case study for procedure

McCombes, S. (2023, January 30). What Is a Case Study? | Definition, Examples & Methods. Scribbr. Retrieved March 8, 2023, from https://www.scribbr.com/methodology/case-study/

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Step by Step Guidelines For Conducting A Case Study

A case study tells a story about something special, interesting or unique. It can be about an individual, an organisation or an event. You can also use it to highlight a project's success or to bring your reader's attention to a particular challenge or difficulty in that project. The case study methodology is about how to conduct research while working on a specific case. This section describes the process of selecting a case, gathering credible data from a wide variety of sources, analysing and interpreting them. There are four primary stages included in the case study research methodology . The authenticity of your case study depends on how perfectly you master all the stages as discussed below.

What are the four main stages in case study research methodology?

Case study methodology encourages an intensive investigation of a particular unit (an organization, an event or even an individual) under considerations. Had it not been for methodologies, it would have been difficult to demonstrate ideas in a case study due to conflicting epistemological presuppositions and other complexities involved in this task. So, let’s check out the basic stages in the methodology of a case study.

Stage 1: Defining the case

Defining the research problem t clearly is the first step of your case-study methodology. You can also consider this as the ‘planning’ phase since it lets you identify research questions or other rationales for writing the case study. You have to formulate the research question, add existing literature and appreciate the theoretical issues related to your topic while defining the case.

What else to remember while defining the case?

For instance, consider the case study topic ‘Introduction of electronic health records in urban hospitals.’ You can define the case based on the use of technology where your focus would be on how technology is implemented in hospitals. You can also define the case based on social and organisational dimensions of technology in hospitals. In that case, you have to talk about the impact of technology on healthcare professionals.

Stage 2: Pick the right type of case study

You need to reflect on the type of information sources you have used to pick the right type of case study. There are three main types of case study methodology you can choose from such as:

Intrinsic case study

In an intrinsic case study, the case itself is of primary interest to the readers. You can pick this genre of case study if your topic is unique as compared to the other similar work. For example, you can analyse the marginalisation of minority people with asthma or study an elderly couple living with dementia.

Instrumental case study

This type of case study lets you investigate an idea, an issue or a phenomenon. Let’s assume you are writing about doctor’s responses to certain health policy initiatives. So, you can use an instrumental case study for interviewing clinicians to generate theory and hypothesis related to this topic.

Collective or multiple case studies

Collective case studies help you compare across several cases so that you can come to a valid conclusion at the end of your case study. Let's say you decide to write a case study about a particular theory. Thus, you need to compare two or three case studies if the theory is straightforward. However, you must use five or more cases for comparison if the theory is subtle.

Picking the right type of case study will help you proceed with the next stages of methodology hassle-free. Whether you need to interview someone or conduct a SWOT analysis, all of that depends on the type of your case study.

Stage 3: Collect relevant and authentic data

To develop a thorough understanding of your case, you must gather valuable data from multiple sources. You can use qualitative techniques such as interviews, observations or focus groups or quantitative techniques like questionnaires or audits. The more sources you use, the more valid your case study will be. Speaking of collecting data, the two most common resources are:

Library and internet research

Note down everything that has been written related to your topic. Read relevant articles, magazines, journals, etc. that can give you more information about your case.

You may find that there are existing problems that need solving while going through online sources. For example, let’s say you are writing a case study on a national park and its endangered ecosystem due to an increased number of visitors. In that case, your research question would be ‘how to solve the park’s ecosystem without affecting tourists?’

Now, what if you find that the place doesn't have a lot of tourists? In that case, your research question would be ‘how to encourage more tourists to come without affecting the park?‘

Careful interviews

Conduct interviews to gather more practical knowledge about the case you are working on. Get hold of knowledgeable people whose opinion can contribute to the internal validity of your case study. Make sure you get the person to tell you whatever it is that he/she knows and thinks.

Considering the national park example, here the questions to ask in an interview:

The research phase is very important as it sets the direction for the rest of the sections in a case study. You can also use secondary information sources such as organisational archives, previously unpublished data, internal reports, memoranda, etc.

Stage four- Analyse the information

If you look at case study methodology examples, you will understand that the writers use only the most significant details throughout the study. You may have gathered a wide plethora of information for the case study. But, you have to complete the project within a specified word count. Thus, evaluate all the sources and use only the most significant information in your paper.

Here’s how to analyse your data:

Take out the excess

You can’t include all kinds of information in your case study. Sort out the information, take out the excess and arrange the information in such a way that your case study is understandable to your readers.

Break down the case problem

Break down the case problem into different parts. Each part is a piece of the puzzle that your reader should understand while reading your case. Ensure that you have enough research findings for each part of your case study question.

Figure out what is really important

Your readers should understand the situation you are trying to portray in the case study. Thus, include the information that really enhances the validity of your work and research.

Let’s assume the following:

The heritage site that you are talking about doesn’t have many visitors. But, people would like to visit if the heritage site has facilities.

Now ask yourself ‘how much information do I need to include so that my readers can discuss the questions mentioned above?’ You can take a look at research methodology samples if you are still confused about how to analyse the data collected.

Final Thoughts,

The quality of your case study depends on the precision of your case study research methods . Get all the stages of your methodology right, and you will be able to craft a perfect case study in no time. The methodology section is also very time-consuming. It is better that you check out online qualitative research methodology examples to attend to each stage carefully. Consult with your professors if you are unable to find research material relevant to your case study question.

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What Is a Case Study?

An in-depth study of one person, group, or event

Kendra Cherry, MS, is an author and educational consultant focused on helping students learn about psychology.

Cara Lustik is a fact-checker and copywriter.

Verywell / Colleen Tighe

Benefits and Limitations

Types of case studies, how to write a case study.

A case study is an in-depth study of one person, group, or event. In a case study, nearly every aspect of the subject's life and history is analyzed to seek patterns and causes of behavior. Case studies can be used in various fields, including psychology, medicine, education, anthropology, political science, and social work.

The purpose of a case study is to learn as much as possible about an individual or group so that the information can be generalized to many others. Unfortunately, case studies tend to be highly subjective, and it is sometimes difficult to generalize results to a larger population.

While case studies focus on a single individual or group, they follow a format similar to other types of psychology writing. If you are writing a case study, it is important to follow the rules of APA format .

A case study can have both strengths and weaknesses. Researchers must consider these pros and cons before deciding if this type of study is appropriate for their needs.

One of the greatest advantages of a case study is that it allows researchers to investigate things that are often difficult to impossible to replicate in a lab. Some other benefits of a case study:

On the negative side, a case study:

Researchers may choose to perform a case study if they are interested in exploring a unique or recently discovered phenomenon. The insights gained from such research can help the researchers develop additional ideas and study questions that might be explored in future studies.

However, it is important to remember that the insights gained from case studies cannot be used to determine cause and effect relationships between variables. However, case studies may be used to develop hypotheses that can then be addressed in experimental research.

Case Study Examples

There have been a number of notable case studies in the history of psychology. Much of Freud's work and theories were developed through the use of individual case studies. Some great examples of case studies in psychology include:

Such cases demonstrate how case research can be used to study things that researchers could not replicate in experimental settings. In Genie's case, her horrific abuse had denied her the opportunity to learn language at critical points in her development.

This is clearly not something that researchers could ethically replicate, but conducting a case study on Genie allowed researchers the chance to study phenomena that are otherwise impossible to reproduce.

There are a few different types of case studies that psychologists and other researchers might utilize:

The three main case study types often used are intrinsic, instrumental, and collective. Intrinsic case studies are useful for learning about unique cases. Instrumental case studies help look at an individual to learn more about a broader issue. A collective case study can be useful for looking at several cases simultaneously.

The type of case study that psychology researchers utilize depends on the unique characteristics of the situation as well as the case itself.

There are also different methods that can be used to conduct a case study, including prospective and retrospective case study methods.

Prospective case study methods are those in which an individual or group of people is observed in order to determine outcomes. For example, a group of individuals might be watched over an extended period of time to observe the progression of a particular disease.

Retrospective case study methods involve looking at historical information. For example, researchers might start with an outcome, such as a disease, and then work their way backward to look at information about the individual's life to determine risk factors that may have contributed to the onset of the illness.

Where to Find Data

There are a number of different sources and methods that researchers can use to gather information about an individual or group. Six major sources that have been identified by researchers are:

Section 1: A Case History

This section will have the following structure and content:

Background information : The first section of your paper will present your client's background. Include factors such as age, gender, work, health status, family mental health history, family and social relationships, drug and alcohol history, life difficulties, goals, and coping skills and weaknesses.

Description of the presenting problem : In the next section of your case study, you will describe the problem or symptoms that the client presented with.

Describe any physical, emotional, or sensory symptoms reported by the client. Thoughts, feelings, and perceptions related to the symptoms should also be noted. Any screening or diagnostic assessments that are used should also be described in detail and all scores reported.

Your diagnosis : Provide your diagnosis and give the appropriate Diagnostic and Statistical Manual code. Explain how you reached your diagnosis, how the client's symptoms fit the diagnostic criteria for the disorder(s), or any possible difficulties in reaching a diagnosis.

Section 2: Treatment Plan

This portion of the paper will address the chosen treatment for the condition. This might also include the theoretical basis for the chosen treatment or any other evidence that might exist to support why this approach was chosen.

This section of a case study should also include information about the treatment goals, process, and outcomes.

When you are writing a case study, you should also include a section where you discuss the case study itself, including the strengths and limitiations of the study. You should note how the findings of your case study might support previous research.

In your discussion section, you should also describe some of the implications of your case study. What ideas or findings might require further exploration? How might researchers go about exploring some of these questions in additional studies?

Here are a few additional pointers to keep in mind when formatting your case study:

A Word From Verywell

Case studies can be a useful research tool, but they need to be used wisely. In many cases, they are best utilized in situations where conducting an experiment would be difficult or impossible. They are helpful for looking at unique situations and allow researchers to gather a great deal of information about a specific individual or group of people.

If you have been directed to write a case study for a psychology course, be sure to check with your instructor for any specific guidelines that you are required to follow. If you are writing your case study for professional publication, be sure to check with the publisher for their specific guidelines for submitting a case study.

Simply Psychology. Case Study Method .

Crowe S, Cresswell K, Robertson A, Huby G, Avery A, Sheikh A. The case study approach . BMC Med Res Methodol . 2011 Jun 27;11:100. doi:10.1186/1471-2288-11-100

Gagnon, Yves-Chantal. The Case Study as Research Method: A Practical Handbook . Canada, Chicago Review Press Incorporated DBA Independent Pub Group, 2010.

Yin, Robert K. Case Study Research and Applications: Design and Methods . United States, SAGE Publications, 2017.

By Kendra Cherry Kendra Cherry, MS, is an author and educational consultant focused on helping students learn about psychology.

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Research Procedures

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Those wishing to investigate the brain have to conduct their research with respect to the core aspects of scientific research. Take, for example, a researcher who wanted to investigate if we can manifest our dreams. Would this be considered scientific? Considering how difficult it is to measure the reliability and validity of such a concept, the majority of psychologists would argue that the research is pseudo-psychology.

Psychologists emphasise the importance of scientific research that is empirical , reliable and valid , which can be inferred when research uses various research procedures.

Research Procedures, Women carrying large magnifying glass with larger questionnaires in the background, StudySmarter

Research in Psychology

When it comes to research in psychology, three core features need to be maintained for a study to be identified as scientific, and these are:

Reliability

The nature of these features is to ensure that research reaches a high standard and reduces the chances of the results being due to chance.

For example, it guarantees that the study measures observable variables via our senses (empiricism).

The point of this is to ensure that researchers do not investigate nonsensical theories or ideas that cannot be proved or disproved. In addition, the features indicate that the results consistently measure what they should (reliability) and accurately measure what they should (validity).

Research Procedures, Venn diagram of the three core features of scientific research, StudySmarter

Researchers can use several research procedures to increase the likelihood of collecting empirical, reliable and valid scientific data.

Types of Research in Psychology

Before we look at how researchers can increase the reliability and validity of research, let's look at the different types of research in psychology.

Some of the common quantitative types of research in psychology are:

Whereas some common qualitative types of research in psychology are:

Some research types can collect quantitative (numerical) and qualitative (non-numerical) data, commonly referred to as mixed designs. Case studies and semi-structured interviews are examples that gather both kinds of data.

Quantitative Research Procedures

Quantitative research is research that collects numerical data. Researchers can use several techniques to increase the reliability and validity of the research. An example is standardising procedures; this is essentially a protocol, e.g. the instructions given to participants or determining the conditions of the experiment before the study. The point of this is to increase the study's internal reliability.

Internal reliability in this context refers to a study consistently measuring the same thing across each participant.

The following research procedures will examine how researchers can improve their research standards using their sample. The research procedure used to increase an experimental study's internal validity is randomisation. Typically in experimental research, there is an experimental and control group. The researchers' subjective opinions should not influence research as this can lower the study's validity.

If a researcher chooses which participants go in which group, then the researcher may unconsciously select them based on factors that may cause the participants to sway the results.

For example, if the researcher suggests all tall people are better at maths, they may place tall people in favourable groups unknowingly, especially if they are biased and believe this to be true.

Researchers typically randomly allocate participants to the experimental or control group to prevent biases from occurring.

A blind experiment is where researchers do not know when they are in the control or experimental group. A double-blind experiment is when the researcher and participant are unaware of who is in which group. The latter is considered the ideal experimental design.

