social case study report meaning

Organizing Your Social Sciences Research Paper: Writing a Case Study

• Purpose of Guide
• Design Flaws to Avoid
• Independent and Dependent Variables
• Glossary of Research Terms
• Narrowing a Topic Idea
• Broadening a Topic Idea
• Extending the Timeliness of a Topic Idea
• Academic Writing Style
• Choosing a Title
• Making an Outline
• Paragraph Development
• Executive Summary
• The C.A.R.S. Model
• Background Information
• The Research Problem/Question
• Theoretical Framework
• Citation Tracking
• Content Alert Services
• Evaluating Sources
• Reading Research Effectively
• Primary Sources
• Secondary Sources
• Tiertiary Sources
• What Is Scholarly vs. Popular?
• Qualitative Methods
• Quantitative Methods
• Using Non-Textual Elements
• Limitations of the Study
• Common Grammar Mistakes
• Writing Concisely
• Avoiding Plagiarism
• Footnotes or Endnotes?
• Further Readings
• Annotated Bibliography
• Dealing with Nervousness
• Using Visual Aids
• Grading Someone Else's Paper
• Types of Structured Group Activities
• Group Project Survival Skills
• Multiple Book Review Essay
• Reviewing Collected Essays
• Writing a Case Study
• About Informed Consent
• Writing Field Notes
• Writing a Policy Memo
• Writing a Research Proposal
• Bibliography

The term case study refers to both a method of analysis and a specific research design for examining a problem, both of which are used in most circumstances to generalize across populations. This tab focuses on the latter--how to design and organize a research paper in the social sciences that analyzes a specific case.

A case study research paper examines a person, place, event, phenomenon, or other type of subject of analysis in order to extrapolate  key themes and results that help predict future trends, illuminate previously hidden issues that can be applied to practice, and/or provide a means for understanding an important research problem with greater clarity. A case study paper usually examines a single subject of analysis, but case study papers can also be designed as a comparative investigation that shows relationships between two or among more than two subjects. The methods used to study a case can rest within a quantitative, qualitative, or mixed-method investigative paradigm.

Case Studies . Writing@CSU. Colorado State University; Mills, Albert J. , Gabrielle Durepos, and Eiden Wiebe, editors. Encyclopedia of Case Study Research . Thousand Oaks, CA: SAGE Publications, 2010 ; “What is a Case Study?” In Swanborn, Peter G. Case Study Research: What, Why and How? London: SAGE, 2010.

How to Approach Writing a Case Study Research Paper

General information about how to choose a topic to investigate can be found under the " Choosing a Research Problem " tab in this writing guide. Review this page because it may help you identify a subject of analysis that can be investigated using a single case study design.

However, identifying a case to investigate involves more than choosing the research problem . A case study encompasses a problem contextualized around the application of in-depth analysis, interpretation, and discussion, often resulting in specific recommendations for action or for improving existing conditions. As Seawright and Gerring note, practical considerations such as time and access to information can influence case selection, but these issues should not be the sole factors used in describing the methodological justification for identifying a particular case to study. Given this, selecting a case includes considering the following:

• Does the case represent an unusual or atypical example of a research problem that requires more in-depth analysis? Cases often represent a topic that rests on the fringes of prior investigations because the case may provide new ways of understanding the research problem. For example, if the research problem is to identify strategies to improve policies that support girl's access to secondary education in predominantly Muslim nations, you could consider using Azerbaijan as a case study rather than selecting a more obvious nation in the Middle East. Doing so may reveal important new insights into recommending how governments in other predominantly Muslim nations can formulate policies that support improved access to education for girls.
• Does the case provide important insight or illuminate a previously hidden problem? In-depth analysis of a case can be based on the hypothesis that the case study will reveal trends or issues that have not been exposed in prior research or will reveal new and important implications for practice. For example, anecdotal evidence may suggest drug use among homeless veterans is related to their patterns of travel throughout the day. Assuming prior studies have not looked at individual travel choices as a way to study access to illicit drug use, a case study that observes a homeless veteran could reveal how issues of personal mobility choices facilitate regular access to illicit drugs. Note that it is important to conduct a thorough literature review to ensure that your assumption about the need to reveal new insights or previously hidden problems is valid and evidence-based.
• Does the case challenge and offer a counter-point to prevailing assumptions? Over time, research on any given topic can fall into a trap of developing assumptions based on outdated studies that are still applied to new or changing conditions or the idea that something should simply be accepted as "common sense," even though the issue has not been thoroughly tested in practice. A case may offer you an opportunity to gather evidence that challenges prevailing assumptions about a research problem and provide a new set of recommendations applied to practice that have not been tested previously. For example, perhaps there has been a long practice among scholars to apply a particular theory in explaining the relationship between two subjects of analysis. Your case could challenge this assumption by applying an innovative theoretical framework [perhaps borrowed from another discipline] to the study a case in order to explore whether this approach offers new ways of understanding the research problem. Taking a contrarian stance is one of the most important ways that new knowledge and understanding develops from existing literature.
• Does the case provide an opportunity to pursue action leading to the resolution of a problem? Another way to think about choosing a case to study is to consider how the results from investigating a particular case may result in findings that reveal ways in which to resolve an existing or emerging problem. For example, studying the case of an unforeseen incident, such as a fatal accident at a railroad crossing, can reveal hidden issues that could be applied to preventative measures that contribute to reducing the chance of accidents in the future. In this example, a case study investigating the accident could lead to a better understanding of where to strategically locate additional signals at other railroad crossings in order to better warn drivers of an approaching train, particularly when visibility is hindered by heavy rain, fog, or at night.
• Does the case offer a new direction in future research? A case study can be used as a tool for exploratory research that points to a need for further examination of the research problem. A case can be used when there are few studies that help predict an outcome or that establish a clear understanding about how best to proceed in addressing a problem. For example, after conducting a thorough literature review [very important!], you discover that little research exists showing the ways in which women contribute to promoting water conservation in rural communities of Uganda. A case study of how women contribute to saving water in a particular village can lay the foundation for understanding the need for more thorough research that documents how women in their roles as cooks and family caregivers think about water as a valuable resource within their community throughout rural regions of east Africa. The case could also point to the need for scholars to apply feminist theories of work and family to the issue of water conservation.

Eisenhardt, Kathleen M. “Building Theories from Case Study Research.” Academy of Management Review 14 (October 1989): 532-550; Emmel, Nick. Sampling and Choosing Cases in Qualitative Research: A Realist Approach . Thousand Oaks, CA: SAGE Publications, 2013; Gerring, John. “What Is a Case Study and What Is It Good for?” American Political Science Review 98 (May 2004): 341-354; Mills, Albert J. , Gabrielle Durepos, and Eiden Wiebe, editors. Encyclopedia of Case Study Research . Thousand Oaks, CA: SAGE Publications, 2010; Seawright, Jason and John Gerring. "Case Selection Techniques in Case Study Research." Political Research Quarterly 61 (June 2008): 294-308.

Structure and Writing Style

The purpose of a paper in the social sciences designed around a case study is to thoroughly investigate a subject of analysis in order to reveal a new understanding about the research problem and, in so doing, contributing new knowledge to what is already known from previous studies. In applied social sciences disciplines [e.g., education, social work, public administration, etc.], case studies may also be used to reveal best practices, highlight key programs, or investigate interesting aspects of professional work. In general, the structure of a case study research paper is not all that different from a standard college-level research paper. However, there are subtle differences you should be aware of. Here are the key elements to organizing and writing a case study research paper.

I.  Introduction

As with any research paper, your introduction should serve as a roadmap for your readers to ascertain the scope and purpose of your study . The introduction to a case study research paper, however, should not only describe the research problem and its significance, but you should also succinctly describe why the case is being used and how it relates to addressing the problem. The two elements should be linked. With this in mind, a good introduction answers these four questions:

• What was I studying? Describe the research problem and describe the subject of analysis you have chosen to address the problem. Explain how they are linked and what elements of the case will help to expand knowledge and understanding about the problem.
• Why was this topic important to investigate? Describe the significance of the research problem and state why a case study design and the subject of analysis that the paper is designed around is appropriate in addressing the problem.
• What did we know about this topic before I did this study? Provide background that helps lead the reader into the more in-depth literature review to follow. If applicable, summarize prior case study research applied to the research problem and why it fails to adequately address the research problem. Describe why your case will be useful. If no prior case studies have been used to address the research problem, explain why you have selected this subject of analysis.
• How will this study advance new knowledge or new ways of understanding? Explain why your case study will be suitable in helping to expand knowledge and understanding about the research problem.

Each of these questions should be addressed in no more than a few paragraphs. Exceptions to this can be when you are addressing a complex research problem or subject of analysis that requires more in-depth background information.

II.  Literature Review

The literature review for a case study research paper is generally structured the same as it is for any college-level research paper. The difference, however, is that the literature review is focused on providing background information and  enabling historical interpretation of the subject of analysis in relation to the research problem the case is intended to address . This includes synthesizing studies that help to:

• Place relevant works in the context of their contribution to understanding the case study being investigated . This would include summarizing studies that have used a similar subject of analysis to investigate the research problem. If there is literature using the same or a very similar case to study, you need to explain why duplicating past research is important [e.g., conditions have changed; prior studies were conducted long ago, etc.].
• Describe the relationship each work has to the others under consideration that informs the reader why this case is applicable . Your literature review should include a description of any works that support using the case to study the research problem and the underlying research questions.
• Identify new ways to interpret prior research using the case study . If applicable, review any research that has examined the research problem using a different research design. Explain how your case study design may reveal new knowledge or a new perspective or that can redirect research in an important new direction.
• Resolve conflicts amongst seemingly contradictory previous studies . This refers to synthesizing any literature that points to unresolved issues of concern about the research problem and describing how the subject of analysis that forms the case study can help resolve these existing contradictions.
• Point the way in fulfilling a need for additional research . Your review should examine any literature that lays a foundation for understanding why your case study design and the subject of analysis around which you have designed your study may reveal a new way of approaching the research problem or offer a perspective that points to the need for additional research.
• Expose any gaps that exist in the literature that the case study could help to fill . Summarize any literature that not only shows how your subject of analysis contributes to understanding the research problem, but how your case contributes to a new way of understanding the problem that prior research has failed to do.
• Locate your own research within the context of existing literature [very important!] . Collectively, your literature review should always place your case study within the larger domain of prior research about the problem. The overarching purpose of reviewing pertinent literature in a case study paper is to demonstrate that you have thoroughly identified and synthesized prior studies in the context of explaining the relevance of the case in addressing the research problem.

III.  Method

In this section, you explain why you selected a particular subject of analysis to study and the strategy you used to identify and ultimately decide that your case was appropriate in addressing the research problem. The way you describe the methods used varies depending on the type of subject of analysis that frames your case study.

If your subject of analysis is an incident or event . In the social and behavioral sciences, the event or incident that represents the case to be studied is usually bounded by time and place, with a clear beginning and end and with an identifiable location or position relative to its surroundings. The subject of analysis can be a rare or critical event or it can focus on a typical or regular event. The purpose of studying a rare event is to illuminate new ways of thinking about the broader research problem or to test a hypothesis. Critical incident case studies must describe the method by which you identified the event and explain the process by which you determined the validity of this case to inform broader perspectives about the research problem or to reveal new findings. However, the event does not have to be a rare or uniquely significant to support new thinking about the research problem or to challenge an existing hypothesis. For example, Walo, Bull, and Breen conducted a case study to identify and evaluate the direct and indirect economic benefits and costs of a local sports event in the City of Lismore, New South Wales, Australia. The purpose of their study was to provide new insights from measuring the impact of a typical local sports event that prior studies could not measure well because they focused on large "mega-events." Whether the event is rare or not, the methods section should include an explanation of the following characteristics of the event: a) when did it take place; b) what were the underlying circumstances leading to the event; c) what were the consequences of the event.

If your subject of analysis is a person. Explain why you selected this particular individual to be studied and describe what experience he or she has had that provides an opportunity to advance new understandings about the research problem. Mention any background about this person which might help the reader understand the significance of his/her experiences that make them worthy of study. This includes describing the relationships this person has had with other people, institutions, and/or events that support using him or her as the subject for a case study research paper. It is particularly important to differentiate the person as the subject of analysis from others and to succinctly explain how the person relates to examining the research problem.

If your subject of analysis is a place. In general, a case study that investigates a place suggests a subject of analysis that is unique or special in some way and that this uniqueness can be used to build new understanding or knowledge about the research problem. A case study of a place must not only describe its various attributes relevant to the research problem [e.g., physical, social, cultural, economic, political, etc.], but you must state the method by which you determined that this place will illuminate new understandings about the research problem. It is also important to articulate why a particular place as the case for study is being used if similar places also exist [i.e., if you are studying patterns of homeless encampments of veterans in open spaces, why study Echo Park in Los Angeles rather than Griffith Park?]. If applicable, describe what type of human activity involving this place makes it a good choice to study [e.g., prior research reveals Echo Park has more homeless veterans].

If your subject of analysis is a phenomenon. A phenomenon refers to a fact, occurrence, or circumstance that can be studied or observed but with the cause or explanation to be in question. In this sense, a phenomenon that forms your subject of analysis can encompass anything that can be observed or presumed to exist but is not fully understood. In the social and behavioral sciences, the case usually focuses on human interaction within a complex physical, social, economic, cultural, or political system. For example, the phenomenon could be the observation that many vehicles used by ISIS fighters are small trucks with English language advertisements on them. The research problem could be that ISIS fighters are difficult to combat because they are highly mobile. The research questions could be how and by what means are these vehicles used by ISIS being supplied to the militants and how might supply lines to these vehicles be cut? How might knowing the suppliers of these trucks from overseas reveal larger networks of collaborators and financial support? A case study of a phenomenon most often encompasses an in-depth analysis of a cause and effect that is grounded in an interactive relationship between people and their environment in some way.

NOTE:   The choice of the case or set of cases to study cannot appear random. Evidence that supports the method by which you identified and chose your subject of analysis should be linked to the findings from the literature review. Be sure to cite any prior studies that helped you determine that the case you chose was appropriate for investigating the research problem.

IV.  Discussion

The main elements of your discussion section are generally the same as any research paper, but centered around interpreting and drawing conclusions about the key findings from your case study. Note that a general social sciences research paper may contain a separate section to report findings. However, in a paper designed around a case study, it is more common to combine a description of the findings with the discussion about their implications. The objectives of your discussion section should include the following:

Reiterate the Research Problem/State the Major Findings Briefly reiterate the research problem you are investigating and explain why the subject of analysis around which you designed the case study were used. You should then describe the findings revealed from your study of the case using direct, declarative, and succinct proclamation of the study results. Highlight any findings that were unexpected or especially profound.

Explain the Meaning of the Findings and Why They are Important Systematically explain the meaning of your case study findings and why you believe they are important. Begin this part of the section by repeating what you consider to be your most important or surprising finding first, then systematically review each finding. Be sure to thoroughly extrapolate what your analysis of the case can tell the reader about situations or conditions beyond the actual case that was studied while, at the same time, being careful not to misconstrue or conflate a finding that undermines the external validity of your conclusions.

Relate the Findings to Similar Studies No study in the social sciences is so novel or possesses such a restricted focus that it has absolutely no relation to previously published research. The discussion section should relate your case study results to those found in other studies, particularly if questions raised from prior studies served as the motivation for choosing your subject of analysis. This is important because comparing and contrasting the findings of other studies helps to support the overall importance of your results and it highlights how and in what ways your case study design and the subject of analysis differs from prior research about the topic.

Consider Alternative Explanations of the Findings It is important to remember that the purpose of social science research is to discover and not to prove. When writing the discussion section, you should carefully consider all possible explanations for the case study results, rather than just those that fit your hypothesis or prior assumptions and biases. Be alert to what the in-depth analysis of the case may reveal about the research problem, including offering a contrarian perspective to what scholars have stated in prior research.

Acknowledge the Study's Limitations You can state the study's limitations in the conclusion section of your paper but describing the limitations of your subject of analysis in the discussion section provides an opportunity to identify the limitations and explain why they are not significant. This part of the discussion section should also note any unanswered questions or issues your case study could not address. More detailed information about how to document any limitations to your research can be found here .

Suggest Areas for Further Research Although your case study may offer important insights about the research problem, there are likely additional questions related to the problem that remain unanswered or findings that unexpectedly revealed themselves as a result of your in-depth analysis of the case. Be sure that the recommendations for further research are linked to the research problem and that you explain why your recommendations are valid in other contexts and based on the original assumptions of your study.

V.  Conclusion

As with any research paper, you should summarize your conclusion in clear, simple language; emphasize how the findings from your case study differs from or supports prior research and why. Do not simply reiterate the discussion section. Provide a synthesis of key findings presented in the paper to show how these converge to address the research problem. If you haven't already done so in the discussion section, be sure to document the limitations of your case study and needs for further research.

The function of your paper's conclusion is to: 1)  restate the main argument supported by the findings from the analysis of your case; 2) clearly state the context, background, and necessity of pursuing the research problem using a case study design in relation to an issue, controversy, or a gap found from reviewing the literature; and, 3) provide a place for you to persuasively and succinctly restate the significance of your research problem, given that the reader has now been presented with in-depth information about the topic.

Consider the following points to help ensure your conclusion is appropriate:

• If the argument or purpose of your paper is complex, you may need to summarize these points for your reader.
• If prior to your conclusion, you have not yet explained the significance of your findings or if you are proceeding inductively, use the conclusion of your paper to describe your main points and explain their significance.
• Move from a detailed to a general level of consideration of the case study's findings that returns the topic to the context provided by the introduction or within a new context that emerges from your case study findings.

Note that, depending on the discipline you are writing in and your professor's preferences, the concluding paragraph may contain your final reflections on the evidence presented applied to practice or on the essay's central research problem. However, the nature of being introspective about the subject of analysis you have investigated will depend on whether you are explicitly asked to express your observations in this way.

Problems to Avoid

Overgeneralization One of the goals of a case study is to lay a foundation for understanding broader trends and issues applied to similar circumstances. However, be careful when drawing conclusions from your case study. They must be evidence-based and grounded in the results of the study; otherwise, it is merely speculation. Looking at a prior example, it would be incorrect to state that a factor in improving girls access to education in Azerbaijan and the policy implications this may have for improving access in other Muslim nations is due to girls access to social media if there is no documentary evidence from your case study to indicate this. There may be anecdotal evidence that retention rates were better for girls who were on social media, but this observation would only point to the need for further research and would not be a definitive finding if this was not a part of your original research agenda.

Failure to Document Limitations No case is going to reveal all that needs to be understood about a research problem. Therefore, just as you have to clearly state the limitations of a general research study , you must describe the specific limitations inherent in the subject of analysis. For example, the case of studying how women conceptualize the need for water conservation in a village in Uganda could have limited application in other cultural contexts or in areas where fresh water from rivers or lakes is plentiful and, therefore, conservation is understood differently than preserving access to a scarce resource.

