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Harvard T.H. Chan School of Public Health Case-Based Teaching & Learning Initiative

Teaching cases & active learning resources for public health education, case library.

The Harvard Chan Case Library is a collection of teaching cases with a public health focus, written by Harvard Chan faculty, case writers, and students, or in collaboration with other institutions and initiatives.

Use the filters at right to search the case library by subject, geography, health condition, and representation of diversity and identity to find cases to fit your teaching needs. Or browse the case collections below for our newest cases, cases available for free download, or cases with a focus on diversity.

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Many of our cases are available for sale through Harvard Business Publishing in the Harvard T.H. Chan case collection . Others are free to download through this website .

Cases in this collection may be used free of charge by Harvard Chan course instructors in their teaching. Contact Allison Bodznick , Harvard Chan Case Library administrator, for access.

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Teaching notes are available as supporting material to many of the cases in the Harvard Chan Case Library. Teaching notes provide an overview of the case and suggested discussion questions, as well as a roadmap for using the case in the classroom.

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Teaching notes for cases available through Harvard Business Publishing may be downloaded after registering for an Educator account .
To request teaching notes for cases that are available for free through this website, look for the "Teaching note available for faculty/instructors " link accompanying the abstract for the case you are interested in; you'll be asked to complete a brief survey verifying your affiliation as an instructor.

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Faculty and instructors with university affiliations can register for Educator access on the Harvard Business Publishing website, where many of our cases are available . An Educator account provides access to teaching notes, full-text review copies of cases, articles, simulations, course planning tools, and discounted pricing for your students.

What's New

Atkinson, M.K. , 2023. Organizational Resilience and Change at UMass Memorial , Harvard Business Publishing: Harvard T.H. Chan School of Public Health. Available from Harvard Business Publishing Abstract The UMass Memorial Health Care (UMMHC or UMass) case is an examination of the impact of crisis or high uncertainty events on organizations. As a global pandemic unfolds, the case examines the ways in which UMMHC manages crisis and poses questions around organizational change and opportunity for growth after such major events. The case begins with a background of UMMHC, including problems the organization was up against before the pandemic, then transitions to the impact of crisis on UMMHC operations and its subsequent response, and concludes with challenges that the organization must grapple with in the months and years ahead. A crisis event can occur at any time for any organization. Organizational leaders must learn to manage stakeholders both inside and outside the organization throughout the duration of crisis and beyond. Additionally, organizational decision-makers must learn how to deal with existing weaknesses and problems the organization had before crisis took center stage, balancing those challenges with the need to respond to an emergency all the while not neglecting major existing problem points. This case is well-suited for courses on strategy determination and implementation, organizational behavior, and leadership.

The case describes the challenges facing Shlomit Schaal, MD, PhD, the newly appointed Chair of UMass Memorial Health Care’s Department of Ophthalmology. Dr. Schaal had come to UMass in Worcester, Massachusetts, in the summer of 2016 from the University of Louisville (KY) where she had a thriving clinical practice and active research lab, and was Director of the Retina Service. Before applying for the Chair position at UMass she had some initial concerns about the position but became fascinated by the opportunities it offered to grow a service that had historically been among the smallest and weakest programs in the UMass system and had experienced a rapid turnover in Chairs over the past few years. She also was excited to become one of a very small number of female Chairs of ophthalmology programs in the country.

Dr. Schaal began her new position with ambitious plans and her usual high level of energy, but immediately ran into resistance from the faculty and staff of the department. The case explores the steps she took, including implementing a LEAN approach in the department, and the leadership approaches she used to overcome that resistance and build support for the changes needed to grow and improve ophthalmology services at the medical center.

This case describes efforts to promote racial equity in healthcare financing from the perspective of one public health organization, Community Care Cooperative (C3). C3 is a Medicaid Accountable Care Organization–i.e., an organization set up to manage payment from Medicaid, a public health insurance option for low-income people. The case describes C3’s approach to addressing racial equity from two vantage points: first, its programmatic efforts to channel financing into community health centers that serve large proportions of Black, Indigenous, People of Color (BIPOC), and second, its efforts to address racial equity within its own internal operations (e.g., through altering hiring and promotion processes). The case can be used to help students understand structural issues pertaining to race in healthcare delivery and financing, to introduce students to the basics of payment systems in healthcare, and/or to highlight how organizations can work internally to address racial equity.

Kerrissey, M.J. & Kuznetsova, M. , 2022. Killing the Pager at ZSFG , Harvard Business Publishing: Harvard T.H. Chan School of Public Health case collection. Available from Harvard Business Publishing Abstract This case is about organizational change and technology. It follows the efforts of one physician as they try to move their department past using the pager, a device that persisted in American medicine despite having long been outdated by superior communication technology. The case reveals the complex organizational factors that have made this persistence possible, such as differing interdepartmental priorities, the perceived benefits of simple technology, and the potential drawbacks of applying typical continuous improvement approaches to technology change. Ultimately the physician in the case is not able to rid their department of the pager, despite pursuing a thorough continuous improvement effort and piloting a viable alternative; the case ends with the physician having an opportunity to try again and asks students to assess whether doing so is wise. The case can be used in class to help students apply the general concepts of organizational change to the particular context of technology, discuss the forces of stasis and change in medicine, and to familiarize students with the uses and limits of continuous improvement methods.

Yatsko, P. & Koh, H. , 2021. Dr. Joan Reede and the Embedding of Diversity, Equity, and Inclusion at Harvard Medical School , Harvard T.H. Chan School of Public Health case collection. Available from Harvard Business Publishing Abstract For more than 30 years, Dr. Joan Reede worked to increase the diversity of voices and viewpoints heard at Harvard Medical School (HMS) and at its affiliate teaching hospitals and institutes. Reede, HMS’s inaugural dean for Diversity and Community Partnership, as well as a professor and physician, conceived and launched more than 20 programs to improve the recruitment, retention, and promotion of individuals from racial and ethnic groups historically underrepresented in medicine (UiMs). These efforts have substantially diversified physician faculty at HMS and built pipelines for UiM talent into academic medicine and biosciences. Reede helped embed the promotion of diversity, equity, and inclusion (DEI) not only into Harvard Medical School’s mission and community values, but also into the DEI agenda in academic medicine nationally. To do so, she found allies and formed enduring coalitions based on shared ownership. She bootstrapped and hustled for resources when few readily existed. And she persuaded skeptics by building programs using data-driven approaches. She also overcame discriminatory behaviors and other obstacles synonymous with being Black and female in American society. Strong core values and sense of purpose were keys to her resilience, as well as to her leadership in the ongoing effort to give historically marginalized groups greater voice in medicine and science.

Cases Available for Free Download

"The foundation of Integrated Health Services is the relentless pursuit of value. Our fundamental purpose is to help IBM win in the marketplace through the health and productivity of our workforce." ---Martín Sepúlveda

Martín Sepúlveda, Vice President of Integrated Health Services at IBM, had played a central role in establishing IHS as a vital and ongoing contributor to the corporation's success. IBM's IHS organization, as it had come to be known in 2008, was a global team of approximately 250 occupational medicine, industrial hygiene, safety, health benefits and wellness professionals responsible for ensuring the health and well-being of IBM's over 400,000 employees worldwide. This case, set in 2011, highlights the many challenges and his team faced in developing strategies and approaches to creating a culture of health within IBM, and maintain its commitment to the well-being of every employee.

Gordon, R., Rottingen, J.-A. & Hoffman, S. , 2014. The Meningitis Vaccine Project , Harvard University: Global Health Education and Learning Incubator. Access online Abstract This case follows the vaccine development for Meningitis A, a disease that routinely caused deadly epidemics in Sub-Saharan Africa. The case explores why such a vaccine had not been developed previously and how the creation of the Meningitis Vaccine Project (MVP) - a partnership between the World Health Organization (WHO) and PATH, a non-governmental organization - enabled the vaccine to be successfully developed over 10 years by creating a novel product development partnership. Students examine why the public/private partnership was successful and how such a model could be applied to the development of other vaccines and health technologies. Additionally, the case explores the strategies applied by Marc LaForce, the MVP’s director and veteran public health advocate, to make the MVP a success. In particular, the case examines the management skills LaForce exercised during his tenure to develop a vaccine that affected African countries could afford through their own health budgets.

The Palestinian Bedouin of the Negev desert are a minority community within Israel, one that has experienced limits on its rights to land use and health access. The Bedouin claim of ownership of their ancestral lands is disputed by the state of Israel, which has attempted to condition access to state services, like health clinics, on the relinquishing of land claims. After the passage of universal healthcare in Israel in 1995, the Bedouin and their representatives developed a legal strategy to secure a right to health on their ancestral lands. This case explores this legal fight, the historical and health contexts of Bedouin citizens of Israel, the limitations of the law in pursuit of justice, and the role of community organizing in the struggle for fundamental rights to health. It highlights the concept of settler colonialism and the relevance of historical context when striving to secure health. Finally, it also emphasizes the distinction between public narratives about vulnerable populations from actors with power such as the State and the narratives of the vulnerable community populations themselves.

Chai, J., Gordon, R. & Johnson, P. , 2013. Steubenville, Ohio: A Community's Reckoning of Responsibility , Harvard University: Global Health Education and Learning Incubator. Access online Abstract This case explores the role of social media in bringing a sexual assault incident to national attention and to trial. Two popular high school athletes sexually assaulted a teenage girl at a party. Despite evidence of their guilt based on their own boasts and eye witnesses, the community refused to hold the boys accountable for their actions because of their status as star athletes on the local football team. "Steubenville, Ohio: A Community’s Reckoning of Responsibility" is part of a case series on violence against women that illustrates the critical role of leadership through an examination of how social factors influence women’s health. Students analyze the situations described by considering the circumstances that placed each protagonist in vulnerable positions. Participants examined the commonalities and differences of these situations in an effort to understand the circumstances that affect women’s well-being. Additionally, using the cases as a framework, students analyzed the connections between collective outrage, reactive action, and leadership.

In February 2015, technical staff reviewed the results from a jointly conducted study on malaria control. This study had major implications for malaria in Zambia—and elsewhere. The preliminary analysis strongly suggested that the study’s Mass Drug Administration (MDA) strategy was reducing the incidence of malaria disease. In addition, MDA seemed to be driving down the infection reservoir among asymptomatic people in the study area of the Southern Province of Zambia. Further analysis with mathematical models indicated that if the intervention was sustained so current trends continued, then the MDA strategy would make it possible to eliminate malaria in the Southern Province.

If malaria could be eliminated in one region of Zambia, that would provide new evidence and motivation to work towards elimination throughout the country, an ambitious goal. But it would not be easy to move from conducting one technical study in a single region to creating a national strategy for malaria elimination. The scientists realized that their new data and analyses—of malaria infections, mosquito populations, and community health worker activities—were not enough. A national malaria elimination effort would require mobilizing many partners, national and local leaders, and community members, and convincing them to get on board with this new approach.

Teaching note available for faculty/instructors .

Focus on Diversity, Equity, and Inclusion

Johnson, P. & Gordon, R. , 2013. Hauwa Ibrahim: What Route to Change? , Harvard University: Global Health Education and Learning Incubator. Access online Abstract This case explores Nigerian attorney Hauwa Ibrahim’s defense of a woman charged with adultery by Islamic Shariah law. One of Nigeria’s first female lawyers, Ibrahim develops a strategy to defend a young married woman, Amina Lawal, against adultery charges that could potentially, if the court judged against her, result in her death. While many Western non-governmental organizations and advocacy groups viewed Lawal’s case as an instance of human rights abuse and called for an abolition of the Shariah-imposed punishment, Ibrahim instead chose to see an opportunity for change within a system that many – especially cultural outsiders – viewed as oppressive. Ibrahim challenged the dominant paradigm by working within it to create change that would eventually reverberate beyond one woman’s case. Willing to start with a framework that saw long-term opportunity and possibility, Ibrahim developed a very measured change approach and theory framed in seven specific principles. Additionally, Ibrahim’s example of challenging her own internal paradigms while also insisting that others do the same invites students to examine their own internal systems and paradigms.

Elizabeth, a middle-aged African American woman living in Minnesota, develops chest pain and eventually presents to a local emergency room, where she is diagnosed with stress-related pain and given Vicodin. Members of a non-profit wellness center where she is also seen reflect on the connection between her acute chest pain and underlying stress related to her socioeconomic status. On a larger level, how much of her health is created or controlled by the healthcare system? What non-medical policy decisions impacted Elizabeth such that she is being treated with Vicodin for stress?

On February 1, 2020, Jessie Gaeta, the chief medical officer for Boston Health Care for the Homeless Program (BHCHP), received news that a student in Boston had tested positive for the novel coronavirus virus that causes COVID-19 disease. Since mid-January, Gaeta had been following reports of the mysterious virus that had been sickening people in China. Gaeta was concerned. Having worked for BHCHP for 18 years, she understood how vulnerable people experiencing homelessness were to infectious diseases. She knew that the nonprofit program, as the primary medical provider for Boston’s homeless population, would have to lead the city’s response for that marginalized community. She also knew that BHCHP, as the homeless community’s key medical advocate, not only needed to alert local government, shelters, hospitals, and other partners in the city’s homeless support network, but do so in a way that spurred action in time to prevent illness and death.

The case study details how BHCHP’s nine-person incident command team quickly reorganized the program and built a detailed response, including drastically reducing traditional primary care services, ramping up telehealth, and redeploying and managing staff. It describes how the team worked with partners and quickly designed, staffed, and made operational three small alternative sites for homeless patients, despite numerous challenges. The case then ends with an unwelcome discovery: BHCHP’s first universal testing event at a large city shelter revealed that one-third of nearly 400 people there had contracted COVID-19, that most of the infected individuals did not report symptoms, and that other large city shelters were likely experiencing similar outbreaks. To understand how BHCHP and its partners subsequently popped up within a few days a 500-bed field hospital, which BHCHP managed and staffed for the next two months, see Boston Health Care for the Homeless (B): Disaster Medicine and the COVID-19 Pandemic.

Yatsko, P. & Koh, H. , 2017. Dr. Jonathan Woodson, Military Health System Reform, and National Digital Health Strategy , Harvard Business Publishing: Harvard T.H. Chan School of Public Health case collection. Available from Harvard Business Publishing Abstract Dr. Jonathan Woodson faced more formidable challenges than most in his storied medical, public health, and military career, starting with multiple rotations in combat zones around the world. He subsequently took on ever more complicated assignments, including reforming the country’s bloated Military Health System (MHS) in his role as assistant secretary of defense for health affairs at the U.S. Department of Defense from 2010 to 2016. As the director of Boston University’s Institute for Health System Innovation and Policy starting in 2016, he devised a National Digital Health Strategy (NDHS) to harness the myriad disparate health care innovations taking place around the country, with the goal of making the U.S. health care system more efficient, patient-centered, safe, and equitable for all Americans. How did Woodson—who was also a major general in the U.S. Army Reserves and a skilled vascular surgeon—approach such complicated problems? In-depth research and analysis, careful stakeholder review, strategic coalition building, and clear, insightful communication were some of the critical leadership skills Woodson employed to achieve his missions.

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Browse our case library

In 2013, New York City Mayor Michael Bloomberg tried and failed to institute a ban on serving sizes of large sugary beverages. Obesity posed a large public health risk to the city. Mayor Bloomberg's proposed ban was one of many attempts to combat the rising threat of obesity. The case discusses the efficacy of the proposed ban on large soda serving sizes in the context of the other anti-obesity initiatives crafted by Bloomberg's administration.

Quelch, J.A. & Xia, Q. , 2015. AIP Healthcare Japan: Investing in Japan's Retirement Home Market , Harvard Business Publishing. Available from Harvard Business Publishing Abstract The CEO of a health care-based REIT is considering alternative nursing home investment strategies. Students must consider macro-industry trends, scale and scope issues and consumer segmentation data in making their recommendations.

Weinberger, E. , 2014. Beauty and the Breast: Mobilizing Community Action to Take on the Beauty Industry , Harvard T.H. Chan School of Public Health: Strategic Training Initiative for the Prevention of Eating Disorders (STRIPED). Download free of charge Abstract How does one learn to become an effective advocate? “Beauty and the Breast: Mobilizing Community Action to Take on the Beauty Industry” tells the story of protagonist Joe Wendell, known as Wendell, an emergency room nurse and widower raising a teenage daughter in Franklin, a largely working class town in the fictional US state of Columbia. One day his daughter announces she would like to have breast implants. The distressing news prompts Wendell into new, unforeseen directions as he learns all he can about implants and surgery, the “beauty culture” permeating society especially in his community, and the psychological development of teenagers. Though relieved to find out that as long as she is a minor she cannot legally obtain the surgery without his consent (and, no doubt, without his cash), Wendell starts to believe that greater protections for teen girls in Columbia are needed. In this effort he is guided by the confident figure of Anna Pinto, director of a community center in an East Franklin neighborhood with a vibrant Brazilian-American community where cosmetic surgery, especially for girls and young women, is something she perceives to be a particular problem and has some ideas about how to address. Teaching note available for faculty/instructors .

Quelch, J.A. , 2016. Consumers, corporations, and public health: A case-based approach to sustainable business , Oxford University Press. Publisher's Version Abstract Edited by John A. Quelch, this book contains 17 peer-reviewed, classroom-tested case studies depicting contemporary intersections of business and health, covering topics across geographies and sectors, including entries on e-cigarettes, recreational marijuana, and soda regulation, and illustrating the role and power of consumer behavior and choice within a health policy and health management context. An ideal primary or companion text for courses at the intersection of these two fields in MPH or MBA programs.

In August of 2020, after a day treating patients, John McAdams, MD, gets ready to meet with a young couple from the community. He is excited to share the latest progress on his institution’s Cancer Treatment and Control Center, which is set to open in 3 years. The $230+ million project is something that Dr. McAdams has been building in his mind for years. Its brick and mortar location will strive to be a truly different cancer center that emphasizes population health alongside acute treatment. Cutting edge technologies and innovative public health initiatives working in tandem will close the gap between rural and urban cancer patient outcomes.

After decades of diligence, vision, and advocacy from John, Midwest Regional Health (MRH) has purchased the physical location of what will be a state-of-the-art cancer treatment and control center—a rarity for rural America. The site is on the main campus and will be connected to the inpatient and pediatric hospitals by tunnels to have the cancer center be better integrated into the continuum of cancer care than an outpatient center at a separate location. According to John, “The architects have worked very hard to make the center what we wanted…very welcoming and reassuring but intertwining all the workings of the various departments.”

However, with just three years before the grand opening, questions remain about how to structure the management of the cancer center relative to the medical center and the oncology service line, how to expand the research base in oncology, and how to drum up excitement and support in the community.

Quelch, J.A. & Rodriguez, M. , 2014. Fresno's Social Impact Bond for Asthma , Harvard Business Publishing. Available from Harvard Business Publishing Abstract In 2014, Social Impact Bonds (SIBs) were quickly gaining popularity as an investment vehicle which joined together private investors and nonprofits to tackle social issues. Although numerous SIB projects and proposals had cropped up across the U.S. following the launch of the first SIB in the UK in 2010, none were explicitly focused on healthcare. Fresno, California announced the first healthcare SIB in 2013 to fund home-based programs to reduce asthma attacks. If successful, the Fresno SIB model would help solve the challenge of delivering preventative care efficiently in at-risk communities.

Milstein, D., Madden, S.L. & MacCracken, L. , 2015. Integrating Private Practice and Hospital-Based Breast Services at Baystate Health (Parts A & B) , Harvard Business Publishing: Harvard T.H. Chan School of Public Health case collection. Available from Harvard Business Publishing Abstract Dr. Laurie Gianturco (“Dr. G.”), Chief of Radiology at Baystate Health and President of the private imaging practice Radiology & Imaging, Inc. (“R&I”), and her partner for this project, Suzanne Hendery, VP of Marketing & Communications at Baystate Health, considered their new assignment. With Baystate leadership’s full executive sponsorship and support, but no additional budget, they were tasked with consolidating two competing practices—one operated by R&I, the other by Baystate Medical Center—to form a new breast services center under the Baystate umbrella. The consolidation would simplify redundant Baystate-affiliated breast services offerings, making the system less confusing for patients and providers while giving Baystate the opportunity to offer more patient-centered services as well as reducing its operating costs and boosting revenues. They knew it would be a complicated project, involving two competing physician practice cultures, three clinical specialty orientations, the potential disruption of existing referral networks, and the merger of imaging services for healthy women along with treatment for women with breast cancer. Despite these challenges, they banded together to define a patient-driven culture, create an integrated program, and build a strong brand anchored by the new facility. Their goal was to gain a competitive advantage by developing a relationship-based approach that would exceed customer (patients and referring physicians) expectations for service. “The financial argument was the easy part,” Dr. G reflected. “How to actually design a model of care is where we came to an impasse.”

Milstein, D. & Bhabha, J. , 2016. Kids in Need of Defense (KIND): The Challenges of Child Migration to the United States , Harvard Business Publishing: Harvard T.H. Chan School of Public Health case collection. Available from Harvard Business Publishing Abstract Since the flood of child migrants from Central America burst upon the southern United States in the summer of 2014—a vast rise in arrivals dubbed “the Surge”—Kids in Need of Defense (KIND) had been facing overwhelming demand for its legal services. Wendy Young, KIND’s president, explained that the organization’s primary mission was to ensure that no child appears alone in immigration court, but KIND also wanted to provide leadership, research, and advocacy to protect these “children on the move” from laws and practices that threatened their fundamental human rights. Ms. Young was facing a critical juncture in the organizational life of KIND: where and how should it focus its resources for greatest effectiveness in protecting child migrants? What limits must the organization set on its activities when facing an almost unlimited need for legal, social, health, and educational support of these vulnerable children?

Health Case Studies

(29 reviews)

Glynda Rees, British Columbia Institute of Technology

Rob Kruger, British Columbia Institute of Technology

Janet Morrison, British Columbia Institute of Technology

Publisher: BCcampus

Language: English

Formats Available

Conditions of use.

Learn more about reviews.

Reviewed by Jessica Sellars, Medical assistant office instructor, Blue Mountain Community College on 10/11/23

Comprehensiveness rating: 5 see less

This is a book of compiled and very well organized patient case studies. The author has broken it up by disease patient was experiencing and even the healthcare roles that took place in this patients care. There is a well thought out direction and plan. There is an appendix to refer to as well if you are needing to find something specific quickly. I have been looking for something like this to help my students have a base to do their project on. This is the most comprehensive version I have found on the subject.

Content Accuracy rating: 5

This is a book compiled of medical case studies. It is very accurate and can be used to learn from great care and mistakes.

Relevance/Longevity rating: 5

This material is very relevant in this context. It also has plenty of individual case studies to utilize in many ways in all sorts of medical courses. This is a very useful textbook and it will continue to be useful for a very long time as you can still learn from each study even if medicine changes through out the years.

Clarity rating: 5

The author put a lot of thought into the ease of accessibility and reading level of the target audience. There is even a "how to use this resource" section which could be extremely useful to students.

Consistency rating: 5

The text follows a very consistent format throughout the book.

Modularity rating: 5

Each case study is individual broken up and in a group of similar case studies. This makes it extremely easy to utilize.

Organization/Structure/Flow rating: 5

The book is very organized and the appendix is through. It flows seamlessly through each case study.

Interface rating: 5

I had no issues navigating this book, It was clearly labeled and very easy to move around in.

Grammatical Errors rating: 5

I did not catch any grammar errors as I was going through the book

Cultural Relevance rating: 5

This is a challenging question for any medical textbook. It is very culturally relevant to those in medical or medical office degrees.

I have been looking for something like this for years. I am so happy to have finally found it.

Reviewed by Cindy Sun, Assistant Professor, Marshall University on 1/7/23

Interestingly, this is not a case of ‘you get what you pay for’. Instead, not only are the case studies organized in a fashion for ease of use through a detailed table of contents, the authors have included more support for both faculty and students. For faculty, the introduction section titled ‘How to use this resource’ and individual notes to educators before each case study contain application tips. An appendix overview lists key elements as issues / concepts, scenario context, and healthcare roles for each case study. For students, learning objectives are presented at the beginning of each case study to provide a framework of expectations.

The content is presented accurately and realistic.

The case studies read similar to ‘A Day In the Life of…’ with detailed intraprofessional communications similar to what would be overheard in patient care areas. The authors present not only the view of the patient care nurse, but also weave interprofessional vantage points through each case study by including patient interaction with individual professionals such as radiology, physician, etc.

In addition to objective assessment findings, the authors integrate standard orders for each diagnosis including medications, treatments, and tests allowing the student to incorporate pathophysiology components to their assessments.

Each case study is arranged in the same framework for consistency and ease of use.

This compilation of eight healthcare case studies focusing on new onset and exacerbation of prevalent diagnoses, such as heart failure, deep vein thrombosis, cancer, and chronic obstructive pulmonary disease advancing to pneumonia.

Each case study has a photo of the ‘patient’. Simple as this may seem, it gives an immediate mental image for the student to focus.

Interface rating: 4

As noted by previous reviewers, most of the links do not connect active web pages. This may be due to the multiple options for accessing this resource (pdf download, pdf electronic, web view, etc.).

Grammatical Errors rating: 4

A minor weakness that faculty will probably need to address prior to use is regarding specific term usages differences between Commonwealth countries and United States, such as lung sound descriptors as ‘quiet’ in place of ‘diminished’ and ‘puffers’ in place of ‘inhalers’.

The authors have provided a multicultural, multigenerational approach in selection of patient characteristics representing a snapshot of today’s patient population. Additionally, one case study focusing on heart failure is about a middle-aged adult, contrasting to the average aged patient the students would normally see during clinical rotations. This option provides opportunities for students to expand their knowledge on risk factors extending beyond age.

This resource is applicable to nursing students learning to care for patients with the specific disease processes presented in each case study or for the leadership students focusing on intraprofessional communication. Educators can assign as a supplement to clinical experiences or as an in-class application of knowledge.

Reviewed by Stephanie Sideras, Assistant Professor, University of Portland on 8/15/22

The eight case studies included in this text addressed high frequency health alterations that all nurses need to be able to manage competently. While diabetes was not highlighted directly, it was included as a potential comorbidity. The five overarching learning objectives pulled from the Institute of Medicine core competencies will clearly resonate with any faculty familiar with Quality and Safety Education for Nurses curriculum.

The presentation of symptoms, treatments and management of the health alterations was accurate. Dialogue between the the interprofessional team was realistic. At times the formatting of lab results was confusing as they reflected reference ranges specific to the Canadian healthcare system but these occurrences were minimal and could be easily adapted.