Now we can examine how the variables investigated can affect reliability and validity. In scientific research, changes observed in the dependent variable must result from manipulating the independent variable, or the naturally occurring changes in the independent variable.

Additional variables that are not being manipulated or measured specifically but can affect the experiment are known as extraneous variables . Extraneous variables reduce the validity of research as they may impact the results. The researcher cannot confidently say the results are due to the manipulated, independent variable being measured when extraneous variables are influencing the experiment, after all.

Some examples of extraneous variables in a study testing how sleep affects driving skills are the time of day participants are tested, any test anxiety they may feel, how long the participant has been driving, or driving conditions.

Research Procedures, Diagram of good research: arrow from independent variable pointing at dependent variable and bad research: arrows from independent variable and extraneous variables affecting dependent variable, StudySmarter

Research procedures that can control extraneous variables, including many of the ones described above, include:

In a repeated measures design, participants are tested in both conditions, e.g., memory performance after rest and sleep deprivation. When a study uses counterbalancing, half of the participants would be tested after rest and the other after sleep deprivation. Then, they are tested in the opposite condition.

The reason is to ensure the results are due to changes in rest and sleep deprivation rather than the order in which the participants are tested.

Quantitative Research Procedure Example

An example of a good quantitative research procedure example is.

A hypothetical study that investigated how poor sleep hygiene affected attentional skills used an experimental design.

The study compared the experimental group (poor sleep hygiene ) results to the control group (good sleep hygiene ); participants were randomly allocated into these groups.

The instructions depended on which group the participants were allocated, but the same instructions were given to participants within the same group. With the exception of the sleep hygiene variables that changed in the experimental versus control group, other factors that may affect the results, such as how long the participants slept, were controlled.

Before you continue reading, can you identify the research procedures that the researcher considered?

The research procedures considered in the research scenario are:

Qualitative Research Methods and Procedures Example

The use of standardised procedures is also common in qualitative research.

For instance, researchers may observe and interview participants in the same conditions.

In terms of observations, researchers commonly identify behaviours they are interested in watching. Well-designed observations typically use standardised procedures that two or more observers follow, with comparisons of the recordings and analysis of each observer to identify if the study has high internal reliability.

Social Research Procedure

An example of an unstructured observation that utilised several research procedures to increase its reliability and validity is:

A study observed whether children had a preference for immediate or delayed gratification.

In the hypothetical study, participants were seated at a desk. The table had a sweet on it. The researcher told the participants they could only eat the sweet after the researcher had returned from the bathroom.

The conditions and instructions used in the experiment were the same for each participant. Later the participants were asked a series of questions to identify if their responses earlier matched how they responded in the interview.

You would be correct if you identified the study as using standardising protocols as a research procedure to increase the study's reliability.

Research Procedures - Key takeaways

When it comes to research in psychology, three core features need to be maintained for a study to be identified as scientific: empiricism, reliability and validity.

Standard quantitative research procedures include standardisation, i.e. giving participants the exact instructions and randomisation, i.e. randomly allocating participants to the control or experimental group. Researchers should also try and control for extraneous variables .

Standardising procedures are also commonly used as a research procedure to increase the reliability of qualitative research.

Frequently Asked Questions about Research Procedures

--> what are the three research procedures.

Three examples of research procedures are:

--> What are the 7 steps of research process?

The seven steps in the research process are as follows:

--> How to write research procedure?

When writing the research procedure, the study needs to be written in great detail so that other researchers can replicate it. The section should cover the materials used, describe the participants that took part and how the study was conducted.

--> What is data collection procedure in research?

The data collection process can vary depending on what type of analysis is being carried out. Generally, the first stage is to conduct the descriptive statistics, then the statistical tests, and finish with post-hoc tests if the researcher wishes to or if the statistical test allows.

--> What are research procedures?

Research procedures are steps that researchers should take to increase the reliability and validity of their research.

For example, standardising an experiment means that participants are tested in the same conditions, increasing the study's internal reliability.

Or, controlling extraneous variables means that the study is more likely to investigate how the independent variable and not other variables affect the dependent variable; this increases the study's validity.

Final Research Procedures Quiz

What are research procedures?

Show answer

Research processes are steps that researchers should take to increase the reliability and validity of their research.

Show question

What are the following examples of "reliability, validity, empiricism"?

The three core features of scientific research.

Researchers can use several research procedures to the likelihood of collecting empirical, reliable and valid scientific data. Fill in the missing word.

What is an extraneous variable?

Extraneous variables are factors other than the independent variable that cause changes in the dependent variable.

Which of the following do extraneous variables affect?

In what type of research design is counterbalancing often used?

Repeated measures design.

What does counterbalancing control?

Order effects.

What is counterbalancing?

Counterbalancing is when half of the participants participate in one condition first, and the other half are tested in the other condition first.

And then, the participants are tested in the other condition they are yet to be tested in.

How may a study be standardised?

The researchers may create a protocol which ensures that participants are tested in the same conditions and that the same instructions are given.

What type of reliability does standardisation increase?

Internal reliability.

A hypothetical study that investigated how poor sleep hygiene affected attentional skills used an experimental design. The study compared the experimental group (poor sleep hygiene) results to the control group (good sleep hygiene); participants were randomly allocated into these groups. The instructions depended on which group the participants were allocated, but the same instructions were given to participants within the same group. With the exception of the sleep hygiene variables that changed in the experimental versus control group, other factors that may affect the results, such as how long the participants slept, were controlled.

Can you identify the research procedures that the researcher considered?

A study observed whether children had a preference for immediate or delayed gratification. In the hypothetical study, participants were seated at a desk. The table had a sweet on it. The researcher told the participants they could only eat the sweet after the researcher had returned from the bathroom. The conditions and instructions used in the experiment were the same for each participant.

Later the participants were asked a series of questions to identify if their responses earlier matched how they responded in the interview.

The study was standardised.

In what type of experiment is randomisation often used?

Experimental.

What does randomisation improve?

Study's validity.

What does randomisation control?

The researcher's subjective opinion and biases from swaying the results.

What is randomisation?

Randomisation is when the participants are randomly assigned to the control or experimental group.

What is a blind experiment?

When the participant does not know if they are in the control or experimental group.

What is a double-blind experiment?

When both the researcher and participant do not know who is in the control or experimental group.

Which of the following is particularly useful at reducing biases in experiments?

Blind research.

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The Important Steps of the Case Study Method

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There are several steps to be taken for the case study method. To know

Determine and define research questions, select cases and determine data collection and analysis techniques.

Preparation for data collection

Collection of data in the field

Evaluate and analyze data, prepare the report.

By following these six steps the case study is complete. For each step to be well understood, let’s look at each separately.

The first step in the scientific research is to establish a firm research focus that the researcher can refer to throughout the study of a complex phenomenon or object. The researcher establishes the focus of the study by asking questions about the situation or problem being studied and determining a purpose for the study. The object of research in a study may often be

a group of people.

Each object is likely to be intrinsically linked to issues

The investigator investigates the object of in-depth study using a variety of data collection methods to produce evidence that leads to the understanding of the case and answers the research questions.

During the research design phase, the researcher determines which approaches will be used in the selection of single or multiple real-life cases to examine in depth, and which instruments and approaches to data collection will be used.

When using multiple cases, each case is treated as unique. The conclusions of each case can then be used as information that contributes to the entire study, however each case remains a single case.

The researcher must determine whether to study cases that are unique in some way or cases that are considered typical and can also select cases to represent a variety of geographic regions, a variety of size parameters or other parameters.

A useful step in the selection process is to repeatedly go back to the purpose of the study in order to draw attention to where to look for cases and evidence that will satisfy the purpose of the study and answer the raised research questions. Selecting multiple or unique cases is a key element.

Preparation for data collection in the Case Study Method

Because case-study research generates a large amount of data from multiple sources, systematic organization of data is important to prevent the researcher from becoming overwhelmed by the amount of data and to prevent the researcher from losing sight of the original goal and questions of the researcher. search.

Prepaid preparation assists in the handling of large amounts of data in a documented and systematic manner. The researchers prepare databases to assist in the categorization, classification, storage and retrieval of data for analysis.

The researcher must collect and store multiple sources of evidence comprehensively and systematically in formats that can be referenced and classified so that convergent lines of inquiry and patterns can be discovered. The researchers carefully observe the object of the case study and identify causal factors associated with the observed phenomenon.

The renegotiation of the arrangements with the objects of the study or the addition of questions to the interviews may be necessary as the study progresses. Case study research is flexible, but when changes are made, they are documented systematically.

The researcher examines the raw data using many interpretations to find links between the search object and the results with reference to the original search questions. Throughout the process of evaluation and analysis, the researcher remains open to new opportunities and insights.

The case study method, using multiple methods of data collection and analysis techniques, offers researchers the opportunity to triangulate data to strengthen the findings and conclusions of the research.

The tactics used in the analysis force researchers to go beyond initial impressions to improve the likelihood of accurate and reliable findings.

Examples of case studies allow you to deliberately sort data in many different ways to expose or create new ideas and look for conflicting data to disallow the analysis. Researchers categorize, tabulate, and recombine data to address the initial propositions or purpose of the study, and perform cross-checks of facts and discrepancies in the accounts.

Examples of case studies report the data in a way that transforms a complex issue into one that can be understood, allowing the reader to question and examine the study and come to an independent understanding of the researcher.

The purpose of the written report is to portray a complex problem in a way that conveys an experience passed on to the reader. The studies present the data in a very accessible way to the public and can lead the reader to apply the experience to their own actual situation.

Researchers pay close attention to sufficient evidence to gain the confidence of the reader that all routes have been explored, clearly communicating the boundaries of the case and giving special attention to conflicting propositions.

The introduction of the report includes acknowledging all participants, indicating the problem, listing the research questions, describing the methods used to conduct the research and any potential flaws in the method used, explaining the data collection and analysis techniques used and concluding with the answers to questions and suggestions for future research.

Key features of the report include a feeling of specific stories related to the successes or losses experienced by organizations that were transmitted during data collection and responses or comments illuminating issues directly related to the research questions.

The researcher develops each question using quotes or other details of the data collected, and points to triangulation of data where applicable. The report also includes confirmation and departures from the conclusions of the literature used.

The report’s conclusion makes affirmations and suggestions for new research activities so that another researcher can apply these techniques to another community network and its participants to determine if similar findings are identifiable in other communities.

We know that studies are complex because they often involve multiple sources of data, can include multiple cases within a study, and produce large amounts of data for analysis. Researchers from many disciplines use the case study method to construct theory, produce a new theory, discuss or challenge theory, explain a situation, provide a basis for applying solutions to situations, exploring or describing an object or phenomenon.

The advantages of this method of study are its applicability to real, contemporary, human situations and its public accessibility through written reports. The results of case studies relate directly to the everyday experience of the average reader and facilitate the understanding of complex real-life situations.

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Procedures in Doing a Case Study Report

Every investigator should have a well-developed set of procedures for analyzing social science data and for composing an empirical report. Numerous texts offer good advice on how you can develop your own customized procedures, including the benefits and pitfalls of using word-processing software (Becker, 1986, p. 160). One common warning is that writing means rewriting—a function not commonly practiced by students and therefore underestimated during the early years of research careers (Becker, 1986, pp. 43-47). The more rewriting, especially in response to others’ comments, the better a report is likely to be. In this respect, the case study report is not much different from other research reports.

However, three important procedures pertain specifically to case studies and deserve further mention. The first deals with a general tactic for starting a composition, the second covers the problem of whether to leave the case identities anonymous, and the third describes a review procedure for increasing the construct validity of a case study.

1. When and How to Start Composing

The first procedure is to start composing early in the analytic process. One guide in fact admonishes that “you cannot begin writing early enough” (Wolcott, 1990, p. 20). From nearly the beginning of an investigation, certain sections of your report will always be draftable, and this drafting should proceed even before data collection and analysis have been completed.

For instance, after the literature has been reviewed and the case study has been designed, two sections of a case study report can be drafted: the bibliography and the methodological sections. The bibliography always can be augmented later with new citations if necessary, but by and large, the major citations will have been covered in relation to the literature review. This is therefore the time to formalize the references, to be sure that they are complete, and to construct a draft bibliography. If some references are incomplete, the remaining details can be tracked down while the rest of the case study proceeds. This will avoid the usual practice among researchers who do the bibliography last and who therefore spend much clerical time at the very end of their research, rather than attending to the more important (and pleasurable!) tasks of writing, rewriting, and editing.

The methodological section also can be drafted at this stage because the major procedures for data collection and analysis should have become part of the case study design. This section may not become a formal part of the final narrative but may be designated as an appendix. Whether part of the text or an appendix, however, the methodological section can and should be drafted at this early stage. You will remember your methodological procedures with greater precision at this juncture.

A third section is the preliminary literature review and how it led to or complemented your research questions and the propositions being studied. Because your case study will already have settled on these questions and propositions in order to proceed with protocol development and data collection, much of the connectivity to the literature will be known. Although you may need to revisit this early version after completing your data collection and analysis, having a preliminary draft never hurts.

After data collection but before analysis begins, a fourth section that can be composed covers the descriptive data about the cases being studied. Whereas the methodological section should have included the issues regarding the selection of the case(s), the descriptive data should cover qualitative and quantitative information about the case(s). At this stage in the research process, you still may not have finalized your ideas about the type of case study format to be used and the type of structure to be followed. However, the descriptive data are likely to be useful regardless of the format or structure. Furthermore, drafting the descriptive sections, even in abbreviated form, may stimulate your thinking about the overall format and structure.

