qualitative research case study design

The Ultimate Guide to Qualitative Research - Part 1: The Basics

• Introduction and overview
• What is qualitative research?
• What is qualitative data?
• Examples of qualitative data
• Qualitative vs. quantitative research
• Mixed methods
• Qualitative research preparation
• Theoretical perspective
• Theoretical framework
• Literature reviews

Research question

• Conceptual framework
• Conceptual vs. theoretical framework

Data collection

• Qualitative research methods
• Focus groups
• Observational research

What is a case study?

Applications for case study research, what is a good case study, process of case study design, benefits and limitations of case studies.

• Ethnographical research
• Ethical considerations
• Confidentiality and privacy
• Power dynamics
• Reflexivity

Case studies

Case studies are essential to qualitative research , offering a lens through which researchers can investigate complex phenomena within their real-life contexts. This chapter explores the concept, purpose, applications, examples, and types of case studies and provides guidance on how to conduct case study research effectively.

Whereas quantitative methods look at phenomena at scale, case study research looks at a concept or phenomenon in considerable detail. While analyzing a single case can help understand one perspective regarding the object of research inquiry, analyzing multiple cases can help obtain a more holistic sense of the topic or issue. Let's provide a basic definition of a case study, then explore its characteristics and role in the qualitative research process.

Definition of a case study

A case study in qualitative research is a strategy of inquiry that involves an in-depth investigation of a phenomenon within its real-world context. It provides researchers with the opportunity to acquire an in-depth understanding of intricate details that might not be as apparent or accessible through other methods of research. The specific case or cases being studied can be a single person, group, or organization – demarcating what constitutes a relevant case worth studying depends on the researcher and their research question .

Among qualitative research methods , a case study relies on multiple sources of evidence, such as documents, artifacts, interviews , or observations , to present a complete and nuanced understanding of the phenomenon under investigation. The objective is to illuminate the readers' understanding of the phenomenon beyond its abstract statistical or theoretical explanations.

Characteristics of case studies

Case studies typically possess a number of distinct characteristics that set them apart from other research methods. These characteristics include a focus on holistic description and explanation, flexibility in the design and data collection methods, reliance on multiple sources of evidence, and emphasis on the context in which the phenomenon occurs.

Furthermore, case studies can often involve a longitudinal examination of the case, meaning they study the case over a period of time. These characteristics allow case studies to yield comprehensive, in-depth, and richly contextualized insights about the phenomenon of interest.

The role of case studies in research

Case studies hold a unique position in the broader landscape of research methods aimed at theory development. They are instrumental when the primary research interest is to gain an intensive, detailed understanding of a phenomenon in its real-life context.

In addition, case studies can serve different purposes within research - they can be used for exploratory, descriptive, or explanatory purposes, depending on the research question and objectives. This flexibility and depth make case studies a valuable tool in the toolkit of qualitative researchers.

Remember, a well-conducted case study can offer a rich, insightful contribution to both academic and practical knowledge through theory development or theory verification, thus enhancing our understanding of complex phenomena in their real-world contexts.

What is the purpose of a case study?

Case study research aims for a more comprehensive understanding of phenomena, requiring various research methods to gather information for qualitative analysis . Ultimately, a case study can allow the researcher to gain insight into a particular object of inquiry and develop a theoretical framework relevant to the research inquiry.

Why use case studies in qualitative research?

Using case studies as a research strategy depends mainly on the nature of the research question and the researcher's access to the data.

Conducting case study research provides a level of detail and contextual richness that other research methods might not offer. They are beneficial when there's a need to understand complex social phenomena within their natural contexts.

The explanatory, exploratory, and descriptive roles of case studies

Case studies can take on various roles depending on the research objectives. They can be exploratory when the research aims to discover new phenomena or define new research questions; they are descriptive when the objective is to depict a phenomenon within its context in a detailed manner; and they can be explanatory if the goal is to understand specific relationships within the studied context. Thus, the versatility of case studies allows researchers to approach their topic from different angles, offering multiple ways to uncover and interpret the data .

The impact of case studies on knowledge development

Case studies play a significant role in knowledge development across various disciplines. Analysis of cases provides an avenue for researchers to explore phenomena within their context based on the collected data.

This can result in the production of rich, practical insights that can be instrumental in both theory-building and practice. Case studies allow researchers to delve into the intricacies and complexities of real-life situations, uncovering insights that might otherwise remain hidden.

Types of case studies

In qualitative research , a case study is not a one-size-fits-all approach. Depending on the nature of the research question and the specific objectives of the study, researchers might choose to use different types of case studies. These types differ in their focus, methodology, and the level of detail they provide about the phenomenon under investigation.

Understanding these types is crucial for selecting the most appropriate approach for your research project and effectively achieving your research goals. Let's briefly look at the main types of case studies.

Exploratory case studies

Exploratory case studies are typically conducted to develop a theory or framework around an understudied phenomenon. They can also serve as a precursor to a larger-scale research project. Exploratory case studies are useful when a researcher wants to identify the key issues or questions which can spur more extensive study or be used to develop propositions for further research. These case studies are characterized by flexibility, allowing researchers to explore various aspects of a phenomenon as they emerge, which can also form the foundation for subsequent studies.

Descriptive case studies

Descriptive case studies aim to provide a complete and accurate representation of a phenomenon or event within its context. These case studies are often based on an established theoretical framework, which guides how data is collected and analyzed. The researcher is concerned with describing the phenomenon in detail, as it occurs naturally, without trying to influence or manipulate it.

Explanatory case studies

Explanatory case studies are focused on explanation - they seek to clarify how or why certain phenomena occur. Often used in complex, real-life situations, they can be particularly valuable in clarifying causal relationships among concepts and understanding the interplay between different factors within a specific context.

Intrinsic, instrumental, and collective case studies

These three categories of case studies focus on the nature and purpose of the study. An intrinsic case study is conducted when a researcher has an inherent interest in the case itself. Instrumental case studies are employed when the case is used to provide insight into a particular issue or phenomenon. A collective case study, on the other hand, involves studying multiple cases simultaneously to investigate some general phenomena.

Each type of case study serves a different purpose and has its own strengths and challenges. The selection of the type should be guided by the research question and objectives, as well as the context and constraints of the research.

The flexibility, depth, and contextual richness offered by case studies make this approach an excellent research method for various fields of study. They enable researchers to investigate real-world phenomena within their specific contexts, capturing nuances that other research methods might miss. Across numerous fields, case studies provide valuable insights into complex issues.

Critical information systems research

Case studies provide a detailed understanding of the role and impact of information systems in different contexts. They offer a platform to explore how information systems are designed, implemented, and used and how they interact with various social, economic, and political factors. Case studies in this field often focus on examining the intricate relationship between technology, organizational processes, and user behavior, helping to uncover insights that can inform better system design and implementation.

Health research

Health research is another field where case studies are highly valuable. They offer a way to explore patient experiences, healthcare delivery processes, and the impact of various interventions in a real-world context.

Case studies can provide a deep understanding of a patient's journey, giving insights into the intricacies of disease progression, treatment effects, and the psychosocial aspects of health and illness.

Asthma research studies

Specifically within medical research, studies on asthma often employ case studies to explore the individual and environmental factors that influence asthma development, management, and outcomes. A case study can provide rich, detailed data about individual patients' experiences, from the triggers and symptoms they experience to the effectiveness of various management strategies. This can be crucial for developing patient-centered asthma care approaches.

Other fields

Apart from the fields mentioned, case studies are also extensively used in business and management research, education research, and political sciences, among many others. They provide an opportunity to delve into the intricacies of real-world situations, allowing for a comprehensive understanding of various phenomena.

Case studies, with their depth and contextual focus, offer unique insights across these varied fields. They allow researchers to illuminate the complexities of real-life situations, contributing to both theory and practice.

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Understanding the key elements of case study design is crucial for conducting rigorous and impactful case study research. A well-structured design guides the researcher through the process, ensuring that the study is methodologically sound and its findings are reliable and valid. The main elements of case study design include the research question , propositions, units of analysis, and the logic linking the data to the propositions.

The research question is the foundation of any research study. A good research question guides the direction of the study and informs the selection of the case, the methods of collecting data, and the analysis techniques. A well-formulated research question in case study research is typically clear, focused, and complex enough to merit further detailed examination of the relevant case(s).

Propositions

Propositions, though not necessary in every case study, provide a direction by stating what we might expect to find in the data collected. They guide how data is collected and analyzed by helping researchers focus on specific aspects of the case. They are particularly important in explanatory case studies, which seek to understand the relationships among concepts within the studied phenomenon.

Units of analysis

The unit of analysis refers to the case, or the main entity or entities that are being analyzed in the study. In case study research, the unit of analysis can be an individual, a group, an organization, a decision, an event, or even a time period. It's crucial to clearly define the unit of analysis, as it shapes the qualitative data analysis process by allowing the researcher to analyze a particular case and synthesize analysis across multiple case studies to draw conclusions.

Argumentation

This refers to the inferential model that allows researchers to draw conclusions from the data. The researcher needs to ensure that there is a clear link between the data, the propositions (if any), and the conclusions drawn. This argumentation is what enables the researcher to make valid and credible inferences about the phenomenon under study.

Understanding and carefully considering these elements in the design phase of a case study can significantly enhance the quality of the research. It can help ensure that the study is methodologically sound and its findings contribute meaningful insights about the case.

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Conducting a case study involves several steps, from defining the research question and selecting the case to collecting and analyzing data . This section outlines these key stages, providing a practical guide on how to conduct case study research.

Defining the research question

The first step in case study research is defining a clear, focused research question. This question should guide the entire research process, from case selection to analysis. It's crucial to ensure that the research question is suitable for a case study approach. Typically, such questions are exploratory or descriptive in nature and focus on understanding a phenomenon within its real-life context.

Selecting and defining the case

The selection of the case should be based on the research question and the objectives of the study. It involves choosing a unique example or a set of examples that provide rich, in-depth data about the phenomenon under investigation. After selecting the case, it's crucial to define it clearly, setting the boundaries of the case, including the time period and the specific context.

Previous research can help guide the case study design. When considering a case study, an example of a case could be taken from previous case study research and used to define cases in a new research inquiry. Considering recently published examples can help understand how to select and define cases effectively.

Developing a detailed case study protocol

A case study protocol outlines the procedures and general rules to be followed during the case study. This includes the data collection methods to be used, the sources of data, and the procedures for analysis. Having a detailed case study protocol ensures consistency and reliability in the study.

The protocol should also consider how to work with the people involved in the research context to grant the research team access to collecting data. As mentioned in previous sections of this guide, establishing rapport is an essential component of qualitative research as it shapes the overall potential for collecting and analyzing data.

Collecting data

Gathering data in case study research often involves multiple sources of evidence, including documents, archival records, interviews, observations, and physical artifacts. This allows for a comprehensive understanding of the case. The process for gathering data should be systematic and carefully documented to ensure the reliability and validity of the study.

Analyzing and interpreting data

The next step is analyzing the data. This involves organizing the data , categorizing it into themes or patterns , and interpreting these patterns to answer the research question. The analysis might also involve comparing the findings with prior research or theoretical propositions.

Writing the case study report

The final step is writing the case study report . This should provide a detailed description of the case, the data, the analysis process, and the findings. The report should be clear, organized, and carefully written to ensure that the reader can understand the case and the conclusions drawn from it.

Each of these steps is crucial in ensuring that the case study research is rigorous, reliable, and provides valuable insights about the case.

The type, depth, and quality of data in your study can significantly influence the validity and utility of the study. In case study research, data is usually collected from multiple sources to provide a comprehensive and nuanced understanding of the case. This section will outline the various methods of collecting data used in case study research and discuss considerations for ensuring the quality of the data.