The focus for learning from these case studies was communication - patient centered communication and interprofessional team communication. Specific details, such as drug dosing, was minimized, which increases longevity and allows for easy individualization of the case data.

While some vocabulary was specific to the Canadian healthcare system, overall the narrative was extremely engaging and easy to follow. Subjective case data from patient or provider were formatted in italics and identified as 'thoughts'. Objective and behavioral case data were smoothly integrated into the narrative.

The consistency of formatting across the eight cases was remarkable. Specific learning objectives are identified for each case and these remain consistent across the range of cases, varying only in the focus for the goals for each different health alterations. Each case begins with presentation of essential patient background and the progress across the trajectory of illness as the patient moves from location to location encountering different healthcare professionals. Many of the characters (the triage nurse in the Emergency Department, the phlebotomist) are consistent across the case situations. These consistencies facilitate both application of a variety of teaching methods and student engagement with the situated learning approach.

Case data is presented by location and begins with the patient's first encounter with the healthcare system. This allows for an examination of how specific trajectories of illness are manifested and how care management needs to be prioritized at different stages. This approach supports discussions of care transitions and the complexity of the associated interprofessional communication.

The text is well organized. The case that has two levels of complexity is clearly identified

The internal links between the table of contents and case specific locations work consistently. In the EPUB and the Digital PDF the external hyperlinks are inconsistently valid.

The grammatical errors were minimal and did not detract from readability

Cultural diversity is present across the cases in factors including race, ethnicity, socioeconomic status, family dynamics and sexual orientation.

The level of detail included in these cases supports a teaching approach to address all three spectrums of learning - knowledge, skills and attitudes - necessary for the development of competent practice. I also appreciate the inclusion of specific assessment instruments that would facilitate a discussion of evidence based practice. I will enjoy using these case to promote clinical reasoning discussions of data that is noticed and interpreted with the resulting prioritizes that are set followed by reflections that result from learner choices.

Reviewed by Chris Roman, Associate Professor, Butler University on 5/19/22

It would be extremely difficult for a book of clinical cases to comprehensively cover all of medicine, and this text does not try. Rather, it provides cases related to common medical problems and introduces them in a way that allows for various... read more

Comprehensiveness rating: 4 see less

The narrative form of the cases is less subject to issues of accuracy than a more content-based book would be. That said, the cases are realistic and reasonable, avoiding being too mundane or too extreme.

These cases are narrative and do not include many specific mentions of drugs, dosages, or other aspects of clinical care that may grow/evolve as guidelines change. For this reason, the cases should be “evergreen” and can be modified to suit different types of learners.

Clarity rating: 4

The text is written in very accessible language and avoids heavy use of technical language. Depending on the level of learner, this might even be too simplistic and omit some details that would be needed for physicians, pharmacists, and others to make nuanced care decisions.

The format is very consistent with clear labeling at transition points.

The authors point out in the introductory materials that this text is designed to be used in a modular fashion. Further, they have built in opportunities to customize each cases, such as giving dates of birth at “19xx” to allow for adjustments based on instructional objectives, etc.

The organization is very easy to follow.

I did not identify any issues in navigating the text.

The text contains no grammatical errors, though the language is a little stiff/unrealistic in some cases.

Cases involve patients and members of the care team that are of varying ages, genders, and racial/ethnic backgrounds

Reviewed by Trina Larery, Assistant Professor, Pittsburg State University on 4/5/22

The book covers common scenarios, providing allied health students insight into common health issues. The information in the book is thorough and easily modified if needed to include other scenarios not listed. The material was easy to understand... read more

Content Accuracy rating: 4

The treatments were explained and rationales were given, which can be very helpful to facilitate effective learning for a nursing student or novice nurse. The case studies were accurate in explanation. The DVT case study incorrectly identifies the location of the clot in the popliteal artery instead of in the vein.

The content is relevant to a variety of different types of health care providers and due to the general nature of the cases, will remain relevant over time. Updates should be made annually to the hyperlinks and to assure current standard of practice is still being met.

Clear, simple and easy to read.

Consistent with healthcare terminology and framework throughout all eight case studies.

The text is modular. Cases can be used individually within a unit on the given disease process or relevant sections of a case could be used to illustrate a specific point providing great flexibility. The appendix is helpful in locating content specific to a certain diagnosis or a certain type of health care provider.

The book is well organized, presenting in a logical clear fashion. The appendix allows the student to move about the case study without difficulty.

The interface is easy and simple to navigate. Some links to external sources might need to be updated regularly since those links are subject to change based on current guidelines. A few hyperlinks had "page not found".

Few grammatical errors were noted in text.

The case studies include people of different ethnicities, socioeconomic status, ages, and genders to make this a very useful book.

I enjoyed reading the text. It was interesting and relevant to today's nursing student. There are roughly 25 broken online links or "pages not found", care needs to be taken to update at least annually and assure links are valid and utilizing the most up to date information.

Reviewed by Benjamin Silverberg, Associate Professor/Clinician, West Virginia University on 3/24/22

Comprehensiveness rating: 3 see less

The appendix reviews the "key roles" and medical venues found in all 8 cases, but is fairly spartan on medical content. The table of contents at the beginning only lists the cases and locations of care. It can be a little tricky to figure out what is going on where, especially since each case is largely conversation-based. Since this presents 8 cases (really 7 with one being expanded upon), there are many medical topics (and venues) that are not included. It's impossible to include every kind of situation, but I'd love to see inclusion of sexual health, renal pathology, substance abuse, etc.

Though there are differences in how care can be delivered based on personal style, changing guidelines, available supplies, etc, the medical accuracy seems to be high. I did not detect bias or industry influence.

Relevance/Longevity rating: 4

Medications are generally listed as generics, with at least current dosing recommendations. The text gives a picture of what care looks like currently, but will be a little challenging to update based on new guidelines (ie, it can be hard to find the exact page in which a medication is dosed/prescribed). Even if the text were to be a little out of date, an instructor can use that to point out what has changed (and why).

Clear text, usually with definitions of medical slang or higher-tier vocabulary. Minimal jargon and there are instances where the "characters" are sorting out the meaning as well, making it accessible for new learners, too.

Overall, the style is consistent between cases - largely broken up into scenes and driven by conversation rather than descriptions of what is happening.

There are 8 (well, again, 7) cases which can be reviewed in any order. Case #2 builds upon #1, which is intentional and a good idea, though personally I would have preferred one case to have different possible outcomes or even a recurrence of illness. Each scene within a case is reasonably short.

Organization/Structure/Flow rating: 4

These cases are modular and don't really build on concepts throughout. As previously stated, case #2 builds upon #1, but beyond that, there is no progression. (To be sure, the authors suggest using case #1 for newer learners and #2 for more advanced ones.) The text would benefit from thematic grouping, a longer introduction and debriefing for each case (there are learning objectives but no real context in medical education nor questions to reflect on what was just read), and progressively-increasing difficulty in medical complexity, ethics, etc.

I used the PDF version and had no interface issues. There are minimal photographs and charts. Some words are marked in blue but those did not seem to be hyperlinked anywhere.

No noticeable errors in grammar, spelling, or formatting were noted.

I appreciate that some diversity of age and ethnicity were offered, but this could be improved. There were Canadian Indian and First Nations patients, for example, as well as other characters with implied diversity, but there didn't seem to be any mention of gender diverse or non-heterosexual people, or disabilities. The cases tried to paint family scenes (the first patient's dog was fairly prominently mentioned) to humanize them. Including more cases would allow for more opportunities to include sex/gender minorities, (hidden) disabilities, etc.

The text (originally from 2017) could use an update. It could be used in conjunction with other Open Texts, as a compliment to other coursework, or purely by itself. The focus is meant to be on improving communication, but there are only 3 short pages at the beginning of the text considering those issues (which are really just learning objectives). In addition to adding more cases and further diversity, I personally would love to see more discussion before and after the case to guide readers (and/or instructors). I also wonder if some of the ambiguity could be improved by suggesting possible health outcomes - this kind of counterfactual comparison isn't possible in real life and could be really interesting in a text. Addition of comprehension/discussion questions would also be worthwhile.

Reviewed by Danielle Peterson, Assistant Professor, University of Saint Francis on 12/31/21

This text provides readers with 8 case studies which include both chronic and acute healthcare issues. Although not comprehensive in regard to types of healthcare conditions, it provides a thorough look at the communication between healthcare workers in acute hospital settings. The cases are primarily set in the inpatient hospital setting, so the bulk of the clinical information is basic emergency care and inpatient protocol: vitals, breathing, medication management, etc. The text provides a table of contents at opening of the text and a handy appendix at the conclusion of the text that outlines each case’s issue(s), scenario, and healthcare roles. No index or glossary present.

Although easy to update, it should be noted that the cases are taking place in a Canadian healthcare system. Terms may be unfamiliar to some students including “province,” “operating theatre,” “physio/physiotherapy,” and “porter.” Units of measurement used include Celsius and meters. Also, the issue of managed care, health insurance coverage, and length of stay is missing for American students. These are primary issues that dictate much of the healthcare system in the US and a primary job function of social workers, nurse case managers, and medical professionals in general. However, instructors that wish to add this to the case studies could do so easily.

The focus of this text is on healthcare communication which makes it less likely to become obsolete. Much of the clinical information is stable healthcare practice that has been standard of care for quite some time. Nevertheless, given the nature of text, updates would be easy to make. Hyperlinks should be updated to the most relevant and trustworthy sources and checked frequently for effectiveness.

The spacing that was used to note change of speaker made for ease of reading. Although unembellished and plain, I expect students to find this format easy to digest and interesting, especially since the script is appropriately balanced with ‘human’ qualities like the current TV shows and songs, the use of humor, and nonverbal cues.

A welcome characteristic of this text is its consistency. Each case is presented in a similar fashion and the roles of the healthcare team are ‘played’ by the same character in each of the scenarios. This allows students to see how healthcare providers prioritize cases and juggle the needs of multiple patients at once. Across scenarios, there was inconsistency in when clinical terms were hyperlinked.

The text is easily divisible into smaller reading sections. However, since the nature of the text is script-narrative format, if significant reorganization occurs, one will need to make sure that the communication of the script still makes sense.

The text is straightforward and presented in a consistent fashion: learning objectives, case history, a script of what happened before the patient enters the healthcare setting, and a script of what happens once the patient arrives at the healthcare setting. The authors use the term, “ideal interactions,” and I would agree that these cases are in large part, ‘best case scenarios.’ Due to this, the case studies are well organized, clear, logical, and predictable. However, depending on the level of student, instructors may want to introduce complications that are typical in the hospital setting.

The interface is pleasing and straightforward. With exception to the case summary and learning objectives, the cases are in narrative, script format. Each case study supplies a photo of the ‘patient’ and one of the case studies includes a link to a 3-minute video that introduces the reader to the patient/case. One of the highlights of this text is the use of hyperlinks to various clinical practices (ABG, vital signs, transfer of patient). Unfortunately, a majority of the links are broken. However, since this is an open text, instructors can update the links to their preference.

Although not free from grammatical errors, those that were noticed were minimal and did not detract from reading.

Cultural Relevance rating: 4

Cultural diversity is visible throughout the patients used in the case studies and includes factors such as age, race, socioeconomic status, family dynamics, and sexual orientation. A moderate level of diversity is noted in the healthcare team with some stereotypes: social workers being female, doctors primarily male.

As a social work instructor, I was grateful to find a text that incorporates this important healthcare role. I would have liked to have seen more content related to advance directives, mediating decision making between the patient and care team, emotional and practical support related to initial diagnosis and discharge planning, and provision of support to colleagues, all typical roles of a medical social worker. I also found it interesting that even though social work was included in multiple scenarios, the role was only introduced on the learning objectives page for the oncology case.

Reviewed by Crystal Wynn, Associate Professor, Virginia State University on 7/21/21

The text covers a variety of chronic diseases within the cases; however, not all of the common disease states were included within the text. More chronic diseases need to be included such as diabetes, cancer, and renal failure. Not all allied health care team members are represented within the case study. Key terms appear throughout the case study textbook and readers are able to click on a hyperlink which directs them to the definition and an explanation of the key term.

Content is accurate, error-free and unbiased.

The content is up-to-date, but not in a way that will quickly make the text obsolete within a short period of time. The text is written and/or arranged in such a way that necessary updates will be relatively easy and straightforward to implement.

The text is written in lucid, accessible prose, and provides adequate context for any jargon/technical terminology used

The text is internally consistent in terms of terminology and framework.

The text is easily and readily divisible into smaller reading sections that can be assigned at different points within the course. Each case can be divided into a chronic disease state unit, which will allow the reader to focus on one section at a time.

Organization/Structure/Flow rating: 3

The topics in the text are presented in a logical manner. Each case provides an excessive amount of language that provides a description of the case. The cases in this text reads more like a novel versus a clinical textbook. The learning objectives listed within each case should be in the form of questions or activities that could be provided as resources for instructors and teachers.

Interface rating: 3

There are several hyperlinks embedded within the textbook that are not functional.

The text contains no grammatical errors.

Cultural Relevance rating: 3

The text is not culturally insensitive or offensive in any way. More examples of cultural inclusiveness is needed throughout the textbook. The cases should be indicative of individuals from a variety of races and ethnicities.

Reviewed by Rebecca Hillary, Biology Instructor, Portland Community College on 6/15/21

This textbook consists of a collection of clinical case studies that can be applicable to a wide range of learning environments from supplementing an undergraduate Anatomy and Physiology Course, to including as part of a Medical or other health care program. I read the textbook in E-reader format and this includes hyperlinks that bring the students to subsequent clinical study if the book is being used in a clinical classroom. This book is significantly more comprehensive in its approach from other case studies I have read because it provides a bird’s eye view of the many clinicians, technicians, and hospital staff working with one patient. The book also provides real time measurements for patients that change as they travel throughout the hospital until time of discharge.

Each case gave an accurate sense of the chaos that would be present in an emergency situation and show how the conditions affect the practitioners as well as the patients. The reader gets an accurate big picture--a feel for each practitioner’s point of view as well as the point of view of the patient and the patient’s family as the clock ticks down and the patients are subjected to a number of procedures. The clinical information contained in this textbook is all in hyperlinks containing references to clinical skills open text sources or medical websites. I did find one broken link on an external medical resource.

The diseases presented are relevant and will remain so. Some of the links are directly related to the Canadian Medical system so they may not be applicable to those living in other regions. Clinical links may change over time but the text itself will remain relevant.

Each case study clearly presents clinical data as is it recorded in real time.

Each case study provides the point of view of several practitioners and the patient over several days. While each of the case studies covers different pathology they all follow this same format, several points of view and data points, over a number of days.

The case studies are divided by days and this was easy to navigate as a reader. It would be easy to assign one case study per body system in an Anatomy and Physiology course, or to divide them up into small segments for small in class teaching moments.

The topics are presented in an organized way showing clinical data over time and each case presents a large number of view points. For example, in the first case study, the patient is experiencing difficulty breathing. We follow her through several days from her entrance to the emergency room. We meet her X Ray Technicians, Doctor, Nurses, Medical Assistant, Porter, Physiotherapist, Respiratory therapist, and the Lab Technicians running her tests during her stay. Each practitioner paints the overall clinical picture to the reader.

I found the text easy to navigate. There were not any figures included in the text, only clinical data organized in charts. The figures were all accessible via hyperlink. Some figures within the textbook illustrating patient scans could have been helpful but I did not have trouble navigating the links to visualize the scans.

I did not see any grammatical errors in the text.

The patients in the text are a variety of ages and have a variety of family arrangements but there is not much diversity among the patients. Our seven patients in the eight case studies are mostly white and all cis gendered.

Some of the case studies, for example the heart failure study, show clinical data before and after drug treatments so the students can get a feel for mechanism in physiological action. I also liked that the case studies included diet and lifestyle advice for the patients rather than solely emphasizing these pharmacological interventions. Overall, I enjoyed reading through these case studies and I plan to utilize them in my Anatomy and Physiology courses.

Reviewed by Richard Tarpey, Assistant Professor, Middle Tennessee State University on 5/11/21

As a case study book, there is no index or glossary. However, medical and technical terms provide a useful link to definitions and explanations that will prove useful to students unfamiliar with the terms. The information provided is appropriate for entry-level health care students. The book includes important health problems, but I would like to see coverage of at least one more chronic/lifestyle issue such as diabetes. The book covers adult issues only.

Content is accurate without bias

The content of the book is relevant and up-to-date. It addresses conditions that are prevalent in today's population among adults. There are no pediatric cases, but this does not significantly detract from the usefulness of the text. The format of the book lends to easy updating of data or information.

The book is written with clarity and is easy to read. The writing style is accessible and technical terminology is explained with links to more information.

Consistency is present. Lack of consistency is typically a problem with case study texts, but this book is consistent with presentation, format, and terminology throughout each of the eight cases.

The book has high modularity. Each of the case studies can be used independently from the others providing flexibility. Additionally, each case study can be partitioned for specific learning objectives based on the learning objectives of the course or module.

The book is well organized, presenting students conceptually with differing patient flow patterns through a hospital. The patient information provided at the beginning of each case is a wonderful mechanism for providing personal context for the students as they consider the issues. Many case studies focus on the problem and the organization without students getting a patient's perspective. The patient perspective is well represented in these cases.

The navigation through the cases is good. There are some terminology and procedure hyperlinks within the cases that do not work when accessed. This is troubling if you intend to use the text for entry-level health care students since many of these links are critical for a full understanding of the case.

There are some non-US variants of spelling and a few grammatical errors, but these do not detract from the content of the messages of each case.

The book is inclusive of differing backgrounds and perspectives. No insensitive or offensive references were found.

I like this text for its application flexibility. The book is useful for non-clinical healthcare management students to introduce various healthcare-related concepts and terminology. The content is also helpful for the identification of healthcare administration managerial issues for students to consider. The book has many applications.

Reviewed by Paula Baldwin, Associate Professor/Communication Studies, Western Oregon University on 5/10/21

The different case studies fall on a range, from crisis care to chronic illness care. read more

The different case studies fall on a range, from crisis care to chronic illness care.

The contents seems to be written as they occurred to represent the most complete picture of each medical event's occurence.

These case studies are from the Canadian medical system, but that does not interfere with it's applicability.

It is written for a medical audience, so the terminology is mostly formal and technical.

Some cases are shorter than others and some go in more depth, but it is not problematic.

The eight separate case studies is the perfect size for a class in the quarter system. You could combine this with other texts, videos or learning modalities, or use it alone.

As this is a case studies book, there is not a need for a logical progression in presentation of topics.

No problems in terms of interface.

I have not seen any grammatical errors.

I did not see anything that was culturally insensitive.

I used this in a Health Communication class and it has been extraordinarily successful. My studies are analyzing the messaging for the good, the bad, and the questionable. The case studies are widely varied and it gives the class insights into hospital experiences, both front and back stage, that they would not normally be able to examine. I believe that because it is based real-life medical incidents, my students are finding the material highly engaging.

Reviewed by Marlena Isaac, Instructor, Aiken Technical College on 4/23/21

This text is great to walk through patient care with entry level healthcare students. The students are able to take in the information, digest it, then provide suggestions to how they would facilitate patient healing. Then when they are faced with... read more

The case studies provided accurate information that relates to the named disease.

It is relevant to health care studies and the development of critical thinking.

Cases are straightforward with great clinical information.

Clinical information is provided concisely.

Appropriate for clinical case study.

Presented to facilitate information gathering.

Takes a while to navigate in the browser.

Cultural Relevance rating: 1

Text lacks adequate representation of minorities.

Reviewed by Kim Garcia, Lecturer III, University of Texas Rio Grande Valley on 11/16/20

The book has 8 case studies, so obviously does not cover the whole of medicine, but the cases provided are descriptive and well developed. Cases are presented at different levels of difficulty, making the cases appropriate for students at different levels of clinical knowledge. The human element of both patient and health care provider is well captured. The cases are presented with a focus on interprofessional interaction and collaboration, more so than teaching medical content.

Content is accurate and un-biased. No errors noted. Most diagnostic and treatment information is general so it will remain relevant over time. The content of these cases is more appropriate for teaching interprofessional collaboration and less so for teaching the medical care for each diagnosis.

The content is relevant to a variety of different types of health care providers (nurses, radiologic technicians, medical laboratory personnel, etc) and due to the general nature of the cases, will remain relevant over time.

Easy to read. Clear headings are provided for sections of each case study and these section headings clearly tell when time has passed or setting has changed. Enough description is provided to help set the scene for each part of the case. Much of the text is written in the form of dialogue involving patient, family and health care providers, making it easy to adapt for role play. Medical jargon is limited and links for medical terms are provided to other resources that expound on medical terms used.

The text is consistent in structure of each case. Learning objectives are provided. Cases generally start with the patient at home and move with the patient through admission, testing and treatment, using a variety of healthcare services and encountering a variety of personnel.

The text is modular. Cases could be used individually within a unit on the given disease process or relevant sections of a case could be used to illustrate a specific point. The appendix is helpful in locating content specific to a certain diagnosis or a certain type of health care provider.

Each case follows a patient in a logical, chronologic fashion. A clear table of contents and appendix are provided which allows the user to quickly locate desired content. It would be helpful if the items in the table of contents and appendix were linked to the corresponding section of the text.

The hyperlinks to content outside this book work, however using the back arrow on your browser returns you to the front page of the book instead of to the point at which you left the text. I would prefer it if the hyperlinks opened in a new window or tab so closing that window or tab would leave you back where you left the text.

No grammatical errors were noted.

The text is culturally inclusive and appropriate. Characters, both patients and care givers are of a variety of races, ethnicities, ages and backgrounds.

I enjoyed reading the cases and reviewing this text. I can think of several ways in which I will use this content.

Reviewed by Raihan Khan, Instructor/Assistant Professor, James Madison University on 11/3/20

The book contains several important health issues, however still missing some chronic health issues that the students should learn before they join the workforce, such as diabetes-related health issues suffered by the patients. read more

The health information contained in the textbook is mostly accurate.

I think the book is written focusing on the current culture and health issues faced by the patients. To keep the book relevant in the future, the contexts especially the culture/lifestyle/health care modalities, etc. would need to be updated regularly.

The language is pretty simple, clear, and easy to read.

There is no complaint about consistency. One of the main issues of writing a book, consistency was well managed by the authors.

The book is easy to explore based on how easy the setup is. Students can browse to the specific section that they want to read without much hassle of finding the correct information.

The organization is simple but effective. The authors organized the book based on what can happen in a patient's life and what possible scenarios students should learn about the disease. From that perspective, the book does a good job.

The interface is easy and simple to navigate. Some links to external sources might need to be updated regularly since those links are subject to change that is beyond the author's control. It's frustrating for the reader when the external link shows no information.

The book is free of any major language and grammatical errors.

The book might do a little better in cultural competency. e.g. Last name Singh is mainly for Sikh people. In the text Harj and Priya Singh are Muslim. the authors can consult colleagues who are more familiar with those cultures and revise some cultural aspects of the cases mentioned in the book.

The book is a nice addition to the open textbook world. Hope to see more health issues covered by the book.

Reviewed by Ryan Sheryl, Assistant Professor, California State University, Dominguez Hills on 7/16/20

This text contains 8 medical case studies that reflect best practices at the time of publication. The text identifies 5 overarching learning objectives: interprofessional collaboration, client centered care, evidence-based practice, quality improvement, and informatics. While the case studies do not cover all medical conditions or bodily systems, the book is thorough in conveying details of various patients and medical team members in a hospital environment. Rather than an index or glossary at the end of the text, it contains links to outside websites for more information on medical tests and terms referenced in the cases.

The content provided is reflective of best practices in patient care, interdisciplinary collaboration, and communication at the time of publication. It is specifically accurate for the context of hospitals in Canada. The links provided throughout the text have the potential to supplement with up-to-date descriptions and definitions, however, many of them are broken (see notes in Interface section).

The content of the case studies reflects the increasingly complex landscape of healthcare, including a variety of conditions, ages, and personal situations of the clients and care providers. The text will require frequent updating due to the rapidly changing landscape of society and best practices in client care. For example, a future version may include inclusive practices with transgender clients, or address ways medical racism implicitly impacts client care (see notes in Cultural Relevance section).

The text is written clearly and presents thorough, realistic details about working and being treated in an acute hospital context.

The text is very straightforward. It is consistent in its structure and flow. It uses consistent terminology and follows a structured framework throughout.

Being a series of 8 separate case studies, this text is easily and readily divisible into smaller sections. The text was designed to be taken apart and used piece by piece in order to serve various learning contexts. The parts of each case study can also be used independently of each other to facilitate problem solving.

The topics in the case studies are presented clearly. The structure of each of the case studies proceeds in a similar fashion. All of the cases are set within the same hospital so the hospital personnel and service providers reappear across the cases, giving a textured portrayal of the experiences of the various service providers. The cases can be used individually, or one service provider can be studied across the various studies.

The text is very straightforward, without complex charts or images that could become distorted. Many of the embedded links are broken and require updating. The links that do work are a very useful way to define and expand upon medical terms used in the case studies.

Grammatical errors are minimal and do not distract from the flow of the text. In one instance the last name Singh is spelled Sing, and one patient named Fred in the text is referred to as Frank in the appendix.

The cases all show examples of health care personnel providing compassionate, client-centered care, and there is no overt discrimination portrayed. Two of the clients are in same-sex marriages and these are shown positively. It is notable, however, that the two cases presenting people of color contain more negative characteristics than the other six cases portraying Caucasian people. The people of color are the only two examples of clients who smoke regularly. In addition, the Indian client drinks and is overweight, while the First Nations client is the only one in the text to have a terminal diagnosis. The Indian client is identified as being Punjabi and attending a mosque, although there are only 2% Muslims in the Punjab province of India. Also, the last name Singh generally indicates a person who is a Hindu or Sikh, not Muslim.

Reviewed by Monica LeJeune, RN Instructor, LSUE on 4/24/20

Has comprehensive unfolding case studies that guide the reader to recognize and manage the scenario presented. Assists in critical thinking process. read more

Has comprehensive unfolding case studies that guide the reader to recognize and manage the scenario presented. Assists in critical thinking process.

Accurately presents health scenarios with real life assessment techniques and patient outcomes.

Relevant to nursing practice.

Clearly written and easily understood.

Consistent with healthcare terminology and framework

Has a good reading flow.

Topics presented in logical fashion

Easy to read.

No grammatical errors noted.

Text is not culturally insensitive or offensive.

Good book to have to teach nursing students.