If you can draft these four sections before analysis has been completed, you will have made a major advance. These sections also may call for substantial documentation (e.g., copies of your final case study protocol), and an opportune time to put such documentation into presentable form (possibly even “camera ready”) occurs at this stage of the research. You also will be at an advantage if all details—citations, references, organizational titles, and spellings of people’s names—have been accurately recorded during data collection and are integrated into the text at this time (Wolcott, 1990, p. 41).

If these sections are drafted properly, more attention can then be devoted to the analysis itself, as well as to the findings and conclusions. To begin composing early also serves another important psychological function: You may get accustomed to the compositional process as an ongoing (possibly even daily) practice and have a chance to routinize it before the task becomes truly awesome. Thus, if you can identify other sections that can be drafted at these early stages, you should draft them as well.

2. Case Identities: Real or Anonymous?

Nearly every case study presents an investigator with a choice regarding the anonymity of the case. Should the case study and its informants be accurately identified, or should the names of the entire case and its participants be disguised? Note that the anonymity issue can be raised at two levels: that of the entire case (or cases) and that of an individual person within a case (or cases).

The most desirable option is to disclose the identities of both the case and the individuals, within the constraints for protecting human subjects, discussed in Chapter 3. Disclosure produces two helpful outcomes. First, the reader has the opportunity to recollect any other previous information he or she may have learned about the same case—from previous research or other sources—in reading and interpreting your case study. This ability to become familiar with a new case study in light of prior knowledge is invaluable, similar to the ability to recall previous experimental results when reading about a new set of experiments. Second, the absence of disguised names will make the entire case easier to review, so that footnotes and citations can be checked, if necessary, and appropriate external comments can be solicited about the published case.

Nevertheless, anonymity is necessary on some occasions. The most common rationale occurs when a case study has been on a controversial topic. Anonymity then serves to protect the real case and its real participants. A second occasion occurs when the issuance of the final case report may affect the subsequent actions of those that were studied. This rationale was used in Whyte’s (1943/1955) famous case study, Street Comer Society (which was about an anonymous neighborhood, “Comerville”). 2 As a third illustrative situation, the purpose of the case study may be to portray an “ideal type,” and there may be no reason for disclosing the tme identities. This rationale was used by the Lynds in their study Middletown (Lynd & Lynd, 1929), in which the names of the small town, its residents, and its industries all were disguised.

On such occasions when anonymity may appear justifiable, however, other compromises should still be sought. First, you should determine whether the anonymity of the individuals alone might be sufficient, thereby leaving the case itself to be identified accurately.

A second compromise would be to name the individuals but to avoid attributing any particular point of view or comment to a single individual, again allowing the case itself to be identified accurately. This second alternative is most relevant when you want to protect the confidentiality of specific individuals. However, the lack of attribution may not always be completely protective— you also may have to disguise the comments so that no one involved in the case can infer the likely source.

For multiple-case studies, a third compromise would be to avoid composing any single-case reports and to report only a cross-case analysis. This last situation would be roughly parallel to the procedure used in surveys, in which the individual responses are not disclosed and in which the published report is limited to the aggregate evidence.

Only if these compromises are impossible should you consider making the entire case study and its informants anonymous. However, anonymity is not to be considered a desirable choice. Not only does it eliminate some important background information about the case, but it also makes the mechanics of composing the case difficult. The case and its components must be systematically converted from their real identities to fictitious ones, and you must make a considerable effort to keep track of the conversions. The cost of undertaking such a procedure should not be underestimated.

EXERCISE 6.3 Maintaining Anonymity in Case Studies

Identify a case study whose “case” has been given a fictitious name (or check some of the boxes in this book for an example). What are the advantages and disadvantages of using such a technique? What approach would you use in reporting your own case study, and why?

3. Reviewing the Draft Case Study: A Validating Procedure

A third procedure to be followed in doing the case study report is related to the overall quality of the study. The procedure is to have the draft report reviewed, not just by peers (as would be done for any research manuscript) but also by the participants and informants in the case. If the comments are exceptionally helpful, the investigator may even want to publish them as part of the entire case study (see BOX 44).

Such review is more than a matter of professional courtesy. The procedure has been correctly identified as a way of corroborating the essential facts and evidence presented in a case report (Schatzman & Strauss, 1973, p. 134). The informants and participants may still disagree with an investigator’s conclusions and interpretations, but these reviewers should not disagree over the actual facts of the case. If such disagreement emerges during the review process, an investigator knows that the case study report is not finished and that such disagreements must be settled through a search for further evidence.

Reviewing Case Studies—and Printing the Comments

A major way of improving the quality of case studies and ensuring their construct validity is to have the draft cases reviewed by those who have been the subjects of study. This procedure was followed to an exemplary degree in a set of five case studies by Alkin, Daillak, and White (1979).

Each case study was about a school district and the way that the district used evaluative information about its students’ performance. As part of the analytic and reporting procedure, the draft for each case was reviewed by the informants from the relevant district. The comments were obtained in part as a result of an open- ended questionnaire devised by the investigators for just this purpose. In some instances, the responses were so insightful and helpful that the investigators modified their original material and also printed the responses as part of their book.

With such presentation of supplementary evidence and comments, any reader can reach her or his own conclusions about the adequacy of the cases—an opportunity that has occurred, unfortunately, all too seldom in traditional case study research.

Often, the opportunity to review the draft also produces further evidence, as the informants and participants may remember new materials that they had forgotten during the initial data collection period.

This type of review should be followed even if the case study or some of its components are to remain anonymous. Under this condition, some recognizable version of the draft must be shared with the case study informants or participants. After they have reviewed this draft, and after any differences in facts have been settled, the investigator can disguise the identities so that only the informants or participants will know the true identities. When Whyte (1943/1955) first completed Street Comer Society, he followed this procedure by sharing drafts of his book with “Doc,” his major informant. He notes,

As I wrote, I showed the various parts to Doc and went over them with him in detail. His criticisms were invaluable in my revision, (p. 341)

From a methodological standpoint, the corrections made through this process will enhance the accuracy of the case study, hence increasing the construct validity of the study. The likelihood of falsely reporting an event should be reduced. In addition, where no objective truth may exist—as when different participants indeed have different renditions of the same event—the procedure should help to identify the various perspectives, which can then be represented in the case study report. At the same time, you need not respond to all the comments made about the draft. For example, you are entitled to your own interpretation of the evidence and should not automatically incorporate your informants’ reinterpretations. In this respect, your discretionary options are no different from how you might respond to comments made in the conventional peer review process.

The review of the draft case study by its informants will clearly extend the period of time needed to complete the case study report. Informants, unlike academic reviewers, may use the review cycle as an opportunity to begin a fresh dialogue about various facets of the case, thereby extending the review period even further. You must anticipate these extensions and not use them as an excuse to avoid the review process altogether. When the process has been given careful attention, the potential result is the production of a high-quality case study (see BOX 45).

Formal Reviews of Case Studies

As with any other research product, the review process plays an important role in enhancing and ensuring the quality of the final results. For case studies, such a review process should involve, at a minimum, a review of the draft case study.

One set of case studies that followed this procedure, to an exemplary degree, was sponsored by the U.S. Office of Technology Assessment (1980-1981). Each of 17 case studies, which were about medical technologies, was “seen by at least 20, and some by 40 or more, outside reviewers.” Furthermore, the reviewers reflected differ- ent perspectives, including those of government agencies, professional societies, consumer and public interest groups, medical practice, academic medicine, and economics and decision sciences.

In one of the case studies, a contrary view of the case—put forth by one of the reviewers—was included as part of the final published version of the case, as well as a response by the case study authors. This type of open printed interchange adds to the reader’s ability to interpret the case study’s conclusions and therefore to the overall quality of the case study evidence.

Source: Yin K Robert (2008), Case Study Research Designs and Methods , SAGE Publications, Inc; 4th edition.

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A new procedure for spare parts inventory management in ETO production: a case study

University of Campania "Luigi Vanvitelli", via Roma 29, Aversa, 81031, Italy

University of Parma, Parco Area delle scienze 181/A, Parma, 43124, Italy

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Spare parts inventory management represents a strategic but critical process in many manufacturing companies, which have to handle a high amount of different items. This work aims at developing a simulation model to manage the inventory level of spare parts of an ETO (engineering to order) company. First, heterogeneous items have been analysed and classified into four different categories. Later, a simulation model has been developed to reproduce the inventory policy currently used to monitor and control them. Finally, a new procedure has been implemented to improve the current inventory management. Results show that the new procedure allows for reducing both the total cost and the maximum amount of space needed to stock the items. In addition, the simulation model could be used by practitioners as a practical tool to identify a proper inventory strategy according to the characteristics of the different items.

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Pulsed af ‘strengthens the case’ for pulsed-field ablation in af, the new modality may offer shorter, safer procedures, with efficacy similar to thermal ablation. next up: comparative studies..

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PULSED AF ‘Strengthens the Case’ for Pulsed-Field Ablation in AF

NEW ORLEANS, LA—Pulsed-field ablation with the PulseSelect system (Medtronic) appears to be a safe and effective way to achieve freedom from arrhythmias in patients with either paroxysmal or persistent atrial fibrillation (AF), results of the nonrandomized PULSED AF pivotal trial show.

The modality achieved acute isolation of the pulmonary vein in all cases, with only one major safety event detected in each cohort. There were no cases of coronary artery spasms and no phrenic, esophageal, or pulmonary vein injuries, Atul Verma, MD (McGill University Health Centre, Montreal, Canada), reported here at the American College of Cardiology/World Congress of Cardiology (ACC/WCC) 2023 meeting.

The primary efficacy endpoint was freedom from a composite of acute procedural failure, arrhythmia recurrence, repeat ablation, direct current cardioversion, left atrial surgery, or antiarrhythmic drug escalation through 12 months. Rates in the paroxysmal and persistent AF subsets (66.2% and 55.1%, respectively) exceeded the performance goals of 50% and 40%.

Moreover, patients had clinically meaningful improvements in quality of life, Verma said.

The study, published simultaneously online in Circulation , represents “a major landmark in terms of the movement of the entire community towards pulsed-field ablation for the reasons that it seems to be promising faster procedure times, safer procedures, and efficacy at least as good as that which we were seeing with thermal energies,” Verma told TCTMD.

Indeed, commented Kalyanam Shivkumar, MD, PhD (UCLA Health, Los Angeles, CA), editor-in-chief of JACC: Clinical Electrophysiology , PULSED AF “strengthens the case for this energy modality, which is nonthermal, for catheter ablation,” and shows that the technology can be introduced across centers and operators.

Low Complication Rates, Improved Quality of Life

Catheter ablation is an established therapy for symptomatic, drug-refractory AF, but thermal modes of ablation using radiofrequency energy, cryoablation, or lasers come with the potential to damage surrounding structures.

Pulsed-field ablation (PFA), on the other hand, is a nonthermal modality, delivering short bursts of high-power electrical fields to ablate via irreversible electroporation, essentially punching holes in cell membranes and causing the cardiomyocytes to die. Use of nonthermal energy helps prevent collateral damage to structures like the esophagus and phrenic nerve. Of note, no PFA systems have yet been approved by the US Food and Drug Administration, though several are under development.

PULSED AF, conducted at 41 centers in nine countries, was a pivotal trial designed to evaluate the PulseSelect PFA system. The primary analysis focused on 150 patients with paroxysmal AF (mean age 63.4 years; 64% men) and 150 with persistent AF (mean age 66.0 years; 75% men)—all had previously failed antiarrhythmic drugs. There were another 83 patients who made up a roll-in cohort, as most operators in the study had never used the PFA system before.

The procedures resulted in acute pulmonary vein isolation in all cases. The median left atrial dwell time—spanning the time from the first to the last ablation in the left atrium—was about 60 minutes in each of the AF groups. That included a protocol-mandated 20-minute waiting period, which means procedures were actually being performed in 30 to 40 minutes, much faster than the 1.5 to 2 hours that is typical with thermal ablations, Verma noted. In addition, energy delivery time was less than 30 seconds, “which again speaks to the efficiency with which this energy can be delivered.”

The primary safety endpoint was a composite of serious procedure- and device-related adverse events. There was one such event in each cohort—a cerebrovascular accident in the paroxysmal group and a cardiac tamponade requiring drainage in the persistent group. The 0.7% event rates came in well below the 13% prespecified performance goal. “This represents one of the lowest complication rates ever reported in a catheter ablation trial globally,” Verma said.

There were no esophageal complications, and no substantial increases in esophageal temperature. A substudy showed no evidence of pulmonary vein stenosis on cardiac CT or MRI at 3 months, and a cerebral MRI substudy revealed a 9% rate of silent cerebral lesions, which, Verma said, is consistent with other ablation technologies.

There were a couple of episodes of phrenic nerve stunning, but they resolved quickly, he reported.

As for the impact on preventing atrial arrhythmias, the observed primary efficacy rates through 1 year were in line with what has been seen with thermal ablation technology, Verma said. He also reported rates of freedom from atrial tachycardia, fibrillation, or flutter of 69.5% and 62.3% in the paroxysmal and persistent cohorts, respectively, and rates of freedom from symptomatic atrial arrhythmia recurrence of 79.7% and 80.8%, respectively.

“Based on these results, I would say that we’re at least as good as radiofrequency or cryoablation,” Verma said.

Moreover, the investigators assessed patients’ health status using the AF Quality of Life Survey and the EQ-5D-5L. “We saw not only statistically significant improvements in numerical quality of life, but the magnitude of the change was consistent with a clinically meaningful benefit,” Verma said.