Interviews are a common method of gathering data in case study research. They can provide rich, in-depth data about the perspectives, experiences, and interpretations of the individuals involved in the case. Interviews can be structured , semi-structured , or unstructured , depending on the research question and the degree of flexibility needed.

Observations

Observations involve the researcher observing the case in its natural setting, providing first-hand information about the case and its context. Observations can provide data that might not be revealed in interviews or documents, such as non-verbal cues or contextual information.

Documents and artifacts

Documents and archival records provide a valuable source of data in case study research. They can include reports, letters, memos, meeting minutes, email correspondence, and various public and private documents related to the case.

These records can provide historical context, corroborate evidence from other sources, and offer insights into the case that might not be apparent from interviews or observations.

Physical artifacts refer to any physical evidence related to the case, such as tools, products, or physical environments. These artifacts can provide tangible insights into the case, complementing the data gathered from other sources.

Ensuring the quality of data collection

Determining the quality of data in case study research requires careful planning and execution. It's crucial to ensure that the data is reliable, accurate, and relevant to the research question. This involves selecting appropriate methods of collecting data, properly training interviewers or observers, and systematically recording and storing the data. It also includes considering ethical issues related to collecting and handling data, such as obtaining informed consent and ensuring the privacy and confidentiality of the participants.

Data analysis

Analyzing case study research involves making sense of the rich, detailed data to answer the research question. This process can be challenging due to the volume and complexity of case study data. However, a systematic and rigorous approach to analysis can ensure that the findings are credible and meaningful. This section outlines the main steps and considerations in analyzing data in case study research.

Organizing the data

The first step in the analysis is organizing the data. This involves sorting the data into manageable sections, often according to the data source or the theme. This step can also involve transcribing interviews, digitizing physical artifacts, or organizing observational data.

Categorizing and coding the data

Once the data is organized, the next step is to categorize or code the data. This involves identifying common themes, patterns, or concepts in the data and assigning codes to relevant data segments. Coding can be done manually or with the help of software tools, and in either case, qualitative analysis software can greatly facilitate the entire coding process. Coding helps to reduce the data to a set of themes or categories that can be more easily analyzed.

Identifying patterns and themes

After coding the data, the researcher looks for patterns or themes in the coded data. This involves comparing and contrasting the codes and looking for relationships or patterns among them. The identified patterns and themes should help answer the research question.

Interpreting the data

Once patterns and themes have been identified, the next step is to interpret these findings. This involves explaining what the patterns or themes mean in the context of the research question and the case. This interpretation should be grounded in the data, but it can also involve drawing on theoretical concepts or prior research.

Verification of the data

The last step in the analysis is verification. This involves checking the accuracy and consistency of the analysis process and confirming that the findings are supported by the data. This can involve re-checking the original data, checking the consistency of codes, or seeking feedback from research participants or peers.

Like any research method , case study research has its strengths and limitations. Researchers must be aware of these, as they can influence the design, conduct, and interpretation of the study.

Understanding the strengths and limitations of case study research can also guide researchers in deciding whether this approach is suitable for their research question . This section outlines some of the key strengths and limitations of case study research.

Benefits include the following:

• Rich, detailed data: One of the main strengths of case study research is that it can generate rich, detailed data about the case. This can provide a deep understanding of the case and its context, which can be valuable in exploring complex phenomena.
• Flexibility: Case study research is flexible in terms of design , data collection , and analysis . A sufficient degree of flexibility allows the researcher to adapt the study according to the case and the emerging findings.
• Real-world context: Case study research involves studying the case in its real-world context, which can provide valuable insights into the interplay between the case and its context.
• Multiple sources of evidence: Case study research often involves collecting data from multiple sources , which can enhance the robustness and validity of the findings.

On the other hand, researchers should consider the following limitations:

• Generalizability: A common criticism of case study research is that its findings might not be generalizable to other cases due to the specificity and uniqueness of each case.
• Time and resource intensive: Case study research can be time and resource intensive due to the depth of the investigation and the amount of collected data.
• Complexity of analysis: The rich, detailed data generated in case study research can make analyzing the data challenging.
• Subjectivity: Given the nature of case study research, there may be a higher degree of subjectivity in interpreting the data , so researchers need to reflect on this and transparently convey to audiences how the research was conducted.

Being aware of these strengths and limitations can help researchers design and conduct case study research effectively and interpret and report the findings appropriately.

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Qualitative study design: Case Studies

• Qualitative study design
• Phenomenology
• Grounded theory
• Ethnography
• Narrative inquiry
• Action research

Case Studies

• Field research
• Focus groups
• Observation
• Surveys & questionnaires
• Study Designs Home

In depth description of the experience of a single person, a family, a group, a community or an organisation.

An example of a qualitative case study is a life history which is the story of one specific person.  A case study may be done to highlight a specific issue by telling a story of one person or one group. 

• Oral recording

Ability to explore and describe, in depth, an issue or event. 

Develop an understanding of health, illness and health care in context. 

Single case can be used to develop or disprove a theory. 

Can be used as a model or prototype .  

Limitations

Labour intensive and generates large diverse data sets which can be hard to manage. 

Case studies are seen by many as a weak methodology because they only look at one person or one specific group and aren’t as broad in their participant selection as other methodologies. 

Example questions

This methodology can be used to ask questions about a specific drug or treatment and its effects on an individual.

• Does thalidomide cause birth defects?
• Does exposure to a pesticide lead to cancer?

Example studies

• Choi, T. S. T., Walker, K. Z., & Palermo, C. (2018). Diabetes management in a foreign land: A case study on Chinese Australians. Health & Social Care in the Community, 26(2), e225-e232. 
• Reade, I., Rodgers, W., & Spriggs, K. (2008). New Ideas for High Performance Coaches: A Case Study of Knowledge Transfer in Sport Science.  International Journal of Sports Science & Coaching , 3(3), 335-354. 
• Wingrove, K., Barbour, L., & Palermo, C. (2017). Exploring nutrition capacity in Australia's charitable food sector.  Nutrition & Dietetics , 74(5), 495-501. 
• Green, J., & Thorogood, N. (2018). Qualitative methods for health research (4th ed.). London: SAGE. 
• University of Missouri-St. Louis. Qualitative Research Designs. Retrieved from http://www.umsl.edu/~lindquists/qualdsgn.html     
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• Next: Field research >>
• Last Updated: Jul 3, 2024 11:46 AM
• URL: https://deakin.libguides.com/qualitative-study-designs

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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.

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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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

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The case study as a type of qualitative research

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The Multiple Case Study Design

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Most organizations today operate in volatile economic and social environments and qualitative research plays an essential role in investigating leadership and management problems. This unique volume offers novice and experienced researchers a brief, student-centric research methods text specifically devoted to the multiple case study design.

The multiple case study design is a valuable qualitative research tool in studying the links between the personal, social, behavioral, psychological, organizational, cultural, and environmental factors that guide organizational and leadership development. Case study research is essential for the in-depth study of participants' perspectives on the phenomenon within its natural context. Rigorously designed management and leadership case studies in the extant literature have a central focus on individual managers' and leaders' stories and their perceptions of the broader forces operating within and outside their organizations.

This is a comprehensive methodology book exploring the multiple case study design with step-by-step and easily accessible guidelines on the topic, making it especially valuable to researchers, academics, and students in the areas of business, management, and leadership.

TABLE OF CONTENTS

Chapter 1 | 6  pages, a refresher on the philosophical foundations of academic research, chapter 2 | 6  pages, research methodologies, chapter 3 | 3  pages, the role of theory in qualitative research, chapter 4 | 6  pages, how does the novice researcher design a multiple case study, chapter 5 | 5  pages, the advantage of the multiple case study design for management researchers, chapter 6 | 6  pages, applying data collection methods in multiple case study research, chapter 7 | 9  pages, the data analysis process for multiple case study research, chapter 8 | 3  pages, extending theory with multiple case study design, chapter 9 | 7  pages, incorporating multiple case design and methodologies into teaching and professional practice, chapter 10 | 9  pages, writing and publishing multiple case study research, chapter 11 | 2  pages, concluding thoughts.

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• Qualitative Descriptive Design
• Design and Development Research (DDR) For Instructional Design
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• Case Study Design in an Applied Doctorate

Qualitative Research Designs

Case study design, using case study design in the applied doctoral experience (ade), applicability of case study design to applied problem of practice, case study design references.

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The field of qualitative research there are a number of research designs (also referred to as “traditions” or “genres”), including case study, phenomenology, narrative inquiry, action research, ethnography, grounded theory, as well as a number of critical genres including Feminist theory, indigenous research, critical race theory and cultural studies. The choice of research design is directly tied to and must be aligned with your research problem and purpose. As Bloomberg & Volpe (2019) explain:

Choice of research design is directly tied to research problem and purpose. As the researcher, you actively create the link among problem, purpose, and design through a process of reflecting on problem and purpose, focusing on researchable questions, and considering how to best address these questions. Thinking along these lines affords a research study methodological congruence (p. 38).

Case study is an in-depth exploration from multiple perspectives of a bounded social phenomenon, be this a social system such as a program, event, institution, organization, or community (Stake, 1995, 2005; Yin, 2018). Case study is employed across disciplines, including education, health care, social work, sociology, and organizational studies. The purpose is to generate understanding and deep insights to inform professional practice, policy development, and community or social action (Bloomberg 2018).

Yin (2018) and Stake (1995, 2005), two of the key proponents of case study methodology, use different terms to describe case studies. Yin categorizes case studies as exploratory or descriptive . The former is used to explore those situations in which the intervention being evaluated has no clear single set of outcomes. The latter is used to describe an intervention or phenomenon and the real-life context in which it occurred. Stake identifies case studies as intrinsic or instrumental , and he proposes that a primary distinction in designing case studies is between single and multiple (or collective) case study designs. A single case study may be an instrumental case study (research focuses on an issue or concern in one bounded case) or an intrinsic case study (the focus is on the case itself because the case presents a unique situation). A longitudinal case study design is chosen when the researcher seeks to examine the same single case at two or more different points in time or to capture trends over time. A multiple case study design is used when a researcher seeks to determine the prevalence or frequency of a particular phenomenon. This approach is useful when cases are used for purposes of a cross-case analysis in order to compare, contrast, and synthesize perspectives regarding the same issue. The focus is on the analysis of diverse cases to determine how these confirm the findings within or between cases, or call the findings into question.

Case study affords significant interaction with research participants, providing an in-depth picture of the phenomenon (Bloomberg & Volpe, 2019). Research is extensive, drawing on multiple methods of data collection, and involves multiple data sources. Triangulation is critical in attempting to obtain an in-depth understanding of the phenomenon under study and adds rigor, breadth, and depth to the study and provides corroborative evidence of the data obtained. Analysis of data can be holistic or embedded—that is, dealing with the whole or parts of the case (Yin, 2018). With multiple cases the typical analytic strategy is to provide detailed description of themes within each case (within-case analysis), followed by thematic analysis across cases (cross-case analysis), providing insights regarding how individual cases are comparable along important dimensions. Research culminates in the production of a detailed description of a setting and its participants, accompanied by an analysis of the data for themes or patterns (Stake, 1995, 2005; Yin, 2018). In addition to thick, rich description, the researcher’s interpretations, conclusions, and recommendations contribute to the reader’s overall understanding of the case study.

Analysis of findings should show that the researcher has attended to all the data, should address the most significant aspects of the case, and should demonstrate familiarity with the prevailing thinking and discourse about the topic. The goal of case study design (as with all qualitative designs) is not generalizability but rather transferability —that is, how (if at all) and in what ways understanding and knowledge can be applied in similar contexts and settings. The qualitative researcher attempts to address the issue of transferability by way of thick, rich description that will provide the basis for a case or cases to have relevance and potential application across a broader context.

