclusions relevant to the research questions.
• Draw conclusions: The conclusions drawn from the case study should be based on the data analysis and should be relevant to the research questions. The conclusions should be supported by evidence and should be clearly stated.
• Validate the findings: The findings of the case study should be validated by reviewing the data and the analysis with participants or other experts in the field. This helps to ensure the validity and reliability of the findings.
• Write the report: The final step is to write the report of the case study research. The report should provide a clear description of the case study phenomenon, the research questions, the data collection methods, the data analysis, the findings, and the conclusions. The report should be written in a clear and concise manner and should follow the guidelines for academic writing.

Examples of Case Study

Here are some examples of case study research:

• The Hawthorne Studies : Conducted between 1924 and 1932, the Hawthorne Studies were a series of case studies conducted by Elton Mayo and his colleagues to examine the impact of work environment on employee productivity. The studies were conducted at the Hawthorne Works plant of the Western Electric Company in Chicago and included interviews, observations, and experiments.
• The Stanford Prison Experiment: Conducted in 1971, the Stanford Prison Experiment was a case study conducted by Philip Zimbardo to examine the psychological effects of power and authority. The study involved simulating a prison environment and assigning participants to the role of guards or prisoners. The study was controversial due to the ethical issues it raised.
• The Challenger Disaster: The Challenger Disaster was a case study conducted to examine the causes of the Space Shuttle Challenger explosion in 1986. The study included interviews, observations, and analysis of data to identify the technical, organizational, and cultural factors that contributed to the disaster.
• The Enron Scandal: The Enron Scandal was a case study conducted to examine the causes of the Enron Corporation’s bankruptcy in 2001. The study included interviews, analysis of financial data, and review of documents to identify the accounting practices, corporate culture, and ethical issues that led to the company’s downfall.
• The Fukushima Nuclear Disaster : The Fukushima Nuclear Disaster was a case study conducted to examine the causes of the nuclear accident that occurred at the Fukushima Daiichi Nuclear Power Plant in Japan in 2011. The study included interviews, analysis of data, and review of documents to identify the technical, organizational, and cultural factors that contributed to the disaster.

Application of Case Study

Case studies have a wide range of applications across various fields and industries. Here are some examples:

Business and Management

Case studies are widely used in business and management to examine real-life situations and develop problem-solving skills. Case studies can help students and professionals to develop a deep understanding of business concepts, theories, and best practices.

Case studies are used in healthcare to examine patient care, treatment options, and outcomes. Case studies can help healthcare professionals to develop critical thinking skills, diagnose complex medical conditions, and develop effective treatment plans.

Case studies are used in education to examine teaching and learning practices. Case studies can help educators to develop effective teaching strategies, evaluate student progress, and identify areas for improvement.

Social Sciences

Case studies are widely used in social sciences to examine human behavior, social phenomena, and cultural practices. Case studies can help researchers to develop theories, test hypotheses, and gain insights into complex social issues.

Law and Ethics

Case studies are used in law and ethics to examine legal and ethical dilemmas. Case studies can help lawyers, policymakers, and ethical professionals to develop critical thinking skills, analyze complex cases, and make informed decisions.

Purpose of Case Study

The purpose of a case study is to provide a detailed analysis of a specific phenomenon, issue, or problem in its real-life context. A case study is a qualitative research method that involves the in-depth exploration and analysis of a particular case, which can be an individual, group, organization, event, or community.

The primary purpose of a case study is to generate a comprehensive and nuanced understanding of the case, including its history, context, and dynamics. Case studies can help researchers to identify and examine the underlying factors, processes, and mechanisms that contribute to the case and its outcomes. This can help to develop a more accurate and detailed understanding of the case, which can inform future research, practice, or policy.

Case studies can also serve other purposes, including:

• Illustrating a theory or concept: Case studies can be used to illustrate and explain theoretical concepts and frameworks, providing concrete examples of how they can be applied in real-life situations.
• Developing hypotheses: Case studies can help to generate hypotheses about the causal relationships between different factors and outcomes, which can be tested through further research.
• Providing insight into complex issues: Case studies can provide insights into complex and multifaceted issues, which may be difficult to understand through other research methods.
• Informing practice or policy: Case studies can be used to inform practice or policy by identifying best practices, lessons learned, or areas for improvement.

Advantages of Case Study Research

There are several advantages of case study research, including:

• In-depth exploration: Case study research allows for a detailed exploration and analysis of a specific phenomenon, issue, or problem in its real-life context. This can provide a comprehensive understanding of the case and its dynamics, which may not be possible through other research methods.
• Rich data: Case study research can generate rich and detailed data, including qualitative data such as interviews, observations, and documents. This can provide a nuanced understanding of the case and its complexity.
• Holistic perspective: Case study research allows for a holistic perspective of the case, taking into account the various factors, processes, and mechanisms that contribute to the case and its outcomes. This can help to develop a more accurate and comprehensive understanding of the case.
• Theory development: Case study research can help to develop and refine theories and concepts by providing empirical evidence and concrete examples of how they can be applied in real-life situations.
• Practical application: Case study research can inform practice or policy by identifying best practices, lessons learned, or areas for improvement.
• Contextualization: Case study research takes into account the specific context in which the case is situated, which can help to understand how the case is influenced by the social, cultural, and historical factors of its environment.

Limitations of Case Study Research

There are several limitations of case study research, including:

• Limited generalizability : Case studies are typically focused on a single case or a small number of cases, which limits the generalizability of the findings. The unique characteristics of the case may not be applicable to other contexts or populations, which may limit the external validity of the research.
• Biased sampling: Case studies may rely on purposive or convenience sampling, which can introduce bias into the sample selection process. This may limit the representativeness of the sample and the generalizability of the findings.
• Subjectivity: Case studies rely on the interpretation of the researcher, which can introduce subjectivity into the analysis. The researcher’s own biases, assumptions, and perspectives may influence the findings, which may limit the objectivity of the research.
• Limited control: Case studies are typically conducted in naturalistic settings, which limits the control that the researcher has over the environment and the variables being studied. This may limit the ability to establish causal relationships between variables.
• Time-consuming: Case studies can be time-consuming to conduct, as they typically involve a detailed exploration and analysis of a specific case. This may limit the feasibility of conducting multiple case studies or conducting case studies in a timely manner.
• Resource-intensive: Case studies may require significant resources, including time, funding, and expertise. This may limit the ability of researchers to conduct case studies in resource-constrained settings.

About the author

Muhammad Hassan

Researcher, Academic Writer, Web developer

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What is the Case Study Method?

Overview Dropdown up

Overview dropdown down, celebrating 100 years of the case method at hbs.

The 2021-2022 academic year marks the 100-year anniversary of the introduction of the case method at Harvard Business School. Today, the HBS case method is employed in the HBS MBA program, in Executive Education programs, and in dozens of other business schools around the world. As Dean Srikant Datar's says, the case method has withstood the test of time.

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How Cases Unfold In the Classroom

How cases unfold in the classroom dropdown up, how cases unfold in the classroom dropdown down, preparation guidelines expand all collapse all, read the professor's assignment or discussion questions read the professor's assignment or discussion questions dropdown down, read the first few paragraphs and then skim the case read the first few paragraphs and then skim the case dropdown down, reread the case, underline text, and make margin notes reread the case, underline text, and make margin notes dropdown down, note the key problems on a pad of paper and go through the case again note the key problems on a pad of paper and go through the case again dropdown down, how to prepare for case discussions dropdown up, how to prepare for case discussions dropdown down, read the professor's assignment or discussion questions, read the first few paragraphs and then skim the case, reread the case, underline text, and make margin notes, note the key problems on a pad of paper and go through the case again, case study best practices expand all collapse all, prepare prepare dropdown down, discuss discuss dropdown down, participate participate dropdown down, relate relate dropdown down, apply apply dropdown down, note note dropdown down, understand understand dropdown down, case study best practices dropdown up, case study best practices dropdown down, participate, what can i expect on the first day dropdown down.

Most programs begin with registration, followed by an opening session and a dinner. If your travel plans necessitate late arrival, please be sure to notify us so that alternate registration arrangements can be made for you. Please note the following about registration:

HBS campus programs – Registration takes place in the Chao Center.

India programs – Registration takes place outside the classroom.

Other off-campus programs – Registration takes place in the designated facility.

What happens in class if nobody talks? Dropdown down

Professors are here to push everyone to learn, but not to embarrass anyone. If the class is quiet, they'll often ask a participant with experience in the industry in which the case is set to speak first. This is done well in advance so that person can come to class prepared to share. Trust the process. The more open you are, the more willing you’ll be to engage, and the more alive the classroom will become.

Does everyone take part in "role-playing"? Dropdown down

Professors often encourage participants to take opposing sides and then debate the issues, often taking the perspective of the case protagonists or key decision makers in the case.

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18 Case Study Method

Ms. Beliyaluxmi Devi

1. Introduction

2. Case Study

3 Techniques used for case studies

4 Sources of data for case studies

5 Types of case Studies

6 Advantage and limitation

Learning Objectives:

•  To learn what is case study and distinction from case history; identify the application of case study;
•  To discuss how to plan case study; and
•  To understand the advantage and limitation of case study
• Introduction

Among the various methods of data collection, case study is certainly one popular form of qualitative analysis involving careful and complete observation of a case. A case is a social unit with a deviant behavior, and may be an event, problem, process, activity, programme, of a social unit. The unit may be a person, a family, an institution, a cultural group, a community or even an entire society (Kothari, 2014). But it is a bounded system that has the boundaries of the case. Case Study therefore is an intensive investigation of the particular unit under consideration. It is extensively used in psychology, education, sociology, anthropology, economics and political science. It aims at obtaining a complete and detailed account of a social phenomenon or a social event of a social unit. In case study, data can be collected from multiple sources by using any qualitative method of data collection like interviews, observation and it may also include documents, artifacts etc. Case study method is a type of data collection that goes in depth understanding rather than breadth. Case study can be descriptive as we observe and write in description as well as it can also be an exploratory that is we wrote what was said. Pierre Guillaume Frederic Le Play (1855), a mathematician and natural scientist, is considered as the founder of case study method as he used it for the first time in his publication Les Ouvriers Europeens.

2.1 Definitions of Case Study Methods

Case study has been defined differently by different scholars from time to time. Some of them are presented below.

• Young, P.V. (1984): Case study is a comprehensive study of a social unit, be it a person, a group of persons, an institute, a community or a family.
• Groode and Hatt (1953): It is a method of exploring and analyzing the life of a social unit
• Cooley, C.H. (2007): Case study depends our perception and gives clear insight into life directory.
• Bogardus, E. S. (1925): The method of examining specially and in detail a given situation
• Robson C. (1993): A strategy for doing research which involves an empirical investigation of a particular contemporary phenomenon within its real life context using multiple sources of evidence.

So critical analysis of these definitions, reveal that case study is a method of minute and detail study of a situation concerning a social unit in an intensive and comprehensive manner in order to understand the personal as well as hidden dimensions of human life.

2.2 Characteristics of Case Study

The main characteristics of the case study are (www.studylecturenotes.com):

A descriptive study:

• The data collected constitute descriptions of psychological processes and events, and of the contexts in which they occurred.
• The main emphasis is always on the construction of verbal descriptions of behavior or experience but rarely quantitative data may be collected. In short case study is more of a qualitative method rather than quantitative method.
• High levels of detail are provided.
• The behavior pattern of the concerned unit is studied directly wherein efforts are made to know the mutual inter-relationship of causal factors.

Narrowly focused:

• Typically a case study offers a complete and comprehensive description of all facets of a social unit, be it a single individual or may be a social group.
• Often the case study focuses on a limited aspect of a person, such as their psychopathological symptoms.

Combines objective and subjective data:

Researchers may combine objective and subjective data. Both the data are regarded as valid data for analysis. It enables case study to achieved in-depth understanding of the behavior and experience of a single individual.

Process-oriented:

• The case study method enables the researcher to explore and describe the nature of processes, which occur over time.
• In contrast to the experimental method, which basically provides a stilled ‘snapshot’ of processes, case study continued over time like for example the development of language in children over time.

2.3. Difference between Case Study and Case History

The Case study method helps retaining the holistic and meaningful characteristics of real life events – such as individual life cycles, small group behavior, etc. It is like a case history of a patient. As a patient goes to the doctor with some serious disease, the doctor records the case history. Analysis of case history helps in the diagnosis of the patient’s illness (http://www.differencebetween.com/difference-between-case-study-and-vs-case-history).

Although most of us confuse case study and case history to be the same, however, there exists a difference between these two terms. They are being used in many disciplines and allow the researcher to be more informative of people, and events. First, let us define the word case study. A case study refers to a research method where a person, group or an event is being investigated which is used by researchers whereas a case history, on the other hand, refers to a record of data which contributes to a case study; usually case history is used by doctors to investigate the patients. This is the main difference between a case study and case history.

(i) What is a Case Study?

A case study is a research method used to investigate an individual, a group of people, or a particular phenomenon. The case study has been used in many disciplines especially in social science, anthropology, sociology, psychology, and political science. A case study allows the researcher to gain an in-depth understanding of the topic. To conduct a case study, the researcher can use a number of techniques. For example, observation, interviews, usage of secondary data such as documents, records, etc. It usually goes on for a longer period because the researcher has to explore the topic deeply.

The case study method was first used in the clinical medicine so that the doctor has a clear understanding of the history of the patient. Various methods can be used in a case study for example a psychologist use observation to observe the individual, use interview method to broaden the understanding. To create a clear picture of the problem, the questions can be directed not only to the individual on whom the case study is being conducted but also on those who are related to the individual. A special feature of case studies is that it produces qualitative data that are rich and authentic.

(ii) What is a Case History?

Unlike the case study that refers to a method, a case history refers to a record of an individual or even a group. Case histories are used in many disciplines such as psychology, sociology, medicine, psychiatry, etc. It consists of all the necessary information of the individual. In medicine, a case history refers to a specific record that reveals the personal information, medical condition, the medication that has been used and special conditions of the individual. Having a case history can be very beneficial in treatment of disease. However, a case history does not necessarily have to be connected to an individual; it can even be of an event that took place. The case history is a recording that narrates a sequence of events. Such a narrative allows the researcher to look at an event in retrospect.

• Techniques used for Case Studies

The techniques of case studies includes –

(i) Observation

It is a systematic data collection approach. Researchers use all of their senses to examine people in natural settings or naturally occurring situations. Observation of a field setting involves: prolonged engagement in a setting or social situation.

(ii) Interview

It is questioning and discussing to a person for the purpose of an evaluation or to generate information. (iii) Secondary Data

Secondary data refers to data that was collected by someone through secondary sources. (iv) Documents

Any writing that provides information, especially information which is of official in nature.

(v) Records

Anything that provides permanent information which can rely on or providing an evident officially.

• Sources of Data for Case Study

In case study, information may be collected from various sources. Some of the important sources include:

• Life histories
• Personal documents
• Letters and records
• Biographies
• Information obtained through interviews
• Observation
• Types of Case Study

The following are the types of case study according to the Graham R Gibbs (2012) –

• Individual case study: This study was first done by Shaw, Clifford R. (1930). In individual case study, life of a particular person, his activities and his totalities were accompanied.
• Set of individual case study: Group of person that practice different culture was studies. As for instance those lives in rural area and those living in urban area there will different cases between them.
• Community studies: In community studies, it may include hundreds of people from a community that picked upon for some reason.
• Social Group Studies: Group of people that defined their social position, for example a group of musician or a group of drugs taker
• Studies of organizations and institutions: Study for a particular organizations or an institutions
• Studies of events, roles and relationships: Similar to individual case study but more focus on events, roles and relationships that involved. For example we can take the role of a housewife.

Identifying a Case Study:

Determine if a case study will answer your research question

Identify the case and find out what type of case study method or technique will be employed

When the researcher makes interpretations, the researcher should be able to learn the meaning of the case data while interpreting

How to plan a case study?

The following points are required to plan a case study such as –

Conceptual Framework: based on the theory it displays the important features of a case study and show relationships between features.

Research Questions: Consist of conceptual framework which is consisting of focused and answerable questions.

Research Design: Plan out of what to include or what not to include before data collection

Methods and Instruments: an appropriate method should be employed to answer the research question

Analysis of Data and interpretation: Collected information should be analysed using statistical tools and interpret the findings incorporating the ideas and knowledge gathered during data collection

• Advantages and Limitations

6.1 Advantages of Case Study

The following are some of the advantages of case study –

a) It facilitates intensive study and in-depth analysis of a social unit which help in contradicting established theory.

b) In-depth and comprehensive information are collected through this method which helps in stimulating new research.

c) It is suitable for collecting data pertaining to sensitive areas of a social phenomenon.

d) It helps to collect details regarding the diverse habits, traits and qualities of the unit under investigation (Kothari, 2014).

e) The researcher can understand better the social change of different facets of a social unit every now and then.

f) This study can be a means to understand the past of a social unit because of its emphasis of historical analysis.

g) The researcher can used any type of methods like interview, questionnaire, documents, self-reports etc.

h) Case study enables to generalize the knowledge amusing from the information collected.

i) A real personal experience can be recorded which enlighten and reveal the real man’s inner determined.

j) The data obtained through case study is useful for formulation of hypothesis and preparation of schedule and questionnaire for such types of study and for further research (Kothari, 2014).

k) It helps in enhancing his/her experience, ability and skill in content analysis of the data.

l) It is useful for therapeutic and administrative purposes, particularly in diagnosis, treatment and therapy etc.

6.2 Limitations of Case Study

a) Case history records could be open to errors due to faulty selection of case and inaccurate observation (Kothari, 2014).

b) There are chances of inaccuracy of the data as no uniform and standardized system of recording case histories has been developed.

c) Data collected from case study usually based on several assumptions which may not be very realistic at times

d) This method is mainly qualitative rather than quantitative, hence there may be question of subjectivity.

e) It is very difficult to draw generalizations on the basis of a few cases.

f) Sampling is not possible in case study as this method can be used only in a limited unit.

g) The information collected from case study is incomparable since each informant gives his/her own opinion. Therefore, replication is not possible.

h) Since this method is fully based on the informant, sometimes the informant himself thinks that he/she have the full knowledge and the information given by them may include some fake also.

i) The investigator’s bias might distort the quality of the case study (Kothari, 2014).

j) Case Study is time-consuming and costly in certain cases.

k) This method cannot be effectively used in big and complex societies (Kothari, 2014).

Case study is an important method employed for collection of qualitative data for an in depth, intensive and comprehensive scientific study of a social unit. This social unit can be an individual, a family, a community, a group or even an entire society. Case study is quite different from the case history which focuses on the recording of personal information. Different methods of case study such as individual, community, social group, organization and events using appropriate techniques (observation, interview, secondary data like documents and records) are used based on the objectives of the research problem. The main sources of data in case studies includes life histories, personal documents, letters and records, biographies, information obtained through interviews and observation. Case studies facilitate intensive study and in-depth analysis of a social unit contradicting established theory. It helps in contradicting established theory and stimulating new research. However, difficulties arises in case studies due to a number of reasons which includes inconsistency in data, not possible to replicate the findings, interviewing key and right informants, expertise of the investigator, constant monitoring of interaction between the theoretical issues being studied and collected data, and interpretation of the data needs to be carefully considered.

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5 Benefits of Learning Through the Case Study Method

• 28 Nov 2023

While several factors make HBS Online unique —including a global Community and real-world outcomes —active learning through the case study method rises to the top.

In a 2023 City Square Associates survey, 74 percent of HBS Online learners who also took a course from another provider said HBS Online’s case method and real-world examples were better by comparison.

Here’s a primer on the case method, five benefits you could gain, and how to experience it for yourself.

Access your free e-book today.

What Is the Harvard Business School Case Study Method?