Unknowns Around PFA

Shivkumar said the study demonstrates a side effect profile that is “acceptable compared to current technologies, if not a little better” than what has been seen with thermal ablation, as well as efficacy that “falls in line with what we have seen in other studies . . . of this energy source.” This is reassuring for a new technology, he added.

There are some remaining questions, however. Regarding the silent cerebral lesions, Shivkumar said “the long-term implications are still a little bit of a mystery, but that is absolutely something that has to be answered by future studies.”

Verma said there aren’t any indications that these lesions, potentially resulting from air inadvertently getting into larger sheaths and issues with maintaining adequate flushes and anticoagulation, are more likely with PFA than with other ablation modalities or are causing clinical consequences. “For operators, just reminding them to be very careful about sheath exchanges, anticoagulation during the procedure, that will get these rates down,” he said.

Shivkumar also said it’s not clear whether the electroporation caused by PFA is actually irreversible . “It wouldn’t surprise me if there is recovery, because we still do not know how to deliver or gauge or dose pulsed-field as an energy source,” he said. “In other words, we don’t fully understand the ways of modulating it.”

Verma acknowledged that it’s possible some of the lesions may not be permanent. “Can there be reversible areas? Absolutely there can be. And how we measure that, how we know that, is still a little bit of an area of investigation.”

For Shivkumar, future studies of PFA will need to focus on how best to deliver the energy, where to ablate, and which patients should or should not be treated in this way.

Still, despite the need for further research, there is excitement around the potential for shorter procedures, which will allow more patients to be treated, he said, predicting that electrophysiologists will start shifting toward PFA when the technologies gain regulatory approval. “The biggest excitement comes from the scalability of this,” he said. “More people can be treated in a shorter duration of time with a reasonably high level of efficacy.”

Taking a longer-term view, Verma said “this is really the first generation of pulsed-field ablation, so I think as pulsed-field ablation gets more optimized, as we start to see it on different platforms, we’re probably going to see even better efficacy rates in the future.” He added that there will need to be RCTs comparing PFA with traditional ablation techniques to see if there are important differences.

Based on some of the expected advantages with PFA—including shorter and potentially safer procedures—Verma predicted that “pulsed-field is going to, over the next 5 to 10 years, take over the majority of the [ablation] market.” But, he said, thermal ablation will still have a role, because it’s not yet known how PFA will perform for conditions like supraventricular and ventricular tachycardia, for example.

“I don’t think thermal is going to disappear completely, but I think the lion’s share is going to be taken over by pulsed-field ablation for atrial fibrillation,” said Verma.

Todd Neale is the Associate News Editor for TCTMD and a Senior Medical Journalist. He got his start in journalism at …

Disclosures

Verma A, et al. Pulsed field ablation for the treatment of atrial fibrillation: PULSED AF pivotal trial . Circulation . 2023;Epub ahead of print.

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First-line Ablation Reduces AF Progression, Boosts Quality of Life

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Pain after interventional radiology in oncology: a case-control study from a 5-year cohort.

Simple Summary

1. introduction, 2. materials and methods, 2.1. patients and procedures, 2.2. design of the studies, 2.3. outcomes, 2.4. statistical analysis, 3.1. cohort study, 3.2. case-control stud, 4. discussion, 5. conclusions, author contributions, institutional review board statement, informed consent statement, data availability statement, conflicts of interest.

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Ayaden, N.; Sitbon, P.; Pages, A.; Tselikas, L.; Bourgain, J.-L. Pain after Interventional Radiology in Oncology: A Case-Control Study from a 5-Year Cohort. Cancers 2022 , 14 , 2576. https://doi.org/10.3390/cancers14112576

Ayaden N, Sitbon P, Pages A, Tselikas L, Bourgain J-L. Pain after Interventional Radiology in Oncology: A Case-Control Study from a 5-Year Cohort. Cancers . 2022; 14(11):2576. https://doi.org/10.3390/cancers14112576

Ayaden, Narimane, Philippe Sitbon, Arnaud Pages, Lambros Tselikas, and Jean-Louis Bourgain. 2022. "Pain after Interventional Radiology in Oncology: A Case-Control Study from a 5-Year Cohort" Cancers 14, no. 11: 2576. https://doi.org/10.3390/cancers14112576

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Multiple Case Studies

Nadia Alqahtani and Pengtong Qu

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The case study approach is popular across disciplines in education, anthropology, sociology, psychology, medicine, law, and political science (Creswell, 2013). It is both a research method and a strategy (Creswell, 2013; Yin, 2017). In this type of research design, a case can be an individual, an event, or an entity, as determined by the research questions. There are two variants of the case study: the single-case study and the multiple-case study. The former design can be used to study and understand an unusual case, a critical case, a longitudinal case, or a revelatory case. On the other hand, a multiple-case study includes two or more cases or replications across the cases to investigate the same phenomena (Lewis-Beck, Bryman & Liao, 2003; Yin, 2017). …a multiple-case study includes two or more cases or replications across the cases to investigate the same phenomena

The difference between the single- and multiple-case study is the research design; however, they are within the same methodological framework (Yin, 2017). Multiple cases are selected so that “individual case studies either (a) predict similar results (a literal replication) or (b) predict contrasting results but for anticipatable reasons (a theoretical replication)” (p. 55). When the purpose of the study is to compare and replicate the findings, the multiple-case study produces more compelling evidence so that the study is considered more robust than the single-case study (Yin, 2017).

To write a multiple-case study, a summary of individual cases should be reported, and researchers need to draw cross-case conclusions and form a cross-case report (Yin, 2017). With evidence from multiple cases, researchers may have generalizable findings and develop theories (Lewis-Beck, Bryman & Liao, 2003).

Creswell, J. W. (2013). Qualitative inquiry and research design: Choosing among five approaches (3rd ed.). Los Angeles, CA: Sage.

Lewis-Beck, M., Bryman, A. E., & Liao, T. F. (2003). The Sage encyclopedia of social science research methods . Los Angeles, CA: Sage.

Yin, R. K. (2017). Case study research and applications: Design and methods . Los Angeles, CA: Sage.

Key Research Books and Articles on Multiple Case Study Methodology

Yin discusses how to decide if a case study should be used in research. Novice researchers can learn about research design, data collection, and data analysis of different types of case studies, as well as writing a case study report.

Chapter 2 introduces four major types of research design in case studies: holistic single-case design, embedded single-case design, holistic multiple-case design, and embedded multiple-case design. Novice researchers will learn about the definitions and characteristics of different designs. This chapter also teaches researchers how to examine and discuss the reliability and validity of the designs.

Creswell, J. W., & Poth, C. N. (2017). Qualitative inquiry and research design: Choosing among five approaches . Los Angeles, CA: Sage.

This book compares five different qualitative research designs: narrative research, phenomenology, grounded theory, ethnography, and case study. It compares the characteristics, data collection, data analysis and representation, validity, and writing-up procedures among five inquiry approaches using texts with tables. For each approach, the author introduced the definition, features, types, and procedures and contextualized these components in a study, which was conducted through the same method. Each chapter ends with a list of relevant readings of each inquiry approach.

This book invites readers to compare these five qualitative methods and see the value of each approach. Readers can consider which approach would serve for their research contexts and questions, as well as how to design their research and conduct the data analysis based on their choice of research method.

Günes, E., & Bahçivan, E. (2016). A multiple case study of preservice science teachers’ TPACK: Embedded in a comprehensive belief system. International Journal of Environmental and Science Education, 11 (15), 8040-8054.

In this article, the researchers showed the importance of using technological opportunities in improving the education process and how they enhanced the students’ learning in science education. The study examined the connection between “Technological Pedagogical Content Knowledge” (TPACK) and belief system in a science teaching context. The researchers used the multiple-case study to explore the effect of TPACK on the preservice science teachers’ (PST) beliefs on their TPACK level. The participants were three teachers with the low, medium, and high level of TPACK confidence. Content analysis was utilized to analyze the data, which were collected by individual semi-structured interviews with the participants about their lesson plans. The study first discussed each case, then compared features and relations across cases. The researchers found that there was a positive relationship between PST’s TPACK confidence and TPACK level; when PST had higher TPACK confidence, the participant had a higher competent TPACK level and vice versa.

Recent Dissertations Using Multiple Case Study Methodology

Milholland, E. S. (2015). A multiple case study of instructors utilizing Classroom Response Systems (CRS) to achieve pedagogical goals . Retrieved from ProQuest Dissertations & Theses Global. (Order Number 3706380)

The researcher of this study critiques the use of Classroom Responses Systems by five instructors who employed this program five years ago in their classrooms. The researcher conducted the multiple-case study methodology and categorized themes. He interviewed each instructor with questions about their initial pedagogical goals, the changes in pedagogy during teaching, and the teaching techniques individuals used while practicing the CRS. The researcher used the multiple-case study with five instructors. He found that all instructors changed their goals during employing CRS; they decided to reduce the time of lecturing and to spend more time engaging students in interactive activities. This study also demonstrated that CRS was useful for the instructors to achieve multiple learning goals; all the instructors provided examples of the positive aspect of implementing CRS in their classrooms.

Li, C. L. (2010). The emergence of fairy tale literacy: A multiple case study on promoting critical literacy of children through a juxtaposed reading of classic fairy tales and their contemporary disruptive variants . Retrieved from ProQuest Dissertations & Theses Global. (Order Number 3572104)

To explore how children’s development of critical literacy can be impacted by their reactions to fairy tales, the author conducted a multiple-case study with 4 cases, in which each child was a unit of analysis. Two Chinese immigrant children (a boy and a girl) and two American children (a boy and a girl) at the second or third grade were recruited in the study. The data were collected through interviews, discussions on fairy tales, and drawing pictures. The analysis was conducted within both individual cases and cross cases. Across four cases, the researcher found that the young children’s’ knowledge of traditional fairy tales was built upon mass-media based adaptations. The children believed that the representations on mass-media were the original stories, even though fairy tales are included in the elementary school curriculum. The author also found that introducing classic versions of fairy tales increased children’s knowledge in the genre’s origin, which would benefit their understanding of the genre. She argued that introducing fairy tales can be the first step to promote children’s development of critical literacy.

Asher, K. C. (2014). Mediating occupational socialization and occupational individuation in teacher education: A multiple case study of five elementary pre-service student teachers . Retrieved from ProQuest Dissertations & Theses Global. (Order Number 3671989)

This study portrayed five pre-service teachers’ teaching experience in their student teaching phase and explored how pre-service teachers mediate their occupational socialization with occupational individuation. The study used the multiple-case study design and recruited five pre-service teachers from a Midwestern university as five cases. Qualitative data were collected through interviews, classroom observations, and field notes. The author implemented the case study analysis and found five strategies that the participants used to mediate occupational socialization with occupational individuation. These strategies were: 1) hindering from practicing their beliefs, 2) mimicking the styles of supervising teachers, 3) teaching in the ways in alignment with school’s existing practice, 4) enacting their own ideas, and 5) integrating and balancing occupational socialization and occupational individuation. The study also provided recommendations and implications to policymakers and educators in teacher education so that pre-service teachers can be better supported.

Multiple Case Studies by Nadia Alqahtani and Pengtong Qu is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License , except where otherwise noted.

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Case Study Research Method in Psychology

Saul Mcleod, PhD

Educator, Researcher

BSc (Hons) Psychology, MRes, PhD, University of Manchester

Saul Mcleod, Ph.D., is a qualified psychology teacher with over 18 years experience of working in further and higher education.

Learn about our Editorial Process

Olivia Guy-Evans

Associate Editor for Simply Psychology

BSc (Hons), Psychology, MSc, Psychology of Education

Olivia Guy-Evans is a writer and associate editor for Simply Psychology. She has previously worked in healthcare and educational sectors.

Case studies are in-depth investigations of a single person, group, event, or community. Typically, data is gathered from various sources and by using several different methods (e.g., observations & interviews ).

What are Case Studies?

The case study research method originated in clinical medicine (the case history, i.e., the patient’s personal history). In psychology, case studies are often confined to the study of a particular individual.

The information is mainly biographical and relates to events in the individual’s past (i.e., retrospective), as well as to significant events which are currently occurring in his or her everyday life.

The case study is not itself a research method, but researchers select methods of data collection and analysis that will generate material suitable for case studies.

Case studies are widely used in psychology, and amongst the best known were the ones carried out by Sigmund Freud, including Anna O and Little Hans .

Freud (1909a, 1909b) conducted very detailed investigations into the private lives of his patients in an attempt to both understand and help them overcome their illnesses. Even today, case histories are one of the main methods of investigation in abnormal psychology and psychiatry.

This makes it clear that the case study is a method that should only be used by a psychologist, therapist, or psychiatrist, i.e., someone with a professional qualification.

There is an ethical issue of competence. Only someone qualified to diagnose and treat a person can conduct a formal case study relating to atypical (i.e., abnormal) behavior or atypical development.

The procedure used in a case study means that the researcher provides a description of the behavior. This comes from interviews and other sources, such as observation.

The client also reports detail of events from his or her point of view. The researcher then writes up the information from both sources above as the case study and interprets the information.

The research may also continue for an extended period of time, so processes and developments can be studied as they happen.

Amongst the sources of data the psychologist is likely to turn to when carrying out a case study are observations of a person’s daily routine, unstructured interviews with the participant herself (and with people who know her), diaries, personal notes (e.g., letters, photographs, notes) or official document (e.g., case notes, clinical notes, appraisal reports).

