Multi-site Case Study Research Articles

O34 - Labouring Together: Clinicians’ Experiences of “Working Together To Get The Best Outcomes” in Maternity Care

Multiple investigations have determined that poor interprofessional collaboration has been detrimental to the safety and experience of maternity care, as evidenced in the publication of the recent Ockenden review in the UK. The Labouring Together study was conducted to explore women's and clinicians' perceptions and experiences of collaboration in maternity care, using a conceptual theory of collaboration to identify barriers and enablers in the context of Victoria, Australia. A sequential, mixed-methods, multi-site case study approach was used to explore collaboration and shared decision-making in maternity care in four diverse case studies of public and private hospitals. Cross-sectional surveys were conducted in each case, using validated scales to determine midwives’, obstetrician’s and GPs’ assessment of organisational context and attitudes toward collaboration, followed by in-depth interviews to explore their perceptions and experiences. Participants rated the context of each case study similarly for the provision of woman-centred care, and whilst the attitudes of most participants were positive toward collaboration, midwives were found to have a significantly more positive attitude than obstetricians ( p <.001 95% CI 2.64-7.93) and GPs ( p <.001 95% CI 5.48-12.10). The conceptual framework of Working Together to Get The Best Outcomes emerged from inductive analysis, with major subthemes of ‘Organisation of care: working for the organisation’ and ‘Partnering in care: working together with women’ . Interprofessional tensions are avoided through professional altruism and positive role-modelling of interprofessional respect and trust. However, multiple barriers to effective collaboration in maternity care were identified; and whilst participants agreed that women should have autonomy for collaborative decision-making, most identified barriers to achieving this ideal. Results of the Labouring Together study indicate that although individual attitudes toward collaboration are largely positive, fundamental barriers to collaboration in maternity care remain, and shared decision-making with women is not routine practice in Victoria, Australia.

Protocol: Remote care as the 'new normal'? Multi-site case study in UK general practice.

Following a pandemic-driven shift to remote service provision, UK general practices offer telephone, video or online consultation options alongside face-to-face. This study explores practices' varied experiences over time as they seek to establish remote forms of accessing and delivering care. This protocol is for a mixed-methods multi-site case study with co-design and national stakeholder engagement. 11 general practices were selected for diversity in geographical location, size, demographics, ethos, and digital maturity. Each practice has a researcher-in-residence whose role is to become familiar with its context and activity, follow it longitudinally for two years using interviews, public-domain documents and ethnography, and support improvement efforts. Research team members meet regularly to compare and contrast across cases. Practice staff are invited to join online learning events. Patient representatives work locally within their practice patient involvement groups as well as joining an online patient learning set or linking via a non-digital buddy system. NHS Research Ethics Approval has been granted. Governance includes a diverse independent advisory group with lay chair. We also have policy in-reach (national stakeholders sit on our advisory group) and outreach (research team members sit on national policy working groups). We expect to produce rich narratives of contingent change over time, addressing cross-cutting themes including access, triage and capacity; digital and wider inequities; quality and safety of care (e.g. continuity, long-term condition management, timely diagnosis, complex needs); workforce and staff wellbeing (including non-clinical staff, students and trainees); technologies and digital infrastructure; patient perspectives; and sustainability (e.g. carbon footprint). By using case study methods focusing on depth and detail, we hope to explain why digital solutions that work well in one practice do not work at all in another. We plan to inform policy and service development through inter-sectoral network-building, stakeholder workshops and topic-focused policy briefings.