Qualitative research methods ask the questions of "what" and "how" a phenomenon is understood in a real-life context (Bloomberg & Volpe, 2019). In the education field, qualitative research methods uncover educational experiences and practices because qualitative research allows the researcher to reveal new knowledge and understanding. Moreover, qualitative descriptive case studies describe, analyze and interpret events that explain the reasoning behind specific phenomena (Bloomberg, 2018). As such, case study design can be the foundation for a rigorous study within the Applied Doctoral Experience (ADE).

Case study design is an appropriate research design to consider when conceptualizing and conducting a dissertation research study that is based on an applied problem of practice with inherent real-life educational implications. Case study researchers study current, real-life cases that are in progress so that they can gather accurate information that is current. This fits well with the ADE program, as students are typically exploring a problem of practice. Because of the flexibility of the methods used, a descriptive design provides the researcher with the opportunity to choose data collection methods that are best suited to a practice-based research purpose, and can include individual interviews, focus groups, observation, surveys, and critical incident questionnaires. Methods are triangulated to contribute to the study’s trustworthiness. In selecting the set of data collection methods, it is important that the researcher carefully consider the alignment between research questions and the type of data that is needed to address these. Each data source is one piece of the “puzzle,” that contributes to the researcher’s holistic understanding of a phenomenon. The various strands of data are woven together holistically to promote a deeper understanding of the case and its application to an educationally-based problem of practice.

Research studies within the Applied Doctoral Experience (ADE) will be practical in nature and focus on problems and issues that inform educational practice.  Many of the types of studies that fall within the ADE framework are exploratory, and align with case study design. Case study design fits very well with applied problems related to educational practice, as the following set of examples illustrate:

Elementary Bilingual Education Teachers’ Self-Efficacy in Teaching English Language Learners: A Qualitative Case Study

The problem to be addressed in the proposed study is that some elementary bilingual education teachers’ beliefs about their lack of preparedness to teach the English language may negatively impact the language proficiency skills of Hispanic ELLs (Ernst-Slavit & Wenger, 2016; Fuchs et al., 2018; Hoque, 2016). The purpose of the proposed qualitative descriptive case study was to explore the perspectives and experiences of elementary bilingual education teachers regarding their perceived lack of preparedness to teach the English language and how this may impact the language proficiency of Hispanic ELLs.

Exploring Minority Teachers Experiences Pertaining to their Value in Education: A Single Case Study of Teachers in New York City

The problem is that minority K-12 teachers are underrepresented in the United States, with research indicating that school leaders and teachers in schools that are populated mainly by black students, staffed mostly by white teachers who may be unprepared to deal with biases and stereotypes that are ingrained in schools (Egalite, Kisida, & Winters, 2015; Milligan & Howley, 2015). The purpose of this qualitative exploratory single case study was to develop a clearer understanding of minority teachers’ experiences concerning the under-representation of minority K-12 teachers in urban school districts in the United States since there are so few of them.

Exploring the Impact of an Urban Teacher Residency Program on Teachers’ Cultural Intelligence: A Qualitative Case Study

The problem to be addressed by this case study is that teacher candidates often report being unprepared and ill-equipped to effectively educate culturally diverse students (Skepple, 2015; Beutel, 2018). The purpose of this study was to explore and gain an in-depth understanding of the perceived impact of an urban teacher residency program in urban Iowa on teachers’ cultural competence using the cultural intelligence (CQ) framework (Earley & Ang, 2003).

Qualitative Case Study that Explores Self-Efficacy and Mentorship on Women in Academic Administrative Leadership Roles

The problem was that female school-level administrators might be less likely to experience mentorship, thereby potentially decreasing their self-efficacy (Bing & Smith, 2019; Brown, 2020; Grant, 2021). The purpose of this case study was to determine to what extent female school-level administrators in the United States who had a mentor have a sense of self-efficacy and to examine the relationship between mentorship and self-efficacy.

Suburban Teacher and Administrator Perceptions of Culturally Responsive Teaching to Promote Connectedness in Students of Color: A Qualitative Case Study

The problem to be addressed in this study is the racial discrimination experienced by students of color in suburban schools and the resulting negative school experience (Jara & Bloomsbury, 2020; Jones, 2019; Kohli et al., 2017; Wandix-White, 2020). The purpose of this case study is to explore how culturally responsive practices can counteract systemic racism and discrimination in suburban schools thereby meeting the needs of students of color by creating positive learning experiences. 

As you can see, all of these studies were well suited to qualitative case study design. In each of these studies, the applied research problem and research purpose were clearly grounded in educational practice as well as directly aligned with qualitative case study methodology. In the Applied Doctoral Experience (ADE), you will be focused on addressing or resolving an educationally relevant research problem of practice. As such, your case study, with clear boundaries, will be one that centers on a real-life authentic problem in your field of practice that you believe is in need of resolution or improvement, and that the outcome thereof will be educationally valuable.

Bloomberg, L. D. (2018). Case study method. In B. B. Frey (Ed.), The SAGE Encyclopedia of educational research, measurement, and evaluation (pp. 237–239). SAGE. https://go.openathens.net/redirector/nu.edu?url=https%3A%2F%2Fmethods.sagepub.com%2FReference%2Fthe-sage-encyclopedia-of-educational-research-measurement-and-evaluation%2Fi4294.xml

Bloomberg, L. D. & Volpe, M. (2019). Completing your qualitative dissertation: A road map from beginning to end . (4th Ed.). SAGE.

Stake, R. E. (1995). The art of case study research. SAGE.

Stake, R. E. (2005). Qualitative case studies. In N. K. Denzin and Y. S. Lincoln (Eds.), The SAGE handbook of qualitative research (3rd ed., pp. 443–466). SAGE.

Yin, R. (2018). Case study research and applications: Designs and methods. SAGE.

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Rethinking external environmental analysis for sustainable development: the case of a beverage manufacturing industry in a southern african country.

1. Introduction

2. literature review, 2.1. external environmental analysis, 2.2. peste forces of change, 2.2.1. political–legal drivers of change, 2.2.2. economic drivers of change, 2.2.3. socio-cultural drivers of change, 2.2.4. technological drivers of change, 2.2.5. ecological (natural environmental) drivers of change, 2.3. sustainable development as megaforce for change, 2.4. the relationship between peste forces and sustainable development goals, 3. methodology, 3.1. research strategy, 3.2. population and sampling, 3.3. data collection, 3.4. data analysis, 3.5. quality assurance/trustworthiness of the study, 3.6. ethical considerations, 4. data analysis and interpretation.

• the importance of sustainable development,
• conceptualising sustainable development, and
• current practices on sustainable development in beverage manufacturing companies.

4.1. The Importance of Sustainable Development

Thanks, so much for considering me to participate in the PhD research. I feel quite humbled to have been considered for this. The topic is centred on sustainable development goals and leadership. I must admit that I am not well versed on the first part, that of sustainable development particularly as it relates to SDGs. It would be unfair to you to even attempt to respond as I feel that this is an area I still need to understand more. In fact, as I went through the questions, I noted how far I lacked information on this topic. I would have loved to participate towards your research topic. Regrettably due to the foregoing, I am unable to assist in this instance.

I know SDGs developed from millennium development goals [MDGs]. I think at that point, which is some years back, it was just academic. We thought these are NGO [non-governmental organisations] and UN issues. But I know for a fact [that] over the last year or two we have focused on SDGs, which we think, at least, are relevant to our industry.

We are fully aware that, although SDGs are UN-sponsored and government-driven, they have an impact at industry level. Corporates have a duty to contribute to poverty eradication, gender sensitivity, renewable energy, energy efficiencies, refrigeration that protects the ozone layer, environmental sustainability, compliance with ISO 14001, buying and designing equipment that contributes to sustainability, and managing profits to include designing processes that consider sustainable development.

We need a plan that engages the UN and the government. Then we need a plan of sharing resources as we set up milestones and sharing the SDGs across the industry so that we cover as much ground as possible. One point that stuck in my mind was that there is no ownership. The government thinks it’s the UN. The UN thinks it’s the government. Then the industry thinks we would want to contribute for sustainable profit.

4.2. Conceptualising Sustainable Development

The understanding we have in our organisation of sustainable development is development that meets the needs of the present without compromising the ability of future generations to meet their own needs. It is also about promoting people, planet, and profit.

My understanding of sustainable development is that, in the process of making livelihoods, where livelihood is when people apply all the means to make a living to [by] either using their competencies and [or] available resources for them to be able to live. In the process of making livelihoods, they should make sure that the natural environment or the ecosystem is preserved, such that the next generation don’t get it worse than we found it or enhance it.

Here, we are saying the world is not just for today, but the world must be there tomorrow, and a better world must be there tomorrow for future generations. For us what legacy are we leaving? So, we are looking at a better world ever improving towards better social welfare, better environmental impacts, better economic welfare, and inclusivity.

We have a responsibility as current citizens of the world to ensure that as we do our day-to-day activities, be it in business, farming or in our communities, we are also mindful of the fact that, there will be future citizens. Therefore, whatever we do today must ensure that we guarantee a future for the next generation. From a business perspective, profit must be obtained responsibly in a sustainable manner.

As we do our business, there should be a sense of responsibility and to do so with minimum harm to the environment so that we safeguard the environment for future generations.

My understanding goes back to the decision by the United Nations to identify the 17 SDGs, as they call them, which ought to be a template to guide leaders whether they are in the public or private sector as they go about the business of running their organisations. Essentially, sustainable development is about looking into the future so that we have a better world in every respect and in a lot of diverse areas.

Sustainable development is a complex term. Very few people understand it so well. It is a scenario that has been evolving over the years. When you think you understand it, then someone comes up with something new to make it a little more complex.

4.3. Current Practices on Sustainable Development in Beverage Manufacturing Companies

We are very much at the beginning of the cycle, if I may say so. We don’t consider ourselves as advanced. But at least we are aware of what SDGs are and we are conscious of the need for measuring ourselves against those SDGs.

My organization is a member of the Business Council for Sustainable Development (BCSD) and a franchised bottler.

My organization has embraced SDGs by selecting what is applicable to its own circumstance, such as gender equality, health and well-being of employees, water usage, sustainable manufacturing, and climate change .

We have a full-time sustainability manager responsible for overseeing our sustainability initiatives across our business.

If you look at our strategic plan, we have said we want to be a forceful good in the communities and environments that we operate. We have set ourselves on a journey that recognises that our activities have a negative impact in many cases of [on] the environment. Therefore, we must take mitigating measures to ensure that as we do our business we do so in a sustainable manner.

Sustainability has become a core element of the business strategy. It is now entrenched in [the] companies’ strategic decisions; it is discussed at companies’ board level; it is now an agenda at board meetings, and companies are even hiring or making investments in decisions in sustainable development.

Management must understand that the resource they are using is finite and it must be used in a manner at best to replenish that resource. Whilst, at the same time, managing the waste created by such a process.

Sustainable development is now an imperative for business and can no longer be ignored; it is the reason why people work every day, with green jobs being the sustainable way of creating jobs, making a difference in people’s lives, taking people out of poverty because poverty is dehumanizing, prevents social exclusion; consideration of ecological risks, and a nexus between the environment and economic development.

In our industry, sustainable development is a social license to operate that has led us to look at SDGs. We have also expanded these to look beyond the factory and the customers we do business with to go into the wider community. That is where our sustainable elements then come in, our social license to operate.

The organization is part of the community and what a favour to be running this organisation in the community! So, serve the community and serve the world in which you are operating, where the [our] children will be operating tomorrow.

5. Implications, Recommendations, and Conclusions

5.1. practical implications for business, 5.2. theoretical implications, 5.3. limitations of study, 5.4. directions for future research, 5.5. conclusions, author contributions, institutional review board statement, informed consent statement, data availability statement, conflicts of interest.