The case study method often involves simply observing what happens to or reconstructing ‘the case history’ of a single participant or group of individuals (such as a school class or a specific social group), i.e., the idiographic approach .

The interview is also an extremely effective procedure for obtaining information about an individual, and it may be used to collect comments from the person’s friends, parents, employer, workmates, and others who have a good knowledge of the person, as well as to obtain facts from the person him or herself.

Most of this information is likely to be qualitative (i.e., verbal description rather than measurement), but the psychologist might collect numerical data as well.

The data collected can be analyzed using different theories (e.g., grounded theory, interpretative phenomenological analysis, text interpretation, e.g., thematic coding).

All the approaches mentioned here use preconceived categories in the analysis, and they are ideographic in their approach, i.e., they focus on the individual case without reference to a comparison group.

Interpreting the information means the researcher decides what to include or leave out. A good case study should always clarify which information is the factual description and which is an inference or the researcher’s opinion.

Case studies allow a researcher to investigate a topic in far more detail than might be possible if they were trying to deal with a large number of research participants (nomothetic approach) with the aim of ‘averaging’.

Because of their in-depth, multi-sided approach, case studies often shed light on aspects of human thinking and behavior that would be unethical or impractical to study in other ways.

Research that only looks into the measurable aspects of human behavior is not likely to give us insights into the subjective dimension of experience, which is important to psychoanalytic and humanistic psychologists.

Case studies are often used in exploratory research. They can help us generate new ideas (that might be tested by other methods). They are an important way of illustrating theories and can help show how different aspects of a person’s life are related to each other.

The method is, therefore, important for psychologists who adopt a holistic point of view (i.e., humanistic psychologists ).

Limitations

Because a case study deals with only one person/event/group, we can never be sure if the case study investigated is representative of the wider body of “similar” instances. This means the conclusions drawn from a particular case may not be transferable to other settings.

Because case studies are based on the analysis of qualitative (i.e., descriptive) data, a lot depends on the psychologist’s interpretation of the information she has acquired.

This means that there is a lot of scope for observer bias , and it could be that the subjective opinions of the psychologist intrude in the assessment of what the data means.

For example, Freud has been criticized for producing case studies in which the information was sometimes distorted to fit particular behavioral theories (e.g., Little Hans ).

This is also true of Money’s interpretation of the Bruce/Brenda case study (Diamond, 1997) when he ignored evidence that went against his theory.

How to reference this article:

McLeod, S. A. (2019, August 03). Case study method . Simply Psychology. simplypsychology.org/case-study.html

Diamond, M., & Sigmundson, K. (1997). Sex Reassignment at Birth: Long-term Review and Clinical Implications. Archives of Pediatrics & Adolescent Medicine , 151(3), 298-304

Freud, S. (1909a). Analysis of a phobia of a five year old boy. In The Pelican Freud Library (1977), Vol 8, Case Histories 1, pages 169-306

Freud, S. (1909b). Bemerkungen über einen Fall von Zwangsneurose (Der “Rattenmann”). Jb. psychoanal. psychopathol. Forsch ., I, p. 357-421; GW, VII, p. 379-463; Notes upon a case of obsessional neurosis, SE , 10: 151-318.

Further Information

How to Do a Case Study

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Many fields require their own form of case study, but they are most widely used in academic and business contexts. An academic case study focuses on an individual or a small group, producing a detailed but non-generalized report based on months of research. In the business world, marketing case studies describe a success story presented to promote a company.

Planning an Academic Case Study

A case study may or may not include both types of research.

Follow this step even if you are conducting a retrospective case study. In some cases, publishing a new interpretation can cause harm to the participants in the original study.

Since you aren't conducting a statistical analysis, you do not need to recruit a diverse cross-section of society. You should be aware of any biases in your small sample, and make them clear in your report, but they do not invalidate your research.

Conducting Academic Case Study Research

Any case study, but especially case studies with a retrospective component, will benefit from basic academic research strategies .

If you are working with more than one person you will want to assign sections for completion together to make sure your case study will flow. For example, one person may be in charge of making charts of the data you gathered, while other people will each write an analysis of one of your bullet points you are trying to answer.

If writing a case study for a non-academic audience, consider using a narrative form, describing the events that occurred during your case study in chronological order. Minimize your use of jargon.

Writing a Marketing Case Study

Request high-level involvement from the client's side for best results. [4] X Research source Even if the client only wants to vet the materials you send them, make sure the person involved is high up in the organization, and knowledgeable about the company–client relationship.

Charts and graphs can be great visual tools, but label these with large letters that make the positive meaning obvious to people who aren't used to reading raw data. [8] X Research source

These are typically brief quotes just one or two sentences long, describing your service in a positive light.

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About This Article

To do a case study, start by defining the subject and goal of your study and then getting ethical approval from the institution or department you're working under. Once you've received approval, design your research strategy and recruit any participants you'll be using. Prepare to work on your case study for 3-6 months by scheduling routine interviews with participants and setting aside time each day to do research and take notes. When you're finished, compile all of your research and write your final case study report. To learn how to do a marketing case study, scroll down! Did this summary help you? Yes No

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Lockout/Tagout eTool

Case studies » case study 4: multiple energy control procedures.

A manufacturing facility has 130 separate lockout procedures. Many of these procedures are unique, and apply to specific pieces of equipment. Some of these procedures, however, are duplicate and address pieces of equipment that are essentially identical to another piece of equipment. The facility has 40 employees authorized to implement the 130 procedures in performing service and maintenance covered by the Lockout/Tagout standard.

The employer has implemented the following procedure for conducting periodic inspections: for the specific energy control procedures, each of the authorized employees is observed by another authorized employee performing a complete lockout of at least one piece of equipment or machinery utilizing each one of the separate energy control procedures. The employer documents each of these inspections. However, there are more specific procedures than there are authorized employees, so consequently some of the specific procedures are not observed being implemented. Instead, these procedures are inspected by holding meetings with small groups of authorized employees responsible for service and maintenance on machines or equipment covered by the procedures being reviewed. At these meetings, the relevant procedures are reviewed by the group to ensure that they are understood and effective, but actual lockout implementation is not required during the inspection.

Does this scenario meet the standard's requirement that the employer conduct a periodic inspection for all energy control procedures?

Incorrect. Not in this case. The periodic inspection must be conducted by an authorized employee other than the one who implements the procedure. This authorized employee is designated by the employer as an inspector. He or she must observe the procedure being implemented by a representative number of authorized employees and must talk with all other authorized employees, even though they may not be implementing the energy control procedure. Of the 130 energy control procedures, the employer is only required to perform a periodic inspection on each of the unique energy control procedures. The inspector or inspectors performing the periodic inspection must observe the implementation of each of the 51 energy control procedures by a representative number of authorized employees. For each procedure, the inspector must also conduct a review with all other authorized employees involved in implementing the energy control procedure to review the procedure and their responsibilities under it. Because the employer's inspection protocol does not include a review of each separate procedure with all authorized employees who may have responsibilities under it, the protocol fails to comply with section 1910.147(c)(6)(i) . Observing only a single authorized employee implementing each lockout procedure, rather than a representative number of employees, also does not meet the intent of the standard. Moreover, the employer's use of group meetings to review the energy control procedures where implementation is not actually inspected also falls short. This is because the implementation of each separate lockout procedure may be observed by a representative number of employees. For more information: Refer to the part 1910.147(c)(6)(i) of the Lockout/Tagout standard.

Correct. The periodic inspection must be conducted by an authorized employee other than the one who implements the procedure. This authorized employee is designated by the employer as an inspector. He or she must observe the procedure being implemented by a representative number of authorized employees and must talk with all other authorized employees, even though they may not be implementing the energy control procedure. Of the 130 energy control procedures, the employer is only required to perform a periodic inspection on each of the unique energy control procedures. The inspector or inspectors performing the periodic inspection must observe the implementation of each of the 51 energy control procedures by a representative number of authorized employees. For each procedure, the inspector must also conduct a review with all other authorized employees involved in implementing the energy control procedure to review the procedure and their responsibilities under it. Because the employer's inspection protocol does not include a review of each separate procedure with all authorized employees who may have responsibilities under it, the protocol fails to comply with section 1910.147(c)(6)(i) . Moreover, the employer's use of group meetings to review the energy control procedures where implementation is not actually inspected also falls short. This is because the implementation of each separate lockout procedure must be observed by the inspector for a representative number of employees who implement the procedure. For more information: Refer to the part 1910.147(c)(6)(i) of the Lockout/Tagout standard.

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The audit procedures Harvard Case Solution & Analysis

Home >> Harvard Case Study Analysis Solutions >> The audit procedures

The audit procedures Case Study Solution

Audit Procedures:

Audit procedures are defined as the procedures which the auditor uses to obtain sufficient and appropriate audit evidence about the financial statements of the company. Hence these procedures can be used to identify the discrepancies in the financial statements.

Granite Bay Jet Ski, Incorporation has a good accounting system such as the company has the corresponding recording for each transaction. Along with this, many linked accounts automatically update when a transaction takes place. We can say that the company has strong control over the transactions therefore, minimum audit procedures will be required to evaluate the transaction. The audit procedures performed by the auditor are categorized in the following main headings:

Inspection: It is an audit procedure which is used to examine internal and external records which are held in various forms such as paper, electronic and others. The inspection provides the evidence for the assertion of existence and policies of the company however, it does not provide any evidence about the assertion of rights and obligation.

Observation: It is the audit procedure in which the auditor looks at a process. The evidence obtained from this procedure has limited use or for a particular time. Mostly audit or use this procedure at the time of counting the inventory.

External Confirmation: It is the audit procedure in which the auditor circulates the confirmation letter to the external parties. The evidence obtained from this procedure is considered as the most appropriate one because it is generated by the external source.

Recalculation: It is the audit procedure that is used to determine the mathematical accuracy of a transaction. In this procedure, auditor recalculates an amount to determine its mathematical accuracy, however, accuracy relating to the estimation cannot be determined through this procedure.

Re-performance: It is the audit procedure in which an auditor re-performs a process to verify the validity of certain assertions.

Analytical Procedures: It is the audit procedure which is used at every stage of the audit to verify the different assertion. In this procedure, auditor verifies the assertion by understanding the plausible relationships between non-financial and financial data and by comparing the current year results with the previous year.

Some of the audit procedures which can be used to find out the discrepancies in our calculated amounts and provided results are as follows:

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Case Study Research Design

The case study research design have evolved over the past few years as a useful tool for investigating trends and specific situations in many scientific disciplines.

This article is a part of the guide:

Browse Full Outline

The case study has been especially used in social science, psychology, anthropology and ecology.

This method of study is especially useful for trying to test theoretical models by using them in real world situations. For example, if an anthropologist were to live amongst a remote tribe, whilst their observations might produce no quantitative data, they are still useful to science.

What is a Case Study?

Basically, a case study is an in depth study of a particular situation rather than a sweeping statistical survey . It is a method used to narrow down a very broad field of research into one easily researchable topic.

Whilst it will not answer a question completely, it will give some indications and allow further elaboration and hypothesis creation on a subject.

The case study research design is also useful for testing whether scientific theories and models actually work in the real world. You may come out with a great computer model for describing how the ecosystem of a rock pool works but it is only by trying it out on a real life pool that you can see if it is a realistic simulation.

For psychologists, anthropologists and social scientists they have been regarded as a valid method of research for many years. Scientists are sometimes guilty of becoming bogged down in the general picture and it is sometimes important to understand specific cases and ensure a more holistic approach to research .

H.M.: An example of a study using the case study research design.

The Argument for and Against the Case Study Research Design

Some argue that because a case study is such a narrow field that its results cannot be extrapolated to fit an entire question and that they show only one narrow example. On the other hand, it is argued that a case study provides more realistic responses than a purely statistical survey.

The truth probably lies between the two and it is probably best to try and synergize the two approaches. It is valid to conduct case studies but they should be tied in with more general statistical processes.

For example, a statistical survey might show how much time people spend talking on mobile phones, but it is case studies of a narrow group that will determine why this is so.

The other main thing to remember during case studies is their flexibility. Whilst a pure scientist is trying to prove or disprove a hypothesis , a case study might introduce new and unexpected results during its course, and lead to research taking new directions.

The argument between case study and statistical method also appears to be one of scale. Whilst many 'physical' scientists avoid case studies, for psychology, anthropology and ecology they are an essential tool. It is important to ensure that you realize that a case study cannot be generalized to fit a whole population or ecosystem.

Finally, one peripheral point is that, when informing others of your results, case studies make more interesting topics than purely statistical surveys, something that has been realized by teachers and magazine editors for many years. The general public has little interest in pages of statistical calculations but some well placed case studies can have a strong impact.

How to Design and Conduct a Case Study

The advantage of the case study research design is that you can focus on specific and interesting cases. This may be an attempt to test a theory with a typical case or it can be a specific topic that is of interest. Research should be thorough and note taking should be meticulous and systematic.

The first foundation of the case study is the subject and relevance. In a case study, you are deliberately trying to isolate a small study group, one individual case or one particular population.

For example, statistical analysis may have shown that birthrates in African countries are increasing. A case study on one or two specific countries becomes a powerful and focused tool for determining the social and economic pressures driving this.

In the design of a case study, it is important to plan and design how you are going to address the study and make sure that all collected data is relevant. Unlike a scientific report, there is no strict set of rules so the most important part is making sure that the study is focused and concise; otherwise you will end up having to wade through a lot of irrelevant information.

It is best if you make yourself a short list of 4 or 5 bullet points that you are going to try and address during the study. If you make sure that all research refers back to these then you will not be far wrong.