Failure to Extrapolate All Possible Implications Just as you don't want to over-generalize from your case study findings, you also have to be thorough in the consideration of all possible outcomes or recommendations derived from your findings. If you do not, your reader may question the validity of your analysis, particularly if you failed to document an obvious outcome from your case study research. For example, in the case of studying the accident at the railroad crossing to evaluate where and what types of warning signals should be located, you failed to take into consideration speed limit signage as well as warning signals. When designing your case study, be sure you have thoroughly addressed all aspects of the problem and do not leave gaps in your analysis.

Case Studies . Writing@CSU. Colorado State University; Gerring, John. Case Study Research: Principles and Practices . New York: Cambridge University Press, 2007; Merriam, Sharan B. Qualitative Research and Case Study Applications in Education . Rev. ed. San Francisco, CA: Jossey-Bass, 1998; Miller, Lisa L. “The Use of Case Studies in Law and Social Science Research.” Annual Review of Law and Social Science 14 (2018): TBD; Mills, Albert J., Gabrielle Durepos, and Eiden Wiebe, editors. Encyclopedia of Case Study Research . Thousand Oaks, CA: SAGE Publications, 2010; Putney, LeAnn Grogan. "Case Study." In Encyclopedia of Research Design , Neil J. Salkind, editor. (Thousand Oaks, CA: SAGE Publications, 2010), pp. 116-120; Simons, Helen. Case Study Research in Practice . London: SAGE Publications, 2009;  Kratochwill,  Thomas R. and Joel R. Levin, editors. Single-Case Research Design and Analysis: New Development for Psychology and Education .  Hilldsale, NJ: Lawrence Erlbaum Associates, 1992; Swanborn, Peter G. Case Study Research: What, Why and How? London : SAGE, 2010; Yin, Robert K. Case Study Research: Design and Methods . 6th edition. Los Angeles, CA, SAGE Publications, 2014; Walo, Maree, Adrian Bull, and Helen Breen. “Achieving Economic Benefits at Local Events: A Case Study of a Local Sports Event.” Festival Management and Event Tourism 4 (1996): 95-106.

Writing Tip

At Least Five Misconceptions about Case Study Research

Social science case studies are often perceived as limited in their ability to create new knowledge because they are not randomly selected and findings cannot be generalized to larger populations. Flyvbjerg examines five misunderstandings about case study research and systematically "corrects" each one. To quote, these are:

Misunderstanding 1 :  General, theoretical [context-independent knowledge is more valuable than concrete, practical (context-dependent) knowledge. Misunderstanding 2 :  One cannot generalize on the basis of an individual case; therefore, the case study cannot contribute to scientific development. Misunderstanding 3 :  The case study is most useful for generating hypotheses; that is, in the first stage of a total research process, whereas other methods are more suitable for hypotheses testing and theory building. Misunderstanding 4 :  The case study contains a bias toward verification, that is, a tendency to confirm the researcher’s preconceived notions. Misunderstanding 5 :  It is often difficult to summarize and develop general propositions and theories on the basis of specific case studies [p. 221].

While writing your paper, think introspectively about how you addressed these misconceptions because to do so can help you strengthen the validity and reliability of your research by clarifying issues of case selection, the testing and challenging of existing assumptions, the interpretation of key findings, and the summation of case outcomes. Think of a case study research paper as a complete, in-depth narrative about the specific properties and key characteristics of your subject of analysis applied to the research problem.

Flyvbjerg, Bent. “Five Misunderstandings About Case-Study Research.” Qualitative Inquiry 12 (April 2006): 219-245.

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• What Is a Case Study? | Definition, Examples & Methods

What Is a Case Study? | Definition, Examples & Methods

Published on May 8, 2019 by Shona McCombes . Revised on November 20, 2023.

A case study is a detailed study of a specific subject, such as a person, group, place, event, organization, or phenomenon. Case studies are commonly used in social, educational, clinical, and business research.

A case study research design usually involves qualitative methods , but quantitative methods are sometimes also used. Case studies are good for describing , comparing, evaluating and understanding different aspects of a research problem .

Table of contents

When to do a case study, step 1: select a case, step 2: build a theoretical framework, step 3: collect your data, step 4: describe and analyze the case, other interesting articles.

A case study is an appropriate research design when you want to gain concrete, contextual, in-depth knowledge about a specific real-world subject. It allows you to explore the key characteristics, meanings, and implications of the case.

Case studies are often a good choice in a thesis or dissertation . They keep your project focused and manageable when you don’t have the time or resources to do large-scale research.

You might use just one complex case study where you explore a single subject in depth, or conduct multiple case studies to compare and illuminate different aspects of your research problem.

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Once you have developed your problem statement and research questions , you should be ready to choose the specific case that you want to focus on. A good case study should have the potential to:

• Provide new or unexpected insights into the subject
• Challenge or complicate existing assumptions and theories
• Propose practical courses of action to resolve a problem
• Open up new directions for future research

TipIf your research is more practical in nature and aims to simultaneously investigate an issue as you solve it, consider conducting action research instead.

Unlike quantitative or experimental research , a strong case study does not require a random or representative sample. In fact, case studies often deliberately focus on unusual, neglected, or outlying cases which may shed new light on the research problem.

Example of an outlying case studyIn the 1960s the town of Roseto, Pennsylvania was discovered to have extremely low rates of heart disease compared to the US average. It became an important case study for understanding previously neglected causes of heart disease.

However, you can also choose a more common or representative case to exemplify a particular category, experience or phenomenon.

Example of a representative case studyIn the 1920s, two sociologists used Muncie, Indiana as a case study of a typical American city that supposedly exemplified the changing culture of the US at the time.

While case studies focus more on concrete details than general theories, they should usually have some connection with theory in the field. This way the case study is not just an isolated description, but is integrated into existing knowledge about the topic. It might aim to:

• Exemplify a theory by showing how it explains the case under investigation
• Expand on a theory by uncovering new concepts and ideas that need to be incorporated
• Challenge a theory by exploring an outlier case that doesn’t fit with established assumptions

To ensure that your analysis of the case has a solid academic grounding, you should conduct a literature review of sources related to the topic and develop a theoretical framework . This means identifying key concepts and theories to guide your analysis and interpretation.

There are many different research methods you can use to collect data on your subject. Case studies tend to focus on qualitative data using methods such as interviews , observations , and analysis of primary and secondary sources (e.g., newspaper articles, photographs, official records). Sometimes a case study will also collect quantitative data.

Example of a mixed methods case studyFor a case study of a wind farm development in a rural area, you could collect quantitative data on employment rates and business revenue, collect qualitative data on local people’s perceptions and experiences, and analyze local and national media coverage of the development.

The aim is to gain as thorough an understanding as possible of the case and its context.

In writing up the case study, you need to bring together all the relevant aspects to give as complete a picture as possible of the subject.

How you report your findings depends on the type of research you are doing. Some case studies are structured like a standard scientific paper or thesis , with separate sections or chapters for the methods , results and discussion .

Others are written in a more narrative style, aiming to explore the case from various angles and analyze its meanings and implications (for example, by using textual analysis or discourse analysis ).

In all cases, though, make sure to give contextual details about the case, connect it back to the literature and theory, and discuss how it fits into wider patterns or debates.

If you want to know more about statistics , methodology , or research bias , make sure to check out some of our other articles with explanations and examples.

• Normal distribution
• Degrees of freedom
• Null hypothesis
• Discourse analysis
• Control groups
• Mixed methods research
• Non-probability sampling
• Quantitative research
• Ecological validity

Research bias

• Rosenthal effect
• Implicit bias
• Cognitive bias
• Selection bias
• Negativity bias
• Status quo bias

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Home » Case Study – Methods, Examples and Guide

Case Study – Methods, Examples and Guide

Table of Contents

A case study is a research method that involves an in-depth examination and analysis of a particular phenomenon or case, such as an individual, organization, community, event, or situation.

It is a qualitative research approach that aims to provide a detailed and comprehensive understanding of the case being studied. Case studies typically involve multiple sources of data, including interviews, observations, documents, and artifacts, which are analyzed using various techniques, such as content analysis, thematic analysis, and grounded theory. The findings of a case study are often used to develop theories, inform policy or practice, or generate new research questions.

Types of Case Study

Types and Methods of Case Study are as follows:

Single-Case Study

A single-case study is an in-depth analysis of a single case. This type of case study is useful when the researcher wants to understand a specific phenomenon in detail.

For Example , A researcher might conduct a single-case study on a particular individual to understand their experiences with a particular health condition or a specific organization to explore their management practices. The researcher collects data from multiple sources, such as interviews, observations, and documents, and uses various techniques to analyze the data, such as content analysis or thematic analysis. The findings of a single-case study are often used to generate new research questions, develop theories, or inform policy or practice.

Multiple-Case Study

A multiple-case study involves the analysis of several cases that are similar in nature. This type of case study is useful when the researcher wants to identify similarities and differences between the cases.

For Example, a researcher might conduct a multiple-case study on several companies to explore the factors that contribute to their success or failure. The researcher collects data from each case, compares and contrasts the findings, and uses various techniques to analyze the data, such as comparative analysis or pattern-matching. The findings of a multiple-case study can be used to develop theories, inform policy or practice, or generate new research questions.

Exploratory Case Study

An exploratory case study is used to explore a new or understudied phenomenon. This type of case study is useful when the researcher wants to generate hypotheses or theories about the phenomenon.

For Example, a researcher might conduct an exploratory case study on a new technology to understand its potential impact on society. The researcher collects data from multiple sources, such as interviews, observations, and documents, and uses various techniques to analyze the data, such as grounded theory or content analysis. The findings of an exploratory case study can be used to generate new research questions, develop theories, or inform policy or practice.

Descriptive Case Study

A descriptive case study is used to describe a particular phenomenon in detail. This type of case study is useful when the researcher wants to provide a comprehensive account of the phenomenon.

For Example, a researcher might conduct a descriptive case study on a particular community to understand its social and economic characteristics. The researcher collects data from multiple sources, such as interviews, observations, and documents, and uses various techniques to analyze the data, such as content analysis or thematic analysis. The findings of a descriptive case study can be used to inform policy or practice or generate new research questions.

Instrumental Case Study

An instrumental case study is used to understand a particular phenomenon that is instrumental in achieving a particular goal. This type of case study is useful when the researcher wants to understand the role of the phenomenon in achieving the goal.

For Example, a researcher might conduct an instrumental case study on a particular policy to understand its impact on achieving a particular goal, such as reducing poverty. The researcher collects data from multiple sources, such as interviews, observations, and documents, and uses various techniques to analyze the data, such as content analysis or thematic analysis. The findings of an instrumental case study can be used to inform policy or practice or generate new research questions.

Case Study Data Collection Methods

Here are some common data collection methods for case studies:

Interviews involve asking questions to individuals who have knowledge or experience relevant to the case study. Interviews can be structured (where the same questions are asked to all participants) or unstructured (where the interviewer follows up on the responses with further questions). Interviews can be conducted in person, over the phone, or through video conferencing.

Observations

Observations involve watching and recording the behavior and activities of individuals or groups relevant to the case study. Observations can be participant (where the researcher actively participates in the activities) or non-participant (where the researcher observes from a distance). Observations can be recorded using notes, audio or video recordings, or photographs.

Documents can be used as a source of information for case studies. Documents can include reports, memos, emails, letters, and other written materials related to the case study. Documents can be collected from the case study participants or from public sources.

Surveys involve asking a set of questions to a sample of individuals relevant to the case study. Surveys can be administered in person, over the phone, through mail or email, or online. Surveys can be used to gather information on attitudes, opinions, or behaviors related to the case study.

Artifacts are physical objects relevant to the case study. Artifacts can include tools, equipment, products, or other objects that provide insights into the case study phenomenon.

How to conduct Case Study Research

Conducting a case study research involves several steps that need to be followed to ensure the quality and rigor of the study. Here are the steps to conduct case study research:

• Define the research questions: The first step in conducting a case study research is to define the research questions. The research questions should be specific, measurable, and relevant to the case study phenomenon under investigation.
• Select the case: The next step is to select the case or cases to be studied. The case should be relevant to the research questions and should provide rich and diverse data that can be used to answer the research questions.
• Collect data: Data can be collected using various methods, such as interviews, observations, documents, surveys, and artifacts. The data collection method should be selected based on the research questions and the nature of the case study phenomenon.
• Analyze the data: The data collected from the case study should be analyzed using various techniques, such as content analysis, thematic analysis, or grounded theory. The analysis should be guided by the research questions and should aim to provide insights and conclusions relevant to the research questions.
• Draw conclusions: The conclusions drawn from the case study should be based on the data analysis and should be relevant to the research questions. The conclusions should be supported by evidence and should be clearly stated.
• Validate the findings: The findings of the case study should be validated by reviewing the data and the analysis with participants or other experts in the field. This helps to ensure the validity and reliability of the findings.
• Write the report: The final step is to write the report of the case study research. The report should provide a clear description of the case study phenomenon, the research questions, the data collection methods, the data analysis, the findings, and the conclusions. The report should be written in a clear and concise manner and should follow the guidelines for academic writing.

Examples of Case Study

Here are some examples of case study research:

• The Hawthorne Studies : Conducted between 1924 and 1932, the Hawthorne Studies were a series of case studies conducted by Elton Mayo and his colleagues to examine the impact of work environment on employee productivity. The studies were conducted at the Hawthorne Works plant of the Western Electric Company in Chicago and included interviews, observations, and experiments.
• The Stanford Prison Experiment: Conducted in 1971, the Stanford Prison Experiment was a case study conducted by Philip Zimbardo to examine the psychological effects of power and authority. The study involved simulating a prison environment and assigning participants to the role of guards or prisoners. The study was controversial due to the ethical issues it raised.
• The Challenger Disaster: The Challenger Disaster was a case study conducted to examine the causes of the Space Shuttle Challenger explosion in 1986. The study included interviews, observations, and analysis of data to identify the technical, organizational, and cultural factors that contributed to the disaster.
• The Enron Scandal: The Enron Scandal was a case study conducted to examine the causes of the Enron Corporation’s bankruptcy in 2001. The study included interviews, analysis of financial data, and review of documents to identify the accounting practices, corporate culture, and ethical issues that led to the company’s downfall.
• The Fukushima Nuclear Disaster : The Fukushima Nuclear Disaster was a case study conducted to examine the causes of the nuclear accident that occurred at the Fukushima Daiichi Nuclear Power Plant in Japan in 2011. The study included interviews, analysis of data, and review of documents to identify the technical, organizational, and cultural factors that contributed to the disaster.

Application of Case Study

Case studies have a wide range of applications across various fields and industries. Here are some examples:

Business and Management

Case studies are widely used in business and management to examine real-life situations and develop problem-solving skills. Case studies can help students and professionals to develop a deep understanding of business concepts, theories, and best practices.

Case studies are used in healthcare to examine patient care, treatment options, and outcomes. Case studies can help healthcare professionals to develop critical thinking skills, diagnose complex medical conditions, and develop effective treatment plans.

Case studies are used in education to examine teaching and learning practices. Case studies can help educators to develop effective teaching strategies, evaluate student progress, and identify areas for improvement.

Social Sciences

Case studies are widely used in social sciences to examine human behavior, social phenomena, and cultural practices. Case studies can help researchers to develop theories, test hypotheses, and gain insights into complex social issues.

Law and Ethics

Case studies are used in law and ethics to examine legal and ethical dilemmas. Case studies can help lawyers, policymakers, and ethical professionals to develop critical thinking skills, analyze complex cases, and make informed decisions.

Purpose of Case Study

The purpose of a case study is to provide a detailed analysis of a specific phenomenon, issue, or problem in its real-life context. A case study is a qualitative research method that involves the in-depth exploration and analysis of a particular case, which can be an individual, group, organization, event, or community.

The primary purpose of a case study is to generate a comprehensive and nuanced understanding of the case, including its history, context, and dynamics. Case studies can help researchers to identify and examine the underlying factors, processes, and mechanisms that contribute to the case and its outcomes. This can help to develop a more accurate and detailed understanding of the case, which can inform future research, practice, or policy.

Case studies can also serve other purposes, including:

• Illustrating a theory or concept: Case studies can be used to illustrate and explain theoretical concepts and frameworks, providing concrete examples of how they can be applied in real-life situations.
• Developing hypotheses: Case studies can help to generate hypotheses about the causal relationships between different factors and outcomes, which can be tested through further research.
• Providing insight into complex issues: Case studies can provide insights into complex and multifaceted issues, which may be difficult to understand through other research methods.
• Informing practice or policy: Case studies can be used to inform practice or policy by identifying best practices, lessons learned, or areas for improvement.

Advantages of Case Study Research

There are several advantages of case study research, including:

• In-depth exploration: Case study research allows for a detailed exploration and analysis of a specific phenomenon, issue, or problem in its real-life context. This can provide a comprehensive understanding of the case and its dynamics, which may not be possible through other research methods.
• Rich data: Case study research can generate rich and detailed data, including qualitative data such as interviews, observations, and documents. This can provide a nuanced understanding of the case and its complexity.
• Holistic perspective: Case study research allows for a holistic perspective of the case, taking into account the various factors, processes, and mechanisms that contribute to the case and its outcomes. This can help to develop a more accurate and comprehensive understanding of the case.
• Theory development: Case study research can help to develop and refine theories and concepts by providing empirical evidence and concrete examples of how they can be applied in real-life situations.
• Practical application: Case study research can inform practice or policy by identifying best practices, lessons learned, or areas for improvement.
• Contextualization: Case study research takes into account the specific context in which the case is situated, which can help to understand how the case is influenced by the social, cultural, and historical factors of its environment.

Limitations of Case Study Research

There are several limitations of case study research, including:

• Limited generalizability : Case studies are typically focused on a single case or a small number of cases, which limits the generalizability of the findings. The unique characteristics of the case may not be applicable to other contexts or populations, which may limit the external validity of the research.
• Biased sampling: Case studies may rely on purposive or convenience sampling, which can introduce bias into the sample selection process. This may limit the representativeness of the sample and the generalizability of the findings.
• Subjectivity: Case studies rely on the interpretation of the researcher, which can introduce subjectivity into the analysis. The researcher’s own biases, assumptions, and perspectives may influence the findings, which may limit the objectivity of the research.
• Limited control: Case studies are typically conducted in naturalistic settings, which limits the control that the researcher has over the environment and the variables being studied. This may limit the ability to establish causal relationships between variables.
• Time-consuming: Case studies can be time-consuming to conduct, as they typically involve a detailed exploration and analysis of a specific case. This may limit the feasibility of conducting multiple case studies or conducting case studies in a timely manner.
• Resource-intensive: Case studies may require significant resources, including time, funding, and expertise. This may limit the ability of researchers to conduct case studies in resource-constrained settings.

