Discussion Post

Qualitative Health Research 23(9) 1267 –1275 © The Author(s) 2013 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1049732313502128 qhr.sagepub.com

Advancing Qualitative Methods

The use of the qualitative case study (QCS) approach by researchers has increased within health care research dur- ing the past decade (Anthony & Jack, 2009). The research conducted by Robert Yin and Robert Stake generally has been cited by researchers in support of the methodology used. Yin (2003, 2009) and Stake (1994, 1995, 2005), however, have differing philosophical orientations, and the simultaneous application and citation of their work ignores these philosophical perspectives. This has threat- ened the credibility of the work conducted. Yin’s work, with its postpositivist perspective, has been most com- monly represented, with Stake’s constructivist approach less so.

In the following narrative we describe how we applied Stake’s recommendations about the QCS approach to the implementation of a nursing best-practice guideline (BPG) in three acute-care organizations in southwestern Ontario, Canada. The focus of this article is on the case study approach we used (Ireland, Kirkpatrick, Boblin, & Robertson, 2012). Using the case study approach, we wanted to know who was involved, the processes they used, the outcomes of their activities, and the context within which these were situated. Our research question was thus, How was the Registered Nurses Association of Ontario’s (RNAO) “Prevention of Falls and Fall Injuries in the Older Adult BPG” (Falls BPG; RNAO, 2005)

implemented in three acute-care hospitals at the organiza- tion and point-of-care levels? We selected Stake’s (1994, 1995, 2005) QCS approach as our research design. We wanted to increase our understanding of the implementa- tion phenomenon to inform subsequent implementation of BPGs. We obtained ethical approval for the research from the affiliated university and each of the participating hospitals.

Qualitative Case Study Approach

Creswell (2013) described the QCS approach as an explo- ration of a “bounded system” or case over time through detailed, in-depth data collection involving multiple sources of information, each with its own sampling, data collection, and analysis strategies. The outcome is a case description comprised of case-based themes. Researchers have characterized the QCS approach as a contextually based tradition; difficulty exists in separating the case

502128QHRXXX10.1177/1049732313502128Qualitative Health ResearchBoblin et al. research-article2013

1McMaster University, Hamilton, Ontario, Canada 2St. Joseph’s Health Care Hamilton, Hamilton, Ontario, Canada

Corresponding Author: Sheryl L. Boblin, McMaster University School of Nursing, HSC 3N28F, 1280 Main St. West, Hamilton, ON L8S 4K1, Canada. Email: boblins@mcmaster.ca

Using Stake’s Qualitative Case Study Approach to Explore Implementation of Evidence-Based Practice

Sheryl L. Boblin1, Sandra Ireland1, Helen Kirkpatrick2, and Kim Robertson2

Abstract Although the use of qualitative case study research has increased during the past decade, researchers have primarily reported on their findings, with less attention given to methods. When methods were described, they followed the principles of Yin; researchers paid less attention to the equally important work of Stake. When Stake’s methods were acknowledged, researchers frequently used them along with Yin’s. Concurrent application of their methods did not take into account differences in the philosophies of these two case study researchers. Yin’s research is postpositivist whereas Stake’s is constructivist. Thus, the philosophical assumptions they used to guide their work were different. In this article we describe how we used Stake’s approach to explore the implementation of a falls-prevention best-practice guideline. We focus on our decisions and their congruence with Stake’s recommendations, embed our decisions within the context of researching this phenomenon, describe rationale for our decisions, and present lessons learned.

Keywords case studies; evidence-based practice; practice guidelines; research design; research, qualitative

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from the context in which it occurs. According to Creswell, the type of case study is determined by the size of the bounded case or the intent of the analysis. Researchers have used the QCS across numerous disci- plines to contribute to the knowledge of individuals, groups, processes, and relationships (Yin, 2003, 2009). As Stake (1995, 2005), Merriam (1988), and Yin (2009) have contended, the case study approach allows for a holistic understanding of a phenomenon within real-life contexts from the perspective of those involved. Stake has depicted the case study approach as possessing the ability to grasp the intricacies of a phenomenon. Case studies have been described as best suited to research that asks “how” and “why” questions (Stake, 2005; Yin, 2003).

