case study design research

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

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

Research question

• Conceptual framework
• Conceptual vs. theoretical framework

Data collection

• Qualitative research methods
• Focus groups
• Observational research

What is a case study?

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

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

Case studies

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

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

Definition of a case study

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

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

Characteristics of case studies

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

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

The role of case studies in research

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

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

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

What is the purpose of a case study?

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

Why use case studies in qualitative research?

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

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

The explanatory, exploratory, and descriptive roles of case studies

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

The impact of case studies on knowledge development

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

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

Types of case studies

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

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

Exploratory case studies

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

Descriptive case studies

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

Explanatory case studies

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

Intrinsic, instrumental, and collective case studies

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

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

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

Critical information systems research

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

Health research

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

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

Asthma research studies

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

Other fields

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

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

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

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

Propositions

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

Units of analysis

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

Argumentation

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

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

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

Defining the research question

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

Selecting and defining the case

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

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

Developing a detailed case study protocol

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

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

Collecting data

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

Analyzing and interpreting data

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

Writing the case study report

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

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

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

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

Observations

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

Documents and artifacts

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

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

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

Ensuring the quality of data collection

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

Data analysis

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

Organizing the data

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

Categorizing and coding the data

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

Identifying patterns and themes

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

Interpreting the data

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

Verification of the data

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

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

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

Benefits include the following:

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

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

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

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

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Methodology

• What Is a Case Study? | Definition, Examples & Methods

What Is a Case Study? | Definition, Examples & Methods

Published on May 8, 2019 by Shona McCombes . Revised on November 20, 2023.

A case study is a detailed study of a specific subject, such as a person, group, place, event, organization, or phenomenon. Case studies are commonly used in social, educational, clinical, and business research.

A case study research design usually involves qualitative methods , but quantitative methods are sometimes also used. Case studies are good for describing , comparing, evaluating and understanding different aspects of a research problem .

Table of contents

When to do a case study, step 1: select a case, step 2: build a theoretical framework, step 3: collect your data, step 4: describe and analyze the case, other interesting articles.

A case study is an appropriate research design when you want to gain concrete, contextual, in-depth knowledge about a specific real-world subject. It allows you to explore the key characteristics, meanings, and implications of the case.

Case studies are often a good choice in a thesis or dissertation . They keep your project focused and manageable when you don’t have the time or resources to do large-scale research.

You might use just one complex case study where you explore a single subject in depth, or conduct multiple case studies to compare and illuminate different aspects of your research problem.

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Once you have developed your problem statement and research questions , you should be ready to choose the specific case that you want to focus on. A good case study should have the potential to:

• Provide new or unexpected insights into the subject
• Challenge or complicate existing assumptions and theories
• Propose practical courses of action to resolve a problem
• Open up new directions for future research

TipIf your research is more practical in nature and aims to simultaneously investigate an issue as you solve it, consider conducting action research instead.

Unlike quantitative or experimental research , a strong case study does not require a random or representative sample. In fact, case studies often deliberately focus on unusual, neglected, or outlying cases which may shed new light on the research problem.

Example of an outlying case studyIn the 1960s the town of Roseto, Pennsylvania was discovered to have extremely low rates of heart disease compared to the US average. It became an important case study for understanding previously neglected causes of heart disease.

However, you can also choose a more common or representative case to exemplify a particular category, experience or phenomenon.

Example of a representative case studyIn the 1920s, two sociologists used Muncie, Indiana as a case study of a typical American city that supposedly exemplified the changing culture of the US at the time.

While case studies focus more on concrete details than general theories, they should usually have some connection with theory in the field. This way the case study is not just an isolated description, but is integrated into existing knowledge about the topic. It might aim to:

• Exemplify a theory by showing how it explains the case under investigation
• Expand on a theory by uncovering new concepts and ideas that need to be incorporated
• Challenge a theory by exploring an outlier case that doesn’t fit with established assumptions

To ensure that your analysis of the case has a solid academic grounding, you should conduct a literature review of sources related to the topic and develop a theoretical framework . This means identifying key concepts and theories to guide your analysis and interpretation.

There are many different research methods you can use to collect data on your subject. Case studies tend to focus on qualitative data using methods such as interviews , observations , and analysis of primary and secondary sources (e.g., newspaper articles, photographs, official records). Sometimes a case study will also collect quantitative data.

Example of a mixed methods case studyFor a case study of a wind farm development in a rural area, you could collect quantitative data on employment rates and business revenue, collect qualitative data on local people’s perceptions and experiences, and analyze local and national media coverage of the development.

The aim is to gain as thorough an understanding as possible of the case and its context.

In writing up the case study, you need to bring together all the relevant aspects to give as complete a picture as possible of the subject.

How you report your findings depends on the type of research you are doing. Some case studies are structured like a standard scientific paper or thesis , with separate sections or chapters for the methods , results and discussion .

Others are written in a more narrative style, aiming to explore the case from various angles and analyze its meanings and implications (for example, by using textual analysis or discourse analysis ).

In all cases, though, make sure to give contextual details about the case, connect it back to the literature and theory, and discuss how it fits into wider patterns or debates.

If you want to know more about statistics , methodology , or research bias , make sure to check out some of our other articles with explanations and examples.

• Normal distribution
• Degrees of freedom
• Null hypothesis
• Discourse analysis
• Control groups
• Mixed methods research
• Non-probability sampling
• Quantitative research
• Ecological validity

Research bias

• Rosenthal effect
• Implicit bias
• Cognitive bias
• Selection bias
• Negativity bias
• Status quo bias

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Home » Case Study – Methods, Examples and Guide

Case Study – Methods, Examples and Guide

Table of Contents

A case study is a research method that involves an in-depth examination and analysis of a particular phenomenon or case, such as an individual, organization, community, event, or situation.

It is a qualitative research approach that aims to provide a detailed and comprehensive understanding of the case being studied. Case studies typically involve multiple sources of data, including interviews, observations, documents, and artifacts, which are analyzed using various techniques, such as content analysis, thematic analysis, and grounded theory. The findings of a case study are often used to develop theories, inform policy or practice, or generate new research questions.

Types of Case Study

Types and Methods of Case Study are as follows:

Single-Case Study

A single-case study is an in-depth analysis of a single case. This type of case study is useful when the researcher wants to understand a specific phenomenon in detail.

For Example , A researcher might conduct a single-case study on a particular individual to understand their experiences with a particular health condition or a specific organization to explore their management practices. The researcher collects data from multiple sources, such as interviews, observations, and documents, and uses various techniques to analyze the data, such as content analysis or thematic analysis. The findings of a single-case study are often used to generate new research questions, develop theories, or inform policy or practice.

Multiple-Case Study

A multiple-case study involves the analysis of several cases that are similar in nature. This type of case study is useful when the researcher wants to identify similarities and differences between the cases.

For Example, a researcher might conduct a multiple-case study on several companies to explore the factors that contribute to their success or failure. The researcher collects data from each case, compares and contrasts the findings, and uses various techniques to analyze the data, such as comparative analysis or pattern-matching. The findings of a multiple-case study can be used to develop theories, inform policy or practice, or generate new research questions.

Exploratory Case Study

An exploratory case study is used to explore a new or understudied phenomenon. This type of case study is useful when the researcher wants to generate hypotheses or theories about the phenomenon.

For Example, a researcher might conduct an exploratory case study on a new technology to understand its potential impact on society. The researcher collects data from multiple sources, such as interviews, observations, and documents, and uses various techniques to analyze the data, such as grounded theory or content analysis. The findings of an exploratory case study can be used to generate new research questions, develop theories, or inform policy or practice.

Descriptive Case Study

A descriptive case study is used to describe a particular phenomenon in detail. This type of case study is useful when the researcher wants to provide a comprehensive account of the phenomenon.

For Example, a researcher might conduct a descriptive case study on a particular community to understand its social and economic characteristics. The researcher collects data from multiple sources, such as interviews, observations, and documents, and uses various techniques to analyze the data, such as content analysis or thematic analysis. The findings of a descriptive case study can be used to inform policy or practice or generate new research questions.

Instrumental Case Study

An instrumental case study is used to understand a particular phenomenon that is instrumental in achieving a particular goal. This type of case study is useful when the researcher wants to understand the role of the phenomenon in achieving the goal.

For Example, a researcher might conduct an instrumental case study on a particular policy to understand its impact on achieving a particular goal, such as reducing poverty. The researcher collects data from multiple sources, such as interviews, observations, and documents, and uses various techniques to analyze the data, such as content analysis or thematic analysis. The findings of an instrumental case study can be used to inform policy or practice or generate new research questions.

Case Study Data Collection Methods

Here are some common data collection methods for case studies:

Interviews involve asking questions to individuals who have knowledge or experience relevant to the case study. Interviews can be structured (where the same questions are asked to all participants) or unstructured (where the interviewer follows up on the responses with further questions). Interviews can be conducted in person, over the phone, or through video conferencing.

Observations

Observations involve watching and recording the behavior and activities of individuals or groups relevant to the case study. Observations can be participant (where the researcher actively participates in the activities) or non-participant (where the researcher observes from a distance). Observations can be recorded using notes, audio or video recordings, or photographs.

Documents can be used as a source of information for case studies. Documents can include reports, memos, emails, letters, and other written materials related to the case study. Documents can be collected from the case study participants or from public sources.

Surveys involve asking a set of questions to a sample of individuals relevant to the case study. Surveys can be administered in person, over the phone, through mail or email, or online. Surveys can be used to gather information on attitudes, opinions, or behaviors related to the case study.

Artifacts are physical objects relevant to the case study. Artifacts can include tools, equipment, products, or other objects that provide insights into the case study phenomenon.

How to conduct Case Study Research

Conducting a case study research involves several steps that need to be followed to ensure the quality and rigor of the study. Here are the steps to conduct case study research:

• Define the research questions: The first step in conducting a case study research is to define the research questions. The research questions should be specific, measurable, and relevant to the case study phenomenon under investigation.
• Select the case: The next step is to select the case or cases to be studied. The case should be relevant to the research questions and should provide rich and diverse data that can be used to answer the research questions.
• Collect data: Data can be collected using various methods, such as interviews, observations, documents, surveys, and artifacts. The data collection method should be selected based on the research questions and the nature of the case study phenomenon.
• Analyze the data: The data collected from the case study should be analyzed using various techniques, such as content analysis, thematic analysis, or grounded theory. The analysis should be guided by the research questions and should aim to provide insights and conclusions relevant to the research questions.
• Draw conclusions: The conclusions drawn from the case study should be based on the data analysis and should be relevant to the research questions. The conclusions should be supported by evidence and should be clearly stated.
• Validate the findings: The findings of the case study should be validated by reviewing the data and the analysis with participants or other experts in the field. This helps to ensure the validity and reliability of the findings.
• Write the report: The final step is to write the report of the case study research. The report should provide a clear description of the case study phenomenon, the research questions, the data collection methods, the data analysis, the findings, and the conclusions. The report should be written in a clear and concise manner and should follow the guidelines for academic writing.

Examples of Case Study

Here are some examples of case study research:

• The Hawthorne Studies : Conducted between 1924 and 1932, the Hawthorne Studies were a series of case studies conducted by Elton Mayo and his colleagues to examine the impact of work environment on employee productivity. The studies were conducted at the Hawthorne Works plant of the Western Electric Company in Chicago and included interviews, observations, and experiments.
• The Stanford Prison Experiment: Conducted in 1971, the Stanford Prison Experiment was a case study conducted by Philip Zimbardo to examine the psychological effects of power and authority. The study involved simulating a prison environment and assigning participants to the role of guards or prisoners. The study was controversial due to the ethical issues it raised.
• The Challenger Disaster: The Challenger Disaster was a case study conducted to examine the causes of the Space Shuttle Challenger explosion in 1986. The study included interviews, observations, and analysis of data to identify the technical, organizational, and cultural factors that contributed to the disaster.
• The Enron Scandal: The Enron Scandal was a case study conducted to examine the causes of the Enron Corporation’s bankruptcy in 2001. The study included interviews, analysis of financial data, and review of documents to identify the accounting practices, corporate culture, and ethical issues that led to the company’s downfall.
• The Fukushima Nuclear Disaster : The Fukushima Nuclear Disaster was a case study conducted to examine the causes of the nuclear accident that occurred at the Fukushima Daiichi Nuclear Power Plant in Japan in 2011. The study included interviews, analysis of data, and review of documents to identify the technical, organizational, and cultural factors that contributed to the disaster.

Application of Case Study

Case studies have a wide range of applications across various fields and industries. Here are some examples:

Business and Management

Case studies are widely used in business and management to examine real-life situations and develop problem-solving skills. Case studies can help students and professionals to develop a deep understanding of business concepts, theories, and best practices.

Case studies are used in healthcare to examine patient care, treatment options, and outcomes. Case studies can help healthcare professionals to develop critical thinking skills, diagnose complex medical conditions, and develop effective treatment plans.

Case studies are used in education to examine teaching and learning practices. Case studies can help educators to develop effective teaching strategies, evaluate student progress, and identify areas for improvement.

Social Sciences

Case studies are widely used in social sciences to examine human behavior, social phenomena, and cultural practices. Case studies can help researchers to develop theories, test hypotheses, and gain insights into complex social issues.

Law and Ethics

Case studies are used in law and ethics to examine legal and ethical dilemmas. Case studies can help lawyers, policymakers, and ethical professionals to develop critical thinking skills, analyze complex cases, and make informed decisions.

Purpose of Case Study

The purpose of a case study is to provide a detailed analysis of a specific phenomenon, issue, or problem in its real-life context. A case study is a qualitative research method that involves the in-depth exploration and analysis of a particular case, which can be an individual, group, organization, event, or community.

The primary purpose of a case study is to generate a comprehensive and nuanced understanding of the case, including its history, context, and dynamics. Case studies can help researchers to identify and examine the underlying factors, processes, and mechanisms that contribute to the case and its outcomes. This can help to develop a more accurate and detailed understanding of the case, which can inform future research, practice, or policy.

Case studies can also serve other purposes, including:

• Illustrating a theory or concept: Case studies can be used to illustrate and explain theoretical concepts and frameworks, providing concrete examples of how they can be applied in real-life situations.
• Developing hypotheses: Case studies can help to generate hypotheses about the causal relationships between different factors and outcomes, which can be tested through further research.
• Providing insight into complex issues: Case studies can provide insights into complex and multifaceted issues, which may be difficult to understand through other research methods.
• Informing practice or policy: Case studies can be used to inform practice or policy by identifying best practices, lessons learned, or areas for improvement.

Advantages of Case Study Research

There are several advantages of case study research, including:

• In-depth exploration: Case study research allows for a detailed exploration and analysis of a specific phenomenon, issue, or problem in its real-life context. This can provide a comprehensive understanding of the case and its dynamics, which may not be possible through other research methods.
• Rich data: Case study research can generate rich and detailed data, including qualitative data such as interviews, observations, and documents. This can provide a nuanced understanding of the case and its complexity.
• Holistic perspective: Case study research allows for a holistic perspective of the case, taking into account the various factors, processes, and mechanisms that contribute to the case and its outcomes. This can help to develop a more accurate and comprehensive understanding of the case.
• Theory development: Case study research can help to develop and refine theories and concepts by providing empirical evidence and concrete examples of how they can be applied in real-life situations.
• Practical application: Case study research can inform practice or policy by identifying best practices, lessons learned, or areas for improvement.
• Contextualization: Case study research takes into account the specific context in which the case is situated, which can help to understand how the case is influenced by the social, cultural, and historical factors of its environment.

Limitations of Case Study Research

There are several limitations of case study research, including:

• Limited generalizability : Case studies are typically focused on a single case or a small number of cases, which limits the generalizability of the findings. The unique characteristics of the case may not be applicable to other contexts or populations, which may limit the external validity of the research.
• Biased sampling: Case studies may rely on purposive or convenience sampling, which can introduce bias into the sample selection process. This may limit the representativeness of the sample and the generalizability of the findings.
• Subjectivity: Case studies rely on the interpretation of the researcher, which can introduce subjectivity into the analysis. The researcher’s own biases, assumptions, and perspectives may influence the findings, which may limit the objectivity of the research.
• Limited control: Case studies are typically conducted in naturalistic settings, which limits the control that the researcher has over the environment and the variables being studied. This may limit the ability to establish causal relationships between variables.
• Time-consuming: Case studies can be time-consuming to conduct, as they typically involve a detailed exploration and analysis of a specific case. This may limit the feasibility of conducting multiple case studies or conducting case studies in a timely manner.
• Resource-intensive: Case studies may require significant resources, including time, funding, and expertise. This may limit the ability of researchers to conduct case studies in resource-constrained settings.

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Case Study | Definition, Examples & Methods

Published on 5 May 2022 by Shona McCombes . Revised on 30 January 2023.

A case study is a detailed study of a specific subject, such as a person, group, place, event, organisation, or phenomenon. Case studies are commonly used in social, educational, clinical, and business research.

A case study research design usually involves qualitative methods , but quantitative methods are sometimes also used. Case studies are good for describing , comparing, evaluating, and understanding different aspects of a research problem .

Table of contents

When to do a case study, step 1: select a case, step 2: build a theoretical framework, step 3: collect your data, step 4: describe and analyse the case.

A case study is an appropriate research design when you want to gain concrete, contextual, in-depth knowledge about a specific real-world subject. It allows you to explore the key characteristics, meanings, and implications of the case.

Case studies are often a good choice in a thesis or dissertation . They keep your project focused and manageable when you don’t have the time or resources to do large-scale research.

You might use just one complex case study where you explore a single subject in depth, or conduct multiple case studies to compare and illuminate different aspects of your research problem.

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Once you have developed your problem statement and research questions , you should be ready to choose the specific case that you want to focus on. A good case study should have the potential to:

• Provide new or unexpected insights into the subject
• Challenge or complicate existing assumptions and theories
• Propose practical courses of action to resolve a problem
• Open up new directions for future research

Unlike quantitative or experimental research, a strong case study does not require a random or representative sample. In fact, case studies often deliberately focus on unusual, neglected, or outlying cases which may shed new light on the research problem.

If you find yourself aiming to simultaneously investigate and solve an issue, consider conducting action research . As its name suggests, action research conducts research and takes action at the same time, and is highly iterative and flexible. 

However, you can also choose a more common or representative case to exemplify a particular category, experience, or phenomenon.

While case studies focus more on concrete details than general theories, they should usually have some connection with theory in the field. This way the case study is not just an isolated description, but is integrated into existing knowledge about the topic. It might aim to:

• Exemplify a theory by showing how it explains the case under investigation
• Expand on a theory by uncovering new concepts and ideas that need to be incorporated
• Challenge a theory by exploring an outlier case that doesn’t fit with established assumptions

To ensure that your analysis of the case has a solid academic grounding, you should conduct a literature review of sources related to the topic and develop a theoretical framework . This means identifying key concepts and theories to guide your analysis and interpretation.

There are many different research methods you can use to collect data on your subject. Case studies tend to focus on qualitative data using methods such as interviews, observations, and analysis of primary and secondary sources (e.g., newspaper articles, photographs, official records). Sometimes a case study will also collect quantitative data .

The aim is to gain as thorough an understanding as possible of the case and its context.

In writing up the case study, you need to bring together all the relevant aspects to give as complete a picture as possible of the subject.

How you report your findings depends on the type of research you are doing. Some case studies are structured like a standard scientific paper or thesis, with separate sections or chapters for the methods , results , and discussion .

Others are written in a more narrative style, aiming to explore the case from various angles and analyse its meanings and implications (for example, by using textual analysis or discourse analysis ).

In all cases, though, make sure to give contextual details about the case, connect it back to the literature and theory, and discuss how it fits into wider patterns or debates.

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• Published: 27 June 2011

The case study approach

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

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

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

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Introduction

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

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

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

What is a case study?

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

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

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

What are case studies used for?

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

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

How are case studies conducted?

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

Defining the case

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

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

Selecting the case(s)

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

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

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

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

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

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

Collecting the data

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

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

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

Analysing, interpreting and reporting case studies

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

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

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

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

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

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

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

Conclusions

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

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

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

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Growing OkraOut: A Case Study

Lessons from 5 years of collaborative design, development, and implementation while building an lgbtq+ library outreach program.

Afton Fawn Ussery and Sofiya Petrova Dahman *

In the past five years, Delta State University’s academic library has made significant efforts to develop sustainable outreach programs that support the LGBTQ+ (Lesbian, Gay, Bisexual, Transgender, Queer+) community. This program has increased the library’s visibility and enhanced its image among its students, faculty, and staff. The article describes the outreach program’s effort, and the collected data will provide a framework for others interested in designing and hosting such programs, including adaptability during the COVID-19 pandemic. 

Background Information

Members of the Roberts-LaForge Library at Delta State University have hosted an LGBTQ+ Pride event for the past five years. The event and committee are known as OkraOut, which refers to the university’s student mascot of the Fighting Okra. The student body voted on the mascot in the late 1980s/early 1990s as the school’s unofficial mascot. Inspired by Boyer’s (1996, p. 18) definition of scholarship of engagement, this committee held diverse events to promote library services, while also increasing the quality of engagement activities for the local community and the university population at a small college campus.

Problem Statement

The LIS literature on the information needs of, and specific outreach to, LGBTQ+ students is an emerging focus of Academic Libraries, yet there are still few examples in the scholarly literature of programs like OkraOut. This case study aims to detail the process of developing such outreach to help address that gap. This study also adds to the current body of research, examples, and knowledge concerning collaborations between universities, across campus, and the community in outreach programs.

Introduction

Many libraries provide inclusive acknowledgments in their mission or vision statements. However, equally important is how libraries can do more to celebrate and proudly serve all users. We, as librarians, must go the extra step to celebrate and give visibility to our most “invisible regulars” (Naidoo, 2013, p. 40). This article suggests ways for academic libraries, specifically, to be more proactive and to move beyond simple steps such as mission statement language, or buying more LGBTQ+ books for June Pride displays.

The Seeding Stage

The authors met and began working together at Delta State University in 2016. They witnessed a need in their community and were motivated to create an event celebrating a specific population of patrons. ALA’s (American Library Association) Gay, Lesbian, Bi, and Transgender (GLBT) Round Table Toolkit states that:

It is vital to create a welcoming environment for GLBT library users in their communities, campuses, and schools. Library users of all ethnic and racial backgrounds, nationalities, socio-economic classes, and abilities look for materials that include and celebrate diverse experiences within GLBT communities and promote accessible and inclusive programming. With this statement in mind, the authors recognized that their academic library was not fulfilling the needed accessible and inclusive programming.

This need was even more crucial as the authors’ library is located in the middle of the Mississippi Delta. Delta State University is a small four-year public university with library services that serves around 5,000 students, faculty, staff, and community members. According to the University’s mini factbook of 2020–2021 (Delta State University, 2021), Mississippi and Tennessee are the top two states represented among the students. Two thousand four hundred forty-one students were from Mississippi, and sixty-two were from Tennessee, two hours north of Cleveland, Mississippi.

Currently, there are no explicit, comprehensive statewide non-discrimination protections for gay, lesbian, bisexual, or transgender people in Mississippi. Instead, there are discriminatory anti-LGBTQ+ laws, including the MS HB 1523 and the Religious Liberty Accommodations Act. The legislature allows people and organizations to decline services to queer people based on religious beliefs. In 2021, Mississippi’s governor signed SB 2536, an anti-transgender sports bill, marking the first piece of specifically anti-transgender legislation to become law. These laws restrict and negatively affect the LGBTQ+ community. Unfortunately, the number of harmful laws against the LGBTQ+ communities is rising nationwide; the Human Rights Campaign (HRC) declared 2021 the “worst year for LGBTQ+ state legislative attacks” (Ronan, 2021).

Tennessee is also home to sweeping anti-LGBTQ+ legislation. Such bills include anti-transgender legislation SB126, which restricts access to gender-affirming care by limiting health providers’ ability to prescribe Hormone Replacement Therapy to prepubertal minors. Violations of this bill result in a misdemeanor. Along with the anti-transgender sports bill that the Tennessee Governor signed into law, the HB3 and SB228 bills prohibit transgender students from participating in school sports and require student-athletes to be gendered as assigned at birth, demonstrated by their original birth certificate. Outside the school buildings and inside the state’s communities, there are the HB1182 and SB1224 bills, which require businesses that allow people to use restrooms according to their gender identity to post a warning at the entrance of the building and bathrooms.

The authors were aware of the political atmosphere in their region; in addition, they witnessed an interest on campus for LGBTQ+ displays within the library, so they sought to create an event or outreach opportunity for inclusion. Previously, there was a Gay and Lesbian Alliance Student Organization, but it had declined in interaction over the years. At the inception of OkraOut, there were no current on-campus, or even in-community, support groups or events for LGBTQ+ individuals. Outreach activities allow libraries to serve users by being more visible, and developing more substantial campus and community relationships, and so the authors started planning what would become OkraOut.

Keeran and Forbes (2018, p. 250) note that the four critical elements of a successful outreach program are: 1. strategic vision and planning; 2. program development and implementation; 3. community outreach; and 4. expanding outreach audiences. This article’s authors relied on these elements and worked specifically to expand outreach to include all patrons. Librarians and staff have an ethical and professional duty to provide information to all they serve. For example, the American Library Association’s Library Bill of Rights and Codes of Ethics urges librarians and libraries to offer resources and services to all persons, regardless of their backgrounds or views. The authors assembled a committee to contribute ideas, planning, and developing and implementing action. The duties of the event planning committee also included providing information on sexuality, gender identity, and coming out for library patrons. This outreach was to position the library as a key information source for the queer community.

Literature Review

As mentioned, the information needs of LGBTQ+ students in academic libraries is an emerging focus of LIS literature. Strategies, case studies, and best practices for providing library support and services to specialized student populations are responses to this need. The authors have included similar studies within this literature review for further interest.

Research suggests that LGBTQ+ students may experience higher than-usual stresses and difficulties when transitioning from high school. According to Dentato et al. (2013), identity formation often occurs during high school and further on through the colligate experience. There is a growing understanding that libraries must also be active in supporting that development (Dentato, et. al, 2013, p. 10). Renn and Bilodeau (2005, p. 42) add that the post-secondary curriculum—including the library—is vital in facilitating LGBTQ identity development. They viewed models of identity development through the perspectives of student affairs professionals. Doing so developed helpful literature concerning LGBTQ+ people of color, life span approach to LGBTQ+ identity development, and approaches to transgender identity development.