Reviewed by april jarrell, associate professor, J. Sargeant Reynolds Community College on 1/7/20

The text is a great case study tool that is appropriate for nursing school instructors to use in aiding students to learn the nursing process. read more

The text is a great case study tool that is appropriate for nursing school instructors to use in aiding students to learn the nursing process.

The content is accurate and evidence based. There is no bias noted

The content in the text is relevant, up to date for nursing students. It will be easy to update content as needed because the framework allows for addition to the content.

The text is clear and easy to understand.

Framework and terminology is consistent throughout the text; the case study is a continual and takes the student on a journey with the patient. Great for learning!

The case studies can be easily divided into smaller sections to allow for discussions, and weekly studies.

The text and content progress in a logical, clear fashion allowing for progression of learning.

No interface issues noted with this text.

No grammatical errors noted in the text.

No racial or culture insensitivity were noted in the text.

I would recommend this text be used in nursing schools. The use of case studies are helpful for students to learn and practice the nursing process.

Reviewed by Lisa Underwood, Practical Nursing Instructor, NTCC on 12/3/19

The text provides eight comprehensive case studies that showcase the different viewpoints of the many roles involved in patient care. It encompasses the most common seen diagnoses seen across healthcare today. Each case study comes with its own set of learning objectives that can be tweaked to fit several allied health courses. Although the case studies are designed around the Canadian Healthcare System, they are quite easily adaptable to fit most any modern, developed healthcare system.

Content Accuracy rating: 3

Overall, the text is quite accurate. There is one significant error that needs to be addressed. It is located in the DVT case study. In the study, a popliteal artery clot is mislabeled as a DVT. DVTs are located in veins, not in arteries. That said, the case study on the whole is quite good. This case study could be used as a learning tool in the classroom for discussion purposes or as a way to test student understanding of DVTs, on example might be, "Can they spot the error?"

At this time, all of the case studies within the text are current. Healthcare is an ever evolving field that rests on the best evidence based practice. Keeping that in mind, educators can easily adapt the studies as the newest evidence emerges and changes practice in healthcare.

All of the case studies are well written and easy to understand. The text includes several hyperlinks and it also highlights certain medical terminology to prompt readers as a way to enhance their learning experience.

Across the text, the language, style, and format of the case studies are completely consistent.

The text is divided into eight separate case studies. Each case study may be used independently of the others. All case studies are further broken down as the focus patient passes through each aspect of their healthcare system. The text's modularity makes it possible to use a case study as individual work, group projects, class discussions, homework or in a simulation lab.

The case studies and the diagnoses that they cover are presented in such a way that educators and allied health students can easily follow and comprehend.

The book in itself is free of any image distortion and it prints nicely. The text is offered in a variety of digital formats. As noted in the above reviews, some of the hyperlinks have navigational issues. When the reader attempts to access them, a "page not found" message is received.

There were minimal grammatical errors. Some of which may be traced back to the differences in our spelling.

The text is culturally relevant in that it includes patients from many different backgrounds and ethnicities. This allows educators and students to explore cultural relevance and sensitivity needs across all areas in healthcare. I do not believe that the text was in any way insensitive or offensive to the reader.

By using the case studies, it may be possible to have an open dialogue about the differences noted in healthcare systems. Students will have the ability to compare and contrast the Canadian healthcare system with their own. I also firmly believe that by using these case studies, students can improve their critical thinking skills. These case studies help them to "put it all together".

Reviewed by Melanie McGrath, Associate Professor, TRAILS on 11/29/19

The text covered some of the most common conditions seen by healthcare providers in a hospital setting, which forms a solid general base for the discussions based on each case. read more

The text covered some of the most common conditions seen by healthcare providers in a hospital setting, which forms a solid general base for the discussions based on each case.

I saw no areas of inaccuracy

As in all healthcare texts, treatments and/or tests will change frequently. However, everything is currently up-to-date thus it should be a good reference for several years.

Each case is written so that any level of healthcare student would understand. Hyperlinks in the text is also very helpful.

All of the cases are written in a similar fashion.

Although not structured as a typical text, each case is easily assigned as a stand-alone.

Each case is organized clearly in an appropriate manner.

I did not see any issues.

I did not see any grammatical errors

The text seemed appropriately inclusive. There are no pediatric cases and no cases of intellectually-impaired patients, but those types of cases introduce more advanced problem-solving which perhaps exceed the scope of the text. May be a good addition to the text.

I found this text to be an excellent resource for healthcare students in a variety of fields. It would be best utilized in inter professional courses to help guide discussion.

Reviewed by Lynne Umbarger, Clinical Assistant Professor, Occupational Therapy, Emory and Henry College on 11/26/19

While the book does not cover every scenario, the ones in the book are quite common and troublesome for inexperienced allied health students. The information in the book is thorough enough, and I have found the cases easy to modify for educational purposes. The material was easily understood by the students but challenging enough for classroom discussion. There are no mentions in the book about occupational therapy, but it is easy enough to add a couple words and make inclusion simple.

Very nice lab values are provided in the case study, making it more realistic for students.

These case studies focus on commonly encountered diagnoses for allied health and nursing students. They are comprehensive, realistic, and easily understood. The only difference is that the hospital in one case allows the patient's dog to visit in the room (highly unusual in US hospitals).

The material is easily understood by allied health students. The cases have links to additional learning materials for concepts that may be less familiar or should be explored further in a particular health field.

The language used in the book is consistent between cases. The framework is the same with each case which makes it easier to locate areas that would be of interest to a particular allied health profession.

The case studies are comprehensive but well-organized. They are short enough to be useful for class discussion or a full-blown assignment. The students seem to understand the material and have not expressed that any concepts or details were missing.

Each case is set up like the other cases. There are learning objectives at the beginning of each case to facilitate using the case, and it is easy enough to pull out material to develop useful activities and assignments.

There is a quick chart in the Appendix to allow the reader to determine the professions involved in each case as well as the pertinent settings and diagnoses for each case study. The contents are easy to access even while reading the book.

As a person who attends carefully to grammar, I found no errors in all of the material I read in this book.

There are a greater number of people of different ethnicities, socioeconomic status, ages, and genders to make this a very useful book. With each case, I could easily picture the person in the case. This book appears to be Canadian and more inclusive than most American books.

I was able to use this book the first time I accessed it to develop a classroom activity for first-year occupational therapy students and a more comprehensive activity for second-year students. I really appreciate the links to a multitude of terminology and medical lab values/issues for each case. I will keep using this book.

Reviewed by Cindy Krentz, Assistant Professor, Metropolitan State University of Denver on 6/15/19

The book covers eight case studies of common inpatient or emergency department scenarios. I appreciated that they had written out the learning objectives. I liked that the patient was described before the case was started, giving some understanding of the patient's background. I think it could benefit from having a glossary. I liked how the authors included the vital signs in an easily readable bar. I would have liked to see the labs also highlighted like this. I also felt that it would have been good written in a 'what would you do next?' type of case study.

The book is very accurate in language, what tests would be prudent to run and in the day in the life of the hospital in all cases. One inaccuracy is that the authors called a popliteal artery clot a DVT. The rest of the DVT case study was great, though, but the one mistake should be changed.

The book is up to date for now, but as tests become obsolete and new equipment is routinely used, the book ( like any other health textbook) will need to be updated. It would be easy to change, however. All that would have to happen is that the authors go in and change out the test to whatever newer, evidence-based test is being utilized.

The text is written clearly and easy to understand from a student's perspective. There is not too much technical jargon, and it is pretty universal when used- for example DVT for Deep Vein Thrombosis.

The book is consistent in language and how it is broken down into case studies. The same format is used for highlighting vital signs throughout the different case studies. It's great that the reader does not have to read the book in a linear fashion. Each case study can be read without needing to read the others.

The text is broken down into eight case studies, and within the case studies is broken down into days. It is consistent and shows how the patient can pass through the different hospital departments (from the ER to the unit, to surgery, to home) in a realistic manner. The instructor could use one or more of the case studies as (s)he sees fit.

The topics are eight different case studies- and are presented very clearly and organized well. Each one is broken down into how the patient goes through the system. The text is easy to follow and logical.

The interface has some problems with the highlighted blue links. Some of them did not work and I got a 'page not found' message. That can be frustrating for the reader. I'm wondering if a glossary could be utilized (instead of the links) to explain what some of these links are supposed to explain.

I found two or three typos, I don't think they were grammatical errors. In one case I think the Canadian spelling and the United States spelling of the word are just different.

This is a very culturally competent book. In today's world, however, one more type of background that would merit delving into is the trans-gender, GLBTQI person. I was glad that there were no stereotypes.

I enjoyed reading the text. It was interesting and relevant to today's nursing student. Since we are becoming more interprofessional, I liked that we saw what the phlebotomist and other ancillary personnel (mostly different technicians) did. I think that it could become even more interdisciplinary so colleges and universities could have more interprofessional education- courses or simulations- with the addition of the nurse using social work, nutrition, or other professional health care majors.

Reviewed by Catherine J. Grott, Interim Director, Health Administration Program, TRAILS on 5/5/19

The book is comprehensive but is specifically written for healthcare workers practicing in Canada. The title of the book should reflect this. read more

The book is comprehensive but is specifically written for healthcare workers practicing in Canada. The title of the book should reflect this.

The book is accurate, however it has numerous broken online links.

Relevance/Longevity rating: 3

The content is very relevant, but some links are out-dated. For example, WHO Guidelines for Safe Surgery 2009 (p. 186) should be updated.

The book is written in clear and concise language. The side stories about the healthcare workers make the text interesting.

The book is consistent in terms of terminology and framework. Some terms that are emphasized in one case study are not emphasized (with online links) in the other case studies. All of the case studies should have the same words linked to online definitions.

Modularity rating: 3

The book can easily be parsed out if necessary. However, the way the case studies have been written, it's evident that different authors contributed singularly to each case study.

The organization and flow are good.

Interface rating: 1

There are numerous broken online links and "pages not found."

The grammar and punctuation are correct. There are two errors detected: p. 120 a space between the word "heart" and the comma; also a period is needed after Dr (p. 113).

I'm not quite sure that the social worker (p. 119) should comment that the patient and partner are "very normal people."

There are roughly 25 broken online links or "pages not found." The BC & Canadian Guidelines (p. 198) could also include a link to US guidelines to make the text more universal . The basilar crackles (p. 166) is very good. Text could be used compare US and Canadian healthcare. Text could be enhanced to teach "soft skills" and interdepartmental communication skills in healthcare.

Reviewed by Lindsey Henry, Practical Nursing Instructor, Fletcher on 5/1/19

I really appreciated how in the introduction, five learning objectives were identified for students. These objectives are paramount in nursing care and they are each spelled out for the learner. Each Case study also has its own learning... read more

As a seasoned nurse, I believe that the content regarding pathophysiology and treatments used in the case studies were accurate. I really appreciated how many of the treatments were also explained and rationales were given, which can be very helpful to facilitate effective learning for a nursing student or novice nurse.

The case studies are up to date and correlate with the current time period. They are easily understood.

I really loved how several important medical terms, including specific treatments were highlighted to alert the reader. Many interventions performed were also explained further, which is great to enhance learning for the nursing student or novice nurse. Also, with each scenario, a background and history of the patient is depicted, as well as the perspectives of the patient, patients family member, and the primary nurse. This really helps to give the reader a full picture of the day in the life of a nurse or a patient, and also better facilitates the learning process of the reader.

These case studies are consistent. They begin with report, the patient background or updates on subsequent days, and follow the patients all the way through discharge. Once again, I really appreciate how this book describes most if not all aspects of patient care on a day to day basis.

Each case study is separated into days. While they can be divided to be assigned at different points within the course, they also build on each other. They show trends in vital signs, what happens when a patient deteriorates, what happens when they get better and go home. Showing the entire process from ER admit to discharge is really helpful to enhance the students learning experience.

The topics are all presented very similarly and very clearly. The way that the scenarios are explained could even be understood by a non-nursing student as well. The case studies are very clear and very thorough.

The book is very easy to navigate, prints well on paper, and is not distorted or confusing.

I did not see any grammatical errors.

Each case study involves a different type of patient. These differences include race, gender, sexual orientation and medical backgrounds. I do not feel the text was offensive to the reader.

I teach practical nursing students and after reading this book, I am looking forward to implementing it in my classroom. Great read for nursing students!

Reviewed by Leah Jolly, Instructor, Clinical Coordinator, Oregon Institute of Technology on 4/10/19

Good variety of cases and pathologies covered. read more

Good variety of cases and pathologies covered.

Content Accuracy rating: 2

Some examples and scenarios are not completely accurate. For example in the DVT case, the sonographer found thrombus in the "popliteal artery", which according to the book indicated presence of DVT. However in DVT, thrombus is located in the vein, not the artery. The patient would also have much different symptoms if located in the artery. Perhaps some of these inaccuracies are just typos, but in real-life situations this simple mistake can make a world of difference in the patient's course of treatment and outcomes.

Good examples of interprofessional collaboration. If only it worked this way on an every day basis!

Clear and easy to read for those with knowledge of medical terminology.

Good consistency overall.

Broken up well.

Topics are clear and logical.

Would be nice to simply click through to the next page, rather than going through the table of contents each time.

Minor typos/grammatical errors.

No offensive or insensitive materials observed.

Reviewed by Alex Sargsyan, Doctor of Nursing Practice/Assistant Professor , East Tennessee State University on 10/8/18

Because of the case study character of the book it does not have index or glossary. However it has summary for each health case study outlining key elements discussed in each case study. read more

Because of the case study character of the book it does not have index or glossary. However it has summary for each health case study outlining key elements discussed in each case study.

Overall the book is accurately depicting the clinical environment. There are numerous references to external sites. While most of them are correct, some of them are not working. For example Homan’s test link is not working "404 error"

Book is relevant in its current version and can be used in undergraduate and graduate classes. That said, the longevity of the book may be limited because of the character of the clinical education. Clinical guidelines change constantly and it may require a major update of the content.

Cases are written very clearly and have realistic description of an inpatient setting.

The book is easy to read and consistent in the language in all eight cases.

The cases are very well written. Each case is subdivided into logical segments. The segments reflect different setting where the patient is being seen. There is a flow and transition between the settings.

Book has eight distinct cases. This is a great format for a book that presents distinct clinical issues. This will allow the students to have immersive experiences and gain better understanding of the healthcare environment.

Book is offered in many different formats. Besides the issues with the links mentioned above, overall navigation of the book content is very smooth.

Book is very well written and has no grammatical errors.

Book is culturally relevant. Patients in the case studies come different cultures and represent diverse ethnicities.

Reviewed by Justin Berry, Physical Therapist Assistant Program Director, Northland Community and Technical College, East Grand Forks, MN on 8/2/18

This text provides eight patient case studies from a variety of diagnoses, which can be utilized by healthcare students from multiple disciplines. The cases are comprehensive and can be helpful for students to determine professional roles, interprofessional roles, when to initiate communication with other healthcare practitioners due to a change in patient status, and treatment ideas. Some additional patient information, such as lab values, would have been beneficial to include.

Case study information is accurate and unbiased.

Content is up to date. The case studies are written in a way so that they will not be obsolete soon, even with changes in healthcare.

The case studies are well written, and can be utilized for a variety of classroom assignments, discussions, and projects. Some additional lab value information for each patient would have been a nice addition.

The case studies are consistently organized to make it easy for the reader to determine the framework.

The text is broken up into eight different case studies for various patient diagnoses. This design makes it highly modular, and would be easy to assign at different points of a course.

The flow of the topics are presented consistently in a logical manner. Each case study follows a patient chronologically, making it easy to determine changes in patient status and treatment options.

The text is free of interface issues, with no distortion of images or charts.

The text is not culturally insensitive or offensive in any way. Patients are represented from a variety of races, ethnicities, and backgrounds

This book would be a good addition for many different health programs.

Reviewed by Ann Bell-Pfeifer, Instructor/Program Director, Minnesota State Community and Technical College on 5/21/18

The book gives a comprehensive overview of many types of cases for patient conditions. Emergency Room patients may arrive with COPD, heart failure, sepsis, pneumonia, or as motor vehicle accident victims. It is directed towards nurses, medical laboratory technologists, medical radiology technologists, and respiratory therapists and their roles in caring for patients. Most of the overview is accurate. One suggestion is to provide an embedded radiologist interpretation of the exams which are performed which lead to the patients diagnosis.

Overall the book is accurate. Would like to see updates related to the addition of direct radiography technology which is commonly used in the hospital setting.

Many aspects of medicine will remain constant. The case studies seem fairly accurate and may be relevant for up to 3 years. Since technology changes so quickly in medicine, the CT and x-ray components may need minor updates within a few years.

The book clarity is excellent.

The case stories are consistent with each scenario. It is easy to follow the structure and learn from the content.

The book is quite modular. It is easy to break it up into cases and utilize them individually and sequentially.

The cases are listed by disease process and follow a logical flow through each condition. They are easy to follow as they have the same format from the beginning to the end of each case.

The interface seems seamless. Hyperlinks are inserted which provide descriptions and references to medical procedures and in depth definitions.

The book is free of most grammatical errors. There is a place where a few words do not fit the sentence structure and could be a typo.

The book included all types of relationships and ethnic backgrounds. One type which could be added is a transgender patient.

I think the book was quite useful for a variety of health care professionals. The authors did an excellent job of integrating patient cases which could be applied to the health care setting. The stories seemed real and relevant. This book could be used to teach health care professionals about integrated care within the emergency department.

Reviewed by Shelley Wolfe, Assistant Professor, Winona State University on 5/21/18

This text is comprised of comprehensive, detailed case studies that provide the reader with multiple character views throughout a patient’s encounter with the health care system. The Table of Contents accurately reflected the content. It should be noted that the authors include a statement that conveys that this text is not like traditional textbooks and is not meant to be read in a linear fashion. This allows the educator more flexibility to use the text as a supplement to enhance learning opportunities.

The content of the text appears accurate and unbiased. The “five overarching learning objectives” provide a clear aim of the text and the educator is able to glean how these objectives are captured into each of the case studies. While written for the Canadian healthcare system, this text is easily adaptable to the American healthcare system.

Overall, the content is up-to-date and the case studies provide a variety of uses that promote longevity of the text. However, not all of the blue font links (if using the digital PDF version) were still in working order. I encountered links that led to error pages or outdated “page not found” websites. While the links can be helpful, continued maintenance of these links could prove time-consuming.

I found the text easy to read and understand. I enjoyed that the viewpoints of all the different roles (patient, nurse, lab personnel, etc.) were articulated well and allowed the reader to connect and gain appreciation of the entire healthcare team. Medical jargon was noted to be appropriate for the intended audience of this text.

The terminology and organization of this text is consistent.

The text is divided into 8 case studies that follow a similar organizational structure. The case studies can further be divided to focus on individual learning objectives. For example, the case studies could be looked at as a whole for discussing communication or could be broken down into segments to focus on disease risk factors.

The case studies in this text follow a similar organizational structure and are consistent in their presentation. The flow of individual case studies is excellent and sets the reader on a clear path. As noted previously, this text is not meant to be read in a linear fashion.

This text is available in many different forms. I chose to review the text in the digital PDF version in order to use the embedded links. I did not encounter significant interface issues and did not find any images or features that would distract or confuse a reader.

No significant grammatical errors were noted.

The case studies in this text included patients and healthcare workers from a variety of backgrounds. Educators and students will benefit from expanding the case studies to include discussions and other learning opportunities to help develop culturally-sensitive healthcare providers.

I found the case studies to be very detailed, yet written in a way in which they could be used in various manners. The authors note a variety of ways in which the case studies could be employed with students; however, I feel the authors could also include that the case studies could be used as a basis for simulated clinical experiences. The case studies in this text would be an excellent tool for developing interprofessional communication and collaboration skills in a variety healthcare students.

Reviewed by Darline Foltz, Assistant Professor, University of Cincinnati - Clermont College on 3/27/18

This book covers all areas listed in the Table of Contents. In addition to the detailed patient case studies, there is a helpful section of "How to Use this Resource". I would like to note that this resource "aligns with the open textbooks... read more

The book appears to be accurate. Although one of the learning outcomes is as follows: "Demonstrate an understanding of the Canadian healthcare delivery system.", I did not find anything that is ONLY specific to the Canadian healthcare delivery system other than some of the terminology, i.e. "porter" instead of "transporter" and a few french words. I found this to make the book more interesting for students rather than deter from it. These are patient case studies that are relevant in any country.

The content is up-to-date. Changes in medical science may occur, i.e. a different test, to treat a diagnosis that is included in one or more of the case studies, however, it would be easy and straightforward to implement these changes.

This book is written in lucid, accessible prose. The technical/medical terminology that is used is appropriate for medical and allied health professionals. Something that would improve this text would to provide a glossary of terms for the terms in blue font.

This book is consistent with current medical terminology

This text is easily divided into each of the 6 case studies. The case studies can be used singly according to the body system being addressed or studied.

Because this text is a collection of case studies, flow doesn't pertain, however the organization and structure of the case studies are excellent as they are clear and easy to read.

There are no distractions in this text that would distract or confuse the reader.

I did not identify any grammatical errors.

This text is not culturally insensitive or offensive in any way and uses patients and healthcare workers that are of a variety of races, ethnicities and backgrounds.

I believe that this text would not only be useful to students enrolled in healthcare professions involved in direct patient care but would also be useful to students in supporting healthcare disciplines such as health information technology and management, medical billing and coding, etc.

Introduction

Case Study #1: Chronic Obstructive Pulmonary Disease (COPD)

Learning Objectives
Patient: Erin Johns
Emergency Room

Case Study #2: Pneumonia

Day 0: Emergency Room
Day 1: Emergency Room
Day 1: Medical Ward
Day 2: Medical Ward
Day 3: Medical Ward
Day 4: Medical Ward

Case Study #3: Unstable Angina (UA)

Patient: Harj Singh

Case Study #4: Heart Failure (HF)

Patient: Meryl Smith
In the Supermarket
Day 0: Medical Ward

Case Study #5: Motor Vehicle Collision (MVC)

Patient: Aaron Knoll
Crash Scene
Operating Room
Post Anaesthesia Care Unit (PACU)
Surgical Ward

Case Study #6: Sepsis

Patient: George Thomas
Sleepy Hollow Care Facility

Case Study #7: Colon Cancer

Patient: Fred Johnson
Two Months Ago
Pre-Surgery Admission

Case Study #8: Deep Vein Thrombosis (DVT)

Patient: Jamie Douglas

Appendix: Overview About the Authors

Ancillary Material

About the book.

Health Case Studies is composed of eight separate health case studies. Each case study includes the patient narrative or story that models the best practice (at the time of publishing) in healthcare settings. Associated with each case is a set of specific learning objectives to support learning and facilitate educational strategies and evaluation.

The case studies can be used online in a learning management system, in a classroom discussion, in a printed course pack or as part of a textbook created by the instructor. This flexibility is intentional and allows the educator to choose how best to convey the concepts presented in each case to the learner.

Because these case studies were primarily developed for an electronic healthcare system, they are based predominantly in an acute healthcare setting. Educators can augment each case study to include primary healthcare settings, outpatient clinics, assisted living environments, and other contexts as relevant.

About the Contributors

Glynda Rees teaches at the British Columbia Institute of Technology (BCIT) in Vancouver, British Columbia. She completed her MSN at the University of British Columbia with a focus on education and health informatics, and her BSN at the University of Cape Town in South Africa. Glynda has many years of national and international clinical experience in critical care units in South Africa, the UK, and the USA. Her teaching background has focused on clinical education, problem-based learning, clinical techniques, and pharmacology.

Glynda‘s interests include the integration of health informatics in undergraduate education, open accessible education, and the impact of educational technologies on nursing students’ clinical judgment and decision making at the point of care to improve patient safety and quality of care.

Faculty member in the critical care nursing program at the British Columbia Institute of Technology (BCIT) since 2003, Rob has been a critical care nurse for over 25 years with 17 years practicing in a quaternary care intensive care unit. Rob is an experienced educator and supports student learning in the classroom, online, and in clinical areas. Rob’s Master of Education from Simon Fraser University is in educational technology and learning design. He is passionate about using technology to support learning for both faculty and students.

Part of Rob’s faculty position is dedicated to providing high fidelity simulation support for BCIT’s nursing specialties program along with championing innovative teaching and best practices for educational technology. He has championed the use of digital publishing and was the tech lead for Critical Care Nursing’s iPad Project which resulted in over 40 multi-touch interactive textbooks being created using Apple and other technologies.

Rob has successfully completed a number of specialist certifications in computer and network technologies. In 2015, he was awarded Apple Distinguished Educator for his innovation and passionate use of technology to support learning. In the past five years, he has presented and published abstracts on virtual simulation, high fidelity simulation, creating engaging classroom environments, and what the future holds for healthcare and education.

Janet Morrison is the Program Head of Occupational Health Nursing at the British Columbia Institute of Technology (BCIT) in Burnaby, British Columbia. She completed a PhD at Simon Fraser University, Faculty of Communication, Art and Technology, with a focus on health information technology. Her dissertation examined the effects of telehealth implementation in an occupational health nursing service. She has an MA in Adult Education from St. Francis Xavier University and an MA in Library and Information Studies from the University of British Columbia.

Janet’s research interests concern the intended and unintended impacts of health information technologies on healthcare students, faculty, and the healthcare workforce.

She is currently working with BCIT colleagues to study how an educational clinical information system can foster healthcare students’ perceptions of interprofessional roles.

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BMJ Journals

Roberta Heale 1 ,
Alison Twycross 2
1 School of Nursing , Laurentian University , Sudbury , Ontario , Canada
2 School of Health and Social Care , London South Bank University , London , UK
Correspondence to Dr Roberta Heale, School of Nursing, Laurentian University, Sudbury, ON P3E2C6, Canada; rheale{at}laurentian.ca

https://doi.org/10.1136/eb-2017-102845

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What is it?