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• Roberta Heale 1 ,
• Alison Twycross 2
• 1 School of Nursing , Laurentian University , Sudbury , Ontario , Canada
• 2 School of Health and Social Care , London South Bank University , London , UK
• Correspondence to Dr Roberta Heale, School of Nursing, Laurentian University, Sudbury, ON P3E2C6, Canada; rheale{at}laurentian.ca

https://doi.org/10.1136/eb-2017-102845

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What is it?

Case study is a research methodology, typically seen in social and life sciences. There is no one definition of case study research. 1 However, very simply… ‘a case study can be defined as an intensive study about a person, a group of people or a unit, which is aimed to generalize over several units’. 1 A case study has also been described as an intensive, systematic investigation of a single individual, group, community or some other unit in which the researcher examines in-depth data relating to several variables. 2

Often there are several similar cases to consider such as educational or social service programmes that are delivered from a number of locations. Although similar, they are complex and have unique features. In these circumstances, the evaluation of several, similar cases will provide a better answer to a research question than if only one case is examined, hence the multiple-case study. Stake asserts that the cases are grouped and viewed as one entity, called the quintain . 6  ‘We study what is similar and different about the cases to understand the quintain better’. 6

The steps when using case study methodology are the same as for other types of research. 6 The first step is defining the single case or identifying a group of similar cases that can then be incorporated into a multiple-case study. A search to determine what is known about the case(s) is typically conducted. This may include a review of the literature, grey literature, media, reports and more, which serves to establish a basic understanding of the cases and informs the development of research questions. Data in case studies are often, but not exclusively, qualitative in nature. In multiple-case studies, analysis within cases and across cases is conducted. Themes arise from the analyses and assertions about the cases as a whole, or the quintain, emerge. 6

Benefits and limitations of case studies

If a researcher wants to study a specific phenomenon arising from a particular entity, then a single-case study is warranted and will allow for a in-depth understanding of the single phenomenon and, as discussed above, would involve collecting several different types of data. This is illustrated in example 1 below.

Using a multiple-case research study allows for a more in-depth understanding of the cases as a unit, through comparison of similarities and differences of the individual cases embedded within the quintain. Evidence arising from multiple-case studies is often stronger and more reliable than from single-case research. Multiple-case studies allow for more comprehensive exploration of research questions and theory development. 6

Despite the advantages of case studies, there are limitations. The sheer volume of data is difficult to organise and data analysis and integration strategies need to be carefully thought through. There is also sometimes a temptation to veer away from the research focus. 2 Reporting of findings from multiple-case research studies is also challenging at times, 1 particularly in relation to the word limits for some journal papers.

Examples of case studies

Example 1: nurses’ paediatric pain management practices.

One of the authors of this paper (AT) has used a case study approach to explore nurses’ paediatric pain management practices. This involved collecting several datasets:

Observational data to gain a picture about actual pain management practices.

Questionnaire data about nurses’ knowledge about paediatric pain management practices and how well they felt they managed pain in children.

Questionnaire data about how critical nurses perceived pain management tasks to be.

These datasets were analysed separately and then compared 7–9 and demonstrated that nurses’ level of theoretical did not impact on the quality of their pain management practices. 7 Nor did individual nurse’s perceptions of how critical a task was effect the likelihood of them carrying out this task in practice. 8 There was also a difference in self-reported and observed practices 9 ; actual (observed) practices did not confirm to best practice guidelines, whereas self-reported practices tended to.

Example 2: quality of care for complex patients at Nurse Practitioner-Led Clinics (NPLCs)

The other author of this paper (RH) has conducted a multiple-case study to determine the quality of care for patients with complex clinical presentations in NPLCs in Ontario, Canada. 10 Five NPLCs served as individual cases that, together, represented the quatrain. Three types of data were collected including:

Review of documentation related to the NPLC model (media, annual reports, research articles, grey literature and regulatory legislation).

Interviews with nurse practitioners (NPs) practising at the five NPLCs to determine their perceptions of the impact of the NPLC model on the quality of care provided to patients with multimorbidity.

Chart audits conducted at the five NPLCs to determine the extent to which evidence-based guidelines were followed for patients with diabetes and at least one other chronic condition.

The three sources of data collected from the five NPLCs were analysed and themes arose related to the quality of care for complex patients at NPLCs. The multiple-case study confirmed that nurse practitioners are the primary care providers at the NPLCs, and this positively impacts the quality of care for patients with multimorbidity. Healthcare policy, such as lack of an increase in salary for NPs for 10 years, has resulted in issues in recruitment and retention of NPs at NPLCs. This, along with insufficient resources in the communities where NPLCs are located and high patient vulnerability at NPLCs, have a negative impact on the quality of care. 10

These examples illustrate how collecting data about a single case or multiple cases helps us to better understand the phenomenon in question. Case study methodology serves to provide a framework for evaluation and analysis of complex issues. It shines a light on the holistic nature of nursing practice and offers a perspective that informs improved patient care.

• Gustafsson J
• Calanzaro M
• Sandelowski M

Competing interests None declared.

Provenance and peer review Commissioned; internally peer reviewed.

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Social case work:Meaning,concept and definition

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Social case work is a technical method of social work (KLEN-1938)

Social casework is process (Deschweinitz-1939)

Social Case work is the science of human relation (Boweres-1949)

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How To Write A Case Study Report In Social Work?

Social work is one of the most important branches or streams of study for students in Australia and around the world. The subject has become so important that even reputed colleges and universities of Australia are offering graduation and postgraduate degree courses in social work.

The institute assigns students large assignments on social work during the courses. In this blog, we will discuss some useful tips for writing an excellent case study report on social work to impress your faculty and get the top grades .

Tips To Write an Effective Case Study Report in Social Work

• Choose an interesting subject: First, you need to choose a very interesting and updated subject for your social work case study. Some such subjects might be domestic violence, corruption, women’s empowerment, drug abuse, and alcohol abuse.
• Do an in-depth analysis: After that, you need to analyse the chosen subject or topic in-depth. You need to explain each and every fact related to that topic. No fiction should be there. Only try, and you will accept the current facts.
• Treat delicate matters likewise: A study on social work is one of the most delicate types of studies in the world. Thus, you need to write your report by treating the matter as seriously as possible and avoiding all types of fluffy language.
• Carry out extensive study and research: You always need to do extensive study and research while writing your case study report on social work. You need to note all the legal, social, and political status of the country, territory, or region in which you are doing your social study.
• Write only true facts: You must always write only true facts in your case study. Writing wrong facts can be very harmful to your paper. You always need to depict a very true picture of the scenario.
• Know how you can help others: The ultimate aim of your social study work is to help the people of your society. Each class of people suffers from particular issues or problems. You need to deal with their issues likewise to solve their problems. Thus, you always need to know the right methods to solve various problems of the suffering people.
• Give proper solutions: You must always give proper solutions to the suffering people of your society to overcome their problems. These solutions must be strictly within the legal limits of your nation. You must keep in mind that people truly benefit from the suggestions and solutions provided by you in your social work case study report.
• Give a picture of future success: In your case study report on social work, you need to depict a true picture of your social work project’s success in the long run and how it will benefit people in the concluding part.
• Always give a proper introduction and conclusion: The introduction and concluding part of your social work case study report are of high importance. The introductory part makes the first impression on your readers. If your concluding part is interesting enough, it will create an everlasting good impression on your reader faculty. Thus, you are bound to get good grades.
• Carry out long surveys: The subject of social work is very much related to practical surveys and studies. Thus, you need to conduct a lot of surveys among the people of society to learn about their real problems in life and find effective solutions for them.
• Take expert consultation: To write an ideal case study report, it is advisable to seek consultation and help from a social service expert. You need to do this under the supervision of an expert social worker.
• Study the reports of various NGOs: There are a number of NGOs or non-government organisations involved in various social studies. You can read their published reports to get an idea of how to do proper social work with true success.

What Common Mistakes Should Be Avoided While Writing a Case Study Report?

You need to avoid certain common mistakes while writing a case study report on social work or any other subject. Some of these are listed below:

• Many errors are often present in the case study paper. You always need to remove these errors by properly proofreading and editing the papers. Manual checking is preferred in this regard rather than any error-detecting software.
• You always need to avoid plagiarism in your report work. You can also use any kind of updated and advanced plagiarism-checking software technology in this regard in order to make your paper a hundred per cent plagiarism-free
• Always submit all your case study papers before the deadlines. If you cross the deadlines, your paper will come under the defaulter list, and you will lose your grades
• Try to complete all your assignment papers within specified time frames
• Do not repeat any idea more than once in any of your case study papers. Add new ideas with to-the-point explanations. This will make your paper more interesting.

How do you avail yourself of the Case Study Report Writing Services?

Writing a good case study report on social work is not an easy task. Thus, you always need expert help in this regard. You can get the best case study report on social work writing help from the most reputed C aseStudyHelp.com online organisation.

We have a team of the best writers with extensive experience in the social service case report writing field. Thus, students can always expect the best service from them. You can easily avail of our services by registering online on the CaseStudyHelp.com official website . We are always here to provide the best solutions for writing social work case study reports.

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Case Series and Case Reports

• First Online: 21 August 2024

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• Peter D. Fabricant MD, MPH 2  

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Summary take-home points for case series and case reports:

Case series may be prospective or retrospective and are essentially single cohort observational studies.

Case series and case reports differ based on the number of study participants evaluated. Typically, case series have five or more patients included, while case reports have fewer than five patients.

Case series and case reports are classified as “level IV” evidence. This is the least rigorous level of evidence (except for expert opinion narratives).

Case series and case reports frequently use descriptive methodology without comparative statistics.

Despite the low level of evidence, case series and case reports comprise important works. They are ideal for reporting rare outcomes or complications, disseminating early clinical results from a new treatment technique, or piloting data to design and power prospective studies.

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McLaren SH, Dayan PS, Fenster DB, et al. Novel coronavirus infection in febrile infants aged 60 days and younger. Pediatrics. 2020;146:e20201550. https://doi.org/10.1542/peds.2020-1550 .

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Fabricant, P.D. (2024). Case Series and Case Reports. In: Practical Clinical Research Design and Application. Springer, Cham. https://doi.org/10.1007/978-3-031-58380-3_12

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Association between social determinants of health and survival among the US cancer survivors population

• Hongbo Huang 1 ,
• Tingting Wei 1 ,
• Ying Huang 1 ,
• Aijie Zhang 2 ,
• Heng Zhang 1 ,
• Ze Zhang 1 ,
• Yijing Xu 1 ,
• Haonan Pan 3 ,
• Lingquan Kong 1 ,
• Yunhai Li 1 &

BMC Medicine volume  22 , Article number:  343 ( 2024 ) Cite this article

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Racial and ethnic disparities in mortality persist among US cancer survivors, with social determinants of health (SDoH) may have a significant impact on these disparities.

A population-based cohort study of a nationally representative sample of adult cancer survivors, who participated in the US National Health and Nutrition Examination Survey from 1999 to 2018 was included. Sociodemographic characteristics and SDoH were self-reported using standardized questionnaires in each survey cycle. The SDoH was examined by race and estimated for associations with primary outcomes, which included all-cause and cancer-specific mortality. Multiple mediation analysis was performed to assess the contribution of each unfavorable SDoH to racial disparities to all-cause and cancer-specific mortality.

Among 5163 cancer survivors (2724 [57.7%] females and 3580 [69.3%] non-Hispanic White individuals), only 881 (24.9%) did not report an unfavorable SDoH. During the follow-up period of up to 249 months (median 81 months), 1964 deaths were recorded (cancer, 624; cardiovascular, 529; other causes, 811). Disparities in all-cause and cancer-specific mortality were observed between non-Hispanic Black and White cancer survivors. Unemployment, lower economic status, education less than high school, government or no private insurance, renting a home or other arrangements, and social isolation were significantly and independently associated with worse overall survival. Unemployment, lower economic status, and social isolation were significantly associated with cancer-specific mortality. Compared to patients without an unfavorable SDoH, the risk of all-cause mortality was gradually increased in those with a cumulative number of unfavorable SDoHs (1 unfavorable SDoH: hazard ratio [HR] = 1.54, 95% CI 1.25–1.89; 2 unfavorable SDoHs: HR = 1.81, 95% CI 1.46–2.24; 3 unfavorable SDoHs: HR = 2.42, 95% CI 1.97–2.97; 4 unfavorable SDoHs: HR = 3.22, 95% CI 2.48–4.19; 5 unfavorable SDoHs: HR = 3.99, 95% CI 2.99–5.33; 6 unfavorable SDoHs: HR = 6.34 95% CI 4.51–8.90). A similar trend existed for cancer-specific mortality.

Conclusions

In this cohort study of a nationally representative sample of US cancer survivors, a greater number of unfavorable SDoH was associated with increased risks of mortality from all causes and cancer. Unfavorable SDoH levels were critical risk factors for all-cause and cancer-specific mortality, as well as the underlying cause of racial all-cause mortality disparities among US cancer survivors.

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An increase in the cancer survivor population poses a significant health care and economic burden worldwide, and cancer is the second leading cause of death in the United States (US). Specifically, there will be approximately 2,001,140 new cancer cases and an estimated 611,720 deaths from cancer in the US in 2024 [ 1 ]. Although cancer mortality has declined overall by 33% since 1991, improved survival outcomes have not benefitted equally for all cancer populations [ 1 , 2 ]. Substantial racial and ethnic disparities in all-cause and cancer-related mortality rates persist in US cancer survivors [ 1 , 2 , 3 , 4 ]. For example, Black individuals have lower relative cancer survival rates than White individuals for almost every cancer type [ 1 , 5 ]. Interestingly, the most striking gaps in survival involve cancers that are most amenable to prevention and early detection, such as cervical cancer [ 5 ]. Recently, the racial and ethnic disparities in cancer mortality have slowly narrowed; however, these disparities in cancer health have become increasingly understood in the context of social determinants of health (SDoH) [ 2 , 5 , 6 ], which are responsible for an extremely important factor associated with cancer risk and treatment [ 7 ]. The World Health Organization (WHO) defined SDoH as non-medical factors that affect health outcomes, including the conditions in which people are born, grow, live, work, and age, and a wider set of forces and systems shaping daily life conditions [ 8 ]. The SDoH included factors related to economic stability, education, health care access, residential environment, and social context and support [ 9 , 10 , 11 ], associated with the health outcomes of cancer survivors [ 12 , 13 ]. Addressing social disparities in cancer health is essential in the quest to improve survival outcomes among cancer survivors, which reflects a commitment to health equity to achieve optimal health for everyone.

Previous studies have tended to examine the contribution of individual variables involving unfavorable SDoHs in the separate associations with mortality or morbidity, most of which focused on the direct and indirect influence of socioeconomic factors on the disparity in survival [ 9 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 ]. Among the general population, a large multicohort study and meta-analysis with more than 1.7 million individuals from 7 WHO member countries reported that low socioeconomic status was associated with a 46% (95% CI, 39–53%) and 43% (95% CI, 34–52%) greater risk of all-cause and cancer mortality, respectively, compared to high socioeconomic status [ 15 ]. A low level of education, poverty, and a lack of health insurance coverage explain in part the continuous widening in mortality inequities across some adult sociodemographic groups in the US [ 14 , 17 , 20 , 24 ]. Additionally, a recent analysis demonstrated that the cumulative SDoH count was associated with an increased premature mortality risk [ 25 ]. However, limited evidence has been reported on the effect of SDoH in cancer survivors. Although previous cohort studies have shown that disadvantaged SDoH are associated with poor mental and physical health [ 26 ], resulting in a delay in medical and surgical treatment [ 27 ], and an increased risk of all-cause and cancer-related mortality among patients with cancers (such as breast and pancreatic cancer) [ 12 , 13 ]. To the best of our knowledge, few studies have examined the impact of the comprehensive and accumulating burden of SDoH on all-cause and cause-specific mortality, using methods published previously [ 13 , 25 ]. There is no study that has reported the relative contributions of these SDoH on racial disparities in the all-cause and cancer-specific mortality rates among the US cancer survivors at the population level.

The objective of the present study was to evaluate the relationships of multiple SDoH with all-cause, cancer-specific, and non-cancer mortality, and to investigate how SDoH mediates racial differences in all-cause and cancer-specific mortality among cancer survivors. We hypothesized that disparities exist in the cumulative number of unfavorable SDoH across racial and ethnic groups and that a higher number of these unfavorable SDoH is associated with higher mortality rates.

Study population

In this retrospective study, 10 cycles of cross-sectional data were collected from the National Health and Nutrition Examination Survey (NHANES) database, which used a complex, multistage, and probability sampling design to recruit participants representative of the civilian non-institutionalized US population [ 28 ]. Each participant was invited to attend an in-person or in-home interview to complete the questionnaire. The present study examined and analyzed existing data involving sociodemographic characteristics and several SDoH co-variables among cancer survivors of 20 years or older with information linked to the National Death Index through 31 December 2019 for 10 survey cycles of NHANES from 1999–2000 to 2017–2018. All the NHANES protocols were approved by the Research Ethics Review Board of the National Center for Health Statistics (NCHS), and written informed consent was provided by all participants at the time of recruitment.

Sociodemographic characteristics

In each 2-year survey, age, gender, and racial or ethnic groups (non-Hispanic White [NHW], Hispanic, non-Hispanic Black [NHB], and other [American Indian/Alaska Native/Pacific Islander, Asian, and multiracial]) were obtained from standardized questionnaires of in-home interviews by self or parent/guardian report from provided categories.

SDoH assessment

We included several variables that reflected SDoH information from standardized questionnaires, which were defined according to the Healthy People 2030 [ 11 ] and World Health Organization [ 29 ] by the following factors: economic stability; education access and quality; health access and quality; neighborhood and built environment; and social and community context. In the present study, we finally chose eight SDoH variables (employment status, family poverty income ratio, food security, education level, regular health care access, type of health insurance, home ownership, and marital status) in each NHANES cycles from 1999 to 2018, according to previously published studies [ 25 , 30 ]. Social support was excluded because it was only visible in surveys conducted between 1999 and 2008. More detailed description information on SDoH was provided in the supplement (Additional file 1: Table S1) [ 31 , 32 , 33 ], and the definition for unfavorable SDoH was based on the conventional cutoff points [ 10 , 11 , 23 , 34 , 35 ]. Furthermore, the associations between several single SDoH measures and all-cause mortality were investigated using various categorizations with adjustment for age, gender, race, and ethnicity regardless of survey weights (Additional file 1: Table S2). Each SDoH was divided into two levels based on the conventional cut-off points [ 11 , 23 , 34 , 35 ]. Unfavorable SDoH was significantly associated with a lower survival rate. During the in-person interview, participants were asked to respond to several questions about these SDoH. Economic stability was operationalized using self-reported measures of the family poverty income ratio (PIR, less than 2.4 [unfavorable SDoH] and more than 2.4 [favorable SDoH]), employment status (employed, student, or retired [favorable SDoH] and unemployed [unfavorable SDoH]) and household food security category, which was dichotomized as fully food security (no affirmative response) or marginal, low, or very low security (1–10 affirmative responses) based on the responses to the US Food Security Survey Module questions (Bickel et al. [ 36 ]). Education access and quality measurement used the highest grade or level of schooling completed or the highest degree received, dichotomized as less than high school (unfavorable SDoH) and high school graduate or higher (favorable SDoH). Health care access and quality were assessed by self-reported questionnaire about routine places for health care (at least one regular health care facility [favorable SDoH] and none or hospital emergency room [unfavorable SDoH]) and health insurance type (private [favorable SDoH] and none or government [unfavorable SDoH]). The residential environment was assessed by home ownership (owned or being bought [favorable SDoH] and rental or other arrangement [unfavorable SDoH]). Social community context was assessed by self-reported marital status (defined as married or living with a partner [favorable SDoH] and not married nor living with a partner [unfavorable SDoH]).

