502128

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

Advancing Qualitative Methods

Qualitative Health Research

Using Stake’s Qualitative Case Study

XX(X) 1­–9
© The Author(s) 2013
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DOI: 10.1177/1049732313502128

of Evidence-Based Practice qhr.sagepub.com

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

The use of the qualitative case study (QCS) approach by implemented in three acute-care hospitals at the organiza-
researchers has increased within health care research dur- tion and point-of-care levels? We selected Stake’s (1994,
ing the past decade (Anthony & Jack, 2009). The research 1995, 2005) QCS approach as our research design. We
conducted by Robert Yin and Robert Stake generally has wanted to increase our understanding of the implementa-
been cited by researchers in support of the methodology tion phenomenon to inform subsequent implementation
used. Yin (2003, 2009) and Stake (1994, 1995, 2005), of BPGs. We obtained ethical approval for the research
however, have differing philosophical orientations, and from the affiliated university and each of the participating
the simultaneous application and citation of their work hospitals.
ignores these philosophical perspectives. This has threat-
ened the credibility of the work conducted. Yin’s work,
Qualitative Case Study Approach
with its postpositivist perspective, has been most com-
monly represented, with Stake’s constructivist approach Creswell (2013) described the QCS approach as an explo-
less so. ration of a “bounded system” or case over time through
In the following narrative we describe how we applied detailed, in-depth data collection involving multiple
Stake’s recommendations about the QCS approach to the sources of information, each with its own sampling, data
implementation of a nursing best-practice guideline collection, and analysis strategies. The outcome is a case
(BPG) in three acute-care organizations in southwestern description comprised of case-based themes. Researchers
Ontario, Canada. The focus of this article is on the case have characterized the QCS approach as a contextually
study approach we used (Ireland, Kirkpatrick, Boblin, & based tradition; difficulty exists in separating the case
Robertson, 2012). Using the case study approach, we
wanted to know who was involved, the processes they 1
McMaster University, Hamilton, Ontario, Canada
used, the outcomes of their activities, and the context 2
St. Joseph’s Health Care Hamilton, Hamilton, Ontario, Canada
within which these were situated. Our research question
Corresponding Author:
was thus, How was the Registered Nurses Association of Sheryl L. Boblin, McMaster University School of Nursing, HSC 3N28F,
Ontario’s (RNAO) “Prevention of Falls and Fall Injuries 1280 Main St. West, Hamilton, ON L8S 4K1, Canada.
in the Older Adult BPG” (Falls BPG; RNAO, 2005) Email: boblins@mcmaster.ca

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2 Qualitative Health Research XX(X)