Case study is a research methodology, typically seen in social and life sciences. There is no one definition of case study research. 1 However, very simply… ‘a case study can be defined as an intensive study about a person, a group of people or a unit, which is aimed to generalize over several units’. 1 A case study has also been described as an intensive, systematic investigation of a single individual, group, community or some other unit in which the researcher examines in-depth data relating to several variables. 2

Often there are several similar cases to consider such as educational or social service programmes that are delivered from a number of locations. Although similar, they are complex and have unique features. In these circumstances, the evaluation of several, similar cases will provide a better answer to a research question than if only one case is examined, hence the multiple-case study. Stake asserts that the cases are grouped and viewed as one entity, called the quintain . 6 ‘We study what is similar and different about the cases to understand the quintain better’. 6

The steps when using case study methodology are the same as for other types of research. 6 The first step is defining the single case or identifying a group of similar cases that can then be incorporated into a multiple-case study. A search to determine what is known about the case(s) is typically conducted. This may include a review of the literature, grey literature, media, reports and more, which serves to establish a basic understanding of the cases and informs the development of research questions. Data in case studies are often, but not exclusively, qualitative in nature. In multiple-case studies, analysis within cases and across cases is conducted. Themes arise from the analyses and assertions about the cases as a whole, or the quintain, emerge. 6

Benefits and limitations of case studies

If a researcher wants to study a specific phenomenon arising from a particular entity, then a single-case study is warranted and will allow for a in-depth understanding of the single phenomenon and, as discussed above, would involve collecting several different types of data. This is illustrated in example 1 below.

Using a multiple-case research study allows for a more in-depth understanding of the cases as a unit, through comparison of similarities and differences of the individual cases embedded within the quintain. Evidence arising from multiple-case studies is often stronger and more reliable than from single-case research. Multiple-case studies allow for more comprehensive exploration of research questions and theory development. 6

Despite the advantages of case studies, there are limitations. The sheer volume of data is difficult to organise and data analysis and integration strategies need to be carefully thought through. There is also sometimes a temptation to veer away from the research focus. 2 Reporting of findings from multiple-case research studies is also challenging at times, 1 particularly in relation to the word limits for some journal papers.

Examples of case studies

Example 1: nurses’ paediatric pain management practices.

One of the authors of this paper (AT) has used a case study approach to explore nurses’ paediatric pain management practices. This involved collecting several datasets:

Observational data to gain a picture about actual pain management practices.

Questionnaire data about nurses’ knowledge about paediatric pain management practices and how well they felt they managed pain in children.

Questionnaire data about how critical nurses perceived pain management tasks to be.

These datasets were analysed separately and then compared 7–9 and demonstrated that nurses’ level of theoretical did not impact on the quality of their pain management practices. 7 Nor did individual nurse’s perceptions of how critical a task was effect the likelihood of them carrying out this task in practice. 8 There was also a difference in self-reported and observed practices 9 ; actual (observed) practices did not confirm to best practice guidelines, whereas self-reported practices tended to.

Example 2: quality of care for complex patients at Nurse Practitioner-Led Clinics (NPLCs)

The other author of this paper (RH) has conducted a multiple-case study to determine the quality of care for patients with complex clinical presentations in NPLCs in Ontario, Canada. 10 Five NPLCs served as individual cases that, together, represented the quatrain. Three types of data were collected including:

Review of documentation related to the NPLC model (media, annual reports, research articles, grey literature and regulatory legislation).

Interviews with nurse practitioners (NPs) practising at the five NPLCs to determine their perceptions of the impact of the NPLC model on the quality of care provided to patients with multimorbidity.

Chart audits conducted at the five NPLCs to determine the extent to which evidence-based guidelines were followed for patients with diabetes and at least one other chronic condition.

The three sources of data collected from the five NPLCs were analysed and themes arose related to the quality of care for complex patients at NPLCs. The multiple-case study confirmed that nurse practitioners are the primary care providers at the NPLCs, and this positively impacts the quality of care for patients with multimorbidity. Healthcare policy, such as lack of an increase in salary for NPs for 10 years, has resulted in issues in recruitment and retention of NPs at NPLCs. This, along with insufficient resources in the communities where NPLCs are located and high patient vulnerability at NPLCs, have a negative impact on the quality of care. 10

These examples illustrate how collecting data about a single case or multiple cases helps us to better understand the phenomenon in question. Case study methodology serves to provide a framework for evaluation and analysis of complex issues. It shines a light on the holistic nature of nursing practice and offers a perspective that informs improved patient care.

Gustafsson J
Calanzaro M
Sandelowski M

Competing interests None declared.

Provenance and peer review Commissioned; internally peer reviewed.

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Fundamentals of case study research in family medicine and community health

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Michael D Fetters 2 .

The aim of this article is to introduce family medicine researchers to case study research, a rigorous research methodology commonly used in the social and health sciences and only distantly related to clinical case reports. The article begins with an overview of case study in the social and health sciences, including its definition, potential applications, historical background and core features. This is followed by a 10-step description of the process of conducting a case study project illustrated using a case study conducted about a teaching programme executed to teach international family medicine resident learners sensitive examination skills. Steps for conducting a case study include (1) conducting a literature review; (2) formulating the research questions; (3) ensuring that a case study is appropriate; (4) determining the type of case study design; (5) defining boundaries of the case(s) and selecting the case(s); (6) preparing for data collection; (7) collecting and organising the data; (8) analysing the data; (9) writing the case study report; and (10) appraising the quality. Case study research is a highly flexible and powerful research tool available to family medicine researchers for a variety of applications.

Significance statement

Given their potential for answering ‘how’ and ‘why’ questions about complex issues in their natural setting, case study designs are being increasingly used in the health sciences. Conducting a case study can, however, be a complex task because of the possibility of combining multiple methods and the need to choose between different types of case study designs. In order to introduce family medicine and community health researchers to the fundamentals of case study research, this article reviews its definition, potential applications, historical background and main characteristics. It follows on with a practical, step-by-step description of the case study process that will be useful to researchers interested in implementing this research design in their own practice.

Introduction

This article provides family medicine and community health researchers a concise resource to conduct case study research. The article opens with an overview of case study in the social and health sciences, including its definition, potential applications, historical background and core features. This is followed by a 10-step description of the process of conducting a case study project, as described in the literature. These steps are illustrated using a case study about a teaching programme executed to teach international medical learners sensitive examination skills. The article ends with recommendations of useful articles and textbooks on case study research.

Origins of case study research

Case study is a research design that involves an intensive and holistic examination of a contemporary phenomenon in a real-life setting. 1–3 It uses a variety of methods and multiple data sources to explore, describe or explain a single case bounded in time and place (ie, an event, individual, group, organisation or programme). A distinctive feature of case study is its focus on the particular characteristics of the case being studied and the contextual aspects, relationships and processes influencing it. 4 Here we do not include clinical case reports as these are beyond the scope of this article. While distantly related to clinical case reports commonly used to report unusual clinical case presentations or findings, case study is a research approach that is frequently used in the social sciences and health sciences. In contrast to other research designs, such as surveys or experiments, a key strength of case study is that it allows the researcher to adopt a holistic approach—rather than an isolated approach—to the study of social phenomena. As argued by Yin, 3 case studies are particularly suitable for answering ‘how’ research questions (ie, how a treatment was received) as well as ‘why’ research questions (ie, why the treatment produced the observed outcomes).

Given its potential for understanding complex processes as they occur in their natural setting, case study increasingly is used in a wide range of health-related disciplines and fields, including medicine, 5 nursing, 6 health services research 1 and health communication. 7 With regard to clinical practice and research, a number of authors 1 5 8 have highlighted how insights gained from case study designs can be used to describe patients’ experiences regarding care, explore health professionals’ perceptions regarding a policy change, and understand why medical treatments and complex interventions succeed or fail.

In anthropology and sociology, case study as a research design was introduced as a response to the prevailing view of quantitative research as the primary way of undertaking research. 9 From its beginnings, social scientists saw case study as a method to obtain comprehensive accounts of social phenomena from participants. In addition, it could complement the findings of survey research. Between the 1920s and 1960s, case study became the predominant research approach among the members of the Department of Sociology of the University of Chicago, widely known as ‘The Chicago School’. 10 11 During this period, prominent sociologists, such as Florian Znaniecki, William Thomas, Everett C Hughes and Howard S Becker, undertook a series of innovative case studies (including classical works such as The Polish peasant in Europe and America or Boys in White ), which laid the foundations of case study designs as implemented today.

In the 1970s, case study increasingly was adopted in the USA and UK in applied disciplines and fields, such as education, programme evaluation and public policy research. 12 As a response to the limitations of quasi-experimental designs for undertaking comprehensive programme evaluations, researchers in these disciplines saw in case studies—either alone or in combination with experimental designs—an opportunity to gain additional insights into the outcomes of programme implementation. In the mid-1980s and early 1990s, the case study approach became recognised as having its own ‘logic of design’ (p46). 13 This period coincides with the publication of a considerable number of influential articles 14–16 and textbooks 4 17 18 on case study research.

These publications were instrumental in shaping contemporary case study practice, yet they reflected divergent views about the nature of case study, including how it should be defined, designed and implemented (see Yazan 19 for a comparison of the perspectives of Yin, Merriam and Stake, three leading case study methodologists). What these publications have in common is that case study revolves around four key features.

First, case study examines a specific phenomenon in detail by performing an indepth and intensive analysis of the selected case. The rationale for case study designs, rather than more expansive designs such as surveys, is that the researcher is interested in investigating the particularity of a case, that is, the unique attributes that define an event, individual, group, organisation or programme. 2 Second, case study is conducted in natural settings where people meet, interact and change their perceptions over time. The use of the case study design is a choice in favour of ‘maintaining the naturalness of the research situation and the natural course of events’ (p177). 20

Third, case study assumes that a case under investigation is entangled with the context in which it is embedded. This context entails a number of interconnected processes that cannot be disassociated from the case, but rather are part of the study. The case study researcher is interested in understanding how and why such processes take place and, consequently, uncovering the interactions between a case and its context. Research questions concerning how and why phenomena occur are particularly appropriate in case study research. 3

Fourth, case study encourages the researcher to use a variety of methods and data types in a single study. 20 21 These can be solely qualitative, solely quantitative or a mixture of both. The latter option allows the researcher to gain a more comprehensive understanding of the case and improve the accuracy of the findings. The four above-mentioned key features of case study are shown in table 1 , using the example of a mixed methods case study evaluation. 22

There are many potential applications for case study research. While often misconstrued as having only an exploratory role, case study research can be used for descriptive and explanatory research (p7–9). 3 Family medicine and community health researchers can use case study research for evaluating a variety of educational programmes, clinical programmes or community programmes.

Case study illustration from family medicine

In the featured study, Japanese family medicine residents received standardised patient instructor-based training in female breast, pelvic, male genital and prostate examinations as part of an international training collaboration to launch a new family medicine residency programme. 22 From family medicine residents, trainers and staff, the authors collected and analysed data from post-training feedback, semistructured interviews and a web-based questionnaire. While the programme was perceived favourably, they noted barriers to reinforcement in their home training programme, and taboos regarding gender-specific healthcare appear as barriers to implementing a similar programme in the home institution.

A step-by-step description of the process of carrying out a case study

As shown in table 2 and illustrated using the article by Shultz et al , 22 case study research generally includes 10 steps. While commonly conducted in this order, the steps do not always occur linearly as data collection and analysis may occur over several iterations or implemented with a slightly different order.

Step 1. Conduct a literature review

During the literature review, researchers systematically search for publications, select those most relevant to the study’s purpose, critically appraise them and summarise the major themes. The literature review helps researchers ascertain what is and is not known about the phenomenon under study, delineate the scope and research questions of the study, and develop an academic or practical justification for the study. 23

Step 2. Formulate the research questions

Research questions critically define in operational terms what will be researched and how. They focus the study and play a key role in guiding design decisions. Key decisions include the case selection and choice of a case study design most suitable for the study. According to Fraenkel et al , 24 the key attributes of good research questions are (1) feasibility, (2) clarity, (3) significance, (4) connection to previous research identified in the literature and (5) compliance with ethical research standards.

Step 3. Ensure that a case study is appropriate

Before commencing the study, researchers should ensure that case study design embodies the most appropriate strategy for answering the study questions. The above-noted four key features—in depth examination of phenomena, naturalness, a focus on context and the use of a combination of methods—should be reflected in the research questions as well as subsequent design decisions.

Step 4. Determine the type of case study design

Researchers need to choose a specific case study design. Sometimes, researchers may define the case first (step 5), for example, in a programme evaluation, and the case may need to be defined before determining the type. Yin’s 3 typology is based on two dimensions, whether the study will examine a single case or multiple cases, and whether the study will focus on a single or multiple units of analysis. Figure 1 illustrates these four types of design using a hypothetical example of a programme evaluation. Table 3 shows an example of each type from the literature.

Types of case study designs. 3 21

In type 1 holistic single case design , researchers examine a single programme as the sole unit of analysis. In type 2 embedded single case design , the interest is not exclusively in the programme, but also in its different subunits, including sites, staff and participants. These subunits constitute the range of units of analysis. In type 3 holistic multiple case design , researchers conduct a within and cross-case comparison of two or more programmes, each of which constitutes a single unit of analysis. A major strength of multiple case designs is that they enable researchers to develop an in depth description of each case and to identify patterns of variation and similarity between the cases. Multiple case designs are likely to have stronger internal validity and generate more insightful findings than single case designs. They do this by allowing ‘examination of processes and outcomes across many cases, identification of how individual cases might be affected by different environments, and the specific conditions under which a finding may occur’ (p583). 25 In type 4 embedded multiple case design , a variant of the holistic multiple case design, researchers perform a detailed examination of the subunits of each programme, rather than just examining each case as a whole.

Step 5. Define the boundaries of the case(s) and select the case(s)

Miles et al 26 define a case as ‘a phenomenon of some sort occurring in a bounded context’ (p28). What is and is not the case and how the case fits within its broader context should be explicitly defined. As noted in step 4, this step may occur before choice of the case study type, and the process may actually occur in a back-and-forth fashion. A case can entail an individual, a group, an organisation, an institution or a programme. In this step, researchers delineate the spatial and temporal boundaries of the case, that is, ‘when and where it occurred, and when and what was of interest’ (p390). 9 Aside from ensuring the coherence and consistency of the study, bounding the case ensures that the planned research project is feasible in terms of time and resources. Having access to the case and ensuring ethical research practice are two central considerations in case selection. 1

Step 6. Prepare to collect data

Before beginning the data collection, researchers need a study protocol that describes in detail the methods of data collection. The protocol should emphasise the coherence between the data collection methods and the research questions. According to Yin, 3 a case study protocol should include (1) an overview of the case study, (2) data collection procedures, (3) data collection questions and (4) a guide for the case study report. The protocol should be sufficiently flexible to allow researchers to make changes depending on the context and specific circumstances surrounding each data collection method.

Step 7. Collect and organise the data

While case study is often portrayed as a qualitative approach to research (eg, interviews, focus groups or observations), case study designs frequently rely on multiple data sources, including quantitative data (eg, surveys or statistical databases). A growing number of authors highlight the ways in which the use of mixed methods within case study designs might contribute to developing ‘a more complete understanding of the case’ (p902), 21 shedding light on ‘the complexity of a case’ (p118) 27 or increasing ‘the internal validity of a study’ (p6). 1 Guetterman and Fetters 21 explain how a qualitative case study can also be nested within a mixed methods design (ie, be considered the qualitative component of the design). An interesting strategy for organising multiple data sources is suggested by Yin. 3 He recommends using a case study database in which different data sources (eg, audio files, notes, documents or photographs) are stored for later retrieval or inspection. See guidance from Creswell and Hirose 28 for conducting a survey and qualitative data collection in mixed methods and DeJonckheere 29 on semistructured interviewing.

Step 8. Analyse the data

Bernard and Ryan 30 define data analysis as ‘the search for patterns in data and for ideas that help explain why these patterns are there in the first place’ (p109). Depending on the case study design, analysis of the qualitative and quantitative data can be done concurrently or sequentially. For the qualitative data, the first step of the analysis involves segmenting the data into coding units, ascribing codes to data segments and organising the codes in a coding scheme. 31 Depending on the role of theory in the study, an inductive, data-driven approach can be used where meaning is found in the data, or a deductive, concept-driven approach can be adopted where predefined concepts derived from the literature, or previous research, are used to code the data. 32 The second step involves searching for patterns across codes and subsets of respondents, so major themes are identified to describe, explain or predict the phenomenon under study. Babchuk 33 provides a step-by-step guidance for qualitative analysis in this issue. When conducting a single case study, the within-case analysis yields an in depth, thick description of the case. When the study involves multiple cases, the cross-comparison analysis elicits a description of similarities and divergence between cases and may generate explanations and theoretical predictions regarding other cases. 26

For the quantitative part of the case study, data are entered in statistical software packages for conducting descriptive or inferential analysis. Guetterman 34 provides a step-by-step guidance on basic statistics. In case study designs where both data strands are analysed simultaneously, analytical techniques include pattern matching, explanation building, time-series analysis and creating logic models (p142–167). 3

Step 9. Write the case study report

The case study report should have the following three characteristics. First, the description of the case and its context should be sufficiently comprehensive to allow the reader to understand the complexity of the phenomena under study. 35 Second, the data should be presented in a concise and transparent manner to enable the reader to question, or to re-examine, the findings. 36 Third, the report should be adapted to the interests and needs of its primary audience or audiences (eg, academics, practitioners, policy-makers or funders of research). Yin 3 suggests six formats for organising case study reports, namely linear-analytic, comparative, chronological, theory building, suspense and unsequenced structures. To facilitate case transferability and applicability to other similar contexts, the case study report must include a detailed description of the case.

Step 10. Appraise quality

Although presented as the final step of the case study process, quality appraisal should be considered throughout the study. Multiple criteria and frameworks for appraising the quality of case study research have been suggested in the literature. Yin 3 suggests the following four criteria: construct validity (ie, the extent to which a study accurately measures the concepts that it claims to investigate), internal validity (ie, the strength of the relationship between variables and findings), external validity (ie, the extent to which the findings can be generalised) and reliability (ie, the extent to which the findings can be replicated by other researchers conducting the same study). Yin 37 also suggests using two separate sets of guidelines for conducting case study research and for appraising the quality of case study proposals. Stake 4 presents a 20-item checklist for critiquing case study reports, and Creswell and Poth 38 and Denscombe 39 outline a number of questions to consider. Since these quality frameworks have evolved from different disciplinary and philosophical backgrounds, the researcher’s approach should be coherent with the epistemology of the study. Figure 2 provides a quality appraisal checklist adapted from Creswell and Poth 38 and Denscombe. 39

Checklist for evaluating the quality of a case study. 38 39

The challenges to conducting case study research include rationalising the literature based on literature review, writing the research questions, determining how to bound the case, and choosing among various case study purposes and designs. Factors held in common with other methods include analysing and presenting the findings, particularly with multiple data sources.

Other resources

Resources with more in depth guidance on case study research include Merriam, 17 Stake 4 and Yin. 3 While each reflects a different perspective on case study research, they all provide useful guidance for designing and conducting case studies. Other resources include Creswell and Poth, 38 Swanborn 2 and Tight. 40 For mixed methods case study designs, Creswell and Clark, 27 Guetterman and Fetters, 21 Luck et al , 6 and Plano Clark et al 41 provide guidance. Byrne and Ragin’s 42 The SAGE Handbook of Case-Based Methods and Mills et al ’s 43 Encyclopedia of case study research provide guidance for experienced case study researchers.

Conclusions

Family medicine and community health researchers engage in a wide variety of clinical, educational, research and administrative programmes. Case study research provides a highly flexible and powerful research tool to evaluate rigorously many of these endeavours and disseminate this information.

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Published: 27 June 2011

The case study approach

Sarah Crowe 1 ,
Kathrin Cresswell 2 ,
Ann Robertson 2 ,
Guro Huby 3 ,
Anthony Avery 1 &
Aziz Sheikh 2

BMC Medical Research Methodology volume 11 , Article number: 100 ( 2011 ) Cite this article

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The case study approach allows in-depth, multi-faceted explorations of complex issues in their real-life settings. The value of the case study approach is well recognised in the fields of business, law and policy, but somewhat less so in health services research. Based on our experiences of conducting several health-related case studies, we reflect on the different types of case study design, the specific research questions this approach can help answer, the data sources that tend to be used, and the particular advantages and disadvantages of employing this methodological approach. The paper concludes with key pointers to aid those designing and appraising proposals for conducting case study research, and a checklist to help readers assess the quality of case study reports.

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Introduction

The case study approach is particularly useful to employ when there is a need to obtain an in-depth appreciation of an issue, event or phenomenon of interest, in its natural real-life context. Our aim in writing this piece is to provide insights into when to consider employing this approach and an overview of key methodological considerations in relation to the design, planning, analysis, interpretation and reporting of case studies.

The illustrative 'grand round', 'case report' and 'case series' have a long tradition in clinical practice and research. Presenting detailed critiques, typically of one or more patients, aims to provide insights into aspects of the clinical case and, in doing so, illustrate broader lessons that may be learnt. In research, the conceptually-related case study approach can be used, for example, to describe in detail a patient's episode of care, explore professional attitudes to and experiences of a new policy initiative or service development or more generally to 'investigate contemporary phenomena within its real-life context' [ 1 ]. Based on our experiences of conducting a range of case studies, we reflect on when to consider using this approach, discuss the key steps involved and illustrate, with examples, some of the practical challenges of attaining an in-depth understanding of a 'case' as an integrated whole. In keeping with previously published work, we acknowledge the importance of theory to underpin the design, selection, conduct and interpretation of case studies[ 2 ]. In so doing, we make passing reference to the different epistemological approaches used in case study research by key theoreticians and methodologists in this field of enquiry.

This paper is structured around the following main questions: What is a case study? What are case studies used for? How are case studies conducted? What are the potential pitfalls and how can these be avoided? We draw in particular on four of our own recently published examples of case studies (see Tables 1 , 2 , 3 and 4 ) and those of others to illustrate our discussion[ 3 – 7 ].

What is a case study?

A case study is a research approach that is used to generate an in-depth, multi-faceted understanding of a complex issue in its real-life context. It is an established research design that is used extensively in a wide variety of disciplines, particularly in the social sciences. A case study can be defined in a variety of ways (Table 5 ), the central tenet being the need to explore an event or phenomenon in depth and in its natural context. It is for this reason sometimes referred to as a "naturalistic" design; this is in contrast to an "experimental" design (such as a randomised controlled trial) in which the investigator seeks to exert control over and manipulate the variable(s) of interest.

Stake's work has been particularly influential in defining the case study approach to scientific enquiry. He has helpfully characterised three main types of case study: intrinsic , instrumental and collective [ 8 ]. An intrinsic case study is typically undertaken to learn about a unique phenomenon. The researcher should define the uniqueness of the phenomenon, which distinguishes it from all others. In contrast, the instrumental case study uses a particular case (some of which may be better than others) to gain a broader appreciation of an issue or phenomenon. The collective case study involves studying multiple cases simultaneously or sequentially in an attempt to generate a still broader appreciation of a particular issue.

These are however not necessarily mutually exclusive categories. In the first of our examples (Table 1 ), we undertook an intrinsic case study to investigate the issue of recruitment of minority ethnic people into the specific context of asthma research studies, but it developed into a instrumental case study through seeking to understand the issue of recruitment of these marginalised populations more generally, generating a number of the findings that are potentially transferable to other disease contexts[ 3 ]. In contrast, the other three examples (see Tables 2 , 3 and 4 ) employed collective case study designs to study the introduction of workforce reconfiguration in primary care, the implementation of electronic health records into hospitals, and to understand the ways in which healthcare students learn about patient safety considerations[ 4 – 6 ]. Although our study focusing on the introduction of General Practitioners with Specialist Interests (Table 2 ) was explicitly collective in design (four contrasting primary care organisations were studied), is was also instrumental in that this particular professional group was studied as an exemplar of the more general phenomenon of workforce redesign[ 4 ].

What are case studies used for?

According to Yin, case studies can be used to explain, describe or explore events or phenomena in the everyday contexts in which they occur[ 1 ]. These can, for example, help to understand and explain causal links and pathways resulting from a new policy initiative or service development (see Tables 2 and 3 , for example)[ 1 ]. In contrast to experimental designs, which seek to test a specific hypothesis through deliberately manipulating the environment (like, for example, in a randomised controlled trial giving a new drug to randomly selected individuals and then comparing outcomes with controls),[ 9 ] the case study approach lends itself well to capturing information on more explanatory ' how ', 'what' and ' why ' questions, such as ' how is the intervention being implemented and received on the ground?'. The case study approach can offer additional insights into what gaps exist in its delivery or why one implementation strategy might be chosen over another. This in turn can help develop or refine theory, as shown in our study of the teaching of patient safety in undergraduate curricula (Table 4 )[ 6 , 10 ]. Key questions to consider when selecting the most appropriate study design are whether it is desirable or indeed possible to undertake a formal experimental investigation in which individuals and/or organisations are allocated to an intervention or control arm? Or whether the wish is to obtain a more naturalistic understanding of an issue? The former is ideally studied using a controlled experimental design, whereas the latter is more appropriately studied using a case study design.

Case studies may be approached in different ways depending on the epistemological standpoint of the researcher, that is, whether they take a critical (questioning one's own and others' assumptions), interpretivist (trying to understand individual and shared social meanings) or positivist approach (orientating towards the criteria of natural sciences, such as focusing on generalisability considerations) (Table 6 ). Whilst such a schema can be conceptually helpful, it may be appropriate to draw on more than one approach in any case study, particularly in the context of conducting health services research. Doolin has, for example, noted that in the context of undertaking interpretative case studies, researchers can usefully draw on a critical, reflective perspective which seeks to take into account the wider social and political environment that has shaped the case[ 11 ].

How are case studies conducted?

Here, we focus on the main stages of research activity when planning and undertaking a case study; the crucial stages are: defining the case; selecting the case(s); collecting and analysing the data; interpreting data; and reporting the findings.

Defining the case

Carefully formulated research question(s), informed by the existing literature and a prior appreciation of the theoretical issues and setting(s), are all important in appropriately and succinctly defining the case[ 8 , 12 ]. Crucially, each case should have a pre-defined boundary which clarifies the nature and time period covered by the case study (i.e. its scope, beginning and end), the relevant social group, organisation or geographical area of interest to the investigator, the types of evidence to be collected, and the priorities for data collection and analysis (see Table 7 )[ 1 ]. A theory driven approach to defining the case may help generate knowledge that is potentially transferable to a range of clinical contexts and behaviours; using theory is also likely to result in a more informed appreciation of, for example, how and why interventions have succeeded or failed[ 13 ].

For example, in our evaluation of the introduction of electronic health records in English hospitals (Table 3 ), we defined our cases as the NHS Trusts that were receiving the new technology[ 5 ]. Our focus was on how the technology was being implemented. However, if the primary research interest had been on the social and organisational dimensions of implementation, we might have defined our case differently as a grouping of healthcare professionals (e.g. doctors and/or nurses). The precise beginning and end of the case may however prove difficult to define. Pursuing this same example, when does the process of implementation and adoption of an electronic health record system really begin or end? Such judgements will inevitably be influenced by a range of factors, including the research question, theory of interest, the scope and richness of the gathered data and the resources available to the research team.