The cumulative number of unfavorable SDoH variables with a range from 0 (no unfavorable SDoH) to 6 or more (≥ 6 unfavorable SDoH) was calculated to explore the cumulative effect of unfavorable SDoH on all-cause and cancer-specific mortality. Because only a small proportion of participants reported having 6, 7, or 8 unfavorable SDoH variables simultaneously, thus we created a category of six or more, indicating the combination of 6, 7, or 8 unfavorable SDoH variables.

Definition of cancer survivors

Information on cancer diagnosis was collected from survey questionnaires during the in-person interview using the computer-assisted personal interview system, including cancer type(s), with up to three cancer diagnoses recorded and the age at first diagnosis for each cancer. Participants were asked, “Have you ever been told by a doctor or other health professional that you had cancer or a malignancy of any kind?” If individuals who answered “yes” were defined as cancer survivors and were asked further, “What kind of cancer was it?” and “How old were you when this cancer was first diagnosed?”.

Ascertainment of mortality

The NCHS provided mortality data that were linked to the National Death Index, with follow-up until 31 December 2019 [ 37 ]. Cause-of-death coding for all US deaths occurring after 1998 followed the 10th revision of the International Statistical Classification of Diseases, Injuries, and Causes of Death (ICD-10) guidelines. Cancer-related mortality was classified as death due to malignant neoplasms (ICD-10, codes C00-C97). The follow-up duration was defined as the interval elapsing from the date of the baseline interview to the date of death or the follow-up cut-off (31 December 2019) for those participants who did not have a death event in the whole study. We investigated the association between SDoH and all-cause, cancer-related, and non-cancer mortality (mortality instead of cancer, ICD-10 codes instead of C00-97). All-cause and cancer-specific mortality were the main outcomes of this study. The all-cause mortality was measured from the date of the baseline interview to the date of death from any cause or the follow-up cut-off. The cancer-specific mortality was calculated from the date of the baseline interview to the date of death from cancer.

Statistical analysis

All statistical analyses were conducted with the use of R (version 4.3.1) following the NHANES analysis guidance. The survey interview weights were used for analysis as appropriate to obtain nationally representative estimates. We calculated weighted sample sizes to be nationally representative and population-weighted percentages according to race and ethnicity. The chi-square test was used to determine the differences in participants’ sociodemographic characteristics and SDoH variables across four classifications of racial and ethnic groups. The pairwise correlation among the eight dichotomous SDoH was evaluated using the Spearman method. The weighted proportions of cancer survivors in each number of unfavorable SDoH category were estimated by gender, race, and ethnicity. Kaplan–Meier survival curves were examined to determine the all-cause cumulative mortality and cancer-specific cumulative mortality rates among cancer survivors stratified by SDoH. Furthermore, Kaplan–Meier analysis was used to plot the cumulative hazard for all-cause and cancer-specific mortality in entire and gender subgroups and race and ethnicity subgroups using age as the timescale [ 38 ].

Multivariable Cox proportional hazards regression models with the use of imputation-adjusted survey weights were applied to estimate the mortality risks (hazard ratio [HR]) and 95% confidence interval (CI) for the associations between cumulative SDoH variables and race with all-cause, cancer-specific, and non-cancer mortality. Final stage multivariable Cox models were adjusted for age, gender, race, and ethnicity, and additionally included the other SDoHs to identify independent, indirect associations. We plotted the HRs of the cumulative SDoH variables to visualize whether the relationship with all-cause and cancer-specific mortality was linear or non-linear. Sensitivity analyses were performed by excluding participants of deaths that occurred within the first 2-year follow-up to lessen the probability of reverse causation [ 39 ]. All statistical tests were 2-sided and P  < 0.05 was considered statistically significant. Data analyses were performed from 1 June to 1 August 2023.

Because of racial disparity in all-cause and cancer-specific mortality between NHW and NHB among cancer survivors in the US, therefore mediation analysis was performed to explore whether SDoH factors contributed to White-Black disparity in mortality or not. We estimated the relative effect (corresponding direct or indirect effect divided by the total effect) of each SDoH variable to explain the racial and ethnic difference in mortality using R package mma [ 31 , 32 , 33 ]. More detailed information was contained in the Supplementary material (Additional file 1: Methods S1).

NHANES (1999–2018) data from 5163 individuals were enrolled in the final analysis (Additional file 1: Fig. S1). A total of 101,316 persons ≥ 1 year of age who participated in the in-person or in-home interview and 96,153 were excluded, as follows: (1) 46 235 participants < 20 years of age; (2) 49,915 whom were not diagnosed with cancer, and (3) 3 individuals who did not have unique identifiers to allow linkage to the National Death Index. Of the 5163 cancer survivors (weighted population, 32,623 176; 57.7% female) in this study cohort, 3580 (69.3%) were NHW, 631 (12.2%) were Hispanic, 718 (13.9%) were NHB, and 234 (4.5%) individuals of were classified as race and ethnicity, including American Indian/native Alaskan, Pacific Islander, Asian, and multiracial (Table  1 ). Compared to NHW, Hispanic, NHB and other race and ethnic cancer survivors were more likely to have unfavorable SDoH factors, including not being married nor living with a partner, education less than high school, a PIR < 2.4, renting a home or other arrangement, unemployment, government or none health insurance, and marginal, low, or very low security. However, a lower proportion of NHB participants had no place routine place when sick or in need of advice about healthcare compared with cancer survivors from all other racial and ethnic subgroups. Approximately 24.9% of cancer survivors did not have a cumulative number of unfavorable SDoH. The higher proportion of NHW cancer survivors with 0 and 1 cumulative unfavorable SDoH was observed compared to patients from all other race and ethnic subgroups. In addition, a higher proportion of Hispanic cancer survivors with 3, 4, 5, and 6 or more unfavorable SDoH was observed compared to patients from all other race and ethnic subgroups. NHB and Hispanic individuals had a higher prevalence of multiple unfavorable SDoH (cumulative of 3 or more) compared to NHW cancer survivors.

Then, we analyzed the relationship between the eight SDoH variables. The results showed that all eight SDoH variables were significantly correlated with each other (Additional file 1: Fig. S2). Furthermore, the proportion of male participants decreased stepwise from 34.8% (0 unfavorable SDoH) to 2.2% (6 or more number of unfavorable SDoH), whereas the proportion of female participants increased from 22.6% (0 unfavorable SDoH) to 24.8% (1 unfavorable SDoH), and then gradually decreased to 4.7% (6 or more number of unfavorable SDoH; Additional file 1: Fig. S3). Breast and prostate cancer were the most common malignant neoplasm type in males and females, respectively (Additional file 1: Table S3).

During the median follow-up of 81 months (ranged 0–249 months) in the 10 NHANES cycles linked mortality file cohort, a total of 1964 deaths occurred (all-cause), including 624 cancer patients who died from cancer (cancer-related mortality), 529 who died from cardiovascular disease, and 811 who died from other cause. Compared to participants who were NHW, NHB adults with cancer had a significantly higher overall mortality rate (HR, 1.57; 95% CI, 1.34–1.89) and cancer-specific mortality (HR, 2.03; 95% CI, 1.60–2.59; Fig.  1 ). Cancer survivors with each unfavorable SDoH variable, except access to regular health care, was significantly associated with higher all-cause, cancer-specific, and non-cancer mortality in the multivariable model adjusted for age (MV model 1), and adjusted for age, gender, race and ethnicity (MV model 2; Table  2 ). After adjustment for age, gender, race and ethnicity and other SDoHs, including unemployment status (HR, 1.83; 95% CI, 1.58–2.12; P  < 0.001), family income-to-poverty less than 2.4 (HR, 1.51; 95% CI, 1.32–1.72; P  < 0.001), education less than high school attached (HR, 1.23; 95% CI, 1.05–1.44; P  = 0.012), government or none of health insurance (HR, 1.19; 95% CI, 1.05–1.36; P  = 0.007), renting a home or other housing arrangement environment (HR, 1.39; 95% CI, 1.20–1.62; P  < 0.001), and not being married nor living with a partner (HR, 1.22; 95% CI, 1.08–1.38; P  < 0.001) were significantly associated with an increased risk for all-cause mortality, which was similar to non-cancer mortality (Table  2 ). Furthermore, unemployed individuals (HR, 2.13; 95% CI, 1.62–2.79; P  < 0.001), family income-to-poverty less than 2.4 (HR, 1.35; 95% CI, 1.09–1.66; P  = 0.006), and not being married nor living with a partner (HR, 1.22; 95% CI, 1.08–1.38; P  < 0.001) were significantly associated with an increased cancer-specific mortality risk compared to those with favorable SDoH (Table  2 ). Specifically, individuals of being unemployed status were associated with almost more than 1.9- and 2.2-fold higher all-cause mortality and cancer-specific mortality rates, respectively.

All-cause mortality ( A ), cancer-specific mortality ( B ), and hazard ratios in US adults diagnosed with cancers aged 20 years or older by race and ethnicity. Note: Kaplan–Meier curves showed cumulative mortality probability race and ethnicity using age as the timescale. The number at risk was unweighted observed frequencies. Cumulative mortality rates were estimated with the use of survey weights. The bar chart showed HRs of all-cause and cancer-specific mortality associated with race and ethnicity, adjusted for age, and gender. Error bars were 95% CIs. NHW indicated non-Hispanic White; NHB indicated non-Hispanic Black; HR indicated hazard ratio; ns was the abbreviation of no significance; *** meant p  < 0.001, ** meant p  < 0.01, and * meant p  < 0.05

Cancer survivors with a greater cumulative number of SDoHs were significantly associated with an increased risk of death from all-cause and cancer (Additional file 1: Fig. S4; P  < 0.001). In the multivariable of MV model 1 (adjusted for age, gender, race, and ethnic), the HRs for all-cause and cancer-specific mortality were 1.54 (95% CI, 1.25–1.89) and 1.52 (95% CI, 1.04–2.22) for cancer survivors with 1 unfavorable SDoH, 1.81 (95% CI, 1.46–2.24) and 1.70 (95% CI, 1.20–2.24) for those with 2 unfavorable SDoHs, 2.42 (95% CI, 1.97–2.97) and 2.22 (95% CI, 1.51–3.26) for those with 3 unfavorable SDoHs, 3.22 (95% CI, 2.48–4.19) and 2.44 (95% CI, 1.60–3.72) for those with 4 unfavorable SDoHs, 3.99 (95% CI, 2.99–5.33) and 3.60 (95% CI, 2.25–5.75) for those with 5 unfavorable SDoHs, and 6.34 (95% CI, 4.51–8.90) and 5.00 (95% CI, 3.00–8.31) for those with 6 or more unfavorable SDoHs, respectively, compared with of whom without unfavorable SDoH (Fig.  2 ). Kaplan–Meier curves were used to estimate the cumulative probability of all-cause and cancer-specific mortality using age as the timescale. The all-cause and cancer-specific mortality rates were significant across the several groups with a cumulative number of unfavorable SDoHs (Fig.  2 , P  < 0.001). Pairwise comparison using log-rank showed that the all-cause mortality rate was similar and not significantly different among cancer survivors with 0, 1, 2, and 3 cumulative number of unfavorable SDoH across the entire age cohort (Additional file 1: Table S4). There was no significant difference in cancer-specific mortality among cancer survivors with 0, 1, 2, 3, and 4 cumulative number of unfavorable SDoH (Additional file 1: Table S5). Based on the linear dose–response analysis fitted curves (unfavorable SDoH ranged from 0 to 8), every cumulative unfavorable SDoH increase was significantly associated with 64% increased risks of death from all-cause (HR per 1-number increase, 1.64 [95% CI, 1.50–1.78]), and 53% of cancer (HR per 1-number increase, 1.53 [95% CI, 1.45–1.60]) (Additional file 1: Fig. S5 and Table  2 ; P  < 0.001 for linear trend).

All-cause mortality ( A ), cancer-specific mortality ( B ), and hazard ratios in US adults diagnosed with cancer aged 20 years or older according to the cumulative number of unfavorable SDoH. Note: Kaplan–Meier curves showed cumulative mortality probability by age and a cumulative number of unfavorable SDoH using age as the timescale. The number at risk is unweighted observed frequencies. Cumulative mortality rates were estimated with the use of survey weights. Bar chart showed hazard ratios of all-cause mortality and cancer-specific mortality associated with a number of unfavorable SDoH, adjusted for age, gender, and race and ethnicity; error bars were 95% CIs. A Compared to those with 0 unfavorable SDoH, all-cause mortality of hazard ratios (95% CI) for cancer survivors with 1, 2, 3, 4, 5, or ≥ 6 unfavorable SDoH were 1.54 (1.25–1.89), 1.81 (1.46–2.24), 2.42 (1.97–2.97), 3.22 (2.48–4.19), 3.99 (2.99–5.33), and 6.34 (4.51–8.90), respectively. B Compared to those with 0 unfavorable SDoH, cancer-specific mortality of hazard ratios (95% CI) for cancer survivors with 1, 2, 3, 4, 5, or ≥ 6 unfavorable SDoH were 1.52 (1.04–2.22), 1.70 (1.20–2.24), 2.22 (1.51–3.26), 2.44 (1.60–3.72), 3.60 (2.25–5.75), and 5.00 (3.00–8.31), respectively. ns was the abbreviation of no significance; *** meant p  < 0.001, ** meant p  < 0.01, and * meant p  < 0.05

Age-adjusted/ age-gender-adjusted all-cause mortality and cancer-specific mortality risk were significantly higher in NHB cancer survivors when compared with NHW. Further adjustment for all SDoH factors, black-white disparity in cancer-specific mortality was still observed (HR 1.45, 95% CI 1.07–1.96), and the all-cause mortality did not show a statistically significant difference (HR, 1.08; 95% CI 0.89–1.30; Table  3 ). In the mediation analysis, the socioeconomic factor of unemployment (17.5% for all-cause mortality; 15.3% for cancer-specific mortality) can mostly explain the racial disparity in all-cause and cancer-specific mortality, and unemployment was associated with a nearly 90% and 120% greater all-cause and cancer-specific mortality, respectively. A family income-to-poverty ratio less than 2.4 (15.7%), an education less than high school (8.1%), government health insurance (6.9%), renting a home or other housing arrangement (15.4%), and not being married nor living with a partner (13.4%) indicated effective relative contribution to the disparity of all-cause mortality between NHB and NHW cancer survivors. An additional factor (not being married nor living with a partner [10.2%]) contributed significantly to the racial difference in cancer-specific mortality (Table  3 ).

In the subgroup analysis, NHW cancer survivors who were unemployed, a lower level of PIR, an education less than high school, government or none of health insurance, renting a home or other housing arrangement, and not being married nor living with a partner were significantly more likely to die of all-cause mortality compared to NHW cancer survivors without unfavorable SDoH. Unemployment and not being married nor living with a partner were significantly associated with a higher risk of cancer-specific mortality (Additional file 1: Table S6). Being unemployed and having no access to a regular health care facility or emergency room was significantly associated with all-cause mortality in NHB cancer survivors. Only unemployed status was associated with cancer-specific mortality (Additional file 1: Table S6). In the stratified analysis by gender (female and male), almost all unfavorable SDoH were significantly associated with greater all-cause and cancer-specific mortality for female and male subgroups after adjusting for age, except for cancer-specific mortality for unfavorable home ownership (Additional file 1: Table S7). In all sensitivity analyses excluding mortalities that happened during the first 2-year follow-up since the baseline interview, all results remained similar in association with unfavorable SDoH with all-cause, cancer-specific, and non-cancer mortality (Additional file 1: Table S8).

In this US nationally representative cohort study of cancer survivors, we found that NHB and Hispanic adult cancer survivors self-reported a higher proportion of multiple unfavorable SDoHs compared to NHW adults diagnosed with cancer. Compared to NHW cancer survivors, NHB cancer survivors had significantly higher all-cause and cancer-specific mortality after adjusting for age and gender. In addition, after further adjusting for all SDoH, there was no longer a difference between NHB and NHW cancer survivors in all-cause mortality, but a significant difference in cancer-specific mortality was still observed. These findings suggest that racial differences in all-cause mortality between NHW and NHB cancer survivors were largely attributable to the explained by differences in SDoH, while cancer-specific mortality disparities were partly explained by differences in SDoH. Furthermore, unfavorable SDoH were associated with a higher risk of all-cause and cancer-specific mortality for cancer survivors. During the 20 years of follow-up, an increasing number of unfavorable SDoHs in the same individual was associated with an increased risk of dying from all causes, cancer, and noncancer causes, even after adjusting for demographic factors, such as age, gender, and race. Of note, there were significantly linear dose–response relationships between the cumulative number of unfavorable SDoHs and all-cause and cancer-specific mortality among cancer survivors, and cancer survivors having six or more unfavorable SDoH increased the HR for mortality of 6.34 and 5.00 compared to those having no unfavorable SDoH, respectively.

NHB cancer survivors were more likely than NHW patients to have unfavorable levels of all SDoH. Compared to NHW cancer survivors, NHB and Hispanic cancer survivors were 3.0 times and 3.9 times more likely to experience six or more unfavorable SDoHs, respectively, which may partly explain the racial disparity in mortality. Most predominantly, NHB cancer survivors were 1.6 times more likely than NHW cancer survivors to have family PIR less than 2.4, which was associated with almost 50% and 25% greater all-cause mortality and cancer-specific mortality, respectively. Most recently, Connolly et al. [ 30 ] conducted a study involving a cohort of 3590 participants from NHANES between 1999 and 2014, and demonstrated that the SDoH level was more favorable for NHW compared to NHB adolescents. Our finding was consistent with another previous study that reported a lower level of PIR, lower level of education attachment, lack of health insurance coverage, dietary insecurity, and limited health access were more common in NHB compared to NHW, which was a key mediator in explaining race disparity in all-cause and cause-specific mortality, especially cardiovascular disease and neoplasms [ 17 , 40 ].

