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Abstract

Case study research facilitates the in-depth, real-life exploration of complex phenomena from multiple perspectives. It is a well-established approach to deal with the complexities involved in palliative care research. Case studies are not aligned to a single epistemological paradigm but are defined by the identification of the case to be studied. This article examines the methodological issues of carrying out constructivist Stakian multi-case study research. It is based on the lessons learned from our case study exploring the experiences of advanced breast cancer in Mauritania, a resource-limited, Muslim majority context. Stake provides suggestions and boundaries for the case study researcher, but there is no blueprint available for a Stakian multi-case study. The researcher is encouraged to employ their creativity, intuition and ingenuity. We exercised this freedom by incorporating mixed methods of data collection within our constructivist paradigm. We resourcefully revisited the identity of the case and embedded mini-cases, we rejected traditional views of triangulation in favor of crystallization, and we employed assorted approaches to guide and enrich our within- and cross-case analyses to formulate overarching themes and multi-case assertions. Stakian case study should not be limited to constructivist researchers. We encourage any case study researchers to consider this approach, especially those who wish to employ their intuition and ingenuity to understand and describe experiences and phenomena.

Keywords

case study methods in qualitative inquiry mixed methods narrative ethnography

Introduction

Palliative care is the holistic care destined for individuals and their families who face potentially life-limiting illnesses (World Health Organization, 2019). Its aim, influenced by the mortality of the individual, is the enhancement of the quality rather than the duration of life. The provision of palliative care expanded across Europe and North America in the decades following the founding of London’s St Christopher’s hospice in 1967 (Payne & Lynch, 2015). In high-income contexts, palliative care has been closely associated with cancer and, at times, became entrenched within cancer services (Dempers & Gott, 2017). This relationship has been identified and challenged. Palliative care is now routinely integrated into non cancer specialities, such as, cardiology, care of the elderly, renal and respiratory (Laird, 2015). In contrast, the development of palliative care in Africa has been much slower, despite the continent’s first hospice being founded in 1979 (Clark et al., 2019). Much of the available palliative care service provision in Africa remains concentrated in Anglophone regions with high rates of Human Immunodeficiency Virus (Gysels et al., 2011; Human Rights Watch, 2015; Rhee et al., 2017). The provision of palliative care is gradually increasing across the African continent. Over the last two decades, many African countries have transitioned from having no palliative care activity to having isolated services, while a small number have integrated palliative care provision in their national healthcare systems (Clark et al., 2019). In Mauritania, West Africa, palliative care has transitioned from no activity in 2006 to isolated provision.

Approaches to understanding and exploring experiences of life-limiting conditions differ according to the research’s underlying paradigm. For example, the experience of pain is often viewed through a positivist lens by scientists and medical professionals who focus on its physiology, pathology and management, with many successes reported (Renqvist, 2012). Much of this genre of research is congruent with a biomedical definition of pain, such as, “an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage” (International Association for the Study of Pain, 2017). This positivist approach has been criticized for attempting to reduce the complex, multifaceted experience of pain into a series of numbers (Fearon et al., 2018). In contrast, research from other disciplines, such as phenomenology, qualitative research, sociology, anthropology and philosophy, tends to employ more subjective and interpretive approaches. They accept that experiences, such as pain, are challenging to measure and describe. Experiences are viewed as personally and socially constructed phenomenon, closely associated with meaning and influenced by the individual’s cultural context (Best, 2007; Neilson, 2016). A person not only lives experiences, but they interpret and give meaning to them (Daher et al., 2017).

This conceptualization of experience has implications for palliative care research. First, experiences and their meanings are unique to the life of the individual, and the extraction and measurement of experiences is incomplete because they need to be interpreted in light of the whole person (Daher et al., 2017). Second, experiences are temporal, and their nature is changed by the acts of recollection and reporting. Any described experience is a construction based on factors such as the person’s memories of past events, their current situation and their anticipation of future events (Luft & Overgaard, 2012). In addition, this process of an individual re-entering an experience is influenced by the presence of the researcher (Davies & Shackleton, 1975). This is especially valid given the vulnerable status of many palliative care research participants, who are asked to discuss sensitive topics and who are themselves unlikely to benefit from the research (Sivell et al., 2019). Therefore, it is important that any attempt at exploring and understanding experiences is sensitive to their subjectivity, temporality, complexity and depth.