Selecting the case(s)

The decision on how to select the case(s) to study is a very important one that merits some reflection. In an intrinsic case study, the case is selected on its own merits[ 8 ]. The case is selected not because it is representative of other cases, but because of its uniqueness, which is of genuine interest to the researchers. This was, for example, the case in our study of the recruitment of minority ethnic participants into asthma research (Table 1 ) as our earlier work had demonstrated the marginalisation of minority ethnic people with asthma, despite evidence of disproportionate asthma morbidity[ 14 , 15 ]. In another example of an intrinsic case study, Hellstrom et al.[ 16 ] studied an elderly married couple living with dementia to explore how dementia had impacted on their understanding of home, their everyday life and their relationships.

For an instrumental case study, selecting a "typical" case can work well[ 8 ]. In contrast to the intrinsic case study, the particular case which is chosen is of less importance than selecting a case that allows the researcher to investigate an issue or phenomenon. For example, in order to gain an understanding of doctors' responses to health policy initiatives, Som undertook an instrumental case study interviewing clinicians who had a range of responsibilities for clinical governance in one NHS acute hospital trust[ 17 ]. Sampling a "deviant" or "atypical" case may however prove even more informative, potentially enabling the researcher to identify causal processes, generate hypotheses and develop theory.

In collective or multiple case studies, a number of cases are carefully selected. This offers the advantage of allowing comparisons to be made across several cases and/or replication. Choosing a "typical" case may enable the findings to be generalised to theory (i.e. analytical generalisation) or to test theory by replicating the findings in a second or even a third case (i.e. replication logic)[ 1 ]. Yin suggests two or three literal replications (i.e. predicting similar results) if the theory is straightforward and five or more if the theory is more subtle. However, critics might argue that selecting 'cases' in this way is insufficiently reflexive and ill-suited to the complexities of contemporary healthcare organisations.

The selected case study site(s) should allow the research team access to the group of individuals, the organisation, the processes or whatever else constitutes the chosen unit of analysis for the study. Access is therefore a central consideration; the researcher needs to come to know the case study site(s) well and to work cooperatively with them. Selected cases need to be not only interesting but also hospitable to the inquiry [ 8 ] if they are to be informative and answer the research question(s). Case study sites may also be pre-selected for the researcher, with decisions being influenced by key stakeholders. For example, our selection of case study sites in the evaluation of the implementation and adoption of electronic health record systems (see Table 3 ) was heavily influenced by NHS Connecting for Health, the government agency that was responsible for overseeing the National Programme for Information Technology (NPfIT)[ 5 ]. This prominent stakeholder had already selected the NHS sites (through a competitive bidding process) to be early adopters of the electronic health record systems and had negotiated contracts that detailed the deployment timelines.

It is also important to consider in advance the likely burden and risks associated with participation for those who (or the site(s) which) comprise the case study. Of particular importance is the obligation for the researcher to think through the ethical implications of the study (e.g. the risk of inadvertently breaching anonymity or confidentiality) and to ensure that potential participants/participating sites are provided with sufficient information to make an informed choice about joining the study. The outcome of providing this information might be that the emotive burden associated with participation, or the organisational disruption associated with supporting the fieldwork, is considered so high that the individuals or sites decide against participation.

In our example of evaluating implementations of electronic health record systems, given the restricted number of early adopter sites available to us, we sought purposively to select a diverse range of implementation cases among those that were available[ 5 ]. We chose a mixture of teaching, non-teaching and Foundation Trust hospitals, and examples of each of the three electronic health record systems procured centrally by the NPfIT. At one recruited site, it quickly became apparent that access was problematic because of competing demands on that organisation. Recognising the importance of full access and co-operative working for generating rich data, the research team decided not to pursue work at that site and instead to focus on other recruited sites.

Collecting the data

In order to develop a thorough understanding of the case, the case study approach usually involves the collection of multiple sources of evidence, using a range of quantitative (e.g. questionnaires, audits and analysis of routinely collected healthcare data) and more commonly qualitative techniques (e.g. interviews, focus groups and observations). The use of multiple sources of data (data triangulation) has been advocated as a way of increasing the internal validity of a study (i.e. the extent to which the method is appropriate to answer the research question)[ 8 , 18 – 21 ]. An underlying assumption is that data collected in different ways should lead to similar conclusions, and approaching the same issue from different angles can help develop a holistic picture of the phenomenon (Table 2 )[ 4 ].

Brazier and colleagues used a mixed-methods case study approach to investigate the impact of a cancer care programme[ 22 ]. Here, quantitative measures were collected with questionnaires before, and five months after, the start of the intervention which did not yield any statistically significant results. Qualitative interviews with patients however helped provide an insight into potentially beneficial process-related aspects of the programme, such as greater, perceived patient involvement in care. The authors reported how this case study approach provided a number of contextual factors likely to influence the effectiveness of the intervention and which were not likely to have been obtained from quantitative methods alone.

In collective or multiple case studies, data collection needs to be flexible enough to allow a detailed description of each individual case to be developed (e.g. the nature of different cancer care programmes), before considering the emerging similarities and differences in cross-case comparisons (e.g. to explore why one programme is more effective than another). It is important that data sources from different cases are, where possible, broadly comparable for this purpose even though they may vary in nature and depth.

Analysing, interpreting and reporting case studies

Making sense and offering a coherent interpretation of the typically disparate sources of data (whether qualitative alone or together with quantitative) is far from straightforward. Repeated reviewing and sorting of the voluminous and detail-rich data are integral to the process of analysis. In collective case studies, it is helpful to analyse data relating to the individual component cases first, before making comparisons across cases. Attention needs to be paid to variations within each case and, where relevant, the relationship between different causes, effects and outcomes[ 23 ]. Data will need to be organised and coded to allow the key issues, both derived from the literature and emerging from the dataset, to be easily retrieved at a later stage. An initial coding frame can help capture these issues and can be applied systematically to the whole dataset with the aid of a qualitative data analysis software package.

The Framework approach is a practical approach, comprising of five stages (familiarisation; identifying a thematic framework; indexing; charting; mapping and interpretation) , to managing and analysing large datasets particularly if time is limited, as was the case in our study of recruitment of South Asians into asthma research (Table 1 )[ 3 , 24 ]. Theoretical frameworks may also play an important role in integrating different sources of data and examining emerging themes. For example, we drew on a socio-technical framework to help explain the connections between different elements - technology; people; and the organisational settings within which they worked - in our study of the introduction of electronic health record systems (Table 3 )[ 5 ]. Our study of patient safety in undergraduate curricula drew on an evaluation-based approach to design and analysis, which emphasised the importance of the academic, organisational and practice contexts through which students learn (Table 4 )[ 6 ].

Case study findings can have implications both for theory development and theory testing. They may establish, strengthen or weaken historical explanations of a case and, in certain circumstances, allow theoretical (as opposed to statistical) generalisation beyond the particular cases studied[ 12 ]. These theoretical lenses should not, however, constitute a strait-jacket and the cases should not be "forced to fit" the particular theoretical framework that is being employed.

When reporting findings, it is important to provide the reader with enough contextual information to understand the processes that were followed and how the conclusions were reached. In a collective case study, researchers may choose to present the findings from individual cases separately before amalgamating across cases. Care must be taken to ensure the anonymity of both case sites and individual participants (if agreed in advance) by allocating appropriate codes or withholding descriptors. In the example given in Table 3 , we decided against providing detailed information on the NHS sites and individual participants in order to avoid the risk of inadvertent disclosure of identities[ 5 , 25 ].

What are the potential pitfalls and how can these be avoided?

The case study approach is, as with all research, not without its limitations. When investigating the formal and informal ways undergraduate students learn about patient safety (Table 4 ), for example, we rapidly accumulated a large quantity of data. The volume of data, together with the time restrictions in place, impacted on the depth of analysis that was possible within the available resources. This highlights a more general point of the importance of avoiding the temptation to collect as much data as possible; adequate time also needs to be set aside for data analysis and interpretation of what are often highly complex datasets.

Case study research has sometimes been criticised for lacking scientific rigour and providing little basis for generalisation (i.e. producing findings that may be transferable to other settings)[ 1 ]. There are several ways to address these concerns, including: the use of theoretical sampling (i.e. drawing on a particular conceptual framework); respondent validation (i.e. participants checking emerging findings and the researcher's interpretation, and providing an opinion as to whether they feel these are accurate); and transparency throughout the research process (see Table 8 )[ 8 , 18 – 21 , 23 , 26 ]. Transparency can be achieved by describing in detail the steps involved in case selection, data collection, the reasons for the particular methods chosen, and the researcher's background and level of involvement (i.e. being explicit about how the researcher has influenced data collection and interpretation). Seeking potential, alternative explanations, and being explicit about how interpretations and conclusions were reached, help readers to judge the trustworthiness of the case study report. Stake provides a critique checklist for a case study report (Table 9 )[ 8 ].

Conclusions

The case study approach allows, amongst other things, critical events, interventions, policy developments and programme-based service reforms to be studied in detail in a real-life context. It should therefore be considered when an experimental design is either inappropriate to answer the research questions posed or impossible to undertake. Considering the frequency with which implementations of innovations are now taking place in healthcare settings and how well the case study approach lends itself to in-depth, complex health service research, we believe this approach should be more widely considered by researchers. Though inherently challenging, the research case study can, if carefully conceptualised and thoughtfully undertaken and reported, yield powerful insights into many important aspects of health and healthcare delivery.

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Acknowledgements

We are grateful to the participants and colleagues who contributed to the individual case studies that we have drawn on. This work received no direct funding, but it has been informed by projects funded by Asthma UK, the NHS Service Delivery Organisation, NHS Connecting for Health Evaluation Programme, and Patient Safety Research Portfolio. We would also like to thank the expert reviewers for their insightful and constructive feedback. Our thanks are also due to Dr. Allison Worth who commented on an earlier draft of this manuscript.

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AS conceived this article. SC, KC and AR wrote this paper with GH, AA and AS all commenting on various drafts. SC and AS are guarantors.

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Crowe, S., Cresswell, K., Robertson, A. et al. The case study approach. BMC Med Res Methodol 11 , 100 (2011). https://doi.org/10.1186/1471-2288-11-100

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Welcome To Open Case Studies

Connecting you with real-world public health data.

The Open Case Studies project showcases the possibilities of what can be achieved when working with real-world data.

Housed in a freely accessible GitHub repository, the project’s self-contained and experiential guides demonstrate the data analysis process and the use of various data science methods, tools, and software in the context of messy, real-world data.

These case studies will empower current and future data scientists to leverage real-world data to solve leading public health challenges.

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The Open Case Studies project provides insights about gathering and working with data for students, instructors, and those with experience in data science or statistical methods at nonprofit organizations and public sector agencies.

Each case study in the project focuses on an important public health topic and introduces methods to provide users with the skills and knowledge for greater legibility, reproducibility, rigor, and flexibility in their own data analyses.

Case Study Bank Overview

Real data on ten public health challenges in the U.S.

The following in-depth case studies use real data and focus on five areas of public health that are particularly pressing in the United States.

Vaping Behaviors in American Youth

This case study explores the trends of tobacco product usage among American youths surveyed in the National Youth Tobacco Survey (NYTS) from 2015-2019. It demonstrates how to use survey data and code books and provides an introduction to writing functions to wrangle similar but slightly different data repetitively. The case study introduces packages for using survey weighting and survey design to perform an analysis to compare vaping product usage among different groups, and covers how to use a logistic regression to compare groups for a variable that is binary (such as true or false — in this case it was using vaping products or not). This case study also covers how to make visualizations of multiple groups over time with confidence interval error bars.

Opioids in the United States

This case study examines the number of opioid pills (specifically oxycodone and hydrocodone, as they are the top two misused opioids) shipped to pharmacies and practitioners at the county-level around the United States from 2006 to 2014 using data from the Drug Enforcement Administration (DEA). This case study demonstrates how to get data from a source called an application programming interface (API). It explores why and how to normalize data, as well as why and how to potentially stratify or redefine groups. It also shows how to compare two independent groups when the data is not normally distributed using a test called the Wilcoxon rank sum test (also called the Mann Whitney U test) and how to add confidence intervals to plots (using a method called bootstrapping).

Disparities in Youth Disconnection

This case study focuses on rates of youth (people between 16-24) disconnection (those who are neither working nor in school) among different racial, ethnic and gender subgroups to identify subgroups that may be particularly vulnerable. It demonstrates that deeper inspection of subgroups yields some differences that are not otherwise discernable, how to import data from a PDF using screenshots of sections of the PDF, and how to use the Mann-Kendall trend test to test for the presence of a consistent direction in the relationship of disconnection rates with time. This case study also shows how to make a visualization that stylistically matches that of an existing report, how to add images to plots, and how to create effective bar plots for multiple comparisons across several groups.

Mental Health of American Youth

This case study investigates how the rate of self-reported symptoms of major depressive episodes (MDE) has changed over time among American youth (age 12-17) from 2004-2018. It describes the impact of self-reporting bias in surveys, how to get data directly from a website, as well as how to compare changes in the frequency of a variable between two groups using a chi-squared test to determine if two variables are independent (in this case if the sex of the students influenced the frequency of reported MDE symptoms in 2004 and 2018). This case study also demonstrates how to create direct labels on visualizations with many groups across time, as well as how to create an animated gif.

Exploring CO2 Emissions Across Time

This case study investigates how CO2 emissions have changed since the 1700s and how the level of emissions has compared for different countries around the world. It explores how yearly average temperature and the number of natural disasters in the United States has changed over time and provides an introduction for examining if two sets of data are correlated with one another. This case study also goes into great detail about how to make what are called heatmaps and other plots to visualize multiple groups over time. This includes adding labels directly to lines on plots with multiple lines.

Predicting Annual Air Pollution

This case study uses machine learning methods to predict annual air pollution levels spatially within the United States based on data about population density, urbanization, road density, as well as satellite pollution data and chemical modeling data among other predictors. Machine learning methods are used to predict air pollution levels when traditional monitoring systems are not available in a particular area or when there is not enough spatial granularity with current monitoring systems. The case study also demonstrates how to visualize data using maps.

Exploring Global Patterns of Obesity Across Rural and Urban Regions

This case study compares average Body Mass Index measurements for males and females from rural and urban regions from over 200 countries around the world, with a particular emphasis on the United States. It provides a thorough introduction to wrangling data from a PDF, how to compare two paired groups using the t test and the nonparametric Wilcoxon signed-rank test using R programming, and how to make visualizations of group comparisons that emphasize a particular subset of the data.

Exploring Global Patterns of Dietary Behaviors Associated with Health Risk

This case study investigates the consumption of dietary factors associated with health risk among males and females from over 200 countries around the world, with a particular emphasis on the United States. It demonstrates how to wrangle data from a PDF; how to combine data from two different sources; how to compare two paired groups and multiple paired groups using t-tests, ANOVA, and linear regression; and how to create visualizations of several groups and how to combine plots together with very different scales.

Influence of Multicollinearity on Measured Impact of Right-To-Carry Gun Laws

This case study focuses on two well-known studies that evaluated the influence of right-to-carry gun laws on violent crime rates. It demonstrates a phenomenon called multicollinearity, where explanatory variables that can predict one another can lead to aberrant and unstable findings; how to make visualizations with labels, such as arrows or equations; and how to combine multiple plots together.

School Shootings in the United States

This case study illustrates ways to communicate trends in a dataset about the number and characteristics of school shooting events for students in grades K-12 in the United States since 1970. It demonstrates how to create a dashboard, which is a website that shows patterns in a dataset in a concise manner; how to import data from a Google Sheets document; how to create interactive tables and maps; and how to properly calculate percentages for data when there are missing values.

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Connecting with the public health data you need.

The Open Case Studies project approaches data in many different ways. The guide below will help connect you with a case study:

Data science projects often start with a question. Here, you may look for case studies that explore a question that is similar to one you are interested in investigating with your data.

How does something change over time?

Investigating how a variable has changed over time can help identify consistent trends.

How do survey responses compare for different groups over time?

Survey data requires special care and attention to the survey design.

How do groups compare?

Public health researchers are often interested to know if one group is more vulnerable than another or if two or more groups are actually different from one another.

How do groups compare over time?

Comparing several groups over time can provide insight into if the change over time is different for different groups.

How do paired groups compare?

Paired groups are those that are not independent in some way. Perhaps you want to know how data from the same person over time compares with that of another person over time, or perhaps you are interested in how something changed in a city before and after an intervention, or perhaps you want to compare groups using data that has structure where there is coupling or matching of data values across samples.

Are certain groups or possibly subgroups more vulnerable?

Understand how to compare subpopulations at a deeper level.

How does something compare across regions?

Often it is useful to investigate if data differs by region, as many environmental, cultural, and political differences can influence public health outcomes.

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Make it easy for others to find your data, see the major trends in your data, or search for specific values in your data.

Data can come from many different sources, from the more obvious like an excel file to the less obvious like an image or a website. These case studies demonstrate how to use data from a variety of possible sources.

Using data from a PDF or just parts of a PDF can be challenging. You could type the data into a new excel file, but this can result in mistakes and it is difficult to reproduce.

Data are often in CSV files and it is typically easy to import data and work with data in this form. However, sometimes it can be difficult if, for example, the first few lines are structured differently or if you have unusual missing value indicators.

If you find data on a website that doesn’t allow you to download in a convenient way, you can actually directly import the data into R programming language.

This is one of the most common data forms, and it is typically easy to import data and work with data in this form. However, sometimes it can be challenging, especially if you have many files.

You can extract text from image files. This can be useful if, for example, you want to only use certain parts of a PDF.

It is possible to find the data that you need to use from an application programming interface (API).

Google Sheet

You can download data from a Google Sheet, copy and paste it into Excel, or directly import the data into R programming language.

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Working with survey data requires special care and attention, and you can do this directly with R programming language.

Multiple files

If you find that you need to import data from multiple files, there is a more efficient way to do so without importing each one by one.

Data wrangling is the process of organizing your data in a more useful format. These case studies explore how to clean, rearrange, reshape, modify, filter, combine, or join your data.

Extracting data from a PDF

Extracting and organizing data from a PDF will make it easier to use.

Geocoding data

The process of assigning relevant latitude and longitude coordinates to data values is called geocoding. This can be helpful (although not always necessary) to create a map of your data.

Recoding data

If you have data values that are confusing and could be changed to something better, or if you want to convert your data to true or false, you might want to consider recoding these values.

Methods of joining data

Sometimes, you obtain data from multiple sources that need to be combined together.

Filtering data

Perhaps you need to filter your data for only specific values for given variables. In other words, you might want to filter census employment data to only values for females who are also Black and live in Connecticut.

Modifying data (normalizing, transforming, scaling etc.)

Sometimes it is difficult to know when or how to normalize data.

Working with text

You can work with, remove, replace, or change words, phrases, letters, numbers, or punctuation marks in your data.

Reshaping data

Sometimes it is useful to shape your data so that you have many columns (for example, when performing certain analyses), however it can be useful at other times (for example, when creating plots) to collapse multiple columns into fewer columns with more rows.

Repetitive process

Sometimes you need to wrangle multiple datasets from different sources in a similar manner.

A picture is worth a thousand words, particularly when it comes to interpreting data. These case studies demonstrate how to make effective visualizations in various contexts. The first ten represent basic visualizations while 11-22 are more advanced.

A table that is easy to interpret

Adding colors or simple graphics can make tables easier to interpret.

Scatter plot

Scatter plots can be a strong option for evaluating the relationship between variables, and especially for evaluating changes in a variable over time.

Line plots are often useful for evaluating changes over time.

Bar plots are a good choice if you want to compare data to a threshold.

Box plots are particularly useful for comparing groups with many data values. They provide information about the spread of the data.

Pie chart/waffle plot

Pie charts or waffle plots can be a strong option when comparing relative percentages.

It can be difficult to visualize multiple groups at simultaneously. In these situations, heat maps can be a great option.

Correlation plots

If you have many variables and need to know if they are correlated to one another, there are methods to efficiently check this.

Visualize missing data

It can be helpful to quickly identify how much of your data is missing (has NA values).

Create a map of your data

Often the best way to interpret regional differences in data is to make a map.

Advanced Visualizations

Matching a style

If you are working with collaborators, you can make your visualizations match the style of their figures.

Faceted plots allow you to quickly create multiple plots at once

It can be difficult to visualize multiple groups at the same time, so faceted plots are a great option in this situation.

Adding labels directly to plots with many different groups

If you compare many groups over time, for example, it can be difficult to see which line corresponds to which group. Adding labels directly to these lines can be very helpful and negates the need for an overcomplicated legend.

Emphasize a particular group

Sometimes you will have several different groups and you want to highlight a specific group.

Adding annotations to plots

Adding labels, such as thresholds, arrows, or equations, can make it easier for people to interpret your plot.

Add error bars to your plot

Adding error bars can help convey information about the confidence of the estimates in your plots.

Combine multiple plots together

Sometimes it is useful to put a variety of plots together and add text to explain what the plot shows.

Create an interactive plot when you have too many groups to label

If you compare a very large number of groups, it can be difficult to tell what is happening. Often it can help to make the plot interactive so that the user can hover over points or lines to see what they indicate.

Create an interactive map of your data

Sometimes it is easiest to see regional differences by interacting with and exploring an interactive map.

Create an interactive table of your data

Sometimes you might want to be able to search through your data or allow others to easily do so.

Add images to your figures

Including images to a plot, such as a logo, can be a helpful addition.

Create an interactive dashboard/website for your data

Dashboards can quickly convey major trends in a dataset, and they can also allow users to interact with the data to choose what aspects about the data they wish to explore.

To better understand data, it is helpful to use statistical tests. These case studies demonstrate a variety of statistical tests and concepts.

Are two groups different?

Correlation

Are two variables related to one another?

Are multiple groups different?

Linear regression

Would you like to compare groups?

Chi-squared test of independence

Do the frequencies of two groups suggest that they are independent?

Mann-Kendall Trend test

Is there a consistent change over time?

Machine learning

Would you like to predict data?

Calculate percentages with missing data?

Would you like to calculate percentages, but you are missing some data?

About The Project

Learn about the team behind the Open Case Studies project.

As part of the larger Open Case Studies project (OCS) at opencasestudies.org , these case studies were developed for and funded by the Bloomberg American Health Initiative. The OCS project is made up of a team of researchers at the Johns Hopkins Bloomberg School of Public Health (JHSPH).

Let us know how the Open Case Studies project has enhanced your educational curriculum or ability to tackle tough data-rich research projects.

JHSPH Faculty Contributors

Jessica Fanzo, PhD

Brendan Saloner, PhD

Megan Latshaw, PhD, MHS

Renee M. Johnson, PhD, MPH

Daniel Webster, ScD, MPH

Elizabeth Stuart, PhD

Bloomberg American Health Initiative

Joshua M. Sharfstein, MD – Director, Bloomberg American Health Initiative

Michelle Spencer, MS – Associate Director, Bloomberg American Health Initiative

Paulani Mui, MPH – Special Projects Officer, Bloomberg American Health Initiative

Other Contributors

Aboozar Hadavand, PhD, MA, MS, Minerva University

Roger Peng, PhD, MS, Johns Hopkins Bloomberg School of Public Health

Kirsten Koehler, PhD, MS, Johns Hopkins Bloomberg School of Public Health

Alex McCourt, PhD, JD, MPH, Johns Hopkins Bloomberg School of Public Health

Ashkan Afshin, MD, ScD, MPH, MSc, University of Washington and Institute for Health Metrics and Evaluation (IHME)

Erin Mullany, BA, Institute for Health Metrics and Evaluation (IHME)

External Review Panel

Leslie Myint, PhD, Macalester College

Shannon E. Ellis, PhD, University of California – San Diego

Christina Knudson, PhD, University of St. Thomas

Michael Love, PhD, University of North Carolina

Nicholas Horton, ScD, Amherst College

Mine Çetinkaya-Rundel, PhD, University of Edinburgh, Duke University, RStudio

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Lessons from the field: case studies in global implementation science

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Published: 10 September 2024

Influence of public health emergency on city image: the case of COVID-19 stigma on Wuhan city

Shanghao Wang 1 &
Xuan Zheng 2

Humanities and Social Sciences Communications volume 11 , Article number: 771 ( 2024 ) Cite this article

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Language and linguistics

This study explored the influence of COVID-19 stigma on the city image of Wuhan by adopting the associative group analysis method. The collected data were free associations of the word “Wuhan” from 39 non-Chinese participants residing outside of China. It found that there were 12 meaning categories related to the city image of Wuhan, half of which were related to COVID-19, and the other half were related to Wuhan city. 56.45% of the associated words were related to COVID-19 and 43.55% to Wuhan city. The results demonstrated that the city image of Wuhan was impacted by the COVID-19 pandemic, mediated by personal experience and perceived media reports. The associated words have constructed a “Wuhan-COVID-19” stereotype, including “Wuhan-birthplace of COVID” and “Wuhan-eating wild animals”. This reflected that the city image of Wuhan endured stigma in the global community. The study provided implications for eliminating stigma and reconstructing group relationships in the global community.

The effects of COVID-19 on the resilience of urban life in China

More than just a mental stressor: psychological value of social distancing in COVID-19 mitigation through increased risk perception—a preliminary study in China

Implications of media reports of crime for public trust and social support: a conceptual analysis of individuals’ psychological wellbeing, introduction.

