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BackgroundEvidence-based practices (EBPs) are shown to improve a variety of outcomes for autistic children. However, EBPs often are mis-implemented or not implemented in community-based settings where many autistic children receive usual care services. A blended implementation process and capacity-building implementation strategy, developed to facilitate the adoption and implementation of EBPs for autism spectrum disorder (ASD) in community-based settings, is the Autism Community Toolkit: Systems to Measure and Adopt Research-based Treatments (ACT SMART Toolkit). Based on an adapted Exploration, Adoption decision, Preparation, Implementation, Sustainment (EPIS) Framework, the multi-phased ACT SMART Toolkit is comprised of (a) implementation facilitation, (b) agency-based implementation teams, and (c) a web-based interface. In this instrumental case study, we developed and utilized a method to evaluate fidelity to the ACT SMART Toolkit. This study responds to the need for implementation strategy fidelity evaluation methods and may provide evidence supporting the use of the ACT SMART Toolkit.MethodsWe used an instrumental case study approach to assess fidelity to the ACT SMART Toolkit during its pilot study with six ASD community agencies located in southern California. We assessed adherence, dose, and implementation team responsiveness for each phase and activity of the toolkit at both an aggregate and individual agency level.ResultsOverall, we found that adherence, dose, and implementation team responsiveness to the ACT SMART Toolkit were high, with some variability by EPIS phase and specific activity as well as by ASD community agency. At the aggregate level, adherence and dose were rated notably lowest during the preparation phase of the toolkit, which is a more activity-intensive phase of the toolkit.ConclusionsThis evaluation of fidelity to the ACT SMART Toolkit, utilizing an instrumental case study design, demonstrated the potential for the strategy to be used with fidelity in ASD community-based agencies. Findings related to the variability of implementation strategy fidelity in the present study may also inform future adaptations to the toolkit and point to broader trends of how implementation strategy fidelity may vary by content and context.

BackgroundAdoption, adaptation, scale-up, spread, and sustainability are ill-defined, undertheorised, and little-researched implementation science concepts. An instrumental case study will track the adoption and adaptation, or not, of a locally developed innovation about dysphagia as a patient safety issue. The case study will examine a conceptual framework with a continuum of spread comprising hierarchical control or ‘making it happen’, participatory adaptation or ‘help it happen’, and facilitated evolution or ‘let it happen’.MethodsThis case study is a prospective, longitudinal design using mixed methods. The fifteen-month (October 2012 to December 2013) instrumental case study is set in large, healthcare organisation in England. The innovation refers to introducing a nationally recognised, inter-disciplinary dysphagia competency framework to guide workforce development about fundamental aspects of care. Adoption and adaptation will be examined at an organisational level and along two, contrasting care pathways: stroke and fractured neck of femur. A number of educational interventions will be deployed, including training a cadre of trainers to cascade the essentials of dysphagia management and developing a Dysphagia Toolkit as a learning resource. Mixed methods will be used to investigate scale-up, spread, and sustainability in acute and community settings. A purposive sample of senior managers and clinical leaders will be interviewed to identify path dependency or the context specific particularities of implementation. A pre- and post-evaluation, using mealtime observations and a survey, will investigate the learning effect on staff adherence to patient specific dysphagia recommendations and attitudes towards dysphagia, respectively. Official documents and an ethnographic field journal allow critical junctures, temporal aspects and confounding factors to be explored.DiscussionResearching spread and sustainability presents methodological and practical challenges. These include fidelity, adaptation latitude, time, and organisational changes. An instrumental case study will allow these confounding factors to be tracked over time and in place. The case study is underpinned by, and will test a conceptual framework about spread, to explore theoretical generalizability.

