Mixed Methods Multiple Case Study Research Articles

Introducing a nursing guideline on depression in dementia: A multiple case study on influencing factors

BackgroundSuccessfully introducing care innovations depends on the type of care setting, the intervention and specific circumstances. In this study the factors influencing the introduction of an evidence based nursing guideline on depression in psychogeriatric nursing home residents were studied. MethodsA mixed methods multiple case study design was used. The cases consisted of nine psychogeriatric wards participating in the intervention group of a controlled clinical trial. Eight types of data source (qualitative and quantitative) were used in the analyses. Triangulation of researchers, data and methods took place. Factors were categorized according to their organizational level: nursing home management (level 1), nursing team (level 2), CNAs (level 3), and residents (level 4). ResultsFactors influencing guideline introduction were mainly found at the levels of the nursing home management and the nursing team. Most factors concern stability of the organization and team (e.g. the inhibiting effects of reorganizations and other innovations), motivation (e.g. the facilitating presence of an opinion leader) and compatibility with current practice and vision (e.g. a facilitating emotion-oriented care vision). Factors influencing a successful application of the guideline are mainly found at CNA and resident level. At CNA level most factors relate to an emotion-oriented care vision (e.g. having a warm and creative personality). At resident level inhibiting factors mainly concern the residents’ health status (e.g. feeling sick and/or having much pain). Important facilitating factors are positive attitudes of relatives and observing a reduction of depression severity. ConclusionsSpecial facilitating factors for the guideline introduction and application seem to be the presence of a local opinion leader and the positive attitudes of relatives. Together they can motivate a nursing team in using the guideline. After a successful introduction of the guideline it's important to focus on its consolidation in daily practice.

Gender identity and coping in female 46, XY adults with androgen biosynthesis deficiency (intersexuality/DSD).

Individuals living with an intersex condition have not received much attention in counseling psychology, although a high need for psychosocial care is obvious. Using a mixed-methods multiple case study with qualitative and quantitative data, the authors explore coping and gender experiences in seven 46, XY intersexual persons with deficiencies of androgen biosynthesis. These were assigned female at birth. At puberty, the participants experienced unexpected physical virilization due to 5alpha-reductase-2 (n = 3) and 17beta-hydroxysteroid dehydrogenase-3 deficiency (n = 4). All 7 received medical treatment (e.g., gonadal removal, genital surgery) to stop virilization and maintain the primarily assigned female sex and gender. The cases illustrate high adjustment challenges caused by the condition itself and the medical treatment experienced. None changed to male during adolescence as reported in previous studies. Highly variable patterns of gender identification become visible with subjectivities that do not only represent a binary gender model. Adult gender identity outcome of the participants is characterized by an increased uncertainty of gender identity, high male and low female gender identity. Implications for clinical management, particularly psychological counseling, are drawn.

Systematically Assessing the Situational Relevance of Electronic Knowledge Resources: A Mixed Methods Study

Electronic Knowledge Resources (EKRs) are increasingly used by physicians, but their situational relevance has not been systematically examined. ObjectiveSystematically scrutinize the situational relevance of EKR-derived information items in and outside clinical settings. BackgroundPhysicians use EKRs to accomplish four cognitive objectives (C1-4), and three organizational objectives (O1-3): (C1) Answer questions/solve problems/support decision-making in a clinical context; (C2) fulfill educational-research objectives; (C3) search for personal interest or curiosity; (C4) overcome limits of human memory; (O1) share information with patients, families, or caregivers; (O2) exchange information with other health professionals; (O3) plan-manage-monitor tasks with other health professionals. MethodsLongitudinal mixed methods multiple case study: Cases were 17 residents’ critical searches for information, using a commercial EKR, during a 2-month block of family practice. Usage data were automatically recorded. Each “opened” item of information was linked to an impact assessment questionnaire, and 1,981 evaluations of items were documented. Interviews with residents were guided by log files, which tracked use and impact of EKR-derived information items. Thematic analysis identified 156 critical searches linked to 877 information items. For each case, qualitative data were assigned to one of the seven proposed objectives. ResultsResidents achieved their search objectives in 85.9% of cases (situational relevance). Additional sources of information were sought in 52.6% of cases. Results support the seven proposed objectives, levels of comparative relevance (less, equally, more), and levels of stimulation of learning and knowledge (individual, organizational). ConclusionOur method of systematic assessment may contribute to user-based evaluation of EKRs.