‘It’s All About Context’: Building School Capacity to Implement a Whole-School Approach to Bullying

Student bullying behaviours are a significant social issue in schools worldwide. Whilst school staff have access to quality bullying prevention interventions, schools can face significant challenges implementing the whole-school approach required to address the complexity of these behaviours. This study aimed to understand how schools’ capacity to implement whole-school bullying prevention interventions could be strengthened to promote sustainability and improve student outcomes. Qualitative methods were used to observe schools over time to gain insight into their implementation capacity to improve student social and emotional wellbeing and prevent and ameliorate harm from bullying. A four-year longitudinal, multi-site case study intensively followed eight schools’ implementation of Friendly Schools, an Australian evidenced-based whole-school bullying prevention intervention. Regular in-depth interviews with school leaders and implementation teams over four years led to the refinement of a staged-implementation process and capacity building tools and revealed four common drivers of implementation quality: (1) strong, committed leadership; (2) organisational structures, processes and resources; (3) staff competencies and commitment; and (4) translating evidence into local school policy and practice. This paper considers the strengths of qualitative data in understanding how and why bullying prevention interventions work as well as actions schools can take to enhance their implementation and sustainability of complex social interventions.

Response to Intervention

This multi-site interpretive case study examined the roles of school culture, personal beliefs, and knowledge of RTI on implementation. Through individual interviews, observations and document reviews, the researcher was able to capture teachers’ and administrators’ pedagogical beliefs and interpret how these factors influence the general educators’ and administrators’ perception of RTI and implementation of programs for the general population of students. The theories that guided this study included cultural theory, conflict theory, and structural-functionalism. A variety of coding methods were used and thirteen themes were developed from the researcher’s interpretation of the participants’ responses. Participants also shared other factors that impact. Key findings also included educators’ varied perceptions of the purpose of RTI, which correlated with their professional disciplines.

Ekstrakurikuler di Pesantren Moderen: Sebuah Upaya dalam Pembentukan Karakter Santri

Private Islamic Boarding Schools have received large audiences. Most people regardless of their economic and social status send their children to Islamic boarding schools. There are reasons parents choose this kind of school over other types of school, one of which is the fact that this type of schooling offers a wide variety of extra-curricular activities. This study seeks to identify the roles of extracurricular in shaping students’ character in a particular boarding school. This qualitative multi-site case study interviewed the management of the boarding schools, teachers, and students. The data for the research was also revealed through observation of students’ activities during the extra-curricular program. Our research suggests that extra-curricular were believed to have shaped students’ characters. The extra-curricular program shape students to become more disciplined, develop time-management skill, become more independent, and develop students’ creativities and students’ critical thinking. Our findings also reveal that the extra-curricular activities were run at a specified time, which does not distract students’ schedule for main learning activities.

Building knowledge ambidexterity using cloud computing: Longitudinal case studies of SMEs experiences

Using a longitudinal multisite case study research design, this study demonstrates how cloud computing helps to build knowledge ambidexterity (K-AMB) capabilities in small- and medium-sized enterprises (SMEs). A cross-theory approach is used to highlight the connections between ambidexterity and knowledge management theories as a basis to explore the benefits of K-AMB capabilities for SMEs. The study investigates how the focus on knowledge exploitation by SMEs limits innovation which can be reconciled using cloud computing by creating multiple ambidextrous knowledge opportunities. In relation to cloud computing and knowledge ambidexterity, the study is the first to measure the effects of a temporal lag in the K-AMB processes resulting in enhanced employee-driven innovation. The results showed that over a 12-month period, employee-driven innovation was significantly amplified from the application of cloud computing that supported more sophisticated ambidextrous processes of knowledge management. The results significantly shift mindsets about the revelatory value of cloud computing to promote K-AMB in SMEs. We draw novel insights to the theory of ambidexterity by proposing that digital technologies and employee innovation contexts lie side-by-side and play an important role in building K-AMB capabilities in SMEs.