Methodology

For this research, we used a single instrumental case study design based on the methodology described by Stake (2005). We chose one issue, the implementation of the Falls BPG, and selected one bounded case to illustrate the issue. Our case was bounded by time, location, and BPG. We chose this approach because of its ability to integrate the complex and variable phenomenon of the Falls BPG implementation and evaluation across three multisite, acute-care hospital contexts into one narrative report. We did not want to tell the individual story of each setting, which would result in three separate case studies (collective case study), or conduct an intrinsic case study. We were interested in a holistic analysis (Stake, 1995), or the gestalt of the implementation of the Falls BPG across three settings during a 3-year time span. As the study unfolded, the boundary of time needed reconsideration. Participants at the three hospitals described efforts directed at the case (implementation of the Falls BPG) that preceded the intended start date of the study. Data collection needed to allow for the inclusion of this infor- mation. Stake’s (1995) methodology allowed for the flex- ibility of this boundary, which speaks to the power of the approach. To exclude this information would have resulted in a less-than-complete picture of the case.

Our decision to use Stake (2005) rather than Yin (2009) as the methodologist to follow was based on our combined consideration of the intent of the research and our philosophical orientation. Yin presented a much more structured approach to case study research than did Stake. Some critics of his work have suggested that Yin’s research has been situated within a postpositivist para- digm, whereas Stake’s has been a constructivist. The philosophical assumptions that underlie Stake’s and Yin’s approaches are presented in Table 1. Stake and Yin are presented according to ontology (the nature of real- ity), epistemology (how reality is known), axiology (the

role of values), and methodology (approach to inquiry; Creswell, 2013).

As illustrated in Table 1, the postpositivist researcher seeks truth through valuing process, stressing the pri- macy of the method, and seeking an ultimate truth or real- ity. For these researchers, control, predictability, and rationality have been emphasized (Crabtree & Miller, 1999). Postpositivist research has elements of being reductionist, logical, cause-and-effect-oriented, and deterministic based on a priori theories (Creswell, 2013). Constructivist researchers have claimed that truth is rela- tive; it is the result of perspective. Discovery and inter- pretation occur concurrently and are embedded in the context (Crabtree & Miller).

In keeping with a postpositivist orientation, Yin (2009) has advocated the use of a formal conceptual framework and propositions that are tested and accepted or refuted as data are collected and analyzed. Stake (1995), in keeping with a constructivist orientation, has directed that researchers can use a conceptual framework to guide the study, but this is not required. With Stake’s approach, issue statements might be developed by the researcher, but are not necessary. We debated whether a conceptual framework as advocated by Yin would constrain the col- lection and analysis of data and whether Stake’s recom- mendation of a flexible conceptual framework would be too lacking in structure.

Consequently, the question of which framework to use, if any, and how to use it, was a significant design decision we encountered. We thought that a focus on proving or disproving rival hypotheses with a rigid con- ceptual framework, rather than uncovering previously unknown elements of the phenomenon, might limit the richness of data collected. We decided to follow Stake’s recommendations, beginning with a flexible, relatively unstructured conceptual framework. Our experiences as the study unfolded, in fact, provided substantiation for the soundness of this decision. Periodically throughout the study, our reflexive journals captured comments such as, “I never would have thought of that,” in response to the information collected.