Aims and objectivesThe study aim was to explore the use of an Intensive Care Unit (ICU) diary within four different ICUs units in Sweden and thereby contribute to practice guidelines regarding the structure, content and use of an ICU diary.BackgroundICU diaries are used to aid psychological recovery among critical care patients, but differences remain in diary writing both within and across countries. Few studies have focused on the combined views and experiences of ICU patients, family members and nursing staff about the use of ICU diaries.DesignAn instrumental multiple case study design was employed.MethodsThree focus groups interviews were carried out with 8 former patients and their family members (n = 5) from the research settings. Individual interviews were carried out with 2 patients, a family member and a nurse respectively. Observations, field notes, documentary analysis and conversations with nursing staff were also conducted. Consolidated criteria for reporting qualitative research (COREQ) was followed.ResultsThe qualitative findings firstly consisted of a matrix and descriptive text of the four ICU contexts and current practices. This highlighted that there were similarities regarding the aims and objectives of the diaries. However, differences existed across the case study sites about how the ICU diary was developed and implemented. Namely, the use of photographs and when to commence a diary. Second, a thematic analysis of the qualitative data regarding patients’ and family members’ use of the ICU diary, resulted in four themes: i) the diary was used to take in and fully understand the situation; ii) the diary was an opportunity to assimilate warm, personalised and human care; iii) the diary was used to manage existential issues; and iv) the diary was a tool in daily activities.ConclusionsAnalysis of the instrumental case study data led to the identification of core areas for inclusion in ICU diary practice guidelines.

Purpose– The purpose of this paper is to describe company renaming as a process among small firms, including the events and actors in and the reasons for company renaming.Design/methodology/approach– The study presents an interpretative narrative process research approach. The empirical part is conducted as an instrumental multiple case study of six cases.Findings– Company renaming is a long-lasting, complex, iterative and management-centric process among small firms. The process consists of six main events that are conducted more or less simultaneously but which need to be further divided into sub-events in order to reveal their order. The reasons for renaming are that the current company name is difficult to use or it is less known than the name of the company's well-known product among stakeholders.Research limitations/implications– The existing research on branding from the viewpoint of organisational change has been scarce. The study suggests that also other reasons than change in the organisation or in its environment may cause corporate rebranding. The empirical data from a specific contest, the B2B software industry, may limit the statistical generalizability of the results.Practical implications– For small business managers, the study suggests actively involving stakeholders to the process. The new name can be developed cheaply, but the process can be long. For ensuring a shorter process, costs need to be accepted.Originality/value– The use of interpretative narrative process research approach and an instrumental multiple case study provide methodological contributions to the field of corporate rebranding.

The purpose of this instrumental qualitative case study was to address the challenges that community college professors face when curating or creating high-quality and low- or no-cost open educational resources (OERs), the accessibility of the resources, and the impact OER has on student success and social justice in education. The goal of this instrumental qualitative case study was to examine faculty's perceptions of OERs and explore whether and how the professors thought use of OERs helps to improve student engagement and student success in the classroom. In seeking to explore community college professors' perceptions of OER and their impact on student engagement and student success, the researcher used an instrumental qualitative case study. The target population for this study was full- and part-time faculty members who have created, curated, or have taught at least one semester (in the face-to-face, blended, or distance learning formats) using OER course content. This study utilized purposeful sampling and an additional participant was identified, invited and accepted the invitation as a result of the snowballing approach to selecting participants. The researcher conducted 12 semistructured interviews using open-ended questions to collect the data for this study. Analysis of the interviews led to the development of 5 themes and 10 subthemes associated with the data. The researcher's interpretations led to three results. Based on the data and research findings, the researcher concluded that social justice in education emerged as being implied and woven through all participants' responses. A comprehensive discussion on social justice in education is a subject for further research. There were three recommendations for practice covering these topic areas: (a) continue to foster the development and curation of OER, working collaboratively with partners internal and external to the institution; and (b) develop and promote OEP that allow students to acquire skills and knowledge, learning from their own and each other's experiences; (c) create flexible and sustainable course design for the post-pandemic environment. There were two recommendations for future research as follows: (a) broaden the approach to work toward social justice in education; and (b) recognize students as producers and creators of content and provide them with interactive learning environments in which to learn and become agents of change. Keywords: open educational resources (OER), social justice in education community college, student engagement, student success, faculty perceptions, benefits to students, inclusive learning environment, student creators of content, OER quality