In late December 2019, an unfamiliar virus began its rapid dissemination from the epicenter in Wuhan, the capital of Hubei, China. The virus had impacted individuals nationwide, with confirmed cases emerging in different countries by January 2020. Simultaneously, in various global contexts, expressions such as ‘Wuhan virus,’ or ‘China virus’ have been frequently employed by both lay individuals and influential politicians, as well as within mass media discourse (Rovetta and Bhagavathula, 2020 ; Su et al., 2020 ). Although the WHO officially named the virus “COVID-19” to avoid stigmatization of specific locations, animals, or individuals on February 11, 2020, there has been usage of these expressions, which not only smears the city of Wuhan but also discriminates against the people of Wuhan and China. During that period, Wuhan was at the epicenter of the early stages of the outbreak, and studies have suggested that both Wuhan and China, as well as broader East Asian regions, encountered social stigma on the global stage concerning the COVID-19 situation (Yang et al., 2022 ). In non-Asian countries, there have even been instances of violent discriminatory crimes targeting Asians during and after the pandemic (Gover et al., 2020 ; Zhou et al., 2021 ; Dhanani et al., 2023 ). While the impact of COVID-19 has passed its acute stage, individuals worldwide continue to grapple with ‘long COVID’, for which diagnostic and treatment options remain insufficient at present (Davis et al., 2023 ); at the international stage, discourses around differences are still prevalent, and conflicts between different countries over resources persist. In order to cope with the post-COVID challenges, it is crucial that we review during the time of a crisis, how group distinctions were accentuated, leading to “double stigmas” (Zuo and Wen, 2022 ) that integrated illness and a certain region/group. Examining the international perception of Wuhan city and analyzing its underlying factors during the initial outbreak stage of COVID-19 holds significant importance for achieving this goal. This study employs the method of associative group analysis, collecting associations to the term “Wuhan” from 39 non-Chinese participants from November 25th to December 15th, 2020. Alongside interviews, the study seeks to explore the impact and insights of the public health emergency on the construction of city image, stereotype, and stigma in people’s psychological meanings.

Literature review

The notion of city image has become a focal point in communication, sociology, and discourse studies, as evidenced by notable contributions from scholars such as Joss et al. ( 2017 ), Huang et al. ( 2021 ), and Jabareen and Eizenberg ( 2021 ). The construction of a city’s image is intricately tied to its distinctive characteristics, shaping perceptions in the minds of its residents and visitors (Nasar, 1990 ). It is crucial to recognize that the city image is a dynamic construction of tangible features of individual perspectives and engagements. Mass media, personal experiences, interpersonal communication, and cultural factors all contribute to the shaping of city’s image (Foot, 1999 ; Avraham, 2004 ). A traumatic event or crisis can result in a transformation of people’s perceptions of a city’s image. A previous study conducted by the corresponding author has found that within China, during the initial outbreak of the virus, the psychological meanings of Wuhan have integrated 40% of COVID-related associations. (Corresponding author et al., 2020 ).

Maintaining a favorable city image is essential not only for garnering support from the community but also for avoiding potential conflicts during crisis situations. When the image is damaged, repairing the image becomes especially important. Benoit and colleagues ( 1991 ) developed image repair theory to investigate strategies employed by communicators to repair or restore a damaged image. Five image repair strategies with subcategories have emerged from this line of research: denial, evasion of responsibility, reducing offensiveness, corrective action, and mortification (Benoit & Pang, 2008 ). In denial, communicative entities may either flatly reject an accusation or shift blame onto others; evasion of responsibility involves arguing provocation, defeasibility, lack of information, accident, or good intentions. To reduce offensiveness, entities employ strategies like bolstering, minimization, differentiation, or transcendence. Corrective action entails presenting a plan to solve or prevent a problem. Mortification, as an image repair strategy, is practiced when communicative entities issue sincere apologies. Image analysis initially applied to analyze apologia employed by political figures in various high-profile cases, has proven to be a framework for understanding and dissecting strategic communication in crisis situations (Benoit, 2006 , 2011 ; Benoit et al., 1991 ; Benoit and McHale, 1999 ). Extending the application of image repair theory to the realm of city image repair, the adaptation of these strategies becomes crucial in addressing challenges and mitigating negative perceptions associated with a city. Stigma and image are closely interconnected and can have a profound influence on each other (Kearns et al., 2013 ). The term stigma is defined as an identifying mark of disgrace attributed to individuals who bear a ‘discreditable attribute’ (Goffman, 1963 ). It is often the result of social activities such as labeling, stereotypes, separation, and discrimination within a power imbalance (Link and Phelan, 2001 ). Prior research has investigated the attitudinal meanings of society towards stigmatized groups with regard to various diseases, including HIV/AIDS (Campbell et al., 2007 ; Kalichman et al., 2022 ), mental illnesses (Corrigan et al., 2012 ), and cancer, (Stergiou-Kita et al., 2016 ). In addition, research has explored social groups such as homelessness (Oppong Asante and Onyeaka, 2022 ), and sexual orientation (Branstrom, 2017 ), where stigmatized groups are subjected to negative stereotypes from more powerful members of society. In addition, negative stereotypes and discriminatory behaviors towards stigmatized individuals have also been a cause for concern during public health emergencies such as severe acute respiratory syndrome (SARS) (Lee et al., 2005 ) and H5N1 (Barrett and Brown, 2008 ). These studies indicate that fear of contracting the epidemic has been identified as a significant precursor for people to engage in stigmatizing behavior towards those who are infected or suspected of being infected due to their association with the spread of the epidemic. This is particularly relevant to COVID-19 stigma in the past few years.

The study of COVID-19 stigma, which refers to the social discrediting of individuals based on their psychological reflection on COVID-19 virus, appeared as instances of racism and discrimination against the Asian community, who were labeled as the “origin groups” (Budhwani and Sun, 2020 ). Several studies have indicated that COVID-19 has the potential to cause psychological effects and emotional challenges on stigmatized individuals, leading to adverse impacts on their mental health, such as helplessness, depression, and loneliness due to social isolation. Additionally, these effects could increase the risk of mental health issues (Dai et al., 2022 ; McLean et al., 2022 ). According to a study conducted by Yu et al. ( 2020 ), during the early stages of the COVID-19 pandemic, individuals residing in Wuhan experienced significantly greater psychological distress than those in other China’s cities and provinces. This is likely due to the increased levels of fear, uncertainty, and concern among residents in Wuhan and Hubei province regarding the potential for stigmatization and discrimination due to their proximity to the epicenter of the outbreak. Although the intersectionality lens is often used to explain the complex social processes underpinning existing stigma, less attention has been applied to illuminating the mechanisms through which stigma related to new diseases emerges to intersect with social identities.

One of the underlying reasons that gives birth to stigma, stereotypes, and discrimination is the social categorization process (Tajfel et al., 1986 , Tajfel and Turner, 2001 ) that makes a distinction between in-group and outgroup members; an “us” versus “them” mentality. In the formation of a disease-related stigma, it is those who have not been infected (“us”) who demonstrate aggressive emotions and behaviors towards the sickly others (“them”). In doing so the un-infected build a strong in-group solidarity in order to avoid contamination. In the COVID-19 crisis, there are more benefits in accentuating such a distinction. Intercultural scholars have pointed out that this “profit of distinction” could involve maintaining a particular social order or ‘a profit in legitimacy’ (Bourdieu, 2000 ), which constitutes an instrument of symbolic domination (Zhu et al., 2022 ). In Zhu et al.’s study, wearing a mask by Chinese international students in UK universities during the initial outbreak was subjected to symbolic violence by the dominant groups through acts of distinction, which reinforced social inequality. Such acts of distinction, as commonly observed during pandemics, only make marginalized groups more vulnerable (Jones, 2007 , 2013 ).

Although studies within the fields of Linguistics and Communication have been keenly aware of such symbolic violence in various forms of discourse such as the media in constructing COVID-19 stigma and related national/regional identities (Katikireddi et al., 2021 ; Miconi et al., 2021 citation), we know very little about how regular people actually perceive other group members during such a sensitive time. Previous studies have already examined how the Chinese population perceives their own group during the COVID-19 (Li et al., 2021 ), and it was found that within China, people from Wuhan, Hubei province, and other provinces differed in how they perceived Wuhan: the closer they resided from Wuhan, the fewer COVID-associations they made, but with more negative emotions (Corresponding author et al., 2023 ). Furthermore, the corresponding author’s team found that while non-Hubei-ers’ associations of Wuhan with COVID decreased significantly 2 months after the initial outbreak, the associated words Hubei-ers who lived in Hubei but outside of Wuhan continued to hold mixed feelings (both positive and negative) towards Wuhan. This revealed the intimate and competitive relationships between Wuhan and its neighboring cities in Hubei province.

While the studies have examined how the Chinese people viewed Wuhan, it is worthy of mentioning that it is outside of China that COVID-19 has become the ‘China virus’ or ‘Kung Flu’ in various media discourses (Walker and Daniel Anders, 2022 ) and the Chinese/Asian people have been largely discriminated against by the non-Chinese, it is urgent to examine how non-Chinese living outside of China perceive Wuhan during the pandemic. In doing so, we cannot only zoom in on the actual content of stigma during the time of crisis again but also understand the relationship between China and other countries reflected in those perceptions. Therefore, we can understand more fully the mechanism by which a crisis such as a public health emergency impacts people’s psychology toward other national groups.

Therefore, in this study, our aim is to address the following research questions:

How do non-Chinese individuals associate meanings with the term “Wuhan”? What are the distributions and characteristics?

How do these distributions and characteristics reflect the impact of the emergent public health event on the city image of Wuhan?

What are the implications for reconstructing Wuhan’s city image, if proven needed, from the distribution and characteristics of these associative words?

Methodology

Associative group analysis.

This study adopted a qualitative design based on associative group analysis (hereafter AGA). The AGA method, developed by Szalay and Brent ( 1967 ) in the study of attitude (Szalay et al., 1993 ; Szalay et al., 1999 ), uses continuous free-word responded from participants by presenting a stimulus word. The method allows the researchers to investigate the spontaneous psychological options of the participants within a limited time. Compared to observing and analyzing people’s opinions on social media which are performances of their identities, the AGA method provides a tool that can peek into people’s subconscious mind. Such advantage is especially crucial for studying stereotypes and attitudes where people tend to think and act differently in order to maintain an open-minded image (e.g., “I don’t discriminate, but…”). In our study, we draw upon the AGA method to gather and analyze the words associated with Wuhan as expressed by the participants. This approach allowed us to investigate the options of the associations so as to explore the psychological meaning (i.e., their attitudes or opinions) of Wuhan.

Participants

The data collection period for this study was from November 25th to December 15th, 2020, spanning 21 days. Initially, the researchers selected 16 familiar non-Chinese friends as participants through social media platforms. Demographic information comprised the country where they currently reside (which has been verified to align with their nationality), their gender, and their past experiences of traveling to China. After the experiment, the participants were trained to apply the same procedure to gather data from their close friends and acquaintances. In the end, a total of 39 research subjects (see Table 1 ) participated in this study.

Procedures of data processing

The data processing is carried out according to the following seven steps:

Before the experiment, the researchers explained the procedures to the participants and informed them that the entire experiment process would be recorded. Upon obtaining participants’ consent, the researchers began the experiment. The experiment was conducted through an online voice call. First, the researchers typed the term “Wuhan” in the chat window, prompting the participants to begin a one-minute free association in their native language, which was done to ensure the accuracy of verbal expression. Then, participants uniformly translated their voice-input associations into corresponding English expressions, sequentially wrote them down, and sent them to the researchers.

The data were recorded in sequence in an Excel spreadsheet.

The data shows that each participant produced a total of 3 to 12 associated words. Based on this, the assignment of values to the words is as follows: the scores for the 1st to 10th words are 6, 5, 4, 3, 3, 2, 2, 1, 1, and 1, respectively. Positions beyond the 10th are ignored. Building upon the data calculation method used in previous studies (Szalay and Deese, 1978 ; Kelly, 1985 ), the score for each position is the value multiplied by the frequency of the word appearing in that position. The scores for the same word across all positions are summed, resulting in the overall score for that word.

Associative words were categorized from bottom to top into three distinct semantic categories: primary, secondary, and tertiary (Note that these categories were mutually exclusive).

Calculate the total scores for each semantic category and the scores for individual associative words via Excel.

Choose the associative words with the highest scores in each semantic category and perform a semantic analysis while considering the total scores of those categories.

Given that AGA is unable to explore the use of discourse in specific contexts, the researchers conducted additional interviews via online voice calls with participants who presented associative words distinct from all other subjects. The interview mainly focused on the question: Why did you think of this word? During the data analysis, researchers employed thematic analysis to summarize potential factors contributing to the responses, adding contextual information to understand the meanings of the words more accurately. Before the interviews, participants were informed that certain interview content might be made public. Upon obtaining their consent, the researchers began the interviews, which were conducted exclusively in English. A total of four individuals participated in these interviews (see Table 2 ).

Overall distribution and characteristics of semantic categories and associative words

In this study, a total of 191 associative words were collected, as shown in Fig. 1 for the word cloud. Based on the results from the AGA experiment, this study gathered the 20 most highly scored associative words, as shown in Fig. 2 . Among the top 5 associative words, the highest scored is COVID-19 , and three out of the first five associative words are related to the COVID-19 (i.e., COVID-19 , covid and virus ), indicating that for most of the participants in the study, COVID-19 has become their primary association with Wuhan. Moreover, the word China ranks third, indicating that for most of the subjects in the study, the association with the city leads to thoughts about the country.

Associative words in the participants.

The top 20 associative words regarding Wuhan as perceived by the participants.

The associative words fall into 2 primary categories: words related to COVID-19 and Wuhan city. Within the primary category related to COVID-19, there are 6 secondary categories (i.e., disease, figure, region, information policy, prevention measure, and impact) and 6 tertiary categories (see Table 3 ). In the primary category associated with Wuhan city, there are 6 secondary categories (i.e., social environment, social welfare, geographical environment, relevant figure, cultural life, and subjective judgment) and 6 tertiary categories (see Table 4 ). The distribution of associative words within secondary categories is shown in Fig. 3 :

Overall distribution of associative words within the secondary categories.

Examining the distribution of associative words within the secondary categories, we observe that those related to COVID-19 (1.1 to 1.6 in the diagram) account for 56.45%, whereas those related to Wuhan (2.1 to 2.6 in the diagram) account for 43.55%. The top 5 with the highest proportion within the secondary categories (constituting 76.93% of all secondary categories) are 1.1 diseases (28.22%), 1.3 regions (15.60%), 2.3 geographical environments (13.30%), 2.1 social environments (11.67%), and 2.6 subjective judgments (8.14%). Moreover, in the tertiary categories, the top 5 categories with the highest scores are as follows: 1.1.1 disease name (157), 1.3.3 spot (63) of the epidemic, 2.1.2 geographical location (51) of Wuhan, 2.3.1 natural environment (49) of Wuhan, and 1.3.1 nation, province or city name (44) related to the epidemic.

Associative words related to COVID-19: medical hard information and misunderstood soft information as sources of stigma

To present the data in a more systematic manner, this study will elucidate the research findings through the distinction between hard information and soft information. Previous research suggests a somewhat basic differentiation, categorizing soft data as subjective and qualitative, and hard data as objective and quantitative (Bertomeu and Marinovic, 2016 ). Goddard and colleagues ( 1999 ) also emphasized a significant distinction between the two information types based on their sources. Hard information typically follows formal channels and is represented by official returns, documents, and records. Previous studies have also classified hard information as definitions found in dictionaries and encyclopedias (e.g., Gao et al., 2003 ). In contrast, soft information often traverses informal channels and networks, with many instances relying on verbal communication and remaining unrecorded. It should also be noted that the associations related to the location are considered soft information within the COVID-19 category but hard information within the Wuhan category. This is because COVID-19’s essence pertains to a kind of disease, so associating a location involves subjective psychological and social aspects. On the other hand, Wuhan is inherently a location, so associating it with other locations or broader geographical concepts constitutes hard information. In this study, hard information is characterized by its objective, factual, and measurable nature, while soft information is characterized by its subjective, qualitative, and interpretive nature. For instance, consider the name of a disease (e.g., COVID-19). It serves as a standardized and factual term used to precisely identify a particular medical condition. This categorization places it within the realm of medical hard information, characterized by its objectivity and clear definability. On the contrary, when the associated word is about a specific spot within a region (e.g., wet market), it may delve into subjective aspects associated with the spot, encompassing personal perceptions, experiences, or narratives related to the “original” wet market. In this sense, this type of information falls under the domain of psychological and social soft information. It is pertinent to highlight that the distinction aims to underscore the diverse characteristics of the information rather than rigidly assigning it to one category over the other.

The word cloud depicted in Fig. 4 illustrates that a significant number of participants may associate Wuhan with the nomenclature related to COVID-19 (e.g., Covid, virus, and coronavirus) than other categories of the pandemic. Within the secondary categories related to COVID-19, disease and prevention measures fall under medical “hard information”, accounting for a proportion of 36.60%. The categories of the figure , spot , information policy , and impact belong to psychological and social “soft information”, totaling 15.39%. Previous research (Goodwin et al., 2010 ) on the psychological meanings or attitudes towards other virus names also indicates that disease-related elements like names and symptoms constitute the foremost associations individuals form with viruses. In light of previous research, people’s psychological reactions to crises can be divided into panic phase, frustration phase, and recovery phase (Gao et al., 2003 ). During the panic phase, people may endeavor to handle the disease efficiently, leading to an increased focus on “hard information” such as disease symptoms and prevention. During the frustration phase and beyond, there is a greater focus on “soft information” such as the impact of the epidemic and control measures on daily life. The data collection for this study occurred well after the panic phase of the Wuhan epidemic. However, the associative words in this study still primarily consist of “hard information”. This might be a reflection of participants’ projection of their local epidemic panic (Allport, 1958 ). Furthermore, it is also possible that foreign COVID-19 news amplified the panic during the outbreak period in Wuhan (Mao et al., 2023 ), without providing detailed coverage of individual stories or effective prevention policies during that period. As a result, there might not have been much “soft information” that non-Chinese people could associate with.

Associative words related to COVID-19 in the participants.

Within the secondary categories shown in Table 3 , associative words related to 1.1 diseases hold the largest proportion (30.75%) and significantly surpass other secondary categories. The tertiary categories within this domain all pertain to medical “hard information”, encompassing the name , cause , transmission , and symptom related to COVID-19. Among these, the category of 1.1.1 name holds the highest score 157, comprised of terms such as COVID-19, as well as its synonyms or hypernyms such as covid , coronavirus , corona , pneumonia , and virus , indicating that when the word Wuhan is mentioned, the associative words of the participants mostly revolve around designations related to COVID-19. This reflects that the city image of Wuhan has been associated with the label of the COVID-19 pandemic, which forms a regional stereotype of “Wuhan-COVID-19”. The tertiary category of 1.1.3 transmission (scored 37) also exhibits similar distributional characteristics. The associative words within this category all encompass the meaning of “origin of COVID-19 pandemic” (such as outbreaks , pandemic , where covid started , etc.), also forming a regional stereotype of “Wuhan—the origin of COVID-19 pandemic”.

When asked about the reason for prioritizing associative words related to COVID-19, the participant indicated that the choice of words was influenced by news media. As described by interviewee A in the following example:

“Typically, all the news about this city will be tagged with corona or pandemic center by those so-called critics, so words like corona and covid always come to my mind first when thinking about the city.”

(Interviewee A)

The example exhibits the characteristic of “approximation” in the nature of stereotype. That is to say, he believes “all” news reports do this, leading him to “always” think this way. The verb “tagged” vividly depicts the action of labeling, where media labels attached to Wuhan have resulted in stereotypical impressions of the city among the participants.

It is worth noting that the distributional characteristics of associative words in the top-scoring subcategory 1.3 spot differ significantly from the same category in the study conducted by the corresponding author et al. ( 2020 ). When the participants are Chinese, the category is composed of associative words such as hospital , fever clinic , and supermarket . However, in this study involving non-Chinese participants, the category consists entirely of associative words such as wet market and its equivalents (e.g., animal market , seafood market , illegal market ). The finding highlights how various languages play a role in the construction of meaning. The initial perception of the Wuhan Huanan Seafood Market as the epicenter of the outbreak led numerous foreign media outlets to directly translate it as “wet market” (Mizumoto et al., 2020 ). This translation resulted in a misunderstanding among non-Chinese individuals, who erroneously associated the common Chinese farmers’ markets (wet markets) with wildlife markets. This could be the underlying cause for the emergence of the “Wuhan-wildlife market” regional stereotype within the spot category in this study.

The data collection for this study took place over seven months after Wuhan emerged from the harshest of lockdown, yet the participants in this study still associated Wuhan with COVID-related names or spots. This indicates that the city image of Wuhan has sustained a lasting stigma due to the COVID-19 pandemic.

The reason for this could be that the global epidemic has not been effectively alleviated during at the time of data collection, leaving individuals outside of China in a prolonged state of concern about the virus. The stigma associated with Wuhan actually reflects the negative emotions of unease, anger, fear, and the like that these populations harbor towards their local outbreaks. In this sense, Wuhan has become a “scapegoat” for releasing these negative emotions (Allport, 1958 ).

Associative words related to Wuhan city: constructing city image beyond COVID-19 pandemic

The word cloud presented in Fig. 5 highlights that the term “city” emerges as the most frequently associated term among participants. Additionally, it signifies that the associative words related to the city of Wuhan extend beyond the realm of the COVID-19 pandemic, suggesting a more factual and nuanced impression held by the participants about Wuhan. It encompasses more specific associations related to nature, society, and culture of the city (see Table 4 ). This indicates that, from their perspective, Wuhan is perceived as a city with a population of more than 10 million inhabitants , characterized by a hot and humid climate, renowned for institutions like Wuhan University , and some even possess knowledge of local cuisine such as Re Ganmian (hot and dry noodles) in Chinese.

Associative words related to Wuhan city in the participants.

From the perspective of information nature shown in Table 4 , the secondary categories related to the city of Wuhan are largely composed of ecological and geographical “hard information”, encompassing Wuhan’s social environment , social undertaking , and geographical environment (34.01%). The remaining categories consist of social and psychological “soft information”, including relevant figure , cultural life , and subjective judgment (14.01%). This distribution pattern aligns with the findings of the corresponding author et al. ( 2020 ). However, unlike their study, the largest proportion in the secondary categories is 2.1 social environment (18.50%), rather than cultural life . The associative words within this category pertain to “hard information” such as the name of the country, province, and landmark, signifying that for those who haven’t visited Wuhan, its cultural life remains somewhat unfamiliar. This also suggests that domestic media extensively employed metaphors related to urban cultural life, such as Re Ganmian , to evoke resonance during the pandemic coverage, a strategy less frequently adopted by foreign media.

The top five scoring categories within the tertiary categories are 2.1.3 area (51), 2.1.1 country (44), 2.3.3 geographical location (43), 2.6.1 positive judgment (36), and 2.3.1 natural environment (31) respectively. The associative words within these categories reflect the accuracy of the study participants’ understanding of the city of Wuhan. For instance, the associative words in the geographical location category such as central China , central , and center (with a total score of 43) indicate that most of the participants can accurately identify Wuhan is located in the central region of China. However, in the other tertiary categories, there exists deviations in the participants’ understanding of Wuhan. For instance, within the 2.1.3 area category, while most of the associative words are city or one of China’s cities (with a total score of 41), the remaining words carry meanings of rural area , village , and small town (with a score of 10). This reflects a cultural stereotype of a “Wuhan-underdeveloped area”. Additionally, there are animal-related associative words such as dogs and armadillo . As shown in Example 2, the participant appeared to have been impacted by baseless reports, linking Wuhan’s epidemic situation with wildlife consumption and generating a regional stereotype of “Wuhan-wildlife consumption”.

“I mean it is reported from the news broadcast that it is because people in there ate some weird animals like bats and maybe dogs that caused the outbreak of coronavirus.”

(Interviewee B)

Yet, some participants recognized that such associations implied a negative attitude and admitted that they actually didn’t understand Wuhan well, as shown in Example 3:

“Okay, I know that’s a bit cold, but I got to admit I am not so familiar with it.”

(Interviewee C)

Additionally, whether individuals have visited Wuhan or China will inevitably have an impact on the psychological meaning of the participants. Interviewee D in Example 4 had studied in China and visited Wuhan. During the interview, he conveyed a positive attitude towards the Wuhan. His associative words were closely aligned with specific categories related to the city, and the scores for associative words linked to it were higher compared to those related to COVID-19.

“I have been to Wuhan once like in 2018, and I really enjoyed the delicious noodles … The city has given me a very good impression and I also have had a precious memory there.”

(Interviewee D)

Indeed, among the participants with a history of residing in China (a total of 7 individuals), the majority of their associative words were tied to Wuhan city. Notably, 3 of them mentioned specific geographical landmarks or local delicacies as their primary associative word, examples being Yangtze River and Re Gan Mian . However, these 7 participants still mentioned associative words related to COVID-19, and the scores were relatively high (ranking within the top 5). This suggests that the quality of their experience while visiting China might hold more significance than the act of visiting itself.

Implications for reconstructing the city image of Wuhan impacted by the COVID-19 pandemic

The findings of this study reveal that during the data collection period, the discourse generated by non-Chinese participants when associating with Wuhan is closely linked to both COVID-19 and the city of Wuhan itself, with slightly more associative words related to COVID-19 than those related to the city. From the overall distributive characteristics of associative words, it can be observed that the study participants are more inclined to associate Wuhan with formal, explicit, and pre-existing “hard information”. Within the associative words related to COVID-19, the study participants often link Wuhan with the “hard information” associated with the outbreak of COVID-19, influenced by media reports and the impact of different languages. This has led to regional stereotypes such as “Wuhan-COVID-19 outbreak” and “Wuhan-wildlife consumption”. Associative words related to Wuhan city reflect the participants’ understanding of the local customs and culture of the city. They associate Wuhan with the city’s social environment, social welfare, and geographical features, encompassing ecological and geographical “hard information”. Their choice of associated words is influenced by their familiarity with Wuhan and their life experiences. For the participants with limited knowledge about Wuhan, there is a tendency to associate Wuhan with inaccurate information, leading to stigmatized psychological meanings like “Wuhan-underdeveloped area” and “Wuhan- wildlife consumption”.

To eliminate such stigma towards the city and advance global pandemic prevention efforts, it becomes crucial to reshape the image of Wuhan and even China. In this study, the term China ranked third in the scores among all associated words. This indicates that the city image of Wuhan is, to a certain extent, metaphorically linked to the national image of the nation. In other words, the psychological meanings of Wuhan could potentially give rise to a “national stereotype” (Bar-Tal, 1997 ) of China, which may lead to biased judgments, misunderstandings, and prejudices when applied to individuals from a specific country. A positive city image can facilitate the external projection of a country’s image. Considering this, promoting Wuhan’s image of epidemic control overseas has become particularly crucial.