The aim of this article is to discuss and reflect on the methodological issues negotiated during a Stakian multi-case study (Stake, 2006). We discuss the lessons we have learned while researching the experiences of advanced breast cancer in the resource limited, Muslim majority country of Mauritania in West Africa, completed as part of the first author’s PhD. We will explain how Stake’s approach served us in our attempts to incorporate multiple perspectives and data in a real-life, real-time context (Denzin & Lincoln, 2011; Swanborn, 2010). We describe how Stakian multi-case study is congruent with the constructivist paradigm, and how it is well-suited for cross-cultural and cross-language exploration of complex phenomena. We hope that we will encourage other researchers to have confidence to carry out Stakian case study research and to employ intuition and reflexivity to understand and describe experiences and phenomena.

Case Study Research

Modern case study research first became established in the field of anthropology in the early 20th century (Stewart, 2014). This was soon followed by education, business science, politics, and healthcare (Merriam & Tisdell, 2015; Payne et al., 2007). The decision to use case study research is related more to what is to be studied, the case, rather than the underlying paradigm or methodology employed (Flyvbjerg, 2011). The actual word “case” derives from the Latin “casus,” meaning “event” or “situation” (Swanborn, 2010). The multiple definitions of case study research tend to have two major components in common: a real-life particular bounded context, and a level of complexity requiring holistic and in-depth exploration. Merriam and Tisdell’s definition is one of the simplest, “an in-depth description and analysis of a bounded system” (Merriam & Tisdell, 2015, p. 37). Case studies may be formed at the micro-level (one or more individuals), meso-level (organization) or macro-level (large communities or governments). The boundaries of a case study can be implicit, such as within a department or a service (Walshe et al., 2010); or more rarely theoretical constructs, such as the social constructs of self-neglect (Lauder, 1999).

Much of current health-related case study research has tended to follow one of two case-study researchers, Yin (2018) or Stake (1995). Yin provides structured plans on how to undertake case study research. Although detailed, his approach is relatively generic in nature and easily accessible to researchers from a range of disciplines. In contrast, Stake’s writings are more clearly founded on his experiences of pioneering case study research as an evaluative approach for complex educational interventions in the 1960s and 1970s. His writings have more in common with a compilation of advice, suggestions and lessons learnt rather than a list of instructions.

Case study research as a methodology does not fit neatly into the traditional spectrum of ontological and epistemological paradigms (Harrison et al., 2017). The centrality of the case as its defining feature positions case study research as a bridge between traditions and epistemologies (Luck et al., 2006). Neither Yin nor Stake are explicit in the epistemological frameworks of their approaches, although they are often considered to have opposing epistemological underpinnings (Baxter & Jack, 2008; Boblin et al., 2013). Yin (2018) is portrayed as leaning toward positivism with Stake (1995) more in line with constructivism. Irrespective of Yin’s personal epistemological framework, his work is positioned as a practical conduit for quantitative researchers to enter into case study research by employing terminology consistent with a quantitative, positivist paradigm, such as “theoretical propositions,” “construct validity,” “external validity” and “reliability” (Yin, 2018). In contrast, Stake’s terminology, for example the use of the term “art” in the title of his first book, is more welcoming to the constructive researcher. We will revisit the evidence for the constructive paradigm of Stake’s approach later in this paper.

In constructivism, knowledge is considered as created as opposed to discovered, and sustained through social processes and interactions between individuals, including the researcher, and communities (Best, 2007; Silverman, 2013). Such a paradigm facilitates the understanding of constructed culturally bounded realities that exist in the real-world of experiences (Järvensivu & Törnroos, 2010). Charmaz describes how constructivism relates to grounded theory:

Constructivist inquiry starts with the experience and asks how members construct it. To the best of their ability, constructivists enter the phenomenon, gain multiple views of it, and locate it in its web of connections and constraints. (Charmaz, 2006, p. 187)

We applied these same ideas in our Stakian multi-case study research, in which we explored the experiences of advanced breast cancer in Mauritania, with the aim of producing rich and deep understanding (Stake, 2006).

Stakian Case Study Research

Stake provides a relatively simple case study typology of intrinsic, instrumental and multi-case studies (1995). An intrinsic case study is used when the researcher is interested in understanding the situation of the case itself and its particularity, its uniqueness. In an instrumental case study, issues or problems as experienced within the case take prominence over the case itself. It moves away from the particular toward the universal. A multi-case study is used to compare the initial case with other cases or to explore a phenomenon as experienced across the cases.