Teaching children and adolescents about mental wellbeing: an exploratory multi-site case study in England

ABSTRACT Attention on children and young people’s (CYP) wellbeing has increased internationally over the past two decades, particularly in the context of education. This small scale, preliminary study was conducted across four state-funded schools in England (two primary; two secondary) amidst a time of policy change that saw the introduction of Mental Wellbeing Support Teams in schools, and the mandating of statutory Health Education curricula. The study investigated whether psycho-informed lessons could be developed aligned to curriculum guidelines, and how pupils would engage with this learning content. Drawing on Positive Education (PE) theory, and Self-Determination theory (SDT) the researchers worked collaboratively to co-develop and deliver lessons to CYP (aged 9–11 years, and 14–15 years). This paper describes the theoretical underpinnings of the lessons, learning activities used, and critically reflects on pupils’ engagement. Implications for practice are considered and recommendations made regarding possible future teaching of mental wellbeing in England.

Labouring Together: Women's experiences of “Getting the care that I want and need” in maternity care

ObjectivePoor interprofessional collaboration and lack of decision-making with women have been identified as being detrimental to the quality, safety, and experience of maternity care. The aim of the Labouring Together study was to explore childbearing women's preferences for and experiences of collaboration and control over decision-making in maternity care. DesignA sequential, mixed-method, multi-site case study approach was used to explore the perceptions and experiences of childbearing women regarding collaboration and decision-making. Women's preferred role for decision-making compared to the actual experiences, and the influences upon their preferences and experiences of collaboration were explored using semi-structured interviews. An inductive approach was used for qualitative analysis of interviews, and cross-case analyses were conducted using replication logic. SettingPostnatal wards of 1 private and 3 public maternity services in both metropolitan and regional Victoria, Australia. ParticipantsPostnatal women, over the age of 18 years (n=182). FindingsHalf (48.3%) of the participants indicated a preference for a shared decision-making role and 35% preferred an active role. Only 16.7% participants indicated a preference for a passive role, however 24.4% of women reported experiencing a passive decision-making role during their maternity care. Statistically significant differences were also identified between preferences for and experiences of decision-making among women who chose the private obstetrician model of maternity care compared to the public maternity care system. Negative impacts upon women's autonomy over decision-making included: poor access to midwifery models of care; poor access to relational continuity of care; poor understanding of the rights of the woman; inadequate information for women about the risks and benefits of all proposed interventions; and a bureaucratic style of decision-making based upon a dominant discourse of risk avoidance that could ultimately veto the woman's choice. Key conclusionsDespite evidence of the benefits for women of having autonomy over decision-making in their own care, fundamental barriers were identified that hindered women's participation in collaboration in maternity care. Shared decision-making with childbearing women is not routine practice in maternity care in Victoria, Australia. Implications for practiceRelational continuity of care is imperative to promote the autonomy of childbearing women and an environment conducive to women's active engagement in maternity care and participation in shared decision-making.

Purposeful Collaboration through Professional Learning Communities: Teacher Educators’ Challenges

The Covid-19 pandemic has affected the teaching practicum component of initial teacher education programmes in significant ways. School-based placement could not take place, but teacher educators still needed to ensure that the teaching practicum component complied with policy. The aim of this study is to indicate how work-integrated learning teacher educators created professional learning communities among an entire population of 7 041 student teachers enrolled for the Baccalaureus Educationis degree, the challenges they faced and how they managed these challenges. The professional learning community model of Hord (2009) was used as a conceptual framework for this study. In this qualitative multi-site case study, document analysis was the primary data collection method. Journals and WhatsApp messages kept by the two work-integrated learning teacher educators and the minutes of virtual work-integrated learning meetings were analysed using narrative and thematic analysis. The findings indicated four main challenges, namely constituting the professional learning communities and developing the alternative task, dealing with issues related to group demographics and diversity, connectivity, technology and collaborating in learning in a remote environment, and lastly, providing continuous feedback, support and guidance. Recommendations for future practice are discussed.

Rendering Artful and Empathic Arts-Based Performance as Action

There is a critical need to consider ways to enrich the educational experiences and well-being of adolescents when the lack of empathy in the world is high. This paper presents the concepts of Artful Empathy and Artful and Empathic Learning Ecology. The concepts are exemplified from a multi-site case study within Australian secondary visual art studio classrooms. The article demonstrates how learning and making art in an artfully empathic ecology can support the legitimacy of diverse and marginalized voices. Arts-based performative approaches may facilitate empathic knowing across disciplines with global traction.