Mehra and Braquet (2011, pp. 401–422) examined the reference department and how they assisted LGBTQ+ patrons. They created an exploratory practice-based framework that identified strategic goals, objectives, and activities for each of the five areas of modern-day references, such as access to electronic resources, user instruction, library commons, outreach liaison, and virtual reference, with a focus on meeting the needs of LGBTQ individuals during the coming out process. They utilized qualitative studies and action research conducted by two library and information science professionals in an academic library. They sought to extend the idea of a traditional reference interaction—one focused solely on information provision—to a more encompassing conceptualization and implementation that designs, delivers, and accesses reference services in a community engagement context to develop fair and equitable services for LGBTQ patrons. Todorinova and Ortiz-Myers (2019, pp. 66–87) engaged public services librarians working in administrative or managerial positions in a conversation about LGBTQ+ needs. There was uncertainty between the library’s role in promoting LGBTQ+ friendliness and the role of the larger university, which may be related to the uncertain position of the library in the campus environment. However, the empathy that librarians, in both decision and non-decision-making roles, have towards LGBTQ students opens up the possibility of deeper conversations and proactive, innovative support services in the future.

Hawkins et al. (2017, p. 316–327) detail conversations among professionals in health sciences librarianship about the needs of LGBTQ patrons. The authors echo the importance of understanding the terminology, and of developing standard cultural competencies in serving LGBTQ users. An example of this in action is hosting safe space training. Safe space training workshops provide information on LGBTQ+ culture and engage in identifying and avoiding microaggressions in speech or actions.

Another example of the importance of providing resources that support and celebrate underrepresented communities is creating helpful library guides. Kohout-Tailor and Klar (2021, p. 173) recommend creating multiple guides and working with various partners on campus. They wrote, “once you identified areas that may need support, creating or growing a partnership to make sure the resources truly meet a need is next. Communicate with colleagues both within and outside of your library or institution to make connections and start the conversation of how best the library can provide resources that support EDI programs or initiatives.” They offer a starting point on how to begin a form of outreach.

Editor and Student Engagement Librarian at the University of Tennessee in Knoxville, Zoe Bastone (2020, p. 24) explains, “that while there is a wide agreement that outreach is a necessary component in an academic library’s operations, there is a gap in the literature regarding how to create outreach programs that are efficient and effective and can account for unexpected additions to the outreach program.” This article helps fill that gap by discussing the programming of a small academic library. The outreach examined in this article developed through collaborations between universities, across campus, and within the community. However, as mentioned, there is a lack of previous research in academic libraries on building LGBTQ+ outreach events within a case study format. For example, while the authors searched in the database LISTA, “case study” and “outreach programs or outreach services” brought up only 90 hits between 1978 and 2022; 42 included academic libraries, and none included the words “queer or LGBTQ or gay or LGBT or lesbian or homosexual or transgender.” The authors will focus intensely on outreach to develop strong outreach campaigns for underserved groups. This is especially important given the continued growth of minority enrollment in higher education (Puente et. al, 2009, p. 30). The article will reveal the methods of adaptability that the committee used to meet the changing needs of their outreach program over five years and during a world pandemic.

Research Questions

The research questions for this study were as follows:

RQ1. How to start an outreach initiative?

RQ2. How to continue to grow an annual program?

RQ3. How to react during a period of dramatic upheaval and change?

Data Collection

Methodology.

There is published research that quantifies the development, and even influence, of library outreach on student and community involvement with their academic library, as academic libraries commonly host events to attract students and the surrounding community. These events can provide opportunities for interaction, generate informative discussion, and familiarize students with the library’s services. Yin (2017, p. 5) describes qualitative case study methodology as: “Whatever the field of interest, the distinctive need for case studies arises out of the desire to understand complex social phenomena. Case studies allow you to focus in-depth on a case and to retain a holistic and real-world perspective.” This article presents a checklist of the four critical elements of a successful outreach program. The checklist includes strategic vision and planning, program development and implementation, community outreach, and expanding outreach audiences. The objective of this article is to provide academic libraries and their staff with practical application of this checklist by linking all its four elements with the authors’ experiences.

The definition of the case study evolved through the work of the library committee, which works tirelessly to conduct an event each year. Collaboration between the authors began during the Summer of 2017. Shortly after, the authors met to work together and—over an extended period—shared similar thoughts and feelings in order to understand and analyze the university’s overall climate, where LGBTQ+ issues remained largely unaddressed. This unified desire for outreach grew into a huge show of celebration of LGBTQ+ people that also provided exploratory data-collecting possibilities. The resulting committee included university staff, faculty, and students. The committee later incorporated more help from community volunteers as well. Officially, the committee was first called to order by two library staff members and three university faculty members. The group’s strategic vision was to grow campus LGBTQ+ support and engagement and then have the student organizations take the eventual reigns. This committee never saw themselves as the sole owners of OkraOut, but as developers and supporters of the campus need. They built the programs and structure. The committee began meeting at the beginning of each Fall semester. For the first couple of years, weekly meetings were held in the library up until the event occurred in October. After the event, a meeting would be held to review and start plans for next year. As the COVID-19 pandemic began, the resulting committee meetings were held through email and occasional Zoom meetings.

Delta State University’s campus is a small area with close collaborations. Because of that, library administration, as well as other departmental administrations, were updated frequently on the developments; this event planning committee would not have been able to accomplish its visions without their support. Committee members were also provided time for the meetings and events. The committee itself had to be built up before building OkraOut. At first, the committee members were similar-minded individuals that were supportive of each other and known to each other through different outreach programs. Then, after the event began to be known throughout campus as an annual event, more volunteers and students reached out. The effort led to the development of a significant LGBTQ and ally network that facilitate future programming and support. This article represents the actualized and envisioned library services for the progressive support of LGBTQ individuals, as described in the following section.

RQ1. How to Start an Outreach Initiative?

Germination Stage

Strategic vision and planning are the first critical elements of a successful outreach program. The beginning of the growing stage of okra is called the germination stage, in which the seeds will produce some roots and leaves. Following this metaphor, the OkraOut program first sprouted in October 2017. That year, Chase Ollis published an article through the Association of College and Research Libraries (2017) calling for libraries to “Standing Up for Our Communities.” He wrote:

Faced with a dramatic policy shift that contradicts the core values of libraries, an awakening of hate groups empowered by the shift, and the perpetual suspense that accompanies uncertain times, librarians are rising to the challenge of maintaining safe spaces in America’s libraries by advocating for intellectual freedom and declaring that libraries are for everyone.

Ollis illustrated the charge for engagement in communities. While providing access to LGBTQ+ resources is essential, providing a diverse, inclusive space and educational opportunities is crucial.

In October 2017, the university held the first LGBTQ+ History Month Celebration with an inaugural event called initially OkraOut Front. The event’s purpose was to bring together the university students, faculty, staff, and local community members who support and advocate for an inclusive and diverse society. More importantly, the event ensured that queer people on campus and in the local community were being represented and recognized with access to diverse collections and services—a priority for the library. The idea for the OkraOut Front library outreach event first appeared in June 2017 after one of the authors posted a picture promoting the academic library’s pride book display. The image received a lot of interest on social media, and the authors began further engaging with students who had revealed that they were queer. The positive engagement revealed a need as little was held to support queer people on campus and locally.

The first step in growing OkraOut was to find collaborators. Both authors held staff positions at the library at the time but were supported by the library’s administration to pursue various campus and community engagements. Identifying nonprofit organizations and LGBTQ+ allies was time-consuming, but not impossible. A partnership with the academic library on the university’s campus and statewide organizations was essential to the development of the event. Locally, there were a few campus and community organizations, including the University’s Quality Enhancement Plan, Diversity, Equity, and Inclusion Committee, the Gender and Sexuality Alliance student organization, and the Mississippi Department of Health with its HIV/AIDS chapter. Most organizations supporting diversity were based in Jackson, a two-hour drive from campus. These groups included the Human Rights Campaign of Mississippi and Free Mom Hugs of Mississippi. The authors also sought assistance from other university organizations. For example, in the program’s first two years, the committee collaborated with the Sarah Isom Center for Women and Gender Studies, as well as the Center for Inclusion and Cross-Cultural Engagement at the University of Mississippi. This partnership helped extend awareness and provided additional educational and planning tips for the OkraOut committee. The University of Mississippi’s organizations had more funding and experience in offering diverse programs. Such support watered OkraOut’s roots. The authors conducted research and held conversations. A small committee began to grow, and their first act was to plan the first pride event for the university.

On October fifth, 2017, the OkraOut outreach celebration was held a week before National Coming Out Day. National Coming Out Day is an annual LGBT+ awareness day observed on October eleventh to support lesbian, gay, bisexual, and transgender people in “coming out of the closet.” The event was advertised in the first-year seminar courses, campus publicity, via social media platforms (Facebook), among staff and faculty members, and printed materials were distributed around campus and placed on community boards. The side of the library’s lawn stood as a stage where student bands, poets, and ensembles performed music written or composed by queer individuals throughout history. The Delta State University’s marching band opened the event by playing “Over the Rainbow.” The authors prepared an LGBTQ+ movement history timeline to provide more information, resources, and facts.

The program included 114 RSVPs and was free, open to the public, and family-friendly. The event educated the audience about the use of pronouns, acknowledged Mississippi organizations that support LGBTQ+ people, illustrated how to find help or answers, and identified persons that would provide support and assistance on campus and in the state. This first event was seen as a success. With that in mind, the committee and the library administration decided that the program should continue to grow and become an annual library outreach event. The first crucial step of starting an outreach initiative was deemed a success by the feedback from participants. For example, a community member wrote on Facebook:

God sent you here for a reason, and keep doing great things so that all people can feel love and acceptance!!! You are amazing and I can say that even though we have never met!!! I feel compelled to share my story of my family and the struggles we have faced Much Love to you and yours (Anonymous, community user, 2017).

Further, a student commented, “Thank you so much for sharing! This is amazing” (Anonymous, DSU student, 2017), and a faculty member added, “Great job tonight! Thank you for your efforts! My class enjoyed!” (Anonymous, DSU Faculty, 2017).

The second step of a successful outreach program is the development and implementation stage. Once ideas are promising, it is important to continue to repeat and build upon them. In 2018 sprouting occurred again, and the OkraOut committee met to repeat the successful library outreach event. Many of the setup props as the previous year were used again. To continue the music essence, “Vogue” was settled as the theme of the 2018 LGBTQ+ History celebration.

The guest speaker in 2018 was someone whom one of the authors befriended the previous year when researching OkraOut, Dr. Jaime Harker. She spoke at the event and again the next day at Delta State University’s art gallery about her book, The Lesbian South . Before the event, the committee advertised a Google form that allowed patrons to share their personal coming out stories, including the option of remaining anonymous or releasing their name. The stories were then printed out and shared at the outreach event. Later, the university’s archives and museum archived the responses with permission.

At the end of the 2018 event, a local dance teacher was invited to teach classic vogue dance moves, and then the crowd could take part in voguing down the stage. The university’s then president and vice president of student affairs led the voguing. Students, faculty, and families took part in the large dance party. The dancing crowd was large, growing from around 100 to 200 participants from the previous year. Officially on the OkraOut Facebook website, 129 people RSVPed. A student later commented on the site, “love that they included an ally flag” (Anonymous, DSU student, 2018). A faculty member wrote, “Love this!” (Anonymous, DSU faculty, 2018). After the event was officially over, an open mic night for poetry was held down the street at a local coffee shop.

RQ2. How to Continue to Grow an Annual Program?

Young Seedling Stage

OkraOut saw a change in its direction and size as it further bloomed in 2019. The third step of a successful outreach program is the inclusion of community outreach; thus, in 2019 the OkraOut committee sought entertainers from outside the university. In a bit of foreshadowing, Liam Stack had written, earlier that year, a piece in the New York Times titled, “Drag Queen Story Hour Continues Its Reign at Libraries, Despite Backlash” (2019). He wrote on the rise of Drag Queen Story hours throughout the country, even in areas with discriminatory laws. Stack (2019) noted that:

Drag performers regularly entertain children at libraries and community centers in progressive enclaves like New York and Los Angeles as well as red-state towns like Juneau, Alaska, and Lincoln, Neb….Melissa Bean, who started the Middle Tennessee chapter of Drag Queen Story Hour, agreed. Unfortunately, backlash often takes place as well. For example, two libraries in central Ohio canceled drag events after receiving what the library council said were “hostile threats.” Stack poignantly added in the interview a quote from Ms. Bean, the statistics of the L.G.B.T. community and how many people might be in it don’t change because of your ZIP code and your population density, said Ms. Bean, who lives near Sparta, population 5,029, There are L.G.B.T. people here who need us.

At OkraOut’s first committee meeting of the year, members agreed that 2019’s outreach event should be more extensive, including multiple activities and outreach formats, as the previous two years had been so successful. Inspiration for a theme came from the New York Public Library, which held a program called Love & Resistance: Stonewall 50, referring to the Stonewall Uprising—a series of protests by members of the gay community in response to a police raid at the Stonewall Inn in New York City—in 1969. Those protests have become a symbol of resistance to social and political discrimination.

With that in mind, the theme emerged as OkraOut Resistance and History: An event to celebrate the 50th Anniversary of the Stonewall Uprising, a milestone in the LGBTQ+ History movement. To celebrate in a larger fashion, the committee enthusiastically chose to host the first-ever drag show on campus. The committee utilized social media, including dressing up in unicorn costumes, printing flyers, creating videos, and advertising on the university’s marquee. This event was free and family-friendly. The music, costumes, and performances fit a family-friendly event. A rainbow cake and cupcakes were shared, and various campus and equality organizations, such as the Human Rights Campaign, MomHugs.org, and My Brother’s Keeper, hosted tables with provided information on resources.

Because of backlash to the wording of being family-friendly and some negative messages on social media in response to a drag show, the location was moved from the library’s lawn to a theater on campus for easier security. Those security concerns were brought to the attention of the campus police. Although they were found unwarranted, the event has moved indoors to monitor entrances better. This proved helpful as, according to the RSVPs on the group’s webpage, the committee was expecting at least 133 people. However, the event had its largest turnout, and the performance theater—which has 350 seats—was standing room only.

The OkraOut committee experienced support from faculty, staff, students, and community members. Before the event, community members posted support on social media by writing, “Y’all come out and support Okra Out! this Thursday. Bring your kids. Show them that the diversity of humans is beautiful. And if you disagree with that, keep your hatefulness to yourself” (Anonymous, Community member A, 2019). After the show, many community members reached out with stories such as the following:

I couldn’t believe people I know and thought I liked were saying horrible things. I lost so much respect for many people bc of all of that I’m proud dsu is doing this and proud people like you guys are here to help They talk about bullies in schools where they are the bullies of this town in my opinion. It’s so sad If there is ever a time for others to learn I’ll be happy to share how my own family learned to accept my trans brother And there is way way more to the story (Anonymous, Community member B, 2019).In response to the first drag show on campus, attendees posted, “This was our 3rd year to go to Okra Out as a family. It was such an amazing event, as usual, and our family and friends had a ball!” (Anonymous, drag show attendee A, 2019) and, “We had so much fun at the 3rd Okra Out! The kids absolutely loved the first-ever drag show at DSU” (Anonymous, drag show attendee B, 2019).

Before the drag show, a faculty member held an OkraOut Pride yoga session outside the theater. Also, an exhibit of the national campaign from Zeiss Lenses Americas shared different interpretations of love in the theater’s lobby. With the permission of the local photographer, Rory Doyle, his photographs of local members of the LGBTQIA+ community—including Delta State University professors and students—were also displayed (with the subjects’ permission).

The OkraOut committee 2019 produced a series of zines for the first time in 2019. Three zines were created and published with information submitted by students, faculty, staff, and community members. The authors and artists included personal stories, poetry, artwork, and words of encouragement. They were promoted by the Language and Literature department. Once printed, student volunteers distributed the zines and left them throughout the student union and other sitting locations throughout campus. Two years before, Kate Kitchens, an academic reference and instruction librarian, presented the idea of zines at the Iowa Library Association conference in a presentation called “Moving Beyond Queer Acceptance: Creating a New Community Culture” (2017). This presentation focused on their guide, “Librarian Field Notes,” for librarians who wanted to provide services to support their queer patrons but did not know where to start. Using zines was an avenue that offered a way to understand queer communities and their unique needs better. During the first year zines were printed in a faculty member’s office, so they were in black and white. Student volunteers used crayons to color in part of the title page. Later, when more funds were available, the committee could print the zines in color. The OkraOut zines became an essential and creative asset to the outreach events and continue today.

RQ3. How to React during a Period of Dramatic Upheaval and Change?

Flowering During Frosting Stage

The fourth element in a successful outreach initiative is to continue to expand the outreach audience. This aspect was even more necessary in the fourth year of OkraOut. Sometimes growth is difficult and must be pushed through, and the year 2020 certainly taught everyone a lesson in resilience. Association of College & Research Libraries’ (ACRL) Standards for Distance Learning Library Services state,

All students, faculty members, administrators, staff members, or any other members of an institution of higher education are entitled to the library services and resources of that institution, including direct communication with the appropriate library personnel, regardless of where they are physically located in relation to the campus; where they attend class with regard to the institution’s main campus; or the modality by which they take courses. Academic libraries must, therefore, meet the information and research needs of all these constituents, wherever they may be. In 2020, every student became a distance learning student due to the pandemic of COVID-19, and the OkraOut committee had to decide how to provide services and outreach safely. Because OkraOut has evolved over the past few years into a multifaceted and flexible program, it could adapt during the COVID-19 pandemic.

Greenblatt (2001) argues that the LGBTQ community has been transformed with the help of the Internet and social media. Those outlets contribute many opportunities for academic libraries to bring value to LGBTQ students in terms of information services, programming, collections, and much more. Many projects were fast-tracked to meet this unique need, including creating a webpage to host our events and present our mission statement and other information. The Systems librarian built an OkraOut online archive ( https://www.deltastate.edu/library/okra-out/ ) to collect and make accessible photographs, personal stories, and additional information about the events of 2020 and previous years. To further spread the program’s outreach and protect the collected stories, the committee contacted the Invisible Histories Project and sent OkraOut information to the Library of Congress for their LGBTQ+ archives.

By October 2020, the committee felt comfortable hosting one in-person event within federal guidelines. A Pride walk on the campus quad, a grassy area at the Delta State University entrance, was held. The event occurred outside, and there was enough room for social distancing while wearing masks. Pride packs were presented to the first 100 attendees. They contained stickers, flags with a tutorial on making them a face mask, zines, and LGBTQ+ fast facts. At the start of the walk, representation flags were displayed, and volunteers were encouraged to write stories and create artwork for future zines.

OkraOut grew in 2020 to be more than just the celebration on or around National Coming Out Day. It was a whole month of celebration, and outreach and virtual events were held throughout October. Through the new webpage, the library shared a drag queen story time of a fabulous reading of Mariah Carey’s “All I Want for Christmas.” The webpage also provided a link to the screening of the independent film Gay Chorus Deep South and a zoom pride yoga session. The site recorded 93 views that month.

Because of the program’s growth, the committee also wanted to help the LGBTQ+ student organization on campus and looked for ways to increase visibility. In 2020, committee members applied for a grant with the L.G.B.T.Q. Fund of Mississippi to do just that. OkraOut was awarded a grant of $3,500, which was used for safe space training on campus for faculty, staff, and students and to help establish the student organization.

The committee sought to find a medium to meet the needs of the students on and off campus, and to continue the trend of increasing the number of events each year. To meet this challenge, they ensured an equal number of virtual events and in-person events in case of cancellations because of COVID-19 case spikes. OkraOut hoped for more in-person events in 2021, but the reality of the COVID-19 pandemic continued to prove challenging. Nonetheless, 2021’s theme was chosen as LOVE IS LOVE, and throughout October, a LOVE is LOVE Wall was present on the first floor of the Student Union. This poignant but straightforward theme reflected the past two years of trauma felt by the unceasing pandemic.

With the support of the Office of Student Life, Delta State University’s Diversity, Equity, and Inclusion committee, and the academic library, OkraOut held an adult drag show and fundraiser for the student pride organization at a local restaurant. Then a Rainbow Run on the campus’s quad and a family-friendly drag show were held on campus. After Delta State University’s second drag show, the audience was welcomed to visit tables with representatives and information about supporting health organizations. One of the article’s authors also created the university’s first Diversity, Equity, and Inclusion library guide in honor of OkraOut. This library guide quickly became the most viewed LibGuide for the Roberts-LaForge Library. As of September 2022, the DEI library guide has been viewed 1,144 times. The following closest number of views is the Dual Credit LibGuide, with 539 views.

Academic presentations were also held, one in-person and one virtually. In a first collaboration with the University of Memphis, author Dr. Phillip Gordon was invited to both campuses to discuss his book, Gay Faulkner , and present a lecture on acknowledging the Queer South. While Delta State University did have a moderately well-attended in-person event, the University of Memphis used live stream technology and witnessed a more significant online presence than the in-person event. OkraOut’s virtual event included a presentation on “Teaching, Learning, and Living the Queer South” by Dr. David Baylis, a former faculty member. The online components were viewed 389 times.

With the grant funds described above, the Diversity, Equity, and Inclusion Committee Chair organized virtual Safe Space training workshops throughout October. It worked with OkraOut committee members to help reorganize the Pride student organization at the university. The Pride student organization now includes 40 members, representing 1.64 percent of the student body.

The committee did recognize the difficulty of having lower on-campus numbers than in previous years. Nonetheless, during Homecoming—the last week of October—OkraOut had a float in the university’s parade for the first time; the float increased visibility on campus and in the community. Responses to that year’s OkraOut effort on social media included a comment from a community member that, “A colorful time was had by all,” and a student posted, “Thank you for making this world a better and a little bit safer place!”

Plans for the Future of the Program, Okra Pod Bearing Stage

Feedback on OkraOut’s outreach events was essential to gather because a few weeks after each event, we held a post-event committee meeting to determine improvements for the next year, and to celebrate our efforts to advocate for diversity and inclusion. Even with the trials of the last few years, the OkraOut committee has retained its excitement and vigor. The committee has only grown and continued to bring in individuals from all university areas. They all look forward to the future of the outreach programs. Most importantly, they plan to continue and strengthen collaborations with other higher education and nonprofit institutions. Building those connections and networking will boost the outreach possibilities. Of course, there is also a need to better utilize technology for virtual attendance in this new era.

Larger ideas include creating a statement about the commitment to diversity and inclusion, publishing that statement on our library site, and possibly planning monthly events instead of only holding in one month to encourage further engagement. More previously discussed, centralized events include having a gay mass in partnership with the local Episcopal Church, and creating a queer and trans-community closet with the university’s Career Services. Currently, the committee is also looking at grants to use within the greater community. Again, these events rely on teamwork and the relationships built from them. The OkraOut program is sprouting new growths every year. The committee, which began with one event in 2017 has, five years later, hosted nine events throughout the month of October.

In repeating a statement from the methodology, this unified hope for outreach grew into a vast celebration of LGBTQ+ people, and provided exploratory data-collecting possibilities.

Through starting an outreach program, the authors realized that initiative and collaboration take time to implement successfully. However, the first step for librarians and staff is to recognize the power of library promotion and embrace the issues of their community. Services, resources, and materials are only small parts of what makes an academic library valuable to its campus community. The librarians and staff also have a one-on-one impact on the students and community. Over the past five years, OkraOut’s committee has grown from five members to sixteen members, and has been chaired by a library staff member in four out of five years. This growth exhibits the volunteer spirit of the committee members.

Also, during that time, the committee witnessed the attendance of events swell from 100 people to over 350 people attending, with an understandable dip to 93 in 2020. (As seen in Figure 1.)

The main takeaway from that growth is that a library’s marketing, outreach, and promotion should illustrate that the library cares and that it, with its partnerships, takes service seriously. This also exhibits the support and the resulting need for the outreach initiative. As illustrated, libraries, especially academic libraries, can and should play an integral role in helping LGBTQ+ students, faculty, and staff feels seen. Support should spread further than just an LGBTQ+ collection in the library. The Library Bill of Rights puts it best: “To that end, libraries and library workers should embrace equity, diversity, and inclusion in everything that they do.” With the spread of outreach and the audience growth, Robert-LaForge Library’s staff members have taken an active role in educating the community by instructing Safe Space sessions and utilizing grant funding. Safe Space training sessions have become a valid workshop on campus. Faculty, staff, and students are welcome to attend these semesterly sessions to learn more about pronouns and stereotypes to reduce the often unwelcoming, and biased, environment that LGBTQ+ people navigate daily. Ally connections are strengthened, and students will be aware that places of shelter are needed. A comment shared by a student after the fifth OkraOut expressed that it was truly appreciated.

This article concludes with the hope that the audience continues to give visibility, celebrate, educate, support marginalized communities, and identify ways to get engaged and advocate for queer people on campus and in their communities. The efforts can be small or large, but the action should remain. OkraOut was planned to be educational, festive, and entertaining while also bringing to the table essential questions about diversity and inclusion, thus showing support, and giving visibility to the queer people and allies on campus, and in the community. By spreading the idea that the library was an institution that guards and supports everyone’s right to access knowledge and culture and advocates for all patrons, OkraOut positioned the library as a safe space. This article exhibits small and large efforts, but the essential fact remains that the ideas were planted, watered with support, and that the outreach began to grow.

Further Impact and Studies

Despite some improving social circumstances for some LGBTQ+ people, much progress still needs to be made. This article, in particular, can be helpful to libraries, librarians, and universities in recognizing the required progress. Librarians may realize that they need more training on LGBTQ+ terminology, culture, and information resources. Library administrators may find this paper useful in identifying connections between librarian outreach goals and the larger vision of library services.

Beyond the library, university and student affairs administrators may find this paper interesting as it emphasizes the role of collaboration. It also provides a valuable example of how the library can partner in broader university outreach initiatives and that wide-reaching impact can be felt with any outreach efforts. Ultimately, research will be needed to illustrate in more detail how well librarians address LGBTQ+ needs within their universities and communities and the role of academic libraries in those outreach initiatives.

