Guidelines For Case Study Research

This set of guidelines provides both instructions and a template for the writing of case reports for publication. You might want to skip forward and take a quick look at the template now, as we will be using it as the basis for your own case study later on. While the guidelines and template contain much detail, your finished case study should be only 500 to 1,500 words in length. Therefore, you will need to write efficiently and avoid unnecessarily flowery language.

These guidelines for the writing of case studies are designed to be consistent with the “Uniform Requirements for Manuscripts Submitted to Biomedical Journals” referenced elsewhere in the JCCA instructions to authors.

After this brief introduction, the guidelines below will follow the headings of our template. Hence, it is possible to work section by section through the template to quickly produce a first draft of your study. To begin with, however, you must have a clear sense of the value of the study which you wish to describe. Therefore, before beginning to write the study itself, you should gather all of the materials relevant to the case – clinical notes, lab reports, x-rays etc. – and form a clear picture of the story that you wish to share with your profession. At the most superficial level, you may want to ask yourself “What is interesting about this case?” Keep your answer in mind as your write, because sometimes we become lost in our writing and forget the message that we want to convey.

Another important general rule for writing case studies is to stick to the facts. A case study should be a fairly modest description of what actually happened. Speculation about underlying mechanisms of the disease process or treatment should be restrained. Field practitioners and students are seldom well-prepared to discuss physiology or pathology. This is best left to experts in those fields. The thing of greatest value that you can provide to your colleagues is an honest record of clinical events.

Finally, remember that a case study is primarily a chronicle of a patient’s progress, not a story about chiropractic. Editorial or promotional remarks do not belong in a case study, no matter how great our enthusiasm. It is best to simply tell the story and let the outcome speak for itself. With these points in mind, let’s begin the process of writing the case study:

  • Title page:
    1. Title: The title page will contain the full title of the article. Remember that many people may find our article by searching on the internet. They may have to decide, just by looking at the title, whether or not they want to access the full article. A title which is vague or non-specific may not attract their attention. Thus, our title should contain the phrase “case study,” “case report” or “case series” as is appropriate to the contents. The two most common formats of titles are nominal and compound. A nominal title is a single phrase, for example “A case study of hypertension which responded to spinal manipulation.” A compound title consists of two phrases in succession, for example “Response of hypertension to spinal manipulation: a case study.” Keep in mind that titles of articles in leading journals average between 8 and 9 words in length.

    2. Other contents for the title page should be as in the general JCCA instructions to authors. Remember that for a case study, we would not expect to have more than one or two authors. In order to be listed as an author, a person must have an intellectual stake in the writing – at the very least they must be able to explain and even defend the article. Someone who has only provided technical assistance, as valuable as that may be, may be acknowledged at the end of the article, but would not be listed as an author. Contact information – either home or institutional – should be provided for each author along with the authors’ academic qualifications. If there is more than one author, one author must be identified as the corresponding author – the person whom people should contact if they have questions or comments about the study.

    3. Key words: Provide key words under which the article will be listed. These are the words which would be used when searching for the article using a search engine such as Medline. When practical, we should choose key words from a standard list of keywords, such as MeSH (Medical subject headings). A copy of MeSH is available in most libraries. If we can’t access a copy and we want to make sure that our keywords are included in the MeSH library, we can visit this address: http://www.ncbi.nlm.nih.gov:80/entrez/meshbrowser.cgi

  • Abstract: Abstracts generally follow one of two styles, narrative or structured.

    A narrative abstract consists of a short version of the whole paper. There are no headings within the narrative abstract. The author simply tries to summarize the paper into a story which flows logically.

    A structured abstract uses subheadings. Structured abstracts are becoming more popular for basic scientific and clinical studies, since they standardize the abstract and ensure that certain information is included. This is very useful for readers who search for articles on the internet. Often the abstract is displayed by a search engine, and on the basis of the abstract the reader will decide whether or not to download the full article (which may require payment of a fee). With a structured abstract, the reader is more likely to be given the information which they need to decide whether to go on to the full article, and so this style is encouraged. The JCCA recommends the use of structured abstracts for case studies.

    Since they are summaries, both narrative and structured abstracts are easier to write once we have finished the rest of the article. We include a template for a structured abstract and encourage authors to make use of it. Our sub-headings will be:
    1. Introduction: This consists of one or two sentences to describe the context of the case and summarize the entire article.

    2. Case presentation: Several sentences describe the history and results of any examinations performed. The working diagnosis and management of the case are described.

    3. Management and Outcome: Simply describe the course of the patient’s complaint. Where possible, make reference to any outcome measures which you used to objectively demonstrate how the patient’s condition evolved through the course of management.

    4. Discussion: Synthesize the foregoing subsections and explain both correlations and apparent inconsistencies. If appropriate to the case, within one or two sentences describe the lessons to be learned.