from the context in which it occurs. According to role of values), and methodology (approach to inquiry;
Creswell, the type of case study is determined by the size Creswell, 2013).
of the bounded case or the intent of the analysis. As illustrated in Table 1, the postpositivist researcher
Researchers have used the QCS across numerous disci- seeks truth through valuing process, stressing the pri-
plines to contribute to the knowledge of individuals, macy of the method, and seeking an ultimate truth or real-
groups, processes, and relationships (Yin, 2003, 2009). ity. For these researchers, control, predictability, and
As Stake (1995, 2005), Merriam (1988), and Yin (2009) rationality have been emphasized (Crabtree & Miller,
have contended, the case study approach allows for a 1999). Postpositivist research has elements of being
holistic understanding of a phenomenon within real-life reductionist, logical, cause-and-effect-oriented, and
contexts from the perspective of those involved. Stake deterministic based on a priori theories (Creswell, 2013).
has depicted the case study approach as possessing the Constructivist researchers have claimed that truth is rela-
ability to grasp the intricacies of a phenomenon. Case tive; it is the result of perspective. Discovery and inter-
studies have been described as best suited to research that pretation occur concurrently and are embedded in the
asks “how” and “why” questions (Stake, 2005; Yin, context (Crabtree & Miller).
2003). 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
Methodology
data are collected and analyzed. Stake (1995), in keeping
For this research, we used a single instrumental case with a constructivist orientation, has directed that
study design based on the methodology described by researchers can use a conceptual framework to guide the
Stake (2005). We chose one issue, the implementation of study, but this is not required. With Stake’s approach,
the Falls BPG, and selected one bounded case to illustrate issue statements might be developed by the researcher,
the issue. Our case was bounded by time, location, and but are not necessary. We debated whether a conceptual
BPG. We chose this approach because of its ability to framework as advocated by Yin would constrain the col-
integrate the complex and variable phenomenon of the lection and analysis of data and whether Stake’s recom-
Falls BPG implementation and evaluation across three mendation of a flexible conceptual framework would be
multisite, acute-care hospital contexts into one narrative too lacking in structure.
report. We did not want to tell the individual story of each Consequently, the question of which framework to
setting, which would result in three separate case studies use, if any, and how to use it, was a significant design
(collective case study), or conduct an intrinsic case study. decision we encountered. We thought that a focus on
We were interested in a holistic analysis (Stake, 1995), or proving or disproving rival hypotheses with a rigid con-
the gestalt of the implementation of the Falls BPG across ceptual framework, rather than uncovering previously
three settings during a 3-year time span. As the study unknown elements of the phenomenon, might limit the
unfolded, the boundary of time needed reconsideration. richness of data collected. We decided to follow Stake’s
Participants at the three hospitals described efforts recommendations, beginning with a flexible, relatively
directed at the case (implementation of the Falls BPG) unstructured conceptual framework. Our experiences as
that preceded the intended start date of the study. Data the study unfolded, in fact, provided substantiation for
collection needed to allow for the inclusion of this infor- the soundness of this decision. Periodically throughout
mation. Stake’s (1995) methodology allowed for the flex- the study, our reflexive journals captured comments such
ibility of this boundary, which speaks to the power of the as, “I never would have thought of that,” in response to
approach. To exclude this information would have the information collected.
resulted in a less-than-complete picture of the case. We selected the Promoting Action Research in Health
Our decision to use Stake (2005) rather than Yin Services (PARiHS) framework (Kitson, Harvey, &
(2009) as the methodologist to follow was based on our McCormack, 1998) to provide a way of thinking about
combined consideration of the intent of the research and the research, direct the data collection, and organize the
our philosophical orientation. Yin presented a much emerging findings without imposing the structure of a
more structured approach to case study research than did conceptual framework advocated by Yin. It provided the
Stake. Some critics of his work have suggested that Yin’s classification schema we needed without confining the
research has been situated within a postpositivist para- data collection and analysis. According to Kitson et al.
digm, whereas Stake’s has been a constructivist. The (1998), Kitson et al. (2008), and Rycroft-Malone et al.
philosophical assumptions that underlie Stake’s and (2004), the PARiHS framework contains three general
Yin’s approaches are presented in Table 1. Stake and Yin areas to consider in preparing for research or action: (a)
are presented according to ontology (the nature of real- the nature of the evidence, (b) the quality of the context
ity), epistemology (how reality is known), axiology (the for coping with change, and (c) the type of facilitation for

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Boblin et al. 3

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

Constructivist Assumptions Postpositivist Assumptions

Philosophical Assumptions (Stake, 1995, 2005) (Yin, 2003, 2009)
Ontology: What is the Reality is subjective; subjectivity is an Reality (ultimate truth) is objective and predictable.
nature of reality? essential aspect of understanding. The Causal explanations can be developed both to
emphasis is on holistic treatment of direct the research and as a result of the findings
phenomena, with elements intricately (process). Control, predictability, and rationality
linked. Understanding phenomena are emphasized. Different strategies are selected
requires looking at a variety of contexts, to accomplish different ends.
such as temporal, spatial, economic,
historical, political, social, and personal.
Epistemology: What is the The researcher interacts with the The researcher is detached, neutral, and
relationship between phenomenon, usually during a prolonged independent of what is being researched. The
the researcher and the period of time. The intent is to lessen desire is to understand complex social phenomena.
researched? the distance between the researcher This allows the researcher to retain holistic and
and who or what is being researched. meaningful characteristics of real-life events.
The researcher might have an insider
view, seeking to understand the human
experience.
Axiology: What is the role The value- and bias-laden nature of the The attempt is to control for bias. An example of
of values? work is acknowledged and embraced. 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 Research methods are inductive and Research has elements of being reductionist, logical,
process of research? flexible. Discovery and interpretation cause-and-effect-oriented, and deterministic based
occur concurrently. No a priori on a priori theories. General theories are used
conceptual framework is required; a to generate propositions that are operationalized
flexible beginning conceptual framework as hypotheses. Prepositions are subjected
might be used. A naturalistic paradigm is to replicable empirical testing, providing the
used. opportunity for confirmation and falsification. A
The search is for “happenings,” not conceptual framework is essential in portraying
causes. The goal is understanding, with a hypothesized cause-and-effect relationship.
interpretation being the primary method Propositions are used to identify relationships
of understanding. among constructs and to direct data collection and
analysis.