The case study method , or case method , is a learning technique in which you’re presented with a real-world business challenge and asked how you’d solve it. After working through it yourself and with peers, you’re told how the scenario played out.

HBS pioneered the case method in 1922. Shortly before, in 1921, the first case was written.

“How do you go into an ambiguous situation and get to the bottom of it?” says HBS Professor Jan Rivkin, former senior associate dean and chair of HBS's master of business administration (MBA) program, in a video about the case method . “That skill—the skill of figuring out a course of inquiry to choose a course of action—that skill is as relevant today as it was in 1921.”

Originally developed for the in-person MBA classroom, HBS Online adapted the case method into an engaging, interactive online learning experience in 2014.

In HBS Online courses , you learn about each case from the business professional who experienced it. After reviewing their videos, you’re prompted to take their perspective and explain how you’d handle their situation.

You then get to read peers’ responses, “star” them, and comment to further the discussion. Afterward, you learn how the professional handled it and their key takeaways.

HBS Online’s adaptation of the case method incorporates the famed HBS “cold call,” in which you’re called on at random to make a decision without time to prepare.

“Learning came to life!” said Sheneka Balogun , chief administration officer and chief of staff at LeMoyne-Owen College, of her experience taking the Credential of Readiness (CORe) program . “The videos from the professors, the interactive cold calls where you were randomly selected to participate, and the case studies that enhanced and often captured the essence of objectives and learning goals were all embedded in each module. This made learning fun, engaging, and student-friendly.”

If you’re considering taking a course that leverages the case study method, here are five benefits you could experience.

5 Benefits of Learning Through Case Studies

1. take new perspectives.

The case method prompts you to consider a scenario from another person’s perspective. To work through the situation and come up with a solution, you must consider their circumstances, limitations, risk tolerance, stakeholders, resources, and potential consequences to assess how to respond.

Taking on new perspectives not only can help you navigate your own challenges but also others’. Putting yourself in someone else’s situation to understand their motivations and needs can go a long way when collaborating with stakeholders.

2. Hone Your Decision-Making Skills

Another skill you can build is the ability to make decisions effectively . The case study method forces you to use limited information to decide how to handle a problem—just like in the real world.

Throughout your career, you’ll need to make difficult decisions with incomplete or imperfect information—and sometimes, you won’t feel qualified to do so. Learning through the case method allows you to practice this skill in a low-stakes environment. When facing a real challenge, you’ll be better prepared to think quickly, collaborate with others, and present and defend your solution.

3. Become More Open-Minded

As you collaborate with peers on responses, it becomes clear that not everyone solves problems the same way. Exposing yourself to various approaches and perspectives can help you become a more open-minded professional.

When you’re part of a diverse group of learners from around the world, your experiences, cultures, and backgrounds contribute to a range of opinions on each case.

On the HBS Online course platform, you’re prompted to view and comment on others’ responses, and discussion is encouraged. This practice of considering others’ perspectives can make you more receptive in your career.

“You’d be surprised at how much you can learn from your peers,” said Ratnaditya Jonnalagadda , a software engineer who took CORe.

In addition to interacting with peers in the course platform, Jonnalagadda was part of the HBS Online Community , where he networked with other professionals and continued discussions sparked by course content.

“You get to understand your peers better, and students share examples of businesses implementing a concept from a module you just learned,” Jonnalagadda said. “It’s a very good way to cement the concepts in one's mind.”

4. Enhance Your Curiosity

One byproduct of taking on different perspectives is that it enables you to picture yourself in various roles, industries, and business functions.

“Each case offers an opportunity for students to see what resonates with them, what excites them, what bores them, which role they could imagine inhabiting in their careers,” says former HBS Dean Nitin Nohria in the Harvard Business Review . “Cases stimulate curiosity about the range of opportunities in the world and the many ways that students can make a difference as leaders.”

Through the case method, you can “try on” roles you may not have considered and feel more prepared to change or advance your career .

5. Build Your Self-Confidence

Finally, learning through the case study method can build your confidence. Each time you assume a business leader’s perspective, aim to solve a new challenge, and express and defend your opinions and decisions to peers, you prepare to do the same in your career.

According to a 2022 City Square Associates survey , 84 percent of HBS Online learners report feeling more confident making business decisions after taking a course.

“Self-confidence is difficult to teach or coach, but the case study method seems to instill it in people,” Nohria says in the Harvard Business Review . “There may well be other ways of learning these meta-skills, such as the repeated experience gained through practice or guidance from a gifted coach. However, under the direction of a masterful teacher, the case method can engage students and help them develop powerful meta-skills like no other form of teaching.”

How to Experience the Case Study Method

If the case method seems like a good fit for your learning style, experience it for yourself by taking an HBS Online course. Offerings span seven subject areas, including:

• Business essentials
• Leadership and management
• Entrepreneurship and innovation
• Finance and accounting
• Business in society

No matter which course or credential program you choose, you’ll examine case studies from real business professionals, work through their challenges alongside peers, and gain valuable insights to apply to your career.

Are you interested in discovering how HBS Online can help advance your career? Explore our course catalog and download our free guide —complete with interactive workbook sections—to determine if online learning is right for you and which course to take.

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What the Case Study Method Really Teaches

• Nitin Nohria

Seven meta-skills that stick even if the cases fade from memory.

It’s been 100 years since Harvard Business School began using the case study method. Beyond teaching specific subject matter, the case study method excels in instilling meta-skills in students. This article explains the importance of seven such skills: preparation, discernment, bias recognition, judgement, collaboration, curiosity, and self-confidence.

During my decade as dean of Harvard Business School, I spent hundreds of hours talking with our alumni. To enliven these conversations, I relied on a favorite question: “What was the most important thing you learned from your time in our MBA program?”

• Nitin Nohria is the George F. Baker Jr. and Distinguished Service University Professor. He served as the 10th dean of Harvard Business School, from 2010 to 2020.

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Understanding Case Study Method in Research: A Comprehensive Guide

Table of Contents

Have you ever wondered how researchers uncover the nuanced layers of individual experiences or the intricate workings of a particular event? One of the keys to unlocking these mysteries lies in the qualitative research focusing on a single subject in its real-life context.">case study method , a research strategy that might seem straightforward at first glance but is rich with complexity and insightful potential. Let’s dive into the world of case studies and discover why they are such a valuable tool in the arsenal of research methods.

What is a Case Study Method?

At its core, the case study method is a form of qualitative research that involves an in-depth, detailed examination of a single subject, such as an individual, group, organization, event, or phenomenon. It’s a method favored when the boundaries between phenomenon and context are not clearly evident, and where multiple sources of data are used to illuminate the case from various perspectives. This method’s strength lies in its ability to provide a comprehensive understanding of the case in its real-life context.

Historical Context and Evolution of Case Studies

Case studies have been around for centuries, with their roots in medical and psychological research. Over time, their application has spread to disciplines like sociology, anthropology, business, and education. The evolution of this method has been marked by a growing appreciation for qualitative data and the rich, contextual insights it can provide, which quantitative methods may overlook.

Characteristics of Case Study Research

What sets the case study method apart are its distinct characteristics:

• Intensive Examination: It provides a deep understanding of the case in question, considering the complexity and uniqueness of each case.
• Contextual Analysis: The researcher studies the case within its real-life context, recognizing that the context can significantly influence the phenomenon.
• Multiple Data Sources: Case studies often utilize various data sources like interviews, observations, documents, and reports, which provide multiple perspectives on the subject.
• Participant’s Perspective: This method often focuses on the perspectives of the participants within the case, giving voice to those directly involved.

Types of Case Studies

There are different types of case studies, each suited for specific research objectives:

• Exploratory: These are conducted before large-scale research projects to help identify questions, select measurement constructs, and develop hypotheses.
• Descriptive: These involve a detailed, in-depth description of the case, without attempting to determine cause and effect.
• Explanatory: These are used to investigate cause-and-effect relationships and understand underlying principles of certain phenomena.
• Intrinsic: This type is focused on the case itself because the case presents an unusual or unique issue.
• Instrumental: Here, the case is secondary to understanding a broader issue or phenomenon.
• Collective: These involve studying a group of cases collectively or comparably to understand a phenomenon, population, or general condition.

The Process of Conducting a Case Study

Conducting a case study involves several well-defined steps:

• Defining Your Case: What or who will you study? Define the case and ensure it aligns with your research objectives.
• Selecting Participants: If studying people, careful selection is crucial to ensure they fit the case criteria and can provide the necessary insights.
• Data Collection: Gather information through various methods like interviews, observations, and reviewing documents.
• Data Analysis: Analyze the collected data to identify patterns, themes, and insights related to your research question.
• Reporting Findings: Present your findings in a way that communicates the complexity and richness of the case study, often through narrative.

Case Studies in Practice: Real-world Examples

Case studies are not just academic exercises; they have practical applications in every field. For instance, in business, they can explore consumer behavior or organizational strategies. In psychology, they can provide detailed insight into individual behaviors or conditions. Education often uses case studies to explore teaching methods or learning difficulties.

Advantages of Case Study Research

While the case study method has its critics, it offers several undeniable advantages:

• Rich, Detailed Data: It captures data too complex for quantitative methods.
• Contextual Insights: It provides a better understanding of the phenomena in its natural setting.
• Contribution to Theory: It can generate and refine theory, offering a foundation for further research.

Limitations and Criticism

However, it’s important to acknowledge the limitations and criticisms:

• Generalizability : Findings from case studies may not be widely generalizable due to the focus on a single case.
• Subjectivity: The researcher’s perspective may influence the study, which requires careful reflection and transparency.
• Time-Consuming: They require a significant amount of time to conduct and analyze properly.

Concluding Thoughts on the Case Study Method

The case study method is a powerful tool that allows researchers to delve into the intricacies of a subject in its real-world environment. While not without its challenges, when executed correctly, the insights garnered can be incredibly valuable, offering depth and context that other methods may miss. Robert K\. Yin ’s advocacy for this method underscores its potential to illuminate and explain contemporary phenomena, making it an indispensable part of the researcher’s toolkit.

Reflecting on the case study method, how do you think its application could change with the advancements in technology and data analytics? Could such a traditional method be enhanced or even replaced in the future?

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Research Methods in Psychology

1 Introduction to Psychological Research – Objectives and Goals, Problems, Hypothesis and Variables

• Nature of Psychological Research
• The Context of Discovery
• Context of Justification
• Characteristics of Psychological Research
• Goals and Objectives of Psychological Research

2 Introduction to Psychological Experiments and Tests

• Independent and Dependent Variables
• Extraneous Variables
• Experimental and Control Groups
• Introduction of Test
• Types of Psychological Test
• Uses of Psychological Tests

3 Steps in Research

• Research Process
• Identification of the Problem
• Review of Literature
• Formulating a Hypothesis
• Identifying Manipulating and Controlling Variables
• Formulating a Research Design
• Constructing Devices for Observation and Measurement
• Sample Selection and Data Collection
• Data Analysis and Interpretation
• Hypothesis Testing
• Drawing Conclusion

4 Types of Research and Methods of Research

• Historical Research
• Descriptive Research
• Correlational Research
• Qualitative Research
• Ex-Post Facto Research
• True Experimental Research
• Quasi-Experimental Research

5 Definition and Description Research Design, Quality of Research Design

• Research Design
• Purpose of Research Design
• Design Selection
• Criteria of Research Design
• Qualities of Research Design

6 Experimental Design (Control Group Design and Two Factor Design)

• Experimental Design
• Control Group Design
• Two Factor Design

7 Survey Design

• Survey Research Designs
• Steps in Survey Design
• Structuring and Designing the Questionnaire
• Interviewing Methodology
• Data Analysis
• Final Report

8 Single Subject Design

• Single Subject Design: Definition and Meaning
• Phases Within Single Subject Design
• Requirements of Single Subject Design
• Characteristics of Single Subject Design
• Types of Single Subject Design
• Advantages of Single Subject Design
• Disadvantages of Single Subject Design

9 Observation Method

• Definition and Meaning of Observation
• Characteristics of Observation
• Types of Observation
• Advantages and Disadvantages of Observation
• Guides for Observation Method

10 Interview and Interviewing

• Definition of Interview
• Types of Interview
• Aspects of Qualitative Research Interviews
• Interview Questions
• Convergent Interviewing as Action Research
• Research Team

11 Questionnaire Method

• Definition and Description of Questionnaires
• Types of Questionnaires
• Purpose of Questionnaire Studies
• Designing Research Questionnaires
• The Methods to Make a Questionnaire Efficient
• The Types of Questionnaire to be Included in the Questionnaire
• Advantages and Disadvantages of Questionnaire
• When to Use a Questionnaire?

12 Case Study

• Definition and Description of Case Study Method
• Historical Account of Case Study Method
• Designing Case Study
• Requirements for Case Studies
• Guideline to Follow in Case Study Method
• Other Important Measures in Case Study Method
• Case Reports

13 Report Writing

• Purpose of a Report
• Writing Style of the Report
• Report Writing – the Do’s and the Don’ts
• Format for Report in Psychology Area
• Major Sections in a Report

14 Review of Literature

• Purposes of Review of Literature
• Sources of Review of Literature
• Types of Literature
• Writing Process of the Review of Literature
• Preparation of Index Card for Reviewing and Abstracting

15 Methodology

• Definition and Purpose of Methodology
• Participants (Sample)
• Apparatus and Materials

16 Result, Analysis and Discussion of the Data

• Definition and Description of Results
• Statistical Presentation
• Tables and Figures

17 Summary and Conclusion

• Summary Definition and Description
• Guidelines for Writing a Summary
• Writing the Summary and Choosing Words
• A Process for Paraphrasing and Summarising
• Summary of a Report
• Writing Conclusions

18 References in Research Report

• Reference List (the Format)
• References (Process of Writing)
• Reference List and Print Sources
• Electronic Sources
• Book on CD Tape and Movie
• Reference Specifications
• General Guidelines to Write References

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• Knowledge Base

Methodology

• 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 .

Table of contents

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.

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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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What is case study research?

Last updated

8 February 2023

Reviewed by

Cathy Heath

Short on time? Get an AI generated summary of this article instead

Suppose a company receives a spike in the number of customer complaints, or medical experts discover an outbreak of illness affecting children but are not quite sure of the reason. In both cases, carrying out a case study could be the best way to get answers.

Organization

Case studies can be carried out across different disciplines, including education, medicine, sociology, and business.

Most case studies employ qualitative methods, but quantitative methods can also be used. Researchers can then describe, compare, evaluate, and identify patterns or cause-and-effect relationships between the various variables under study. They can then use this knowledge to decide what action to take. 

Another thing to note is that case studies are generally singular in their focus. This means they narrow focus to a particular area, making them highly subjective. You cannot always generalize the results of a case study and apply them to a larger population. However, they are valuable tools to illustrate a principle or develop a thesis.

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• What are the different types of case study designs?

Researchers can choose from a variety of case study designs. The design they choose is dependent on what questions they need to answer, the context of the research environment, how much data they already have, and what resources are available.

Here are the common types of case study design:

Explanatory

An explanatory case study is an initial explanation of the how or why that is behind something. This design is commonly used when studying a real-life phenomenon or event. Once the organization understands the reasons behind a phenomenon, it can then make changes to enhance or eliminate the variables causing it. 

Here is an example: How is co-teaching implemented in elementary schools? The title for a case study of this subject could be “Case Study of the Implementation of Co-Teaching in Elementary Schools.”

Descriptive

An illustrative or descriptive case study helps researchers shed light on an unfamiliar object or subject after a period of time. The case study provides an in-depth review of the issue at hand and adds real-world examples in the area the researcher wants the audience to understand. 

The researcher makes no inferences or causal statements about the object or subject under review. This type of design is often used to understand cultural shifts.

Here is an example: How did people cope with the 2004 Indian Ocean Tsunami? This case study could be titled "A Case Study of the 2004 Indian Ocean Tsunami and its Effect on the Indonesian Population."

Exploratory

Exploratory research is also called a pilot case study. It is usually the first step within a larger research project, often relying on questionnaires and surveys . Researchers use exploratory research to help narrow down their focus, define parameters, draft a specific research question , and/or identify variables in a larger study. This research design usually covers a wider area than others, and focuses on the ‘what’ and ‘who’ of a topic.

Here is an example: How do nutrition and socialization in early childhood affect learning in children? The title of the exploratory study may be “Case Study of the Effects of Nutrition and Socialization on Learning in Early Childhood.”

An intrinsic case study is specifically designed to look at a unique and special phenomenon. At the start of the study, the researcher defines the phenomenon and the uniqueness that differentiates it from others. 

In this case, researchers do not attempt to generalize, compare, or challenge the existing assumptions. Instead, they explore the unique variables to enhance understanding. Here is an example: “Case Study of Volcanic Lightning.”

This design can also be identified as a cumulative case study. It uses information from past studies or observations of groups of people in certain settings as the foundation of the new study. Given that it takes multiple areas into account, it allows for greater generalization than a single case study. 

The researchers also get an in-depth look at a particular subject from different viewpoints.  Here is an example: “Case Study of how PTSD affected Vietnam and Gulf War Veterans Differently Due to Advances in Military Technology.”

Critical instance

A critical case study incorporates both explanatory and intrinsic study designs. It does not have predetermined purposes beyond an investigation of the said subject. It can be used for a deeper explanation of the cause-and-effect relationship. It can also be used to question a common assumption or myth. 

The findings can then be used further to generalize whether they would also apply in a different environment.  Here is an example: “What Effect Does Prolonged Use of Social Media Have on the Mind of American Youth?”

Instrumental

Instrumental research attempts to achieve goals beyond understanding the object at hand. Researchers explore a larger subject through different, separate studies and use the findings to understand its relationship to another subject. This type of design also provides insight into an issue or helps refine a theory. 

For example, you may want to determine if violent behavior in children predisposes them to crime later in life. The focus is on the relationship between children and violent behavior, and why certain children do become violent. Here is an example: “Violence Breeds Violence: Childhood Exposure and Participation in Adult Crime.”

Evaluation case study design is employed to research the effects of a program, policy, or intervention, and assess its effectiveness and impact on future decision-making. 

For example, you might want to see whether children learn times tables quicker through an educational game on their iPad versus a more teacher-led intervention. Here is an example: “An Investigation of the Impact of an iPad Multiplication Game for Primary School Children.” 

• When do you use case studies?

Case studies are ideal when you want to gain a contextual, concrete, or in-depth understanding of a particular subject. It helps you understand the characteristics, implications, and meanings of the subject.

They are also an excellent choice for those writing a thesis or dissertation, as they help keep the project focused on a particular area when resources or time may be too limited to cover a wider one. You may have to conduct several case studies to explore different aspects of the subject in question and understand the problem.

• What are the steps to follow when conducting a case study?

1. Select a case

Once you identify the problem at hand and come up with questions, identify the case you will focus on. The study can provide insights into the subject at hand, challenge existing assumptions, propose a course of action, and/or open up new areas for further research.

2. Create a theoretical framework

While you will be focusing on a specific detail, the case study design you choose should be linked to existing knowledge on the topic. This prevents it from becoming an isolated description and allows for enhancing the existing information. 

It may expand the current theory by bringing up new ideas or concepts, challenge established assumptions, or exemplify a theory by exploring how it answers the problem at hand. A theoretical framework starts with a literature review of the sources relevant to the topic in focus. This helps in identifying key concepts to guide analysis and interpretation.

3. Collect the data

Case studies are frequently supplemented with qualitative data such as observations, interviews, and a review of both primary and secondary sources such as official records, news articles, and photographs. There may also be quantitative data —this data assists in understanding the case thoroughly.

4. Analyze your case

The results of the research depend on the research design. Most case studies are structured with chapters or topic headings for easy explanation and presentation. Others may be written as narratives to allow researchers to explore various angles of the topic and analyze its meanings and implications.

In all areas, always give a detailed contextual understanding of the case and connect it to the existing theory and literature before discussing how it fits into your problem area.