We selected the Promoting Action Research in Health Services (PARiHS) framework (Kitson, Harvey, & McCormack, 1998) to provide a way of thinking about the research, direct the data collection, and organize the emerging findings without imposing the structure of a conceptual framework advocated by Yin. It provided the classification schema we needed without confining the data collection and analysis. According to Kitson et al. (1998), Kitson et al. (2008), and Rycroft-Malone et al. (2004), the PARiHS framework contains three general areas to consider in preparing for research or action: (a) the nature of the evidence, (b) the quality of the context for coping with change, and (c) the type of facilitation for

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a successful change. As the research unfolded, we used the PARiHS framework to guide the questions for the interviews, promote completeness of data collection, and classify emerging findings. For example, as the role of the point-of-care staff in implementing the Falls BPG emerged, we categorized these findings within the evi- dence component of the PARiHS framework.

The Context

Nursing BPGs have been described as a compilation of the best available evidence related to nursing practice issues (RNAO, 2009). Experts at the RNAO used a rigor- ous process to compile and summarize evidence, and pro- vide succinct recommendations to assist nurses in implementing best practice (RNAO, 2005). In 2002, expert nurses at the RNAO produced the Falls BPG

(revised in 2005). The RNAO is the registered nurses’ professional organization in Ontario, Canada; almost 50 BPGs can be found on the RNAO Web site.1 Guidelines, however, do not implement themselves, and implementa- tion does not necessarily proceed in a straightforward manner (Wallin, Profetto-McGrath, & Levers, 2005). In recognition of this, a RNAO initiative supported the eval- uation of the implementation of a Falls BPG by three hos- pitals. Our research fell within this rubric: we explored how the Falls BPG was implemented.

Participants

In 2006, nursing leadership at each of the three hospitals involved in this research joined in a partnership with the RNAO. All three hospitals had university affiliations. They ranged in size from approximately 300 to 900 beds,

Table 1. A Comparison of Stake’s and Yin’s Philosophical Assumptions.

Philosophical Assumptions Constructivist Assumptions

(Stake, 1995, 2005) Postpositivist Assumptions

(Yin, 2003, 2009)

Ontology: What is the nature of reality?

Reality is subjective; subjectivity is an essential aspect of understanding. The emphasis is on holistic treatment of phenomena, with elements intricately linked. Understanding phenomena requires looking at a variety of contexts, such as temporal, spatial, economic, historical, political, social, and personal.

Reality (ultimate truth) is objective and predictable. Causal explanations can be developed both to direct the research and as a result of the findings (process). Control, predictability, and rationality are emphasized. Different strategies are selected to accomplish different ends.

Epistemology: What is the relationship between the researcher and the researched?

The researcher interacts with the phenomenon, usually during a prolonged period of time. The intent is to lessen the distance between the researcher and who or what is being researched. The researcher might have an insider view, seeking to understand the human experience.

The researcher is detached, neutral, and independent of what is being researched. The desire is to understand complex social phenomena. This allows the researcher to retain holistic and meaningful characteristics of real-life events.

Axiology: What is the role of values?

The value- and bias-laden nature of the work is acknowledged and embraced.

The attempt is to control for bias. An example of this is seen in the consideration of interviews as “verbal reports only,” full of reporter bias. The researcher is encouraged to corroborate interview data with other sources of evidence. Yin suggests that case study researchers have allowed biased views to influence the findings and conclusions.

Methodology: What is the process of research?

Research methods are inductive and flexible. Discovery and interpretation occur concurrently. No a priori conceptual framework is required; a flexible beginning conceptual framework might be used. A naturalistic paradigm is used.

The search is for “happenings,” not causes. The goal is understanding, with interpretation being the primary method of understanding.

Research has elements of being reductionist, logical, cause-and-effect-oriented, and deterministic based on a priori theories. General theories are used to generate propositions that are operationalized as hypotheses. Prepositions are subjected to replicable empirical testing, providing the opportunity for confirmation and falsification. A conceptual framework is essential in portraying a hypothesized cause-and-effect relationship. Propositions are used to identify relationships among constructs and to direct data collection and analysis.