BackgroundProvision of culturally safe care has been proposed to address health inequity, including in the areas of mental health and addiction. The factors that influence the provision of culturally safe care remain understudied. This paper explores the factors influencing the efforts of a mainstream residential addiction rehabilitation centre to provide culturally appropriate and quality care for Inuit.MethodsAn instrumental case study was conducted, informed by ethnographic and creative research methods. Over 700 h of participant observation were carried out between March 2018 and January 2020, in addition to qualitative semi-structured interviews (34 participants) and/or member-checking activities (17 participants) conducted with a total of 42 individuals: 20 Inuit residents, 18 clinical/specialized staff, and 4 clinical/administrative managers. An interpretive thematic analysis was performed to examine the factors that may influence the provision of culturally safe care for Inuit residents.ResultsTen categories of interrelated factors were identified and classified according to whether they relate to individual, programmatic, organizational, or systemic levels. These categories covered: (1) residents’ and staff’s life experiences; (2) personal and relational qualities and skills; (3) the model of care; (4) model flexibility; (5) ways in which relational aspects were considered; (6) sensitivity of the organization towards the population served; (7) human resources and professional development issues; (8) social climate; (9) political, relational, and funding climate; and (10) legislative, regulatory, and professional environment. While system-level factors generally had a negative effect on experiences of cultural safety, most factors at other levels had both favourable and unfavourable effects, depending on the context and dimensions examined.ConclusionsThe results offer insight into the interplay between the challenges and barriers that mainstream organizations face when working with Inuit, and the opportunities and enablers that organizations can build on to improve their services. This paper contributes to a better understanding of the challenges and opportunities to providing culturally safe addiction programs to Inuit within a complex intervention setting. It concludes by highlighting some areas for improvement to advance cultural safety in this context.

Tourism is being utilized as a key economic development tool of the 21st century. Serious concern over the benefit of tourism for the poor has contributed to discussion on community involvement and community participation in contemporary literature. In particular, sustainable development has become a way to address the long-term viability of income and employment in least-developed countries while attempting to preserve traditional customs and culture in the face of globalization. Sustainability refers to finding solutions to poverty without compromising the natural and cultural resource base needed by future generations to pursue their own economic goals. This task requires attention to the economic, cultural and social needs of all groups while focusing on solutions that are also viable for the long term (Bramwell, 2001; Davidson, 2007; Mfaume & Leonard, 2004). It is also important to note that social structures and cultural references vary noticeably within countries and regions. Therefore, three separate, independent instrumental case studies (also known as collective case studies) were conducted in three distinct Tanzanian communities in or around tourism destinations. The objective was to allow for the autonomy of specific cultural, social and business networks to be reflected in the research methodology.Case studies allow for the investigation of constraints to economic participation within real-life experiences, as there is no clear distinction between the phenomenon and the context. Instrumental case studies strive to develop theory, or in this case, facilitate understanding of pervasive problems and do not require typical study populations (Stake, 1995). An instrumental case study is utilized where a ‘particular case is examined mainly to provide insight’ into a phenomenon and the case supports understanding of the phenomenon (Denzin & Lincoln, 2005). The emphasis is placed on specific issues rather than on the case itself. The case in then used as a vehicle to develop a better understanding of the situation or problem (Stake, 2003). Single case studies are ideal for investigating a phenomenon that has not been previously studied and can make a significant contribution to knowledge (Yin, 2003). Since constraints to economic participation within Tanzania have not yet been empirically studied, each individual case study is exploratory in nature.Once the specific case studies were independently derived and themes developed, a cross-case comparison offered insight into reoccurring themes or case-specific constraints. Using an iterative process, the strength of this methodology lies in the inductive approach that provides suggestive rather than definitive analysis (Welch, 1994). The first phase of analysis results in ‘within’ themes specific to a particular region. Using cross-case comparisons, emergent patterns provide similarities and differences between the three communities.

ABSTRACTBackground: Semantic variant primary progressive aphasia (svPPA) is an uncommon neurodegenerative condition that causes prominent changes in communication skills, personality and behaviour. Insidious deterioration in conceptual–semantic memory abilities is the hallmark feature underpinning these impairments from the early-to-middle phases. Very little research has explored how svPPA is experienced by spouses/partners, particularly how they “make sense” of the presenting difficulties, deal with everyday issues and manage the changing psychosocial aspects of their intimate relationship.Aims: This instrumental case study explored the experience of a spouse who supported her husband with svPPA throughout the course of the condition, with a particular focus on how she dealt with the relational changes svPPA imposed on them.Methods & Procedures: Instrumental case study design with thematic narrative analysis was applied to the in-depth interview data, in order to obtain an understanding of the lived experience from the perspective of a wife whose husband had svPPA.Outcome & Results: Analysis of the interview data revealed five main themes of the spousal experience of svPPA: (1) Us, (2) The way he was … The way he is now, (3) Floundering with unpredictability, (4) Adjusting and accepting support and (5) Taking control. This case study explored how and why this spouse worked towards renegotiating the relational context of their relationship over the illness course.Conclusions: From the spouse’s perspective, learning to live with a “different person” was traumatic and involved floundering with unpredictability, adjusting and accepting support, and taking control. Clinicians need to remain sensitive to the pivotal role the spouse has in their partner’s life and mindful of that they may benefit from assistance and support to modify the relational aspects of their relationship with their partner throughout the course of the condition.