  • Introduction: At the beginning of these guidelines we suggested that we need to have a clear idea of what is particularly interesting about the case we want to describe. The introduction is where we convey this to the reader. It is useful to begin by placing the study in a historical or social context. If similar cases have been reported previously, we describe them briefly. If there is something especially challenging about the diagnosis or management of the condition that we are describing, now is our chance to bring that out. Each time we refer to a previous study, we cite the reference (usually at the end of the sentence). Our introduction doesn’t need to be more than a few paragraphs long, and our objective is to have the reader understand clearly, but in a general sense, why it is useful for them to be reading about this case.

  • Case presentation: This is the part of the paper in which we introduce the raw data. First, we describe the complaint that brought the patient to us. It is often useful to use the patient’s own words. Next, we introduce the important information that we obtained from our history-taking. We don’t need to include every detail – just the information that helped us to settle on our diagnosis. Also, we should try to present patient information in a narrative form – full sentences which efficiently summarize the results of our questioning. In our own practice, the history usually leads to a differential diagnosis – a short list of the most likely diseases or disorders underlying the patient’s symptoms. We may or may not choose to include this list at the end of this section of the case presentation.

    The next step is to describe the results of our clinical examination. Again, we should write in an efficient narrative style, restricting ourselves to the relevant information. It is not necessary to include every detail in our clinical notes.

    If we are using a named orthopedic or neurological test, it is best to both name and describe the test (since some people may know the test by a different name). Also, we should describe the actual results, since not all readers will have the same understanding of what constitutes a “positive” or “negative” result.

    X-rays or other images are only helpful if they are clear enough to be easily reproduced and if they are accompanied by a legend. Be sure that any information that might identify a patient is removed before the image is submitted.

    At this point, or at the beginning of the next section, we will want to present our working diagnosis or clinical impression of the patient.

  • Management and Outcome: In this section, we should clearly describe the plan for care, as well as the care which was actually provided, and the outcome.

    It is useful for the reader to know how long the patient was under care and how many times they were treated. Additionally, we should be as specific as possible in describing the treatment that we used. It does not help the reader to simply say that the patient received “chiropractic care.” Exactly what treatment did we use? If we used spinal manipulation, it is best to name the technique, if a common name exists, and also to describe the manipulation. Remember that our case study may be read by people who are not familiar with spinal manipulation, and, even within chiropractic circles, nomenclature for technique is not well standardized.

    We may want to include the patient’s own reports of improvement or worsening. However, whenever possible we should try to use a well-validated method of measuring their improvement. For case studies, it may be possible to use data from visual analogue scales (VAS) for pain, or a journal of medication usage.

    It is useful to include in this section an indication of how and why treatment finished. Did we decide to terminate care, and if so, why? Did the patient withdraw from care or did we refer them to another practitioner?

  • Discussion: In this section we may want to identify any questions that the case raises. It is not our duty to provide a complete physiological explanation for everything that we observed. This is usually impossible. Nor should we feel obligated to list or generate all of the possible hypotheses that might explain the course of the patient’s condition. If there is a well established item of physiology or pathology which illuminates the case, we certainly include it, but remember that we are writing what is primarily a clinical chronicle, not a basic scientific paper. Finally, we summarize the lessons learned from this case.

  • Acknowledgments: If someone provided assistance with the preparation of the case study, we thank them briefly. It is neither necessary nor conventional to thank the patient (although we appreciate what they have taught us). It would generally be regarded as excessive and inappropriate to thank others, such as teachers or colleagues who did not directly participate in preparation of the paper.

  • References: References should be listed as described elsewhere in the instructions to authors. Only use references that you have read and understood, and actually used to support the case study. Do not use more than approximately 15 references without some clear justification. Try to avoid using textbooks as references, since it is assumed that most readers would already have this information. Also, do not refer to personal communication, since readers have no way of checking this information.

    A popular search engine for English-language references is Medline: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi

  • Legends: If we used any tables, figures or photographs, they should be accompanied by a succinct explanation. A good rule for graphs is that they should contain sufficient information to be generally decipherable without reference to a legend.

  • Tables, figures and photographs should be included at the end of the manuscript.

  • Permissions: If any tables, figures or photographs, or substantial quotations, have been borrowed from other publications, we must include a letter of permission from the publisher. Also, if we use any photographs which might identify a patient, we will need their written permission.

  • In addition, patient consent to publish the case report is also required.

    The acceptance of empirical studies in software engineering and their contributions to increasing knowledge is continuously growing. The analytical research paradigm is not sufficient for investigating complex real life issues, involving humans and their interactions with technology. However, the overall share of empirical studies is negligibly small in computer science research; Sjøberg et al. (2005), found 103 experiments in 5,453 articles Ramesh et al. (2004) and identified less than 2% experiments with human subjects, and only 0.16% field studies among 628 articles. Further, existing work on empirical research methodology in software engineering has a strong focus on experimental research; the earliest by Moher and Schneider (1981), Basili et al. (1986), the first methodology handbook by Wohlin et al. (2000), and promoted by Tichy (1998). All have a tendency towards quantitative approaches, although also qualitative approaches are discussed during the later years, e.g. by Seaman (1999). There exist guidelines for experiments’ conduct (Kitchenham et al. 2002; Wohlin et al. 2000) and reporting (Jedlitschka and Pfahl 2005), measurements (Basili and Weiss 1984; Fenton and Pfleeger 1996; van Solingen and Berghout 1999), and systematic reviews (Kitchenham 2007), while only little is written on case studies in software engineering (Höst and Runeson 2007; Kitchenham et al. 1995; Wohlin et al. 2003) and qualitative methods (Dittrich 2007; Seaman 1999; Sim et al. 2001). Recently, a comprehensive view of empirical research issues for software engineering has been presented, edited by Shull et al. (2008).