Our study was guided by the research question: How is the quintain of advanced breast cancer experienced over time by Mauritanian women, their families and their healthcare providers? The quintain, a term coined by Stake (2006), is used here to replace and expand on the term phenomenon that is considered too narrow to describe the relatively wider research target of a multi-case study. The word quintain originally referred to a medieval lancing target used by knights practising jousting, typically with a sandbag attached that would swing around and strike an unsuccessful jouster (Allen, 2006). Stake (2006) argues that while the aim to understand the quintain can help maintain the boundaries of the case study, it is a larger target than a phenomenon that Stake compares to a bull’s eye on a dartboard (Hernández-Leo et al., 2010). It is not known whether Stake chose this term purposefully with a veiled warning, that if unsuccessful multi-case study research could result in the researcher being knocked off their horse.

Research Paradigm

Stake avoids an explicit label of a research paradigm, but there is evidence that his approach is congruent with the constructivist paradigm of our research (Baxter & Jack, 2008; Boblin et al., 2013). The concept of the quintain, for example, easily accommodates the multiple realities constructed across the cases (Stake, 2006). However, an emphasis on understanding the quintain can result in a restricted understanding of the individual cases. The individual experiences and narratives become relevant to the case study only as they relate to the quintain; with limited intrinsic value (Stake, 2006). In a constructivist underpinned multi-case study, both the particularity of the individual cases and the quintain are important. Stake encourages this balancing between case and quintain, describing it as the case-quintain dialectic,

I think it best that the issues of the individual Cases do not merge too quickly into the main research questions of the overall multi-case study. They need to be heard a while, then put aside a while, then brought out again, and back and forth (the dialectic). (Stake, 2006, p. 47, emphasis in original text)

Stake’s (2006) pragmatic suggestions on how to carry out this dialectic serve to maintain the study’s balance between the validity and richness of individual narratives and the broader socially constructed concept of advanced breast cancer. This helps reduce the risk of extreme relativism, in which all views are accepted as equally valid with no reality external to the subjective (Järvensivu & Törnroos, 2010).

Foreshadowed Issues

Case study research can create vast quantities of redundant data (Simons, 2009). To manage this and maintain the focus and feasibility of a study, Stake provides suggestions for case study boundaries. One such suggestion is the use of foreshadowed issues or problems. These are theoretical orientations determined a priori through personal experience and a review of the literature (Dinkelman, 2001; Stake, 2006). They create a framework for the case study by maintaining its boundaries and feasibility, directing the researcher toward or away from certain concepts (Silverman, 2013; Stake, 2006). We did not consider foreshadowed issues as hypotheses and our aim was not to prove or disprove them.

This multi-case study was guided by four foreshadowed issues (Table 1). These were developed from literature on experiences of advanced breast cancer and other life-limiting illnesses in Arab and African contexts, and on our experiences of palliative care across Africa (Gysels et al., 2011; Murray et al., 2003). The foreshadowed issues helped guide the formulation and construction of the cases, the data collection, and the evaluation of the utility of each case. They served as theories to be explored during the data analysis stage, similar to Braun and Clarke’s (2019) description of theory-driven thematic analysis. The provisional foreshadowed issues underwent modification and maturation in response to the emerging data over the course of the research (Simons, 2009; Stake, 2006). We adopted Stake’s (2006) terminology to refer to the modified issues as multi-case assertions (Table 1).

Table 1.

Foreshadowed Issues and Multicase Assertions.

Foreshadowed Issues	Multicase Assertions
	Maure women with breast cancer prefer not to acknowledge or express certain negative experiences because of cultural and religious beliefs.
The belief in an omnipresent being is a comforting influence for the patient and their family as they face challenges to health and well-being	Maure women and their families are reassured that breast cancer and their destiny are under the control of Allah. They are comforted when they can demonstrate their devotion to Him, despite negative experiences.
Mauritanian extended families experience difficulty in adapting to crises and in supporting their members	Mauritanian families find it challenging to cope with expressions of physical, emotional or spiritual distress
There may be unacknowledged burnout, loss of hope and breakdown in the family cohesiveness	Mauritanian families cope well with many physical and material difficulties associated with breast cancer
Healthcare providers have a sense of ownership and responsibility toward their patients, and this affects the care they provide	Healthcare providers have a sense of responsibility toward the spiritual well-being of their patients. This may outweigh other domains of well-being and be used to justify disempowering women, concealing or providing trivializing information.