BackgroundSwallowing difficulties challenge patient safety due to the increased risk of malnutrition, dehydration and aspiration pneumonia. A theoretically driven study was undertaken to examine the spread and sustainability of a locally developed innovation that involved using the Inter-Professional Dysphagia Framework to structure education for the workforce. A conceptual framework with 3 spread strategies (hierarchical control, participatory adaptation and facilitated evolution) was blended with a processual approach to sustaining organisational change. The aim was to understand the processes, mechanism and outcomes associated with the spread and sustainability of this safety initiative.MethodsAn instrumental case study, prospectively tracked a dysphagia innovation for 34 months (April 2011 to January 2014) in a large health care organisation in England. A train-the-trainer intervention (as participatory adaptation) was deployed on care pathways for stroke and fractured neck of femur. Data were collected at the organisational and clinical level through interviews (n = 30) and document review. The coding frame combined the processual approach with the spread mechanisms. Pre-determined outcomes included the number of staff trained about dysphagia and impact related to changes in practice.ResultsThe features and processes associated with hierarchical control and participatory adaptation were identified. Leadership, critical junctures, temporality and making the innovation routine were aspects of hierarchical control. Participatory adaptation was evident on the care pathways through stakeholder responses, workload and resource pressures. Six of the 25 ward based trainers cascaded the dysphagia training. The expected outcomes were achieved when the top-down mandate (hierarchical control) was supplemented by local engagement and support (participatory adaptation).ConclusionsFrameworks for spread and sustainability were combined to create a ‘small theory’ that described the interventions, the processes and desired outcomes a priori. This novel methodological approach confirmed what is known about spread and sustainability, highlighted the particularity of change and offered new insights into the factors associated with hierarchical control and participatory adaptation. The findings illustrate the dualities of organisational change as universal and context specific; as particular and amendable to theoretical generalisation. Appreciating these dualities may contribute to understanding why many innovations fail to become routine.Electronic supplementary materialThe online version of this article (doi:10.1186/s12913-016-1653-6) contains supplementary material, which is available to authorized users.

For enhanced access to treatment and outcomes, it is imperative that counselors and therapists be aware of and confident in adapting their techniques to the needs of neurodiverse individuals. The shortage of trained professionals and limited training in professional counseling and other mental health support services specific to neurodiverse adults has deprived them of therapy. The purpose of this qualitative case study was to explore the challenges of licensed counselors and other licensed mental health providers who work with neurodiverse adults. Ensuring that neurodiverse adults receive appropriate socio-psychological assistance and competent services from licensed counselors requires a proper understanding of the current challenges that these professionals face. Findings from an instrumental case study comprising individual open-ended interviews to investigate the challenges faced by five licensed counselors and other licensed mental health providers who work with neurodivergent clients were analyzed in a thematic fashion and are presented herein. This instrumental case study identified concerns that were built on existing knowledge that allowed adaptation to and evolution within new cultural norms that characterize neurodiversity, which should be treated as a cultural difference and not “a less than” or “more than” condition. The evidence provided in this thematic analysis is connected to social emotional learning, universal design for learning, universal design, and social learning theories that have significant implications for practitioners.

South Africa has the highest number of HIV-positive people in the world and also boasts the most comprehensive antiretroviral treatment (ART) programme to date. Long-term ART adherence requires a range of identity negotiations in order for treatment success to materialise in the long term. However, some patients on ART develop a treatment side effect known as ‘lipodystrophy’, which is a condition that can severely undermine a person’s sense of self and identity given the bodily alterations that take place given notions of anticipated, felt or internalised stigma. In this article, we explore two women’s narratives who suffer from this side effect of ART. Their narratives are used as an ‘instrumental case study’ inasmuch as these instances provide insights into their contextual realities of being on ART in post-apartheid South Africa. Both these women are black African, have limited means and resources, and already face serious everyday challenges despite their HIV infection and lipodystrophy. We subsequently conclude that this embodied experience is a reflection of individual and social realities of multiple layers of precarity that characterise the HIV/AIDS and ART landscape in South Africa. The article also emphasises the corporeal aspects of chronic disease that has not been amply studied in the context of HIV and ART, especially in developing countries where HIV infection is disproportionately high. Moreover, studying lipodystrophy interpretatively has also been largely neglected.