Acknowledgments

We wish to acknowledge and thank those who helped grow OkraOut. This was a collaborative effort within the library, the institution, the community, and the state. The following is just a snapshot of organizations and people who made this outreach event possible:

Okra Out Planning Committee | DSU Library Services Administration | DSU Department of Music | DSU Department of Languages and Literature | DSU Diversity, Equity, and Inclusion Committee | DSU Pride Alliance | DSU Office of Student Affairs | Delta Music Institute | Campaign for Southern Equality | DSU Department of Art | DSU Division of Social Sciences and History | DSU Canterbury Ministry | DSU Office of Student Life | DSU Police Department | Human Rights Campaign of MS |  Free Mom Hugs of MS | Sarah Isom Center for Women and Gender Studies | Center for Inclusion and Cross-Cultural Engagement at the University of Mississippi |

Dr. David Baylis | Dr. Jaime Harker | Danza Locke Reifers | Kayla Selby | Michelle E. Johansen | Brandy N. Collins | Jonathan Szot | Dr. Karen Fosheim | Robin Webb | Brittany K. Mann | Haley B. Scroggins | Holly E. Senter | Elizabeth C. Swindle | Charles T. Salazar | Rochelle Owsley | Maia Elgin-Wegmann | Maya M. McGinnis | Dr. William J. Ash-Houchen | Dr. Kelsey Evans-Amalu | Dr. Melanie R. Anderson | Sykina Butts | Mr. Bill LaForge and Mrs. Nancy LaForge | Jeff Slagell | Dr. Vernell Bennett-Fairs | Dr. Jamie Dahman | Denisha Cook | Dr. Jacqueline Goldman | Kara Goldman | Lynne Lambdin | Celeste ArgiFlex | Tiko Jones | Gunter McCourt | Aubrey Ombre | Zoey Adams | Iris Lefluer | 

ACLU. (2021). Legislation Affecting LGBTQ Rights Across the Country 2021 . American Civil Liberties Union. Accessed in February 2022. https://www.aclu.org/legislation-affecting-lgbtq-rights-across-country-2021

American Library Association. (2006). Library Bill of Rights. Accessed November 2021. https://www.ala.org/advocacy/intfreedom/librarybill

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Anonymous, Drag show attendee B. (2019, October). “We had so much fun…” Facebook comment.

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Boyer, E. L. (1996). The Scholarship of Engagement. Bulletin of the American Academy of Arts and Sciences , 49(7), 18–33.

Bastone, Z. (2020). Creating an Outreach Plan that Accounts for the Seen and Unseen. Journal of Library Outreach & Engagement , 1 (1), 24–39.  

Campaign for Southern Equality. (2021). Five Anti-LGBTQ Bills Passed in Tennessee You Should Know About . Accessed November 2021. https://southernequality.org/five-anti-lgbtq-bills-passed-in-tennessee-you-should-know-about/

Dentato, M.P., Craig, S.L., Messinger, L., Lloyd, M., and McInroy, L.B. (2013). Outness among LGBTQ Social Work Students in North America: The Contribution of Environmental Supports and Perceptions of Comfort. Social Justice , 10.

Delta State University. (2021). Mini Factbook 2020–2021 . Accessed November 2021. https://www.deltastate.edu/PDFFiles/irp/factbooks/2020-21-Mini-Factbook.pdf

Greenblatt, E. (2005). Exploring LGBTQ Online Resources.  Journal of Library Administration,  43(3–4), 85–101.

Hawkins, B.W., Morris, M., Nguyen, T., Siegel, J., and Vardell, E. (2017). Advancing the Conversation: Next Steps for Lesbian, Gay, Bisexual, Trans, and Queer (LGBTQ) Health Sciences Librarianship. Journal of the Medical Library Association, 10 5 (4), 316–27.

Keeran, P., and Forbes, C. (2018). Successful Campus Outreach for Academic Libraries: Building Community through Collaboration . New York City: Rowman & Littlefield Publishers.

Kitchens, K. (2017). Librarian Field Notes . Accessed November 2021. https://www.ala.org/advocacy/intersections-queer-library-outreach-zine

Kohout-Tailor, J., and Klar, L. (2021). COVID-19, Collections, and Collaboration: Promoting Inclusivity from the Ground Up. C&RL News, 82(4), 171–174

Koontz, C., and Mon, L. (2014). Marketing and Social Media: A Guide for Libraries, Archives, and Museums. New York: Rowman& Littlefield. 

Kraemer, E., Keyse, D., and Lombardo, S. (2003). Beyond these walls: Building a library outreach program at Oakland University. The Reference Librarian, 39(82), 5–17.

Mehra, B., and Braquet, D. (2011). Progressive LGBTQ reference: Coming out in the 21st century. Reference Services Review, 39, 401–422.

Monnier, R. (2021). Pivoting Partnership Programming During a Pandemic: Centennial Celebrations in 2020. Public Services Quarterly, 17(1), 53–58.

Naidoo, J. (2013). Over the Rainbow and under the Radar: Library Services and Programs to LGBTQ Families. Children and Libraries, 11(3), 34–40.

Ollis, C. (2017). Standing Up for Our Communities: Best practices and resources for public libraries serving LGBTQ youth. American Libraries. Accessed November 2021. https://americanlibrariesmagazine.org/2017/06/21/standing-up-lgbtq-youth-communities/

Puente, M.A., Gray, L., and Agnew, S. (2009). The expanding library wall: Outreach to the University of Tennessee’s multicultural/international student population. Reference Services Review, 37(1), 30–43.

Renn, K., and Bilodeau, B. (2005). Leadership Identity Development Among Lesbian, Gay, Bisexual, and Transgender Student Leaders. Journal of Student Affairs Research and Practice , 42(3).

Ronan, W. (2021). 2021 Slated to Become Worst Year for LGBTQ State Legislative Attacks as Unprecedented Number of States Poised to Enact Record-Shattering Number of Anti-LGBTQ Measures I nto Law . Human Rights Campaign. Accessed November 2021. https://www.hrc.org/press-releases/2021-slated-to-become-worst-year-for-lgbtq-state legislative-attacks

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* Afton Fawn Ussery is Instructional and Access Services Librarian at Delta State University, email: [email protected] ; Sofiya Petrova Dahman is Resource Delivery/ILL Librarian at University of Memphis, email: [email protected] . ©2024 Afton Fawn Ussery and Sofiya Petrova Dahman, Attribution-NonCommercial ( https://creativecommons.org/licenses/by-nc/4.0/ ) CC BY-NC.

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The case study approach

Sarah crowe.

1 Division of Primary Care, The University of Nottingham, Nottingham, UK

Kathrin Cresswell

2 Centre for Population Health Sciences, The University of Edinburgh, Edinburgh, UK

Ann Robertson

3 School of Health in Social Science, The University of Edinburgh, Edinburgh, UK

Anthony Avery

Aziz sheikh.

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

Introduction

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

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

This paper is structured around the following main questions: What is a case study? What are case studies used for? How are case studies conducted? What are the potential pitfalls and how can these be avoided? We draw in particular on four of our own recently published examples of case studies (see Tables ​ Tables1, 1 , ​ ,2, 2 , ​ ,3 3 and ​ and4) 4 ) and those of others to illustrate our discussion[ 3 - 7 ].

Example of a case study investigating the reasons for differences in recruitment rates of minority ethnic people in asthma research[ 3 ]

Example of a case study investigating the process of planning and implementing a service in Primary Care Organisations[ 4 ]

Example of a case study investigating the introduction of the electronic health records[ 5 ]

Example of a case study investigating the formal and informal ways students learn about patient safety[ 6 ]

What is a case study?

A case study is a research approach that is used to generate an in-depth, multi-faceted understanding of a complex issue in its real-life context. It is an established research design that is used extensively in a wide variety of disciplines, particularly in the social sciences. A case study can be defined in a variety of ways (Table ​ (Table5), 5 ), the central tenet being the need to explore an event or phenomenon in depth and in its natural context. It is for this reason sometimes referred to as a "naturalistic" design; this is in contrast to an "experimental" design (such as a randomised controlled trial) in which the investigator seeks to exert control over and manipulate the variable(s) of interest.

Definitions of a case study

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

These are however not necessarily mutually exclusive categories. In the first of our examples (Table ​ (Table1), 1 ), we undertook an intrinsic case study to investigate the issue of recruitment of minority ethnic people into the specific context of asthma research studies, but it developed into a instrumental case study through seeking to understand the issue of recruitment of these marginalised populations more generally, generating a number of the findings that are potentially transferable to other disease contexts[ 3 ]. In contrast, the other three examples (see Tables ​ Tables2, 2 , ​ ,3 3 and ​ and4) 4 ) employed collective case study designs to study the introduction of workforce reconfiguration in primary care, the implementation of electronic health records into hospitals, and to understand the ways in which healthcare students learn about patient safety considerations[ 4 - 6 ]. Although our study focusing on the introduction of General Practitioners with Specialist Interests (Table ​ (Table2) 2 ) was explicitly collective in design (four contrasting primary care organisations were studied), is was also instrumental in that this particular professional group was studied as an exemplar of the more general phenomenon of workforce redesign[ 4 ].

What are case studies used for?

According to Yin, case studies can be used to explain, describe or explore events or phenomena in the everyday contexts in which they occur[ 1 ]. These can, for example, help to understand and explain causal links and pathways resulting from a new policy initiative or service development (see Tables ​ Tables2 2 and ​ and3, 3 , for example)[ 1 ]. In contrast to experimental designs, which seek to test a specific hypothesis through deliberately manipulating the environment (like, for example, in a randomised controlled trial giving a new drug to randomly selected individuals and then comparing outcomes with controls),[ 9 ] the case study approach lends itself well to capturing information on more explanatory ' how ', 'what' and ' why ' questions, such as ' how is the intervention being implemented and received on the ground?'. The case study approach can offer additional insights into what gaps exist in its delivery or why one implementation strategy might be chosen over another. This in turn can help develop or refine theory, as shown in our study of the teaching of patient safety in undergraduate curricula (Table ​ (Table4 4 )[ 6 , 10 ]. Key questions to consider when selecting the most appropriate study design are whether it is desirable or indeed possible to undertake a formal experimental investigation in which individuals and/or organisations are allocated to an intervention or control arm? Or whether the wish is to obtain a more naturalistic understanding of an issue? The former is ideally studied using a controlled experimental design, whereas the latter is more appropriately studied using a case study design.

Case studies may be approached in different ways depending on the epistemological standpoint of the researcher, that is, whether they take a critical (questioning one's own and others' assumptions), interpretivist (trying to understand individual and shared social meanings) or positivist approach (orientating towards the criteria of natural sciences, such as focusing on generalisability considerations) (Table ​ (Table6). 6 ). Whilst such a schema can be conceptually helpful, it may be appropriate to draw on more than one approach in any case study, particularly in the context of conducting health services research. Doolin has, for example, noted that in the context of undertaking interpretative case studies, researchers can usefully draw on a critical, reflective perspective which seeks to take into account the wider social and political environment that has shaped the case[ 11 ].

Example of epistemological approaches that may be used in case study research

How are case studies conducted?

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

Defining the case

Carefully formulated research question(s), informed by the existing literature and a prior appreciation of the theoretical issues and setting(s), are all important in appropriately and succinctly defining the case[ 8 , 12 ]. Crucially, each case should have a pre-defined boundary which clarifies the nature and time period covered by the case study (i.e. its scope, beginning and end), the relevant social group, organisation or geographical area of interest to the investigator, the types of evidence to be collected, and the priorities for data collection and analysis (see Table ​ Table7 7 )[ 1 ]. A theory driven approach to defining the case may help generate knowledge that is potentially transferable to a range of clinical contexts and behaviours; using theory is also likely to result in a more informed appreciation of, for example, how and why interventions have succeeded or failed[ 13 ].

Example of a checklist for rating a case study proposal[ 8 ]

For example, in our evaluation of the introduction of electronic health records in English hospitals (Table ​ (Table3), 3 ), we defined our cases as the NHS Trusts that were receiving the new technology[ 5 ]. Our focus was on how the technology was being implemented. However, if the primary research interest had been on the social and organisational dimensions of implementation, we might have defined our case differently as a grouping of healthcare professionals (e.g. doctors and/or nurses). The precise beginning and end of the case may however prove difficult to define. Pursuing this same example, when does the process of implementation and adoption of an electronic health record system really begin or end? Such judgements will inevitably be influenced by a range of factors, including the research question, theory of interest, the scope and richness of the gathered data and the resources available to the research team.

Selecting the case(s)

The decision on how to select the case(s) to study is a very important one that merits some reflection. In an intrinsic case study, the case is selected on its own merits[ 8 ]. The case is selected not because it is representative of other cases, but because of its uniqueness, which is of genuine interest to the researchers. This was, for example, the case in our study of the recruitment of minority ethnic participants into asthma research (Table ​ (Table1) 1 ) as our earlier work had demonstrated the marginalisation of minority ethnic people with asthma, despite evidence of disproportionate asthma morbidity[ 14 , 15 ]. In another example of an intrinsic case study, Hellstrom et al.[ 16 ] studied an elderly married couple living with dementia to explore how dementia had impacted on their understanding of home, their everyday life and their relationships.

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

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

The selected case study site(s) should allow the research team access to the group of individuals, the organisation, the processes or whatever else constitutes the chosen unit of analysis for the study. Access is therefore a central consideration; the researcher needs to come to know the case study site(s) well and to work cooperatively with them. Selected cases need to be not only interesting but also hospitable to the inquiry [ 8 ] if they are to be informative and answer the research question(s). Case study sites may also be pre-selected for the researcher, with decisions being influenced by key stakeholders. For example, our selection of case study sites in the evaluation of the implementation and adoption of electronic health record systems (see Table ​ Table3) 3 ) was heavily influenced by NHS Connecting for Health, the government agency that was responsible for overseeing the National Programme for Information Technology (NPfIT)[ 5 ]. This prominent stakeholder had already selected the NHS sites (through a competitive bidding process) to be early adopters of the electronic health record systems and had negotiated contracts that detailed the deployment timelines.

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

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

Collecting the data

In order to develop a thorough understanding of the case, the case study approach usually involves the collection of multiple sources of evidence, using a range of quantitative (e.g. questionnaires, audits and analysis of routinely collected healthcare data) and more commonly qualitative techniques (e.g. interviews, focus groups and observations). The use of multiple sources of data (data triangulation) has been advocated as a way of increasing the internal validity of a study (i.e. the extent to which the method is appropriate to answer the research question)[ 8 , 18 - 21 ]. An underlying assumption is that data collected in different ways should lead to similar conclusions, and approaching the same issue from different angles can help develop a holistic picture of the phenomenon (Table ​ (Table2 2 )[ 4 ].

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

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

Analysing, interpreting and reporting case studies

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

The Framework approach is a practical approach, comprising of five stages (familiarisation; identifying a thematic framework; indexing; charting; mapping and interpretation) , to managing and analysing large datasets particularly if time is limited, as was the case in our study of recruitment of South Asians into asthma research (Table ​ (Table1 1 )[ 3 , 24 ]. Theoretical frameworks may also play an important role in integrating different sources of data and examining emerging themes. For example, we drew on a socio-technical framework to help explain the connections between different elements - technology; people; and the organisational settings within which they worked - in our study of the introduction of electronic health record systems (Table ​ (Table3 3 )[ 5 ]. Our study of patient safety in undergraduate curricula drew on an evaluation-based approach to design and analysis, which emphasised the importance of the academic, organisational and practice contexts through which students learn (Table ​ (Table4 4 )[ 6 ].

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

When reporting findings, it is important to provide the reader with enough contextual information to understand the processes that were followed and how the conclusions were reached. In a collective case study, researchers may choose to present the findings from individual cases separately before amalgamating across cases. Care must be taken to ensure the anonymity of both case sites and individual participants (if agreed in advance) by allocating appropriate codes or withholding descriptors. In the example given in Table ​ Table3, 3 , we decided against providing detailed information on the NHS sites and individual participants in order to avoid the risk of inadvertent disclosure of identities[ 5 , 25 ].

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

The case study approach is, as with all research, not without its limitations. When investigating the formal and informal ways undergraduate students learn about patient safety (Table ​ (Table4), 4 ), for example, we rapidly accumulated a large quantity of data. The volume of data, together with the time restrictions in place, impacted on the depth of analysis that was possible within the available resources. This highlights a more general point of the importance of avoiding the temptation to collect as much data as possible; adequate time also needs to be set aside for data analysis and interpretation of what are often highly complex datasets.

Case study research has sometimes been criticised for lacking scientific rigour and providing little basis for generalisation (i.e. producing findings that may be transferable to other settings)[ 1 ]. There are several ways to address these concerns, including: the use of theoretical sampling (i.e. drawing on a particular conceptual framework); respondent validation (i.e. participants checking emerging findings and the researcher's interpretation, and providing an opinion as to whether they feel these are accurate); and transparency throughout the research process (see Table ​ Table8 8 )[ 8 , 18 - 21 , 23 , 26 ]. Transparency can be achieved by describing in detail the steps involved in case selection, data collection, the reasons for the particular methods chosen, and the researcher's background and level of involvement (i.e. being explicit about how the researcher has influenced data collection and interpretation). Seeking potential, alternative explanations, and being explicit about how interpretations and conclusions were reached, help readers to judge the trustworthiness of the case study report. Stake provides a critique checklist for a case study report (Table ​ (Table9 9 )[ 8 ].

Potential pitfalls and mitigating actions when undertaking case study research

Stake's checklist for assessing the quality of a case study report[ 8 ]

Conclusions

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

Competing interests

The authors declare that they have no competing interests.

Authors' contributions

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

Pre-publication history

The pre-publication history for this paper can be accessed here:

http://www.biomedcentral.com/1471-2288/11/100/prepub

Acknowledgements

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

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What is case study research?

Last updated

8 February 2023

Reviewed by

Cathy Heath

Short on time? Get an AI generated summary of this article instead

Suppose a company receives a spike in the number of customer complaints, or medical experts discover an outbreak of illness affecting children but are not quite sure of the reason. In both cases, carrying out a case study could be the best way to get answers.

Organization

Case studies can be carried out across different disciplines, including education, medicine, sociology, and business.

Most case studies employ qualitative methods, but quantitative methods can also be used. Researchers can then describe, compare, evaluate, and identify patterns or cause-and-effect relationships between the various variables under study. They can then use this knowledge to decide what action to take. 

Another thing to note is that case studies are generally singular in their focus. This means they narrow focus to a particular area, making them highly subjective. You cannot always generalize the results of a case study and apply them to a larger population. However, they are valuable tools to illustrate a principle or develop a thesis.

Analyze case study research

Dovetail streamlines case study research to help you uncover and share actionable insights

• What are the different types of case study designs?

Researchers can choose from a variety of case study designs. The design they choose is dependent on what questions they need to answer, the context of the research environment, how much data they already have, and what resources are available.

Here are the common types of case study design:

Explanatory

An explanatory case study is an initial explanation of the how or why that is behind something. This design is commonly used when studying a real-life phenomenon or event. Once the organization understands the reasons behind a phenomenon, it can then make changes to enhance or eliminate the variables causing it. 

Here is an example: How is co-teaching implemented in elementary schools? The title for a case study of this subject could be “Case Study of the Implementation of Co-Teaching in Elementary Schools.”

Descriptive

An illustrative or descriptive case study helps researchers shed light on an unfamiliar object or subject after a period of time. The case study provides an in-depth review of the issue at hand and adds real-world examples in the area the researcher wants the audience to understand. 

The researcher makes no inferences or causal statements about the object or subject under review. This type of design is often used to understand cultural shifts.

Here is an example: How did people cope with the 2004 Indian Ocean Tsunami? This case study could be titled "A Case Study of the 2004 Indian Ocean Tsunami and its Effect on the Indonesian Population."

Exploratory

Exploratory research is also called a pilot case study. It is usually the first step within a larger research project, often relying on questionnaires and surveys . Researchers use exploratory research to help narrow down their focus, define parameters, draft a specific research question , and/or identify variables in a larger study. This research design usually covers a wider area than others, and focuses on the ‘what’ and ‘who’ of a topic.

Here is an example: How do nutrition and socialization in early childhood affect learning in children? The title of the exploratory study may be “Case Study of the Effects of Nutrition and Socialization on Learning in Early Childhood.”

An intrinsic case study is specifically designed to look at a unique and special phenomenon. At the start of the study, the researcher defines the phenomenon and the uniqueness that differentiates it from others. 

In this case, researchers do not attempt to generalize, compare, or challenge the existing assumptions. Instead, they explore the unique variables to enhance understanding. Here is an example: “Case Study of Volcanic Lightning.”

This design can also be identified as a cumulative case study. It uses information from past studies or observations of groups of people in certain settings as the foundation of the new study. Given that it takes multiple areas into account, it allows for greater generalization than a single case study. 

The researchers also get an in-depth look at a particular subject from different viewpoints.  Here is an example: “Case Study of how PTSD affected Vietnam and Gulf War Veterans Differently Due to Advances in Military Technology.”

Critical instance

A critical case study incorporates both explanatory and intrinsic study designs. It does not have predetermined purposes beyond an investigation of the said subject. It can be used for a deeper explanation of the cause-and-effect relationship. It can also be used to question a common assumption or myth. 

The findings can then be used further to generalize whether they would also apply in a different environment.  Here is an example: “What Effect Does Prolonged Use of Social Media Have on the Mind of American Youth?”

Instrumental

Instrumental research attempts to achieve goals beyond understanding the object at hand. Researchers explore a larger subject through different, separate studies and use the findings to understand its relationship to another subject. This type of design also provides insight into an issue or helps refine a theory. 

For example, you may want to determine if violent behavior in children predisposes them to crime later in life. The focus is on the relationship between children and violent behavior, and why certain children do become violent. Here is an example: “Violence Breeds Violence: Childhood Exposure and Participation in Adult Crime.”

Evaluation case study design is employed to research the effects of a program, policy, or intervention, and assess its effectiveness and impact on future decision-making. 

For example, you might want to see whether children learn times tables quicker through an educational game on their iPad versus a more teacher-led intervention. Here is an example: “An Investigation of the Impact of an iPad Multiplication Game for Primary School Children.” 

• When do you use case studies?

Case studies are ideal when you want to gain a contextual, concrete, or in-depth understanding of a particular subject. It helps you understand the characteristics, implications, and meanings of the subject.

They are also an excellent choice for those writing a thesis or dissertation, as they help keep the project focused on a particular area when resources or time may be too limited to cover a wider one. You may have to conduct several case studies to explore different aspects of the subject in question and understand the problem.

• What are the steps to follow when conducting a case study?

1. Select a case

Once you identify the problem at hand and come up with questions, identify the case you will focus on. The study can provide insights into the subject at hand, challenge existing assumptions, propose a course of action, and/or open up new areas for further research.

2. Create a theoretical framework

While you will be focusing on a specific detail, the case study design you choose should be linked to existing knowledge on the topic. This prevents it from becoming an isolated description and allows for enhancing the existing information. 

It may expand the current theory by bringing up new ideas or concepts, challenge established assumptions, or exemplify a theory by exploring how it answers the problem at hand. A theoretical framework starts with a literature review of the sources relevant to the topic in focus. This helps in identifying key concepts to guide analysis and interpretation.

3. Collect the data

Case studies are frequently supplemented with qualitative data such as observations, interviews, and a review of both primary and secondary sources such as official records, news articles, and photographs. There may also be quantitative data —this data assists in understanding the case thoroughly.

4. Analyze your case

The results of the research depend on the research design. Most case studies are structured with chapters or topic headings for easy explanation and presentation. Others may be written as narratives to allow researchers to explore various angles of the topic and analyze its meanings and implications.

In all areas, always give a detailed contextual understanding of the case and connect it to the existing theory and literature before discussing how it fits into your problem area.

• What are some case study examples?

What are the best approaches for introducing our product into the Kenyan market?

How does the change in marketing strategy aid in increasing the sales volumes of product Y?

How can teachers enhance student participation in classrooms?

How does poverty affect literacy levels in children?

Case study topics

Case study of product marketing strategies in the Kenyan market

Case study of the effects of a marketing strategy change on product Y sales volumes

Case study of X school teachers that encourage active student participation in the classroom

Case study of the effects of poverty on literacy levels in children

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• Section 2: Home
• Developing the Quantitative Research Design
• Qualitative Descriptive Design
• Design and Development Research (DDR) For Instructional Design
• Qualitative Narrative Inquiry Research
• Action Research Resource
• Case Study Design in an Applied Doctorate

Qualitative Research Designs

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

• SAGE Research Methods
• Research Examples (SAGE) This link opens in a new window
• Dataset Examples (SAGE) This link opens in a new window
• IRB Resource Center This link opens in a new window

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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The impact of evidence-based nursing leadership in healthcare settings: a mixed methods systematic review

• Maritta Välimäki 1 , 2 ,
• Shuang Hu 3 ,
• Tella Lantta 1 ,
• Kirsi Hipp 1 , 4 ,
• Jaakko Varpula 1 ,
• Jiarui Chen 3 ,
• Gaoming Liu 5 ,
• Yao Tang 3 ,
• Wenjun Chen 3 &
• Xianhong Li 3  

BMC Nursing volume  23 , Article number:  452 ( 2024 ) Cite this article

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Metrics details

The central component in impactful healthcare decisions is evidence. Understanding how nurse leaders use evidence in their own managerial decision making is still limited. This mixed methods systematic review aimed to examine how evidence is used to solve leadership problems and to describe the measured and perceived effects of evidence-based leadership on nurse leaders and their performance, organizational, and clinical outcomes.

We included articles using any type of research design. We referred nurses, nurse managers or other nursing staff working in a healthcare context when they attempt to influence the behavior of individuals or a group in an organization using an evidence-based approach. Seven databases were searched until 11 November 2021. JBI Critical Appraisal Checklist for Quasi-experimental studies, JBI Critical Appraisal Checklist for Case Series, Mixed Methods Appraisal Tool were used to evaluate the Risk of bias in quasi-experimental studies, case series, mixed methods studies, respectively. The JBI approach to mixed methods systematic reviews was followed, and a parallel-results convergent approach to synthesis and integration was adopted.