• What are some case study examples?

What are the best approaches for introducing our product into the Kenyan market?

How does the change in marketing strategy aid in increasing the sales volumes of product Y?

How can teachers enhance student participation in classrooms?

How does poverty affect literacy levels in children?

Case study topics

Case study of product marketing strategies in the Kenyan market

Case study of the effects of a marketing strategy change on product Y sales volumes

Case study of X school teachers that encourage active student participation in the classroom

Case study of the effects of poverty on literacy levels in children

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Continuing to enhance the quality of case study methodology in health services research

Shannon l. sibbald.

1 Faculty of Health Sciences, Western University, London, Ontario, Canada.

2 Department of Family Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.

3 The Schulich Interfaculty Program in Public Health, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.

Stefan Paciocco

Meghan fournie, rachelle van asseldonk, tiffany scurr.

Case study methodology has grown in popularity within Health Services Research (HSR). However, its use and merit as a methodology are frequently criticized due to its flexible approach and inconsistent application. Nevertheless, case study methodology is well suited to HSR because it can track and examine complex relationships, contexts, and systems as they evolve. Applied appropriately, it can help generate information on how multiple forms of knowledge come together to inform decision-making within healthcare contexts. In this article, we aim to demystify case study methodology by outlining its philosophical underpinnings and three foundational approaches. We provide literature-based guidance to decision-makers, policy-makers, and health leaders on how to engage in and critically appraise case study design. We advocate that researchers work in collaboration with health leaders to detail their research process with an aim of strengthening the validity and integrity of case study for its continued and advanced use in HSR.

Introduction

The popularity of case study research methodology in Health Services Research (HSR) has grown over the past 40 years. 1 This may be attributed to a shift towards the use of implementation research and a newfound appreciation of contextual factors affecting the uptake of evidence-based interventions within diverse settings. 2 Incorporating context-specific information on the delivery and implementation of programs can increase the likelihood of success. 3 , 4 Case study methodology is particularly well suited for implementation research in health services because it can provide insight into the nuances of diverse contexts. 5 , 6 In 1999, Yin 7 published a paper on how to enhance the quality of case study in HSR, which was foundational for the emergence of case study in this field. Yin 7 maintains case study is an appropriate methodology in HSR because health systems are constantly evolving, and the multiple affiliations and diverse motivations are difficult to track and understand with traditional linear methodologies.

Despite its increased popularity, there is debate whether a case study is a methodology (ie, a principle or process that guides research) or a method (ie, a tool to answer research questions). Some criticize case study for its high level of flexibility, perceiving it as less rigorous, and maintain that it generates inadequate results. 8 Others have noted issues with quality and consistency in how case studies are conducted and reported. 9 Reporting is often varied and inconsistent, using a mix of approaches such as case reports, case findings, and/or case study. Authors sometimes use incongruent methods of data collection and analysis or use the case study as a default when other methodologies do not fit. 9 , 10 Despite these criticisms, case study methodology is becoming more common as a viable approach for HSR. 11 An abundance of articles and textbooks are available to guide researchers through case study research, including field-specific resources for business, 12 , 13 nursing, 14 and family medicine. 15 However, there remains confusion and a lack of clarity on the key tenets of case study methodology.

Several common philosophical underpinnings have contributed to the development of case study research 1 which has led to different approaches to planning, data collection, and analysis. This presents challenges in assessing quality and rigour for researchers conducting case studies and stakeholders reading results.

This article discusses the various approaches and philosophical underpinnings to case study methodology. Our goal is to explain it in a way that provides guidance for decision-makers, policy-makers, and health leaders on how to understand, critically appraise, and engage in case study research and design, as such guidance is largely absent in the literature. This article is by no means exhaustive or authoritative. Instead, we aim to provide guidance and encourage dialogue around case study methodology, facilitating critical thinking around the variety of approaches and ways quality and rigour can be bolstered for its use within HSR.

Purpose of case study methodology

Case study methodology is often used to develop an in-depth, holistic understanding of a specific phenomenon within a specified context. 11 It focuses on studying one or multiple cases over time and uses an in-depth analysis of multiple information sources. 16 , 17 It is ideal for situations including, but not limited to, exploring under-researched and real-life phenomena, 18 especially when the contexts are complex and the researcher has little control over the phenomena. 19 , 20 Case studies can be useful when researchers want to understand how interventions are implemented in different contexts, and how context shapes the phenomenon of interest.

In addition to demonstrating coherency with the type of questions case study is suited to answer, there are four key tenets to case study methodologies: (1) be transparent in the paradigmatic and theoretical perspectives influencing study design; (2) clearly define the case and phenomenon of interest; (3) clearly define and justify the type of case study design; and (4) use multiple data collection sources and analysis methods to present the findings in ways that are consistent with the methodology and the study’s paradigmatic base. 9 , 16 The goal is to appropriately match the methods to empirical questions and issues and not to universally advocate any single approach for all problems. 21

Approaches to case study methodology

Three authors propose distinct foundational approaches to case study methodology positioned within different paradigms: Yin, 19 , 22 Stake, 5 , 23 and Merriam 24 , 25 ( Table 1 ). Yin is strongly post-positivist whereas Stake and Merriam are grounded in a constructivist paradigm. Researchers should locate their research within a paradigm that explains the philosophies guiding their research 26 and adhere to the underlying paradigmatic assumptions and key tenets of the appropriate author’s methodology. This will enhance the consistency and coherency of the methods and findings. However, researchers often do not report their paradigmatic position, nor do they adhere to one approach. 9 Although deliberately blending methodologies may be defensible and methodologically appropriate, more often it is done in an ad hoc and haphazard way, without consideration for limitations.

Cross-analysis of three case study approaches, adapted from Yazan 2015

The post-positive paradigm postulates there is one reality that can be objectively described and understood by “bracketing” oneself from the research to remove prejudice or bias. 27 Yin focuses on general explanation and prediction, emphasizing the formulation of propositions, akin to hypothesis testing. This approach is best suited for structured and objective data collection 9 , 11 and is often used for mixed-method studies.

Constructivism assumes that the phenomenon of interest is constructed and influenced by local contexts, including the interaction between researchers, individuals, and their environment. 27 It acknowledges multiple interpretations of reality 24 constructed within the context by the researcher and participants which are unlikely to be replicated, should either change. 5 , 20 Stake and Merriam’s constructivist approaches emphasize a story-like rendering of a problem and an iterative process of constructing the case study. 7 This stance values researcher reflexivity and transparency, 28 acknowledging how researchers’ experiences and disciplinary lenses influence their assumptions and beliefs about the nature of the phenomenon and development of the findings.

Defining a case

A key tenet of case study methodology often underemphasized in literature is the importance of defining the case and phenomenon. Researches should clearly describe the case with sufficient detail to allow readers to fully understand the setting and context and determine applicability. Trying to answer a question that is too broad often leads to an unclear definition of the case and phenomenon. 20 Cases should therefore be bound by time and place to ensure rigor and feasibility. 6

Yin 22 defines a case as “a contemporary phenomenon within its real-life context,” (p13) which may contain a single unit of analysis, including individuals, programs, corporations, or clinics 29 (holistic), or be broken into sub-units of analysis, such as projects, meetings, roles, or locations within the case (embedded). 30 Merriam 24 and Stake 5 similarly define a case as a single unit studied within a bounded system. Stake 5 , 23 suggests bounding cases by contexts and experiences where the phenomenon of interest can be a program, process, or experience. However, the line between the case and phenomenon can become muddy. For guidance, Stake 5 , 23 describes the case as the noun or entity and the phenomenon of interest as the verb, functioning, or activity of the case.

Designing the case study approach

Yin’s approach to a case study is rooted in a formal proposition or theory which guides the case and is used to test the outcome. 1 Stake 5 advocates for a flexible design and explicitly states that data collection and analysis may commence at any point. Merriam’s 24 approach blends both Yin and Stake’s, allowing the necessary flexibility in data collection and analysis to meet the needs.

Yin 30 proposed three types of case study approaches—descriptive, explanatory, and exploratory. Each can be designed around single or multiple cases, creating six basic case study methodologies. Descriptive studies provide a rich description of the phenomenon within its context, which can be helpful in developing theories. To test a theory or determine cause and effect relationships, researchers can use an explanatory design. An exploratory model is typically used in the pilot-test phase to develop propositions (eg, Sibbald et al. 31 used this approach to explore interprofessional network complexity). Despite having distinct characteristics, the boundaries between case study types are flexible with significant overlap. 30 Each has five key components: (1) research question; (2) proposition; (3) unit of analysis; (4) logical linking that connects the theory with proposition; and (5) criteria for analyzing findings.

Contrary to Yin, Stake 5 believes the research process cannot be planned in its entirety because research evolves as it is performed. Consequently, researchers can adjust the design of their methods even after data collection has begun. Stake 5 classifies case studies into three categories: intrinsic, instrumental, and collective/multiple. Intrinsic case studies focus on gaining a better understanding of the case. These are often undertaken when the researcher has an interest in a specific case. Instrumental case study is used when the case itself is not of the utmost importance, and the issue or phenomenon (ie, the research question) being explored becomes the focus instead (eg, Paciocco 32 used an instrumental case study to evaluate the implementation of a chronic disease management program). 5 Collective designs are rooted in an instrumental case study and include multiple cases to gain an in-depth understanding of the complexity and particularity of a phenomenon across diverse contexts. 5 , 23 In collective designs, studying similarities and differences between the cases allows the phenomenon to be understood more intimately (for examples of this in the field, see van Zelm et al. 33 and Burrows et al. 34 In addition, Sibbald et al. 35 present an example where a cross-case analysis method is used to compare instrumental cases).

Merriam’s approach is flexible (similar to Stake) as well as stepwise and linear (similar to Yin). She advocates for conducting a literature review before designing the study to better understand the theoretical underpinnings. 24 , 25 Unlike Stake or Yin, Merriam proposes a step-by-step guide for researchers to design a case study. These steps include performing a literature review, creating a theoretical framework, identifying the problem, creating and refining the research question(s), and selecting a study sample that fits the question(s). 24 , 25 , 36

Data collection and analysis

Using multiple data collection methods is a key characteristic of all case study methodology; it enhances the credibility of the findings by allowing different facets and views of the phenomenon to be explored. 23 Common methods include interviews, focus groups, observation, and document analysis. 5 , 37 By seeking patterns within and across data sources, a thick description of the case can be generated to support a greater understanding and interpretation of the whole phenomenon. 5 , 17 , 20 , 23 This technique is called triangulation and is used to explore cases with greater accuracy. 5 Although Stake 5 maintains case study is most often used in qualitative research, Yin 17 supports a mix of both quantitative and qualitative methods to triangulate data. This deliberate convergence of data sources (or mixed methods) allows researchers to find greater depth in their analysis and develop converging lines of inquiry. For example, case studies evaluating interventions commonly use qualitative interviews to describe the implementation process, barriers, and facilitators paired with a quantitative survey of comparative outcomes and effectiveness. 33 , 38 , 39

Yin 30 describes analysis as dependent on the chosen approach, whether it be (1) deductive and rely on theoretical propositions; (2) inductive and analyze data from the “ground up”; (3) organized to create a case description; or (4) used to examine plausible rival explanations. According to Yin’s 40 approach to descriptive case studies, carefully considering theory development is an important part of study design. “Theory” refers to field-relevant propositions, commonly agreed upon assumptions, or fully developed theories. 40 Stake 5 advocates for using the researcher’s intuition and impression to guide analysis through a categorical aggregation and direct interpretation. Merriam 24 uses six different methods to guide the “process of making meaning” (p178) : (1) ethnographic analysis; (2) narrative analysis; (3) phenomenological analysis; (4) constant comparative method; (5) content analysis; and (6) analytic induction.

Drawing upon a theoretical or conceptual framework to inform analysis improves the quality of case study and avoids the risk of description without meaning. 18 Using Stake’s 5 approach, researchers rely on protocols and previous knowledge to help make sense of new ideas; theory can guide the research and assist researchers in understanding how new information fits into existing knowledge.

Practical applications of case study research

Columbia University has recently demonstrated how case studies can help train future health leaders. 41 Case studies encompass components of systems thinking—considering connections and interactions between components of a system, alongside the implications and consequences of those relationships—to equip health leaders with tools to tackle global health issues. 41 Greenwood 42 evaluated Indigenous peoples’ relationship with the healthcare system in British Columbia and used a case study to challenge and educate health leaders across the country to enhance culturally sensitive health service environments.

An important but often omitted step in case study research is an assessment of quality and rigour. We recommend using a framework or set of criteria to assess the rigour of the qualitative research. Suitable resources include Caelli et al., 43 Houghten et al., 44 Ravenek and Rudman, 45 and Tracy. 46

New directions in case study

Although “pragmatic” case studies (ie, utilizing practical and applicable methods) have existed within psychotherapy for some time, 47 , 48 only recently has the applicability of pragmatism as an underlying paradigmatic perspective been considered in HSR. 49 This is marked by uptake of pragmatism in Randomized Control Trials, recognizing that “gold standard” testing conditions do not reflect the reality of clinical settings 50 , 51 nor do a handful of epistemologically guided methodologies suit every research inquiry.

Pragmatism positions the research question as the basis for methodological choices, rather than a theory or epistemology, allowing researchers to pursue the most practical approach to understanding a problem or discovering an actionable solution. 52 Mixed methods are commonly used to create a deeper understanding of the case through converging qualitative and quantitative data. 52 Pragmatic case study is suited to HSR because its flexibility throughout the research process accommodates complexity, ever-changing systems, and disruptions to research plans. 49 , 50 Much like case study, pragmatism has been criticized for its flexibility and use when other approaches are seemingly ill-fit. 53 , 54 Similarly, authors argue that this results from a lack of investigation and proper application rather than a reflection of validity, legitimizing the need for more exploration and conversation among researchers and practitioners. 55

Although occasionally misunderstood as a less rigourous research methodology, 8 case study research is highly flexible and allows for contextual nuances. 5 , 6 Its use is valuable when the researcher desires a thorough understanding of a phenomenon or case bound by context. 11 If needed, multiple similar cases can be studied simultaneously, or one case within another. 16 , 17 There are currently three main approaches to case study, 5 , 17 , 24 each with their own definitions of a case, ontological and epistemological paradigms, methodologies, and data collection and analysis procedures. 37

Individuals’ experiences within health systems are influenced heavily by contextual factors, participant experience, and intricate relationships between different organizations and actors. 55 Case study research is well suited for HSR because it can track and examine these complex relationships and systems as they evolve over time. 6 , 7 It is important that researchers and health leaders using this methodology understand its key tenets and how to conduct a proper case study. Although there are many examples of case study in action, they are often under-reported and, when reported, not rigorously conducted. 9 Thus, decision-makers and health leaders should use these examples with caution. The proper reporting of case studies is necessary to bolster their credibility in HSR literature and provide readers sufficient information to critically assess the methodology. We also call on health leaders who frequently use case studies 56 – 58 to report them in the primary research literature.

The purpose of this article is to advocate for the continued and advanced use of case study in HSR and to provide literature-based guidance for decision-makers, policy-makers, and health leaders on how to engage in, read, and interpret findings from case study research. As health systems progress and evolve, the application of case study research will continue to increase as researchers and health leaders aim to capture the inherent complexities, nuances, and contextual factors. 7

New Methods for Old Questions: The Use of Elliptic Fourier Analysis for the Formal Study of Palaeolithic Art

• Open access
• Published: 21 June 2024

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• Miguel García-Bustos 1 ,
• Paula García Bustos 2 &
• Olivia Rivero 1  

One of the main objectives of Palaeolithic art researchers is to study and systematise the form of artistic representations. Some methodologies include the analysis of qualitative variables, linear measurements or the use of geometric morphometry with landmarks. However, these techniques depend to a large extent on the subjectivity of the researcher, which often leads to biased results. To overcome this issue, we present an application of geometric morphometry using Elliptic Fourier Analysis (EFA), together with multivariate statistics and hypothesis testing, for the first time to the study of form in prehistoric art. In order to explain its use, the “duck-bill” convention of pre-Magdalenian horses, often used as a chronological and geographical marker, has been used as a case study. This formalism is described disparately in the literature, so the main objective is to use EFA to determine whether it is possible to characterise this type of convention according to the definitions given by certain authors. The results indicate a possible classification of the heads of these animals. Through this taxonomic proposal, it has been possible to verify the great diversity of forms in which the authors classify the duck-bill horses and, therefore, to demonstrate that this peculiar form can be considered neither a conventionalism nor a chronological/regional marker. In conclusion, the methodology based on EFA combined with multivariate statistics for the objective study of form in prehistoric art is effective and opens a new avenue of analysis in the art of prehistoric societies.

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Introduction

Since the discovery of European Palaeolithic art in the nineteenth century, one of the main objectives has been the description and formal study of the figures. The results obtained have usually influenced the chronological ascription of the motifs, as well as the interpretation of the art from a symbolic and cultural point of view, especially with regard to the notion and evolution of “style” (Breuil, 1952 ; Graziosi, 1956 , 1973 ; Jordá, 1964 ; Leroi-Gourhan, 1965 ). The authors who approached this analysis established the basic guidelines for the study of these Palaeolithic graphic manifestations based on three pillars that supported the concept and meaning of “form” and “style” (Palacio-Pérez, 2017 ). First, the linear and progressive evolution from a simple form to a more complex one. Second, the importance of technical and formal innovations as the main driving force for progress. And third, the positive correlation between greater naturalism and greater artistic skill. These criteria were used as true axioms, applying style as a fundamental factor of spatial and temporal discrimination (Domingo & Fiore, 2014 ). Likewise, variables such as conventionalisms, proportion, type of perspective or type of animation were used as indirect dating methods in the manner of fossil directors.

Today, traditional chronostylistic frames, of which those of Breuil ( 1952 ) and Leroi-Gourhan ( 1965 ) are the most widely used, have been overcome by the revolution in direct dating of Palaeolithic art and the discovery of Chauvet (Clottes et al., 1995 ; Lorblanchet & Bahn, 1993 ; Quiles et al., 2016 ). In addition to this, it should be noted that Palaeolithic art shows tendencies that go beyond the search for realism. Thus, schematic representations do not imply, as was thought in early research, “backwardness” or “antiquity” (Apellániz, 2004 ), as in the case of ibex in frontal view or the Gonnërsdorf-type venuses of the Upper Magdalenian. Currently, the main interest in the analysis of form is the attempt to assess regional connections rather than chronological periods (e.g. Fano & Rivero, 2007 ; Fuentes et al., 2019 ; García-Diez et al., 2015 ; González Sainz, 2007 ; Honoré et al., 2019 ; Petrognani, 2015 ; Rivero, 2010 ; Sauvet et al., 2014 ), although they still rely on traditional variables such as perspective, animation, anatomical details, proportion, outline or conventions of representation (e.g. Hernando, 2013 , 2014 ; Petrognani, 2009 ; Rivero, 2020 ; Ruiz-Redondo, 2014 ).

If one animal has been most important in the attempt to systematise and study form, it is undoubtedly the horse, the most numerous figurative representation in Palaeolithic art (García-Bustos, 2021 ; García-Bustos & Rivero, 2023 ; Groenen, 2007 ; Sauvet, 2018 , 2019 ). Analyses of qualitative variables have been applied to this motif, focusing on the outline and the presence or absence of anatomical details such as the mane, eyes or ears. On the one hand, studies such as those by Corchón et al. ( 2013 ), Corchón and Rivero ( 2010 ), Huard ( 2010 ), Petrognani ( 2009 ), Petrognani and Sauvet ( 2012 ), Pigeaud ( 2004 ) and Villaverde ( 1994 ) stand out, applied to specific cases such as La Griega, Las Caldas, Gargas, Lascaux, Gabillou, Mayenne-Sciences and Parpalló, respectively, determining specific graphic morphotypes for certain sites or periods. But also others, such as those carried out by Buisson et al., ( 1996a , 1996b ), Pigeaud ( 2005 ), Sauvet and Rivero ( 2016 ), Schmid ( 1984 ), Rivero and Sauvet ( 2014 ) and Tosello ( 2003 ), who propose global studies of form use this animal as an example.