a successful change. As the research unfolded, we used (revised in 2005). The RNAO is the registered nurses’
the PARiHS framework to guide the questions for the professional organization in Ontario, Canada; almost 50
interviews, promote completeness of data collection, and BPGs can be found on the RNAO Web site.1 Guidelines,
classify emerging findings. For example, as the role of however, do not implement themselves, and implementa-
the point-of-care staff in implementing the Falls BPG tion does not necessarily proceed in a straightforward
emerged, we categorized these findings within the evi- manner (Wallin, Profetto-McGrath, & Levers, 2005). In
dence component of the PARiHS framework. 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
The Context how the Falls BPG was implemented.
Nursing BPGs have been described as a compilation of
the best available evidence related to nursing practice
Participants
issues (RNAO, 2009). Experts at the RNAO used a rigor-
ous process to compile and summarize evidence, and pro- In 2006, nursing leadership at each of the three hospitals
vide succinct recommendations to assist nurses in involved in this research joined in a partnership with the
implementing best practice (RNAO, 2005). In 2002, RNAO. All three hospitals had university affiliations.
expert nurses at the RNAO produced the Falls BPG They ranged in size from approximately 300 to 900 beds,

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4 Qualitative Health Research XX(X)

with the total number of nursing staff (registered nurses 1994). Rather, we used an iterative or recursive process in
and registered practical nurses) in each hospital ranging which the ongoing analysis and interpretation of existing
from approximately 800 to 3,400. All three hospitals rep- data helped us decide when and if more data were needed,
resented an amalgamation of smaller hospitals. They and from which sources.
were recognized as “Best Practice Spotlight Organization”
(BPSO) candidates by the RNAO. An important element
Focus Groups and Individual Interviews
was the shared vision by the hospital leaders about the
3-year partnership with the RNAO as a new incentive to We used a purposeful, criterion-based convenience sam-
assist them to reengage their nursing staff in creating an pling method (Patton, 1990) to identify data, participants,
evidence-based culture, building sustainable nursing and sources. At each site, individuals thought to possess
infrastructures, and evaluating outcomes to promote best the knowledge about the implementation of the Falls
practices for the future. The RNAO required the hospitals BPG were identified and their involvement was requested.
to establish partnerships with academic affiliates to sup- We identified nurses with particular criteria for involve-
port the evaluation of their work and the conduct of ment. Questions were raised in research team meetings as
research. 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
Data Collection was appropriate (Kuzel, 1999). We thought that our use
The use of multiple sources of data, rich in real-life situ- of multiple sources of data and the number of individuals
ations, has been described as a distinguishing characteris- involved would offset any challenges to credibility.
tic of case study methodology (Stake, 1995). According We used a member-checking process to further sub-
to Stake (1995), varied sources of data are collected and stantiate credibility. Member checking involves taking
analyzed to obtain multiple perspectives and points of data and interpretations back to the participants in a study
view to obtain a holistic understanding of the phenome- so they can confirm the credibility of the information and
non being researched. Triangulation is a term that has narrative account (Creswell & Miller, 2000). We identi-
been frequently used to describe this use of multiple data fied further informants as data collection and analysis
sources (Hentz, 2012). Unlike Yin, who has suggested ensued. For example, through a review of documents
that the purpose of using multiple sources is to assist the (minutes of meetings) we identified further informants,
researcher in identifying convergence of findings (2003), who were then contacted to request their involvement.
Stake (1995) has suggested that triangulation can also be Informants possessing special knowledge were identified
used by researchers to identify divergence. In our study, through the interviews themselves. Coinvestigators and
we used triangulation for both purposes. research liaisons at each site were asked to identify and
We collected data from multiple sources to ensure that organize interviews/focus groups. Consents were
our data were as rich as possible and to confirm our find- obtained by the research interviewers at the time of the
ings. An example of how we used triangulation to demon- interview.
strate divergence is illustrated as follows: in our interview Participants were situated at multiple levels within the
with M., we asked an open question to determine this hospitals, ranging from nurses providing direct care to
nurse’s experience with implementing the Falls BPG. We patients, whom we termed point-of-care nurses, to nurses
soon realized that this experience had begun much earlier at the highest levels within the organizations. Typically,
than we had been led to understand from leadership per- we organized the interviews around a specific unit or a
sonnel who had been interviewed previously. Several specific category of staff (e.g., educators or managers).
years earlier, as a baccalaureate in nursing student and We interviewed 95 individuals about their perspectives
subsequently as a new manager, this individual had led on the implementation of the Falls BPG within their hos-
the implementation of the RNAO Falls BPG within a pitals. Most participants belonged to the point-of-care
nursing unit. Nurses on this unit had not only imple- category (n = 41). In some groups, there was another pro-
mented some of the guideline recommendations; they had fessional category represented; at other times another
also developed an evaluation plan. individual/role participated (e.g., a manager in a point-of-
Our data sources included focus groups and individual care group). The interest in the Falls BPG implementa-
interviews, documents and artifacts, and observations of tion was illustrated by the willingness of these individuals
the environments. Key individuals within the hospitals to be involved in this research.
presented the richest source of data, and for this reason We conducted18 focus groups. Participants were pro-
comprised the principal source. As with all qualitative vided release time from their work to attend the ses-
inquiry, there was no clear differentiation between the sions. We used a semistructured format with a
collection, analysis, and interpretation phases (Janesick, semistructured interview guide (Brown, 1999). There