Thirty-one publications were eligible for the analysis: case series ( n  = 27), mixed methods studies ( n  = 3) and quasi-experimental studies ( n  = 1). All studies were included regardless of methodological quality. Leadership problems were related to the implementation of knowledge into practice, the quality of nursing care and the resource availability. Organizational data was used in 27 studies to understand leadership problems, scientific evidence from literature was sought in 26 studies, and stakeholders’ views were explored in 24 studies. Perceived and measured effects of evidence-based leadership focused on nurses’ performance, organizational outcomes, and clinical outcomes. Economic data were not available.

Conclusions

This is the first systematic review to examine how evidence is used to solve leadership problems and to describe its measured and perceived effects from different sites. Although a variety of perceptions and effects were identified on nurses’ performance as well as on organizational and clinical outcomes, available knowledge concerning evidence-based leadership is currently insufficient. Therefore, more high-quality research and clinical trial designs are still needed.

Trail registration

The study was registered (PROSPERO CRD42021259624).

Peer Review reports

Global health demands have set new roles for nurse leaders [ 1 ].Nurse leaders are referred to as nurses, nurse managers, or other nursing staff working in a healthcare context who attempt to influence the behavior of individuals or a group based on goals that are congruent with organizational goals [ 2 ]. They are seen as professionals “armed with data and evidence, and a commitment to mentorship and education”, and as a group in which “leaders innovate, transform, and achieve quality outcomes for patients, health care professionals, organizations, and communities” [ 3 ]. Effective leadership occurs when team members critically follow leaders and are motivated by a leader’s decisions based on the organization’s requests and targets [ 4 ]. On the other hand, problems caused by poor leadership may also occur, regarding staff relations, stress, sickness, or retention [ 5 ]. Therefore, leadership requires an understanding of different problems to be solved using synthesizing evidence from research, clinical expertise, and stakeholders’ preferences [ 6 , 7 ]. If based on evidence, leadership decisions, also referred as leadership decision making [ 8 ], could ensure adequate staffing [ 7 , 9 ] and to produce sufficient and cost-effective care [ 10 ]. However, nurse leaders still rely on their decision making on their personal [ 11 ] and professional experience [ 10 ] over research evidence, which can lead to deficiencies in the quality and safety of care delivery [ 12 , 13 , 14 ]. As all nurses should demonstrate leadership in their profession, their leadership competencies should be strengthened [ 15 ].

Evidence-informed decision-making, referred to as evidence appraisal and application, and evaluation of decisions [ 16 ], has been recognized as one of the core competencies for leaders [ 17 , 18 ]. The role of evidence in nurse leaders’ managerial decision making has been promoted by public authorities [ 19 , 20 , 21 ]. Evidence-based management, another concept related to evidence-based leadership, has been used as the potential to improve healthcare services [ 22 ]. It can guide nursing leaders, in developing working conditions, staff retention, implementation practices, strategic planning, patient care, and success of leadership [ 13 ]. Collins and Holton [ 23 ] in their systematic review and meta-analysis examined 83 studies regarding leadership development interventions. They found that leadership training can result in significant improvement in participants’ skills, especially in knowledge level, although the training effects varied across studies. Cummings et al. [ 24 ] reviewed 100 papers (93 studies) and concluded that participation in leadership interventions had a positive impact on the development of a variety of leadership styles. Clavijo-Chamorro et al. [ 25 ] in their review of 11 studies focused on leadership-related factors that facilitate evidence implementation: teamwork, organizational structures, and transformational leadership. The role of nurse managers was to facilitate evidence-based practices by transforming contexts to motivate the staff and move toward a shared vision of change.

As far as we are aware, however, only a few systematic reviews have focused on evidence-based leadership or related concepts in the healthcare context aiming to analyse how nurse leaders themselves uses evidence in the decision-making process. Young [ 26 ] targeted definitions and acceptance of evidence-based management (EBMgt) in healthcare while Hasanpoor et al. [ 22 ] identified facilitators and barriers, sources of evidence used, and the role of evidence in the process of decision making. Both these reviews concluded that EBMgt was of great importance but used limitedly in healthcare settings due to a lack of time, a lack of research management activities, and policy constraints. A review by Williams [ 27 ] showed that the usage of evidence to support management in decision making is marginal due to a shortage of relevant evidence. Fraser [ 28 ] in their review further indicated that the potential evidence-based knowledge is not used in decision making by leaders as effectively as it could be. Non-use of evidence occurs and leaders base their decisions mainly on single studies, real-world evidence, and experts’ opinions [ 29 ]. Systematic reviews and meta-analyses rarely provide evidence of management-related interventions [ 30 ]. Tate et al. [ 31 ] concluded based on their systematic review and meta-analysis that the ability of nurse leaders to use and critically appraise research evidence may influence the way policy is enacted and how resources and staff are used to meet certain objectives set by policy. This can further influence staff and workforce outcomes. It is therefore important that nurse leaders have the capacity and motivation to use the strongest evidence available to effect change and guide their decision making [ 27 ].

Despite of a growing body of evidence, we found only one review focusing on the impact of evidence-based knowledge. Geert et al. [ 32 ] reviewed literature from 2007 to 2016 to understand the elements of design, delivery, and evaluation of leadership development interventions that are the most reliably linked to outcomes at the level of the individual and the organization, and that are of most benefit to patients. The authors concluded that it is possible to improve individual-level outcomes among leaders, such as knowledge, motivation, skills, and behavior change using evidence-based approaches. Some of the most effective interventions included, for example, interactive workshops, coaching, action learning, and mentoring. However, these authors found limited research evidence describing how nurse leaders themselves use evidence to support their managerial decisions in nursing and what the outcomes are.

To fill the knowledge gap and compliment to existing knowledgebase, in this mixed methods review we aimed to (1) examine what leadership problems nurse leaders solve using an evidence-based approach and (2) how they use evidence to solve these problems. We also explored (3) the measured and (4) perceived effects of the evidence-based leadership approach in healthcare settings. Both qualitative and quantitative components of the effects of evidence-based leadership were examined to provide greater insights into the available literature [ 33 ]. Together with the evidence-based leadership approach, and its impact on nursing [ 34 , 35 ], this knowledge gained in this review can be used to inform clinical policy or organizational decisions [ 33 ]. The study is registered (PROSPERO CRD42021259624). The methods used in this review were specified in advance and documented in a priori in a published protocol [ 36 ]. Key terms of the review and the search terms are defined in Table  1 (population, intervention, comparison, outcomes, context, other).

In this review, we used a mixed methods approach [ 37 ]. A mixed methods systematic review was selected as this approach has the potential to produce direct relevance to policy makers and practitioners [ 38 ]. Johnson and Onwuegbuzie [ 39 ] have defined mixed methods research as “the class of research in which the researcher mixes or combines quantitative and qualitative research techniques, methods, approaches, concepts or language into a single study.” Therefore, we combined quantitative and narrative analysis to appraise and synthesize empirical evidence, and we held them as equally important in informing clinical policy or organizational decisions [ 34 ]. In this review, a comprehensive synthesis of quantitative and qualitative data was performed first and then discussed in discussion part (parallel-results convergent design) [ 40 ]. We hoped that different type of analysis approaches could complement each other and deeper picture of the topic in line with our research questions could be gained [ 34 ].

Inclusion and exclusion criteria

Inclusion and exclusion criteria of the study are described in Table  1 .

Search strategy

A three-step search strategy was utilized. First, an initial limited search with #MEDLINE was undertaken, followed by analysis of the words used in the title, abstract, and the article’s key index terms. Second, the search strategy, including identified keywords and index terms, was adapted for each included data base and a second search was undertaken on 11 November 2021. The full search strategy for each database is described in Additional file 1 . Third, the reference list of all studies included in the review were screened for additional studies. No year limits or language restrictions were used.

Information sources

The database search included the following: CINAHL (EBSCO), Cochrane Library (academic database for medicine and health science and nursing), Embase (Elsevier), PsycINFO (EBSCO), PubMed (MEDLINE), Scopus (Elsevier) and Web of Science (academic database across all scientific and technical disciplines, ranging from medicine and social sciences to arts and humanities). These databases were selected as they represent typical databases in health care context. Subject headings from each of the databases were included in the search strategies. Boolean operators ‘AND’ and ‘OR’ were used to combine the search terms. An information specialist from the University of Turku Library was consulted in the formation of the search strategies.

Study selection

All identified citations were collated and uploaded into Covidence software (Covidence systematic review software, Veritas Health Innovation, Melbourne, Australia www.covidence.org ), and duplicates were removed by the software. Titles and abstracts were screened and assessed against the inclusion criteria independently by two reviewers out of four, and any discrepancies were resolved by the third reviewer (MV, KH, TL, WC). Studies meeting the inclusion criteria were retrieved in full and archived in Covidence. Access to one full-text article was lacking: the authors for one study were contacted about the missing full text, but no full text was received. All remaining hits of the included studies were retrieved and assessed independently against the inclusion criteria by two independent reviewers of four (MV, KH, TL, WC). Studies that did not meet the inclusion criteria were excluded, and the reasons for exclusion were recorded in Covidence. Any disagreements that arose between the reviewers were resolved through discussions with XL.

Assessment of methodological quality

Eligible studies were critically appraised by two independent reviewers (YT, SH). Standardized critical appraisal instruments based on the study design were used. First, quasi-experimental studies were assessed using the JBI Critical Appraisal Checklist for Quasi-experimental studies [ 44 ]. Second, case series were assessed using the JBI Critical Appraisal Checklist for Case Series [ 45 ]. Third, mixed methods studies were appraised using the Mixed Methods Appraisal Tool [ 46 ].

To increase inter-reviewer reliability, the review agreement was calculated (SH) [ 47 ]. A kappa greater than 0.8 was considered to represent a high level of agreement (0–0.1). In our data, the agreement was 0.75. Discrepancies raised between two reviewers were resolved through discussion and modifications and confirmed by XL. As an outcome, studies that met the inclusion criteria were proceeded to critical appraisal and assessed as suitable for inclusion in the review. The scores for each item and overall critical appraisal scores were presented.

Data extraction

For data extraction, specific tables were created. First, study characteristics (author(s), year, country, design, number of participants, setting) were extracted by two authors independently (JC, MV) and reviewed by TL. Second, descriptions of the interventions were extracted by two reviewers (JV, JC) using the structure of the TIDIeR (Template for Intervention Description and Replication) checklist (brief name, the goal of the intervention, material and procedure, models of delivery and location, dose, modification, adherence and fidelity) [ 48 ]. The extractions were confirmed (MV).

Third, due to a lack of effectiveness data and a wide heterogeneity between study designs and presentation of outcomes, no attempt was made to pool the quantitative data statistically; the findings of the quantitative data were presented in narrative form only [ 44 ]. The separate data extraction tables for each research question were designed specifically for this study. For both qualitative (and a qualitative component of mixed-method studies) and quantitative studies, the data were extracted and tabulated into text format according to preplanned research questions [ 36 ]. To test the quality of the tables and the data extraction process, three authors independently extracted the data from the first five studies (in alphabetical order). After that, the authors came together to share and determine whether their approaches of the data extraction were consistent with each other’s output and whether the content of each table was in line with research question. No reason was found to modify the data extraction tables or planned process. After a consensus of the data extraction process was reached, the data were extracted in pairs by independent reviewers (WC, TY, SH, GL). Any disagreements that arose between the reviewers were resolved through discussion and with a third reviewer (MV).

Data analysis

We were not able to conduct a meta-analysis due to a lack of effectiveness data based on clinical trials. Instead, we used inductive thematic analysis with constant comparison to answer the research question [ 46 , 49 ] using tabulated primary data from qualitative and quantitative studies as reported by the original authors in narrative form only [ 47 ]. In addition, the qualitizing process was used to transform quantitative data to qualitative data; this helped us to convert the whole data into themes and categories. After that we used the thematic analysis for the narrative data as follows. First, the text was carefully read, line by line, to reveal topics answering each specific review question (MV). Second, the data coding was conducted, and the themes in the data were formed by data categorization. The process of deriving the themes was inductive based on constant comparison [ 49 ]. The results of thematic analysis and data categorization was first described in narrative format and then the total number of studies was calculated where the specific category was identified (%).

Stakeholder involvement

The method of reporting stakeholders’ involvement follows the key components by [ 50 ]: (1) people involved, (2) geographical location, (3) how people were recruited, (4) format of involvement, (5) amount of involvement, (6) ethical approval, (7) financial compensation, and (8) methods for reporting involvement.

In our review, stakeholder involvement targeted nurses and nurse leader in China. Nurse Directors of two hospitals recommended potential participants who received a personal invitation letter from researchers to participate in a discussion meeting. Stakeholders’ participation was based on their own free will. Due to COVID-19, one online meeting (1 h) was organized (25 May 2022). Eleven participants joined the meeting. Ethical approval was not applied and no financial compensation was offered. At the end of the meeting, experiences of stakeholders’ involvement were explored.

The meeting started with an introductory presentation with power points. The rationale, methods, and preliminary review results were shared with the participants [ 51 ].The meeting continued with general questions for the participants: (1) Are you aware of the concepts of evidence-based practice or evidence-based leadership?; (2) How important is it to use evidence to support decisions among nurse leaders?; (3) How is the evidence-based approach used in hospital settings?; and (4) What type of evidence is currently used to support nurse leaders’ decision making (e.g. scientific literature, organizational data, stakeholder views)?

Two people took notes on the course and content of the conversation. The notes were later transcripted in verbatim, and the key points of the discussions were summarised. Although answers offered by the stakeholders were very short, the information was useful to validate the preliminary content of the results, add the rigorousness of the review, and obtain additional perspectives. A recommendation of the stakeholders was combined in the Discussion part of this review increasing the applicability of the review in the real world [ 50 ]. At the end of the discussion, the value of stakeholders’ involvement was asked. Participants shared that the experience of participating was unique and the topic of discussion was challenging. Two authors of the review group further represented stakeholders by working together with the research team throughout the review study.

Search results

From seven different electronic databases, 6053 citations were identified as being potentially relevant to the review. Then, 3133 duplicates were removed by an automation tool (Covidence: www.covidence.org ), and one was removed manually. The titles and abstracts of 3040 of citations were reviewed, and a total of 110 full texts were included (one extra citation was found on the reference list but later excluded). Based on the eligibility criteria, 31 studies (32 hits) were critically appraised and deemed suitable for inclusion in the review. The search results and selection process are presented in the PRISMA [ 52 ] flow diagram Fig.  1 . The full list of references for included studies can be find in Additional file 2 . To avoid confusion between articles of the reference list and studies included in the analysis, the studies included in the review are referred inside the article using the reference number of each study (e.g. ref 1, ref 2).

Search results and study selection and inclusion process [ 52 ]

Characteristics of included studies

The studies had multiple purposes, aiming to develop practice, implement a new approach, improve quality, or to develop a model. The 31 studies (across 32 hits) were case series studies ( n  = 27), mixed methods studies ( n  = 3) and a quasi-experimental study ( n  = 1). All studies were published between the years 2004 and 2021. The highest number of papers was published in year 2020.

Table  2 describes the characteristics of included studies and Additional file 3 offers a narrative description of the studies.

Methodological quality assessment

Quasi-experimental studies.

We had one quasi-experimental study (ref 31). All questions in the critical appraisal tool were applicable. The total score of the study was 8 (out of a possible 9). Only one response of the tool was ‘no’ because no control group was used in the study (see Additional file 4 for the critical appraisal of included studies).

Case series studies . A case series study is typically defined as a collection of subjects with common characteristics. The studies do not include a comparison group and are often based on prevalent cases and on a sample of convenience [ 53 ]. Munn et al. [ 45 ] further claim that case series are best described as observational studies, lacking experimental and randomized characteristics, being descriptive studies, without a control or comparator group. Out of 27 case series studies included in our review, the critical appraisal scores varied from 1 to 9. Five references were conference abstracts with empirical study results, which were scored from 1 to 3. Full reports of these studies were searched in electronic databases but not found. Critical appraisal scores for the remaining 22 studies ranged from 1 to 9 out of a possible score of 10. One question (Q3) was not applicable to 13 studies: “Were valid methods used for identification of the condition for all participants included in the case series?” Only two studies had clearly reported the demographic of the participants in the study (Q6). Twenty studies met Criteria 8 (“Were the outcomes or follow-up results of cases clearly reported?”) and 18 studies met Criteria 7 (“Q7: Was there clear reporting of clinical information of the participants?”) (see Additional file 4 for the critical appraisal of included studies).

Mixed-methods studies

Mixed-methods studies involve a combination of qualitative and quantitative methods. This is a common design and includes convergent design, sequential explanatory design, and sequential exploratory design [ 46 ]. There were three mixed-methods studies. The critical appraisal scores for the three studies ranged from 60 to 100% out of a possible 100%. Two studies met all the criteria, while one study fulfilled 60% of the scored criteria due to a lack of information to understand the relevance of the sampling strategy well enough to address the research question (Q4.1) or to determine whether the risk of nonresponse bias was low (Q4.4) (see Additional file 4 for the critical appraisal of included studies).

Intervention or program components

The intervention of program components were categorized and described using the TiDier checklist: name and goal, theory or background, material, procedure, provider, models of delivery, location, dose, modification, and adherence and fidelity [ 48 ]. A description of intervention in each study is described in Additional file 5 and a narrative description in Additional file 6 .

Leadership problems

In line with the inclusion criteria, data for the leadership problems were categorized in all 31 included studies (see Additional file 7 for leadership problems). Three types of leadership problems were identified: implementation of knowledge into practice, the quality of clinical care, and resources in nursing care. A narrative summary of the results is reported below.

Implementing knowledge into practice

Eleven studies (35%) aimed to solve leadership problems related to implementation of knowledge into practice. Studies showed how to support nurses in evidence-based implementation (EBP) (ref 3, ref 5), how to engage nurses in using evidence in practice (ref 4), how to convey the importance of EBP (ref 22) or how to change practice (ref 4). Other problems were how to facilitate nurses to use guideline recommendations (ref 7) and how nurses can make evidence-informed decisions (ref 8). General concerns also included the linkage between theory and practice (ref 1) as well as how to implement the EBP model in practice (ref 6). In addition, studies were motivated by the need for revisions or updates of protocols to improve clinical practice (ref 10) as well as the need to standardize nursing activities (ref 11, ref 14).

The quality of the care

Thirteen (42%) focused on solving problems related to the quality of clinical care. In these studies, a high number of catheter infections led a lack of achievement of organizational goals (ref 2, ref 9). A need to reduce patient symptoms in stem cell transplant patients undergoing high-dose chemotherapy (ref 24) was also one of the problems to be solved. In addition, the projects focused on how to prevent pressure ulcers (ref 26, ref 29), how to enhance the quality of cancer treatment (ref 25) and how to reduce the need for invasive constipation treatment (ref 30). Concerns about patient safety (ref 15), high fall rates (ref 16, ref 19), dissatisfaction of patients (ref 16, ref 18) and nurses (ref 16, ref 30) were also problems that had initiated the projects. Studies addressed concerns about how to promote good contingency care in residential aged care homes (ref 20) and about how to increase recognition of human trafficking problems in healthcare (ref 21).

Resources in nursing care

Nurse leaders identified problems in their resources, especially in staffing problems. These problems were identified in seven studies (23%), which involved concerns about how to prevent nurses from leaving the job (ref 31), how to ensure appropriate recruitment, staffing and retaining of nurses (ref 13) and how to decrease nurses’ burden and time spent on nursing activities (ref 12). Leadership turnover was also reported as a source of dissatisfaction (ref 17); studies addressed a lack of structured transition and training programs, which led to turnover (ref 23), as well as how to improve intershift handoff among nurses (ref 28). Optimal design for new hospitals was also examined (ref 27).

Main features of evidence-based leadership

Out of 31 studies, 17 (55%) included all four domains of an evidence-based leadership approach, and four studies (13%) included evidence of critical appraisal of the results (see Additional file 8 for the main features of evidence-based Leadership) (ref 11, ref 14, ref 23, ref 27).

Organizational evidence

Twenty-seven studies (87%) reported how organizational evidence was collected and used to solve leadership problems (ref 2). Retrospective chart reviews (ref 5), a review of the extent of specific incidents (ref 19), and chart auditing (ref 7, ref 25) were conducted. A gap between guideline recommendations and actual care was identified using organizational data (ref 7) while the percentage of nurses’ working time spent on patient care was analyzed using an electronic charting system (ref 12). Internal data (ref 22), institutional data, and programming metrics were also analyzed to understand the development of the nurse workforce (ref 13).

Surveys (ref 3, ref 25), interviews (ref 3, ref 25) and group reviews (ref 18) were used to better understand the leadership problem to be solved. Employee opinion surveys on leadership (ref 17), a nurse satisfaction survey (ref 30) and a variety of reporting templates were used for the data collection (ref 28) reported. Sometimes, leadership problems were identified by evidence facilitators or a PI’s team who worked with staff members (ref 15, ref 17). Problems in clinical practice were also identified by the Nursing Professional Council (ref 14), managers (ref 26) or nurses themselves (ref 24). Current practices were reviewed (ref 29) and a gap analysis was conducted (ref 4, ref 16, ref 23) together with SWOT analysis (ref 16). In addition, hospital mission and vision statements, research culture established and the proportion of nursing alumni with formal EBP training were analyzed (ref 5). On the other hand, it was stated that no systematic hospital-specific sources of data regarding job satisfaction or organizational commitment were used (ref 31). In addition, statements of organizational analysis were used on a general level only (ref 1).

Scientific evidence identified

Twenty-six studies (84%) reported the use of scientific evidence in their evidence-based leadership processes. A literature search was conducted (ref 21) and questions, PICO, and keywords were identified (ref 4) in collaboration with a librarian. Electronic databases, including PubMed (ref 14, ref 31), Cochrane, and EMBASE (ref 31) were searched. Galiano (ref 6) used Wiley Online Library, Elsevier, CINAHL, Health Source: Nursing/Academic Edition, PubMed, and the Cochrane Library while Hoke (ref 11) conducted an electronic search using CINAHL and PubMed to retrieve articles.

Identified journals were reviewed manually (ref 31). The findings were summarized using ‘elevator speech’ (ref 4). In a study by Gifford et al. (ref 9) evidence facilitators worked with participants to access, appraise, and adapt the research evidence to the organizational context. Ostaszkiewicz (ref 20) conducted a scoping review of literature and identified and reviewed frameworks and policy documents about the topic and the quality standards. Further, a team of nursing administrators, directors, staff nurses, and a patient representative reviewed the literature and made recommendations for practice changes.

Clinical practice guidelines were also used to offer scientific evidence (ref 7, ref 19). Evidence was further retrieved from a combination of nursing policies, guidelines, journal articles, and textbooks (ref 12) as well as from published guidelines and literature (ref 13). Internal evidence, professional practice knowledge, relevant theories and models were synthesized (ref 24) while other study (ref 25) reviewed individual studies, synthesized with systematic reviews or clinical practice guidelines. The team reviewed the research evidence (ref 3, ref 15) or conducted a literature review (ref 22, ref 28, ref 29), a literature search (ref 27), a systematic review (ref 23), a review of the literature (ref 30) or ‘the scholarly literature was reviewed’ (ref 18). In addition, ‘an extensive literature review of evidence-based best practices was carried out’ (ref 10). However, detailed description how the review was conducted was lacking.

Views of stakeholders

A total of 24 studies (77%) reported methods for how the views of stakeholders, i.e., professionals or experts, were considered. Support to run this study was received from nursing leadership and multidisciplinary teams (ref 29). Experts and stakeholders joined the study team in some cases (ref 25, ref 30), and in other studies, their opinions were sought to facilitate project success (ref 3). Sometimes a steering committee was formed by a Chief Nursing Officer and Clinical Practice Specialists (ref 2). More specifically, stakeholders’ views were considered using interviews, workshops and follow-up teleconferences (ref 7). The literature review was discussed with colleagues (ref 11), and feedback and support from physicians as well as the consensus of staff were sought (ref 16).

A summary of the project findings and suggestions for the studies were discussed at 90-minute weekly meetings by 11 charge nurses. Nurse executive directors were consulted over a 10-week period (ref 31). An implementation team (nurse, dietician, physiotherapist, occupational therapist) was formed to support the implementation of evidence-based prevention measures (ref 26). Stakeholders volunteered to join in the pilot implementation (ref 28) or a stakeholder team met to determine the best strategy for change management, shortcomings in evidence-based criteria were discussed, and strategies to address those areas were planned (ref 5). Nursing leaders, staff members (ref 22), ‘process owners (ref 18) and program team members (ref 18, ref 19, ref 24) met regularly to discuss the problems. Critical input was sought from clinical educators, physicians, nutritionists, pharmacists, and nurse managers (ref 24). The unit director and senior nursing staff reviewed the contents of the product, and the final version of clinical pathways were reviewed and approved by the Quality Control Commission of the Nursing Department (ref 12). In addition, two co-design workshops with 18 residential aged care stakeholders were organized to explore their perspectives about factors to include in a model prototype (ref 20). Further, an agreement of stakeholders in implementing continuous quality services within an open relationship was conducted (ref 1).

Critical appraisal

In five studies (16%), a critical appraisal targeting the literature search was carried out. The appraisals were conducted by interns and teams who critiqued the evidence (ref 4). In Hoke’s study, four areas that had emerged in the literature were critically reviewed (ref 11). Other methods were to ‘critically appraise the search results’ (ref 14). Journal club team meetings (ref 23) were organized to grade the level and quality of evidence and the team ‘critically appraised relevant evidence’ (ref 27). On the other hand, the studies lacked details of how the appraisals were done in each study.

The perceived effects of evidence-based leadership

Perceived effects of evidence-based leadership on nurses’ performance.

Eleven studies (35%) described perceived effects of evidence-based leadership on nurses’ performance (see Additional file 9 for perceived effects of evidence-based leadership), which were categorized in four groups: awareness and knowledge, competence, ability to understand patients’ needs, and engagement. First, regarding ‘awareness and knowledge’, different projects provided nurses with new learning opportunities (ref 3). Staff’s knowledge (ref 20, ref 28), skills, and education levels improved (ref 20), as did nurses’ knowledge comprehension (ref 21). Second, interventions and approaches focusing on management and leadership positively influenced participants’ competence level to improve the quality of services. Their confidence level (ref 1) and motivation to change practice increased, self-esteem improved, and they were more positive and enthusiastic in their work (ref 22). Third, some nurses were relieved that they had learned to better handle patients’ needs (ref 25). For example, a systematic work approach increased nurses’ awareness of the patients who were at risk of developing health problems (ref 26). And last, nurse leaders were more engaged with staff, encouraging them to adopt the new practices and recognizing their efforts to change (ref 8).