Crystallization and Mixed Methods of Data Collection

A common characteristic of the constructivist approach is the collection of data from multiple perspectives, explicit in the research question (Merriam & Tisdell, 2015). These data can help understand the quintain, but it can be difficult to synthesize data from diverse views. One approach to this challenge is triangulation, the incorporation of more than one data point, methodology or theoretical framework in order to develop a deeper understanding of a phenomenon (Stake, 1995; Torrance, 2012). Earlier interpretations of triangulation were based on a mechanistic, positivist search for a single objective truth (Koro-Ljungberg, 2008; Simons, 2009). In 1995, Stake suggested there was limited congruence between these early interpretations and constructivism.

The stronger one’s belief in constructed reality, the more difficult it is to believe that any complex observation or interpretation can be triangulated. (Stake, 1995, p. 114)

More recent work on triangulation has repainted it for a constructivist audience, suggesting that it should enable the deeper understanding of a phenomenon rather than a closer approximation of an objective truth (Denzin & Lincoln, 2011; Ingleton & Davies, 2007). Stake’s later work demonstrates a shift in his thinking.

The qualitative researcher is interested in diversity of perception, even the multiple realities within which people live. Triangulation helps to identify these different realities. (Stake, 2006, p. 38)

Stake describes nuanced triangulation in the within-case and cross-case analyses. Within-case triangulation is used to move the researcher away from the anecdotal selection of ideas and concepts toward the grounding of any findings in the collected data. Any interpretations should be clear and well supported by the data, for example by providing supporting quotations. Cross-case triangulation refers to the broad, sceptical exploration of different perspectives and experiences of the quintain. This includes the researcher discussing the quintain with others, peers and critical persons inside and outside the case study.

Stake’s more recent views of triangulation are congruent with constructivism. In our case study, we decided to stress our constructivist framework by avoiding the term triangulation in favor of the term crystallization. Crystallization describes the unscheduled refraction of light and colors through a prism creating multiple fluctuating images, representing the multiple co-existing realities as opposed to an empirical dot on a map traditionally associated with triangulation (Ellingson, 2009; Järvensivu & Törnroos, 2010; Simons, 2009).

Crystallization is not limited to multiple perspectives, it also refers to bringing together multiple genres of data collection that are capable of providing reflections of light without the need to complete the image (Ellingson, 2009). In our study we employed qualitative methods, semi-structured interviews and audio journals; and quantitative methods, the Palliative Performance Scale version 2 (PPSv2) (Paiva & Paiva, 2014) and the African Palliative Care Association’s African Palliative Care Outcome Scale (APCA African POS) (Harding et al., 2010; Powell et al., 2007). Quantitative methods of data collection are often absent from constructivist case study research because of their positivist heritage (Simons, 2009). We suggest that our chosen methods are consistent with our chosen paradigm. Their use is supported by Stake’s encouragement to use intuitive and pragmatic approaches to data collection in which data are valued for their utility in understanding the quintain, rather than the method through which they are collected (Stake, 2006). In addition, we argue that it would be contradictory to reject quantitative methods on the basis that their resulting data were partial and incomplete, when in constructivism all knowledge is considered to be limited and partial (Abma & Stake, 2014; Kukla, 2000).

The Case and Mini-Cases

In our study, a case was defined as a Mauritanian woman over the age of 18 with advanced breast cancer, aware of her diagnosis and who was willing to share her experiences. In multi-case study research, Stake suggests that individual cases can be embedded with smaller cases, termed mini-cases. These mini-cases can help the researcher to better understand the case, the quintain, or the broader context. Stake provides a practical example of this in his Ukraine case study (2006). He identified the child, Liubchyk, as the case with his mother and teacher, Oksana, as mini-cases embedded into the case (Figure 1).

Figure 1.

Plan for the Ukraine case study demonstrating the embedded mini-cases (Stake, 2006, p. 120).

We anticipated that each case would be embedded with mini-cases representing individual family members, healthcare professionals and traditional practitioners nominated by the women (Figure 2). These groups of constituents were selected on the basis of their usefulness to answer the research question and to provide boundaries for the case study research.