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Boblin et al. 5

Table 2.  Focus Group and Individual Interview Questions.

Historical Issues Related

Participant Context to Implementation Implementation Evaluation
Point-of-Care Tell me about your Who decided to How was the BPG on Has the implementation
Staff nursing unit and the implement the falls and falls injuries been successful?
  patients you provide guideline? implemented at your Is it working?
  care for. How were you site? In what way?
  Do you know your fall informed about the What resources were How has falls reporting
rates? implementation of the used to implement the changed since
What do you consider a BPG? plan? implementation of the
fall to be? Were patients or guidelines?
How are falls recorded in families involved in the
your nursing unit? implementation of the
BPG?
Organizational- Tell me about your What was happening How did you Has the implementation
Level Staff hospital and the patients within the organization decide which been successful?
  you provide care for. at that time that may recommendations Have falls changed since
  Tell me about your have contributed to the within the BPG to the implementation of
  nursing and other implementation of the implement? the guideline?
  professional staff. BPG? Who has/what disciplines How has implementation
What are their strengths? How was the have been involved? been evaluated?
What type of falls do you implementation plan Are you planning on
see? developed? implementing other
How much of a fall does What were the objectives BPGs?
it need to be in order of your implementation What have been the key
to be reported? plan? successes of guideline
implementation? At
the point-of-care level?
Organization level?
Externally?

Note. BPG = best practice guideline.

were four components to the interview guide. We based focus groups in conducting the individual interviews. The
the questions on a broad conceptualization of the interviews typically took place in the offices of the par-
PARiHS framework; questions addressed (a) context, ticipants or in meeting rooms arranged for us by hospital
(b) historical issues related to the decision to imple- staff. We conducted 38 individual interviews in total at
ment, (c) implementation, and (d) evaluation. The ques- the three sites. We used field notes to assist us in record-
tions were broad statements, modified to suit the ing the responses to the interview questions.
category of participant. We used prompts to assist us in
clarifying responses and in seeking a richer understand-
Documents
ing of the participants’ perspectives. Examples of the
interview questions can be found in Table 2. In case study research, researchers use documents as a
The focus groups were facilitated by a principal inves- source of contextual information about events that cannot
tigator (PI) and research coordinator (RC). The PI posed be directly observed; documents also are used by
the questions; the RC documented the responses. The PI researchers to confirm or question information from other
was an experienced interviewer and qualitative researcher. sources (Stake, 1995). We collected a variety of docu-
Both the PI and RC had extensive expertise in risk man- ments, including project proposals, reports, presenta-
agement and in the implementation of BPGs. The focus tions, email communication, minutes of meetings,
groups were not audiotaped; detailed field notes were abstracts, policies, graduate student theses, Web site data,
kept by the RC during the interviews. Immediately fol- corporate falls data, audit data, and executive letters.
lowing the interviews, the PI and RC discussed and docu- Nurses and key informants had identified these docu-
mented further data to ensure completeness. ments as important as data collection proceeded.
We modeled the individual interviews after the focus In this study, we used our analysis of the 787 docu-
groups. We used the interview guides developed for the ments that were recorded during the implementation of