• Cengiz, H. External Environment Analysis. In Strategic Management ; Ulukan, C., Ed.; Anadolu University: Eskişehir, Turkey, 2020; pp. 59–84. [ Google Scholar ]
• Çitilci, T.; Akbalık, M. The Importance of PESTEL Analysis for Environmental Scanning Process. In Handbook of Research on Decision-Making Techniques in Financial Marketing ; Dinçer, H., Yüksel, S., Eds.; IGI Global: Hershey, PA, USA, 2020; pp. 336–357. [ Google Scholar ]
• Santoso, R.; Permana, E. Analysis of the Business Environment in Construction Service Industry in DKI Jakarta, Indonesia. Maj. Ilm. Bijak 2021 , 18 , 182–195. [ Google Scholar ] [ CrossRef ]
• Abu Amuna, Y.M.; Al Shobaki, M.J.; Abu Naser, S.S. Strategic Environmental Scanning: An Approach for Crises Management. Int. J. Inf. Technol. Electr. Eng. 2017 , 6 , 28–34. [ Google Scholar ]
• Sammut-Bonnici, T.; Galea, D. PEST analysis. Wiley Encycl. Manag. 2015 , 12 , 1–8. [ Google Scholar ]
• Sadiku, K.M. External Factors and Their Impact on Enterprise Strategic Management—A Literature Review. Eur. J. Hum. Resour. Manag. Stud. 2022 , 6 , 24–33. [ Google Scholar ] [ CrossRef ]
• Ajayi, A. Impact of External Business Environment an Organisational Performance of Small and Medium Scale Enterprises in Osun State, Nigeria. Sch. Int. J. Bus. Policy 2016 , 3 , 155–166. [ Google Scholar ]
• Shatilo, O. The Impact of External and Internal Factors on Strategic Management of Innovation Processes at Company Level. Ekonomika 2019 , 98 , 85–96. [ Google Scholar ] [ CrossRef ]
• Sturup, S.; Low, N. Sustainable development and mega infrastructure: An overview of the issues. J. Mega Infrastruct. Sustain. Dev. 2019 , 1 , 8–26. [ Google Scholar ]
• Teodorescu, A.M. Sustainable Development, a Multidimensional Concept. Inf. Soc. Sustain. Dev. 2015 , 82–86. Available online: https://www.utgjiu.ro/revista/ec/pdf/2015-03%20Special/14_Teodorescu%20A1.pdf (accessed on 4 April 2024).
• Borowski, P.F.; Patuk, I. Environmental, social and economic factors in sustainable development with food, energy and eco-space aspect security. Present Environ. Sustain. Dev. 2021 , 15 , 153–169. [ Google Scholar ] [ CrossRef ]
• General Assembly. Outcome document of the United Nations summit for the adoption of the post-2015 development agenda. In Sixty-Ninth Session Agenda13(a) &115 ; United Nations: New York, NY, USA, 2015; pp. 1–35. [ Google Scholar ]
• Shtal, T.V.; Buriak, M.M.; Amirbekuly, Y.; Ukubassova, G.S.; Kaskin, T.T.; Toiboldinova, Z.G. Methods of analysis of the external environment of business activities. Revista 2018 , 39 , 22–31. [ Google Scholar ]
• Kinange, U.; Patil, N. A Conceptual Paper on External Environment Analysis Models. In Proceedings of the 13th International Conference on Marketing MARKCON 2020, Karnataka, India, 9–11 January 2020; Indus Business Academy: Bangalore, India, 2020. [ Google Scholar ]
• Yıldırım, S. The Methods of External Environmental Analysis in Health Institutions. Dan. Sci. J. 2023 , 71 , 109–125. [ Google Scholar ]
• Gurel, E. SWOT Analysis: A Theoretical Review. J. Int. Soc. Res. 2017 , 10 , 994–1006. [ Google Scholar ] [ CrossRef ]
• Ghicajanu, M. Analysis of factors from the external environment in changing business processes. MATEC Web Conf. 2019 , 290 , 07008. [ Google Scholar ] [ CrossRef ]
• Aguilar, F.J. Scanning the Business Environment ; Macmillan: New York, NY, USA, 1967. [ Google Scholar ]
• Kotler, P.; Keller, K.L. Marketing Management , 14th ed.; Pearson Education: London, UK, 2012. [ Google Scholar ]
• Perera, R. The PESTLE Analysis ; Nerdynaut: Avissawella, Sri Lanka, 2017. [ Google Scholar ]
• Athishec, G. International Business Environment: Challenges and Changes. Res. J. Manag. Sci. 2013 , 2 , 34–38. [ Google Scholar ]
• DESA. Global Governance and Global Rules for Development in the Post-2015 Era ; United Nations: New York, NY, USA, 2014; Available online: http://www.un.org/en/development/desa/policy/cdp/cdp_publications/2014cdppolicynote.pdf (accessed on 2 May 2024).
• Hwang, K.D. The Historical Evolution of SADC(C) and Regionalism in Southern Africa. Int. Area Stud. Rev. 2007 , 10 , 55–72. [ Google Scholar ] [ CrossRef ]
• International Monetary Fund. Global Prospects and Policies. In World Economic Outlook: Steady but Slow: Resilience Amid Divergence ; IMF: Washington, DC, USA, 2024. [ Google Scholar ]
• Shurkin, M.; Noyes, A.; Adgie, M.K. The COVID-19 Pandemic in Sub-Saharan Africa: An Opportunity to Rethink Strategic Competition on the Continent ; Rand Corporation: Santa Monica, CA, USA, 2021; Available online: https://www.rand.org/content/dam/rand/pubs/perspectives/PEA1000/PEA1055-1/RAND_PEA1055-1.pdf (accessed on 22 April 2024).
• Lutz, C.; Meyer, B. Economic impacts of higher oil and gas prices: The role of international trade for Germany. Energy Econ. 2009 , 31 , 882–887. [ Google Scholar ] [ CrossRef ]
• Bush, R. Africa: A Political Economy of Continued Crisis. Afr. Focus 2018 , 31 , 23–46. [ Google Scholar ] [ CrossRef ]
• International Monetary Fund. Global Prospects and Policies. In World Economic Outlook: Subdued Demand—Symptoms and Remedies ; IMF: Washington, DC, USA, 2016; pp. 1–62. [ Google Scholar ]
• Mazorodze, B.T.; Tewari, D.D. Real exchange rate undervaluation and sectoral growth in South Africa. Afr. J. Econ. Manag. Stud. 2018 , 9 , 462–476. [ Google Scholar ] [ CrossRef ]
• Teachout, M.; Zipfel, C. The Economic Impact of COVID-19 Lockdowns in Sub-Saharan Africa ; International Growth Centre: London, UK, 2020; Available online: https://www.theigc.org/sites/default/files/2020/05/Teachout-and-Zipfel-2020-policy-brief-.pdf (accessed on 22 April 2024).
• Siemieniuch, C.E.; Sinclair, M.A.; Henshaw, M.J. Global drivers, sustainable manufacturing and systems ergonomics. Appl. Ergon. 2015 , 51 , 104–119. [ Google Scholar ] [ CrossRef ]
• Oosthuizen, M.; Schutte, J. SADC Futures of Green Infrastructure: Visionary Scenarios and Transformative Pathways to Regeneration ; South African Institute of International Affairs: Johannesburg, South Africa, 2023; pp. 1–37. [ Google Scholar ]
• United Nations, Department of Economic and Social Affairs, Population Division. World Population Ageing 2015 (ST/ESA/SER.A/390) ; United Nations: New York, NY, USA, 2015; Available online: https://www.un.org/en/development/desa/population/publications/pdf/ageing/WPA2015_Report.pdf (accessed on 14 May 2024).
• Graf, M.; Ghez, J.; Khodyakov, D.; Yakub, O. Indvidual Empowerment: Global Societal Trends to 2030 ; Rand Corporation: Cambridge, UK, 2015. [ Google Scholar ]
• Sahay, A. Reverse Brain Drain: New Strategies by Developed and Developing Countries. In Global Diasporas and Development ; Sahoo, S., Pattanaik, B.K., Eds.; Springer: New Delhi, India, 2014; pp. 183–201. [ Google Scholar ]
• Ayittey, F.K.; Ayittey, M.K.; Chiwero, N.B.; Kamasah, J.S.; Dzuvor, C. Economic impacts of Wuhan 2019-nCoV on China and the world. J. Med. Virol. 2020 , 92 , 473–475. [ Google Scholar ] [ CrossRef ]
• Dauda, A.; Ismaila, M. Influence of Technological Environmental Factors on Strategic Choice of Quoted Manufacturing Firms in Nigeria’s Food and Beverage Industry. Int. J. Bus. Humanit. Technol. 2013 , 3 , 159–169. [ Google Scholar ]
• Deloitte. Like it or not, here I am Social media and the workplace. In A Middle East Point of View ; Deloitte: Abu Dhabi, United Arab Emirates, 2015; pp. 29–35. [ Google Scholar ]
• Sassenberg, K. It Is About the Web and the User: The Effects of Web Use Depend on Person Characteristics. Psychol. Inq. 2013 , 24 , 333–340. [ Google Scholar ] [ CrossRef ]
• Fanta, A.B.; Mutsonziwa, K.; Goosen, R.; Emanuel, M.; Kettles, N. The Role of Mobile Money in Financial Inclusion in the SADC Region: Evidence Using FinScope Surveys ; FinMark: Johannesburg, South Africa, 2016; Available online: https://finmark.org.za/system/documents/files/000/000/258/original/mobile-money-and-financial-inclusion-in-sadc-1.pdf?1602600110 (accessed on 29 July 2024).
• Zeufack, A.G.; Calderon, C.; Kambou, G.; Kubota, M.; Korman, V.; Canales, C.C.; Aviomoh, H.E. COVID-19 and the Future of Work in Africa: Emerging Trends in Digital Technology Adoption. Afr. Pulse 2021 , 23 . [ Google Scholar ]
• Mittal, V. FinTechs in Sub-Saharan Africa an Overview of Market Developments and Investment Opportunities ; EY: Birmingham, UK, 2020. [ Google Scholar ]
• Fox, W. Ethics and Sustainable Development. In Quest for Sustainable Development ; Juta and Company: Cape Town, South Africa, 2004. [ Google Scholar ]
• Doherty, T.J.; Clayton, S. The Psychological Impacts of Global Climate Change. Am. Psychol. 2011 , 66 , 265–276. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Barson, M. Land Management Practice Trends in South Australia’s Horticulture Industry: Caring for Our Country. Sustain. Pract. Fact Sheet 2013 , 29 , 1–7. [ Google Scholar ]
• Gadallah, M.A.; Sayed, Z. Impact of Different Water Pollution Sources on Antioxident Defense Ability in Three Acquatic Macrophytes in Assiut Province, Egypt. J. Stress Physiol. Biochem. 2014 , 10 , 47–61. [ Google Scholar ]
• IUCN. The IUCN Programme 2013–2016 ; IUCN: New York, NY, USA, 2016; Available online: https://www.iucn.org/sites/dev/files/content/documents/the_business_journey_for_the_iucn_congress_2016.pdf (accessed on 14 May 2024).
• Perrings, C.; Halkos, G. Agriculture and the Threat to Biodiversity in Sub-Saharan Africa. Environ. Res. Lett. 2015 , 10 , 095015. [ Google Scholar ] [ CrossRef ]
• Wolff, C.; Haig, G.H.; Timmermann, A.; Damste, J.S.; Sigman, B.D.; Can, M.A.; Verschuren, D. Reduced Interannual Rainfall Variability in East Africa During the Last Ice Age. Science 2011 , 333 , 743–747. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Baxter, J.; Howard, A.C.; Mills, T.; Rickard, S.; Macey, S. A bumpy road: Maximising the value of a resource corridor. Extr. Ind. Soc. 2017 , 4 , 339–442. [ Google Scholar ] [ CrossRef ]
• Kleinbooi, K. Review of Land Reform in Southern Africa ; PLAAS University of Western Cape: Cape Town, South Africa, 2010. [ Google Scholar ]
• Byamugisha, F.F. Agricultural Land Redistribution and Land Administration in Sub-Saharan Africa: Case Studies of Recent Reforms ; Byamugisha, F.F., Ed.; World Bank: Washington, DC, USA, 2014. [ Google Scholar ]
• Victor Ongoma, V.; Epule, T.E.; Brouziyne, Y.; Tanarhte, M.; Chehbouni, A. COVID-19 response in Africa: Impacts and lessons for environmental management and climate change adaptation. Environ. Dev. Sustain. 2024 , 26 , 5537–5559. [ Google Scholar ] [ CrossRef ]
• Shikwambana, L.; Kganyago, M. Assessing the Responses of Aviation-Related SO2 and NO2 Emissions to COVID-19 Lockdown Regulations in South Africa. Remote Sens. 2021 , 13 , 4156. [ Google Scholar ] [ CrossRef ]
• Lozano, R. A Holistic Perspective on Corporate Sustainability Drivers. Corp. Soc. Responsib. Environ. Manag. 2015 , 22 , 32–44. [ Google Scholar ] [ CrossRef ]
• Gainullina, Y.R. Formation of Innovative Approaches to the Designing of a Three-Pronged Concept of Sustainable Development of Economic Systems in the Age of Globalisation. J. Internet Bank. Financ. 2016 , 21 , 1–21. [ Google Scholar ]
• Halisçelik, E.; Soytas, M.A. Sustainable development from millennium 2015 to Sustainable Development Goals 2030. Sustain. Dev. 2019 , 27 , 545–572. [ Google Scholar ] [ CrossRef ]
• Iqbal, Q.; Ahmad, N.H. Sustainable Development: The colors of sustainable leadership in learning organization. Sustain. Dev. 2021 , 29 , 108–119. [ Google Scholar ] [ CrossRef ]
• Wheeler, S. Sustainable Development. In Encyclopedia of Quality of Life and Well-Being Research ; Michalos, A.C., Ed.; Springer: Berlin/Heidelberg, Germany, 2014; pp. 278–331. [ Google Scholar ]
• Kantabutra, S. Toward a System Theory of Corporate Sustainability: An Interim Struggle. Sustainability 2022 , 14 , 15931. [ Google Scholar ] [ CrossRef ]
• Spijkers, O. Intergenerational Equity and the Sustainable Development Goals. Sustainability 2018 , 10 , 3836. [ Google Scholar ] [ CrossRef ]
• Puaschunder, J.M. On the Social Representations of Intergenerational Equity. In Governance & Climate Justice: Global South & Developing Nations ; Puaschunder, J.M., Ed.; Palgrave Macmillan Cham: New York, NY, USA, 2020; pp. 9–14. [ Google Scholar ]
• Stazyk, E.C.; Moldavanova, A.; Frederickson, H.G. Sustainability, Intergenerational Social Equity, and the Socially Responsible Organisation. Adm. Soc. 2016 , 48 , 655–682. [ Google Scholar ] [ CrossRef ]
• Kibert, C.J.; Thiele, L.; Peterson, A.; Monroe, M. The Ethics of Sustainability. 2012. Available online: http://rio20.net/wp-content/uploads/2012/01/Ethics-of-Sustainability-Textbook.pdf (accessed on 14 May 2024).
• Brundtland Commission. Our Common Future: Report of the World Commission on Environment and Development ; United Nations: New York, NY, USA, 1987. [ Google Scholar ]
• Baumgartner, R.J.; Ebner, D. Corporate Sustainability Strategies: Sustainability Profiles and Maturity Levels. Sustain. Dev. 2010 , 18 , 76–89. [ Google Scholar ] [ CrossRef ]
• United Nations. The Global Sustainable Development Report 2016 ; Department of Economic and Social Affairs: New York, NY, USA, 2016; Available online: https://sustainabledevelopment.un.org/content/documents/2328Global%20Sustainable%20development%20report%202016%20(final).pdf (accessed on 4 May 2024).
• Wysokinska, Z. Millenium Development Goals/UN and Sustainable Development Goals/UN as Instruments for Realising Sustainable Development Concept in the Global Economy. Comp. Econ. Res. 2017 , 20 , 100–118. [ Google Scholar ] [ CrossRef ]
• Nicolai, S.; Hoy, G.; Berliner, T.; Aedy, T. Projecting Progress: Reaching the SDGs by 2030 ; Overseas Development Institute: London, UK, 2015; Available online: https://odi.org/en/publications/projecting-progress-reaching-the-sdgs-by-2030/ (accessed on 30 July 2024).
• Carat, J.B. Unhead Voices: A Critical Discourse Analysis of the Milleninum Development Goals’ Evolution into SDGs. Third World Quartely 2017 , 38 , 16–41. [ Google Scholar ] [ CrossRef ]
• Mai, T.; Smith, C. Addressing the threats to tourism sustainability using systems thinking: A case study of Cat Ba Island, Vietnam. J. Sustain. Tour. 2015 , 23 , 1504–1528. [ Google Scholar ] [ CrossRef ]
• Terres, Z.; Baxter, G.; Rivera, A.; Nelson, J. Business and the United Nations. Working Together towards the Sustainable Development Goals: A Framework of Action. 2015. Available online: https://www.sdgfund.org/sites/default/files/business-and-un/SDGF_BFP_HKSCSRI_Business_and_SDGs-Web_Version.pdf (accessed on 3 April 2024).
• Lee, K. A Phenomenological Exploration of the Student Experience of Online PHD Studies. Int. J. Dr. Stud. 2020 , 15 , 575–593. [ Google Scholar ] [ CrossRef ]
• Creswell, J.W.; Creswell, J.D. Research Design: Qualitative, Quantitative, and Mixed Methods Approaches , 5th ed.; SAGE: London, UK, 2018. [ Google Scholar ]
• Naderifar, M.; Ghaljaie, F. Snowball Sampling: A Purposeful Method of Sampling in Qualitative Research. Strides Dev. Med. Educ. 2017 , 14 , 1–5. [ Google Scholar ] [ CrossRef ]
• Quinlan, C. Business Research Methods ; Cengage Learnin: Boston, MA, USA, 2011. [ Google Scholar ]
• Patton, M.Q. Qualitative Research and Evaluation Methods , 3rd ed.; Sage Publications: Thousand Oaks, CA, USA, 2002. [ Google Scholar ]
• Vasileiou, K.; Barnett, J.; Thorpe, S.; Young, T. Characterising and justifying sample size sufficiency in interview-based studies: Systematic analysis of qualitative health research over a 15-year period. BMC Med. Res. Methodol. 2018 , 18 , 148. [ Google Scholar ] [ CrossRef ]
• Morse, J.M. Determining Sample Size. Qual. Health Res. 2000 , 10 , 3–5. [ Google Scholar ] [ CrossRef ]
• Gentles, S.J.; Charles, C.; Ploeg, J.; McKibbon, K. Sampling in Qualitative Research: Insights from an Overview of the Methods Literature. Qual. Rep. 2015 , 20 , 1772–1789. [ Google Scholar ] [ CrossRef ]
• Liamputtong, P. Focus Group Methodology: Principles and Practice ; SAGE Publications: Thousand Oaks, CA, USA, 2011. [ Google Scholar ]
• Birchall, J. Qualitative Inquiry as a Method to Extract Personal Narratives: Approach to Research into Organizational Climate Change Mitigation. Qual. Rep. 2014 , 19 , 75. [ Google Scholar ] [ CrossRef ]
• Reid, S.; Mash, B. African Primary Care Research: Qualitative interviewing in primary care. Afr. J. Prim. Health Care Fam. Med. 2014 , 6 , a632. [ Google Scholar ] [ CrossRef ]
• Khankeh, H.; Ranjbar, M.; Khorasani-Zavareh, D.; Zargham-Boroujeni, A.; Johansson, E. Challenges in conducting qualitative research in health: A conceptual paper. Iran. J. Nurs. Midwifery Res. 2015 , 20 , 635–641. [ Google Scholar ]
• Gunawan, J. Ensuring Trustworthiness in Qualitative Research. Belitung Nurs. J. 2015 , 1 , 10–11. [ Google Scholar ] [ CrossRef ]
• Guba, E.G. Criteria for assessing the trustworthiness of naturalistic inquiries. Assoc. Educ. Commun. Technol. 1981 , 29 , 75–91. [ Google Scholar ] [ CrossRef ]
• Merriam, S.B. Qualitative Research and Case Study Applications in Education ; Jossey-Bass Publishers: San Francisco, CA, USA, 1998. [ Google Scholar ]
• Lincoln, Y.; Guba, E.G. Naturalistic Inquiry ; Sage Publications: Thousand Oaks, CA, USA, 1985. [ Google Scholar ]
• Shenton, A.K. Strategies for Ensuring Trustworthiness in Qualitative Research Projects. Educ. Inf. 2004 , 22 , 63–75. [ Google Scholar ] [ CrossRef ]
• Sekaran, U.; Bougie, R. Research Methods for Business: A Skill-Building Approach , 6th ed.; Wiley: New York, NY, USA, 2013. [ Google Scholar ]
• Miles, M.B.; Huberman, A.M.; Saldana, J. Qualitative Data Analysis: A Methods Sourcebook ; SAGE Publications: Thousand Oaks, CA, USA, 2013. [ Google Scholar ]
• Bowen, G.A. Document Analysis as a Qualitative Research Method. Qual. Res. J. 2009 , 9 , 27–40. [ Google Scholar ] [ CrossRef ]
• Jelsma, J.; Clow, S. Ethical Issues Relating to Qualitative Research. SA J. Physiother. 2005 , 61 , 3–6. [ Google Scholar ] [ CrossRef ]
• United Nations. Transforming Our World: The 2030 Agenda for Sustainable Development ; United Nations: New York, NY, USA, 2015; Available online: https://documents.un.org/doc/undoc/gen/n15/291/89/pdf/n1529189.pdf?token=uxziuBxZJ5TBuYTha9&fe=true (accessed on 3 April 2024).