Based on the findings, the first implication for reconstructing the Wuhan image is to utilize media reports to effectively disseminate authentic information about epidemic control and prevention measures and establish a more positive city and national image. The results indicate that currently, individuals from foreign countries still primarily acquire information about Wuhan and China from their own domestic mainstream media (as seen in Example 1 and 2). This reflects the significant challenges ahead in terms of effectively disseminating the image of epidemic control and prevention to the international community. This requires China to effectively utilize media channels for international dissemination, enabling global audiences to witness the authentic measures taken by Wuhan and China in the fight against the epidemic. By doing so, a sense of value connectedness that Knight ( 2010 ) termed “communal identification” can be fostered in aligning around global audiences, which may lead to the elimination of stigma and the establishment of an authentic new city and national image. Moreover, we suggest that establishing communication channels with media outlets can encourage responsible reporting, and sharing accurate and timely information becomes crucial in counteracting negative narratives and stereotypes perpetuated by the media. At the current stage, it may be helpful to use the bolstering strategy (Benoit & Pang, 2008 ), which emphasizes the amplification of positive qualities to enhance the perception of the city. For instance, the media can showcase Wuhan’s cultural richness, geographical significance, and contributions to academia (e.g., Wuhan University). It can also encourage individuals who have visited Wuhan to share their positive experiences (e.g., through online postings), which will provide counter-narratives to negative stereotypes.

The second implication is the need for targeted interventions addressing the persistent stigma surrounding Wuhan. The results of the study indicate that even though Wuhan had already ended its lockdown at the time of data collection, a significant portion of the participants still associate Wuhan with COVID-19. This suggests that the stigma attached to Wuhan remains stable. Stigmatization can intensify over time and transform into cultural biases. One of its contributing factors is the process of “in-group” developing contrasting perceptions of the “out-group”, leading to positive self-esteem gained from their group membership and biases towards outgroup members (Tajfel, 1982 ). In response to the COVID-19 pandemic, the participants tend to associate unfamiliar places like Wuhan with negative traits as a way to distinguish between themselves and other group members (i.e., “outgroup derogatory”). The other factor leading to stabilized stigma is probably because when faced with an unfamiliar and deadly disease, the natural instinct for human beings is to keep alive; and the quickest way for self-protection is to separate themselves from the “infected group” (Zuo and Wen, 2022 ). Although those reactions in crisis situations are mechanisms for individual and group preservation and are not always deliberate, the consequences of such stigmatization are profound: It can not only hinder the city’s development but also obstruct global collaboration in combating the pandemic. To undo these mechanisms, interventions can be provided to enhance people’s feelings of safety such as enhancing healthcare infrastructure, implementing strict public health measures, and providing mental health support to individuals affected by stigma. Additionally, community outreach initiatives such as public lectures, cultural events, and online campaigns could raise awareness about the impact of stigma and promote dialog and mutual respect among diverse communities. These programs could focus on debunking stereotypes and providing accurate information about the city’s situation and contributions.

The third implication is that direct contact can largely reduce one’s biases towards a certain place and several participants are aware of this. In the study, it found that those who had visited Wuhan associated more positive words and less negative, and COVID-related words with the city. For instance, one participant who had visited Wuhan shared that their experience of enjoying local delicacies like hot and dry noodles ( Re Ganmian ) left them with fond memories of the city. Conversely, those without direct contact with Wuhan were more likely to associate the city with negative COVID-related terms. Moreover, certain participants recognized their limited familiarity with Wuhan (e.g., never been there , not familiar ), and expressed a keen interest in visiting the city in the future, aiming to gain a firsthand experience of it (e.g., future travel destination ). This interestingly is a positive side-effect of the COVID-19 pandemic in Wuhan. By encouraging more people to visit the city and experience its unique attractions, such as its local cuisine and cultural landmarks, Wuhan can effectively reshape its image and achieve greater understanding and appreciation among visitors. It is worth mentioning that the quality of direct experiences also matters. If the visit is short and stressful, it may lead to new biases or reinforced stereotypes.

The fourth implication is to pay attention to cross-cultural differences in the use of language. The study underscores the necessity of acknowledging cross-cultural differences in language usage, particularly in terms like “wet market,” which are crucial for image repair. Proactive measures are essential for addressing linguistic challenges, including ensuring accurate translations and minimizing misinterpretations in global media. Establishing official glossaries or guidelines tailored for translating Wuhan-related terms is a key strategy. Additionally, providing training and support to translators and media professionals is vital to enhance their understanding of Wuhan’s cultural and linguistic nuances. Workshops, seminars, and online resources can also facilitate improved translation skills and promote cross-cultural competence among those responsible for communicating information about the city to global audiences.

The last implication is to stress the commonalities and unities among different groups. Paradoxical effects of COVID-19 are found in this study: although many of the associated words with Wuhan are negative and can be considered stigmas, a few expressions also showcase a sense of human empathy that goes beyond group distinctions, creating a positive identification with the people of Wuhan and nurturing a sense of unity with them. For instance, a Japanese participant who had studied in China mentioned cherry blossom . Cherry blossoms are symbolic of both Wuhan and Japan. The term cherry blossom psychologically links the two places, illustrating this participant’s sense of identification with Wuhan. Similarly, the term together was mentioned by a participant who had visited Wuhan. Although together implies differences between groups, it also conveys the communal identity of being fellow fighters against the pandemic, emphasizing that together we are united in spite of our individual distinctions. This indicates that although humans can make terrible mistakes in crisis, one of our most valuable characteristics is that we also hold empathy toward other fellow humans. This empathetic instinct can be used to counterbalance the tendency to make harmful distinctions. A suggestion for the media to restore Wuhan’s image, therefore, is to emphasize the commonalities between Wuhan and other cities in the world, especially the vulnerable feelings we all face under crisis. As a result, we can unite better and combat the pandemic together.

Concluding remarks

This research examines the content of stigma brought about by the COVID-19 pandemic in Wuhan. Drawing on the AGA method, it delves into the impact of public health emergencies on city’s image, reflecting non-Chinese group’s perceptions and relationships to Wuhan and China. The study demonstrates that non-Chinese participants, when mentioning Wuhan , associate it with terms related to either COVID-19 or the city of Wuhan, with a greater proportion of associations being related to COVID-19. During the time when epidemic prevention measures had become routine in Wuhan, non-Chinese residents outside of China still tended to associate Wuhan with COVID-19, giving rise to regional stereotypes such as “Wuhan-epicenter of COVID-19 outbreak” and “Wuhan-wildlife consumption”. This reflects how a public health emergency can lead to a lasting stigma of a city’s image, and people who live in the city, or even the country. The results also indicate the mentality of ingroup-outgroup distinction exists during times of crisis, and it will probably take a long time to reduce stigma related to Wuhan.

Some may argue that the psychological impact of COVID-19 may diminish over time with repeated exposure (Lu et al., 2021 ). However, in the post-pandemic era, recent empirical studies still indicate that the pandemic continues to have psychological effects on individuals, leading to mental health issues (Glinianowicz et al., 2023 ; Matsumoto et al., 2023 ), and negative consequences such as anti-Asian sentiments (Huang et al., 2023 ). For instance, Rastogi et al. ( 2023 ) revealed in their study during the spring of 2022 that lingering effects of COVID-19 can still cause significant mental distress in social groups. To describe the COVID-19 stigma in the post-pandemic era (Damant et al., 2023 ), researchers have even devised the Post COVID-19 Condition Stigma Questionnaire (PCCSQ), suggesting the long-lasting effects of pandemic-related stigmas.

Since our results showed that the selection of associated words by the participants in the study can be influenced by factors such as personal experiences or mass media, to help eliminate the stereotypes, it would be helpful to use these sources: e.g., report Wuhan continuously in the post-COVID time, covering more well-rounded aspects such as its industry, universities, and people’s lives. For instance, it is one of the largest university towns in the world; its weather can get extremely hot, as one of the three “Furnace cities” in China; many Olympic swimmers live in Wuhan because there are many lakes there and so on. It would also be helpful for people outside of China to know the “truth” of how people cope with COVID-19 during the most difficult times. In fact, research on international students during the lockdown in Wuhan has found that despite anxiety and fear, the students also felt supported and safe due to great determination and strong actions to control the situation in Chinese communities (English et al., 2022 ). Lastly, traveling to Wuhan and China personally and international collaboration with similar goals will greatly reduce the imagined stereotypes.

One of the limitations of this study lies in the restricted sample size. Future research endeavors could overcome this limitation by expanding the sample size and delving more comprehensively into demographic variables. Another limitation is that the data was collected at the end of 2020. A recent study by the corresponding author and colleagues ( 2023 ) indicates that the associations of Chinese university students with the city in the later stages of the pandemic have seen an increase in “hard information”. This suggests that, with the improvement of the pandemic situation, the psychological significance of Wuhan is gradually returning to its objective dictionary definition, and the stigma based on subjective judgments are decreasing. Subsequent research will collect data from global citizens to compare with previous studies, providing an in-depth observation of the historical changes in the psychological meanings of Wuhan among people worldwide.

This will subsequently offer more targeted insights to assist in reshaping a new, positive image of Wuhan and even China on the global stage, as they work to rebuild their international reputation in the context of public health emergency control.

Data availability

The data supporting the findings of this study have been uploaded to a cloud storage service ( https://disk.pku.edu.cn/link/AAE6943D4E1A2A4318B62F73D6CC33EB61 ). Due to ethical approval requirements, the privacy of participants must be strictly protected. Therefore, access to the data is available upon reasonable request. Interested researchers can contact Shanghao Wang (Email: [email protected]) to obtain the extraction code necessary to access the data.

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Wang, S., Zheng, X. Influence of public health emergency on city image: the case of COVID-19 stigma on Wuhan city. Humanit Soc Sci Commun 11 , 771 (2024). https://doi.org/10.1057/s41599-024-03280-2

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DOI : https://doi.org/10.1057/s41599-024-03280-2

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A study on the relationship between campus environment and college students’ emotional perception: a case study of yuelu mountain national university science and technology city.

1. Introduction

1.1. background, 1.2. literature review, 2. materials and methods, 2.1. research framework, 2.2. research data, 2.2.1. study area, 2.2.2. research data, 2.3. research methodology, 2.3.1. deeplab v3+, 2.3.2. maxdiff perceptual quantization and the xgboost prediction model, 2.3.3. spatial autocorrelation analysis of emotional perception, 3.1. campus environment image semantic segmentation results, 3.2. predictive maps for emotional perception, 3.3. results of correlation analysis, 4. discussion, 4.1. natural environment and emotional perception, 4.2. built environment and emotional perception, 4.3. disciplinary environment and emotional perception, 4.4. campus planning and emotional perception, 5. conclusions, 5.1. environmental perception and quantification of emotions, 5.2. limitations, author contributions, data availability statement, conflicts of interest.

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Click here to enlarge figure

	XGBoost	Random Forest	KNN	BP Neural Network
Accuracy (%)	70.61	60.40	60.75	62.07

	Security	Depression	Disappointment	Relaxation	Happiness	Concentration
Accuracy (%)	70.45	75.79	69.89	77.42	68.75	61.36
Precision (%)	67.39	78.57	65.90	76.60	71.42	60.42
Recall (%)	73.80	70.21	69.04	78.26	68.63	65.91
F1 (%)	70.45	74.15	67.44	77.42	70.00	63.04

Z-Score	p-Value	Confidence Level
<−1.65 or >+1.65	<0.10	90 percent
<−1.96 or >+1.96	<0.05	95 percent
<−2.58 or >+2.58	<0.01	99 percent

	Global Moran’s I Index	Z-Score	Confidence Coefficient	Pattern
Happiness	0.173687	44.972916	99 per cent	Clustered
Concentration	0.287764	74.493483	99 per cent	Clustered
Disappointment	0.329239	85.226579	99 per cent	Clustered
Depression	0.379017	98.107986	99 per cent	Clustered
Security	0.164829	42.680497	99 per cent	Clustered
Relaxation	0.228221	59.085108	99 per cent	Clustered

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Share and Cite

Peng, Z.; Zhang, R.; Dong, Y.; Liang, Z. A Study on the Relationship between Campus Environment and College Students’ Emotional Perception: A Case Study of Yuelu Mountain National University Science and Technology City. Buildings 2024 , 14 , 2849. https://doi.org/10.3390/buildings14092849

Peng Z, Zhang R, Dong Y, Liang Z. A Study on the Relationship between Campus Environment and College Students’ Emotional Perception: A Case Study of Yuelu Mountain National University Science and Technology City. Buildings . 2024; 14(9):2849. https://doi.org/10.3390/buildings14092849

Peng, Zhimou, Ruiying Zhang, Yi Dong, and Zhihao Liang. 2024. "A Study on the Relationship between Campus Environment and College Students’ Emotional Perception: A Case Study of Yuelu Mountain National University Science and Technology City" Buildings 14, no. 9: 2849. https://doi.org/10.3390/buildings14092849

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Case Study: Helping an East Coast Medical Group Become a Lean Enterprise

magnifying glass icon with text reading Case Study

Client Background

The client is a large East Coast health system that has been a leading health care provider for over 150 years, serving the Mid-Atlantic and Southern states. Employing over 24,000 individuals, the system operates 20 hospitals and various health care facilities, including a medical group that provides outpatient primary and specialty care services.

The Situation

The medical group faced several challenges as it pursued four strategic goals:

Establishing consistent practices to unify the organization under its “One Health System” motto.
Improving patient access by enhancing appointment availability and optimizing care locations.
Increasing capacity to serve more patients effectively.
Evolving into a lean enterprise to eliminate waste, streamline operations, and enhance patient care across primary, specialty, and acute care settings.

The Solution & Results

To address these challenges, the Moss Adams Lean Healthcare Practice implemented several targeted interventions:

Kaizen Workshops. Fifteen teams across primary and specialty care participated in workshops aimed at improving access, reducing waste, and enhancing efficiency in processes like revenue cycles and rooming.
Lean Management System Development. The client developed a lean management system to enhance management control structures, conduct A3 problem-solving, and foster lean leadership development.
Flow Improvement in a Pulmonary Clinic and Beyond. A cellular design was introduced to streamline clinical and administrative tasks, reducing physician workload, and improving patient flow. Cellular design was subsequently spread to multiple clinics.
Revenue Cycle Improvements. Standardized work for registration processes and reduced registration-related errors.
Standard Work for Rooming and Annual Wellness Visits (AWV). Created standard procedures to improve patient safety, screening rates, and Medicare reimbursements.

These actions led to significant improvements across the medical group:

Access and Scheduling. Appointment availability increased by over 10,000 annually, and no-show rates were reduced, saving $155,000 in lost revenue. Time-to-third-next-available appointments decreased dramatically, improving patient access.
Surgical Access. Added 1,708 visits across three specialties, with operating room utilization improving from 85.5% to 93.4%.
Workplace Organization. Reclaimed over 900 square feet of space, valued at approximately $15,000, and centralized inventory, freeing up 0.8 full-time equivalent of staff time using the principles of 5S—sort, set-in-order, shine, standardize, and sustain.
Revenue Cycle. Freed over 4,400 hours per year of staff time, worth over $100,000, and boosted reimbursement rates.
Clinical Improvements. Safety errors dropped by 6%, depression-screening compliance increased by 20%, and patient satisfaction rose by 5%. AWVs as a proportion of total visits jumped from 29% to 67%, with significant increases in cancer screenings and fall risk assessments.
Lean Leadership Development. Empowered staff at all levels to pursue critical thinking strategies that advanced professional development and improved performance—not only for leaders coached directly, but also for direct reports. In one example, the cardiology program director and manager led a team effort to eliminate over 200 prescription refill calls weekly.
Cellular Design Implementation. Reduced clinic lead time for patients by 14.5 minutes and physician time by 12.2 minutes per patient, generating significant capacity and cost savings.

Overall, these interventions resulted in an estimated financial improvement of $1.7 million since 2017, demonstrating the successful transformation of the Medical Group into a lean enterprise.

Additional Resources

Health Care Consulting Services
Lean Health Care Consulting Services

The material appearing in this communication is for informational purposes only and should not be construed as legal, accounting, tax, or investment advice or opinion provided by Moss Adams LLP or its affiliates. This information is not intended to create, and receipt does not constitute, a legal relationship, including, but not limited to, an accountant-client relationship. Although these materials have been prepared by professionals, the user should not substitute these materials for professional services, and should seek advice from an independent advisor before acting on any information presented. Moss Adams LLP and its affiliates assume no obligation to provide notification of changes in tax laws or other factors that could affect the information provided.

Case-Based Learning and its Application in Medical and Health-Care Fields: A Review of Worldwide Literature

Susan f. mclean.

Department of Surgery, Texas Tech University Health Sciences Center El Paso, El Paso, TX, USA.

Introduction

Case-based learning (CBL) is a newer modality of teaching healthcare. In order to evaluate how CBL is currently used, a literature search and review was completed.

A literature search was completed using an OVID© database using PubMed as the data source, 1946-8/1/2015. Key words used were “Case-based learning” and “medical education”, and 360 articles were retrieved. Of these, 70 articles were selected to review for location, human health care related fields of study, number of students, topics, delivery methods, and student level.

All major continents had studies on CBL. Education levels were 64% undergraduate and 34% graduate. Medicine was the most frequently represented field, with articles on nursing, occupational therapy, allied health, child development and dentistry. Mean number of students per study was 214 (7–3105). The top 3 most common methods of delivery were live presentation in 49%, followed by computer or web-based in 20% followed by mixed modalities in 19%. The top 3 outcome evaluations were: survey of participants, knowledge test, and test plus survey, with practice outcomes less frequent. Selected studies were reviewed in greater detail, highlighting advantages and disadvantages of CBL, comparisons to Problem-based learning, variety of fields in healthcare, variety in student experience, curriculum implementation, and finally impact on patient care.

Conclusions

CBL is a teaching tool used in a variety of medical fields using human cases to impart relevance and aid in connecting theory to practice. The impact of CBL can reach from simple knowledge gains to changing patient care outcomes.

Medical and health care-related education is currently changing. Since the advent of adult education, educators have realized that learners need to see the relevance and be actively engaged in the topic under study. 1 Traditionally, students in health care went to lectures and then transitioned into patient care as a type of on-the-job training. Medical schools have realized the importance of including clinical work early and have termed the mixing of basic and clinical sciences as vertical integration. 2 Other human health-related fields have also recognized the value of illustrating teaching points with actual cases or simulated cases. Using clinical cases to aid teaching has been termed as case-based learning (CBL).

There is not a set definition for CBL. An excellent definition has been proposed by Thistlewaite et al in a review article. In their 2012 paper, a CBL definition is “The goal of CBL is to prepare students for clinical practice, through the use of authentic clinical cases. It links theory to practice, through the application of knowledge to the cases, using inquiry-based learning methods”. 3

Others have defined CBL by comparing CBL to a similar yet distinct clinical integration teaching method, problem-based learning (PBL). PBL sessions typically used one patient and had very little direction to the discussion of the case. The learning occurred as the case unfolded, with students having little advance preparation and often researching during the case. Srinivasan et al compared CBL with PBL 4 and noted that in PBL the student had little advance preparation and very little guidance during the case discussion. However, in CBL, both the student and faculty prepare in advance, and there is guidance to the discussion so that important learning points are covered. In a survey of students and faculty after a United States medical school switched from PBL to CBL, students reported that they enjoyed CBL better because there were fewer unfocused tangents. 4

CBL is currently used in multiple health-care settings around the world. In order to evaluate what is now considered CBL, current uses of CBL, and evaluation strategies of CBL-based curricular elements, a literature review was completed.

This review will focus on human health-related applications of CBL-type learning. A summary of articles reviewed is presented with respect to fields of study, delivery options for CBL, locations of study, outcomes measurement if any, number of learners, and level of learner's education. These findings will be discussed. The rest of this review will focus on expanding on the article summary by describing in more detail the publications that reported on CBL. The review is organized into definitions of CBL, comparison of CBL with PBL, and the advantages of using CBL. The review will also examine the utility and usage of CBL with respect to various fields and levels of learner, as well as the methods of implementation of CBL in curricula. Finally, the impact of CBL training on patient and health-care outcomes will be reviewed. One wonders with the proliferation of articles that have CBL in the title, whether or not there has been literature defining exactly what CBL is, how it is used, and whether or not there are any advantages to using CBL over other teaching strategies. The rationale for completing this review is to assess CBL as a discrete mode of transmitting medical and related fields of knowledge. A systematic review of how CBL is accomplished, including successes and failures in reports of CBL in real curricula, would aid other teachers of medical knowledge in the future. Examining the current use of CBL would improve the current methodology of CBL. Therefore, the aims of this review are to discover how widespread the use of CBL is globally, identify current definitions of CBL, compare CBL with PBL, review educational levels of learners, compare methods of implementation of CBL in curricula, and review CBL reports on outcomes of learning.

A literature search was completed using an OVID© database search with PubMed as the database, 1946 to August 1, 2015. The search key words were “Case Based Learning, Medical Education”. Investigational Review Board declined to review this project as there were no human subjects involved and this was an article review. A total of 360 articles were retrieved. Articles were excluded for the following reasons: unable to find complete article on the search engine OVID, unable to find English language translation, article did not really describe CBL, article was not medically or health related, or article did not describe human beings. Articles that originated in another language but had English language translation were included.

After excluding the articles as described, 70 of these articles were selected to review for location of study, description of CBL used, human health care-related fields of study, number of students if available, topics of study, method of delivery, and level of student (eg, graduate or undergraduate). Students were considered undergraduate if they were considered undergraduate in their field. For example, medical students were considered undergraduate, because they would still have to undergo more training to become fully able to practice. If the student was in the terminal degree, then that was considered a study of graduate students. For example, nutrition students were listed as graduate students. CBL encounters for both residents and independent practitioners who were in their final training prior to practice were listed as graduates. Residents were listed under graduate medical education. If a group had already graduated, they were listed as graduates. For example, MDs who participated in a continuing medical education (CME)-type CBL were listed as graduate type of student. Articles that did not list the total number of students were included, as one of the purposes of this review was to discover how widespread the use of CBL was globally, and what types of students and types of delivery were used. By including descriptive articles that were not specific, the global use of CBL could attempt to be assessed. Including locations of studies would then help decide whether CBL was isolated from the Western countries or has it truly spread around the world.

In order to review how CBL was used, in addition to where it was used, the method of delivery was assessed. Method of delivery refers to how the total educational content was delivered. Articles were reviewed for description of exactly how material was imparted to learners. Since many authors described their learning methods in detail, an attempt was undertaken to classify these methods. Method of delivery was classified as follows: live was considered a live presentation of the case, this could be a description, a patient, or a simulated patient. Computer or web based meant that the case and content were web based. Mixed modalities meant that more than two modalities were used during presentation. For example, if an article described assigned reading, lectures, small group discussions, a live case-based session, and patient interactions, then that article would be described as mixed modalities.

Method of evaluation of the educational intervention was also reviewed. The multiple ways in which the interventions were evaluated varied. A survey of how the learners viewed the intervention was frequent. Tests of knowledge gained were frequent, and these ranged from written, to oral, to Observed Skills Clinical Examination (OSCE). Another way by which CBL intervention knowledge was evaluated was review of practice behavior in clinicians. These multiple ways to evaluate the introduction of CBL into a curriculum are summarized in a table.

Results are presented in simple frequencies and percentages. SPSS (Statistical Program for the Social Sciences, IBM) version 22 was used for analysis.

All continuously inhabited continents had studies on CBL ( Fig. 1 ). North America is represented with the most with 54.9% of articles, followed by Europe (25.4%) and Asia, including India, Australia, and New Zealand (15.5%). South America had 2.8% and Africa had 1%. 5 – , 75

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CBL use worldwide.

Level of education was undergraduation in 45 (64%) articles and graduation in 24 (34%) articles, with one article having both levels. One study with both faculty and residents was considered as a type of graduate education. The types of fields of study varied ( Fig. 2 ). The most represented field was medicine including traditional Chinese medicine, with articles also on nursing, occupational therapy, allied health, child development, and dentistry. The number of students ranged from 7 to 3105 and the mean number of students was 214. One study reported on the use of teams of critical care personnel, in which it was mentioned that there were three persons per team usually. Thus, the number of students was multiplied: 40 teams x 3 = 120 in total. The total number of students were 9884 from the 46 papers that explicitly stated the number of students.

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Fields of study.

Methods of delivery also varied ( Fig. 3 ). The most common method of delivery was live presentation (49%), followed by computer or web based (20%) and then mixed modalities (19%). Method of evaluation or outcomes was studied ( Fig. 4 ). Survey (36%), test (17%), and test plus survey (16%) were the top three methods of evaluation of a CBL learning session. Lesser in frequency was review of practice behavior (9%), test plus OSCE (9%), and others. Review of practice behavior could include reviewing prescription writing, or in one case reviewing the number of adverse drug events reported spontaneously in Portugal. 65

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Mode of delivery of CBL.

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Method of evaluation.

Discussion and Review

CBL is used worldwide. There was a large variety of fields of medicine. The numbers reported included a wide range of number of learners. Some studies were descriptive, and it was hard to know exactly how many students were involved. This problem was noted in another recent review. 3 CBL was used in various educational levels, from undergraduate to graduate. The number of students ranged from very small studies of 7 students to over 3000 students. The media used to deliver a CBL session varied, from several live forms to paper and pencil or internet-based media. The outcomes measurement to review if CBL sessions were successful ranged from surveys of participants to knowledge tests to measures of patient outcomes. In order to further analyze the worldwide use of CBL, the articles are reviewed below in more detail.

Definition of CBL

CBL has been used in medical fields since at least 1912, when it was used by Dr. James Lorrain Smith while teaching pathology in 1912 at the University of Edinburgh. 63 , 68 Thistlewaite et al 3 pointed out in a recent review of CBL that “There is no international consensus as to the definition of case-based learning (CBL) though it is contrasted to problem based learning (PBL) in terms of structure. We conclude that CBL is a form of inquiry based learning and fits on the continuum between structured and guided learning.” They offer a definition of CBL: “The goal of CBL is to prepare students for clinical practice, through the use of authentic clinical cases. It links theory to practice, through the application of knowledge to the cases, using inquiry-based learning methods.” 3

Another pathology article from Africa, describing a course in laboratory medicine for mixed graduate medical education (residents) and CME for clinicians, defines CBL: “Case-based learning is structured so that trainees explore clinically relevant topics using open-ended questions with well-defined goals.” 7 The exploring that students or trainees do factors into other definitions. In a dental education article originating in Turkey, the authors remark: “The advantages of the case-based method are promotion of self-directed learning, clinical reasoning, clinical problem solving, and decision making by providing repeated experiences in class and by enabling students to focus on the complexity of clinical care.” 8 Another definition of CBL was offered in a physiology education paper regarding teaching undergraduate medical students in India: “What is CBL? By discussing a clinical case related to the topic taught, students evaluated their own understanding of the concept using a high order of cognition. This process encourages active learning and produces a more productive outcome.” 13 In an article published in 2008, regarding teaching graduate pharmacology students, CBL was defined as “Case-based learning (CBL) is an active-learning strategy, much like problem-based learning, involving small groups in which the group focuses on solving a presented problem.” 45 Another study, which was from China regarding teaching undergraduate medical student's pharmacology, describes CBL as “CBL is a long-established pedagogical method that focuses on case study teaching and inquiry-based learning: thus, CBL is on the continuum between structured and guided learning.” 63 It is apparent that the definition requires at least: (1) a clinical case, (2) some kind of inquiry on the part of the learner, which is all of the information to be learned, is not presented at first, (3) enough information presented so that there is not too much time spent learning basics, and (4) a faculty teaching and guiding the discussion, ensuring that learning objectives are met. In most studies, CBL is not presented as free inquiry. The inquiry may be a problem or question. Based on the fact that a problem is expected to be solved or question answered, the information covered cannot be completely new, or the new information must be presented alongside the case.