Additionally, the measurements and proportions of equids have been the subject of various analyses with the aim of comparing the horses that lived in Palaeolithic times with their hypothetical representatives today (Bernáldez-Sánchez & García-Viñas, 2019 ; Bourdelle, 1958 ) and thus determining the species (Bourdelle, 1938 ; Capitan et al., 1924 ; Madariaga de la Campa, 1969 ; Prat, 1986 ). This metric methodology has also been used to calculate the homogeneity of a graphic set (Huard, 2007 ), to characterise the style, authorship and chronology (Apellániz, 1990 ; Apellániz & Calvo, 1999 ; Lión, 1971 ; Pigeaud, 1997 , 2000 , 2007 ) or to seek an explanation for the deformity of the outlines of equid representations (Rouzaud et al., 1992 ).

However, there are two fundamental problems with all these studies. Either they are based on qualitative variables whose definition is not always entirely objective, or they present large numbers of proportions or measurements that make it difficult to generalise the results. This paper introduces a new methodology based on geometric morphometrics to analyse variation in the form of Palaeolithic parietal and portable art, an innovative proposal aimed at overcoming the prevailing chronostylistic criteria, many of which are based on subjective considerations. In order to demonstrate its application, the analysis of a paradigmatic example in the formal study of equid figures called the “duck-billed” muzzle has been chosen as a case study.

Materials and Methods

A case  study: the “duck-bill” conventionalism.

The conventionalism known as a “duck-bill” is a particular way of describing the beak-like muzzle of equine depictions (Fig.  1 ). The term was coined in theory by Breuil (Capitan et al., 1910 ) for the first time, although it does not actually appear in the aforementioned work. The lack or loss of an initial definition, as already indicated by Hernando ( 2013 ), has led to the proliferation of a variety of definitions, with important differences between authors. As a result, there is currently a lack of consensus on the definition of this graphic convention that generates as many proposals as authors who write about it, and they sometimes differ significantly (Table  1 ).

Examples of duck-bill horses. At a glance, it is possible to observe the great variability with which experts categorise this type of formalism (the orientation of the tracings has been modified). A Pair non Pair (Delluc & Delluc, 1992 ). B Chauvet (Tosello & Fritz, 2004 ). C La Griega (Corchón, 1997 ). D Ardales (Cantalejo et al., 2006 ). E Mayenne-Sciences (Pigeaud, 2004 ). F Parpalló (Villaverde, 1994 ). G La Pileta (Breuil et al., 1915 ). H Gargas (Barrière, 1976 )

The importance of this stereotyped form lies in its use as a chronological and territorial marker. In principle, the “duck-bill” was regarded as an artistic resource typical of the Mediterranean Solutrean (Fortea, 1978 ) on the basis of the Solutrean chronology of plaquettes at Parpalló (Villaverde, 1994 ). The same chronology is attributed to the representation of a “duck-bill” equid at La Pileta, assuming that the figure is coeval with the aurochs dated to 20,130 ± 350 BP (Sanchidrián et al. 2001 ). Another case is Cosquer, where most of the figurative representations (including horses with this formalism) are usually ascribed to its Solutrean phase, although there are some problems derived from direct dating that make it difficult to clearly ascribe them to the Solutrean or Gravettian (Clottes et al., 2005 ). We now know that this conventionalism might date back to the Aurignacian, although the few examples that can prove it, such as Bouil-Bleu, are found in poorly characterised contexts (Sauvet et al., 2013 ). What does seem more certain is its use during the Gravettian period, although again we find no directly dated figures. The most cited example is at Mayenne-Sciences where one of the horses with an open muzzle was dated to 24,220 ± 850 and 24,900 ± 360 BP (Pigeaud et al., 2003 ). This chronology has then been extended to the rest of the cave figures, including duck-bill equids. Chauvet, Ardales and Croze-à-Gontran are other caves that house potential Gravettian representations with this type of conventionalism (Hernando, 2014 ; Sauvet et al., 2013 ).

As for its geographical distribution, it is found in practically all the territories of western Europe: from the south of Spain (Ardales, La Pileta), to the north and north-east of France (Mayenne-Sciences, Margot, Gorges), via the centre of the Iberian Peninsula (La Griega), the Cantabrian region in Spain (La Pasiega, Askondo), the Pyrenees (Gargas), the Quercy (Roucadour), the Dordogne (La Croze-à-Gontran, Pair-non-Pair) and the Ardèche (Chauvet, Cosquer) (Petrognani, 2015 ) as well as in the open-air art of Siega Verde and Foz Côa. This is, therefore, a characteristic example of the extensive geographical and chronological extension of a particular type of representation in Palaeolithic art, a key to determining the existence of contacts, albeit indirect ones, over long distances of more than 1200 km.

As we have tried to show, despite its relevance, the inaccuracy and lack of consensus in the determination of this convention is evident, so the present study aims to precisely define this formalism on the basis of a comprehensive study of the complete outline of the horses’ heads. To this end, 287 representations covering five regions have been analysed in order to determine whether or not this type of formal convention exists and whether it is a determining factor in characterising a chronological period or a specific region.

GMM in Archaeology and Rock Art

Geometric Morphometric Methods (GMM) can be defined as “the scientific description of biological or medical shape variation and shape change” (Bookstein, 1996 ), “a class of multivariate methods for measuring and analyzing the shapes of objects” using Cartesian coordinates (Polly, 2018 : 1) or “the analysis of size and shape derived numerically from landmarks (topographically corresponding points) on biological/ nonbiological organisms”, where the shape can be either the whole object or a specific part of it (Seetah, 2014 : 3033).

This method, initiated in the 1980s and called traditional morphometry or multivariate morphometry for application in the field of biology (Adams et al., 2004 ), consists of taking linear measurements (measures, angles or proportions) with the aim of applying multivariate statistical analyses (Rohlf, 1999 ; Marcus, 1990 ; Reyment, 1991 ; Rohlf & Marcus, 1993 ; Zelditch et al., 2012 ). Two sources of information are used in geometric morphometrics: biological homology (biological elements of structures of individuals) and geometric localisation (2D or 3D spatial configuration of biological structures of specimens) (Klingenberg and Monteiro, 2005 ). Once the data are obtained, a Generalized Procrustes Analysis (GPA) or Proclustes overlay is performed to eliminate errors due to translation, rotation and scale of the samples taken.

Although the main field where this type of methodology has been applied is biology, it is now used in other disciplines such as archaeology. The main examples of its application in the latter discipline come from taphonomic studies for the recognition of cut marks (Maté-González et al., 2015 ), carnivore tooth marks (Arriaza et al., 2017 , 2023 ; Yravedra et al., 2017a , 2017b ) or trampling marks for their characterisation (Courtenay et al., 2019 , 2020 ), thus facilitating the identification and determination of different bone modifications. Likewise, it has also allowed the differentiation in the use of different flint and quartzite materials through experimentation (Maté-González et al., 2018 ), even developing specific software for their detection (Palomeque-González et al., 2017 ).

The field of archaeobotany has applied this method for the examination of the remains of plant species (Portillo et al., 2020 ), such as vine seeds (Terral et al., 2010 ), date palm ( Phoenix dactylifera L.) (Terral et al., 2012 ), cherry ( Prunus avium L.) pits (Burger et al., 2011 ) or olive ( Olea europaea L.) pits (Newton et al., 2014 ), including studies based on seed experiments before and after carbonisation (Charles et al., 2015 ) in the case of barley (Ros et al., 2014 ) and wheat (Bonhomme et al., 2017 ).

With regard to material culture such as lithic, bone, metallurgical or ceramic industries, GMM provides information such as the chronology or functional character of the site where these artefacts are found (Martínez-Carrillo et al., 2010 ). This method has been incorporated in recent studies to compare lithic or ceramic assemblages from the same site (Hashemi et al., 2021 ; Wang & Marwick, 2020 ), examine taxonomic variability (Matzig et al., 2021 ; Méndez-Quintas, 2022 ; Serwatka, 2015 ; Vestergaard & Hoggard, 2019 ), analyse the diachronic evolution of artefacts (Cortell-Nicolau et al., 2020 ; Hoggard et al., 2019 ; Loftus, 2022 ) or better understand the manufacturing design, level of standardisation, degree of specialisation and possible uses for which they were employed (Birch & Martinón-Torres, 2019 ; Chacón et al., 2016 ; Timbrell et al., 2022 ).

In reference to rock art, studies that have applied GMM have been limited and recent. This methodology has been applied to the analysis of dimorphism in Palaeolithic hands, based on experimentation (Nelson et al., 2017 ), in the study of late Holocene camelids from the Quebrada de Humahuaca (Charlin & Llosas, 2016 ) and the recognition of camelid morphological variability in southern Pozuelos (Puna de Jujuy, Argentina). But also in the identification of extinct fauna in Arnhem Land rock art (Cobden et al., 2017 ) or the comparison of representations between Leang Tumpuseng and Sulawesi rock art (Hayes and van den Bergh, 2018 ).

At the moment, the most common method for applying GMM in rock art is the landmark technique. This is a study that calculates the variation of the samples taken through a series of invariable points that act as anatomical references. These points, known as landmarks, are processed by means of Procrustes Analysis, which is necessary to be able to incorporate all the samples in the same Cartesian space. The latter allows the application of a series of multivariate statistical analyses to reduce variability and classify the samples into different groups. However, the use of this methodology has certain drawbacks and disadvantages (Table  2 ). The most notorious is the subjectivity in planning and choosing landmarks. By definition, these points must be placed at locations that are continuously replicated in the sample for use in the comparison. Unlike in the biological domain, in the archaeological field, their selection might depend on the researcher and the type of sample. Also, the level of complexity of the figures to be analysed can produce certain biases in the precision of the analysis, especially if they are shapes with a high level of curves.

In an attempt to overcome this important limitation, this article presents an application of Elliptic Fourier Analysis (EFA) on representations from Franco-Cantabrian Palaeolithic art. This technique is based on Fourier transforms, a mathematical tool by means of which it is possible to quantitatively decompose a geometric figure into functions known as harmonics (Bonhomme et al., 2014 ; Caple et al., 2017 ; Crampton, 1995 ; Kuhl & Giardina, 1982 ). The outline of the figure is expressed in a set of coordinates (x, y) in a 2D plane that can be mathematically processed to calculate the four Fourier coefficients ( a , b , c , d ), a and b for the x-coordinate and c and d for the y-coordinate (Giardina & Kuhl, 1977 ). Ultimately, from these coefficients (four for each harmony retained), it is possible to define the variability in the shape of a set of samples through a series of statistical analyses.

This methodology has certain advantages over the use of landmarks, bearing in mind that the samples must still be capable of being compared by means of reproducible geometric characteristics (Cardillo, 2010 ; Crampton, 1995 ). Firstly, it is a method in which the continuous function of the figure to be studied is taken into account and not only key points that the researcher deliberately considers significant for discretising the shape. Secondly, it involves a greater optimisation of time. By using landmarks, the researcher must plan which common points should unite his samples and proceed to incorporate them for the subsequent analytical study. However, with EFA, the contour as a whole is taken into account, and it is the subsequent analysis that specifies which areas produce the most variability. Finally, with EFA, a continuous and smoother representation of the sample is achieved as opposed to the greater rigidity and possible fragmentation of the landmark. In conclusion, with this methodology, we obtain a greater ability to apprehend morphological variation and fewer limitations when interpreting the factors that cause it (Table  2 ).

Tracing Digitalisation

For the study of equid heads, sites with cave or portable art from before 14,500 BP were sampled. A total of 287 graphic units were collected (257 rock art and 30 portable), of which 237 came from sites in the Iberian Peninsula and 50 from France (Fig.  2 ). Only the head has been taken as a sample because the conventionalism only appears and refers to this anatomical part, so the rest of the body has not been considered (Fig.  3 ). Those samples with an outline that is open in lines whose continuation is predictable, such as frontonasal straight lines, have been included in the study. On the other hand, samples with an open outline where it is not possible to reproduce the continuation of the line, such as the muzzle or the mandible, were not taken into account (Fig. 4 ).

Sites whose Palaeolithic art is part of the created corpus

Anatomical delimitation of the head in the tracings made on the art samples taken. A , B Theoretical delimitation of the head taken from a real horse (Modified photograph by Lars Schmitt/ CC-BY-2.5). C , D Delimitation of the head tracing on a rock art sample (Photograph by J. Sanchidrián and tracing by H. Breuil)

Examples of horses discarded in the study. A Pech Merle (Lorblanchet, 2010 ). B La Griega (Corchón,  1997 ). C Roucadour (Lorblanchet, 2010 ). D Las Chimeneas (Echegaray,  1974 ). E Parpalló (Villaverde, 1994 ). F Mayenne-Sciences (Pigeaud, 2004 ). G SiegaVerde (Alcolea & Balbín, 2006 )

Once the final corpus had been compiled, the next step was to trace the head of each sample taken. To do this, Illustrator software was used, as meticulously as possible when tracing the outline of the animal by hand. We have used both bibliographical resources and photographs of the art sites we are investigating to obtain these tracings.

The contours were then processed to obtain the morphometric variables using the freely available software R (R Core Team, 2022 ), which allows the use of customisable code through a large number of predefined packages. We used the “Momocs” package, which specialises in the study of outlines using EFA (Bonhomme et al., 2014 ). As indicated in the introduction section, the use of landmarks to study shapes in archaeology has certain disadvantages. For this reason, this technique, which includes the complete outline, has been used for the first time to study Palaeolithic rock art.

Once all the traces have been included in R, it is necessary to run a Procrustes analysis, a step in which the proposal and part of the code of Smith and Kriebel ( 2018 ) has been used. In this way, all the outlines could be homogeneously oriented, scaled and rotated, thus eliminating the bias that these conditioning factors could cause and definitively preparing the samples for statistical analysis. After having described each contour as a list of coordinates (x, y), four reference points were positioned to align all the samples and apply the aforementioned Procrustes analysis. In this section, it was also important to choose the number of harmonics to be used in the statistical tests. This is an important step since the number of harmonics selected must be manageable for the researcher but at the same time sufficient to retain the optimum information to ensure reliable results. As a sine wave describing a shape breaks down into harmonics, the harmonics lose power and convey less and less information. To assess this process, we have examined a cumulative power graph represented in boxplots.

Statistical Analysis

To examine the shape variability, a Principal Component Analysis (PCA) was performed on Fourier coefficients, a dimensional reduction technique that facilitates the possible interpretation of the data (López-Roldán & Fachelli, 2015 ). We also applied a cluster analysis to the total set of principal component scores using the Euclidean distance and the Ward method as a grouping system (López-Roldán & Fachelli, 2015 ). The Euclidean distance, the type of distance most used with quantitative variables, is the shortest line that joins two samples in the graphic space created. The Ward method is used to create groups that are as homogeneous as possible, to minimise internal variance. In summary, the multivariate analyses were applied to identify the most objective commonalities between the analysed samples.

The clusters created are then analysed in greater depth using three other techniques; some also included through different functions in the Momocs package. First, a grid deformation map through isolines ( tps_iso ) and a graph of the differences between the average shapes ( coo_ruban ) as it has been used in other works (e.g. Jeanty et al., 2024 ). These functions are a first approximation to locate intuitively and visually the parts of the outline that a priori contribute most to creating the mean shapes of equine heads.

Next, an attempt was made to test more objectively for significant differences between the clusters. To do this, the PC scores were used as the data to be analysed, testing whether they follow a normal distribution in order to choose the most appropriate test. In addition, a linear discriminant analysis (LDA) was used to validate the results of the cluster analysis and evaluate its effectiveness. In this way, it will be possible to determine whether the samples forming each of the four groups can be well distinguished from the samples of the rest (Cortell-Nicolau et al., 2020 ; Matzig et al., 2021 ; Timbrell et al., 2022 ).

Finally, following the work and methodology of Wang and Marwick ( 2020 ), the coefficient of variation (CV) was used to analyse the degree of standardisation of the samples according to certain variables such as the geographical region, the type of deposit, the technique used or the groups created by the cluster analysis (Eerkens & Bettinger, 2001 ; Krishnamoorthy & Lee, 2014 ). For this purpose, the first four principal components have been used as variables of the shape of the samples (Hoogard et al. 2019 , Loftus, 2022 ). These principal components have also been normalised between 0 and 1 to be as informative as possible. A low CV means a high degree of standardisation and vice versa. To compare whether there are significant differences in the CVs of the variables, the Modified Signed-Likelihood Ratio (MSLR) test and the asymptotic test were used (Wang & Marwick, 2020 ; Loftus, 2022 ).

For the application of this methodology, we have chosen to extract up to seven harmonics, enough to retain more than 99% of the information with which to analyse the outline of the pre-Magdalenian horses (Fig.  5 ). With this number of harmonics, a PCA has been created obtaining 28 components in total, which is the result of multiplying the seven retained harmonics by the four Fourier coefficients. The first component explains 47.7% and the second component 24.5%, giving a total inertia of 72.2% (Fig.  6 A and 6 C). In an attempt to complement the analytical study, the third and fourth components have also been consulted, although their impact on the graphic distribution accounts for only 8.4% and 6.7%, respectively.

Cumulative power of harmonics. As can be seen, as they increase, the information they provide is reduced increasingly. From seven harmonics, it is possible to retain 99% of the outline

Graphic summary of the results of the multivariate analysis. A PCA of the first two dimensions (72.2%) created on the coefficients in the Fourier matrix. B Cluster analysis applied to the PCA with Euclidean distance and Ward method, which divides the corpus into four possible groups. C Forms created as a function of the first four components that explain the variation in the outline in the order of the largest percentage contribution. First component: vertical length of the back of the head. Second component: accentuation of the frontonasal or maxillary line. Third component: deviation of the muzzle. Fourth component: muzzle breadth. The samples that most contribute to the creation of these forms are shown at the end of each component line

The first component explains the variation according to the opening of the back part of the animal’s head. The second component emphasises the accentuation with which the frontonasal or maxillary line is marked in exclusion of each other. The third component explains the variation in the deviation of the muzzle, from a downward to a more upright orientation. Finally, the fourth component indicates the width of the muzzle from narrower to more rounded, globular head shape. This technique reveals the first aspect to take into account: the main differences in the samples are related more to the shape of the head in posterior anatomical areas (transition to the neck, final frontonasal line and maxillary line) than with the type of outline with which the animal’s muzzle was represented.

Through a cluster analysis applied on the principal component scores, it has been possible to classify the head shape of the pre-Magdalenian equids into four groups (Fig.  6 B). The first and third groups, which are the most numerous, can be divided along the Y-axis. Similarly, the second and fourth clusters can be divided along the X-axis. In this way, the epicentres of distribution of each cluster are marked in each quadrant. Throughout this clusters, it has been possible to extract four average shapes (hereafter “morphotypes”).

The first model is characterised by a rather oblique frontonasal and maxillary line, with a broad muzzle. The second morphotype in comparison is represented by a less pronounced jaw drawn along the entire lower line of the head, resulting in a narrow muzzle. In contrast to the latter, the third morphotype has a less oblique frontonasal line, with a more pronounced jaw towards the end of the head and an even narrower muzzle. The last model arises from a combination of the frontonasal line and the jaw of this third morphotype, but slightly more oblique, and a muzzle with a wider opening. The four models found have an unequal percentage of occurrence, with the third head type standing out above the rest (34.1%), followed by the first (32.4%), the fourth (20.2%) and the second (13.2%) (Fig.  7 ).