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with the total number of nursing staff (registered nurses and registered practical nurses) in each hospital ranging from approximately 800 to 3,400. All three hospitals rep- resented an amalgamation of smaller hospitals. They were recognized as “Best Practice Spotlight Organization” (BPSO) candidates by the RNAO. An important element was the shared vision by the hospital leaders about the 3-year partnership with the RNAO as a new incentive to assist them to reengage their nursing staff in creating an evidence-based culture, building sustainable nursing infrastructures, and evaluating outcomes to promote best practices for the future. The RNAO required the hospitals to establish partnerships with academic affiliates to sup- port the evaluation of their work and the conduct of research.

Data Collection

The use of multiple sources of data, rich in real-life situ- ations, has been described as a distinguishing characteris- tic of case study methodology (Stake, 1995). According to Stake (1995), varied sources of data are collected and analyzed to obtain multiple perspectives and points of view to obtain a holistic understanding of the phenome- non being researched. Triangulation is a term that has been frequently used to describe this use of multiple data sources (Hentz, 2012). Unlike Yin, who has suggested that the purpose of using multiple sources is to assist the researcher in identifying convergence of findings (2003), Stake (1995) has suggested that triangulation can also be used by researchers to identify divergence. In our study, we used triangulation for both purposes.

We collected data from multiple sources to ensure that our data were as rich as possible and to confirm our find- ings. An example of how we used triangulation to demon- strate divergence is illustrated as follows: in our interview with M., we asked an open question to determine this nurse’s experience with implementing the Falls BPG. We soon realized that this experience had begun much earlier than we had been led to understand from leadership per- sonnel who had been interviewed previously. Several years earlier, as a baccalaureate in nursing student and subsequently as a new manager, this individual had led the implementation of the RNAO Falls BPG within a nursing unit. Nurses on this unit had not only imple- mented some of the guideline recommendations; they had also developed an evaluation plan.

Our data sources included focus groups and individual interviews, documents and artifacts, and observations of the environments. Key individuals within the hospitals presented the richest source of data, and for this reason comprised the principal source. As with all qualitative inquiry, there was no clear differentiation between the collection, analysis, and interpretation phases (Janesick,

1994). Rather, we used an iterative or recursive process in which the ongoing analysis and interpretation of existing data helped us decide when and if more data were needed, and from which sources.

Focus Groups and Individual Interviews

We used a purposeful, criterion-based convenience sam- pling method (Patton, 1990) to identify data, participants, and sources. At each site, individuals thought to possess the knowledge about the implementation of the Falls BPG were identified and their involvement was requested. We identified nurses with particular criteria for involve- ment. Questions were raised in research team meetings as to whether this approach to sampling influenced the transferability of the findings. We decided that this approach provided the richest data, and for this reason was appropriate (Kuzel, 1999). We thought that our use of multiple sources of data and the number of individuals involved would offset any challenges to credibility.

We used a member-checking process to further sub- stantiate credibility. Member checking involves taking data and interpretations back to the participants in a study so they can confirm the credibility of the information and narrative account (Creswell & Miller, 2000). We identi- fied further informants as data collection and analysis ensued. For example, through a review of documents (minutes of meetings) we identified further informants, who were then contacted to request their involvement. Informants possessing special knowledge were identified through the interviews themselves. Coinvestigators and research liaisons at each site were asked to identify and organize interviews/focus groups. Consents were obtained by the research interviewers at the time of the interview.

Participants were situated at multiple levels within the hospitals, ranging from nurses providing direct care to patients, whom we termed point-of-care nurses, to nurses at the highest levels within the organizations. Typically, we organized the interviews around a specific unit or a specific category of staff (e.g., educators or managers). We interviewed 95 individuals about their perspectives on the implementation of the Falls BPG within their hos- pitals. Most participants belonged to the point-of-care category (n = 41). In some groups, there was another pro- fessional category represented; at other times another individual/role participated (e.g., a manager in a point-of- care group). The interest in the Falls BPG implementa- tion was illustrated by the willingness of these individuals to be involved in this research.