The persistent disparities in survival by race and ethnicity among cancer patients have been well-documented [ 2 , 3 , 4 , 6 , 41 ], and these disparities between NHB and NHW cancer survivors were particularly stark [ 42 ]. Indeed, the overall cancer mortality in 2022 for male and female together was 12% (166.8 vs. 149.3 per 100,000 persons, respectively) higher in NHB compared to NHW cancer survivors [ 6 ]. However, racial differences were not the only factor that contributed to observed mortality disparity and the underlying causes attributed to these disparities have not been well established [ 43 ]. Various factors have been suggested as contributors to these racial and ethnic disparities in survival outcomes among cancer survivors, including differences in tumor characteristics [ 44 , 45 ], neighborhood socioeconomic deprivation [ 42 ], and accessibility to health care. In the current study, disparities in the all-cause mortality HR for NHB cancer survivors compared to NHW cancer survivors decreased from 1.59 (95% CI, 1.36–1.86) to 1.09 (95% CI, 0.91–1.31) after adjusting for all SDoHs, which mostly mediated the racial disparity in all-cause mortality. With respect to cancer-specific mortality, the HR for NHB cancer survivors compared to NHW cancer survivors decreased from 2.04 (95% CI, 1.60–2.62) to 1.45 (95% CI, 1.07–1.96) after adjusting for all SDoHs, which has a partly mediator role in the racial difference. We found that cancer survivors with employed, student or retired status (17.5% relative contribution), and PIR more than 2.4 (15.7% relative contribution) explained the greatest percentage of disparities in all-cause mortality. Furthermore, we also showed that employed, student, or retired status (15.3% relative contribution) and being married or living with a partner (10.2% relative contribution) explained the largest portions of disparities in cancer-specific mortality. Taken together, the traditional socioeconomic factors consisting of household income, level of education completed, and unemployment status were important explanatory factors, that mediated around 45% and 25% of all-cause and cancer-specific mortality in survival inequities between NHB and NHW cancer survivors, respectively, which was consistent with the findings of Bundy et al. (nearly 50% mediated the differential in all-cause premature mortality) [ 25 ]. The SDoH, through an impact on occupational opportunities and income levels, have a substantial influence on insurance coverage, which was one of the main factors determining access to and delivery of health care services in the US as well as associated disparities in survival [ 40 ]. Conversely, these traditional economic factors have a greater effect on the racial/ethnic disparities in the general population compared to cancer patients. Specifically, Luo et al. [ 20 ] suggested that income mediated 62% of the association in mortality between NHB and NHW, which was consistent with the dominant contributors to family income (40%) and education (19%) to the gap between NHB and NHW adult populations [ 17 ]. Interestingly, NHW cancer survivors were approximately 25% more likely to be married or living with a partner compared to NHB cancer survivors. Being married or living with a partner was associated with the cancer-related survival benefits, possibly due to increased social support and higher psychological well-being and instrumental support, helping navigate the health care system [ 46 , 47 ]. According to Fuzzel et al. [ 48 ], barriers to health care accessibility and insurance coverage have a significant impact on rates of cancer screening, as well as the burden and attributions of the disease. These findings suggested SDoH factors, as an important mediator, drive racial health disparities, as well as all-cause and cancer-specific mortality, highlighting the necessity of the level of SDoH contexts for all people, especially those who are more vulnerable to unfavorable SDoH.

The cumulative adverse SDoHs were associated with poor all-cause survival and cause-specific survival rates among the cancer-free population have been previously reported, e.g., among patients with cardiovascular disease. Sameroff et al. [ 49 ] reported that cumulative unfavorable social risk factors, such as food insecurity combined with social isolation and loneliness, have a higher relevance to poor health outcomes than single social risk factors. Jilani et al. [ 50 ] suggested that greater SDoH adversity was linked to a higher burden of cardiovascular risk factors and poor health outcomes, such as stroke, myocardial infarction, coronary heart disease, heart failure, and mortality. Similarly, Zhang et al. [ 16 ] combined family income level, occupation, education level, and health insurance to measure socioeconomic status, and reported that participants who met low socioeconomic status had higher risks of all-cause mortality (HR, 2.13 and 95% CI, 1.90–2.38 in the US NHANES; HR, 1.96 and 95% CI, 1.87–2.06 in the UK Biobank), cardiovascular disease mortality (HR, 2.25; 95% CI, 2.00–2.53), and incident cardiovascular disease (HR, 1.65; 95% CI, 1.52–1.79) in UK Biobank, compared to high socioeconomic status. Our results were consistent with the findings of a study in which each additional SDoH conferred additional cancer-related mortality, compared to cancer survivors without any SDoH (1 SDoH [HR, 1.39; 95% CI, 1.11–1.75], 2 SDoHs [HR, 1.61; 95% CI, 1.26–2.07], and ≥ 3 SDoHs [HR, 2.09; 95% CI, 1.58–2.75]) [ 13 ]. In contrast, Weires et al. [ 51 ] observed that women with a higher socioeconomic status showed increased mortality due to breast cancer in Sweden. This finding may be due to the structure of the Swedish family cancer database (Swedes born after 1931 and their biological parents), as well as analytical restrictions on individuals 30–60 years of age in 1960, which may exclude low-socioeconomic adults with severe health problems. Previous studies have shown that these unfavorable SDoH have a tendency to cluster in individuals [ 13 , 23 ]. For example, individuals in the general US population who self-reported food insecurity were more likely to be combined with a low level of education attachment, not being married, a low level of family income, and a bad lifestyle. This finding was consistent with our observation that these unfavorable SDoH were not isolated but interrelated, and each unfavorable SDoH included in our study has been found to independently increase the risk of mortality. Compared to most previous studies based on a single SDoH, we found that there was a simple linear dose–response relationship reflecting the cumulative effect of multiple unfavorable SDoHs on all-cause and cancer-specific mortality. Collectively, these SDoH appear to synergistically increase the risk of all-cause and cancer-specific mortality among cancer survivors. However, the cumulative risk derived from a sum of the number of unfavorable SDoH assumed that all SDoH had equal and independent effects on survival outcomes, which might not be precise. We suggest that future research may need to use more complex models, such as interaction models, to more accurately capture the complex interactions of unfavorable SDoH.

Strengths and limitations

The major strength of this study was the use of large sample size data from the NHANES, which provides an opportunity to comprehensively evaluate the complex relations of SDoH with all-cause and cancer-specific mortality among cancer survivors. In addition, we focused on multiple SDoH factors and estimated the effect of accumulating unfavorable SDoH burden on mortality. We also performed mediation analysis to show the contribution of SDoH to disparities in all-cause and cancer-specific mortality. There were some limitations in the present study. First, we conducted the analyses based on the follow-up of time-to-event, however, all data on SDoH variables were only assessed at the baseline interview, which may not reflect factors that changed during the follow-up period. Therefore, our study was not able to quantify the effect of changes in eight SDoH on the mortality of cancer survivors over time. It is essential to conduct several repeated interviews about the level of SDoH during the follow-up period to reveal the influence of SDoH factors on survival among cancer survivors. Second, the assessment of SDoH was limited by the availability of variables in the NHANES database. Some SDoH such as neighborhood environment, social support, and exposure to racism, were not widely available, which may also contribute to the all-cause and cancer-specific mortality. Third, the follow-up duration was relatively short (median, 81 months) and an important bias among these cancer survivors such that socially disadvantaged who died during the study period might have had severe disease at baseline.

In conclusion, in this cohort study of a nationally representative sample of US cancer survivors between 1999 and 2018, there were significant differences in SDoH and mortality rates across self-reported racial and ethnic groups. Unfavorable SDoH were more common among NHB cancer survivors than NHW cancer survivors, were strongly associated with an increased risk of all-cause and cancer-specific mortality, and largely explained the difference between NHB and NHW cancer survivors in all-cause mortality, as well as partially explained these racial disparities in cancer-specific mortality. In addition, the cancer participants with a greater cumulative number of unfavorable SDoHs also appeared to be associated with higher risks of death from all-causes, and cause-specific (cancer and non-cancer). Taken together with previous findings, the unfavorable SDoH levels were the major risk factors for all-cause and cancer-specific mortality and were the underlying causes in all-cause racial health disparities among US cancer survivors. The entire government, civil society, local communities, businesses, and international agencies must pay more attention to the upstream SDoH, such as economic resources, employment, education quality, and racial discrimination [ 52 ]. We believe that these findings shed highlight on the cumulative burden of SDoHs on all-cause and cancer-specific mortality among cancer survivors, providing insight for ongoing and future initiatives aimed at mitigating mortality rates within vulnerable populations, including racial/ethnic minorities and individuals with an unfavorable level of SDoH status. Addressing social disparities in cancer health is a very important part of improving survival outcomes for cancer survivors, reflecting a commitment to health equity—aimed at achieving the optimal health for everyone.

Availability of data and materials

The US NHANES are publicly available database and all data can be accessed from https://wwwn.cdc.gov/nchs/nhanes/ . The statistical code and data required to reproduce the results presented in this article can be requested from Hongbo Huang ([email protected]) or Fan Li ([email protected]).

Abbreviations

• Social determinants of health

World Health Organization

National Center for Health Statistics

International Statistical Classification of Diseases, Injuries, and Causes of Death

Non-Hispanic White

Non-Hispanic Black

Hazard ratio

National Health and Nutrition Examination Survey

United States

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Acknowledgements

We thank Dr Jing Yi (School of Public Health, Chongqing Medical University, Chongqing, 400016, China) for suggestions on the used in mediation analysis and International Science Editing ( http://www.internationalscienceediting.com ) for editing this manuscript.

This study was supported by grant 82202913 (Dr Yunhai Li) and 82372996 (Dr Fan Li) from the National Natural Science Foundation of China.

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HBH, YHL and FL designed the study. HBH, YHL, TTW, and YH conducted the statistical analyses. HBH, TTW, YH, AJZ, ZZ, HZ, YJX, HNP, YHL, and FL drafted the original manuscript. HBH, YHL, LQK and FL review the manuscript. All authors approved the final version of manuscript.

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Additional files 1: Method S1. Details about mediation analysis. Table S1. SDoH based on the Office of Disease Prevention and Health Promotion’s Healthy People 2030 and World Health Organization in NHANES 1999–2018. Table S2. Candidate social determinants of healthand associations with all-cause mortality in the US cancer survivors, NHANES 1999–2018. Table S3. Number of cancer survivor by cancer type and gender, NHANES 1999–2018. Table S4. P value for overall survival outcomes pairwise comparisons using log-rank test with Bonferroni adjustment. Table S5. P value for cancer-specific survival outcomes pairwise comparisons using log-rank test with Bonferroni adjustment. Table S6. Associations of social determinants of healthwith all-cause and cancer-specific mortality in US cancer survivors by race/ethnicity, NHANES 1999–2018. Table S7. Associations of social determinants of healthwith all-cause and cancer-specific mortality in US cancer survivors by gender, NHANES 1999–2018. Table S8. Sensitivity analyses of association social determinants of healthand all-cause, cancer-specific and non-cancer mortality in weighted and fully adjusted multivariable analysis among cancer survivors, NHANES 1999–2018. Fig. S1 Flowchart of participants selection for current analysis from NHANES 1999–2018. Fig. S2 The pairwise correlation between social determinants of healthusing Spearman method. Fig. S3 The proportion for each cumulative number of social determinants of healthby gender. Fig. S4 All-cause mortalityand cancer-specific mortalityfor cancer survivors aged 20 years or older in US between 1999 and 2018 stratified by cumulative number of unfavorable social determinants of health. Fig. S5 Linear dose–response association between cumulative number of unfavorable social determinants of healthand all-cause of death, and cancer deathamong US cancer survivors.

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Trump indicted again in federal election interference case following Supreme Court immunity ruling

WASHINGTON — Former President Donald Trump has once again been indicted over his efforts to overturn his 2020 presidential election loss, an effort that culminated in the Jan. 6 attack on the U.S. Capitol.

A federal grand jury on Tuesday returned a superseding indictment that charges Trump with the same four counts he faced in the original indictment last August : conspiracy to defraud the United States, conspiracy to obstruct an official proceeding, obstruction of and attempt to obstruct an official proceeding and conspiracy against rights.

The new indictment was returned following the Supreme Court's decision on presidential immunity last month , which barred the government from using certain "official acts" Trump took in his role as president in its prosecution.

“The superseding indictment, which was presented to a new grand jury that had not previously heard evidence in this case, reflects the Government’s efforts to respect and implement the Supreme Court’s holdings and remand instructions,” special counsel Jack Smith's office said in Tuesday's filing.

Trump blasted the new indictment as “shocking” and “a direct attack on democracy” in a string of social media posts. “The case has to do with ‘Conspiracy to Obstruct the 2020 Presidential Election,’ when they are the ones that did the obstructing of the Election, not me,” he wrote . His campaign also sent out a fundraising email within two hours of the filing, saying Trump was "just indicted again" and urging supporters to "stand with Trump" by donating.

While the charges are the same, some of the evidence has been whittled down in light of the Supreme Court's ruling, which expanded what could be considered official acts.

Gone from the superseding indictment are the sections that detailed Trump’s conversations with Justice Department officials in which he is alleged to have asked them to support his false claims of election fraud. Former Justice Department official Jeffrey Clark , who backed Trump's claims and was almost named acting attorney general, has been removed as an unindicted co-conspirator. Prosecutors also removed references to advice Trump got from or conversations he had with direct advisers in the Oval Office, like White House counsel Pat Cipollone, and references to some of his tweets from that period.

The new indictment also notes Vice President Mike Pence's role as president of the Senate on the day of the electoral vote count — Jan. 6, 2021 — in an apparent nod to concerns from the Supreme Court about whether evidence of Trump's campaign to get Pence to intervene in the count should be allowed. The Supreme Court ruling said, "Whenever the President and Vice President discuss their official responsibilities, they engage in official conduct," and there is therefore a "presumption of immunity" around their conversations. But the ruling also noted that Pence's responsibility of "'presiding over the Senate' is 'not an ‘executive branch’ function.”

Other parts of the new indictment are the same, with prosecutors again taking the position that Trump didn't actually believe the lies he was spreading in the wake of his 2020 election loss and that he knew that they were, in fact, lies.

“These claims were unsupported, objectively unreasonable, and ever-changing, and the Defendant and his co-conspirators repeated them even after they were publicly disproven," the indictment says. "These claims were false, and the Defendant knew that they were false."

While many Jan. 6 defendants have told courts that they now recognize they were tricked and lament that they were “gullible” enough to fall for the misinformation about the 2020 election that Trump promoted , Trump himself has never publicly admitted that he realizes he was spreading misinformation.

Trump's state of mind will be a major issue at a future trial , which won't take place before Election Day and could be complicated if he wins. If Trump is victorious, he or his appointees would almost certainly kill the case, as well as other Jan. 6 prosecutions: Trump has referred to Capitol rioters as " hostages " and " unbelievable patriots ," and he has indicated he would pardon many, if not all, Jan. 6 defendants. (Trump said he would "absolutely" consider pardoning every Jan. 6 criminal defendant, but his campaign has said pardons would be issued case by case.)

Trump's legal team had prepared for the possibility of a new indictment, according to a source familiar with the defense team's thinking, but believes the revised indictment still contains "fatal" flaws under the Supreme Court's reasoning.

“We don’t think they’ll be able to prove this was all purely campaign-related,” the source added, suggesting the timing works in the former president's favor.

The defense team is expected to ask for briefing schedule to argue why the superseding indictment should be dismissed too — a process that could drag out for months.

Trump's original challenge on immunity grounds led U.S. District Judge Tanya Chutkan to fr e eze the underlying case in December while he appealed. The case was returned to her court this month; the defense and the prosecution are scheduled to file a joint status report Friday laying out their proposed schedules for proceeding.

Any litigation on pending immunity questions must be settled before other action in the case, the Supreme Court ruling said. That could take multiple forms, from a public evidentiary hearing with witnesses or a fully on-paper process consisting of multiple rounds of briefings followed by written rulings from the judge.

Trump is also using the immunity ruling to fight his conviction on charges of falsifying business record in New York. His attorneys contend that the indictment in that case should be dismissed because the grand jury was presented with evidence of official acts — tweets and conversations with advisers — that shouldn't have been considered.

A new grand jury brought the new indictment in the federal case. The slimmed-down allegations could also be a way for prosecutors to avoid extensive fights over evidence they were concerned wouldn't be allowed because of the Supreme Court ruling.

Ryan J. Reilly is a justice reporter for NBC News.

Daniel Barnes reports for NBC News, based in Washington.

Dareh Gregorian is a politics reporter for NBC News.

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Exploring the association between forgiveness, meaning-making, and post-traumatic stress symptoms: The case of Hurricane Maria in Puerto Rico

Prior research suggests that meaning-making and forgiveness are associated with lower post-traumatic stress symptoms (PTSS) following exposure to trauma. Few studies have examined these factors in the aftermath of natural disasters. This study therefore aimed to investigate the relationship between meaning-making and forgiveness, and their association with PTSS after the 2017 Hurricane Maria in Puerto Rico. Bivariate correlations and hierarchical regression analyses indicated that meaning-making and forgiveness were negatively correlated with PTSS. Higher levels of “presence of meaning,” “self-forgiveness,” “forgiveness of others,” and “feeling forgiven by God” were significantly associated with lower levels of PTSS. Conversely, “search for meaning” was positively associated with PTSS. The results suggest the importance of meaning-making and forgiveness education for building and promoting well-being in the face of extreme stressors.

DOI: 10.1016/j.ijer.2022

Organizing Your Social Sciences Research Assignments

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Case Studies. Writing@CSU. Colorado State University; Mills, Albert J. , Gabrielle Durepos, and Eiden Wiebe, editors. Encyclopedia of Case Study Research . Thousand Oaks, CA: SAGE Publications, 2010 ; “What is a Case Study?” In Swanborn, Peter G. Case Study Research: What, Why and How? London: SAGE, 2010.

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General information about how to choose a topic to investigate can be found under the " Choosing a Research Problem " tab in the Organizing Your Social Sciences Research Paper writing guide. Review this page because it may help you identify a subject of analysis that can be investigated using a case study design.