With a case study, even more than a questionnaire or survey , it is important to be passive in your research. You are much more of an observer than an experimenter and you must remember that, even in a multi-subject case, each case must be treated individually and then cross case conclusions can be drawn .

How to Analyze the Results

Analyzing results for a case study tends to be more opinion based than statistical methods. The usual idea is to try and collate your data into a manageable form and construct a narrative around it.

Use examples in your narrative whilst keeping things concise and interesting. It is useful to show some numerical data but remember that you are only trying to judge trends and not analyze every last piece of data. Constantly refer back to your bullet points so that you do not lose focus.

It is always a good idea to assume that a person reading your research may not possess a lot of knowledge of the subject so try to write accordingly.

In addition, unlike a scientific study which deals with facts, a case study is based on opinion and is very much designed to provoke reasoned debate. There really is no right or wrong answer in a case study.

Martyn Shuttleworth (Apr 1, 2008). Case Study Research Design. Retrieved Mar 08, 2023 from Explorable.com: https://explorable.com/case-study-research-design

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Exposure risk management: Personal protective equipment and the risk of accidents occurring during aerosol generating procedures applied to COVID-19 patients

Roles Conceptualization, Methodology, Supervision, Writing – original draft, Writing – review & editing

Affiliation Department of Management, Marketing and Business Administration, Alexandru Ioan Cuza University of Iași, Iași, Romania

Roles Methodology, Writing – original draft, Writing – review & editing

Roles Conceptualization, Methodology, Writing – original draft, Writing – review & editing

* E-mail: [email protected] , [email protected]

Roles Investigation

Affiliation Faculty of Medicine and Biological Sciences, University “Stefan cel Mare”, Suceava, Romania

Roles Conceptualization, Investigation, Methodology, Writing – review & editing

Affiliation Grigore T. Popa University of Medicine and Pharmacy, Iași, Romania

COVID-19 is considered to be very contagious as it can be spread through multiple ways. Therefore, exposure risk of healthcare workers (HCWs) treating COVID-19 patients is a highly salient topic in exposure risk management. From a managerial perspective, wearing personal protective equipment and the risk of accidents occurring during aerosol generating procedures applied to COVID-19 patients are two interconnected issues encountered in all COVID-19 hospitals.

The study was conducted to understand the realistic impact of exposure risk management on HCWs exposed to risks of SARS-CoV-2 virus infection in a healthcare unit. In particular, this study discusses the role of personal protective equipment (PPEs) used in aerosol generating procedures (AGPs) to protect HCWs, and the related risk of accidents occurring when performing AGPs.

Methodology

This is a cross-sectional single-hospital study conducted at the “Sf. Ioan cel Nou” Hospital in Suceava, Romania, that had to ensure safety of healthcare workers (HCWs) getting in contact with COVID-19 cases. Data used in the study were collected between 10.12.2020–19.03.2021 by means of a questionnaire that collected information on risk assessment and healthcare workers’ exposure management, and which was translated and adapted from the World Health Organization (WHO) and applied to respondents online. For this purpose, ethical approval was obtained, doctors and nurses from all hospital departments being invited to complete the questionnaire. Data processing, as well as descriptive, correlation and regression analyses have been done by using the 21.0 version of the Statistical Package for Social Sciences software.

Most of the 312 HCWs reported having always used disposable gloves (98.13%), medical masks N95 (or equivalent) (92.86%), visors or googles (91.19%), disposable coverall (91.25%) and footwear protection (95.00%) during AGPs. The waterproof apron had always been worn only by 40% of the respondents, and almost 30% of staff had not used it at all during AGPs. Over the last three months, the period when the questionnaire was completed, 28 accidents were reported while performing AGPs: 11 accidents with splashing of biological fluids/ respiratory secretions in the eyes, 11 with splashing of biological fluids/ respiratory secretions on the non-idemn skin, 3 with splashing of biological fluids/ respiratory secretions in the oral/ nasal mucosa and 3 with puncture/ sting with any material contaminated with biological fluids/ respiratory secretions. Also, 84.29% of respondents declared having changed their routine, at least, moderately due to COVID-19.

An effective risk exposure management is based on wearing protective equipment. The only protection offered by the disposable coverall, as it results from our analysis, is related to splashing of biological fluids/ respiratory secretions on the non-idemn skin. In addition, the results show that the number of accidents should decrease due to the fact that disposable gloves and footwear protection are used while performing AGPs on patients with COVID-19 and hand hygiene is practised before and after touching a patient with COVID-19 (regardless of glove wearing).

Citation: Neştian ȘA, Tiţă S-M, Turnea E-S, Stanciu O, Poroch V (2023) Exposure risk management: Personal protective equipment and the risk of accidents occurring during aerosol generating procedures applied to COVID-19 patients. PLoS ONE 18(3): e0282673. https://doi.org/10.1371/journal.pone.0282673

Editor: Anshuman Mishra, Institute of Advanced Materials, IAAM, SWEDEN

Received: July 4, 2022; Accepted: February 20, 2023; Published: March 7, 2023

Copyright: © 2023 Neştian et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All relevant data are within the manuscript and its Supporting Information files.

Funding: The author(s) received no specific funding for this work.

Competing interests: The authors have declared that no competing interests exist.

1. Introduction

Because of the high number of COVID-19 infections reported across the globe, on March 11, 2020, was declared the pandemic [ 1 ]. For this reason, many public health centres and hospitals were opened for treating COVID-19 [ 2 ].

COVID-19 can be spread through aerosol/aerated solids, fluids from human secretions, droplets from normal breathing, coughing, sneezing and surface contact, and therefore is considered very contagious [ 3 ]. According to Wong SCY et al. (2020), SARS-CoV-2 is not spread by an airborne route [ 4 ]. So, one of the largest Chinese medicine hospitals in China, the Guangdong Provincial Hospital of Chinese Medicine, set in January 2020 a set of prevention rules aimed at avoiding hospital-related infections during the COVID-19 epidemic [ 5 ] in order to ensure the protection of healthcare workers (HCWs) during Aerosol generating procedures (AGPs). For this purpose, HCWs wore the following personal protective equipment (PPE): N95 respirators, goggles or protective screens, latex gloves, and medical protective clothing [ 5 ] for such procedures as bronchoscopy, tracheal intubation, sputum suction and aerosol or splash operations.

Although a lot of effort was put into vaccine introduction and use, COVID-19 still has an impact on healthcare services, while personnel working in medical systems are at higher risk of infection [ 6 , 7 ]. Frontline HCWs remain at high risk of getting the COVID-19 infection [ 8 ], despite all the effort made to limit virus spreading, therefore it has become essential to perform real-time activities monitoring, apply immediate corrections and pay more constant attention to infection prevention than the treatment itself [ 6 , 9 , 10 ]. As it has been reported, 90000 HCWs across the globe had been infected with COVID-19 in the first year of the pandemic [ 8 ]. So, it is crucial for HCWs to wear an appropriate PPE and actively participate in prevention programmes [ 11 ] as it has been widely recognised that infected patients are the main cause for COVID-19 transmission [ 12 ].

This study was conducted using a questionnaire translated and adapted from the World Health Organization (WHO) [ 13 ] with the purpose of understanding the realistic impact of exposure risk management on HCWs exposed to risks of SARS-CoV-2 virus infection in a healthcare unit. In particular, this paper discusses the role of personal protective equipment (PPEs) used in aerosol generating procedures (AGPs) to protect HCWs, and the related risk of accidents occurring when performing AGPs. In this regard, 312 confidential answers were collected online between 10.12.2020–19.03.2021 from medical doctors and nurses at the “Sf. Ioan cel Nou” County Emergency Hospital in Suceava, Romania. The ethical approval has been obtained for this study.

2. Literature review

2.1. agps applied to covid-19 patients.

Aerosols are small liquids or solid particles present in the air, ranging from 0.001 μm to 100 μm [ 14 ]. Small particles can live at far distance for a long period of time, these are named “airborne”, the bigger aerosols being named “droplets” [ 14 ].

Nurses have been exposed to COVID-19 since they have a direct contact with COVID-19 patients, especially in the context of AGPs [ 9 , 12 ]. In China, HCWs infection with this virus was associated with aerosol transmission and high-concentration pathogen aerosol environments [ 12 ]. Lately, such procedures as suctioning before intubation, and auxiliary intubation have been classified as high-risk activities [ 12 ]. Another source explains that some AGPs made on unprotected COVID-19 patients have led to SARS-CoV-2 HCWs’ infection [ 15 ]. There is a concern that this virus can be transmitted even during talking and breathing while AGPs are performed [ 16 ]. While the Chinese National Hygiene and Health Committee confirmed the possibility of getting the COVID-19 infection through aerosols [ 14 ], according to Mahmood et al. (2020), when AGPs are performed, the virus spreads irrespective whether patients present or not COVID-19 symptoms [ 17 ].

In Zhongnan Hospital of Wuhan University, out of 103 infected employees, before getting the infection, almost half worked over 7 hours per day in a COVID-19 contaminated environment [ 18 ]. In the same hospital, aerosol transmission was cited among top three ways of getting the infection [ 18 ].

An adequate PPE is strongly recommended against the risk of HCW getting infected with COVID-19 [ 9 , 19 ]. To avoid any contamination with COVID-19 during aerosols, PPE is recommended for eyes, face and head protection, together with reusable equipment (glasses, visors or face shields) [ 17 , 20 ]. A study of 85% of HCWs being involved in AGPs showed that hand hygiene and PPE were the measures having protected them against COVID-19 infection [ 9 ]. WHO recommends that HCWs use PPE considering the AGPs types [ 12 ]. HCWs should wear a gown, gloves, respirator N95, an apron, and eye protection when they apply AGPs to COVID-19 patients [ 12 ]. In the absence of AGPs, the apron and the respirator are not necessary, and the respirator should be replaced by a medical mask [ 12 ]. According to the Emergency Medical Services Commission, to perform intubation or cardiopulmonary resuscitation, which are considered AGPs, PPE should mandatorily contain a N95 mask [ 21 ].

One study conducted in Australia, identified such barriers as supplier availability, workplace rationing, delivery delays, high costs, no PPE supply at the workplace, denial of PPE based on a low perception of risk or inappropriateness by management [ 22 ]. The major risk in AGP is nosocomial infections [ 23 ].

2.2. PPE during AGPs applied to COVID-19 patients

PPE has fulfilled for over 100 years its main purpose of protecting the patient and the surgeon, and it includes: eye protection, gowns, gloves, surgical face masks, non-powered filtering face piece respirators, and powered air-purifying respirators [ 24 ]. Full PPE for HCWs should contain face shields, goggles, masks, coverall/ gowns, head covers, and shoe covers [ 25 ]. According to the Minister of Health ORDER no. 533 of March 29, 2020 in Romania, medical staff involved in direct patient care must use the following PPE: gowns, gloves, mask and eye protection (goggles or face shield) [ 26 ]. Specifically, in case of AGPs performed for patients with COVID-19 (for example, intubation, non-invasive ventilation, tracheostomy, cardiopulmonary resuscitation, manual ventilation before intubation, bronchoscopy, gastroscopy and collection of PCR COVID tests), medical staff must use the following protection: gloves, gowns, FFP2 and FFP3 masks, and waterproof aprons if the coveralls/gowns are not waterproof [ 26 ].

In the context of COVID-19, wearing different pieces of PPE has become very questionable [ 24 ]. However, it has been proven that this virus can be transmitted especially through contact with infected patients without wearing PPE [ 12 ]. Wearing a PPE is not always the best way of getting protected against COVID-19. For example, it has been stated that eye googles are less beneficial in reducing exposure risks when treating COVID-19 patients than face masks and coverall [ 3 ]. In a study conducted by Al Youha et al. (2021), it was found that reuse of PPE is positively correlated with risk infections [ 6 ]. In a study made on HCWs at the Zhongnan Hospital of Wuhan University, out of 105 HCWs infected with COVID-19, 43 saw PPE problems as being the cause of their infection [ 18 ]. Compared to the times before the outbreak, a focus definitely was on wearing special PPE comprising: clothing, googles, a face shield and also isolation clothing [ 18 ]. In another study conducted on 120 HCWs at the First Affiliated Hospital of Chongqing Medical University in China, the following PPE weaknesses during pandemic were reported: inappropriate sizes, uncomfortable design, complexity of use, doubts related to the quality and effectiveness of PPE [ 27 ].

During this pandemic, PPE supply was a concern. In a busy tertiary care hospital in the United Kingdom, a negative factor in the fight against the virus was the supply of PPE for HCWs [ 28 ]. In a study conducted at the Patan Hospital in Nepal, out of t 58 respondents, 32.7% reported having felt more comfortable in non-Covid emergencies [ 29 ]. Also, in the same study, HCWs from non-Covid emergencies reported having felt safer in the presence of PPE wearing [ 29 ]. Other case-study in India observed that a breach in masking had been associated with a positivity of 9.6% in all exposures and 33.3% in the high-risk exposure group among HCWs, while a breach in goggles wearing had been associated with a total and high-risk exposure COVID-19 positivity of 4.6% and 22.2%, respectively [ 30 ].

The case of South America was analysed in one study. The rates of SARS-CoV-2 infection among HCW in São Paulo city ranged from 5.5% (IgG ELISA) in a private hospital to 14% (IgG/IgM antibody, WONDFO) in a large public hospital in 2020 due to adoption of high-quality hospital infection control and provision of complete PPE in the early stages of the COVID-19 pandemic [ 31 ].