The Role of Kyai in Pesantren Business Development: A Case Study on Leadership in The Traditional Pesantrens

The objective of this research is to explore the role of kyai leadership in developing pondok pesantren business unit to analyses the contribution of kyai in economy institution. This research is multisite case study in two pondok pesantren that are Sidogiri Pasuruan and Minhajut Thullab Banyuwangi. Analysis units of this research are kyai, teacher, ustadz, cooperative staffs, santri (student), society around pondok pesantren and pesantren cooperation members. The data were conducted by interview, observation, and document analysis. The design of this research is qualitative design applying multi sites case study technique model. Data analysis and data validity test using triangulation i.e source, method and time triangulation. The research shows that kyais have an important role in developing business unit of pesantren.

Promoting creativity: Secondary visual art teachers’ perceptions and understanding of creativity in Ghana

Developing creativity in learners is contingent on how teachers define and understand creativity. This qualitative multi-site case study investigated secondary visual arts teachers’ perceptions and understanding of creativity in Sekondi-Takoradi in Ghana and the influences that impact their perceptions. Data were gathered from 16 secondary visual arts teachers in Ghana using interviews and documents review. It was evidenced that the secondary visual arts teachers’ perceptions and understanding of creativity are limited and built on historical Ghanaian educational materials. The findings suggest teacher training materials and school-based educational resources in Ghana must be upgraded to extend teachers’ understanding of creativity within education.

Implementing and evaluating online advance care planning training in UK nursing homes during COVID-19: findings from the Necessary Discussions multi-site case study project

BackgroundAdvance care planning in nursing homes is important to ensure the wishes and preferences of residents are recorded, especially during the COVID-19 pandemic. However, care staff and family members frequently report feeling unprepared for these conversations. More resources are needed to support them with these necessary discussions. This research aimed to develop, implement and evaluate a website intervention for care staff and family members to provide training and information about advance care planning during COVID-19.MethodsThe research was a primarily qualitative case study design, comprising multiple UK nursing home cases. Data collection included semi-structured interviews with care staff and family members which were coded and analysed thematically. A narrative synthesis was produced for each case, culminating in a thematic cross-case analysis of the total findings. Theoretical propositions were refined throughout the research.ResultsEight nursing homes took part in the study, involving 35 care staff and 19 family members. Findings were reported according to the RE-AIM framework which identified the reach, effectiveness, adoption, implementation and maintenance of the intervention. Themes included: website content that was well received; suggestions for improvement; implementation barriers and facilitators; examples of organisational and personal impact.ConclusionsFour theoretical propositions relating to advance care planning in nursing homes are presented, relating to: training and information needs, accessibility, context, and encouraging conversations. Implications for practice and training include an awareness of diverse learning styles, re-enforcing the right to be involved in advance care planning and encouraging opportunities for facilitated discussion.Trial registrationISRCTN registry (ID 18003630) on 19.05.21.

Increasing harms for bingo players: digitisation, commercialisation and regulatory inadequacy: a multi-site case study