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6 Qualitative Health Research XX(X)

the Falls BPG to provide contextual and historical infor- behaviors, words and dialogues were noted and fixed in
mation within which to frame the case. We initially visu- the form of text” (p. 153). As we conducted further inter-
ally scanned the documents to get a sense of which views and made observations, we clumped the coded data
aspects of the documents pertained to the implementation into categories (categorical aggregation) and amassed
of the Falls BPG. We noted these sections within the doc- these textual documents into files that members of the
uments and returned to them for further analysis. We research team then compiled and reviewed. We noted
coded the documents and journaling to allow linkages meaningful segments of data and documented patterns
between the data contained within the documents and and themes. We arrived at plausible explanations using a
those presented by the participants. process of inductive analysis (Patton, 1999). We dis-
cussed our perspectives and interpretations during team
meetings; we used a constant comparative approach to
Artifacts
look for other ways of organizing the data so that differ-
We used artifacts associated with the implementation of ent findings might be revealed.
the Falls BPG as both contextual and facilitative evi- As we cycled through the process of data collection,
dence. The coinvestigators identified the artifacts first at analysis, and interpretation, we became aware of the sim-
each site and then through interviews and document ilarities between a description of the Falls BPG imple-
reviews. These artifacts included assessment tools, BPSO mentation and a journey. It became evident that
logos and marketing materials, patient and staff educa- participants at the three hospitals shared experiences, yet
tional materials, posters, and event invitations. 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-
Observations of the Context facts enabled the situating of these experiences within the
These data included observations of each hospital’s envi- complex context of health care. We used the analogy of a
ronment, which we gathered as we attended the hospitals journey to present the findings. We shared our interpreta-
for data collection. They also included information col- tions and the portrayal of the Falls BPG implementation
lected from hospital Web sites. A review of these data, as as a journey with participants at the three hospitals. This
with artifacts, contributed to our understanding of the member checking (Creswell & Miller, 2000) increased
contextual factors influencing the implementation of the our confidence in the robustness of our findings.
Falls BPG. Participants, from point-of-care staff to top nursing exec-
utives, attested to how the findings resonated with their
experiences.
Analysis
We followed the editorial analysis style described by
Results
Addison (1999) in combination with the phases of data
analysis (i.e., description, categorical aggregation, estab- The following represents a brief synopsis of the results.
lishing patterns, and naturalistic generalizations) described We present the phases of the journey traveled by the par-
by Stake (1995, 2005). We considered Addison’s approach ticipants, followed by the four major themes. Details of
to be congruent with the constructivist orientation advo- the findings, including exemplars, can be found else-
cated by Stake. Addison described the editorial or herme- where (Ireland et al., 2012). We identified six stages or
neutic style of analysis as beginning with data collection phases of their journey: (a) the early journey, (b) shifting
itself. In keeping with this description, we began our anal- sands, (c) gaining traction, (d) reinvesting in the journey:
ysis with all data sources as we asked participants ques- a new vehicle, (e) on the road, and (f) moving forward.
tions, reviewed the documents, and made observations of We portrayed the stages as movements from one phase to
the artifacts and environments. another. Participants’ voices and documents reflected
While we collected the data, we noted assertions about early efforts made in an attempt to reduce patient falls.
what was being described, and what we observed happen- Long before the three hospitals came together as RNAO
ing. These assertions (Stake, 1995) reflected our interpre- BPSO candidates, all had begun their respective journey
tations and our understandings of how the Falls BPG had toward falls prevention.
been implemented. As an example, as focus group inter- These early journeys were frought with hurdles (shift-
views were conducted, we made notes in the margins and ing sands) that reflected the nature of the contexts at those
white spaces left alongside the interview questions. We times. The support and funding provided by the RNAO
made notations that not only described the responses the and the development of practice standards for the use of
participants made, but also of our initial interpretations of restraints (College of Nurses of Ontario, 2009) allowed
their responses. Using Addison’s (1999) words, “Events, the organizations to gain traction and move forward. As a