Not only PPE is important during AGPs, it seems that HCWs’ hand hygiene is also significant, and should be monitored [ 32 – 34 ]. In this regard, the five times during the day when hand hygiene should be complied with are: before touching a patient, cleaning/ aseptic procedures, after performing procedures/ body fluid exposures, after touching a patient, or a patient’s surroundings [ 34 ].

2.3. Accidents occurring during AGPs applied to COVID-19 patients and ways of protecting HCWs

In a study conducted on 80 frontline nurses in COVID-19 hospitals in the north of Saudi Arabia, 3.8% of the respondents reported such accidents related to biological material handling as splashes of a biological fluid (into the eyes) [ 9 ]. In a study conducted at the Jaber Al Ahmad Hospitali n Kuwait comprising 847 HCWs, it was found that working as a nurse and wearing gloves had been strongly associated with an increased likelihood of contracting SARS-CoV-2 infection, while monitoring other factors [ 6 ]. Also, the same study reported that PPE had been available most of the time in the hospital, coveralls being the least available [ 6 ]. Other study showed that risk for the first responder workforce primarily originated from non-patient sources; 29 of 30 COVID-19 illnesses among Emergency Medical Services providers had not been directly attributed to COVID-19 patient encounters, and collectively, the involvement of such a large proportion of the first responder conducted in the King County, Washington, workforce, the heterogeneous nature of patient characteristics, and the time-pressured need among some patients for AGP intervention could pose major COVID-19 risk to public safety personnel and infrastructure [ 35 ].

In laboratories, SARS-CoV-2 aerosols live on average 5.6 hours on stainless steel, and 6.8 hours on plastic [ 24 ]. The number of healthcare-associated infections can be reduced among HCWs by adopting a proper hygiene compliance, constant audits and timely feedback to prevent infections [ 7 , 34 ]. The United States Centres for Disease Control and Prevention strongly recommend the use of eye protection when contacting a patient suspected of having COVID-19 [ 24 ]. The surgical N95 masks are also helpful in triages and during AGPs as they prevent getting the infection [ 24 ]. But the reuse of N95 masks is questionable as there has been so far limited research on this issue [ 25 ]. If medical surgical masks are correctly worn, they can block particles exceeding 5μm, which can curb the spread of droplets [ 10 ]. These should be replaced once contaminated [ 10 ]. HCWs have to ensure that there is no gap between the mask and the face [ 3 ].

Face shields are recommended as a substitute to goggles, and offer protection against splashes and splatter of aerosols on a larger area of face [ 25 ]. Goggles are extremely important in protecting the exposed conjunctiva against infected droplets and aerosols from patients, while aprons, gowns and coveralls offer full protection to HCWs [ 10 , 25 ]. In high-risk areas, it is recommended that two or even three layers of surgical gloves be worn [ 10 ]. Poor glove usage by nurses can bring COVID-19 infections of HCWs [ 6 ]. Also, HCWs should pay attention to prolonged glove use as it is associated with higher likelihood of SARS-CoV-2 infection [ 6 ].

In procedures involving splashing of body fluids, blood, etc., use of goggles and protective face shields/ face screens are mandatory [ 10 ]. Shoe covers should be worn when entering into a contaminated area [ 10 ]. The coverall gown is highly efficient in protecting HCWs from airborne pathogens, including aerosols/ aerated solids [ 3 ]. Despite the protection that N95 masks and face shields offer, the coveralls play a key role in protecting HCWs from the virus [ 3 ]. When AGPs are performed, air isolation measures, frequent ventilation and powered air-purifying respirators are also needed to prevent against COVID-19 infection [ 12 ].

To formulate the research hypotheses, this study started from data provided by earlier studies, which have been described above, following three main research lines: AGPs applied to COVID-19 patients, PPE during AGPs applied to COVID-19 patients, and accidents occurring during AGPs for COVID-19 patients and ways of protecting HCWs. In the first phase, the assumption was made that when performing AGPs, the coverall is worn with all the other accessories for ensuring the highest protection. Therefore, the following H1 hypothesis was formulated:

H1 . There is a positive correlation between wearing disposable coverall when performing aerosol generating procedures (AGPs) on a COVID-19 patient and wearing disposable gloves , medical masks N95 (or equivalent) , visor or goggles , and footwear protection .

Also, it has been assumed that the waterproof apron is worn during AGPs with all the other accessories for providing the highest protection. So, the following H2 hypothesis was formulated:

H2 . There is a positive correlation between wearing waterproof apron when performing aerosol generating procedures (AGPs) on a COVID-19 patient and wearing disposable gloves , medical masks N95 (or equivalent) , visor or goggles , disposable coverall , and footwear protection .

We started from the premise that coverall equipment, which offers the highest and complete protection, should lead to a decrease in accident frequency when performing AGPs, so the H3 hypothesis was formulated, as follows:

H3 . There is a negative correlation between wearing disposable coverall when performing aerosol generating procedures (AGPs) on a COVID-19 patient and the occurrence of the following accidents : splashing of biological fluids/ respiratory secretions in the eyes; splashing of biological fluids/ respiratory secretions in the oral/ nasal mucosa; splashing of biological fluids/ respiratory secretions on the non idemn skin; puncture/ sting with any material contaminated with biological fluids/ respiratory secretions .

Although we have found in the literature that disposable gloves can spread infection with the SARS-CoV-2 virus, we started from a positive hypothesis, which underlines the role of disposable gloves in preventing the infection with the virus:

H4 . The average number of accidents (SPLASY_EYES , SPLASH_ORAL , SPLASH_SKIN , PUNCTURE_FS) decreases when the use of disposable gloves (AGP_GLOVES) increases when applying the aerosol generating procedures (AGPs) on a COVID-19 patient .

3. Methodology

This study was conducted using a questionnaire translated and adapted from the WHO [ 13 ] questionnaire on HCWs exposure risk assessment and management. Our aim was to understand the real impact of specific PPEs used for managing the risk of SARS-CoV-2 virus infection of HCWs exposed to the virus in a healthcare unit by analysing the PPEs used in AGPs for HCWs protection, and against the accidents occurring when performing AGPs. More precisely, data were collected online from the medical staff of the “Sf. Ioan cel Nou” County Emergency Hospital in Suceava in Romania, the confidentiality of responses having been ensured.

As a result, 312 answers were collected between 10.12.2020–19.03.2021. Given the fact that the pandemic generated by the SARS-CoV-2 virus appeared globally in December 2019, and its first effects began to appear in Romania in March 2020, the time period of data collection (until March 2021) enabled us to provide a plausible interpretation of responses due to long time period for analysis of what had happened at the “St. Ioan cel Nou” County Emergency Hospital in Suceava, Romania during the pandemic. This study was given an ethical approval by the “St. Ioan cel Nou” County Emergency Hospital before data collection, an ethical approval from Grigore T. Popa University of Medicine and Pharmacy, Iași, Romania (Approval from 15.06.2020), the collaboration protocol having been signed by three parties–National Authority for Quality Management in Health, Grigore T. Popa University of Medicine and Pharmacy, Iași, and Alexandru Ioan Cuza University of Iași (Approval number 12677/ 27.07.2020). The consent of the respondents in the research was informed, and implicitly. Before completing the questionnaire, was mentioned that the answers are confidential, and that respondents are kindly asked to continue only if they agree to participate in the study.

The instrument includes a complex questionnaire comprising several parts that were applied to medical staff who had been in contact with patients diagnosed with COVID-19. All questions referred to the last 3 months of activity prior to questionnaire completion. Table 1 presents the questions and answers clarifying the methodology used in this research.

https://doi.org/10.1371/journal.pone.0282673.t001

As it can be seen from the table above, 82.05% and 17.95% of respondents are female and male, respectively. Most respondents are nurses (81.73%) belonging to the following departments: ER (27.25%); Obstetrics—Gynaecology (8.34%); ICU (7.69%) and Infectious diseases (7.37%). The dispersion of answers obtained for 21 departments is quite high for the 312 answers, as we aimed to cover all hospital disciplines that would generate most realistic results.

An open-ended question asking respondents to specify their age was also included into the questionnaire. The average age of medical staff included in the study was 41.75 years.

For all 22 items used in this research and presented in Table 2 , the Cronbach’s Alpha coefficient had a value of 0.623, which shows a high reliability of the questionnaire.

https://doi.org/10.1371/journal.pone.0282673.t002

The study used 312 answers to perform descriptive, correlation and regression analyses. Descriptive analysis was used to provide an overview of PPEs used during AGPs on COVID-19 patients. The actions of medical staff during AGPs applied to patients with COVID-19, the episodes of accidental exposure to biological fluids/ respiratory secretions during interactions with COVID-19 patients, and personnel’ satisfaction with COVID-19 measures implemented in the hospital–were analysed using correlation and regression analyses, which helped us validate the research hypotheses.

The main descriptive results are shown in Table 2 . All asked questions covered the last three months at the time of questionnaire application.

Over 50% of respondents reported having taken part in performing AGPs on COVID-19 patients in the previous 3 months. In this regard, the questionnaire included an item filtering the respondents before applying the main questions that helped us obtain valid results for our analysis.

Most respondents reported always having used disposable gloves (98.13%), medical masks N95 (or equivalent) (92.86%), visor or goggles (91.19%), disposable coverall (91.25%) and footwear protection (95.00%) during AGPs. The waterproof apron had been always used by only 40% of staff, while almost 30% had not used it at all during AGPs.

As for the actions that are required when PPE is used, most respondents reported always having done the following: hand hygiene before and after any procedure requiring asepsis conditions (96.93%).

We expected that a higher percentage of respondents would report having always removed and replaced their PPE in line with the protocol (82.82%), and having practised hand hygiene after touching objects in COVID-19 patient proximity (bed, door handle etc., regardless of wearing gloves) (87.12%). We also expected a higher percentage that could indicate that most touched surfaces had been decontaminated, at least, 3 times a day (84.05%). All these expectations appeared since all the preventive actions had been in place in case of COVID-19 infections.

Asked if they had any episodes of accidental exposure to biological fluids or respiratory secretions during the period in which respondents had interacted with COVID-19 patients for their care in the previous 3 months, they mentioned only 28 accidents: 11 accidents with splashing biological fluids/ respiratory secretions in the eyes, 11 accidents with splashing biological fluids/ respiratory secretions on the non-idemn skin, 3 accidents with splashing biological fluids/ respiratory secretions in the oral/ nasal mucosa and 3 accidents with puncture/ sting with any material contaminated with biological fluids/ respiratory secretions. We cannot sort these types of accidents by categories of more or less risky but we are aware of the fact that any type of accident with exposure to COVID-19 infection attracts a risk of COVID-19 infection for anyone not wearing PPE.

During the study (December 2021-March 2022), there were 116 cases of Covid-19 throughout the hospital, of which 60 cases were in the departments involved in the study. Moreover, in the same period, 58 employees from the entire hospital who came into contact with the infected with Covid 19 staff were quarantined, of which 33 employees were coming from the departments participating in the study.

In the Fig 1 we have also presented the graphical view for the measures implemented in the hospital and the changes in the routine of the HCWs, which complete the descriptive statistics in the previous table.

Source: authors’ contribution.

https://doi.org/10.1371/journal.pone.0282673.g001

According to our collected data, personnel’s’ satisfaction with COVID-19 measures implemented in the health unit was ranked as very good by only 50.32% of the respondents, and, at least, as moderate by 92.63%. This means that the measures implemented in the hospital still needed improvements at that time.

The access to PPE was very good for 73.08% of respondents, and, at least, moderate for 94.87%. The COVID-19 test access was very good only for 55.45% of respondents, and, at least, moderate for 89.75%. All in all, these statistics lead us to the idea that improvements are required to have better COVID-19 measures in place in the organization. Also, 57.70% of respondents are, at least, moderately worried that they may become infected with COVID-19 because of the work they do, 66.35% are, at least, moderately worried that they might spread COVD-19 to their family members. Basically, they are more concerned about avoiding the COVD-19 spreading to their family members than about getting the infection themselves. More than half of respondents (50.32%) reported having changed significantly their routine due to COVID-19, and 84.29%, at least moderately.

According to the results presented in Table 3 , we have found that there are no differences between male and female participants in the study when using specific PPE items while performing aerosol generating procedures on COVID-19 patients, except the case when the waterproof apron is used (PPE AGP_SORT) (p = 0.015<0.05).

https://doi.org/10.1371/journal.pone.0282673.t003

This result may not necessarily reflect the reality due to low number of male respondents (N = 312 respondents, from which 56 males and 256 females). For this reason, a further research could analyse in detail gender differences in wearing PPE items.

Table 4 shows Hypotheses H1 and H2 validation using the Pearson coefficients.

Testing hypotheses H1 and H2.

https://doi.org/10.1371/journal.pone.0282673.t004

All Pearson coefficients presented above for the variables mentioned in Hypothesis H1 indicate positive correlations, most of them having medium to strong intensities: there is a positive correlation between wearing disposable coverall (AGP_COVERALL), when performing AGPs on a COVID-19 patient, and wearing disposable gloves (AGP_GLOVES) (Pearson coefficient = 0.429; p = 0.000<0.01), medical masks N95 (or equivalent) (AGP_MASK) (Pearson coefficient = 0.178; p = 0.027<0.05), visor or goggles (AGP_VISOR) (Pearson coefficient = 0.409; p = 0.000<0.01), and footwear protection (AGP_FOOTPROT) (Pearson coefficient = 0.605; p = 0.000<0.01). Therefore, hypothesis H1 has been confirmed:

The main idea, from which stemmed this hypothesis, was that when medical doctors participate in AGPs and wear a coverall, they also wear disposable gloves, a surgical mask, a visor or goggles and protective footwear, which offer the highest caution equipment for preventing medical staff against COVID-19 infections.