We conducted18 focus groups. Participants were pro- vided release time from their work to attend the ses- sions. We used a semistructured format with a semistructured interview guide (Brown, 1999). There

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were four components to the interview guide. We based the questions on a broad conceptualization of the PARiHS framework; questions addressed (a) context, (b) historical issues related to the decision to imple- ment, (c) implementation, and (d) evaluation. The ques- tions were broad statements, modified to suit the category of participant. We used prompts to assist us in clarifying responses and in seeking a richer understand- ing of the participants’ perspectives. Examples of the interview questions can be found in Table 2.

The focus groups were facilitated by a principal inves- tigator (PI) and research coordinator (RC). The PI posed the questions; the RC documented the responses. The PI was an experienced interviewer and qualitative researcher. Both the PI and RC had extensive expertise in risk man- agement and in the implementation of BPGs. The focus groups were not audiotaped; detailed field notes were kept by the RC during the interviews. Immediately fol- lowing the interviews, the PI and RC discussed and docu- mented further data to ensure completeness.

We modeled the individual interviews after the focus groups. We used the interview guides developed for the

focus groups in conducting the individual interviews. The interviews typically took place in the offices of the par- ticipants or in meeting rooms arranged for us by hospital staff. We conducted 38 individual interviews in total at the three sites. We used field notes to assist us in record- ing the responses to the interview questions.

Documents

In case study research, researchers use documents as a source of contextual information about events that cannot be directly observed; documents also are used by researchers to confirm or question information from other sources (Stake, 1995). We collected a variety of docu- ments, including project proposals, reports, presenta- tions, email communication, minutes of meetings, abstracts, policies, graduate student theses, Web site data, corporate falls data, audit data, and executive letters. Nurses and key informants had identified these docu- ments as important as data collection proceeded.

In this study, we used our analysis of the 787 docu- ments that were recorded during the implementation of

Table 2. Focus Group and Individual Interview Questions.

Participant Context Historical Issues Related

to Implementation Implementation Evaluation

Point-of-Care Staff

Tell me about your nursing unit and the patients you provide care for.

Do you know your fall rates?

What do you consider a fall to be?

How are falls recorded in your nursing unit?

Who decided to implement the guideline?

How were you informed about the implementation of the BPG?

How was the BPG on falls and falls injuries implemented at your site?

What resources were used to implement the plan?

Were patients or families involved in the implementation of the BPG?

Has the implementation been successful?

Is it working? In what way? How has falls reporting

changed since implementation of the guidelines?

Organizational- Level Staff

Tell me about your hospital and the patients you provide care for.

Tell me about your nursing and other professional staff.

What are their strengths? What type of falls do you

see? How much of a fall does

it need to be in order to be reported?

What was happening within the organization at that time that may have contributed to the implementation of the BPG?

How was the implementation plan developed?

What were the objectives of your implementation plan?

How did you decide which recommendations within the BPG to implement?

Who has/what disciplines have been involved?

Has the implementation been successful?

Have falls changed since the implementation of the guideline?

How has implementation been evaluated?

Are you planning on implementing other BPGs?

What have been the key successes of guideline implementation? At the point-of-care level? Organization level? Externally?

Note. BPG = best practice guideline.

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the Falls BPG to provide contextual and historical infor- mation within which to frame the case. We initially visu- ally scanned the documents to get a sense of which aspects of the documents pertained to the implementation of the Falls BPG. We noted these sections within the doc- uments and returned to them for further analysis. We coded the documents and journaling to allow linkages between the data contained within the documents and those presented by the participants.

Artifacts

We used artifacts associated with the implementation of the Falls BPG as both contextual and facilitative evi- dence. The coinvestigators identified the artifacts first at each site and then through interviews and document reviews. These artifacts included assessment tools, BPSO logos and marketing materials, patient and staff educa- tional materials, posters, and event invitations.