    The term “case study” appears every now and then in the title of software engineering research papers. However, the presented studies range from very ambitious and well organized studies in the field, to small toy examples that claim to be case studies. Additionally, there are different taxonomies used to classify research. The term case study is used in parallel with terms like field study and observational study, each focusing on a particular aspect of the research methodology. For example, Lethbridge et al. use field studies as the most general term (Lethbridge et al. 2005), while Easterbrook et al. (2008) call case studies one of five “classes of research methods”. Zelkowitz and Wallace propose a terminology that is somewhat different from what is used in other fields, and categorize project monitoring, case study and field study as observational methods (Zelkowitz and Wallace 1998). This plethora of terms causes confusion and problems when trying to aggregate multiple empirical studies.

    The case study methodology is well suited for many kinds of software engineering research, as the objects of study are contemporary phenomena, which are hard to study in isolation. Case studies do not generate the same results on e.g. causal relationships as controlled experiments do, but they provide deeper understanding of the phenomena under study. As they are different from analytical and controlled empirical studies, case studies have been criticized for being of less value, impossible to generalize from, being biased by researchers etc. This critique can be met by applying proper research methodology practices as well as reconsidering that knowledge is more than statistical significance (Flyvbjerg 2007; Lee 1989). However, the research community has to learn more about the case study methodology in order to review and judge it properly.

    Case study methodology handbooks are superfluously available in e.g. social sciences (Robson 2002; Stake 1995; Yin 2003) which literature also has been used in software engineering. In the field of information systems (IS) research, the case study methodology is also much more mature than in software engineering. For example, Benbasat et al. provide a brief overview of case study research in information systems (Benbasat et al. 1987), Lee analyzes case studies from a positivistic perspective (Lee 1989) and Klein and Myers do the same from an interpretive perspective (Klein and Myers 1999).

    It is relevant to raise the question: what is specific for software engineering that motivates specialized research methodology? In addition to the specifics of the examples, the characteristics of software engineering objects of study are different from social science and also to some extent from information systems. The study objects are 1) private corporations or units of public agencies developing software rather than public agencies or private corporations using software systems; 2) project oriented rather than line or function oriented; and 3) the studied work is advanced engineering work conducted by highly educated people rather than routine work. Additionally, the software engineering research community has a pragmatic and result-oriented view on research methodology, rather than a philosophical stand, as noticed by Seaman (1999).

    The purpose of this paper is to provide guidance for the researcher conducting case studies, for reviewers of case study manuscripts and for readers of case study papers. It is synthesized from general methodology handbooks, mainly from the social science field, as well as literature from the information systems field, and adapted to software engineering needs. Existing literature on software engineering case studies is of course included as well. The underlying analysis is done by structuring the information according to a general case study research process (presented in Section 2.4). Where different recommendations or terms appear, the ones considered most suited for the software engineering domain are selected, based on the authors’ experience on conducting case studies and reading case study reports. Links to data sources are given by regular references. Specifically, checklists for researchers and readers are derived through a systematic analysis of existing checklists (Höst and Runeson 2007), and later evaluated by PhD students as well as by members of the International Software Engineering Research Network and updated accordingly.

    This paper does not provide absolute statements for what is considered a “good” case study in software engineering. Rather it focuses on a set of issues that all contribute to the quality of the research. The minimum requirement for each issue must be judged in its context, and will most probably evolve over time. This is similar to the principles by Klein and Myers for IS case studies (Klein and Myers 1999), “it is incumbent upon authors, reviewers, and exercise their judgment and discretion in deciding whether, how and which of the principles should be applied”. We do neither assess the current status of case study research in software engineering. This is worth a study on its own, similar to the systematic review on experiments by Sjøberg et al. (2005). Further, examples are used both to illustrate good practices and lack thereof.

    This paper is outlined as follows. We first define a set of terms in the field of empirical research, which we use throughout the paper (Section 2.1), set case study research into the context of other research methodologies (Section 2.2) and discuss the motivations for software engineering case studies (Section 2.3). We define a case study research process (Section 2.4) and terminology (Section 2.5), which are used for the rest of the paper. Section 3 discusses the design of a case study and planning for data collection. Section 4 describes the process of data collection. In Section 5 issues on data analysis are treated, and reporting is discussed in Section 6. Section 7 discusses reading and reviewing case study report, and Section 8 summarizes the paper. Checklists for conducting and reading case study research are linked to each step in the case study process, and summarized in the Appendix.

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