Health Effects and Exposure Assessment to Bio-aerosols in Indoor Environments- An Instrumental Case Study

Objective: Our objective was to evaluate, through the analysis of the ‘business model,’ the strategy of a public agricultural research company for the creation and launch of an innovation for the agro-industrial coffee chain. Method: We developed a single instrumental case study for the qualitative research. For data collection we used bibliographic and documentary research, as well as in-depth interviews and analyzed based on the thematic content analysis technique. The instrumental case study has proved to be the most suitable methodology since it is used when a particular case is examined to provide information on an issue that can be generalized and used to understand a larger reality. Originality/relevance: In this paper we reexamined an unsuccessful innovation case associated with the lens of the business model theoretical construct. This paper is willing to raise issues that restrict innovation in public research companies. Results: The paper unveiled difficulties related to the inconsistency of innovation promotion policies and legal uncertainty, in particular, by the contradictory positions of legal advisors, which inhibit researchers from engaging in innovative activities and in partnerships with private companies. Theoretical/methodological contributions: The instrumental case study developed, together with the analysis based on the construct of the business model, allowed a better understanding of the problems faced in public research environments in Brazil. This analysis can be applied to similar cases, since the issue of innovation in the public sector and the difficulties of appropriateness are common to other companies.

PurposeThe purpose of this paper is to investigate the application of a customer performance measurement system (CPMS) to demonstrate how facilities management (FM) organisations can enhance their existing processes for measuring the customer satisfaction of their service provision.Design/methodology/approachCustomer performance measurement in FM is the process of capturing, measuring, and improving the satisfaction of FM customers. A generic CPMS was developed that FM organisations can adopt to improve their existing service provision. The CPMS was developed using a mixed methods approach was adopted. An instrumental case study was used to test the CPMS. The case study represented what was deemed as a typical FM organisation in the UK. The effectiveness of the CPMS application was first validated internally by the instrumental case study. A series of collective case studies were then used to validate the CPMS externally, by testing a series of other FM companies in the UK to provide further understanding of the potential application of the CPMS.FindingsThe findings suggest that by adopting a strategic model that incorporates a balance of quantitative and qualitative methods to gain customer satisfaction of FM service provision, can enhance an FM organisation's existing processes of gaining customer satisfaction.Originality/valueAlthough there are many studies researching performance measurement in FM, there is a lack of knowledge on the application of customer performance measurement. This paper contends that there is a need to develop a mixed methods system that is not limited to gaining quantitative findings of customer satisfaction, but also gains wider qualitative findings that investigate customer expectations and perceptions of FM service provision. Generic customer satisfaction benchmarks in the UK FM industry were also established, and formed a crucial component of the CPMS.

People with complex needs often have unmet biopsychosocial needs that require integrated services through intersectoral collaboration. Few studies have evaluated the factors influencing intersectoral collaboration for health improvement of a vulnerable population between non-profit organizations (NPOs) and primary health care partners in rural areas. The objectives of the study are: (1) to describe intersectoral collaboration between an NPO and its social and primary health care partners in a rural setting; and (2) to identify the elements that facilitate or hinder this collaboration. An instrumental case study was conducted through field research. Data collection included non-participant observation, semi-structured interviews, and analysis of documents. A thematic analysis was then carried out, and a case story was written. The case study provides an in-depth account of the case, its context, and the key factors influencing intersectoral collaboration. Fourteen factors were identified as having a significant impact on intersectoral collaboration with the NPO. These factors had positive and negative effects on collaboration efforts. Several of these effects are also factors that had, in turn, effects on collaboration. Implementing intersectoral collaborations requires a shared vision, healthy relationships, and transparent, respectful communication, among other important factors. Our study provides leaders of healthcare projects in rural areas with actionable advice to address potential challenges and enhance the effectiveness of their collaborative efforts.