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Ruwanika, E.Q.F.; Massyn, L. Rethinking External Environmental Analysis for Sustainable Development: The Case of a Beverage Manufacturing Industry in a Southern African Country. Sustainability 2024 , 16 , 6759. https://doi.org/10.3390/su16166759

Ruwanika EQF, Massyn L. Rethinking External Environmental Analysis for Sustainable Development: The Case of a Beverage Manufacturing Industry in a Southern African Country. Sustainability . 2024; 16(16):6759. https://doi.org/10.3390/su16166759

Ruwanika, Eliot Quinz Farai, and Liezel Massyn. 2024. "Rethinking External Environmental Analysis for Sustainable Development: The Case of a Beverage Manufacturing Industry in a Southern African Country" Sustainability 16, no. 16: 6759. https://doi.org/10.3390/su16166759

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• Published: 06 August 2024

Starting continuous improvement; creating a common understanding of stroke care delivery in a general hospital

• Are Fjermeros 1 , 2 ,
• Geir Vegard Berg 2 , 5 ,
• Halvor Holtskog 1 &
• Jos Benders 3 , 4  

BMC Health Services Research volume  24 , Article number:  899 ( 2024 ) Cite this article

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Continuous improvement is based on fostering practitioners’ suggestions to modify their own work processes This improvement strategy is widely applied in healthcare but difficult to maintain. The cross-disciplinary nature of many care processes constitutes an extra impediment.