Perceived effects on organizational outcomes

Nine studies (29%) described the perceived effects of evidence-based leadership on organizational outcomes (see Additional file 9 for perceived effects of evidence-based leadership). These were categorized into three groups: use of resources, staff commitment, and team effort. First, more appropriate use of resources was reported (ref 15, ref 20), and working time was more efficiently used (ref 16). In generally, a structured approach made implementing change more manageable (ref 1). On the other hand, in the beginning of the change process, the feedback from nurses was unfavorable, and they experienced discomfort in the new work style (ref 29). New approaches were also perceived as time consuming (ref 3). Second, nurse leaders believed that fewer nursing staff than expected left the organization over the course of the study (ref 31). Third, the project helped staff in their efforts to make changes, and it validated the importance of working as a team (ref 7). Collaboration and support between the nurses increased (ref 26). On the other hand, new work style caused challenges in teamwork (ref 3).

Perceived effects on clinical outcomes

Five studies (16%) reported the perceived effects of evidence-based leadership on clinical outcomes (see Additional file 9 for perceived effects of evidence-based leadership), which were categorized in two groups: general patient outcomes and specific clinical outcomes. First, in general, the project assisted in connecting the guideline recommendations and patient outcomes (ref 7). The project was good for the patients in general, and especially to improve patient safety (ref 16). On the other hand, some nurses thought that the new working style did not work at all for patients (ref 28). Second, the new approach used assisted in optimizing patients’ clinical problems and person-centered care (ref 20). Bowel management, for example, received very good feedback (ref 30).

The measured effects of evidence-based leadership

The measured effects on nurses’ performance.

Data were obtained from 20 studies (65%) (see Additional file 10 for measured effects of evidence-based leadership) and categorized nurse performance outcomes for three groups: awareness and knowledge, engagement, and satisfaction. First, six studies (19%) measured the awareness and knowledge levels of participants. Internship for staff nurses was beneficial to help participants to understand the process for using evidence-based practice and to grow professionally, to stimulate for innovative thinking, to give knowledge needed to use evidence-based practice to answer clinical questions, and to make possible to complete an evidence-based practice project (ref 3). Regarding implementation program of evidence-based practice, those with formal EBP training showed an improvement in knowledge, attitude, confidence, awareness and application after intervention (ref 3, ref 11, ref 20, ref 23, ref 25). On the contrary, in other study, attitude towards EBP remained stable ( p  = 0.543). and those who applied EBP decreased although no significant differences over the years ( p  = 0.879) (ref 6).

Second, 10 studies (35%) described nurses’ engagement to new practices (ref 5, ref 6, ref 7, ref 10, ref 16, ref 17, ref 18, ref 21, ref 25, ref 27). 9 studies (29%) studies reported that there was an improvement of compliance level of participants (ref 6, ref 7, ref 10, ref 16, ref 17, ref 18, ref 21, ref 25, ref 27). On the contrary, in DeLeskey’s (ref 5) study, although improvement was found in post-operative nausea and vomiting’s (PONV) risk factors documented’ (2.5–63%), and ’risk factors communicated among anaesthesia and surgical staff’ (0–62%), the improvement did not achieve the goal. The reason was a limited improvement was analysed. It was noted that only those patients who had been seen by the pre-admission testing nurse had risk assessments completed. Appropriate treatment/prophylaxis increased from 69 to 77%, and from 30 to 49%; routine assessment for PONV/rescue treatment 97% and 100% was both at 100% following the project. The results were discussed with staff but further reasons for a lack of engagement in nursing care was not reported.

And third, six studies (19%) reported nurses’ satisfaction with project outcomes. The study results showed that using evidence in managerial decisions improved nurses’ satisfaction and attitudes toward their organization ( P  < 0.05) (ref 31). Nurses’ overall job satisfaction improved as well (ref 17). Nurses’ satisfaction with usability of the electronic charting system significantly improved after introduction of the intervention (ref 12). In handoff project in seven hospitals, improvement was reported in all satisfaction indicators used in the study although improvement level varied in different units (ref 28). In addition, positive changes were reported in nurses’ ability to autonomously perform their job (“How satisfied are you with the tools and resources available for you treat and prevent patient constipation?” (54%, n  = 17 vs. 92%, n  = 35, p  < 0.001) (ref 30).

The measured effects on organizational outcomes

Thirteen studies (42%) described the effects of a project on organizational outcomes (see Additional file 10 for measured effects of evidence-based leadership), which were categorized in two groups: staff compliance, and changes in practices. First, studies reported improved organizational outcomes due to staff better compliance in care (ref 4, ref 13, ref 17, ref 23, ref 27, ref 31). Second, changes in organization practices were also described (ref 11) like changes in patient documentation (ref 12, ref 21). Van Orne (ref 30) found a statistically significant reduction in the average rate of invasive medication administration between pre-intervention and post-intervention ( p  = 0.01). Salvador (ref 24) also reported an improvement in a proactive approach to mucositis prevention with an evidence-based oral care guide. On the contrary, concerns were also raised such as not enough time for new bedside report (ref 16) or a lack of improvement of assessment of diabetic ulcer (ref 8).

The measured effects on clinical outcomes

A variety of improvements in clinical outcomes were reported (see Additional file 10 for measured effects of evidence-based leadership): improvement in patient clinical status and satisfaction level. First, a variety of improvement in patient clinical status was reported. improvement in Incidence of CAUTI decreased 27.8% between 2015 and 2019 (ref 2) while a patient-centered quality improvement project reduced CAUTI rates to 0 (ref 10). A significant decrease in transmission rate of MRSA transmission was also reported (ref 27) and in other study incidences of CLABSIs dropped following of CHG bathing (ref 14). Further, it was possible to decrease patient nausea from 18 to 5% and vomiting to 0% (ref 5) while the percentage of patients who left the hospital without being seen was below 2% after the project (ref 17). In addition, a significant reduction in the prevalence of pressure ulcers was found (ref 26, ref 29) and a significant reduction of mucositis severity/distress was achieved (ref 24). Patient falls rate decreased (ref 15, ref 16, ref 19, ref 27).

Second, patient satisfaction level after project implementation improved (ref 28). The scale assessing healthcare providers by consumers showed improvement, but the changes were not statistically significant. Improvement in an emergency department leadership model and in methods of communication with patients improved patient satisfaction scores by 600% (ref 17). In addition, new evidence-based unit improved patient experiences about the unit although not all items improved significantly (ref 18).

Stakeholder involvement in the mixed-method review

To ensure stakeholders’ involvement in the review, the real-world relevance of our research [ 53 ], achieve a higher level of meaning in our review results, and gain new perspectives on our preliminary findings [ 50 ], a meeting with 11 stakeholders was organized. First, we asked if participants were aware of the concepts of evidence-based practice or evidence-based leadership. Responses revealed that participants were familiar with the concept of evidence-based practice, but the topic of evidence-based leadership was totally new. Examples of nurses and nurse leaders’ responses are as follows: “I have heard a concept of evidence-based practice but never a concept of evidence-based leadership.” Another participant described: “I have heard it [evidence-based leadership] but I do not understand what it means.”

Second, as stakeholder involvement is beneficial to the relevance and impact of health research [ 54 ], we asked how important evidence is to them in supporting decisions in health care services. One participant described as follows: “Using evidence in decisions is crucial to the wards and also to the entire hospital.” Third, we asked how the evidence-based approach is used in hospital settings. Participants expressed that literature is commonly used to solve clinical problems in patient care but not to solve leadership problems. “In [patient] medication and care, clinical guidelines are regularly used. However, I am aware only a few cases where evidence has been sought to solve leadership problems.”

And last, we asked what type of evidence is currently used to support nurse leaders’ decision making (e.g. scientific literature, organizational data, stakeholder views)? The participants were aware that different types of information were collected in their organization on a daily basis (e.g. patient satisfaction surveys). However, the information was seldom used to support decision making because nurse leaders did not know how to access this information. Even so, the participants agreed that the use of evidence from different sources was important in approaching any leadership or managerial problems in the organization. Participants also suggested that all nurse leaders should receive systematic training related to the topic; this could support the daily use of the evidence-based approach.

To our knowledge, this article represents the first mixed-methods systematic review to examine leadership problems, how evidence is used to solve these problems and what the perceived and measured effects of evidence-based leadership are on nurse leaders and their performance, organizational, and clinical outcomes. This review has two key findings. First, the available research data suggests that evidence-based leadership has potential in the healthcare context, not only to improve knowledge and skills among nurses, but also to improve organizational outcomes and the quality of patient care. Second, remarkably little published research was found to explore the effects of evidence-based leadership with an efficient trial design. We validated the preliminary results with nurse stakeholders, and confirmed that nursing staff, especially nurse leaders, were not familiar with the concept of evidence-based leadership, nor were they used to implementing evidence into their leadership decisions. Our data was based on many databases, and we screened a large number of studies. We also checked existing registers and databases and found no registered or ongoing similar reviews being conducted. Therefore, our results may not change in the near future.

We found that after identifying the leadership problems, 26 (84%) studies out of 31 used organizational data, 25 (81%) studies used scientific evidence from the literature, and 21 (68%) studies considered the views of stakeholders in attempting to understand specific leadership problems more deeply. However, only four studies critically appraised any of these findings. Considering previous critical statements of nurse leaders’ use of evidence in their decision making [ 14 , 30 , 31 , 34 , 55 ], our results are still quite promising.

Our results support a previous systematic review by Geert et al. [ 32 ], which concluded that it is possible to improve leaders’ individual-level outcomes, such as knowledge, motivation, skills, and behavior change using evidence-based approaches. Collins and Holton [ 23 ] particularly found that leadership training resulted in significant knowledge and skill improvements, although the effects varied widely across studies. In our study, evidence-based leadership was seen to enable changes in clinical practice, especially in patient care. On the other hand, we understand that not all efforts to changes were successful [ 56 , 57 , 58 ]. An evidence-based approach causes negative attitudes and feelings. Negative emotions in participants have also been reported due to changes, such as discomfort with a new working style [ 59 ]. Another study reported inconvenience in using a new intervention and its potential risks for patient confidentiality. Sometimes making changes is more time consuming than continuing with current practice [ 60 ]. These findings may partially explain why new interventions or program do not always fully achieve their goals. On the other hand, Dubose et al. [ 61 ] state that, if prepared with knowledge of resistance, nurse leaders could minimize the potential negative consequences and capitalize on a powerful impact of change adaptation.

We found that only six studies used a specific model or theory to understand the mechanism of change that could guide leadership practices. Participants’ reactions to new approaches may be an important factor in predicting how a new intervention will be implemented into clinical practice. Therefore, stronger effort should be put to better understanding the use of evidence, how participants’ reactions and emotions or practice changes could be predicted or supported using appropriate models or theories, and how using these models are linked with leadership outcomes. In this task, nurse leaders have an important role. At the same time, more responsibilities in developing health services have been put on the shoulders of nurse leaders who may already be suffering under pressure and increased burden at work. Working in a leadership position may also lead to role conflict. A study by Lalleman et al. [ 62 ] found that nurses were used to helping other people, often in ad hoc situations. The helping attitude of nurses combined with structured managerial role may cause dilemmas, which may lead to stress. Many nurse leaders opt to leave their positions less than 5 years [ 63 ].To better fulfill the requirements of health services in the future, the role of nurse leaders in evidence-based leadership needs to be developed further to avoid ethical and practical dilemmas in their leadership practices.

It is worth noting that the perceived and measured effects did not offer strong support to each other but rather opened a new venue to understand the evidence-based leadership. Specifically, the perceived effects did not support to measured effects (competence, ability to understand patients’ needs, use of resources, team effort, and specific clinical outcomes) while the measured effects could not support to perceived effects (nurse’s performance satisfaction, changes in practices, and clinical outcomes satisfaction). These findings may indicate that different outcomes appear if the effects of evidence-based leadership are looked at using different methodological approach. Future study is encouraged using well-designed study method including mixed-method study to examine the consistency between perceived and measured effects of evidence-based leadership in health care.

There is a potential in nursing to support change by demonstrating conceptual and operational commitment to research-based practices [ 64 ]. Nurse leaders are well positioned to influence and lead professional governance, quality improvement, service transformation, change and shared governance [ 65 ]. In this task, evidence-based leadership could be a key in solving deficiencies in the quality, safety of care [ 14 ] and inefficiencies in healthcare delivery [ 12 , 13 ]. As WHO has revealed, there are about 28 million nurses worldwide, and the demand of nurses will put nurse resources into the specific spotlight [ 1 ]. Indeed, evidence could be used to find solutions for how to solve economic deficits or other problems using leadership skills. This is important as, when nurses are able to show leadership and control in their own work, they are less likely to leave their jobs [ 66 ]. On the other hand, based on our discussions with stakeholders, nurse leaders are not used to using evidence in their own work. Further, evidence-based leadership is not possible if nurse leaders do not have access to a relevant, robust body of evidence, adequate funding, resources, and organizational support, and evidence-informed decision making may only offer short-term solutions [ 55 ]. We still believe that implementing evidence-based strategies into the work of nurse leaders may create opportunities to protect this critical workforce from burnout or leaving the field [ 67 ]. However, the role of the evidence-based approach for nurse leaders in solving these problems is still a key question.

Limitations

This study aimed to use a broad search strategy to ensure a comprehensive review but, nevertheless, limitations exist: we may have missed studies not included in the major international databases. To keep search results manageable, we did not use specific databases to systematically search grey literature although it is a rich source of evidence used in systematic reviews and meta-analysis [ 68 ]. We still included published conference abstract/proceedings, which appeared in our scientific databases. It has been stated that conference abstracts and proceedings with empirical study results make up a great part of studies cited in systematic reviews [ 69 ]. At the same time, a limited space reserved for published conference publications can lead to methodological issues reducing the validity of the review results [ 68 ]. We also found that the great number of studies were carried out in western countries, restricting the generalizability of the results outside of English language countries. The study interventions and outcomes were too different across studies to be meaningfully pooled using statistical methods. Thus, our narrative synthesis could hypothetically be biased. To increase transparency of the data and all decisions made, the data, its categorization and conclusions are based on original studies and presented in separate tables and can be found in Additional files. Regarding a methodological approach [ 34 ], we used a mixed methods systematic review, with the core intention of combining quantitative and qualitative data from primary studies. The aim was to create a breadth and depth of understanding that could confirm to or dispute evidence and ultimately answer the review question posed [ 34 , 70 ]. Although the method is gaining traction due to its usefulness and practicality, guidance in combining quantitative and qualitative data in mixed methods systematic reviews is still limited at the theoretical stage [ 40 ]. As an outcome, it could be argued that other methodologies, for example, an integrative review, could have been used in our review to combine diverse methodologies [ 71 ]. We still believe that the results of this mixed method review may have an added value when compared with previous systematic reviews concerning leadership and an evidence-based approach.

Our mixed methods review fills the gap regarding how nurse leaders themselves use evidence to guide their leadership role and what the measured and perceived impact of evidence-based leadership is in nursing. Although the scarcity of controlled studies on this topic is concerning, the available research data suggest that evidence-based leadership intervention can improve nurse performance, organizational outcomes, and patient outcomes. Leadership problems are also well recognized in healthcare settings. More knowledge and a deeper understanding of the role of nurse leaders, and how they can use evidence in their own managerial leadership decisions, is still needed. Despite the limited number of studies, we assume that this narrative synthesis can provide a good foundation for how to develop evidence-based leadership in the future.

Implications

Based on our review results, several implications can be recommended. First, the future of nursing success depends on knowledgeable, capable, and strong leaders. Therefore, nurse leaders worldwide need to be educated about the best ways to manage challenging situations in healthcare contexts using an evidence-based approach in their decisions. This recommendation was also proposed by nurses and nurse leaders during our discussion meeting with stakeholders.

Second, curriculums in educational organizations and on-the-job training for nurse leaders should be updated to support general understanding how to use evidence in leadership decisions. And third, patients and family members should be more involved in the evidence-based approach. It is therefore important that nurse leaders learn how patients’ and family members’ views as stakeholders are better considered as part of the evidence-based leadership approach.

Future studies should be prioritized as follows: establishment of clear parameters for what constitutes and measures evidence-based leadership; use of theories or models in research to inform mechanisms how to effectively change the practice; conducting robust effectiveness studies using trial designs to evaluate the impact of evidence-based leadership; studying the role of patient and family members in improving the quality of clinical care; and investigating the financial impact of the use of evidence-based leadership approach within respective healthcare systems.

Data availability

The authors obtained all data for this review from published manuscripts.

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Acknowledgements

We want to thank the funding bodies, the Finnish National Agency of Education, Asia Programme, the Department of Nursing Science at the University of Turku, and Xiangya School of Nursing at the Central South University. We also would like to thank the nurses and nurse leaders for their valuable opinions on the topic.

The work was supported by the Finnish National Agency of Education, Asia Programme (grant number 26/270/2020) and the University of Turku (internal fund 26003424). The funders had no role in the study design and will not have any role during its execution, analysis, interpretation of the data, decision to publish, or preparation of the manuscript.

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Department of Nursing Science, University of Turku, Turku, FI-20014, Finland

Maritta Välimäki, Tella Lantta, Kirsi Hipp & Jaakko Varpula

School of Public Health, University of Helsinki, Helsinki, FI-00014, Finland

Maritta Välimäki

Xiangya Nursing, School of Central South University, Changsha, 410013, China

Shuang Hu, Jiarui Chen, Yao Tang, Wenjun Chen & Xianhong Li

School of Health and Social Services, Häme University of Applied Sciences, Hämeenlinna, Finland

Hunan Cancer Hospital, Changsha, 410008, China

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Contributions

Study design: MV, XL. Literature search and study selection: MV, KH, TL, WC, XL. Quality assessment: YT, SH, XL. Data extraction: JC, MV, JV, WC, YT, SH, GL. Analysis and interpretation: MV, SH. Manuscript writing: MV. Critical revisions for important intellectual content: MV, XL. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Xianhong Li .

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No ethical approval was required for this study.

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Differences between the original protocol

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Välimäki, M., Hu, S., Lantta, T. et al. The impact of evidence-based nursing leadership in healthcare settings: a mixed methods systematic review. BMC Nurs 23 , 452 (2024). https://doi.org/10.1186/s12912-024-02096-4

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Examining the experiences related to the psychological needs and future perceptions of Turkish adolescents on the basis of reality therapy: a qualitative study

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• Asiye Dursun   ORCID: orcid.org/0000-0002-4033-0034 1 &
• Nergis Canbulat   ORCID: orcid.org/0000-0002-1599-3856 2  

This qualitative study investigates adolescents’ perceptions and psychological needs regarding the future in the perspective of reality therapy. Employing a case study design as a qualitative research method, the study reached a total of 181 adolescent participants, including 125 (69.1%) girls and 56 (39.1%) boys. The data obtained from participants were analyzed using thematic analysis by the researchers. As a result of the analysis, their perceptions of the future were categorized into two themes: “Future Perception” and “Future-Oriented WDEP System.” Additionally, it is observed that they formulated various metaphors related to psychological needs. Adolescents’ perceptions of the future encompass both positive emotions, thoughts, and actions, as well as negative expressions. The findings of this research provide insights for developmental experts and mental health professionals in understanding the psychological needs and future perceptions of individuals during the crucial stage of adolescence.

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Introduction

The importance of perception for the future has been emphasized years ago and is considered a phenomenon that needs to be examined. Indeed, without perception, the future cannot be envisaged, and how to behave in the present also remains unknown. In short, when there is no perception and the future cannot be perceived, the world can become a labyrinth where inhabitants lose their sense of direction (Von Foerster, 1972 ). Evaluating the cognitive developments during the transition from childhood to adolescence and the formation of identity, individuals are observed to develop a multi-dimensional time perception that encompasses the past, present, and future (Mello & Worrell, 2014 ). However, adolescents tend to form perceptions more towards the future than the past and the present. Additionally, it is indicated that the perception of the future is an effective structure in different developmental stages (Allemand et al., 2022 ). In adolescence, perceptions of whether there is one or more paths or opportunities for the future differentiate. Therefore, examining future expectations during adolescence becomes crucial for understanding individuals, as research highlights the association of future perception with identity development, hope, and depression during this period (Allemand et al., 2022 ).

Psychological needs are expressed in different ways in different theoretical contexts. However, the satisfaction of psychological needs, emphasized in every developmental stage, increases the likelihood of healthy development and leading a fulfilling life; failure to meet these needs can lead to maladaptive functioning and pathological conditions. Similarly, it is emphasized that psychological needs have individual differences and are related to motivation and self (Deci & Ryan, 2011 ). Moreover, individuals who satisfy their needs are seen to exhibit high levels of self-regulation, perseverance, academic performance, and positive emotions, while controlling their levels of anxiety and achievement-focused success (Vansteenkiste et al., 2004 ). Considering that issues such as self, motivation, healthy development, anxiety, achievement, maladaptive functioning, and satisfaction frequently emerge during adolescence, addressing psychological needs during this period becomes crucial. Therefore, in this study, metaphors are used to explore adolescents’ perceptions regarding the satisfaction and hindrance of psychological needs and what they mean. Different perspectives are presented in detail to shed light on these perceptions.

Future perceptions of adolescents

The adolescent period can be characterized as a transitional phase preparing for adult roles. During this period, adolescents not only prepare for higher education but also make decisions about their future careers. At this juncture, adolescents, faced with tasks such as planning for the future, making choices, and decision-making, are essentially structuring their future expectations. It is observed that the most common future expectation encountered during adolescence tends to focus on career outcomes and educational success (McCabe & Barnett, 2000 ), emphasizing its significance as a crucial construct that needs to be addressed (Turcios Cotto & Milan, 2013 ). Adolescents, while preparing for higher education, are also making decisions about their future careers. At this point, adolescents facing tasks such as future planning, making choices, and decision-making are actually structuring their future expectations. Future expectations, which are expressed as cognitive maps that encompass individuals’ views, interests, and concerns about the future (Yam et al., 2018 ), are also related to emotional states such as self-concept, locus of control, coping strategies, and well-being (Şimşek, 2012 ). Another aspect of future expectations is future perception. Individuals’ perceptions of the future are expressed as the images they create in their consciousness about the future based on their perceptions of the present moment (Yam et al., 2018 ).

The fact that adolescents exhibit a greater orientation towards and engage in more future planning than adults (Prenda & Lachman, 2001 ) suggests the importance of addressing the concept during this developmental period in shaping future developmental stages. Furthermore, the significance of the concept of the future is evident in its impact on adolescents’ behavior, attitudes, and personality formation. Therefore, the examination of concepts such as future perception, anxiety, and expectations that influence individuals’ motivation is emphasized (Aytar & Soylu, 2019 ). In light of all these explanations, understanding how adolescents shape their perceptions of the future can provide insights for professionals working with individuals during this period. The evaluation of future perception and psychological needs is approached within different theoretical frameworks (Daltrey & Langer, 1984 ; Ryan, 1995 ). This study aims to assess adolescents’ perceptions of the future and psychological needs through the perspective of reality therapy.

The relationship between reality therapy, future perception, and psychological needs

When evaluating future perceptions, one can draw upon various theoretical frameworks, and it can be argued that insights from reality therapy’s theoretical explanations can also be beneficial. Glasser ( 2014 ) emphasizes that individuals can control their behaviors, choose for themselves, and underscores the importance of internal control. Furthermore, he anticipates success and happiness in the future when interpersonal relationships are healthy. Glasser also highlights the importance of focusing on the present and the future rather than the past, indicating that using the WDEP system to focus on individuals’ desires and behaviors and planning based on necessary evaluations would be functional. In this process, it is essential to focus on the client’s perceptions. Indeed, perception is a necessary element to plan for the future and evaluate the present (Von Foerster, 1972 ). Therefore, it can be considered that reality therapy provides a theoretical framework to navigate when assessing perceptions of the future.

Moreover, although reality therapy is applicable for professionals working with adolescents in psychology, social work, counseling, classroom teaching, administration, and other disciplines, more research is needed (Wubbolding, 2015 ). Given the known impact of reality therapy on increasing adolescents’ self-efficacy, responsibility, mental well-being, and mental health while reducing anxiety (Jamalabadi et al., 2022 ), it is believed to provide guidance in framing adolescents’ perceptions of the future.

Another focus of the study is adolescents’ perceptions of the four fundamental psychological needs defined within the context of reality therapy (belongingness, power, freedom, and fun). Evaluating the impact of adolescents shaping their future perceptions based on these psychological needs, as well as considering cultural structures reflecting differences in socio-cultural values, underscores the importance of examining psychological needs in the Turkish adolescent sample. Although adolescents’ needs in different cultures are often evaluated in the context of three fundamental psychological needs—autonomy, relatedness, and competence (González-Cutre et al., 2020 ; Fraguela-Vale et al., 2020 ; Liu et al., 2023 ; Vansteenkiste et al., 2020 )—there are few studies that specifically address the dimensions of love-belonging, power, freedom, and fun (Dursun, 2022 ; Harvey & Retter, 2002 ). It is emphasized that psychological needs should be addressed in these four dimensions (Harvey & Retter, 2002 ).