BackgroundBingo is often understood as a low-harm form of gambling. This view has been challenged by a growing body of literature identifying gambling harm to bingo players in a range of countries. In this study, we aimed to identify which conditions enabled, facilitated, intensified or mitigated gambling harm for bingo players in three populations in Victoria in the context of corporate, technological and regulatory changes.MethodsOur qualitative study investigated experiences of bingo-related gambling harm in three populations in Victoria, Australia where bingo was popular and structural disadvantage common: Indigenous people in the east, Pacific people in the state’s north and older people on low or fixed incomes in the capital. Data was generated through interviews with 53 bingo players and 13 stakeholders as well as 12 participant observations of bingo sessions.ResultsWe found that while bingo is overwhelmingly positive for many players, a minority of bingo players and their families experience notable harm. Harm was generated through traditional paper-based bingo games, new technologies such as tablet-based bingo and by the widespread tactic of placing bingo sessions in close proximity to harmful electronic gambling machines. Overall, the risk of harm to bingo players appears to be escalating due to commercial, technological and regulatory changes.ConclusionsThese changes can be better managed by regulators: reforms are needed to safeguard bingo’s distinct character as a lower-risk form of gambling at a time when it, and its players, are under threat. Significantly, we found that harm to bingo players is intensified by factors external to gambling such as racialised poverty and adverse life events. Strategies that recognise these factors and grapple with gambling harm to bingo players are needed.

“Oh, I thought we’d be different”: A multifocal, interdisciplinary examination of the fidelity/adaptation challenge

The purpose of this instrumental, multisite case study is to examine fidelity, adaptation, and differentiation challenges found at Wood Badge, a nationwide Boy Scouts of America training for adult volunteer leaders. Our iterative analysis of more than 900 pages of fieldnotes and 400 pages of documents revealed facilitators often explicitly taught syllabus content during the trainings. Observers noted 119 minor differentiations across trainings, notably involving facilitator delivery methods and the duration and scheduling of training segments. Facilitators observed 16 adaptations, which appeared to be based on external conditions at trainings or facilitator preferences, and just three instances of differentiation. Our analysis of the trainings surfaced key fidelity/adaptation issues like overadherence, conflicting notions of deviation, and the impact of preparation on fidelity. In addition, we identified factors influencing facilitators’ use of adaptation and differentiation. Recommendations for large-scale trainings are made based on the study’s findings.

Assessment of the obesogenic environment in primary schools: a multi-site case study in Jakarta

BackgroundChildhood overweight and obesity have increasingly been recognized as a significant global public health crisis, including in Asia. This study aimed to assess the obesogenic environment in primary schools in Jakarta, Indonesia.MethodsA qualitative, multi-site, case study design was used to capture different elements of the school environment and policies related to obesity, with a focus on nutrition and physical activity. An adaptation of the Primary School Environmental Assessment tool was used. Six primary schools in Jakarta were purposively selected based on their location, socioeconomic status, and type (public or private). In addition to direct observation at each school, interviews were conducted with the principal, physical education teacher, canteen staff, street food vendors, and students.ResultsAmong the six schools, two were private and four were public. The most popular foods consumed by students were unhealthy, such as deep-fried foods and sugar-sweetened beverages. Students had easy and constant access to unhealthy foods, whereas only limited variation of healthy foods were available in the school canteen. Some schools also allowed the student to have access to street food vendors. School policies related to healthy eating and physical activities had been implemented, mainly in the form of teaching these topics as part of the school curriculum. However, promotion of healthy eating and physical activities by the schools was still limited.ConclusionsThis study showed the usefulness of the Primary School Environmental Assessment tool in identifying obesogenic factors in urban area of Indonesia. Effective implementation of guidelines to foster good nutritional practices and healthy lifestyles at school should be prioritized to improve the health and nutritional status of the students.

A Multi-site Case Study of Care Coordination Between Primary Care and Specialty Care.

Care coordination is critical for patients with multiple chronic conditions, but fragmentation of care persists. Providers' perspectives of facilitators and barriers to coordination are needed to improve care. We sought to understand providers' perspectives on care coordination for patients having multiple chronic diseases served by multiple providers. Based upon our earlier survey of patients with multiple chronic conditions, we selected 8 medical centers having high and low coordination. We interviewed providers to identify facilitators and barriers to coordination and compare them between patient-rated high sites and low sites and between primary care (PC)-mental health (MH) and PC-medical/surgical specialty care. Physicians, nurses and other clinicians in PC, cardiology, and MH (N=102) in 8 Veterans Affairs medical centers. We identified warm handoffs, professional relationships, and physical proximity as facilitators, and service agreements, reporting relationships and staffing as barriers. PC-MH coordination was reported as better than PC-medical/surgical specialty coordination. Facilitators were more prevalent and barriers less prevalent in sites rated high by patients than sites rated low, and between PC-MH than between PC-specialty care. We noted that professional relationships were highly related to coordination and both affected other facilitators and barriers and were affected by them. We suggested actions to improve relationships directly, and to address other facilitators and barriers that affect relationships and coordination. Among these is the use of the Primary Care Mental Health Integration model.