The study had an explorative design with a qualitative single-case approach. The case presents a project to improve the treatment of patients with thrombotic stroke. Data was obtained via hands on involvement, documents, observations, and interviews with participants in a cross-functional improvement group. A thematic analysis method was employed.

Through learning how tasks were carried out in other disciplines, the participants developed a common understanding of why it took so long to provide treatment to stroke patients. These insights were used to implement practical changes, leading to immediate improvements in stroke care delivery. The results were fed back so that successes became visible. Participants’ understandings of the local context enabled them to convince peers of the rationale of changes, setting in motion a permanent improvement structure. The participants considered that mapping and then assessing the entire workflow across disciplines were relevant methods for improving the quality of patient care.

Starting an improvement project in a cross disciplinary environment requires deep engagement on the part of professionals. A quintessential prerequisite is therefore the realization that the quality of care depends on cross-disciplinary cooperation. A facilitated learning arena needs to (1) create insights into each other’s colleagues’ tasks and process interdependencies, (2) increase understanding of how the distribution of tasks among specialist units affects the quality of care, and (3) frequently report and provide feedback on results to keep the process going.

Peer Review reports

General hospitals tend to be organized in disciplinary silos. Such an organizational structure seriously impedes organizational learning and the ability to improve care processes. Improving care processes that involve multiple silos requires close coordination between those silos. This is hampered when individual silos are managed as stand-alone units, as tends to be the case.

This study explores and describes how a common understanding between disciplinary silos was created. By distilling key factors and mechanisms, we aim to further our collective knowledge on how to start continuous improvement projects in hospitals. To our knowledge, due to a dearth of papers on continuous improvement in healthcare and general hospitals in particular, this aspect has not yet been focused on. In their seminal paper Why hospitals don’t learn from failure , Tucker and Edmondson [ 1 ] came close in pointing to barriers between disciplinary silos, yet they did not relate this to continuous improvement. We show how healthcare professionals in different disciplines need to understand each other’s tasks as a starting point for improvement. This goes beyond cognition, as seeing how one’s tasks impact those of others in a cross-disciplinary treatment process also motivates involvement in improving care paths. Knowing the context of the entire workflow will create opportunities for reflection and improve practitioners’ assessments of the quality of the overall treatment process.

A general principle of the organizational structure of hospitals is to grouping practitioners into communities according to their medical competence. The surgery, neurology, internal medicine, radiology, etc. communities usually have their own manager, budget, and separate arenas for follow-up of outcomes. This organizational principle has led organizational researchers to classify hospitals as institutions with their own inherited ideological appeal and complex power relations constituted around various categories of expert knowledge [ 2 ]. Another typical feature of hospitals is that most outcomes are created through work processes that include contributions from many of the autonomous professional units, i.e. diagnosis and treatment of emergency medical conditions such as myocardial infarction, femoral neck fracture, stroke, and sepsis. In daily work, practitioners in the ambulance service, emergency departments, intensive care unit, radiology, medical laboratories, groups of doctors (MD), and wards will be involved in solving defined subtasks that are part of one continuous treatment path.

Research has revealed that the discipline-based organization of healthcare creates dysfunctions [ 3 , 4 , 5 , 6 , 7 ]. Studies report that lack of interaction and communication between the functional units leads to lower efficiency [ 8 ], discontinuity in the flow to the patients that decreases both productivity and satisfaction [ 9 ], duplication of work [ 7 ], and a lack of trust between employees working in different parts of the organization [ 6 , 7 ].

A frequently cited study conducted at eight US hospitals highlights why it is difficult to find solutions to achieve better coordination across units [ 1 ]. It was found that practitioners experienced repeated problems due to a lack of coordination between professional units. However, these problems did not constitute a starting point for involving other units in the search for better solutions. Instead, practitioners solved problems as they arose by detouring or reworking inside their unit, without involving others. Results indicate that hospital-related cultural norms could explain the practitioners’ way of dealing with coordination problems. Firstly, efficiency concerns prompt staff to resolve issues quickly to prioritize patient care. Secondly, individual vigilance norms encouraged practitioners to solve problems without bothering other professional units. Finally, a widespread empowerment norm leads practitioners to solve problems themselves without involving managers.

These previous research findings have an impact on the conclusions in a summary review of organizational science in healthcare conducted by Mayo, Myers, and Sutcliffe [ 10 ]. Their systematic literature review of organizational science in the health sector describes research findings and trends through an analysis of the 730 most cited articles in the field over the past decade. They reported a lack of research on how different dependencies between subsystems create challenges and require solutions. These researchers argue that increasing specialization requires the development of new knowledge that can inform how different parts of the organization contribute to the overall care system [ 10 ].

The present study aims to answer the call from Mayo and colleagues. We argue that sustainable solutions need to create insights among practitioners so that they understand why coordination between professional units is relevant to the quality of patient services. Such knowledge creation will also need to develop an understanding of why accurate interaction between professional units is crucial for avoiding duplication of efforts and waste of valuable medical expertise. Based on this premise, we pose the following research question:

What were the key factors and mechanisms in starting the continuous improvement of cross-disciplinary care processes in a general hospital?

We regard the initial period of an improvement intervention to be of specific interest for answering this question. Therefore, this study describes and analyzes changes in practitioners’ organizational problem understanding in facilitated improvement work aimed at improving stroke treatment in a Norwegian hospital. Several researchers describe such startup periods as a problem clarification phase [ 11 , 12 , 13 , 14 ]. Interviews with employees deeply involved in the start-up phase of this improvement effort provide information to increase understanding of how this happened in the present case.

Design and methods

To gain an in-depth understanding of the underlying mechanisms behind the process of improving stroke treatment in the hospital we applied a single-case design. A case study is useful for understanding both complex social occurrences and organizations [ 17 ]. The case was selected because it contains comprehensive data relevant to the topic of the study. We explore and describe the startup period of cross-functional improvement work in a typical small Norwegian hospital. The improvement work was part of a larger effort to introduce lean thinking in the hospital. The lean approach aimed to develop the hospital’s ability to continually improve cross-disciplinary work processes by designing coherent flows with the least amount of waste [ 15 , 16 ].

The hospital had chosen value stream analysis as the preferred methodology, and specialist units with practical tasks in value streams should be a part of improvement work. The narratives in this case are crucial aspects of the findings and constitute opportunities for obtaining complex knowledge and achieving a comprehensive understanding [ 15 , 16 , 17 ]. Utilizing multiple data sources is advisable in case studies because it allows diverse perspectives to be captured. The present case includes data from participant observations, individual interviews, documents, and statistics on the duration of treatment times. Participant selection is reported in the Case Study section.

Data collection

We present data from two different time periods. The first dataset is a systematization of documents and observations from the period May–October 2013. This information was originally gathered to document work conducted in an inter-disciplinary group to improve stroke treatment. It includes meeting minutes, action lists, flowcharts, electronic mail exchanges, field notes, and statistics reporting outcomes. The field notes are important as observational data collected by the first author when working as an internal change agent in the cross-functional working group. The second data source includes interviews with five employees who participated in the group mentioned above. We were particularly interested in their reflections on how activities carried out in the start-up phase contributed to the development of organizational understanding. An interview guide was developed in collaboration between the first and second authors, please see Supplemental file 1. The interviews were conducted face to face by the first author between November 2022 and February 2023, lasted from 55 to 72 min, and were transcribed verbatim by the first author. The informants comprise two MDs, a radiographer, a nurse, and an employee of the ambulance service. Employees who participated in the cross-functional working group interviews voluntarily consented to participate in this study and completed an informed written consent form. SIKT (Norwegian Agency for Shared Services in Education and Research) has approved the research project in a decision by the Data Protection Officer at Innlandet Hospital (Protocol nr.19,449,967).

A thematic analysis [ 18 ] was conducted to identify the main themes and concepts related to the research question. Field notes and documents were chronologically organized to gain a timeline of activities conducted in the cross-disciplinary improvement group. The interview data was analyzed as a separate data set, which proved to be important. These post-working group reflections demonstrate sustained learning and support the themes identified through the observational documents. Secondly, they provided the basis for the development of two new themes (themes 3 and 4 in the result section). The data was assessed as a complete set and read several times in the search for patterns and themes. All authors were involved in the analysis work and discussed the findings at several meetings. The back-and-forth process between codes and themes involved reviewing relevant research and theoretical perspectives to help us understand the data. Development of the main and sub-themes was guided by the research question. Table  1 presents an example of how the analysis was conducted.

Cross-disciplinary measure to improve stroke treatment

In May 2013, a concerned senior neurologist brought forward an issue to the hospital`s quality advisor. The MD had recently participated in a national stroke forum, which made her realize that patients suffering from stroke received poor-quality care at our hospital. According to the neurologist, poor organizing resulted in a delay in providing intravenous drug treatment to dissolve a blood clot in the brain. She called for immediate action, as patients with blood clots suffer extensive brain cell damage for every minute the condition remains untreated. The quality advisor agreed and suggested establishing an improvement group consisting of representatives from all specialized units involved in the treatment process. The neurologist objected, as she thought such a strategy would delay improvements. Instead, she sought the quality advisor’s help to reformulate procedures in the quality system, ensuring formal approval among hospital leaders, and dissemination of the updated procedures to all involved units with instructions to follow the new standard. After a discussion, the neurologist agreed to carry out the work using a group, on condition that the quality advisor took responsibility for gathering representatives from all the involved units.

At the next leader meeting, the quality advisor asked managers to support this work by selecting suitable representatives to form an interdisciplinary group. The selection should be based on two criteria. Firstly, the participants must possess good practical knowledge of the stroke treatment practice in the unit. Secondly, they must have a high professional reputation among employees in their unit.

The cross-functional stroke improvement group had its first meeting four weeks later. The participants consisted of nine skilled professionals without any formal leadership positions. They comprised a neurologist, a specialist nurse from the intensive care unit, a biomedical laboratory scientist, a radiologist, a radiographer, a nurse from the emergency department, a MD employed by the medical department, a local head of the ambulance service, and a quality advisor in the director’s leader group. Two of the participants in the interdisciplinary group were employed in cross-cutting divisions in the health trust. The representative from the ambulance service was affiliated with the Prehospital Services Division, and the biomedical laboratory scientist belonged to the Medical Services Division. In total, the group represented about 300 employees.

Before the meeting, the quality advisor arranged the meeting room. Eight chairs were set up in a semicircle in the middle of the room. Yellow and red post-it sticky notes and a pen were placed in front of each chair. After all the participants had introduced themselves, the quality advisor put two notes on the wall. These represented the first ( ambulance picks up patient ) and last task ( patient receives treatment to dissolve the blood clot in the brain ) of the entire stroke work process at the hospital. Participants were told to write every work task their unit performed when treating stroke patients and place these notes on the wall. A couple of the professionals were alert and the quality advisor sensed that unrest was spreading in the group. One participant approached the quality advisor and said: “Is the problem that you don’t you know how we work as professionals?” One MD shook his head and said, “We don’t have time for such nonsense. I believe we need to work more efficiently. Let’s start changing the stroke procedure , that’s why we’re here.” The quality advisor ignored these inputs, as he deemed it essential to obtain detailed knowledge about actual work tasks. He had noticed that the ambulance driver and nurse from the emergency department were writing down tasks and asked them to put their notes on the wall and explain the tasks to the rest of the group. One note from the ambulance driver read: “driving the patient to the municipal emergency room”. One of the MDs now raised his voice and exclaimed: ‘No , you can’t do that , it delays the treatment’ . The representative from the ambulance service explained that they had been told by the municipal MDs to stop by the municipal emergency room as this would ensure that the patient was “properly medically clarified” . The quality advisor stated that this was important information and explained that the red notes placed in front of the chairs could be used to register what the participants perceived as bottlenecks in the care process. He told the MD who had provided input to write; “delay ” on a red note and place it on the wall in connection with the ambulance driver’s description of the action. The next person to place task notes on the wall was the nurse from the emergency room. One note read “ conducts patient examination – takes vital parameters”. Both the ambulance driver and the MD then told the nurse that this action was unnecessary and delayed treatment because these data had already been gathered. The emergency department nurse responded that this was a standard routine for all patients and nurses were instructed to do it by their manager. Again, the quality advisor requested that this should be written on a red post-it note and placed on the wall. Several of the clinical staff now began to write notes describing tasks performed in their unit and placed them on the wall. The neurologist hung up a note that read “order emergency X-ray examination” , and at the same time a red bottleneck note, which read; “unnecessary waiting”. The participant from the X-ray department now reacted, raising his voice in an irritated manner. He approached the neurologist and said: “We`re doing the best we can , but equipment is always in use by another patient. Surely , we can’t just evict another patient who has nearly completed an extensive examination?” . The quality advisor interrupted this somewhat heated discussion, stating that the issue could not be resolved at today’s meeting. At this stage of the meeting, activity in the group increased, participants brought up more yellow notes outlining tasks and several red notes describing bottlenecks. During the next two hours, more than 60 task notes were placed on the wall and more than 20 bottlenecks identified. Figure  1 presents a simplified version of the workflow mapping conducted by the group at this meeting.