Comparison of the average shapes by means of a grid deformation map using isolines (for the whole head) and a graph of the differences between the average shapes (for the contour). A warmer colour, such as red, indicates more marked deformations

To determine whether these results are statistically relevant, i.e. whether the groups are objectively different, a comparison of samples test was applied. To do this, we determined whether the principal components followed a normal distribution. First, it has been observed through a Q-Q plot (Fig. S1-S2) that the data fit well to the normal distribution. However, the Kolmogorov–Smirnov test (with Lilliefors correction) shows that not all principal components follow a normal distribution (Table S 1 ). Therefore, the data have been treated with a non-parametric method to be as rigorous as possible. As has been done in other studies (Falcucci & Peresani, 2022 ; Matzig et al., 2021 ; Radinović & Kajtez, 2021 ; Rossini et al., 2022 ), we used a Permutational Multivariate Analysis of Variance (PERMANOVA) on the 28 principal components and a p -value estimated on 10,000 permutations. A pairwise PERMANOVA using Euclidean distance and with Bonferroni-corrected p -value was also used to find significant differences.

The PERMANOVA results indicate that there are significant morphological differences between the four groups (Table  3 ), as well as in all cases of the pairwise comparison with a p -value < 0.05 (Table  4 ). To corroborate this results, an LDA was then applied, a test that returns a formula with which the program tries to correctly classify the samples into their respective morphotypes. For the first morphotype, it correctly classified 85%, for the second 89%, for the third 85% and the fourth 79% (Fig.  8 ). Although there are sample transfers from one group to another, especially in the fourth case, in the form of a global computation, the validation of the models using this last methodology returns an 84.7% accuracy rate (243/287). All this indicates that the use of this morphometric technique is effective and can be used for future formal studies in rock art.

LDA of the samples taken. A Graph showing the classification of the samples into their respective groups. B Table showing the percentage of success for each morphotype, giving an overall result of 84.7% success in the classification

As for the study of these morphotypes, we finally believe that it is important to assess the intra-group variability, i.e. whether each group has very different samples. Although the PCA graph can give us a clue as to the level of homogeneity of the shape according to the dispersion of each group, thanks to the CV applied to the first four components, we can observe two important aspects (Fig.  9 ). Firstly, morphotype no. 2 is the one with the least intra-group variation, with a CV always below the rest and in almost all cases with significant differences (Table S 2 -S 3 ). On the other hand, a greater variability is observed in the morphotype 3, which, except for PC2, is the most variable group of all. From this, it can be inferred that it groups formally more disparate samples than in the other cases. At the geographical level, certain aspects of these formal models should be highlighted.

Violin plot showing the distribution of PC scores normalised from 0 to 1 as a function of the groups formed by the cluster analysis. The coefficient of variation (CV) is shown next to each distribution

The CVs indicate little standardisation depending on the type of site (Fig. S 3 ), although it increases in the case of outdoor art motifs for the first component (26%) and the fourth (29%), being statistically significant in the latter case (Table S4) . This is reflected in a formal tendency that they share in open-air sites: broad head and round snout, similar to what is illustrated in morphotype 1. Precisely, if we study the proportion in which the morphotypes appear according to the type of site, we can observe that the first morphotype is over-represented in open-air sites in the west of the Iberian Peninsula ( p -value = 97.1%). In this sense, only three sites (Foz Côa, Siega Verde and Domingo García) account for around 40% of this first model, with the Portuguese site standing out with 22.4%. Furthermore, compared to open-air sites, the representation of morphotype no. 3 is more common in caves ( p -value = 97.4%), as can be seen in a nucleus of samples taken from Ardales, Roucadour, Parpalló, La Griega and Gargas, among others (Table  5 ).

These results may indicate a relationship between the type of site and one of the styles with which the horse was represented. However, we must not forget that there is a diversity of head types in both types of sites and these “preferences” must be taken only as trends.

Another similar analysis has made use of macro-geographical zones defined based on a geographic division and the distance between site clusters: the Mediterranean coast, the interior of the Iberian Peninsula, the Cantabrian region, the Dordogne, the Pyrenees and the Ardèche. Before presenting the results, something fundamental must be considered. In this work, we have used as many samples as possible, but these samples are very limited in archaeology and, particularly, in Palaeolithic art. For this reason, there may be regions where it has not been possible to collect a high number of samples, which could lead to biased results of which we are fully aware. Nevertheless, we have carried out this regional analysis as a first exploratory study that can be improved over time.

Excluding both the Ardèche and the Pyrenees because of their low representativeness, in general, we find a poor standardisation in all regions, although the Cantabrian region is particularly noteworthy, with 25 - 30% between the four components. Likewise, we also found no significant differences comparing the CVs between the regions (Table S 5 -S 6 ). From this, it can be inferred that the equine head is represented in a variety of forms within the same region.

However, we can observe whether there is an over- or under-representation of a type of morphotype according to the region. Comparison using the Z-score test considered the proportion of each morphotype with its overall proportion in each territory. The results indicate that the first three head types are over- or under-represented in three different areas. Starting with those with the lowest numbers, the Mediterranean coast and Aquitaine show a small number of morphotype no. 2 ( p -value = 97.3%) and morphotype no. 1 ( p -value = 96.9%), respectively. In contrast, the areas where there is a higher number than expected are the Cantabrian region with the first morphotype ( p -value = 97.7%) and Aquitaine with the third morphotype ( p -value = 96.2%) (Table  6 ).

In short, this study shows it is possible to analyse form in Palaeolithic art and to establish more objective classifications than those currently proposed. Through this analysis, it can be shown that the greatest variability in the shape of the head of pre-Magdalenian equids lies in two variables: the vertical length of the back of the head and the pronunciation of the jaw or the end of the forehead. Although the angle and breadth of the muzzle are factors to be considered, their contribution to creating significantly different groups is very small. As we can see, there are significant results if we take into account the type of site and the geographical area. From a territorial point of view, we can only speak in terms of preference and not exclusivity of a model, since the representation of one form or another does not eliminate the possibility of finding other types of heads. In addition, the shape and the style of this anatomical segment do not allow us to delimit cultural areas. We could hypothesise that the artist’s preference for depicting one type of head could also respond to chronological variables which, however, cannot be detected in the absence of direct dating of the motifs. Ultimately, a possible classification of this anatomical part is presented, which can be used for cataloguing purposes and can be improved as more specimens are added.

Discussion: The “Duck-Bill” Muzzle Conventionalism Through EFA

Palaeolithic art is characterised by thematic, technical and formal homogeneity. However, it was not until the Middle Magdalenian that this reached its zenith. During the Pre-Magdalenian period, the conventions of representation followed less strict norms than those observed from the Middle Magdalenian onwards (Petrognani, 2015 ; Sauvet, 2014 ). This resulted in a greater variety of art forms that gradually diminished and became restricted from generation to generation through mechanisms such as apprenticeship (Rivero, 2010 , 2016 ). Although conventionalisms are factors that fossilise form, it is possible that they are sometimes simply attempts by the archaeologist to systematise and organise the accumulated information used to interpret form and style in a more objective way. To further explore this aspect, we analysed the morphotypes from the previous analysis to determine if the “duck-bill” convention, as defined in the literature, is discernible. This will help establish if it can still be used as a fossil director of the pre-Magdalenian phase in both portable and parietal art or we should use it with more caution.

The aspect that most closely resembles what authors refer to as the duck-bill in our study is reflected in the first, third and fourth principal components beyond a standard deviation of − 1.5 (Fig.  10 ). These three components precisely explain the variation of the average form with some of the features of this convention according to some authors (Moure et al., 1991 ; Villaverde, 1994 ): a short distance between the end of the frontonasal and maxillary, the muzzle directed downwards, and a narrowing between the lip and the jaw. However, this does not prove its characterisation as conventionality. Only when a large group of samples sharing these anatomical traits can be isolated or grouped together can the existence of such formalism be discussed.

Diagram of the morphological features of a “duck-billed” conventionalism according to some of the researchers’ definitions. Above, the shape that explains the PCA. Below, an archaeological example that has been documented as a duck-billed horse. From right to left: Ardales (Cantalejo et al., 2006 ), Gargas (Barrière, 1976 ) and Cussac (Feruglio et al., 2019 )

In the principal component analysis, samples described by the authors as having a duck-bill have been identified. As shown in Fig.  11 , samples with this convention in all four factorial dimensions typically extend along the X-axis, always overlapping with the group of samples that do not have a duck bill, indicating the enormous morphological variability of this type of formality. This is the case, even taking into account the first, third and fourth components (Fig.  11 B, 11 C and 11 F), which, as mentioned above, are in principle the most similar forms to those defined by the authors. If it were a formal norm, all samples would have to be constrained and clustered in a particular place in the factor space, which is not the case. The difficulty of defining the duck-bill as a conventionalism is also demonstrated by the LDA, which only identifies 59% of the samples with a duck-bill.

PCA of the pairwise combination of the first four components as a function of the presence (black colour) and absence (red colour) of the duck-bill formalism in the samples taken. In all cases, both groups appear widely overlapped, showing the lack of difference between the sets if we take the presence or absence of this formalism. A Components 1–2. B Components 1–3. C Components 1–4. D Components 2–3. E Components 2–4. F Components 3–4

All this leads us to consider the morphological inaccuracy when cataloguing representations with this type of muzzle. A conclusion also reached by Hernando ( 2013 ) who, using a homogeneity index with qualitative variables, points out that the samples referred to by various authors as duck-bills actually display marked anatomical dissimilarity.

The results of this homogeneity index are also reflected in our study from other points of view. Firstly, if we look at the calculated CV (Fig.  12 ), the samples that present the conventionalism have a low degree of standardisation (48–33%) in the first four components. The difference in standardisation between samples that show the conventionalism and those that do not is significantly different only in PC1 and PC3, where the CV of the samples with “duck bill” is also higher (44% and 48% respectively) (Table S7 ). And secondly, as can be seen in Table  7 , in the four morphotypes detected, there are at least three samples that present this type of conventionalism, other proof of the variability of this formalism. However, the number found in morphotype no. 3 is particularly noteworthy. A Z -score test applied for each pair indicates that the percentage of duck-bill morphotype 3 is statistically significant ( p -value < 0.05).

Violin plot showing the distribution of PC scores normalised from 0 to 1 depending on the absence or presence of the “duck-bill” conventionalism. The coefficient of variation (CV) is shown next to each distribution

Trying to go deeper into the possibility of discerning the characteristics that may distinguish the “duck-bill” muzzle, the same method has been replicated but only on the samples that make up group three, where most of the samples with this formalism are concentrated. The PCA and cluster analysis show the possibility of clearly distinguishing two subgroups separated by the second principal component (Fig.  13 A). The first subgroup consists of 35 samples, of which 16 are duck-billed horses, while the second subgroup consists of 63 samples, of which 17 have such a conventionalism. The Z -score test indicates that the differences in this distribution are not significant ( p -value > 0.05). If we disregard the partitioning of the cluster analysis (which seeks to create groups that are as different as possible) and instead differentiate two groups according to the presence or absence of duck-bill, it is even more complicated to distinguish graphically between the two sets (Fig.  13 B). In this latter case, it would only be possible to discern some extreme cases, since most of the samples overlap with the group of cases without “duck-bill” head.

Division by means of different criteria of the samples that make up morphotype no. 3. A Division on the basis of cluster analysis, which seeks to create as homogeneous sets as possible. B Division according to the presence (black) or absence (red) of the duck-bill convention in the samples

To sum up, the results that have been shown call into question the distinction of the duck-bill as a conventionalism on the basis of the definitions that can be found in the literature. In other words, we conclude that the way in which the conventionalism has been defined up to now is dependent on the interpretation of researchers, an aspect that other authors have already highlighted (Hernando, 2013 ; Villaverde, 2017 ).

Three arguments support that conclusion. First, it is a type of shape that is present in all the groups that multivariate analysis has differentiated. If we take into account that these techniques seek to create sets that are as different as possible, the characteristics of the duck-bill head are not significant in the morphological study and the subsequent partitioning of the cluster analysis. Besides, although most of the samples with a duck-bill muzzle are included in morphotype no. 3, they coexist with other types of muzzle that differ completely from this conventionalism. This corroborates the difficulty in defining this formalism, whose morphological characteristics are described by the authors in a subjective and widely variable way. Finally, as the CV shows it cannot be concluded that the two main variables with which a priori it is possible to distinguish the four morphotypes described (amplitude of the beginning of the neck and muzzle and the accentuation of the jaw or the frontonasal line) are determinant in the definition of the conventionalism. Nor if we consider the third and fourth components centred on the variation of the muzzle, considering its minimal impact on the differentiation and grouping of the samples.

All this leads to an important conclusion: it is not possible to consider the duck-bill as a type of equine head or conventionalism, but as a set of independent anatomical features that all horses could have. For this reason, it is impossible to isolate a general model representing the so-called duck-bill muzzle.

The analysis of form has been an object of study since the discovery of prehistoric art. However, it is extremely difficult to approach its study from an objective point of view. Many analyses have tried to propose a research method based on linear measurements (e.g. Apellániz & Calvo, 1999 ; Lión, 1971 ; Pigeaud, 1997 , 2000 , 2007 ) or to characterise form depending on the description of qualitative variables (e.g. Corchón et al., 2013 ; Petrognani & Sauvet, 2012 ; Sauvet & Rivero, 2016 ; Tosello, 2003 ; Villaverde, 1994 ). Similarly, few attempts have been made to use geometric morphometry and the vast majority use the landmark technique, with all the disadvantages that this entails (e.g. Charlin & Llosas, 2016 ; Cobden et al., 2017 ; Nelson et al., 2017 ).

This paper opens the possibility of applying Elliptic Fourier Analysis (EFA) to rock art in general and Palaeolithic art in particular. This method is currently the only way of objectifying the study of form and offers advantages that cannot be achieved by the other techniques described above. However, it also has certain limitations, mainly the obligatory reproducibility of the part of the entity to be analysed or the need to have somewhat advanced notions in the creation of codes and statistics. Nevertheless, this study, focused on the head outline of pre-Magdalenian equids and on the duck-bill conventionalism, shows that this type of application can provide excellent results that enable both the proposal of new ideas and the correction of more traditional ones.

The complete study of the shape of the head of these animals has followed a methodological protocol that has already been applied to other types of archaeological remains such as pottery, lithics or seed remains. Its application has not only made it possible to study the variables that best explain the differences between the heads of the pre-Magdalenian equids or to propose a possible classification of the latter but also to address an important issue within the discipline, namely the need for rigour when using “conventionalisms” as a method of analysing figures.

Anatomical characteristics, which can be defined as a recurrent formal peculiarity, have been repeatedly used by researchers not only to analyse the style of figures but also to locate, geographically and above all chronologically, the documented graphic units that present the conventionalism. Of all these, the so-called “duck-bill” stands out, a trait that Palaeolithic horses display in their muzzles and that is usually dated to the pre-Magdalenian period. In principle, this is a formal peculiarity that is easy to recognise. However, the definitions of different authors do not converge in a single model, leading to a wide variety of forms that are regarded as a duck-bill muzzle.

From the morphometric analysis, we can conclude that this conventionalism is indeed highly variable and that it is not possible to define a single model to serve as a paradigm. In this situation, we should redefine what can be considered a duck-bill or stop using it as a chronological and spatial marker of the Palaeolithic representation under study.

Data Availability

The data and code supporting the conclusions of this study are available only upon request from the corresponding author, as restrictions apply as part of an ongoing doctoral thesis.

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Acknowledgements

We would like to thank the two reviewers who have helped to improve this work with their advice and corrections.

Open Access funding provided thanks to the CRUE-CSIC agreement with Springer Nature. This work has been supported financially by the Consejería de Educación de la Junta de Castilla y León and the European Social Fund through a pre-doctoral researcher contract [ORDEN EDU/875/2021] and Proyecto PID2021-125166OB-I00 financiado por MCIN/ AEI/10.13039/501100011033/ y por FEDER Una manera de hacer Europa. PI: Olivia Rivero.

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Using unfolding case studies to develop critical thinking for Graduate Entry Nursing students: an educational design research study

• Rachel Macdiarmid   ORCID: orcid.org/0000-0003-4791-7417 1 ,
• Eamon Merrick   ORCID: orcid.org/0000-0003-4269-6360 2 , 3 &
• Rhona Winnington   ORCID: orcid.org/0000-0002-6504-2856 1  

BMC Nursing volume  23 , Article number:  399 ( 2024 ) Cite this article

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Graduate Entry Nursing (GEN) programmes have been introduced as another entry point to nurse registration. In the development of a new GEN programme, a problem-based approach to learning was used to develop critical thinking and clinical reasoning skills of motivated and academically capable students.

To explore and evaluate the design and delivery of course material delivered to GEN students embedded in authentic learning pedagogy from the perspectives of both GEN students and academic staff using an unfolding case study approach.

An educational design research approach was used to explore the learning experiences of GEN students using an unfolding case study approach situated in experiential pedagogy and the teaching experiences of the academics who designed it. Data were collected through semi-structured interviews with students once they had finished the course and weekly reflective diary recordings by academic staff throughout implementation. Thematic analysis was used to analyse the data.

Student reflections highlighted that this cohort had insight into how they learned and were comfortable voicing their needs to academic staff. While the unfolding case studies were not liked by all participants, for some it offered a unique learning opportunity; particularly when scaffolded with podcasts, simulation labs, tutorials and clinical placements. Staff reflections primarily aligned with student experiences.

The gaps highlighted in the delivery of the course suggest that a blended pedagogical approach to graduate entry nurse education is required. Specifically, GEN students are aware of the learning needs and are happy to express these to academic staff, thus suggesting that engaging with a co-design curriculum approach will benefit future cohorts.

Peer Review reports

Graduate entry nursing students begin their degrees as experienced learners and must develop critical thinking skills within the shortened degree time frame.

What is already known

Graduate entry students are experienced and academically capable learners who begin with a diverse range of life and career experiences.

What this paper adds

Graduate entry students would benefit by being involved in curriculum design to acknowledge the unique skill set that they bring.

Introduction

Graduate Entry Nursing (GEN) degrees, or second degrees leading to eligibility for nursing registration, have recently been introduced to New Zealand. GEN students are known to be academically capable, motivated, and driven, bringing with them a range of life experiences, and have often had significant careers before enrolment [ 1 , 2 ]. Previous research has identified that teaching and learning methods must be carefully planned and innovative [ 1 ].

Pre-registration nursing education programmes prepare nursing students to provide safe nursing care with crucial skills expected of nursing graduates, including critical thinking and clinical reasoning. Clinical reasoning enables students to approach clinical issues with a problem-solving lens that relies on gathering assessment data and intervening and evaluating the patient’s response to the intervention [ 3 ].

Problem-Based Learning (PBL) aligns with the fundamental elements of authentic learning approaches [ 4 ], where learning is situated in real-world contexts [ 5 ]. Problem-based learning is considered to be an experiential teaching and learning approach that helps students develop a critical lens and clinical reasoning skills [ 6 , 7 ]. The use of PBL in nursing education is well established with previous research focused on students’ experiences and satisfaction [ 8 ]; factors that facilitate or hinder students' learning [ 9 ]; and the development of critical thinking skills [ 10 ].

Graduate entry nursing students report enjoyment of the active learning sets that enabled discussion surrounding case studies, scenarios, and practice issues [ 11 ]. Cangelosi’s [ 12 ] phenomenological study found that although time-poor, GEN students welcomed learning opportunities that were not traditional and facilitated their development and growth.

However, there is conflicting evidence regarding the effectiveness of PBL in nursing. For example, McCormick et al. [ 13 ] compared undergraduate student performance using differing teaching approaches, such as unfolding simulation scenarios versus recorded lectures and found these to be of benefit to students. Carter and Welch [ 14 ] compared the results of associate degree nursing students who attended lectures to those whose learning was informed by an unfolding case study. In contrast to McCormick’s et al.’s [ 13 ] earlier positive results, these authors found both groups of students performed worse in the post-test.