The importance of qualitative assessment of future perception and psychological needs

While there are various quantitative studies examining future perception and psychological needs (Allemand et al., 2022 ; Thomas et al., 2017 ), qualitative research on these topics is rarely encountered (Dursun, 2022 ). However, no study has been found that evaluates the concept of future perception, thought to be related to concepts such as responsibility, decision-making, control focus, psychological needs, and total behavior, within the context of reality therapy. Examining adolescents’ future perceptions in-depth through qualitative research methods is likely to facilitate a better understanding of their emotions, thoughts, and expectations regarding the future. Similarly, exploring their psychological needs can contribute to guiding them towards healthy directions. As a matter of fact, the basic concepts of reality therapy such as making choices, taking responsibility, evaluating the functionality of their own behaviors, making plans and implementing them (Banks, 2009 ) enable adolescents to continue to be successful. It also motivates adolescents to continue making choices that will enable them to take personal responsibility for their future behavior (Mabeus & Rowland, 2016 ). In addition, reality therapy helps adolescents increase their self-confidence and express their own needs without hesitation (Wahyuningsih, 2018 ), and reduces the risk of experiencing hopelessness and identity crisis (Mahmoodi et al., 2013 ). In light of all these explanations, it is thought that it would be appropriate to examine concepts that may be related to adolescents’ future perceptions and psychological needs with the concepts of reality therapy. Because it can be said that experiencing an identity crisis, having a sense of hope and being motivated in future-oriented behaviors will shape the perception of the future. Similarly, it is emphasized that meeting psychological needs is very important for adolescents (Dursun, 2022 ). As stated, one of the important concepts of reality therapy is psychological needs. Consequently, this study is considered important as the first research to investigate adolescents’ future perceptions in the light of reality therapy, focusing on adolescents’ psychological needs in conjunction with evolving and changing life conditions, and utilizing qualitative research methods. Additionally, it is expected that the findings of this study will serve as a foundation and provide data for future research on adolescents’ future perceptions and reality therapy. Lastly, it is believed that the results of this research will offer insights into psychological counseling and guidance services provided to adolescents in schools, particularly in terms of planning their futures and addressing important topics such as psychological needs, responsibility, and control.

Methodology

Participants.

In the research, a convenient sampling method, which is one of the sampling methods in qualitative research, has been used. Convenient or accessible sampling relies on readily available, easily accessible elements (Patton, 2005 ). However, adolescents who are still in the adolescence period, attending formal education, and willingly informed their families about the research, participated in the study. In this context, interviews were conducted with a total of 181 adolescents, with an average age of 15.36, including 125 (69.1%) girls and 56 (39.1%) boys. Care was taken to interview participants from each grade level. Among the participants, 55 (30.4%) were in the 9th grade, 77 (42.5%) in the 10th grade, 26 (14.4%) in the 11th grade, and 23 (12.7%) in the 12th grade. Additionally, an effort was made to reach participants from different types of schools. Indeed, 157 participants (86.7%) attend Anatolian High Schools, 13 (7.2%) attend Social Sciences High Schools, 7 (3.9%) attend Anatolian Imam Hatip High Schools, and 4 (2.2%) attend Vocational High Schools. Their academic averages vary between 41 and 88, with an average of 73.74. Although this study was planned in a qualitative pattern, the reason for the large number of participants is that it was tried to explain the future perceptions and psychological needs of adolescents in the context of maximum diversity sampling. In this way, different situations can be represented and situations can be fully described from multiple perspectives (Henwood, 2014 ). In this study, adolescents of different genders, different grade levels, different school types, and parents with different education levels were included in the study to ensure maximum diversity. Thus, this research, planned in a qualitative pattern, will provide repeatable and convincing results, and the sample will be included in the universe. It has been supported to include all its elements (Creswell, 2013 ).

In the research, ethical approval for the study Scientific Research Publication Ethics Committee. This study was approved by The Humanitarian Sciences Scientific Research and Publication Ethics Committee on 04.04.2022 (ReferenceNo: 2022/11 − 05). The author declare that they have no conflict of interest. Furthermore, an informed consent form and parental consent form were added to the online interview questionnaire. The reason for choosing the online environment to collect data through in-depth interviews in the study is cost and time efficiency (Abidin & de Seta, 2020 ). Adolescents willing to participate in the interviews were informed about the research and provided with a link to the interview questionnaire. Responding to the interview questions in the online environment took an average of 20 min, and the interview data were collected between May and November 2022. Participants no incentives (money, food, gifts, etc.) were provided for participating in the interviews. Due to the large number of participants, numerical ordering was used instead of names.

Validity and reliability studies

In order to enhance the validity and reliability of the research, several measures were taken. To improve validity, the research process and participants (gender, grade level, academic average) were described in detail. Additionally, in the findings section, participant sentences that could serve as examples for codes were presented in detail, including the participant’s gender and grade level information. To ensure reliability in the research, participants were provided with detailed information about the scope of the study, and their voluntary participation was encouraged. Furthermore, the roles of the researchers were predefined, and the process was systematically carried out.

Throughout the research process, including question formulation and analysis, literature-supported procedures were followed, and the research method was thoroughly described. Moreover, one of the measures taken to enhance reliability was seeking expert opinions, as suggested by Creswell ( 2013 ). In this study, opinions were obtained from two experts. Finally, in accordance with Miles and Huberman’s ( 1994 ) formulation, inter-rater reliability is expected to exceed 70%. In this study, reliability was calculated as 86%.

The interview questions included in the interview form prepared by the researchers were grounded in the theoretical foundation of reality therapy. The form underwent modifications after three expert reviews who were knowledgeable about reality therapy and had experience in qualitative question formulation. The questions were designed to delve into adolescents’ future perceptions, starting more broadly and aiming to access both positive and negative aspects of adolescents’ future perceptions. The questions include: (i) How do you imagine your future life? (ii) What are you doing today to achieve your future life? (What are the obstacles, resources, and strengths? ) (iii) When you evaluate what you are doing/not doing today to achieve your future life, what comes to mind? (iv) When you evaluate what you are doing/not doing today to achieve your future life, what advice would you give to yourself? (v) What are your thoughts about the future? (vi) What are your feelings about the future? (vii) What are your beliefs about the future? (viii) How do you meet your psychological needs (love, power, freedom, fun)?.

Coding and analysis

The data analysis in the study employed theoretical thematic analysis to thoroughly organize and describe the data. The process began with the researcher deciphering and repeatedly reading the data, followed by the creation of initial codes, searching for themes, reviewing and creating a thematic map of the themes, and finally, naming and reporting the themes (Braun & Clarke, 2006 ).

In this context, after collecting data from the AD and NC researchers, the process involved rereading the data set multiple times, eliminating unanswered or tangentially answered, and incomplete interview forms from the data mass to reach the final data set for analysis. Subsequently, two researchers simultaneously focused on key terms related to the concepts of reality therapy to perform initial coding. The codes were then categorized and a map was created by AD, which was presented to NC. NC examined the data set in the context of her own code categories, and the process continued with several iterations. Throughout this process, the fundamental concepts of reality therapy were taken into consideration.

Finally, after obtaining the themes, the researchers presented them to experts for their feedback. Following feedback from two experts knowledgeable in reality therapy and qualitative research, the findings were finalized and compiled into a report. The themes, codes, and categories related to adolescents’ future perceptions are presented in Table  1 , while metaphors related to their psychological needs are provided in Table  2 .

Adolescents’ views on future perception

The findings related to adolescents’ future perceptions are presented in Table  1 . These are organized into two main themes: ‘Future Perception’ and ‘Future-Oriented WDEP System.’ Under the theme of Future Perception, six categories were identified, including psychological needs, control, quality world, total behavior, responsibility, and identity formation.

• Psychological needs

The adolescents who participated in the research mentioned their needs for love-belongingness (f = 162) , fun (f = 157) , freedom (f = 110) , and power (f = 90). Adolescents who perceived the need for love-belongingness as essential, healing, and fundamental expressed meeting this need through environmental resources such as social support and hobbies. They fulfill this need by showing love, feeling valued, meeting the power need through physical, spiritual, verbal, and internal contact. Similarly, the need for fun is met through social contacts and support, hobbies, technology use, showing love, and using humor. Adolescents believe that unhealthy coping mechanisms and lack of awareness or fulfillment hinder meeting the need for fun. Regarding the need for freedom, adolescents meet it through hobbies, taking responsibility, self-control, expression, questioning, and relaxation. However, they find it challenging to satisfy the need for freedom due to reasons such as avoiding responsibility and lack of awareness. Adolescents meet the need for power through hobbies, social support, sports activities, academic efforts, personal development, internal motivation, and taking responsibility. The difficulty in recognizing and defining the need for power makes it challenging for adolescents to satisfy this need. The findings indicate that adolescents engage in different actions to satisfy various psychological needs.

These results highlight the exploration of situations where adolescents cannot meet and satisfy their needs and the need for necessary interventions. Some examples of expressions related to adolescents’ struggles in meeting or satisfying their psychological needs are presented below:

The need for love is important to me. Many things in life pass through love and beauty. I meet my need for love by spending time with my friends and family. [Girl, 10th Grade, Anatolian High School] Fun plays a small part in my life. I spend time with my friends during school breaks, I spend some time on the phone at home, but I love spending time with my mother, going out… [Girl, 9th Grade, Anatolian High School]. In my opinion, freedom is a feature that only exists in birds. There is no freedom in the family; clothing, traveling, reading… And if we are women, of course. The reason for this is the trust between them. [Girl, 12th Grade, Anatolian High School] Power is the meaning of life for me, and I provide the power I need by acting without delay, aware of my position in society, my rank, and what I can do. [Male, 12th Grade, Anatolian High School] The need for love is my raison d’être. It is the best help to start something, I meet my needs in a completely different world by reading books. [Girl, 10th Grade, Anatolian High School] In my opinion, love is necessary for every human being and this need arises from loneliness. I meet my need for love by motivating myself. [Girl, 11th Grade, Anatolian High School] It’s like a painkiller. With hugging… [Girl, 11th Grade, Anatolian High School].

As a result, as can be seen from the statements of the research participants, the psychological needs (Love-belonging, Power, Freedom, Fun) that are fundamental to reality therapy are also effective on their lives. It is particularly noteworthy that their efforts to meet Love-Belongingness and Fun needs are intense. This is clearly seen in the metaphors in which they express their perception of need. Adolescents often compare their Love, Belonging and Fun needs to vital needs such as eating and breathing. In this regard, it can be considered important to focus on meeting these needs and how they are met in preventive and therapeutic studies with adolescents.

Under the category of control, the desire to satisfy psychological needs (f = 84) , effort/dream to achieve goals (f = 74) , positive perception of the future (f = 17) , and negative perceptionsof the future (f = 21) emerged. Adolescents express a desire to control and satisfy their psychological needs, such as being happy and strong in the future, gaining economic power, and meeting the needs for fun and freedom. Additionally, efforts to achieve future goals, such as acquiring a profession, being goal-oriented, and exhibiting perfectionism, indicate a sense of control. Moreover, it is observed that adolescents may have negative perceptions of the future based on a lack of awareness, loneliness, and hopelessness, leading to a feeling of lack of control in this regard. According to reality therapy, gaining internal control is crucial for adolescents. These findings suggest the need to focus on adolescents’ negative perceptions of control and situations where they do not feel in control. In this study examined from the perspective of Reality therapy, the efforts of the participants to gain control over their lives in their statements about the future draw attention. In this respect, it can be said that it is important to provide opportunities for adolescents to feel in control in their future planning and studies on this subject. Some statements expressing adolescents’ feelings related to the control category are provided below:

My biggest dream is that I can express my thoughts freely, that people accept me as I am, and that my thoughts and decisions I make are respected. [Girl, 11th Grade, Vocational High School] It’s like seeing cheerful faces every day, my career being as I expected, and a peaceful life. [Girl, 10th Grade, Anatolian High School] Going to another city or even country for university. [Male, 10th Grade, Anatolian High School] Living a perfect life with family or alone. [Male, 10th Grade, Anatolian High School]

World of quality

In this category, adolescents mentioned positive motivation for the future (f = 100) and negative motivation for the future (f = 39). The quality world is a structure that includes situations, events, people, and perceptions that individuals value. It is effective in meeting and motivating individuals to take action to satisfy their psychological needs. In this context, positive motivation for the future that facilitates adolescents in taking action and satisfying their needs includes positive beliefs about themselves, beliefs about goals, positive beliefs about the environment, spiritual beliefs, and hope. Additionally, it has been found that some adolescents have negative beliefs about themselves and the environment in their quality world. This situation may negatively impact adolescents’ perceptions of the future and lead to a lack of motivation in satisfying their psychological needs. Therefore, there may be a need for interventions addressing the negative perceptions in adolescents’ quality world. Some statements expressing adolescents’ feelings related to the quality world category are provided below:

We will be a happy country, we will leave the difficult days behind. [Girl, 11th Grade, Anatolian High School] I believe that I will be rewarded for my efforts in the future. [Girl, 9th Grade, Vocational High School] Even though I want to be successful, I believe that I will fail when I see my grades. [Girl, 11th Grade, Anatolian High School]

Total behavior pattern

Adolescents’ efforts to achieve future-oriented goals (f = 158) , their emotions about the future (f = 209) , and thoughts about satisfying their psychological needs (f = 32) are evaluated within the pattern of total behavior. Total behavior assesses individuals’ emotions, thoughts, actions, and physiology. In this context, adolescents believe that to reach the lives they envision in the future, they need to be goal-oriented, set goals, be organized, be determined, and have internal control. Additionally, adolescents experiencing hopelessness, feelings of insecurity, and future anxiety believe that meeting economic, motivational, entertainment, power, and time needs is crucial when planning their futures. It is noteworthy that adolescents generally express negative emotions about the future. Adolescents mentioned positive emotions (f = 75), negative emotions (f = 107), and neutral emotions (f = 27) when talking about their future feelings. In positive emotions, they feel happy, hopeful, proud, and peaceful, while in negative emotions, they feel stressed, hopeless, unhappy, excited, sad, anxious, worried, and uneasy. Some adolescents also had difficulty describing and naming their emotions. These findings suggest the importance of paying attention to negative emotions related to future perceptions when working with adolescents. Below are some statements expressing adolescents’ feelings in the total behavior category:

I worked very hard and got the job I wanted… [Girl, 9th Grade, Anatolian High School]. I recommend doing what I want, when I want, without stressing myself too much, so I can be more productive. [Girl, 10th Grade, Anatolian High School] I should take better care of myself, I should plan better… [Girl, 12th Grade, Anatolian High School]. No one can guarantee that they will be with us in 5 years, so we need to chart and evaluate our path accordingly. [Male, 10th Grade, Anatolian High School] Spending more time watching movies and TV series and not worrying so much about the future… [Girl, 10th Grade, Anatolian High School]. I dream motivating dreams for myself and my only wish is to pass the class this year, and if I pass, I want to shine as a different person from everything and everyone for the next 2 years. [Girl, 10th Grade, Anatolian High School] I would say use your time wisely because these times will never come again. Even if you become a very successful and rich person in the future, the only thing you cannot buy is time. [Girl, 12th Grade, Anatolian High School]

Responsibility

Adolescents also mentioned the concept of responsibility for the future in their statements. They stated that there are internal sources (f = 136) and external sources (f = 6) regarding responsibility. While talking about internal resources such as economic, academic, personal development efforts and personal power source, they also stated the importance of external resources such as academic support and social support resources. Responsibility is a very important concept for reality therapy. Similarly, it is very important to be able to take responsibility in terms of both developmental tasks and the career decision-making process during adolescence. It is noteworthy that the participants frequently expressed internal resources. It is thought that it will make it easier to take responsibility since the continuity of internal resources is under the individual’s control compared to external resources.

I’m working too hard. I try new things to discover myself. [Girl, 11th Grade, Anatolian High School] I don’t have a disability, it can’t happen. I am a patient person, my diction is good. I’ll do whatever it takes to get what I want. [Girl, 9th Grade, Anatolian High School] My obstacles are myself, my resources are my books, my strength is my best friend… [Girl, 10th Grade, Anatolian High School]. My resources: My family’s support, highly disciplined and qualified teachers… [Male, 10th Grade, Anatolian High School].

Identity achievement

Adolescents also talked about identity achievement, which is one of the important concepts of reality therapy and adolescence, by talking about successful identity patterns (f = 30) and unsuccessful identity patterns (f = 8) for the future. In their statements, adolescents stated successful identity patterns when talking about concepts such as the desire for control, the acquisition of autonomy, and the desire for social order. They also mentioned unsuccessful identity patterns by including unrealistic expectations and avoiding responsibility. Therefore, according to the research results, it becomes crucial to pay attention to adolescents’ unrealistic expectations and tendencies to avoid responsibility and to intervene as necessary. This way, support can be provided for adolescents to achieve successful identity formation.

I want my feet to be firmly on the ground and to live a life without depending on anyone. [Girl, 12th Grade, Anatolian Imam Hatip High School] I would like to have what I want at my fingertips at any time. [Girl, 10th Grade, Anatolian High School]

Future-oriented emotions

Adolescents’ feelings about the future are categorized under three headings: positive affect (f = 75) , negative affect (f = 107) , and neutral affect (f = 27). Under positive affect, adolescents mentioned feeling hopeful , happy , peaceful , and proud , while also expressing feelings such as hopelessness , anxiety , worry , stress , and unease . Some adolescents also had difficulty describing their emotions. It is noteworthy that adolescents experience negative emotions more frequently than positive emotions. On the basis of reality therapy, attention is paid to the relationship of negative emotions with needs that are not met or are not met in a healthy way.

When I think about my feelings towards the future, I feel hopeful. At least, there are positive feelings inside me for my own future. It’s like everything is going to be really great. [Girl, 9th Grade, Anatolian High School] I feel very sad and scared when I think about not being able to succeed or not reaching my dreams…[Girl, 10th Grade, Anatolian High School]. I don’t know…[Girl, 10th Grade, Anatolian High School].

Four categories were obtained under Future-oriented WDEP system theme in Table  1 . These are wants , doing , evaluation and planning , which are the concepts of reality therapy.

Under this category, adolescents mentioned their expectations of meeting physical (f = 36) and psychological needs for the future (f = 52). They emphasized future economic well-being and physical health in their expectations of meeting physical needs. They also talked about meeting their needs for fun, power and freedom in the future, and their desire to start a family and socialize. When evaluated in the context of future perceptions, wants become highly important as they have the potential to shape the future. This is because wants are qualitative in nature. In this regard, it can be considered that professionals working with adolescents can focus on wants with a perspective of meeting their psychological and physical needs when examining their future perceptions. The wants section could be considered the part where professionals working with adolescents would gain the most information about the perception of the future. This is because adolescents form their wants based on their perceptions of the future. Therefore, considerations could be made for wants such as family, socialization, and meeting needs to be part of adolescents’ perception of the future. Below are some statements expressing adolescents’ wants:

To have a good economic income and to be a happy and healthy person. [Girl, 10th Grade, Anatolian High School] I want to be someone who made my name known. [Girl, 12th Grade, Anatolian Imam Hatip High School] No matter what happens to me, I just need someone to support me. [Girl, 9th Grade, Social Sciences High School] A free life without interference. [Male, 11th Grade, Anatolian High School] A comfortable, fun, non-tiring life [Girl, 10th Grade, Anatolian High School].

Under this category, adolescents have discussed what they do concerning their future-oriented actions. They have mentioned avoidance of responsibility (f = 20) and efforts to achieve their goals (f = 47). Additionally, they have emphasized efforts to achieve their goals when discussing what they do for their future. In their statements, they have mentioned concepts like motivating themselves, setting goals, and making plans. In their expressions, they have talked about inaction, a perception of inadequacy, and procrastination behaviors. These statements reveal a range of attitudes and behaviors among adolescents regarding their actions and aspirations for the future, including both challenges and efforts to reach their goals. In the doing phase, adolescents can gain awareness as they evaluate their own behaviors. Indeed, experiences such as avoiding responsibility, procrastination, and feeling inadequate may arise, negatively impacting their future perceptions. In the context of avoiding responsibility, it becomes crucial for professionals working with adolescents to focus on the adolescents’ current situations and behaviors.

I try to study, try to understand. I’m not doing my best at everything, but I can if I want to, yet I still procrastinate. [Girl, 10th Grade, Anatolian High School] I don’t have many obstacles; my family is supportive. I’ve already started preparing for the university entrance exam. I’ll study all summer, no matter what happens, and I won’t give up. Over the next two years, I plan to study a lot and secure a good major so that I won’t be unemployed. [Girl, 10th Grade, Anatolian High School]

Adolescents’ evaluations of their future can be categorized into three main areas: avoidance of responsibility (f = 87) , efforts to achieve goals (f = 58) and confronting reality (f = 38). They have used concepts representing avoidance behavior such as procrastination, insufficient effort, external locus of control, perception of obstacles, negative self-efficacy beliefs, negative emotions, and neutrality. Regarding their efforts to achieve the goal, they mentioned that they work goal-oriented, have positive efficacy beliefs, need to plan, and internal locus of control. While evaluating their future behavior, they also made statements regarding their awareness that they were facing the truth. Adolescents’ healthy evaluation of their current situation may make it easier for their future perceptions and goals to be more realistic. In this regard, it is important to support adolescents who need evaluation at this stage or who have low self-awareness.

I start studying very late; I prolong my start time, and I check my phone too much. [Boy, 10th Grade, Anatolian High School] I feel like I can’t make it, even if I study, it feels like I can’t survive in this country or achieve a profession in this education system. [Girl, 9th Grade, Anatolian High School] I feel like I can succeed in one way and not in another. I’m in a void. [Boy, 11th Grade, Anatolian High School] I’m making an effort, but I feel exhausted, just like Mac-Ready in the movie ‘The Thing’. [Boy, 10th Grade, Anatolian High School] I believe that if everything I plan goes well, I will hit my target right in the middle. [Girl, 12th Grade, Anatolian High School] I get stressed a lot, I shouldn’t do this, and that’s why I usually lose in the future. I think if I continue like this, I will lose. Mostly, sometimes my self-confidence is shaken. If I do this, I may lose again in the future. [Girl, 10th Grade, Anatolian High School]

Adolescents have shared action-oriented (f = 106) and emotion-focused thoughts (f = 53) regarding their future. In their future plans, they have discussed goal-oriented, family-building, migration, personal growth, economic, and responsibility-oriented behaviors. In addition, their statements included positive expressions such as hopeful future perception, as well as economic anxiety, future anxiety, negative perception of social order and thoughts of uncertainty. It is thought that adolescents’ positive or negative feelings and perceptions about the future may have an impact on their plans. As a matter of fact, emotions are an element related to thoughts and behaviors from a total behavioral perspective. In this respect, negative perceptions and emotions about the future need to be intervened. In addition, it is considered important to raise awareness about the future, which is perceived with unrealistic optimism.

I want to live in South Korea and this is not a dream for two days, I have been thinking about it for about a year and a half and now I am sure that I really want it. [Girl, 9th Grade, Anatolian High School] I want to be advanced in every field, for example, I want to learn different languages, play the guitar and piano, and improve more in painting. And I want to do more sports in the future. [Girl, 11th Grade, Anatolian High School] I hope that animal laws will become stricter and that those who hurt animals, violence, harass and rape women will be punished up to death. [Girl, 10th Grade, Anatolian High School] I don’t know what kind of life I will live, what kind of life is waiting for me, I am definitely worried that if I lose out on this path, I will experience great difficulties. [Male, 11th Grade, Anatolian High School]

Perceptions of adolescents regarding psychological needs

In Table  2 , findings related to metaphors used by adolescents to understand their perceptions of psychological needs are presented. Adolescents used metaphors to express their perceptions of these needs in the psychological needs category. They emphasized the fundamental nature and necessity of all psychological needs, creating metaphors that conveyed meanings such as basic needs and requirements, healing properties like medicine and vitamins for the love-belongingness need. For the power need, they used metaphors conveying the meanings of necessity, struggle, effort, protection, and healing. In expressing the freedom need, adolescents used metaphors like a bird, flying, and self-discovery to highlight relaxation and self-awareness. Regarding the fun need, they discussed its basic and necessary aspects, as well as its motivational properties, using metaphors like going to an amusement park, zest for life, and support. When metaphors are examined, it is seen that psychological needs are very important for adolescents. It is particularly noteworthy that they attach vital importance to the need for love and belonging. Therefore, it is important to understand to what extent psychological needs are necessary for adolescents and to support them in meeting their needs in a healthy way.

Love is a need for me, it is the reason for my existence. It is the best help to start something, and I meet my needs by reading books, entering a whole different world. [Female, 10th grade, Anatolian High School] Power is very important to me. Sometimes, I don’t know how I will do it. I feel like I am in a race. [Male, 12th grade, Anatolian High School] The need for freedom is like the most necessary thing for me to live comfortably in the future. [Female, 10th grade, Anatolian High School] For me, it is one of the body’s greatest needs, and I meet my needs by walking around in friend environments.’ [Male, 12th grade, Anatolian High School].

This study examines the meanings attributed by adolescents to future perceptions and psychological needs within the framework of reality therapy concepts. In this context, six categories were initially identified under the theme of future perception: psychological needs, control, quality world, total behavior pattern, responsibility, and identity achievement. When examining research findings, the importance of psychological needs, one of the fundamental concepts of reality therapy, is frequently emphasized during adolescence. Similarly, needs that are stated to be innate and universal in research (Glasser, 2014 ) are considered as the source of behaviors (Wubbolding, 2015 ). In research findings, adolescents particularly emphasize the significance of the need for love and belongingness, considering it essential and one of the healing and basic needs, also reflected in the metaphors they use. Similarly, in reality therapy, this need is recognized as a fundamental requirement (Wubbolding, 2015 ). Furthermore, during adolescence, which is a transitional period, the degree to which an adolescent satisfies psychological needs from the individuals in their relationships becomes crucial. Indeed, the importance of the need for relationship building during adolescence is emphasized. On the other hand, the need for love and belongingness is known theoretically as one of the most challenging psychological needs to fulfill. This is because it is acknowledged that at least one other person is required to meet this need. Therefore, how this need is met is also crucial. In research findings, adolescents state that they meet their needs for love and belongingness by using environmental resources such as social support and hobbies. Parallel to this, Booker ( 2004 ) emphasizes that the development of a strong sense of belonging is part of adolescence. From this perspective, it is essential for adolescents to meet their need for love and belongingness and to use various sources such as social support and hobbies. This is because the healthy fulfillment of needs in reality therapy is crucial for successful identity formation. According to the research results, adolescents consider the need for entertainment, such as the need for love and belongingness, as a fundamental need. The need for entertainment is known within the framework of reality therapy as the easiest need to fulfill, seen as necessary for increasing and sustaining well-being (Yorgun & Voltan-Acar, 2014 ). When considering adolescents, the need for entertainment is crucial. Adolescents mention that they can meet this need through social contact and support, hobbies, technology use, expressing love, and using humor. However, attention may need to be paid to the positive or negative use of humor in interactions with individuals or environments where the need for entertainment is met. Using dark humor or establishing contact in risky environments while meeting the need for entertainment can be considered unhealthy use. This situation may pose a risk to unsuccessful identity formation and damage the need for freedom. In this context, adolescents, in their metaphors, emphasize that the need for entertainment is fundamental and necessary, providing motivation. Adolescents state that the need for freedom is necessary for the present and future, fundamental, vital, and associated with relaxation. They emphasize this through metaphors. From this perspective, it can be considered that adolescents intensely feel the need for freedom. This is because adolescents under the age of 18 act together with individuals who are responsible for them in terms of financial aspects and the implementation of decisions (Dursun, 2020 ). This may make it difficult to meet this need. In the study, adolescents mentioned that they can meet the need for freedom through hobbies, taking responsibility, self-control, expression, questioning, and relaxation. Another perspective is that situations may arise where the need for freedom conflicts with the need for love and belongingness. While an adolescent satisfies the need for love and belongingness by being part of a group such as family, friend group, religion, etc., it is thought that this situation may make it difficult to meet the need for freedom (Yorgun & Voltan-Acar, 2014 ). However, Glasser emphasizes the importance of not harming others’ needs and taking responsibility when satisfying the need for freedom. In this regard, adolescents’ efforts to control themselves and take responsibility may be an indicator that they are trying to meet their needs successfully. Adolescents believe that they meet the need for power through hobbies, social support, sports activities, academic effort and activities, personal development efforts, internal motivation, and taking responsibility. Attempting to discover one’s internal strength, being able to make decisions by taking one’s responsibility, and building positive relationships with people are important for development and psychological well-being (Yorgun & Voltan-Acar, 2014 ; Wubbolding, 2015 ; Dursun, 2022 ). The research results also show that adolescents meet these needs positively, not by exerting power over others.