However, identifying a case to investigate involves more than choosing the research problem . A case study encompasses a problem contextualized around the application of in-depth analysis, interpretation, and discussion, often resulting in specific recommendations for action or for improving existing conditions. As Seawright and Gerring note, practical considerations such as time and access to information can influence case selection, but these issues should not be the sole factors used in describing the methodological justification for identifying a particular case to study. Given this, selecting a case includes considering the following:

• The case represents an unusual or atypical example of a research problem that requires more in-depth analysis? Cases often represent a topic that rests on the fringes of prior investigations because the case may provide new ways of understanding the research problem. For example, if the research problem is to identify strategies to improve policies that support girl's access to secondary education in predominantly Muslim nations, you could consider using Azerbaijan as a case study rather than selecting a more obvious nation in the Middle East. Doing so may reveal important new insights into recommending how governments in other predominantly Muslim nations can formulate policies that support improved access to education for girls.
• The case provides important insight or illuminate a previously hidden problem? In-depth analysis of a case can be based on the hypothesis that the case study will reveal trends or issues that have not been exposed in prior research or will reveal new and important implications for practice. For example, anecdotal evidence may suggest drug use among homeless veterans is related to their patterns of travel throughout the day. Assuming prior studies have not looked at individual travel choices as a way to study access to illicit drug use, a case study that observes a homeless veteran could reveal how issues of personal mobility choices facilitate regular access to illicit drugs. Note that it is important to conduct a thorough literature review to ensure that your assumption about the need to reveal new insights or previously hidden problems is valid and evidence-based.
• The case challenges and offers a counter-point to prevailing assumptions? Over time, research on any given topic can fall into a trap of developing assumptions based on outdated studies that are still applied to new or changing conditions or the idea that something should simply be accepted as "common sense," even though the issue has not been thoroughly tested in current practice. A case study analysis may offer an opportunity to gather evidence that challenges prevailing assumptions about a research problem and provide a new set of recommendations applied to practice that have not been tested previously. For example, perhaps there has been a long practice among scholars to apply a particular theory in explaining the relationship between two subjects of analysis. Your case could challenge this assumption by applying an innovative theoretical framework [perhaps borrowed from another discipline] to explore whether this approach offers new ways of understanding the research problem. Taking a contrarian stance is one of the most important ways that new knowledge and understanding develops from existing literature.
• The case provides an opportunity to pursue action leading to the resolution of a problem? Another way to think about choosing a case to study is to consider how the results from investigating a particular case may result in findings that reveal ways in which to resolve an existing or emerging problem. For example, studying the case of an unforeseen incident, such as a fatal accident at a railroad crossing, can reveal hidden issues that could be applied to preventative measures that contribute to reducing the chance of accidents in the future. In this example, a case study investigating the accident could lead to a better understanding of where to strategically locate additional signals at other railroad crossings so as to better warn drivers of an approaching train, particularly when visibility is hindered by heavy rain, fog, or at night.
• The case offers a new direction in future research? A case study can be used as a tool for an exploratory investigation that highlights the need for further research about the problem. A case can be used when there are few studies that help predict an outcome or that establish a clear understanding about how best to proceed in addressing a problem. For example, after conducting a thorough literature review [very important!], you discover that little research exists showing the ways in which women contribute to promoting water conservation in rural communities of east central Africa. A case study of how women contribute to saving water in a rural village of Uganda can lay the foundation for understanding the need for more thorough research that documents how women in their roles as cooks and family caregivers think about water as a valuable resource within their community. This example of a case study could also point to the need for scholars to build new theoretical frameworks around the topic [e.g., applying feminist theories of work and family to the issue of water conservation].

Eisenhardt, Kathleen M. “Building Theories from Case Study Research.” Academy of Management Review 14 (October 1989): 532-550; Emmel, Nick. Sampling and Choosing Cases in Qualitative Research: A Realist Approach . Thousand Oaks, CA: SAGE Publications, 2013; Gerring, John. “What Is a Case Study and What Is It Good for?” American Political Science Review 98 (May 2004): 341-354; Mills, Albert J. , Gabrielle Durepos, and Eiden Wiebe, editors. Encyclopedia of Case Study Research . Thousand Oaks, CA: SAGE Publications, 2010; Seawright, Jason and John Gerring. "Case Selection Techniques in Case Study Research." Political Research Quarterly 61 (June 2008): 294-308.

Structure and Writing Style

The purpose of a paper in the social sciences designed around a case study is to thoroughly investigate a subject of analysis in order to reveal a new understanding about the research problem and, in so doing, contributing new knowledge to what is already known from previous studies. In applied social sciences disciplines [e.g., education, social work, public administration, etc.], case studies may also be used to reveal best practices, highlight key programs, or investigate interesting aspects of professional work.

In general, the structure of a case study research paper is not all that different from a standard college-level research paper. However, there are subtle differences you should be aware of. Here are the key elements to organizing and writing a case study research paper.

I.  Introduction

As with any research paper, your introduction should serve as a roadmap for your readers to ascertain the scope and purpose of your study . The introduction to a case study research paper, however, should not only describe the research problem and its significance, but you should also succinctly describe why the case is being used and how it relates to addressing the problem. The two elements should be linked. With this in mind, a good introduction answers these four questions:

• What is being studied? Describe the research problem and describe the subject of analysis [the case] you have chosen to address the problem. Explain how they are linked and what elements of the case will help to expand knowledge and understanding about the problem.
• Why is this topic important to investigate? Describe the significance of the research problem and state why a case study design and the subject of analysis that the paper is designed around is appropriate in addressing the problem.
• What did we know about this topic before I did this study? Provide background that helps lead the reader into the more in-depth literature review to follow. If applicable, summarize prior case study research applied to the research problem and why it fails to adequately address the problem. Describe why your case will be useful. If no prior case studies have been used to address the research problem, explain why you have selected this subject of analysis.
• How will this study advance new knowledge or new ways of understanding? Explain why your case study will be suitable in helping to expand knowledge and understanding about the research problem.

Each of these questions should be addressed in no more than a few paragraphs. Exceptions to this can be when you are addressing a complex research problem or subject of analysis that requires more in-depth background information.

II.  Literature Review

The literature review for a case study research paper is generally structured the same as it is for any college-level research paper. The difference, however, is that the literature review is focused on providing background information and  enabling historical interpretation of the subject of analysis in relation to the research problem the case is intended to address . This includes synthesizing studies that help to:

• Place relevant works in the context of their contribution to understanding the case study being investigated . This would involve summarizing studies that have used a similar subject of analysis to investigate the research problem. If there is literature using the same or a very similar case to study, you need to explain why duplicating past research is important [e.g., conditions have changed; prior studies were conducted long ago, etc.].
• Describe the relationship each work has to the others under consideration that informs the reader why this case is applicable . Your literature review should include a description of any works that support using the case to investigate the research problem and the underlying research questions.
• Identify new ways to interpret prior research using the case study . If applicable, review any research that has examined the research problem using a different research design. Explain how your use of a case study design may reveal new knowledge or a new perspective or that can redirect research in an important new direction.
• Resolve conflicts amongst seemingly contradictory previous studies . This refers to synthesizing any literature that points to unresolved issues of concern about the research problem and describing how the subject of analysis that forms the case study can help resolve these existing contradictions.
• Point the way in fulfilling a need for additional research . Your review should examine any literature that lays a foundation for understanding why your case study design and the subject of analysis around which you have designed your study may reveal a new way of approaching the research problem or offer a perspective that points to the need for additional research.
• Expose any gaps that exist in the literature that the case study could help to fill . Summarize any literature that not only shows how your subject of analysis contributes to understanding the research problem, but how your case contributes to a new way of understanding the problem that prior research has failed to do.
• Locate your own research within the context of existing literature [very important!] . Collectively, your literature review should always place your case study within the larger domain of prior research about the problem. The overarching purpose of reviewing pertinent literature in a case study paper is to demonstrate that you have thoroughly identified and synthesized prior studies in relation to explaining the relevance of the case in addressing the research problem.

III.  Method

In this section, you explain why you selected a particular case [i.e., subject of analysis] and the strategy you used to identify and ultimately decide that your case was appropriate in addressing the research problem. The way you describe the methods used varies depending on the type of subject of analysis that constitutes your case study.

If your subject of analysis is an incident or event . In the social and behavioral sciences, the event or incident that represents the case to be studied is usually bounded by time and place, with a clear beginning and end and with an identifiable location or position relative to its surroundings. The subject of analysis can be a rare or critical event or it can focus on a typical or regular event. The purpose of studying a rare event is to illuminate new ways of thinking about the broader research problem or to test a hypothesis. Critical incident case studies must describe the method by which you identified the event and explain the process by which you determined the validity of this case to inform broader perspectives about the research problem or to reveal new findings. However, the event does not have to be a rare or uniquely significant to support new thinking about the research problem or to challenge an existing hypothesis. For example, Walo, Bull, and Breen conducted a case study to identify and evaluate the direct and indirect economic benefits and costs of a local sports event in the City of Lismore, New South Wales, Australia. The purpose of their study was to provide new insights from measuring the impact of a typical local sports event that prior studies could not measure well because they focused on large "mega-events." Whether the event is rare or not, the methods section should include an explanation of the following characteristics of the event: a) when did it take place; b) what were the underlying circumstances leading to the event; and, c) what were the consequences of the event in relation to the research problem.

If your subject of analysis is a person. Explain why you selected this particular individual to be studied and describe what experiences they have had that provide an opportunity to advance new understandings about the research problem. Mention any background about this person which might help the reader understand the significance of their experiences that make them worthy of study. This includes describing the relationships this person has had with other people, institutions, and/or events that support using them as the subject for a case study research paper. It is particularly important to differentiate the person as the subject of analysis from others and to succinctly explain how the person relates to examining the research problem [e.g., why is one politician in a particular local election used to show an increase in voter turnout from any other candidate running in the election]. Note that these issues apply to a specific group of people used as a case study unit of analysis [e.g., a classroom of students].

If your subject of analysis is a place. In general, a case study that investigates a place suggests a subject of analysis that is unique or special in some way and that this uniqueness can be used to build new understanding or knowledge about the research problem. A case study of a place must not only describe its various attributes relevant to the research problem [e.g., physical, social, historical, cultural, economic, political], but you must state the method by which you determined that this place will illuminate new understandings about the research problem. It is also important to articulate why a particular place as the case for study is being used if similar places also exist [i.e., if you are studying patterns of homeless encampments of veterans in open spaces, explain why you are studying Echo Park in Los Angeles rather than Griffith Park?]. If applicable, describe what type of human activity involving this place makes it a good choice to study [e.g., prior research suggests Echo Park has more homeless veterans].

If your subject of analysis is a phenomenon. A phenomenon refers to a fact, occurrence, or circumstance that can be studied or observed but with the cause or explanation to be in question. In this sense, a phenomenon that forms your subject of analysis can encompass anything that can be observed or presumed to exist but is not fully understood. In the social and behavioral sciences, the case usually focuses on human interaction within a complex physical, social, economic, cultural, or political system. For example, the phenomenon could be the observation that many vehicles used by ISIS fighters are small trucks with English language advertisements on them. The research problem could be that ISIS fighters are difficult to combat because they are highly mobile. The research questions could be how and by what means are these vehicles used by ISIS being supplied to the militants and how might supply lines to these vehicles be cut off? How might knowing the suppliers of these trucks reveal larger networks of collaborators and financial support? A case study of a phenomenon most often encompasses an in-depth analysis of a cause and effect that is grounded in an interactive relationship between people and their environment in some way.

NOTE:   The choice of the case or set of cases to study cannot appear random. Evidence that supports the method by which you identified and chose your subject of analysis should clearly support investigation of the research problem and linked to key findings from your literature review. Be sure to cite any studies that helped you determine that the case you chose was appropriate for examining the problem.

IV.  Discussion

The main elements of your discussion section are generally the same as any research paper, but centered around interpreting and drawing conclusions about the key findings from your analysis of the case study. Note that a general social sciences research paper may contain a separate section to report findings. However, in a paper designed around a case study, it is common to combine a description of the results with the discussion about their implications. The objectives of your discussion section should include the following:

Reiterate the Research Problem/State the Major Findings Briefly reiterate the research problem you are investigating and explain why the subject of analysis around which you designed the case study were used. You should then describe the findings revealed from your study of the case using direct, declarative, and succinct proclamation of the study results. Highlight any findings that were unexpected or especially profound.

Explain the Meaning of the Findings and Why They are Important Systematically explain the meaning of your case study findings and why you believe they are important. Begin this part of the section by repeating what you consider to be your most important or surprising finding first, then systematically review each finding. Be sure to thoroughly extrapolate what your analysis of the case can tell the reader about situations or conditions beyond the actual case that was studied while, at the same time, being careful not to misconstrue or conflate a finding that undermines the external validity of your conclusions.

Relate the Findings to Similar Studies No study in the social sciences is so novel or possesses such a restricted focus that it has absolutely no relation to previously published research. The discussion section should relate your case study results to those found in other studies, particularly if questions raised from prior studies served as the motivation for choosing your subject of analysis. This is important because comparing and contrasting the findings of other studies helps support the overall importance of your results and it highlights how and in what ways your case study design and the subject of analysis differs from prior research about the topic.

Consider Alternative Explanations of the Findings Remember that the purpose of social science research is to discover and not to prove. When writing the discussion section, you should carefully consider all possible explanations revealed by the case study results, rather than just those that fit your hypothesis or prior assumptions and biases. Be alert to what the in-depth analysis of the case may reveal about the research problem, including offering a contrarian perspective to what scholars have stated in prior research if that is how the findings can be interpreted from your case.

Acknowledge the Study's Limitations You can state the study's limitations in the conclusion section of your paper but describing the limitations of your subject of analysis in the discussion section provides an opportunity to identify the limitations and explain why they are not significant. This part of the discussion section should also note any unanswered questions or issues your case study could not address. More detailed information about how to document any limitations to your research can be found here .

Suggest Areas for Further Research Although your case study may offer important insights about the research problem, there are likely additional questions related to the problem that remain unanswered or findings that unexpectedly revealed themselves as a result of your in-depth analysis of the case. Be sure that the recommendations for further research are linked to the research problem and that you explain why your recommendations are valid in other contexts and based on the original assumptions of your study.

V.  Conclusion

As with any research paper, you should summarize your conclusion in clear, simple language; emphasize how the findings from your case study differs from or supports prior research and why. Do not simply reiterate the discussion section. Provide a synthesis of key findings presented in the paper to show how these converge to address the research problem. If you haven't already done so in the discussion section, be sure to document the limitations of your case study and any need for further research.

The function of your paper's conclusion is to: 1) reiterate the main argument supported by the findings from your case study; 2) state clearly the context, background, and necessity of pursuing the research problem using a case study design in relation to an issue, controversy, or a gap found from reviewing the literature; and, 3) provide a place to persuasively and succinctly restate the significance of your research problem, given that the reader has now been presented with in-depth information about the topic.

Consider the following points to help ensure your conclusion is appropriate:

• If the argument or purpose of your paper is complex, you may need to summarize these points for your reader.
• If prior to your conclusion, you have not yet explained the significance of your findings or if you are proceeding inductively, use the conclusion of your paper to describe your main points and explain their significance.
• Move from a detailed to a general level of consideration of the case study's findings that returns the topic to the context provided by the introduction or within a new context that emerges from your case study findings.

Note that, depending on the discipline you are writing in or the preferences of your professor, the concluding paragraph may contain your final reflections on the evidence presented as it applies to practice or on the essay's central research problem. However, the nature of being introspective about the subject of analysis you have investigated will depend on whether you are explicitly asked to express your observations in this way.

Problems to Avoid

Overgeneralization One of the goals of a case study is to lay a foundation for understanding broader trends and issues applied to similar circumstances. However, be careful when drawing conclusions from your case study. They must be evidence-based and grounded in the results of the study; otherwise, it is merely speculation. Looking at a prior example, it would be incorrect to state that a factor in improving girls access to education in Azerbaijan and the policy implications this may have for improving access in other Muslim nations is due to girls access to social media if there is no documentary evidence from your case study to indicate this. There may be anecdotal evidence that retention rates were better for girls who were engaged with social media, but this observation would only point to the need for further research and would not be a definitive finding if this was not a part of your original research agenda.

Failure to Document Limitations No case is going to reveal all that needs to be understood about a research problem. Therefore, just as you have to clearly state the limitations of a general research study , you must describe the specific limitations inherent in the subject of analysis. For example, the case of studying how women conceptualize the need for water conservation in a village in Uganda could have limited application in other cultural contexts or in areas where fresh water from rivers or lakes is plentiful and, therefore, conservation is understood more in terms of managing access rather than preserving access to a scarce resource.

Failure to Extrapolate All Possible Implications Just as you don't want to over-generalize from your case study findings, you also have to be thorough in the consideration of all possible outcomes or recommendations derived from your findings. If you do not, your reader may question the validity of your analysis, particularly if you failed to document an obvious outcome from your case study research. For example, in the case of studying the accident at the railroad crossing to evaluate where and what types of warning signals should be located, you failed to take into consideration speed limit signage as well as warning signals. When designing your case study, be sure you have thoroughly addressed all aspects of the problem and do not leave gaps in your analysis that leave the reader questioning the results.

Case Studies. Writing@CSU. Colorado State University; Gerring, John. Case Study Research: Principles and Practices . New York: Cambridge University Press, 2007; Merriam, Sharan B. Qualitative Research and Case Study Applications in Education . Rev. ed. San Francisco, CA: Jossey-Bass, 1998; Miller, Lisa L. “The Use of Case Studies in Law and Social Science Research.” Annual Review of Law and Social Science 14 (2018): TBD; Mills, Albert J., Gabrielle Durepos, and Eiden Wiebe, editors. Encyclopedia of Case Study Research . Thousand Oaks, CA: SAGE Publications, 2010; Putney, LeAnn Grogan. "Case Study." In Encyclopedia of Research Design , Neil J. Salkind, editor. (Thousand Oaks, CA: SAGE Publications, 2010), pp. 116-120; Simons, Helen. Case Study Research in Practice . London: SAGE Publications, 2009;  Kratochwill,  Thomas R. and Joel R. Levin, editors. Single-Case Research Design and Analysis: New Development for Psychology and Education .  Hilldsale, NJ: Lawrence Erlbaum Associates, 1992; Swanborn, Peter G. Case Study Research: What, Why and How? London : SAGE, 2010; Yin, Robert K. Case Study Research: Design and Methods . 6th edition. Los Angeles, CA, SAGE Publications, 2014; Walo, Maree, Adrian Bull, and Helen Breen. “Achieving Economic Benefits at Local Events: A Case Study of a Local Sports Event.” Festival Management and Event Tourism 4 (1996): 95-106.

Writing Tip

At Least Five Misconceptions about Case Study Research

Social science case studies are often perceived as limited in their ability to create new knowledge because they are not randomly selected and findings cannot be generalized to larger populations. Flyvbjerg examines five misunderstandings about case study research and systematically "corrects" each one. To quote, these are:

Misunderstanding 1 :  General, theoretical [context-independent] knowledge is more valuable than concrete, practical [context-dependent] knowledge. Misunderstanding 2 :  One cannot generalize on the basis of an individual case; therefore, the case study cannot contribute to scientific development. Misunderstanding 3 :  The case study is most useful for generating hypotheses; that is, in the first stage of a total research process, whereas other methods are more suitable for hypotheses testing and theory building. Misunderstanding 4 :  The case study contains a bias toward verification, that is, a tendency to confirm the researcher’s preconceived notions. Misunderstanding 5 :  It is often difficult to summarize and develop general propositions and theories on the basis of specific case studies [p. 221].