Figure 2.

Anticipated formulation of the case. F-P, Family member embedded mini-case; H-P, Healthcare professional embedded mini-case; T-P, Traditional practitioner embedded mini-case.

We encountered two challenges to the creation of this anticipated case and embedded mini-cases. First, no traditional practitioners were nominated by the women in the cases. Second, the same healthcare professionals tended to be nominated for each case. Several of these healthcare professionals had limited knowledge and recollection of the nominating women and their families. This resulted in the re-evaluation of the role and utility of the health professional mini-cases, consistent with Stake’s (2006) suggestion to revisit the usefulness and identity of any case or mini-case during a case study. To overcome this challenge, we modified the idea of each mini-case representing a single healthcare professional to create a single, combined health-care mini-case. This mini-case was populated with all the recruited health professionals (n = 9) and embedded in each of the eight cases (see Figure 3). This decision was inspired by Stake’s Ukraine multi-case study (Stake, 2006), in which a parents’ association was identified as a mini-case and embedded in the case during the data collection phase.

Figure 3.

Final composition of cases. F-M, Embedded mini-cases of family member; H-C, Embedded healthcare mini-case.

Data Collection and Analysis

Observation, interviews and documentary sources are common sources of data in Stakian case study research (Stake, 1995, 2006). Our methods of data collection for this case study included serial semi-structured interviews, audio journals, and measurements of patient reported outcomes and performance status. The analysis of healthcare records was considered but omitted as much documentation was lost, illegible or incomplete.

Our plan for data collection allowed a contemporaneous exploration of issues and experiences. It provided the occasion to follow the changing perceptions of the women, family members and relevant health professionals around certain events in the women’s journey. For example, episodes of conflict between family members and health professionals, or the different perspectives of emergency visits to the cancer center with troublesome symptoms. Such events were captured through the interviews, journals and the quantitative measurements of well-being and performance status.

Data analysis in a Stakian multi-case study involves oscillating between the case and the quintain (Stake, 2006). Stake provides limited direction on how to analyze data, allowing the researcher to analyze data in ways suitable to their data and the research context. We employed a structured approach to manage the large quantity of data collected from 58 interviews, 31 journal entries, 63 APCA African POS and 32 PPSv2 entries, for up to 9 months per case. This involved within-case analyses focused on understanding the uniqueness and particularity of the individual cases, followed by a cross-case analysis focused on describing the quintain.

Within-case analyses

Data were analyzed at the case level to explore and understand the contexts of the individual cases prior to seeking to understand the quintain (Stake, 2006). The within-case analyses followed four steps:

Retelling of the cases’ stories with the use of “thick descriptions” (Stake, 1995, p. 39). The individual journeys and experiences were summarized in narrative descriptions to create rich accounts of how participants interpreted and experienced advanced breast cancer, with help from field notes and a reflective journal.

Description and plotting against time the quantitative data from the APCA African POS and PPSv2

Thematic analysis of the qualitative data at three levels within each case: transcript-, participant- and case-level (Braun & Clark, 2019).

Transcript-level: Individual interviews and audio journals were analyzed and coded line-by-line independent from one another.

Participant-level: The available qualitative and quantitative data from each participant (woman, family member and health professional) were analyzed and synthesized in light of the chronological narrative and concurrent events described in the case such as, hospital visits and new symptoms. Analysis of the data from each participant produced multiple provisional themes specific and unique to the participants within each case.

Case-level: The findings from the analyses of women’s data were then synthesized with the data arising from the embedded mini-cases. The identification and description of case-level themes tended to concentrate on the experiences of the women with advanced breast cancer.

Evaluation of each case’s utility in understanding the foreshadowed issues

Thematic analysis is an approach to qualitative data analysis, in which themes or patterns in the data are identified and described (Braun & Clarke, 2019). Using NVivo for Mac v.10.2.2^®, all transcripts of interviews and audio-journal entries were read and re-read to enable familiarization with the data. Transcripts were then coded line by line. Coding frameworks were created for each participant within the case. NVivo’s annotation function was used to record impressions and contemplations on aspects of the data that were considered to be unusual, surprising, interesting or being representative of common experiences (Saldana, 2012).