One of the strong findings in this study is the ways in which adolescents meet their psychological needs. It is emphasized that discussing adolescents’ future needs and expectations is crucial and significantly contributes to their development (Ege, 2018 ). The indication of how psychological needs in adolescent development are met in this research will serve as a guiding factor for parents, mental health professionals, and social support sources in addressing these needs. Additionally, the evaluation of psychological needs in the context of four fundamental psychological needs—namely, love and belonging, power, freedom, and fun—in this study aims to broaden the relevant literature, emphasizing the necessity of approaching needs from this perspective (Harvey & Retter, 2002 ).

While adolescents strive to meet their psychological needs, the perception of control in adolescents is active, and their quality world is also in the process of renewal (Ünüvar, 2012 ). Adolescents aspire to control future happiness, gain economic power, and meet entertainment and freedom needs. However, efforts to achieve future goals, efforts to have a profession, goal-oriented behavior, and tendencies toward perfectionism are indicative of adolescents feeling in control. Additionally, some adolescents lack awareness of their future, have negative perceptions based on loneliness and hopelessness, and, in this regard, feel a lack of control. According to reality therapy, it is crucial for adolescents to gain internal control. These findings suggest a need to focus on adolescents’ negative perceptions of control and situations where they do not feel in control. Moreover, considering that motivation increases when psychological needs are met (Maralani et al., 2016 ), adolescents may increase the likelihood of creating a positive perception of the future by feeling in control. In short, in the process of planning future expectations, it becomes crucial for adolescents to have positive orientations toward the future, be aware of their values, and internal motivational sources. This is because when adolescents have high internal motivation, they can make their own decisions, cope with the negative effects of stress, and establish healthier relationships with their environment. In other words, they can feel in control. Planning various studies to help adolescents gain control over their future perceptions, develop their quality worlds, and acquire responsibility could be beneficial. Additionally, interventions focused on reality therapy have been shown to be effective for adolescents in terms of internal control and academic motivation (Kim & Hwang, 2001 ).

In the study, adolescents discussed concepts such as the desire for control, gaining autonomy, and the desire for social order, effectively indicating successful identity patterns. They also emphasized unsuccessful identity patterns by including expressions related to creating unrealistic expectations and avoiding responsibility. Adolescents with positive attitudes towards the future are thought to be able to develop a healthy identity. Therefore, during adolescence, Seginer ( 2003 ) considers the orientation towards the future or individuals’ images of the future as an important developmental task since it lays the groundwork for planning goals. When adolescents explore opportunities for the future, they discover new things and support the formation of their own identities. In parallel, attention is drawn to vocational tendencies regarding identity acquisition and development. Becoming a professional and receiving education for it, and thus preparing for life, is important for identity acquisition during adolescence. These studies highlight future expectations such as professional success, economic gain, and a happy marriage (Yavuzer et al., 2005 ; Öztürk & Uluşahin, 2011 ; Konate & Ergin, 2018 ; Avar, 2019 ). The research findings also indicate that adolescents have similar perceptions of the future. Within the focus of reality therapy, the successful development of adolescent identities, the formation of a positive self-perception, making healthy choices, taking responsibility, and meeting basic psychological needs are effective in shaping adolescents’ future perceptions and assisting them in becoming healthy adults (Zeira & Dekel, 2005 ; Yalçın, 2007 ). Furthermore, in the research, adolescents also mentioned unsuccessful identity patterns. Similarly, in a study, adolescents who perceived themselves as unable to use personality resources efficiently and questioned identity acquisition during this period were found to have anger and inadequacy perceptions towards themselves and the environment (Gümüşel, 2017 ). This could lead to unrealistic expectations and behavioral tendencies to avoid responsibility.

One of the important findings in the research is the feelings that adolescents express regarding the future. It can be said that adolescents’ positive feelings towards the future are parallel to findings in other studies. It can be stated that adolescents experiencing positive feelings towards the future have an increased subjective well-being, and the likelihood of experiencing depression and anxiety feelings decreases (Young et al., 2019 ). In another study, it is indicated that individuals who exhibit positive feelings towards the future and approach it with an optimistic, hopeful perspective will be determined to achieve their goals, make efforts, and demonstrate a positive attitude (İmamoğlu & Güler-Edwards, 2007 ). Similarly, it has been revealed in a parallel study that as adolescents’ hopes increase, their levels of psychological well-being also increase. The source of negative feelings can stem from unmet psychological needs according to reality therapy. These felt emotions challenge the adolescent because adolescence is a period of emotional difficulty and also carries the risk of new onset of anxiety and depressive disorders (Young et al., 2019 ). Therefore, working on emotion regulation skills during this period will contribute to the adolescent’s development of a positive perception towards the future and psychological well-being. Additionally, due to the uncertainties of the future, it can lead to negative feelings in adolescents. For these reasons, adolescents may need motivation, planning, and evaluation for a positive perception of the future (Şimşek, 2011 ).

The second theme obtained from the research findings is the WDEP system for the future. Under this theme, four categories were identified: wants, doing, evaluations, and planning. In the wants category, there was an emphasis on the expectation of economic well-being and physical health in the future as part of meeting physical needs. Additionally, adolescents expressed wants related to meeting the future needs for entertainment, power, and freedom, as well as aspirations for family formation and socialization. It is observed that social support is an important factor in shaping adolescents’ expectations for the future (Sulimani-Aidan & Benbenishty, 2011 ). Wants are an important stage in understanding the needs that drive behavior in reality therapy. In a study, it was found that adolescents want a satisfying job, family, and economic power, and they aspire to have job security, similar to the research results (Briones et al., 2011 ).

The WDEP system in reality therapy aligns closely with three fundamental processes present in the perception of the future. These three fundamental processes are motivation, planning, and evaluation. In a study on how adolescents perceive the future, it is shown that the goals and interests of adolescents relate to the core developmental tasks of late adolescence and early adulthood, reflecting expected lifelong development. The family context has also been found to influence adolescents’ interests, plans, causal attributions, and emotional responses regarding the future (Nurmi, 2004 ). Adolescents’ evaluations of the future are categorized under three headings: avoidance of responsibility, striving for goals, and confronting reality. In their expressions, adolescents included concepts representing avoidance behavior, such as procrastination, insufficient effort, external locus of control, perception of obstacles, negative self-efficacy beliefs, negative emotions, and neutrality. The overall structure of avoidance of responsibility may involve behaviors that prevent individuals from accepting their own wrongdoings through faulty attributions, cognitive biases, and distortions. Similarly, in a study where adolescents indicated obstacles to achieving their future expectations, they believed that obstacles stemmed from negative environmental conditions and themselves. Factors such as not working hard enough, fear of failure, exam stress, lack of self-confidence, and laziness are considered obstacles originating from themselves (Ege, 2018 ). In contrast to these findings, it is also observed that some adolescents are optimistic about their future. It is thought that increasing optimism or reducing pessimism about the future could contribute to a healthy perception of the future.

Adolescents have mentioned action-oriented and emotion-oriented thoughts about the future. In their future plans, they have talked about goal-oriented, family formation, migration, development, economic, and responsibility-oriented behaviors. Expectations, goal setting, planning, and decision-making about the future are important in adolescence, making adolescents’ choices critical. Adolescents have thoughts about the future, such as completing school, building a career, starting a family, having children, experiencing a romantic relationship, having a profession, leading a happy life, achieving economic well-being, taking social responsibility, and maintaining health (Ege & Erbay, 2022 ). Additionally, it is stated that adolescents’ future goals have a multidimensional structure (Giota, 2010 ). The results of this study also indicate that adolescents are similarly goal-oriented. The multidimensional nature of adolescents’ plans for the future is a crucial factor to be considered in future studies. In the current behaviors of adolescents, there is observed procrastination, inaction, and a perception of inadequacy. This is a factor that needs attention. Adolescents who do not take responsibility due to procrastination, inaction, and a perception of inadequacy may develop a negative perception of the future. Similarly, adolescents have expressed negative statements such as economic anxiety, future anxiety, negative perception of social order, and thoughts of uncertainty. While waiting for the future, adolescents plan activities to achieve their goals and evaluate the likelihood of achieving them. Emotional components, whether positive or negative, can motivate life planning, decision-making processes, and behaviors by reflecting how much they believe they can influence their future. Having a positive or optimistic orientation toward the future can help adolescents make decisions while preparing for adulthood. An adolescent with a positive future orientation is more willing to set goals, make plans, and be successful in problem-solving, tolerating disappointment, or maintaining flexibility (Neblett & Cortina, 2006 ). Therefore, studies focusing on encouraging adolescents to make optimistic evaluations and plan for the future become crucial. When the statements of the participants are evaluated in the context of the stages of the WDEP system, it is seen that the psychological and physical needs of adolescents mostly create their wishes. Again, avoiding responsibility is a risk factor for adolescents who think they need to strive for their goals and be action-oriented. however, adolescents prefer their plans to be action-oriented rather than emotion-oriented. In this respect, it can be emphasized that when working with adolescents, the WDEP system will contribute to their awareness, that responsibility should be taken into consideration and that it is important to be action-oriented with plans.

Lastly, adolescents have emphasized the fundamental nature and necessity of all psychological needs and used metaphors to convey this. Adolescents who do not have their psychological needs met are reported to experience emotional and behavioral problems, struggling to establish and manage relationships (Glasser, 2014 ). In a study, adolescents expressed a greater need for freedom and a lower need for power and control as fundamental needs. It was found that girls expressed a greater need for love and belonging and a lower need for entertainment compared to boys (Harvey & Retter, 2002 ). Another study found a positive relationship between adolescents’ psychological well-being, psychological needs, and positive outcomes (Hamurcu & Sargın, 2011 ). Research supports that as psychological needs are met, subjective well-being, motivation, life satisfaction, and the desire for learning increase, leading to more successful initiation and maintenance of relationships (Demirbaş-Çelik, 2018 ; Guo, 2018 ). Therefore, the opinions of adolescents regarding the satisfaction of their psychological needs in the future are highly important. In studies examining the level and satisfaction of psychological needs, it has been found that as psychological needs are met, aggression, submissive behavior, and exam anxiety decrease, while motivation, life satisfaction, the desire for learning, and competence increase (Hamurcu & Sargın, 2011 ; Maralani et al., 2016 ; Guo, 2018 ). One of the strengths of this research is the use of metaphors to express psychological needs. Metaphors created separately for each need have specific meanings and qualities. Metaphors are powerful mental maps that can be learned, helping individuals make sense of their lives. No studies have been found in which adolescents’ psychological needs are expressed through metaphors in the literature.

Implications for theory, research and practice

This study provides some important suggestions for new research. Within the scope of this research, suggestions for both research and practice are included. Adolescents’ awareness and healthy fulfillment of their psychological needs are seen as factors that can contribute to the development of a positive future outlook. Therefore, when working with adolescents, interventions focused on understanding and satisfying their psychological needs can be designed. Elements within the quality worlds of adolescents and the total behavior that forms their emotions, thoughts, and actions are seen as influential factors in shaping their perceptions of the future. Consequently, professionals working with adolescents may consider focusing on their cognitive and emotional states, working with distorted cognitions, and supporting adolescents in emotion regulation. In interventions aimed at planning the future with adolescents, the Reality Therapy WDEP system can be employed, especially to understand the status of their desires and aspirations. Metaphors can be utilized to explore the meanings adolescents attach to their psychological needs. Furthermore, based on the guidance of research results, intervention programs can be developed to assist adolescents in forming a positive future outlook and addressing their psychological needs in a healthy manner. Finally, it’s worth noting that this research was conducted in a qualitative design. Future studies could be planned using a mixed-methods approach, incorporating quantitative or experimental designs into the process.

Methodological limitations

The research findings and recommendations come with certain limitations that should be considered. Firstly, the study is exclusively designed in a qualitative manner. Given the qualitative nature of the research and the sample size, different designs may be needed to explain individual variations in experiences related to factors such as age, gender, and birth order. Additionally, the sample is limited to Turkish adolescents. Including different cultures and developmental stages in the research could provide a broader perspective. Lastly, the future outlook and psychological needs are presented from the perspective of reality therapy. Evaluating cases in different theoretical contexts could contribute to the development of a more comprehensive knowledge base for professionals.

This study has evaluated adolescents’ perceptions of the future and psychological needs in the perspective of reality therapy. The adolescents who participated in the research exhibit both positive and negative expressions that can be assessed concerning their perceptions of the future. Moreover, adolescents place importance on needs such as love and belonging, power, freedom, and entertainment, attempting to fulfill them through various means. The study contributes to the literature by examining adolescents’ experiences in the context of the four psychological needs of reality therapy. Additionally, it is observed that adolescents feeling internal control, and having positive emotions and thoughts that constitute their quality worlds and total behaviors are crucial. Finally, it can be stated that the WDEP system is functional in understanding adolescents’ perceptions of the future.

Data availability

The datasets generated and analyzed during the current study are available from the corresponding author on request.

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BRIEF RESEARCH REPORT article

Emotionally-oriented design in museums: a case study of the jewish museum berlin.

• 1 Escola Tècnica Superior d'Arquitectura de Barcelona, Universitat Politècnica de Catalunya, Barcelona, Spain
• 2 Faculty of Architecture and City Planning, Kunming University of Science and Technology, Kunming, Yunnan, China
• 3 The Chinese University of Hong Kong, Hong Kong, Hong Kong SAR, China

Objective: This study examines the intricate interplay between architectural design and visitor emotional responses at the Jewish Museum Berlin, focusing on how specific spatial elements such as the Holocaust Tower, Garden of Exile, The Voids, and The Axis elicit varied affective experiences. The research aims to extend the discourse on environmental psychology and architectural empathy, particularly within the context of memorial museums.

Method: Employing a non-intrusive approach, the study gathered emotional response data using the Positive and Negative Affect Schedule (PANAS) from 113 museum visitors, with 102 valid responses analyzed. Environmental conditions such as light, sound, and spatial design were quantitatively measured to correlate with emotional responses captured at the end of visitors' tours across the designated museum spaces.

Results: Findings revealed that architectural elements significantly influence emotional responses. High levels of negative emotions like fear and anxiety were markedly evident in the Holocaust Tower due to its minimal lighting and stark concrete structure. Conversely, the Garden of Exile induced more positive emotions through its use of natural light and greenery, emphasizing the role of biophilic design in enhancing emotional well-being. Statistical analysis supported these observations, with variations in emotional impact across different spaces demonstrating the profound effect of architectural design on visitor experiences.

Conclusion: This study confirms that a variety of design elements and spatial strategies not only facilitate the presentation of historical narratives but also actively sculpt the emotional involvement and experiences of visitors. Our findings highlight the efficacy of emotionally-oriented architectural design in deepening the impact and engagement of museum visitors, emphasizing the transformative power of these environments in shaping visitor perceptions and interactions.

1 Introduction

Emotions, as complex psychological states involving subjective experiences, physiological responses, and behavioral expressions, are central to the human experience. They play a critical role in how we perceive, interact with, and remember our environments. In architectural contexts, emotions can range from awe and tranquility to anxiety and discomfort, influenced by elements such as spatial proportions, lighting, acoustics, and material finishes ( Bower et al., 2019 ; Li, 2019 ; Shemesh et al., 2021 ; Zhang et al., 2022 , 2023b ). Understanding these emotional responses is crucial for creating spaces that not only serve functional needs but also foster well-being and meaningful experiences.

The interplay between architectural design and human emotion is a profound and complex subject that sits at the heart of environmental psychology and design studies. Architecture, transcending its utilitarian functions, wields the power to evoke a spectrum of emotions, shape behaviors, and create lasting memories. It is a tangible expression of culture and history, one that communicates and influences at a visceral level. Theoretical explorations in this domain affirm that the manipulation of light, volume, texture, and materiality in built environments can significantly sway individuals' mood states and psychological well-being ( Webb, 2006 ; Ergan et al., 2018 ; Jafarian et al., 2018 ; Jiang et al., 2021 ; Zhang et al., 2022 ; Kim and Hong, 2023 ).

Consider the poignant role of memorial museums, where architectural design is tasked with the delicate balance of embodying historical narratives and facilitating reflective experiences. The Jewish Museum Berlin, designed by Daniel Libeskind, serves as a prime exemplar of how spatial design is intricately woven with emotional narrative ( Sodaro, 2013 ; Tzortzi, 2017 ). This institution houses a confluence of spaces–The Axis, Garden of Exile, Holocaust Tower, and The Voids–each architecturally orchestrated to invoke distinct emotional responses from its visitors. The design embodies a dialogue between the stark realities of history and the potential for hope and renewal, leveraging the emotive capacity of architectural cues to guide visitors through a journey of collective memory and individual introspection ( Feldman and Peleikis, 2014 ).

Given this context, the Jewish Museum Berlin was selected as a case study due to Libeskind's unique architectural vision. His design deliberately creates spaces intended to evoke both positive and negative emotions, which represents a significant departure from conventional architectural goals that typically prioritize comfort and positivity. This approach provides an ideal context for investigating how architectural elements shape emotional responses. By challenging visitors to engage with historical narratives on a deeply emotional level, Libeskind's design makes the Jewish Museum Berlin a compelling subject for studying the impact of architectural empathy.

The Axis, a metaphorical intersection of pathways, not only directs physical movement but also choreographs the emotional pacing of the visitor experience. The Garden of Exile, with its forest of pillars and disorienting angles, contrasts against the Holocaust Tower's imposing walls and constrained slivers of light, illustrating how light manipulation can be a powerful affective tool ( Edensor, 2017 ; Zhang et al., 2022 ). The Voids, silent and resonant, offer a multisensory engagement that is as much about the presence of sound as it is about the voids of silence, echoing research that highlights the deep connection between sensory environments and emotional states ( Henshaw and Mould, 2013 ; Fiebig et al., 2020 ; Algargoosh et al., 2022 ).

To effectively measure these emotional responses, various psychometric tools have been developed. One such tool is the Profile of Mood States (POMS), which assesses transient, distinct mood states through a series of adjectives rated by the respondent ( McNair et al., 1971 ). Another is the Positive and Negative Affect Schedule (PANAS), which evaluates positive and negative affective states and is widely recognized for its reliability and validity in diverse settings ( Watson et al., 1988 ). Additionally, tools like the Self-Assessment Manikin (SAM) provide a non-verbal pictorial assessment of emotional response, particularly useful in environments where verbal articulation may be challenging ( Bradley and Lang, 1994 ).

Within this architectural milieu, the present study seeks to quantitatively investigate the emotional impact of these spaces on visitors. It draws upon the Positive and Negative Affect Schedule (PANAS) scale, a widely recognized metric for assessing affective dimensions ( Watson et al., 1988 ). By grounding the subjective in the empirical, this research aims to contribute substantively to the dialogue on the empathetic capacity of architectural environments. It posits that designed spaces, particularly within the context of memorial museums, can function as catalysts for empathy, eliciting a range of emotions from contemplative sorrow to uplifting tranquillity ( Watson, 2015 ; Golańska, 2015 ; Oren et al., 2022 ).

In synthesizing the PANAS findings with theoretical discourse, the study will explore how architectural form and content can act synergistically to enhance visitor engagement. It will address the interplay of memory, emotion, and place, offering insights into how spatial narratives can be thoughtfully constructed to resonate with visitors on an emotional and cognitive level. Such insights are anticipated to extend the current frameworks for architectural and environmental psychology, providing nuanced understandings of how spaces can be crafted to not just house experiences, but to actively shape and define them ( Manzo, 2003 ; Shin, 2016 ).

Through this exploration, the study underscores the dynamic role of architecture in emotional storytelling within museum contexts. It is poised to offer valuable implications for design practices that seek to engage visitors beyond the visual, delving into the affective realm where architecture meets emotion, memory, and meaning ( Lukas, 2012 ; Tolia-Kelly et al., 2017 ).

2.1 Participants

This study adopted a non-intrusive method of data collection with visitors at the Jewish Museum Berlin, ensuring the authenticity of the emotional responses ( Webb et al., 1999 ). Data were gathered from museum-goers at the conclusion of their visit to the Holocaust Tower, Garden of Exile, the “The Voids”, and the Axis spaces designed to provoke a range of emotional experiences. Research staff approached visitors at the exit of the museum, inviting those who had completed their tour to participate in the study. This strategy prioritized capturing the spontaneous emotional reactions of visitors, rather than pre-selected volunteers, thereby preserving the natural behavior and experiences within the museum environment.

Upon exiting, participants were asked to complete the Positive and Negative Affect Schedule (PANAS), a questionnaire that assesses a spectrum of emotional states triggered by the architectural and environmental attributes of the spaces visited. In addition to the PANAS, demographic data such as age, gender, and nationality were collected to facilitate a demographic breakdown of the emotional responses. The study engaged a total of 113 participants. After processing, 102 questionnaires were considered valid for analysis, with 11 discarded due to incompleteness. The demographics of the sample were diverse, with 59.46% identifying as female and 40.54% as male. The age distribution was as follows: 18–30 years old (33 participants), 31–40 years old (32 participants), 41–50 years old (31 participants), and over 50 years old (17 participants). All participants provided informed consent, ensuring ethical research practice.

2.2 Architectural space description

The Jewish Museum Berlin, designed by Daniel Libeskind, is a striking example of contemporary memorial architecture. The museum comprises several distinctive spaces, each with its unique architectural features intended to evoke a range of emotional responses ( Figure 1 ). Below is a comprehensive description of these spaces, encompassing their spatial dimensions and design solutions.

Figure 1 . (A) Schematic Overview of the Jewish Museum Berlin: the four main architectural spaces explored in this study–Holocaust Tower, Garden of Exile, The Axis, and The “Voids.”, (B) Plan of the Jewish Museum Berlin.

The Axis is a series of intersecting corridors that connect different parts of the museum. These pathways are designed to create a sense of direction and movement, guiding visitors through the museum's narrative. The walls are adorned with exhibits that provide context to the historical events commemorated by the museum. The Garden of Exile is an outdoor space featuring 49 concrete stelae, each 6 meters high, arranged in a grid pattern. The ground is tilted, creating a sense of disorientation and confusion, symbolizing the experience of exile. The stelae are filled with earth from Berlin and Jerusalem, emphasizing the connection between the past and the present. The Holocaust Tower is a tall, narrow, and empty space, measuring 24 meters in height with a small slit at the top allowing minimal natural light. The space is designed to evoke feelings of isolation, confinement, and introspection. The concrete walls and the stark, cold atmosphere contribute to the somber experience intended by the architect. The Voids are a series of empty spaces that run vertically through the building. These voids are intended to represent the absence of Jews in Berlin following the Holocaust. The largest of these voids, the Memory Void, contains an installation called “Shalekhet” (Fallen Leaves) by artist Menashe Kadishman, consisting of thousands of metal faces spread across the floor.

Libeskind's design employs sharp angles, irregular forms, and voids to convey the complexity and trauma of Jewish history. The use of materials such as concrete and steel, along with the interplay of light and shadow, enhances the emotional impact of the spaces. These architectural solutions are not merely aesthetic but are deeply symbolic, intended to engage visitors on both an intellectual and emotional level.

2.3 Measures

The Positive and Negative Affect Schedule (PANAS) was used to assess participants' emotional responses. PANAS is a widely recognized scale that measures two dimensions of affect: Positive Affect (PA) and Negative Affect (NA). Each dimension consists of 10 items. Participants rate the extent to which they feel each emotion on a scale from 1 (very slightly or not at all) to 5 (extremely). The Positive Affect items include interested, excited, strong, enthusiastic, proud, alert, inspired, determined, attentive, and active. The Negative Affect items include distressed, upset, guilty, scared, hostile, irritable, ashamed, nervous, jittery, and afraid ( Watson et al., 1988 ).

2.4 Environmental measurements

In the Jewish Museum Berlin, comprehensive environmental and acoustic measurements were gathered from four distinct spaces using a suite of instruments: a sound level meter (Smart sensor AS804), light meter (UNI-T UT383), temperature and humidity meter (UNI-T UT333), audio recorder (Tascam DR-100MK III), and spectrometer (Sekonic C-700). These instruments were employed to collect precise data, as shown in Figure 2 .

Figure 2 . Comparative Environmental Measurements across Four Spaces of the Jewish Museum Berlin: (A) Holocaust Tower, (B) The Voids, (C) The Axis, and (D) Garden of Exile. Each panel presents light and sound spectra, accompanied by temperature, humidity, and decibel range data.