As previous research has identified that new graduate nurses do not always have critical thinking skills, using an unfolding case study approach can reflect the reality of clinical practice where not all the relevant information is known at the first encounter with the patient [ 14 , 15 , 16 ].

Nonetheless, while several studies have investigated the use of unfolding case studies in undergraduate preregistration programmes there is little evidence that supports the use of these with more academically capable GEN students. This article reports on a qualitative interpretivist study that used an educational design methodology to explore the experiences of GEN students who participated in the programme of learning and the experiences of the academics who designed it.

Educational Design Research (EDR) is an iterative, pragmatic, and reflective methodology well suited to small projects [ 17 ]. It has arisen from design-based research and can include both quantitative and qualitative data collection methods. EDR was selected as it fitted with our desire to develop new ways of teaching alongside gaining feedback from both academic staff and students. In the first phase of this research, we redesigned the teaching and learning strategies for a component of the GEN programme [ 18 ].

EDR has four phases (Table  1 ) [ 17 ]:

Aims and objectives

The study aimed to explore and evaluate the design and delivery of course material delivered to GEN students embedded in authentic learning pedagogy from the perspectives of both GEN students and academic staff using an unfolding case study approach.

Theoretical framework

To enable the development of clinical reasoning skills a scaffolded learning approach was implemented that involved unfolding case studies designed to represent the health needs of the New Zealand population, thus, encouraging critical thinking. Unfolding case studies reflective of situations that students might face in the future were used to encourage students to consider and analyse information, provoke further questioning and identify the information required to narrow their inquiries [ 14 , 15 ]. Supported by this evidence the academic staff built a learning environment where a regular teaching schedule (two days of lectures and one day of clinical labs per week), was complemented with online resources. Initial questions about the case study were provided on the learning management system. Students attended simulations where they responded to the case and answered questions critical to unpacking the ‘patients’ reality. Alongside the unfolding case studies were podcasts where experts were interviewed on topics related to the case. Tutorials enabled students to collaboratively construct answers and share their perspectives; at the end of each week students shared their answers in an online discussion forum.

Methods and setting

This study was conducted at an education facility in New Zealand offering undergraduate and GEN programmes. The participants are academics involved in the design and delivery of the course and one cohort of students of the GEN programme. This article reports on Phase 2 and 3 of the EDR approach, the academic staff’s reflective diary during course delivery, and students' feedback after the course was completed the first time. The methods were reported using the Consolidated Criteria for Reporting Qualitative Studies (COREQ) [ 19 ].

Participants

Purposeful sampling was used as the researchers were keen to explore the experiences of a specific GEN cohort [ 20 ]. Academic staff involved in the weekly reflective diaries are also the research team ( n  = 3). All students in the identified cohort ( n  = 7) were invited to participate, totalling ten possible participants. Student participants were approached via an advertisement on the university’s learning management system. Students were asked to contact the research assistant, who was separate from the academic staff and was not involved in the delivery of the GEN programme; five students agreed to participate. A $20 petrol voucher was offered to those who participated.

Data collection and analysis

In keeping with education design methodology, the authors met weekly to reflect on their experiences of delivering the content and guiding students. The weekly reflective conversations, between 60–90 min in length, followed a simple format of ‘what worked, what didn’t work, and what would we (as academic staff) change?’ Face to face student interviews were conducted by the research assistant at a time and place convenient to the students using semi-structured questions that were developed by the research team (see Additional file 1 ).

The semi-structured interviews ( n  = 5) and reflective meetings ( n  = 9) were recorded and transcribed verbatim by a research assistant who had signed a confidentiality agreement. All identifying information was deleted from the transcripts by the research assistant before the research team reviewed the data; each recording and transcript was allocated a unique identifier, for example ‘participant one’.

Thematic analysis [ 21 , 22 ] was used to analyse the data. First, the research team independently read the transcribed interviews to familiarise themselves with the data and identified initial codes. Second, the researchers met and reviewed all transcripts to identify themes and reached consensus on the themes emerging from the data. Themes were established once more than 50% of the participants stated the same issue/thought/perception. A matrix was developed whereby common themes were identified, with quotes demonstrating the themes collated to establish an audit trail.

Reflexivity

Central to this study given the proximity of staff to this student cohort, a reflexive stance was essential. Reflexivity is an engendered practice and was used in this instance not to influence the direction and outcome of the research but to allow the researchers to engage in the data to produce viable and valuable outcomes for future staff and students. Specifically, this reflexive practice provided a means for the research to be rigorous through the consideration of the vulnerability of the participating student cohort, thus inciting reflection-before-action [ 23 ].

Ethical considerations

Ethical approval for this study was obtained from the Auckland University of Technology Ethics Committee (AUTEC) (19/233). Given the potential power differential in the student/staff relationship present, participants were approached via an online advertisement and followed up by an independent research assistant. This is key to the success of the project, as such research undertakings have the potential for conflict of interest to exist [ 24 ]. The academic staff recordings were also undertaken with the knowledge that these would remain confidential to the participants and transcriber only, with a memorandum of understanding completed to this effect. Participant information sheets were given to students interested in joining the study to ensure they knew what it entailed and how their safety and identity would be managed. Written consent was obtained before the interviews were undertaken, with oral consent obtained at the beginning of each interview.

Three dominant themes emerged, which focused on the experiences of both GEN students and teaching staff. These were:

Reflective learning: Students and staff ability to clarify what worked and what did not work

Evaluation of learning: Students and staff being insightful about their ways of learning and needs

Challenges: Planning and delivering appropriate content for GEN students is challenging for teaching staff.

Within these overarching themes, subthemes were developed and will be presented in the following data results (Table 2 ).

Reflective learning

The exploration of student and staff experiences and responses to the unfolding case studies unearths what worked and what was problematic for both parties.

Unfolding case study as problem-based approach

The student experiences of using an unfolding case study approach were divided. Some students enjoyed the case scenarios but did not necessarily find them beneficial in terms of knowledge advancement as.

“ I personally, like the case studies but personally I didn’t really find that they enhanced my learning in like the clinical setting ” (P1)

or that they were relevant to clinical practice in that.

“… some of it was definitely relatable but I just found it was very different in the clinical setting compared with doing this theoretical case setting ” (P1).

A second student supported this idea that the case studies did not add practical clinical knowledge value as.

“ I mean for me the case studies weren’t challenging…I didn’t think the case studies added anything extra into my practice, they didn’t challenge my clinical reasoning or anything like that ” (P2).

Of note was that those students with previous professional healthcare backgrounds found the use of an unfolding case study approach problematic in that.

“ I found that quite a challenge. I think because with my clinical background I was sort of going straight into, yeah like I wanted more information so you know I probably would have preferred…to have a different case study every week or have all the information…and I’d be like well what about this, what about that? ” (P5).

Participant One, however, noted that while the case studies may not have added knowledge value, they were helpful at times as.

“ …one example is we learnt about arterial blood gases and then I was on placement I came across that literally [on] day one, so was really nice to be able to put something that I’d learnt in class into practice ” (P1).

While some students were less keen on the case study approach and found them hard work, others thought they provided opportunities to encourage discussion, clinical reasoning, and autonomous thinking as.

“ there was no right or wrong answer, you just had to prove your point to say I think it is this because of this, and someone else can say something else and just kind of still prove it because it was a quite grey [area] but I actually found that it really got us thinking ” (P3).

Moreover, the same participant acknowledged that.

“…I think that’s the whole idea of the course [GEN Programme] because at this level they shouldn’t be spoon-feeding you…you should be able to think for yourself and reason things out ” (P3).

Although some discord was present with regard to the case study approach, one participant did acknowledge the value of being able to break down a huge scenario into manageable sections to enhance understanding and clinical decision-making, as.

“ when you break it down it makes it easier to kind of work out what you’re going to do and what steps you’re going to do ” (P4), and that “ because you start looking at the smaller things that you need to do rather than just the big bits ” (P4).

It appears, however, that staff involved in the programme of learning were pleased with the overall notion that problem-based learning approach offered a ‘practical’ means through which to discuss what is the hands-on job of nursing. Specifically,

“ the second session around child abuse and recognising child abuse…took me a bit by surprise as I wasn’t expecting that to go very well and it went extraordinarily well, mostly because it was case based again and story based ” (L1).

Moreover, with regard to encouraging discussion and clinical reasoning at a postgraduate level,

“ I think we’ve really pulled out the difference [of] what we’re expecting of them [GEN students] as opposed to what they may have been used to” (L1).

Use of podcasts

While the use of technology is not necessarily a completely new strategy in tertiary education, here we have linked podcasts recorded with experts in their fields which related to the unfolding case studies, Again, however, there was division in the value of podcast recordings, with some students really enjoying them, saying.

“ I liked the podcasts yeah, I found the podcasts really good especially when there was [sic] different people talking about it, yeah...podcasts are good, like to just chuck on in the car or at the gym ” (P2).

Moreover, some found them easy to listen to because.

“… it’s a different way to learn because like you’ve got YouTube videos and you’ve got books and stuff but podcasts are kind of like easy ” (P2).

Some students found the podcasts particularly engaging saying.

…I just remember listening to it and I think I was in the car and I had stopped because I was on my way home…and I was still listening to it in the garage like when I was home and I was like oh this is a really interesting podcast ” (P2).

Participant three also thought podcasts a positive addition to the resources saying.

“ yeah they were helpful…there was one I listened to…they were talking about dying…I know that [one of the lecturers’] kind of research is kind of talking about death, euthanasia and all this kind of thing, and for some reasons, I don’t know why, maybe that’s why I still remember, I can say it’s the only podcast I really listened to and it was really good because it gave me a good insight as to what is happening… ” (P3)

This positive response was also noted in face-to-face class time as one staff member reported that.

“ they [the students] loved the person who was interviewed, and the feedback was it was really nice to hear a conversation about different perspectives ” (L1).

Yet, not all students were of this opinion, with some advising the podcasts were too long (approximately 60 min each), that they can be distracting, that they preferred videos and images or an in-person discussion, saying.

“ I find podcasts…I tend to switch off a bit, a bit quicker than if I was watching something, I would probably prefer, rather than watching a podcast [sic] I’d rather have an in-class discussion with the person” (P4).

Participant one said that they too struggled with podcasts because.

“ I’m more visual so I like to look at things and see like a slide I guess or what they’re talking about or, so I sort of zone out when it’s just talking and nothing to look at, so that’s what I personally struggle with, they [podcasts] are helpful it’s just I’m more a visual learner ” (P1).

While there were some negative responses to the podcasts, another participant acknowledged their value but offered their own solutions to learning, saying that.

“ I listened to a few podcasts that were put up, because they’re just easy to listen to ” (P2).

but felt that overall there were insufficient resources made available to students and therefore.

“ just went to YouTube and just, any concepts that I was unfamiliar with or stuff in class that we went over and when I went home I was like [I have] no idea what they talked about, I just found my own videos on YouTube… ” (P2).

Evaluation of learning

Learning experiences are unique to each GEN student, as are those experienced by the teaching staff. The data collected highlighted this clearly from both perspectives, offering a particularly strong insight into how this cohort of students’ function.

Approaches to learning

It was evident that these GEN students were aware of their approach to learning and that perhaps the structure of the teaching module did not align with their needs as.

“ I’m not really the best at utilising online things I’m a really hands on learner and things like a lecture…but you know if it’s yeah, more like class time, it’s sort of more my, my learning style [I] guess ” (P5).

A number of students were able to identify that they were visual learners as.

“ I use videos more because I guess I’m more of a visual learner as well and I learn better by seeing things instead of reading a huge article, I think that [videos] it helps me a bit more” (P4).

Another student, however, preferred a discussion based approach as opposed to either videos or podcasts saying that.

“ if it’s interesting, if it’s a topic that you can like relate to [through a podcast] or something it’s fine, but for me I just switch off not really taking a lot of the information [in] whereas in a discussion setting you can ask questions and you can interact with the person, yeah I find that would be a bit more helpful ” (P4).

This approach to learning through discussion was also noted when the teaching staff reflected on their experiences in that in one teaching session the GEN students.

“ were engaged, they were round a table with the second speaker talking and what I think enabled the discussion was that she [the speaker] was using her data as stories and so she was reading them, actually she got them [the students] to read them out” (L3).

The notion of learning styles, however, was not as linear as being visual or auditory or practical, as one student noted that a combination of styles was preferable to enhance learning, saying that.

“ if we weren’t able to have lectures like a recorded lecture so that there was a PowerPoint and just someone actually talking you through it, like I know there’s the YouTube videos…some of them were a little bit helpful, but like I just felt that sometimes we missed the teaching aspect of it. There’s a lot of self-directed stuff but definitely like a recorded lecture every week to go along with the readings and extra videos to watch ” (P5).

Students as insightful and engaged

While GEN students are known for their tenacity and ability to cope with the pressure and fast paced delivery, some students discovered that this did not necessarily equate with their preferred approach to learning. This cohort of GEN students were insightful in terms of their strengths and weaknesses in relation to knowledge acquisition. The use of the unfolding case studies, however, caused some frustrations as.

“ for me it was challenging in the fact that I felt I actually got frustrated because I’m thinking well I want to know this, I want to know that and yeah not getting all the information that I wanted at the time ” (P5).

This participant went further, saying that.

“ I definitely found that difficult [lack of information] I felt like [I] wasn’t getting as much information as I wanted to be able to make my clinical decisions ” (P5),

however this may have been due to the student’s background as their.

“my background is in paramedicine ” where “ we get a lot of information in a very short amount of time ” (P5).

Some fundamental issues were raised by the participants in terms of how much study is required for them to acquire the new knowledge. As one student highlighted,

“ I have a really terrible memory, so I kind of need to listen to things a few times or write it down and then watch a video and do some more reading and then like it’s good having another element to get into your brain you know ” (P2).

For one student, a solution to this was to ensure they did their preparation before attending class as.

“ you’re supposed to have read these things before coming to class, some people don’t but my kind of person, I’d read before coming to class and I tended to answer those questions so the critical, analytical part of me would be trying to find out and come up with a reasonable answer…” (P3).

For another participant, they took an alternative pathway to learning as they.

“ I just watch it and I don’t take [it in], it just sits in the back of my head because sometimes it’s building on top of previous knowledge so just, I just watch it to see if I can gain anything from that, I don’t necessarily take down notes or anything, but I just watch it so that it’s there you know ” (P4).

The pace of content delivery appeared problematic for some students, especially in relation to the practical sessions, with one student highlighting that.

“ personally I didn’t’ really like it and most of the time they were rushing, I was always like can I write this down to go back home to like really make sense of it and then sometimes obviously, sometimes I would have to say can I stay back and practice this thing again [as] I didn’t grab it as quickly as others did and the essence of the labs is that it’s grab all of these things ” (P3).

Challenges: Teaching staff experiences of GEN student learning

While on the whole the teaching staff were able to gauge the learning needs of this GEN cohort, the expectations of both parties did not always align, with one staff member reporting that.

“ the two biggest challenges was [sic] getting them [the students] to unpack already learned behaviour and [to] acknowledge their own limitations or bias ” (L1),

however by the end of the semester the same staff member reported that.

“ I think we made a lot of progress in getting them to acknowledge how they learn ” (L1).

Moreover, the challenges anticipated in teaching GEN students were not those that transpired in that.

“ I actually thought going into the first paper I was pretty excited as to how it was going to roll out, the problems I encountered were not the problems I anticipated ” (L3).

The vocality of this cohort was tangible, however, when content did not meet their needs, interest or expectations with the students saying,

“ that they didn’t do the materials because it wasn’t of interest to them and requested other teaching very much related to the assignment as opposed to anything else …” (L1).

It was expected that the GEN students would be participatory both in class and online irrespective of their ways of learning, but there was a difference in both responses and comfort with this form of engagement. One student that talked about the unfolding case study and the online component of assessment as being problematic said that.

“.. we had to put up about 250 words of something related to the case study every week and then we spoke to someone else, [I] didn’t really like the responses…I didn’t really like having to respond to someone else ” (P3).

Yet in contrast to this statement, the teaching staff were delighted that.

“…actually I got some fantastic questions from one of the students…emailed to me on Monday night about the case that was online for them, questions that I didn’t talk about in [the] lecture, I didn’t introduce the concept…they’re talking about concepts that are currently undergoing international clinical trials” (L1).

This study explored the experiences of both GEN students and academics using unfolding case studies situated in experiential learning pedagogy. The use of unfolding case studies supported with podcasts embraced our idea of developing content situated in real-life contexts. Learning was scaffolded using different teaching approaches such as podcasts, and experiential simulated learning, to offer learners multiple ways of engaging with content. Scaffolding is recognised as learning material being broken into smaller chunks of learning and in this way aligns with case-based learning [ 25 ]. In this way, we hoped that not only would students engage in problem-solving, and develop clinical decision-making skills [ 26 , 27 ], but that they would also achieve deep and lifelong learning and ultimately have an ‘aha’ moment when it all made sense.

Reflections on using an unfolding case study approach

Findings were divided, with some students enjoying the unfolding case studies and others describing them as not sufficiently challenging. The scaffolded learning approach that we developed incorporated a range of teaching approaches that enabled them to engage with the content in a way that fitted in with their lifestyle, even if the teaching method did not align with their individual learning preferences. Students reported differing views about the case studies; some enjoyed the unfolding nature while others wanted more context and direction to feel that they could make an informed clinical decision. Nonetheless, even though they did not like information being presented in smaller chunks one student recognised it meant they analysed the information they received more deeply.

Other learning tools such as podcasts were not always valued by participants and yet, the fact that students were able to provide feedback on their use does indicate that they at least attempted to engage with them.

Student reflections indicate that perhaps the use of unfolding case studies as a learning approach is not the solution to engagement, and that often more traditional teaching methods were preferred Indeed, Hobbs and Robinson’s [ 28 ] study of undergraduate nursing students in the US supported Carter and Welch’s [ 14 ] findings that the use of unfolding case studies were of no direct benefit, whilst Ellis et al.’s., [ 29 ] study confirmed that for final year nurse practitioner students unfolding case studies were beneficial in developing critical thinking and stimulating clinical reasoning. Considering these two conflicting findings, further consideration is needed of how to engage highly motivated GEN students.

As such, our results suggest it can be difficult to predict the needs of the GEN students given the diversity of their previous academic qualifications, career, and often significant life experience they bring to the programme [ 30 , 31 ]. Interestingly students in this study simultaneously demonstrated insight into their needs supporting their previous academic study experience and felt sufficiently secure to voice them, which supports evidence found in D’Antonio et al.’s [ 32 ] study. This suggests that GEN students’ capabilities need to be embraced and incorporated when planning curriculum and scaffolding learning. Anecdotally, we have found that students embrace experiential learning such as that offered in simulation labs whether this involves the use of simulated manikins or not, it seems the hands-on learning offers not only the opportunity to experience simulated reality but also fosters collaboration and problem solving with peers that enables them to dwell in learning of what it is to be a nurse.

Graduate entry students recognised as experienced learners

Our students were not overwhelmingly supportive of the pedagogical approach of unfolding case studies we adopted. As previously recognised GEN students are experienced learners and whilst having differing educational backgrounds bring individual experience and knowledge of their own approach to their learning. Nonetheless, the value of their previous learning experience appears problematic in that those learned behaviours and attitudes need to be refocused to engage with learning how to become a nurse, as demonstrated in the academic staff reflections. Despite this background experience and perceived confidence, some students reflected that online engagement that involved exploring the case studies in discussion forums with colleagues was uncomfortable. This was surprising to the academic staff and contrasted sharply with their reflections on the activity but has been previously noted by Boling et al., [ 33 ].