Doing Case Study Research Collaboratively: The Benefits for Researchers

Collaborative research teams are an effective strategy to combine the knowledge and skills of like-minded researchers across tertiary education settings and international borders. Research collaborations have the potential to increase research capacity for both individuals and the team alike. The purpose of the study was to explore the experiences and perceptions of a team of seven Australasian nurse academics undertaking a longitudinal multi-site case study. We used a nominal group technique in this deductive qualitative exploratory study. The key findings from this study indicate establishing safe academic relationships is paramount to successful collaborative teams. Collaborative research teams offer opportunities to learn research processes from other members through sharing of expertise and skillsets, together with upholding a positive engagement with technology to ensure full research participation is achievable irrespective of geographical location. To conclude, in this study we have identified multi-site collaborative research teams provide an opportunity to leverage the strengths of individuals to enhance research outcomes across organisations. The synergistic effect of the team builds research blue skies thinking and capacity building through mentorship and support. The potential for positive change through mentorship and support, alongside the forged new relationships, are all key drivers of researcher wellbeing, never more important as we transition into new ways of working both now and into the future.

Students’ Learning Experience in a Mixed Reality Environment: Drivers and Barriers

Mixed reality technologies have the potential to provide students with an effective learning experience by bridging the gap between the digital and physical world. Mixed reality enables the user to see their real-world surroundings with virtual features overlayed in order to create a digitally enhanced experience. As we strategically move towards large-scale integration of mixed reality technologies to maximize the learning affordances in the future, there is a need to understand the drivers of and barriers to students’ learning in a mixed reality environment. We present in this paper a multi-site case study to evaluate the feedback from 223 students on their learning experiences after using Microsoft HoloLens, a mixed reality device, in their classroom. While we found that interactivity, immersion, and presence are the main drivers, the key barriers identified were difficulty using the device, accessibility issues, and the lack of flexibility. Affordances and fatigue are the two themes that evolved in this study. We recommend three design principles that will contribute toward designing mixed reality technologies to effectively build new embodied learning environments.

Staying and studying: narratives of local higher education in small island colleges

ABSTRACT Due to the unequal geographical distribution of HE institutions in many national HE systems, living in a rural or remote area and attending HE can be mutually exclusive. The implication is that those who remain in a rural area beyond school age do not study at the undergraduate level. In discussions of rural stayers, HE is therefore understood as a crucial point of transition between staying and leaving; HE requires or offers the opportunity to move from a rural or remote location in order to continue education. This article asks how the figure of the rural and remote stayer is changed by the relatively recent provision of HE opportunities in some rural and remote contexts in and around the UK, making it possible both to ‘stay’ and to study for an undergraduate degree. The article brings together literature on HE mobilities and on remote and rural staying to develop the new figure of the ‘stayer-student’, using a spatial narrative framework to analyse findings from a multi-sited case study of HE providers on small islands with relationships to the UK. The analysis identifies three types of spatial story that articulate the boundaries of students’ remote location and HE. In the first of these stories, the boundary around the island is solidified by the decision to stay for HE, reinforcing belonging to and possibilities within place. The second focuses on the role of the spatial boundary in distinguishing between common definitions of the role and purpose of HE. In the final story, the boundary enables the disruption of linear and normative HE trajectories. Each of these findings challenges traditional understandings of the role of HE in prompting social and geographical transition away from remote and rural areas.