Simplified version of the employees’ mapping of tasks and associated bottlenecks in the treatment of stroke patients conducted in September 2013

At the end of this session, several participants commented that they had doubts about whether all tasks and bottlenecks had been included in the map. To verify the accuracy of the workflow, the group decided to collect more data by observing actual stroke practice before the next meeting.

Two weeks later, the cross-functional stroke improvement group met again. The participants had new information. A MD, involved in the treatment of a stroke patient, had noticed that treatment had been postponed due to the patient`s high blood pressure. The MD applied a red bottleneck tag on the wall that read “high blood pressure”. The ambulance driver replied, «Perhaps ambulance personnel could prescribe drugs to patients to lower blood pressure before arrival at the hospital?” The intensive care nurse had also experienced a new bottleneck, as treatment had been delayed because of the time required to insert a peripheral venous catheter. The ambulance driver replied that the ambulance crew “had time to insert venous catheters during transport to the hospital” , but he had another issue. Several of his colleagues thought it was difficult to assess stroke diagnosis because similar symptoms could occur in other medical conditions. The neurologist replied that the MD at the hospital could help in such cases. She said paramedics could “ get a direct number for the neurologist on duty at the hospital , and in case of doubt , they could call for professional support 24/7 ”.

At the end of the second meeting, the participants agreed that the wall map now represented a credible picture of how tasks were distributed throughout the entire workflow. As the group assessed the entire care path, the quality advisor asked: “ Is this design well suited for providing the patient with the fastest viable treatment?” The clinicians smiled exasperatedly and shook their heads, - all participants agreed that the design was weak. They summarized that delay in treatment was due to: patients being diagnosed several times by different actors, and four separate transport stages with delays between each stage. Finally, the process was slow because all units were unprepared when the patient arrived. Employees lacked knowledge of the arrival of a stroke patient and conflicts arose because everyone was busy attending other tasks. The quality advisor then posed the following question to the participants: “Who decided that the hospital should organize stroke treatment in this way?” Several of the employees laughed, and one said: “It is obvious that whoever designed it was not a genius!” At the end of the meeting, the group agreed to meet again two weeks later to work out a redesigned standard for stroke treatment.

The analysis revealed four main themes.

Practitioners acknowledged the relevance of utilizing a facilitated process to improve/enhance patient care. This theme includes the following subthemes: Use of an inter-disciplinary group, mapping the entire workflow identified the main problem as weak coordination between tasks, and assessing the entire workflow - ownership of new knowledge led to an obligation to contribute.

Practical changes with intermediate results.

Theme three

Transferring new organizational insights to colleagues is challenging.

Development of an awareness of the importance of cross-disciplinary cooperation.

Practitioners acknowledged the relevance of utilizing a facilitated process to improve patient care

Use of an inter-disciplinary group.

The first meeting between the quality advisor and the experienced neurologist involved a dialogue that over time resulted in a common understanding of the change strategy. Firstly, they agreed that tardiness in stroke treatment was related to the weak coordination in task distribution among sub-units. Their understandings differed in terms of strategy. The neurologist wanted help from the quality advisor to distribute a revised stroke protocol initiated by a single unit to all departments for implementation. To maximize meaningful, sustainable change, the quality advisor introduced a strategy involving employees to develop their understanding. Thanks to the dialogue, the neurologist accepted that the quality advisor had expertise in how to organize work to achieve behavioral change among 300 hospital employees. Because the quality adviser received assistance from the hospital’s senior management team, the group was composed of practitioners who had relevant practical experience in the field to be improved, and high professional standing among employees in their unit. Many years later, the neurologist expressed her «new» understanding as follows: “I had the answer , but not the recipe…. I’ve learned a lot from the work that we’ve done. It’s made me understand that there’s no point in getting someone to change if they don’t understand why ” (Quote from interview M.D November 2022).

The interdisciplinary group became an arena for the neurologist to explain the significance of changes for the future health of patients with thrombotic stroke. A participant expressed; “ I was surprised at the damage to patients if treatment was delayed by a few minutes.” “In this case , the benefits for the patient’s health were so obvious that it made it easier to make an effort in the work” (Radiographer, December 2022).

Mapping the entire workflow identified the main problem as weak coordination between tasks

At the first meeting, participants brought different goals, motives, and understanding of problems to the improvement work, which were influenced by their own practice experiences. A common denominator for the focus on problems can be summed up by the statement “At the beginning , everyone thought of themselves ” (radiographer, Dec.2022). One of the nurses recounted; “The instruction from my unit was to not play an active part in this work. The reason was that stoke treatment could be a time waster in terms of us having to leave our unit , thus affecting the care of the other patients in the intensive care unit.» . How can this focus be understood? At this stage of the improvement work, the stroke workflow was organized, so that units performed tasks in separate stages. This indicates that each unit only had experience of a limited part of the complete care delivery process.

Together, the practitioners used their clinical practice experience to create a wall image, revealing the entire stroke workflow. Later, they revised this description after collecting additional information from practice. Over time, it led members of the group to develop confidence that the image represented a truthful description of how work was carried out. The graphic wall picture made it possible for all participants to assess the entire work process at the same time. When they assessed the entire workflow, they found that units’ problems described as workflow bottlenecks (in Fig.  1 ) were part of another problem, namely a lack of logic and coordination in the distribution of tasks between units. Participants realized that different units attended to the same tasks at different times in the process (e.g., diagnosis and repeated documentation in medical records). Lack of communication (e.g., no notification to the next unit of the arrival of a stroke patient) created simultaneous conflicts and delays because equipment and personnel were busy. The map made it obvious to everyone that the delay in the treatment of patients was a consequence of the way the process was designed. A member of the improvement group remarked: “To consider all stages of a workflow was new to us , and we discovered connections we hadn’t been aware of before.” (Ambulance driver , Dec. 2022) . Several participants who were interviewed found it difficult to point out a particular time or event that changed their understanding of the problem. “I learned a lot from this with mapping the bottlenecks , but we spent quite a lot of time formulating a description of reality that we all agreed was truthful. I think this ( authors remark: knowledge development ) takes time , and it’s important in itself.” (Nurse , Feb. 2023) .

The mapping also helped participants identify cross-unit improvement opportunities. They even brought forward suggestions about how other disciplines could change how they performed their tasks to ensure speedy treatment. A paramedic participant commented: “For us , it was very useful to gain an understanding of the entire work process , and not just our tasks. It created a better understanding of how we could work to contribute to better patient care.” (Ambulance driver Nov. 2022) .

Assessing the entire workflow ownership of new knowledge led to an obligation to contribute

During the mapping process, the practitioners discovered that no one person or unit was responsible for the entire stroke process. They also understood that nobody deliberately created the poor design. They realized that the task distribution was something that had evolved, probably due to an accumulation of changes within each professional unit. At this point, these insights were not familiar to other professionals in the hospital. Together, these factors contributed to an understanding that if someone was to take responsibility for improving treatment for stroke patients, the group had to play an active role. A specialist nurse stated: “ I had a different feeling about whether we should be involved after the group had completed the workflow mapping. I went directly to my manager after this meeting and said that here we need to play an active part in the change work if stroke patients were to receive better treatment” (Nurse- Feb. 2023).

Practical changes with intermediate results

Practitioners’ new insights made them implement some practical changes in the task distribution that resulted in patients with stroke receiving much faster treatment to dissolve blood clots in the brain, as evident in “door to needle time” outcomes (Fig.  2 ). The rapid changes were possible because the improvement group was mandated by the director’s leader group and the quality adviser who led the work was part of the director’s management team. An agreement was made with all sub-unit managers that ongoing changes in the stroke procedures would be implemented without their formal approval. Instead, members of the improvement group discussed proposed changes with peers before implementing them in the revised stroke protocol. Important changes included ambulance personnel receiving assistance from a neurologist at the hospital to make a preliminary diagnosis. Subsequently, all units were notified before the patient arrived at the hospital, and patients were brought directly to the radiology department. There, professionals from various units gathered as a team to finalize the diagnosis and provide treatment.

Door to needle times. Source Manuel registers made by the secretary of emergency medicine, based on the extracts from patient records

Information from the reflexive interviews confirms that the changes implemented in 2013, were still maintained ten years later. Statistics from the National Stroke Registry (Norwegian Stroke Registry | National Service Environment for Medical Quality Registries) for the period 2016–2022 confirms that the results are permanent and place the hospital among the best at national level in the years 2021 and 2022.

Transferring new organizational insights to colleagues is challenging

A common feature from the interviews is that the participants found it difficult to transfer their new organizational understanding to colleagues. “It wasn’t just me who had to understand , others also had to understand” (quotation from an interview with an MD in December, 2022). The participants’ new organizational understanding was developed through a process in which they first mapped out a complex work process consisting of more than 60 tasks. Because this was visualized on a wall, it became possible to assess whether the overall division of tasks was appropriate. This process was difficult to replicate in one’s professional unit. “It was difficult to get others to understand the flowchart” (interview nurse, January, 2023). One doctor stated: “In the beginning , it was easier to discuss relevant changes with the professional staff in the working group because we had a common understanding of the flowchart”. All participants said they spent quite a lot of time convincing colleagues of “the big picture”. They pointed to three factors that enabled them to succeed in developing employees’ understanding.

1. Focus on results; Door to needle times were published continuously – and motivated employees to find measures to reduce the time 2. Understanding local context. The participants considered their efforts necessary to develop understanding among peers in their professional unit. They had access to professional meetings, personnel meetings, or daily discussions with colleagues, and understood the operations of the professional unit. “You or someone else at the hospital would not have been able to do this if you had brought a flowchart to our department. I understood how I had to do this in order to lower the level of resistance in our department” (quotation from the interview with the radiographer, November 2022). 3. Finally, the practitioners thought it was of great importance that the knowledge had been developed in a group of peers. The interdisciplinary improvement group consisted of highly recognized clinicians, which gave participants the confidence to argue that new understandings was rooted in the clinic.

Awareness of the importance of cross-disciplinary cooperation

The hospital has several work processes that cross professional hierarchies. It is not unreasonable to assume that weak coordination also creates problems in other cross-cutting work processes. The question is whether employees have developed a generalized understanding of the importance of coordination. If so, this would mean that they understand that weak coordination can be the cause of several quality problems at the hospital.