Observations of the Context

These data included observations of each hospital’s envi- ronment, which we gathered as we attended the hospitals for data collection. They also included information col- lected from hospital Web sites. A review of these data, as with artifacts, contributed to our understanding of the contextual factors influencing the implementation of the Falls BPG.

Analysis

We followed the editorial analysis style described by Addison (1999) in combination with the phases of data analysis (i.e., description, categorical aggregation, estab- lishing patterns, and naturalistic generalizations) described by Stake (1995, 2005). We considered Addison’s approach to be congruent with the constructivist orientation advo- cated by Stake. Addison described the editorial or herme- neutic style of analysis as beginning with data collection itself. In keeping with this description, we began our anal- ysis with all data sources as we asked participants ques- tions, reviewed the documents, and made observations of the artifacts and environments.

While we collected the data, we noted assertions about what was being described, and what we observed happen- ing. These assertions (Stake, 1995) reflected our interpre- tations and our understandings of how the Falls BPG had been implemented. As an example, as focus group inter- views were conducted, we made notes in the margins and white spaces left alongside the interview questions. We made notations that not only described the responses the participants made, but also of our initial interpretations of their responses. Using Addison’s (1999) words, “Events,

behaviors, words and dialogues were noted and fixed in the form of text” (p. 153). As we conducted further inter- views and made observations, we clumped the coded data into categories (categorical aggregation) and amassed these textual documents into files that members of the research team then compiled and reviewed. We noted meaningful segments of data and documented patterns and themes. We arrived at plausible explanations using a process of inductive analysis (Patton, 1999). We dis- cussed our perspectives and interpretations during team meetings; we used a constant comparative approach to look for other ways of organizing the data so that differ- ent findings might be revealed.

As we cycled through the process of data collection, analysis, and interpretation, we became aware of the sim- ilarities between a description of the Falls BPG imple- mentation and a journey. It became evident that participants at the three hospitals shared experiences, yet maintained individual differences. The nature of the jour- ney crystallized for us as we revealed our understandings of the experiences of participants. Documents and arti- facts enabled the situating of these experiences within the complex context of health care. We used the analogy of a journey to present the findings. We shared our interpreta- tions and the portrayal of the Falls BPG implementation as a journey with participants at the three hospitals. This member checking (Creswell & Miller, 2000) increased our confidence in the robustness of our findings. Participants, from point-of-care staff to top nursing exec- utives, attested to how the findings resonated with their experiences.

Results

The following represents a brief synopsis of the results. We present the phases of the journey traveled by the par- ticipants, followed by the four major themes. Details of the findings, including exemplars, can be found else- where (Ireland et al., 2012). We identified six stages or phases of their journey: (a) the early journey, (b) shifting sands, (c) gaining traction, (d) reinvesting in the journey: a new vehicle, (e) on the road, and (f) moving forward. We portrayed the stages as movements from one phase to another. Participants’ voices and documents reflected early efforts made in an attempt to reduce patient falls. Long before the three hospitals came together as RNAO BPSO candidates, all had begun their respective journey toward falls prevention.

These early journeys were frought with hurdles (shift- ing sands) that reflected the nature of the contexts at those times. The support and funding provided by the RNAO and the development of practice standards for the use of restraints (College of Nurses of Ontario, 2009) allowed the organizations to gain traction and move forward. As a

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result of RNAO support, organizations were identified as BPSO candidates; champions were trained and in place in clinical units. The 3-year partnerships established with the RNAO caused a reinvesting in the journey: a new vehicle. As BPSO candidates, hospital leadership in the hospitals was responsible to ensure that executive spon- sors, staff, structures, and processes were in place to facilitate successful BPG implementation and evaluation work and research (Ireland et al., 2012).