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Boblin et al. 7

result of RNAO support, organizations were identified as between advocacy and paternalism, and beneficence
BPSO candidates; champions were trained and in place in and autonomy. Collaborating with patients and families
clinical units. The 3-year partnerships established with to create a care plan based on the guideline became
the RNAO caused a reinvesting in the journey: a new incredibly complex when respect for autonomy, overall
vehicle. As BPSO candidates, hospital leadership in the goals of care, varied life experiences, learning needs of
hospitals was responsible to ensure that executive spon- patients and families, and available resources were fac-
sors, staff, structures, and processes were in place to tored into the equation (Ireland et al., 2012).
facilitate successful BPG implementation and evaluation As the three hospitals traveled along their journey
work and research (Ireland et al., 2012). toward implementation of the Falls BPG, what became
The road to implementation of the Falls BPG required evident was the participants’ awareness that the journey
the involvement of nurses at multiple levels within the was the destination. The sustained commitment of point-
hospitals, ranging from point-of-care nurses to top nurs- of-care nursing staff and leadership to continue to imple-
ing executives. Moving forward required the adoption of ment and reimplement evidence-based practices to meet
innovative strategies within each hospital, including the the fall-prevention needs of patients in their care became
involvement of graduate students, bundling of multiple evident. During 2 years, the fall-prevention journey of the
safety procedures, and launching of a major educational three hospitals had become an informally implemented,
initiative (Ireland et al., 2012). As is to be expected with continuous quality improvement process, rather than a
the initiation of any major initiative, the three hospitals well-mapped journey with a predetermined end point
experienced roadblocks. Participants discussed how (Ireland et al., 2012).
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-
Discussion: Lessons Learned
nizations attempting to implement BPGs. Four primary There were a number of lessons we learned as we reflected
themes/beacons were revealed: (a) listen to and recognize on how we conducted this research. We captured these
the experiential knowledge and clinical realities of staff, lessons in our individual reflexive journals and in the
(b) keep it simple, (c) when the simple becomes complex, minutes of the research team meetings. They related to
and (d) the journey is the destination (Ireland et al.). the use of the QCS approach in general and the use of
As reported by Ireland et al. (2012), point-of-care Stake’s work as a methodology in particular. The strengths
nursing staff in particular became frustrated and resistant and opportunities offered by the QCS approach were evi-
to change when they perceived a mismatch between the dent with this research. In particular, we found Stake’s
Falls BPG prescribed at the organizational level and their approach (1995, 2005) to be an appropriate method for
experience in fall risk reduction, knowledge of the needs this case study. Using Stake’s recommendations, we were
of specific patient populations, and the resources avail- able to understand the complex phenomenon of the Falls
able to them. All participants described the frustration of BPG implementation within the context of three acute-
leaders, managers, and educators regarding the number of care hospitals. We concluded that Stake’s constructivist
competing priorities and the lack of dedicated time for approach provided adequate guidance without creating
staff. Participants described the necessity for hospitals to undue restriction. Our experience was that new ideas
keep it simple in implementing fall-prevention best prac- were revealed that might not have emerged if more struc-
tices. Success was experienced on those units where ture, such as Yin’s (2003, 2009) approach, had been
teams were allowed to identify, develop, and evaluate imposed. The lack of a highly structured, predetermined
strategies and tools tailored to the needs of their patient conceptual framework with accompanying propositions
populations and clinical realities (Ireland et al.). did not inhibit our exploration of this phenomenon. Our
Additionally, participants described success on units use of the PARiHS framework (Kitson et al., 1998) fit
where basic tools to guide implementation were pro- well with Stake’s approach, providing flexible guidance
vided, adaptation at the unit level was encouraged, and to the collection and analysis of data.
competing priorities were minimized. Conversely, resis- Our use of multiple sources of data, characteristic of
tance resulted when the tools provided did not match with the QCS, contributed to a holistic and in-depth under-
clinical realities and competing pressures. standing of the phenomenon (the implementation of the
Participants described the complexity of the envi- Falls BPG). In particular, the use of documents, observa-
ronments within which the Falls BPG was imple- tions, and artifacts alongside individual interviews and
mented, acknowledging not only the clinical focus groups enhanced our understanding of the context
environments but also the characteristics of the patients within which this phenomenon occurred. Our use of mul-
and the nature of nursing work itself. Point-of-care tiple data sources contributed to credibility, offsetting the
nursing staff described having to walk a thin line purposeful, criterion-based convenience sampling that