The thematic coding and analysis were guided by two conceptual approaches. First, preliminary themes were derived inductively from the data within each case, an approach described as data-driven by Braun and Clarke (2019). Second, these provisional findings were explored and described through the lens of the foreshadowed issues (Dinkelman, 2001; Stake, 2006)

Finally, the utility of each case was appraised. This followed Stake’s suggestion that each case should be evaluated for its usefulness in exploring and understanding the foreshadowed issues (2006). He recommends a three-point rating scale of utility; low, middling, or high utility recorded as 1, 2, or 3, respectively (Stake, 2006). These utilities were depicted on radar charts in which the outer diamond represents the maximum utility (3) and the inner diamond the minimum (1) (see Figure 4). These ratings of usefulness helped the identification of themes in each case and the evaluation of how well each foreshadowed issue had been addressed in the data.

Figure 4.

Example of a radar chart depicting the utility of case eight.

Cross-case analysis

The cross-case analysis sought to explore and understand the quintain, the experiences of advanced breast cancer in Mauritania. While the within-case thematic analyses were primarily inductive, the cross-case analysis was directed more by the foreshadowed issues, that served as lenses and boundaries to the data, influencing which provisional themes were further explored and developed to best understand the quintain. The cross-case analysis built and expanded on the findings from the eight within-case analyses. Throughout this process, the transcript-, participant- and case-level qualitative data along with the quantitative data were iteratively revisited to seek deeper understanding of the developing interpretations and patterns in the data. For example, the APCA African POS and PPSv2 data were pooled across the cases and presented in frequency charts to identify patterns within the scales, such as the frequency of severe worry and rate of decline over all data points and cases. Mind mapping served to visualize and identify the relationships and variance between cases and themes.

The cross-case analysis of our case study identified three overarching themes and ten sub-themes. These formed the essence of our “findings.” The foreshadowed issues helped in understanding the hierarchy of these themes and guided the order in which they are presented in our original research. Finally, our reflections on the study processes directed us to look again at our foreshadowed issues. While these were founded on our personal experiences and the literature form other Arab countries, we recognized that they were not fully congruent with our findings. We decided that updating these issues would be an appropriate step for the completion of our study. These may be used as more suitable foreshadowed issues for future case studies in similar contexts. We adopted Stake’s term for these modified issues, “multi-case assertions,” despite us feeling the term was somewhat incongruous with the constructivist paradigm.

Discussion

We encountered several strengths and limitations to employing a constructivist Stakian multi-case study approach in our exploration of experiences of advanced breast cancer in Mauritania. These relate to both the constructivist paradigm and Stake’s approach.

Strengths and Limitations of the Constructivist Paradigm

The constructivist approach allows an appreciation for how knowledge is constructed differently by individuals and groups through their experiences, observations and interpretations. First, this helps balance the power between the researcher and the researched (Weinberg, 2007). The constructivist researcher plays a role in any construction of knowledge, and the portrayal of findings as one interpretation of knowledge can mitigate the risk of the researcher perceiving themselves as the ultimate authority and knowledge keeper (Karnieli-Miller et al., 2008; Stake & Kerr, 1995). In our original study, we acknowledge that the first author was not a neutral conduit through whom the women’s voices can be heard unaltered or in their entirety. At its essence, the study was an exploration, analysis and description of what Mauritanian, Muslim, Arabic-speaking women with advanced breast cancer, living in resource-limited settings, reported to a male, UK trained medical doctor in the presence of an interpreter.

There are limitations or challenges associated with employing a constructivist approach. It is well adapted to incorporating and understanding experiences from different perspectives, but it can be challenging to synthesize data from different methods of data collection. We described above how our study employed mixed methods of data collection although it remains that the constructivist approach is most congruent with qualitative methods of data collection. These methods produce rich, in-depth data on experiences and interpretations apt for analysis. It is more challenging to incorporate data from quantitative data, such as the patient reported outcome and performance status measurements we employed. While we have argued and demonstrated that such methods should not be rejected as incompatible, we do caution others to carefully consider the value and effort involved.

A further challenge we encountered related to the constructivist acceptance of the validity of every individuals’ experience, the women, family members and health professionals. While this attitude helped avoid a judgmental binary view of true or false, it was less useful in how we addressed the power imbalances experienced by women with significant palliative care needs. In our study, we described how families and health professionals systematically wielded power over the women’s understanding and experiences, emotional, physical and spiritual. While we challenged these norms in our report writing, it is feasible that our understanding of constructivism directed us away from challenging these during the case study. This critique perhaps reflects more on us as researchers rather than on constructivism, but it raises the question of how our research would have differed had we undertaken participatory action or feminist social theory research.