While writing your paper, think introspectively about how you addressed these misconceptions because to do so can help you strengthen the validity and reliability of your research by clarifying issues of case selection, the testing and challenging of existing assumptions, the interpretation of key findings, and the summation of case outcomes. Think of a case study research paper as a complete, in-depth narrative about the specific properties and key characteristics of your subject of analysis applied to the research problem.

Flyvbjerg, Bent. “Five Misunderstandings About Case-Study Research.” Qualitative Inquiry 12 (April 2006): 219-245.

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The design, implementation, and evaluation of a blended (in-person and virtual) Clinical Competency Examination for final-year nursing students

• Rita Mojtahedzadeh 1 ,
• Tahereh Toulabi 2 , 3 &
• Aeen Mohammadi 1  

BMC Medical Education volume  24 , Article number:  936 ( 2024 ) Cite this article

7 Altmetric

Metrics details

Introduction

Studies have reported different results of evaluation methods of clinical competency tests. Therefore, this study aimed to design, implement, and evaluate a blended (in-person and virtual) Competency Examination for final-year Nursing Students.

This interventional study was conducted in two semesters of 2020–2021 using an educational action research method in the nursing and midwifery faculty. Thirteen faculty members and 84 final-year nursing students were included in the study using a census method. Eight programs and related activities were designed and conducted during the examination process. Students completed the Spielberger Anxiety Inventory before the examination, and both faculty members and students completed the Acceptance and Satisfaction questionnaire.

The results of the analysis of focused group discussions and reflections indicated that the virtual CCE was not capable of adequately assessing clinical skills. Therefore, it was decided that the CCE for final-year nursing students would be conducted using a blended method. The activities required for performing the examination were designed and implemented based on action plans. Anxiety and satisfaction were also evaluated as outcomes of the study. There was no statistically significant difference in overt, covert, and overall anxiety scores between the in-person and virtual sections of the examination ( p  > 0.05). The mean (SD) acceptance and satisfaction scores for students in virtual, in-person, and blended sections were 25.49 (4.73), 27.60 (4.70), and 25.57 (4.97), respectively, out of 30 points, in which there was a significant increase in the in-person section compared to the other sections. ( p  = 0.008). The mean acceptance and satisfaction scores for faculty members were 30.31 (4.47) in the virtual, 29.86 (3.94) in the in-person, and 30.00 (4.16) out of 33 in the blended, and there was no significant difference between the three sections ( p  = 0.864).

Evaluating nursing students’ clinical competency using a blended method was implemented and solved the problem of students’ graduation. Therefore, it is suggested that the blended method be used instead of traditional in-person or entirely virtual exams in epidemics or based on conditions, facilities, and human resources. Also, the use of patient simulation, virtual reality, and the development of necessary virtual and in-person training infrastructure for students is recommended for future research. Furthermore, considering that the acceptance of traditional in-person exams among students is higher, it is necessary to develop virtual teaching strategies.

Peer Review reports

The primary mission of the nursing profession is to educate competent, capable, and qualified nurses with the necessary knowledge and skills to provide quality nursing care to preserve and improve the community’s health [ 1 ]. Clinical education is one of the most essential and fundamental components of nursing education, in which students gain clinical experience by interacting with actual patients and addressing real problems. Therefore, assessing clinical skills is very challenging. The main goal of educational evaluation is to improve, ensure, and enhance the quality of the academic program. In this regard, evaluating learners’ performance is one of the critical and sensitive aspects of the teaching and learning process. It is considered one of the fundamental elements of the educational program [ 2 ]. The study area is educational evaluation.

Various methods are used to evaluate nursing students. The Objective Structured Clinical Examination (OSCE) is a valid and reliable method for assessing clinical competence [ 1 , 2 ]. In the last twenty years, the use of OSCE has increased significantly in evaluating medical and paramedical students to overcome the limitations of traditional practical evaluation systems [ 3 , 4 ]. The advantages of this method include providing rapid feedback, uniformity for all examinees, and providing conditions close to reality. However, the time-consuming nature and the need for a lot of personnel and equipment are some disadvantages of OSCE [ 5 , 6 ]. Additionally, some studies have shown that this method is anxiety-provoking for some students and, due to time constraints, being observed by the evaluator and other factors can cause dissatisfaction among students [ 7 , 8 ].

However, some studies have also reported that this method is not only not associated with high levels of stress among students [ 9 ] but also has higher satisfaction than traditional evaluation methods [ 4 ]. In addition, during the COVID-19 pandemic, problems such as overcrowding and student quarantine during the exam have arisen. Therefore, reducing time and costs, eliminating or reducing the tiring quarantine time, optimizing the exam, utilizing all facilities for simulating the clinical environment, using innovative methods for conducting the exam, reducing stress, increasing satisfaction, and ultimately preventing the transmission of COVID-19 are significant problems that need to be further investigated.

Studies show that using virtual space as an alternative solution is strongly felt [ 10 , 11 , 12 ]. In the fall of 2009, following the outbreak of H1N1, educational classes in the United States were held virtually [ 13 ]. Also, in 2005, during Hurricane Katrina, 27 universities in the Gulf of Texas used emergency virtual education and evaluation [ 14 ].

One of the challenges faced by healthcare providers in Iran, like most countries in the world, especially during the COVID-19 outbreak, was the shortage of nursing staff [ 15 , 16 ]. Also, in evaluating and conducting CCE for final-year students and subsequent job seekers in the Clinical Skills Center, problems such as student overcrowding and the need for quarantine during the implementation of OSCE existed. This problem has been reported not only for us but also in other countries [ 17 ]. The intelligent use of technology can solve many of these problems. Therefore, almost all educational institutions have quickly started changing their policies’ paradigms to introduce online teaching and evaluation methods [ 18 , 19 ].

During the COVID-19 pandemic, for the first time, this exam was held virtually in our school. However, feedback from professors and students and the experiences of researchers have shown that the virtual exam can only partially evaluate clinical and practical skills in some stations, such as basic skills, resuscitation, and pediatrics [ 20 ].

Additionally, using OSCE in skills assessment facilitates the evaluation of psychological-motor knowledge and attitudes and helps identify strengths and weaknesses [ 21 ]. Clinical competency is a combination of theoretical knowledge and clinical skills. Therefore, using an effective blended method focusing on the quality and safety of healthcare that measures students’ clinical skills and theoretical expertise more accurately in both in-person and virtual environments is essential. The participation of students, professors, managers, education and training staff, and the Clinical Skills Center was necessary to achieve this important and inevitable goal. Therefore, the Clinical Competency Examination (CCE) for nursing students in our nursing and midwifery school was held in the form of an educational action research process to design, implement, and evaluate a blended method. Implementing this process during the COVID-19 pandemic, when it was impossible to hold an utterly in-person exam, helped improve the quality of the exam and address its limitations and weaknesses while providing the necessary evaluation for students.

The innovation of this research lies in evaluating the clinical competency of final-year nursing students using a blended method that focuses on clinical and practical aspects. In the searches conducted, only a few studies have been done on virtual exams and simulations, and a similar study using a blended method was not found.

The research investigates the scientific and clinical abilities of nursing students through the clinical competency exam. This exam, traditionally administered in person, is a crucial milestone for final-year nursing students, marking their readiness for graduation. However, the unforeseen circumstances of the COVID-19 pandemic and the resulting restrictions rendered in-person exams impractical in 2020. This necessitated a swift and significant transition to an online format, a decision that has profound implications for the future of nursing education. While the adoption of online assessment was a necessary step to ensure student graduation and address the nursing workforce shortage during the pandemic, it was not without its challenges. The accurate assessment of clinical skills, such as dressing and CPR, proved to be a significant hurdle. This underscored the urgent need for a change in the exam format, prompting a deeper exploration of innovative solutions.

To address these problems, the research was conducted collaboratively with stakeholders, considering the context and necessity for change in exam administration. Employing an Action Research (AR) approach, a blend of online and in-person exam modalities was adopted. Necessary changes were implemented through a cyclic process involving problem identification, program design, implementation, reflection, and continuous evaluation.

The research began by posing the following questions:

What are the problems of conducting the CCE for final-year nursing students during COVID-19?

How can these problems be addressed?

What are the solutions and suggestions from the involved stakeholders?

How can the CCE be designed, implemented, and evaluated?

What is the impact of exam type on student anxiety and satisfaction?

These questions guided the research in exploring the complexities of administering the CCE amidst the COVID-19 pandemic and in devising practical solutions to ensure the validity and reliability of the assessment while meeting stakeholders’ needs.

Materials and methods

Research setting, expert panel members, job analysis, and role delineation.

This action research was conducted at the Nursing and Midwifery School of Lorestan University of Medical Sciences, with a history of approximately 40 years. The school accommodates 500 undergraduate and graduate nursing students across six specialized fields, with 84 students enrolled in their final year of undergraduate studies. Additionally, the school employs 26 full-time faculty members in nursing education departments.

An expert panel was assembled, consisting of faculty members specializing in various areas, including medical-surgical nursing, psychiatric nursing, community health nursing, pediatric nursing, and intensive care nursing. The panel also included educational department managers and the examination department supervisor. Through focused group discussions, the panel identified and examined issues regarding the exam format, and members proposed various solutions. Subsequently, after analyzing the proposed solutions and drawing upon the panel members’ experiences, specific roles for each member were delineated.

Sampling and participant selection

Given the nature of the research, purposive sampling was employed, ensuring that all individuals involved in the design, implementation, and evaluation of the exam participated in this study.

The participants in this study included final-year nursing students, faculty members, clinical skills center experts, the dean of the school, the educational deputy, group managers, and the exam department head. However, in the outcome evaluation phase, 13 faculty members participated in-person and virtually (26 times), and 84 final-year nursing students enrolled in the study using a census method in two semesters of 2020–2021 completed the questionnaires, including 37 females and 47 males. In addition, three male and ten female faculty members participated in this study; of this number, 2 were instructors, and 11 were assistant professors.

Data collection tools

In order to enhance the validity and credibility of the study and thoroughly examine the results, this study utilized a triangulation method consisting of demographic information, focus group discussions, the Spielberger Anxiety Scale questionnaire, and an Acceptance and Satisfaction Questionnaire.

Demographic information

A questionnaire was used to gather demographic information from both students and faculty members. For students, this included age, gender, and place of residence, while for faculty members, it included age, gender, field of study, and employment status.

Focus group discussion

Multiple focused group discussions were conducted with the participation of professors, administrators, experts, and students. These discussions were held through various platforms such as WhatsApp Skype, and in-person meetings while adhering to health protocols. The researcher guided the talks toward the research objectives and raised fundamental questions, such as describing the strengths and weaknesses of the previous exam, determining how to conduct the CCE considering the COVID-19 situation, deciding on virtual and in-person stations, specifying the evaluation checklists for stations, and explaining the weighting and scoring of each station.

Spielberger anxiety scale questionnaire

This study used the Spielberger Anxiety Questionnaire to measure students’ overt and covert anxiety levels. This questionnaire is an internationally standardized tool known as the STAI questionnaire that measures both overt (state) and covert (trait) anxiety [ 22 ]. The state anxiety scale (Form Y-1 of STAI) comprises twenty statements that assess the individual’s feelings at the moment of responding. The trait anxiety scale (Form Y-2 of STAI) also includes twenty statements that measure individuals’ general and typical feelings. The scores of each of the two scales ranged from 20 to 80 in the current study. The reliability coefficient of the test for the apparent and hidden anxiety scales, based on Cronbach’s alpha, was confirmed to be 0.9084 and 0.9025, respectively [ 23 , 24 ]. Furthermore, in the present study, Cronbach’s alpha value for the total anxiety questionnaire, overt anxiety, and covert anxiety scales were 0.935, 0.921, and 0.760, respectively.

Acceptance and satisfaction questionnaire

The Acceptability and Satisfaction Questionnaire for Clinical Competency Test was developed by Farajpour et al. (2012). The student questionnaire consists of ten questions, and the professor questionnaire consists of eleven questions, using a four-point Likert scale. Experts have confirmed the validity of these questionnaires, and their Cronbach’s alpha coefficients have been determined to be 0.85 and 0.87 for the professor and student questionnaires, respectively [ 6 ]. In the current study, ten medical education experts also confirmed the validity of the questionnaires. Regarding internal reliability, Cronbach’s alpha coefficients for the student satisfaction questionnaire for both virtual and in-person sections were 0.76 and 0.87, respectively. The professor satisfaction questionnaires were 0.84 and 0.87, respectively. An online platform was used to collect data for the virtual exam.

Data analysis and rigor of study

Qualitative data analysis was conducted using the method proposed by Graneheim and Lundman. Additionally, the criteria established by Lincoln and Guba (1985) were employed to confirm the rigor and validity of the data, including credibility, transferability, dependability, and confirmability [ 26 ].

In this research, data synthesis was performed by combining the collected data with various tools and methods. The findings of this study were reviewed and confirmed by participants, supervisors, mentors, and experts in qualitative research, reflecting their opinions on the alignment of findings with their experiences and perspectives on clinical competence examinations. Therefore, the member check method was used to validate credibility.

Moreover, efforts were made in this study to provide a comprehensive description of the research steps, create a suitable context for implementation, assess the views of others, and ensure the transferability of the results.

Furthermore, researchers’ interest in identifying and describing problems, reflecting, designing, implementing, and evaluating clinical competence examinations, along with the engagement of stakeholders in these examinations, was ensured by the researchers’ long-term engagement of over 25 years with the environment and stakeholders, seeking their opinions and considering their ideas and views. These factors contributed to ensuring confirmability.

In this research, by reflecting the results to the participants and making revisions by the researchers, problem clarification and solution presentation, design, implementation, and evaluation of operational programs with stakeholder participation and continuous presence were attempted to prevent biases, assumptions, and research hypotheses, and to confirm dependability.

Data analysis was performed using SPSS version 21, and descriptive statistical tests (absolute and relative frequency, mean, and standard deviation) and inferential tests (paired t-test, independent t-test, and analysis of variance) were used. The significance level was set at 0.05. Parametric tests were used based on the normality of the data according to the Kolmogorov-Smirnov statistical test.

Given that conducting the CCE for final-year nursing students required the active participation of managers, faculty members, staff, and students, and to answer the research question “How can the CCE for final-year nursing students be conducted?” and achieve the research objective of “designing, implementing, and evaluating the clinical competency exam,” the action research method was employed.

The present study was conducted based on the Dickens & Watkins model. There are four primary stages (Fig.  1 ) in the cyclical action research process: reflect, plan, act, observe, and then reflect to continue through the cycle [ 27 ].

The cyclical process of action research [ 27 ]

Stage 1: Reflection

Identification of the problem.

According to the educational regulations, final semester nursing students must complete the clinical competency exam. However, due to the COVID-19 pandemic and the critical situation in most provinces, inter-city travel restrictions, and insufficient dormitory space, conducting the CCE in-person was not feasible.

This exam was conducted virtually at our institution. However, based on the reflections from experts, researchers have found that virtual exams can only partially assess clinical and practical skills in certain stations, such as basic skills, resuscitation, and pediatrics. Furthermore, utilizing Objective Structured Clinical Examination (OSCE) in skills assessment facilitates the evaluation of psychomotor skills, knowledge, and attitudes, aiding in identifying strengths and weaknesses.

P3, “Due to the COVID-19 pandemic and the critical situation in most provinces, inter-city travel restrictions, and insufficient dormitory space, conducting the CCE in-person is not feasible.”

Stage 2: Planning

Based on the reflections gathered from the participants, the exam was designed using a blended approach (combining in-person and virtual components) as per the schedule outlined in Fig.  2 . All planned activities for the blended CCE for final-year nursing students were executed over two semesters.

P5, “Taking the exam virtually might seem easier for us and the students, but in my opinion, it’s not realistic. For instance, performing wound dressing or airway management is very practical, and it’s not possible to assess students with a virtual scenario. We need to see them in person.”

P6"I believe it’s better to conduct those activities that are highly practical in person, but for those involving communication skills like report writing, professional ethics, etc., we can opt for virtual assessment.”

Design and implementation of the blended CCE

Stage 3: Act

Cce implementation steps.

The CCE was conducted based on the flowchart in Fig.  3 and the following steps:

Steps for conducting the CCE for final-year nursing students using a blended method

Step 1: Designing the framework for conducting the blended Clinical Competency Examination

The panelists were guided to design the blended exam in focused group sessions and virtual panels based on the ADDIE (Analysis, Design, Development, Implementation, Evaluation) model [ 28 ]. Initially, needs assessment and opinion polling were conducted, followed by the operational planning of the exam, including the design of the blueprint table (Table  1 ), determination of station types (in-person or virtual), designing question stems in the form of scenarios, creating checklists and station procedure guides by expert panel groups based on participant analysis, and the development of exam implementation guidelines with participant input [ 27 ]. The design, execution, and evaluation were as follows:

In-person and virtual meetings with professors were held to determine the exam schedule, deadlines for submitting checklists, decision-making regarding the virtual or in-person nature of stations based on the type of skill (practical, communication), and presenting problems and solutions. Based on the decisions, primary skill stations, as well as cardiac and pediatric resuscitation stations, were held in person. In contrast, virtual stations for health, nursing ethics, nursing reports, nursing diagnosis, physical examinations, and psychiatric nursing were held.

News about the exam was communicated to students through the college website and text messages. Then, an online orientation session was held on Skype with students regarding the need assessment of pre-exam educational workshops, virtual and in-person exam standards, how to use exam software, how to conduct virtual exams, explaining the necessary infrastructure for participating in the exam by students, completing anxiety and satisfaction questionnaires, rules and regulations, how to deal with rejected individuals, and exam testing and Q&A. Additionally, a pre-exam in-person orientation session was held.

To inform students about the entire educational process, the resources and educational content recommended by the professors, including PDF files, photos and videos, instructions, and links, were shared through a virtual group on the social media messenger, and scientific information was also, questions were asked and answered through this platform.

Correspondence and necessary coordination were made with the university clinical skills center to conduct in-person workshops and exams.

Following the Test-centered approach, the Angoff Modified method [ 29 , 30 ] was used to determine the scoring criteria for each station by panelists tasked with assigning scores.

Additionally, in establishing standards for this blended CCE for fourth-year nursing students, for whom graduation was a prerequisite, the panelists, as experienced clinical educators familiar with the performance and future roles of these students and the assessment method of the blended exam, were involved [ 29 , 30 ](Table 1 ).

Step 2: Preparing the necessary infrastructure for conducting the exam

Software infrastructure.

The pre- and post-virtual exam questions, scenarios, and questionnaires were uploaded using online software.