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8 Qualitative Health Research XX(X)

we used. Additionally, our use of constructivist analysis Conclusion

strategies was effective in facilitating the exploration of
this phenomenon. The QCS approach has received increased attention
We found the establishment of clear boundaries to be within health care research. Yin’s (2003, 2009) and
essential. As with many QCSs, we tended to want to Stake’s (1995, 2005) work has frequently been cited
expand beyond the time constraints and sources of data in simultaneously without giving consideration to their
an attempt to understand even further the phenomenon differing philosophical orientations. This dual applica-
being explored. We found the interest and enthusiasm of tion of approaches with differing philosophical assump-
the nurses and participants within the hospitals exciting tions has challenged the credibility of reported QCS
and motivating. It would have been easy for us to drown research. Readers and researchers have been left with no
in data if the established boundaries were not maintained. clear description of which approach to follow and how
Three suggestions are included for how the research to make the significant design decisions that must be
could have been done differently. Tape recording focus made. Additionally, the methodologist followed most
groups and individual interviews is a recommendation often has been Yin, resulting in QCSs that have been
frequently made when using these data collection meth- more postpositivist than constructivist in nature. In this
ods. We had deliberately chosen to refrain from tape article, we focused on our use of Stake’s (1995, 2005)
recording as a way of containing costs. We did not antici- QCS approach using his constructivist methods to
pate any difficulty or reticence by the participants in understand the implementation of a Falls BPG in three
answering questions; this conclusion was borne out dur- acute-care hospitals. The unique contributions included
ing the data collection. We thought that the combined in this article are the detailed description of the QCS
expertise of the PI and RC also supported our design approach used and the application of Stake’s recommen-
decision. The luxury of having two researchers conduct- dations to research design. The design decisions we
ing the interviews and focus groups might not be the real- faced are described within the context of our research.
ity for some research, which might result in a different The description of researcher lessons learned might be
decision. Whether auditability could have been enhanced of use to researchers wishing to use Stake’s approach to
by the use of taped sessions is open to debate. QCS.
We could have analyzed documents for context as well
as content (Miller & Alvarado, 2005). Whereas we were Declaration of Conflicting Interests
experienced in the analysis of documents for content, and The authors declared no potential conflicts of interest with
documents were analyzed using this approach, we were respect to the research, authorship, and/or publication of this
less experienced with analyzing for context; we therefore article.
followed the recommendations for context analysis as
advocated by Miller and Alvarado only minimally. Funding
Understanding further why documents were produced, by The authors disclosed receipt of the following financial support
whom, and for what purpose might have contributed to an for the research, authorship, and/or publication of this article:
enhanced understanding of the phenomenon. The obser- This work was supported by the Registered Nurses’ Association
vations were not guided by any particular tool; they were of Ontario.
directed by what we deemed was important at the time of
the observation. We might have collected more informa- Note
tion with the use of a framework such as that described by 1. See http://rnao.ca/bpg.
Spradley (1980).
Spradley (1980) identified nine dimensions that can be References
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lenges. Implementation Science, 3(1). doi:10.1186/ Sheryl L. Boblin, RN, PhD, is an associate professor at
1748-5908-3-1 McMaster University School of Nursing in Hamilton, Ontario,
Kuzel, A. J. (1999). Sampling in qualitative inquiry. In B. F. Canada.
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Miller, F. A., & Alvarado, K. (2005). Incorporating docu- Helen Kirkpatrick, RN, PhD, is coordinator of the Best
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Nursing Scholarship, 37(4), 348-353. doi:10.1111/j.1547- Hamilton, Ontario, and an assistant clinical professor at
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1189-1208. Retrieved from www.ncbi.nlm.nih.gov/pmc/ clinical professor at McMaster University School of Nursing.
articles/PMC1089059/ Hamilton, Ontario, Canada.

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