Strengths and Limitations of Stakian Multicase Study Research

We have offered our insights into following Stake’s suggestions for multi-case study research. The distinction between strength and limitation are likely to be dependent on the epistemological paradigm of the reader. We, as constructivist researchers, see many strengths in his approach, and we encourage other constructivist researchers to consider a Stakian case study. Much of the methodology and terminology fits nicely with the underlying paradigm, and there is an openness for a more explicit interpretative stance, such as our use of crystallization. There are few exceptions where Stakian terminology seems incongruous with constructivism. Multi-case assertions and the quantification of an individual case’s utility appear relatively positivist and reductionist in nature. Some of these may reflect the single editions of Stake’s seminal works in contrast to Yin’s refinements over several editions.

Stakian case study research should not be limited to constructivist projects. We propose that the approach could be considered by any researcher who view themselves as intuitive and creative. There is a need for flexibility in any case study exploring a real-life, real-time complex quintain or phenomenon. Stake encourages the case study researcher to think of the case as a living entity, with purpose and “a strong sense of self” (Stake, 2006, p. 3). Intuition is encouraged at the data collection and analysis stages. Stake suggests that these choices should be guided by the foreshadowed issues and the case study question. Importantly, Stakian case study should be sufficiently flexible to change and adapt to new and emerging knowledge of the case. This includes the possibility of redefining the case or embedded cases, as we demonstrated in our study. Yin (2018) emphasizes the need for a detailed protocol at the start of any case study, whereas Stake’s (2006) approach could be described more as a journey. While we recommend that the case study researcher has a map, they also need to be attentive and responsive to signposts, roadworks and diversions.

Our appreciation for flexibility had limitations. While we appreciated the freedom in the identification of the case and embedded cases and the data collection, we missed the lack of structure in the analysis stages. Where possible we explicitly followed Stake’s (2006) analysis structure such as his suggestions on the creation of multi-case assertions and the measurement of the case utility. Much of our analysis remain founded on other sources such as Braun and Clark (2019).

Conclusion

This article has shown that a constructivist paradigm is an appropriate choice for case study research in a real-life, complex cross-cultural settings such as palliative care in a resource limited setting. The Stakian multi-case study approach allows rich descriptions of experiences, with attention given to their complexity and contextuality (Stake, 1995). Stake provides suggestions and boundaries for the case study researcher, but there is no blueprint for a Stakian multi-case study. It should be considered as a potential framework for any case study but is most likely to be attractive to constructivist, intuitive and creative researchers. We consider that undertaking a Stakian multi-case study provided us with the freedom to reflexively complete a case study that we believe resulted in valid and interesting insights. The potential challenge of this flexibility is that Stakian case study is not a complete package. The approach does allow the researcher freedom to use their intuition and ingenuity to construct and undertake a case study, however it is likely that they will need borrow from other case study authors, research designs and approaches to data analysis.

Footnotes

Acknowledgments

We thank all those who participated in the original research,especially the women. We thank the director and staff of the Centre National d’Oncologie in Nouakchott,Mauritania. We thank Ndiaye,the palliative care champion in Mauritania.

Declaration of Conflicting Interests

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

Funding

The author(s) disclosed receipt of the following financial support for the research,authorship,and/or publication of this article: Many thanks to the Swiss charity “Consulting,Training and Support” who funded the interpretation and translation services during the multi-case study which this article is founded on.

ORCID iDs

David Fearon

Sean Hughes

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Constructivist Stakian Multicase Study: Methodological Issues Encountered in Cross-Cultural Palliative Care Research

Abstract

Keywords

Introduction

Case Study Research

Stakian Case Study Research

Research Paradigm

Foreshadowed Issues

Crystallization and Mixed Methods of Data Collection

The Case and Mini-Cases

Data Collection and Analysis

Within-case analyses

Cross-case analysis

Discussion

Strengths and Limitations of the Constructivist Paradigm

Strengths and Limitations of Stakian Multicase Study Research

Conclusion

Footnotes

Acknowledgments

Declaration of Conflicting Interests

Funding

ORCID iDs

References