Implications

Given the disparity that exists between student and academic staff experiences, as demonstrated in our study, co-designing content delivery may offer a progressive solution. By engaging ‘students as partners’ it offers them a much deeper level of involvement in future teaching delivery through collaboration and reciprocation of ideas, thus culminating in appropriate curriculum design [ 34 ]. Collaborating with students in course design might facilitate students learning as they become cognisant of the active engagement of academic staff [ 9 , 10 , 35 ]. In the future, we aim to involve students in any curriculum review and course development to ensure their perspectives influence curriculum design and content delivery.

Even so, our initial intention of scaffolding learning by offering different ways for students to engage with content is supported by recent research by Dong et al. [ 36 ] who found that students performed better academically in a flipped classroom. This point, in association with our findings, suggests that the best approach to content delivery for graduate entry nursing students is to ensure students are involved in curriculum and course design alongside the delivery of learning experiences that are well facilitated and supported by faculty so that students are aware of the expectations, required of them, and importantly how they will be assessed.

Limitations

We acknowledge that the sample size in this study is small in terms of generalisability. However, our findings offer interesting, detailed and in-depth insights into the experiences and needs of both GEN students and the academic staff involved in the development and delivery of educational material. Further work needs to be undertaken to evaluate the experiences of GEN students from a range of educational providers. A longitudinal study has been undertaken to explore the motivations and experiences of GEN students in Australasia [ 37 ], which will also support these findings regarding the learning needs of GEN students.

This study has provided a platform through which academics and GEN students can share their insights of teaching and learning experiences. The results offer a clear insight into what these students expect and need to expedite their learning and how teaching staff must respond. While participants' views were somewhat mixed in relation to the use of unfolding case studies and scaffolded learning these results demonstrate how GEN students are aware of their personal ways of learning and how this translates in terms of education needs. The sharing of these experiences provides an insightful lens through which to re-evaluate pedagogical approaches for GEN students. As such, we suggest that to meet the needs of GEN student’s not only is a blended pedagogical approach appropriate but expanding education design boundaries further through a co-design focused approach to GEN programme design.

Availability for data and materials

The datasets generated and analysed during the current study are not publicly available due privacy and ethical restrictions of the participants, but are available from the corresponding author on reasonable request.

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RM*: Conceptualisation, methodology, investigation, formal analysis, writing original draft and review/editing. EM: Conceptualisation, methodology, investigation, formal analysis, writing original draft and review/editing. RW: Conceptualisation, methodology, investigation formal analysis, writing original draft and review/editing. The author(s) read and approved the final manuscript.

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Macdiarmid, R., Merrick, E. & Winnington, R. Using unfolding case studies to develop critical thinking for Graduate Entry Nursing students: an educational design research study. BMC Nurs 23 , 399 (2024). https://doi.org/10.1186/s12912-024-02076-8

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Semantic segmentation of some rock-forming mineral thin sections using deep learning algorithms: a case study from the nikeiba area, south eastern desert, egypt.

1. Introduction

2. materials and methods, 2.1. geologic setting and petrography of the study area, 2.2. image datasets, 2.3. preparing thin-section samples for deep learning analysis, 2.3.1. train, validation, and testing datasets, 2.3.2. cnn architectures and models.

• Exploring the U-Net Architecture:   An Overview of its Structure for Efficient Image Segmentation U-Net is a convolutional neural network architecture developed primarily for biomedical image segmentation. This architecture is notable for its efficiency and accuracy in segmenting images, even with limited data. The structure of U-Net can be described in four main sections:
• Downsampling (Contracting Path): The first part of U-Net is the contracting path, which is a typical convolutional network. This path contains the continual application of two 3 × 3 convolutions (unpadded convolutions), each followed by a rectified linear unit (ReLU) and a 2 × 2 max pooling operation with stride 2 for downsampling. At each downsampling step, the number of feature channels is doubled. This part of the network captures the context in the input image, essential for accurate segmentation.
• Bottleneck: After several layers of downsampling, the U-Net reaches its bottleneck. This is the lowest level of the network, where it has the smallest spatial dimension of feature maps. In the bottleneck, two 3 × 3 convolutions are applied, followed by a ReLU. This section is crucial as it allows the network to process features at the lowest resolution, capturing the most abstract representations of the input data.
• Upsampling (Expanding Path): Following the bottleneck, the network then transitions into the expansive path, which includes a sequence of upsampling and convolution operations. The upsampling of the feature map is followed by a 2 × 2 convolution (“up-convolution”) that halves the number of feature channels. Then, a concatenation is performed with the correspondingly cropped feature map from the contracting path. This step is crucial for the network to learn precise localization, a critical aspect of accurate segmentation.
• Final Layer: The final layer of the network is a 1 × 1 convolution that maps each feature vector to the desired number of classes in the output segmentation map. This layer produces the final segmentation map, where each pixel in the image is classified into a specific class. The architecture’s use of expansive paths and concatenation with high-resolution features from the contracting path allows for precise localization and detailed segmentation.

3. Results and Discussion

3.1. experiments setup, 3.2. comparing the two datasets.

• Quartz: The first dataset shows strong precision at 0.81 and recall at 0.85, leading to a balanced F1 score of 0.83, whereas the second dataset of the Gabal Nikeiba area displays excellent precision at 0.91 and recall (0.79) ( Table 2 ), leading to a very high F1 score. This indicates a reliable performance in correctly identifying quartz and effectively reducing false negatives ( Figure 8 and Figure 9 ).
• Plagioclase and Biotite: These minerals demonstrate high precision in the two datasets, ranging from 0.77 to 0.90, and recall from 0.77 to 0.98 ( Table 2 ), suggesting the model’s strong capability in accurately identifying these minerals and consistently detecting their instances ( Figure 8 and Figure 9 ).
• K-feldspar: In the Nikeiba area, it has strong precision (0.91) and recall (0.94), resulting in a very high F1 score (0.91) ( Table 2 ). This result indicates that the model is very accurate in the detection of K-feldspar ( Figure 9 ).
• Riebeckite and Arfvedsonite: These minerals belong to alkali amphibole and are present in the three different types of the Gabal Nikeiba granites (syenogranite, alkali feldspar granites, and quartz syenites) ( Figure 5 ). They show a very high precision range from 0.84 to 0.95 and recall range from 0.77 to 0.90, leading to a strong F1 score of 0.80 and 0.92 ( Table 2 ). This result exhibits the accuracy of the model in identifying and detecting these minerals ( Figure 9 ).
• Muscovite: It shows moderate precision (0.79) and moderate recall (0.62), resulting in a moderate F1 score of 0.69 in the Nikeiba area, which implies the moderate performance of the model in both identifying and detecting the muscovite ( Figure 9 d).
• Chlorite, Olivine, and Serpentine: These minerals run only in the first dataset, and they exhibit excellent precision ranging from 0.87 to 0.89 and recall from 0.80 to 0.98, resulting in a high F1 score of 0.84, 0.91, and 0.93, respectively ( Table 2 ), indicating that the model shows exceptional performance in both accurately identifying and consistently detecting chlorite, olivine, and serpentine ( Figure 8 d–h).
• Titanite and Talc: These classes belong to the first dataset, and they have high precision (0.78 and 0.94, respectively; Table 2 ) but moderate recall (both at 0.77 and 0.76; Table 2 ), indicating the model’s effectiveness in correctly identifying them, though with some missed instances ( Figure 8 g–i).
• Tourmaline: It also runs in the first dataset and has perfect precision (1.00); its recall is significantly lower at 0.62, leading to an F1 score of 0.77 ( Table 2 ). This suggests that while the model accurately identifies tourmaline, when it detects it, it misses a considerable number of instances ( Figure 8 j).
• Zircon: In the Nikeiba area, it is a prevalent accessory mineral ( Figure 4 e and Figure 8 e). It has high precision (0.76) and strong recall (0.89), leading to a strong F1 score of 0.82 ( Table 2 ). This indicates that the model accurately identifies and consistently detects the zircon ( Figure 9 e).
• Apatite: It is an accessory mineral in all the granitic phases of the Nikeiba area ( Figure 4 a). It has excellent precision (0.92) and low recall (0.51), leading to an F1 score of 0.66 ( Table 2 ). This implies that the model accurately identifies and detects apatite with some missed instances ( Figure 9 a).
• Background: Notably, the model achieves a moderate to high precision range (0.68 to 0.92) in identifying the background in the two datasets but has a low recall (0.26 to 0.46, respectively), leading to a lower F1 score range from 0.40 to 0.55 ( Table 2 ). This implies that while the model accurately identifies background, when it does, it often fails to detect it.

4. Conclusions

Author contributions, data availability statement, acknowledgments, conflicts of interest.

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Hassan, S.M.; Laban, N.; Abo Khashaba, S.M.; El-Shibiny, N.H.; Bashir, B.; Azer, M.K.; Drüppel, K.; Keshk, H.M. Semantic Segmentation of Some Rock-Forming Mineral Thin Sections Using Deep Learning Algorithms: A Case Study from the Nikeiba Area, South Eastern Desert, Egypt. Remote Sens. 2024 , 16 , 2276. https://doi.org/10.3390/rs16132276

Hassan SM, Laban N, Abo Khashaba SM, El-Shibiny NH, Bashir B, Azer MK, Drüppel K, Keshk HM. Semantic Segmentation of Some Rock-Forming Mineral Thin Sections Using Deep Learning Algorithms: A Case Study from the Nikeiba Area, South Eastern Desert, Egypt. Remote Sensing . 2024; 16(13):2276. https://doi.org/10.3390/rs16132276

Hassan, Safaa M., Noureldin Laban, Saif M. Abo Khashaba, N. H. El-Shibiny, Bashar Bashir, Mokhles K. Azer, Kirsten Drüppel, and Hatem M. Keshk. 2024. "Semantic Segmentation of Some Rock-Forming Mineral Thin Sections Using Deep Learning Algorithms: A Case Study from the Nikeiba Area, South Eastern Desert, Egypt" Remote Sensing 16, no. 13: 2276. https://doi.org/10.3390/rs16132276

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• Study protocol
• Open access
• Published: 19 June 2024

Early parent-child intervention with Dialogic Book-Sharing: effects on child communicative and socio-emotional development and on parenting. Study protocol for a multicentre randomised controlled trial in Italy

• Cena Loredana 1 ,
• Trainini Alice 1 ,
• Murray Lynne 2 ,
• Cooper Peter 2 ,
• Calza Stefano 3 &
• Belluardo Mauro 4  

Trials volume  25 , Article number:  395 ( 2024 ) Cite this article

28 Accesses

Metrics details

Research in the neurosciences has highlighted the importance of intersubjective relationships in promoting neuromental development of the child. Children’s learning in early childhood occurs mainly in a dyadic context of an interaction with their parents: from this perspective, good dialogic parent–child communication is required to be promoted also through good educational practices. Dialogic Book-Sharing (DBS), a dialogic form of parent–child communication through the use of wordless picture books, provides a privileged ‘intersubjective’ space and is highly effective in promoting communication, language, attention, behavioural development and the parent–child relationship. DBS programme, successfully previously trialled in South Africa and the UK, will be applied for the first time in Italy for research purposes in Italian health, educational and maternal-child centres.

A multicentre randomised controlled trial is being conducted to evaluate DBS parenting intervention for children aged between 14 and 20 months. Parent–child dyads are randomly allocated to a book-sharing intervention group or to a wait-list control group. In the intervention, parents are trained in supportive book-sharing with their children by local staff of the centres. DBS intervention is carried out in small groups over a period of 4 weeks. Data are collected at baseline, post-intervention and at 6 months post-intervention with a questionnaire and video recording of parent–child interaction.

DBS programme in early childhood could enhance the educational resources offered by Italian health, educational and maternal-child centres, in support of child’s development and parenting. DBS represents a strategic opportunity for bringing about positive effects, also in terms of prevention of socio-emotional and cognitive difficulties. As such it represents a promising response to the new social, health and educational needs of the post-COVID-19 pandemic era caused by the social isolation measures. Furthermore, the application of the DBS methodology is a way to promote the use of books, and thereby counteract the excessive use of technological devices already present in early childhood.

Trial registration

The trial is registered on the International Standard Randomised Controlled Trial Number database, registration number ISRCTN11755019 Registered on 2 November 2023. This is version 1 of the protocol for the trial.

Peer Review reports

Introduction

In the first years of life, non-verbal communication and language skills develop rapidly, and children learn that their caregivers’ behaviour contains important information about the world [ 1 , 2 ]. One of the first aspects of early parent–child interactions that help child development is the emergence of joint visual attention between an adult and an infant about a common focus, for example, an object. Another critical aspect of early development that underpins shared understanding and communication is the acquisition of language [ 3 ]. Language is a skill that influences other domains, such as social and cognitive development, and requires social interaction [ 4 , 5 , 6 ]: language learning relies on children’s desire to imitate [ 7 ] and on their appreciation of their caregivers’ communicative intentions [ 8 ]. Young children’s learning occurs mainly in a dyadic context of an interaction with a knowledgeable caregiver: from this perspective, good dialogic parent–child communication that involves reading to the child at an early age is highly effective in promoting communication and language development [ 9 , 10 , 11 ]. Research on parent–child shared-reading interventions in early childhood [ 12 ] has highlighted the benefits for early language acquisition [ 13 ] and for accelerating language development [ 14 ]. Benefits for child’s linguistic development occur following regular and dialogic reading [ 15 ], results confirmed by meta-analyses [ 16 , 17 ]. Language learning through situation-specific practices, such as reading, in which parents label items more frequently than during other activities such as playtime or mealtime, provides children with particularly consistent and informative linguistic feedback [ 18 , 19 ]. By reading books to children, caregivers support a wide range of skills. These include reinforcing the acquisition of new words and concepts [ 20 , 21 ], promoting the child’s literacy skills [ 22 ] and providing a ‘lexical reservoir’ that widens vocabulary [ 23 ]. In addition, the activity of parent–child shared reading has a significant impact on the development of preschoolers’ abstract language [ 24 ], syntactic quality, complexity of sentence construction [ 25 ], literal and inferential language [ 26 ], listening comprehension, phonemic awareness [ 27 ] and receptive and expressive vocabulary [ 28 ].

The enrichment of the child’s expressive vocabulary in early childhood is promoted by the cognitive ability to make predictions, an ability that is enhanced by shared reading with the adult: preschoolers develop their language skills when they have opportunities to predict upcoming information during shared reading, through strategic pauses or targeted questions [ 29 ]. Shared-reading also increases preschoolers’ oral narrative skills [ 30 ]. Improvements in narrative comprehension have shown that conversational reading programmes can also support broader language skills, such as inferential understanding [ 31 ], where the opportunity that adult–child book sharing presents for initiating conversations may be key to its effectiveness [ 32 ], and where parent-infant conversations promote the parent’s use of metacognitive language [ 33 ]. The adult and the child can focus on common aspects of interest in the book by looking at the illustrations, asking questions and talking about the story [ 34 ]. Furthermore, parent–child book-reading is a favoured context for parents to prompt mental state discussion with their children [ 35 , 36 , 37 ], important for the development of theory of mind skills [ 38 , 39 ]. Indeed, it has been found that such parental behaviour during picture book reading is associated with child social understanding [ 40 , 41 ], with positive effects particularly evident in peer relationships [ 38 , 42 , 43 ] and prosocial behaviour [ 44 ]. These skills are important as they are associated with subsequent school progress and literacy [ 45 , 46 ] and predict later educational progress [ 47 ].

A structured parent–child shared reading intervention, different from simply reading a book by an adult to a passively listening child, which includes the aforementioned aspects, was developed in the ‘Dialogic Book-Sharing’ programme (DBS) [ 48 ]. This methodology consists of a dialogic form of parent–child communication through the use of wordless picture books, beneficial for children in early childhood and preschool age. The colourful illustrations that carry the story line in these books attract the attention of children who do not yet know written language. However, the narrative and textual content of any book does not define a good DBS intervention, but rather it is the interaction that is activated between adult and child which stimulates, through a structured dialogue, lexical learning, attention, and, above all, the awareness and verbalisation of emotions, thoughts and relationships [ 49 ]. The main objective of DBS is to share with the child what the images narrate, respecting the pace and the rhythm of the child; thus, a circularity and a reciprocal exchange of parent–child ideas and emotions are facilitated. The DBS training methodology consists of progressive sessions, in a group learning context, in which trained facilitators present ways of using the book to parents, according to a defined programme, where parents learn the methodology and then apply it autonomously in daily life with their children [ 49 ]. This methodology requires that the adult pays attention to what interests the child, following their interest, and actively involves them by naming and indicating what the child is looking at, formulating comments, asking questions and sustaining their interest through the use of vocalisations and gestures [ 48 , 50 ]. Specific conversational techniques used by the adult are included, such as asking questions aligned with the child’s ‘proximal development zone’ [ 51 ]. The content of the book is linked to the child’s experience, a technique widely adopted in book-sharing interactions [ 52 , 53 ] that promotes child language development [ 54 , 55 ]. DBS methodology thereby allows the child to develop linguistic and cognitive skills and is of potential benefit to children’s future ability to adapt to the school environment [ 56 ].

Several randomised controlled trials have been conducted to evaluate the effectiveness of the DBS methodology, especially in populations where, by virtue of exposure to socioeconomic and familial risk factors, children have poor language [ 57 ], cognitive [ 58 ] and literacy skills [ 59 ]. In these contexts, the sharing of books has been found to be particularly beneficial for narrowing the social gap. In a pilot randomised controlled trial (RCT) in South Africa, socially disadvantaged mothers’ behaviour while sharing books or toys with their 14–18-month-old children was assessed before and after a DBS intervention programme [ 48 ]. Positive outcomes were found for child attention and language: compared to a play-support control group, mothers receiving DBS training became more sensitive, facilitating and elaborative with their infants, and the infants evidenced a significantly greater increase in expressive and receptive language, as well as in sustained attention. A follow on full RCT study conducted in the same South African community with carer-infant dyads of 14–16-month-olds found the same benefits for child language and attention [ 60 ], as well as benefits to prosocial behaviour social awareness [ 49 ]. The benefits to child language and attention were shown to have been mediated by improvements in maternal sensitivity and reciprocity. A recent review and meta-analysis of 19 RCTs of DBS also confirmed the efficacy of DBS interventions for improving the development of child language [ 17 ]. Notably, Dowdall et al. reported that dialogic book-sharing is effective even when caregivers had low levels of education, underlining the importance of including this methodology in programmes that aim to support early literacy and language development in infants and children, especially in socially disadvantaged contexts. The benefits of Dialogic Book-Sharing have also been studied in European populations: for example, a study conducted in UK on dyads including carers of 28- and 45-month-old children [ 56 ] found substantial benefits especially concerning carers’ sensitivity and cognitive scaffolding [ 61 ].

On the basis of extensive research, it has been argued that Dialogic Book-Sharing provides a privileged ‘intersubjective’ space for the promotion of child learning and cognitive and language development [ 50 ]. The intersubjective process that arises in DBS interactions provides a contained space for joint visual attention, in a physically close intimate setting, that is associated with shared physiological and affectively positive states [ 62 ]. The affective messages that the caregiver transmits allow the relational experience to be memorised [ 63 , 64 , 65 ] and can contribute to the promotion of secure attachment [ 25 , 66 , 67 ]. Current research in the neurosciences has highlighted the importance of intersubjective relationships as well as the neurobiological underpinnings of such processes [ 68 ]. Within the intersubjective space of the parent–child reading relationship, one aspect that we believe to be of fundamental importance is the ‘affective predispositions’ with which parents conduct book-sharing ‘with’ their children [ 69 ]. These dispositions are mainly transmitted through non-verbal communication. Visual-facial, tactile-gestural, auditory-prosodic expressions (the prosody of the mother’s voice is already memorised and learned during the prenatal period) [ 70 ] constitute the primary mother-infant affective communications, including empathic mirroring during mutual gaze transactions. From a neurobiological perspective, one of the most supported models posits the existence of a distributed network involved in bodily and non-verbal interactions, especially for facial expressions [ 71 ]. A crucial component of such model is represented by the Mirror Neuron System (MNs), with sensorimotor neuronal networks that are active during both the production and the passive observation of actions and of emotional facial expressions [ 72 , 73 , 74 , 75 ]. In addition to premotor and somatosensory parietal regions, such network includes also specific limbic structures (i.e. the anterior insula, the amygdala and the anterior cingulate cortex) which are also involved in the modulation of autonomic and vegetative responses coupled with expressions of emotions [ 74 , 75 , 76 , 77 ]. Several studies in typical developing individuals as well as in pathological conditions (such as congenital facial palsy) [ 78 ] suggest that such network could crucially subserve critical bodily and non-verbal aspects of intersubjective processes since early social interactions [ 68 , 79 , 80 ], such as reciprocal behavioural synchronicity [ 81 , 82 , 83 ], intentions and emotion processing [ 84 ] and reciprocal ‘affective attunement’ [ 68 , 78 , 84 , 85 , 86 ].