The exam was conducted on a trial basis in multiple sessions with the participation of several faculty members, and any issues were addressed. Students were authenticated to enter the exam environment via email and personal information verification. The questions for each station were designed and entered into the software by the respective station instructors and the examination coordinator, who facilitated the exam. The questions were formatted as clinical scenarios, images, descriptive questions, and multiple-choice questions, emphasizing the clinical and practical aspects. This software had various features for administering different types of exams and various question formats, including multiple-choice, descriptive, scenario-based, image-based, video-based, matching, Excel output, and graphical and descriptive statistical analyses. It also had automatic questionnaire completion, notification emails, score addition to questionnaires, prevention of multiple answer submissions, and the ability to upload files up to 4 gigabytes. Student authentication was based on national identification numbers and student IDs, serving as user IDs and passwords. Students could enter the exam environment using their email and multi-level personal information verification. If the information did not match, individuals could not access the exam environment.

Checklists and questionnaires

A student list was prepared, and checklists for the in-person exam and anxiety and satisfaction questionnaires were reproduced.

Empowerment workshops for professors and education staff

Educational needs of faculty members and academic staff include conducting clinical competency exams using the OSCE method; simulating and evaluating OSCE exams; designing standardized questions, checklists, and scenarios; innovative approaches in clinical evaluations; designing physical spaces and setting up stations; and assessing ethics and professional commitment in clinical competency exams.

Student empowerment programs

According to the students’ needs assessment results, in-person workshops on cardiopulmonary resuscitation and airway management and online workshops were held on health, pediatrics, cardiopulmonary resuscitation, ethics, nursing diagnosis, and report writing through Skype messenger. In addition, vaccination notes, psychiatric nursing, and educational files on clinical examinations and basic skills were recorded by instructors and made available to students via virtual groups.

Step 3: CCE implementation

The CCE was held in two parts, in-person and virtual.

In-person exam

The OSCE method was used for this section of the exam. The basic skills station exam included dressing and injections, and the CPR and pediatrics stations were conducted in person. The students were divided into two groups of 21 each semester, and the exam was held in two shifts. While adhering to quarantine protocols, the students performed the procedures for seven minutes at each station, and instructors evaluated them using a checklist. An additional minute was allotted for transitioning to the next station.

Virtual exam

The professional ethics, nursing diagnosis, nursing report, health, psychiatric nursing, and physical examination stations were conducted virtually after the in-person exam. This exam was made available to students via a primary and a secondary link in a virtual space at the scheduled time. Students were first verified, and after the specified time elapsed, the ability to respond to inactive questions and submitted answers was sent. During the exam, full support was provided by the examination center.

The examination coordinator conducted the entire virtual exam process. The exam results were announced 48 h after the exam. A passing grade was considered to be a score higher than 60% in all stations. Students who failed in various stations were given the opportunity for remediation based on faculty feedback, either through additional study or participation in educational workshops. Subsequent exams were held one week apart from the initial exam. It was stipulated that students who failed in more than half of the stations would be evaluated in the following semester. If they failed in more than three sessions at a station, a decision would be made by the faculty’s educational council. However, no students met these situations.

Step 4: Evaluation

The evaluation of the exam was conducted by examiners using a checklist, and the results were announced as pass or fail.

Stage 4: Observation / evaluation

In this study, both process and outcome evaluations were conducted:

Process evaluation

All programs and activities implemented during the test design and administration process were evaluated in the process evaluation. This evaluation was based on operational program control and reflections received from participants through group discussion sessions and virtual groups.

Sample reflections received from faculty members, managers, experts, and students through group discussions and social messaging platforms after the changes:

P7: “The implementation of the blended virtual exam, in the conditions of the COVID-19 crisis where the possibility of holding in-person exams was not fully available, in my opinion, was able to improve the quality of exam administration and address the limitations and weaknesses of the exam entirely virtually.”

P5: “In my opinion, this blended method was able to better evaluate students in terms of clinical readiness for entering clinical practice.”

Outcomes evaluation

The study outcomes were student anxiety, student acceptance and satisfaction, and faculty acceptance and satisfaction. Before the start of the in-person and virtual exams, the Spielberger Anxiety Questionnaire was provided to students. Additionally, immediately after the exam, students and instructors completed the acceptance and satisfaction questionnaire for the relevant section. After the exam, students and instructors completed the acceptance and satisfaction questionnaire again for the entire exam process, including feasibility, satisfaction with its implementation, and educational impact.

Design framework and implementation for the blended Clinical Competency Examination

The exam was planned using a blended method (part in-person, part virtual) according to the Fig.  2 schedule, and all planned programs for the blended CCE for final-year nursing students were implemented in two semesters.

Evaluation results

In this study, 84 final-year nursing students participated, including 37 females (44.05%) and 47 males (55.95%). Among them, 28 (33.3%) were dormitory residents, and 56 (66.7%) were non-dormitory residents.

In this study, both process and outcome evaluations were conducted.

All programs and activities implemented during the test design and administration process were evaluated in the process evaluation (Table  2 ). This evaluation was based on operational program control and reflections received from participants through group discussion sessions and virtual groups on social media.

Anxiety and satisfaction were examined and evaluated as study outcomes, and the results are presented below.

The paired t-test results in Table  3 showed no statistically significant difference in overt anxiety ( p  = 0.56), covert anxiety ( p  = 0.13), and total anxiety scores ( p  = 0.167) between the in-person and virtual sections before the blended Clinical Competency Examination.

However, the mean (SD) of overt anxiety in persons in males and females was 49.27 (11.16) and 43.63 (13.60), respectively, and this difference was statistically significant ( p  = 0.03). Also, the mean (SD) of overt virtual anxiety in males and females was 45.70 (11.88) and 51.00 (9.51), respectively, and this difference was statistically significant ( p  = 0.03). However, there was no significant difference between males and females regarding covert anxiety in the person ( p  = 0.94) and virtual ( p  = 0.60) sections. In addition, the highest percentage of overt anxiety was apparent in the virtual section among women (15.40%) and the in-person section among men (21.28%) and was prevalent at a moderate to high level.

According to Table  4 , One-way analysis of variance showed a significant difference between the virtual, in-person, and blended sections in terms of acceptance and satisfaction scores.

The results of the One-way analysis of variance showed that the mean (SD) acceptance and satisfaction scores of nursing students of the CCE in virtual, in-person, and blended sections were 25.49 (4.73), 27.60 (4.70), and 25.57 (4.97) out of 30, respectively. There was a significant difference between the three sections ( p  = 0.008).

In addition, 3 (7.23%) male and 10 (76.3%) female faculty members participated in this study; of this number, 2 (15.38%) were instructors, and 11 (84.62%) were assistant professors. Moreover, they were between 29 and 50 years old, with a mean (SD) of 41.37 (6.27). Furthermore, they had 4 to 20 years of work experience with a mean and standard deviation of 13.22(4.43).

The results of the analysis of variance showed that the mean (SD) acceptance and satisfaction scores of faculty members of the CCE in virtual, in-person, and blended sections were 30.31 (4.47), 29.86 (3.94), and 30.00 (4.16) out of 33, respectively. There was no significant difference between the three sections ( p  = 0.864).

This action research study showed that the blended CCE for nursing students is feasible and, depending on the conditions and objectives, evaluation stations can be designed and implemented virtually or in person.

The blended exam, combining in-person and virtual elements, managed to address some of the weaknesses of entirely virtual exams conducted in previous terms due to the COVID-19 pandemic. Given the pandemic conditions, the possibility of performing all in-person stations was not feasible due to the risk of students and evaluators contracting the virus, as well as the need for prolonged quarantine. Additionally, to meet the staffing needs of hospitals, nursing students needed to graduate. By implementing the blended exam idea and conducting in-person evaluations at clinical stations, the assessment of nursing students’ clinical competence was brought closer to reality compared to the entirely virtual method.

Furthermore, the need for human resources, station setup costs, and time spent was less than the entirely in-person method. Therefore, in pandemics or conditions where sufficient financial resources and human resources are not available, the blended approach can be utilized.

Additionally, the evaluation results showed that students’ total and overt anxiety in both virtual and in-person sections of the blended CCE did not differ significantly. However, the overt anxiety of female students in the virtual section and male students in the in-person section was considerably higher. Nevertheless, students’ covert anxiety related to personal characteristics did not differ in virtual and in-person exam sections. However, students’ acceptance and satisfaction in the in-person section were higher than in the virtual and blended sections, with a significant difference. The acceptance and satisfaction of faculty members from the CCE in in-person, virtual, and blended sections were the same and relatively high.

A blended CCE nursing competency exam was not found in the literature review. However, recent studies, especially during the COVID-19 pandemic, have designed and implemented this exam using virtual OSCE. Previously, the CCE was held in-person or through traditional OSCE methods.

During the COVID-19 pandemic, nursing schools worldwide faced difficulties administering clinical competency exams for students. The virtual simulation was used to evaluate clinical competency and develop nursing students’ clinical skills in the United States, including standard videos, home videos, and clinical scenarios. Additionally, an online virtual simulation program was designed to assess the clinical competency of senior nursing students in Hong Kong as a potential alternative to traditional clinical training [ 31 ].

A traditional in-person OSCE was also redesigned and developed through a virtual conferencing platform for nursing students at the University of Texas Medical Branch in Galveston. Survey findings showed that most professors and students considered virtual OSCE a highly effective tool for evaluating communication skills, obtaining a medical history, making differential diagnoses, and managing patients. However, professors noted that evaluating examination techniques in a virtual environment is challenging [ 32 ].

However, Biranvand reported that less than half of the nursing students believed the in-person OSCE was stressful [ 33 ]. At the same time, the results of another study showed that 96.2% of nursing students perceived the exam as anxiety-provoking [ 1 ]. Students believe that the stress of this exam is primarily related to exam time, complexity, and the execution of techniques, as well as confusion about exam methods [ 7 ]. In contrast to previous research results, in a study conducted in Egypt, 75% of students reported that the OSCE method has less stress than other examination methods [ 9 ]. However, there has yet to be a consensus across studies on the causes and extent of anxiety-provoking in the OSCE exam. In a study, the researchers found that in addition to the factors mentioned above, the evaluator’s presence could also be a cause of stress [ 34 ]. Another survey study showed that students perceived the OSCE method as more stressful than the traditional method, mainly due to the large number of stations, exam items, and time constraints [ 7 ]. Another study in Egypt, which designed two stages of the OSCE exam for 75 nursing students, found that 65.6% of students reported that the second stage exam was stressful due to the problem-solving station. In contrast, only 38.9% of participants considered the first-stage exam stressful [ 35 ]. Given that various studies have reported anxiety as one of the disadvantages of the OSCE exam, in this study, one of the outcomes evaluated was the anxiety of final-year nursing students. There was no significant difference in total anxiety and overt anxiety between students in the in-person and virtual sections of the blended Clinical Competency Examination. The overt anxiety was higher in male students in the in-person part and female students in the virtual section, which may be due to their personality traits, but further research is needed to confirm this. Moreover, since students’ total and overt anxiety in the in-person and virtual sections of the exam are the same in resource and workforce shortages or pandemics, the blended CCE is suggested as a suitable alternative to the traditional OSCE test. However, for generalization of the results, it is recommended that future studies consider three intervention groups, where all OSCE stations are conducted virtually in the first group, in-person in the second group, and a blend of in-person and virtual in the third group. Furthermore, the results of the study by Rafati et al. showed that the use of the OSCE clinical competency exam using the OSCE method is acceptable, valid, and reliable for assessing nursing skills, as 50% of the students were delighted, and 34.6% were relatively satisfied with the OSCE clinical competency exam. Additionally, 57.7% of the students believed the exam revealed learning weaknesses [ 1 ]. Another survey study showed that despite higher anxiety about the OSCE exam, students thought that this exam provides equal opportunities for everyone, is less complicated than the traditional method, and encourages the active participation of students [ 7 ]. In another study on maternal and infant care, 95% of the students believed the traditional exam only evaluates memory or practical skills. In contrast, the OSCE exam assesses knowledge, understanding, cognitive and analytical skills, communication, and emotional skills. They believed that explicit evaluation goals, appropriate implementation guidelines, appropriate scheduling, wearing uniforms, equipping the workroom, evaluating many skills, and providing fast feedback are among the advantages of this exam [ 36 ]. Moreover, in a survey study, most students were satisfied with the clinical environment offered by the OSCE CCE using the OSCE method, which is close to reality and involves a hypothetical patient in necessary situations that increase work safety. On the other hand, factors such as the scheduling of stations and time constraints have led to dissatisfaction among students [ 37 ].

Furthermore, another study showed that virtual simulations effectively improve students’ skills in tracheostomy suctioning, triage concepts, evaluation, life-saving interventions, clinical reasoning skills, clinical judgment skills, intravenous catheterization skills, role-based nursing care, individual readiness, critical thinking, reducing anxiety levels, and increasing confidence in the laboratory, clinical nursing education, interactive communication, and health evaluation skills. In addition to knowledge and skills, new findings indicate that virtual simulations can increase confidence, change attitudes and behaviors, and be an innovative, flexible, and hopeful approach for new nurses and nursing students [ 38 ].

Various studies have evaluated the satisfaction of students and faculty members with the OSCE Clinical Competency Examination. In this study, one of the evaluated outcomes was the acceptability and satisfaction of students and faculty members with implementing the CCE in blended, virtual, and in-person sections, which was relatively high and consistent with other studies. One crucial factor that influenced the satisfaction of this study was the provision of virtual justification sessions for students and coordination sessions with faculty members. Social messaging groups were formed through virtual and in-person communication, instructions were explained, expectations and tasks were clarified, and questions were answered. Students and faculty members could access the required information with minimal presence in medical education centers and time and cost constraints. Moreover, with the blended evaluation, the researcher’s communication with participants was more accessible. The written guidelines and uploaded educational content of the workshops enabled students to save the desired topics and review them later if needed. Students had easy access to scientific and up-to-date information, and the application of social messengers and Skype allowed for sending photos and videos, conducting workshops, and questions and answering questions. However, the clinical workshops and examinations were held in-person to ensure accuracy. The virtual part of the examination was conducted through online software, and questions focused on each station’s clinical and practical aspects. Students answered various questions, including multiple-choice, descriptive, scenario, picture, and puzzle questions, within a specified time. The blended examination evaluated clinical competency and did not delay these individuals’ entry into the job market. Moreover, during the severe human resource shortage faced by the healthcare system, the examination allowed several nurses to enter the country’s healthcare system. The blended examination can substitute in-person examination in pandemic and non-pandemic situations, saving facilities, equipment, and human resources. The results of this study can also serve as a model to guide other nursing departments that require appropriate planning and arrangements for Conducting Clinical Competency Examinations in blended formats. This examination can also be developed to evaluate students’ clinical performance.

One of the practical limitations of the study was the possibility that participants might need to complete the questionnaires accurately or be concerned about losing marks. Therefore, in a virtual session before the in-person exam, the objectives and importance of the study were explained. Participants were assured that it would not affect their evaluation and that they should not worry about losing marks. Additionally, active participation from all nursing students, faculty members, and staff was necessary for implementing this plan, achieved through prior coordination, virtual meetings, virtual group formation, and continuous reflection of results, creating the motivation for continued collaboration and participation.

Among other limitations of this study included the use of the Spielberger Anxiety Questionnaire to measure students’ anxiety. It is suggested that future studies use a dedicated anxiety questionnaire designed explicitly for pre-exam anxiety measurement. Another limitation of the current research was its implementation in nursing and midwifery faculty. Therefore, it is recommended that similar studies be conducted in nursing and midwifery faculties of other universities, as well as in related fields, and over multiple consecutive semesters. Additionally, for more precise effectiveness assessment, intervention studies in three separate virtual, in-person, and hybrid groups using electronic checklists are proposed. Furthermore, it is recommended that students be evaluated in terms of other dimensions and variables such as awareness, clinical skill acquisition, self-confidence, and self-efficacy.

Conducting in-person Clinical Competency Examination (CCE) during critical situations, such as the COVID-19 pandemic, is challenging. Instead of virtual exams, blended evaluation is a feasible approach to overcome the shortages of virtual ones and closely mimic in-person scenarios. Using a blended method in pandemics or resource shortages, it is possible to design, implement, and evaluate stations that evaluate basic and advanced clinical skills in in-person section, as well as stations that focus on communication, reporting, nursing diagnosis, professional ethics, mental health, and community health based on scenarios in a virtual section, and replace traditional OSCE exams. Furthermore, the use of patient simulators, virtual reality, virtual practice, and the development of virtual and in-person training infrastructure to improve the quality of clinical education and evaluation and obtain the necessary clinical competencies for students is recommended. Also, since few studies have been conducted using the blended method, it is suggested that future research be conducted in three intervention groups, over longer semesters, based on clinical evaluation models and influential on other outcomes such as awareness and clinical skill acquisition self-efficacy, confidence, obtained grades, and estimation of material and human resources costs. This approach reduced the need for physical space for in-person exams, ensuring participant quarantine and health safety with higher quality. Additionally, a more accurate assessment of nursing students’ practical abilities was achieved compared to a solely virtual exam.

Data availability

The datasets generated and analyzed during the current study are available on request from the corresponding author.

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Acknowledgements

We want to thank the Research and Technology deputy of Smart University of Medical Sciences, Tehran, Iran, the faculty members, staff, and officials of the School of Nursing and Midwifery, Lorestan University of Medical Sciences, Khorramabad, Iran, and all individuals who participated in this study.

All steps of the study, including study design and data collection, analysis, interpretation, and manuscript drafting, were supported by the Deputy of Research of Smart University of Medical Sciences.

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Department of E-Learning in Medical Education, Center of Excellence for E-learning in Medical Education, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran

Rita Mojtahedzadeh & Aeen Mohammadi

Department of Medical Education, Smart University of Medical Sciences, Tehran, Iran

Tahereh Toulabi

Cardiovascular Research Center, School of Nursing and Midwifery, Lorestan University of Medical Sciences, Khorramabad, Iran

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RM. Participating in study design, accrual of study participants, review of the manuscript, and critical revisions for important intellectual content. TT : The investigator; participated in study design, data collection, accrual of study participants, and writing and reviewing the manuscript. AM: Participating in study design, data analysis, accrual of study participants, and reviewing the manuscript. All authors read and approved the final version of the manuscript.

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Correspondence to Tahereh Toulabi .

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This action research was conducted following the participatory method. All methods were performed according to the relevant guidelines and regulations in the Declaration of Helsinki (ethics approval and consent to participate). The study’s aims and procedures were explained to all participants, and necessary assurance was given to them for the anonymity and confidentiality of their information. The results were continuously provided as feedback to the participants. Informed consent (explaining the goals and methods of the study) was obtained from participants. The Smart University of Medical Sciences Ethics Committee approved the study protocol (IR.VUMS.REC.1400.011).

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Mojtahedzadeh, R., Toulabi, T. & Mohammadi, A. The design, implementation, and evaluation of a blended (in-person and virtual) Clinical Competency Examination for final-year nursing students. BMC Med Educ 24 , 936 (2024). https://doi.org/10.1186/s12909-024-05935-9

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Received : 21 July 2023

Accepted : 20 August 2024

Published : 28 August 2024

DOI : https://doi.org/10.1186/s12909-024-05935-9

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