Several of the participants in the interdisciplinary improvement group suspected that other quality problems in the hospital could be understood by considering weak coordination in cross-cutting work processes. For example, one MD explained that “a lack of quality in referrals from municipal MDs leads to the hospital staff spending a lot of time assessing low quality referrals , and this weakens the quality of patient services” ( MD, Nov. 2022). Similarly, an employee from the ambulance service believed that patients with a type of acute heart disease would receive improved health services if the entire patient pathway was better coordinated. Furthermore, they considered that the organizing principles used to improve stroke treatment would also be efficient for enhancing other cross-cutting work processes. However, the analysis of the data in this study does not provide sufficient support for claiming that the participants have developed a basic understanding that many quality problems in the hospital are due to poor coordination between units.

This study specifies key factors and mechanisms in the start-up period of cross-disciplinary improvement work in hospitals enabling all disciplines to pull in the same direction. The facilitated improvement working group process resulted in the identification of several tasks that emerged as opportunities for improving care across the stroke continuum. Reflective interviews confirmed the most important result of this improvement approach was a sustained insight/understanding on the part of practitioners that a poorly coordinated workflow resulted in a significant delay in the provision of effective treatment to stroke patients. To our knowledge, this has not been demonstrated in previous research. However, several studies have called for research that can provide such knowledge [ 10 , 19 , 20 , 21 ] Previous studies also call for scientific approaches that can clarify how context influences the outcomes of organizational change [ 10 , 16 , 17 , 19 , 22 ]. This study presents an approach that includes a rich description of the context surrounding the start-up period of this improvement work. This provides opportunities for readers to assess whether the findings represent reasonable interpretations.

The findings can also be seen in light of theories of organizational learning. In a conceptual understanding of organizational learning, the mapping process can be described as an activity in which employees’ uncovered “theory in use“ [ 11 , 12 ]. The VSM process revealed that none of the professionals knew the overall task solution. When given the possibility to access the entire workflow, it changed their understanding of what caused delays in the treatment of stroke patients. Could practitioners have achieved their new understanding without being directly involved in the improvement group? An alternative may have involved having process consultants map the entire workflow by walking the stroke pathway (following the patient’s footsteps). This could provide a workflow quite like the one produced in the interdisciplinary group (illustrated in Fig.  1 ), which could save time and allow representatives from the various units to reflect on the fully mapped workflow. However, the results of the present study indicate that this strategy is not a workable shortcut. Feedback from the participants in the improvement group reveals that the interaction with other professionals was crucial for the development of their understanding of the problem. These findings correspond with studies reporting that active involvement of and engaging the workforce seem to be driving forces behind maintaining continuous improvement in healthcare [ 23 ]. Several participants reported that their understanding changed over time because of the learning process. This can be understood by considering how their increased comprehension was obtained. Understanding was acquired when assessing the logical consistency in a complex graphic workflow consisting of more than sixty work tasks and more than twenty bottlenecks (see Fig.  1 ). It is difficult to recreate this reflection opportunity for employees who have not been part of the learning process. This finding is supported by a study reporting that healthcare professionals benefit most from learning styles that focus on the discovery of connections through own participation [ 24 ].

The interviews indicate that the employees’ new insights made them suspect that poorly coordinated cross-cutting processes resulted in other quality problems in the hospital. Such generalized organizational knowledge will be very valuable to hospitals that have numerous hidden cross-disciplinary processes in which the appropriateness of the distribution of tasks between units has not been assessed. However, the data analysis does not support the assumption that participants have developed a basic understanding that many other quality problems in the hospital are because of poorly coordinated cross-cutting processes. This is beyond the scope of the present study but might be an idea for future studies.

Ethical and methodological reflections

Conducting research as an insider is challenging [ 25 ].The first author of this study had a defined responsibility for organizing the interdisciplinary working group and his participation has potentially affected the outcomes of this study (data collection, analyses, and results). The co-authors maintain positions as the first author’s supervisors. Throughout the development of the study, they challenged the first author’s interpretation of the data by proposing alternative interpretations. This led to reflections and discussions on what constitutes the most important findings of the study. As a result, the first author has been forced to reflect on why it is so important to involve practitioners. Or - why was it important that practitioners understood the necessity of changing the distribution of tasks between units?

Interview data was collected almost 10 years after the improvement work was initiated. It had the consequence that participants no longer remembered all the details from the start-up phase. Among other things, several participants mixed up the order of activities out at the time. This weakened the precision of the data but was somewhat remedied because the author had an excellent overview of the course of events based on meeting minutes and field notes.

We set out to answer the following research question: What were the key factors and mechanisms in starting the continuous improvement of cross-disciplinary care processes in a general hospital?

Starting such an improvement project requires deep engagement on the part of healthcare professionals. A quintessential prerequisite is making healthcare professionals realize how the quality of care depends on cross-disciplinary cooperation. A facilitated learning arena needs to (1) create insights into each other’s colleagues’ tasks and process interdependencies, (2) increase understanding of how the distribution of tasks among specialist units affects the quality of care, and (3) frequently report and provide feedback on results to keep the process going.

Data availability

The datasets generated in the present study are not publicly available but are available from the corresponding author on reasonable request.

Abbreviations

Medical Doctor

Value Stream Mapping

Tucker AL, Edmondson AC. Why hospitals don’t learn from failures: Organizational and Psychological Dynamics that Inhibit System Change. Calif Manage Rev. 2003;45(2):55–72. https://doi.org/10.2307/41166165 .

Article   Google Scholar  

Doolin B. Enterprise Discourse, Professional Identity and the Organizational Control of Hospital Clinicians. Organ Stud. 2002;23(3):369–90. https://doi.org/10.1177/0170840602233003 .

Alves J, Meneses R. Silos mentality in healthcare services. In: 11th Annual Conference of the EuroMed Academy of Business. vol. 2018; 2018.

Bento F, Tagliabue M, Lorenzo F. Organizational silos: a scoping review informed by a behavioral perspective on systems and networks. Societies. 2020;10(3):56.

Kreindler SA, Dowd DA, Dana Star N, Gottschalk T. Silos and social identity: the social identity approach as a framework for understanding and overcoming divisions in health care. Milbank Q. 2012;90(2):347–74.

Article   PubMed   PubMed Central   Google Scholar  

Hajek AM. Breaking down clinical silos in healthcare. Front Health Serv Manage. 2013;29(4):45–50.

Article   PubMed   Google Scholar  

McCartney M. Margaret McCartney: breaking down the silo walls. BMJ. 2016;354.

Vatanpour H, Khorramnia A, Forutan N. Silo effect a prominence factor to decrease efficiency of pharmaceutical industry. Iran J Pharm Research: IJPR. 2013;12(Suppl):207.

PubMed Central   Google Scholar  

Drupsteen J, van der Vaart T, van Pieter D. Integrative practices in hospitals and their impact on patient flow. Int J Oper Prod Manage. 2013;33(7):912–33.

Mayo AT, Myers CG, Sutcliffe KM, Organizational Science and Health Care. Acad Manag Ann. 2021;15(2):537–76. https://doi.org/10.5465/annals.2019.0115 .

Argyris C. Double loop learning in organizations. Harv Bus Rev. 1977;55(5):115–25.

Google Scholar  

Argyris C, Schön DA. Organizational Learning II: Theory. Method and Practice. 1996;2.

Klev R, Levin M. Participative transformation: learning and development in practising change. Routledge; 2016.

Lewin K. Field theory in social science: selected theoretical papers (Edited by Dorwin Cartwright.). Oxford, England: Harpers; 1951.

Walshe K. Understanding what works–and why–in quality improvement: the need for theory-driven evaluation. Int J Qual Health Care. 2007;19(2):57–9. https://doi.org/10.1093/intqhc/mzm004 .

Walshe K. Pseudoinnovation: the development and spread of healthcare quality improvement methodologies. Int J Qual Health Care. 2009;21(3):153–9. https://doi.org/10.1093/intqhc/mzp012 .

Øvretveit J. Understanding the conditions for improvement: research to discover which context influences affect improvement success. BMJ Qual Saf. 2011;20(Suppl 1):i18–23. https://doi.org/10.1136/bmjqs.2010.045955 .

Braun V, Clarke V. Using thematic analysis in psychology. Qualitative Res Psychol. 2006;3(2):77–101. https://doi.org/10.1191/1478088706qp063oa .

Ramaswamy R, Reed J, Livesley N, Boguslavsky V, Garcia-Elorrio E, Sax S, et al. Unpacking the black box of improvement. Int J Qual Health Care. 2018;30(suppl1):15–9.

Hill JE, Stephani A-M, Sapple P, Clegg AJ. The effectiveness of continuous quality improvement for developing professional practice and improving health care outcomes: a systematic review. Implement Sci. 2020;15(1):1–14.

Endalamaw A, Khatri RB, Mengistu TS, Erku D, Wolka E, Zewdie A, Assefa Y. A scoping review of continuous quality improvement in healthcare system: conceptualization, models and tools, barriers and facilitators, and impact. BMC Health Serv Res. 2024;24(1):487.

Moraros J, Lemstra M, Nwankwo C. Lean interventions in healthcare: do they actually work? A systematic literature review. Int J Qual Health Care. 2016;28(2):150–65.

Kunnen Y, Roemeling O, Smailhodzic E. What are barriers and facilitators in sustaining lean management in healthcare? A qualitative literature review. BMC Health Serv Res. 2023;23(1):958.

Article   CAS   PubMed   PubMed Central   Google Scholar  

Weggelaar-Jansen AM, van Wijngaarden J, Slaghuis S-S. Do quality improvement collaboratives’ educational components match the dominant learning style preferences of the participants? BMC Health Serv Res. 2015;15:1–13.

Coghlan D, Casey M. Action research from the inside: issues and challenges in doing action research in your own hospital. J Adv Nurs. 2001;35(5):674–82. https://doi.org/10.1046/j.1365-2648.2001.01899.x .

Article   CAS   PubMed   Google Scholar  

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Acknowledgements

We would like to express our sincere thanks to the employees who participated in this study.

This project is funded by Innlandet Hospital Trust, Norway. The funding body had no role in the study design, data collection, analyses and interpretation of data or writing the manuscript.

Open access funding provided by NTNU Norwegian University of Science and Technology (incl St. Olavs Hospital - Trondheim University Hospital)

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Are Fjermeros & Halvor Holtskog

Innlandet Hospital Trust, Lillehammer, Norway

Are Fjermeros & Geir Vegard Berg

Norway Department of Industrial Economics and Technology Management, Norwegian University of Science and Technology, Alfred Getz vei 3, Gløshaugen, Trondheim, 7491, Norway

Jos Benders

Centre for Sociological Research, KU Leuven, Parkstraat 45, Leuven, 3000, Belgium

Inland Norway University of Applied Sciences, Elverum, Norway

Geir Vegard Berg

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AF: change agent, data collection, gather feedback, research design, interpretation, main author. JB: conceptualization, frequent discussions during writing process, co-author. GVB: Contributed in designing and planning the study, responsible project leader on behalf of the Hospital, participating in the analytical process and discussions during writing process, co-author. HH: conceptualization, frequent discussions during writing process, co-author. All authors read an approved the final manuscript.

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The Norwegian Centre for Research data (NSD) was notified about this study. The data protection officer of Innlandet Hospital Trust`s Institutional Review Board, where the study was conducted also approved the study. In addition, the hospital director has given approval for the researcher to obtain information to shed light on research questions in this study. All authors declare that the methods were carried out in accordance with relevant guidelines and regulations. Participation in this research depended on informed and voluntary consent. All participants received verbal and written information about the study. All participants who consented to participate signed informed consent forms. They were free to withdraw from the study at any time.

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Fjermeros, A., Berg, G.V., Holtskog, H. et al. Starting continuous improvement; creating a common understanding of stroke care delivery in a general hospital. BMC Health Serv Res 24 , 899 (2024). https://doi.org/10.1186/s12913-024-11327-y

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DOI : https://doi.org/10.1186/s12913-024-11327-y

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