A modern definition of CBL is that CBL is a form of learning, which involves a clinical case, a problem or question to be solved, and a stated set of learning objectives with a measured outcome. Included in this definition is that some, but not all, of the information is presented prior to or during the learning intervention, and some of the information is discovered during the problem solving or question answering. The learner acquires some of the learning objectives during the CBL session, whether it is live, web based, or on paper. In contrast, if all of the information were given prior or during the session, without the need for inquiry, then the session would just be a lecture or reading.

Comparison of CBL and PBL

CBL is not the first and only method of inquiry-based education. PBL is similar, with distinct differences ( Fig. 5 ). In many papers, CBL is compared and contrasted with PBL in order to define CBL better. PBL is also centered around a clinical case. Often the objectives are less clearly defined at the outset of the learning session, and learning occurs in the course of solving the problem. There is a teacher, but the teacher is less intrusive with the guidance than in CBL. One comparison of CBL to PBL was described in an article on Turkish dental school education: “… CBL is effective for students who have already acquired foundational knowledge, whereas PBL invites the student to learn foundational knowledge as part of researching the clinical case.” Study, of postgraduate education in an American Obstetrics and Gynecology residency, describes CBL as “CBL is a variant of PBL and involves a case vignette that is designed to reflect the educational objectives of a particular topic.” 54 In an overview of CBL and PBL in a dental education article from the United States, the authors note that the main focus of PBL is on the cases and CBL is more flexible in its use of clinical material. 16 The authors quote Donner and Bickley, 70 stating that PBL is “… a form of education in which information is mastered in the same context in which it will be used … PBL is seen as a student-driven process in which the student sets the pace, and the role of the teacher becomes one of guide, facilitator, and resource … (p294).” The authors note that where PBL has the student as the driver , in CBL the teachers are the drivers of education, guiding and directing the learning much more than in PBL. 16 The authors also note that there has not been conclusive evidence that PBL is better than traditional lecture-based learning (LBL) and has been noted to cover less material, some say 80% of a curriculum. 71 It is apparent that PBL has been used to aid case-related teaching in medical fields.

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Differences in CBL and PBL.

Two studies highlight the advantages and disadvantages of CBL compared with PBL. Both studies report on major curriculum shifts at three major medical schools. The first study, published in 2005, reported on the performance outcomes during the third-year clerkship rotations at Southern Illinois University (SIU). 19 At SIU, during the 1994–2002 school years, there was both a standard (STND) and PBL learning tract offered for the preclinical years, years 1–2. During the PBL tract, basics of medicine were taught in small group tutoring sessions using PBL modules and standardized patients. In addition, there was a weekly live clinical session. The two tracts were compared over all those years with respect to United States Medical Licensing Exam© (USMLE) test performance on Steps 1 and 2, and also overall grades and subcategories on the six third-year clerkships. So the two tracks had differing years 1–2 and the same year 3. Results noted that the PBL track had more women and older students, so these variables were set out as covariates analyzing other scores. Comparing the PBL versus STND tracks, USMLE scores were statistically equal over the years 1994–2002. PBL was 204.90 ± 21.05 and STND was 205.09 ± 23.07 ( P , 0.92); Step 2 scores were PBL 210.17 ± 21.83, STND 201.32 ± 23.25 ( P , 0.15). Clerkship overall scores were overall statistically significantly higher for PBL tract students in Obstetrics and Gynecology and Psychiatry ( P = 0.02, P < 0.001, respectively) and statistically not different for other clerkships. Clerkship subcategory analysis demonstrated statistically significantly higher scores for PBL tract students in clinical performance, knowledge and clinical reasoning, noncognitive behaviors, and percent honors grades, with no difference in the percentage of remediations. The school decided to switch to a single-tract curriculum after 2002. The problems noted with the PBL curriculum involved recruiting PBL faculty and faculty acceptance of student interactions, and also assessment issues. Faculty had to be trained to teach in PBL, which was time consuming and interfered with the process of learning by students. In addition, some faculty felt that the teachers should determine the learner's needs and not vice versa. The PBL assessment tools were novel and not immediately accepted by the faculty. 19 Other schools noted similar problems with PBL: it is different than LBL, and difficult to teach, as it is extremely learner centered. Learning objectives are essentially generated by the student, making faculty control over learning difficult. At this school, the difficulties in using PBL contributed to its abandonment as a stand-alone curriculum tract.

The difficulties in using PBL were associated with changes in other medical schools. Two medical schools in the United States, namely, University of California, Los Angeles, and University of California, Davis, changed from a PBL method to a CBL method for teaching a course entitled Doctoring , which was a small group faculty led course given over years 1–3 in both schools. 4 Both schools had a typical PBL approach, with little student advance preparation, little faculty direction during the session, and a topic that was initially unknown to the student. After the shift in curriculum to CBL, there were still small group sessions, but the students were expected to do some advance reading, and the faculty members were instructed to guide or direct the problem solving. Since in both schools the students and faculty had some experience with PBL before the shift, a survey was used to assess student and faculty experiences and perceptions of the two methods. Both students and faculty preferred CBL (89% of students and 84% of faculty favored CBL). Reasons for preference of CBL over PBL were as follows: fewer unfocused tangents (59% favoring CBL, odds ratio [OR] 4.10, P = 0.01), less busywork (80% favoring CBL, OR 3.97 and P = 0.01), and more opportunities for clinical skills application (52%, OR 25.6, P = 0.002). 4 In summary, these two reports indicate that while a case-oriented learning session can prepare students for both tests of knowledge and also clinical reasoning, PBL has the problems of difficult to initiate faculty or teachers in teaching this way, difficult to cover a large amount of clinical ground, and difficulty in assessment. CBL, on the other hand, has advantages of flexibility in using the case and offers the same reality base that offers relevance for the adult health-care learner. In addition, CBL appears to be accepted by the faculty that may be practicing clinicians and offers a way to teach specific learning objectives. These advantages of CBL led to it being the preferred method of case-related learning at these two large medical schools.

Advantages of CBL and deeper learning

Another touted advantage of CBL is deeper learning. That is, learning that goes beyond simple identification of correct answers and is more aligned with either evidence of critical thinking or changes in behavior and generalizability of learning to new cases. Several articles described this aspect of CBL. One article was set at a tertiary care hospital, the Mayo Clinic, and was a teaching model for quality improvement to prevent patient adverse events. 33 The students were clinicians, and the course was a continuing education or postgraduate course. The authors in the Quality Improvement, Information Technology, and Medical Education departments created an online CBL module with three cases representing the most common type of patient adverse events in internal medicine. The authors use Kirkpatrick's outcomes hierarchy to assess the level of critical thinking after the CBL intervention. Kirkpatrick's outcomes hierarchy is based on four levels: the first, reaction of learner to educational intervention, the second, actual learning: acquiring knowledge or skills, the third, behavior or generalizing lessons learned to actual practice, and the fourth, results that would be patient outcomes. 72 The authors note that as one moves up this hierarchy, learning is more difficult to measure. A survey can measure hierarchy level 1, a written test, and level 2. Behavior is more difficult but still able to be measured. The authors measured critical thinking in physicians, taking their Quality Improvement course by measuring critical reflection by a survey. The authors constructed a reflection survey, which asked course participants about items constructed to assess their level of reflection on the cases. Least reflective levels consisted of habitual action, and most critically, reflective items asked physicians if they would change the way they do things based on the cases. The results of their intervention showed that physicians had the lowest scores in reaching the higher levels of reflective thinking. However, the reflection scores were shown to be associated with physicians’ perceptions of case relevance ( P = 0.01) and event generalizability ( P = 0.001). This study was the first to evaluate physician's reflections after a CBL module on adverse events. The assumption is that deeper learning will be more likely to lead to behavioral changes.

Another attempt to measure deeper learning was reported from a dental school in Turkey. 8 The authors compared a CBL course with an older LBL course from the previous year by using “SOLO” taxonomy, developed by Biggs and Collis. 73 SOLO taxonomy rates the learning outcomes from prestructural through extended abstract. For example, in unistructural, the second item of SOLO, items could be “define”, “identify”, or “do a simple procedure”, whereas in the “extended abstract” level, the items are “evaluate”, “predict”, “generalize”, “create”, “reflect”, or “hypothesize” in higher mental order tasks. 8 A post-test was used to measure the responses on the test. The test questions were assigned to SOLO categories. In the first three categories of SOLO taxonomy questions, there was no statistical difference in scores between LBL and CBL groups. In the last two or higher categories of questions based on SOLO taxonomy, there was a statistically significant increase in the scores for relational and extended types of questions for the CBL group ( P = 0.014 and 0.026, respectively). This review shows a benefit in higher level learning using a CBL program. Again, the assumption is that by inducing higher order mental tasks, deeper learning will occur and behavioral change will follow.

Two other studies discussed the levels of thinking and preparation for practice. One study compared students in interdisciplinary (ID) versus single-discipline students (SD; clinical anatomy) in a Graduate School for Health Sciences in Missouri, U.S. The two groups had slightly different cases. The ID group had complex ID cases and answered multiple choice questions about the cases. The SD group had cases in their discipline and answered multiple choice cases around the case. The assessment tool was the Watson-Glaser Critical Thinking Appraisal. The mean scores of both groups were not statistically different. However, ID students who scored below the median on the pretest scored significantly higher on the posttest. While this study set out to compare the differences in SD vs ID teaching using CBL, it also compared the effects of an ID course on critical thinking and it appears to be synergistic with improving scores for students who started below the median on testing. This is important in education programs, because while mean scores may not rise, if less students are scoring lower, then less students will fail the course and have to repeat.

The second paper that attempted to measure higher learning outcomes queried dental school graduates who had completed a CBL course during their dental school training. 22 The survey was designed to assess the CBL curriculum with respect to actual job requirements of practicing dentists. The graduates spanned 16 years, from 1990 to 2006, and the survey was conducted in 2007–2008. The response rate was 41%. The findings were that the CBL course was associated with positive correlations in “research competence”, “interdisciplinary thinking”, “practical dental skills”, “team work”, and “independent learning/working”. Other items including “problem-solving skills”, “psycho-social competence”, and “business competence” were not scored as highly with respondents. This article measured self-reported competencies and not the competencies as assessed by independent observers. However, it does attempt to link CBL with the actual practice with which it was attempting to teach, which is one of the generally accepted benefits of CBL.

In summary, CBL is defined as an inquiry structured learning experience utilizing live or simulated patient cases to solve, or examine a clinical problem, with the guidance of a teacher and stated learning objectives. Advantages of using CBL include more focusing on learning objectives compared with PBL, flexibility on the use of the case, and ability to induce a deeper level of learning by inducing more critical thinking skills.

Uses of CBL with respect to various fields and various levels in health-care training

CBL is used to impart knowledge in various fields in health care and various fields of medicine. The findings in this review showed that articles demonstrated the use of CBL in medicine, 2 , 4 – , 7 , 9 , 10 , 12 – , 14 , 18 – , 21 , 24 – , 26 , 30 , 33 , 34 , 36 , 37 , 39 – , 44 , 46 , 48 – , 62 , 64 – , 67 dentistry, 8 , 15 , 16 , 22 , 23 , 28 pharmacology, 11 , 27 , 29 , 35 , 45 , 63 occupational and physical therapy, 31 nursing, 5 , 21 , 38 , 47 , 51 allied health fields, 32 and child development. 17

Eighteen fields of medicine were seen in this review, from internal medicine and surgery to palliative medicine and critical care ( Fig. 2 , “fields of study”). Several articles highlight ID care or interprofessional care. A 2011 article in critical care medicine demonstrated the utility of both simulators and CBL on behaviors in critical situations of critical care teams of physicians and nurses. 5 Palliative care 21 and primary care 51 , 59 articles also reported on using a CBL course for learning with physicians and nurses. An article from the United Arab Emirates discussed how CBL better prepared participants for critical situations as well as basic primary care. 59

CBL is also used in various levels, including undergraduate education in the professions, graduate education, and postgraduate education. One field that uses CBL for all levels is surgery. Several articles describe surgical undergraduate medical education. One article describes using a paper and pencil plus live review sessions on improving student knowledge as tested by a standardized test in surgery. 6 Another paper from Germany describes initiation of a CBL curriculum for medical students and lists the pitfalls in establishing this curriculum. 26 A third undergraduate paper in a medical school course in surgery describes utilizing CBL and a more structured curriculum to aid in knowledge gains. A study utilizing both surgical simulators for laparoscopic procedural skills and CBL for clinical knowledge and reasoning demonstrates learning enhancement using CBL in surgical residents, or graduate surgical training. 20 In this study, scores in both procedural ratings during surgery for residents and also knowledge scores when presented with complications from surgery both rated higher in the CBL-enhanced course. Graduate use of CBL in surgery is frequent. CME courses are taught in trauma, which features lectures, skill stations, and simulation-based CBL. 74 Advanced Trauma Life Support (ATLS) certification is required for all surgeons who practice in a designated trauma center in the United States. 74 In addition, the American College of Surgeons publishes a self-assessment course entitled “SESAP” or Surgical Education and Self-Assessment Program, which is a web or CD-ROM course that is largely case based, with commentaries. 75 These two courses are widely available and are constantly revised to reflect new advances in patient care research. The use of CBL programs was employed in undergraduate and graduate including postgraduate fields in this review.

Use of CBL in rural and underserved areas

One practical use of CBL is to use CBL to enhance knowledge in rural or underserved areas. An excellent example of CBL is the Project Extension for Community Healthcare Outcomes (ECHO) program in Arizona and Utah states, United States. 10 , 12 This program was based on the Project ECHO program initially devised at the University of New Mexico Health Sciences Center in 2003. 10 In Arizona and Utah, the CDC helped fund a program to teach primary care providers and also provide access to specialist to treat hepatitis C virus (HCV)-infected patients. The primary aim was to increase treatment, as new drugs have become available, which are highly effective in treating HCV. The program works by recruiting primary care physician to participate. An initial teaching session is held on site at the health-care clinic in the rural or underserved area. Then, the provider teams are asked to participate in “tele ECHO” clinics in which participants present cases and have experts in HCV treatment comment. There are also educational sessions. Ninety providers participated, with 66% or 73% being primary care providers in rural or community health centers and not at universities. Over one and a half years, 280 patients were enrolled with 46.1% starting treatment. Other patients were likely not able to be treated, as their laboratory values indicated advanced liver disease. The percentage starting treatment was more than twice as many as expected to receive treatment prior to the project, based on historical controls. In addition to showing how CBL can impact rural medical care, this study is an example of learning assessment measured in patient outcomes.

A second CBL project was used in the United Arab Emirates to train rural practitioner's vital aspects of primary and emergency care using a CBL project. 60 The learners were able to provide feedback to the teachers as to the topics needed. This demonstrates the potential for interaction between teachers and learners using CBL, as it is a practical way to teach active practitioners. A third demonstration of using CBL in rural areas is in a report on teaching laboratory medicine in Africa. 7 In Sub-Saharan Africa, there is low trust in laboratory medicine services due in part to lower the quality of laboratories. This problem directly impacts patient care. Multiple international agencies are assisting the clinical laboratories in Sub-Saharan Africa in order to improve the quality of service. According to this report, the quality problem has led to decreased trust in laboratory medicine in the region. The course, given at Addis Ababa University in Ethiopia, was initiated to provide knowledge and also increase trust in laboratory medicine. The participants were 21 residents (graduate medical education), 3 faculty members, and 4 laboratory workers. The course was structured with both lectures and cases. Students were given homework for the differing cases. The assessments were both knowledge gains and also surveys of satisfaction for the course. Ratings on the survey were by ratings on a Likert scale of 1 (least valuable) to 5 (most valuable). Regarding the methods of delivery, the CBL sessions were rated highest with 85% of learners rating them as most valuable. In all, 81% rated case discussions as most valuable. Lectures received the most valuable rating by 65%. On the 12 question pre-/posttest, the mean score rose and also the number of questions answered correctly by the majority of learners. 7 These reports from three continents demonstrate that CBL is a practical way to impart knowledge in a diverse range of topics to clinicians who may be remote from a medical university.

Delivery of CBL: implementation and media

As illustrated in the above examples of use of CBL in rural settings, CBL use is varied as to the delivery method and implementation. Several articles demonstrate the importance of preparation for use in CBL. As many practitioners and students in all fields likely have more experience with LBL, participating in a course with CBL requires a different strategy and mindset in order to reach learning objectives. Preparation of both students and teachers in a CBL format is also very important for success. Two studies highlight the preparation and implementation of CBL: one not as successful as the other. In a qualitative study of introducing a new CBL format series to undergraduate medical students based in Sweden, the authors found that preparation of both students and faculty was likely inadequate for complete success. This study, held at the Karolinska Institutet, described the implementation of a CBL format for learning surgery during a semester course. All LBL classes were replaced with CBL sessions. The authors noted that at this time, there were organizational obstacles to starting a CBL course: lack of time and funds for faculty training. As such, faculty training was delayed and decreased. The study was a survey of five students and five faculty, who were picked from larger pools. There was a lot of criticism by students that the CBL needed more structure, or that the faculty often turned the CBL session more into a lecture session. The faculty described problems with getting the students to engage, and also with the lack of preparation for teaching in that format. Still, the overall impression was that CBL could increase interactive learning for this level of student. 26 This study demonstrates how lack of adequate preparation can impact a CBL experience for both faculty and students.

Another article demonstrated the differences in student motivation for autonomous learning, which was different, depending on how CBL was introduced. In a study of child development students in Sweden, there were four group methods to compare how students learned, depending on how CBL was introduced. The four groups were as follows: (1) LLL or all lecture, (2) CCCC or all CBL, (3) LCLC in which lecture and CBL were alternated in each session after the introduction, and (4) LLCC, in which there were three sessions with all lectures, two mixed lecture plus CBL, and two CBL only lectures to finish. There was a knowledge pretest and post-test to assess what the authors call prior knowledge (pretest) and achievement (posttest). Student motivation for learning was assessed by means of a modified Academic Self-Regulation Scale. 76 The results were that achievement scores and also autonomous motivation were both the highest in the LLCC group, or the group in which CBL was introduced after LBL. The authors conclude that students are more prepared for CBL after some foundational knowledge is imparted. These two articles demonstrate that both teacher and student preparation is necessary for a successful CBL learning encounter.

Use of CBL to impact patients and measurement of results

As described earlier, the Kirkland model of learning and assessment of outcomes includes assessment of the results of the training as its final method of assessing an intervention. In other words, how did the training impact patient care or its surrogate marker? Four recent studies illustrated how CBL can impact patient care. 10 , 12 , 40 , 54 , 69 The first, already described, is the Project ECHO for HCV treatment, which resulted in 46.1% of patients in the areas affected being started on treatment, and a large proportion of those treated being started on the newer antivirals. The second study was a study on practices by primary care physicians on treating diabetic patients. In this study, 122 primary care physicians (Family and Internal Medicine) at 18 sites were divided into three groups to enhance diabetes care. Group A received surveys and no intervention and served as a control group; group B received Internet-based software with three cases in a virtual patient encounter. The cases had simulated time and could include laboratory and medication orders and follow-up visits. After the cases, the physicians received feedback in the form of what an expert would do. Group C received the same CBL as group B with the addition of 60 minutes of verbal feedback and instruction from a physician opinion leader. The authors were able to obtain clinical data for the results. The results were that group B had a significant decline in hemoglobin A1C measures, the most common means of assessing glucose control over time in diabetics, while groups A and C did not. Groups B and C had a significant decline in prescribing metformin in patients with contraindications also. This demonstrates favorable clinical results using a CBL intervention. 40 The third was a study to institute chlamydia screening in offices. While the intervention did not globally increase chlamydia screening, the impact was that there was less of a decay on chlamydia screening in the intervention groups. 54 The last study demonstrated a CBL study in Portugal, which demonstrated an increase in reporting of adverse drug events after a CBL intervention in a study population of over 4000 physicians. 69 These four articles describe the use of CBL to impart medical knowledge and the use of patient outcomes to assess that learned knowledge. This is the ultimate test of learning for health-care practitioners: knowledge that improves patient care.

Limitations of this Review

This review was an attempt to classify a term, case-based learning , which is used frequently. In reviewing articles, this term was used as a search term. It is possible that articles written which would fit the definition of CBL but were termed differently by the individuals writing that article might have been missed. In addition, foreign language articles were not retrieved if there was not an English translation. There may be additional articles that would be instructional in other languages. The higher number of articles retrieved from North America may be biased by using a United States database. In an attempt to describe the various articles, which were termed case-based learning , the methods of delivery and evaluation were described in terms familiar to medical personnel. In the learning situation, these terms might be describing slightly different experiences. For example, several articles described the use of an observed skills examination to evaluate the learner; this examination was classified as “observed skills clinical examination or OSCE”. These OSCEs might have been more, or less, stringent. In defense of the search strategy, since the objective of the article was to write about what is currently considered case-based learning , this item was used as the search term. In order to classify and further define what exactly is CBL and how it is used, putting into discrete categories the described methods of delivery and evaluation was necessary, or else the review would reduce to a listing of separate articles without being able to provide a meaningful commentary.

CBL is a tool that involves matching clinical cases in health care-related fields to a body of knowledge in that field, in order to improve clinical performance, attitudes, or teamwork. This type of learning has been shown to enhance clinical knowledge, improve teamwork, improve clinical skills, improve practice behavior, and improve patient outcomes. CBL advantages include providing relevance to the adult learner, allowing the teacher more input into the direction of learning, and inducing learning on a deeper level. Learners or students in health care-related fields will one day need to interact with patients, and so education that relates to patient is particularly relevant. Relevance is an important concept in adult education. CBL was found to be used in all continents. Even limiting the search to English and English translations, articles were found on all continuously inhabited continents. This finding demonstrates that the use of CBL is not isolated to Western countries, but is used worldwide. In addition, based on the number and variety of fields of medicine and health care reported, CBL is used across multiple fields.

In reviewing the worldwide use of CBL, several constants became apparent. One is that this involves a case as a stimulant for learning. The second is that advance preparation of the learner is necessary. The third is that a set of learning objectives must be adhered to. A comparison with PBL across several articles revealed that most teachers who use CBL, in contrast to PBL, need to get through a list of learning objectives, and in so doing, must provide enhanced guidance to the learning session. That adherence to learning objectives was evident in most articles. There were varied methods of delivery, depending on the learning situation. That is one of the practical aspects of learning sessions termed case-based learning or CBL. The teachers used cases within their realm of teaching and adapted a CBL approach to their situation; for example, live CBL might be used with medical students, video cases might be used with practitioners. CBL differs from PBL in that it can cover a larger amount of topics because of the stated learning objectives, and guidance from the teacher or facilitator who does not allow unguided tangents, which may delay covering the stated objectives. Contrasting CBL with CBL, in PBL, the focus is on the process of learning as much as the topic, whereas in CBL, the learning objectives are stated at the outset, and both learners and teachers try to adhere to these. Because there are stated objectives at the outset of the learning experience in CBL, these objectives can be tested to see if they are met. These tests of knowledge were explored as methods of evaluation, which varied.

The methods of evaluation ran the range of Kirkpatrick's hierarchy of learning. One of the important aspects of CBL which was explored was that perhaps CBL could induce learning on a deeper level. And so going up the hierarchy of learning, some evaluations were simple surveys of the learners/and or the teachers on how they liked the CBL intervention. Some were tests of knowledge or skills learned. A few studies evaluated practice behavior; that is, going beyond knowledge learned into what behaviors that knowledge induced. The last hierarchy was how the knowledge learned from CBL affected actual patients: a few studies revealed that patient outcomes were affected positively from CBL. Thus, published studies of CBL spanned the hierarchy of learning, from opinions of the activity to actual patients affected by the learning of practitioners.

In summary, CBL was found to be practiced worldwide, by various practitioners, in various fields. CBL delivery was found to be varied to the situation. Methods of evaluation for CBL included all the steps on Kirkpatrick's hierarchy of learning and demonstrated that CBL could be shown conclusively to produce deeper learning.

To repeat the definition included earlier in this review, CBL is a form of learning that involves a clinical case, a problem or question requiring student thought, a set of learning objectives, information given prior and during the learning intervention, and a measured outcome.

CBL imparts relevance to medical and related curricula, is shown to tie theory to practice, and induce deeper learning. CBL is practical and efficient as a mode of teaching for adult learners. CBL is certain to become part of every medical and health profession's curriculum.

Author Contributions

Conceived the concepts: SFM. Analyzed the data: SFM. Wrote the first draft of the manuscript: SFM. Made critical revisions: SFM. The author reviewed and approved of the final manuscript.

Peer Review: Four peer reviewers contributed to the peer review report. Reviewers’ reports totaled 779 words, excluding any confidential comments to the Academic Editor.

Competing Interests: Author discloses no external Funding sources.

Funding: SFM has been selected as a local site primary investigator for a study of a new tissue insert for use in surgical repair of ventral hernia. The study is sponsored by BARD-Davol Inc.

Paper subject to independent expert single-blind peer review. All editorial decisions made by independent Academic Editor. Upon submission manuscript was subject to anti-plagiarism scanning. Prior to publication all authors have given signed confirmation of agreement to article publication and compliance with all applicable ethical and legal requirements, including the accuracy of author and contributor information, disclosure of Competing Interests and Funding sources, compliance with ethical requirements relating to human and animal study participants, and compliance with any copyright requirements of third parties. This journal is a member of the Committee on Publication Ethics (COPE).

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Fundamentals of case study research in family medicine and community health

Step 1. Conduct a literature review

Step 2. Formulate the research questions

Step 3. Ensure that a case study is appropriate

Step 4. Determine the type of case study design

Step 5. Define the boundaries of the case(s) and select the case(s)

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Collecting the data

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