All Pearson coefficients presented in Table 4 for the variables mentioned in hypothesis H2 do not indicate any correlations: there is no correlation between wearing waterproof apron (AGP_SORT), when performing AGPs on a COVID-19 patient, and wearing disposable gloves (AGP_GLOVES) (Pearson coefficient = 0.025; p = 0.763>0.05), medical masks N95 (or equivalent) (AGP_MASK) (Pearson coefficient = 0.096; p = 0.239>0.05), visor or goggles (AGP_VISOR) (Pearson coefficient = 0.065; p = 0.425>0.05), disposable coverall (AGP_COVERALL) (Pearson coefficient = -0.054; p = 0.510>0.05), and footwear protection (AGP_FOOTPROT) (Pearson coefficient = 0.112; p = 0.168>0.05). Therefore, hypothesis H2 has not been confirmed:

H2 . There is a positive correlation between wearing waterproof apron , when performing aerosol generating procedures (AGPs) on a COVID-19 patient and wearing disposable gloves , medical masks N95 (or equivalent) , visor or goggles , disposable coverall , and footwear protection .

These results are abnormal in our opinion, since the waterproof apron should be completed with disposable gloves, medical masks, visor or goggles, and footwear protection, except disposable coverall. Once a doctor wears a disposable coverall, they cannot wear at the same time a waterproof apron. So, in this case, there should have appeared a significant negative correlation, and it was not noted. We believe the reason that led to the appearance of these statistics that invalidated hypothesis H2 was the high dispersion of the respondents’ declarations on wearing or not of a waterproof apron during AGPs (“Always” frequency = 62.00; “Most of the time” frequency = 20.00; “Occasionally” frequency = 21.00; “Rarely” frequency = 6.00; “Never” frequency = 46.00, as it can be seen in Table 2 ).

The validation of hypothesis H3 is shown in Table 5 using a correlation analysis.

Testing hypothesis H3.

https://doi.org/10.1371/journal.pone.0282673.t005

The Pearson coefficients presented in Table 5 for the variables mentioned in hypothesis H3 indicate no correlations between wearing disposable coverall (AGP_COVERALL) when performing AGPs on a COVID-19 patient, and the following accidents: splashing biological fluids/ respiratory secretions in the eyes (SPLASH_EYES) (Pearson coefficient = -0.110; p = 0.166>0.05), splashing biological fluids/ respiratory secretions in the oral/ nasal mucosa (SPLASH_ORAL) (Pearson coefficient = -0.125; p = 0.115>0.05), and puncture/ sting with any material contaminated with biological fluids/ respiratory secretions (PUNCTURE_FS) (Pearson coefficient = -0.125; p = 0.115>0.05).

However, the Pearson coefficients show a very weak negative correlation between wearing disposable coverall (AGP_COVERALL) when performing AGPs on a COVID-19 patient and splashing biological fluids/ respiratory secretions on the non-idemn skin (SPLASH_SKIN) (Pearson coefficient = -0.178; p = 0.024<0.05). It shows that the frequency of accidents, namely, splashing biological fluids/ respiratory secretions on the non-idemn skin (SPLASH_SKIN) lowers when the PPE disposable coveralls are worn often. Consequently, we agree that the disposable coverall is the more efficient type of PPE preventing possible infections with COVID-19.

The H3 hypothesis was formulated starting from the premise that the disposable coverall is the best method for medical staff to protect themselves against any type of accident. However, the correlations between the variables of this hypothesis are mostly statistically insignificant (p>0.05), showing that even if the disposable coverall is worn when AGPs are performed on patients with COVID-19, there is still exposure to the risk of infection. The only protection offered by wearing disposable coverall, in line with our analysis, and as it results from the correlations, is related to splashing biological fluids/ respiratory secretions on the non-idemn skin.

All these being said, the hypothesis H3 has not been confirmed:

H3 . There is a negative correlation between wearing disposable coverall when performing aerosol generating procedures (AGPs) on a COVID-19 patient and the following accidents : splashing biological fluids/ respiratory secretions in the eyes; splashing biological fluids/ respiratory secretions in the oral/ nasal mucosa; splashing biological fluids/ respiratory secretions on the non idemn skin; puncture/ sting with any material contaminated with biological fluids/ respiratory secretions .

The validation of hypothesis H4 is shown in Tables 6 and 7 using the regression analysis.

Testing hypothesis H4.

https://doi.org/10.1371/journal.pone.0282673.t006

https://doi.org/10.1371/journal.pone.0282673.t007

The dependent variable in the model is the average number of accidents reported by respondents, in numbers, during AGPs on patients with COVID-19. Initially, 11 independent variables were introduced into the model. These are listed in detail in Table 2 and include PPE and preventive protective measures against COVID-19: AGP_SURFACES_DECONT, AGP_SORT, AGP_RR_PPE, AGP_MASK, AGP_HANDH_ASEPSIS, AGP_COVERALL, AGP_VISOR, AGP_HANDH_OBJECTS, AGP_GLOVES, AGP_HANDH_TOUCH, AGP_FOOTPROT. From these 11 predictors, using Backward method, only 4 predictors remained in the final model (Model no. 8): AGP_HANDH_ASEPSIS, AGP_GLOVES, AGP_HANDH_TOUCH, AGP_FOOTPROT.

The eighth variant of the model is the best, with R of 0.620, R 2 of 0.384, adjusted R 2 of 0.367, and an estimated Std. Error of 0.09507. As it can be seen, the value of R (0.620) indicates a relatively good correlation between the average number of accidents, as opposed to the elements of PPE, and preventive protective measures against COVID-19. The values of R 2 (0.384) and adjusted R 2 (0.367) indicate a relatively low to average proportion of the variation in the dependent variable explained by the regression model.

The final model (Model no. 8) is explained in proportion of 36.7%, which is a realistic percentage, if we consider the number of reported accidents (only 28 in total, as it is shown in Table 2 ).

The average number of accidents decreases as the coefficients of AGP_GLOVES, AGP_FOOTPROT and AGP_HANDH_TOUCH grow. In other words, as disposable gloves and footwear protection are used in performing AGPs on patients with COVID-19, and hand hygiene is done before and after touching a patient with COVID-19 (regardless of wearing gloves), the number of accidents should decrease.

All these being said, the hypothesis H4 has been confirmed:

H4 . The average number of accidents (SPLASY_EYES , SPLASH_ORAL , SPLASH_SKIN , PUNCTURE_FS) decreases when the use of disposable gloves (AGP_GLOVES) increases during performing aerosol generating procedures (AGPs) on a COVID-19 patient .

The problem in this model is that the results indicate that the number of accidents increases as the coefficient of AGP_HANDH_ASEPSIS increases. So, as long as there is hand hygiene before and after any procedure requiring asepsis conditions (for example: peripheral vascular catheterization, urinary catheterization, intubation, etc.), the number of accidents increases. We think this could be possible only if hygiene before and after any procedure requiring asepsis conditions was not properly done. Another reason for such an output could also be the low number of accidents (28, detalis in Table 2 ), which could statistically explain this abnormal last result.

5. Conclusions

This study started from the results reported by earlier studies broken down into three research lines: AGPs to COVID-19 patients, PPE during AGPs on COVID-19 patients, and accidents during AGPs involving COVID-19 patients and ways of protecting HCWs. Further, we presented PPEs used during AGPs for the protection of HCWs and against accidents that appear when performing AGPs, after analysing 312 confidential answers collected from the medical staff of the “Sf. Ioan cel Nou” County Emergency Hospital, Suceava, Romania. For this study, the ethical approval was given.

The main results indicate good compliance with the recommendations for managing and lowering the risk of exposure. Most respondents always used, during AGPs, disposable gloves (98.13%), medical masks N95 (or equivalent) (92.86%), visor or googles (91.19%), disposable coverall (91.25%) and footwear protection (95.00%). The waterproof apron was always used by only 40% of staff, and almost 30% not using it at all during AGPs. More than half of respondents (50.32%) reported having changed very much their routine because of COVID-19, and 84.29%, at least, moderately.

We derived from the WHO recommendations [ 13 ] no less than 11 independent factors (details in Table 6 ) related to risk exposure management, defined as hygienic actions or wearing of protective equipment, and used them as variables in a regression analysis. We proposed 4 hypotheses, from which, 2 have been validated (H1 and H4), and 2 have not (H2 and H3). We have found a positive correlation between wearing disposable coverall when performing AGPs on COVID-19 patients, and wearing disposable gloves, medical masks N95 (or equivalent), visor or goggles, and footwear protection, and the fact that the average number of accidents (SPLASY_EYES, SPLASH_ORAL, SPLASH_SKIN, PUNCTURE_FS) decreases when the use of disposable gloves grows during performing AGPs on COVID-19 patients.

We found no positive correlation between wearing a waterproof apron when performing AGPs on COVID-19 patients, and wearing disposable gloves, medical masks N95 (or equivalent), visor or goggles, disposable coverall, and footwear protection. We believe this result has a statistical reason, namely the high dispersion of the respondents’ declarations on wearing or not of a waterproof apron during AGPs. Thus, we consider hypothesis H2 a future interesting investigation topic. Also, we found no negative correlation between wearing disposable coverall when performing AGPs on COVID-19 patients, and the analysed accidents.

The only protection offered by a disposable coverall, as it results from our analysis, is related to splashing biological fluids/ respiratory secretions on a non-idemn skin. Also, the results show that as disposable gloves and footwear protection are used in performing AGPs on patients with COVID-19 and hand hygiene is also done before and after touching a patient with COVID-19 (regardless of wearing gloves), the number of accidents should decrease.

According to the results, there were no differences between male and female participants when using specific PPE items while performing AGPs on COVID-19 patients, except the case when the waterproof apron is used. For this reason, a further research could analyse in detail gender differences in wearing PPE items.

6. Discussions

We found in the literature that COVID-19 could be spread through aerosol/ aerated solids, fluid from human secretions, droplets from normal breathing, coughing, sneezing and surface contact, and, thus, it is considered to be very contagious [ 3 ], and that nurses are extremely exposed to COVID-19 since they have a direct contact with COVID-19 patients, especially in the context of AGPs [ 9 , 12 , 31 ]. In managing the health workers exposure risk, and to avoid any contamination with COVID-19 during aerosols, the use of PPE is recommended for eye, face and head protection, together with reusable equipment (glasses, visors or face shields) [ 17 , 20 ]. Goggles are extremely important in protecting the exposed conjunctiva from infected droplets and aerosols from patients, while aprons, gowns and coveralls offer full protection to HCWs [ 10 , 25 ]. Glove usage can bring a false safety feeling, and Al Youha el al. (2021) found a positive correlation between wearing gloves by nurses, and COVID-19 infections to HCWs [ 6 ].

In line with the exposure risk management recommendations, in our study we expected that a higher percentage of respondents had taken off and replaced their PPE, in accordance with the protocol (82.82%), and had always performed hand hygiene after touching an object found in close proximity to a COVID-19 patient (bed, door handle etc., regardless whether gloves are worn or not) (87.12%).

The present research was carried out at the “Sf. Ioan cel Nou” Hospital in Suceava, Romania, which was the first outbreak of infection in Romania. Thus, the novelty of our research consisted in suggestions for risk management, extremely complicated at the intersection of three large areas of analysis: PPE, AGP, Covid-19.

According to Girma et al., 2020, HCWs’ risk perceptions may be a factor that could influence the wearing of PPE [ 36 ]. This study did not include this factor in its analysis. Also, we did not consider the hand hygiene goals set in the analysed unit, so useful in this pandemic [ 37 , 38 ]. Another limitation of the study is related to the time span covered when asking the questions: three months into the past. This time interval was set by us considering the possibility of respondents to recall events, decreasing as time span increases, and the need to get relevant statistical figures about expected rare contamination events, increasing as the time span increases. Hence, we consider that studies with a different time span can lead to different results.

7. Future prospect and application of this study

Previous studies adressed the challenge to further analyzes related to PPEs [ 37 ], others pointed out that PPE is generally used at an acceptable level [ 36 ], while others focused on the importance of PPE wearing by HCWs [ 20 , 22 , 30 ].

The results presented in our study are useful for risk management, when the following are put together: PPE, AGP, and Covid-19. Given the fact that AGPs are procedures through which infections can easily spread, and the management of any hospital wants to prevent the spread of Covid-19 infections, we conclude that only with adequate PPEs, HCWs could avoid accidents.

Because we found no positive correlation between wearing a waterproof apron when performing AGPs on COVID-19 patients, and wearing disposable gloves, medical masks N95 (or equivalent), visor or goggles, disposable coverall, and footwear protection, we consider this result a starting point for future investigation. Also, given the fact that between wearing disposable coverall when performing AGPs on COVID-19 patients, and the analysed accidents no correlation were found, we expect further research results related to this conclusion.

Future research perspectives on the mix composed by PPE, AGP, and Covid-19 could also be analyzed in the post pandemic times. An interesting comparative analysis between the using of PPE during AGPs in Covid and non-Covid times would be also useful for hospitals management in the future.

Supporting information

https://doi.org/10.1371/journal.pone.0282673.s001

IMAGES

Multiple-Case Study Procedure (Yin, 2009)
Outline of the multiple case study procedure (adapted from Yin, 2009).
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