The purpose of presenting the data about color temperature, light intensity, sound levels, temperature, and humidity is to provide a detailed environmental context for each space within the museum. These environmental factors are known to significantly influence human emotional and psychological responses ( De Rojas and Camarero, 2008 ). By measuring and documenting these parameters, the study aims to explore how specific environmental conditions may influence the emotional responses reported by visitors, thereby offering a more comprehensive understanding of how architectural elements affect visitor experiences ( Goulding, 2000 ; Bigné et al., 2005 ; Halpenny, 2010 ).

For example, in the Holocaust Tower, illumination ranged from 2.7 to 5.7 Lux, with a natural spectrum color temperature of 4918K. The low lighting and cooler color temperature contribute to the overall somber and reflective atmosphere of the space. The temperature was recorded at 16.3 °C, and humidity at 46.3%, with sound levels varying between 39 and 84 decibels. The significant height of the space, 21 meters, created an echo effect, intensifying the auditory experience and potentially heightening feelings of isolation and introspection.

The Garden of Exile was illuminated much more variably, between 2,940 and 18,400 Lux, with natural light color temperatures from 5986 to 6234K, temperature at 16.6 °C, and humidity at 37.4%. Sound levels here ranged from 43.7 to 71.5 decibels, with ambient sounds such as bird calls enriching the outdoor environment. The variation in light intensity and the presence of natural elements like vegetation are intended to evoke feelings of confusion, displacement, but also a sense of connection to nature, promoting reflection and contemplation.

In “The Voids”, indoor natural light levels were measured from 279 to 429 Lux and color temperatures between 5716 to 5914K. The space was warmer at 19.7 °C and more humid at 58.7%, with sound levels reaching up to 98.2 decibels due to the presence of art installations and specific architectural acoustics. These environmental characteristics contribute to a complex sensory experience that engages visitors on multiple levels.

Finally, The Axis, defined as a pathway, recorded illumination levels from 67.5 to 115 Lux and cooler color temperatures of 3056 to 3081K. The temperature there was around 22 °C and humidity at 36.7%. Sound levels, affected by visitor interactions, reached up to 77.8 decibels, with LED lighting that limited the depth of sensory engagement.

The time frame used for measuring the sound spectrum in each space was standardized to a continuous 10-minute interval during peak visiting hours. This period was selected to capture the typical ambient noise levels and visitor interactions within each environment. The audio recordings were analyzed to determine the average and peak decibel levels, as well as the frequency distribution of sounds, ensuring a comprehensive acoustic profile of each space.

By presenting these environmental measurements, the study aims to explore how the physical characteristics of each space may influence the emotional reactions they elicit. This approach provides a nuanced understanding of how specific environmental conditions might contribute to the overall emotional impact of architectural design in a museum setting.

2.5 Analysis strategy

The study utilized the Positive and Negative Affect Schedule (PANAS) to measure emotional responses after visitors explored four distinct sections of the Berlin Jewish Museum: the Holocaust Tower, The Axis, The Voids, and the Garden of Exile. Data processing was meticulously carried out using Python, leveraging libraries such as Pandas for data manipulation and NumPy for numerical operations. This ensured the precision of the PANAS scores, which are crucial for assessing the immediate impact of each spatial design on visitors' emotions ( Hovy, 2022 ).

Statistical analyses were conducted using independent samples t-tests to evaluate emotional variances across different spatial elements, with 'The Axis' serving as a baseline comparison. This analysis was facilitated by the SciPy library, a tool integral to executing statistical tests in Python. Additionally, the effect sizes were computed using Cohen's d, providing insights into the magnitude of emotional responses elicited by each architectural element ( Howell, 1992 ).

The Axis was selected as the baseline for comparison due to its transitional nature and relative neutrality in emotional design. Unlike the Holocaust Tower, The Voids, and the Garden of Exile, which are explicitly designed to evoke strong emotional responses, The Axis serves primarily as a connective pathway linking different parts of the museum. Additionally, The Axis features exhibits along its sides, embodying characteristics typical of a standard museum exhibition space. This makes it an ideal reference point for measuring variations in emotional impact across more emotionally charged spaces. By using The Axis as a baseline, the study can more accurately isolate and identify the specific emotional influences of the other architectural elements.

The entire analysis was conducted and documented using a Jupyter Notebook, which facilitates the integration of live code with narrative text, enhancing the clarity and reproducibility of the research. We adhered to a conventional significance threshold of p < 0.05 throughout our analyses to ensure the statistical validity of our findings. The use of the SciPy library was central to our statistical analysis, allowing us to perform robust t-tests and calculate effect sizes efficiently. This, along with other Python tools such as Pandas for data manipulation, greatly streamlined the process and enhanced our ability to manipulate and visualize data effectively ( Virtanen et al., 2020 ; McKinney, 2022 ).

By employing robust statistical tools and a reliable data analysis environment, the study effectively quantified the emotional impacts of architectural design, setting a precedent for future research in the domain of emotional architecture.

3.1 Emotional responses across different spaces

This study conducted a comprehensive analysis of emotional responses to the architectural spaces within the Berlin Jewish Museum, namely the Holocaust Tower, The Axis, The Voids, and the Garden of Exile. Data extracted from Table 1 , which displays the average PANAS (Positive and Negative Affect Schedule) scores for each space, reveals nuanced patterns in emotional engagement.

Table 1 . Average PANAS scores for emotional responses across architectural spaces at the Jewish Museum Berlin: the table delineates the intensity of each emotion reported by visitors in the Holocaust Tower, The Axis, The Voids, and the Garden of Exile.

Low affect emotions: Emotions such as guilt (Guilty) and shame (Ashamed) consistently scored low across all spaces, with average scores of 1.97, 1.70, 1.93, and 1.38 for Guilty and 1.57, 1.54, 1.43, and 1.45 for Ashamed in the Holocaust Tower, The Axis, The Voids, and Garden of Exile respectively. These low scores suggest that the museum's exhibits are less likely to evoke feelings of personal responsibility or embarrassment, likely reflecting the thematic elements focused more on historical reflection than on personal culpability.

Stable affect emotions: Emotions such as alertness (Alert) and activeness (Active) manifested moderately across all spaces, indicating a general state of engagement. For example, Alert scores were 4.13, 2.99, 3.72, and 2.44, while Active scores were 2.12, 2.64, 2.67, and 4.02 across the Holocaust Tower, The Axis, The Voids, and Garden of Exile respectively. These scores indicate that the museum's design consistently engages visitors, maintaining their attention and physical activity throughout the exhibits.

Highly variable emotions: Within the Berlin Jewish Museum, thematic and design differences had a pronounced impact on emotional responses in specific spaces. The Holocaust Tower exhibit, for instance, significantly elicited higher levels of distress-related emotions, with fear (Afraid) and anxiety (Nervous) scoring 3.80 and 3.94 respectively. These heightened scores likely reflect the intense historical context that the exhibit aims to convey. In stark contrast, the Garden of Exile area proved to be a space that fostered positive emotional states, achieving scores of 3.59 for inspiration (Inspired) and 4.06 for interest (Interested). These results highlight the Garden of Exile's effectiveness in evoking feelings of reflection and positive engagement, showcasing how different environmental themes can distinctly influence visitor emotions.

Positive emotions:

Active ( Figure 3E ): Among the positive emotions, the feeling of activeness showed the largest variance across the spaces. The scores for Active were 2.12 in the Holocaust Tower, 2.64 in The Axis, 2.67 in The Voids, and significantly higher at 4.02 in the Garden of Exile. This results in a maximum difference of 1.90, indicating that the Garden of Exile notably enhances visitors' feelings of activeness compared to the other spaces.

Figure 3 . Emotional profiles and distributions in the Jewish Museum Berlin's architectural spaces: (A) Positive emotions radar chart. (B) Negative emotions radar chart. (C) Box plot of the distribution of positive emotion PANAS scores across different spaces. (D) Box plot of the distribution of negative emotion PANAS scores across different spaces. (E) Violin plot comparison for active across spaces. (F) Violin plot comparison for afraid across spaces. (G) Violin plot comparison for attentive across spaces. (H) Violin plot comparison for ashamed across spaces. Asterisks denote significance levels ( * p < 0.05, ** p < 0.01, *** p < 0.001).

Attentive ( Figure 3G ): In contrast, the emotion of attentiveness exhibited the smallest variance among the positive emotions. Scores were 2.98 in the Holocaust Tower, 2.73 in The Axis, 3.95 in The Voids, and 3.96 in the Garden of Exile, with a maximum difference of 1.23. This suggests a relatively consistent level of attentiveness across all exhibits, with slightly higher engagement in the latter two spaces.

Negative emotions:

Afraid ( Figure 3F ): For negative emotions, the feeling of fear (Afraid) showed the greatest variance. Scores were 3.80 in the Holocaust Tower, 2.10 in The Axis, 3.33 in The Voids, and 1.56 in the Garden of Exile, resulting in a maximum difference of 2.24. This indicates that the Holocaust Tower significantly elicits higher levels of fear compared to the other spaces, reflecting its intense historical context.

Ashamed ( Figure 3H ): Conversely, the emotion of shame (Ashamed) exhibited the smallest variance among negative emotions. The scores were 1.57 in the Holocaust Tower, 1.54 in The Axis, 1.43 in The Voids, and 1.45 in the Garden of Exile, with a minimal maximum difference of 0.14. These consistently low scores suggest that the museum's exhibits are less likely to evoke feelings of personal responsibility or embarrassment, likely due to their focus on historical reflection rather than personal culpability.

3.2 T-test results of emotional responses

Drawing on data visualized in the radar charts ( Figures 3A , B ) and the box plots ( Figures 3C , D ), this study offers an in-depth examination of the emotional responses to different spatial environments within the Berlin Jewish Museum: Holocaust Tower, The Axis, The Voids, and Garden of Exile. The Positive and Negative Affect Schedule (PANAS) scores provide a nuanced exploration of how each space influences visitors' emotional states.

From the radar charts, it's evident that certain spaces amplify specific emotions. The Holocaust Tower exhibit, as shown in Figure 3B , registers pronounced distress-related responses, particularly fear and anxiety, while the Garden of Exile, depicted in Figure 3A , facilitates positive emotions such as inspiration and interest.

The box plots in Figures 3C , D quantify these observations:

• Holocaust Tower vs. The Axis: While the Holocaust Tower space did not significantly differ from the Axis in terms of positive emotional responses (t-statistic of -0.997; p-value of 0.320; Cohen's d of -0.14), it markedly elevated negative emotions (t-statistic of 6.625; p -value of 3.15 × 10 −10 ; Cohen's d of 0.93), as Figure 3D illustrates.

• The Voids vs. The Axis: Figure 3C reveals that The Voids space engendered a significant increase in positive emotions compared to the Axis (t-statistic of 3.555; p -value of 4.74 × 10 −4 ; Cohen's d of 0.50). Figure 3D reflects a similar trend in negative emotions (t-statistic of 3.849; p-value of 1.60 × 10 −4 ; Cohen's d of 0.54).

• Garden of Exile vs. The Axis: As the most positively impactful environment, the Garden of Exile's influence on positive emotions is statistically significant (t-statistic of 9.376; p -value of 1.48 × 10 −17 ; Cohen's d of 1.31). Conversely, it substantially reduces negative emotions (t-statistic of -8.174; p -value of 4.24 × 10 −14 ; Cohen's d of -1.14), reinforcing its restorative role as seen in Figure 3D .

These detailed results, grounded in statistical analysis and visual evidence, underscore the profound and varied emotional impacts that architectural elements have on museum visitors, highlighting the importance of thoughtful spatial design in influencing visitor experience.

4 Discussion

The findings of this study provide a comprehensive analysis of the influence of architectural design on emotional responses, as illustrated by the experiences of visitors to the Jewish Museum Berlin. The statistical data from the PANAS questionnaires, along with the radar charts ( Figures 3A , B ) and box plots ( Figures 3C , D ), provided a multidimensional view of how each distinct space within the museum evoked varying emotional states among the participants.

4.1 Interpretation of findings

The results of this study, particularly the heightened negative emotional responses in the Holocaust Tower exhibit, suggest a complex interplay of environmental factors rather than solely the impact of low lighting on mood. Contrary to the expected calming effects of low lighting identified in studies by de Ruyter and van Dantzig (De Ruyter and Van Dantzig, 2019) , Kombeiz ( Kombeiz et al., 2017 ), and others, the Holocaust Tower's unique combination of minimal natural light, the stark, cold concrete architecture, and the towering voids, uniquely contributed to visitors' feelings of fear and anxiety ( Campens, 2017 ). This distinct atmosphere, characterized by its chilling austerity and vast, empty spaces, was effectively aligned with the exhibit's thematic intent to invoke deep reflection on a dark period in history.

Conversely, the Garden of Exile leverages the principles of biophilic design through its integration of natural light and vegetation, echoing Evensen et al.'s assertion of nature's positive effects on human emotion ( Dash, 2017 ; Evensen et al., 2017 ). This space consistently evoked feelings of inspiration and interest among visitors, suggesting that biophilic elements in architectural design can significantly contribute to the promotion of positive emotional states.

Furthermore, the auditory experience provided by “The Voids” sound installations played a crucial role in shaping the museum's emotional atmosphere, substantiating DeNora's findings on the emotive power of sound ( DeNora, 2000 ; Ebbensgaard, 2017 ; Tavakoli et al., 2017 ). This multisensory approach appears to have been successful in enhancing visitors' emotional engagement, underpinning the significance of considering auditory elements within architectural spaces.

This study extends the current discourse on environmental psychology by empirically demonstrating the differential emotional impacts elicited by distinct architectural elements within a museum context. The substantial variance in emotional responses to each space underlines the potential for architecture to serve not merely as a backdrop for exhibits but as an active participant in the storytelling process of a museum. These insights offer valuable contributions to the field, suggesting that architectural design, when thoughtfully executed, has the power to evoke a deeply emotional narrative and profoundly affect the visitor experience.

4.2 Implications for architectural design

The quantitative findings of this research underscore the complex role that architectural spaces play as dynamic mediators of emotional experience within museums. The design of the Axis in the Jewish Museum Berlin, acting as a connector between the various thematic spaces, effectively sets the stage for an emotional transition, thereby heightening the contrast in affective responses as visitors move from one space to another.

This relational dynamic between the spaces suggests that the emotional impact of a museum visit is not solely dependent on the artefacts displayed but is significantly influenced by the journey the architecture curates. The Axis, therefore, serves a pivotal role in the emotional narrative of the museum, underpinning the importance of considering the sequence of spatial experiences in museum design. It is an interesting and essential aspect that architects and designers need to deliberate upon–the emotional interplay between successive spaces and its cumulative effect on visitor engagement.

The empirical evidence from this study supports the argument for a holistic approach to museum architecture, one that includes the intentional use of varying architectural elements to evoke and modulate emotions throughout the visitor's journey. The affective dimension of spatial design, as observed in the Jewish Museum Berlin, is a testament to the capacity of thoughtful architectural planning to not only showcase exhibits but also to elicit a spectrum of emotions that enrich the overall narrative and experience.

4.3 Limitations and future research

The present study, while offering valuable insights, has several limitations that warrant mention. The timing of the questionnaires was not synchronized with the measurement of environmental factors, which may affect the accuracy of capturing visitors' immediate emotional responses, particularly in the Garden of Exile space. As an outdoor area, the Garden is subject to environmental and weather variations, making it challenging to ensure a consistent experience for all visitors. This variability was not controlled for in the study and represents a potential confound in interpreting the emotional impact of this space.

The discrepancy in timing between the visitors' experiences and the administration of the PANAS questionnaire could lead to recall bias, where participants may not accurately remember or may reinterpret their emotional states after the fact. Cultural backgrounds and the age of participants were also not factored into the analysis, which could influence the interpretation of the emotional responses elicited by the museum's spaces. Additionally, the possibility of repeat visits by participants was not a consideration in the study's design, potentially affecting the novelty of the experience and subsequent emotional responses.

To address these limitations, future research could consider employing virtual reality (VR) technology to simulate the museum environment under controlled conditions, ensuring uniformity in visitors' experiences regardless of external factors such as weather. VR technology allows for the control of environmental variables, providing a consistent and replicable experience for all participants. Additionally, VR can facilitate the collection of physiological measures of emotional responses, such as galvanic skin response or heart rate variability, providing a more objective and nuanced understanding of the emotional effects of architectural spaces. Moreover, VR technology can be used to capture and analyze facial expressions to quantify emotions, adding another layer of emotional data. This method, as demonstrated in previous research ( Zhang et al., 2023a ), can provide real-time insights into participants' emotional states, offering a more comprehensive assessment of their experiences. Further investigation with a larger and more diverse sample, taking into account cultural and age differences, would also be beneficial in enhancing the generalizability of the findings to other commemorative architectural contexts. This approach would ensure that the emotional impacts of architectural design are understood across a broad spectrum of visitors, contributing to more inclusive and effective design strategies.

5 Conclusions

This study tentatively suggests that architectural elements such as lighting, vegetation, and sound may have a significant impact on the emotional responses of visitors to the specific spaces analyzed within the Jewish Museum Berlin. The findings indicate that minimal lighting in the Holocaust Tower likely intensified visitor experiences of sombre reflection, while the use of natural light and greenery in the Garden of Exile might have enhanced feelings of inspiration and interest. Similarly, sound installations in The Voids appear to have deepened the emotional engagement of the visitors.

These preliminary observations propose that the thoughtful integration of architectural and environmental factors can potentially enrich the visitor experience in commemorative spaces, offering a nuanced approach to museum design that goes beyond traditional exhibit presentation. However, it is important to note that this study focused solely on four specific spaces within the museum and did not include the exhibition spaces. Therefore, while our findings provide valuable insights, further research is necessary to confirm these observations and to explore their applicability in other settings within memorial museums.

Data availability statement

The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.

Ethics statement

The studies involving humans were approved by Universitat Politécnica de Catalunya Ethics Committee. The studies were conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study.

Author contributions

ZZ: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Validation, Visualization, Writing – original draft, Writing – review & editing. JL: Funding acquisition, Methodology, Resources, Validation, Visualization, Writing – original draft, Writing – review & editing. XZ: Conceptualization, Funding acquisition, Investigation, Methodology, Visualization, Writing – original draft, Writing – review & editing.

The author(s) declare that no financial support was received for the research, authorship, and/or publication of this article.

Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher's note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

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Keywords: emotionally-oriented design, emotional architecture, museum design, architectural psychology, visitor experience, environmental psychology

Citation: Zhang Z, Lu J and Zhang X (2024) Emotionally-oriented design in museums: a case study of the Jewish Museum Berlin. Front. Psychol. 15:1423466. doi: 10.3389/fpsyg.2024.1423466

Received: 25 April 2024; Accepted: 18 June 2024; Published: 05 July 2024.

Reviewed by:

Copyright © 2024 Zhang, Lu and Zhang. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Jing Lu, lujing@ymcc1993.com

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

2024 Theses Doctoral

Mortality Myths?: Testing the Claims of the Theory of Deaths of Despair

Segura, Luis Esteban

A groundbreaking narrative, which would come to be known as the theory of “deaths of despair”, emerged in 2015 from a study by Case and Deaton analyzing mortality rates in the United States between 1999 and 2013. They found an increasing trend in all-cause mortality rates due to drug poisonings, alcohol-related liver disease, and suicides, which they called “deaths of despair”, among non-Hispanic (NH) white Americans aged 45 to 54—this age group was called the midlife. Case and Deaton’s findings and their narrative about the hypothetical causes of their findings garnered significant attention. The authors of this narrative hypothesized that the observed increases in mortality rates were due to white individuals in midlife increasingly suffering from “despair” and proposed a causal link between increasing “despair” rates and increased mortality rates only among white Americans in midlife. Case and Deaton did not provide a clear definition of “despair”; they presumed that white Americans in midlife were hopeless about their prospects for the future compared to what their parents had attained. This provocative narrative persisted and gained momentum because it functioned as an explanation of recent events like the 2016 U.S. presidential election, rise in white nationalism, and far right extremism. These white-related events were thought to be expressions of an agonizing, poor, under-educated generation of white Americans increasingly suffering from hypothetical feelings of "despair”, which have led them to self-destructive behaviors and premature death. However, no study has investigated the central claim of this theory: whether there is evidence of an association between increased “despair” rates and increased mortality rates only among white individuals in midlife, particularly for those with low education. Moreover, there is little evidence of their hypothesis of an increasing epidemic of “despair” affecting only white Americans in midlife, particularly those with low education. The theory of “deaths of despair” can be understood through Geoffrey Rose’s framework of causes of incidence and causes of cases, which highlights the difference between between-population and inter-individual causes of disease. Rose’s argues that causes of incidence explain the changes in outcome rates between populations, and may be uniform and imperceptible within populations. On the other hand, the causes of cases explain why some individuals within a population are susceptible or at high risk of the outcome. Like Rose’s causes of incidence, the authors of the theory of “deaths of despair” argue that “despair” increased between the midlife white American population in 1999 and in 2014, which led to increased mortality rates. Conversely, this theory does not claim that some individuals are at higher risk of death due to “despair”, which would be analogous to causes of cases. Therefore, the contrast of interest to test the central claim of Case and Deaton’s theory of “deaths of despair” is a between-population contrast (causes of incidence). As such, this dissertation aims to test the claims of the theory of “deaths of despair” proposed by Case and Deaton at the right level (causes of incidence). I began by conducting a scoping review of the current literature providing empirical support to the different elements of this theory: 1) socioeconomic causes as causes of “despair”, “diseases of despair”, “deaths of despair”, and all-cause mortality, and 2) “despair” as the cause of “diseases of despair”, “deaths of despair”, and all-cause mortality. I found 43 studies that I organized and displayed in two graphs according to Rose’s causes of cases (individual-level causes of “deaths of despair”) and causes of incidence (between-population level causes of “deaths of despair” rates). In each graph, I showed the number of studies that provided evidence for the individual- or population-level elements of the theory of “deaths of despair”. Of these 43 studies, I found that only 13 studies explicitly stated that they tested this theory. Three studies provided different definitions of “despair”, which did not align with the previous vague definition provided by Case and Deaton about white individuals’ hopeless about their prospects for the future. Most studies provided individual-level evidence for “despair” increasing the likelihood of death and despair-related outcomes, which is analogous to a type III error—a mismatch between the research question and the level at which the studies’ design and analyses were conducted to answer that question. Further, no study addressed at the right level—between populations—the central claim of the theory of “deaths of despair”. This led me to review the literature around concepts similar to “despair” and propose a suitable indicator to test the claims of the theory of “deaths of despair”. I leveraged data from the National Health Interview Survey and the Centers for Disease Control mortality data to test whether increases in the prevalence of “despair” were associated with increases in all-cause mortality rates only among white individuals in midlife and whether this effect was bigger among low educated white individuals. To obtain a valid estimate of this association, I adapted econometric methods to develop a valid estimator of the association between increasing “despair” prevalence and increased all-cause mortality rates. After adjusting for potential confounders at the between-population level, I found that the trends in the prevalence of “despair” were negligible across all race and ethnic groups and that an increasing trend could not be identified. Further, I found no evidence that increasing prevalences of “despair” were associated with increased all-cause mortality rates among NH white individuals in midlife, or that this association was more pronounced for those with low education. Lastly, I conducted a similar analysis looking at the association between increased prevalences of “despair” and increased rates of “deaths of despair”. I replicated Case and Deaton’s observed increased rates of “deaths of despair” among white individuals in midlife. However, I found no evidence that increased prevalences of “despair” were associated with increased “deaths of despair” rates among white individuals in midlife or that this association was higher for those with low education. Together, these findings suggest that the claims about the causes of increased mortality rates among white Americans in midlife are at best, questionable, and at worst, false. My aim with this work is to challenge and provide a critical examination of the theory of "deaths of despair", which has fueled the narrative of a suffering white generation and justified recent problematic events as white individuals lashing out for being forgotten to despair and die. While Case and Deaton’s observed rise in mortality rates among whites is a reproducible fact, their narrative ignores other evidence of white racial resentment as the cause of rise in mortality among white individuals. With this work, I intend to help stopping the perpetuation of narratives that favor structural whiteness by promoting an unsubstantiated narrative of psychosocial harm experienced by white Americans. Ultimately, I hope this work helps shift the focus in public health away from Case and Deaton's findings, which may overshadow and detract from the stark reality that mortality rates for Black individuals significantly exceed those for white individuals.

Geographic Areas

• United States
• Epidemiology
• Depression, Mental--Epidemiology
• White people
• Centers for Disease Control and Prevention (U.S.)

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Research on the effective sheltering rates of public buildings in villages in western sichuan, china—a case study of ganbao tibetan village.

1. Introduction

2. research subjects and methods, 2.1. research subjects, 2.2. research methods, 2.3. basis for indicator values, 2.3.1. basis for indicator values of post-disaster conversion of public buildings, 2.3.2. basis for shelter area calculation, 3. selection of sheltering buildings and calculation results of effective sheltering rate, 3.1. field survey results of public service buildings in ganbao tibetan village, 3.2. selection of shelter buildings in ganbao tibetan village, 3.3. calculation results of effective sheltering rates for ganbao tibetan village’s sheltering buildings, 4. strategies for improving the efficiency of post-disaster conversion of public service buildings, 4.1. strategies to enhance the effective sheltering rate in typical small spaces of ganbao tibetan village, 4.2. strategies to enhance effective sheltering rates in typical large spaces in ganbao tibetan village, 5. conclusions, author contributions, data availability statement, conflicts of interest.

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Yong, L.; Zhang, Y.; Wu, J.; Xiong, J. Research on the Effective Sheltering Rates of Public Buildings in Villages in Western Sichuan, China—A Case Study of Ganbao Tibetan Village. Buildings 2024 , 14 , 2086. https://doi.org/10.3390/buildings14072086

Yong L, Zhang Y, Wu J, Xiong J. Research on the Effective Sheltering Rates of Public Buildings in Villages in Western Sichuan, China—A Case Study of Ganbao Tibetan Village. Buildings . 2024; 14(7):2086. https://doi.org/10.3390/buildings14072086

Yong, Lingling, Yin Zhang, Jing Wu, and Jianwu Xiong. 2024. "Research on the Effective Sheltering Rates of Public Buildings in Villages in Western Sichuan, China—A Case Study of Ganbao Tibetan Village" Buildings 14, no. 7: 2086. https://doi.org/10.3390/buildings14072086

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