The road to implementation of the Falls BPG required the involvement of nurses at multiple levels within the hospitals, ranging from point-of-care nurses to top nurs- ing executives. Moving forward required the adoption of innovative strategies within each hospital, including the involvement of graduate students, bundling of multiple safety procedures, and launching of a major educational initiative (Ireland et al., 2012). As is to be expected with the initiation of any major initiative, the three hospitals experienced roadblocks. Participants discussed how resolving these roadblocks resulted in the identification of beacons: navigational devices that help travelers reach their destination, and which might be used by other orga- nizations attempting to implement BPGs. Four primary themes/beacons were revealed: (a) listen to and recognize the experiential knowledge and clinical realities of staff, (b) keep it simple, (c) when the simple becomes complex, and (d) the journey is the destination (Ireland et al.).

As reported by Ireland et al. (2012), point-of-care nursing staff in particular became frustrated and resistant to change when they perceived a mismatch between the Falls BPG prescribed at the organizational level and their experience in fall risk reduction, knowledge of the needs of specific patient populations, and the resources avail- able to them. All participants described the frustration of leaders, managers, and educators regarding the number of competing priorities and the lack of dedicated time for staff. Participants described the necessity for hospitals to keep it simple in implementing fall-prevention best prac- tices. Success was experienced on those units where teams were allowed to identify, develop, and evaluate strategies and tools tailored to the needs of their patient populations and clinical realities (Ireland et al.). Additionally, participants described success on units where basic tools to guide implementation were pro- vided, adaptation at the unit level was encouraged, and competing priorities were minimized. Conversely, resis- tance resulted when the tools provided did not match with clinical realities and competing pressures.

Participants described the complexity of the envi- ronments within which the Falls BPG was imple- mented, acknowledging not only the clinical environments but also the characteristics of the patients and the nature of nursing work itself. Point-of-care nursing staff described having to walk a thin line

between advocacy and paternalism, and beneficence and autonomy. Collaborating with patients and families to create a care plan based on the guideline became incredibly complex when respect for autonomy, overall goals of care, varied life experiences, learning needs of patients and families, and available resources were fac- tored into the equation (Ireland et al., 2012).

As the three hospitals traveled along their journey toward implementation of the Falls BPG, what became evident was the participants’ awareness that the journey was the destination. The sustained commitment of point- of-care nursing staff and leadership to continue to imple- ment and reimplement evidence-based practices to meet the fall-prevention needs of patients in their care became evident. During 2 years, the fall-prevention journey of the three hospitals had become an informally implemented, continuous quality improvement process, rather than a well-mapped journey with a predetermined end point (Ireland et al., 2012).

Discussion: Lessons Learned

There were a number of lessons we learned as we reflected on how we conducted this research. We captured these lessons in our individual reflexive journals and in the minutes of the research team meetings. They related to the use of the QCS approach in general and the use of Stake’s work as a methodology in particular. The strengths and opportunities offered by the QCS approach were evi- dent with this research. In particular, we found Stake’s approach (1995, 2005) to be an appropriate method for this case study. Using Stake’s recommendations, we were able to understand the complex phenomenon of the Falls BPG implementation within the context of three acute- care hospitals. We concluded that Stake’s constructivist approach provided adequate guidance without creating undue restriction. Our experience was that new ideas were revealed that might not have emerged if more struc- ture, such as Yin’s (2003, 2009) approach, had been imposed. The lack of a highly structured, predetermined conceptual framework with accompanying propositions did not inhibit our exploration of this phenomenon. Our use of the PARiHS framework (Kitson et al., 1998) fit well with Stake’s approach, providing flexible guidance to the collection and analysis of data.

Our use of multiple sources of data, characteristic of the QCS, contributed to a holistic and in-depth under- standing of the phenomenon (the implementation of the Falls BPG). In particular, the use of documents, observa- tions, and artifacts alongside individual interviews and focus groups enhanced our understanding of the context within which this phenomenon occurred. Our use of mul- tiple data sources contributed to credibility, offsetting the purposeful, criterion-based convenience sampling that

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we used. Additionally, our use of constructivist analysis strategies was effective in facilitating the exploration of this phenomenon.