Indeed, if the mother is psychobiologically attuned to her infant, she synchronises the spatiotemporal behaviour pattern of her stimulation with the spontaneous manifestations of the child’s organic rhythms and promotes their emotional regulation [ 87 ]. The mother accepts the non-verbal expressions of her child, the arousal of emotional states and can repair any child emotional dysregulation [ 88 ]. This transition from a mismatched or negative state into a matched or positive state, referred to as ‘repair’ [ 89 ], is the process by which children internalise regulatory abilities [ 90 , 91 ]. Another important aspect of early shared reading is that it can be considered a ‘transitional space’ [ 92 ], in which the child experiences his own fantasies, expectations and hypotheses, and shares representations of reality with others. In a suitable shared reading context, the parent becomes more available and sensitive to the child, dedicates attention and time to them in a ‘potential space’ in which the parent presents the book (object presenting) in a playful and creative way.

The DBS intervention involves cognitive, socio-emotional and affect-regulating elements, as well as well-being in the parent–child relationship, and we believe that this psycho-educational intervention is also important as a support for parenting. These positive emotional effects of moments of interaction in a privileged intersubjective space are also extendable to the parent. The possibility of being involved in pleasant activities with the child could also have positive effects in cases of parental affective disorders (depression, anxiety, stress). The parent can be pleasantly involved with the child, and the book can be used in the interaction as a resource when the relationship may otherwise present communication challenges for the parent. In parent–child interaction, the parent’s emotional state is of fundamental importance, and a parent with affective disorders, oriented towards his or her inner problems [ 93 , 94 ], may have greater difficulties in relating intersubjectively with their child, with long-term effects on the child’s cognitive development at later ages [ 95 ]. The illustrated book with colourful and interesting images, therefore, can be considered as a ‘mediator’ between adult and child, as it could activate a positive emotional state in the parent and involve them more in interaction with the child.

We propose conducting a trial of DBS in a study ‘Early parent–child intervention with Dialogic Book-Sharing: effects on child communicative and socio-emotional development and on parenting’. Not only could the DBS programme promote benefits to child development and parenting, but providing parenting training in a small group could also represent a moment for the promotion of sociality among families, especially relevant as a response to the social, health and educational needs of the post-COVID-19 pandemic era caused by the social isolation measures adopted to curb the spread of the virus. Finally, it is a way to promote the use of books and counteract the excessive use of technological devices already present in early childhood.

The objectives of the study are to evaluate the impact of a Dialogic Book-Sharing programme delivered to parents within 12 health, educational and maternal-child centres, on (a) the child’s linguistic, cognitive, attention and behavioural development; (b) the parent–child interaction; (c) the parent’s mood (anxiety, depression and stress) and (d) decreasing amount of screen time compared to an increase in parent–child book sharing at home.

Selection of health, educational and maternal-child centres

The Observatory of Perinatal Clinical Psychology at the University of Brescia has invited health, educational and maternal-child centres that indicated an interest in taking part in a study of the impact of a dialogic book-sharing training provided to parents. Following approval from each centre’s director, 12 centres were formally accepted into the study (see Table  1 ). In each participating centre, local staff were identified to run the research project within their centre, with minor adaptations to accommodate their own operational reality. These local staff are responsible for over-seeing identification and recruitment of families, baseline data collection, intervention delivery and follow-up assessment of study participants.

During the study, there is regular contact between the coordinating centre (the Observatory of Perinatal Clinical Psychology) and the participating health, educational and maternal-child centres. Weekly conference calls are held, as are telephone consultations and periodic meetings to monitor the study progress and to keep all coordinators abreast of the progress of the project.

Training programme for healthcare professionals

Several meetings with the participating health, educational and maternal-child centres have taken place to plan and finalise the project organisation. Profs Lynne Murray and Peter Cooper of the University of Reading (UK) have adapted the Dialogic Book-Sharing programme that they developed and have successfully previously trialled in South Africa and the UK [ 17 , 48 , 49 , 50 , 60 ], specifically for the current project. The core feature is that parents are trained in how to support their child’s interest and active engagement, rather than simply ‘reading’ to their child. Responsiveness is emphasised that is sensitive to the child’s developmental capacity and experience, as well as the importance of a positive encouraging approach. The intervention is being delivered in centres by local staff who, over a 2-day training course, have been trained (by Dr Mauro Belluardo of University of Parma) to act as facilitators. Participants receive ongoing supervision from LM and PJC. In accordance with the literature (e.g. [ 96 ]), the supervision sessions help to ensure fidelity with programme delivery (see details below in ‘ Measures ’). The intervention programme is delivered within each centre in Italian, using PowerPoints and embedded demonstration videos. The course is structured into four, weekly, meetings of the parents lasting 90 min each, which take place at the health, educational and maternal-child centres.

The sessions are conducted with groups of up to six parents, during which children are cared for in an adjoining play space by centre staff. In each session, the facilitator presents parents with different ways to share the book with their children, according to a defined programme. At the beginning of the training course, the trained facilitator promotes discussion among the parents and the sharing of their personal experiences within the group in order to facilitate a collective commitment to the programme. This sense of corporate endeavour is maintained throughout the programme by group discussion of progress. At the end of each group session there is a brief period of one-to-one interaction between the facilitator and each parent together with their child, who are given a book to take home with them, and they are given support and encouragement in applying the acquired dialogic book-sharing techniques with their child using this book. After being exposed to new techniques of book-sharing during each group session, parents are advised to apply these techniques autonomously during the following week in their daily life with their children. After the four sessions of the intervention, parents will be encouraged to continue to apply the full set of techniques with their child over the next 6 months.

Recruitment

All parent–child dyads attending the included health, educational and maternal-child centres who meet the inclusion criteria (see below) are being invited by local staff to participate in the study. Participation is voluntary and no charge is levied for receiving the training course. Those parents who agree to participate sign the consent form in which it was made clear that they could withdraw from the study at any time without explanation (Fig. 1 ).

Schedule of enrolment, interventions and assessments

Selection criteria

Inclusion criteria.

Mothers and fathers who are able to speak and read Italian

Children aged 14–20 months at the time of the baseline assessment

Exclusion criteria

Children who have a diagnosed physical or intellectual impairment

Mothers and/or fathers with a diagnosed physical or psychiatric condition that could compromise their ability to participate in the intervention programme

Study design

This is a multicentre, two parallel arms, single blinded randomised controlled superiority trial, with a 1:1 arms allocation ratio. The study followed the SPIRIT reporting guidelines (Supplementary File).

Within each health, educational and maternal-child centres, parent–child dyads are randomly assigned by local staff to either the index group or the control condition based on a randomisation list compiled using random blocks algorithm. The index group receive the DBS intervention immediately, and the control group enter a waiting list and receive the DBS intervention after the final study assessment. The local staff, not involved in the participant treatment and blinded to treatment allocation, collect the baseline data during an interview before randomisation and again after the four group sessions. A follow-up evaluation is to be carried out 6 months after the end of the training.

Sample size estimation

The sample size was calculated based on the difference of the number of words between the two study groups (index and control group) at post-test. In the Dowdall meta-analysis, the average effect size for expressive language adjusted for baseline pre-test value was 0.41. Taking this value as the reference to compute the sample size for our study, assuming a t -test for independent samples, a two-sided 5% significance level, a sample size of 190 (95 in each groups) will provide a power of at least 80% (PASS 2021).

In each assessment session, the parent is invited to participate in a video recording of a 5-min parent–child interaction and asked to complete a self-report questionnaire taking approximately 30 min.

Socio-demographic information

We are obtaining information on the parent’s socio-demographic details (age, nationality, educational level, professional occupation, economic condition) and information about pregnancy and post-partum period.

The primary outcome is the child’s language development. Secondary outcomes are the child’s behaviour, parental mood (anxiety, depression and stress) and parenting.

Primary outcome

The macarthur-bates communicative development inventory (cdi).

Parents are asked to complete the short form of the CDI [ 97 ], one of the most widely used and recommended measures of language and communication for young children. This provides an assessment of the expressive and receptive vocabulary of 8–36-month infants. Parents identify words that the child is able to understand and those that the child can enunciate from a 100-word checklist. A raw score for expressive and for receptive language is obtained. The Italian version of the CDI [ 98 ] has been employed in several cross-cultural studies investigating the linguistic development of young children [ 99 , 100 ]. The instrument showed adequate validity: high correlations between parent-report scores and child performance on concurrent standardised tests have been reported [ 101 , 102 , 103 ].

Secondary outcomes

Child outcome.

Child behaviour

The Achenbach System of Empirically Based Assessment (ASEBA) is being used to assess child behaviour [ 104 ] with the Child Behavior Checklist 1½-5 (CBCL), a widely used parent report checklist that measures a broad range of behavioural and emotional problems among young children. Parents complete the questionnaire by providing ratings to descriptive statements (0 = not true, 1 = somewhat or sometimes true, 2 = very true or often true). For the current study, the questionnaire comprises 27 items that provide an index of Emotionally Reactive, Attention Problems, Affective Problems and Attention Deficit/Hyperactivity Problems. The CBCL’s scales demonstrated good instrument quality and validity and showed good psychometric properties with regard to consistency, reliability and cross-informant agreement [ 105 ].

Parental outcomes.

Anxiety and depression

To assess parental mood, the Hospital Anxiety and Depression Scale (HADS) is being used [ 106 ]. This is a 14-item self-report questionnaire which aims to identify the presence of anxious and depressive symptoms. Each item is rated on a 4-point Likert scale reflecting severity. The HADS is completed on the basis of the emotional state felt over the previous week. Although it was initially developed for patients in hospital settings, several studies have shown that it is appropriate in a wide range of setting, including within the general population [ 107 ]. The validation of the original version of this psychometric scale was followed by translations into various languages, including Italian [ 108 ].

Parenting stress

The short form of the Parenting Stress Index (PSI-SF) [ 109 ] is being used. This measure is commonly used to assess parenting stress both in clinical and research contexts. For the current study, we only administer one subscale of the PSI-SF, namely Parent–Child Dysfunctional Interaction (P-CDI). This consists of 12 items rated from 1 (strongly disagree) to 5 (strongly agree) assessing the extent to which parents feel satisfied with their child and their interactions with them.

The secondary outcome is parenting which is assessed on all three data collection occasions by direct observation. Parents are asked to share the same text-light book with their child (‘Yes’ by Jez Alborourgh) in the way they would at home. The interactions are filmed. Five minutes of interaction are rated on measures of parental behaviour and parent–child interaction [ 48 ]. The measures concern dimensions of book-sharing that the intervention is designed to enhance, and they therefore provide an objective measure of how well parents had implemented the strategies covered in the training programme. Videos and transcripts are scored by trained researchers blind to group and child outcome. Random samples will be scored by independent trained assessors to establish interrater reliability. The principal dimension of parenting assessed is sensitivity . This concerns parental appropriate and warm responsiveness to the child [ 48 , 49 ]. Key aspects include the parent’s awareness of the child’s focus of interest (e.g. gaze direction, pointing, efforts to turn the page) and their communication, as well as the extent to which parental responses to these behaviours were supportive and well timed. The level of sensitivity is rated from the videos on a 5-point scale.

Reciprocity is also rated from these videos. This concerns shared affect (e.g. smiles, expressions of surprise, concern) and joint attention to the book (e.g. gazing and pointing together at the same part of the page), vocal exchanges and gestural turn taking (e.g. stroking motions on depicted book characters) and mutual gaze [ 48 , 49 ], and was rated from the videos (score = rating on 5-point scale).

Statistical analysis plan

Descriptive statistics will be performed on socio-demographic and baseline child cognitive-behavioural variables using summary statistics such as mean, standard deviation, median and interquartile range. Comparison of test scores measure, derived as combination of individual score items, at post-test between the two groups will be performed using a linear mixed model accounting for baseline (pre-test) test scores values and a random term to account for recruitment centre effect. Individual items measured on an ordinal scale will be compared using cumulative link models for ordinal measures. Results will be reported as effect estimates and corresponding 95% confidence intervals. All tests will be two-sided and will be evaluated assuming a 5% significance level. This analysis will be performed by an independent statistician, blinded for the treatment allocation. The statistician will report to the Data Monitoring Committee. Data will be analysed based on intention to treat principles. A sensitivity analyses will also be performed, excluding not-adherent participants from the analyses.

The Dialogic Book-Sharing programme will be implemented in Italian health, educational and maternal-child centres through the study ‘Early parent–child intervention with Dialogic Book-Sharing: effects on child communicative and socio-emotional development and on parenting’. It will represent an early parent–child intervention in the first thousand days of life and will aim to explore the impact of the DBS method on the child’s linguistic, cognitive, attention and behavioural development in the first 2 years of life, on parent mood (anxiety, depression and stress) and parent–child interactions.

The implementation of the DBS psycho-educational programme in early childhood could enhance the educational resources offered by educational, social and health services, early childhood centres and maternal-child services, in support of parenting and the parent–child relationship. This intervention could represent added value for assistance to families, in terms of the improvement of the psychophysical well-being, the quality of life of the child and their parents, as well as the social well-being of the territory.

The provision of the DBS model has been found to be feasible, acceptable and effective in different ecological contexts and educational services [ 48 , 60 , 61 , 110 ]. It represents a strategic opportunity for bringing about positive effects, also in terms of prevention of socio-emotional and cognitive difficulties, and for the promotion of the psychosocial health of the population that attends Italian health, educational and maternal-child centres. As such it represents a promising response to the new social, health and educational needs currently accentuated by the COVID-19 pandemic and the imposition of social isolation adopted by governments to curb the spread of the virus, with consequent adverse impact on the most vulnerable populations [ 111 , 112 ].

Furthermore, the application of the DBS methodology is also a way to promote the use of books, and thereby counteract the excessive use of technological devices already present in early childhood. In the past decade, screen time has become ubiquitous in children’s daily routines, with an impact across multiple domains of their development [ 113 ]: an excessive exposure to screen resulted negatively associated with developmental health outcomes in children [ 114 ] since it might harm their cognitive [ 115 ], linguistic and social-emotional growth [ 116 ].

Availability of data and materials

The data that support the findings of this study are available from the corresponding author upon reasonable request.

Abbreviations

Analysis of variance

Analysis of covariance

Achenbach System of Empirically Based Assessment

Child Behavior Checklist

Communication Development Inventory

Coronavirus disease 2019

Dialogic Book-Sharing

Hospital Anxiety and Depression Scale

Mirror Neuron System

Parent-Child Dysfunctional Interaction

Parenting Stress Index

Randomised controlled trial

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Acknowledgements

We would like to thank all the parents and children who give their consent to participate in the study. We also would like to thank the facilitators who will be trained in the DBS methodology and the directors who have given their authorisation to apply it in their health, educational and maternal-child centres in the Italian territory.

Dissemination

We will publish the findings of this study in peer-reviewed international journals indexed in Web of Science or Scopus databases and present them at national and international conferences.

Patient and public involvement

Parents were not involved in the design, or conduct, or reporting of this research. The results of this nationwide study will be communicated to the participating facilitators, health, educational and maternal-child centres, and parents in an aggregated and anonymous form, and feedback from these agencies will be incorporated into public communication of the study findings.

Trial status

At the point of submitting this manuscript to the journal the sample is being recruited. Recruitment began in March 2023. The estimated date when recruitment will be completed is December 2024. The trial is registered on the International Standard Randomised Controlled Trial Number database, registration number ISRCTN11755019 Registered on 2 November 2023. This is version 1 of the protocol for the trial.

Data monitoring

Data will be collected using an online database developed using the REDCap framework hosted on ASST Spedali Civili of Brescia servers. The secure access will depend on a two-factor password and OTP procedure. The database will be backed-up daily. All free entry fields will be validated according to specific data entry rules and regular check of data quality will be performed by the data manager staff. All data modification will be audited using logging features available in REDCap.

The Institutional Ethics Board of the ASST Spedali Civili of Brescia Italy periodically monitors the progress of the trial. The Principal Investigator communicates to the Data Monitoring Committee information on study start date, recruitment of the sample, any subjects who choose to withdraw from the study, subjects conducting the follow-up and on any adverse events. The University of Brescia protects the personal data of research participants in compliance with the General Data Protection Regulation EU 2016/679 and Legislative Decree 196/2003 (‘Privacy Code’). All data will be collected and gathered anonymously.

This work was funded by the Observatory of Perinatal Clinical Psychology ( https://www.unibs.it/it/node/988 ) of the Department of Clinical and Experimental Science, University of Brescia (Italy).

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Authors and affiliations.

Department of Clinical and Experimental Sciences, Section of Neuroscience, Observatory of Perinatal Clinical Psychology, University of Brescia, Viale Europa 11, Brescia, 25123, Italy

Cena Loredana & Trainini Alice

School of Psychology and Clinical Language Sciences, University of Reading, Reading, UK

Murray Lynne & Cooper Peter

Unit of Biostatistics and Bioinformatics, Department of Molecular and Translational Medicine, University of Brescia, Brescia, Italy

Calza Stefano

Unit of Neuroscience, Department of Medicine and Surgery, University of Parma, Parma, Italy

Belluardo Mauro

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Contributions

Loredana Cena designed the study and developed the assessment protocol. Loredana Cena and Alice Trainini drafted the original draft of the manuscript. Lynne Murray and Peter Cooper developed the intervention, supervised trainers in its delivery and contributed to writing the paper. Mauro Belluardo conducted the training and helped with supervision and with writing the manuscript. Stefano Calza drafted the statistical analysis plan, which has been reviewed by all authors. Alice Trainini supported the recruitment and running of the trial. All authors approved the final version of the manuscript.

Corresponding author

Correspondence to Cena Loredana .

Ethics declarations

Ethics approval and consent to participate.

Our protocol was reviewed and approved by the Institutional Ethics Board of the ASST Spedali Civili of Brescia, Italy (reference number NP5205 27.09.2022). All procedures performed in this study are in accordance with the ethical standards of the Institutional Ethics Board of the Spedali Civili of Brescia and with the 1964 Declaration of Helsinki and its later amendments. Before taking part in the study, all parents receive oral and written information about the intervention content and the assessment procedure. To ensure confidentially it maintained, each health, educational and maternal-child centre will only have access to their own data, and all forms related to study data will be kept in locked cabinets at the centres. All data will be collected and gathered anonymously. Data files will contain no personally identifiable information.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

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Loredana, C., Alice, T., Lynne, M. et al. Early parent-child intervention with Dialogic Book-Sharing: effects on child communicative and socio-emotional development and on parenting. Study protocol for a multicentre randomised controlled trial in Italy. Trials 25 , 395 (2024). https://doi.org/10.1186/s13063-024-08232-4

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Published : 19 June 2024

DOI : https://doi.org/10.1186/s13063-024-08232-4

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• Early childhood development
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