title: Using case study within a sequential explanatory design to evaluate the impact of specialist and advanced practice roles on clinical outcomes: the SCAPE study.
abstract: BACKGROUND
  The role of the clinical nurse/midwife specialist and advanced nurse/midwife practitioner is complex not least because of the diversity in how the roles are operationalised across health settings and within multidisciplinary teams. This aim of this paper is to use The SCAPE Study: Specialist Clinical and Advanced Practitioner Evaluation in Ireland to illustrate how case study was used to strengthen a Sequential Explanatory Design.
  
  
  METHODS
  In Phase 1, clinicians identified indicators of specialist and advanced practice which were then used to guide the instrumental case study design which formed the second phase of the larger study. Phase 2 used matched case studies to evaluate the effectiveness of specialist and advanced practitioners on clinical outcomes for service users. Data were collected through observation, documentary analysis, and interviews. Observations were made of 23 Clinical Specialists or Advanced Practitioners, and 23 matched clinicians in similar matched non-postholding sites, while they delivered care. Forty-one service users, 41 clinicians, and 23 Directors of Nursing or Midwifery were interviewed, and 279 service users completed a survey based on the components of CS and AP practice identified in Phase 1. A coding framework, and the generation of cross tabulation matrices in NVivo, was used to make explicit how the outcome measures were confirmed and validated from multiple sources. This strengthened the potential to examine single cases that seemed 'different', and allowed for cases to be redefined. Phase 3 involved interviews with policy-makers to set the findings in context.
  
  
  RESULTS
  Case study is a powerful research strategy to use within sequential explanatory mixed method designs, and adds completeness to the exploration of complex issues in clinical practice. The design is flexible, allowing the use of multiple data collection methods from both qualitative and quantitative paradigms.
  
  
  CONCLUSIONS
  Multiple approaches to data collection are needed to evaluate the impact of complex roles and interventions in health care outcomes and service delivery. Case study design is an appropriate methodology to use when study outcomes relate to clinical practice.
authors.affiliation: School of Nursing and Midwifery, Trinity College Dublin, Dublin, Ireland. jlalor@tcd.ie
authors.forename: Joan G
authors.initials: JG
authors.lastname: Lalor
authors.forename: Dympna
authors.initials: D
authors.lastname: Casey
authors.forename: Naomi
authors.initials: N
authors.lastname: Elliott
authors.forename: Imelda
authors.initials: I
authors.lastname: Coyne
authors.forename: Catherine
authors.initials: C
authors.lastname: Comiskey
authors.forename: Agnes
authors.initials: A
authors.lastname: Higgins
authors.forename: Kathy
authors.initials: K
authors.lastname: Murphy
authors.forename: Declan
authors.initials: D
authors.lastname: Devane
authors.forename: Cecily
authors.initials: C
authors.lastname: Begley
mesh_terms: D006801:Humans; D007407:Interviews as Topic; D008880:Midwifery; D009718:Nurse Administrators / Q000523:psychology; D019982:Organizational Case Studies / Q000706:statistics & numerical data*; D024382:Professional Role; D015397:Program Evaluation; D036301:Qualitative Research; D019984:Quality Indicators, Health Care / Q000706:statistics & numerical data*; D012107:Research Design; D013038:Specialization; D016896:Treatment Outcome; D000078329:Workforce