We found the establishment of clear boundaries to be essential. As with many QCSs, we tended to want to expand beyond the time constraints and sources of data in an attempt to understand even further the phenomenon being explored. We found the interest and enthusiasm of the nurses and participants within the hospitals exciting and motivating. It would have been easy for us to drown in data if the established boundaries were not maintained.

Three suggestions are included for how the research could have been done differently. Tape recording focus groups and individual interviews is a recommendation frequently made when using these data collection meth- ods. We had deliberately chosen to refrain from tape recording as a way of containing costs. We did not antici- pate any difficulty or reticence by the participants in answering questions; this conclusion was borne out dur- ing the data collection. We thought that the combined expertise of the PI and RC also supported our design decision. The luxury of having two researchers conduct- ing the interviews and focus groups might not be the real- ity for some research, which might result in a different decision. Whether auditability could have been enhanced by the use of taped sessions is open to debate.

We could have analyzed documents for context as well as content (Miller & Alvarado, 2005). Whereas we were experienced in the analysis of documents for content, and documents were analyzed using this approach, we were less experienced with analyzing for context; we therefore followed the recommendations for context analysis as advocated by Miller and Alvarado only minimally. Understanding further why documents were produced, by whom, and for what purpose might have contributed to an enhanced understanding of the phenomenon. The obser- vations were not guided by any particular tool; they were directed by what we deemed was important at the time of the observation. We might have collected more informa- tion with the use of a framework such as that described by Spradley (1980).

Spradley (1980) identified nine dimensions that can be used by researchers to focus observations and increase the range and depth of observations: space, actors, activi- ties, objects, acts, events, time, goals, and feelings. If we had developed a data recording form that captured sev- eral of these dimensions, we might have collected richer data. For example, a form documenting actors, goals, and feelings might have enhanced our understanding of par- ticipants’ responses to the implementation of the Falls BPG. This recognition of the importance of context is in keeping with the QCS approach and the PARiHS frame- work (Creswell, 2013; Kitson et al., 2008).

Conclusion

The QCS approach has received increased attention within health care research. Yin’s (2003, 2009) and Stake’s (1995, 2005) work has frequently been cited simultaneously without giving consideration to their differing philosophical orientations. This dual applica- tion of approaches with differing philosophical assump- tions has challenged the credibility of reported QCS research. Readers and researchers have been left with no clear description of which approach to follow and how to make the significant design decisions that must be made. Additionally, the methodologist followed most often has been Yin, resulting in QCSs that have been more postpositivist than constructivist in nature. In this article, we focused on our use of Stake’s (1995, 2005) QCS approach using his constructivist methods to understand the implementation of a Falls BPG in three acute-care hospitals. The unique contributions included in this article are the detailed description of the QCS approach used and the application of Stake’s recommen- dations to research design. The design decisions we faced are described within the context of our research. The description of researcher lessons learned might be of use to researchers wishing to use Stake’s approach to QCS.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Registered Nurses’ Association of Ontario.

Note

1. See http://rnao.ca/bpg.

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Author Biographies

Sheryl L. Boblin, RN, PhD, is an associate professor at McMaster University School of Nursing in Hamilton, Ontario, Canada.

Sandra Ireland, RN, PhD, is an assistant clinical professor at McMaster University School of Nursing, in Hamilton, Ontario, Canada.

Helen Kirkpatrick, RN, PhD, is coordinator of the Best Practices Spotlight Organization at St. Josephs’ Healthcare, Hamilton, Ontario, and an assistant clinical professor at McMaster University School of Nursing, Hamilton, Ontario, Canada.

Kim Robertson, RN, MScCH, is a risk management specialist at St. Joseph’s Healthcare in Hamilton, Ontario, and an assistant clinical professor at McMaster University School of Nursing. Hamilton, Ontario, Canada.